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The 3rd National Graduate Conference (NatGrad2015), Universiti Tenaga Nasional, Putrajaya Campus, 8-9 April 2015.
Barriers to the Effective Use of
Diabetes Self-Management Applications
Ananthidewi Maniam
College of Information Technology, Universiti Tenaga Nasional, Malaysia. E-mail: [email protected]
Jaspaljeet Singh Dhillon
College of Information Technology, Universiti Tenaga Nasional, Malaysia. E-mail: [email protected]
Abstract— Diabetes is a serious disease in which the levels of
glucose (sugar) in the blood are too high. In people with diabetes
the body is unable to properly use and store glucose. However, if
patients could manage their health conditions effectively, they
can prevent or delay diabetes complications. By introducing
diabetes self-management (DSM) applications, patients with
diabetes can gain the knowledge and skills needed to modify their
behavior and successfully manage the disease and its related
conditions. DSM applications can enable patients to take better
care of their health and consolidate effective self-care habits into
their daily lives. However, despite of the immense potential of
such tools in empowering patients, many challenges remain in the
design and use of DSM applications. In this study, we investigate
the barriers that hinder effective usage of DSM applications for
diabetes self-management. Results indicate that the primary
barriers resulted from the limited access to the applications, a
challenge to comprehend the technology and the inability to pick
the right application that is clinically proven. The barriers to selfmanagement identified in this study are amenable to novel DSM
applications that could improve health outcomes.
Keywords— diabetes self-management; diabetes; selfcare; consumer health informatics
I.
INTRODUCTION
Diabetes is often referred to by doctors as diabetes mellitus
that describes a group of metabolic diseases in which there are
high blood sugar levels continuing for a long time. Symptoms
of high blood sugar include frequent urination, increased
thirst, and increased hunger. According to the International
Diabetes Federation, 387 million people have diabetes
globally and almost 138 million people are affected in the
Western Pacific Region, which is projected to rise to 202
million by 2035 [1]. There were 3.2 million cases of diabetes
in Malaysia in 2014 [1]. Diabetes mellitus requires continuing
medical care and patient’s commitment to reduce the risk of
long-term disability and prevention problems.
Poor health outcomes among patients with diabetes are due
to poor self-management practices [32]. Diabetes selfmanagement (DSM) refers to personal actions towards
diabetes mellitus, its treatment and progress of disease
prevention. These actions include with medical management,
role management, and emotional management and selfmanagement. Self-management can be achieved by leveraging
DSM applications that are designed and developed to manage
diabetes mellitus. These applications are tools that specially
offer functionality and services to control diabetes.
Healthcare providers should perform evaluations to
determine patients’ knowledge and understanding of the
disease and assess their ability to learn and apply new selfcare skills since diabetes requires daily problem solving to
meet overall clinical outcomes [27]. Patient-centered care is an
approach to ‘providing care that is respectful of and
responsive to individual patient preferences, needs, and values
and ensuring that patient values guide all clinical decisions’
[19]. Paradigm shift in the healthcare industry is apparent
following from the emergence of advanced technologies made
accessible on different platforms such as smartphone-, weband desktop-based applications. The focus of improving health
outcomes is shifting gradually from doctors to patients which
shows that more patient-centric applications are being
designed and developed. Doctor-centric systems are important
as they allow doctors to provide better treatments as well as
follow up on patient health conditions, but patient selfmanagement can save cost, reduce burden on professional
time, and most importantly encourage patients to become
more involved in their own care and activated to better
manage their symptoms [26].
Patient-centric health management systems are gaining
rapid attention from healthcare consumers as enabler to
encourage the development of health self-management
initiatives that can enable patients to take responsibility
towards their own care. Patient-centric care goes beyond
educating patients about a diagnosis, potential treatment, or
