Background
The burden of diabetes mellitus (DM) has grown enormously over the years with its prevalence is estimated to be more than 500 million globally in 2018, being one of the leading causes of death worldwide with an estimated economic burden of around US$1.3 trillion as of 2015.1–3 DM is characterised by two major types: type 1 DM and type 2 diabetes mellitus (T2D), the latter constituting the majority of all known DM cases. Major risk factors for the disease include obesity and lack of exercise with long-term complications leading to stroke, leg amputation, and kidney and heart or eye problems.4 T2D has no cure and, as such, patients are bound to lifelong treatment of which, if committed to, is associated with prevention of complications, lower medical costs and consequently better quality of life.5 6
A commitment to T2D treatment means being fully adherent to medical prescriptions, diet and exercise plans. Treatment adherence is the extent to which a person’s behaviour, medication use, and diet or lifestyle changes correspond to agreed recommendations from a healthcare provider.7 However, treatment adherence in patients with chronic diseases, including DM, has been reported to be suboptimal.8 9
Several techniques, such as single-dose regimens, reminders and easy packaging, have been used to improve treatment adherence.10 One of these techniques, diabetes self-management education and support (DSMES), has been used to cover lifestyle, medication, blood glucose monitoring and other psychosocial aspects of treatment—all of which have been associated with improved health outcomes and reduced medical costs.11 DSMES is a patient-centred and holistic approach that makes it one of the most ideal techniques to improve treatment adherence of patients with T2D.
Furthermore, delivery of DSMES through technologies such as mobile health (m-health) may improve coverage and convenience for patients. m-health helps to improve adherence including by setting automated reminders and messages, and simplifying tracking of medication and prescriptions.10 12 It is the the most common technology adopted by WHO member states.13 In addition, the American Diabetes Association includes m-health into ‘standard of medical care’ for DM.14 Unfortunately despite this endorsement, m-health is often underused in managing DM.15 There is even lower patronage for apps that would help improve medication adherence.16
There is even fewer literature covering the effect of mobile app-delivered interventions that aim at improving adherence in the T2D population. Majority of prior reviews have concentrated on assessing effectiveness of SMS interventions on medication adherence.10 17 One review did report the effect of app-delivered interventions; however, the study population was heterogeneous with little representation of patients with T2D.18 Other reviews have aimed at assessing m-health intervention effects on glycaemic control.19 20
However, to our knowledge, no review was found to evaluate impact of mobile app-delivered DSMES on adherence specifically in the T2D population. Studies have concentrated on medication adherence rather than lifestyle modification adherence. Furthermore, prior reviews have reported inconsistent findings, lack of clarity on definition and measurement of medication adherence, and inadequate use of theoretical frameworks in the study interventions.10 21
Results of the current review would help add clarity to existing literature and offer quantitative evidence on the impact of app-delivered diabetes education and self-management support on treatment adherence of patients with T2D. The review’s findings would also offer crucial applicability details to information technology and health professionals involved in efforts to reduce global DM burden.
Thus, we aimed to assess the effectiveness of mobile app-delivered DSMES to improve medication adherence and clinical outcomes in patients with T2D. We conducted a systematic review and meta-analysis of experimental studies to address this goal.