DISCUSSION OF EXPLORE HEALTHCARE PROFESSIONALS’ PERCEPTIONS AND EXPERIENCES ABOUT OPPORTUNITIES FOR LEVERAGING HEALTH INFORMATION TECHNOLOGY

In this chapter the researcher reflects upon the findings and discusses the themes and sub-themes in the light of the current literature to justify the research title which is challenges and opportunities of MHA to engage healthcare professionals in treating patients with diabetes

5.1. Knowledge of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

5.1.1. Patients’ knowledge as a barrier of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

The lack of patient health knowledge was viewed by many of the participants in this study as one of the largest barriers in DSM, the participants describing several reasons for this perception. DSM is central to the care and treatment of diabetes and most of DSM entails changes in patients’ behaviours. However, despite the evidence about the benefits of such behaviour changes, it is still a significant challenge for many individuals with diabetes. The participants highlighted that patients’ overall health knowledge, perceived seriousness of their disease, and not having access to reliable information source may be the reasons behind not self-managing their diabetes in a proper way. Patient education includes the information provided to them at clinic visits and sometimes in offered supplemental leaflets. Patients tend to acquire knowledge about ailments from other sources, including internet searches, family, and friends, which might be misleading

According to the WHO, health knowledge is defined as the perception and social skills needed to determine the motive and ability of individuals to obtain access to, understand, and use information in ways that maintain better health (133). Evidence suggests that health knowledge is highly inadequate in Kuwait (134). Patients with lower levels of health education have trouble dealing with chronic conditions and face more extended hospital admissions (135, 136).

Health knowledge can be considered a cornerstone of better outcomes among patients with diabetes in many studies. One large cohort study involving 27,278 type 2 diabetes patients found that giving structured diabetes education reduced overall mortality by 44 percent (137). Another significant retrospective cohort with 26,790 patients with diabetes reported that the provisions of one educational setting reduced health-related expenses after one year in contrast to patients who did not have an informative session (138).

Reinforcing scientific evidence from meta-analyses has also indicated that DSME can be attributed to health benefits in patients dealing with diabetes such as a reduction in HbA1c and subsequent complications such as foot disease (139). Several meta-analyses have shown that DSME is associated with clinically significant benefits in people with diabetes such as the reduction in HbA1c and improvements in cardiovascular risk factors and reductions in foot ulcerations, infections, and amputations (139).

A large population-based cohort study covering 27,278 people with type 2 diabetes and no known history of cardiovascular disease (CVD) affirmed that attending structured DSME is associated with a reduction in all-cause mortality by 44 percent, first CVD episode by 20 percent and stroke by 30 percent (137). Likewise, a retrospective cohort study of 26,790 people revealed that patients with at least one DSME session showed lower diabetes-related healthcare expenses after 12 months compared to individuals who did not receive any diabetes education (138). DSME  has been found to improve the quality of life (140) and sustain weight loss and CV fitness for up to 4 years following education (141). DSME also improved short and long-term self-efficacy and reduced diabetes-related stress (142). 

As this research has noted and emphasised the lack of education is one of the largest challenges, it might be addressed by incorporating the health behaviour models into MHAs and promote DSME. Along with challenges in patients’ knowledge and education, there are also several other issues; like addressing the attitude and behaviour of the patients, which is discussed next.

5.1.2. Patients’ attitude as a barrier of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

Participants in this study not only highlighted the importance of DSME but they also commented on the lack of adherence to the instructions offered to the patients during clinical visits or educational programs. A majority of the participants said that patients may ignore or forget the information provided to them overtime. Certain literature focused on other chronic illnesses points out that patients are frequently non-adherent to utilise the knowledge with poor SM of their disease (11). One of the most significant causes of non-adherence is decreased patient satisfaction because of doctor-patient discordance. Reports suggest that 40-60 percent of the patients cannot recall the doctor's advice as soon as 10-80 minutes after the visit and 60 percent of patients interviewed immediately after a clinic visit misunderstood the directions provided by a clinician (143). 

