Jeffrey et al.

Diabetol Metab Syndr (2019) 11:84

https://doi.org/10.1186/s13098-019-0480-4 Diabetology &
Metabolic Syndrome

RESEARCH Open Access

Mobile phone applications and their use

in the self‑management of Type 2 Diabetes
Mellitus: a qualitative study among app users
and non‑app users
Bronte Jeffrey1, Melina Bagala1†, Ashley Creighton1†, Tayla Leavey1†, Sarah Nicholls1†, Crystal Wood1†,
Jo Longman2, Jane Barker2 and Sabrina Pit3,4* 

Abstract 
Background:  Mobile phone applications (apps) have been shown to successfully facilitate the self-management of
chronic disease. This study aims to evaluate firstly the experiences, barriers and facilitators to app usage among peo-
ple with Type 2 Diabetes Mellitus (T2DM) and secondly determine recommendations to improve usage of diabetes
apps.
Methods:  Participants were aged ≥ 18 years with a diagnosis of T2DM for ≥ 6 months. Semi-structured phone-
interviews were conducted with 16 app and 14 non-app users. Interviews were based on the Technology Acceptance
Model, Health Information Technology Acceptance Model (HITAM) and the Mobile Application Rating Scale. Data
were analysed using deductive content analysis.
Results:  Most app-users found apps improved their T2DM self-management and health. The recommendation of
apps by health professionals, as well as positive interactions with them, improved satisfaction; however, only a minor-
ity of patients had practitioners involved in their app use. All non-app users had never had the concept discussed with
them by a health professional. Facilitators to app use included the visual representation of trends, intuitive navigation
and convenience (for example, discretion and portability). Barriers to app use were participant’s lack of knowledge
and awareness of apps as healthcare tools, perceptions of disease severity, technological and health literacy or practi-
cal limitations such as rural connectivity. Factors contributing to app use were classified into a framework based on
the Health Belief Model and HITAM. Recommendations for future app design centred on educational features, which
were currently lacking (e.g. diabetes complications, including organ damage and hypoglycaemic episodes), monitor-
ing and tracking features (e.g. blood glucose level monitoring with trends and dynamic tips and comorbidities) and
nutritional features (e.g. carbohydrate counters). Medication reminders were not used by participants. Lastly, partici-
pants felt that receiving weekly text-messaging relating to their self-management would be appropriate.
Conclusions:  The incorporation of user-centred features, which engage T2DM consumers in self-management tasks,
can improve health outcomes. The findings may guide app developers and entrepreneurs in improving app design
and usability. Given self-management is a significant factor in glycaemic control, these findings are significant for GPs,

*Correspondence: s.pit@westernsydney.edu.au
†
Melina Bagala, Ashley Creighton, Tayla Leavey, Sarah Nicholls and Crystal
Wood contributed equally to this work
3
Western Sydney University, University Centre for Rural Health, 61 Uralba
Street, Lismore, NSW 2480, Australia
Full list of author information is available at the end of the article

© The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creat​iveco​mmons​.org/licen​ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Jeffrey et al. Diabetol Metab Syndr (2019) 11:84 Page 2 of 17

nurse practitioners and allied health professionals who may integrate apps into a holistic management plan which
considers strategies outside the clinical environment.
Keywords:  Type two diabetes mellitus, Mobile phone apps, Self-management, Smart phone, mhealth, ehealth,
Digital technology, User experience

Background [12, 16–18]. Recent data from an Australian qualitative

In Australia, people living in regional or remote areas study demonstrated that people with T2DM would prefer
have higher rates of diabetes and experience worse health an app to address the practical aspects of diabetes self-
related outcomes than people living in urban areas [1]. management and to improve, and reduce the cognitive
Type 2 Diabetes Mellitus (T2DM) is a major contributor burden of self-management [17]. Further studies using
to higher death rates outside major cities and accounts focus groups for app development have highlighted the
for 6% of excess deaths in all age groups [1, 2]. This is importance of blood glucose monitoring, dietary track-
attributed to several factors, including decreased acces- ing, education, interactive content, peer support and
sibility to health services (fewer health professionals realistic goal setting [19–22]. Despite this, the uptake of
and decreased financial accessibility), decreased testing apps usage to support diabetes self-management remains
for diabetes and possibly less effective management [2]. low, [12]. Additionally, current research has concluded
Facilitation of self-management strategies may help to that there is a paucity of qualitative data on current user
overcome these issues. app experience and factors influencing consumer engage-
Self-management is considered the most important ment [5, 11, 12, 18].
factor in ensuring well-controlled blood glucose lev- The lack of qualitative evidence surrounding health
els (BGL) and, thereby, preventing diabetes complica- app usage was addressed by Anderson et al. [5] who con-
tions [3, 4]. It has the potential to ease the burden on ducted the first study combining three theoretical frame-
the healthcare system by encouraging patient autonomy works to qualitatively explore users’ experience of apps in
and allowing disease monitoring outside clinical set- relation to chronic conditions; The Technology Accept-
tings [5–8]. Self-management strategies include tracking ance Model (TAM) measures how users accept technol-
blood glucose trends, adhering to medication or insulin ogy and is based on the Theory of Reasoned Action [23].
therapy, monitoring nutrition and increasing physical The Health Information Technology Acceptance Model
activity [9]. Current research has established that apps (HITAM) furthers the concepts in TAM to focus on
are feasible tools to improve self-management of diabe- health by incorporating the Health Belief Model [24]. The
tes [4, 6, 10]. App use has been demonstrated to result in Mobile Application Rating Scale (MARS) includes theo-
positive self-management behaviours, such as improved retical constructs of engagement, functionality, aesthet-
diets and attitudes towards diabetes self-management, ics and information quality [25]. The integration of these
increased physical activity and BGL monitoring [4, 11]. frameworks provides robust theoretical grounding for
Furthermore, a recent meta-analysis has demonstrated research into the consumer experience of mobile phone
that among people with T2DM, the use of diabetes apps apps [5].
as an adjuvant to standard self-management results in a The present study uses the interview guide developed
clinically significant reduction in HBA1C, a long-term by Anderson et al. [5], based on the three frameworks, in
marker of BSL control [6, 8]. relation to T2DM. To our knowledge, there are no studies
Despite these positive outcomes, in Australia, only 8% that have focused on app use in an Australian rural popu-
of people with T2DM are reported to use apps to support lation where issues of healthcare access may increase the
diabetes self-management [12]. This poor uptake is mul- importance of self-management strategies.
tifactorial, with limitations including a lack of education Overall, further qualitative evidence is required to
integration into app technology, generic and impersonal obtain an accurate summary of consumer experiences
information, perceived difficulty of use and an inabil- and preferences to shape targeted app innovation and
ity to export data or integrate with health professionals’ development. User-centred diabetes apps have the poten-
records [4, 7, 9, 13]. Additionally, there is concern about tial to improve health outcomes, particularly in rural
the feasibility of sustained use of apps [14–16] with mini- areas where access to formal health services is relatively
mal data exploring long term app usage outside of short restricted. Therefore, this study aims to acquire a greater
randomised control trials. From the patient perspec- understanding of the perceived useful features, facilita-
tive, studies have identified that people with T2DM do tors and barriers to app usage for the self-management of
not believe apps will be useful, resulting in low uptake T2DM in a rural population.
Jeffrey et al. Diabetol Metab Syndr (2019) 11:84 Page 3 of 17

