Petersen and Hempler BMC Medical Informatics and Decision Making (2017) 17:91

DOI 10.1186/s12911-017-0493-6

RESEARCH ARTICLE Open Access

Development and testing of a mobile

application to support diabetes self-
management for people with newly
diagnosed type 2 diabetes: a design
thinking case study
Mira Petersen and Nana F. Hempler*

Abstract
Background: Numerous mobile applications have been developed to support diabetes-self-management. However,
the majority of these applications lack a theoretical foundation and the involvement of people with diabetes during
development. The aim of this study was to develop and test a mobile application (app) supporting diabetes self-
management among people with newly diagnosed type 2 diabetes using design thinking.
Methods: The app was developed and tested in 2015 using a design-based research approach involving target users
(individuals newly diagnosed with type 2 diabetes), research scientists, healthcare professionals, designers, and app
developers. The research approach comprised three major phases: inspiration, ideation, and implementation. The first
phase included observations of diabetes education and 12 in-depth interviews with users regarding challenges and
needs related to living with diabetes. The ideation phrase consisted of four interactive workshops with users focusing
on app needs, in which ideas were developed and prioritized. Finally, 14 users tested the app over 4 weeks; they were
interviewed about usability and perceptions about the app as a support tool.
Results: A multifunctional app was useful for people with newly diagnosed type 2 diabetes. The final app comprised
five major functions: overview of diabetes activities after diagnosis, recording of health data, reflection games and goal
setting, knowledge games and recording of psychological data such as sleep, fatigue, and well-being. Users found the
app to be a valuable tool for support, particularly for raising their awareness about their psychological health and for
informing and guiding them through the healthcare system after diagnosis.
Conclusions: The design thinking processes used in the development and implementation of the mobile health app
were crucial to creating value for users. More attention should be paid to the training of professionals who introduce
health apps.
Trial registration: Danish Data Protection Agency: 2012-58-0004. Registered 6 February 2016.
Keywords: Mobile application, Type 2 diabetes, Diabetes support, Diabetes self-management, Design thinking,
Qualitative methods

* Correspondence: [email protected]
Health Promotion Research, Steno Diabetes Center Copenhagen, Niels
Steensens Vej 6, Copenhagen 2820, Gentofte, Denmark

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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Petersen and Hempler BMC Medical Informatics and Decision Making (2017) 17:91 Page 2 of 10

