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IntroductionIt is thought that access to informa-tion about diabetes could help people with the condition empowerthemselves to manage it more effec-tively.1 For many young people, com-munication and peer support arenow delivered through social net-works, which are increasingly beingaccessed through mobile devices.However, use of mobile functionality(e.g. phones) for clinical interven-tions in diabetes has to date yieldedlittle impact and it seems that technology cannot as yet remove the largely behavioural barriers togood diabetes control at a youngerage, although offering opportunitiesto engage young people moreclosely.2,3 At the time of writing,there is little research relating to thedemand for, design processes, devel-opment, regulation and use of type 1diabetes-related apps by individualsor groups. By using qualitative meth-ods we were able to include youngpeople with type 1 diabetes in theprocess of generating ideas, whichmight improve their health-related

quality of life (HRQoL) and askthem to use and feed back on itera-tions of any tools developed. Threetechnological suggestions weretaken forward for prototyping. One– an alcohol guide – was taken for-ward for development, as a clinicallyapproved app. Alcohol is a recog-nised risk factor for hypoglycaemiain people with type 1 diabetes;4 it isrecommended that these individualsshould be alerted to this possibilityand advised regarding appropriatepreventative measures. This is animportant issue for young peoplewith diabetes,5 as highlighted by thefact that it was their choice for actualdevelopment. This article describesthe development of this guide.

MethodsQualitative research methodologyhas become more recognised andvalued in diabetes behaviouralresearch6 as it helps to answer ques-tions that quantative research mightnot answer – by exploring individualmotivations, preceptions and expec-tations. This study aimed to gain a

Innovative mobile technology alcohol educationfor young people with type 1 diabetes

AbstractViews of young people with type 1 diabetes are vital in developing quality services andimproving health-related quality of life (HRQoL), yet research on their lifestyle and use of weband mobile technology to support their condition and in non-health related areas is sparse.The aim of this research was to develop an insight into young people’s current use of web andmobile technology and its potential impact on HRQoL by constructing an in-depth picture oftheir day-to-day experiences, exploring how they made use of technology in their lives and inrelation to their condition and treatment – then, building something to help them.

Data were collected by semi-structured, in-depth qualitative interviews (n=9) of youngpeople with type 1 diabetes and aged 18–21 years. Interviews were transcribed and loadedonto NVivo for theme identification. Data analysis was also undertaken during initialinterviews (n=4) to locate potential ideas for technical development. Latter interviews (n=5)assisted in the iterative sociotechnical design process. Three suggestions for improvementwere taken forward for prototyping with one – an alcohol education guide – being developedinto a clinically approved app.

This article documents the procedures and sociotechnical design principles involved in thecreation of a patient-centric app. It provides an innovative example of how education with theaim of improving HRQoL can be designed in a way which meets the needs of a particular groupand values and encourages their input to assist in the creative process, while at the same timeconforming to clinical guidelines. Copyright © 2013 John Wiley & Sons.

Practical Diabetes 2013; 30(9): 376–379

Key wordseducation; type 1 diabetes; alcohol; mobile; apps; Apple; android

Andy Pulman Web Team Leader, School of Health & Social Care,Bournemouth University, UK

Jai HillDiabetes Nurse Specialist, Diabetes Centre, PooleHospital NHS Foundation Trust, UK

Jacqui TaylorAssociate Professor, Psychology Research Group,Bournemouth University, UK

Kathleen GalvinProfessor, Faculty of Health and Social Care, Universityof Hull, UK

Mike G MasdingConsultant Physician, Diabetes Centre, Poole HospitalNHS Foundation Trust, UK

Correspondence to: Andy Pulman, Bournemouth University – The Schoolof Health & Social Care, R109 Royal London House,Christchurch Road, Bournemouth BH1 3LT, UK; email: apulman@bournemouth.ac.uk

Received: 3 December 2012Accepted in revised form: 2 July 2013

deep understanding of the perspec-tive of young people with type 1 dia-betes and connect with their views,by building a picture of their every-day experiences with the conditionand how they use technology bothsocially and for health – influencedby approaches from qualitativeresearch in health care.7,8 We thenaimed to integrate this perspectivein the creation of a technical toolinfluenced by these views, whichmight improve an aspect of HRQoLby utilising humanising sociotechni-cal principles9 during the designand build.

