Access to and Interest in Using Smartphone Technology for the Management of Type 1 Diabetes in Ethnic Minority Adolescents and Their Parents

Abstract

Background:

A better understanding of parent and adolescent interest in using smartphone technology for type 1 diabetes (T1D) management is needed prior to developing technology-based interventions for ethnic minorities. This study examined access to and interest in technology-based programs for T1D in primarily Hispanic adolescents and their parents.

Subjects and Methods:

During a scheduled clinic visit, adolescents with T1D (n = 50; 52% female; 13.6 ± 2.0 years old; 74% Hispanic; hemoglobin A1c = 8.9 ± 1.7%) and their parents (n = 49; 54% household income <$49,000) completed brief self-report surveys.

Results:

Adolescents reported having access to the Internet (98%) and their own smartphones (86%). Thirty-seven percent reported using smartphone applications (apps) for their diabetes care, with 88% reporting carbohydrate counting as its primary function. Although most participants reported high/moderate interest in diabetes-specific apps, girls were more likely than boys to endorse high interest in apps to calculate and track insulin doses. A greater proportion of parents than of adolescents expressed high interest in apps to track glucose, count carbohydrates, calculate insulin doses, track insulin use, and receive diabetes-related reminders. A greater proportion of parents than of adolescents also endorsed interest in a program that combined Internet use with smartphone apps.

Conclusions:

Results suggest ethnic minority adolescents with T1D across a range of income levels have access to smartphones. Although most parents expressed high interest in diabetes-specific apps, there was greater variability in adolescent interest. Understanding barriers and facilitators to the use of smartphone apps for diabetes care in ethnic minority adolescents may increase their interest in and ultimate adoption of this technology.

Background

Type 1 diabetes (T1D) affects approximately 1.93 in 1,000 youth in the United States,¹ and its incidence is increasing worldwide.^2,3 Recent projections indicate up to a 144% increase in T1D for those <20 years old by the year 2050, with the greatest increase estimated for ethnic minority youth.² Ethnic minority youth with T1D are more likely to have poor glycemic control than are non-Hispanic white youth, placing them at higher risk for serious health complications (e.g., retinopathy, neuropathy, cardiovascular disease).⁴ In fact, most youth, but particularly those from lower-income, ethnic minority backgrounds, do not meet national or international clinical guidelines for proper glycemic control.⁵ Because increased self-monitoring and tight glycemic control early in the disease course have been shown to reduce risks for health complications among youth,^6,7 the need to develop, evaluate, and disseminate innovative interventions to improve self-monitoring behaviors and glycemic control for ethnic minority youth, and specifically adolescents, who are known to experience a high rate of regimen adherence issues (e.g., insulin omission, failure to bolus, low blood glucose self-monitoring),⁸ is warranted.

Although previous randomized controlled trials highlight efficacious approaches for improving regimen adherence and achieving good glycemic control in adolescents with T1D (e.g., family-based interventions focused on enhancing behavioral skills and positive parenting),^9,10 few of these programs have been evaluated in “real world” practice settings within the context of an effectiveness trial. In addition, a high proportion of patients experience considerable barriers to adequate clinical care due to a range of individual- (e.g., patients' distance from clinics) and/or broader system- (e.g., lack of trained behavioral health specialists, difficulties with reimbursement) level factors.^11,12 One way to address this lack of access to evidence-based behavioral health services and generally poor reach to adolescents with T1D may be through the use of Web-based and smartphone technology.

Technology use among adolescents has become pervasive, with data from a nationally representative survey indicating 95% of adolescents access the Internet and 78% have a cell phone.¹³ Between 2011 and 2013, the percentage of youth with smartphones increased from 23% to 37%.¹³ Although adolescents with more educated parents and/or from higher-income households are more likely to have a cell phone, this same linear relationship has not been found for smartphones. Instead, data indicate adolescents from the lowest earning households (<$30,000 per year) are just as likely to own a smartphone as those from the highest earning households (≥$75,000 per year).¹³ Surprisingly, a slightly higher percentage of ethnic minority youth, including Hispanic (43%) and African American (40%) adolescents, reported owning smartphones in 2012 than did non-Hispanic white youth (35%).¹³ The use of Web-based and mobile/smartphone technology thus presents a promising and viable option for reaching ethnic minority populations and improving T1D management in those at greatest risk for poor glycemic control.

