This document reviews 28 studies on mobile terminal-based applications to support self-management of diabetes. Most studies involved mobile phones and evaluated feasibility and acceptability through questionnaires and log files. Fifteen studies also conducted clinical evaluations and 10 found statistically significant decreases in HbA1c levels. Key findings were that applications were generally well accepted but faced technical challenges. Long-term adherence and motivating unmotivated patients require more research.

1. A Review of Mobile Terminal-Based Applications for Self-
Management of Patients with Diabetes
Naoe Tataraa,b, Eirik Årsanda,b, Heidi Nilsena, and Gunnar Hartvigsenb,a
a Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North
Norway, Norway
b Department of Computer Science, University of Tromsø, Norway
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

2. Outline
• Introduction
• Methods
– Literature search
– Inclusion and exclusion criteria
• Results
– Data extracted and summarized in 9 categories
• Discussion
• Conclusion
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

3. Introduction
High preverance of diabetes and the importance of self-
management
Regular Blood Glucose
(BG) measuremenet
Maintain BG level
within a safe range
Proper nutrition Physical activity
All images are from Google Image

4. Introduction
High preverance of diabetes and the importance of self-
management
Regular Blood Glucose
(BG) measuremenet
Leading to BG level
Maintain additional
and complex diseases
within a safe range
Proper nutrition Physical activity
All images are from Google Image

5. Introduction
High preverance of diabetes and the importance of self-
management
Regular Blood Glucose
(BG) measuremenet
MobileMaintain BG level
phones
Leading to additional
and complex diseases
within a safe range
• Pervasiveness
• Portability
• Inherent technologies
Proper nutrition Promising support device? Physical activity
All images are from Google Image

6. Introduction
High preverance of diabetes and the importance of self-
management
Purpose of this study
–Identify studies that examined feasibility, acceptability
or effectiveness of mobile terminal-based applications
–Review research methods and technologies used
–Summarize useful findings by empirical methods
involving prospective users

7. Literature search
• Data sources
– Pubmed, ISI Web of Science, INSPEC, EMBASE, CINAHL, PsycINFO,
Cochrane Library, ACM digital library, IEEExplore, and JMIR
• Search terms
– Diabetes AND (mobile OR handheld OR cellular phone OR cell
phone OR PDA)
• June to July 2008
• No restriction by year of publication
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

8. Inclusion and exclusion criteria
• A mobile terminal-based application is used, examined or developed
for
 supporting diabetes self-management
the health care professionals’ side only
collection of medical data only
• Qualitative or quantitative results obtained by empirical methods
involving subjects or clinical outcome evaluation are concretely
described
Reviews without primary data
Concept work or only technological work
• Publications should appear in peer-reviewed journals or reviewed
international conference proceedings
Publications written not in English
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

9. Data extraction categories
• Study design
• Targeted population
• Terminals used
• People involved in the application
• Data input by patients and data entry methods
• Functions of the applications
• Methods used to evaluate feasibility, acceptability or
effectiveness
• Methods and results of clinical outcome evaluations
• Research findings (positive/negative aspects)

10. Results of literature search
Search results after removal of duplicates: 817 publications
review of titles and abstracts
94 publications
examination of full texts following inclusion
and exclusion criteria
36 publications
describing 27 studies
Removal of 3 publications reporting midterm results of clinical
evaluation, whose final results were included in newer ones
Addition of 3 publications describing 1 study
Addition of 3 publications relevant to 2 of the studies included
39 publications describing 28 studies
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

11. Study design
Commercial
Self-developed applications: 20 applications Other: 1
:7
In 25 studies: applications were tested in field
settings (inc. 15 studies clinical evaluation were
conducted)
In 3 studies: results from usability engineering
process were described
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

12. Targeted population
Type2
Type not specified
Type1 diabetes: 13 diabetes
:9
:6
Other specification of target
• Child, adolescent, or young adult patients (8 studies)
• Parents of child patients (1 study)
• Insulin-treated patients (5 studies)
• Newly diagnosed patients (1 study)
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

