Type 2 diabetes (T2D) is a metabolic condition characterized by elevated blood glucose levels and can lead to complications such as coronary heart disease and kidney failure [1]. Currently, approximately 90% of global diabetes cases are classified as type 2, affecting over 300 million individuals [2]. This represents about 8.3% of the world’s population. In Nigeria, a significant percentage of the population is affected by T2D. Similar to the rest of the world, the country is experiencing an increasing prevalence of the condition alongside other noncommunicable diseases [3]. According to the International Diabetes Federation, the estimated number of T2D cases in Nigeria is projected to increase from 3.6 million in 2021 to nearly 5 million by 2045 [4]. However, it is important to note that data regarding its prevalence in Nigeria appear inconsistent, with some research papers reporting rates of 5.7% [5], 4.3% [6], or even 11% [7]. In the South-South geopolitical zone of Nigeria, which includes Port Harcourt, some studies have indicated a prevalence of 9.8% and 6.8% of T2D in Port Harcourt itself, with varying values for other communities [8,9]. The increasing prevalence of T2D coexists with significant rates of communicable diseases, such as HIV [10,11]; infectious diseases, such as malaria [12,13]; and other noncommunicable diseases, such as cardiovascular and renal diseases [14]. The distinction between type 1 diabetes and T2D has also become blurred, and studies have shown that there has been no national consensus on diabetes prevalence since 1992 [15,16]. Given this disease burden and the lack of sufficient epidemiological data, T2D demands significant attention due to its association with distinct complications, many of which result in increased mortality.

Certain risk factors, such as obesity, genetics, sedentary lifestyle, and certain comorbidities, contribute to the incidence and onset of T2D. However, sociodemographic factors, including gender, age, ethnicity, and environmental influences, also play a significant role in increasing T2D risk and influencing the provision of care [17-20]. For instance, studies have shown that people with T2D residing in rural and remote regions face challenges with access to health care [21], such as lacking direct contact with a physician or registered pharmacist [22-24], dealing with unlicensed practitioners or complementary care providers [25], or being unable to manage referrals to secondary or tertiary health care institutions because of their physical inaccessibility [26,27]. Studies show that, globally, Black and Hispanic people face the highest risks of illness and death [28-30]. Another 20-year study found that Asian, Hispanic, and Black women have a much higher risk of T2D compared to White women, with increased BMI being especially harmful for Asian people [31]. Although T2D is mostly linked to wealthier and more developed areas, it is increasingly becoming a significant issue in developing countries like Nigeria [32-34]. This could result from cultural assimilation concerning food and lifestyle behaviors [35], potentially exacerbated by a lack of financial, educational, and infrastructural resources unique to the societal and community context.

The management of the condition involves pharmacotherapy, which includes using hypoglycemic drugs (eg, sulfonylureas and meglitinides) and lifestyle modifications focusing on exercise and diet [36,37]. Digital interventions also play a role across different stages of T2D care, including diagnosis or prognosis with rapid test kits or machine-learning algorithms [38] and providing information, remote monitoring, and lifestyle modifications through mobile apps and websites [2,39,40]. Continuous glucose monitoring systems for blood sugar sensing and personalized medicine [41-43] are also critical components. Because T2D is a long-term condition that requires constant monitoring, its care involves self-management by people with the condition and collaborative care with both caregivers and health care practitioners in both formal and informal settings. However, we recognize that in certain contexts, such as Nigeria, there are limitations affecting the provision of care and the use of digital health technologies. There is also a dearth of contributions providing insight into the scope of T2D care and its intersection with sociodemographic and contextual factors influencing the use of digital health technologies. In light of these observations, we explore the Nigerian landscape by focusing on a notable developing city, Port Harcourt, to achieve the following objectives: (1) to explore the sociodemographic profile of people with T2D and understand how it directly influences their care; (2) to generate an accurate understanding of collaborative care practices, with a focus on nuances in the contextual provision of T2D care; and (3) to identify opportunities for improving the adoption of digital health technologies based on the current understanding of technology use and T2D care.

This was achieved through a quantitative study involving the collection of data from 110 people with T2D using traditional paper surveys and automated WhatsApp (Meta Platforms, Inc) surveys via Twilio (Twilio Inc), a cloud communications platform. We recognized the intersection between self-care and collaborative care practices, contextual influences, and technology use. We propose that insights from our study will contribute to the body of work on T2D incidence and prevalence in Port Harcourt, Nigeria, as well as provide guidance on the design of context-specific digital interventions for T2D care.