Adherence is often complicated and cannot necessarily be improved by a single method. In fact, a multidimensional approach is often needed. As mentioned above in the literature review, TPB has contributed to many human behaviour changes, such as increasing awareness about social norms and helping humans reach higher levels of behavioural control. MHAs based on the TPB might play a significant role in this regard by regularly sending patients’ advice and getting feedback from them, which was highlighted by the participants in this research.

5.1.3. Patient and family education in the utilisation of MHAs of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

This research adds to this area by suggesting that improving the overall health status of the patient to reduce complications requires, the patient’s family members to be involved in the patient’s educational programs. A majority of the participants in the study said that it is important to involve the patient’s family along with the patient in DSME. Much of the management of patients with diabetes takes place outside of the healthcare facility with input from family and social settings (144). This was also highlighted by one of the participants by stating that patients and their families should know what to do in the case of an emergency. Patients’ families have a crucial role if the patient is elderly or has a disability that can hinder his or her DSM. This aligns with Peek et al. (145) showing significant improvement in DSM by inviting family and friends to educational classes to promote sustained diabetes-related behavioural changes. Similarly, a study with over 5,000 participants with diabetes showed the value of DSM by a patient’s family and friends (146). Adults and middle-aged people with diabetes value social support, which is linked to improved outcomes with long-term follow-up (147). Thus, these findings side with the current literature that also reinforces this, suggesting that engaging the family members of patients with diabetes knowledge also removes disbelief and myths regarding diabetes and helps them with supporting a patient’s DSM (148-154).

5.1.4. Impact of diabetes self-management of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

Chronic diseases are due in part to risk factors for adjustable behaviour such as obesity, malnutrition, and lack of exercise. Although healthcare professionals have a vital role in guiding patients’ during the care process, the patient’s part in DSM has a significant impact on long-term outcomes. 100 percent of the participants in this study highlighted the impact of SM. One of the findings was that age has a role in SM as younger patients are more likely to SM, for example, they are particularly good in carbohydrate calculation to calculate the insulin units to be injected.

Many educational programs centred on SM have addressed the modifiable risk factors of behaviour to reduce the occurrence of the disease and its complications while improving its management (155-159). The findings of such educational programs suggest that there is an improvement in SM in patients with chronic diseases, including diabetes. The educational programs supported by medical professionals are useful for those without services (160). This research enhances this evidence by suggesting that DSM is the most challenging aspect and should be dealt with more aggressively, which might be brought about by utilising the technology and incorporating in the theory of health behaviour change intervention.

Recent chronic patient care models (CCMs) promoting a patient's SM have shown positive outcomes; (161) CCM calls for drastic changes in the way healthcare is given to patients with chronic disease (162). These models highlighted the need for (i) Information systems for disease-related patient registries (ii) Computer-based decision support for practitioners, (iii) Development of the healthcare system and community change and (iv) Programs to support effective DSM of patients. In short, CCM appeals for drastic changes in the way healthcare is given to patients with chronic disease. Therefore, healthcare systems should consider CCMs as supported by the results from this work.

5.2. MHAs Characteristics of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

MHAs can be beneficial for improving health and healthcare. However, medical professionals and citizens are being overloaded with MHAs. Thus, they may have difficulty finding the right application and the information and features could be fragmented via many applications, ultimately limiting their usefulness (163). The following barriers were highlighted by research participants as the main reasons for the slow adoption of the MHAs for DSM.

5.2.1. Regulating MHAs of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

In this research, participants alluded to the need for the use of regulated applications. Some of the participants in this study highlighted that the MHAs available are not regulated and considered it as a barrier to the utility of MHAs. This research suggests that health policymakers should regulate the MHAs; for example, The National Health Service Scotland has an interactive digital tool titled “My Diabetes My Way” to help support people with diabetes and their family and friends. This view was particularly presented by one of the participants who have worked in the National Health Service (NHS) in the United Kingdom. Most of the current modern-day MHAs are not regulated by the government and most often adapted for use as a pilot project by mainly non-governmental bodies and are primarily funded by donors with variable quality assurance (164).

