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Cited by 62Mobile Health and mHealth ApplicationsDiabetes Management and EducationDigital Mental Health Interventions

Long-Term Engagement With a Mobile Self-Management System for People With Type 2 Diabetes

Open access
Tatara, Naoe, Årsand, Eirik, Skrøvseth, Stein Olav, Hartvigsen, Gunnar·2013·JMIR mHealth and uHealth
DOI 10.2196/mhealth.2432PMC PMC4114413
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Abstract

BACKGROUND: In a growing number of intervention studies, mobile phones are used to support self-management of people with Type 2 diabetes mellitus (T2DM). However, it is difficult to establish knowledge about factors associated with intervention effects, due to considerable differences in research designs and outcome measures as well as a lack of detailed information about participants' engagement with the intervention tool. OBJECTIVE: To contribute toward accumulating knowledge about factors associated with usage and usability of a mobile self-management application over time through a thorough analysis of multiple types of investigation on each participant's engagement. METHODS: The Few Touch application is a mobile-phone-based self-management tool for patients with T2DM. Twelve patients with T2DM who have been actively involved in the system design used the Few Touch application in a real-life setting from September 2008 until October 2009. During this period, questionnaires and semistructured interviews were conducted. Recorded data were analyzed to investigate usage trends and patterns. Transcripts from interviews were thematically analyzed, and the results were further analyzed in relation to the questionnaire answers and the usage trends and patterns. RESULTS: The Few Touch application served as a flexible learning tool for the participants, responsive to their spontaneous needs, as well as supporting regular self-monitoring. A significantly decreasing (P<.05) usage trend was observed among 10 out of the 12 participants, though the magnitude of the decrease varied widely. Having achieved a sense of mastery over diabetes and experiences of problems were identified as reasons for declining motivation to continue using the application. Some of the problems stemmed from difficulties in integrating the use of the application into each participant's everyday life and needs, although the design concepts were developed in the process where the participants were involved. The following factors were identified as associated with usability and/or usage over time: Integration with everyday life; automation; balance between accuracy and meaningfulness of data with manual entry; intuitive and informative feedback; and rich learning materials, especially about foods. CONCLUSION: Many grounded design implications were identified through a thorough analysis of results from multiple types of investigations obtained through a year-long field trial of the Few Touch application. The study showed the importance and value of involving patient-users in a long-term trial of a tool to identify factors influencing usage and usability over time. In addition, the study confirmed the importance of detailed analyses of each participant's usage of the provided tool for better understanding of participants' engagement over time.

AI snapshot

Written from the paper’s full text.

TL;DR

This year-long field trial of the Few Touch mobile self-management application found that it served as a flexible learning tool for people with Type 2 diabetes, but usage significantly decreased over time for most participants. The study identifies design factors related to integration into everyday life, automation, manual-entry trade-offs, feedback, and food-related learning materials as associated with long-term usability and usage.

Key findings

  • A significantly decreasing (P<.05) usage trend was observed among 10 of 12 participants, though the magnitude varied widely; P03 and P09 used the blood glucose and physical activity systems very consistently (e.g., P03 used blood glucose on 390/395 days [99%] and physical activity on 210/219 days [96%]; P09 used blood glucose on 348/352 days [99%] and physical activity on 129/132 days [98%]).
  • Perceived usefulness of the whole application remained high over time: mean scores were 6.3 at 3-4 months, 6.4 at 6 months, and 6.5 at 1 year on a 7-point scale; the average System Usability Scale score was 84.0 (SD 13.5, range 67.5-100).
  • Reasons for declining motivation included having achieved a sense of mastery over diabetes and experiences of problems; factors associated with usability and/or usage over time were integration with everyday life, automation, balance between accuracy and meaningfulness of manually entered data, intuitive and informative feedback, and rich learning materials especially about foods.
  • Usage patterns varied widely, including intensive use to find relationships between self-management and blood glucose, constant regular use for overview, sporadic use in out-of-the-ordinary situations, and experimental use.