Method Table 1  Summary of participant characteristics

Participants Patient characteristic N (%)
Participants were recruited through responding to a flyer.
These were distributed amongst general practices, allied App use
health clinics, Facebook groups and pages which were  Current or prior 17 (57%)
specific to either diabetes or rural communities, and dia-  Never 13 (43%)
betes support groups. Participants were also recruited Age
through snowballing techniques, whereby participants  30–39 1 (3%)
already in the study recruited future participants by  40–49 7 (23%)
informing people in their social network about the study  50–59 5 (17%)
[26]. These participants contacted researchers to express  60–69 12 (40%)
interest in taking part in the study. The inclusion crite-  70–79 5 (17%)
ria were: participants aged over 18 years from rural loca- Gender
tions in Australia (RA2 or above), with a self-reported  Female 14 (47%)
T2DM diagnosis for greater than 6  months, and smart-  Male 16 (53%)
phone ownership. Defined by the Australian Government Rural classification
Department of Health, RA2 or above is any area outside  RA2 18 (60%)
of major cities, including inner (RA2) and outer regional  RA3 7 (23%)
(RA3), remote (RA4) and very remote locations (RA5) in  RA4 5 (17%)
Australia. In this classification, remoteness is determined Distance to GP (mins)
according to population and distance to services [27].  0–30 22 (74%)
Participants were separated into app and non-app users.  31–60 6 (20%)
All health apps which could be used to facilitate diabe-  61–90 1 (3%)
tes self-management behaviours were accepted, including  301–360 1 (3%)
diabetes specific participants ranged in age, sex, rurality, Distance to endocrinologist (mins)
app use experience, distance to GP and endocrinologist  0–60 6 (20%)
(time to reach measured in minutes) and diabetes man-  61–120 1 (3%)
agement (management strategies identified by partici-  181–240 2 (6%)
pant) (Table 1).  301–360 2 (6%)
 NA 19 (63%)
Diabetes management
Interview guide  Lifestyle modifications 6 (20%)
Semi-structured interview guides were developed for  Medication 11 (37%)
app and non-app users (Appendix: Tables  5 and 6)  Medication and insulin 7 (23%)
adapted from Anderson et al. [5]. Briefly, the following  Insulin 4 (13%)
constructs used by Anderson et  al. were used in this  NA 2 (6%)
study: ‘perceived ease of use’ and ‘perceived usefulness’ Diabetes was not managed by an endocrinologist or chose not to state
from TAM, personal and social factors (self-reflection, management
motivation and recommendations) from HITAM and NA not applicable

aesthetics (font size, text and dialogue boxes) from

MARS. Any constructs that were duplicated across the
three frameworks were included once only by Ander- improvement of future versions of diabetes apps. Peo-
son et  al. [5]. Additional questions were added to ple who do not use diabetes apps may have preferences
explore factors related to mobile phone acceptance and or perspectives about diabetes apps that diabetes app
health app usage [5]. Upon review of the Scheibe et al. users may not think of. Additionally, people who are
[28] study from which the supplementary questions currently not using diabetes apps may well be using
had been derived, an additional question was added other apps for other purposes so could translate their
to the non-app user guide: “What features would you experiences to diabetes specific apps. Subsequently,
want in the app to make it useful for you?” [5]. Asking a pilot test was undertaken by the researchers. This
this question allowed the guide to gain more compre- revealed that, whilst all questions were necessary, the
hensive insight into the features of a useful diabetes app flow was poor in an interview setting. Minor adjust-
[28]. It is important to get multiple perspectives from ments were made to the order of questions to facilitate
different types of people including non-users to allow a more conversational tone.
Jeffrey et al. Diabetol Metab Syndr (2019) 11:84 Page 4 of 17

Data collection (one app and one non-app user) were undertaken. Coding
Participants were sent an information sheet prior to pro- these final two interviews confirmed saturation (Research-
viding verbal consent. Interviews were audio-recorded ers: AC, TL and SN).
and a reflective journal was written immediately following
each interview using a previously published format [29]. Results
The reflective journal helped to capture practical details of Thirty participants were recruited: 20 from Facebook
the interview and to assist with recollection subsequently (including rural ‘buy/swap/sell’ and ‘community notice-
of initial impressions, key issues and ideas of interview- board’ groups and the Diabetes Australia Facebook page),
ers which were used in discussion with the rest of the eight from snowballing techniques and two from diabetes
interview team as part of developing a growing under- support groups. Interviews lasted between 25 and 45 min
standing of the data across the team. The demographics and were conducted between September 2017 and Febru-
of the participants, including age, gender, education level, ary 2018 with 17 current or prior app users and 13 peo-
occupation, location, distance from general practitioner ple who had never used an app (Table 1). There were 14
(GP) and endocrinologist, and diabetes management female participants (47%) and 16 male participants (53%).
were collected. Information on features included in apps Ages ranged between 30 and 79  years, with the most
used by participants was also recorded including: exer- common age bracket being 60–69 (40%). Eighteen were
cise tracking, timely medication administration, BGL, from inner regional areas (RA2), 7 from outer regional
diet monitoring and suggestions, self-management educa- areas (RA3) and 5 from remote areas (RA4).
tion, weight management, blood pressure monitoring and None of the apps used by participants included all self-
patient monitoring by clinicians (Appendix: Table 4) [4]. management tasks listed by El-Gayer et  al. [6]: frequent
BSL monitoring, suitable diet, physical exercise, timely
medications dosage, blood pressure monitoring, weight
Data analysis management and self-management education (Appendix:
Interviews were transcribed verbatim by the person who Table  4). The most comprehensive apps were Diabetes
had conducted the interview (BJ, MB, AC, TL, SN and CW) Journal and Accu-Chek. The most supported self-man-
and accuracy checked against the audio recordings by a dif- agement tasks were diet and exercise monitoring.
ferent researcher (AC, TL and SN). In this way, all research- Table 2 shows the summary of key findings of barriers
ers became familiar with all interviews. All interviews were and facilitators of app usage and useful features of app
coded using NVivO 11.0 [30]. Data were analysed using use. Factors influencing app use are summarised in Fig. 1
deductive content analysis following Elo and Kyngas [31], and are based on a modified version from the Health
with initial broad categories based on each of the constructs Belief Model and HITAM.
in the MARS, TAM and HITAM. An initial structured
analysis matrix was developed from these frameworks. This
1. Barriers to using an app
initial matrix was then trialled and refined against three
App-specific barriers were defined as issues app users
different transcripts from the actual respondents (two app
had when using apps, discouraging them from further
and one non-app user) and in response to a review of the
use. User-specific barriers were defined as factors inher-
notes from the reflective journal. Subsequently, a number
ent to the user, encountered both in app and non-app
of more nuanced sub-categories were added into the matrix
users.
(Researchers: BJ, MB, AC, TL, SN and CW). The matrix
was again trialled and refined on a further four transcripts
from the actual respondents (two app and two non-app 1.1 App‑specific
users) (Researchers: AC, TL and SN)., allowing for continu- Technological issues were the most common problem of
ous discussion and reflection until a matrix was finalised. the app, and included technology failing, not being user-
Two authors then independently coded one transcript and friendly or difficult to navigate. Issues with technology
coding was concordance-tested in NVivO, showing good failure included connectivity, such as Bluetooth connec-
agreement (Researchers AC and TL). A final codebook was tion, and the app crashing. Some participants faced this
agreed and the remaining interviews were coded by pairs as an ongoing issue.
between researchers AC, TL and SN. During the analysis, “…it has failed four times [the app]. It has been
data categorised within constructs were scrutinised to iden- working, and now suddenly I lose the link. So I’ve
tify commonalities and differences in views and experiences had to re-establish that link with my smartphone,
across the range of participants. To ensure data saturation, even though the smartphone is sitting right next to
data was collected until no new information was elicited, it… I’ve finally given up.” (Participant 4, 65  year
at which point (after 28 interviews) two further interviews old male, app user)
Jeffrey et al. Diabetol Metab Syndr (2019) 11:84 Page 5 of 17