Background which the target group is actively involved in develop-

In Denmark and internationally, the prevalence of ing and testing the usability and usefulness of an app
type 2 diabetes is growing rapidly, especially in high- [10, 13, 14].
income countries [1]. The increase is related to aging The objective of this study was to use the principles
populations, economic development, a less healthy of design thinking to collaborate with newly diag-
diet, increasing urbanization, and reduced physical nosed individuals with type 2 diabetes to create an
activity [1]. As a consequence, diabetes has a signifi- app supporting diabetes self-management and test the
cant economic impact on nations and national health usability and usefulness of the app.
systems because of increased use of health services,
lower productivity, and the need for long-term sup- Methods
port to reduce diabetes-related complications [2, 3]. The study was conducted collaboratively by the Capital
Consequently, in diabetes care, self-management Region of Denmark, the Municipality of Copenhagen, an
and education are considered core elements of redu- information technology company, a general practice, and
cing risk factors and long-term disability and prevent- Steno Diabetes Center. Collaborators shared roles and
ing diabetes-related complications [4, 5]. People with responsibilities, such as recruiting patients, validating
type 2 diabetes provide the majority of their own care content of the app in relation to evidence-based clinical
between clinic visits that total less than two hours of guidelines, and app design and development. The study
formal diabetes care per year [6]. However, advances was conducted on the basis of a public grant for the
in smartphone technology have led to new opportun- development of digital solutions for management of
ities for supporting diabetes self-management and newly diagnosed type 2 diabetes.
delivering diabetes education. A promising approach Individuals who were newly diagnosed with type 2
is Mobile Health (mHealth). MHealth is defined as diabetes were involved in all processes. Each activity
“medical and public health practices supported by such as workshops, observations, interviews or testing
mobile devices, such as mobile phones, patient involved new participants (users); only one user
monitoring devices, personal digital assistants and participated in all three phases of the study. In addition,
other wireless devices [7]. Benefits related to diabetes we involved healthcare professionals (five GPs, a
care may include improved health behavior and physician, two diabetes nurses and two GP secretaries)
clinical outcomes, an easier transition to life with in app development and testing. Researchers from Steno
diabetes, and increased access to the healthcare Diabetes Center with backgrounds in public health,
system brand [8–11]. behavioral, and educational science were the primary
The adoption of smartphones by the general public investigators of the study, which took place between
has increased dramatically. In Denmark, 77% of all December 2014 and January 2016.
families own at least one smartphone and 50% own a
tablet [12]. The rising numbers emphasize the potential Study design
for developing mobile applications (apps) as support We applied the methodology of design thinking,
tools for diabetes self-management. A multitude of which is an innovative human-centered approach to
diabetes apps are already available. As shown by Vitger developing new solutions [15]. Design thinking
et al., the number of diabetes apps available through addresses the needs of the people who will consume
Apple’s App Store has increased steadily from approxi- a product and the infrastructure that enables it [15];
mately 600 in 2003 to more than 1000 by 2015 [13]. it takes into account the perspectives of multiple
Although the field of mHealth is still in its infancy, stakeholders. In this case, patients newly diagnosed
some studies have explored mobile apps in relation to with type 2 diabetes were the primary users of the
diabetes self-management [8–10, 13, 14]. The general app (referred to hereafter as ‘users’), but healthcare
findings show that the majority of the apps studied professionals were also stakeholders and were
lacked a theoretical foundation and did not involve involved closely in the design process.
the needs and preferences of the target group in the Design thinking focuses on rapid prototyping, which
development process. Some ‘diabetes management’ means turning ideas into actual products that are then
apps do not follow medical guidelines or incorporate tested, iterated, and refined, based on user feedback [15].
clinical best practices established by diabetes The study process was inspired by Brown and Wyatt’s
professionals [8]. Several apps have usability issues, three phases of inspiration, ideation, and implementation
and app functions focus narrowly on insulin dosage [15], which are depicted in Table 1. In practice, the
suggestions, recording medications, and diet and phases overlap and iterate. We used qualitative methods
weight management. Several studies identify a need to such as observations, semi-structured interviews, and
employ a more user-centered and holistic approach in interactive workshops to promote participation with
Table 1 Types of data generated in workshops, observations and individual interviews using a design thinking approach
Three phases Aim Participants Methods Data
(n)
Phase 1 - Workshop 1 (HCPa) To identify needs and challenges in the communication between 9 Dialogue tools Minutes Video
inspiration users and HCP recordings
Observations (Individual To identify user needs and challenges 11 Open observation strategy Field notes
consultation in GP, patient To gain insight into the working procedure and consultation/ patient
education in CHC education
To recruit users for a workshop
Individual To identify user needs and challenges 12 Semi-structured individual interviews Transcribed
Interviews individual
interviews
Workshop 2 (Users) To validate the results from workshop 8 1, the individual interviews 8 Personas of user needs and challenges, Audio-recorded
and the observations Visualized ideas Minutes
To identify and discuss users’ needs and challenges
Phase 2- Workshop 3 (Users) To discuss five refined ideas To refine and adjust the ideas 8 Visualized ideas, User Journey, Flowchart Audio- recorded
ideation Minutes
Workshop 4 (Users) To discuss seven refined ideas 7 Visualized ideas, Audio- recorded
To prioritize the ideas with the participants Dialogue tools Minutes
To refine and adjust the ideas
Petersen and Hempler BMC Medical Informatics and Decision Making (2017) 17:91

