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Evaluation of a Computerized Self-Management Tool for Children with Type 1 Diabetes: A Pilot Project
ARTICLE IN PRESS Can J Diabetes xxx (2016) 1–5
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: w w w. c a n a d i a n j o u r n a l o f d i a b e t e s . c o m
Innovations in Diabetes Care
Evaluation of a Computerized Self-Management Tool for Children with Type 1 Diabetes: A Pilot Project Navita Dyal BHS, M Eng (cand) a,*, Karen McAssey BA, MD, MEd, FRCPC b, Gina Agarwal MBBS, PhD, MRCGP, CCFP c a
McMaster University, Faculty of Engineering, Hamilton, Ontario, Canada Department of Pediatric Endocrinology, McMaster Children’s Hospital, Michael G. DeGroote School of Medicine, Hamilton, Ontario, Canada c Gina Agarwal, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada b
a r t i c l e i n f o Article history: Received 20 May 2015 Received in revised form 29 September 2016 Accepted 29 September 2016
Introduction Pediatric diabetes is a rising global public health concern that is increasing in prevalence in developed and developing countries alike. The World Health Organization appeals to the medical community to develop effective interventions that will counteract the long-term negative health outcomes and high costs associated with diabetes (1). Self-monitoring blood glucose (SMBG) more than 3 times per day is significantly correlated with lower glycated hemoglobin (A1C) levels (2–6). However, traditional self-management tools do not coincide easily with the lifestyles of children. As a result, adherance to SMBG is compromised. Poor adherance to SMBG undermines its optimal benefits (7,8). A significant decline in SMBG is reported after the first year of diagnosis (5). Children as young as 10 years of age report that they are reluctant to self-monitor their blood glucose levels actively when they receive too many reminders from their parents (9). Thus, striking the right balance with the type and number of reminders is imperative (3). Creative interventions are needed to encourage and motivate patients to selfmonitor their blood glucose levels (10,11). Web-based interventions are showing promise as a means of increasing adherance to SMBG by individuals with chronic disease (12). KiDi SMS (Kids with Diabetes Self-Management System) is an interactive online tool designed for children with type 1 diabetes between the ages of 8 and 12 years. It was developed to improve patients’ adherence to SMBG. The purpose of this study was to assess whether KiDi SMS is an effective tool for motivating children to self-monitor their blood
* Address for correspondence: Navita Dyal, BHS, M Eng (cand), McMaster University, W Booth School of Engineering Practice & Technology, ETB-509, 1280 Main St. West, Hamilton, ON L8S 0A3, Canada. E-mail address: [email protected] 1499-2671 © 2016 Canadian Diabetes Association. http://dx.doi.org/10.1016/j.jcjd.2016.09.021
glucose levels daily. This study leverages off research that provides guiding principles concerning how technological interventions engage patients and facilitate necessary behaviour changes (13–15). Newton and Ashley evaluated the feasibility and effectiveness of a web-based intervention among adolescents with type 1 diabetes. This study found that 90% of participants indicated that they were more willing to adhere to their treatment protocol using the web-based intervention (14). Padman et al evaluated a mobile application, that targeted young adults and was available only on the Android platform (15). Both interventions were designed to increase adherence to SMBG (14,15). To our knowledge, this is the first web-based intervention targeting preteens, with the goal of improving SMBG.
Methods Intervention We recruited 13 participants by using a convenience sample from McMaster Children’s Hospital Pediatric Diabetes Clinic. Clinic staff identified potential participants based on their average rate of SMBG. Those who were logging their blood glucose fewer than 3 times per day were approached. Children between the ages of 8 and 12 years who had been diagnosed with type 1 diabetes for more than 1 year were included. Participants were also required to have Internet access at home. Participants who were already logging blood glucose levels more than 3 times per day were excluded. Access to this program was provided free of charge. The researchers did not provide any instructions about how to use the program so that intuitiveness and ease of use could be observed. Participants’ data were stored on an encrypted cloud-based server.
