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

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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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