Methods

  • Twelve patients with Type 2 diabetes (4 men, 8 women; age range 44-70, mean 55.1, SD 9.6; mean disease duration 8.1, SD 3.8 years) who had been involved in the system design used the Few Touch application in a real-life setting from September 2008 until October 2009.
  • Data included recorded application data (blood glucose, step counts, nutrition habits), questionnaires including the System Usability Scale, and semistructured interviews/focus groups.
  • Usage rate was defined as number of days per week each function was used; Mann-Kendall trend tests assessed usage trends, kernel density estimation examined time-of-day patterns, and interview transcripts were thematically analyzed and triangulated with questionnaire and usage data.

Limitations

  • Stated in the paper: the first author was neither a Norwegian citizen nor a native Norwegian speaker and needed help from the second author to interpret interviews, which might have caused bias in the analysis.
  • Stated in the paper: generalizability is limited by intrinsically high motivation among many participants and the small number of participants (12).
  • Evident in the text: step counters had battery/technical problems and shorter availability than other functions; P09’s recorded data were accidentally deleted at Meeting 2, so only post-Meeting 2 data were analyzed; and no deterministic associations were observed between questionnaire answers and usage of functions.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.2196/mhealth.2432

Cites

74 of 74 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 62 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The authors' literature review revealed considerable differences among studies in the level of detail regarding reports on participants' engagement with the intervention tools over time.

    “Our review also revealed considerable differences among the studies in terms of the level of detail regarding reports on participants’ engagement with the intervention tools over time.”
    Quote in the paperSubstantial claim
  • Findingown data

    P01 used the function moderately: once a day for most of the times when used (75%, 76 out of 102 days).

    “P01 used the function moderately: once a day for most of the times when used (75%, 76 out of 102 days) (Figure 2).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The user interface update at Meeting 4 did not appear to influence usage patterns or usage rate for participants other than P08.

    “whereas this modification did not seem to influence either usage patterns or usage rate for the other participants.”
    Quote in the paperNot a substantial claim
  • Findingown data

    A change in nutrition habit recording usage patterns was observed for some participants (P01, P07, and P11) in a relatively early phase.

    “Regarding nutrition habit recordings, we could observe a change in usage patterns for some participants (eg, P01, P07, and P11) in a relatively early phase (Multimedia Appendix 3).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The Few Touch application was generally perceived as satisfactory.

    “The Few Touch application was generally perceived as satisfactory.”
    Quote in the paperSubstantial claim
  • May combine two claims. 45
  • Classified as probably not a substantial claim. 41
  • The quote only partly states this claim. 1

  • May combine two claims.

    Findingown data

    A significantly decreasing (P<.05) usage trend was observed among 10 out of the 12 participants, though the magnitude of the decrease varied widely.

    “A significantly decreasing (P<.05) usage trend was observed among 10 out of the 12 participants, though the magnitude of the decrease varied widely.”
    • Also stated in: § Usage Trends and Patterns · plain
      “Results from the Mann-Kendall trend test on usage rates confirmed a significantly decreasing (P<.05) usage trend among 10 out of the 12 participants, though the magnitude of the decrease varied widely (Table 2).”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Days with step counts greater than zero were the days on which the physical activity system was used, unless participants reported problems.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    P07 shifted nutrition habit recording activity to morning time.

    “while P07 shifted recording activity to morning time.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    P10 measured in the morning more or less regularly and otherwise rather sporadically, while P06 usually measured very sporadically.

    “From the kernel density estimates (Multimedia Appendix 2), it is observed that P10 measured in the morning more or less regularly and otherwise rather sporadically, while P06 usually measured very sporadically.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    P06 and P10 used the blood glucose sensor system for more than 70% of days when the function was available, and often they measured blood glucose more than once a day.

    “For example, P06 and P10 used the blood glucose sensor system for more than 70% of days when the function was available, and often they measured blood glucose more than once a day (Figure 2).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A significant decreasing usage trend (P<.05) was observed among 5 of the participants for the physical activity sensor system, which is less than for the other two functions.

