Transforming diabetes management in China through mobile health

The growing prevalence of Type 2 Diabetes Mellitus (T2DM), particularly in low- and middle-income countries, poses significant healthcare challenges. China faces immense healthcare burdens despite the government’s efforts through the Basic Public Health Service (BPHS) programme. Diabetes-related healthcare costs in China are expected to rise from $250.2 billion to $460.4 billion between 2020 and 2030, with per-capita costs increasing from $231 to $414. Unfortunately, critical outcomes like glycaemic control and combined ‘ABC’ targets (HbA1c, Blood Pressure, and LDL-cholesterol) remain unmet, highlighting the urgent need for innovative strategies to improve the primary healthcare system’s management of T2DM.

Mobile health (mHealth) technologies have emerged as a promising avenue in managing chronic conditions like T2DM. However, existing research from high-income countries presents mixed results and lacks large-scale evaluations. While family-supported mHealth interventions are effective globally, China is in its early stages of exploring supporting Family Health Promoters (FHPs) with mHealth tools.

The SMARTDiabetes project aimed to enhance T2DM management with the SMARTDiabetes digital health platform, endorsed by local authorities. It integrates the Behaviour Change Wheel framework and T2DM guideline recommendations. The platform features two mobile apps for patients/FHPs and PHC providers, and a web interface for administrators. It facilitates patients’ self-management with optional FHP support and offers PHC staff decision-making and monitoring tools. The project hopes this innovation will improve routine diabetes and hypertension care in settings under the national BPHS.

SMARTDiabetes includes common mHealth functions like self-monitoring, education, reminders, and feedback/counselling, as well as unique features required by the national BPHS package. It includes personalized cardiovascular disease (CVD) risk assessments, goal setting, and tailored reminders for blood pressure measurements based on individual health status. The platform fosters social support by notifying patients and families before doctors, reducing unnecessary PHC provider contact time. It also introduced algorithms to assess real-time performance and offer incentives for engagement, involving patients, families, caregivers, and policymakers in realistic disease management in PHC.

An open-label parallel cluster randomised controlled trial in Hebei Province from August 2017 to October 2019 assessed the feasibility, effectiveness, and scalability of SMARTDiabetes. It enrolled 2,000 T2DM individuals from 80 community clusters (split evenly between urban and rural settings). Participants were randomly assigned to intervention or usual care groups and monitored over 24 months.

The intervention group showed a 20% improvement in achieving combined glycaemic, blood pressure, and cholesterol targets, with significant reductions of 0.33% in HbA1c and 0.58 mmol/l in fasting plasma glucose levels.

 

This improvement was significantly higher in rural areas, indicating a potentially greater benefit of digital health interventions in non-urban settings, with reduced peripheral arterial disease and ischemic heart disease events.

 

However, SMARTDiabetes did not significantly impact other CVD risk factors such as blood pressure, LDL-cholesterol, and body weight compared to usual care. This is consistent with most other studies, indicating that additional strategies are needed to generate clinically meaningful improvements in these risk factors.

SMARTDiabetes showed high engagement with its digital health platform, marked by an average monthly active user rate of 46.4% and 72.5% of the users showed adherence to fasting blood glucose monitoring frequency recommended by the app. Individuals who consistently used the app for more than 12 months experienced a 29% improvement in health metrics.

The high and sustained engagement with the platform was likely due to behaviour change techniques (e.g. rewards, feedback, reminders) and effective digital delivery strategies. Contextual factors such as age, education, FHP involvement, trust also influenced effectiveness across settings. The users valued the reminders within the app and it improved doctor-patient communication. A patient said, “The app sends reminders if you forget to measure your blood glucose or blood pressure. When you receive the warning message, it serves as a reminder, which is very helpful. As an elderly person, I often forget to do this.” FHP support enhanced platform use by patients, but FHPs may not always be available to patients. In summary, the project found that personalised, engaging digital health interventions proved most effective.

The project findings have profound implications for diabetes management practices, particularly in resource-limited settings.

 

The increased engagement and improved health outcomes in rural areas suggest that digital health interventions can bridge critical gaps in healthcare delivery.

 

Moreover, the use of FHPs and personalised app functionalities reflects the importance of tailored approaches that consider familial support and individual health behaviours.

The intervention’s success in improving the detection and management of diabetes highlights the value for encouraging its use and scale-up in different contexts. However, the varied outcomes observed between urban and rural settings reinforce the need for contextual adaptations to maximise its impact.

The project also highlights the importance of integrating digital health platforms within existing healthcare infrastructures to enhance its sustainability. Beyond serving as a self-management tool, SMARTDiabetes can be embedded with the existing BPHS information systems and used by PHC providers to reduce their workload and improve performance, as well as the doctor station system that assist PHC doctors and workers with routine clinical tasks. This integration will significantly enhance the effectiveness of disease management, increase PHC efficiency, and ensure the validity and transparency when reporting data to patients and governments. Accurate data is crucial for reflecting true performance in disease control and for promoting the efficient and correct use of national subsidies for BPHS services.

The main novelty of this study is the deployment of an implementation strategy that could achieve large scale reach if embedded into routine care. Although the effect sizes were modest, if such a strategy can be adopted as an upgraded BPHS with policy endorsement and the financial subsidies for diabetes and hypertension management, the benefits could be substantial. An economic evaluation is currently being conducted to quantify these benefits.

The SMARTDiabetes project in China demonstrated the potential of digital health interventions in transforming diabetes management. Its success in improving health outcomes, especially in rural settings, offers key insights for the design and implementation of similar initiatives across the globe. Moving forward, addressing diverse community needs is crucial to ensure that digital health interventions remain effective, equitable, and accessible for all.

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This research was funded by the Australian National Health and Medical Research Council under the Global Alliance for Chronic Diseases (GACD) Diabetes Research Programme. 

To access publications relating to this project, see GACD’s publications webpage (under Diabetes Research Programme publications, Authors DM02) 

For further information, please contact David Peiris, The George Institute for Global Health Australia, or Puhong Zhang, The George Institute for Global Health China.