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J Telemed Telecare OnlineFirst, published on May 29, 2015 as doi:10.1177/1357633X15586641
RESEARCH/Original article
Use of and interest in mobile health for diabetes self-care in vulnerable populations
Journal of Telemedicine and Telecare 0(0) 1–7 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X15586641 jtt.sagepub.com
James R Humble1,2, Elizabeth A Tolley1,3, Rebecca A Krukowski1,3, Catherine R Womack2,3, Todd S Motley4 and James E Bailey1,2,3
Abstract Objective: We aimed to assess use of and interest in mobile health (mHealth) technology and in-person services for diabetes self-care in vulnerable populations. Methods: We delivered a self-administered cross-sectional survey. Participants were recruited at two primary care practices (P1 and P2) with P1 located in a medically underserved area and P2 in an affluent suburb. Two-sample t-tests and chi-square tests were used with p < 0.05 significant. In addition, a secondary analysis was performed to analyse differences in use and interest in mHealth by age. Results: Of 75 eligible patients, 60 completed the survey (80% response rate). P1 patients had significantly higher interest in three of five categories of in-person diabetes support services, one of four categories of health-related text messages (TM), and three of eight categories of mHealth applications (p < 0.05). Smartphone users reported higher interest in TM (p ¼ 0.004) and mHealth applications for diabetes self-care (p ¼ 0.004). Younger patients were more likely to have a smartphone (p < 0.006), use the Internet (p < 0.0012), use smartphone applications (p < 0.0004), and to be interested in using applications to manage their diabetes (p < 0.004). Discussion: This study shows substantial patient interest in TM and mHealth applications for diabetes self-care and suggests that patients in underserved areas may have particularly high interest in using mHealth solutions in primary care. Younger patients and smartphone users were more likely to be interested in using applications to manage their diabetes. As more patients use smartphones, interest in using mHealth to support patient self-care and strengthen primary care infrastructure will continue to grow. Keywords Ehealth, home telecare, self-care, telehealth Date received: 18 February 2015; Date accepted: 21 April 2015
Introduction Over 28 million Americans currently have diabetes,1,2 and their adherence with medications and recommended lifestyle changes is often poor.3 Recent population-based estimates indicate that less than 40% of type 2 diabetics have ‘‘good’’ adherence to their medication regimens,3 and even fewer adhere to other recommended diabetes self-care behaviours such as physical activity, weight loss, and smoking cessation.4 New approaches are needed to improve patient engagement in diabetes selfcare to prevent long-term complications. Mobile health (mHealth) solutions including health-related text messages (TM) and mHealth applications (Apps) have been proposed as important emerging technologies to assist in patient self-care.4–6 Early evidence from several studies supports effectiveness for health-related TM7–10 and mHealth Apps11–13 in improving diabetes self-care behaviours.4 On average over 83% of Americans report owning
a cell phone, and the use of cell phones for more than simply making calls continues to grow.14 Although interest is growing in using mHealth tools to improve diabetes self-care in vulnerable populations, major feasibility issues remain unanswered. First, only a few studies have documented interest in mHealth in 1 Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA 2 Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA 3 Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN,USA 4 Motley Internal Medicine Group, 1264 Wesley Dr. Suite 606, Memphis, TN 38116, USA
Corresponding author: James E Bailey, Division of General Internal Medicine, Department of Medicine, University of Tennessee Health Science Center, 956 Court Avenue, Coleman D222, Memphis, TN 38163, USA. Email: [email protected]
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vulnerable groups,15,16 and the current study explored what patients wanted in a mHealth programme. Likewise, implementation feasibility and effectiveness in primary care practice settings is unclear.17 One recent study demonstrated that even though patients prefer entering their personal diabetes health data using mobile rather than web-based technology, their engagement diminishes over time.18 Another recent survey showed that physicians were willing to incorporate mHealth tools into their practices, provided they showed value and were not too cumbersome.19 Furthermore, a major study is underway in three countries investigating whether clinical outcomes for diabetics are improved using healthrelated TM for diabetes self-care.20 The current research assesses use of and interest in mHealth tools in vulnerable populations in order to help determine the feasibility of encouraging vulnerable patients to use mHealth technology more broadly to assist in diabetes self-management. In particular, we sought to assess diabetic patients’ current cell phone, smartphone, and mHealth usage practices, and their interest in using mHealth tools to help them take charge of their own chronic illness. Furthermore, we hoped to document vulnerable patients’ use of and interest in various types of health-related TM and mHealth Apps in the primary care setting, and patient use of and interest in in-person diabetes support services. We particularly wanted to know whether use of and interest in mHealth and in-person services varied according to smartphone use and/or according to practice location and predominant population served. We hypothesized that smartphone users would be much more interested in mHealth Apps, and that interest in health-related TM and mHealth Apps would be significantly lower among patients seen in a practice serving a medically underserved area.