Individual To discuss seven refined ideas 1 Visualized ideas, Audio-recorded

Interview To prioritize the ideas Dialogue tools Minutes
To refine and adjust the ideas Minutes with users
Workshop 5 (Users) To get feedback on the preliminary app content and design 9 Wireframes Minutes
To refine and adjust the wireframes
Individual To get feedback on the preliminary app content and design 3 Wireframes Minutes
Interviews (GPs) To discuss a potential implementation of the app in practice
Phase 3 - Observations (GP, CHC) To observe introductions to the app conducted by HCP Open observation strategy Minutes
implementation
Individual interviews To explore users’ experiences with the prototype in practice 14 Semi-structured individual interview Transcribed
individual
interviews
Workshop 6 (HCPa) To discuss a potential implementation of the app in practice based on 7 Visualized recruitment overview of app in Minutes
the pilot study and the HCP’s experiences practice
a
HCP workshops included GPs, a physician (only workshop 1), two GP secretaries (only workshop 6) and two diabetes nurses
Abbreviations: GP general practitioner, HCP healthcare professional, CHC Community health center
Page 3 of 10
Petersen and Hempler BMC Medical Informatics and Decision Making (2017) 17:91 Page 4 of 10

users and healthcare professionals in developing and Phase 2: ideation

testing the app. Tools and methods from the educational In the ideation phase, we analyzed data and rans-
concept ‘Next Education’ (NEED) were applied to formed them into insights about innovative solutions
promote active involvement, reflection, and dialog in for change [15]. Analysis was inspired by Malterud’s
workshops [16–18]. ‘systematic text condensation’ [21]. First, we captured
an overall impression of all data and then identified
preliminary themes. Secondly, we identified the
Phase 1: inspiration meaning units relevant to the study question and
The inspiration phase focused on understanding users’ sorted them into categories representing different
needs and challenges in everyday life after diagnosis themes. Thirdly, the units of meaning were sorted
with type 2 diabetes. Users were recruited in a gen- into subgroups and the meaning in each subgroup
eral practice and a community health center provid- was refined and condensed. Finally, the content of the
ing patient education in the municipality of subgroups was synthesized to generate descriptions
Copenhagen. We conducted an interactive workshop and concepts [21].
with healthcare professionals (e.g., general practi- We conducted three interactive workshops with
tioners [GPs] and diabetes nurse specialists), observa- users and healthcare professionals. The purpose was
tions of patient education in a community health to develop, discuss, and prioritize ideas for app
center and individual consultations in general practice content and design. We used tools from the Next
as well as 12 semi-structured individual interviews Education concept, visualized ideas, and used dialog
with users. We intended to include individuals who tools such as a flowchart of a user journey experience
had been diagnosed within the previous 2 years, but inspired by participants’ experiences and challenges.
we broadened this criterion to facilitate recruitment; The number of ideas, app content, and design were
users’ duration of disease ranged up to 10 years. We adjusted and refined throughout the ideation process.
asked users who had been diagnosed longer than 2 Relevant app content was validated by the study
years to focus on their needs and challenges in the collaborators in general practice, the community
period after diagnosis. health center, the hospital and by the Danish Diabetes
Data collection focused on three themes: everyday life Association, the Danish Podiatry Association as well
with type 2 diabetes, communication with the healthcare as the Eye Clinic at Steno Diabetes Center in
system, and technology knowledge and readiness. An Copenhagen.
interview guide was compiled, based on recommenda-
tions from Brinkmann and Tanggaard [19]. The guide
also included questions related to demographics, such as Phase 3: implementation
age, education, employment status, and marital status, The app prototype was pilot tested with users for a
and questions related to diabetes, such as use of medica- period of 4 weeks. Fourteen users were recruited from
tion, blood sugar monitoring and control, disabilities, general practice and the community health center
and other chronic diseases (Table 2). The semi- (Table 3). Further three users had agreed to test the app,
structured interviews were inspired by the model ‘The but dropped out of the study before they had
Balancing Person’, which describes patients’ challenges downloaded the app due to family circumstances, lack of
with a chronic condition [20]. The interviews varied in acceptance and readiness in relation to a diabetes
length from 20 to 60 min and were transcribed verbatim; diagnosis, and technical issues. An inclusion criterion
the findings were validated in a workshop with users. was access to an iPhone or iPad because the app was
only developed for Apple’s iOS platform. Users agreed to
test the app for 4 weeks and participate in an interview
Table 2 Participant characteristics – individual interviews (phase
one)
regarding usability and usefulness. To assist healthcare
professionals in the recruitment process, we created
Female (n) 7
Male (n) 5 Table 3 Participant characteristics – app test (phase three)
Age, mean, (range), years 56 (43-70) Female (n) 7
Diabetes duration, mean, (ranges), years 2.5 (0-11) Male (n) 7
Employed (n) 7 Age, mean, (range), years 52 (33-64)
Retired (n) 5 Diabetes duration, mean (range), years 3 (0-16)
Married/living with a partner (n) 6 Employment (n) 8
Own a smartphone/tablet (n) 10 Married/living with a partner (n) 10
Petersen and Hempler BMC Medical Informatics and Decision Making (2017) 17:91 Page 5 of 10