Table 2  Key findings of barriers and facilitators of app usage and useful features of app use
Barriers to using apps

App-specific
 Technological issues: app failing to work as intended (e.g. connectivity ongoing issue), not being user friendly, difficult to navigate
 Initial setup issues: units of measurement (American vs Australian), cost of app, font size
User-specific
 Perceptions of app use:
  Feeling they did not need an app
  Not knowing about available apps
  Not having thought of using an app for self management before
 Self-perception of diabetes
  “Not being bad enough”
  Current care being sufficient
 Self-perception of technological literacy
 Internet connectivity
Perceived facilitators and useful features of app use

Apps perceived to be useful and majority would recommend the app

App specific
 App user-friendly: easy navigation, clear designs, intuitive technology
 Convenience: ease of blood glucose monitoring, discretion of using phone, inbuilt exercise technology, time taken to perform tasks
 Features of apps: BGL connectivity with glucometer, calculating content of food
User-specific
 Personal and social factors
  Health literacy and technical literacy likely to influence positive attitudes towards app use
  Many open to the idea of using an app; however, some felt current management was sufficient
 Interaction with health-care professionals
  Recommendation by healthcare profession well received. Others stated they would use an app if their GP would recommend it
  Use of app not often disclosed to health professional
  Healthcare professional discussing app use encouraged self-reflection on diabetes management

Some participants had issues with units of measure- which they believed was one of health equity, relating
ment, which were American, and could not be adjusted back to user-specific issues of affordability.
to an Australian measurement standard.
“It’s a medical issue. They should be free really, to
“a lot of them were American made so therefore access full features and everything else… you know,
their blood glucose measurements are different to it can be life and death. If someone has a smart
ours… they also didn’t have an option to change phone they can have an app, but they can’t access it
the blood to our readings…it was just I found it like I said because they can’t afford to.” (Participant
was a headache.” (Participant 21, 45  year old 21, 45 year old female, app user)
female, app user)
One participant reported that small font size was a
Other participants found the app navigation cumber- significant barrier to app use and consequently favoured
some and unintuitive, with too many steps to perform other methods of self-management, such as printing
tasks and complicated layouts. information with larger font size, diabetes magazines and
journals.
“To me it just wasn’t user friendly… Hard to navi-
gate, that’s the only words I can give you. And tedi-
1.2 User‑specific
ous, it seemed to be tedious.” (Participant 14, 63 year
There were three main barriers amongst non-app users:
old female, app user)
feeling they didn’t need an app, not knowing about avail-
Multiple participants spontaneously discussed the cost able apps, not having previously considered the use of
of the app. For one participant this was a significant issue, apps for self-management. Firstly, many participants
Jeffrey et al. Diabetol Metab Syndr (2019) 11:84 Page 6 of 17

Fig. 1  Factors which contribute to the likelihood of app use modified from the Health Belief Model and HITAM [24, 32]

(almost exclusively non-app users) stated they did not Further user-specific barriers were also identified
need an app to manage their diabetes. Participants often across app users and non app users. Several participants
described their diabetes as ‘not bad enough’ to need an self-identified as having poor technological literacy.
app, or thought that their current management was suf- This had some overlap with participants who had nega-
ficient and wouldn’t be improved by an app. tive attitudes towards technology. Some attributed their
lack of technological literacy to their age. Participants
“Researcher: Would you ever consider using a mobile
expressed difficulty with newer technologies, including
phone app to help manage your diabetes?
not knowing how to download an app, and frequently a
lack of desire to learn these newer technologies.
Participant: probably not, no I’m, I think I’m keeping
it well under control…taking the bloods every day, “Researcher: Do you know why you wouldn’t use
and, following you know what the doctor says.” (Par- those bits [features of the app]?
ticipant 29, 58 year old male, non-app user)
Participant: Probably ignorance or my age probably
Secondly, many participants were not aware of apps or
has a factor in that…that’s an older person’s think-
their features and often struggled to answer questions spe-
ing, you know, I won’t fiddle because it might bite
cifically relating to app features without prompting. Thirdly,
me.” (Participant 19, 49 year old female, app user)
many participants stated they had simply never thought of
using an app to manage their diabetes, despite using other
“I wouldn’t know how to download an app to be
apps on their phones. Some non-app users considered man-
quite honest with you.” (Participant 2, 69  year old
agement the domain of their GPs and did not see the need
male, non-app user)
for app use unless specifically asked by their GP to do so.
Lastly, internet connection was an issue noted for some
“…my GP and all that, I’m extremely confident in
participants due to their rural location.
them, they haven’t mentioned it to me at this stage…
I would be quite happy to move to an app if my GP “I do have trouble setting up my phone to get apps
agrees to that.” (Participant 28, 70  year old male, because my internet service is not very strong here.
non-app user) To use my computer, I have to hotspot and some-
Jeffrey et al. Diabetol Metab Syndr (2019) 11:84 Page 7 of 17