Methods The current investigation employs a self-administered cross-sectional survey of patients with diabetes assessing their use of and interest in both mHealth and in-person support services for diabetes self-care.
Setting and participants In order to contrast use of and interest in mHealth and inperson support services for diabetes self-management in diverse populations in the Southern United States, two representative primary care practices in West Tennessee were selected: one general internal medicine practice serving a majority African-American medically underserved community (Practice 1), and a second general internal medicine and endocrinology practice serving a majority white and more affluent suburban community (Practice 2). The Whitehaven, Tennessee community in which Practice 1 is located is primarily AfricanAmerican (96.0%) and has a median income of $37,016, with about 45.4% of residents having completed at least
1 year of college, and about 35% having not completed high school.21 Nearly 28% of individuals live below the poverty level, with 37.4% single-mother households.22 This region is a medically underserved area and a primary care shortage area according to the Health Resources and Services Administration.23 In contrast, the Germantown, Tennessee community in which Practice 2 is located is primarily white (86.6%) and has a median income of $126,196, with about 83.6% of residents having completed at least 1 year of college, and only about 2.2% having not completed high school.21 These disparate populations were targeted in order to investigate whether use of and interest in in-person and mHealth diabetes support services differed among people from neighbourhoods with diverse geographic, racial, and socioeconomic characteristics. The subject population included all adult diabetes patients seen in the participating practices for an outpatient visit for a representative 1-week period in July and August 2013. All survey participants met the following inclusion criteria: they were between 18 and 90 years of age and carried a physician-confirmed diagnosis of either type 1 or 2 diabetes. Patients with significant cognitive impairment or inability to communicate their responses to survey questions as determined by their physician or family members were excluded.
Survey development The survey instrument was designed to collect general demographic data and to investigate use of and interest in mHealth and in-person support services for diabetes self-care. The survey instrument was developed using standardized questions from several sources including the Behavioral Risk Factor Surveillance System (BRFSS),24 National Health Interview Survey,25 and several peerreviewed articles.26,27 Questions regarding diabetes diagnosis and treatment were derived from BRFSS.24 Questions regarding use of and interest in mHealth for diabetes self-care were adapted from the De Reuver et al. cell phone and mobile application survey,26 and all employed a 5-point Likert scale. Diabetes communications experts assisted in refining the survey content in an iterative fashion both before and after pilot testing the draft survey instrument with adult diabetic patients in the Memphis area.
Survey administration A medical student explained the role and scope of the survey to each eligible participant during a routine primary care visit. Patients were left to complete the survey as they waited on their physician. A written consent statement was included at the beginning of each survey and consent for participation was indicated by completion of the self-administered survey. Surveys were generally selfadministered but for patients who desired assistance, either a companion of the patient or a medical student
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Humble et al.
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read the survey aloud and collected the patient’s responses. Each survey was individually numbered in order to track participation, and incomplete surveys were collected to assess response rate.
