User engagement with type 2 diabetes self-management apps

There is an urgent need to develop novel, population-level interventions to support an increasing number of people living with type 2 diabetes in Australia. The ubiquity and technological capabilities of smartphone apps make them ideal vehicles to provide T2D self-management support at the required intensity. However, low user engagement in real-world settings limits their impact. Thus, the overall aim of this research was to understand user engagement with T2D self-management apps and investigate strategies to improve their uptake. Consequently, this thesis addressed four research questions: 1. What is the role of user engagement in the effectiveness of T2D self-management apps? 2. What do people with T2D want from a self-management app? 3. How do people with T2D engage with self-management apps in their everyday lives? 4. Is an embodied conversational agent (ECA) delivering self-management support via an app acceptable to people with T2D? A mixed-methods approach was adopted, including a systematic review and data from two studies, 1) a national cross-sectional survey of Australian adults with T2D, and 2) a two-armed randomised controlled trial in a real-world setting, testing the efficacy of a T2D self-management app over 12 months of use. The findings are presented as four empirical reports within this thesis. A systematic review of user engagement with T2D self-management apps in trials that assess their effectiveness was conducted (Chapter 3). An overall trend towards a dose-response relationship between usage and effectiveness was observed. The review also demonstrated that user engagement is operationalised ubiquitously as synonymous with the quantity of use. In the second study, responses to an open-ended question in a national survey of adults with T2D asking what they would want from a hypothetical ‘perfect’ T2D self-management app were analysed (Chapter 4). The data suggest that automated, personalised diabetes coaching and assistance with the emotional aspects of diabetes management are likely to be valuable additions to T2D self-management apps. The third study (Chapter 5) used a qualitative approach to investigate the lived experiences of people with T2D using a self-management app for up to 12 months via their own devices. The findings indicate that perceived autonomy in self-management can influence user preferences for a T2D self-management app. This study also highlighted a role for healthcare professionals in initiating and sustaining engagement with T2D self-management apps. The final study used a survey and interviews to assess the acceptability of an ECA providing T2D self-management education and support via a T2D self-management app (Chapter 6). The results demonstrate that an ECA is an acceptable means to provide self-management support for people with T2D and may be especially suited to delivering diabetes-specific emotional support. The findings from this program of PhD research enhance our understanding of what matters to users of T2D self-management apps, what works for them and what translates to improvements in their health outcomes, all of which are necessary to improve engagement with and, therefore, the therapeutic impact of T2D self-management apps.