times that’s just, there’s just no coverage… I think it’s Visual representations of trends, particularly graphs of
just the lack of service.” (Participant 23, 69 year old BGLs, were highly valued and were a significant reason
female, app user) for continuation of app use.
In addition to these user specific barriers amongst non “It produces an average for the beginning period
app users, lack of health care professional recommenda- which is customisable, so I can go back three months,
tions was a barrier identified by app users and non app 6  months, whatever, so you can immediately spot
users. Most participants had not received a recommenda- any trend, the exercise level and the carbohydrates
tion to use an app from a healthcare professional, nor had graph, they’re bar charts and very easy to follow…
they told their GP they were using an app. Reasons for You can see the pattern all together so I find it very,
this included thinking their GP would not have time or very useful.” (Participant 26, 74  year old male, app
an interest in addressing app use, or having an older GP user)
whom they assumed was unfamiliar with the technology.
“No, not at all… when I was using the app I had 2.2 User‑specific
an elderly gentlemen [GP] and so he wouldn’t have User-specific facilitators were often the counterparts to
been interested in that sort of thing.” (Participant 14, barriers experienced by some participants.
63 year old female, app user) Many app users self-identified as having good techno-
logical literacy, which meant they found it easier to use
Participants who had spoken to their GP had positive
apps. Some participants also had positive attitudes to
experiences, indicating that their GP found the app help-
technology, which meant they were more likely to con-
ful, and worked alongside the participant to use the app
sider and continue using apps. Only two participants had
for management. One participant said their GP has since
been recommended an app by a healthcare professional,
recommended their app to other patients.
neither of whom were GPs. Recommendations are sig-
“Oh, he sits there and looks at it and we look at each nificant as participants may not have otherwise known
other and we say yep, everything’s fine. But no… he about apps.
scans them and files them on my record so it must
be of some use to him… I’m telling him that I’m feel- 3. Experiences of using apps
ing OK and everything’s fine and I guess it reinforces 3.1 Tracking and monitoring
that. He can’t argue with a graph.” (Participant 26, A commonly used feature was recording BGL and uti-
74 year old male, app user) lising associated graphs showing trends. This was aided
in apps which had glucometer to app connections and
allowed direct transmission of data from the glucometer.
2. Facilitators to using an app Tracking BGL measurements was associated with daily
2.1 App‑specific use of the app, thus increasing engagement. Other apps
The majority of app users found their apps very user- had features that encouraged and tracked exercise or
friendly. They described simple and straightforward nutritional monitoring.
navigation, clear layouts and designs and intuitive tech-
“But um with this it’s actually averaging it all out.
nology. Many participants also identified convenience as
And I really like that side of things, it helps me keep
something they liked in their app. What this meant var-
at it.” (Participant 30, 60 year old male, app user)
ied from app to app and included: being able to measure
BGL easily and discreetly while away from home, being
able to carry your phone and thus the app with you, or 3.2 Education
having the app count steps automatically. As a first line educational resource, most participants used
Google. This was the most easily accessible source. Issues
“Sometimes it’s actually just easier to smartphone it
noted with this source were the difficulty of assessing the
than it is to find your book and write it down and
reliability of information and the lack of personalised
fiddle around like that, you just tap it in.” (Partici-
information. Most participants liked accessing informa-
pant 21, 45 year old female, app user)
tion from healthcare professionals, usually their GP. Par-
Most of the participants reported that their technol- ticipants perceived this information to be reliable and
ogy worked well without any significant issues. They also personalised. Other participants read articles, magazines
were happy with the time taken to perform tasks and or pamphlets as their most utilised form of education.
thought they worked quickly and efficiently. Another form of education participants liked was face-
to-face communication and/or peer education, including
Jeffrey et al. Diabetol Metab Syndr (2019) 11:84 Page 8 of 17

support groups, informal chatting with friends diagnosed them with certain aspects of their diabetes, but believed
with diabetes and phone-based services. This was gener- that improved management overall was ultimately their
ally perceived as reliable and personalised information. responsibility with help from the GP. Those who did
notice an improvement in management felt it could be
3.3 Personal and social factors attributed to a particular app feature. These included
In terms of self-management, participants struggled the being able to associate trends in BGL with foods they
most with regular BGL monitoring and meeting target had eaten, being able to calculate the carbohydrate con-
levels, weight management and diet, despite these factors tent of food, and having BGL measurements all stored
being available for tracking and monitoring. in one place.
Some participants also mentioned factors that were
specific to living rurally and indicative of health inequity. 4.3 Non‑app users
These included GP accessibility, a reduction of services in Many non-app users were responsive to the idea of
the area and poor phone and internet service. app use, saying they were open to trying it or would
“There used to be a Diabetic Association office here consider using one in the future, especially if recom-
in (RA 2)… But with the changes, where the phar- mended by a GP.
macist took that over, those offices were closed… “Researcher: Would you ever consider using a
they used to provide free sessions on a variety of mobile phone app to help manage your diabetes?
things like diet, or managing diabetes, or testing your
equipment, and I used to go to those quite regularly, Participant: Uh, yes, if it needs managing. I don’t
they were very useful. And you know, there was talk- know I feel fine.” (Participant 12, 68 year old male,
ing, swapping of ideas, here’s the latest trends, here’s non-app user)
the latest equipment. It was really, really useful. But
since, you know, that’s been a loss, a big loss, where I
think a lot of people, particularly in regional areas.” 5. Recommendations
(Participant 4, 65 year old male, app user) Table 3 summarises features participants would like in
an app and are broadly placed into five categories: edu-
cational features, monitoring and tracking of health
information features, nutritional features, medication
4. Perceptions of usefulness reminders, text messaging. Quotes are added to sup-
App users generally perceived their apps to be useful. port the findings.
Additionally, most people who were asked would recom-
mend their app to others. Only one participant would not
Discussion
recommend their app.
This study examined the attitudes of people with T2DM
regarding their experience, perceived useful features,
4.1 Did not meet participant needs
facilitators and barriers to the use of mobile phone
Three of seventeen app users said their app did not meet
applications for self-management as elicited by the the-
their needs. Of these participants, two thought the app
oretical frameworks of TAM, HITAM and MARS [23–
did not provide anything superior to what they could do
25]. Mobile phone applications can improve T2DM
themselves without an app, for example, writing their
self-management. Overall, the results demonstrate
BGL down physically.
the potential of apps to improve self-management and
One participant specifically wanted trends and aver-
perceptions of self-efficacy. Useful features reported
ages and found her app did not meet that need.
included visual representation of health trends (i.e.
“…what I wanted was like, a reading for the day, like BGL graphs), convenience including the discretion and
a total reading and, and how much insulin I’d had portability of mobile phones, and user-friendly func-
each day and then sort of to see over a month what tions and designs. The most notable barriers to app
my average reading was…” (Participant 23, 69  year use were a general lack of awareness of apps as poten-
old female, app user) tial healthcare tools (that is non-user participants
had never considered them before), inadequate inter-
net access in rural areas, perception of their current
4.2 Impact on management T2DM management and severity, costs and techno-
Ten app users talked about how the app had improved logical literacy. Significantly, very few participants were
their diabetes management. Of those who thought it recommended or encouraged to use an app by their
had not, many referred to their apps as tools to help
Jeffrey et al. Diabetol Metab Syndr (2019) 11:84 Page 9 of 17

