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Article Title: Participant experience in a smartphone-based health

coaching intervention for type 2 diabetes: A qualitative inquiry

 Setting: Black Creek Community Health Centre (BCCHC) in Toronto,

Canada
 Participants: Individuals diagnosed with type 2 diabetes mellitus
(T2DM) who used smartphones and self-monitoring software as a
health coaching intervention
 Method: Individuals were invited by phone or in person to participate
in qualitative face to face interviews. Using in person, semi-structured
interviews following study completion, participants reflected on their
smartphone-based experiences in relation to the role of the health
coach in the enhanced intervention arm.
 Statistical Analysis approach: Thematic analytic approach that
thoroughly explored relevant themes surfacing during the interviews.
Thematic analysis provides a systematic identification of emergent
patterns, and logically organizes qualitative data into broader
common and representative themes
 Objective: Compare the effectiveness of six months of smartphone
use with health coaching vs health coaching of equal intensity
without smartphone support.

Results:
 Thematic analysis identified four major themes:
a. smartphone and software
b. health coach theme
c. overall experience (of program); and
d. frustrations managing chronic conditions
 Smartphone and Software
- Participants discussed exercise tracking, food tracking (via photo
journaling), health coach communication and
self-generated/coach-generated reminders. They emphasized
about the benefits of self-monitoring changes in blood glucose,
diet and exercise.
- Participants viewed meal photographing as conveying helpful
dietary feedback. Co-monitoring with the health coach was helpful
in modifying portions
- Participants identified self-awareness, feedback, and self-
management as important factors associated with self-activation.
They said that smartphone increased self-awareness of habitual
behaviors, especially dietary choices.
- Having pictures of their food before eating increased awareness of
portion size and carbohydrate intake. The participants’ application
also helped them connect blood sugar levels to food choice.
 - Participants identified the feedback as motivating. When
participants shared meal photographs, they received immediate
feedback from coaches on where improvements could be made.
- The smartphone supported self-management and monitoring, as
individuals monitored patterns of behaviors, giving them a chance
to ‘think twice’ about consumption.
 Health Coach
- All participants shared positive experiences about their
smartphone interactions with health coaches, emphasizing the
understanding and encouragement received in the behavior
change process.
- Various descriptions of the health coach included: strong,
meticulous, confident, responsible, respectful and hardworking,
especially in terms of monitoring and providing feedback.
Appreciation was expressed in multiple forms, with representative
descriptors being: best, nice, positive, generous, supportive,
helpful and dedicated.
- Individuals described health coach support as having someone
‘always by their side’. This helped reduce feelings of isolation and
being misunderstood. Trust was important in relationship
strengthening as individuals discussed their diabetes management
but also felt comfortable discussing personal struggles.
- Good listening skills were mentioned by participants who felt
‘being heard’ by the health coach built trust and therapeutic
alliance. Their logged behaviors on the smartphone provided the
ability for participants and health coaches to communicate by
phone and in person. This feedback was perceived valuable in
meeting personal goals. For example, a photo-journalled meal
allowed participants to pause, think, and communicate with the
coach. On the health coach side, there could be reference to
specific food pictures, specific blood glucose readings and specific
exercise sessions; a strong tie appeared to develop in relation to
program specific activities (diet, exercise, glucose monitoring,
medication).
- All participants agreed that the health coach assisted with diet,
glucose testing, medication, and exercise. Individuals also
discussed more specific ways in which their coach helped improve
their self-management. In terms of diet, individuals worked on
portion control, monitoring carbohydrate intake and ethnic specific
food choices. Participants described how health coaches addressed
various domains of diet, such as amounts/ types of food
consumed in routine and celebrative situations.
- On the issue of medication, few subjects spoke in detail,
explaining that medications were mostly discussed with their
health coach at the start and thereafter the main emphasis was on
healthy behaviors
 - All participants discussed blood glucose monitoring. Their
conversations included daily glucose readings and insights on
using food and exercise logs for interpretation.
- Exercise was also part of participant conversations with health
coaches, who encouraged participants by teaching techniques
tailored to individual preferences and needs.
 Overall Experience
- Overall experience highlights factors that influenced participants
after intervention completion. This theme reflects what
participants ‘took away’ from the program. They described
increased control and confidence in dealing with their condition
and a substantial gain of knowledge about diabetes management.
- When discussing the program, participants described it as helpful
and were motivated to participate in other programs where
financial costs and burdens were nonexistent.
 Frustration and managing chronic conditions
- Participants expressed frustrations in managing chronic conditions
with a particular focus on medication and blood glucose;
diet/weight; and comorbidities
- Both injection and oral medication were noted as a combined
adherence challenge and the self-administration of multiple
medications was deemed frustrating. There was a common
pattern of aversion to medications, as well as honest disclosures
of adherence lapses.
- Participants were further frustrated by having to check blood
sugar levels in relation to medications and were not often
confident their regulation was accurately reflected in readings
- Participants struggled with modifications in diet and with weight
loss goals, specifically mentioning cooking practices and diet
restrictions, and their impact on family members.
- Individuals suffered comorbidities (e.g. chronic pain, mental health
difficulties, hypertension) further hindering diabetes management

