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narrative_review·endocrinology, diabetology, digital_health, primary_care·PMC10176130

Integration of the Vision of People With Diabetes Into the Development Process to Improve Self-management via Diabetes Apps: Qualitative Interview Study

JMIR Diabetes · 6 authors, 5 centres

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This qualitative study explored perspectives of 24 people with type 1 diabetes on desired features for future diabetes apps, using a vision assessment framework within Responsible Research and Innovation. Participants identified six priority areas: AI-based personalized glucose predictions, smartwatch integration to reduce signal loss and enable discreet vibrating alarms, improved communication via physician chat and peer forums, personalized information resources, and transparent indication of value delays. The guiding vision emphasizes that personalized self-management support combined with technological fixes for anticipated stigma would improve quality of life and enable more normal living. The authors recommend extending vision assessment to other stakeholders to create a shared vision guiding responsible diabetes app development and DiGA regulation.

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## Background Diabetes mellitus is a major global public health issue, with projections of 700 million affected worldwide by 2045. Approximately 10% have type 1 diabetes (T1D), which requires continuous 24/7 self-management, including blood glucose monitoring, insulin correction, and metabolic balance. This persistent burden reduces quality of life (QoL) and poses challenges to health systems. While numerous diabetes apps exist, they fail to adequately address user needs, lack integration of physical activity, education, and health feedback, and have inconsistent interoperability and data security. In Germany, where approximately 341,000 T1D cases exist, no diabetes app was registered in the Digitale Gesundheitsanwendungen (DiGA) directory at the time of study, and the fast-track approval procedure does not sufficiently evaluate medical benefit for users.

## Methods The study employed an exploratory qualitative design grounded in the Responsible Research and Innovation framework, using vision assessment to explore user perspectives before technology development. Between February and March 2021, 24 semistructured interviews were conducted with T1D patients recruited via a diabetologist using purposive sampling. Of participants, 10/24 (42%) currently used an app, 7/24 (29%) wanted to use an app but were prevented by external circumstances, and 7/24 (29%) did not want or consider using an app. Half (12/24, 50%) were female; ages ranged from 23 to 81 years. Interviews lasted 45 minutes to 1 hour, with 62% (15/24) conducted face-to-face at a diabetologist practice and 38% (9/24) via videoconference due to COVID-19 restrictions. Data were analyzed inductively and deductively using ATLAS.ti, following Creswell's qualitative analysis approach. Four subquestions operationalized the four elements of the vision assessment (Arentshorst et al).

## Key Results The analysis identified one guiding vision: diabetes apps should improve QoL and enable living as normally as possible without anticipated stigma, achieved through (1) personalized self-management options and (2) technological fixes for anticipated stigmatization.

Six main topics emerged regarding desired app features:

1. **Alarm tone**: 9/10 users (90%) wanted customizable alarm sounds and time slots, as alarms attracted unwanted attention in work, restaurant, and sports settings. 17/24 interviewees (71%) wanted smartwatch installation with vibrating alerts to minimize stigmatization.

2. **Sensor and app connection**: All 10/10 users (100%) reported that delayed value transmission hampered self-management. 3/24 (13%) avoided apps entirely because of value delay. 17/24 (71%) preferred smartwatch installation to reduce signal loss.

3. **AI features**: 7/10 users (70%) felt they adapted to apps rather than vice versa. 8/24 (33%) forgot insulin doses during work due to phone restrictions or attention concerns. 5/24 (21%) avoided new sports due to self-management fears. 8/10 users (80%) wanted personalized AI-based predictions for sports, nutrition, and insulin dosing. 17/24 (71%) wanted a photo AI to calculate bread units discreetly at restaurants.

4. **Information and communication features**: 17/24 (71%) wanted reliable, individualized in-app information. 11/24 (46%) valued peer exchange at diagnosis. 13/24 (54%) preferred direct chat with their physician over a chatbot, while 12/24 (50%) considered forums suitable for daily peer exchange. 5/24 (21%) recognized challenges ensuring medically accurate forum content.

5. **Contextual aspects**: 18/24 (75%) cited fast technological innovation and digitalization as supporting factors, while 10/24 (42%) identified data security measures and lack of inter-company collaboration as barriers. Notably, 17/24 (71%) did not prioritize data security if it hindered useful features.

6. **Desirable states**: The combination of personalized features (AI predictions, tailored information, communication options) and stigma-reducing features (discreet smartwatch alerts, photo AI for bread units) was considered necessary to improve QoL.