5.2.2. MHA Standardisation of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

As well as regulation, apps are not in any way standardised and a few of the participants in this research have reflected upon this. MHAs can be classified as clinical programs into high risk and low-risk software applications such as clinical decision support apps for high-end medical devices and low-risk ones such as monitoring weight control or fitness. Participants said that MHAs having good standards can help develop products suitable for the purpose If we talk about the reasons behind the vast number of low-quality MHAs, then one primary factor is the lack of agreed standards in developing them, evaluating them and assessing them (165). Standardisation can mitigate the risks of health applications, be they clinical, privacy or economic risks (166). MHA developers should always follow evidence-based guidelines, consider the needs of their users, and comply with any local or international laws. Doing so can help facilitate a better level of standardization of MHAs against evidence-based best-practices. Given the evidence unveiled in this study, the standardisation of MHAs while ensuring their quality and safety can remove one of the barriers to the adoption of MHAs.

5.2.3. MHA Customisation of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

The participants in this study highlighted that the MHAs are not customised to the needs of the patients. Some of the participants said that they would like MHAs customisable and flexible to their patients’ need. The content of health apps is not always reliable, as often non-expert writers (167) create them. Increased regulation is required if we were to improve accountability for app content (167). This issue was something that the participants of this research were mindful of highlighting.

Demidowich et al. (168) described deficiencies and other issues that hinder usability in their reviewed sample of DSM apps for Android smartphones. In another study by Visvanathan et al. (169), the accuracy and reliability of the content of apps were highlighted in their use in diagnosis and patient management. In the latter’s work, 94 microbiology-themed apps were surveyed, with only 34 percent saying any medical professional involvement. These figures suggested a lack of medical professional association in the designing of such applications resulting in an undermining of MHA content quality. Visvanathan et al. (169) concluded that it should increase their regulatory measures in place to safeguard the patient's welfare (169): something that we see echoed in this Kuwait research.

5.2.4. MHAs reliability and dependability of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

In this research, participants also believed that MHAs conformance to the technical requirements and their ability to reliably record and transfer information was important. Apps need to be dependable and work in a reliable fashion (i.e. not crashing on the devices running or transferring inaccurate readings). These issues should be carefully addressed because if left unaddressed, wrong readings could mislead the healthcare professional to take wrong decisions that can harm the patient. There is an added task of assessing and ensuring the quality of these apps. From a health point of view, the medical content or advice offered by MHAs should be sound, safe, and up-to-date. These are not trivial tasks and could prove to be very demanding.

5.2.5. MHA benefits of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

Like reliability, the actual benefits of MHAs also need careful consideration. In regards to the benefits of MHAs all of the participants in this research agreed that MHAs can be used in the benefits of their patients such as the diabetes clinics can be made more effective by reducing the waiting time, real-time assistance can be provided when needed, patients monitoring and education can help increase the compliance and adherence, and immediate blood sugar levels can be exchanged with the healthcare professionals. Nundy et al. concluded that mHealth promises the improved delivery of chronic care (170). A meta-analysis on computer-based interventions for DSM showed a small beneficial effect on HbA1c (0.2 percent), compared to the MHAs (0.5 percent) thus exhibiting its benefits (171). Mobile applications such as text messaging, used as educational media, might appear to improve patients with diabetes' outcomes (172, 173). However, all the above can only be reached if we can address and solve the governance issues discussed below.

5.3. Factors Related to Governance Issues of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

Governance issues address the necessary socio-technical ecosystem to support MHA adoption as well as the role of governmental bodies, policymakers, and healthcare organizations in promoting MHAs for DSM. To help influence and facilitate behaviour change in patients with diabetes, policies should consider the theory of health behaviour change intervention and investigate how to catalyse the adoption of MHAs. Overall, these issues relate to lack of DSM training, lack of a trained workforce, technology adoption, training healthcare professionals and the role of policy.

5.3.1. Lack of DSM training of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

Given that MHAs’ utility is robust and rigorous, its governance is crucial. One of the governance issues, as the participants in this research highlighted, has been the lack of DSM training for patients. The participants in this study highlighted that healthcare is not utilising its resources to convey DSME to patients. When compared to the literature, there is a considerable amount of data that has emphasised this issue. Type 2 diabetes is a chronic disease that requires many decisions with respect to DSM, and thus, educating patients about DSM is very important in disease management (174). The same was said by the participants in this study. DSME lays the foundation to guide patients with diabetes with DSM to achieve better health outcomes (174). Previous studies have shown that DSME associated with better diabetes knowledge and DSM, decreased HbA1c levels and body weight, and reduced the healthcare economic burden (174). Thus, DSME is the cornerstone of diabetes management (175, 176) and should be initiated at the onset of diagnosis and continue thereafter as well. The importance of DSME was also highlighted by participants in this study and MHAs were purposed as a solution to provide continuous education.