Despite the wide use of Web- (eHealth) and cell phone– (mHealth) based interventions across a range of physical and mental health outcomes,^14,15 including diabetes in adults,¹⁶ few studies have used these approaches for T1D in youth.^{17

–25} One study using an Internet–based problem-solving program for adolescents with T1D demonstrated improvements in youth self-management, problem solving, and glycemic control.¹⁷ Similarly, in a large multisite trial, the combination of diabetes education and coping skills training delivered by the Internet was found to be efficacious in improving glycemic control, self-efficacy, and quality of life in 11–14-year-old youth with T1D.^20,21 Cell phone–based approaches have additionally been explored,^23
–25 with a text messaging intervention showing improvements in youth self-efficacy and T1D regimen adherence.²⁵ More recently, the use of smartphone applications (apps) for diabetes self-management has proliferated.^26,27 Although these apps have demonstrated improved glycemic control with primarily adult samples, a pilot study demonstrating improvements in adolescent blood glucose monitoring following the use of a diabetes app²⁴ suggests these approaches are promising in youth.

Overall, available evidence indicates the potential for eHealth and mHealth programs for youth with T1D to improve health behaviors. However, the majority of studies have not tested technology-based approaches in ethnic minority adolescents. Prior to developing, evaluating, and disseminating smartphone apps for ethnic minority adolescents with T1D, a better understanding of parent and adolescent interest in these types of programs is needed. This study examined access to and interest in using Web-based and smartphone technology for managing T1D in a sample of primarily Hispanic adolescents and their parents.

Subjects and Methods

Participants

Participants were adolescents with T1D (n = 50) and their parents (n = 49) who volunteered to complete separate anonymous surveys during a regularly scheduled visit to a pediatric diabetes specialty clinic that serves a high percentage of low-income, ethnic minority youth and their families.

Procedure

Upon arrival in the clinic, patients between the ages of 11 and 16 years and their caregivers were asked by clinic staff to complete brief, anonymous surveys related to technology and its role in the management of T1D. If patients agreed to complete the surveys, they were offered a choice between English- and Spanish-language versions and instructed to complete them while they waited to see their doctors. The majority of parents (82%) and all adolescents completed English language surveys. Once surveys were completed, nursing staff collected them and placed them in a de-identified folder kept separate from patients' medical charts. A waiver of consent was approved by the local institutional review board. Surveys were distributed and collected in the fall of 2013.

Measures

Demographic data were collected from parent surveys, and t tests were used to examine demographic mean differences in hemoglobin A1c between boys versus girls and pump users versus nonusers. Parent and adolescent surveys assessed current access to various forms of technology (e.g., Internet, texting, smartphones) and interest (not, somewhat, or very interested) in using Web-based technology and smartphone apps for diabetes self-management (e.g., tracking glucose, counting carbohydrates, and calculating insulin doses). These data are presented as frequencies based on parent and adolescent responses, and χ² tests were additionally conducted to examine differences in access to and interest in technology between boys versus girls, pump users versus nonusers, and current app users versus nonusers.

Results

Participants

Participants were primarily from racial and/or ethnic minority groups: 66% Hispanic white, 4% Hispanic black, 4% Hispanic (race not reported), 14% non-Hispanic black, 8% non-Hispanic white, 2% Asian, and 2% not reported. The average adolescent was female (52%) and 13.55 ± 1.98 years old and was covered by Medicaid health insurance (52%) at the time surveys were completed. Participants reported being diagnosed with T1D at the age of 6.95 ± 3.53 years of age. The majority used multiple daily insulin injections (i.e., 54%) or insulin pumps (32%). Most recent adolescent hemoglobin A1c level was 8.91 ± 1.73%, with no significant mean differences between boys versus girls or pump users versus nonusers. Annual household income ranged from ≤$24,000 (38%), $25,000–49,000 (16%), $50,000–74,000 (6%), to >$100,000 (16%), with 10% of caregivers not reporting income.