Table 3  Recommendations
Features Items Quotes

Educational features Educational component as part of the app: preferred Researcher: “What diabetes issues do you think are important
topics were related to diabetes complications for people to have information on?
including: end organ damage (e.g. nephropathy, Participant: “Um, the diabolical effect that diabetes has on your
stroke, myocardial infarction) and hypoglycaemic body…Effect on …you know your organs. (Participant 10,
episodes 68 year old female, non-app user)
Nil interest in in-app educational features and prefer-
ence of information from other sources
Features that include moni- BGL monitoring with trends paired with dynamic tips “I’ve got a useless memory and I can’t remember. I wouldn’t be
toring and tracking health Additional self-management tasks: blood pressure able to remember < BGL > what the um… If I did happen to
information monitoring, weight monitoring and activity tracking check multiple times a day, I wouldn’t remember what they
Reminders for exercise and appointments were anyway. So I wouldn’t be able to give an average or trend
or anything like that. If I had to do it off memory. “(Participant
27, 37 year old male, app user)
Nutritional features Carbohydrate calculators, diabetes specific recipes or Researcher:”… and if you were to use an app, what features
meal suggestions would you want in the app to make it useful to you?” Par-
Diabetes friendly food suggestions, an app that says if ticipant:” um, the biggest issue is trying to um, decide with a
a food is/is not suitable for people with diabetes decent menu… yeah. So much stuff out there’s got sugar in
it and you’ve got to try to avoid it you know.” (Participant 11,
48 year old male, non-app-user).
Medication reminders Content with their own medication routine “I think a feature such as being alerted about your medication,
Medication features, such as an app that allows a I think could be highly useful. I mean I get messages about
medication list to be uploaded or reminds one these things I have to go to, so that was highly useful.” (Partici-
when it is time to collect a new script (such an app pant 4, 65 year old male, app user)
exists and is used by the participant who brought
this up)
Text messaging Weekly text messaging would be an appropriate time “You get sick of seeing it. But if it was weekly one or a fortnightly
frame one or something, then I’d be more likely to read it because I’m
not just going to flick it off and get rid of it, so.” (Participant 9,
44 year old male, app user)

healthcare professionals; however, participants who BGL readings, particularly as increased awareness of
interacted with their healthcare professional around BGL has previously been proposed as a mechanism by
an app found this useful. These results have important which apps improve HBA1C levels of users [33, 34].
implications for clinical practice and future application Notably, the incorporation of BGL tracking was linked
design. by participants to their daily app use in the present
study. This is significant as frequent self-monitoring is
known to improve glycaemic control [3, 4], although
Perceived usefulness and facilitators this effect may be limited in individuals with T2DM
In general, participants perceived their applications who are not insulin dependent [35]. Another major per-
to be useful, with a majority of participants conclud- ceived advantage, when compared to traditional forms
ing app use improved their diabetes management. This of monitoring health, included the discretion of using a
may be attributable to findings by El-Gayer et  al. [4] mobile phone as well as the constant ability to monitor
who reported app use was associated with improved and record due to portability. Consistent with the find-
attitudes toward diabetes self-management. A reported ings of Brzan et al. [9], participants also reported their
useful app feature was the visual representation of apps to be useful for self-management tasks, including
trends in the form of graphs and averages, with partici- monitoring nutrition and increasing physical activity.
pants describing these trends as a source of motivation. An important potential facilitator was the app being
This is consistent with findings from Anderson et  al. recommended by a healthcare professional. Whilst only
[5], which suggest motivation to sustain app usage is two participants in this study were recommended the
dependent on the inclusion of features with high quality app by their healthcare professional, these participants
aesthetics, functionality and user engagement. A recent found that using it in conjunction with their GP facili-
qualitative study suggests that data tracking and visual- tated improved self-reported app satisfaction and pro-
isation allows users to gain understanding of how BGLs gress. Data from a recent meta-analysis demonstrates
interact with other factors [17]. Significantly, this pro- that healthcare professional feedback augments the
vides an advantage over traditional forms of recording decrease in HbA1c associated with diabetes app use [6],
Jeffrey et al. Diabetol Metab Syndr (2019) 11:84 Page 10 of 17

reiterating the importance of health care professional intake which are interchangeable or that comply with
involvement. Another systematic review suggests that current guidelines utilised by health professionals in their
apps that include tools to remotely communicate with respective countries to simplify and propagate use. Mini-
health professionals or apps used in association with fre- mising these technical issues is essential as frustration
quent healthcare visits have improved benefits on HbA1c with app technology is recognised to lead to loss of moti-
[36]. Our study expands on this information and high- vation and dropout for people with T2DM [33, 41].
lights that people with T2DM would be willing to engage Three main user-specific barriers which prevented
in self-management tasks facilitated by an app if recom- participants using apps were identified: feeling they did
mended by or used in conjunction with their healthcare not need an app, a lack of knowledge of available apps
team. Despite this, many professionals remain cautious and not having previously considered an app for self-
and a previous study identified that over one-third of management. Those who felt they did not require an app
health professionals would like guidance on app rec- also held the perception that their diabetes is “not bad
ommendations [37]. Diabetes applications that enable enough” or that their current care is sufficient. Similar
data exporting provide a mechanism of incorporating results were described in the MILES-2 study in which
the health professional in the person with diabetes self- the main identified barrier to app use was the percep-
management [9]. Developing evidence-based apps, which tion apps would not help diabetes management [12].
clearly adhere to up-to-date guidelines, is a priority to Desveaux [33] further demonstrates that an individual’s
engage clinicians in recommending diabetes health apps beliefs about apps not only impacts on engagement, but
in a currently unregulated market [38, 39]. also clinical outcomes (including HBA1C). This is con-
sistent with the Health Belief Model (Fig.  1), on which
Barriers HITAM is based, whereby a decreased belief in personal
Barriers to engaging with diabetes apps encountered by threat, together with decreased belief in the effectiveness
participants were related to either technical issues or user of a proposed behaviour, predicts the likelihood of engag-
perception of app use. Technical issues related to poor ing with that behaviour [32]. There is likely, however, an
app design: the app failing to work as intended, not being incongruence with perceived and actual “seriousness” of
user friendly and difficult to navigate. Perceived ease of diabetes as the literature suggests rural populations are
use of health technology, a concept explored in the TAM particularly vulnerable to poor outcomes of T2DM [1, 2].
and HITAM (Fig.  1), alters self-efficacy and, therefore, Lack of knowledge around applications was apparent
these technical barriers can serve to decrease intention to in the majority of interviews with non-app users. All the
use the app [23, 24]. Brzan et al. [9] propose face-to-face non-app users in our study had never been introduced
training in app use to overcome this barrier. Compound- to the concept of apps by their health professionals and
ing the technical issues, was perceived technological illit- many also commented on the trust and value they placed
eracy, a concern more prevalent in older respondents. on their professionals’ opinions. Previous studies have
Older people have reported increased difficulty navigat- also emphasised that lack of patient–provider interac-
ing and engaging with diabetes apps [28] and in compar- tions as a barrier to engaging with diabetes apps [33, 41,
ison to younger age groups have been shown to be less 42]. This reiterates that healthcare professionals should
likely to benefit from diabetes app use [6]; however, as have a role in introducing reliable and effective apps. As
younger individuals are familiarised with the use of tech- previously mentioned, this would require an enhanced
nology and apps for health purposes, their incorporation awareness of the benefits and formulation of guide-
into management of T2DM is rendered more valuable in lines for the recommendation of reputable and verified
the future, particularly in Australia’s ageing population applications.
[12, 13, 36]. Furthermore, the age of diagnosis of T2DM
is decreasing, which again increases the technology liter- Recommendations
ate audience for health apps [40]. Key recommendations from the present study for future
A technical barrier explored, which was specific to rural app development centred on improving the education
populations, was data connectivity. Participants noted provided by apps and increasing customisation fea-
inability to use some app features when out of range of tures. Participants described a self-perceived difficulty
data signals. Developing “off-line” features, in future in accessing reliable and personalised diabetes informa-
applications, could further engage rural populations. Fur- tion, with most utilising multiple information modali-
thermore, app users also noted issues with glucose units ties. The majority of apps used by participants did not
being presented in mg/dL compared to mmol/L, which provide any educational information and those that did
is the predominant unit used in Australia. Therefore, app provided generic information (Appendix: Table  4). This
design should include units for glucose and nutritional is reflective of the overall market of available diabetes
Jeffrey et al. Diabetol Metab Syndr (2019) 11:84 Page 11 of 17

