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Pulman et al
Original Paper
Ideas and Enhancements Related to Mobile Applications to
Support Type 1 Diabetes
Andy Pulman1, MA; Jacqui Taylor2*, BSc, MSc, PhD; Kathleen Galvin3*, BSc, PhD; Mike Masding4*, MBBS, MA,
FRCP
1
The School of Health & Social Care, Bournemouth University, Bournemouth, United Kingdom
2
Bournemouth University, Bournemouth, United Kingdom
3
Faculty of Health and Social Care, University of Hull, Hull, United Kingdom
4
Diabetes Centre, Poole Hospital NHS Foundation Trust, Poole, United Kingdom
*
these authors contributed equally
Corresponding Author:
Andy Pulman, MA
The School of Health & Social Care
Bournemouth University
R109
Royal London House, Christchurch Road
Bournemouth, BH1 3LT
United Kingdom
Phone: 44 1202 962749
Fax: 44 1202 962736
Email: apulman@bournemouth.ac.uk
Abstract
Background: Mobile devices have become increasingly important to young people who now use them to access a wide variety
of health-related information. Research and policy related to the integration of health information and support with this technology
do not effectively consider the viewpoint of a younger patient. Views of young people with type 1 diabetes are vital in developing
quality services and improving their own health-related quality of life (HRQOL), yet research on their lifestyle and use of Web
and mobile technology to support their condition and in non–health-related areas is sparse.
Objective: To develop insight into young people with type 1 diabetes and their current use of Web and mobile technology and
its potential impact on HRQOL. This can be achieved by constructing an in-depth picture of their day-to-day experiences from
qualitative interviewing and exploring how they make use of technology in their lives and in relation to their condition and
treatment. The goal was then to build something to help them, using the researcher’s technical expertise and seeking users’
opinions during the design and build, utilizing sociotechnical design principles.
Methods: Data were collected by semistructured, in-depth qualitative interviews (N=9) of young people with type 1 diabetes
aged 18-21. Interviews were transcribed and loaded onto NVivo for theme identification. Data analysis was undertaken during
initial interviews (n=4) to locate potential ideas and enhancements for technical development. Latter interviews (n=5) assisted
in the iterative sociotechnical design process of the development and provided additional developmental ideas.
Results: Six themes were identified providing an understanding of how participants lived with and experienced their condition
and how they used technology. Four technological suggestions for improvement were taken forward for prototyping. One prototype
was developed as a clinically approved app. A number of ideas for new mobile apps and enhancements to currently existing apps
that did not satisfactorily cater to this age group’s requirements for use in terms of design and functionality were suggested by
interviewees but were not prototyped.
Conclusions: This paper outlines the nonprototyped suggestions from interviewees and argues that young people with type 1
diabetes have a key role to play in the design and implementation of new technology to support them and improve HRQOL. It
is vital to include and reflect on their suggestions as they have a radically different view of technology than either their parents
or practitioners. We need to consider the relationship to technology that young people with type 1 diabetes have, and then reflect
on how this might make a difference to them and when it might not be a suitable mechanism to use.
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Pulman et al
(JMIR Mhealth Uhealth 2013;1(2):e12) doi:10.2196/mhealth.2567
KEYWORDS
patient education; type 1 diabetes; mobile; apps; sociotechnical design; lifeworld; humanising healthcare; patient voice; empathy;
ideas; enhancements
Introduction
important decisions was becoming the sole burden of the
individual with the condition [9].
The World Health Organization has identified the treatment and
care of diabetes as a major challenge for health care systems
worldwide [1]. In the United Kingdom, the National Health
Service (NHS) spends at least £3.9 billion a year on diabetes
services, with around 80% spent on treating avoidable
complications [2].
Education about long-term complications via access to
information could help patients with diabetes empower
themselves to manage their condition more effectively, thereby
reducing complications. It has been acknowledged [10] that
better information on the ways in which social support operated
was vital for enhancing diabetes patient self-care, insuring
adherence to advice, encouraging lifestyle changes, helping to
improve outcomes of care, and increasing personal freedom.
Type 1 diabetes occurs when the body produces no insulin
because of autoimmune destruction of the pancreatic cells that
normally produce it [3]. It can occur at any age but usually
develops before the age of 40, often during teenage years.
Patients with type 1 diabetes need to take insulin injections for
life and, in order to reduce their risk of developing
complications, must ensure their blood glucose levels are
sufficient to balance their insulin doses, diet, and activity. They
must also carry out regular blood testing. The primary diabetes
outcome is glycemic control, as measured by a blood test
(glycosylated hemoglobin or HbA1c) that indicates average
plasma glucose for the previous 2-3 months [4]. Poor glycemic
control has been related to short-term consequences such as
hypoglycemia and diabetic ketoacidosis, as well as serious
health consequences later in life [4]. Completion of
recommended self-care tasks is considered critical to glycemic
control, with the primary tasks that help maintain control—such
as monitoring blood glucose levels, injecting insulin, and dosing
insulin according to meter results or other factors—needing to
be carried out several times per day, often around mealtimes in
different contexts and locations [4]. Type 1 diabetes is the most
common form of diabetes in most parts of the world, although
wide variations exist between the incidence rates of different
populations [5]. In the United Kingdom, it accounts for 10% of
all people with diabetes and 90% of young people with diabetes
[6].
