Smartphone Application for Diabetes in Indonesia: A Narrative Review

Perdani Adnin Maiisyah¹, Zullies Ikawati², Zainol Akbar Zainal³

¹Post-graduate Master of Clinical Pharmacy Program, Faculty of Pharmacy,

Universitas Gadjah Mada, Yogyakarta, Indonesia.

²Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy,

Universitas Gadjah Mada, Yogyakarta, Indonesia.

³Faculty of Pharmacy, University of Cyberjaya, Selangor, Malaysia.

*Corresponding Author E-mail: ashujinagal12@gmail.com

ABSTRACT:

In 2017, Indonesia was ranked sixth in the top ten countries with the highest diabetes cases. The prevalence is expected to continue increasing. The use of Smartphone applications is one of the alternative methods in promoting better disease management and preventing diabetes. The purpose of this review is to identify existing studies regarding Smartphone applications for diabetes in Indonesia and to highlight the important findings. There are only a few original clinical studies about Smartphone applications for diabetes in Indonesia. A total of 5 studies were reviewed here. There are the Nutri Diabetic Care, the Teman DM, the DM Calendar App, the E-diary DM, and the Salam Sehat. The study was conducted on several respondents with the use of short-term applications and using the variable method. Nevertheless, the studies found that Smartphone applications for diabetes can be beneficial for improving self-care, self-efficacy, increased knowledge, and medication and diet compliance among diabetic patients in Indonesia. The information and utility criteria for diabetes application which should be relevant to clinical guidelines are not discussed. The implementation of Smartphone applications for diabetes is suitable for Indonesian condition. The best application with the right information, utility, and supported by clinical studies is suggested as a complement to the diabetes management by a health professional.

KEYWORDS: Smartphone application, Diabetes mellitus, Self-management, Telemedicine.

INTRODUCTION:

Diabetes is a long-term disease that requires continuous medical care^1,2. Diabetes can interfere with human productivity, which ultimately inhibits economic growth. Therefore, diabetes not only affects people but also the whole country³.

International Diabetes Federation in 2017 estimated that 425 million or 8.8% of people in the world suffer from diabetes. Indonesia ranks sixth in the top ten countries/territories with the highest diabetes cases in 2017, reaching up to 10 million people throughout Indonesia. The latest data based on Riskesdas Indonesia 2018 showed that the prevalence of diabetes in Indonesia was 10.9%⁴.

Since the rates continue to increase, the promotion, prevention, and curative management for diabetes are required⁵.

According to the standards of diabetes medical care established by the American Diabetes Association in 2020, besides the pharmacology intervention, supporting behavioral changes can be useful to achieve the purposes of diabetes management. In addition, the evolution of behavior is very important to prevent acute and long-term complications. The evolution also includes diabetes self-management education and support (DSMES), medical nutrition therapy (MNT), routine physical activity, smoking cessation counseling when needed, and psychosocial care.

The behavior change of diabetic patients needs to be supported by excellent diabetes education. A good perception of diabetes builds the patient to recognize the course of the disease, prevention, complication, and management. Thus, an accurate understanding of diabetes can provide clinical results that benefit patients². The study also revealed that health education program was highly effective in prevention of complication of diabetes⁶.

A study in rural community in India revealed that only 14.28% of the respondent had adequate knowledge. Other study revealed that 46.66% patients had poor self-care. Hence, the patient with poor knowledge, self- efficacy, and self- care important to receive repeated and longer duration education⁷. The education method to provide the diabetes education is available in many kinds such as pamphlets, workshops and several media⁸. The structured teaching program and self-instructional module were the effective method that evident to provide the knowledge of diabetic patients, but this method was not sustainable^9,10.

The financial situation, medical condition, and access are some of the potential limitations encountered by diabetic patients to participate in diabetes education in Indonesia⁵. Telemedicine is one of the alternative development methods which have been shown to be able to overcome the limitation. Telemedicine improves access and accelerates remote delivery of health-related care and medical education¹¹. Around 8% people with good knowledge of diabetes receive information through television¹². In India, the awareness of e-health services improves such as online consultation with physician¹³. The cellular health application is one of telemedicine in the form of Smartphone software. Telehealth is easy to use anytime and anywhere, and this impacts many people at once^14,15. Indonesia, as the country with the fifth most internet users in the world, is optimistic that the application will be useful.

The Study of a Smartphone application for diabetic patients in other countries have been conducted through several systematic reviews. The results showed that the use of the application as a method of promotion and prevention was also practical. The application improves self-management, self-care, use of healthcare, time and cost efficiency effectively^15-19. The purpose of this narrative review is to identify existing clinical studies about Smartphone applications for diabetic patients in Indonesia and to highlight important findings.

