Diabetes Self-Management Care via Cell Phone: A Systematic Review

Abstract

The objective of this study was to evaluate the evidence on the impact of cell phone interventions for persons with diabetes and/or obesity in improving health outcomes and/or processes of care for persons with diabetes and/or obesity.
We searched Medline (1966-2007) and reviewed reference lists from included studies and relevant reviews to identify additional studies. We extracted descriptions of the study design, sample size, patient age, duration of study, technology, educational content and delivery environment, intervention and control groups, process and outcome measures, and statistical significance.
In this review, we included 20 articles, representing 18 studies, evaluating the use of a cell phone for health information for persons with diabetes or obesity. Thirteen of 18 studies measured health outcomes and the remaining 5 studies evaluated processes of care. Outcomes were grouped into learning, behavior change, clinical improvement, and improved health status. Nine out of 10 studies that measured hemoglobin A1c reported significant improvement among those receiving education and care support. Cell phone and text message interventions increased patient-provider and parent-child communication and satisfaction with care.
Providing care and support with cell phones and text message interventions can improve clinically relevant diabetes-related health outcomes by increasing knowledge and self-efficacy to carry out self-management behaviors.

Full text

509
Diabetes Self-Management Care via Cell Phone:
A Systematic Review
Santosh Krishna, Ph.D., Ed.S.1 and Suzanne Austin Boren, Ph.D., M.H.A.2,3,4
Author Afl iations: 1School of Public Health, Saint Louis University, St. Louis, Missouri; 2Health Services Research and Development, Harry S.
Truman Memorial Veterans’ Hospital, Columbia, Missouri; and 3Department of Health Management and Informatics and 4Center for Health Care
Quality, School of Medicine, University of Missouri, Columbia, Missouri
Abbreviations: (MeSH) Medical Subject Headings, (PDA) personal digital assistants, (SMS) short message service
Keywords: cellular phone, diabetes mellitus, outcomes of care, process of care randomized controlled trials, SMS, text messaging, wireless
Corresponding Author: Suzanne Austin Boren, Ph.D., M.H.A., Health Services Research and Development, Harry S. Truman Memorial Veterans’
Hospital, 800 Hospital Drive, Columbia, MO 65201; email address borens@health.missouri.edu
Journal of Diabetes Science and Technology
Volume 2, Issue 3, May 2008
© Diabetes Technology Society
Abstract
Background:
The objective of this study was to evaluate the evidence on the impact of cell phone interventions for persons
with diabetes and/or obesity in improving health outcomes and/or processes of care for persons with diabetes
and/or obesity.
Methods:
We searched Medline (1966–2007) and reviewed reference lists from included studies and relevant reviews to
identify additional studies. We extracted descriptions of the study design, sample size, patient age, duration of
study, technology, educational content and delivery environment, intervention and control groups, process and
outcome measures, and statistical signicance.
Results:
In this review, we included 20 articles, representing 18 studies, evaluating the use of a cell phone for health
information for persons with diabetes or obesity. Thirteen of 18 studies measured health outcomes and the
remaining 5 studies evaluated processes of care. Outcomes were grouped into learning, behavior change,
clinical improvement, and improved health status. Nine out of 10 studies that measured hemoglobin A1c
reported signicant improvement among those receiving education and care support. Cell phone and text
message interventions increased patient–provider and parent–child communication and satisfaction with care.
Conclusions:
Providing care and support with cell phones and text message interventions can improve clinically relevant
diabetes-related health outcomes by increasing knowledge and self-efcacy to carry out self-management
behaviors.
J Diabetes Sci Technol 2008;2(3):509-517
PERSPECTIVES on
Diabetes Information Technology

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(1) diabetes mellitus (medical subject headings (MeSH)),
type 1 diabetes mellitus (MeSH), type 2 diabetes mellitus
(MeSH), or obesity (MeSH); (2) telephone (MeSH),
cellular phone (MeSH), handheld computers (MeSH), cell
phones, mobile phones, text messages, short message
service (SMS), or personal digital assistants (PDA); and
(3) patient education as topic (MeSH), health education
(MeSH), patient education, or health education. We also
systematically searched the reference lists of included
studies and relevant reviews.
