Technology and diabetes self-management: An integrative review

Table 1 Summary of reviewed articles

Ref.	Technology	Study purpose	Brief description of intervention	Major study results
Arsand et al[11]	Mobile phones	Qualitative evaluation of a mobile system for monitoring of blood glucose, nutrition habits, and physical activity as motivation for increasing and benefitting from these self-management behaviors in patients with type 2 diabetes	Participants assisted with development and testing of the mobile phone application. The application included blood glucose monitoring, a step counter that downloaded to the phone, and software for recording food habits and providing feedback on how users performed in relation to their own personal goals	Participant feedback demonstrated good usability of the system and several participants made adjustments in blood glucose, food habits, and/or physical activity based on the tracked self-management behaviors
Avdal et al[15]	Internet-based education program	Evaluation of the effect of providing internet-based diabetes education to individuals with type 2 diabetes	Participants in the intervention group viewed individualized diabetes education, asked questions of researchers, and monitored daily blood glucose levels using the internet-based system. Control group participants received education from a diabetes nurse in a clinic setting	After six months, HA1C levels in the intervention group significantly decreased and rates of health check attendance significantly increased. No differences in HA1C or health check attendance were noted for the control group
Fisher et al[16]	Internet-based diabetes self-management improvement program	Comparison of effectiveness of internet-based, CASM, CAPS, and computer-administered minimal support interventions	Participants in the CASM group received an internet-based diabetes self-management improvement program that included education, goal-setting, feedback from healthcare providers, and periodic phone calls to monitor progress. CAPS participants received the same plus a 60 min in person intervention to discuss problem-solving therapy related to diabetes distress. The minimal support intervention included computer-delivered health risk appraisal and diabetes information and phone calls from healthcare providers to answer questions about the information	Significant decreases were noted for diabetes distress and significant improvements in healthy eating, physical activity, and medication adherence in all three conditions, with no significant between-group differences
Glasgow et al[2]	Internet based DSMP	Comparison of an internet-based DSMP, internet-based DSMP with additional support, and enhanced usual care on healthy eating, physical activity, medication-taking, HA1C, body mass index, lipids, blood pressure, and psychosocial factors	Participants were randomized to one of the three groups. The internet-based DSMP participants used a website to select individual goals related to medication adherence, physical activity, and food choices, record progress, create action plans, identify barriers to self-management, and choose problem-solving strategies. Participants in the internet-based DSMP with additional support group received the above and two follow-up phone calls and three 120 min group sessions with other study participants	Internet conditions improved health behaviors significantly compared to usual care over the 12-mo period. No significant differences were noted between the two internet-based groups. All conditions improved moderately on biological and psychosocial outcomes
Hanauer et al[10]	Mobile phones	Pilot study for feasibility of a fully automated, two-way text messaging system to encourage increased blood glucose monitoring	Participants were randomized to receive electronic reminders to check blood glucose levels via mobile phone text messaging or email reminders. Participants determined the frequency and timing of reminders. Reminders were sent to check blood glucose. After entering the value, users received motivational feedback and, if the value was out of range, a warning to take appropriate action was sent. Participants could also receive daily diabetes facts to the mobile phone or email	Compared to the email group, participants in the mobile phone group received more reminders and responded with blood glucose results significantly more often. During the first month, mobile phone group participants submitted twice as many blood glucose values as email users
Lim et al[12]	Mobile phones	Improve glycemic control without hypoglycemia in elderly people living with type 2 diabetes using patient-specific messages and reminders delivered to mobile phones	All participants received diabetes education and then were randomly assigned to intervention, routine care, or SMBG groups. Participants in the intervention group received glucometers with a public switched telephone network-connected cradle that automatically transferred blood glucose results to a hospital-based server. Once the data was transferred to the server, an automated system generated and sent patient-specific messages by mobile phone. Routine care participants did not receive an intervention and were told to follow-up with their current medical care. SMBG participants were told to measure blood glucose at least eight times per week	After 6 mo of follow-up, HA1C was significantly decreased from 7.8 to 7.4 in the intervention group and from 7.9 to 7.7 in the SMBG group, compared with 7.9 to 7.8 in the control group. The proportion of patients with HA1C < 7% without hypoglycemia was 30.6% in the intervention group, 23.4% in the SMBG group, and 14.0% in the control group
