THE IMPACT OF INFORMATION

TECHNOLOGY ON THE MANAGEMENT

OF DIABETES – A CASE STUDY OF THE

TRUST HOSPITAL, ACCRA.

DORIS OHUI AGBETTOR

MSc HEALTH INFORMATICS

INDEX NO: PG7202816

STUDENT ID: 204776622

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The impact of information technology (IT) on the management of Diabetes – A case study of

The Trust Hospital, Accra.

A thesis Submitted to the School of Graduate Studies, Kwame Nkrumah University of

Science and Technology in partial fulfillment of Degree of Master Science in Health Informatics

June 2018.

By Doris Ohui Agbettor

KWAME NKRUMAH UNIVERSITY OF SCIENCE AND TECHNOLOGY

KUMASI. JUNE 2018

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 CERTIFICATION

I hereby declare that this submission is my own work towards the MSc and that, to the best of
my knowledge, it contains no material previously published by another person nor material
which has been accepted for the award of any other degree of the University, except where due
acknowledgment has been made in the text.

………….………………… ……………………………… ………………………

DORIS OHUI AGBETTOR Signature Date

Certified by

……………………………………. ………………… ………………………

DR MICHAEL ASANTE Signature Date

SUPERVISOR

Certified by

…………………………………... .…….……………… ……………………….

HEAD OF DEPARTMENT Signature Date

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ACKNOWLEDGEMENTS

I am very grateful to God Almighty for His grace to complete this work. Dr Michael Asante my

supervisor helped me tremendously to complete this work. I am grateful to him for the maximum

effort and commitment he put in to make this work possible.

I am also indebted to Dr. Joseph Nelson and Dr William Klah both of the Trust Hospital for their

guidance and support and Humphrey Tetteh for his financial support and encouragement.

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 ABSTRACT

Diabetes is a chronic condition and it can cause very serious, life-threatening complications like

amputation, impotence, stroke, heart attack and blindness. The prevalence of diabetes has

increased in the last twenty years. Wild et al (2004) suggest that the total number of people with

diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. The World Health

Organization (WHO) states that over 347 million people worldwide have diabetes. The Ghana

Diabetes Association has revealed that an estimated 4 million people are said to be living with

diabetes; and 4,790 adult deaths due to diabetes occurred in 2015 whilst 266,200 new cases were

also recorded (Ministry of Health Ghana, 2015). In Ghana most Diabetic patients visit the health

facility quarterly except when they are ill or need to refill their prescriptions and that is when

they check their blood sugar levels. This study therefore sought to ascertain the impact the

introduction of IT tools such as the glucometer, Mobile ‘app’ and the use of the phone on

diabetes patients’ self-management of the disease and how that is reflected in their glycemic

control.

A randomized controlled trial was used for the study. It involved 20 people diagnosed with

diabetes type 1, type 2 or gestational diabetes. The study was to evaluate the impact of the

Glucometer, Blood glucose tracker system and the mobile phone in the treatment and

management of diabetes patients. Two groups were involved in the study; a control group and an

experimental group comprising of 10 participants each. The experimental group had their blood

glucose monitored constantly over a period of 12 weeks using a glucometer and a mobile ‘app’

and interventions given as and when needed. Glycated haemoglobin values were estimated for all

participants at the beginning and at the end of the study.

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Within the group that used the tools (Experimental Group), the HBA1c final measurements

showed significant improvement and none of them was diagnosed with additional Diabetic

complications at the end of the study period.

Within the group that did not use the tools (Control Group) the HBA1c final measurements did

not show any significant improvement and 80% were diagnosed with other Diabetic

complications including hypertension, eye problems, neuropathy and dyslipidaemia by the end of

the study period. Comparing the group that used the tools (Experimental Group) and the group

that did not use the tools (Control Group), the HBA1c final measurement in the Experimental

Group was significantly better (lower) than that of the Control Group.

This shows that using IT based tools to assist in the management of diabetes is effective and

gives short term positive outcomes in terms of controlling blood glucose levels. It also shows

that diabetic patients can be monitored at home to help them achieve normal blood glucose levels

hence reduce emergency room visits and complications associated with diabetes as well as

reduce the burden on Health professionals and Healthcare facilities.

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 CONTENTS

TITLE PAGE

CERTIFICATION

ACKNOWLEDGEMENTS

ABSTRACT

CONTENTS

LIST OF TABLES

LIST OF FIGURES

ABBREVIATIONS

CHAPTER ONE:

INTRODUCTION

1.1 Background

1.2 Problem Statement

1.3 Objectives of the study

1.3.1 Main Objective

1.3.2 Specific Objectives

1.4 Research Questions

1.5 Significance Of the study

1.6 Organization of the study

CHAPTER TWO:

LITERATURE REVIEW

2.1 Overview of Diabetes disease burden and WHO Diabetes profile of Ghana

2.2 Classification of Diabetes mellitus

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2.3 Self- management of Diabetes mellitus and patients’ role in managing their disease