5.3.2. Lack of trained workforce of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

The trained workforce to enable patients with DSM was vital from the participants’ perspective. Many of the participants in this study said that the MoH lack trained healthcare professionals to provide DSME. Sufficient trained healthcare professionals can be seen as the cornerstone of an efficient and adequate working healthcare system (177). The issue of healthcare professionals having knowledge about MHAs caused debate within the participants and was emphasised by evidence of unsatisfactory trained healthcare professionals to comply with the increasing number of patients with diabetes (178). However, this shortage of doctors in Kuwait is also frequently seen worldwide at the current time (179, 180), and leads to conversations about adopting technology to compensate differently. DSME can be provided by MHAs, thus compensating for the lack of trained healthcare workforce as recommended by the participants in this study.

5.3.3. Technology adoption of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

The technology adoption was a topic for a small number of participants in this study and they regarded the use of MHAs inadequately powered or having a higher risk of bias in their methods (182). Although MHAs appear to improve the SM of chronic diseases (182-186) failure of balancing demands versus needs, interests, or end-user finances may undermine their adoption in practice (181-184). The financial burden of MHAs is an interesting finding but was only highlighted by one participant and was not considered by the rest of the study participants.

A review of the literature also highlighted the scarcity of project assessments and the general lack of management frameworks and policies to guide and coordinate the adoption of MHAs in broader healthcare (185). The researcher has reviewed the literature to bring the above points to support the similar concerns highlighted by the participants in this study. To tackle this issue, many things must be addressed like healthcare professionals training and addressing policy issues as discussed below.

5.3.4. Training healthcare professionals  of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

The education and training of healthcare professionals play a vital role in DSME. Patients can be enabled, with DSM, if the healthcare professionals already have current and advanced knowledge about DSM and MHAs as highlighted by some of the participants in this study. Kripalani and Weiss (186) explained how medical professionals were provided with training on health knowledge and communication skills. This plan became integrated into training programs for medical residents and the outcome was positive (187). One of the crucial facts is improving education and training in the field of MHAs for medical professionals. However, medical professionals lack the knowledge to harvest the benefits of technology in addition to struggling to understand and learn new mobile applications (188, 189).

5.3.5. Role of policy of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

It might be viewed as the responsibility of the state to supply an ideal environment for MHAs to succeed in terms of regulation, standardisation, infrastructure support, and reimbursement models. Additionally, the state could play a vital role in evaluating and replicating successful pilot models and then turning them into full-fledged programmes (190). Considering the theme of policy that emerged from this research, one of the reasons or explanations for MHAs not being a priority for the state might be the scarcity of evidence on the cost-effectiveness outcomes of these applications (191), which may have reduced investment into MHAs. Therefore, the evaluation of how MHAs alters the behaviours of both healthcare professionals and patients in improving healthcare may be viewed as an essential focus in the future (192).

5.4.   Privacy and Security Concerns of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

Concerning privacy and security, the study’s participants said they were not confident in prescribing MHAs to their patients because they thought the MHAs might breach the patients’ privacy and security. App stores bombard users with new MHAs every day but usually, they do not focus on privacy and security measures for the protection of user data; for example, they may not ask for users’ consent or provide a privacy policy (193). Some of the standard features of MHAs for SM may include activity tracking, details of patients’ medical condition, and health diaries, which requires patients to save personal data and can sometimes be risky (194). Data security and privacy are a relevant issue for people using MHAs to DSM (194). This concern was also highlighted by this study’s participants and emphasising that it is crucial to make sure that great care is taken when gathering and processing the end user’s health details. In this section, the researcher makes recommendations for MHAs that may satisfy patient needs in this regard. Studying the laws related to privacy and security in other regions such as Asian countries could be an excellent approach in future studies to come up with more detailed recommendations. The research by Albrecht et al. (195) is of particular interest here as they suggest guidelines for developers that include being transparent about their applications and adding privacy and security information (195).