both a script and an information letter to give to users type of information they received and the type of
who showed interest in the pilot study. information they needed.
To access the app, users installed a secure develop-
ment platform app that required an invitation with a Non-transparent diabetes journey
username and a password. We observed the processes of Users reported a lack of overview of diabetes care
recruitment and introduction to the app to gain insight activities, such as visits to podiatrists and eye specialists,
into potential implementation challenges. For this pur- patient education in community health centers, the
pose, we developed an observation guide that contained Danish Diabetes Association, and the like. Nevertheless,
questions related to how recruitment was conducted in they were very interested in being introduced to these
practice, the types of questions that potential users had, activities by their GP. Several users mentioned they were
and the characteristics of people who declined to disappointed that they had not been informed about or
participate. referred to particular activities after diagnosis.
We conducted semi-structured interviews with 14
users. They focused on the participant’s experience with
the app and also included data such as duration of Lack of care coordination
disease, age, education, employment status, and marital Users often described the period of time following a
status (Table 3). The interviews, which lasted 22 to diagnosis of type 2 diabetes as difficult because they
55 min, were transcribed verbatim. Furthermore, found it hard to navigate the healthcare system (Fig. 1).
implementation issues were discussed in a workshop They suddenly needed to coordinate a great deal of
with healthcare professionals. The findings from inter- information and keep track of numerous appointments
views and the workshop were used to create a list of with different healthcare professionals. Users often
recommended adjustments to the app. described this experience as extremely stressful and
time-consuming. In addition, some users felt lonely and
insecure in their role as ‘coordinator of information’.
Results Some users also received conflicting information from
In the process of developing and testing the app, we
different healthcare professionals about how to manage
conducted 6 workshops and 26 interviews with people
their diabetes.
with newly diagnosed type 2 diabetes.