    “A significant decreasing usage trend (P<.05) was observed among 5 of the participants, which is less than for the other two functions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Nine of the 12 participants had problems with the physical activity sensor system and their step counters were repaired or replaced.

    “Regarding the physical activity sensor system, 9 (P01, P02, P03, P05, P07, P08, P09, P10, and P11) of the 12 participants had problems and their step counters were repaired or replaced.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Four participants (P01, P05, P06, and P11) reported at Meetings 2 and 3 that they tried to record nutrition data right after eating but sometimes recorded it at the end of the day to summarize their food intake.

    “This corresponds to what 4 participants (P01, P05, P06, and P11) told us at Meetings 2 and 3: they tried to record the data right after eating, but sometimes they recorded it at the end of the day to summarize their food intake”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    P03 and P09 measured once a day for most of the days on which they had measurements (370 out of 390 days (95%) for P03 and 297 out of 348 days (85%) for P09).

    “From Figure 2, it is clear that P03 and P09 measured once a day for most of the days on which they had measurements (370 out of 390 days (95%) for P03 and 297 out of 348 days (85%) for P09).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Overall satisfaction levels with knowledge about diabetes and with skills in diabetes management were not drastically changed over 1 year.

    “Also, overall satisfaction levels with their knowledge about diabetes and with skills in diabetes management were not drastically changed in the course of 1 year (Multimedia Appendix 4, Questionnaire 5).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Most participants stated that using the application as a "self-help" tool was enough for them, though collaborative use might be motivating.

    “Most of the participants stated that using the application as a “self-help” tool was enough for them, though collaborative use of the application might be motivating.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    No other items were perceived as explicitly unsatisfactory for the Few Touch application in Questionnaire 1.

    “No other items were perceived as explicitly unsatisfactory for the Few Touch application in this questionnaire.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Depending on their status, participants increased their motivation for either maintaining good habits or improving attitudes and behavior, and eventually experienced a sense of control over their diabetes.

    “Depending on their status, the participants increased their motivation for either maintaining their good habits or improving their attitudes and behavior, and eventually experienced a sense of control over their diabetes.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The blood glucose sensor system was perceived as the most motivating, followed by the physical activity sensor system and the nutrition habit recording system.

    “The blood glucose sensor system was perceived as the most motivating, followed by the physical activity sensor system and the nutrition habit recording system (Multimedia Appendix 4, Questionnaire 2).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In the questionnaire on preferences for potential functionalities, "A smaller step counter that is easier to wear" was highest rated, and "automatically popping-up tips" ranked second.

    ““A smaller step counter that is easier to wear” was highest rated, and “automatically popping-up tips” ranked as second.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Only one user expressed dissatisfaction about the size of the mobile phone in Questionnaire 1.

    “The result from Questionnaire 1 shows that only one user expressed dissatisfaction about the size of the mobile phone, which is 107 x 55 x 16 mm and weighs 120 gram.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    Although participants considered the tips concise and useful, 5 participants (P01, P03, P05, P09, and P12) suggested improvements.

    “Although the participants considered the tips concise and useful, 5 participants (P01, P03, P05, P09, and P12) suggested improvements, as reported previously [42].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [42] ÅrsandEThe Few Touch Digital Diabetes Diary: User-Involved Design of Mobile Self-Help Tools for People with Diabetes. doctoral thesis20092012-06-22TromsøUniversity of Tromsøhttp://munin.uit.no/handle/10037/276268bcp2CtG

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The other items that no one disagreed with were "automatic" functions.

    “The other items that no one disagreed with were “automatic” functions.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    P08 admitted at Meeting 6 using the step counter extensively despite having problems attaching it, and used it in either a pocket or a handbag.

    “For example, P08 admitted at Meeting 6 using the step counter extensively, despite having problems in attaching the step counter, and used it in either a pocket or a handbag.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Although most participants liked and wanted to keep the simplicity of the nutrition habit recording system, some found the categorization not appropriate for their reflective thinking or not matching their individual preferences based on accumulated personal experiences.

