JMIR Publications

ABSTRACT

Background:

Mobile health (mHealth) interventions show promise for supporting diabetic foot self-care; however, sustained engagement remains a challenge, particularly in low- and middle-income countries (LMICs). While educational strategies are commonly used to address diabetic foot ulcers (DFU), they often fail to translate knowledge into long-term self-care. Understanding behavioral mechanisms underlying mHealth use, including the role of caregivers, is critical for improving implementation and effectiveness.

Objective:

This study explored how behavioral interactions between people with diabetes and caregivers shape the use of a mHealth application (app) for diabetic foot self-care.

Methods:

This qualitative explanatory study was embedded within a parent study of an mHealth app for diabetic foot care that was conducted in primary care settings in Peru. It used the Capability, Opportunity, and Motivation-Behavior (COM-B) model and the Theoretical Domains Framework (TDF) to identify mechanisms relevant for intervention design and scale-up. Semi-structured interviews were conducted with people with diabetes and caregivers about experiences related to accessing our app. Data were analyzed using deductive and inductive thematic analysis informed by COM-B and TDF.

Results:

In total, 14 people with diabetes (median age 54 years, 8 women and 6 men) and 10 caregivers (median age 28.5 years, all women) were interviewed. App use depended on varying interactions between COM-B domains while other behavior determinants aligned with a single domain. Caregivers often compensated for physical capability limitations through foot positioning or environmental adjustments. Environmental context and resources, including internet access, lighting, and device compatibility, affected app use for all participants. Motivation for all participants was driven largely by beliefs about the app’s preventive value, although reassurance from health professionals and altruism also emerged.

Conclusions:

App use often depended on collaboration between people with diabetes and caregivers as a dyad, highlighting the need to design digital interventions around caregiving demographics, competing responsibilities, and the additional responsibilities an app may introduce. Participants’ preference for individual follow-up suggests that non-physician health personnel and other human support may help maintain continuity and reassurance alongside digital monitoring. Although the app was an early prototype intended for algorithmic training, participant experiences provided insight into real-world usability and contextual barriers for future app development.