2.4 Information Technology and Health Information Technology

2.5 The use of Information Technology can improve the management of Diabetes

2.6 Use of IT can reduce morbidity and mortality in Diabetics

2.7 IT can reduce cost of Healthcare and ease the pressure on Healthcare facilities

2.8 Diabetes management using telephone consultations

2.9 Management of Diabetes using blood glucose transmission to a provider with feedback

2.10 Diabetes and Global Public Health agenda

2.11 Glucometer

2.11.1 Glucometer technology

2.11.2 How the glucometer works

2.11.3 Android smartphone

2.11.4 Blood glucose tracker application

CHAPTER THREE:

MATERIALS AND METHODS

3.1 Study site

3.2 Study design

3.3 Target population

3.3.1 Inclusion criteria

3.3.2 Exclusion criteria

3.4 Sampling method

3.5 Instrumentation

3.5.1 Participant Information

3.6 Data collection

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3.8 Data analysis

3.7 Validity

CHAPTER FOUR:

ANALYSIS OF FINDINGS AND DISCUSSION

4.1 Introduction

4.2 Normality testing

4.3 Statistical analysis

4.3.1 Paired t-test; The ‘Before’ and ‘After Test results of the experimental and control groups

4.3.2 Independent t-test between the experimental and control groups

4.4 Post exercise questionnaire outcome

4.5 Discussion

CHAPTER FIVE:

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

5.1 Introduction

5.2 Summary

5.3 Conclusions

5.4 Recommendations

References

Appendices

LIST OF TABLES

Table 2.1: Prevalence of Diabetes and related risk factors in Ghana, 2016: WHO country profile

Table 3.1: Monthly average glucose reading(mmol/l) for control group

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Table 3.2: Glycated haemoglobin (HBA1c) values for control group

Table 3.3: Weekly average blood glucose (mmol/l) for experimental group

Table 3.4: Monthly average blood glucose (mmol/l) for experimental group

Table 3.5: Glycated haemoglobin (HBA1c) values for experimental group

Table 3.6: Evaluating the usability, acceptance and effectiveness of the mobile ‘app’

Table 4.1: Normality Test for the Before and After Differences of the Control Group and
Experimental Group
Table4.2: Summary Statistics of the "Before" and "After" Measurements of HBA1c in both
Control and Experimental Group
Table 4.3: Paired Test Results of the measurement of HBA1c in both Experimental and Control
Group

Table 4.4: Summary Statistics of the "After" Measurements of HBA1c in both Experimental and
Control Group
Table 4.5: Independent t-test Output of HBA1c "After" Measurements in both Experimental and
Control Group

LIST OF FIGURES

Figure 2.1: Glucometer and strips

Figure 2.2: Accu-check Glucose reagent strips

Figure 2.3: Android smartphone

Figure 2.4: Android application

ABBREVIATIONS

WHO – World Health Organization

IT – Information Technology

CHPS – Community based Health Planning

HBA1c – Glycated Haemoglobin

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FBS – Fasting blood sugar

DM – Diabetes mellitus

‘app’ – Applications

GHS – Ghana Health Service

HIT – Health Information Technology

EMR – Electronic Medical Records

U.S.A – United States of America

EHR – Electronic Health Records

CPoE – Computerized Physician order Entry

BarD – Dispensing bar code

ADM – Automated Dispensing Machine

ICT – Information and Communication Technology

GPRS –

LDL – Low density lipoproteins

GDP – Gross Domestic Product

IDF – International Diabetes Federation.

mmol/l – millimol per litre

NCD – Non-Communicable Diseases

HBGM – Home blood glucose monitoring

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 CHAPTER ONE

INTRODUCTION

1.1 Background of Study

Diabetes is a chronic condition and it can cause very serious, life-threatening complications like

amputation, impotence, stroke, heart attack and blindness. The prevalence of diabetes has

increased in the last twenty years. Wild et al (2004) suggest that the total number of people with

diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. The World Health

Organization (WHO) states that over 347 million people worldwide have diabetes. The Ghana

Diabetes Association has revealed that an estimated 4 million people are said to be living with

diabetes; and 4,790 adult deaths due to diabetes occurred in 2015 whilst 266,200 new cases were

also recorded (Ministry of Health Ghana, 2015). The disease is highly prevalent in managed care

populations and is frequently associated with comorbid conditions; it requires multiple

medications in its management. Furthermore, effective diabetes care involves the monitoring of

several measures of disease control, such as glycated hemoglobin (HBA1c) and lipid levels, by

several different levels of providers, such as physicians, nurse practitioners, physician assistants,

pharmacists, and dieticians. All of these factors combined make diabetes an opportune disease

state for a case study of the implementation of IT in managed care (Wyne, 2008). HbA1c is an

important indicator of long-term glycemic control with the ability to reflect the cumulative

glycemic history of the preceding two to three months. HbA1c not only provides a reliable

measure of chronic hyperglycemia but also correlates well with the risk of long-term diabetes

complications, (Sherwani et al, 2016).

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The use of Information technology has boosted healthcare provider educational and motivational

support for healthcare providers. Balas et al (1998) suggest that information technology (IT) can

support the formation of patient–health professional relationships, improve care balance, and

create new education methods. Present-day IT enables more active education of people with

diabetes than ever before. Several studies have shown that a follow up and guidance system

based on IT and self-monitoring of blood glucose can have favourable effects on care balance.

Reports suggest that effective monitoring through IT applications provides statistically

significant results in decreasing HbA1c (Murata et al, 2003).