The lead researcher, who is also the first author, has a diverse background as a pharmacist, health care manager, and digital health scholar. Having resided, studied, and practiced in Port Harcourt, Nigeria, for >2 decades, their motivation for undertaking this study is deeply rooted in personal experiences acquired while working as both a hospital and community pharmacist. During this period, they had the opportunity to interact with a wide range of patients, which led to a profound realization of the critical role that cultural diversity plays in the delivery of pharmaceutical care.

The second and third authors, specializing in human-computer interaction, have a collective research focus on the use of health and wellness technologies within various contexts. They bring a valuable interdisciplinary perspective to the study. The fourth author, based in Nigeria, is a pharmacist and academic with a wealth of expertise in the field of T2D research. His work has primarily concentrated on the development of context-specific public health interventions, and he also demonstrates a keen interest in exploring the potential of digital health interventions.

This quantitative cross-sectional study, which was conducted from February through April 2023, involved respondents who were contacted using random and snowball sampling techniques.

The study was made possible by ethics approval from the research ethics committee of the University of Port Harcourt, Nigeria (UPH/CEREMAD/REC/MM85/044). Participants were required to provide informed consent twice, the first being when they signed and filled in the expression of interest form on the web, and the second when they began to answer the questionnaire. Participants were not financially compensated and personal identifiable data such as names were anonymized.

Nigeria is currently the most populous country in Africa, with an estimated 223 million people and >371 tribes [44]. This population is expected to grow steadily in the coming years, which will place additional demands on the health care system. Our study was conducted in Port Harcourt, a major developing city in Nigeria with a significant prevalence of T2D [45]. It has a rich colonial history and is a vibrant melting pot of diverse ethnicities, with numerous languages spoken.

On the basis of the objectives of this study, the intended questionnaire respondents were people with T2D residing in Port Harcourt, Nigeria. Eligibility criteria required participants to have been diagnosed with T2D for >6 months, be aged >18 years old, and be capable of providing informed consent. We obtained a total of 110 questionnaire responses, comprising 27 valid responses from the automated WhatsApp questionnaires and 83 responses from the questionnaires distributed in person.

Data were obtained using paper questionnaires and WhatsApp, automated with Twilio. The data were analyzed using descriptive and inferential statistics with the SPSS Premium (version 29; IBM Corp) and JASP (version 0.16.4; University of Amsterdam) software.

WhatsApp is the most pervasive instant messaging platform in Nigeria, with at least 40% of its population being active users [46]. While quantitative data collection in contexts such as that in Nigeria mostly involves distributing surveys either electronically through Microsoft Forms (Microsoft Corp) or other avenues or in person through paper, the collection of quantitative data using WhatsApp remains underexplored. WhatsApp offers a cost-effective approach for both respondents and researchers. It is user-friendly for people already accustomed to WhatsApp chat functions and ensures sustained participation among mobile populations, as users can retain their WhatsApp number even when changing SIM cards or phones. To recruit WhatsApp respondents, we used a different approach (discussed subsequently) compared to traditional survey distribution methods. This allowed us to reach a hard-to-reach audience, including participants who might otherwise have been unreachable in person. This validates WhatsApp’s utility and adds to its list of advantages. However, researchers lacking technical skills or familiarity with web-based recruitment methods may perceive this approach as a limitation.

We obtained quantitative data by automating WhatsApp using Twilio. This approach was a replication of the method used by Fei et al [47] in their work on automated WhatsApp questionnaires in panel surveys. The phone numbers of people who expressed interest via the form we disseminated on social media were securely stored in a password-protected Google Sheet (Google LLC). Subsequently, we created a WhatsApp questionnaire using Twilio’s studio dashboard for questionnaire flow. Google Apps Scripts were used for automating questions, allowing participants to respond within the WhatsApp environment. In the Twilio platform, each response from the participants led to the transfer of the response to the password-protected Google Sheet used. On the participants’ part, they were instructed to respond using single letters to indicate their chosen answers for each question. Subsequently, this action triggered the presentation of the next question, which also necessitated a single-letter response (Figure 1). This process continued until the questionnaire was completed, and every respondent who expressed interest filled out the WhatsApp questionnaire.