prevention methods. The fast growth in mobile and computer
technology coupled with the advancement of data connectivity
has resulted in increased interest and unparalleled growth in
self-care applications for diabetes self-management. A variety
of DSM applications are available on different platforms such
as smartphones, web and desktop, which includes personalized
decision support to achieve personal goals and to improve
value of life.
Desktop, laptop or handheld computers and mobile phones
have the advanced processing power and connectivity to allow
the patients to achieve better diabetes self-management. These
devices also have the potential to be relatively cheap, easily
distributable, delivered at multiple locations (communitybased, at home or on the move) at times convenient for
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patients, offer patients as many interventions to enable them to
have knowledge on self-care and patients capable to produce
better clinical outcome by their own [29]. Web-based
applications are being developed for continuous selfmonitoring, feedback, and information exchange. These
applications have improved diabetes patient’s awareness and
knowledge towards self-management, the extent of behavior
change, and clinical outcomes for a range of conditions.
Smartphones have become a fundamental component of daily
life for many people globally. Most people own mobile
phones and have access to the internet. Advances in
smartphones technology, web-based technology and wireless
networks have resulted in increased adoption and enhanced
capability, leading to high chances for improved diabetes selfmanagement [2]. Moreover, desktop applications which can
work without internet connection provides program that can
support people with diabetes. These applications can be
installed on desktop computers and laptops. Patient’s data can
be entered either directly from the software which is installed
or by syncing/importing from a mobile device.
DSM applications can aid diabetes patients to track almost
all aspects of the diabetes treatment including their blood
glucose levels, insulin dosages, weight, carbohydrate intake,
and exercise. Apart from health monitoring, there are
applications that integrate social aspects and experiencesharing among people with diabetes [5]. In spite of their
immense potential of DSM applications in empowering patient
to take charge of their healthcare, many challenges remain in
the design and use of these applications. Although these
applications are known to be useful for self-management, there
are barriers which limit patients’ usage of these off-the-shelf
applications. In this study, we investigate the barriers that
hinder effective usage of DSM applications for diabetes selfmanagement. The emphasis is on DSM applications that are
accessible via the following platforms: smartphones, web and
desktop. These barriers were derived from previous studies.
These barriers are amenable to novel DSM applications that
could improve health outcomes.
This paper is organized as follows. The first section
summarises the related work that has been done about DSM
applications and the second section explains the barriers to the
effective use of such applications. The subsequent section
discusses the results and the paper is then concluded in the
final section with a summary and future work.
II.
RELATED WORK
Previous studies have been conducted to identify the
barriers and limitations to effective use of DSM applications. A
review was conducted to specify the usability of smartphone
applications and the limitations with the current state of the art
[7]. Finding of this review explains how to improve the
medical legitimacy of digital health solutions and they agreed
that despite the abounding number of options on the market,
significant barriers to entry remain for diabetes-related
smartphone applications [11]. Researchers in Germany
conducted a systematic review of diabetes applications for iOS
and Android. Most of the iOS applications required payment
while most of the android/cross-platform applications were free
and over half of the applications only had one function which
is Glucose Logbook [11]. A review attests to the value and
potential for diabetes applications to improve diabetes selfmanagement. However, it is important to note that smartphone
applications-based self-management is not a “silver bullet” and
it is critical to understand that its effect is based on strong
behavioral change theory [2]. While a wide selection of
smartphone applications seems to be available for people with
diabetes, this study shows there are huge gaps between the
evidence-based recommendations and the functionality used in