Solutions identified in the ideation phase

Themes identified in the inspiration phase
Gaining a deep understanding of users’ needs inspired
The analysis of data interviews, observations, and
two solutions for an app prototype. The first solution
workshops from the needs assessment in Phase 1 revealed
aimed to strengthen users’ ability to navigate diabetes
four themes: 1) diabetes – a real illness?; 2) lack of action
care activities and coordinate information (health data)
competency; 3) non-transparent diabetes journey; and 4)
by providing an overview of vital diabetes care activities
lack of care coordination.
and stimulating reflection about their diabetes-related
needs, goals, and challenges. The second solution
Diabetes - a real illness? focused on supporting newly diagnosed individuals in
Most users were symptom free and stated that they had making health behavior changes and maintaining
no complications of diabetes. Several users considered psychosocial health by addressing well-being, stress, and
diabetes to be an illness from which one could suffer to sleep. During discussions about the relative priority of
varying degrees, and they identified themselves as being these solutions with users and healthcare professionals, a
on the low end of that continuum. The husband of one collaborative decision was reached to integrate both
user described her condition as ‘diabetes light’. The lack of solutions into a single app prototype (Fig. 2). After
perceived illness had a negative impact on users’ diabetes prototyping was completed, the app comprised five
self-management, which affected their motivation to functions:
participate in diabetes education.
1) overview of diabetes activities after diagnosis
Lack of action competency This function includes an overview of the resources
Users described receiving recommendations to ‘eat in the local community in relation to diabetes care.
healthy’, ‘stop eating sweets’, and ‘lose weight’ from Resources are listed by options and activities e.g.
healthcare professionals after diagnosis. However, they health activities in the community health center,
reported a need for concrete, simple information about podiatrist and GPs. It is possible to add
diabetes and about how to integrate changes into their appointments for each activity and personalize the
daily lives. Several users also reported a gap between the overview. There is also short information associated
Petersen and Hempler BMC Medical Informatics and Decision Making (2017) 17:91 Page 6 of 10

My overview: Personalized overview of

diabetes care activities, a calendar of
appointments, and roles of the patient
and healthcare professionals

Status: Recording of data

related to well-being, sleep, New habits: Reflections about
and stress challenges, tests, and goal-setting

My health data: Recording Quiz: Knowledge games related to

of health data over time diabetes (e.g., exercise, type 2 diabetes,
(e.g., blood sugar, HbA1c, foot care, diet)
blood pressure, weight,
BMI)

Fig. 1 Summary of feedback from workshops with users

with the activities such as ‘you can prevent each quiz the user may find information and links
complications by…’ and ‘why see a podiatrist?’ etc. about options and activities relating to the subject of
2) recording of and knowledge about health data the quiz.
The function includes short and concise knowledge 5) recording of psychosocial data, such as sleep, fatigue,
of blood sugar, including old and new measurement, and well-being
HbA1c, blood pressure, cholesterol, weight and BMI. This function of the app contains psychosocial data
The user can add values, set goals and watch his or which the user can assess each day (using smileys).
her ‘health data history’. It is possible to visualize in graphs. The data contain
3) a reflection game about challenges and goal setting, the questions: 1 “Have you been feeling nervous and
This function of the app makes it possible to set goals stressed?”, 2 “Do you feel that you get enough sleep
within the categories “My disease and I”, “Food” and and do you feel rested?” and 3 “How are you
“Exercise”. The user can also test if he or she shares doing?”.
the same challenges as other patients with type 2
diabetes (by prioritizing real patient quotes). The
aim of this function is to promote reflection of Themes identified in the implementation phase
priorities and challenges of living with diabetes. We identified four themes from the interviews with users
4) knowledge games and from a focus group with healthcare professionals
This function contains 4 quizzes; “Exercise”, “Type 2 about implementation. The themes were: 1) a viable tool
diabetes”, “Feed”, and “Food and diabetes”. After to support diabetes self-management, 2) patterns of app

Fig. 2 App functions

Petersen and Hempler BMC Medical Informatics and Decision Making (2017) 17:91 Page 7 of 10