Study Selection and Data Extraction
The investigators reviewed the titles and abstracts of the
identied citations and identied eligible articles based
on the following criteria. Inclusion criteria included any
randomized controlled trial, quasi-experimental study,
or pre–post study evaluating the use of cell phones for
health information for persons with diabetes and/or
obesity. The included studies measured health outcomes
or processes of care. Studies published in a language
other than English with a complete English abstract
were included if they met the specied inclusion criteria.
The investigators collected the following information
from each article that was eligible: descriptions of the
study design, country, sample size, patient age, duration
of study, technology, frequency, intervention and control
groups, educational content and delivery, process and
outcome measures, and statistical signicance.
Results
Comprehensive literature searches identied 51 articles.
The titles and abstracts of these articles were read, and
26 articles were determined to be potentially relevant.
After reading the full articles, 20 articles representing 18
studies met the eligibility criteria. Articles were excluded
if they did not focus on diabetes or obesity (8 articles),
a cell phone or text messaging for health information or
education was not used (15 articles), or health outcomes
or processes of care were not measured (8 articles)
(Tables 1 and 2).
The nal set of 18 studies included 1176 participants, with
6 studies involving 221 children and 12 involving 955
adults. Sample sizes ranged from 7 to 274 participants
for adult studies and 11 to 92 participants for studies
involving children. Three studies enrolled more than 130
participants.
Study duration ranged from 3 to 12 months, with the
exception of one study lasting for the duration of a
It is an ongoing challenge to provide care and support
that will produce and sustain the desired improvements
in the health of persons with a chronic illness such as
diabetes. Quality health care requires effective collaboration
between clinicians and patients.1,2 Finding novel ways to
enhance communication and improve the health of those
with chronic diseases is also a continuing part of providing
care. Interventions involving automated telephone message
systems have been shown to improve knowledge and
health outcomes.3–5 Telephone-based interventions have
had positive results even among persons of low
socioeconomic status and ethnic minorities.6
According to the Cellular Telecommunications and
Internet Association, there are over 255 million cell
phone subscribers in the United States.7 Although income
may seem to be a major barrier in cell phone ownership,
every two out of three households in the United States
have a cell phone.8 In a survey of those owning a cell
phone, 35% said that they use it for text messaging.9
There is a need to examine if the various functions of
cell phones, including text messaging, can help with
providing better health care and lead to improved health
outcomes.
Education and information technology are parts of
diabetes care that have been studied. There are other
reviews on health care telephone technology,10,11 automated
telephone messages,4,12 cell phone technology,13 diabetes
Web-assisted interventions,14 and diabetes-computerized
learning technologies.15 However, no systematic review
or meta-analysis of cell phone-based interventions for
persons with diabetes and/or obesity exists to our
knowledge that analyzes the evidence on the use of cell
phones and text messaging interventions to improve
health outcomes, processes of care, acceptance by users,
and whether it is cost-effective.
The objective of this study was to evaluate the evidence
on the impact of cell phone interventions in improving
health outcomes and/or processes of care for persons
with diabetes and/or obesity. We systematically reviewed
studies to evaluate the impact of care and support
interventions via cell phone in improving health
outcomes and processes of care for persons with diabetes
and/or obesity.
Methods
Data Sources
We searched Medline (1966–2007) for eligible trials
using combinations of the following search terms:

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Table 1.
