title: Improving diabetes care for young people with type 1 diabetes through visual learning on mobile phones: mixed-methods study.
abstract: BACKGROUND
  Only 17% of Norwegian children and adolescents with diabetes achieve international treatment goals measured by glycated hemoglobin (HbA(1c)). Classic patient-physician consultations seem to be poorly adapted to young children. New strategies that are better attuned to young people to improve support of adolescents' self-management of diabetes need to be tested and evaluated.
  
  
  OBJECTIVE
  (1) To explore how applications for mobile phones can be used in follow-up of adolescents with type 1 diabetes, and (2) to use the findings to guide further development of the applications and as a basis for future studies.
  
  
  METHODS
  We pilot tested two mobile phone applications: (1) an application that contained a picture-based diabetes diary to record physical activity and photos taken with the phone camera of food eaten, where the phone also communicated with the glucometer by Bluetooth technology to capture blood glucose values, and (2) a Web-based, password-secured and encrypted short message service (SMS), based on access using login passwords received via SMS to be used by participants to send messages to their providers when they faced obstacles in everyday life, and to send educational messages to the participants. At the end of the 3-month pilot study, 12 participants (7 girls and 5 boys ) aged 13-19 years completed semistructured interviews. The participants had a mean HbA(1c )value of 8.3 (SD 0.3), mean age of 16.2 (SD 1.7) years, mean body mass index of 23.3 (SD 3.2) kg/m(2), and mean diabetes duration of 7.5 (SD 4.6) years. We applied three additional measurements: change in metabolic control as measured by HbA(1c), the System Usability Scale, and diabetes knowledge.
  
  
  RESULTS
  From the interviews, three main categories emerged: visualization, access, and software changes. Participants appreciated the picture-based diary more than the SMS solution. Visualization of cornerstones in diabetes self-care (ie, diet, insulin dosage, physical activity, and pre- and postprandial glucose measurements all transformed into one picture) in the mobile diary was found to be an important educational tool through reflections in action. This led to a change in participants' applied knowledge about the management of their disease. Additional measurements supplemented and supported the qualitative findings. However, changes in HbA(1c )and participants' theoretical knowledge as tested by a 27-item questionnaire, based on a national health informatics' diabetes quiz, before and after the intervention were not statistically significant (P = .38 and P = .82, respectively, paired-samples t test). Participants suggested additional functionality, and we will implement this in the design of the next software generation.
  
  
  CONCLUSIONS
  Participants reported an increased understanding of applied knowledge, which seem to positively affect diabetes self-care. Visual impressions seem well adapted to the maturation of the adolescent brain, facilitating the link between theoretical knowledge and executive functions. SMS gave the adolescents a feeling of increased access and security. Participants gave valuable input for further development of these applications.
authors.affiliation: Research Centre for Child and Youth Competence Development, Lillehammer University College, Lillehammer, Norway.
authors.forename: Dag Helge
authors.initials: DH
authors.lastname: Frøisland
authors.forename: Eirik
authors.initials: E
authors.lastname: Arsand
authors.forename: Finn
authors.initials: F
authors.lastname: Skårderud
mesh_terms: D022126:Access to Information; D000293:Adolescent; D040421:Cell Phone; D003196:Computer Graphics; D003922:Diabetes Mellitus, Type 1 / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D009664:Norway; D010865:Pilot Projects; D012648:Self Care / Q000379:methods*; D012984:Software; D060145:Text Messaging; D055815:Young Adult