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Participants had to sign up online using their parents’ e-mail addresses to join KiDi SMS. The users were engaged the moment their profiles were created. The children enter basic data (age, gender, etc.) with the help of 2 animated characters, Julie and Tom. Julie is a fun-loving Canadian girl with pigtails, and Tom a hip island surfer with a Jamaican accent. Crisp graphics enable users to create animated avatars, which they can accessorize. Julie and Tom encourage users to enter their blood glucose readings in their online logbook at least 3 times per day. When entering blood glucose readings, users faced no constraints based on specific time intervals. As such, blood glucose readings could be entered at any time during the day. The online logbook was e-mailed to the participants’ parents at the end of each week, thereby facilitating any necessary discussions between parents and their children. Each day the children log a minimum of 3 blood glucose readings, a video game is unlocked. The KiDi SMS database houses hundreds of different games; therefore, no game is accessed twice. The games are equally appealing to boys and girls so as to keep the users engaged. Individuals prefer instant gratification to delayed rewards (13). Having the opportunity to access a new game daily can be considered an early reward. Once a game is unlocked, it is available only until midnight. Thus, in order to unlock another game, the user is required to log 3 more readings the following day. A system in which children are encouraged but not overwhelmed by reminders to self-manage is optimal. To avoid inundating users with diabetes-related information, KiDi SMS’ database of games is unrelated to diabetes self-management or education. Every time users enter blood glucose readings within their target ranges, an animated character giving them a thumbs-up praises them. Likewise, participants who enter readings that are outside of their target ranges receive pop-up messages alerting them that their readings are either too high or too low. The animated characters, Tom and Julie, subsequently provide tips on how to adjust lifestyle factors, such as diet and exercise, to achieve readings that are within the target range. Bar graphs are generated, illustrating average blood sugar levels at various time intervals. Tom and Julie encourage users to print these graphs and present them to their physicians at their next visits. There is an Ask Doctor function, where participants can e-mail their pediatric endocrinologists. After clicking this help button, a window pops up where the users can type their questions. These questions are immediately e-mailed to the children’s pediatric endocrinologists. Design and sample This was a descriptive pilot study that assessed feasibility primarily. Quantitative data, such as frequency of entering blood glucose levels and the use of the Ask Doctor function, were monitored. At the end of the study, participants and their parents were asked to participate in an online survey to determine the strengths and weaknesses of KiDi SMS from users’ perspectives. Ethical approval was obtained from the Faculty of Health Sciences Student Research Committee, McMaster University.
Results This study spanned 3 months and included 7 male and 6 female participants who had been diagnosed with diabetes for at least 1 year. The mean age of participants was 10 years (SD 1.05). Patient characteristics are presented in the Table 1. Of participants who created accounts, 85% (11 of 13) logged their blood glucose readings daily, and 82% (9 of 11) of participants who used KiDi SMS daily demonstrated a mean daily frequency of at least 3 logs. The mean daily frequency of SMBG, per participant, can be found in Figure 1.
Table 1 Variables of patients’ characteristics Study population (n=13) Gender, n (%) Female Male Age (years); (mean ± SD) Diagnosed with type 1 diabetes >1 year Logged blood glucose <3 times per day prior to intervention KiDi SMS usage Created an account Used online log book Never used program after creating an account
7 (54%) 6 (47%) 10.00±1.05 13 (100%) 13 (100%) 13 (100%) 11 (85%) 2 (15%)
SD, standard deviation.
Prior to this intervention, none of the participants had logged blood glucose ≥3 times per day (Figure 2). Of the 13 participants, 2 created online accounts but never logged their readings (Figure 1). The average frequency with which participants logged their blood glucose readings ranged between 2 and 6 times per day; 69% (9 of 13) of participants self-managed their blood glucose with an average daily frequency of more than 3 logs during the study period. Although 2 of 13 participants logged <3 readings per day, on average, these individuals reported that they had not logged their blood glucose readings at all prior to this intervention. Therefore, all participants who used the logbook function in KiDi SMS (11 of 13) demonstrated an increased average daily rate of SMBG during this study (Figure 2). During the first 2 weeks of the study, participants averaged 3 logged readings daily. The daily average frequency of logging increased significantly between weeks 3 and 5. In week 3, participants logged an average of 13 readings per day. In week 4, participants logged an average of 16 readings per day; and in week 5, participants logged an average of 34 readings per day. Although the daily average frequency decreased between weeks 6 and 7, relative to previous weeks, the rate was still above the target number of 3 logged readings per day. Users were very active during week 8, averaging 31 logged readings per day. There was a decrease between weeks 8 and 9, but the daily average did not fall below 3 daily logs. The average rate of logging remained constant between weeks 9 and 13, at 3 times per day (Figure 3). These average rates of SMBG correlate with participants’ utilizing the video game incentive. No one used the Ask Doctor function. Changes in A1C levels were not measured due to the relatively short duration of the study and the limited number of participants. Participants were surveyed online to determine whether they felt more encouraged to self-monitor their blood glucose levels daily after participating in this intervention, and 91% (10 of 11) answered in the affirmative. When users were asked to comment on their favourite feature of KiDi SMS, the majority (9 of 11) reported that they enjoyed being able to play a new game every day. The remaining participants noted an appreciation for the diversity of the animated characters, Tom and Julie. Some participants (3 of 11) indicated that their least favourite aspect of KiDi SMS was that it could not be accessed from their mobile phones or tablets. Parents were also asked to complete a online survey at the end of the study, and 100% of parents felt that KiDi SMS encouraged their children to log their blood glucose readings daily.