Cell Phone Interventions and Health Outcomes
Author/
year
Study
design
Sample,
age
Duration
in months
Clinical
area Control Intervention Measures Results
C vs I or pre–post
Benhamou et al.,
200716
RCT,
crossover
30,
41.3 years 12 Type 1
diabetes
No weekly SMS
suppor t
Weekly clinical suppor t via
SMS
HbA1c
SMBG
QOL score
Satisfaction with life
Hypoglycemic episodes
No. of BG tests/day
+0.12 vs -0.14%, P < 0.10
+5 vs -6 mg/dl, P = 0.06
0.0 vs +5.6, P < 0.05
-0.01 vs + 8.1, P < 0.05
79.1 vs 69.1/patient, NS
-0.16 vs -0.11/day, NS
Durso et al.,
200317 Pre–post 7,
78.43 years 3Type 2
diabetes N/A Personalized diabetes
management messages
Convenience CP vs HP
Ease of use CP vs HP
Ease of recording
Communication aid
pre vs post:
average knowledge score
HbA1c (%)
Check BG ≥once/day
Check feet daily
Never miss medication
PA ≥5–6 days/week
Hypo symptoms: never
Hyper symptoms: never
BMI
3.71 vs 4.17
2.57 vs 4.33
3.86
4.28
74 vs 82
8 vs 7
57% vs 72%
100% vs 100%
85% vs 85%
29% vs 57%
43% vs 14%
57% vs 43%
30 vs 29
Franklin et al.,
200618 RCT 92,
8–18 years 12 Type 1
diabetes CIT- Grp1 CIT+ST - Grp2,
IIT+ST- Grp3
HbA1c
Self-efcacy
Adherence
10.3 vs 10.1 vs 9.2%, P < 0.01
56.0 vs 62.1, P < 0.01
70.4 vs 77.2, P < 0.05
Hurling et al.,
200719 RCT 77,
40.4 years 4 Healthy
Verbal advice
during clinic visit,
no phone support
Cell phone support, i.e.,
exercise plan, PA charts,
reminders, tailored advice
Change in:
PA overall, MET min/week
PA leisure time, ME T min/week
Hours sitting: overall
Hours sitting: weekday
Hours sitting: weekends
Accelerometer epochs
BMI
Lost % body fat
BP, diastolic
BP, systolic
Perceived control
Intention to exercise
Internal control
External control
4.0 vs 12, NS
-5.5 vs 4.1, P < 0.05
-0.17 vs -2.18, P < 0.05
1.4 vs -5.9, P < 0.05
-0.2 vs -5.2, NS
208.7 vs 218.5, P < 0.05
0.10 vs -0.24, NS
-0.17% vs -2.18%, P < 0.05
0.73 vs 0.69, NS
0.41 vs 0.13, NS
-0.37 vs 0.57, P < 0.01
-0.01 vs 0.45, P < 0.01
5.85 vs 7.24, P < 0.001
5.33 vs 6.38, P < 0.01
Kim et al., 200520 Pre– post 42,
41.5 years 3Type 2
diabetes N/A Blood glucose transfer and
advice
FPG
2HPPG
TC
HDL
Satisfaction with care
-28.6 mg/dl, P < 0.05
-78.4 mg/dl, P < 0.05
-13.5, NS
+27.3, NS
+10.9, P < 0.05
Kim, 200521 RCT 34 adults 3
Type 2
diabetes
and
obesit y
N/A Educational messages
HbA1c
2HPPG
Total cholesterol
TG
HDL
-120.1 mg/dl, P < 0.05
1.2% vs 0%, P < 0.05
NS
NS
NS

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Table 1. Continued
Author/
year
Study
design
Sample,
age
Duration in
months
Clinical
area Control Intervention Measures Results
C vs I or pre–post
Kim et al., 200622 Pre –post 45,
43.5 years 3Type 2
diabetes N/A Educational messages
HbA1c
Diabetic diet
Exercise
Medication
Foot care
-1.1%, P < 0.01
-0.8, days/week, NS
0.9 days/week, P < 0.05
1.1 days/week, P < 0.05
