JMIR Publications

ABSTRACT

Background:

Despite the high prevalence of type 2 diabetes (T2DM) in China, few patients are achieving adequate management targets. While digital behaviour change interventions (DBCIs) are promising solutions, sustained long-term user engagement with these new technologies remains challenging.

Objective:

The objectives of this study were to (1) describe the long-term user engagement with the SMARTDiabetes app; (2) explore the associations between user engagement and trial effectiveness; and (3) identify main influencing factors of user engagement.

Methods:

A mixed-methods process evaluation was conducted alongside the two-year SMARTDiabetes trial to assess long-term user engagement with the DBCI, investigate its association with trial effectiveness, and explore its influencing factors. Quantitative data included clinical outcomes and app usage data; qualitative data included an expert review of the DBCI and semi-structured interviews with key stakeholders. Findings were synthesized using Michie’s conceptual framework for engagement with DBCIs.

Results:

A total of 1,038 participants in the intervention arm were included in quantitative analyses and 12 in-depth interviews were conducted. On average, 46.4% (SD: 7.8%) of participants were monthly active users and 38.3% were sustained active users. Sustained engagement with the app, involvement of family members, and frequent interaction with app functions were associated with improved clinical outcomes. Key drivers of user engagement and trial effectiveness included six known behaviour change techniques (BCTs) underpinning the 15 app functions (i.e., reward, feedback, reminders, goal setting, self-monitoring, social support features); four implementation facilitators (credibility features, professional support, guidance, ease of use); and finally, five contextual contributors (younger age, better education, greater smartphone literacy, closer patient-doctor relationship, stronger primary healthcare facilities commitment).

Conclusions:

Long-term, sustained engagement with a mobile app intervention for T2DM self-management is achievable in the PHC setting in China. Higher engagement is associated with better health outcomes. The influencing factors identified in the SMARTDiabetes study provide valuable insights for developing targeted strategies to enhance user engagement with DBCIs and improve overall program effectiveness. Clinical Trial: The trial was registered at ClinicalTrials.gov (registration record NCT02726100, 03/22/2016).