Recruitment was conducted at a diabetes centre located within a district hospital in the South West(SWDC) and a local university, withdata collected by qualitative inter-views with young people with type 1diabetes aged 18–21 years. Althoughthe clinic had children under 18attending, it was decided to focus onolder members as this alleviated theneed for parental consent. The upperlimit of 21 was set as this was the age at which participants no longerattended the clinic on a regular basis.

The sampling strategy utilised anon-random, convenience sampleand was purposive, with participantsconsidered eligible if they had type 1diabetes, were six months post diag-nosis, were within the age range attime of recruitment, and were fluentin English.

The design used in-depth, 1-hour,semi-structured interviews, with aninterview guide prepared before-hand. The pool of participants willingto be interviewed in the target agegroup was deemed to be low. Thisgroup were particularly time poor:they had busy lifestyles and were usu-ally juggling a combination of jobs orliving and studying away from thearea, which meant it was difficult forthem to make extra visits to the clinicin addition to their biannual sched-uled appointments.

We therefore wanted to ensurethat any willing interviewee wasgranted a full qualitative interviewrather than piloting. Each interviewcovered: interviewee experiencesand usage of mobile and computertechnology; their diagnosis and howthey had utilised technology (if atall) since then; different aspects oftheir day-to-day life with diabetes;

how they coped with and used tech-nology relating to their condition;and if they had used any social orhealth-related apps.

When discussing problems theyhad experienced, we would thenexplore ideas or enhancements theyhad around improving that aspect oftheir lifestyle or others and whethera technical solution might help.

In total, nine interviews wereconducted (with two males andseven females), and analysed usingthe qualitative data analysis toolNVivo to gain a deeper understand-ing of the perspective of the inter-viewees and to construct a picture oftheir everyday experience. Six mainexperiential themes were identified,providing an understanding of howparticipants lived with and experi-enced their condition and how theyused technology.10

Data analysis was also undertakenduring initial interviews (n=4) tolocate potential ideas for technicaldevelopment. Suggestions needed tomeet SWDC goals, reflect intervie-wee requirements and follow localtrust guidelines. In collaborationwith the SWDC, we were able to filterpossible ideas for prototype develop-ment.11 Three ideas were created inprototype (around alcohol, illnessand hypoglycaemia education), withone (alcohol) subsequently chosenby latter interviewees (n=5) to betaken forward for final development.Latter interviews also assisted in theiterative sociotechnical designprocess of prototype development.Non-prototyped ideas and sugges-tions are described separately.10

Design principlesPrototype development utilisedsociotechnical design principles.9,12

Recent examples within diabetesresearch have used this approach asa means of collecting data for sys-tems designed for staff13 and peoplewith diabetes.14 A key characteristicof sociotechnical thinking lies inhighlighting the importance ofdeveloping new ways of workingwhich significantly meet the needsof clients (people with diabetes) andusers (service providers). Mumford9

contended that the definition ofhuman needs should come from thepeople associated with, and affectedby, the technology. This meant that

democratic and participative com-munication and decision makingmust always be available to give thesepeople a voice. Therefore, the initialstage of the design process was toseek ideas generated by those whowould be using the technologicalsolutions and making use of them.We needed to ensure that anythingdeveloped was actually required bythis audience and that they would belikely to use anything subsequentlydeveloped. This ensured theirhuman needs affected by the tech-nology would be met. The continual

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Figure 1. First iteration: examples of thedifferent screens covering areas of educationalinterest to the target group

redesign of prototypes over severaliterations with feedback from SWDCstaff and interviewees aimed to create an iteratively valid product foruse, while acknowledging the con-tinuous process of informationaland technological change likely tooccur in the future.