Kruger et al (2003) found that patients are content with the way IT is applied to support self-care

and feel that data transfer to the care institution through a modem and the use of the required

equipment is easy and time-saving. The diabetes team also appreciated the precision and efficacy

of the method. Meneghini et al (1998) point out that in addition to saving time, the method is

also cost-efficient and reliable. According to Funnell et al, (2004), self-management of diabetes

involves a number of considerations and choices that the patient with diabetes must make on a

daily basis. It requires that patients are able to reconcile their resources, values and preferences

with a therapeutic regimen of a healthy diet, exercise, no smoking, low alcohol intake, glucose

monitoring and, for some patients, medication.

Understanding of how various IT applications support self-management interventions in patients

in dealing with diabetes in everyday life is imperative for implementation of diabetes treatment

aiming at improving and maintaining self-care activities. Self-management through IT

application has grown to be very important for patients with diabetes, and health care provided

via mobile applications (apps) has a great advantage when applied to patients with diabetes

(Kaufman and Khurana, 2016). Also the adherence to activities for the management of diabetes,

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such as regular medication and insulin injection, self-monitoring of blood glucose (SMBG), diet,

and exercise, can be improved through mobile apps (Quinn, 2011). Today, self-management of

diabetes has been impacted by the use of various technologies. These technologies have

supplemented healthcare through the internet and mobile applications.

1.2 Problem statement

Chronic diseases management has been challenging for most patients. This is because patients

require knowledge and skill in understanding their needed care. In Ghana most Diabetic patients

visit the health facility quarterly except when they are ill or need to refill their prescriptions and

that is when they check their blood sugar levels because most Diabetic patients do not own

personal glucometers. According to American diabetes Association (2014), Self-management is

critical, as part of a patient’s commitment to preventing disease complications. Self-

management of diabetes has created educational and motivational benefits for the control and

prevention of the disease.

This study therefore sought to ascertain the impact the introduction of IT tools such as the

glucometer, Mobile ‘app’ and the use of the phone on diabetes patients’ self-management of the

disease and how that is reflected in their glycemic control.

1.3 Objective of the Study

1.3.1 Main Objective

Investigation of the impact of using information technology tools in assisting in the treatment

and self- management of diabetes.

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1.3.2 Specific Objectives

1. To evaluate the effectiveness of the IT-based tools conceived for diabetes management

and treatment.

2. Seek to find out if patient’ self-management of the disease will improve diabetes short-

term outcomes.

1.4 Research Questions

1. What is the impact of the IT-based tools, conceived for diabetes management, on the

therapy and treatment of the disease?

2. How can self-management of the disease improve diabetes short-term outcomes?

1.5 Significance of the Study

It is hoped that this study will be a critical contribution and an effective tool in the management

of diabetes. The study will also provide health practitioners and consultants with knowledge on

the use of Information technology tools on the management of Diabetes. It is also expected that

this study will make insightful contribution to university teaching. In addition, new knowledge

generated through this study may benefit donor partners involved in diabetes awareness and

policy making.

1.6 Organization of the Study.

Chapter one talks about the background of the study, problem statement, objectives of the study

and significance of the study. Chapter two presents the reviewed literature in relation to diabetes

and the use Information Technology Management in diabetes. Chapter three presents

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methodology of the study which includes the study design, study area, population of the study,

sampling procedures, methods of data collection, study instruments, quality control, ethical

considerations and limitations of the study. Chapter four presents the study findings and

discussions. Chapter five presents conclusions and recommendations of the study and

recommendations for further research.

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 CHAPTER TWO

LITERATURE REVIEW

2.1 Overview of diabetes disease burden and WHO Diabetes profile of Ghana

Patients with Diabetes have a high-risk factor for other diseases. In developing countries,

diabetes is spreading very fast and has become an important cause of illness; prevalence is high

among elderly people; younger adults in their productive ages also have their prevalence rates

increasing. Developing countries are now adopting the dietary lifestyle of Western countries as a

result of economic development and this is a major cause of increase in Diabetes. If effective

prevention and control programs are not put in place, more and more people will develop the

disease. (International Diabetes Federation, Diabetes Atlas, 2015)

Diabetes is a major cause of adult ill health and deaths in Ghana (de Graft Aikins et al), in 2015,

4,790 of adult deaths reported in Ghana were due to diabetes and the prevalence rate in adults

between 20 and 79 years was 2.3 according to International Diabetes Federation, Diabetes Atlas

in 2015. It was estimated in 2015 that about 2.2 million people had diabetes in Ghana with

approximately 189,900 cases undiagnosed (National Diabetes Association). Diabetes is a chronic

condition and it can cause very serious, life-threatening complications like amputation,

impotence, stroke, heart attack and blindness. WHO estimates that one person dies every 10

seconds due to diabetes, it also reiterates that about 360 million people will become diabetic by

the year 2025. Countries that are affected most are the lower middle-income countries and Ghana

falls within that category. Most developing countries around the world including Ghana are

moving away from traditional lifestyles and diet and adopting the Western sedentary life style;

thus the increase in diabetic cases. A statement made by the then president of the Ghana diabetes

6
association iterated that, many Ghanaians have reduced their intake of traditional foods and are

consuming more processed, polished and animal-sourced foods that are rich in fats and sugars.