In November 2012, a UK Public Accounts Committee (PAC)
published its report on the management of adult diabetes services
in the NHS, stating that the standard of care for diabetes in
England was “depressingly poor”, causing unnecessary deaths
and disabilities. This report followed critical studies on diabetes
care from both the National Audit Office [7] and Diabetes UK
[8]. The PAC Chair stated [2] that although the Department of
Health had set out clear minimum standards for diabetes
care—including nine basic checks for the early signs of
avoidable complications—fewer than half of people with
diabetes were receiving all nine tests. Variations in the level of
progress across the NHS also meant that there was an
unacceptable “postcode lottery” of care, whereby quality of care
varied dramatically around the country. In November 2012,
members of the House of Lords debated the management of
diabetes services in the NHS following the PAC report. Lord
Harrison, who had lived with type 1 diabetes for 43 years, stated
his biggest concern was that the onus of care and of making
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Lamb’s article on integrating technology into adolescent type
1 diabetes care highlighted how metabolic control varied with
age [11]. Results from this study showed a progressive rise in
HbA1c values throughout adolescence, peaking through the
ages of 18 and 22, before falling again in early adulthood. Lamb
considered a number of factors to be at work that could affect
an inability to control HbA1c during late adolescence, and for
these reasons, suggested that it was not surprising that metabolic
control deteriorated while the incidence of acute complications
such as diabetic ketoacidosis increased during adolescence [11].
Walker [12] defined health-related quality of life (HRQOL) as
the level of well-being and satisfaction associated with an
individual’s life and how this was affected by disease, accidents,
and treatment.
To date, there exists little data analyzing how young people
with type 1 diabetes make use of Web and mobile technology
and its impact on their HRQOL. Franklin’s [13] study was the
first randomized control trial (RCT) that explored the impact
of SMS text messaging (short message service)-enabled
behavioral support, with intensive therapy in a young age group.
However, the study made no mention of engaging with the target
audience to discuss what they would like to use, in order to
influence the hypothesis of the study. Similarly, Pena’s [14]
cross-sectional Web-based survey of parents with children who
had diabetes focused on adults, again lacking a focus on the
concerns of the young people, which were neither addressed
nor included. Reporting on an Internet-based self-management
intervention, the authors [15] stated that their research was the
first trial of an Internet program to improve problem solving in
adolescents with type 1 diabetes. However, the study again
made no reference to having asked young people their opinions
during the design of the intervention. In 2012, an article [4]
highlighted how little was currently known about how young
people used mobile phones for diabetes and as yet only a small
proportion of apps available had been the subject of any research
[16]. This view was most recently reaffirmed [17] in research
that noted a lack of literature available on strategies to promote
greater engagement of youth in behavioral interventions for
type 1 diabetes, with even less information on the use of the
Internet and mobile technologies for minority and low-income
youth.
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This poses the question as to why more health professionals,
researchers, and technologists have not approached this age
group for their opinions and suggestions. Why have these views
seemingly been ignored? Is it a trust issue or perhaps
professionals consider themselves more knowledgeable about
the condition and its effects than the actual people with the
long-term condition? There is a real need to explore how young
people with type 1 diabetes relate to their condition; how they
use and interact with technology and the Internet in health and
non–health-related situations; and what they think would be
useful in new health-based technological innovations. This could
be achieved by talking to them and asking them for their
opinions and suggestions. The research question was: How do
young people with type 1 diabetes interact with technology in
their lives and in relation to their condition and how can their
views and experiences inform the development of a
patient-centric mobile health app?
In recent years, qualitative research methodology has become
more recognized and valued in diabetes behavioral research
[18] because it helps answer questions that quantative research
might not, by exploring patient motivations, perceptions, and
expectations. Lifeworld studies concerning diabetes [19-21]
have also started to appear more often in research literature.
The study aimed to gain a deep understanding of the perspective
of young people with type 1 diabetes and connect with their
views by building a picture of their everyday experiences with
the condition and how they used technology both socially and
for health, as influenced by approaches from qualitative research
in health care such as the lifeworld. Then, aiming to integrate
this perspective within the creation of a mobile or Web tool
influenced by these opinions, which would help to improve an
aspect of HRQOL by using humanizing sociotechnical principles
[22] during the design and build.
Methods
A generic qualitative approach was adopted that would allow
for the development of a breadth (allowing participants
“maximum freedom in expressing the range, scope, and
boundaries of the complex experience” [23]) and depth (further
exploration of specific events and experiences in the
participants’ lives [24]) of understanding regarding the nature
of the studied experience. Recruitment was conducted at a
district hospital located in south west England (SWDC) and a
local university, with data collected by qualitative interviews
with young people with type 1 diabetes aged 18-21. Although
the clinic had children under 18 attending, the focus was on
older members as this alleviated the need for parental consent.
The upper limit was set at 21 years as this was the age
participants no longer attended the Young Person’s Clinic on
a regular basis. The sampling strategy utilized a nonrandom
convenience sample, as selection was from participants who
had type 1 diabetes within the population definition. The
sampling strategy was purposive (nonrandomized). Participants
were considered eligible if they had type 1 diabetes, were 6
months post diagnosis, were within age range at time of
recruitment, and were fluent in English.
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The design used in-depth, 1-hour, semistructured interviews.
Semistructured interviews are used when the researcher knows
what questions they want to ask but does not know what answers
to expect [25]. Question stems are usually asked in the same
order during each interview and responses to open-ended
questions can then be probed, so that the interviewee has the
freedom to respond as they wish [25]. In-depth interviews are
typically used when seeking information on individual, personal
experiences from people about a specific issue, to capture their
own voices and stories [26]. It was decided to progress with
individual interviews rather than use focus groups, as SWDC
staff indicated that a young age group with a mix of male and
females would not produce good quality results. It was also
noted that this age group had a preference for talking
individually and that some interviewees might find talking about
particular aspects of their condition and lifestyle embarrassing
or stressful within a group setting. Finally, as Morse [25] noted,
focus group opinions are offered publically, so they might not
always reflect the interviewee’s actual response.