use, 3) barriers and facilitators of app use, and 4) barriers user (male, 64 years old) said that recording his weight
and facilitators of implementation. in the app had motivated him to eat a healthier diet.
Another participant (female, 46 years old) gained
A viable tool to support diabetes self-management important insight into her daily routines by using the self-
The findings suggested that the app was a viable tool to reported outcomes (e.g., sleep, stress, and well-being)
support diabetes self-management among people with visualized in graphs, which led her to make changes in her
type 2 diabetes. It provided assistance in initiating or daily routines.
maintaining lifestyle changes, routines, or habits in daily
life. Many users stated they would continue using the Patterns of app use
app if it was optimized technically and some app The majority of users reported frequent app use dur-
features were adjusted, such as receiving continuous ing the testing period (Table 4). App use was driven
feedback in knowledge games in addition to a final score by users’ individual contexts, needs, and expectations;
(Table 4). Several users reported that the app provided a the study was not sufficiently powered to to identify
useful overview of diabetes-related activities, which patterns of use related to age, educational level, or
improved their ability to navigate both the healthcare duration of disease.
system and local diabetes activities. Information on The two most frequently used app functions were ‘My
diabetes was very useful, particularly information about health data’, in which users could record health data such
preventive diabetes activities that included different roles as blood sugar, HbA1c, blood pressure, weight, and BMI
and responsibilities. Users also reported that the app over time, and ‘Status’, which allowed them to record
contained concise diabetes-specific information they data related to well-being, sleep, and stress. In contrast,
could easily access when they needed it, such as the dif- the least frequently used app function was ‘New habits’,
ference between blood sugar and glycated hemoglobin which aimed to stimulate reflection about diabetes-
(HbA1c). Furthermore, users described the self-reported related challenges through tests of knowledge and goal
data about sleep, stress, and well-being as promoting setting. Users usually favored one or two functions. Men
awareness about how they could improve these areas of tended to favor ‘My health data’, whereas the ‘Status’
their lives. Some users reported that increasing aware- function was more appealing to women. All users agreed
ness of their own health and well-being from the app that the function ‘My overview’ was extremely useful for
improved their decision-making about their health. One people who were just diagnosed with type 2 diabetes.
Several users with diabetes of longer duration stated they
Table 4 Self-reported app use
would have benefitted from this function in the period
immediately after diagnosis.
n
Device downloads
Barriers and facilitators of app use
iPhone 9 The development platform was subject to technical
iPad 5 issues, such as data entry problems and crashes.
App use over 4 weeks According to some users, these technical issues inhib-
Less than 3 times in total 2 ited frequent app use. Two users were ambivalent
Once a week 1
about continuing to use the app due to these
technical issues. The lack of a version for an Android
Several times a week 9
operating system was also mentioned as a barrier. In
On a daily basis 2 general, most users had a smartphone or a tablet and
Functions primarily used were familiar with using apps. They also found the
My overview 1 app easy to navigate; only a few users had trouble
Status 4 with navigation. There was no pattern regarding use
New habits 0
during test and whether users wished to continue
using the app. Three persons stated that they would
My health data 6
not continue to use the app. Reasons for this
Quiz 3 included not experiencing problems with diabetes,
Would continue app use general skepticism about technology and lack of time.
Yes 4
Yes after improvements 5 Barriers and facilitators of implementation
Maybe 2
Interviews with users and one focus group with healthcare
professionals about implementation of the app revealed
No 3
two findings of note. The first was related to
Petersen and Hempler BMC Medical Informatics and Decision Making (2017) 17:91 Page 8 of 10