For this trend to be reversed, central government needs to put certain policies and measures in

place instead of leaving it all to government bodies responsible for the control of diabetes like

the Ghana Health Service. (www.diabetes.co.uk/news/2007/Oct/diabetes-alert-in-ghana.html).

According to the World Health Organization’s report on Diabetes profile for Ghana in 2016, a

total of 4490 people aged 30 and above years died due to Diabetes and 6790 deaths in the same

age group was as a result of high blood glucose levels. The report also indicated that prevalence

of Diabetes and its related risk factors were high as indicated in the table below:

Table 2.1 Prevalence of Diabetes and related risk factors in Ghana, 2016: Adapted from

WHO – Diabetes Country Profile, 2016.

Male Female Total

Diabetes 4.6% 5.0% 4.8%

Overweight 21.5% 39.9% 30.8%

Obesity 4.9% 16.8% 10.9%

Physical inactivity 11.9% 17.0% 14.6%

Evidence based national Diabetes guidelines, protocols and standards are not available, standard

criteria used to refer patients suspected to be diabetic at the primary level as diabetic registry are

not available. Urine strip measurement is the main test procedure for diabetes at the primary

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facilities. Blood glucose, Oral glucose tolerance tests, glycosylated haemoglobin tests are

generally not available at the primary facility level (WHO – Diabetes Country Profile, 2016).

2.2 Classification of Diabetes Mellitus

Three types of diabetes mellitus exist: (1) type 1 diabetes (formerly called juvenile diabetes); (2)

type 2 diabetes (formerly called adult onset diabetes); and (3) gestational diabetes.

Alberti and Zimmet (1998) suggest that Type 1 diabetes results from autoimmune mediated

destruction of the beta cells of the pancreas. Insulin is vital for individuals with type 1 diabetes to

avoid ketoacidosis, coma and death. Type 1 diabetes occurs because the body’s immune system

attacks and destroys the insulin-producing cells in the pancreas. If not diagnosed and treated with

insulin, an individual with type 1 diabetes can lapse into a life-threatening coma, called diabetic

ketoacidosis. Most people who develop type 1 are otherwise healthy (Kasper et al., 2005).

Type 2 diabetes is characterized by resistance to the action of insulin and disorder of insulin

secretion, either of which may be the predominant feature. Individuals with this type of diabetes

do not need insulin to survive. Type 2 diabetes, which is the most common type, is often a result

of excess body weight and physical inactivity in genetically predisposed individuals (Poulsen et

al, 1999). About 90-95% of diabetics have type 2 diabetes, which is most often associated with

older age, obesity, family history of diabetes, previous history of gestational diabetes, physical

inactivity, and certain ethnicities.

Gestational Diabetes is triggered by pregnancy, (pregnancy, to some degree, leads to insulin

resistance). It is often diagnosed in middle or late pregnancy, (Cash, 2014; WHO. 2013).

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2.3 Self-management of Diabetes mellitus and Diabetic patients’ role in managing their

disease.

The concern about educating patients to take care of their diabetes began more than 100 years

ago and was emphasized with the publication in 1918 by Joslin of the Diabetic Manual for the

Doctor and Patient. Reiber and King and World Health Organization. Division of Non

communicable Diseases and Health Technology in1991 developed guidelines for diabetes care

and education. Diabetes self-management intervention has emerged as a resource to assist

patients in managing daily diabetes care through dissemination of information and facilitation of

self-management behaviours. Knowledge about the disease and specific lifestyle guidelines is

necessary but not an adequate factor to facilitate the appropriate behavioral changes (Steed,

2003).

Self-management of diabetes involves a number of considerations and choices that the patient

with diabetes must make on a daily basis. It requires that patients are able to reconcile their

resources, values and preferences with a therapeutic regimen of a healthy diet, exercise, no

smoking, low alcohol intake, glucose monitoring and, for some patients, medication (Funnell et

al ,2004).

Diabetic patients have a significant role to play in the management of their illness. They must

actively take part in intervention programs that will enable them improve on their quality of life.

A study was conducted to investigate the effect of a self-management program based on a 5As

model (assess, advise, agree, assist, arrange) which used indicators of metabolic control of

patients with diabetes. The need for investigating the impact of the self-management diabetes

education delivery format on diabetes health-related outcomes has been highlighted by Tang et

al. (2006).

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The 5A model is an evidence-based approach for behavioral change and health promotion. This

model includes assessing the behavior and beliefs as well as motivation of the patient (Assess); It

also provides information about individual health risks and benefits of behavioral change

(Advise); Both patients and health care provider contribute to setting realistic goals based on the

interest of the patient and their ability to change certain behaviors (Agree); develop practical

applications based on the identified patient’s approaches, problem-solving methods and social

and environmental support (Assist) and layout follow-up plans such as Visits or Phone calls and

also providing support in the process of follow up (Arrange). (Glasgow et al, 2003; Berwick et

al, 2003). This model was first used in Iran in a research conducted on post-coronary artery

bypass graft (CABG) patients and it was confirmed to be effective, (.Safabakhsh L., 2004).