A semistructured interview guide [27] was developed. Some
broad questions and areas of interest were prepared beforehand,
but it was recognized there was also a need for improvisation
during each interview, based on anticipated and unanticipated
responses. The general purpose of each interview was to discuss,
in detail, specific topics related to the interviewee’s knowledge
and its relevance to the research question and objectives [28],
which were to explore young people with type 1 diabetes
perspectives of their day-to-day lives and how they made use
of Web and mobile technology and to identify from these views
and experiences, how they used technology (if at all) in relation
to their condition and treatment. The core focus of each
interview moved from the interviewee’s first mobile phone and
the historical timeline of different phones they had owned, to
questions about the history of other mobile and computer
technology they used. This usually led to a discussion about
their usage of different Internet software and social media tools.
This was then followed at an appropriate point by a question
about their diagnosis date, which might then lead to talking
about their diagnosis and how they had used technology (if at
all) since then. This could then lead into a discussion of different
aspects of their day-to-day life with diabetes; their experiences
of the clinic, GP surgeries, and other health services they
encountered; experiences socially, at school, at home, and at
work; how they coped with and used technology related to
diabetes; and, if they had used any health-related apps. When
discussing any problems they had experienced, we would then
explore what ideas or enhancements they might have for
something that could improve that aspect of their lifestyle or
others, and whether a technical solution might be of any help.
In total, (N=9) interviews were conducted (m=2 and f=7),
transcribed, and loaded onto the qualitative data analysis tool,
NVivo. The interviews were then analyzed to gain a deeper
understanding of the perspective of the young person with type
1 diabetes and to construct a picture of their everyday
experiences. Credibility refers to the accuracy of information
obtained during a study and is maintained via triangulation of
data sources, methods, and investigators. One way that
credibility was achieved was by prolonged exposure to the
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subject being investigated. By spending a substantial period of
time in the clinic and observing the day-to-day activities and
routines of its staff, it was possible to become immersed in the
world of the clinic. During numerous visits there, the researcher
was able to build relationships with practitioners, dietitians, and
receptionists. By spending longer periods of time with
interviewees, they were able to build their trust over the course
of interviews. A further method of establishing credibility came
from regular supervisory contact, with a requirement to satisfy
the supervisory team that research procedures and ethical
standards were being followed at all times and also to defend
ideas, methods, and analysis during extended questioning on
all aspects of this study.
Results
Six main experiential themes were identified providing an
understanding of how participants lived with and experienced
their condition and how they used technology: (1) living with
diabetes, (2) diabetes technology, (3) in the clinic, (4) obtaining
information and support, (5) mobile technology, and (6) mobile
apps and mobile health apps.
Besides providing an understanding of their day-to-day
experiences and how type 1 diabetes affected their HRQOL,
interviewing enabled the identification of possible ideas for the
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development of prototype mobile apps. The suggestions needed
to meet SWDC goals, reflect interviewee requirements and
comments, and follow local trust guidelines (eg, patient data
were not allowed to be recorded). By asking for their
suggestions, in collaboration with the clinical team, we were
able to focus on four ideas for prototype development [29].
Three of these were created in prototype, with one subsequently
chosen by later interviewees (n=5) to be taken to final
development [30]. The prototype development used
sociotechnical design principles [31]. This approach has recently
started to re-emerge in health literature, with examples within
diabetes research using it as a means of collecting data for
systems designed for both staff [32] and patients [33]. A key
characteristic of sociotechnical thinking lies in highlighting the
importance of developing new ways of working that
significantly meet the needs of clients (patients) and users
(service providers) [34]. This developmental work and the final
app produced could help contribute to new knowledge and
understanding of young people’s requirements and concerns,
which could then improve their HRQOL. Additionally, a number
of other innovative ideas and suggestions for enhancements
were made for improving their lifestyle and making a difference
in other areas of their lives affected by their condition—these
ideas were suggested during the interview process but not taken
forward for prototype development (see Figure 1).
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Figure 1. Methodological structure.
Blood Sugar Recorder
Capillary Blood Glucose Monitors (CBGM) are capable of
holding a large number of historical readings and can sometimes
be linked to a computer to transfer data. However, this cannot
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currently be performed wirelessly. This compares to cloud
systems like Apple’s iCloud, where data is transferred
seamlessly between devices. The constant proximity of the
mobile phone to the user makes it an attractive option for use
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as a recorder. If it could be linked to the data cloud, information
might then be accessed and displayed across multiple devices.
Cause again that’s something then you’re looking at
that’s more visual, that you can see oh ok, maybe it’s
not as good as I thought, whereas just doing it, doing
your sugars once every day and just seeing the
numbers, just seeing it on a chart, seeing how it is
over a period of months, that could be quite…
[T1-QOL-05]
So maybe an App that could give more advice,’cause
coming to the hospital’s really good, like they do set
you targets, like I came before Christmas and they
set me the target of just doing er, my sugars once a
day which I’ve stuck to. [T1-QOL-05]
And then, the personal notifications, I wondered if
you could put other things up like erm, like your
insulin, or what you’ve eaten. Sometimes they weigh
you, measure your height and things. Maybe you
could put that on there. [T1-QOL-09]
This could then be taken to a clinic to show to staff or also be
used for creating historical graphs to pinpoint times of good
and bad control, making it easier to see where somebody was
going wrong by highlighting higher than normal readings.
