A pilot study has taken place to examine how mHealth can empower people to adhere to diet, exercise, and medication plans to manage their disease. Experts from the Bulgarian National Centre of Public Health and Analyses tell us about the results, and what it can mean for the development of future mHealth interventions.
Written by Prof. Plamen Dimitrov, MD, PhD & Mirela Strandzheva, MSc
How can we improve the prevention, early detection and quality of care for people with chronic diseases? Between 2014 and 2017, experts from across Europe came together to identify a set of quality criteria and formulate recommendations under the Joint Action CHRODIS. Since 2017, pilot projects have been carried out based on those reconditions covering primary prevention, quality care, integrated multimorbidity care, and employment and chronic diseases. This work is being carried out under the successor action CHRODIS PLUS (2017-2020).
A Bulgarian intervention: empowering diabetes patients to take control of their disease
Following pre-defined steps for designing, implementing and evaluating interventions, the Bulgarian National Centre of Public Health and Analyses (NCPHA) has set up a pilot intervention and is now evaluating the applicability of JA CHRODIS’s recommendations and criteria.
Diabetes self-management is a cornerstone in preventing long-term complications. NCPHA’s pilot aimed to assist and empower people who are diagnosed with diabetes. The intervention relied on mHealth technology to assist participants to adhere to diet, exercise, and medication plans in view of the ever-changing world of faced-paced technology and the redesigning of healthcare systems.
For the intervention, two groups of participants were recruited by the NCPHA with the close collaboration of the Bulgarian Diabetes Association. Participants’ were over 18 years of age, had been diagnosed with diabetes, had access to a smartphone and were familiar with smartphone technology basics. Participants were first contacted via an email and/or a telephone call. They received a detailed instruction package containing information about the nature of the study, an information sheet, and a detailed video with written instructions on how to download and use the mobile application. To prevent technology-related issues with the app, participants were given the opportunity to receive further assistance via e-mail or telephone.
The first group of participants (N=11) received the enhanced version on the mobile app with personalised feedback from a healthcare practitioner and an embedded health education module, while the second one (N=8) received a basic version of the app. The involved practitioner went through a face-to-face training with the local working implementation group. Two teams of the University of Ulm and of the Otto von Guericke University Magdeburg provided troubleshooting support and delivered statistical insights on participants’ performance. The pilot aimed to examine the extent to which both versions of the mHealth app helped patients to obtain more control over their disease and also investigated the extent to which the practitioner was satisfied with the patients’ performance.
Evaluating the impact of the intervention
The impact of the intervention was evaluated through an analysis of the participants’ performance with the mHealth application through structured end-of-study questionnaires, conducted through a telephone interview session or a questionnaire, received via the email. The statistical results were based on approximately 22 days of interaction for the basic app and 60 days of interaction for the enhanced version.
The results indicated that participants that worked with the extended app had higher involvement and lower dropout rates. Patients that used the basic app had a significant increase of physical exercises, as well as better control over the disease halfway throughout the intervention, although, this result may be explained by the low number of participants at the time of the analysis. Further analysis is still to be conducted, as the intervention that used the basic app took place several weeks after the intervention that used the extended app and the intervention was not yet finished during the preliminary statistical analysis.
Reports from the end-of-study interviews indicated that participants benefited from the interventions in place, whether using the basic or the extended app. 12 out of all 19 participants said that the mHealth tool met their diabetic needs, and 11 of them indicated that their control over the disease had improved. Participants from the enhanced intervention appreciated the fact that a practitioner was involved in the provision of feedback and stressed the need to formulate feedback in a more personalised manner. This perspective was reinforced by the practitioner, who stressed the importance of two-way communication between patients and healthcare providers. The practitioner appreciated the weekly statistical reports of the patients’ data (which were extracted from the app) and was satisfied by the performance of the participants. Additionally, the practitioner highlighted that close relationships between patient and practitioner should be considered as a prerequisite for motivation to use and benefit from a mobile app, and that the real value in the system resides in human interactions.
Patient care is about to evolve dramatically, and the NCPHA’s pilot intervention proposes alternative therapeutic support for people with diabetes. It gives individuals the opportunity to benefit from an easy-to-use application, meant to facilitate and stimulate monitoring of one’s daily condition not only through daily monitoring features, but also through expert feedback and educational features. Quality healthcare outcomes depend upon patients’ adherence to recommended regimens. If patients are guided towards better self-management, they feel more motivated to take control of their disease and need less medical attention, which in return, will lower the financial impact on our healthcare systems. Future implementations of the pilot may help tackle difficulties related to the scarcity of specialists in remote and disadvantaged regions by promoting self-control and self-discipline among people with chronic diseases by means of a mobile device.
 These pilot action is financed through the funding mechanism of JA CHRODIS+, under the third EU Health Programme 2014-2020
 Zaletel, J.& Maggini, M. (2020). Fostering the Quality of Care for People with Chronic Diseases, from Theory to Practice: The Development of Good Practices in Disease Prevention and Care in JA CHRODIS PLUS Using JA CHRODIS Recommendations and Quality Criteria. International Journal of Environmental Research and Public Health. 17 (3), 951. https://www.ncbi.nlm.nih.gov/pubmed/32033038
Header photo courtesy of World Obesity Federation/ Image bank