The traditional teaching strategies in involving patients’ active participation in their treatment

process and the necessity to help and support them during behavior change process had its

weaknesses, the 5A model was used as a conceptual framework for self-management to find out

its effect on metabolic control of insulin dependent diabetic patients. The study concluded that a

3-month self-management program based on the model can effectively reduce fasting blood

sugar and hemoglobin A1C levels. It was recommended that self-management programs based on

the 5A model should be adopted and applied in diabetic clinics (Moatarri et al, 2012).

2.4 Information technology and Health information technology

Technology is a broad concept that deals with the usage and knowledge of tools and crafts, and

the ability to control and adapt to it.

Information Technology (IT) is the study or use of systems such as computers and

telecommunications for storing, retrieving, and sending information. It is the technology which

10
involves the development, maintenance, and use of computers and software for processing and

distribution of information. (www.merriam-webster.com/dictionary/information%20technology).

The term IT is usually used for computers and computer networks, but other information

distribution technologies such as television and telephones also use information technology. A

number of industries, including computer hardware, software, electronics, semiconductors,

internet, telecom equipment, and e-commerce are associated with information technology,

(Chandler et al, 2012).

Health information technology (HIT) is information technology applied to health and health care

and it assists in the management of health information using computerized systems and the safe

movement of health information between consumers, providers, payers, and quality monitors. It

involves applying information processing of both software and hardware that is concerned with

storage, retrieving, sharing, and use of health care information, data, and knowledge for

communication and decision making, ( Brailer, D., 2004). A 2008 report on a series of studies

conducted at four sites that provide ambulatory care in three U.S. medical centers and one

medical centre in the Netherlands, electronic health records (EHRs) turned out to be a promising

tool that can improve the overall quality, safety and efficiency of the health care delivery system.

(Chaudhry et al, 2006).

A report by the Agency for Healthcare Research and Quality states that; consistent use of HIT

will improve quality of health care or effectiveness as well as increase health care productivity

and efficiency. It will also prevent medical errors and increase accuracy and ensure correct

procedures. This could lead to a reduction in health care cost and enhance administrative

efficiencies and healthcare work processes. Paperwork will be reduced and unproductive or idle

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work time will be eliminated. It will extend real-time communications of health informatics

among health care professionals; and improve access to affordable care, (Shekelle et al, 2006).

Sharing health information between patients and providers helps to improve diagnosis, promotes

self-care, and patients have access to information about their health. The use of electronic

medical records (EMRs) is now increasing in most countries especially in Canada, American and

British primary care. EMRs are important sources of information for clinical, research, and

policy formulation, (Perera et al, 2011)

In a study about the adoption of technology in the United States, applications that are used for

prescribing include electronic medical records (EMR), and computerized physician order entry

(CPOE). The applications for dispensing are bar-coding at medication dispensing (BarD), robot

for medication dispensing (ROBOT), and automated dispensing machines (ADM). Electronic

medication administration records (eMAR) and bar-coding at medication administration (BarA

or BCMA) are applications for administration (Furukawa et al, 2008).

The advanced use of data science and machine learning can lead to rapid growth in health care

innovations. The key opportunities here are: Health Monitoring and Diagnosis;

Medical Treatment and Patient Care; Pharmaceutical Research and Development; Clinic

Performance Optimization are the key opportunities for Health care innovations, (AltexSoft Inc.,

2016).

2.5 The use of information technology can improve the management of Diabetes:

The rapid advancement of Information and Communication Technology (ICT) can be used to

improve health care especially in the management of diabetes. This is an area in which the use of

internet and mobile devices such as phones could be beneficial. These technologies and devices

12
can overcome time and location barriers through real-time and remote monitoring of data such as

blood glucose levels at home and timely adjustment of insulin dosage as well as improvement in

blood glucose control by means of dietary and/or physical activity changes. It can also facilitate

communication between patients and Healthcare providers for timely interventions to be made

when the need arises.

Several studies have been conducted especially in the U.S. on the use of information technology

to manage diabetes. Several investigations have demonstrated how effective the use of the

telephone is in Diabetes management because it serves as a means to reach patients who live far

away and thus have difficulty in accessing healthcare facilities (Hayes et al 2001.) Older adults

with diabetes tend to adopt sedentary behaviours, and this is associated with high levels of

functional impairment, the use of information technology can improve this because patients will

be encouraged and monitored remotely by their healthcare provider, (Sinclair et al 2008).

Pedometers were used to promote walking and goals were set for participants in a study and the

outcome indicated that participants who were able to use the pedometer had less physical

impairment over time. This information technology intervention reduced rates of decline in

physical activity and impairment in older adults with diabetes (Weinstock et al, 2010). Putting

patients with chronic illnesses in charge of their own health could improve healthcare across the

country. Diabetic patients if given the chance could participate more in the management of their

care.

Information technology systems have been recommended as a means of supporting people with

diabetes in the self-management of their condition. Requirements for monitoring parameters of

care, including blood sugar control, extent of analysis and interpretation of data, contacts

between patients and clinicians, and involving a multidisciplinary care team with effective

13
communication, can be addressed by information technology systems. Mobile phones were used

to transmit data and receive response on the data in the study conducted in the U.S.A. involving

young adults with type1 diabetes. Blood glucose meters were connected to mobile phones via

internet for patient use. Blood glucose data were transmitted immediately and information about

insulin dose, eating patterns and physical exercise were collected. There was immediate response

to the phone; a colour histogram to draw attention to levels of control of glycaemia over the

previous two weeks was drawn. Care providers guiding patients had access to summary

information that identified patients who were not testing, and those whose blood glucose levels

outside pre-defined limits. The GPRS mobile phone diabetes tele technology system described

here takes an innovative approach to implementing transmission of blood glucose results to care

providers and providing decision support and patient feedback, (Farmer et al, 2005).