study interventions or found in online markets. Result of this
study confirms that personalized education as an
underrepresented feature in diabetes smartphone applications
and its potential remains largely unexplored [8]. Previous
research efforts provide less emphasis on barriers to effective
use of DSM applications and are mostly focused on the
implementation of novel DSM applications as an effective
means to reduce the progression of diabetes and improving
quality of life.
Previous study concentrated on applications that were
designed for frequent logging of data, but which also offered
the capability for data visualization, transmission and
personalization. This research results in terms of exposing
problems with efficiency and various other attributes
corresponding to smartphone heuristics, as well as helping to
elicit functional requirements, and this has resulted in a list of
guidelines for development [17].
III.
BARRIERS TO DIABETES SELF-MANAGEMENT
APPLICATIONS
The common barriers that obstruct patients’ to accept and
utilize DSM applications can be classified according to
different platforms: smartphones, web-, and desktop-based
applications. The classification helps to form a better
understanding about the requirements and expectations of
patients towards the adoption of DSM applications.
A. Web-based DSM Applications
The Internet is an expanding source of information and
resources. Today’s health care industry is highly dependent on
the internet that have changed the way we communicate with
the physician or doctors. Web-based interventions have the
potential to bridge gaps in diabetes self-care and selfmanagement. Web-based DSM applications allow patients to
upload data directly to the applications, receive feedback and
support at a time and place most convenient for them, and not
limited to clinicians' office hours. However, in spite of the
immense potential of these applications in enabling patients to
manage their conditions online, many challenges remain in the
design and use of web-based DSM applications. Examples of
web-based DSM applications are mysugarlevel.com,
Glooko.com, and GlucoseBuddy.com.
1) Poor user friendliness: Patients forgot to use the
application because of the absence of a reminder feature (lack
of push factors). The usability tests showed that patients
wished to get reminders to use the application, preferably
through their regular (daily) email program. Patients wished to
get notifications on newly posted and updated information on
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the site. Integrating the web application with existing
traditional “offline” care could also serve as a push factor.
Patients fail to gain motivation from their general physician to
use the DSM application [28].
2) Competing life concerns: Diabetes patients compete
with their own life concerns such as health issues surround
migraines and fatigue. They have no free time to use the
available applications and their lifestyle and other stresses
from business can be a major barrier for them to use webbased DSM applications [14].
3) Competing health concerns: Those people who have
diabetes not only poses diabetes but also compete with other
health concerns such as cancer, stroke and heart disease.
Their concerns are not only on diabetes self-management but
also on other diseases.
4) Frustration with diabetes: When diabetes patients
know that their blood sugar level is really high, they already
know it’s high and they refuse to take medication and even not
managing their health. So to log the fact that they are high,
ends up making them to be more frustrated. Their concern is
only the frustration but not to find methods to manage the
illness [14].
5) Limited access: Website use by patients was limited.
They competing priorities in their lives and website
accessibility were barriers to use. Most people do not have too
much time to look access the applications because they do not
have a computer at home [28].
6) Login and password requirement: Some people do
not prefer using the available DSM applications because most
of the applications require credentials such as login ID and
passwords. They keep forgetting their passwords and hence
they avoid using the web applications. [14].
7) Little adherence to health promotion theories:
Principles of effective education, self-management support,
and behavior change have not been incorporated into current
diabetes-related websites [15].
Table I shows the barriers to the effective use of web-based
DSM applications.
TABLE I.
SUMMARY OF BARRIERS TO THE EFFECTIVE USE OF
WEB-BASED DSM APPLICATIONS
Poor user friendliness

