App use and patient empowerment in diabetes self-management : advancing theory-guided mHealth research

Patient empowerment is examined as a multi-dimensional factor influencing the use of diabetes self-management apps. The research design includes three studies conducted in Singapore. Study 1 examines how features of diabetes self-management apps correspond with theoretical indicators of empowerment, as well as app quality. Study 2 uses semi-structured face-to-face interviews with diabetes patients to draw first conclusions about the relevance of empowerment for diabetes app use. Study 3 includes an online patient survey, and uses cluster analytical methods to test the preliminary Study 2 results (typology of app use), as well as binary logistic regression to compare the strength of influence of various anteceding factors on the likelihood of diabetes app use. The studies show that especially the support by private social patient networks and the medical specialties of supervising physicians play a crucial role for technology-supported self-management. Contents Defining and Categorizing Diabetes Apps for Self-Management Anteceding Factors of Diabetes App Use Empowerment and its Relevance for Diabetes Management Target Groups Researchers, students and practitioners in the fields of Public Health, Medicine, Health Communication, Endocrinology, Diabetes Care, Epidemiology, Health Management The Author Dr. Nicola Brew-Sam holds an MA in health communication (UZH Zurich) and a Ph. D. from University of Erfurt (Germany) in cooperation with Nanyang Technological University (Singapore) Acknowledgements 5 Table of Contents 7 Table of Contents 8 List of Figures 13 List of Tables 14 List of Abbreviations 16 Abstract 17 1 Introduction 21 1.1 The Urgency of Self-Management in Diabetes Care 21 1.2 Research Interest: Empowerment as an Anteceding Factor of Diabetes App Use for Self-Management 22 1.3 Chapter Overview 25 2 Background on Diabetes Self-Management 27 2.1 What is Diabetes? – Types of Diabetes Mellitus 27 2.2 Diabetes Self-Management – Definition and Development 29 2.3 Factors Influencing Diabetes Self-Management 32 3 Defining and Categorizing Diabetes Apps for Self-Management 37 3.1 Diabetes Apps for Self-Management as Second Generation mHealth Tools 37 3.2 Purpose, Types and Features of Diabetes Apps for Self-Management 40 3.3 Shortcomings of Diabetes Apps and Diabetes App Quality 43 4 Diabetes App Use – Previous mHealth Research 49 4.1 Defining Diabetes App “Use” 49 4.2 Categorizing Studies on Diabetes App Use: The Inputs-Mechanisms-Outputs Pathway 50 4.2.1 Input: Feasibility and Accessibility Studies 52 4.2.2 Output: Diabetes App Usage Effect Studies 55 4.2.3 Mechanisms: Lacking Research on Antecedents of Health App Use 58 5 Anteceding Factors of Diabetes App Use 59 5.1 Defining “Antecedents” of mHealth Use 59 5.2 The Relevance of Studies Looking into Antecedents of mHealth Use 60 5.3 Previous Studies Looking into Antecedents of mHealth Use 61 5.4 Antecedents of the Unified Theory of Acceptance and Use of Technology 62 5.5 Shortcomings of the Unified Theory of Acceptance and Use 65 6 Summarizing mHealth Research Gaps I: Alternative Theory is Needed 70 7 Empowerment as an Antecedent of Diabetes App Use 72 7.1 The Empowerment Approach in Psychology and Management Research 72 7.1.1 Psychological Empowerment 75 7.1.2 Behavioral Empowerment 78 7.1.3 Empowerment as a Motivational Approach 85 7.1.4 Empowerment and Self-Determination 87 7.2 Empowerment and its Relevance for Diabetes Self-Management 89 7.3 Empowerment and Diabetes App Use 92 7.3.1 Research on Empowerment and Diabetes App Use: Outcome Perspectives 92 7.3.2 Understanding the Overall Process of Empowerment and Diabetes App Use 97 7.3.3 Empowerment as an Antecedent of Diabetes App Use 99 8 Summarizing mHealth Research Gaps II: Empowerment and Diabetes App Use 103 8.1 Empowerment as a Multi-Dimensional Antecedent of Diabetes App Use 103 8.2 Two Research Perspectives on Empowerment as an Antecedent of Diabetes App Use 104 9 Summarizing Model on Empowerment and Diabetes App Use 107 10 Research Questions and Hypotheses 110 11 Overview of the Research Design 114 11.1 mHealth Research on Diabetes App Use in Singapore 114 11.2 Research Procedure 115 12 Study 1 – Diabetes App Features Corresponding to Indicators of Empowerment: An App Feature and Quality Analysis 117 12.1 Method 118 12.1.1 Operationalization 118 12.1.2 App Collection Procedure 120 12.1.3 Pretesting and Coding Procedure 123 12.1.4 Data Analysis 126 12.2 Results 126 12.2.1 Features and Types of Diabetes Apps 126 12.2.2 App Features Corresponding to Psychological Empowerment Indicators 127 12.2.3 App Features Corresponding to Behavioral Empowerment Indicators 131 12.2.4 Diabetes App Quality Assessment 133 12.2.5 MySugr App Series Chosen for Study 2 136 12.3 Discussion 138 12.4 Study Limitations 142 12.5 Conclusion 144 13 Study 2 – Interviews on App Use for Diabetes Self-Management and the Relevance of Empowerment 146 13.1 Method 146 13.1.1 Operationalization 148 13.1.2 Sampling and Data Collection Procedure 151 13.1.3 Data Analysis – Thematic Analysis 152 13.1.4 Data Analysis – Diabetes App User Typology 155 13.2 Results 156 13.2.1 Sample Description 156 13.2.2 Diabetes App Use in the Sample 161 13.2.3 Potential Antecedents of Diabetes App Use Represented in the Interviews 165 13.2.4 Diabetes App (Non-) User Group Differences – Typology 179 13.3 Discussion 205 13.4 Study Limitations 208 13.5 Conclusion 210 14 Study 3 – An Online Survey on Empowerment as an Antecedent of Diabetes App Use 212 14.1 Method 212 14.1.1 Operationalization 214 14.1.2 Pretest and Sampling 216 14.1.3 Data Analysis 218 14.2 Results 221 14.2.1 Sample Description 221 14.2.2 Diabetes App Use 224 14.2.3 Types of Diabetes App (Non-) Users – Results from Hierarchical Cluster Analysis 226 14.2.4 Differences between Diabetes App Users and Non-Users – Hypotheses 238 14.2.5 Most Relevant Factors’ Strength of Influence on Diabetes App Use 241 14.3 Discussion 248 14.4 Study Limitations 254 14.5 Conclusion 256 15 Discussion and Deriving Research Gaps 257 15.1 Summary on Study Results from Studies 1 to 3 257 15.2 What does Empowerment Explain? 263 15.2.1 Empowerment and Diabetes App Use 263 15.2.2 Empowerment and Other Influencing Factors 265 15.3 The Value of Empowerment for mHealth Research 272 15.4 The Operationalization of Empowerment 274 16 Learning from Research Results – Implications for Research and Diabetes Care Practice 279 16.1 Implications for Other Health Domains 279 16.2 Advancing Methodology 280 16.3 Implications for Diabetes Care – The Practical Value of Diabetes Apps 281 16.4 Designing Diabetes Apps for Specific Target Groups 284 17 Summarizing Research Limitations 287 18 Conclusion 289 References 291