The Clinical Studies of Smartphone Applications for Diabetes in Indonesia:

Five clinical studies of Smartphone applications for diabetes in Indonesia are reviewed and presented in Table 1. There are Nutri Diabetic Care, Teman DM, DM Calendar App, E-diary DM, and Salam Sehat, which had different methods and sample size of clinical studies.

Table 1: The clinical studies of Smartphone applications for diabetes in Indonesia

No	Application	Aim	Methods	Sample size	Conclusion
1.	Nutri Diabetic Care^20	To assess the influence of Nutri Diabetic Care in diet compliance	A quasi-experimental study, one group, pre- and post-test.	20 respondents	Nutri diabetic care as a method of counseling significantly influences the patient compliance before and after the use.
2.	Teman DM^21	To assess the effect of Teman DM Application (Medication Reminder Application) on compliance and knowledge of diabetic patients.	A prospective cohort design, one group, has pre-test and post-test	30 respondents	Teman DM Application is effective to increase the knowledge and compliance of Diabetes Mellitus patients
3	DM Calendar App^22	To assess the effect of the DM-calendar app on self-efficacy, HbA1c, lipid profile, and insulin.	A randomized experimental design, pre- and post-test in intervention group and control group	15 respondents	The DM-calendar Application shows a much increase in higher self-efficacy than leaflet method, and the application is able to reduce the levels of HbA1c, lipid profile, and insulin.
4	E-diary DM^23	To assess the effect of E-diary DM on self-care: patients diet management.	A quasi-experimental, pre and post-test with the control group	30 respondents	The E-diary DM effectively enhances the self-care: diet management.
5	Salam Sehat^24	To assess the impact of "Salam Sehat" app on self-care	A pre-experimental design, one group pre- and post-test	384 respondents	Salam Sehat application shows a significant effect on the patients self-care

Nutri Diabetic Care²⁰:

One of the applications for diabetic patients is Nutri Diabetic Care. This smartphone application has several features, which are meal time reminders, diabetes information, 3J Jumlah Jenis Jadwal Makan/Number of Types of Eating Schedule (proper quantity, type, and schedule of daily intake), nutrition status calculator, dietary needs based on gender, age, physical activity and monitoring of intake. A study to assess the effectiveness of the Nutri diabetic care on diet compliance was conducted with a quasi-experimental study on 20 respondents, one group with the pre-test and post-tests design. This application was used for two weeks by each respondent. Before and after the study, the respondents were assessed for their compliance using food recall 24 and the Food Frequency Questionnaire (FFQ). The result showed that Nutri Diabetic Care significantly increased patients compliance with dietary behavior (p value = 0.025) by increasing 25% of 3J compliance after the use of the application. However, this study only represents the use of the application from the nutritional aspect, despite its content that includes diabetes information.

Teman DM²¹:

Another application is Teman DM that contains diabetes and drug information, medication reminders, and consultation schedules. The researcher created the contents of the Teman DM application through the Alpha test and Beta test. A cohort prospective design study was implemented to assess the effect of Teman DM Application (Medication Reminder Application) on the compliance and knowledge of diabetic patients at the University Hospital of North Sumatera. As many as 30 respondents were involved in one group to do pre-test and post-test. The respondents used the Medication Reminder Application, and their knowledge and compliance were evaluated using the Diabetes Knowledge Questionnaire-24 (DKQ-24) and the Morisky Medication Adherence Scale-8 (MMAS-8). The knowledge score after Teman DM intervention has significantly increased, from 17.5667±0.52 to 21.00±0.20 (P < 0.001). The same thing applies with compliance, where compliance scores increase significantly, from 5.43±0.207 to 6.77±0.177 (p-value <0.001). Hence, Teman DM Application was effective in increasing the knowledge and compliance of Diabetes Mellitus patients. Unfortunately, the duration of the use of Teman DM application was not explained.

DM-calendar App²²:

The third application is DM-calendar application, an alternative method for the Diabetes Self-Management Education (DSME), which is estimated to unlock the patient limitation to access diabetes health education. DM-calendar comprises of blood sugar control, education program, nutritional therapy, and physical activity. Regularly, the DM calendar will send notifications to remind the users to keep the activities related to self-care diabetes. To assess the effect of the DM-calendar application on self-efficacy, HbA1c, lipid profiles, and insulin therapy, a randomized experimental design, pre-test and post-test, with 15 respondents in the intervention and control group respectively, has been conducted. All respondents in both groups received DSME sessions about the basic concepts of diabetes mellitus, nutritional therapy, physical activity, foot care, and the monitoring, recent stress management, psychosocial support, and patient access to healthcare facilities. Respondents in the intervention group used the DM-Calendar application for three months, while those in the control group were given leaflet media. Self-efficacy was measured with a diabetes management self-efficacy scale (DMSES). The result shows that the DM-calendar Application as medium of DSME could result higher self-efficacy than the leaflet media significantly (p < 0.001). The use of DM-calendar application was also able to reduce the levels of HbA1c (p=0.005), lipid profiles (cholesterol (p = 0.009), triglyceride (p < 0.001), HDL-c (p = 0.048), LDL-c (p = 0.010), and insulin (p < 0.001).