self-management applications, which currently fail to in response to blood glucose trends, which is consistent
integrate educational information [4]. This is particularly with the preferences of the participants in our study [36].
surprising as both clinical guidelines and the literature
emphasise the role of education in improving motivation Strengths and limitations
for self-management and behaviour change [4, 43]. Inter- The recruitment process for this study was largely imple-
estingly, most participants were enthusiastic about the mented through social media. This may have resulted in
inclusion of information in diabetes apps, with preferred an oversaturation of self-selecting, technology literate
topics revolving around complications, such as end individuals; however, we were able to identify 14 non-app
organ damage and hypoglycaemic episodes. This corre- users in the study. We only included rural participants
lates with the literature which states that education may who may have different needs than their urban counter-
increase competence and reduce fear surrounding these parts in terms of internet access and transport, although
situations [36]. Furthermore, the areas of management the remainder of our findings would apply to both urban
which participants identified as struggling with most, and rural populations. The majority of participants,
glycaemic control, nutrition and weight management, however, were less than 60  min from their GP. Voices
can be addressed with education provided in apps; how- of people living further away from services are there-
ever, the effectiveness of remote education alone without fore missing from our study. These may be an important
a face-to-face component is not yet robustly determined group in terms of our research questions driving this
in the literature [44]. Respondents suggested that fea- study because accessibility of healthcare may change par-
tures such as carbohydrate calculators, diabetes specific ticipant engagement with apps. We also did not keep a
recipes or meal suggestions could be incorporated into log of how long participants used the apps, which may
apps to improve their self-reported management defi- have provided additional insight into sustainability of app
cits. Respondents also suggested incorporating dynamic usage. A further limitation was the use of deductive con-
advice in response to their changes in BGL. tent analysis. As this is a relatively new area of research,
Most participants responded positively to the suggestion an inductive analysis approach may have allowed more
of tailored educational text messages. Text messages rep- novel findings to be included in the data analysis.
resent a relatively novel approach to address management There are a variety of items we did not explore but
non-adherence and health beliefs [45] and have been dem- could be considered for future research such as: what
onstrated to improve self-reported adherence to treatment motivates participants to install diabetes apps, how do
regimes [10, 33]. Participants indicated that weekly would people chose to install any of the apps, patients’ aware-
be an appropriate time interval to receive such messages. ness about apps that breach data privacy policies and
Future studies could elucidate ways to individualise mes- erroneous insulin dose calculator apps.
sages using information stored by diabetes apps. A strength of the study was the use of validated theo-
Several suggestions for features that monitor and track retical constructs to conceptualise the study. The pre-
health information were also made, such as incorporating sent study is to our knowledge the 1st study that uses the
additional monitoring features including blood pressure, interview guide developed by Anderson et  al. [5], based
weight and activity tracking. A cross-sectional survey of on the three frameworks, in relation to T2DM. Another
current use of diabetes apps in Australia found that peo- strength was that the person with diabetes perspective of
ple with T2DM were likely to use multiple functions in self-management using mobile phone applications was
apps to support self-management behaviours, with the sought, a previously identified limitation [5]. Further-
most used features being blood sugar monitoring and more, this study is the first qualitative study to report the
activity and weight tracking [12]. Importantly, El-Gayer attitudes and experiences of individuals living in rural
and Brzan suggest that these features have the capacity Australia regarding app use in T2DM, where issues of
to improve people’s self-management of diabetes [4, 9]. healthcare access may increase the importance of self-
Furthermore, Anderson et  al. [5], in alignment with the management strategies. Further research could explore
MARS theme of engagement, found apps that can sus- the opinions of healthcare professionals to elicit more in-
tain positive behaviours were more likely to be used on depth understanding of app use to improve T2DM self-
a continual basis. The inclusion of additional features is management [29, 46].
also important as participants noted their T2DM to be
accompanied by comorbidities, which they also consid- Conclusions
ered health priorities. A recent systematic review and Features perceived as useful or facilitated use included
meta-analysis have shown that for applications to have the visual representation of trends, encouragement of
a significant effect on HbA1c readings, more than 2 fea- self-motivation, convenience and user-friendly designs.
tures must be available, particularly including feedback Important barriers included a lack of awareness and
Jeffrey et al. Diabetol Metab Syndr (2019) 11:84 Page 12 of 17