Discussion Of the 13 participants, 11 used KiDi SMS daily, and most were able to unlock a new game each day. Of participants who used KiDi
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Figure 1. Mean frequency of SMBG before and after the intervention.
Figure 2. Mean daily frequency of blood sugar logging for the entire group.
SMS daily, 82% (9 of 11) demonstrated a mean daily frequency of at least 3 logs. All participants had logged their blood glucose readings fewer than 3 times per day prior to this intervention. This suggests that the use of KiDi SMS was an effective incentive. Studies have shown that intrinsic motivation, the internal desire to perform a task, is a longer lasting type of motivation (16). Furthermore, informational rewards like praise can enhance intrinsic motivation (17). It can be postulated that the steady daily average of SMBG between the first 2 weeks was a result of users’ familiarizing themselves with the program just enough so they could unlock the game. The significant increase in SMBG between weeks 3 and 5 could be attributed to participants’ being intrigued by the program and motivated to log their blood glucose readings frequently. However, logging an average of 34 times per day during week 5 is extraordinarily high. Perhaps, once users realized that a game was unlocked every time they logged 3 blood glucose readings, they became curious about whether they would be able to unlock a new game after logging an additional 3 readings. There is also a possibility of a novelty effect, whereby the users are so enthralled by the technology at the beginning of the intervention that they use it frequently. KiDi SMS was designed to provide an incentive for SMBG, but we did not want to encourage sedentary behaviour. As such, a maximum of 1 game could be unlocked each day. Participants were not given instructions about how to use the program prior to creating their accounts, so they were not aware of this. Thus, we believe that the high influx of SMBG readings during weeks 3 to 5 could be attributed to children trying earnestly to access more than 1 game within a 24-hour period. A future modification of the program could be implementation of a maximum amount of SMBG data to be
entered per day. Once this maximum is reached, participants will not be able enter additional readings until the following day. KiDi SMS could be refined to limit the number of entries per time interval that a user could enter (e.g. 6 am to 10 am, 10 am to 12 pm, etc.). Perhaps a maximum of 2 entries per time interval would also ensure that users are checking their blood glucose at the recommended times, i.e. before meals and at bedtime. An area for future exploration would be to compare the blood glucose entries on KiDi SMS with the patients’ glucometers. This would provide a better understanding of the accuracy of the users’ daily logs. Weeks 8 and 9 corresponded with the Christmas season. This may explain why there was a decrease in the rate of logging during these weeks. It is encouraging to observe that participants’ usage of KiDi SMS did not cease after the study period concluded. Instead, this program has become an important part of the users’ selfmanagement regimes. The 2 participants who created online accounts but never logged a single blood glucose reading did not withdraw from the study. These 2 individuals never used the online logbook, so they did not experience the full dynamic of the program. Thus, it would be unfair to assume that the program was insufficient in motivating these 2 users to log their blood sugar readings regularly. Feedback from 1 of these 2 families indicated that the reason their children did not use KiDi SMS was that the children could not juggle this commitment with school and extracurricular activities. These 2 individuals also indicated that the program had a “younger feel.” Both children were 12 years old and therefore on the cusp of being teenagers. It is possible that they felt that it was not well suited for their age and subsequently decided against using the program.
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Figure 3. Sample image from program.