    “Although most of the participants liked and wanted to keep the simplicity of the system for nutrition habit recording, some of them found that the categorization for this system was not appropriate for their reflective thinking or that it did not match their individual preferences based on their accumulated personal experiences (Table 5).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    At Meeting 5, P01 told us "it does not work for me, at least" because "it is impossible to record for the past dates though it is easy to forget recording".

    “However, at Meeting 5, P01 told us “it does not work for me, at least” because “it is impossible to record for the past dates though it is easy to forget recording”.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Problems that stemmed from outside the design concepts included battery attrition for a step counter and a Bluetooth adapter, some features of the provided smartphone that took time to get used to in the first month, and problems with the smartphone.

    “Problems that stemmed from outside the design concepts included battery attrition for a step counter and a Bluetooth adapter, some features of the provided smartphone that had taken some time to get used to for the first month, and problems with the smartphone.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    From data extracts relevant to application design and questionnaire results, five factors associated with usability and/or usage over time were identified: integration with everyday life, automation, balance between accuracy and meaningfulness of data with manual entry, intuitive and informative feedback, and rich learning materials especially about foods.

    “From data extracts relevant to the application design and results from questionnaires, we identified the following factors associated with usability and/or usage over time: (1) integration with everyday life, (2) automation, (3) balance between accuracy and meaningfulness of data with manual entry, (4) intuitive and informative feedback, and (5) rich learning materials, especially about foods.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    At Meeting 4, P01 expressed a positive perception of the nutrition habit recording system as "it has worked" despite forgetting to record data and complaints about the categorization.

    “For example, at Meeting 4, P01 expressed a positive perception of the nutrition habit recording system as “it has worked” despite forgetting to record data and complaints about the categorization.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    P03 continued to write down blood glucose values for a while but became used to getting the values on the smartphone.

    “P03 admitted to continuing to write down blood glucose values for a while, but s/he became used to getting the values on the smartphone.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    At Meeting 2, P10 said s/he had used to write a very precise paper diary before the trial, found no difference in the Diabetes Diary, and even the blood glucose graph did not provide anything new.

    “P10 told us in the Meeting 2 that s/he had used to write a very precise paper diary before the trial started, so s/he found no difference in the Diabetes Diary, and even the blood glucose graph did not provide anything new.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Participants appreciated not having to write down values and that graphical feedback was automatically prepared based on transferred data.

    “The participants appreciated not only that they did not have to write down the values any more but also the fact that the graphical feedback was automatically prepared based on the transferred data.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Despite generally high satisfaction with the application, experiences of problems were also reported.

    “Despite generally high satisfaction with the application, experiences of problems were also reported.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    The Few Touch application was equipped with neither "push" factors nor an advanced decision support system providing feedback based on accumulated data and other personal profiles.

    “The application was equipped with neither “push” factors nor an advanced decision support system providing feedback based on accumulated data and other personal profiles, which are advocated for long-term usage, according to relevant studies [62-65].”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [62] source

      Not checked in the free run.

    • cites [63] source

      Not checked in the free run.

    • cites [64] source

      Not checked in the free run.

    • cites [65] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    One suggestion for improvement included a function to show a filtered list of fasting blood glucose measurements only, which illustrates a need for feedback to be more informative.

    “One of the suggestions for improvement of the application included a function to show a filtered list of fasting blood glucose measurements only, which also illustrates a need for feedback to be more informative.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    At Meeting 3, P05 mentioned the importance of keeping a self-management tool simple so that s/he would not become confused with complicated information.

    “At Meeting 3, P05 also mentioned the importance of keeping a self-management tool simple so that s/he would not become confused with complicated information.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Most participants appreciated the tips about food, and even more enriched content was requested.

    “Most of the participants appreciated the tips about food, and even more enriched content was requested.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingreasoning

    Frequent meetings facilitated quick responses to the participants' feedback by improving the prototype and by organizing new inquiries for further iterative design processes.