Analysis Frequencies were enumerated for patient characteristics and responses by practice site and smartphone ownership. Two-sample t-tests and chi-square tests for contingency tables were employed to identify differences between practices and between smartphone users and non-users, with p < 0.05 considered significant. In addition, we conducted a post-hoc secondary analysis to assess the impact of age on use and interest in mHealth opportunities, comparing those
(JTT)
[1–7] [PREPRINTER stage]
J Telemed Telecare OnlineFirst, published on May 29, 2015 as doi:10.1177/1357633X15586641
RESEARCH/Original article
Use of and interest in mobile health for diabetes self-care in vulnerable populations
Journal of Telemedicine and Telecare 0(0) 1–7 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X15586641 jtt.sagepub.com
James R Humble1,2, Elizabeth A Tolley1,3, Rebecca A Krukowski1,3, Catherine R Womack2,3, Todd S Motley4 and James E Bailey1,2,3
Abstract Objective: We aimed to assess use of and interest in mobile health (mHealth) technology and in-person services for diabetes self-care in vulnerable populations. Methods: We delivered a self-administered cross-sectional survey. Participants were recruited at two primary care practices (P1 and P2) with P1 located in a medically underserved area and P2 in an affluent suburb. Two-sample t-tests and chi-square tests were used with p < 0.05 significant. In addition, a secondary analysis was performed to analyse differences in use and interest in mHealth by age. Results: Of 75 eligible patients, 60 completed the survey (80% response rate). P1 patients had significantly higher interest in three of five categories of in-person diabetes support services, one of four categories of health-related text messages (TM), and three of eight categories of mHealth applications (p < 0.05). Smartphone users reported higher interest in TM (p ¼ 0.004) and mHealth applications for diabetes self-care (p ¼ 0.004). Younger patients were more likely to have a smartphone (p < 0.006), use the Internet (p < 0.0012), use smartphone applications (p < 0.0004), and to be interested in using applications to manage their diabetes (p < 0.004). Discussion: This study shows substantial patient interest in TM and mHealth applications for diabetes self-care and suggests that patients in underserved areas may have particularly high interest in using mHealth solutions in primary care. Younger patients and smartphone users were more likely to be interested in using applications to manage their diabetes. As more patients use smartphones, interest in using mHealth to support patient self-care and strengthen primary care infrastructure will continue to grow. Keywords Ehealth, home telecare, self-care, telehealth Date received: 18 February 2015; Date accepted: 21 April 2015
Introduction Over 28 million Americans currently have diabetes,1,2 and their adherence with medications and recommended lifestyle changes is often poor.3 Recent population-based estimates indicate that less than 40% of type 2 diabetics have ‘‘good’’ adherence to their medication regimens,3 and even fewer adhere to other recommended diabetes self-care behaviours such as physical activity, weight loss, and smoking cessation.4 New approaches are needed to improve patient engagement in diabetes selfcare to prevent long-term complications. Mobile health (mHealth) solutions including health-related text messages (TM) and mHealth applications (Apps) have been proposed as important emerging technologies to assist in patient self-care.4–6 Early evidence from several studies supports effectiveness for health-related TM7–10 and mHealth Apps11–13 in improving diabetes self-care behaviours.4 On average over 83% of Americans report owning
a cell phone, and the use of cell phones for more than simply making calls continues to grow.14 Although interest is growing in using mHealth tools to improve diabetes self-care in vulnerable populations, major feasibility issues remain unanswered. First, only a few studies have documented interest in mHealth in 1 Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA 2 Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA 3 Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN,USA 4 Motley Internal Medicine Group, 1264 Wesley Dr. Suite 606, Memphis, TN 38116, USA
Corresponding author: James E Bailey, Division of General Internal Medicine, Department of Medicine, University of Tennessee Health Science Center, 956 Court Avenue, Coleman D222, Memphis, TN 38163, USA. Email: [email protected]
Downloaded from jtt.sagepub.com at University of Birmingham on June 1, 2015
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vulnerable groups,15,16 and the current study explored what patients wanted in a mHealth programme. Likewise, implementation feasibility and effectiveness in primary care practice settings is unclear.17 One recent study demonstrated that even though patients prefer entering their personal diabetes health data using mobile rather than web-based technology, their engagement diminishes over time.18 Another recent survey showed that physicians were willing to incorporate mHealth tools into their practices, provided they showed value and were not too cumbersome.19 Furthermore, a major study is underway in three countries investigating whether clinical outcomes for diabetics are improved using healthrelated TM for diabetes self-care.20 The current research assesses use of and interest in mHealth tools in vulnerable populations in order to help determine the feasibility of encouraging vulnerable patients to use mHealth technology more broadly to assist in diabetes self-management. In particular, we sought to assess diabetic patients’ current cell phone, smartphone, and mHealth usage practices, and their interest in using mHealth tools to help them take charge of their own chronic illness. Furthermore, we hoped to document vulnerable patients’ use of and interest in various types of health-related TM and mHealth Apps in the primary care setting, and patient use of and interest in in-person diabetes support services. We particularly wanted to know whether use of and interest in mHealth and in-person services varied according to smartphone use and/or according to practice location and predominant population served. We hypothesized that smartphone users would be much more interested in mHealth Apps, and that interest in health-related TM and mHealth Apps would be significantly lower among patients seen in a practice serving a medically underserved area.