An expert panel consisting of the first author, 2 human-computer interaction experts, and an academic pharmacist residing in Port Harcourt designed the questionnaires in accordance with the research objectives and outcomes derived from preorganized synchronous WhatsApp interviews. To provide context, a total of 36 individuals participated in the preceding WhatsApp interviews, including 15 (42%) people with T2D, 9 (25%) community pharmacists, and 12 (33%) caregivers. Through these interviews, we gathered valuable insights regarding the scope of T2D care in Port Harcourt, the influence of health care providers on community T2D care, potential design opportunities for T2D care, and the role of instant messengers and social media in data collection and T2D care. These insights informed the iterations made to the questionnaire during its design phase. The questionnaires were specifically targeted at people with T2D to obtain statistical information that would answer questions regarding demographics, disease prevalence and coexistence with other morbidities, the role of technology, and how technology is adopted and integrated into their care.

We used a mixed-question format in the design of the questionnaire, incorporating both open-ended questions that required written responses, such as “What approach best describes how you manage your condition?” and closed-ended questions with predefined options, such as “Do you use any form of technology in the management of your condition?” Following the completion of the questionnaire design, we conducted a pilot study involving 6 participants. Among them, 2 (33%) participants resided in the United Kingdom, while the remaining 4 (67%) were based in Nigeria. The 2 pilot participants from the United Kingdom came from diverse backgrounds, including psychology and statistics. Their feedback was invaluable in assessing the questionnaire’s readability and statistical validity. The individuals who participated in the pilot study from Nigeria were primarily pharmacists and academics. They offered insights into the sociocultural relevance of the questions and provided feedback on the questionnaire’s reproducibility and comprehensibility. Following the conclusion of the pilot study, we made iterative improvements to the questionnaires, and the final versions were either printed or manually transferred to Twilio’s dashboard for data collection.

In the absence of consistent epidemiological data on the prevalence of T2D in Port Harcourt and Rivers state, we used a standard formula to estimate the required sample size based on the established prevalence rate of T2D in Nigeria [9]. The formula required the input of a constant (SD set at 1.96), corresponding to a 95% CI; the estimated proportion of the population with T2D, which was calculated to be 0.036 (3.6% prevalence rate); and a margin of error of 0.05. The ideal sample size for this study was determined to be 55.31.

Using the formula for design effect to calculate anticipated attrition of 10%, we obtained 61 as the recommended number of responses in the study. Since this systematic sampling technique ensures the appropriate sample size is obtained, but not necessarily an equitable representation of the sample, and due to inconsistencies with data on the prevalence rate of T2D in Port Harcourt or Rivers state, we aimed to double the initially recommended sample size (N×2=110) to achieve an adequate representation of people with T2D.

Participant recruitment was carried out through a combination of random and snowball sampling techniques. For the WhatsApp questionnaires, an expression-of-interest form was created and distributed on social media. An advertisement designed to run for 2 weeks at US $2 per day was created on a designated Facebook (Meta Platforms, Inc) page with no followers for the questionnaire. It featured an image depicting the disease condition in people of color and a concise title: “Have Type 2 Diabetes? Sign up; let’s take action.” A summary of the study was included in the description section, and the advertisement was targeted at people living in Port Harcourt. Although the advertisement reached 3127 individuals and received approximately 46 likes, 10 shares, 2 comments, and 107 link clicks, we excluded 23 invalid responses and obtained only 27 valid responses, as the form was designed to filter out ineligible participants. Out of the 23 invalid responses, 15 (65%) were excluded because the respondents did not have T2D, and 8 (35%) were excluded because they did not provide contact information. Selected participants were contacted using the email addresses or WhatsApp phone numbers they provided on the forms.

Conversely, the distribution of physical questionnaires was facilitated through referrals from pharmacists; nongovernmental organizations, such as The Diabetes Care Network (a Port Harcourt–based nongovernmental organization focused on the provision of diabetes-related health education and digital health care); and random distributions in open markets, academic institutions, and churches. Although we distributed hundreds of questionnaires, we obtained a total number of 87 questionnaires, out of which 83 (95%) were valid. Questionnaires were invalidated for reasons such as being incomplete, ineligible, or suspicious.

The key findings of this study have been summarized in Textbox 1.

