Experiences of Using Web-Based and Mobile Technologies to Support Self-Management of Type 2 Diabetes: Qualitative Study

Background The prevalence of type 2 diabetes is rising, placing increasing strain on health care services. Web-based and mobile technologies can be an important source of information and support for people with type 2 diabetes and may prove beneficial with respect to reducing complications due to mismanagement. To date, little research has been performed to gain an insight into people’s perspectives of using such technologies in their daily management. Objective The purpose of this study was to understand the impact of using Web-based and mobile technologies to support the management of type 2 diabetes. Methods In-depth interviews were conducted with 15 people with type 2 diabetes to explore experiences of using Web-based and mobile technologies to manage their diabetes. Transcripts were analyzed using the framework method. Results Technology supported the users to maintain individualized and tailored goals when managing their health. A total of 7 themes were identified as important to participants when using technology to support self-management: (1) information, (2) understanding individual health and personal data, (3) reaching and sustaining goals, (4) minimizing disruption to daily life, (5) reassurance, (6) communicating with health care professionals, and (7) coordinated care. Conclusions Patients need to be supported to manage their condition to improve well-being and prevent diabetes-related complications from arising. Technologies enabled the users to get an in-depth sense of how their body reacted to both lifestyle and medication factors—something that was much more difficult with the use of traditional standardized information alone. It is intended that the results of this study will inform a new questionnaire designed to assess self-management in people using Web-based and mobile technology to manage their health.


Introduction
The number of people diagnosed with diabetes in the United Kingdom rose from 1.4 million in 1996 to nearly 3.6 million in 2016 [1][2][3][4][5]. By 2025, diabetes prevalence is expected to rise further to an estimated 5 million [1]. The vast majority of those diagnosed with diabetes are categorized as having type 2 diabetes (diabetes mellitus), which is estimated to cost the UK National Health Service (NHS) approximately £8.8 billion per year in direct costs and a further £13.0 billion per year in indirect costs [6]. These costs are largely spent on treating complications, such as hypoglycemia, nerve damage, heart disease, foot ulcers, and amputations, many of which can arise through the mismanagement of the condition [6]. Health services are increasingly advocating the importance of self-management to delay complications and recommend education provision and ongoing support for people with type 2 diabetes [7][8][9]. However, developing the knowledge and skills needed to consistently manage and perform multiple self-care tasks can be difficult to achieve, with successful management more likely in the presence of continued support [10,11]. With greater demand placed upon diabetes health services, it is increasingly difficult to support patients in the complex task of managing their diabetes. It is, however, conceivable that use of Web-based and mobile (apps and wearables) technologies could reduce strain on health care professionals and services by supporting patients in their daily decisions regarding factors, such as diet, exercise, and medication.
Many Web-based and mobile technologies have already been developed to help users manage diabetes [12][13][14]. The majority of these platforms offer stand-alone functions, addressing one aspect of self-management, with their use depending entirely on the individual's desire to manage their health. For example, few mobile apps have any input from health care professionals and do not incorporate a range of basic diabetes self-care functions, such as blood glucose tracking, insulin therapy, nutrition, and physical activity [14,15]. In time, however, it is thought that technology may become more integrated with services through the transmission of data and subsequent feedback [12]. There is some evidence of this integration already in place in the United Kingdom with several systems currently being phased into existing health care pathways' collaborative care services [16,17]. Although the effectiveness and evaluation of implementing these technologies are still underway [16], people with diabetes have indicated that the use of technology may help them to set and achieve health goals, help to track progress, access helpful information, and facilitate communication with health care professionals or peers [18]. Technology-based interventions have also been effective in reinforcing diabetes self-care behavior, although some behaviors may still be best reinforced in person [19]. Improvements, for example, have been shown in relation to being active, healthy eating, problem solving, and blood glucose control [20][21][22][23][24]. In contrast, the effects of technology-based interventions on behaviors related to taking medicine and coping are less clear and are not always as effective when compared with "in-person" delivery [11,19]. Research has also indicated that some mobile apps on the market carry risks to the patient, for example, incorrect insulin dosage calculations following data input error [25].
To broaden our understanding of how Web-based and mobile technologies can support self-management, further research is needed. Key biomedical outcomes, such as HbA 1c (glycated hemoglobin) levels, of using technologies designed to support self-management are important; however, assessing these outcomes alone neglects the complexity of how technology can assist a person to develop skills to live well with type 2 diabetes. An in-depth view on people's perspectives of using such technologies is needed to get an insight into how they can influence daily management while taking into account broader social and contextual factors. Of the relatively small proportion of diabetes-related qualitative studies in the past 30 years, only one-quarter looked at the aspects of self-management, with an even smaller number looking specifically at the experiences of using devices to aid self-management [26]. The aim of this qualitative study was to gain an insight into the experiences and views of those using Web-based or mobile technologies to support the management of type 2 diabetes.

