This study is part of a larger randomized intervention project aimed at designing and implementing person-centered interactive self-management support (iSMS) in primary health care in northern Sweden. The overall project has a cocreation design, and participants’ perceptions are therefore of great value for designing a forthcoming intervention that is registered at ClinicalTrials.gov (NCT03165084).

The participants were treated in primary health care in a county in northern Sweden. Inclusion criteria in this study were Swedish-speaking individuals diagnosed with T2D. In total, 11 people (3 women, 8 men) aged from 50 to 78 years (median 65 years) were interviewed.

The purpose was to reach a purposeful sample with an even gender distribution, but it was difficult to recruit women in the study. The duration of T2D among the participants varied from 4 months up to about 10 years. Of these 11 participants, 7 participants lived together with a partner, while 4 were single. Each participant owned a smartphone. Initially, the aim of the study was presented by the first author at an information meeting held at the Local Diabetes Association, where 4 participants declared their interest in participating. A snowball selection was then used to include the remaining 7 participants into the study, that is, enrolled participants suggested names of other people who could be contacted for interviews.

The first author conducted interviews with the participants individually, either in their homes (n=8) or at the university (n=3) during 2016. All participants were contacted in person or by telephone in advance. They received information about the study, and date and place for the interview were decided. At the interview session, each interviewee was informed again and had the opportunity to ask questions or withdraw participation. The interviews performed by the first author lasted between 40 and 80 (median=60) min and were digitally recorded. During the interview, a semistructured interview guide was used, as well as an ambition to get answers that were narrative in nature. The opening question was, “If I say information technology and eHealth, what do you think of?” Examples of other questions were as follows:

Probing questions and prompts were used to deepen the topics and to get answers on issues not already mentioned.

The interview data were transcribed verbatim by the first author and analyzed using qualitative content analysis as described by Graneheim and Lundman [36]. Qualitative content analysis is a systematic way to describe variations of content in a verbal or written communication [36,37]. The epistemological basis of qualitative content analysis is that data and interpretation are cocreations between the interviewee and the interviewer, and interpretation during the analysis phase is a cocreation of the researchers and the text [38,39]. The analysis was performed in several steps. First, all text was read through thoroughly to get a sense of the whole. This reading revealed 2 overarching domains—Potentials and Concerns—into which the text was sorted. The text in each domain was then divided into meaning units consisting of words or sentences related to each other through their content and context.

The identified meaning units were then condensed, that is, made shorter without losing the core meaning, and interpreted and labeled with codes. The codes were sorted, based on similarities and dissimilarities, into 12 subcategories within the 2 domains. The subcategories were then abstracted to 5 categories as follows:

Following the steps of the analysis should not be seen as a linear process, rather a process of going back and forth between the steps and between original data and analyzed data. All authors also discussed the interpretations within every step of the analysis until consensus was achieved [36].

The Regional Ethical Review Board at Umeå University approved the study (Dnr 2014-179-31M) and was conducted according to the ethical principles described in the Helsinki Declaration [40]. Before giving informed consent, the participants received oral and written information. It was emphasized that participation was voluntary and that they could withdraw from the study at any time without giving explanation; they were also assured of confidentiality. The transcripts were made anonymous by removing personal information. In addition, quotations were made anonymous with small changes in wordings that did not alter their core meaning.

Within the domain Potentials, which referred to the positive perceptions of using digital health services as self-management support, the categories Involvement, Empowerment, and Security were highlighted.

Within the domain Concerns, which referred to the more negative side of the participants’ perceptions of using digital health services for self-management support, the categories Ambivalence and Uncertainty were highlighted.

This study has provided insight about the perceptions that people with T2D may have about using ICT and digital health services for self-management support, and the findings show that the participants are mainly positive, but they have mixed feelings regarding use of eHealth services and digital devices irrespective of whether it concerned a Web or mobile app. On one hand, they experienced potentials such as increased involvement, empowerment, and security; on the other hand, they expressed concerns such as ambivalence and uncertainty. One explanation for the variation in perceptions of using digital health services or eHealth services for self-management support could be the participants’ differing capabilities such as education and computer training and experience. From literature we know that age, gender, as well as SOS situations influence people’s perceptions [32-34].

Several studies report that eHealth is promising with regard to self-management support and that people with chronic conditions desire tools that effectively reduce the limitations of life caused by disease [41-43]. Alpay et al [44] concluded that by removing barriers of time and geographical distance in health care services—using digital and technological services such as video consultations and telehealth—the patients gain flexibility. They get an easier and more convenient access to health care, they may even have fewer time-demanding health care center visits, and finally, patients can receive care at a location that does not require transportation and in an environment that can be experienced as less threatening.