5.4.1. Data security 

The participants in this research showed concerns about the security of the data as the MHAs would access the patients’ sensitive medical data. Even when the participants talked about developed countries, they said that the laws related to MHAs data security are not well defined, and the laws currently in action came into force when the term “MHAs” did not yet exist. There are many issues related to breaches of data security. The Global Study on Application Security, a study conducted in 2018 by surveying 1,400 IT professionals around the globe, concluded that about 75 percent of companies are affected by data breaches of some kind through unprotected apps (196).

5.4.2. Patient privacy of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

Finally, on further reason for the slow adoption of MHAs was patient privacy; MHAs can be a target of theft of patients’ data, as highlighted by participants in this study, who stated that the MHAs available these days do access information such as the location of the user and other sensitive information, which if leaked can severely damage the privacy of the patients. These privacy concerns can undermine the information sharing by the users, thus reducing the benefits of MHAs. Keeping in mind the diversity of MHAs the way forward might be to acknowledge that a one-size-fits-all approach does not address the privacy issue. Therefore, this has made healthcare professionals cautious about adopting such apps at the clinical level (197). The National Health Service recently closed its apps library after finding out that 89 percent of the apps transmitted information to online services and even unencrypted identifying data was sent online (198). The privacy issues can undermine the information sharing by the users, thus holding back the benefits of MHAs. Moreover, a breach of privacy such as leaking of sensitive medical information might have consequences like depression or even death of the patient (199). As a future recommendation, MHA developers and users should acknowledge the risk and further research should be carried out to implement the required privacy protection, as it is undesirable to reduce the beneficial potential of MHAs.

5.5. Study Strengths and Limitations of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

Like other studies, this study also had its limitations. First, the patient’s perspective was not included in this study. Secondly, in the context of case study, the participants came from DDI, although great attention was paid to data collection methods to avoid the researcher’s bias. Still, the self-selection bias might exist. Thirdly, the data collected through interviews, display individual interpretation and may face recall bias issues (101). Fourthly, the researcher has used limited triangulation methods via participant’s checking; as a small-scale exploratory research project, this does not provide the chance of comparison with different perspectives institutionally.

Because of the nature of the research, the findings of the study consideration must be given to the transferability of the findings to other medical centres. Sampling is another complicated process influenced as a social phenomenon by these specific participants. There might be cultural findings that stand true for one part of society or this institute but may not be true for the others (22). Therefore, the perception of participants might not apply to other parts of the world or social settings. What might be valid for one social environment might not be correct for another social setting? Despite the above limitations, this research does add some valuable qualitative evidence about the present knowledge on the adoption issues of MHAs for DSM through the perspective of healthcare professionals in Kuwait.

6. Conclusions of explore healthcare professionals’ perceptions and experiences about opportunities for leveraging health information technology

This study highlights existing opportunities for MHAs for DSM and highlights the barriers to their adoption to improve patient health outcomes. The participants in the study were not always experts in MHAs. For healthcare professionals, managing patients with diabetes knowing the subjective norms of MHAs could help them address the barriers better. The MHAs adoption in some developing countries is increasing faster than the developed countries. This study highlighted how the adoption of MHAs could be integrated into new policy initiatives. Similarly, this study informs other researchers who are interested to know the enablers and barriers regarding the MHAs in the context of Kuwait. The researcher believes that if all the stakeholders collectively removed the barriers found, the full potential of MHAs to enhance DSM will be realized and costs will be reduced. The research undertaken provides evidence to suggest that policymakers should consider facilitating the adoption of MHAs for DSM through policies concerned with technological, governance, privacy, and security issues while serving the needs of the various stakeholders. To conclude, this research supplies valuable insight to other researchers and MHAs developers to make MHAs for a behaviour change intervention. The researcher recommends that further research on MHAs and MHAs based change in behaviour focusing on delivering DSME, addressing technological issues, addressing security and privacy issues, and addressing governance issues.