In a similar study conducted in the Democratic Republic of Congo, a health information system

has been put in place to enable the organization and collection of all relevant diabetes data in one

central place. The data is accessed by only authorized medical staff. The system will improve the

quality of service in the care and management process of diabetes by taking advantage of the

rapid advances in mobile, web, and communication technologies. Educational programs to

increase awareness on diabetes are also provided by the system. The Mobil Diab system used in

the study, can serve as a complete hospital management system and is capable of supporting

several hospitals with their own medical staff and patients led by a clinician who has a group of

patients assigned to him. Information technology has been proven to be a suitable instrument to

support health care providers to effectively manage diabetes and also assist in the prevention of

diabetic complications. Charpentier et al, 2010, Tkenga et al, 2014.

14
Most rural communities in Ghana do not have access to basic health care; the nearest primary

health care facility may be a community-based health planning and services (CHPS) compound

which is manned by a community health nurse who may not have the expertise to manage a

diabetic patient, the use of information technology will go a long way to reduce morbidity and

mortality in diabetes patients. The use of information technology in clinics has proved to be an

effective and efficient way to provide diabetes care in underserved areas in the U.S.A. This has

shown to improve health and health care costs as in the Florida Initiative in Telehealth and

Education (FITE) which provides online care to patients with type1 diabetes in rural Volusia and

Flagler counties, (Toree et al, 2013). The studies done so far on the use of information

technology has been on chronic diseases with diabetes being the most common. Those studies

evaluated self-management and home monitoring of chronic diseases. The studies had similar

end points, the outcomes were positive. The use of information technology can overcome some

of the barriers to health care such as; distance and shortage of health care providers and thus

improve access to health care and reduce health care cost. The results from the Florida (FITE)

project showed an increase in access to health care and reduced urgent health and hospitalization

and there has been a reduction in cost involved in health care for patients. (Malasanos et al,

2013).

If diabetic patients are given access to monitoring devices and devices that send messages such

as mobile phones, laptops, access to the internet, and the healthcare providers at the primary

healthcare levels such as CHPS compounds could also have such devices that can enable them

communicate with other health care providers and treat patients without the patients having to

travel long distances for Physician care, this will make a great impact in the management of

diabetes. These devices are aimed at promoting patient self- management, patient education,

15
clinical monitoring and follow up activities. This is because many Diabetic patients struggle to

keep up with managing their blood glucose levels, (Hopp et al 2007).

2.6 Information technology can reduce morbidity and mortality rates in Diabetics:

The use of information technology for case management services for patients who have chronic

diseases will go a long way to reduce morbidity and mortality rates. This is especially so in

patients who have difficulty in accessing healthcare. A study done in which two sets of Diabetes

patients were managed was conducted in New York State in the U.S.A. The outcome after one

year showed improvements in Glycated haemoglobin (HBA1c) levels, blood pressure and low

density lipoprotein (LDL) levels in those patients who used information technology, (Shea et al,

2007) .Another study was conducted by Izquierdo et al, in 2003 to compare Diabetes education

using information technology to educating the patients in person; there was improvement in

glycated haemoglobin levels and patient satisfaction was high in Diabetics who used information

technology. Diabetes education using information technology turned out to be as effective as

person to person interactions in healthcare facilities. In another study, patients self-monitored

their blood glucose levels and results were transmitted by phone. There was feedback for patients

with type 1 diabetes using the phone and this saw an improvement in parameters after nine

months of intervention (Farmer et al, 2005). Diabetes education can be provided effectively

through information technology just like through person to person encounters with Healthcare

providers.

16
2.7 Information technology can reduce cost of health care and ease the pressure on

Healthcare facilities.

Diabetes has put a large burden economically on the global health-care system and the world

wide economy. Estimating the direct medical costs, indirect costs associated with productivity

loss, premature mortality and the negative impact of diabetes on nations’ gross domestic product

(GDP), are some of the means that can be used to measure the economic burden.

Expenses made from preventing and treating diabetes and its complications are some of the

direct medical costs associated with the disease. Such expenses include outpatient and

emergency care; inpatient hospital care; medications and medical supplies such as injection

devices and self-monitoring consumables; and long-term care.

It has been estimated that the direct annual cost of diabetes to the world is more than US$ 827

billion, this estimation is based on cost estimated from a current systematic review, (27,28).

According to estimates made by the International Diabetes Federation (IDF), healthcare spending

on diabetes increased more than three times over the period 2003 to 2013, this is as a the result of

increase in the number of people with diabetes and increases in per capita diabetes spending

(IDF Diabetes Atlas, 6th ed. Brussels, International Diabetes Federation; 2013).