1.1 days/week, P < 0.05
Kim, 200724 RCT 51,
47 years 3Type 2
diabetes
Standard care
during clinic visit
Weekly BG-based optimal
recommedations
via SMS
Group 1: <7%, pre–post:
HbA1c
FPG levels mg/dl
2HPMG
Group 2: ≥7%:
HbA1c
FPG levels mg/dl
2HPMG
0.53 NS vs -0.21, P < 0.05
-5.8 NS vs -13.4, P < 0.05
-3.1 NS vs -56.0, P < 0.05
0.22 NS vs -2.15, P < 0.05
14.5 NS vs -3.3 NS
24.8, NS vs -115.2, NS
Kubota et al.,
200426 Pre– post 136 adults 3 Obesit y N/A i-exerM health education
program
Weight reduction–M
Weight reduction–F
% perceived it effective
-2.1 kg, P < 0.01
-1.2 kg, P < 0.01
32%
Kwon et al.,
200427 Pre– post 185,
42.4 years 3
Type 1
and type 2
diabetes
N/A
Advice on, dose
adjustment, diet, exercise,
and diabetes information
HbA1c, all patients
HbA1c, >7.0%
FPG levels
Total cholesterol
Triglycerides
HDL–cholesterol
-0.5%, P < 0.01
-0.9%, P < 0.01
+6.6 mg/dl, NS
-0.9 mg/dl, NS
-24.4 mg/dl, P < 0.01
5.7 mg/dl, P < 0.05
Liu et al., 200528 Pre– post 274,
63 years 8Type 2
diabetes Usual care POEM system and
reminders
FPG
HbA1c
Total cholesterol
Log-ins, 1–3 months
Log-ins, 4–6 months
F = 7.898, P < 0.05
F = 7.345, P < 0.05
F = 4.139, P < 0.05
9.6/mo per patient
8.5/mo per patient
Rami et al.,
200629 RCT 36,
15.3 years
6,
3-month
cross-over
Type 1
diabetes
Conven-tional
suppor t and paper
diary
Monitoring and support by
SMS
HbA1c change 3 months
HbA1c change 6 months
+1.0 vs -0.15
+0.15 vs -0.05
Kim, 200723
Kim and Jeong,
200725
Yoon and Kim,
200730
RCT 51,
47 years
3
6
12
Type 2
diabetes
Usual care and
suppor t
Weekly patient input of
SMBG, medication details,
diet, and exercise and
optimal advice from a nurse
via SMS or the Internet
3 months: HbA1c
FPG levels mg/dl
2HPMG
6 months: HbA1c
FPG levels mg/dl
2HPMG
9 months: HbA1c
FPG levels mg/dl
2HPMG
12 months: HbA1c
FPG levels mg/dl
2HPMG
3-, 6-, 9-, 12-month change in:
total cholesterol
triglycerides
HDL
0.07 vs -1.15%, P < 0.05
5.4 vs -8.0, NS
14.7 vs -85.1 mg/dl, P < 0.05
0.11 vs -1.05%, P < 0.05
7.3 vs -5.8, NS
13.8 vs -63.6 mg/dl, P < 0.05
0.33 vs -1.31, P < 0.05
12.2 vs -10.5, NS
-17.4 vs -66.8, P < 0.05
0.81 vs -1.32, P < 0.05
27.7 vs -10.7, NS
18.1 vs -100, P < 0.05
NS
NS
NS
Notes: 2HPPG, 2-hour postprandial blood glucose; 2HPMG, 2-hour postmeal glucose, BG, blood glucose; BMI, body mass index; BP, blood pressure; CIT, conventional insulin therapy;
CP, cell phone; F, female; FPG, fasting plasma glucose; HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; HP, home phone; I, Internet; IIT, intensive insulin therapy; M, male;
MET, metabolic equivalent; N/A, not available; NS, not signicant; PA, physical activity; POEM, patient-oriented education management; QOL, quality of life; RCT, randomized controlled trial;
SMBG, self-monitored blood glucose; SMS, short message service; ST, Sweet Talk.