Regarding the category Involvement, our results highlight that self-monitoring may increase patients’ independence. Similar results are reported by Holtz and Lauckner [45], and by Alvarado et al [46], who showed that people with diabetes could adapt easier to their condition by using their mobile phones in self-monitoring and management of diabetes. Kruis et al [47] presented that innovative eHealth self-management solutions can support or improve independence among people with chronic conditions. Ahern et al [48] concluded that the potential of patient technologies can only be accomplished by motivating patients to become more engaged and responsible for their own care. In a study by Nijland et al [42], the authors argued that interactive eHealth applications must be continuously changed and developed to promote individual self-care, through feedback and exchange of information, something that is in line with the value of independence. Interactive eHealth tools designed to provide feedback on patients’ self-monitoring appear to engage patients the most, since personalized and interactive features stimulate active participation by both patients and nurses. Nijland et al [42] reported that the diabetes patients in their study felt better monitored by the feedback they received and were therefore more motivated to take a more active role in the self-management of their illness—something that also led to increased independence.

Regarding the category Empowerment, our results suggest that use of interactive eHealth platforms seems to have a potential to increase patient empowerment through increased knowledge, participation, engagement, and freedom. Our findings support previous studies that report that empowerment can be improved using digitized approaches in health care [5,44,49]. Empowerment implies participation and responsibility through increased awareness and knowledge [50,51]. Self-efficacy is an important aspect of empowerment and relates to change in behavior, which is important for self-management in chronic conditions [52]. Patient empowerment and PCC are closely related complementary concepts. These do not oppose each other, and indeed patient empowerment can be achieved through PCC [53]. Both patient empowerment and PCC are emphasized by health researchers and policy makers and expressed in care policy documents nationally and internationally [7,20]. Furthermore, it has been suggested that PCC increases patient outcomes and satisfaction in chronic illnesses [54,55] and T2D [54]. Thus, using the Web for medical and health facts is an approach in health care that can support empowerment and is facilitated by a shift to PCC that can subsequently improve self-management [25,30,55,56]. Digitized access increases patient empowerment and enables them to participate more actively in making better informed choices regarding their health in interaction with health care. Technological advances for self-monitoring are changing the conditions for chronic disease management. The use of different communication tools and interactive platforms may improve patient participation in decision making and facilitate for patients to communicate easily with health care professionals [49,57]. Medical and health information on the internet, digital health that patients use as in-home monitoring, virtual consultations, and mobile apps are also available to users 24 hours a day, 7 days a week [58] to provide alternatives to them apart from the primary health care centers, and this gives a certain degree of freedom [59]. However, a benefit for health care professionals using digitalized technology in self-management support is the option to be in contact with patients more frequently than semiannually or annually, as is common today [60,61].

Regarding the category Security, our results shows that participants in this study experienced that use of Web-based technology was seen as something safe and reduced privacy exposures, which is confirmed by other studies [62,63]. Participants were not bothered much about security concerns; they trusted that the different technical safeguards, such as passwords or encryption systems, were safe enough. Similar results are reported by Spanakis et al [63] who stated that most patients seem to be willing to disclose information relevant to their condition to their health provider, with no particular awareness of how the patient information is transferred. The use of digital health services can also reduce the number of visits to the health care centers, something that can be experienced as stressful, time-consuming, and expensive. Fewer face-to-face visits might also imply changes in the patients’ perception of self-management support as well as reconfiguring work activities for the diabetes nurse [64]. Encouraging patients to share their self-monitored data with the diabetes nurse to a higher degree may become a trade-off for fewer visits, thus having health economic implications. This is in line with a study by Eland-de Kok et al [65] who showed that adapted and person-centered support increased more than semiannual visits. This may lead to quality improvements and a higher priority for those patients who need face-to-face visits the most. A literature review by Hardiker and Grant [66] showed that the use of different Web-based services depended on a number of factors such as the characteristics of users, the kinds of technological issues, characteristics of the digital health services social aspects of users, and the digitized services in use. This requires health care professionals to concentrate their efforts where they are needed most, by tailoring services to meet the needs of a broad range of users.