The use of information technology can reduce cost and ease the pressure on Healthcare facilities

as well as reduce the burden on the few care providers who attend to so many patients. Patients

with Diabetes frequently visit Health facilities for management and treatment of their disease at a

high cost and the cost. The use of information technology can help reduce this cost as well as the

pressure on health facilities and burden on healthcare providers. The use of information

technology will result in fewer visits to the emergency room and hospitalization; and

17
consequently, reduce cost of providing healthcare care to patients with diabetes. To effectively

practice information technology, electronic medical records must be well developed and there

should be proper training for this type of service. A program to evaluate cost effectiveness of the

use of information technology to manage Diabetes was conducted among the natives of the

northern regions of British Columbia, Canada was conducted in 2004. A diabetic nurse educator

and an ophthalmic technician went to them to offer services and advice and they interacted with

an Endocrinologist and an Ophthalmologist from Vancouver to review their findings and

supervise the mobile clinics by means of ICT. The outcome was satisfactory, clients appreciated

it and the cost involved reduced. The mobile clinic effectively reduces cost and gives more

people access to standard recommended diabetic care, (Jin et al, 2004). It has been established

that information technology is more convenient for treating diabetes than other diseases because

most of the tests can be measured at home by the patient, Information technology or ICT is a

promising tool for Diabetes management by health care providers in this twenty first century.

Diabetic patients who face the challenges in the access of health care can use tele technology.

Clinicians can also fall on information technology to treat and manage diabetes due to the

growing number of patients with Diabetes.

2.8 Diabetes Management using Telephone Consultations

Ładyzynski and Wójcicki ( 2007) and Lehmkuhl et al., (2010) in their studies on use of

traditional (i.e., landline) telephone contacts to better manage type 1, suggested that both

experimental and control groups demonstrated decreased mean HbA1c levels at the program, but

neither group’s decrease was statistically significant. Similar study by Thompson, Kozak, and

Sheps, (1999) suggested that Regular telephone contacts were proposed for patients with poorly

18
controlled type 1 diabetes (HbA1c > 8.5%). Patients in the experimental group had 15 minute

telephone contacts three times a week. After 6 months, the mean HbA1c in this group had

decreased from 9.6% to 7.8% while in the standard-care control group, the decrease in mean

HbA1c was from 9.4% to only 8.9%. This difference in mean improvement in HbA1c levels

between the two groups was statistically significant (P < 0.01) and clinically relevant, and

therefore the system was considered effective, as (the researchers noted) would any system

involving close management of diabetic patients. However, patient follow-up was expensive:

nurses spent an average of 17.25 hours per week calling patients, the equivalent of an almost

half-time employee to cover 23 patients.

(Weinberger et al., 1995; Aubert et al., 1998) showed nurses’ telephone follow-up of diabetic

patients improved patients’ blood glucose. However, these early interventions proved expensive

and time-consuming. Telephone interventions using a call center manned by non-medical staff

have also been tested. One such study was conducted in England. Using a call center to monitor

a large population of type 2 diabetes patients with limited resources (Young et al., 2005) yielded

a 0.31% reduction in HbA1c in the intervention group compared with the control group (P =

0.003).

(Walker et al., 2011) conducted a study involving a low-income insured minority population

with type 2 diabetes and poor blood glucose control. They showed modest results of a telephone

compared to a printed intervention, with a small but statistically improvement in HbA1c (p =

0.009) between the two groups at 1 year.

A study by Carroll et al., (2011) on the combination of a glucose meter combined with the

battery pack of a cell phone for the determination of blood glucose for type 1 diabetes negative

19
results were noted. Interestingly, when this same approach was used by Cho et al. (2009) for

patients with type 2 diabetics, statistically significant (P = 0.01) improvements in blood glucose

were observed.

Krishna and Boren (2008), in a review of the literature, found that 9 out of 10 studies that

examined the use of a cell phone for health information for persons with diabetes or obesity

reported significant improvement in HbA1c levels of experimental groups.

2.9 Management of Diabetes using Blood Glucose Data Transmission to a Provider with

Feedback

In one study (Montori et al., 2004), patients with type 1 diabetes who were poorly controlled

despite receiving intensive insulin therapy sent their blood glucose data to the care team

regularly over a 6-month period using a modem. The experimental group received telephone

“feedback” from a nurse within 24 hours of each transmission, and these patients’ mean HbA1c

levels decreased significantly (p = 0.03). Reduction in mean HbA1c in the control group did

occur but was thought to be potentially related to a possible study effect.

A study by Jansà et al., (2004) patients with type 1 diabetes and poorly controlled blood sugar

transmitted their data regularly by telephone from a glucose meter. After 6 months, both the

experimental and control groups results were similar, but the experimental group’s costs were

considerably higher than those of the control group.

Brown, Lustria, and Rankins (2007) study suggest that the most frequently used technology in

diabetes management is the Internet, which has been shown to increase patients’ knowledge,

20
support their engagement with treatment, increase patients’ self-efficacy, and facilitate behavior

change.

A study by Quinn et al. (2008) found that patients receiving real-time cellphone feedback

regarding blood glucose levels analyzed by WellDoc proprietary software had significantly

decreased (P < 0.02) decreased HbA1c levels compared with patients not receiving such

feedback.

Yoo et al. (2009) study found that statistically significant reduction of HbA1c in their

experimental group, but as the study was short (only 12 weeks), it could not be determined if the

effects observed were long term ones or not.