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information, diet, weight, physical activities, and other
information input by the participants as required by the
study protocol. In providing personalized advice, health
care providers also took into consideration patient history,
such as age, years with diabetes, comorbidities, family
history of diabetes, and laboratory results. Participants in
studies focusing on weight reduction and management
received personalized tips on diet and nutrition, how
to overcome barriers, and how to maintain a regular
physical activity program leading to weight reduction.19,26
As part of the intervention, patients also received
reminders to perform diabetes self-management activities
(e.g., check their blood sugar and feet,17,33 take
medication,17 log-in and input information,25,30,34 complete
assessment questionnaires,17,18,34 or review information on
the next follow-up visit28). In two studies, motivational
messages were sent to the intervention group participants
for maintaining their exercise schedule and overcoming
barriers to maintaining a healthy life style.19,26 The
personalized messages were generated by algorithms
based on data the patients input.
Technology of Intervention
Technology used to provide education and information
interventions in all studies included cell phones and SMS.
diabetes summer camp.31 Eight studies were of 3 months
duration,17,20–22,25–27,35 two of 8 months duration,28,32 one of
4 months duration,33 and two of 6 months duration.23,29
Four of the selected studies were of 12 months’
duration.16,18,30,34 In studies lasting more than 3 months,
return visits for diabetes patients were scheduled for
regular checkups and to obtain data for laboratory
measurements.
Studies took place in nine different countries, including
one in Austria,29 two in Japan,26,31 one in France,16 six in
Korea,20–25,27,30 two in Norway,33,35 one in Spain,32 one in
Taiwan,28 two in the United Kingdom,18,34 and one in the
United States.17
Education Content and Method
In addition to general information on diabetes17,18,27,31,32,35
or weight reduction,19,26 educational intervention and
support in the studies were personalized to an individual
care plan of the participants. Patients were requested to
send information via voice mail or text message or at the
Web site, which became the basis of personalized advice
and support from the diabetes care team.16,17,19,26,27, 29,32,33
Participants in diabetes studies, for example, were
provided monitoring and advice based on individual
blood sugar measurements, medications, insulin dose
Table 2.
Cell Phone Interventions and Process of Care
Author/
year
Study
design
Sample/
age Duration Clinical
Area Control Intervention Measures Results
C vs I
Aoki et al.,
200531 Pre –post 30,
12–24 years N/A Type 1
diabetes N/A
Educational
game
INSULOT
Entertainment score (1–7)
Usability score (1–7)
Recommend to others
5.57
5.44
>80%
Ferrer-Roca
et al., 200432 Pre –post 23,
18–75 years 8 months Type 2
diabetes N/A
Diabetes
management
messages
Satisfaction
Running costs
System usage
3.4 (range 1–5)
€3.0 to patient €3.75 to
system
33 messages/month
Gammon et
al., 200533 Pre–post 15,
9–15 years 4 months Type 1
diabetes N/A Data transfer
3 times/day
Parent vs child:
Receiving BG
Easier mgmt.
Manual/auto BG transfer
93% vs 80%
40% vs 13%
93% vs 53%
Tasker et al.,
200734 RCT 37,
7–18 years
12
months
Type 1
diabetes
Paper
diary
during
clinic
visit
Daily text
message
requesting
response to
questions
Frequency of hypos
Hypos response rate
(Paper diary, CBI, CP)
Preference over diary
5.2/month
65% vs 89% vs 95%
CBI 54%
CP 65%
Wangberg
et al., 200635 Pre –post
11,
9–15 years
and parents
3 months Type 1
diabetes N/A
Diabetes
education
messages
User satisfaction
Perceived pros
Perceived cons
Satised
Parent–child
communication
Easily made part of daily
lives
Unable to store or print all
messages
Notes: BG, blood glucose; CBI, computer-based inter viewing; CP, cell phone; hypos, hypoglycemic events; N/A, not available.