Historical graphing could also provide a useful incentive for
improving control, as it would allow the ability to immediately
call up and view the data at any time. This may also be more
accessible to a user with pleasing figures and colors. Historical
readings are available on newer CBGMs, but they are not as
accessible or as attractive to view when compared to a digital
display. Personalized goals and targets could also be set, which
could then be flagged if they were met or missed. A more
interactive diabetes assistant could also be provided to tell users
when they were doing well or not. This may be more effective
because interviewees view their phone as a friendly device, not
automatically associated with their condition [11], as opposed
to their CBGM, which might be viewed as more specifically
linked to their condition—similar to how interviewees
differentiated Facebook usage for health and personal use.
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Functionality might also be provided to remind the user to take
a reading by using the push function of a mobile device, which
could then display alarms and reminders as pop-up SMS text
messages. This could also be tailored to include personalized
information about insulin, weight, food intake, height, and other
useful data. However, some users might not wish to enter the
data twice, as it is already on their CBGM, or they might find
the task of inputting figures from a blood sugar reading onto a
mobile device just too bothersome—even if the task was simple
and easy to perform. Some of these suggested features appear
on the iBGStar [35], which is the first CBGM that can be used
on its own or connected directly to an Apple iPhone or iPod
Touch to display, manage, and communicate diabetes
information, and which also works in conjunction with a
specifically written self-management app. However, no research
is available on how this CBGM and app have been utilized to
date. It is only available to buy in the United Kingdom (rather
than offered for free through clinics), so alternative methods of
support could be offered via a free app that worked across a
range of different CBGM rather than locking the individual and
the clinic into one particular device with its associated costs.
Alarms
Some interviewees had already used the alarm clock function
of their mobile phone to remind them to take insulin or to obtain
a blood sugar reading. Expanding on this idea and once again
applying the principle of utilizing push technology on a mobile
device, it would be relatively straightforward to produce a
simple-to-use alarm app (see Textbox 1).
This could allow users to set up multiple reminders on insulin,
blood sugar level checking, and eating, thus helping individuals
to be persuaded or even nagged into doing something specific.
However, some users might simply choose to ignore the alarms,
which could be addressed by changing the tone of the
information contained within the message, received over a
longer time period. While acknowledging that some of this
functionality already exists within apps like OnTimeRX Pro
[36], interviewees had been unable to locate anything that
satisfactorily catered to their requirements or their preferences
for design and functionality.
Textbox 1. Comments on alarms ( I: = interviewer speaking / P: = participant speaking / [T1-QOL-XX] = participant interview number ).
I: Right and does that mean you’re occasionally forgetting to look or you might be missing meals or…
P: Missing injections and or given too much insulin
[T1-QOL-01]
I: Yeah. Ok, so do you think having a reminder or a something on there that sort of nagged you…?
P: Yeah, definitely. I definitely need a push with it…
[T1-QOL-05]
I: A little box to say “Have you taken it yet?”, “Why haven’t you taken it yet?”
P: Yeah (laughs).
I: You need to take it now!
P: Yeah (laughs).
[T1-QOL-09]
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Local Social Network
The belief that users of this age group were happy to share every
aspect of their personal life on Facebook (including health) was
contradicted. Some interviewees wanted to use Facebook only
for talking to friends about their life outside of type 1 diabetes,
rather than using it for diabetes-related searches and communal
group discussions. It is also important to consider how quickly
popular opinion in this age range changes concerning different
brands and products. Indeed, it seemed as if the amount of
discussion in the media about certain social media tools like
Twitter was in some cases harming its ability to attract this age
group toward using it. Some mentioned the problem of having
too much information being constantly tweeted at them by too
many people—similar to the Facebook phenomenon of too
many people being available to connect with, causing them to
exert tight controls on what they looked at and where they
visited online.
Consequently, the idea of a small personalized social network
was discussed by interviewees (see Textbox 2) in the style of
a local, private Facebook or Twitter community, which might
encourage communication between clinic attendees and help
them to make new friends with the same condition—quite
difficult for this age group—in order to address the isolation
they sometimes experienced at that age. This could then link
into wider regional, national, and international networks. The
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forum could be split into private and professional areas, with
the private area being used for making friends and venting
personal opinions in a secure environment with, notably, people
of the same age. Establishing this private forum that clinic staff
could not access, but which had their patronage, rather than
setting up a group administered within Facebook, might even
encourage wider participation (interviewees suggested this
point). The other part of the forum might be managed by clinic
staff, although cost could be an issue, and be accessible to
patients for their queries and feedback. Private queries—which
users might not want clinic staff to see for whatever
reason—could be made within the secure private space. Again,
easy access via a mobile phone might encourage some to more
actively participate in this type of discussion. Previous research
by Pew has shown that wireless connections are associated with
deeper engagement in health-related social media, with mobile
Internet users more likely than those with tethered access to
post comments and reviews online about health and health care
[37]. TuDiabetes [38] was praised by one interviewee as being
a particularly friendly communal environment that raised general
awareness and provided other information related to their
condition, as well as for ease of posting personal queries in the
discussion forum. However, only 1 out of the 9 interviewees
knew about this community, which suggests that awareness of
this forum is not currently high with this age group in the United
Kingdom.
Textbox 2. Comments on local social networks.
I: if we wanted to keep it to [clinic location] would you be happy if it went further say if it was used nationally or would you really want it sort of kept
specific to [clinic location]
P: Yeah, it could be used nationally, but then if you same, in sense under it have like separate departments where you could go to
I: Almost like, little mini networks...