Conclusion:
 The health coaches were highly regarded by subjects who used
positive adjectives (nice, positive, generous, supportive, helpful,
hardworking, persistent) in descriptions. We interpret these findings
as reflecting the positive therapeutic alliance that was established
with the assistance of smartphone support.
 Findings suggest that the smartphone-based behavior monitoring
software helped individuals track behavior and communicate with
their health coach, and, generally adopt an active role in improving
health.
 Overall intervention was most effective when software use was
optimally coordinated with personalized health coaching interactions.
Positive impact of the smartphone tracking appeared enhanced by
 health coaching, while, reciprocally, positive coach interactions were
enhanced by smartphone tracking
 Smartphone connectivity represents a new context for precise health
intervention as each client/coach contact leaves a digital record
describing what was done and not done. While digital data analyses
require participants to use smartphones with some frequency,
intensity of smartphone/software use, itself, provides information
related to benefit.
 Participants in this subsample had a clinically significant mean HbA1c
reduction (–1.38%, standard deviation (SD)¼2.08).
 However, positive views of smartphone functionality were expressed
by individuals who did not achieve significant benefits, either in terms
of glucose regulation or personal support, and negative views were
expressed by individuals who demonstrated considerable benefits (in
each area). These findings provide some confirmation that
participants were not biased by their overall glucose regulation.
 The study has more intensive protocol with smartphone and health
coach contacts summating to one hour of contact weekly per patient.
 Training and supervision were also more intense as health coaches
received continuous supervision throughout the trial, totaling 100 hrs.
per coach, delivered by a registered clinical psychologist

Article Title: Patient-Centred Outcomes of Tele-Diabetes

 Setting: Gold Coast Hospital and Robina Hospital, Australia
 Participants: Patients randomly extracted from the patient register of
most recently conducted diabetes outpatient and telemedicine clinics
 Method: A retrospective study that evaluated the efficacy and
potential for video-conferencing in the management of diabetes using
Cisco Jabber desktop video-conferencing software
 Statistical Analysis approach: Differences between the face-to-face
and telemedicine groups were analyzed using independent samples t-
tests for the following study variables: age, sex, number of years
since diabetes diagnosis, type of diabetes, insulin only treatment,
number of comorbidities, initial HbA1c measurement, and number of
months between HbA1c measurements
 Objective: To determine if there is a non-inferiority in diabetes
management (HbA1c measurements) using tele-diabetes video-
conferencing in comparison to face-to-face consultations in an
Australian cohort