The DM-calendar application has reduced the limited access of the patients to diabetes health education. This method can regularly inform them in a long period and is accessible everywhere. This application eliminates cost, time, and availability, which usually inhibits diabetic patients from accessing diabetes and self-management education programs. Unfortunately, 50% of respondents dropped out during the study because they were unable to follow the specified program, did not carry out this program seriously, and moved outside Bali. So that, the result cannot be projected to accurately reflect conditions on the number of respondents more significantly.

E-diary DM²³:

The next application is an E-diary DM, an application that accommodates the diet management of diabetic patients. To assess the effect of E-diary DM on self-care of diet management patient, a quasi-experimental, pre-test and post-test with control group design were implemented in the study. There were 30 respondents in this study who were assigned to either the intervention or control groups and observed for two weeks using the E-diary DM. Significant improvement in diet management before and after the adoption of the E-diary DM (p-value = 0.006). Then, it can be concluded that E-diary DM effectively improves self-care diet management.

Salam Sehat²⁴:

The last application reviewed was Salam Sehat, an application providing information about diabetes and self-management. The users of Salam Sehat are also able to watch diabetes videos and use the chat room feature which allows them to ask questions related to diabetes information.

The impact of the Salam Sehat application on self-care was observed in 384 respondents through a pre-experimental design, one group pre-test and post-test. The self-care was assessed using the Summary of Diabetes Self Care Activities (SDSCA) questionnaire. The duration of the Salam Sehat application implementation was two weeks. The SDSCA measured several indicators, i.e., diet, physical exercise, independent blood glucose monitoring, and foot care. Every three days, researcher reminded the respondents to use the application by sending several topics related to self-care of diabetes via WhatsApp® chat. There is an alteration score of self-management before and after using the Salam Sehat application (by 29.76). The result showed that the Salam Sehat application had a significant effect on patients self-care (p<0.001). The increase in diabetes information is comparable to better self-care, and finally, the purposes of therapy are achieved. Salam Sehat seems to be more interesting than the usual method where the delivery of information is tedious through dialogues, lectures, and presentations. The advantages are that people with diabetes can afford information about diabetes everywhere through the Salam Sehat application, without time and space limitation.

DISCUSSION:

The high prevalence and complexity of diabetes in Indonesia needs tactics to elucidate. Besides the regular medication therapy, proper education is needed to complement diabetes management. The previous education method was claimed to be difficult to access, limited in choice, and less attractive.

Recently, Indonesia only has one physician per 3,333 citizens. This condition does not fit to the WHO’s recommendation that a country requires one physician per 1,000 citizens. This ratio is the lowest in South-East Asia. Furthermore, the distribution of physicians in Indonesia is imbalance. Only 20% of the total number of practices in rural areas and the rest localized in cities²⁵.

The fact, almost 51.8% of Indonesians are internet users. This number can be a consideration to implement telemedicine as one of the alternative methods for better healthcare in Indonesia. Telemedicine can be a method of healthcare for promotion and prevention purposes²⁵.

The patient satisfaction with health service was also influenced by the participation of pharmacists. Where in pharmaceutical care, one of the roles of pharmacist was giving counseling which was aimed to identify and solve therapeutic problems such as drug-related problems and to improve the quality of life, so that therapeutic goals are achieved. However, Indonesia had been implemented by National Health Insurance (JKN) recently. This implementation made general pharmaceutical services such as prescription services, drug availability, and accelerated waiting times to be the most important matters. The work load and limitation of pharmacists, especially clinical pharmacists also being other disruptions^26-30. Finally, on a daily basis, diabetes information provided by pharmacists was specifically related to medicine due to the pharmacist’s limited ability. Hence, counseling was an additional educational method; the pharmacist could not provide complete diabetes information to every patient regularly. Meanwhile, diabetes is a long-term disease that also requires long-term education.

A Smartphone application is one of telemedicine that rapidly develops. Such an application is able to facilitate the long-lasting requirement of diabetes education. As an alternative method, the quality of the diabetes Smartphone application content shall be reviewed and improved to fulfill specific criteria³¹. Besides, clinical study about the effectiveness of the application is essential to do to evaluate the application which is distributed in community and to select the best application which can be offered to patients as a complement diabetes management.