Design and Ethics
Qualitative in-depth interviews were used to explore experiences of using Web-based and mobile technologies to support the self-management of type 2 diabetes. Ethical approval for this research was granted by the Medical Sciences Inter Divisional Research Ethics Committee of the University of Oxford (reference MS-IDREC-C1-2015-109).

Study Participants and Recruitment
Participants were aged ≥18 years with a (self-reported) clinical diagnosis of type 2 diabetes and experience of using one or more technology-based resource to support self-management. Participants were recruited through Web-based advertisements on Diabetes UK and other diabetes-related online forums. Advertisements included an electronic link that provided further information about the study and a portal to collect contact details, demographic information, and health-related technology use. The aim of this recruitment strategy was to gain a rich and comprehensive insight into experiences of using technology to support self-management among people with a range of characteristics within the study timeframe. Responders were contacted to explain the study further and arrange an in-depth interview.
As the research aim was focused, the recruitment strategy specifically targeted rich sources of data (ie, experienced users of Web-based or mobile technologies), and interviews were conducted by an experienced interviewer, it was thought that the sample size was likely to be small [27]. A specific sample size was not predetermined, however, and sampling remained continuous throughout the study until it was believed that data saturation had been achieved (ie, where no new themes are appearing) [28].

Data Collection
In-depth interviews were conducted either face-to-face or over the telephone over a 12-week period. A topic guide was informed through relevant literature relating to self-management in people with type 2 diabetes and their use of technology-based systems. Topics in the interview guide broadly included the following: knowledge and understanding, controlling and managing symptoms using technology, self-monitoring, tailored goals, dealing with complications, use of services, and feeling supported. Prompts were used to gain a deeper understanding of participant responses on important topics. Participants were also encouraged to discuss any other topics they deemed appropriate. Interviews lasted, on average, 48 min and were recorded and transcribed. Transcription of the interviews was outsourced and accuracy checked on their return by LK. Informed consent was obtained before commencing interviews, and participants were given a £20 voucher for taking part.

Data Analysis
Interview transcripts were analyzed using the framework method, allowing the authors to look at the data and conduct analysis in a systematic and comprehensive manner [29]. The framework method supports thematic qualitative analysis and consists of 5 stages: (1) familiarization with the interview data; (2) identification of a thematic framework to allow emerging issues, concepts, and themes to be listed; (3) indexing transcripts according to the thematic framework; (4) charting data through a process of extracting and synthesizing it to allow within-case and between-case comparison; and (5) mapping and interpretation of data [29,30]. All authors became familiarized with the transcripts and devised a suitable coding guide. Using a deductive approach, codes were preselected based on previous literature; however, analysis did allow for open coding where unexpected codes arose [31]. After the first few transcripts were independently coded by 2 authors to check for consistency, indexing of transcripts was performed using QSR International's NVIVO software [32]. Charting of summarized data was performed in EXCEL with illustrative quotes from participants added in comment boxes. On its completion, the charting document was circulated among the team for discussion of commonalities and differences between the data and themes finalized [31].

Information
Participants felt empowered to make informed decisions with the help of instant and in-depth information found on diabetes-related websites and forums. Participants reported initiating their own online research. However, some also reported being guided by health care professionals when looking for specific information. One woman described how informed, positive changes to her diet helped her to lose weight, reduce her medication, and feel better about herself: Online information also made participants aware of the potential risks and side effects of decisions they made when managing their health, particularly in relation to medication. One woman, who had experienced significant hair loss and depression after being prescribed medication in the past, used the Internet to research subsequent medications prescribed:

Understanding Individual Health and Personal Data
Participants sought to understand the impact of diet and, in some cases, exercise on their blood glucose levels. All participants took regular blood glucose readings. In most cases, readings were tracked and monitored throughout the day, with 2 participants wearing a continuous blood glucose (CBG) monitor that offered readings (and alerts) in real-time. Regular monitoring enabled participants to learn about daily patterns in their blood glucose levels and gave a greater understanding of its relationship with diet and exercise. Having a greater understanding of how their body behaved contributed to an overall sense control when managing diabetes:

Reaching and Sustaining Goals
Having an in-depth understanding of the relationship between factors such as diet, exercise, and medication on blood glucose levels helped participants to refine their goals when managing diabetes. Looking for patterns in personal data helped participants to consider adjustments to their lifestyle that they could maintain: Technology not only enabled participants to investigate deviations in blood glucose levels from their targeted range, it could also act as a warning system to alert participants to make them more aware of when they needed to be careful about specific aspects their management for the remainder of the day: In addition to progress reports and practical reminders to reach targets, technology emotionally supported participants by allowing them to record feelings or feel encouraged to continue practicing good behaviors through feedback. Participants described how seeing progress and receiving positive signals motivated them to continue managing their health. A small number of participants had experience of using mobile apps that used gamification techniques to encourage motivation. Although one man felt this style of encouragement was not pitched to his level, one woman described how these techniques kept her engaged and motivated:

Minimizing Disruption to Daily Life
Technology was used as a tool to maximize convenience when managing diabetes and to minimize the chances of disruption to everyday life. CBG sensors reduced the time taken to manually check blood glucose levels and conveniently gave alerts, warning the wearer when they were approaching specific thresholds. This resulted in minimum disruption to daily plans. For example, wearers could schedule appointments or get to and from work knowing their blood glucose levels would be within the "safe limits" for driving: Apps were used as a management aid when participants were not in their usual routine. Participants discussed using a range of apps that helped them research the nutritional content of food on a menu when dining out. This resource reduced the anxiety associated with not knowing what to eat in a restaurant. Other useful feature of apps when eating out was the opportunity to log food on the go so that diet could be accurately recorded with minimal effort:

Reassurance
Participants reported feeling reassured when they knew they were managing their diabetes well. In 6 cases, where blood glucose levels were consistently stable, participants described only taking blood glucose readings periodically, acting as a "checking" system, whereas another participant described checking her blood glucose levels periodically to reassure herself that symptoms she was experiencing were not related to her diabetes:

Communicating with Health Care Professionals
Technology used in daily management routines, usually apps, aided participants when describing their general health trends and communicating with health care professionals during consultations. A total of 7 participants (7/15, 47%) cited times where their electronic recordings helped them during consultations by providing real-time "evidence" on daily patterns. Providing a detailed picture of their daily well-being conveyed whether their current management practices were working effectively for them and enabled them to have some control of how to proceed with their care. Moreover, 3 participants (3/15, 20%) reported a change in treatment due to the use of technology within their consultation. One man gives an account of how technology helps him to be a partner in his health care decisions: Although this approach generally helped to make efficient use of consultation time, one respondent noted the presentation of data could be misleading in consultations as her app used thresholds to color code blood glucose reading ranges. In a busy consultation, this could be misinterpreted:

Coordinated Care
Electronic tools were rarely provided by or integrated with health care services. One participant, however, discussed using an electronic record that detailed medical history and upcoming appointments. This enabled him to coordinate aspects of his care. The effect was a more streamlined approach to managing his health, more certainty on what to expect when meeting health care professionals and sense of partnership in decisions:

Principal Findings
Health care services are under increasing pressure to cope with the rising number of people diagnosed with type 2 diabetes. Patients need to be supported to manage their condition to improve well-being and prevent further diabetes-related complications arising. Web-based and mobile technologies may offer one solution to supporting those with type 2 diabetes with this management, but there is currently limited qualitative research into their effect on self-management [26]. This study explored the views and experiences of men and women using technology to support self-management. This research demonstrates how technology supported users to maintain individualized and tailored plans when managing their health. It was clear that participants wanted to feel informed when managing their health, feel reassured that they were managing their health effectively, and, where possible, wanted self-care tasks to be minimally intrusive to their daily life. Technologies enabled users to get an in-depth sense of how their body reacted to both lifestyle and medication factors, something that was much more difficult with the use of traditional "standardized" information alone. Understanding how their body reacted to lifestyle and medication factors was welcomed among the sample and this understanding was enhanced through resources which helped to organize and make sense of vast amounts of longitudinal data (eg, through output in the form of graphs and charts). Wearable devices, such as the CBG monitors, were particularly helpful in that they offered real-time solutions and alerts. The use of available technologies appeared to motivate participants to achieve and sustain healthy goals when managing their diabetes. It is important to note, however, that participants responded to aspects of technology designed to motivate and incentivize engagement in different ways. The success of engagement features, which Nelson et al [33] refer to as functions for "engagement promotion," was dependent on the preferences of the user. For example, although one woman enjoyed gamification techniques (unlocking achievements), one man considered them as childish elements of an otherwise useful resource. Participants also voiced frustrations with the need to buy new, compatible devices (such as wireless devices with Bluetooth functionality) and difficulties in entering data (eg, the requirement of inserting imperial units).
Participants were very focused in their wants and needs from technology and indicated that they "shopped around" to find mobile apps or other tools, such as CBG sensors, that targeted their requirements. If a particular app, for example, did not provide the right information or was not easy to use, they proceeded to try alternatives reasonably quickly. Furthermore, although data were not collected on how long participants had been using specific technologies, some participants did reflect on periods of high and low technology usage. For those with varying usage intensity, periods of high intensity tended to reflect an "event" (eg, the introduction of a new diet) and low usage reflected periods when they felt their blood glucose levels were under control. Understanding more about the reasons behind swift dropout when using a new mobile app and reasons for varying intensity of usage are interesting as digital health interventions are frequently faced with challenges of high attrition rates [34,35]. Attrition and periods of low usage are problematic from a research perspective when trying to prove the effectiveness of a Web-based or mobile technology; however, this study indicates that this challenge is reflective of how people use technology in real life. That is, they often use multiple apps to cater for a complex condition when self-managing, they are selective when looking for self-management tools and swiftly discard those that do not complement their lifestyle, and the intensity of their use will vary over time.
This study builds on existing research by providing an in-depth overview on how people can use multiple Web-based and mobile technologies to support diabetes management in their daily lives. Many previous studies have evaluated how a specific intervention was used [36][37][38]; however, this study encouraged participants to share experiences of using a combination of resources, more comparable to practices in daily life. Although the use of multiple apps may, in part, be due to the limited functions provided by one mobile app alone [12,39], this research indicated users appreciate multiple functions to have a holistic view of the relationships between various lifestyle factors on their health. Supporting previous research [40], these interviews showed that health technologies can give people with diabetes a heightened awareness of lifestyle factors on their blood glucose levels and encourage problem-solving through making changes to their diet and/or activity levels after identifying reasons for highs and lows. As this study explored current and past experiences of technologies, it also provided examples of how participants sustained changes in behavior. Related research in the context of other long-term conditions [41] can also be drawn upon to support these findings, which demonstrate the importance of having the flexibility to tailor, personalize, and prioritize self-management approaches using health technologies.

Limitations
Some limitations of this study must be acknowledged. These are largely related to the transferability of the findings. Despite efforts to include a range of backgrounds within the sample, those from a nonwhite background were not represented and only 3 classified themselves in a non-British category. Older people, however, were represented in the sample, which was particularly welcomed given that they can have problems engaging with technology [33,42]. This sample also represented a self-selecting group of people with type 2 diabetes who were comfortable using technology. As such, these findings are limited in their transferability to people with type 2 diabetes who do not use technology and have low motivation to use technology in the management of their health. However, the authors purposely chose to recruit rich sources of data in the time available to them. Exploring possible reasons why people do not use technology in the management of their health was not in the scope of this study.
In contrast to the research reported by Ancker [43], participants in this sample were largely enthusiastic when tracking and monitoring their own health. This may have been due to self-selection; however, it may have also been related to participants being able to move on from apps that were inconvenient in favor of technology more suited to their preferences. Furthermore, although participants in this sample reported multiple long-term conditions, Ancker's focus was on people with multiple conditions, which may have resulted in feelings of being overwhelmed. Although participants discussed negative aspects of using technology in functional terms, for example, frustration with data entry, there was limited information on possible negative health effects of using these technologies. This may, in part, be due to participants swiftly moving on from technologies that did not meet their requirements. Negative aspects of using technology to support self-management may be something that would benefit from further research in the future.

Conclusions
Patients need to be supported to manage their condition to improve well-being and to prevent diabetes-related health complications arising. Technologies enabled users to get an in-depth sense of how their body reacted to both lifestyle and medication factors, something that was much more difficult with the use of traditional "standardized" information alone. Health care professionals who are responsible for educating and supporting those with type 2 diabetes may find Web-based and mobile technologies to be invaluable tools for engaging with their patients and tailoring information during a consultation.
These findings demonstrate how those engaged in technology use multiple apps to optimize self-management. Developers in Web-based and mobile technologies should aim to help the user manage a range of self-care tasks from one app to offer a more holistic experience. This study also highlights the difficulties for developing and assessing digital behavioral interventions due to users' adoption of multiple technologies and swift dropout. Researchers and Web developers should place more emphasis on rates of retention in the use of technology-based interventions as opposed to rates of initial adoption of the intervention.