Neither participants nor their parents were provided with any instructions about how to navigate this online tool. Because 85% of the participants used KiDi SMS daily, it can be deduced that the program was fairly intuitive and easy to use. Feedback from participants and their parents indicated that a mobile application would be more convenient and, therefore, more appealing. Social media features were found to be a key factor driving user engagement in a mobile application targeting young adults with diabetes (15). Participants in the mobile application study were able to friend other users and chat with them online (15). This is an area for exploration, should KiDi SMS be developed into a mobile application in the future. No one used the Ask Doctor function, but it is noteworthy that participants are patients of a highly specialized, intradisciplinary diabetes clinic where patients and their families receive ongoing diabetes education. However, not all children with type 1 diabetes have access to this level of care. An area of future study could be to compare this pilot study to a similar study of children with diabetes who are not patients of a specialized pediatric diabetes clinic. The Ask Doctor function may be an untapped potential for children in medically underserved areas. However, it is noteworthy that in its current form, KiDi SMS does require an Internet connection, so it would implicitly exclude certain populations who lack access to this technology. The online logbook was e-mailed to the participants’ parents at the end of each week. We hoped that this would facilitate discussion between parents and their children. However, we did not develop any empirical method for determining whether this function did, indeed, increase family discussion.
It may be argued that glucometers that store blood glucose readings on a USB drive makes KiDi SMS redundant. However, when blood glucose readings are automatically stored, the users are not actively involved in SMBG (18). These data are valuable to physicians, but they do not motivate users to make diabetes management adjustments immediately (18). By entering blood glucose readings in KiDi SMS and receiving instant feedback, users are encouraged to make any required adjustments to their daily activities. An area for future exploration would be to determine the effect KiDi SMS has on A1C levels.
Conclusions KiDi SMS motivated 85% of its users to self-manage their blood glucose readings daily. This is a significant improvement in this group; all participants logged fewer than 3 times per day prior to the intervention. This study was designed as a simple feasibility study; future development of this program could explore the effect KiDi SMS has on A1C levels. Another area of future study would be to determine whether KiDi SMS as a cell phone application would motivate more children to self-monitor. A reward system for having blood glucose readings within the users’ target ranges might be included. Participants could gain health points for each reading that is within the target range. The study population could be broadened to include children who are currently logging 3 times per day or more to determine whether these children would become more engaged in SMBG after using KiDi SMS. These additional trials may serve to further improve KiDi SMS.
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More than 250 000 health-related mobile applications are available for iPhones, and more than 30 000 for Android phones (15). Mobile phones are available worldwide and have simple user interfaces. Thus, an evaluation of the utilization of the Ask Doctor function among children who lack access to care would be an intriguing area of future study. We plan to use the data collected in this study to pursue the development of KiDi SMS as a mobile application.
Acknowledgments This work originated at McMaster University, and study participants were recruited from McMaster Children’s Hospital. We sincerely thank Mrs. Victoria Rajkumar for volunteering her time to assist with the computer programming.
Author Contributions ND designed the computer program KiDi SMS. She analyzed the data obtained, in addition to drafting and revising the manuscript; GA supervised the design of KiDi SMS, provided insight into the analysis of the data and critically revised the manuscript; KM substantially contributed to the development of KiDi SMS, provided guidance for interpreting the data and critically revised the manuscript before giving final approval of the version to be published.
References 1. Aanstoot HJ, Anderson BJ, Daneman D, et al. The global burden of youth diabetes: Perspectives and potential. Pediatr Diabetes 2007;88:1–44.