The reference for the content of the application is limited. The global overview assessed the clinical relevance of Smartphone applications for diabetes management in 10 countries with different languages, which have the most significant number of diabetic patients. The global overview makes a list that refers to the 2017 American Diabetes Association (ADA) clinical guidelines and is called the global overview list. The list divides the application description into diabetes information and application utilities. Based on the ADA clinical guidelines, the information should be provided for self-management diabetes are physical activity, nutrition therapy, blood glucose level monitoring, smoking cessation, weight management, medication, foot care, and eye care. The information provides self-management diabetes, which is still pertinent to the Standards of Medical Care in Diabetes-2020 ADA¹.

Meanwhile, the utility of the application includes physical activity, blood pressure, cholesterol, and mood tracking, food, oral medication, and insulin logging, blood glucose level goal setting and monitoring, weight management. The feature of the selected diabetes application was compared to the list. Indonesia is one of the countries whose application was selected³¹.

Of all selected applications in this overview, none of them fulfilled the information and utility criteria on the global overview list. The selected applications which use Bahasa Indonesia (Indonesian Language) also did not meet some of the information criteria, i.e., the medication, foot care, and eye care information. The application in Bahasa Indonesia also did not have physical activity, cholesterol, and mood tracking, blood glucose level setting, oral medication, and insulin logging.

Nutri diabetic care, E-diary DM, Teman DM, Salam Sehat, and DM Calendar Application are applications for diabetes in Bahasa Indonesia, which had been clinically studied. These clinical studies did not criticize the application content, such as information and utility criteria on the global overview list. The content of the application is an aspect that should be considered for assessing the application quality. Recently, the development of applications had increased rapidly, but its quality is less improved compared to the content quality of applications in the overview's list³¹. The list of criteria was selected based on the requirements which have the highest use in diabetes self-management. Besides, the global overview list was also based on the ADA 2017 clinical guidelines, which are more relevant to the patient's clinical condition and the aim of diabetes therapy. The physician implemented therapeutic management based on clinical guidelines. The complementary therapy, such as application as an education method, is expected to be in accordance with the guidance. The application as an alternative method should meet all of the criteria in the list so that it can be reliable and capable of contributing an optimal effect on the health status of the diabetic patient. The quality of application content in selected study has a lack of evidence. The application content needs to be assessed and improved.

The study selected from the Indonesian diabetes Smartphone application only reported the effectiveness of the applications. They used various study methods. The sample number was relatively small. Only one of the five studies had enormous sample number, which is 384 respondents. It discusses mostly on the effectiveness of the humanistic outcome, such as self-care, compliance, self-management, and self-efficacy. The clinical outcome assessed were HbA1c, insulin levels, and lipid profiles in one study. Nutri Diabetic care and E-diary are applications that focus on nutrition management, despite diabetes education also exists. The result presented that the application is beneficial for diabetic patients. Improved health status occurred in diabetic patients who used diabetes Smartphone application^20-24. The implementation of diabetes application might be able to overcome the limited distribution of physicians, difficulties on healthcare access in Indonesia, also to assist healthcare professionals in maximizing expansion of diabetes education. Furthermore, this could be an alternative method of promotion to minimize the increase in prevalence.

There are numerous benefits of the application. First, the healthcare professional is able to deliver health education efficiently. Second, it is able to facilitate on health access in Indonesia. Third, patients would be able to achieve better health, efficiency, quality, and cost-effectiveness²⁵. A diabetes Smartphone application is also broadly available, long-lasting, and has many optional information and utilities that can be adjusted depending on the needs of diabetic patients^22,32,33.

CONCLUSION:

Diabetes Smartphone application is suitable for the characteristics of diabetic patients in Indonesia. Unfortunately, there are only a few clinical studies of a diabetes Smartphone application. Based on those studies, patients who use diabetes Smartphone applications have better self-management, especially self-efficacy, self-care, knowledge, diet, and medication compliance. Clinical studies on other diabetes applications are required, with various study methods, long term use of the application, and adequate sample number. The increase of application expansion must be accompanied by information and utility of application which is relevant to clinical guideline. Lastly, a healthcare professional should recommend the best diabetes Smartphone application, which has good quality content, clinical research, and individuals related to diabetic patients as a complement for diabetes therapy management.

ACKNOWLEDGEMENT:

This article was supported financially by Tubel Nusantara Sehat BPPSDMK of the Ministry of Health of the Republic of Indonesia.

CONFLICT OF INTEREST:

The authors declare no conflict of interest.

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Received on 22.07.2020           Modified on 18.09.2020

Accepted on 28.10.2020         © RJPT All right reserved

Research J. Pharm. and Tech. 2021; 14(7):3955-3960.

DOI: 10.52711/0974-360X.2021.00686