    “Frequent meetings also facilitated quick responses to the participants’ feedback by improving the prototype and by organizing new inquiries for further iterative design processes.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Automation is associated with usability and/or usage over time.

    “The following factors were identified as associated with usability and/or usage over time: Integration with everyday life; automation; balance between accuracy and meaningfulness of data with manual entry; intuitive and informative feedback; and rich learning materials, especially about foods.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Integration with everyday life is associated with usability and/or usage over time.

    “The following factors were identified as associated with usability and/or usage over time: Integration with everyday life; automation; balance between accuracy and meaningfulness of data with manual entry; intuitive and informative feedback; and rich learning materials, especially about foods.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Some of the problems stemmed from difficulties in integrating the use of the application into each participant's everyday life and needs, although the design concepts were developed in the process where the participants were involved.

    “Some of the problems stemmed from difficulties in integrating the use of the application into each participant’s everyday life and needs, although the design concepts were developed in the process where the participants were involved.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Having achieved a sense of mastery over diabetes and experiences of problems were identified as reasons for declining motivation to continue using the application.

    “Having achieved a sense of mastery over diabetes and experiences of problems were identified as reasons for declining motivation to continue using the application.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The Few Touch application served as a flexible learning tool for the participants, responsive to their spontaneous needs, as well as supporting regular self-monitoring.

    “The Few Touch application served as a flexible learning tool for the participants, responsive to their spontaneous needs, as well as supporting regular self-monitoring.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A growing number of studies report interventions using mobile phones and development projects of mobile self-management tools for people with diabetes.

    “Reflecting this situation, a growing number of studies report interventions using mobile phones and development projects of mobile self-management tools for people with diabetes [9-11].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [9] source

      Not checked in the free run.

    • cites [10] source

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    • cites [11] source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The findings from the interview data were investigated by collating both the results of questionnaires and the results of usage patterns and trends.

    “The findings from the interview data were investigated by collating both the results of questionnaires and the results of usage patterns and trends.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Mobile phones have been considered promising intervention platforms to support self-management of lifestyle-related diseases in general because of their pervasiveness and ubiquity.

    “Mobile phones have been considered promising intervention platforms to support self-management of lifestyle-related diseases in general because of their pervasiveness and ubiquity [5].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [5] Blake, H, 2008, Nurs Stand source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Due to limited battery life of the step counter and limited human resources after the end of the 6-month trial planned initially, all the step counters stopped working before the meetings held in October 2009.

    “Due to the limited battery life of the step counter and the limited human resources after the end of the 6-month trial planned initially, all the step counters stopped working before the meetings held in October 2009.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The interview data were examined by following the framework suggested by Braun and Clarke, in which codes and themes were identified at semantic level using a theoretical approach.

    “Because the questions were strongly connected to the aim of the analysis, we examined data from interviews by following the framework suggested by Braun and Clarke [54], in which codes and themes were identified at semantic level using a theoretical approach.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [54] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationnone given

    The study confirmed the importance of detailed analyses of each participant's usage of the provided tool for better understanding of participants' engagement over time.

    “In addition, the study confirmed the importance of detailed analyses of each participant’s usage of the provided tool for better understanding of participants’ engagement over time.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The number of mobile self-management tools for diabetes available both commercially and free of charge is rapidly increasing.

    “Especially with the emergence of smartphones, the number of mobile self-management tools for diabetes available both commercially and free of charge is rapidly increasing [6-8].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [6] source

      Not checked in the free run.

    • cites [7] Årsand, E, 2011, Handbook of Research on Mobility and Computing: Evolving Technologies and Ubiquitous Impacts source

      Not checked in the free run.

    • cites [8] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    For effective medical care of chronic illness, such as T2DM, adequate and sustainable self-management initiated by patients is important.

