The potential of improving care in diabetes through mobile devices, patient empowerment and financial incentives
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<bold>Introduction:</bold> The rapid adoption of smartphones and the increasing prevalence of diabetes have led to the growing interest in use of mobile devices to support diabetes self-management. In my dissertation, I present three studies to explore how smartphones can be used for diabetes management. The first study focuses on the reach of smartphones in the diabetic population, and (1) compares smartphone use in individuals with diabetes to those without diabetes, and (2) explores predictors of smartphone use among those with diabetes. Although many applications have been developed for diabetes, no reports have described smartphone use among individuals with diabetes, nor explored the characteristics of the smartphone users. Smartphone applications offer a large range of features to support diabetes. In the second study, I seek to understand how individuals with diabetes use smartphone applications to support their diabetes self-management. In particular, I focus on how needs for supportive technology evolve over time as both diabetes and diabetes self-management change with time. Finally, I explore the use of financial incentives to drive behavior change in diabetes. Patient incentives are increasingly used to increase patient engagement in health and wellness, but have not been well studied in diabetes. In the third study, I examine the acceptability of financial incentives to improve diabetes self-management among patients and providers. <bold>Results:</bold> In the first study, I found that individuals with diabetes are less likely to use smartphones than those without diabetes, even after adjusting for age, race/ethnicity and socioeconomic factors. In my results, smartphones bear potential in reaching racial ethnic minorities who also have a higher prevalence of diabetes, as smartphone use is higher among Blacks, Asians and Hispanics. As expected, young age, high income and high education are also associated with higher smartphone use among individuals with diabetes. In the second study, I found that diabetes self-management can be framed in three stages: an initial stage (after diagnosis), a stabilization stage and a response to change stage. Many of the tracking features guide individual learning and are particularly useful in the initial stage. After creating habits, however, these features become less useful the benefits of the tedious tracking diminish during the stabilization phase. Finally, when changes occur, transitory tracking is useful to recalibrate treatments and return to the stabilization stage. In the third study, participants liked the idea of financial incentives and expected them to be useful in helping them take the small steps for behavior change. They also expected rewards to help acknowledge the constant efforts made for self-management. Yet participants also raised concerns for equity and privacy when using incentives. <bold>Conclusions:</bold> Compared to individuals without diabetes, those with diabetes were less likely to use smartphones in our study. This gap in smartphone use has the potential to increase disparities in diabetes care, and suggests that standard diabetes care needs to be pursued while other studies are needed to confirm and explore this gap. Future applications for diabetes need to address long-term management of diabetes, as the needs in supportive technology changes over time. Although financial incentives seem acceptable, many unresolved issues including equity and privacy still need to be addressed for the design of incentive programs. In particular, careful consideration is needed to avoid undesired consequences of decreased intrinsic motivation.
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