[T1-QOL-01]
P: But I would definitely use, um, a smartphone to do more for my diabetes with it, even if there was just some specific forum where people could
talk…
[T1-QOL-03]
P: maybe like erm, a forum, erm, which had erm, both people with diabetes and medical professionals who were part of the forum so if you posted
something like if you had a query, you could get feedback from people who possibly have gone through it and from like a medical point of view as
well
[T1-QOL-04]
Carb Counting
While positively viewing Carbs & Cals [39] as a good quality
mobile app for diabetes information, interviewees suggested
that it was not a perfect product in every aspect. They responded
positively to the ability to access more localized information
on a mobile platform (see Textbox 3) for their age range and
younger, remembering back to just after diagnosis. They valued
an app covering items that they had not eaten before,
highlighting the importance of a continually updated food
database; an app that also provided a better UK perspective on
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foods, including more detailed information on certain UK
restaurants, takeaways, and fast food establishments, more akin
to what this age range were actually eating; and one that
provided a more practical guide to UK-specific snacks, crisps,
biscuits, and chocolate bars. This information could then be
presented in a searchable, indexed format within the app,
providing a more portable way of carrying around large amounts
of information. Or, for simplicity, this information could be
made available as a specially tailored eBook or PDF, instead
of an app, so that it could be accessed without the need for a
constant Internet connection.
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Textbox 3. Comments on carb counting.
I: … say you put that paper booklet of carb values on there er, would you use that? Sort of call that up?
P: Yeah, probably. Because every now and then you come across something that you haven’t really eaten before so it’s quite good to be able to
reference somewhere, what, how many carbohydrates are in them…
[T1-QOL-09]
P: …I quite liked looking at all like the [fast food chain] and restaurant ones, I think they’re the most difficult, because you don’t see the ingredients…
I: Hmm.
P: …so I think an App like that would be useful…
[T1-QOL-06]
P: But rather than carrying around a book, if you’ve got your phone with you, and you’ve got the app that’s the carb counter, the only thing is, most
apps require Internet or like a decent signal to get it. It would be better if you got one that you downloaded as maybe a PDF file or something that
was constantly on your phone as an e-book or something rather than an app...
[T1-QOL-08]
General Type 1 Diabetes Directory
When a young person is diagnosed with type 1 diabetes, they
need instant access to a vast array of information concerning
all aspects of their lifestyle. This is also applicable initially to
parent caregivers. Interviewees suggested a general type 1
diabetes app directory to hold information on a number of topics
(see Textbox 4). This might include a welcome message to be
read in their own time, once they had been initially diagnosed,
responding to some of their main fears and concerns in a
sensitive, personalized style, and also featuring ways they could
deal with some of the most challenging aspects of the condition.
In addition to containing the contents of the generally
informative patient education pamphlets offered by clinics,
which this age range seemed to either throw away or lose and
then only wanted to access again when they had a specific query,
this directory could also include the specifics of how type 1
diabetes occurred rather than on the mechanics of insulin. It
might also provide a tip sheet written for other parents and
friends, which could be emailed to them as a PDF prior to a
sleepover (like the parental handout that one interviewee’s
mother had created for them) and could offer more
lifestyle-focused information such as exercise, nights out, and
alcohol. It would need to be updated regularly to provide the
latest information, such as when new policy was formulated on
areas like diabetes and driving laws. This would have the
advantage of providing up-to-date clinically validated
information offered for quick and easy access to users at a
particular moment, rather than their having to trawl through
different websites.
Textbox 4. Comments on general type 1 diabetes directory.
P: …if it was kind of like erm, an App which had like, like a contents like, Diabetes, erm, Alcohol, sorry, illnesses, things like that and you could
quickly go and it had like Q&A’s that would be really handy…
[T1-QOL-04]
P: If it was a straightforward, easy to use, I’ve just done exercise and my bloods have gone high. It would take you to the sports page and give you
an explanation why. That would be great…
I: Yeah
P: You know, if it was, if it was well-organized and um, sort of sub-sectioned so that you could find your problem within the space of maybe 5 minutes,
rather than an hour...
[T1-QOL-08]
Podcasts and Vodcasts
Podcasts were positively received as a potential source for
distributing and receiving engaging, good quality, useful
information (see Textbox 5). Sometimes this was mentioned as
being preferable to reading the information. Although podcasts
can be made available for download directly through Apple’s
App Store or via a website, interviewees preferred they be made
available directly through an app to save time when accessing
them.
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Participants were mostly happy to view the information, such
as via a vodcast, rather than listen to it. They preferred a less
formal style than traditional informational messages from health
services, either encouraging users on eating healthily for
example or by offering a more serious tone if required. A final
important note to consider was the type of presenter; a more
professional one might garner the best results and engage the
most users in the message being given to them.
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Textbox 5. Comments on podcasts and vodcasts.
I: …thinking back to since eleven, if there was podcast information on particular subjects. Is that something you might listen to?
P: Yeah I probably would have listened to it, because I don’t really like reading and things so, listening to it would have been much better…
[T1-QOL-09]
P: So, I think I would be interested in watching YouTube videos if it was sort of educational. But I wouldn’t want to watch them if it was just somebody
talking about…
I: Ok.
P: …you know like a vid- blog or something, er, not a blog a, where they record themselves and talk about their own thing. I don’t think I’d watch
something like that...
[T1-QOL-06]
Health Appointment Tracker
The ability to monitor and book appointments over a mobile
device via an app was also suggested (see Textbox 6). This app
could also feature the ability to immediately record information
obtained on the day of the appointment, such as the eyes and
feet, which could then be accessed historically by the user.
The app could feature more generic recorded data functions
than the idea suggested for recording blood sugar levels but
might also have options for ketones and other general
information. It would be possible to program this app so that
the information entered could be customized and personalized
for each user, enabling them to configure it to meet their needs
more effectively. However, it should be noted that even within
this age group, there were still some young people who preferred
using paper rather than digital means for recording information
and that some of this functionality already existed on the
Diabetes Tracker app [40], although it did not appear to have
been well used by those interviewees who had downloaded it.