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2. Silverstein J, Klingensmith G, Copeland K, et al. Care of children and adolescents with type 1 diabetes: A statement of the American Diabetes Association. Diabetes Care 2005;28:186–212. 3. Nabors L, Lehmkuhl H, Christos N, et al. Children with diabetes: Perceptions of supports for self-management at school. J Sch Health 2003;73:216–21. 4. Bui H, Perlman K, Daneman D. Self-monitoring of blood glucose in children and teens with diabetes. Pediatr Diabetes 2005;6:50–62. 5. Evans JM, Newton RW, Ruta DA, et al. Frequency of blood glucose monitoring in relation to glycemic control: Observational study with diabetes database. BMJ 1999;319:83–6. 6. Haller MJ, Stalvey MS, Silverstein JH. Predictors of control of diabetes: Monitoring may be the key. J Pediatr 2004;144:660–1. 7. Harris MI, National Health and Nutrition Examination Survey (NHANES III). Frequency of blood glucose monitoring in relation to glycemic control in patients with type-2 diabetes. Diabetes Care 2001;24:979–82. 8. Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care: Translating evidence into action. Health Aff 2001;20:64–77. 9. Sawyer SM, Aroni RA. Self-management in adolescents with chronic illness: What does it mean and how can it be achieved? Med J Aust 2005;138:405–9. 10. Wilson DP, Endres RK. Compliance with blood glucose monitoring in children with type 1 diabetes mellitus. J Pediatr 1986;108:1022–4. 11. Perwien AR, Johnson SB, Dymtrow D, et al. Blood glucose monitoring skills in children with type 1 diabetes. Clin Pediatr (Phila) 2000;39:351–7. 12. Murray E, Burns J, See TS, et al. Interactive health communication applications for people with chronic disease. Cochrane Database Syst Rev 2005;(4):CD004274. 13. Krishnan D, Padman R. On behavioral decision making and mobile health: A case study. Stud Health Technol Inform 2013;192:837–40. 14. Newton K, Ashley A. Pilot study of a web-based intervention for adolescents with type 1 diabetes. J Telemed Telecare 2013;198:443–9. 15. Padman R, Jaladi S, Kim S, et al. An evaluation framework and a pilot study of a mobile platform for diabetes self-management. Stud Health Technol Inform 2013;192:333–8. 16. Deci E. Intrinsic motivation: Perspectives in social psychology, vol. 1. New York: Plenum; 1975. 17. Vallerand R, Reid G. On the causal effects of perceived competence on intrinsic motivation: A test of cognitive evaluation theory. J Sports Psychol 1984;6:94– 102. 18. Crowe D. Analysis of the evaluation of a new glucose meter with integrated selfmanagement software and USB connectivity. J Diabetes Sci Technol 2011;55:1154–6.
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: w w w. c a n a d i a n j o u r n a l o f d i a b e t e s . c o m
Innovations in Diabetes Care
Evaluation of a Computerized Self-Management Tool for Children with Type 1 Diabetes: A Pilot Project Navita Dyal BHS, M Eng (cand) a,*, Karen McAssey BA, MD, MEd, FRCPC b, Gina Agarwal MBBS, PhD, MRCGP, CCFP c a
McMaster University, Faculty of Engineering, Hamilton, Ontario, Canada Department of Pediatric Endocrinology, McMaster Children’s Hospital, Michael G. DeGroote School of Medicine, Hamilton, Ontario, Canada c Gina Agarwal, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada b
a r t i c l e i n f o Article history: Received 20 May 2015 Received in revised form 29 September 2016 Accepted 29 September 2016
Introduction Pediatric diabetes is a rising global public health concern that is increasing in prevalence in developed and developing countries alike. The World Health Organization appeals to the medical community to develop effective interventions that will counteract the long-term negative health outcomes and high costs associated with diabetes (1). Self-monitoring blood glucose (SMBG) more than 3 times per day is significantly correlated with lower glycated hemoglobin (A1C) levels (2–6). However, traditional self-management tools do not coincide easily with the lifestyles of children. As a result, adherance to SMBG is compromised. Poor adherance to SMBG undermines its optimal benefits (7,8). A significant decline in SMBG is reported after the first year of diagnosis (5). Children as young as 10 years of age report that they are reluctant to self-monitor their blood glucose levels actively when they receive too many reminders from their parents (9). Thus, striking the right balance with the type and number of reminders is imperative (3). Creative interventions are needed to encourage and motivate patients to selfmonitor their blood glucose levels (10,11). Web-based interventions are showing promise as a means of increasing adherance to SMBG by individuals with chronic disease (12). KiDi SMS (Kids with Diabetes Self-Management System) is an interactive online tool designed for children with type 1 diabetes between the ages of 8 and 12 years. It was developed to improve patients’ adherence to SMBG. The purpose of this study was to assess whether KiDi SMS is an effective tool for motivating children to self-monitor their blood
* Address for correspondence: Navita Dyal, BHS, M Eng (cand), McMaster University, W Booth School of Engineering Practice & Technology, ETB-509, 1280 Main St. West, Hamilton, ON L8S 0A3, Canada. E-mail address: [email protected] 1499-2671 © 2016 Canadian Diabetes Association. http://dx.doi.org/10.1016/j.jcjd.2016.09.021
glucose levels daily. This study leverages off research that provides guiding principles concerning how technological interventions engage patients and facilitate necessary behaviour changes (13–15). Newton and Ashley evaluated the feasibility and effectiveness of a web-based intervention among adolescents with type 1 diabetes. This study found that 90% of participants indicated that they were more willing to adhere to their treatment protocol using the web-based intervention (14). Padman et al evaluated a mobile application, that targeted young adults and was available only on the Android platform (15). Both interventions were designed to increase adherence to SMBG (14,15). To our knowledge, this is the first web-based intervention targeting preteens, with the goal of improving SMBG.
