A total of 7 girls and 5 boys participated. Their mean HbA1c was 8.3 (SD 0.3) before the intervention. Mean age was 16.2 (SD 1.7) years, mean disease duration was 7.5 (SD 4.6) years, and mean body mass index was 23.3 (SD 3.2) kg/m2. All the participants used insulin pumps, compared with 75% in the background population. All participants used a mobile phone daily, and 8 (67%) reported accessing the Internet via a mobile phone daily. The participants were asked to commit to completing 2 sets of diabetes diary records, each covering a continuous period of 3 days, during the intervention. This would yield approximately 24 pictures for each participant (288 pictures). During the study, 691 pictures were downloaded (mean 50, minimum 25, maximum 94).
The overall result from the qualitative data demonstrated that the adolescents found both mobile applications useful as a support to their diabetes self-management. They appreciated the picture based diabetes application more than the SMS solution. give a brief overview of the process of analyzing the interviews, from which three main categories emerged: visualization, access, and software changes. The quotes used to illustrate these themes use fictitious names for the participants.
Brief overview of the process of analyzing the interviews.
All the adolescent participants used the verb “to see” in relation to the first application’s functionality. They reported a better visual understanding of the cornerstones of diabetes self-management: food intake, insulin dosage, physical activity, and blood glucose measurements. The participants reported that the pictures of food they had consumed, integrating pre- and postprandial glucose measurements and insulin dosages as well as information on physical activity, gave them a visual and tangible understanding of how physical activity, food intake, and the insulin dosage interact and affect postprandial glucose measurements.
Tom: Before, I really thought that the blood sugar was one thing and giving insulin was one thing and eating was one thing, but now I see more all three of them as a whole, that they all belong together. Because if not all three of them come together, I feel it’s like I miss a part of the puzzle.
Ann: It is just to browse back in the picture diary and look at how much [insulin] I actually needed to the food I had eaten, that is an advantage...I have learned to think about what to eat and the value of measuring my blood sugar before I eat and think about the insulin dosage in relation to these factors, then to measure again 1.5 hours later in order to evaluate if the dosage of insulin was correct.
Erik: The Diamob application helped the most...I became tougher in taking insulin doses. Because I saw how the glucose measurements changed and the value of giving enough insulin.
The participants also said that they preferred the mobile phone-based diabetes diary to paper-based diaries, and that it provided an incentive for communication about their diabetes self-management both with their parents and with their health care providers.
Oda: I think it is a lot easier to understand and to have it explained when I can see things.
Beth: When I met Mom or Dad I could show them what I had done during the day instead of writing. I liked that a lot.
The adolescents also reported that seeing the pictures of their own food in the Diamob application gave them a visual understanding of their own unhealthy diet.
Erik: I just photographed the food I usually eat, but I thought during the process that I should apply more healthy eating habits, because I saw I had a lot of unhealthy canteen food in school.
The participants experienced Web-based SMS as a positive instrument for bidirectional contact with health care providers. It provided a safety net that gave them a sense of protection because it made it easy for them to access their physician with questions and concerns.
Jan: I liked the project and the follow-up. I could send an SMS whenever I wanted. I got an answer within half an hour. I especially liked the SMS—in the Netherlands, where I lived prior to this, I knew I could call, but I like the message system a lot better.
Oda: The fact that you have someone to support you—someone who knows the subject, and if you get into difficulties you can get an answer—it gives a certain feeling of security.
All participants greatly appreciated the possibility of contacting their health care provider and receiving an immediate response. They indicated that it gave them a feeling of closeness to the health care practitioner.
Tom: It is usually not easy to get in touch with your doctor...it was nice, because usually you call in and you are told he is for lunch or are busy and then it ends up you don’t do anything.
The participants also reported feeling empowered in that they could access the health care practitioner so readily.
Beth: It has been pretty good to know that if I have an issue, then I can just send a message...Instead of calling Mom or Dad and ask them to call [the physician], and when they have the answer it might be an answer to something I was not wondering about.
The participants reported that they appreciated having access to information through the mobile phone. They described the educational text messages as useful in increasing their understanding of diabetes self-management. However, they also stated that they appreciated simple and practical self-management advice more than large amounts of information that was not relevant to their immediate situation.
Oda: It is more about those messages and the information. It has been practical advice, easy to understand, simple facts that are very nice to know. It is better to have it in such small portions instead of reading a lot of information, then everything is poorly read and poorly understood. I liked the way the information was given.
Kristin: ...it is easier to access the information in this way, than listening to a doctor who talks about it for 5 hours.
Despite their appreciation for the accessibility of the device, several participants indicated that the Web-based SMS system was unduly cumbersome.
Jan: But it was a bit cumbersome to have to remember a code [to get access].
David: But what is cumbersome is that you have to access that Internet browser on the mobile. I would prefer to send normal SMS on the phone...that would make it even easier if you could access it using the usual SMS [on the phone].
Another category of data was the software changes that the participants recommended. Although the participants described the applications as highly usable in general, they also identified particular problems that required resolution. They reported technical problems that we attributed to the immaturity of the applications and the chosen mobile platform. Some of the participants explained that they experienced problems and found it troublesome to use the applications.
Jan: The Diamob app didn’t work at the end of the project. The glucometer with Bluetooth worked, but batteries ran out of power quickly.
David: Yes, the project was tailored to me, but it could have been better on the glucose transmission [from the glucometer to the phone] because it didn’t work all the time.
The participants agreed that the applications were highly usable, but requested the possibility of downloading the applications to their own mobile phones in the future. With 1 exception, the participants indicated that if the applications were available for downloading to their own phones, they would continue to use the applications. They contributed technical advice on how the applications could be improved.
Oda: It would give a better overview as a matter of fact, when you think about it, when you have to go from picture to picture, but if you had all 3 days in 1 page, as a complete overview of 1 day, then I think it would be better.
Eva: I didn’t like the diagram thing [in the Diamob apps]. It was a mess, and I didn’t like that it could not be tailored to each patient...And for instance I think it is stupid that it [the pictograms for activity] only marks sitting, lying, standing, and training, but maybe you don’t do the physical activity, and then, after an hour, it is time to go for a run.
Qualitative data were supported by glycemic control, SUS scores, and knowledge tests. Metabolic control had improved (ie, lowered HbA1c) in 7 participants at the end of the study, but was unchanged in 2 participants. During the study period, 3 of the participants increased their HbA1c (). Statistically, we found no significant changes in HbA1c over the course of the intervention (). None of the participants who completed the 3-month intervention had severe hypoglycemia or severe ketoacidosis or were hospitalized during the intervention period.
Participants’ glycated hemoglobin (HbA1c) and knowledge test score (maximum score 27), before and after the intervention, and System Usability Scale (SUS) score (maximum score 100) after the intervention.
Glycated hemoglobin (HbA1c) values, knowledge test scores, and System Usability Scale score before and after the intervention.
The mean score on the SUS was 73 (SD 22) (); 10 participants had a high SUS score: mean 81 (SD 10). These 10 reported positive experiences with the 2 mobile applications. However, 2 participants had a considerably lower SUS score than the others (each scoring 30).
All the participants had relatively high scores on the theoretical diabetes knowledge tests, with a mean of 22 (SD 2) (maximum score 27; ). Scores were nearly the same prior to the project and at the end; no statistical differences were found ().