First iteration The U-CAIR course is run for peoplewith type 1 diabetes at SWDC.Information on type 1 diabetes andalcohol was initially extracted fromcore U-CAIR materials, after theyhad been examined and amendedfor consistency and currency by adietitian at SWDC. The informationwas then ported to the app develop-ment platform for individual screendesign. The first iteration containeda number of different screens cover-ing areas of educational interest tothe target group (see Figure 1).

Development was initially under-taken on the iPhone platform as thiswas considered the most popularplatform for developing and approv-ing apps at the time of work com-mencing and would also have themost impact on the target group,based on discussions during inter-views on which phones they ownedor were anticipating upgrading to inthe future. However, materials devel-oped could also be easily transferredto other mobile systems, such asandroid, as the prototype app wasdeveloped using the PhoneGaparchitecture – an open source solu-tion allowing deployment acrossmultiple platforms. For latter inter-views (n=5), a percentage of thetime allocated concentrated onascertaining from participants theirfeelings on the prototype app mostclosely aligned to their particulararea of interest – highlighted duringprevious parts of each interview – toprovide deep, meaningful feedback.This was important as in terms ofusability engineering, unstructuredinterviews are able to provide awealth of information the inter-viewer might not anticipate.15 Forthese interviews, it was possible torecord and segregate differing opin-ions on the prototypes and subse-quently feed this back into thedesign process for the developer –look and feel and navigational purposes – and for SWDC staff – text

content and the quality of the infor-mation. We were also able to observelatter interviewees (n=5) using the prototypes for a concentratedperiod of time, which assisted indemonstrating how they were usingthem and highlighted any problemsthey might experience in workingout how to navigate them – notapparent when listening to an audiorecording or reading an interviewtranscription. In each latter inter-view, out of the three prototypesavailable, the alcohol guide was cho-sen by each interviewee as the appmost closely aligned to their lifestylerequirements, the one which theywanted to explore in more depthand the one which they viewed asbeing the most useful to them.

Second iterationFeedback on the first version of theprototype was encouraging, thoughit was considered by some intervie-wees that specific pieces of informa-tion could be expanded upon andoccasionally the pathway of naviga-tion through different screensneeded further clarification. Toensure that from a clinical perspec-tive anything developed met thegoals of SWDC and the local hospi-tal, a questionnaire was distributedto clinic staff (n=5) who had firsthad a chance to try out the proto-types. Key feedback focused on theneed for a better explanation ofsome of the terms listed within theapp – such as ‘carbohydrate’ – andalso on clarification of some textstatements and rewording of othersto reduce the risk of informationbeing viewed incorrectly. In addi-tion, it was suggested that the information taken from U-CAIRmaterials needed to be more care-fully adapted and displayed – interms of the different categoriesused and how they were split. Likeinterviewees, SWDC staff also feltthat the number of different drinksincluded could be expanded uponbut, overall, felt the app was gener-ally well designed. New functionalitywas added to the second iterationregarding a podcast about alcohol asinterviewees had expressed a desirefor this feature to be available tothem in any developed apps.10 Textwas also amended as it had becomeapparent, once the information was

displayed on a mobile screen, that itneeded to be reformatted to make iteasier to read and understand.

Third iterationDue to the current lack of NHS reg-ulation, to ensure that the app metclinical validation standards we for-mally approached the local PatientAdvice and Liaison Service (PALS).Future iterations of the app weresubmitted to PALS for approval, as apart of the five-step process for stan-dardised patient information. Priorto submission, a new launch screenwith revised content was added tofocus on the ‘Start Safe, Stay Safe’message, which SWDC staff wishedto convey each time a user openedthe app (see Figure 2). Links to NHS Choices internet resources onalcohol were also added to provideadditional information if a user hadaccess to the internet.