Methods Intervention We recruited 13 participants by using a convenience sample from McMaster Children’s Hospital Pediatric Diabetes Clinic. Clinic staff identified potential participants based on their average rate of SMBG. Those who were logging their blood glucose fewer than 3 times per day were approached. Children between the ages of 8 and 12 years who had been diagnosed with type 1 diabetes for more than 1 year were included. Participants were also required to have Internet access at home. Participants who were already logging blood glucose levels more than 3 times per day were excluded. Access to this program was provided free of charge. The researchers did not provide any instructions about how to use the program so that intuitiveness and ease of use could be observed. Participants’ data were stored on an encrypted cloud-based server.
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Participants had to sign up online using their parents’ e-mail addresses to join KiDi SMS. The users were engaged the moment their profiles were created. The children enter basic data (age, gender, etc.) with the help of 2 animated characters, Julie and Tom. Julie is a fun-loving Canadian girl with pigtails, and Tom a hip island surfer with a Jamaican accent. Crisp graphics enable users to create animated avatars, which they can accessorize. Julie and Tom encourage users to enter their blood glucose readings in their online logbook at least 3 times per day. When entering blood glucose readings, users faced no constraints based on specific time intervals. As such, blood glucose readings could be entered at any time during the day. The online logbook was e-mailed to the participants’ parents at the end of each week, thereby facilitating any necessary discussions between parents and their children. Each day the children log a minimum of 3 blood glucose readings, a video game is unlocked. The KiDi SMS database houses hundreds of different games; therefore, no game is accessed twice. The games are equally appealing to boys and girls so as to keep the users engaged. Individuals prefer instant gratification to delayed rewards (13). Having the opportunity to access a new game daily can be considered an early reward. Once a game is unlocked, it is available only until midnight. Thus, in order to unlock another game, the user is required to log 3 more readings the following day. A system in which children are encouraged but not overwhelmed by reminders to self-manage is optimal. To avoid inundating users with diabetes-related information, KiDi SMS’ database of games is unrelated to diabetes self-management or education. Every time users enter blood glucose readings within their target ranges, an animated character giving them a thumbs-up praises them. Likewise, participants who enter readings that are outside of their target ranges receive pop-up messages alerting them that their readings are either too high or too low. The animated characters, Tom and Julie, subsequently provide tips on how to adjust lifestyle factors, such as diet and exercise, to achieve readings that are within the target range. Bar graphs are generated, illustrating average blood sugar levels at various time intervals. Tom and Julie encourage users to print these graphs and present them to their physicians at their next visits. There is an Ask Doctor function, where participants can e-mail their pediatric endocrinologists. After clicking this help button, a window pops up where the users can type their questions. These questions are immediately e-mailed to the children’s pediatric endocrinologists. Design and sample This was a descriptive pilot study that assessed feasibility primarily. Quantitative data, such as frequency of entering blood glucose levels and the use of the Ask Doctor function, were monitored. At the end of the study, participants and their parents were asked to participate in an online survey to determine the strengths and weaknesses of KiDi SMS from users’ perspectives. Ethical approval was obtained from the Faculty of Health Sciences Student Research Committee, McMaster University.
Results This study spanned 3 months and included 7 male and 6 female participants who had been diagnosed with diabetes for at least 1 year. The mean age of participants was 10 years (SD 1.05). Patient characteristics are presented in the Table 1. Of participants who created accounts, 85% (11 of 13) logged their blood glucose readings daily, and 82% (9 of 11) of participants who used KiDi SMS daily demonstrated a mean daily frequency of at least 3 logs. The mean daily frequency of SMBG, per participant, can be found in Figure 1.
Table 1 Variables of patients’ characteristics Study population (n=13) Gender, n (%) Female Male Age (years); (mean ± SD) Diagnosed with type 1 diabetes >1 year Logged blood glucose <3 times per day prior to intervention KiDi SMS usage Created an account Used online log book Never used program after creating an account
7 (54%) 6 (47%) 10.00±1.05 13 (100%) 13 (100%) 13 (100%) 11 (85%) 2 (15%)
SD, standard deviation.
