Table 1.

Characteristics of studies included in this review

Authors [reference]	Country	Study Design; Assessed proposed or actual implementation	Sample size; Population/Setting	Intervention characteristics/technology	Purpose/Area of Implementation Studied	Results
Abidi et al. [20]	Canada	Qualitative study; Proposed implementation	Usability study: N=11 patients with T2D; Focus group study: N=3 PCPs & 4 patients with T2D	Diabetes Web-Centric Information and Support Environment (DWISE) is a computerized decision support platform with PCP (accessible via web) and patient (accessible via web and mobile app) tools for behavior change support.	Explore PCP and patient perspectives on DWISE usefulness, and implementation barriers and facilitators	Usability study: most issues related to screen layout, design features, clarity of content, and navigation Focus group study: barriers included PCP time constraints and PCPs’ and patients’ lack of technology adeptness; facilitators included personalized self-management
Ayre et al. [21]	Australia	Qualitative study; Proposed implementation	N=25 PCPs recruited from 50 clinics	Self-management mobile app for patients featuring individualized care plan, self-monitoring data, prompts to visit PCP, and education.	Explore PCP perspectives on proposed features for a self-management mobile app, including implementation barriers and facilitators	Barriers included PCPs’ concerns about increased workload and liability, and preference for communicating information face-to-face. Facilitators included PCPs’ perception the app might facilitate communication between visits and complement rather than replace in-person visits.
Bolin et al. [22]	United States	Mixed-methods pilot study; 11-month study period; Actual implementation	Tracked usage across 5 sites serving low-income populations in South Texas; Collected exit interviews with N=179 users; 45% T2D, 21% at-risk for T2D, 66% Latino	Diosk is a touch-screen kiosk providing diabetes self-management education “on-demand” to patients in English and Spanish language; 12 modules on self-management topics (e.g., exercise, meal planning)	Examine the implementation, use, and sustainability of Diosk	Diosk was accessed 5377 times; 1328 users were return users. Challenges maintaining Diosk included organizational capacity to host wireless Internet and establishing “office champions” responsible for overseeing Diosk. Users unfamiliar with technology experienced challenges with the touch screen. 3 of 5 study sites anticipated sustaining Diosk past the study period.
Cooper et al. [23]	England	Mixed methods feasibility study, pre-post design; 6-month study period; Actual implementation	Evaluation: N=89 adolescents with T1D; Survey: N=11 clinic staff; Focus group: N=12 clinic and research staff; Recruited from three pediatric diabetes centers in the North West of England	Adolescent Diabetes Needs Assessment Tool (ADNAT) app supports diabetes self-care decision-making. Accessed via Internet on mobile devices. Results of a needs assessment are communicated to providers to guide patients’ care plan.	Examine the feasibility of implementing ADNAT in pediatric diabetes care	Adoption: 89 patients recruited of which 44 patients (49%) completed ADNAT and 45 (51%) were non-completers. After adjusting for baseline HbA1c and site, completers had a post-intervention mean HbA1c 0.5% (5.42 mmol/mol) lower than non-completers. Survey and focus group data from diabetes care teams demonstrated positive perceptions of ADNAT’s effectiveness.
Dickenson et al. [24]	United States	3-arm cluster randomized trial; 18-month study period; Actual implementation	N=36 primary care practices (18 in Colorado, 18 in California); 27 were community health centers; practices randomized to one of 3 arms	Connection to Health (CTH) uses interactive behavior change technology to help clinics deliver diabetes self-management support; Components include an online patient assessment, decision support tools for clinicians, and online self-management resources for patients.	Compare implementation and effectiveness of the 3 study arms: (1) self-management support, (2) self-management support plus CTH, and (3) self-management support plus CTH with brief practice facilitation	In intent-to-treat analysis, HbA1c trajectories did not differ significantly between study arms. However, patients who used CTH at study sites assigned to self-management education plus CTH with practice facilitation showed an improvement in HbA1c trajectory compared to patients at practices assigned to non-technology self-management support education (p=.0422).
