title: Long-term engagement with a mobile self-management system for people with type 2 diabetes.
abstract: BACKGROUND
  In a growing number of intervention studies, mobile phones are used to support self-management of people with Type 2 diabetes mellitus (T2DM). However, it is difficult to establish knowledge about factors associated with intervention effects, due to considerable differences in research designs and outcome measures as well as a lack of detailed information about participants' engagement with the intervention tool.
  
  
  OBJECTIVE
  To contribute toward accumulating knowledge about factors associated with usage and usability of a mobile self-management application over time through a thorough analysis of multiple types of investigation on each participant's engagement.
  
  
  METHODS
  The Few Touch application is a mobile-phone-based self-management tool for patients with T2DM. Twelve patients with T2DM who have been actively involved in the system design used the Few Touch application in a real-life setting from September 2008 until October 2009. During this period, questionnaires and semistructured interviews were conducted. Recorded data were analyzed to investigate usage trends and patterns. Transcripts from interviews were thematically analyzed, and the results were further analyzed in relation to the questionnaire answers and the usage trends and patterns.
  
  
  RESULTS
  The Few Touch application served as a flexible learning tool for the participants, responsive to their spontaneous needs, as well as supporting regular self-monitoring. A significantly decreasing (P<.05) usage trend was observed among 10 out of the 12 participants, though the magnitude of the decrease varied widely. Having achieved a sense of mastery over diabetes and experiences of problems were identified as reasons for declining motivation to continue using the application. Some of the problems stemmed from difficulties in integrating the use of the application into each participant's everyday life and needs, although the design concepts were developed in the process where the participants were involved. The following factors were identified as associated with usability and/or usage over time: Integration with everyday life; automation; balance between accuracy and meaningfulness of data with manual entry; intuitive and informative feedback; and rich learning materials, especially about foods.
  
  
  CONCLUSIONS
  Many grounded design implications were identified through a thorough analysis of results from multiple types of investigations obtained through a year-long field trial of the Few Touch application. The study showed the importance and value of involving patient-users in a long-term trial of a tool to identify factors influencing usage and usability over time. In addition, the study confirmed the importance of detailed analyses of each participant's usage of the provided tool for better understanding of participants' engagement over time.
authors.affiliation: Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway. naoe.tatara@telemed.no.
authors.forename: Naoe
authors.initials: N
authors.lastname: Tatara
authors.forename: Eirik
authors.initials: E
authors.lastname: Arsand
authors.forename: Stein Olav
authors.initials: SO
authors.lastname: Skrøvseth
authors.forename: Gunnar
authors.initials: G
authors.lastname: Hartvigsen
keywords: Type 2 diabetes; mHealth; mobile phone; self-management; usability; usage; user-involved design process
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