Access to and interest in technology for T1D management

Table 1 and Figure 1 give summaries of parent and adolescent responses to survey items related to access to technology, their current use of technology for T1D management, and their interest in using Web-based and smartphone technology for T1D management.

FIG. 1.

(Left) Type of smartphone used and (right) most frequently reported applications (apps) for types 1 diabetes (T1D) management reported by adolescents.

Table 1.

Participant Access to and Interest in Using Technology for Type 1 Diabetes Management

	Parent (n = 49)	Adolescent (n = 50)
Access to technology
Adolescent has Internet access (multiple locations)	98%	98%
Adolescent has Internet access (at home)	92%	94%
Adolescent uses e-mail	63%	64%
Adolescent texts	94%	92%
Adolescent has smartphone	83%	86%
Parent has smartphone	72%	—
Adolescent's smartphone ever disconnected	20%	19%
Current use of technology for T1D management
Adolescent uses apps for diabetes	37%	37%
Purpose of diabetes apps for adolescent app users
Track glucose	20%	0%
Count carbohydrates	87%	88%
Calculate insulin dose	13%	25%
Reminders for care	13%	19%
Adolescent uses computer software to track glucose	26%	14%
Adolescent uses computer software to track insulin	50%	25%
Interest in using technology for T1D management
Very interested in diabetes-specific apps
For tracking glucose	76%	44%
For counting carbohydrates	80%	46%
For calculating insulin dose	71%	36%
For tracking insulin use	69%	36%
For diabetes reminders	80%	52%
Somewhat interested in diabetes-specific apps
For tracking glucose	14%	40%
For counting carbohydrates	12%	36%
For calculating insulin dose	18%	44%
For tracking insulin use	18%	26%
For diabetes reminders	8%	24%
Interested in using Internet/smartphone program for T1D management
Yes	86%	48%
Maybe	10%	40%
No	4%	12%

T1D, type 1 diabetes.

Access to technology

Most adolescents reported having access to the Internet (98%), using e-mail regularly (63%), texting (92%), and having a smartphone (86%). There were no differences in access to technology between boys versus girls or between pump users versus nonusers. Sixty percent of adolescents with smartphones reported having an Apple (Cupertino, CA) iPhone^®, and approximately one-fifth (19%) reported occasional problems with their smartphones being disconnected because of billing issues. The majority of parents (72%) also reported having smartphones.

Current use of technology for T1D management

Over one-third of adolescents who reported having smartphones (37%) reported using existing apps to aid in their diabetes care. These adolescents (n = 16) were primarily Hispanic (63%), female (63%), 13.69 ± 1.92 years old, and covered by private insurance (50%) at the time surveys were completed. In addition, their most recent hemoglobin A1c measurement was 8.81 ± 2.19%. There were no significant demographic differences between current diabetes app users and nonusers. The majority of diabetes app users (88%) reported carbohydrate counting as the apps' primary function. Other reported uses for current apps included the calculation of insulin doses (25%) and reminders for care (19%). The three most frequently cited apps used for T1D management included “Calorie King” (44%), “Bolus Calc” (25%), and “My Fitness Pal” (19%). Parents and adolescents also reported using computer software programs to track the adolescents' glucose level (14% adolescents, 26% parents) and, for pump users, to track insulin (25% adolescents, 50% parents).