Lorig et al[17]	Internet-based self-management program	Evaluation of effect of an internet-based DSMP on HA1C, diabetes symptoms, exercise, self-efficacy, and patient activation	Participants were randomized to the internet-based program, the internet-based program with e-mail reinforcement, or a usual care control group. The internet-based program consisted of six asynchronous educational sessions, weekly learning activities, discussion boards, and individualized action plans for self-management. Participants in the reinforcement group received the intervention followed by an online discussion group	At 6 mo, HA1C, patient activation, and self-efficacy were significantly improved for program participants compared with usual care control subjects. There were no changes in other health or behavioral indicators. The subgroup with initial HA1C > 7% demonstrated greater significant improvement in HA1C. The reinforcement intervention showed no additional improvements over the intervention alone
Lyles et al[9]	Mobile phones and gaming system	Qualitative evaluation of a disease management program utilizing mobile phones and gaming systems for individuals living with type 2 diabetes	Participants received a smartphone to upload blood glucose values and email or text message with a healthcare provider and a gaming system to gain access to a shared medical record that provided summaries of clinical information related to diabetes	Participants expressed frustration with using cell phones and gaming system, but liked collaborating with a healthcare provider on uploaded glucoses and receiving automatic feedback on blood glucose trends
Noh et al[18]	Internet-based information system for computers and mobile phones	Evaluation of the effect of a computer and mobile phone accessible internet-based system on blood glucose control	A web-based information system for mobile phone users and a website for Internet users provided diabetes education. Participants in this group were compared to a control group receiving conventional diabetes education	HA1C and postprandial glucose levels were significantly decreased in the intervention group, but not in the control group. There was a significant relationship between the change in HA1C and the frequency of web-based system access
Nundy et al[13]	Mobile phones	Qualitative exploration of mechanisms by which a text-message based diabetes program affected self-management among African-Americans living with type 2 diabetes	Participants completed a 4-wk text messaged based diabetes program in which they received text message reminders about diabetes self-management	Themes that emerged from the study included self-awareness and control of diabetes, reinforcement of success in managing diabetes, acceptance and awareness of seriousness of diabetes, and caring and support
Pacaud et al[19]	Internet-based system to provide education for newly diagnosed people with type 2 diabetes	Comparison of three varied media educational systems on diabetes knowledge, self-efficacy, and diabetes self-management activities	Participants were randomly assigned to either the web interactive group who received electronic education and virtual appointments using both synchronous and asynchronous communication, the web static group who received electronic education and virtual appointments using asynchronous communication, or the control group who received face-to-face education and synchronous and asynchronous communication	All three groups had similar improvements in diabetes knowledge, self-efficacy, and diabetes self-care activities. Independent of which group subjects were randomized to, findings were significant when examining correlation between website usage and outcomes: a higher total use was significantly associated with a higher diabetes knowledge score, a higher total diabetes self-efficacy score, and lower HA1C by final study visit
Quinn et al[14]	Mobile phones	Evaluation of a diabetes coaching system that used mobile phones and patient-provider portals for individualized treatment and communication	Participants were randomly assigned to one of three treatment conditions or a usual care control group. Participants utilized a patient-coaching system consisting of a mobile diabetes management software application that allowed them to enter diabetes self-care data including blood glucose values, carbohydrate intake, and medications into mobile phones and receive automated, real-time educational, behavioral, and motivational messages related to entered data. The intervention also included a web portal consisting of a secure messaging center for patient and provider communication, personal health record, a learning library, and logbook to review entered data	The mobile phone-based intervention significantly improved HA1C compared to the usual care group. No differences were observed between groups for diabetes distress, depression, diabetes symptoms, blood pressure, or lipid levels
Song et al[3]	Internet-based DSMP	Evaluation of the efficacy of an internet-based diabetes self-management education program for newly diagnosed patients with type 2 diabetes as an alternative to group lectures	Participants in the intervention group participated in an internet-based diabetes self-management program and control group participants attended three hours of group lectures provided by healthcare professionals specializing in diabetes care	HA1C and diabetes care knowledge improved significantly in the intervention group at six weeks and diabetes care behaviors improved significantly at six weeks and three months. Diabetes
				care knowledge and diabetes care behaviors improved significantly in the control group at six weeks, but HA1C did not significantly change at six weeks or three months
Tang et al[20]	Internet-based system	Evaluation of an online disease management system supporting patients with uncontrolled type 2 diabetes	Multicomponent intervention that included: wirelessly uploaded home glucometer readings with graphical feedback; patient-specific diabetes summary status report; nutrition and exercise logs; insulin record; online messaging with healthcare providers; self-management advice and medication management; and personalized text and video educational messages	Participants in the intervention group had significantly reduced HA1C levels at 6 mo compared to a usual care group. At 12 mo, the differences were not significant

SMBG: Self-monitored blood glucose; CASM: Computer-assisted self-management; CAPS: Computer-assisted self-management plus diabetes distress specific problem-solving; DSMP: Diabetes self-management program; HA1C: Hemoglobin A1C.