    “For effective medical care of chronic illness, such as Type 2 diabetes mellitus (T2DM), adequate and sustainable self-management initiated by patients is important [1-3].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [1] Von Korff, M, 1997, Ann Intern Med source

      Not checked in the free run.

    • cites [2] Wagner, EH, 1998, Eff Clin Pract

      Not checked in the free run.

    • cites [3] source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    The patterns of times at which measurements were taken were quite different from one participant to another, which reflects different needs for blood glucose measurements.

    “However, the kernel density estimates (Multimedia Appendix 2) also revealed that the patterns of times at which measurements were taken were quite different from one participant to another, which reflects different needs for blood glucose measurements.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationown data

    The study showed the importance and value of involving patient-users in a long-term trial of a tool to identify factors influencing usage and usability over time.

    “The study showed the importance and value of involving patient-users in a long-term trial of a tool to identify factors influencing usage and usability over time.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    The physical activity sensor system was available for a much shorter period than the other two functions, so the decreasing usage trend result may need careful interpretation.

    “However, this result may need to be interpreted carefully due to the much shorter period in which the physical activity sensor system was available than the other two functions.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    The generally decreasing trend is in line with the result for blood glucose measurements found previously.

    “The generally decreasing trend is in line with the result for blood glucose measurements found previously [43].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [43] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    The local regional ethical committee approved the study protocol in 2006.

    “The local regional ethical committee approved the study protocol in 2006 (Regional komité for medisinsk forskningsetikk Nord, Ref. No. 13/2006).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The System Usability Scale (SUS) is widely used and has been found valid.

    “To evaluate the usability of the whole system, at Meeting 4 we administered the System Usability Scale (SUS) [49], which is widely used [51] and has been found valid [52].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [51] Rubin, J, 2008, Handbook of usability testing: how to plan, design, and conduct effective tests. 2nd edition

      Not checked in the free run.

    • cites [52] source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The wide variety of usage shows that the application was used flexibly according to users' spontaneous purposes as well as for regular self-monitoring every day.

    “Such a wide variety of usage shows that the application was used flexibly according to users’ spontaneous purposes as well as for regular self-monitoring every day.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationown data

    Many issues in Table 5 illustrate the importance and difficulty of application design that can be easily integrated into each individual's everyday life.

    “Many of the issues listed in Table 5 also illustrate the importance and difficulty of application design that can be easily integrated into each individual’s everyday life.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    Not all issues in Table 5 were clearly specified as direct reasons for immediate decrease in usage, but they at least degraded the usability of the application.

    “Not all the issues in Table 5 were clearly specified as direct reasons for the immediate decrease in usage, but they at least degraded the usability of the application.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Such needs correspond to the wide variety of usage of the application described earlier.

    “Such needs correspond to the wide variety of usage of the application described earlier.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    The application's ease and simplicity played an important role not only in enhancing motivation to use the application but also in the learning process because keeping track of performed actions in self-management activities is notoriously difficult.

    “Such characteristics played an important role not only in enhancing motivation to use the application but also in the learning process because “keeping track of performed actions in self-management activities is notoriously difficult” [48].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [48] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Previous studies claim that a supporting tool for people with diabetes should facilitate the learning process based on personal experiences on top of necessary knowledge provided by diabetes education.

    “It is also claimed in previous studies that a supporting tool for people with diabetes should facilitate this learning process [48,58].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [48] source

      Not checked in the free run.

    • cites [58] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The relatively high usage over the 1-year trial period might have been caused by intrinsically high motivation of participants in the design process.

    “This might have been caused by intrinsically high motivation of participants in the design process.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The ability to customize a feature is important for the function to be meaningful for individual users, and this idea resonates with design implications described in a study by Chen et al.

    “The ability to customize a feature is important for the function to be meaningful for individual users, and this idea resonates with design implications described in a study by Chen et al [58].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Chen et al [58]

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Accuracy of data obtained by a sensor is critical in terms of giving proper credit to users.

    “Accuracy of data obtained by a sensor is critical in terms of giving proper credit to users [48,68].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [48] source

      Not checked in the free run.