## Clinical Implications This vision assessment provides the patient perspective needed to inform diabetes app development and DiGA evaluation criteria in Germany. The findings suggest that current app approval processes should incorporate assessment of patient benefit beyond safety and conformity certification. Healthcare professionals and policymakers should recognize that people with T1D prioritize features that enable normalization of life and reduction of anticipated stigma over data security concerns, highlighting the need for patient education on cybersecurity risks. Developers should focus on AI-driven personalization, smartwatch-compatible designs, transparent value-delay indicators, and integrated physician communication channels. The authors call for vision assessments with other stakeholders, including patient organizations, healthcare professionals, insurers, policymakers, device manufacturers, app developers, researchers, ethicists, and data security experts, to create a shared vision guiding responsible innovation in diabetes apps, ultimately aiming to reduce acute metabolic complications, hospitalizations, and long-term comorbidities.

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ORIGINAL PAPER

PMC10176130

Integration of the Vision of People With Diabetes Into the Development Process to Improve Self-management via Diabetes Apps: Qualitative Interview Study

JMIR Diabetes

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ABSTRACT

Abstract Background Diabetes is a major global epidemic and serious public health problem. Diabetes self-management is a 24/7 challenge for people with type 1 diabetes that influences their quality of life (QoL). Certain apps can support the self-management of people with diabetes; however, current apps do not meet the needs of people with diabetes appropriately, and their safety is not ensured. Moreover, there are a multitude of hardware and software problems associated with diabetes apps and regulations. Clear guidelines are required to regulate medical care via apps. In Germany, apps must undergo 2 examination processes to be listed in the Digitale Gesundheitsanwendungen directory. However, neither examination process considers whether the medical use of the apps is sufficient for users’ self-management. Objective This study aims to contribute to the technology development process of diabetes apps by exploring individual perspectives on desired features and content of diabetes apps among people with diabetes. The vision assessment conducted is a first step toward creating a shared vision among all relevant stakeholders. To ensure adequate research and development processes for diabetes apps in the future, guiding visions from all relevant stakeholders are required. Methods In a qualitative study, 24 semistructured interviews with patients with type 1 diabetes were conducted, among whom 10 (42%) were currently using an app. To clarify the perceptions of people with diabetes regarding the functions and content of diabetes apps, a vision assessment was conducted. Results People with diabetes have concrete ideas of features and content in apps to improve their QoL and allow them to live as comfortably as possible, such as informative predictions through artificial intelligence, improvements in signal loss and value delay through smartwatches, improved communication and information-sharing capabilities, reliable information sources, and user-friendly and discreet messaging options through smartwatches. In addition, according to people with diabetes, future apps should show improved sensors and app connectivity to avoid incorrect values being displayed. They also wish for an explicit indication that displayed values are delayed. In addition, personalized information was found to be lacking in apps. Conclusions People with type 1 diabetes want future apps to improve their self-management and QoL and reduce stigma. Desired key features include personalized artificial intelligence predictions of blood glucose levels, improved communication and information sharing through chat and forum options, comprehensive information resources, and smartwatch alerts. A vision assessment is the first step in creating a shared vision among stakeholders to responsibly guide the development of diabetes apps. Relevant stakeholders include patient organizations, health care professionals, insurers, policy makers, device manufacturers, app developers, researchers, medical ethicists, and data security experts. After the research and development process, new apps must be launched while considering regulations regarding data security, liability, and reimbursement. Keywords: people with type 1 diabetes, self-management, diabetes apps, vision assessment, anticipated stigma, qualitative research, Digitale Gesundheitsanwendungen, DiGA, mobile phone

CITATION EXPORT

Isabel Klemme, Kamil J Wrona, Irja Marije de Jong et al.. Integration of the Vision of People With Diabetes Into the Development Process to Improve Self-management via Diabetes Apps: Qualitative Interview Study. JMIR Diabetes. (2023). https://doi.org/10.2196/38474

AUTHORS

6 · 5 CENTRES

Isabel Klemme, Kamil J Wrona, Irja Marije de Jong, Christoph Dockweiler, Leona Aschentrup, Joanna Albrecht

1School of Public Health, Bielefeld University, Bielefeld, Germany
2Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
3Faculty of Engineering and Mathematics, Bielefeld University of Applied Sciences, Bielefeld, Germany
4Faculty of Health, Bielefeld University of Applied Sciences, Bielefeld, Germany
5Department Digital Health Sciences and Biomedicine, School of Life Sciences, University of Siegen, Siegen, Germany