Prior to this intervention, none of the participants had logged blood glucose ≥3 times per day (Figure 2). Of the 13 participants, 2 created online accounts but never logged their readings (Figure 1). The average frequency with which participants logged their blood glucose readings ranged between 2 and 6 times per day; 69% (9 of 13) of participants self-managed their blood glucose with an average daily frequency of more than 3 logs during the study period. Although 2 of 13 participants logged <3 readings per day, on average, these individuals reported that they had not logged their blood glucose readings at all prior to this intervention. Therefore, all participants who used the logbook function in KiDi SMS (11 of 13) demonstrated an increased average daily rate of SMBG during this study (Figure 2). During the first 2 weeks of the study, participants averaged 3 logged readings daily. The daily average frequency of logging increased significantly between weeks 3 and 5. In week 3, participants logged an average of 13 readings per day. In week 4, participants logged an average of 16 readings per day; and in week 5, participants logged an average of 34 readings per day. Although the daily average frequency decreased between weeks 6 and 7, relative to previous weeks, the rate was still above the target number of 3 logged readings per day. Users were very active during week 8, averaging 31 logged readings per day. There was a decrease between weeks 8 and 9, but the daily average did not fall below 3 daily logs. The average rate of logging remained constant between weeks 9 and 13, at 3 times per day (Figure 3). These average rates of SMBG correlate with participants’ utilizing the video game incentive. No one used the Ask Doctor function. Changes in A1C levels were not measured due to the relatively short duration of the study and the limited number of participants. Participants were surveyed online to determine whether they felt more encouraged to self-monitor their blood glucose levels daily after participating in this intervention, and 91% (10 of 11) answered in the affirmative. When users were asked to comment on their favourite feature of KiDi SMS, the majority (9 of 11) reported that they enjoyed being able to play a new game every day. The remaining participants noted an appreciation for the diversity of the animated characters, Tom and Julie. Some participants (3 of 11) indicated that their least favourite aspect of KiDi SMS was that it could not be accessed from their mobile phones or tablets. Parents were also asked to complete a online survey at the end of the study, and 100% of parents felt that KiDi SMS encouraged their children to log their blood glucose readings daily.
Discussion Of the 13 participants, 11 used KiDi SMS daily, and most were able to unlock a new game each day. Of participants who used KiDi
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Figure 1. Mean frequency of SMBG before and after the intervention.
Figure 2. Mean daily frequency of blood sugar logging for the entire group.
SMS daily, 82% (9 of 11) demonstrated a mean daily frequency of at least 3 logs. All participants had logged their blood glucose readings fewer than 3 times per day prior to this intervention. This suggests that the use of KiDi SMS was an effective incentive. Studies have shown that intrinsic motivation, the internal desire to perform a task, is a longer lasting type of motivation (16). Furthermore, informational rewards like praise can enhance intrinsic motivation (17). It can be postulated that the steady daily average of SMBG between the first 2 weeks was a result of users’ familiarizing themselves with the program just enough so they could unlock the game. The significant increase in SMBG between weeks 3 and 5 could be attributed to participants’ being intrigued by the program and motivated to log their blood glucose readings frequently. However, logging an average of 34 times per day during week 5 is extraordinarily high. Perhaps, once users realized that a game was unlocked every time they logged 3 blood glucose readings, they became curious about whether they would be able to unlock a new game after logging an additional 3 readings. There is also a possibility of a novelty effect, whereby the users are so enthralled by the technology at the beginning of the intervention that they use it frequently. KiDi SMS was designed to provide an incentive for SMBG, but we did not want to encourage sedentary behaviour. As such, a maximum of 1 game could be unlocked each day. Participants were not given instructions about how to use the program prior to creating their accounts, so they were not aware of this. Thus, we believe that the high influx of SMBG readings during weeks 3 to 5 could be attributed to children trying earnestly to access more than 1 game within a 24-hour period. A future modification of the program could be implementation of a maximum amount of SMBG data to be
entered per day. Once this maximum is reached, participants will not be able enter additional readings until the following day. KiDi SMS could be refined to limit the number of entries per time interval that a user could enter (e.g. 6 am to 10 am, 10 am to 12 pm, etc.). Perhaps a maximum of 2 entries per time interval would also ensure that users are checking their blood glucose at the recommended times, i.e. before meals and at bedtime. An area for future exploration would be to compare the blood glucose entries on KiDi SMS with the patients’ glucometers. This would provide a better understanding of the accuracy of the users’ daily logs. Weeks 8 and 9 corresponded with the Christmas season. This may explain why there was a decrease in the rate of logging during these weeks. It is encouraging to observe that participants’ usage of KiDi SMS did not cease after the study period concluded. Instead, this program has become an important part of the users’ selfmanagement regimes. The 2 participants who created online accounts but never logged a single blood glucose reading did not withdraw from the study. These 2 individuals never used the online logbook, so they did not experience the full dynamic of the program. Thus, it would be unfair to assume that the program was insufficient in motivating these 2 users to log their blood sugar readings regularly. Feedback from 1 of these 2 families indicated that the reason their children did not use KiDi SMS was that the children could not juggle this commitment with school and extracurricular activities. These 2 individuals also indicated that the program had a “younger feel.” Both children were 12 years old and therefore on the cusp of being teenagers. It is possible that they felt that it was not well suited for their age and subsequently decided against using the program.