Fourth iteration At the first review, PALS suggestedthat using block capitals removedthe shape of a word, which couldaffect legibility – relevant when people have low health literacy orare in an emergency situation. Forthe menu screen, it was decided touse upper case with two key wordsand one key phrase, with everythingelse in lower case. Other suggestionsincluded: certain terminologychanges and rewording sentences to

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Figure 2. Third iteration: launch screen

improve legibility; expanding sometext to make it more understand-able; standardising bullet points;ensuring text was the right colour(for consistency); and adding inadditional screens – for differinglocale contact information andinformation on the term ‘hypo’.

Fifth iterationAfter further review, the third sub-mission required only minor cos-metic changes before approval wasgranted. Developers submitting appsto Apple must ensure that they comply with their developmentguidelines. Post PALS approval, thealcohol app successfully passedApple’s authentication process andwas offered as a free download inDecember 2012.16 A duplicate ver-sion was then ported to the GooglePlay Store and approved as anandroid app in February 2013.16

Like Apple, Google’s developerguidelines contain no specific infor-mation on designing health andmedical apps and the Googleapproval process is quite basic withhardly any technical checks beingmade on either the clinical qualityor the purpose of the app beingoffered for download. This has ram-ifications on wrongful informationbeing made available and subse-quently used by someone within ahealth context.17

As of May 2013, the app has beendownloaded 669 times worldwide(with 603 Apple and 66 androiddownloads). This means that thepotential user base is now largeenough to warrant further researchon its use. Future research mightconcern any HRQoL impact thatcan be seen to be associated with theapp locally, nationally and interna-tionally – and also investigate anybenefits or problems, which havecome from downloading and use ofthe app in a mobile environment. Itis hoped that further work will thenbe undertaken to evaluate theusability and any potential impactson HRQoL as a result of the use ofthe alcohol guide.

ConclusionMobile and web technology can beseen as innovative ways of improvingcommunication between health pro-fessionals and people with diabetes,

which could be used for educationand helping to improve self-manage-ment in young people with type 1diabetes – although this carries thecaveat that not everyone has accessto such technology or might want touse it in their own diabetes manage-ment. However, just as each personhad their own unique perspectiveand a completely different personalexperience of living with type 1 dia-betes, so they also require differentapproaches and suggestions basedon their own personal preferencestoward technology. Current researchand policy concerning the integra-tion of health information and support with technology do noteffectively consider this viewpoint.18

This is all the more important astoday’s young adults have a view oftechnology and how they make useof it which is radically different fromthat of either parents or health carepractitioners.10,11

The global rise in usage ofmobile technology offers excitingopportunities for developing a vari-ety of different diabetes resourcesaimed at practitioners and clients.However, care must be taken toensure that any information pro-vided through such devices is accurate, and that adapted forms ofdelivery – such as apps – take fullyinto consideration the specific needsof the individual. An app alsorequires careful design to suit themobile platform and considerationalso needs to be given to how effec-tively apps might be regulated,deployed and used across differenthealth care settings and how theycould be supported technically.2,10,11

Aspects of technology use whichmight be divisive, use the wrong

medium to spread a health message,try to manipulate something enter-taining into something educationalwithout clear explanation and sup-port, or exclude through cost or software system used, could nega-tively impact on any technologicalenhancement implemented; forexample, by excluding people in low socioeconomic groups withoutaccess to smartphone technology.Such aspects need to be given clearand careful consideration therefore,before any solution is developed.

It is hoped that dissemination ofthis research will assist in highlight-ing a more patient-centric approachto the development and productionof high quality, health-based mobileapps which can be applied withindiabetes and other long-term condi-tions. It provides an innovativeexample of how patient educationwith the aim of improving HRQoLcan be designed in a way whichmeets the needs of a particulargroup and values and encouragestheir input to assist in the creativeprocess, while at the same time conforming to clinical guidelines.