Levy et al. [25]	United States	Single group, pre-post design; 12-week study period; Actual implementation	N=113 patients with T2D from 2 safety net health care systems in New York City; 79% Hispanic	Mobile Insulin Titration Intervention (MITI) uses daily weekday text messaging and weekly phone calls from registered nurses to help patients achieve their optimal (basal) insulin dose without coming into clinic for care. Texts available in English and Spanish.	Examine MITI’s effectiveness and implementation outside of a randomized controlled trial	Clinicians referred 170 patients to MITI, 129 (76%) were eligible and 113 (88%) enrolled. 95/113 (84%) reached their optimal (basal) insulin dose in an average of 24 days. HbA1c decreased from 11.4% to 10.0%, p<.001. Patients responded to 90% of text message prompts, and 85% of attending physicians made ≥1 referral to MITI. Patients reported comfort sharing information over text and texts reminded them to take insulin, check glucose, and eat healthy.
Oberg et al. [26]	Sweden	Qualitative study; Proposed implementation	N=20 primary care nurses from 5 health centers in northern Sweden; 100% female	Did not study a specific intervention, but rather focused generally on eHealth services to support self-management	Describe nurses’ perceptions of using eHealth systems and services to support patient self-management	Nurses perceived eHealth interventions as inevitable and with some advantages. However, nurses expressed concerns about loss of visibility and control in their daily routines as care transitions from in-person visits to eHealth. Nurses were concerned about losing their expert role in providing advice to patients and noted the growth of eHealth required them to not only have clinical knowledge but also be tech savvy.
Okazaki et al. [27]	Japan	Cross-sectional survey; Proposed implementation	N=471 physicians across Japan; diverse medical specialties; 87% male	Mobile diabetes monitoring (MDM) is accessible via mobile device and enables self-monitoring of blood glucose and other behaviors (e.g., exercise and medication taking) data export, physician-patient communication, and synchronization with patients’ personal health data at the hospital’s information hub.	Validate the explanatory model of factors affecting adoption of MDM among physicians	Physicians’ intention to use MDM was primarily influenced by perceived net benefits and value, and subjective norms. Privacy and security concerns had no significant influence on the intention to use MDM.
Rogers et al. [28]	United States	Qualitative study; Actual implementation	N= 39 patients with T2D; N=19 clinic staff members	MITI, see above (Levy, 2018)	Identify barriers and facilitators to MITI implementation	Facilitators to implementation included: convenience, no cost to patients, ease of use, patients’ confidence in their ability to use it, compatibility with patients’ daily routines and clinic workflow, patients’ and staff’s perceptions of value, and strong implementation climate and program champion. Barriers included: language limitations, nursing concerns about scope of practice, clinicians’ initial lack of knowledge about the program and perceptions that MITI might not be appropriate for some patients (e.g., older patients).
Ross et al. [29]	England	Mixed methods, descriptive study; Actual implementation	N=21 clinic staff (including physicians, nurses, administrators, and support staff); recruited from 34 general practices in London	Healthy Living for People with Type 2 Diabetes (HeLP-Diabetes) is an online self-management program accessible via computer, tablet, or mobile device; Content includes 8 topics in self-managements including emotional management, lifestyle change, etc.	Describe the development of a theoretically-based implementation plan for HeLP-Diabetes and identification of barriers and facilitator to implementation	Normalization Process Theory informed the development and selection of individual implementation strategies including engagement of local leaders, provision of educational materials, visits and meetings, and audits, feedback and reminders. Facilitators to implementation included strong understanding about HeLP-Diabetes and its value among clinic staff. Barriers included time constraints and limited resources.
Watterson et al. [30]	United States	Mixed-methods, quasi experimental pilot study; 12-week study period; Actual implementation	Evaluation: N=50 patients with T2D from 2 FQHCs in Los Angeles, CA; 66% Spanish-speaking Interviews: N=11 patient users and N=8 clinic staff	CareMessage is a text message-based program sending 3–4 educational messages per week; Most messages are bidirectional; Available in English and Spanish language. Includes 10 self-management themes including understanding diabetes, medication adherence, and nutrition.	Examine clinical effectiveness and implementation of CareMessage including barriers and facilitators to implementation	Mean HbA1c decreased by 0.4% among patients receiving CareMessage relative to the comparison group (p=0.06). Highly engaged patients (response rate ≥median of 64.5%) had a 2.2% reduction in HbA1c compared to patients who were less engaged (p<.001). Implementation facilitators included the need for relatively few resources. Barriers included reliance on volunteers to enroll patients in program limiting integration into routine care.

PCP primary care practitioner, T2D type 2 diabetes T1D type 1 diabetes; FQHCs federally qualified health centers, HbA1c hemoglobin A1c