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While the majority of studies utilized the text messaging
feature of cell phones to provide tailored advice and
support, in some studies,22–26,30 patients had the option of
using wireless or wired Internet to input their glucose
measurements. One study sent reminders about the next
appointment to the cell phone and via email.28 Another
study also utilized PDAs.16 Only one study performed all
interactions with study participants through technology-
based communication and did not provide any face-to-
face meeting opportunity during the study duration.26
Regardless of the mode of communication, all studies
provided advice tailored to individual needs and the
treatment regimen. Tables 3 and 4 provide the details of
specic education and information provided.
Table 3.
Technology in Studies with Outcomes of Care
Author/year Technology/
functionality Frequency Educational content and delivery
Benhamou et al.,
200716
Cell phone
SMS
PDA
Internet
Weekly
Participants performed weekly transfer of SMBG using a palm PDA that communicated with
the glucometer and cell phone, and 3-monthly transfer of Diabetes Quality of Life survey
responses plus any comments. They received weekly SMS treatment advice from their
health care providers based on glucose values.
Durso et al.,
200317
Cell phone
SMS
Voice mail
Daily
Patients used a cell phone to input blood sugar, weight, any diabetic symptoms, medication
side effects, or any problems with the care plan. They received daily personalized SMS
messages from the nurse practitioner reinforcing knowledge and self-care behaviors and
a phone call if any health problems needing immediate attention were identied from the
data input.
Franklin et al.,
200618
Cell phone
SMS Daily
Goals set during clinic visits were reinforced by daily text messages from the Sweet Talk
software system, containing personalized goal-specic prompts and messages tailored to
patients’ age, sex and insulin regimen.
Hurling et al.,
200719
Cell phone
Internet
Voice mail
email
Weekly
Internet, email, and mobile phone behavior change system, which included a Web-based
interactive system for users to input perceived barriers, repor t exercise levels during
the previous week, and plan physical activity for the next 7 days. Participants received
personalized advice and motivational tips on how to overcome barriers and maintain an
appropriate level of activity, as well as information about various types of physical activities.
Charts were displayed with daily, weekly, and overall activity levels.
Kim et al., 200520;
Kim et al., 20062 2;
Kim, 200724;
Yoon and Kim, 200730
Cell phone
SMS
Internet
Weekly
Patient input their SMBG, medications, and insulin with doses, diet, and exercise level via cell
phone, SMS, or the Internet and viewed their electronic chart, including lab results and nurse
sent weekly recommendations (e.g., increase insulin by xx units, add another tablet of …, etc.)
via cell phone, SMS, or the Internet. Also, patients received reminders if did not input
information at least once a week.
Kubota et al., 200426
Cell phone
Internet
email
Daily
The i-exerM health education program was used to send participants informational
message once a day to their mobile phone on weight reduction. They were asked to input
their weight via the Internet from time to time. Information for each individual at the start
and the end of the i-exerM monitoring session was collected with a questionnaire covering
physical conditions, lifestyle, and program evaluation, without any face-to-face meeting
during the study period.
Kwon et al., 200427 Cell phone
Internet Variable
Participants sent their self-measured blood glucose, medication and its dosages,
hypoglycemic events, amount of meals, and degree of exercise and questions. Their
dietitians, endocrinologists, and nurses sent individualized recommendations for adjustment
to dose, diet, and exercise for diabetes management based on data inputs.
Liu et al., 200528
Cell phone
Internet
email
Following
each visit
throughout
the study
period
The POEM system was used to present on the Web each patient’s education materials,
medication data, and laboratory test results from each visit for patients to review. The
system also sent reminders for the next follow-up via emails and short messages via cell
phone.