AcknowledgmentsThe authors would like to acknowl-edge and thank the staff at the dis-trict hospital in the South West fortheir valued help and support inrelation to this study to date.

Declaration of interestsThere are no conflicts of interestdeclared.

ReferencesReferences are available in PracticalDiabetes online at www.practicaldiabetes.com.

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Innovative mobile technology alcohol education for young people with type 1 diabetes

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● This article highlights a forward-thinking, patient-centric approach to the development ofa mobile app concerning diabetes education about alcohol

● Mobile and web technology can be seen as innovative ways of improving communicationbetween health professionals and people with diabetes. With the caveat that noteveryone has access to such technology or might want to use it in their diabetesmanagement, it could nevertheless be used for education and helping to improve self-management in young people with type 1 diabetes

● At the time of writing, there is little research relating to the demand for, design processes,development, regulation and use of type 1 diabetes-related apps by individuals or groups

● This article provides an example of how education can be designed in a unique way,meeting the needs of a specific group and valuing and encouraging their input to assist inthe creative process, while also conforming to clinical guidelines

Key points

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References1. Van Dam HA, et al. Social support in diabetes: A sys-

tematic review of controlled intervention studies.Patient Educ Couns 2005;59:1–12.

2. Lamb WH. Integrating technology into adolescentcare. Pract Diabetes 2012;29:201–4a.

3. Bowen ME, et al. Health care transition in adoles-cents and young adults with diabetes. Clin Diabetes2010;28:99–106.

4. Turner BC, et al. The effect of evening alcohol consumption on next-morning glucose control in type 1 diabetes. Diabetes Care 2001;24:1888–93.

5. Barnard K, et al. Alcohol-associated risks for youngadults with type 1 diabetes: a narrative review. DiabetMed 2012;29:434–40.

6. Ritholz MD, et al. Digging deeper: the role of quali-tative research in behavioral diabetes. CurrDiabetes Reports 2011;11:494–502.

7. Johansson K, et al. A lifeworld phenomenological

study of the experience of falling ill with diabetes.Int J Nurs Studies 2008;46:197–203.

8. Kneck A, et al. Learning to live with diabetes – inte-grating an illness or objectifying a disease. J AdvNurs 2012;68:2486–95.

9. Mumford E. The story of socio-technical design:reflections on its successes, failures and potential.Information Systems J 2006;16:317–42.

10. Pulman A, et al. Ideas and enhancements concern-ing mobile applications to support type 1 diabetes.JMIR Mhealth 2013. In press.

11. Pulman A, et al. Designing useful type 1 diabeteseducation mobile apps. In mLearn 2012 ConferenceProceedings, 15–18 October 2012, Helsinki, Finland.

12. Berg M. Patient care information systems andhealth care work: a sociotechnical approach. Int JMedical Inform 1999;55:87–101.

13. Adaji A, et al. Web-based diabetes care planning –sociotechnical barriers to implementation in gen-eral practice. Austr Fam Phys 2011;40:915–8.

14. Ma J, et al. Use Smart Phones to Promote DiabetesSelf-Management: Robust Elderly in Urban and RuralChina. Phase 2: Design, Prototyping, and Testing. In:Microsoft External Research Symposium, 30–31March 2009, Redmond, WA, USA. Available from:http://research.microsoft.com/en-us/events/mhealth2009/presenters.aspx [accessed 27 July 2012].

15. Faulkner X. Usability engineering. Basingstoke:Palgrave, 2000.

16. Type 1 diabetes friend. Type 1 diabetes friend: alcoholguide blog. 2013. Available from: http://type1diabetesfriend.wordpress.com/ [accessed 21 May2013].

17. Visser BJ, et al. There’s a medical app for that. 2012.Available from: http://careers.bmj.com/careers/advice/view-article.html?id=20007104 [accessed 18 April2013].

18. Pulman A. A patient centred framework for improv-ing LTC quality of life through web 2.0 technology.Health Informatics J 2010;16:15–23.