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Figure 3. Sample image from program.
Neither participants nor their parents were provided with any instructions about how to navigate this online tool. Because 85% of the participants used KiDi SMS daily, it can be deduced that the program was fairly intuitive and easy to use. Feedback from participants and their parents indicated that a mobile application would be more convenient and, therefore, more appealing. Social media features were found to be a key factor driving user engagement in a mobile application targeting young adults with diabetes (15). Participants in the mobile application study were able to friend other users and chat with them online (15). This is an area for exploration, should KiDi SMS be developed into a mobile application in the future. No one used the Ask Doctor function, but it is noteworthy that participants are patients of a highly specialized, intradisciplinary diabetes clinic where patients and their families receive ongoing diabetes education. However, not all children with type 1 diabetes have access to this level of care. An area of future study could be to compare this pilot study to a similar study of children with diabetes who are not patients of a specialized pediatric diabetes clinic. The Ask Doctor function may be an untapped potential for children in medically underserved areas. However, it is noteworthy that in its current form, KiDi SMS does require an Internet connection, so it would implicitly exclude certain populations who lack access to this technology. The online logbook was e-mailed to the participants’ parents at the end of each week. We hoped that this would facilitate discussion between parents and their children. However, we did not develop any empirical method for determining whether this function did, indeed, increase family discussion.
It may be argued that glucometers that store blood glucose readings on a USB drive makes KiDi SMS redundant. However, when blood glucose readings are automatically stored, the users are not actively involved in SMBG (18). These data are valuable to physicians, but they do not motivate users to make diabetes management adjustments immediately (18). By entering blood glucose readings in KiDi SMS and receiving instant feedback, users are encouraged to make any required adjustments to their daily activities. An area for future exploration would be to determine the effect KiDi SMS has on A1C levels.
Conclusions KiDi SMS motivated 85% of its users to self-manage their blood glucose readings daily. This is a significant improvement in this group; all participants logged fewer than 3 times per day prior to the intervention. This study was designed as a simple feasibility study; future development of this program could explore the effect KiDi SMS has on A1C levels. Another area of future study would be to determine whether KiDi SMS as a cell phone application would motivate more children to self-monitor. A reward system for having blood glucose readings within the users’ target ranges might be included. Participants could gain health points for each reading that is within the target range. The study population could be broadened to include children who are currently logging 3 times per day or more to determine whether these children would become more engaged in SMBG after using KiDi SMS. These additional trials may serve to further improve KiDi SMS.
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More than 250 000 health-related mobile applications are available for iPhones, and more than 30 000 for Android phones (15). Mobile phones are available worldwide and have simple user interfaces. Thus, an evaluation of the utilization of the Ask Doctor function among children who lack access to care would be an intriguing area of future study. We plan to use the data collected in this study to pursue the development of KiDi SMS as a mobile application.
Acknowledgments This work originated at McMaster University, and study participants were recruited from McMaster Children’s Hospital. We sincerely thank Mrs. Victoria Rajkumar for volunteering her time to assist with the computer programming.
Author Contributions ND designed the computer program KiDi SMS. She analyzed the data obtained, in addition to drafting and revising the manuscript; GA supervised the design of KiDi SMS, provided insight into the analysis of the data and critically revised the manuscript; KM substantially contributed to the development of KiDi SMS, provided guidance for interpreting the data and critically revised the manuscript before giving final approval of the version to be published.
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