13. Terminals used
Mobile phone: 20 PDA: 8 Other: 1
Both mobile phone and PDA: 1
Among the 20 studies where mobile phones are used:
• In 5 studies, the participants used their own mobile phones.
• In 5/8 studies targeting child or young patients with Type1
diabetes, a mobile phone is used.
• In 8 studies, SMS is used for data entry, feedback, or reminder
• In 3 studies, WAP is used as an alternative data entry means
besides SMS and a web browser on a PC.
In 10 studies, a PC is used as an additional terminal.
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

14. People involved in the applications
Family of
Health Care Professionals (HCPs): 20 Patients None: 5
:3
Among the studies where HCPs are involved in applications
• In 13 studies: HCPs give manual feedback to the patients
• In 3 studies: HCPs can only view the uploaded data by patients
• In 2 studies: HCPs are involved at the patients’ regular clinic visits
• In 1 study: HCPs participate in usability engineering process
All studies where family of patients are involved are targeting young
patients with Type1 diabetes

15. Data input methods and data type
• Blood glucose data
Both automatic
Automatic: 13 and mannual Mannual: 14 Not used: 4
:3
• Activity data
Automatic
Mannual: 12 Not used: 14
:2
• Other mannually input data
food intake (15 studies), medication (10 studies), general comments
(7 studies), general health (4 studies), other daily measurements (3
studies)
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

16. Functions of the applications
• Data view: in 16 studies
– By only using a mobile terminal (6 studies)
– By only accessing through a website using a PC (5 studies)
– By using more than one terminals (5 studies)
• Automatic feedback: in 8 studies
– Alarms are generated according to blood glucose values (4
studies)
• Reminder: in 9 studies
• Educational tool: in 6 studies
• Communication platform: in 5 studies
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

17. Evaluation methods
• Questionnaires (in 24 studies)
– The Summary of Diabetes Self-Care Activities (SDSCA) is used in 4
studies
– In most of the studies, self-developed questionnaires are used
• Log files (in 18 studies)
• Qualitative methods
– Interviews (in 7 studies)
– Focus group meetings (in 3 studies)
– Feedback through free comments (in 3 studies)
– User meeting (in 2 studies)
• Clinical evaluation (in 15 studies)
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

18. Clinical evaluations
• The 15 studies vary in design of:
– Clinical evaluation (Randomized controlled trial, one group pre-
post intervention study, randomized crossover trial, or a non-
randomized parallel group trial)
– Duration of intervention (4 weeks to 12 months)
– The number of patients (10 to 203)
– Statistical analysis methods
– Features of applications
• In 10/15 studies, a significant decrease in HbA1c is
shown (inc. 3 studies with certain conditions)
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

19. Findings [positive aspects]
• Automatic and wireless data transmission
• Ease of use, menu structure, data presentation (fast
analysis, data visualization, no difficulty in reading)
• Use of mobile phone > PC
– Participants’ own mobile phone
– SMS > WAP
– Reminding effect
• Message delivery at a frequency of 1-2 times a day
• Better communication and feeling of security
• Statistically significant improvement in various aspects of
diabetes self-management

20. Findings [negative aspects]
• Technical problems
– Data transmission failures, difficulties
– Hardware (small size of buttons or displays, short battery-life, slow
processors, small memories)
– Software (menu structures, data entry methods and little flexibility in
data entry rules)
• Time requried (too time-consuming)
• Difficulties in long-term use
• Dropping-out users and enthusiastic users
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

21. Discussion
• Key Assessment points
– Motivation in self-management
– Long-term adherence (Dropping-out ratio)
– Relationship between patients, HCPs and families
– Glycemic control as a result
• Features that applications should consider
– Automation, manual operation by patients, and support by HCPs
or patient peers
– Time required to use and reflection-in-action
– Intuitive and informative user interface
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

22. Conclusion
• Studies that examined feasibility, acceptability or
effectiveness of mobile terminal-based applications were
identified and reviewed.
• Mobile terminal-based applications for self-management
of diabetes are generally well accepted by patient users.
• Useful findings in development of such applications were
summarized.
• Long-term adherence and enhancing motivation on
unmotivated patients are left as future works.
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico

23. Thank you for your attention!
Questions?
Acknowledgement
This work was supported by the Centre for Research-based Innovation, Tromsø
Telemedicine Laboratory (TTL), Norwegian Research Council Grant No.174934
eTELEMED 2009, 1-7 Feb 2009, Cancun, Mexico