prior consideration of apps in healthcare, inadequate and transcribing, writing abstract, co-writing of introduction, discussion and
conclusions, editing of manuscript, referencing and preparation of manuscript for
internet access in rural areas, and technological and submission. AC: study design, ethics, recruitment, data collection—interviewing/
health literacy. A notable conclusion is the importance of transcribing/audio check, data analysis including forming code book and coding
healthcare professionals being aware of apps as a self-man- interviews, co-writing methods, co-writing results, co-writing abstract methods,
editing methods and results, references. TL: study design, literature search, co-
agement option and being involved in their use to facilitate wrote initial introduction, refinement of interview guide, explanation of interview
improved patient outcomes and education. The findings schedule and theoretical frameworks, recruitment, data collection including
may guide app developers in improving app design and interviewing, transcribing and audio check, data analysis including forming code
book and coding interviews, co-writing methods, co-writing results, editing meth-
usability. Given self-management is a significant factor in ods and results, references. SN: study design, ethics amendments, recruitment,
glycaemic control, these findings are significant for GPs, data collection including interviewing, transcribing and audio-checking, data
nurse practitioners and allied health professionals who analysis including forming code book and coding interviews, co-writing methods,
co-writing results and editing results. CW: study design, literature search, recruit-
may integrate apps into a holistic management plan which ment (20 participants) and organised interview times, 7 interviews, transcribing,
considers strategies outside the clinical environment. co-writing of initial introduction and assisted with revision of introduction, small
Further research is needed to examine the perspective of part of methods, co-writing of discussion and conclusion, editing manuscript,
acknowledgements/community engagement sections. JL: co-supervisor of
health professionals in recommending app usage. research project, assisted with qualitative data analysis, editing of manuscript. JB:
co-supervisor of research project, editing of manuscript. SP: primary supervisor
of research project, team coordination, editing of manuscript and overseeing all
Abbreviations components of the project. All authors read and approved the final manuscript.
T2DM: Type Two Diabetes Mellitus; Apps: mobile phone applications; BGL:
blood glucose level(s); GP: general practitioner; MARS: Mobile Application Funding
Rating Scale; TAM: Technology Acceptance Model; HITAM: Health Information Western Sydney University funded small costs such as printing.
Technology Acceptance Model.
Availability of data and materials
Acknowledgements All data generated or analysed during this study are included in this published
We would like to thank our research supervisors, Dr. Sabrina Pit, Dr. Jo long- article and in Appendix.
man and Dr. Jane Barker, for their guidance and encouragement with our
study. Thank you to Dr. Jo Longman for her time, effort and enthusiasm in Ethics approval and consent to participate
facilitating the use of NViVO to aid the qualitative analysis process. This study was approved by the Human Research Ethical Committee of West-
We would like to acknowledge and thank the people who participated ern Sydney University. HREC: H11327 “Exploring health, illness and disability in
in phone interviews for their generous contribution to our research as well the community”.
as the various community groups on Facebook for allowing us to invite their
members to participate. We thank Diabetes Australia for their assistance with Consent for publication
recruitment via social media. Additionally, we would like to acknowledge the Not applicable.
various general practices and allied health clinics that displayed our recruit-
ment poster: The Southern Cross University Health Clinic Lismore, Riverside Competing interests
Family Medical Practice Casino, Focus Medical Centre Port Macquarie, North- The authors declare that they have no competing interests.
coast Podiatry Ballina and Dr Richard Friehaut’s consulting suites in Lismore.
We are also thankful for the assistance of the Albury-Wodonga Diabetes Sup- Author details
port group in distributing our recruitment flyer to its members. 1
 Western Sydney University, Sydney, Australia. 2 University of Sydney, Univer-
We are also grateful for the interest and attention of several media organi- sity Centre for Rural Health, Sydney, Australia. 3 Western Sydney University, Uni-
sations: Camden-Narellan Advertiser, ABC Southern Queensland and ABC versity Centre for Rural Health, 61 Uralba Street, Lismore, NSW 2480, Australia.
Kimberley Western Australia. 4
 School of Medicine, University of Sydney, Sydney, Australia.

Authors’ contributions
BJ: Team coordination, study design including revisions, literature search, pilot
study, recruitment, media contact, data collection including interviewing and
transcribing, co-writing of article, editing manuscript. MB: study design and
Appendix
revisions, literature search, recruitment, data collection including interviewing See Tables 4, 5 and 6.

Table 4  Applications used by participants and self-management tasks supported by each app [4]
Application Blood glucose Exercise Diet Medication Blood pressure Weight Self-management education

Dario Y Y Y Y N Y Y
Fitbit N Y Y N N Y N
Accu-Chek Y Y Y Y Y Y N
My Fitness Pal N Y Y N N Y Y
CronoMeter Y Y Y N Y Y N
Map My Walk N Y Y N N N N
BG Star Y N N Y N N N
MedAdvisor N N N Y N N Y
Diabetes Journal Y Y Y Y Y Y N
Glucose Buddy Y Y Y Y N N N
Table 5  Interview guide app users. Frameworks adapted from tool used by Anderson et al. [5]
Question Elaboration questions Theory, study, construct

Your gender? Acceptance factors of mobile apps—sociodemographics

What age bracket do you fit into? 18–25; 26–35, 36–45, 46–55, > 55
What is your occupation?
What is your highest level of education? Year 10, Year 12, TAFE, University
Where do you currently live? Is it classified as regional, remote or very remote?
Jeffrey et al. Diabetol Metab Syndr

How far away are you from your GP and endocrinologist? How long does it take you to get there?
How frequently are you supposed to attend appointments?
How difficult is it for you to attend all of your required Do you ever miss any because it is too hard?
appointments?
How is your diabetes currently managed? Lifestyle interventions, medication or insulin Acceptance factors of mobile apps—current state of health
(2019) 11:84

Do you currently use an app or did you use one in the

past?
(if they previously used an app) Were there any particular things that lead you to stop using the app? Acceptance factors of mobile apps—reasons against using smart-
Why did you stop using the app? phones, tablets, and apps
Please tell me about how you use your health app How did you set it up? What problems do you recall in setting it up? Usability risk level evaluation
(Prompts: user interface, prompts, permissions, language used)
For approximately how long have you used (did you use) How often do/did you use it? (If discontinued) Why did you stop using Usability risk level evaluation
this app? the app?
On which platform do/did you use this app? Iphone, Ipad, android phone, android tablet Usability risk level evaluation; design evaluation-leverage technol-
ogy familiar to clients
What do/did you like about this app? Does/did the app fulfil your needs? Why or why not? TAM—usefulness
Do/did you enjoy sessions with your health app? Mobile App Rating Scale
How is/was working with your app satisfying?
Is/was your health app worth recommending to others?
How easy is/was using your app? What makes/made the app information clear and understandable? TAM—ease of use
How do/did you find the font size and representation? Acceptance factors of mobile apps—perceived ease of use
How do/did you add remarks to your readings?
Have you sometimes not known (did you sometimes not Are/were there any parts of the app you don’t use, because they’re Acceptance factors of mobile apps—technological literacy
know) what to do next with your app? complicated? What app features do/did you find unreasonable?
Do/did you sometimes wonder if you’re using the app the right way?
Who do/would/did you turn to for help using the app (prompts: fam-
ily, friends, or online forum)?
Have you found any ‘bugs’ in your health app, or things it If the app crashes or freezes (crashed or froze), is/was it easy to restart? Acceptance factors of mobile apps—limitations of the app
can’t do? Have you ever given up due to technical glitches?
Have you ever contacted the company about any technical glitches?
How much sight, sound and tactile stimulation do/did you (Prompts: graphs, things that flash up, reminders about personal Mobile App Rating Scale—engagement
get from your health app? targets, warnings, sound effects/reminders, vibration alerts)
What customization features would you like to see in your Mobile App Rating Scale—engagement, aesthetics
health app?
What is your view of information stored on the cloud? Do you have concerns about privacy? Acceptance factors of mobile apps—perceived data security
Page 13 of 17
Table 5  (continued)
Question Elaboration questions Theory, study, construct