    • cites [68] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    Visual feedback showing the historical distribution of nutrition habits, physical activity, and blood glucose level would have made it easier for participants to find relationships between them, especially those who had difficulty keeping focus or tended to lose motivation.

    “To better support “learning processes”, visual feedback showing the historical distribution of all three factors—nutrition habits, physical activity, and blood glucose level—would have made it easier to find relationships between them, especially for the participants who had difficulty in keeping focus or tended to easily lose motivation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Usability is important to patients who need encouragement or help in self-management activities.

    “This implication is consistent with findings by Russell-Minda et al [15] regarding the importance of usability to patients who need encouragement or help in self-management activities.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [15] Russell-Minda, E, 2009, J Diabetes Sci Technol source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Relevant studies advocate push factors and an advanced decision support system providing feedback based on accumulated data and other personal profiles for long-term usage.

    “The application was equipped with neither “push” factors nor an advanced decision support system providing feedback based on accumulated data and other personal profiles, which are advocated for long-term usage, according to relevant studies [62-65].”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [62] source

      Not checked in the free run.

    • cites [63] source

      Not checked in the free run.

    • cites [64] source

      Not checked in the free run.

    • cites [65] source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    As shown in Questionnaire 8, participants expressed preferences for features such as push factors and advanced decision support, suggesting the role these would play for stronger engagement with the application.

    “As shown in Multimedia Appendix 4 Questionnaire 8, the participants expressed preferences for such features, suggesting the role these would play for stronger engagement with the application.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The first author needed help from the second author to interpret and understand what the participants meant in interviews.

    “The first author needed some help from the second author to interpret and understand better exactly what the participants meant in interviews.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Learning from others in similar situations was one of patients' motives to attend meetings in a user-involved program for improvement of health services for people with stroke.

    “Fudge et al [73] also found that learning from others in similar situations was one of patients’ motives to attend meetings in a user-involved program for improvement of health services for people with stroke.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [73] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    The implication that participants need to learn more about food by referring to external information is plausible.

    “Given that behavior change in diet is the most challenging of the self-management activities and that lack of knowledge about diet is the highest ranked barrier [72], this implication is plausible.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [72] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The first author is neither a Norwegian citizen nor a native Norwegian speaker, though she understands the Norwegian language.

    “Though the first author of this paper understands the Norwegian language, she is neither a Norwegian citizen nor a native Norwegian speaker.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    Participants experienced a need to learn more about food by referring to external information in their reflective thinking process.

    “This implies that the participants experienced a need to learn more about food by referring to external information in their reflective thinking process.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationown data

    The present study showed the importance of a thorough analysis of results from multiple types of investigations focusing on each participant's engagement with the tool over time.

    “The present study showed the importance of the following two factors: (1) a thorough analysis of results from multiple types of investigations focusing on each participant’s engagement with the tool over time, and (2) involving patient-users from an early phase of design-concept making to a longitudinal trial of the system.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Patients' experimentally accumulated personal knowledge about relationships between foods and health, and external knowledge of a recommended diet, comprise part of complex and dynamic processes of behavior change in diet.

    “This is consistent with findings by Savoca et al [71] that not only the patient’s experimentally accumulated personal knowledge about the relationships between foods and health, but also external knowledge of a recommended diet, comprise a part of complex and dynamic processes of behavior change in diet.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [71] Savoca, M, 2001, J Nutr Educ source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductnone given

    The extent to which the findings can be generalized is limited by intrinsically high motivation among many participants and the small number of participants.

    “The extent to which our findings can be generalized is limited by intrinsically high motivation among many of our participants as well as the small number of the participants.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    It is highly probable that the factors this study identified as reducing usability or usage would do so when users were less motivated.

    “However, it is highly probable that the factors that this study identified as reducing usability or usage would do so when users were less motivated.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Lack of knowledge about diet is the highest ranked barrier.