Regarding the category Ambivalence, our results highlight that some of the participants stressed concerns regarding, for example, lacking digital skills and knowledge about how to use digital health services, which is in line with other studies [67,68] that have also reported an existing age-related digital division. This division concerns everything from the design of the digital device and screen design to complex commands and procedures, including inadequate training and instructions that can prevent older people from interacting with digital systems. Czaja and Lee [67] reported that predictors of not using digitized technology were primarily the very old with cognitive decline associated with different aging processes such as vision impairment, and attitudes such as anxiety about computer use and the perception that technology is not useful to them, both of which are compatible with our results. Usually participants in our study were also reluctant about using digital health services and preferred face-to-face meetings with health care professionals. Similar results are reported by Currie et al [27] who conclude that digitized solutions are not the key for every patient and thus do not have the same impact as a face-to-face meeting with health care professionals, since they may create feelings of loss of proximity for some patients. The lack of proximity in digital health services is also highlighted in other studies and is a challenge to overcome. Video consultations could sometimes compensate for the lack of proximity in digitized meetings [69,70]. Technological barriers could therefore be solved and personalized to meet the needs of those who have physical barriers such as cognitive, sensory, and motor deficits.

Regarding the category Uncertainty, our results highlighted that participants were ambivalent about their views of the reliability and quality of Web-based digital health information. Similar findings report individuals having difficulties using the internet to find complete and proper information concerning health issues. Not relying on Web-based information in making decisions about treatment and self-management, including whether or not to seek care, may negatively influence the user’s decisions [71,72]. In Sweden, 93% of the population have access to the internet at home, and outside the home, 71% connect to the internet using mobile phones or smartphones. Although access to internet is high in Sweden among the people aged 16 to 85 years, still 7% of households in Sweden do not have access to the internet. Those who have never used the internet are found mostly in the age group 75 to 85 years [73]. Even if Sweden is a country with very high internet access, we have interpreted limited access to internet connections or broadband as a factor that affects the usefulness of digital health services. This is concurrent with Currie et al [27] who reported problems for patients living in rural areas compared with those living in urban areas concerning the use of technology for health purposes. They highlighted challenges related to slow and unreliable broadband services. Fuji et al [74], on the other hand, conclude that instead of primarily focusing on issues concerning internet infrastructure or a lack of internet access in rural areas, focus should be placed on overcoming other concerns and barriers among the users.

Our results could guide such development. The result also indicates that future digital health solutions preferably should have high demands on functionality, personalization, and an easy-to-use design to be user-friendly. Self-monitoring and measurements should also be smooth to integrate with the health care records and communication channels. Furthermore, a “universal” digital solution does not exist. One size rarely suits everyone. To improve user customization, people with T2D from various socioeconomic backgrounds, gender, and ages need to be involved in the development of future digital tools.

The findings in this qualitative study cast some light on the experiences of using various digital health services in self-management support among people with T2D treated in Swedish primary health care. We view our results as transferable to other groups of patients with similar lifestyle-related chronic conditions in societies similar to Sweden. However, according to Graneheim and Lundman [36], it is up to the reader’s judgment as whether or not the reported findings are transferable to other contexts.

We recruited 11 people with T2D for individual interviews, using a combination of purposive and subsequent sampling [75], which made it possible to expand the group of participants. However, there is a risk of bias, since our sample may consist of participants with an interest in eHealth. Despite that, our result pointed to a variation of perceptions about the use of eHealth services and could thereby be useful.

The majority of the participants were men, and the age range was 50 to 74 years. It is possible that the outcome of this study would have been different if more women had been included and if the age range had been different, including, for example, very old patients. Nevertheless, the participants in this study are representative of people with T2D and provided rich data.

There are no rules for how large the selection of participants should be in qualitative research methodology, but the selection is generally determined by the need for information data. In this case, it was considered that it had come to the stage where further data collection would not provide more knowledge and that the collected data was sufficient for the study. The saturation point was judged as reached. The term saturation derives from grounded theory, but it is also used in other qualitative approaches [76].

The interviews were conducted by the first author alone. However, all authors listened to and discussed the interviews and then were involved in interpretations at every step of the analytical process, something we believe has strengthened the trustworthiness of the study and resulted in a consolidation of the findings.

The results from this study indicate that persons with T2D have diverse perceptions on using digital health technologies and eHealth services for self-management support. They are interested in digital health technologies and services for self-management support, however, ambivalence was also expressed. Our findings indicate that targeted training and support is needed to overcome barriers and that utilized devices for good reason should be personalized or carefully adapted to the specific situations at hand.

The use of digital health technologies for person-centered self-management support is challenging but can—if implemented appropriately—lead to increasing patient responsibility for their own health and strengthen patients’ empowerment and self-management capabilities. Although digital health technologies of today allow for innovative approaches, there are also ethical aspects to consider when new digital health tools or solutions and eHealth services are introduced in health care. Some people may neither wish to nor be able to use digital technology for various reasons on their own, whereas others see it as an important complement to or even substitute for the traditional health care visits.