Results:
 There was a marginally greater decrease in the HbA1c following
clinicians’ reviews for the telemedicine group compared to the face-
to-face group (-.725% vs -.711%). Although the figure does not
make a material difference, these results do suggest there is non-
 inferiority in the management of diabetes by telemedicine when
compared to face-to-face consultations.
 It has noteworthy implications for the application of tele-diabetes in
Australia if there is a cost-effective scheme in operation
simultaneously. Preliminary cost-effective research has suggested
feasibility and potential for telemedicine’s application in Australia,
with the main driver of net savings coming from avoidance of travel
costs for patients, their escorts and for specialists
 Telemedicine is more effective in patients over the age of 40.
 There was a significantly lower length of time between the initial and
most recent HbA1c measurements for the telemedicine group.
Subsequently, they were managed for less time (average 5.91
months) and had less consultations than their face-to-face
counterparts.
 Whilst patient satisfaction was not measured in this study, it has
been suggested that video-conferencing provides better patient
satisfaction and health outcomes over telephone conferences
 Nonetheless, telemedicine represents a viable option for providing
effective and cost-effective management of chronic diseases,
particularly in countries with larger rural and remote communities.

Conclusion
 Tele-diabetes represents a viable option in improving diabetes care in
patients dwelling in remote regions of Australia. To our knowledge,
this is the largest comparison of HbA1c measures between patients
seen via video-conferencing and patients seen at routine out-patient
clinics in Australia.

COMPARISON and CONTRAST:

 Both articles provide an alternative tele and techno management
schemes that focuses on assisting health care for diabetic patients
 The first article discusses about Smartphone-based self-monitoring
and health coaching that provides health care assistance to diabetic
patient through phones with a close monitoring of their health coach.
Meanwhile, the second article focuses on evaluating the efficacy and
potential for video-conferencing in the management of diabetes using
Cisco Jabber desktop video-conferencing software.
 The first article used in person, semi-structured interviews following
study completion and participants reflected on their smartphone-
based experiences in relation to the role of the health coach in the
intervention. On the other hand, the second article used independent
samples t-tests for the age, sex, number of years since diabetes
diagnosis, type of diabetes, insulin only treatment, number of
comorbidities, initial HbA1c measurement, and number of months
between HbA1c measurements as study variables both in face-to-
face and telemedicine groups
 Jaana and Pare (2007) said that telemedicine programs can impact
various aspects of patient care, including informational, clinical,
behavioral, structural, and economic. Economic impact of
telemedicine is much reflective in the second article especially since
video-conferencing consultation indicates less costs and expenses for
patients and clinicians. Preliminary cost-effective research has
suggested feasibility and potential for telemedicine’s application in
Australia, with the main driver of net savings coming from avoidance
of travel costs for patients, their escorts and for specialists.
 Meanwhile, the first article involves more on the behavioral and
informational aspect of patient care. It turns out, smartphone
connectivity represents a new context for precise health intervention
as each client/coach contact leaves a digital record that describe
what was done and what was not done. While digital data analyses
require participants to use smartphones with some frequency,
intensity of smartphone/software use, itself, provides information
related to benefit.
 Several researchers have also found that smartphone self-monitoring
paired with health coaching is associated with improved glucose
regulation, dietary control and medication adherence.
 Flodgren G, Rachas A, Farmer AJ, Inzitari M, Shepperd S (2015) said
that tele-diabetes has primarily used telephone consultations as their
means of telecommunication. The first article enhances this kind of
consultations from telephone to a now more technologically
advanced telecommunication and worldwide medium which is a
smartphone.
 Bailey CJ, Kodack M. (2011) stated that the abundance of mobile
medical apps targeting diabetes self-management is showing the vital
need for ameliorated methods to address poor rates of behavioral
adherence in diabetic patients. While the first article do not focus on
medical apps, it opens the possibility of integrating these functions
since smartphones could obtain these medical apps that will assist
patients especially in their adherence to medications. Participants in
the first article found it hard to adhere with their prescriptions while
trying to control intake as facilitated by their health coach. An
integration of medical apps in this aspect can be helpful
 Meanwhile, the second article appears to be a non-inferior alternative
of face-to-face consultations. In fact, Verhoeven et al (2007)
discovered that the benefits of videoconferencing can be particularly
demonstrated at the usability level (convenient and easy to use) and
care coordination level. Videoconferencing seemed to maintain
quality of care while producing cost savings in patient at-home care
settings. When it comes to cost-effective management,
videoconferencing appears to be practical especially in countries with
larger rural and remote communities
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