Textbox 6. Comments on health appointment trackers.
P: …and then you have your eyes, and then you have your feet, and all things like that, so maybe, erm, something where you could put in when your
last one was, what the results were, when your next one was…
I: Ok
P: …and when you’re next due one…
[T1-QOL-04]
P: Yeah, just write the appointments, I mean I had a letter with um, recently and I’ve booked it and I have put it on here as well (on phone) but I, I
just find it easier to have on paper in front of me…
[T1-QOL-06]
Medication Tracker
Although not required by all interviewees, the use of a
medication tracker was also suggested as a method of improving
daily HRQOL (see Textbox 7). This app could allow the user
to simply tick a box once a medication had been taken, perhaps
with a date and time stamp attached, and could be customizable
to include a number of different medications. Using mobile
phone push technology, this could also include pop-up reminders
to be configured based on the different medications and the
times they were due to be taken.
These warnings could increase in severity if not acted upon,
similar to the alarm app idea. Again, this functionality does
already exist on other apps [36], but interviewees had not located
something usable or found existing products to be designed
with them or their condition in mind.
Textbox 7. Comments on medication trackers.
P: …I’ve got levemir, I’ve got a couple of other daily medications as well, just be able to sign and say push, yes I’ve done my levemir today and if I,
um, ’cause sometimes I do my levemir and I’m like, “Have I done my levemir today?” and have this horrible panicky feeling that I might not have
done my levemir but I don’t want to do more, do it again if I’ve done it already…
[T1-QOL-02]
I: Yeah, so just a little tick thing then, that would sort of say like, right, I’ve had this and…
P: Yes, possibly, probably one that could be customized to a number of medications as well…
[T1-QOL-02]
Mentor App
Some participants expressed a desire to be able to talk to people
younger than themselves who had just been diagnosed, to act
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as their mentors and help them work through the various aspects
of being diagnosed with type 1 diabetes, based on their own
experiences post diagnosis. This could include the use of
podcasts or vodcasts, where they discussed particular situations,
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including times when they had been feeling particularly low
and how they had gone about counteracting those feelings. This
would not aim to preach, but rather offer supportive
understanding from a different perspective, away from their
usual group of family and friends. Alternatively, they could
offer advice from within a forum on particular questions that
other young people just diagnosed might have.
I’d like to be like, be able to talk not to, yeah like
younger people who are like fourteen, fifteen, sort of,
who don’t really know where they’re going and they
can talk to someone who’s actually been the worst
diabetic, and who probably is the worst diabetic, you
know, but who can see the other side of it as well like
I’ve, I’d like to be able to talk to all different people
about that I suppose… [T1-QOL-03]
Because I like to be able to help the people that don’t
have such good control [T1-QOL-06]
The most positive aspect of this suggestion is that it shows how
young people with type 1 diabetes are keen on sharing their
knowledge, providing information and support, and helping out
others in a similar position to themselves or who were just
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beginning their post-diagnosis journey. There does not appear
to be the right set of circumstances or opportunities for this to
currently occur according to interviewees.
Diet and Calorie Counter App
While acknowledging that there were a number of existing
dietary and calorie counting apps already available, such as My
Diet Diary [41], the limitations mentioned with them made the
design of a newer, more effective app attractive to interviewees
(see Textbox 8).
The new app could help take some of the guesswork out of
calculating calorific and carbohydrate values and allow users
access at convenient times and in different locations. The major
factor for something like this was to be able to replace the vast
amounts of literature that would need to be carried around on
visits to an external location or restaurant. Enhanced
functionality might also include offering advice on healthy
eating, weight recording, historical tracking, and offering
encouraging messages via SMS text alerts, podcasts, or vodcasts
to make the process of controlling weight and eating healthily
more attractive and supportive.
Textbox 8. Comments on diet and calorie counter apps.
P: I have the books at home or in my flat, but I wouldn’t carry it around in a bag like this or something to go out for a meal or I’d just try and guess
work how much carbs I was eating but whereas if you can just flick it onto, on an app it would be much easier wouldn’t it? I think it would be good
for accessing it really...
[T1-QOL-03]
I: …maybe a little sort of weight related in terms of um, encouraging you to um, sort of put your readings in to keep…
P: Yeah
I: …to keep going with that, when you’ve started…
P: To stick to healthier eating, yeah.
[T1-QOL-05]
SOS App
A free BlackBerry app, the Personal Guardian [42], allows a
user to summon help with the press of a button in an emergency
situation. Users send an SOS by triggering a silent alarm to call
911 in the United States (or any other number entered), in
addition to sending an email, text message, or Twitter post with
the user’s current location, using GPS technology within the
device. Users do not have to unlock their phone or wait for the
app to open; they simply hold down the convenience button on
the side of their BlackBerry. Being able to provide a similar
function to this app within a diabetes environment would offer
several similar benefits (eg, in the event of a hypoglycemic
episode) and might also offer improved HRQOL solutions for
other conditions like epilepsy. This was viewed as being a very
useful solution because young people with type 1 diabetes were
reluctant or often forgot to wear medical alert bracelets as they
got older: “…because if you did collapse, you know, they’re
going to look for your home number or someone to contact it
might be really useful to say [laughs nervously] in the event of
an emergency you know, just click on that thing on the iPhone
or a BlackBerry...” [T1-QOL-03]
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24-Hour Online Help Desk
Another beneficial suggestion, though appreciably more difficult
to maintain due to the high cost implications, was the production
of a 24-hour online help desk that could be accessed via an app,
SMS text message, email, Twitter, or real-time chat facility.