Rami et al., 200629 Cell phone
SMS Daily
Participants sent their data (date, time, blood glucose, carbohydrate intake, and insulin
dosage, divided into short- and long-acting insulin) every time they measured a blood
glucose value or at least once a day. For safety reasons, they continued their diary notes
during the telemedical support phase. Patients received either an automatically generated
SMS message if no treatment changes were needed or a personalized message with more
specic advice on insulin dose adjustment.
Notes: PDA, personal digital assistant; POEM, patient-oriented education management; SMBG, self-monitored blood glucose;
SMS, shor t message service.

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Studies with Health Outcomes
Outcomes of care were dened as changes in diabetes-
related health outcomes because of an educational or
informational intervention delivered through cell phones
using voice or short message service. We grouped the
outcome measures according to the diabetes self-
management education core outcome measures continuum:
learning, behavior change, clinical improvement, and
improved health status.36 Table 1 lists studies that
evaluated the impact of diabetes educational interventions
on the control of blood sugar levels and other related
health outcomes.
Learning. Two studies measured outcomes related to
knowledge and skills.17,19 These outcomes included average
knowledge scores as measured by the Diabetes Knowledge
Test from The Michigan Diabetes Research and Training
Center,17 as well as perceived control, internal control,
external control, and intention related to exercise.19
Behavior Change. Behavior change was measured in ve
of the studies.16–19,22 These measures included general
measures of self-efcacy and adherence to behavioral
change,18 as well as self-management behaviors such
as blood glucose monitoring,16,17 taking medication,17,22
eating appropriately,22 physical activity,17,19,22 and foot
care.17,2 2
Clinical Improvement. Thirteen studies measured clinical
changes.16-30 The clinical measures were related to
hemoglobin A1c (10 studies),16-18,21-25,27-30 blood glucose
(7 studies),16,20,21,23-25,27,28,30 cholesterol (5 studies),20,21,23,24,27,28,30
weight (3 studies),17,19,26 and blood pressure (1 study).19
Nine of the 10 studies that measured hemoglobin A1c
observed a signicant improvement. The results regarding
blood glucose, cholesterol, and weight were mixed, while
the results for blood pressure were nonsignicant.
Health Status. Two studies measured health status
outcomes.16,17 Quality of life was determined using the
Diabetes Quality of Life questionnaire and satisfaction
with life was also measured.16 Diabetes complications
were measured as hypoglycemic symptoms16,17 and
hyperglycemic symptoms.17
Studies with Processes of Care
Table 2 lists studies that evaluated the impact of
educational intervention on the process of diabetes
care.31-35 In addition, three studies that measured
diabetes-related health outcomes also measured process
of care.17,26,28 The processes of care commonly measured
included system convenience or ease of use,17,26, 31,33,35
system usage,28,32 satisfaction with the system,31,32,34,35 time
to use the system,17 or running costs.32 The processes of
care measures were generally favorable to cell phone use.
Table 4.
Technology in Studies with Process of Care
Author/year Technology/
functionality Frequency Educational content and delivery
Aoki et al., 200531 Cell phone Not repor ted;
camp activity
Cell phone-based game “INSULOT” was used to teach children during a summer
camp for those with type 1 diabetes relationships among plasma glucose level, food
(carbohydrate grams), and insulin dosage.
Ferrer-Roca et al.,
200432
Cell phone
SMS Variable
Patient input biological measures via SMS, with immediate display of patient data
on the Web available for review to both patients and physicians. Patients received
automated diabetes warning messages from the system based on data input and
preset ranges by physicians. Patients accessed the Web site on the average every 2
days, while physicians reviewed patient data on average every 4 days.
Gammon et al., 200533 Cell phone
SMS Daily
Patients were to send their blood glucose readings at least three times per day, ask
questions, and report technical difculties. Both parents and patients received text
messages with response to their questions, information, decision support, and social
suppor t.