Absence of reminders
Competing life concerns

Work/business stress
Competing health
concerns
Frustration with
diabetes
Limited access

Other health concerns




High blood sugar
Frustrate with illness
Competing priorities
No computer at home
Login and password
requirement

Keep forget password
B. Smartphone-based DSM Applications
The smartphone interface supports a limited subset of
functionality that enables users to perform common tasks.
Advancements in smartphone technology coupled with the
proliferation of data connectivity have resulted in increased
interest and unprecedented growth in smartphone applications
for diabetes self-management. Smartphones are also equipped
with DSM applications which must be downloaded and
installed from an application market place such as Apple store,
Android market and blackberry that can enable patients to
better manage their health conditions. Examples of such
applications are Glucose Buddy, Diabetes Pilot, and iDiabetes.
A smartphone application is designed specifically for smaller
screens and touch-screens. These applications can aid diabetes
patients to monitor their blood sugar levels conveniently. Once
installed on the phone, users can use these applications without
accessing the Internet. Nevertheless, many challenges exist in
the design and use of smartphone-based DSM applications. As
new applications continue to emerge and become more refined,
smartphone users will have more options to conveniently track
their glycemic control and overall health, which can ultimately
improve their ability to effectively manage their diabetes.
1) Non-evidence-based applications: Although the
number of DSM applications has increase rapidly, patients do
not know whether the applications are evidence-based or were
developed by reliable health or medical organizations. Almost
anyone can write and post a smartphone app. Most
applications are not clinically relevant and do not follow any
guidelines [11].
2) Security and confidentiality:
Another concern,
especially with personally owned smartphones, is security.
Smartphones are embraced for their convenience. Malicious
software ("malware") for cell phones could pose a greater risk
for consumers' personal and financial well-being than
computer viruses. However, smartphone used to access
diabetes applications raised several security- and privacyrelated issues, such as vulnerability to loss personal
information’s due to small size, authentication, encryption of
data, and use of unsecure public Wi-Fi [12].
3) Connectivity: The slow and unreliable wireless
network connection with low bandwidth is a common
hindrance for smartphone-based applications [34]. Strength of
signals and data transfer speed in a wireless network may vary
at different time and locations, compounded by user mobility
[33]. This mainly affects those smartphone users who were
trying to install a DSM application on their mobile.
4) Manual and limited data entry: Patients tend to
perceive data entry automation as an important driver for ease
of use and ultimately for satisfaction with the technology.
Small buttons and labels limit users’ effectiveness and
efficiency in entering data, which may reduce the input speed
and increase errors. The data entry method is crucial in
diabetes management applications, since people are expected
to log data frequently, and they could be hindered by
peripheral neuropathy - a common complication of diabetes
[17].
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5) Lack of key features: The existence of thousands of
applications claiming to assist with diabetes self-management,
the diabetes app market remains relatively immature with no
clear dominating market leader. Among thousands of available
DSM applications there are very few with dominating key
features. Smartphone users will have more options to
conveniently track their glycemic control and overall health,
which can ultimately improve their ability to effectively
manage their diabetes. Hence, they expect better and enhanced
features to manage their self from diabetes [6].
6) Difficulty in understanding the technology:
Moreover, the major technological improvements of both
hardware and software are still relatively new and thus,
sometimes unreliable. It might be at a disadvantage if the use
of smartphones becomes more requisite within medicine.
Similarly, elderly patients may find it difficult to use and
interpret the information provided to them via their
smartphones, possibly putting them at greater risk than those
who are more technologically savvy [9].
7) Programs too difficult to navigate: Programs on
smartphones are too small and particularly fonts that become
smaller or vanish off the side of the screen as the length of the
text increases. The interface of the DSM applications shows
very unclear graphs and poor color contrast. Icons that change
with a “long-press” (holding down the button too long) makes
the user to skip using the applications. The buttons even more
sensitive compare to computer-based applications. Direct
presentation of most applications pages on small smartphone
devices can be aesthetically unpleasant, un-navigable, and in
the worst case, completely illegible [35].
Table II shows the barriers to the effective use of
smartphone-based DSM applications.
work when there is no internet connection. Examples of
available desktop applications on market are SiDiary, Diabetes
Pilot and Glucofacts Deluxe.
Diabetes Pilot is a software developed to aid diabetics
manage their diabetes though logging glucose readings,
medications, weight, blood pressure and exercise and analyzing
the data through log books, reports, and charts while
Glucofacts Deluxe is for charting blood glucose levels and
seeing patterns in levels using several useful graphs [21].
1) Less computer use: There are relatively very low use
of computers among diabetes patients. This is because most of
them are not technologically savvy and not able to understand
the new technology. Patients do not have sufficient time to use
computer at home or at office. This cause them not to use the
DSM applications [31].
2) Low health literacy: The desktop or laptop users with
lower health literacy demonstrated gains in knowledge, selfefficacy, and perceived susceptibility to complications
compared with those having higher health literacy. Diabetes
patient’s procrastination behavior leads to very low concern
on their health and they fail to manage their health properly
[28]
3) Lacks proper references for medical information:
SiDiary app does not contain any references to source
materials but does present the user with a disclaimer. This is
because there is no internet connection for it to provide up to
date information. In term of real world applicability, SiDiary
app lacks sources for the information but it can be useful [21].
Table III shows summarizes common barriers to the
effective use of desktop based DSM applications.
TABLE III.
SUMMARY OF BARRIERS TO THE EFFECTIVE USE
OF SMARTPHONE-BASED DSM APPLICATIONS
SUMMARY OF BARRIERS TO THE EFFECTIVE USE
OF DESKTOP-BASED DSM APPLICATIONS
TABLE II.
Non-evidence based
applications
Security and
confidentiality
Connectivity
Manual and limited data
entry
Lack of key features
Difficulty in
understanding the
technology
Programs too difficult to
navigate (Small screen
size)