Interest in using technology for T1D management

Most parents and adolescents reported being either “very” or “somewhat” interested in using apps for diabetes. Girls were more likely than boys (55% vs. 13%) to endorse high interest in apps to calculate insulin dose [χ²(2) = 10.59, P < 0.05] and to track insulin use [48% vs. 21%; χ²(2) = 7.65, P < 0.05]. There were no other differences between boys and girls in interest in using technology; there were also no differences between pump users and nonusers or between current app users and nonusers in interest in using technology. A greater proportion of parents versus adolescents, however, expressed high interest in apps to track glucose (76% vs. 44%), count carbohydrates (80% vs. 46%), calculate insulin doses (71% vs. 36%), track insulin use (69% vs. 36%), and receive diabetes-related reminders (80% vs. 52%). A greater proportion of parents versus adolescents (86% vs. 48%) also endorsed high interest in a program that combined Internet use with smartphone apps for the management of T1D.

Discussion

The present study examined access to and interest in using Web-based and smartphone technology for the management of T1D in ethnic minority youth and their parents who were attending a diabetes clinic. Adolescents reported having a high degree of access to both the Internet and their own smartphones. Over one-third reported using smartphone apps to manage different aspect of their diabetes care. In terms of their interest in diabetes-specific apps, girls were more highly interested than boys in apps to calculate and track insulin use, and a greater proportion of parents versus adolescents expressed a high degree of interest in apps and in a program that combined Internet use with smartphone apps. Results highlight the relevance of smartphone technology for future T1D intervention efforts and the importance of conducting formative work that seeks to better integrate the perspectives of ethnic minority adolescents in the process of developing smartphone apps for diabetes care.

This study expands on previous work by providing data on access to technology in an underserved clinical population (i.e., ethnic minority adolescents with T1D) as well as information on how they currently use technology to manage their diabetes care. Results are consistent with previous research demonstrating that ethnic minority adolescents across a range of household income levels have a high degree of access to various forms of technology, including Internet use and cell phones (of any kind).¹³ Findings from the present study are additionally encouraging given double the participants reported owning their own smartphone in 2013 (86%) than did either Hispanic (43%) or African American youth (40%) from a nationally representative survey collected in 2012.¹³ These differences may be attributed to differences in sample characteristics or may reflect an overall growth in adolescent smartphone access. Nearly 40% of adolescents in this study also reported using either diet/fitness-related or diabetes-specific apps (i.e., “Calorie King,” “Bolus Calc,” “My Fitness Pal”) primarily for counting carbohydrates and calculating insulin doses. Importantly, because participants in the present study completed surveys during a regularly scheduled clinic visit, findings may not generalize to those who are not receiving continuous medical care. Overall, however, the high rate of smartphone access by ethnic minority youth coupled with the fact that most existing apps for diabetes do not conform to evidence-based guidelines^28,29 highlights an opportunity for increased research on diabetes-specific smartphone app development and evaluation in ethnic minority youth.

As apps are developed and tested, results from this study also suggest there is a need to better understand potential barriers and facilitators to app use by ethnic minority families, and adolescents in particular, to increase their interest in and ultimate adoption of this technology. In the pilot test of a mobile health app for diabetes self-management in adolescents with T1D, Cafazzo et al.²⁴ used “user-centered design methods” to involve end users in the design process through qualitative interviews and focus groups. As a result of this process, apps were designed to be simple, to automatically transfer glucose readings, and to use games to reward adherence behaviors in the form of iTunes^® (Apple) music and apps. Participants reported being highly satisfied with the app, noting they were likely to continue using it beyond the study period. Given adolescents in this study demonstrated greater variability in their interest in these types of programs than did parents, it is recommended that similar app development methods be used for ethnic minority youth and their parents who face unique barriers to care.¹² Additionally, and because 40% of youth reported owning smartphones other than Apple's iPhone, ensuring apps are compatible with multiple operating systems throughout this process will be important in maximizing their reach. If designed with participant input and found to be highly acceptable, mobile health technology has the potential to reduce significant barriers in access and therefore improve racial/ethnic disparities in glycemic control for youth with T1D.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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