Does/did your doctor (or other main health care provider) (If yes) How would you describe his/her reaction? TAM—social influence/subject norms
Jeffrey et al. Diabetol Metab Syndr

know you have used this app? Are you encouraged by a health professional (pharmacist, general
practitioner) to self-reflect on your chronic condition?
What medical or technical jargon have you seen in your Design and evaluation guidelines—leverage technology familiar
app which you don’t understand? to clients
Does your app use technology you are already familiar Are the dialogue boxes and input fields similar to what you are used Design and evaluation guidelines—leverage technology familiar
(2019) 11:84

with? to? to clients

What features of your app do you think conflict with each For example: inconsistent short cuts, conflicting educational informa- Usability risk level evaluation
other? tion
Are you satisfied with the time taken to perform tasks on (Prompts: time to display graphs, time to synchronize information, Usability risk level evaluation
your app? Are you able to upload data from your blood glucose measuring
device?)
Do you think that using the app has allowed you to better Prompts: Improved sugar levels, improved medication compliance, Mobile App Rating Scale—subjective quality
manage your diabetes? encouraged more physical activity, healthy eating, etc.
What (if any) educational features does your current app Prompt: Do you find it easy to access reliable diabetes information? Acceptance factors of mobile apps—features and design of a use-
provide? Where do you go for this information? ful app; Mobile App Rating Scale—information quality
What type of information would you be seeking from a Prompt – your medication, recipes, nutrition information, general info Usability risk level evaluation—interest in new technologies for
mobile phone application? about diabetes, stress and psychological health diabetes treatment and current usage
What diabetes issues do you think are important to have information
on? (can prompt- diet, foot care, hypoglycaemia, hyperglycaemia)
What part of your diabetes do you struggle with managing Do you find it hard to find personalized, relevant information? Mobile App Rating Scale—information targeted
the most?
How do you currently access information if you want to What are the issues you find with current diabetes education plat- Usability risk level evaluation—interest in new technologies for
educate yourself? forms? diabetes treatment and current usage; design evaluation—lev-
erage technology familiar to clients
What form of information would you find most useful? Prompts: videos, reading articles, talking to others Mobile App Rating Scale—information targeted; design evalua-
What are the perceived benefits and barriers to using these different tion—leverage technology familiar to clients
forms
Do you think receiving daily text messages or emails with If not, how often would you like to receive information? Acceptance factors of mobile apps—features and design of a
reliable diabetes information would be useful for you? useful app; design evaluation—leverage technology familiar to
clients
Page 14 of 17
Table 6  Interview guide non-app users. Frameworks adapted from tool used by Anderson et al. [5]
Question Elaboration questions Theory, study, construct

Your gender? Acceptance factors of mobile apps—sociodemographics

What age bracket do you fit into? 18–25; 26–35, 36–45, 46–55, > 55
What is your occupation?
What is your highest level of education? Year 10, Year 12, TAFE, University
Where do you currently live? Is it classified as regional, remote or very remote?
How far away are you from your GP and endocrinologist? How long does it take you to get there?
Jeffrey et al. Diabetol Metab Syndr

How frequently are you supposed to attend appoint-

ments?
How difficult is it for you to attend all of your required Do you ever miss any because it is too hard?
appointments?
How is your diabetes currently managed? Lifestyle interventions, medication or insulin Acceptance factors of mobile apps—current state of health
(2019) 11:84

Do you currently or have you ever used a mobile phone If yes than refer to other interview guide for app users.
app to help manage your diabetes?
What are your main reasons for not using a diabetes app? Do you have concerns about using a mobile phone app for Acceptance factors of mobile apps—reasons against using smart-
health purposes? phones, tablets, and apps
Would you ever consider using a mobile phone app to Usability risk level evaluation
help manage your diabetes?
If you were to use an app, what features would you want in May prompt: Education, reminders to check blood sugars, TAM—usefulness
the app to make it useful to you? recipes/diet info, exercise
How does your current practitioner encourage you to Has your practitioner ever mentioned/recommended a health TAM—social influence/subject norms
monitor your own health? app to you?
Do you regularly record blood sugar levels? What methods do you use to keep track of your sugar levels? Acceptance factors of mobile apps—features and design of a useful app
What techniques, if any, do you use to ensure you always Do you ever forget? Acceptance factors of mobile apps—features and design of a useful app
remember to take your medications? Would an app that reminded you to take your medication be
helpful?
Do you have any alternative methods to motivate yourself If so, please describe them. Acceptance factors of mobile apps—features and design of a useful app
to eat healthy and exercise regularly?
What type of information would you be seeking from a Prompt—your medication, recipes, nutrition information, gen- Mobile App Rating Scale—information targeted
mobile phone application? eral info about diabetes, stress and psychological health
What diabetes issues do you think are important to have
information on? (can prompt- diet, foot care, hypoglycaemia,
hyperglycaemia)
What part of your diabetes do you struggle with managing Do you find it hard to find personalized, relevant information? Mobile App Rating Scale—information targeted
the most?
How do you currently access information if you want to What are the issues you find with current diabetes education Usability risk level evaluation—interest in new technologies for diabetes
educate yourself? platforms? treatment and current usage; design evaluation—leverage technology
familiar to clients
What form of information would you find most useful? Prompts: videos, reading articles, talking to others Acceptance factors of mobile apps—features and design of a useful app;
What are the perceived benefits and barriers to using these design evaluation—leverage technology familiar to clients
different forms
Do you think receiving daily text messages or emails with If not, how often would you like to receive information? Acceptance factors of mobile apps—features and design of a useful app;
reliable diabetes information would be useful for you? design evaluation—leverage technology familiar to clients
Page 15 of 17
Jeffrey et al. Diabetol Metab Syndr (2019) 11:84 Page 16 of 17

Received: 3 June 2019 Accepted: 9 October 2019 hospital diabetes clinic and diabetes health professionals in New Zealand.
JMIR Mhealth Uhealth. 2017;5:e85.
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