The challenges may include funding this idea, along with the
complexities of the design and programming, rather than the
use of specific communication media; any of the above
suggestions would provide an improved service to help improve
HRQOL. One interviewee noted: “In the event of an emergency,
I mean if someone could just tweet on there ‘Help what do I
do? So and so’s got a nose bleed and she’s diabetic’ or
something like that you know”. [T1-QOL-03]
It is more likely that this age group would want to engage with
these sorts of media rather than older users based on current
literature [43,44]. But, by providing this service at a younger
age, it could be argued that over time health services would
actually benefit, saving money by decreasing the number of
complications experienced by this age group, which in some
cases led to their hospitalization [2].
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Discussion
This research highlights that there are many ways in which the
HRQOL of young people with type 1 diabetes could be
improved, through the design and implementation of new
technological innovations and enhancements that use Web and
mobile technology. This research tells us that there is a need to
consider three factors before anything is actually developed:
(1) considering young people’s relationship to technology, (2)
reflecting on how this might be able to effectively make a
difference to them, and (3) considering when it might not be a
suitable mechanism to use.
Young People’s Relationship With Technology
The age when most interviewees obtained their first mobile
phone was quite young in comparison to previous
generations—on average, at the start of teenage years, although
some interviewees had obtained them even earlier, in some
cases, from the age of 9 or 10. Therefore, from a relatively
young age this generation has viewed their phone as a constant
companion, accompanying them at play, through school,
university, and then work use: “because I wasn’t carrying the
book around with me, whereas with my phone…it’s always
with me wherever I go”. [T1-QOL-05]
It appears that newer smartphone devices have gradually started
to replace other electronic media that interviewees owned like
MP3 players, laptops, cameras, and paper-based systems like
diaries. As the capabilities of smartphones have increased, they
can be viewed as ever more attractive options for use in relation
to type 1 diabetes. Indeed, 60% of 16 to 24-year-olds in the
United Kingdom now use a mobile phone to access the Internet
every day [43], while in the United States, 42% of mobile
owners aged 18-29 have looked for health and medical
information on their mobile devices [44]. Because this
generation of users has become more attached to their mobile
device, there are important implications on how future
education, awareness, and management of type 1 diabetes could
be changed or integrated with technology. For example, it has
been noted [45] that the majority of adolescents wished to
communicate only by SMS text message for follow-up post
education, highlighting the need for health professionals to adapt
to the lifestyle and mechanisms of communication adopted by
today’s adolescents. Literature suggests that there is a thirst for
new technology to be applied in the care of type 1 diabetes and
on the rare occasions when young patients have been asked
[46], they were keen on trying new solutions, although there
remain doubts as to whether technology can effectively help
them in all aspects of education and self-management [11].
How Technology Can Make a Difference
In some cases, the closeness of technology to the young person
had already led to it being used innovatively in relation to their
condition, such as using alarm functionality on a mobile phone.
It is important to note that some users would be more likely to
engage with diabetes-specific, app-related technology if cost
were not an issue. The main benefits mentioned by interviewees
of using diabetes apps tended to focus on their ability to replace
paper-based information, like logbooks and books, which they
previously had to carry around with them, in addition to their
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Pulman et al
other diabetes equipment. However, there was a feeling that
current apps, although helpful, were not actually worth using.
This could be due to the cost, flexibility, design, and usefulness
of the apps themselves, or the lack of a cohesive guiding
framework for using them, which could involve the clinic in
some way. For example, if a CBGM automatically logged blood
glucose, what was gained by interviewees having to additionally
enter it themselves on their phone? The lack of a decent quality
app for blood glucose monitoring was mentioned by one
participant directly while others lamented the lack of UK-centric
apps; the dietary values on those available were slightly
different, making them difficult to use effectively. This was a
comment also directed at some of the data held on the Carbs &
Cals app [39], even though the app itself was well regarded.
Participants could see the value of accessing up-to-date
information via some form of technology like Twitter [29] as
a means of providing them with support and information, such
as increasing awareness of information on new CBGM about
to be released and other technological innovations, highlighting
news on scientific advances, and helping with support
immediately after diagnosis.
Technology could also be used to ease the transition between
different clinics and prevent issues such as the lack of
notification of changes in guidance [29]. This could help
minimize the problems of receiving differing, seemingly
contradictory, advice from different parts of the health service.
Technological enhancements were suggested for the
development of health apps that might be useful to them in the
areas of Twitter [29], illness and diabetes [29], hypoglycemia
and diabetes [29], and alcohol and diabetes [30]. These were in
addition to the many other ideas and suggestions they had for
improving their lifestyle and making a difference in other areas
of their lives affected by their condition, which were not taken
forward to development (see Results).
As can be seen from these suggestions, there are a number of
areas where new technological solutions might help to bridge
a gap and offer new opportunities to improve HRQOL for this
age group and condition. It is a surprising aspect of this research
that there were so many areas mentioned that have yet to be
adequately addressed, either not existing at all or existing in an
inadequate or unsatisfactory product for this age group. It is
more surprising in light of the current poor performance of UK
diabetes care and the length of time these technologies have
now been around for: “There is apps on here but I’ve never used
them because they don’t seem that good. Just seems like
someone in the back shed’s made them”. [T1-QOL-01]
Considering When Not to Use Technology
There was a strong feeling expressed by interviewees that
although the condition, type 1 diabetes, might be the same, the
experience of living with it was completely different for each
individual. Just as each person had their own unique perspective
and a completely different personal experience of living with
type 1 diabetes, so they also required different approaches and
suggestions based on their own personal preferences toward
technology: “no one, no two people are the same with diabetes,
everybody is different”. [T1-QOL-08]
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This means not assuming that everybody in a particular age
group will automatically adopt any new form of social media
or technology. It is notable that not all interviewees were drawn
to engage with new products if they did not directly appeal to
them in some way. For the majority of users, from a mobile
perspective, apps were quite a new development even though
launched some time ago, and some interviewees had not made
much use of them. One of the reasons for this was financial;
users were reluctant to try them out because they were frightened
about the implications of creating an account or they were
reluctant to pay for an Internet connection as a part of their
mobile contract. The general theory concerning Web 2.0 and
social media suggests that it facilitates and encourages use and
collaboration. So, it is in stark contrast that this particular age
group does not always feel inclined to use it as a mechanism
for obtaining information and support for their condition. It
might be that aspects of their character or personal feelings limit
them from interaction in online environments with people they
do not know. Or they might have conditions precluding certain
areas or functions of online activity, like Asperger’s syndrome.