Tasker et al., 200734
Cell phone
SMS
Internet
email
Daily
The mobile group received a SMS message every day that asked to respond to
questions if they had a hypoglycemic event that day; the computer-based interviewing
group received an email to log in and complete the same questions on the Web site.
Wangberg et al.,
200635
Cell phone
SMS Daily
Children sent their blood glucose data to parents’ cell phones via SMS, which were
sent to the electronic patient record. Diabetes educational messages were sent up to
three times per day, on themes such as diabetes denitions, blood glucose, insulin,
nutrition, physical activity, illness, and rights at school.
Note: SMS, short message service.

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Diabetes Self-Management Care via Cell Phone: A Systematic Review Krishna
www.journalofdst.org
J Diabetes Sci Technol Vol 2, Issue 3, May 2008
Unfortunately, the diversity of process measures used
made it impossible to provide a summary of signicant
results from process measures beyond what is shown in
Table 2.
Discussion
The purpose of this review was to evaluate the
contribution of cell phone interventions in the control
and management of diabetes. In this review, most
studies provided standard diabetes care utilizing face-to-
face communication during clinic visits. In addition, the
intervention group participants received care through
cell phones using one or more of their functional aspects
(e.g., SMS, voice mail, Internet, or email). Cell phones
were used as a management tool to enable information
to ow between patients and providers. In a chronic
disease such as diabetes, maintaining blood sugar levels
and related clinical and physiological measurements to
acceptable levels requires monitoring and management
through regular self-care behaviors. In some studies, cell
phones and text messaging facilitated regular treatment
advice and support in between clinic visits. In other
studies, cell phones and text messaging proved to be
good tools to deliver regular alerts and reminders
to achieve desired goals. Nine out of 10 studies that
used cell phone technology and measured hemoglobin
A1c showed signicant decreases in hemoglobin A1c
values. Results of our study indicate that educational
interventions providing personalized advice and support
delivered through a cell phone can help avoid diabetes
symptoms by providing timely treatment adjustments
and can lead to improved health outcomes.
The concept of using interactive voice mail messages to
deliver information or education in disease management
and control is not new.37 Computer and communication
technology-based education and support are becoming
vital components of quality diabetes care.38 Diabetes
education and diabetes management support through
automated telephone reminders and support have been
shown to increase knowledge, increase frequency of
self-care behaviors among persons with diabetes, and
improve health outcomes for patients who need regular
care and monitoring and self-care management.39 Because
monitoring and support from a health care provider play
important roles in achieving the desired clinical goals,
the use of cell phones, especially text messaging, is a
step further in achieving the health and quality of life
for persons with diabetes. Using cell phones and text
messaging offers great opportunities to improve patient
self-management by facilitating education, monitoring,
and feedback between scheduled clinic visits. The
ubiquitous nature of cell phones provides the mobility
and exibility so that care can be provided wherever
a patient may be.40 A potential implication of this is
licensure issues if a health care provider is licensed in
one state and the patient is receiving treatment in another
state. As more and more people own cell phones, text
messaging may even provide cost-effective alternatives to
regular phone communication when combined with other
methods of education and support.41,42 Unfortunately,
only one study in this review provided information on
the costs of running the system.32
Results of this systematic review should be interpreted
with limitations in mind. The studies did not provide
the reliability and validity of the information that patients
entered into the cell phones; however, two studies
provided examples of how a automated system could be
programmed to check if the value entered was within
a predened range.16,17 The heterogeneity of the studies
prevented a meta-analysis, which could have allowed
for a quantitative assessment. We attempted to search
comprehensively; however, we may have unknowingly
left out some work that was eligible for inclusion.
Regardless, the benets offered or limitations involved in
the use of cell phones in diabetes care are estimated to
be the same.
Funding:
A Department of Veterans Affairs VISN 15 Research Award (S.A.B.)
supported this research.
Disclosure:
The views expressed in this article are those of the authors and do not
necessarily represent the views of the Department of Veterans Affairs.
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