Methods The current investigation employs a self-administered cross-sectional survey of patients with diabetes assessing their use of and interest in both mHealth and in-person support services for diabetes self-care.
Setting and participants In order to contrast use of and interest in mHealth and inperson support services for diabetes self-management in diverse populations in the Southern United States, two representative primary care practices in West Tennessee were selected: one general internal medicine practice serving a majority African-American medically underserved community (Practice 1), and a second general internal medicine and endocrinology practice serving a majority white and more affluent suburban community (Practice 2). The Whitehaven, Tennessee community in which Practice 1 is located is primarily AfricanAmerican (96.0%) and has a median income of $37,016, with about 45.4% of residents having completed at least
1 year of college, and about 35% having not completed high school.21 Nearly 28% of individuals live below the poverty level, with 37.4% single-mother households.22 This region is a medically underserved area and a primary care shortage area according to the Health Resources and Services Administration.23 In contrast, the Germantown, Tennessee community in which Practice 2 is located is primarily white (86.6%) and has a median income of $126,196, with about 83.6% of residents having completed at least 1 year of college, and only about 2.2% having not completed high school.21 These disparate populations were targeted in order to investigate whether use of and interest in in-person and mHealth diabetes support services differed among people from neighbourhoods with diverse geographic, racial, and socioeconomic characteristics. The subject population included all adult diabetes patients seen in the participating practices for an outpatient visit for a representative 1-week period in July and August 2013. All survey participants met the following inclusion criteria: they were between 18 and 90 years of age and carried a physician-confirmed diagnosis of either type 1 or 2 diabetes. Patients with significant cognitive impairment or inability to communicate their responses to survey questions as determined by their physician or family members were excluded.
Survey development The survey instrument was designed to collect general demographic data and to investigate use of and interest in mHealth and in-person support services for diabetes self-care. The survey instrument was developed using standardized questions from several sources including the Behavioral Risk Factor Surveillance System (BRFSS),24 National Health Interview Survey,25 and several peerreviewed articles.26,27 Questions regarding diabetes diagnosis and treatment were derived from BRFSS.24 Questions regarding use of and interest in mHealth for diabetes self-care were adapted from the De Reuver et al. cell phone and mobile application survey,26 and all employed a 5-point Likert scale. Diabetes communications experts assisted in refining the survey content in an iterative fashion both before and after pilot testing the draft survey instrument with adult diabetic patients in the Memphis area.
Survey administration A medical student explained the role and scope of the survey to each eligible participant during a routine primary care visit. Patients were left to complete the survey as they waited on their physician. A written consent statement was included at the beginning of each survey and consent for participation was indicated by completion of the self-administered survey. Surveys were generally selfadministered but for patients who desired assistance, either a companion of the patient or a medical student
Downloaded from jtt.sagepub.com at University of Birmingham on June 1, 2015
XML Template (2015) [25.5.2015–10:17am] //blrnas3.glyph.com/cenpro/ApplicationFiles/Journals/SAGE/3B2/JTTJ/Vol00000/150042/APPFile/SG-JTTJ150042.3d
(JTT)
[1–7] [PREPRINTER stage]
Humble et al.
3
read the survey aloud and collected the patient’s responses. Each survey was individually numbered in order to track participation, and incomplete surveys were collected to assess response rate.
Analysis Frequencies were enumerated for patient characteristics and responses by practice site and smartphone ownership. Two-sample t-tests and chi-square tests for contingency tables were employed to identify differences between practices and between smartphone users and non-users, with p < 0.05 considered significant. In addition, we conducted a post-hoc secondary analysis to assess the impact of age on use and interest in mHealth opportunities, comparing those