    “Given that behavior change in diet is the most challenging of the self-management activities and that lack of knowledge about diet is the highest ranked barrier [72], this implication is plausible.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [72] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). The quote only partly states this claim.

    Study design and conductreasoning

    The first author's need for help from the second author to interpret interviews might have caused a certain bias in the analysis.

    “This might have caused a certain bias in the analysis.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The second author is a native Norwegian, has T1DM himself, and has the same cultural background as the participants.

    “On the other hand, the second author is a native Norwegian, has T1DM himself, and has the same cultural background as the participants.”
    Quote in the paperNot a substantial claim
76 of 76

  • The authors state this as an assumption.

    Days with step counts greater than zero were the days on which the physical activity system was used, unless participants reported problems.

    “For the physical activity system, unless participants reported any problems with it, we assumed that days with step counts greater than zero were the days on which the system was used, because the step counter automatically transmits data once a day at a regular time, even if it has not been used on that day.”

  • The paper relies on this without support.

    The step counter automatically transmits data once a day at a regular time, even if it has not been used on that day.

    “For the physical activity system, unless participants reported any problems with it, we assumed that days with step counts greater than zero were the days on which the system was used, because the step counter automatically transmits data once a day at a regular time, even if it has not been used on that day.”

  • The paper relies on this without support.

    No standard measure has been specifically designed to assess usability of a mobile-phone-based self-management tool for diabetes.

    “To our knowledge, no standard measure has been specifically designed to assess usability of a mobile-phone-based self-management tool for diabetes.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Ability to integrate app use into one's daily routine is an important potential facilitator and/or barrier to intervention usage.

    “The impact of users’ availability to interact with the app and take advantage of free moments echoes reports that ability to integrate app use into one’s daily routine is an important potential facilitator and/or barrier to intervention usage [16,24,32,46].”

    From Understanding Usage of a Hybrid Website and Smartphone App for Weight Management: A Mixed-Methods Study (2014) · cites this paper as [24]

  • In-line with previous research, the POWeR Tracker app was viewed by most participants as a convenient means of accessing desired information and tools on-the-go as needed.

    “In-line with previous research [24,50,65], the POWeR Tracker app was viewed by most participants as a convenient means of accessing desired information and tools on-the-go as needed.”

    From Understanding Usage of a Hybrid Website and Smartphone App for Weight Management: A Mixed-Methods Study (2014) · cites this paper as [24]

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. Wagner, EH, 1998, Eff Clin Pract, 1, 2
  2. KanstrupAMBertelsenPGlasemannMBoyeNDesign for More: An Ambient Perspective on DiabetesProceedings of the Tenth Anniversary Conference on Participatory Design2008Tenth Anniversary Conference on Participatory DesignSept. 30-Oct. 4, 2008Bloomington, Indiana118127

Cited by

Sorted by citations

Related

Authors
Tatara, N., Årsand, E., Skrøvseth, S. O., & Hartvigsen, G.
Affiliations
University Hospital of North Norway (NO)
Corresponding author
Tatara, Naoe
ORCID
Venue
JMIR mHealth and uHealth
Publisher
JMIR Publications Inc.
Published
2013-03-27
Volume
1
Issue
1
Pages
e1
ISSN
2291-5222 (ISSN-L)
DOI
10.2196/mhealth.2432
PMC
PMC4114413
OpenAlex
W2135692350
Semantic Scholar
d906a2afff4a49055a25885cc724157b4101cb6d
Cited by
62
References
74
Citations by year
2025: 1 · 2024: 2 · 2023: 1 · 2022: 5 · 2021: 8 · 2020: 6 · 2019: 11 · 2018: 4 · 2017: 6 · 2016: 6 · 2015: 8 · 2014: 2 · 2013: 2
FWCI
10.87
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • JMIR mhealth and uhealth (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • NORA - Norwegian Open Research Archives (submittedVersion, other-oa)
Topics
  • Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
Keywords
type 2 diabetes, user engagement, usability, self-monitoring, diabetes self-management education, food knowledge, feedback, automation

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

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