Our findings align with global trends suggesting an increasing prevalence of T2D with advancing age, likely influenced by hormonal and lifestyle factors [48,49]. Older individuals tend to have higher educational attainment and increased household income, although this correlation may not always hold true in rural areas. Studies conducted in Nigeria indicate that these factors significantly influence health-seeking behaviors [50,51], including preferences for hospital visits, community pharmacies, or traditional medicine practices. Moreover, our observations reveal that cultural differences based on ethnicity or state of origin do not significantly impact the scope of T2D care, emphasizing the need for nationwide health policies and interventions tailored to address regional disparities. These policies should promote holistic approaches that consider contextual factors influencing health-seeking behaviors [52]. Findings from our study also highlight several opportunities for context-specific health care solutions, such as implementing health literacy programs, developing culturally appropriate diabetes management guidelines, and advocating for policy reforms to ensure equitable health care provision across diverse sociodemographic groups.

Our study indicates that a significant portion (71/110, 64.5%) of respondents do not use any form of technology for managing their T2D, with a notable proportion citing cost, ignorance about technology use, preference for physical contact, and religious preferences as barriers to adopting technologies, such as glucometers. This finding underscores the need for targeted educational campaigns to address misconceptions and enhance awareness about the benefits of technological tools, for example, large language models, such as Nigerian-owned “Awarri” in diabetes management [53-57]. This could be a significant opportunity for improvement by the Nigeria Digital in Health Initiative focused on transforming the digital health care landscape of Nigeria. Furthermore, the prevalence of mobile phone ownership (109/110, 99.9%) among respondents, predominantly Android phones with internet access, suggests an opportunity to leverage mobile platforms for delivering health information and interventions. Our study, similar to others [6,58,59], reveals that “word-of-mouth” is the most accessible source of T2D-related health information for respondents. This preference suggests a reliance on interpersonal networks and community-based information dissemination rather than formal health care channels. Integrating digital health practices and locally relevant health messaging into community networks could enhance the dissemination of digital health information and improve health and technology literacy among person with T2D.

Key findings from this study indicate the need for technological interventions to support T2D selfcare and collaborative care. They are relevant to not only people living with T2D in Port Harcourt but also those in Nigeria as a whole. Opportunities for improvement are summarized in Textbox 2.

The limitations of this study are follows. First, we did not inquire about the number of people per household, nor did we consider the purchasing power parity of the Naira to estimate the adequacy of their household income. Our study did not account for the presence of other financially demanding factors or the influx of income through secondary activities. Such considerations would, in turn, have provided a more accurate perception of the affordability of relevant technological interventions. Second, the questionnaire did not include questions about suitable digital alternatives other than WhatsApp for specifically communicating with pharmacists. In addition, there were no questions related to understanding their precise digital health needs. We omitted these questions intentionally to gather initial insights from the questionnaire, which would then inform subsequent interviews involving more in-depth probing. Third, our approach to disseminating the questionnaires may have led to an unfair representation of people with T2D in Port Harcourt, resulting in a high percentage of educated individuals earning above the country’s average. In-person questionnaires were likely administered to individuals who appeared literate and were easily accessible. The primary researcher received fewer responses from dissemination campaigns in open markets compared to dissemination campaigns in outpatient primary health diabetes centers, academic institutions, and churches. In addition, it is anticipated that individuals with limited education or restricted access to mobile phones, social media, or the internet would be less likely to express interest in the study on the internet. Fourth, unlike paper questionnaires that can be shared in person, respondents for automated WhatsApp questionnaires need to be recruited beforehand. While this offers the advantage of ensuring that potential participants understand the study and are genuinely interested in participating, it can also be a potentially stressful and expensive process. Researchers would need to learn about the automation of WhatsApp using suitable cloud communication platforms such as Twilio or infobip and run targeted social media campaigns on designated pages. Considering that we spent approximately US $28 for our campaign and obtained only 27 valid responses, we assume that obtaining a significant amount of data would be costly and potentially stressful using this approach.

On the basis of the scarcity of research addressing sociodemographic factors influencing the use of technology for T2D care in our research context, this study highlights significant opportunities for fostering self-care and collaborative care using technology. This study unveils key relationships between contextual and epidemiological factors of the condition and how they influence health-seeking behaviors and care practices, which, in turn, would inform design decisions. We can assert that people with T2D residing in the city of Port Harcourt are receptive to technological interventions for managing their condition. Although the specific nature of this intervention remains uncertain, we are confident that, with the right approach, issues related to use, adoption, compliance, and referral will not pose significant challenges. We advocate for the replication of this study in similar Global South contexts, incorporating any overlooked questions, exploring alternative platforms to Twilio, and refining sampling or recruitment practices.