implementation in practice. Users stated that it was documentation of data, data forwarding, information
important that the app was introduced by the GP where function, analysis function, reminder function, but
most patients had received their diagnosis. However, GPs usually only one function per diabetes app [14].
emphasized that the app should also be implemented in Recorded data often concern psychosocial aspects
other settings, such as community health centers, podia- (well-being), health behaviour (diet and physical
trists, eye specialists, patients associations, drugstores, etc. activity) or diabetes specific data such as HbA1c, but
Users preferred a brief oral introduction to the app about not the interplay between these factors [13]. With the
purpose, content, and download procedures. For users, exeption of data forwarding, our app included all the
the introduction by a healthcare professional meant that mentioned functions. However, most users used only
they trusted the content of the app. Testing showed that one or two functions but favored different functions
the download process and subsequent use were facilitated and different types of recorded data. None of the test
if users could download the app with a healthcare users mentioned that the app contained too many
professional when they preferred to do so. functions or that multifunctionaly inhibited their app
The other finding was related to technical competencies use. In addition, a clear finding emerged in the design
and knowledge of apps in general. Downloading the app (in process that users preferred a multifunctional model
particular, the development platform) was challenging for with the ability to choose between different functions
some healthcare professionals. Reasons included a lack of focusing on diabetes specific data and knowledge as
technical competence, lack of knowledge of the app, and well as psychosocial and health behavioural aspects.
lack of experience with apps, iPhone/iPads, or both. Similarly, Arnhold et al. argues that multifunctional
Consequently, they found it difficult to introduce and sup- apps combining documentation, reminder, and
port the app, which caused them to feel less sure about its advisory functions are more suited for newly diag-
use. Another reason was the challenge of fitting the app nosed individuals and elderly people with diabetes
introduction into existing workflow processes due to lack [14]. Our study also suggests the value of developing
of time, resources, and motivation. Thus, app use was af- multifunctional apps for individuals newly diagnosed
fected by both knowledge among healthcare professionals with type 2 diabetes, including the possibility of
and their technical competence to support implementation. personalizing apps to individual needs.
Individuals who are newly diagnosed with type 2
Discussion diabetes are a diverse group in terms of technical skills,
People with newly diagnosed type 2 diabetes preferred age, individual needs, preferences, diabetes knowledge,
a multifunctional app to support daily life with and interaction with different healthcare professionals. It
diabetes. The prototype app offered five major is also unknown whether the benefit of the app we
functions which were informed by users’ needs and developed is confined to only those who are newly
ideas: overview of diabetes activities after diagnosis, diagnosed and how long a diagnosis should be consid-
recording of health data, self-reflection games and ered new. Some users in our study stated they would not
goal setting, knowledge games, and recording of have been ready to use an app during the first years after
psychosocial data, such as sleep, fatigue, and well- diagnosis because they had not accepted their diabetes
being. Users found the app to be a viable tool for diagnosis. In addition, users who had been diagnosed
support, particularly for increasing their awareness of longer than two years found the function providing an
issues related to sleep, stress, and well-being and for overview of diabetes activities valuable because their
informing and guiding them in the healthcare system diabetes care and prevention activities had changed
after diagnosis. Users during the testing period dramatically since diagnosis. We did not find significant
considered introduction of the app by healthcare differences in terms of app use or preferences for
professionals as essential to their ability and motiv- functions when comparing those diagnosed within the
ation to download and use the app. previous 6 months or later. However, including more
participants might have enabled analyses of the value of
Multifunctional app vs. a single function app the app to different user groups.
Simple and understandable design, content, and menu
navigation are pivotal and seem to encourage app Implementation of app in the healthcare system
usability [14]. In addition, recent studies have ob- The implementation process for an app is crucial for
served a negative correlation between usability and usability and effect [13]. Most health apps are down-
apps comprising several functions [13]. According to loaded by patients through online app stores, and
Arnhold et al., the majority of apps offer similar func- some are introduced to patients as part of their
tionalities but combine only one or two of them [14]. contact with the healthcare system. Some apps are
The most common functions in diabetes apps involve stand-alone solutions with the objective of supporting
Petersen and Hempler BMC Medical Informatics and Decision Making (2017) 17:91 Page 9 of 10

the patient, and others involve some degree of Conclusions

communication between patients and healthcare The co-creation inherent in the design thinking pro-
professionals or other patients. cesses during app development and testing were vital to
In our study, it was evident in the preliminary creating value for users. People with newly diagnosed
workshops that a potential app would not be type 2 diabetes found the multifunctional app useful but
integrated with the separate information technology perceived that introduction to the app by a healthcare
systems of GPs and community health centers professional is crucial for subsequent use. Healthcare
because these systems are not interoperable. In professionals may require additional training and guid-
addition, no healthcare professionals were interested ance to feel comfortable introducing the app to patients.
in a supplementary system that would operate in
parallel to their existing technology, nor did health- Abbreviations
care professionals feel competent or ready to use a GP: General practice; HbA1c: Glycated hemoglobin