Thousands of applications
Not clinically relevant
Malware attack
Lose of personal data
Slow and unreliable network (data)
Low signal strength and data transfer
Not ease of use
Small buttons

No clear dominating market leader

Not technologically savvy



Too small text
Unclear graph
Poor color contrast
C. Desktop-based DSM Applications
Desktop based programs work on most home computers
running Windows and on Macs. Most programs can be
downloaded from the manufacturer’s web site, and many are
also available on CD upon request. These applications can
Less computer use
Low health literacy
Lacks proper references
for medical information






IV.
Do not own a computer
Not technologically savvy
Insufficient of time
Less awareness towards diabetes
Procrastination
Does not contain any references to
source materials
DISCUSSION
DSM applications are widely available and continuously
being developed for different platforms. In the above section,
we have identified the barriers that limit the effective usage of
DSM applications that were categorized into different
platforms, i.e. web-, smartphone- and desktop-based. Each of
these categories of applications differs in terms of the user
interface, development, capabilities, monetization, and method
of delivery. Since there are different needs to meet for each
category of DSM applications, classification of barriers for
each category provides developers with a better understanding
of the needs and expectations of patients towards specific type
of DSM applications.
We noted from previous studies that the focus had mainly
been on the features and implementation of DSM applications.
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Hence, this study is essential to diabetes patients as well as
healthcare professionals, and application developers where it
can enable them to identify the major barriers. Such
identification could lead developers to be more alert about
these issues and possibly address these issues in the design and
development of novel applications.
Most of the barriers revealed could be managed by
involving the target users, i.e. diabetes patients, in the
development process of the applications from the outset. Usercentred methods could be useful in meeting the needs and
expectations of potential users of these applications.
In addition, health behaviour change theories should be
integrated to realise applications that would bring positive
health outcomes, e.g. encourage users to take charge of their
health and most importantly to be persistent in looking after
their healthcare independently. For instance, DSM applications
could be designed based on effective health behavior change
theories such as self-efficacy which refers to “beliefs in one’s
capabilities to organize and execute the courses of action
required to produce given attainments”. DSM applications
designed using this theory can allow patients to adopt the
applications to their own specific needs, because patients are
increasingly demanding appropriate approach to a high level of
personalized health care [27].
The outstanding integration, platform differences, and
security issues need to be solved to improve the development
of the applications that are more integrated and secured [20].
Clinical guidelines highlight the role of self-management
education as an essential part of diabetes self-care and most
DSM applications that aim to support self-management tasks
do not integrate educational information [12].
There is also a need to develop standards for smartphone
applications so that they can be user-friendly and the patients
feel secure to use the applications for DSM. With the
implementation of such applications the main determinant of
the DSM app’s value may ultimately be its ability to provide
meaningful, accurate, and timely information and guidance to
the diabetes patients in order to serve the vital purpose of
improving patient health care.
V.
conditions. DSM applications are available on both specific as
well as cross-platforms platforms. In this paper, we
investigated the barriers that limit the effective usage of DSM
applications by diabetics. In particular, this paper provides a
summary of the barriers to use DSM across three different
platforms, i.e. smartphones, web and desktop. This work will
be useful to system designers and developers for implementing
novel DSM applications. Some of the main barriers that limit
the usage of DSM applications include usability, security
issues, unfamiliarity with the technology and inability to select
suitable evidence-based application. Now that we have
identified the factors that influence patients’ intention to adopt
DSM applications, we are geared to develop an acceptance
framework to increase the effective and widespread usage of
these applications by diabetes patients in taking control of their
health conditions.
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LIMITATIONS
The major limitation of the review stems from the
methodology employed in conducting the study, as we did not
use systematic literature review method and hence we could
have missed to identify, assess, and interpret all available
research concerning barriers to DSM applications. Moreover,
the review did not include cross-platform DSM applications.
Furthermore, the paper does not include solutions to overcome
all the barriers identified; only general suggestions are
provided.
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VI.
CONCLUSION AND FUTURE WORK
The number of research in the use of DSM applications is
rapidly growing, but there are few studies to answer questions
about its barriers to their effective use. The usage of DSM
applications by patients is increasing due to the potential of
these applications in enabling users to manage their health
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