They may not wish to share information about their condition
online—the technological equivalent of Williams’ [47] findings
on how diabetes is sometimes kept separate from social identity.
Aspects of technology use that might be diversive; use the wrong
medium to spread a health message; try to manipulate something
entertaining into something educational without clear education,
explanation or support; or exclude through cost or software
system could negatively impact on any technological
enhancement implemented. They need to be given clear and
careful consideration before any solution is developed.
Limitations
The main limitations of this study are that it was not able to test
the impact of the innovative tool that was created [29-30] and
that more of the other suggested enhancements were not able
to be taken forward for development (see Results). However,
future research projects can help to address this, by measuring
the impact of the created app locally, nationally and overseas
using a validated HRQOL measure. Additional health apps
based on this research approach can also be designed, tested,
built and implemented using the same approach and then be
subsequently measured for any positive or negative impact on
HRQOL.
Conclusions
We need to consider in depth the relationship to technology that
young people with type 1 diabetes now have and then consider
how this might make a difference to them. But we also need to
Pulman et al
decide when it might not be a suitable mechanism to use. By
reflecting on these areas, any technology to be created will be
much more usable and suitable for the target users. Reflecting
on the tenets of good sociotechnical design related to the
creation of new or enhancements to existing health apps,
democratic and participative communication and decision
making must always be available to give users a voice [22].
Future developments concerning the use of mobile phones and
health apps should reflect and focus on how this generation has
become accustomed to using them and where they might best
fit best in a health context - acknowledging that this will not
naturally be successful in every circumstance. This will be a
key way to address a broad range of enhancements to improve
HRQOL that will be used regularly and make a real difference.
For example, a new CBGM app could be tailored to include
personalized information about insulin, weight, food intake,
height and other useful data, without replicating the functionality
of existing CBGM that already have the ability to record these
data. Stepping back and taking a more practical, logistical
approach to some of the problems users experienced, a tip sheet
written for other parents and friends could be emailed to them
as a PDF prior to a sleepover. Calorie and carbohydrate counting
material could be provided as a specially tailored e-Book or
PDF instead of as an app, so that it could be accessed without
the need for an Internet connection via a simple and quick
indexing system. Another options would be enhancing (based
on user requirements) or using existing mobile phone technology
in new ways to harness improvements to HRQOL, such as using
push technology for pop-up reminders about insulin injecting,
blood sugar level checking and having something to eat (but in
a more attractive and interactive way for younger users).
The need is there and has been highlighted—we just need to
create the proper technological solutions that this user base is
asking for. The World Health Organization estimates that more
than 80% of diabetes deaths occur in low- and middle-income
countries and projects that diabetes deaths will increase by two
thirds between 2008 and 2030 [48]. We hope that the
dissemination of these innovative ideas and enhancements for
possible mobile interventions, education, and support will offer
ways to help reduce these figures. It is vital for policy makers,
health practitioners, and technicians to take note of and reflect
on these ideas and the issues that they raise. Helping to build
an enhanced understanding of young people with type 1 diabetes
and what they might use, what is not being provided to them in
the format and design they require, and what they would like
to see in future type 1 diabetes education and support could
improve HRQOL and reduce the health care burden.
Acknowledgments
Publication of this article has been made possible by funding from the Bournemouth University Open-Access Publishing Fund
(OAPF).
The authors would also like to acknowledge and thank the staff at the district hospital in the South West (England) for their valued
help and support in relation to this study.
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Pulman et al
Authors' Contributions
Authors' Contributions: All of the authors are responsible and qualified for the reported research. They have all participated in
the concept and design, analysis and interpretation of data, and drafting and revision of the manuscript, and approve the manuscript
as submitted.
Conflicts of Interest
Conflicts of Interest: None declared.
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JMIR MHEALTH AND UHEALTH
Pulman et al
Abbreviations
CBGM: capillary blood glucose monitor
HRQOL: health-related quality of life
NHS: National Health Service
PAC: Public Accounts Committee
RCT: randomized control trial
SMS: short message service
SWDC: district hospital in South West England
Edited by G Eysenbach; submitted 20.02.13; peer-reviewed by S Mulvaney, B Irwin; comments to author 26.03.13; revised version
received 09.05.13; accepted 08.06.13; published 25.07.13
Please cite as:
Pulman A, Taylor J, Galvin K, Masding M
Ideas and Enhancements Related to Mobile Applications to Support Type 1 Diabetes
JMIR Mhealth Uhealth 2013;1(2):e12
URL: http://mhealth.jmir.org/2013/2/e12/
doi:10.2196/mhealth.2567
PMID:25100684
©Andy Pulman, Jacqui Taylor, Kathleen Galvin, Mike Masding. Originally published in JMIR mHealth and uHealth
(http://mhealth.jmir.org), 25.07.2013. This is an open-access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic
information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must
be included.
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