mobile app in their consultations with patients. This

correlates with other studies finding that lack of Acknowledgments
We thank The Capital Region of Denmark and the Municipality of Copenhagen
human and technical skills are barriers for integration for initiating a Public-Private-Innovation Collaboration about developing
of health technology in practice [8, 10, 22]. A survey innovative solutions for newly diagnosed people with T2DM. We thank the
among 173 health centers and clinics showed that the collaborators in this project: BridgeIT, the Health Community Center in
Vanløse-Brønshøj-Husum, the medical practice of Tine Lindinger and Thomas
three main barriers to implementing cell phone Saxild, and Frederiksberg Hospital. In addition, we thank all the participants for
interventions were limited human and technical taking time to participate in the study and Jennifer Green, Caduceus Strategies,
organizational resources to support implementation, for editorial assistance.

lack of external funding sources to finance investment

Funding
in mobile technology solutions, and challenges to the
The development and test of the mobile app was supported by a
technical integration of mobile health solutions with Public-Private-Innovation programme initiated by The Capital Region of
electronic health records and other health information Denmark and the Municipality of Copenhagen.
technology infrastructure [22]. These barriers suggest
the importance of including healthcare professionals Availability of data and materials
The authors do not wish to make the data available as it contains information
in the development, testing, and implementation that could identify specific individuals.
processes to create a sense of ownership among
healthcare professionals and to identify organizational Authors’ contributions
needs and possibilities. NFHR designed and conceptualised the study. MMPR and NFHR were drivers
Users in our study considered it crucial that health- of the development process and the testing of the mobile app. Both
coordinated, collected and analyzed data. Both authors drafted the paper
care professionals introduced the app because it and approved the manuscript.
created trust. Some users were afraid of using self-
selected apps because they might contain out-of-date Author’s information
or incorrect information. This concern is rational MMPR: Candidate in Master of Science (MSc) in Health Promotion and
because few apps are research-based, and they may Strategies and Educational Studies and research assistant at Diabetes
Management Research, Steno Diabetes Center Copenhagen. NFHR:
not convey guidelines or content that have been Candidate in Master of Science in Public Health, University of Copenhagen,
validated by experts [8]. Another issue concerns PhD, and senior researcher at Diabetes Management Research, Steno
health economic analysis of health apps. There is a Diabetes Center Copenhagen
need for studies about apps focusing on both benefits
and disadvantages in terms of resources [23]. Ethics approval and consent to participate
All users were informed of the aim of the study and gave their written
There are some limitations to this study. Only 14 users consent to participate. The study was conducted in compliance with the
tested the app, and results cannot be generalized to all Helsinki Declaration and was approved by the Danish Data Protection
individuals with newly diagnosed type 2 diabetes. Three Agency (2012-58-0004) and processed by the National Committee on Health
Research Ethics (16048960).
users stated that they would not continue to use the
app. Due to the small number of test users, it is difficult
Consent for publication
to predict how many newly diagnosed that would in fact Not applicable.
accept and use the app in a real life setting. Many users
included in the study were well informed about Competing interests
diabetes-related activities, because 10 users were The authors declare that they have no competing interests.
recruited from the community health centers, where re-
cruitment was easier than through GPs. In addition, our
Publisher’s Note
criterion for identifying users as newly diagnosed was Springer Nature remains neutral with regard to jurisdictional claims in published
broad. Consequently, the app requires further testing. maps and institutional affiliations.
Petersen and Hempler BMC Medical Informatics and Decision Making (2017) 17:91 Page 10 of 10

Received: 10 March 2017 Accepted: 16 June 2017

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