The Informatics for Diabetes Education and Telemedicine (IDEATel) study was a large (1665

participants) randomized trial involving older, ethnically diverse, medically underserved,

Medicare beneficiaries with type 2 diabetes. Participants in the intervention group received a

computer with Internet access via modem to an existing telephone line and videoconferencing

capabilities. The patients’ existing primary care physicians were contacted when a case managed

determined that a change in patient management was indicated. The intervention group had a

statistically significant decrease in HbA1c relative to usual care (P = 0.001), but the decrease was

not deemed to be clinically significant. Unfortunately, no Medicare cost savings were observed

(Moreno et al., 2008).

2.10 Diabetes and the global public health agenda

The United Nations recognizes Diabetes as important because it is rated as a high cause of

premature death and disability. It is one of four priority non-communicable diseases (NCDs)

21
targeted by world leaders in the 2011 Political Declaration on the Prevention and Control of

NCDs (United Nations General Assembly. New York: United Nations; 2011). The declaration

indicated that the incidence and impacts of diabetes and other NCDs can be largely prevented or

reduced using methods that include evidence-based, affordable, cost-effective, population wide

and multi-sectorial interventions. These commitments were re-emphasized in 2015 by the United

Nations General Assembly when they adopted the 2030 Agenda for Sustainable Development.

Having access to affordable treatment is critical in order to reduce mortality from diabetes that

can be avoided as well as improve outcomes. Patients in some countries and communities do not

have access to Insulin and this continues to be a critical impediment to successful treatment

efforts. Oral hypoglycaemic medication is not easily accessible, and medication to control blood

pressure and lipids is also a problem. Improving management at the primary care level with

continuous support by community health workers can lead to better control of diabetes and fewer

complications (New York: United Nations General Assembly; 2015). This is where the use of

information technology can make an impact.

In 2012 alone, 1.5 million deaths worldwide were directly caused by diabetes. It was the eighth

leading cause of death among both males and females and the fifth leading cause of death in

women. (Global report on Diabetes - World Health Organization, 2016). Higher than normal

blood glucose levels even if below the diagnostic threshold for diabetes, are a major cause of

mortality and morbidity. A fasting plasma glucose ≥ 7.0 mmol/L is significant in the diagnosis of

diabetes. This is a diagnostic value selected as a result of micro-vascular complications such as

diabetic retinopathy. Patients are at the risk of macro-vascular diseases, such as heart attack or

stroke, because the risk starts increasing well before this diagnostic point (Bellamy et al, 2009).

22
 A look at mortality in relation to blood glucose as a risk factor will help us understand better the

full impact of blood glucose levels on mortality. About 3.7 million worldwide are estimated to

have died as a result of high blood glucose levels in 2012. This number includes 1.5 million

diabetes deaths and an additional 2.2 million deaths from cardiovascular diseases, chronic kidney

disease, and tuberculosis as a result of higher than normal blood glucose levels. This shows that

more people die as a result of complications relating to high blood glucose levels than deaths

caused by diabetes. A greater number of deaths caused by high blood glucose levels is from

upper middle-income countries (1.5 million) whilst the low income countries registered the least

number of deaths (0.3 million), (Singh et al, 2013, WHO, 2016). Generally, most lower and

middle-income countries lack the basic technologies for detecting at the early stages as well as

diagnosing and monitoring of diabetes at the primary healthcare level. Information technology

can therefore be used to breach the gap achieve the set goals.

2.11 Glucometer

A glucometer is a medical device used to measure the approximate concentration of glucose in

the blood. It can also be in the form of a strip of glucose paper dipped into blood or urine and

compared to the glucose chart. It is used mainly for home blood glucose monitoring (HBGM) by

people with diabetes mellitus or hypoglycemia. A lancet is used to prick the finger and a small

drop of blood is obtained. This is placed on a test strip which is then inserted into the glucometer.

The blood sugar level is calculated and displayed on the screen of the glucometer. The value is

displayed by the meter in units of mg/dl or mmol/l.

23
.

Figure 2.1: Glucometer and strips

Since the early 1980s, achieving a normal level of glucose in the blood has been the main focus

in the management of type 1 and type 2 diabetes mellitus. This is guided by home blood glucose

measurement at specific intervals daily or several times a day. Regular checks using the

glucometer has certain advantages; such as the reduction in the rate of occurence and intensity of

long-term complications from hyperglycemia .It can also reduce in the short-term, potentially

life-threatening complications of hypoglycemia, (Lipkowski et al, 2011).

2.11.1 Glucometer Technology

Most glucometers use this principle; glucose is oxidized to gluconolactone. Glucose oxidase

serves as a catalyst in this reaction. Others use a similar reaction but the catalyst this time is

another enzyme called glucose dehydrogenase (GDH). Glucose dehydrogenase is more sensitive

24
than glucose oxidase but is more susceptible to interfering reactions with other substances,

(Jensen 2011).

Figure 2.2: Accu-check Glucose reagent strips manufactured by Roche Diabetes Care Inc.

2.11.2 How the Glucometer works

Test strips containing glucose oxidase, an enzyme that reacts to glucose in the blood droplet are

what the glucometer uses; there is an interface to an electrode inside the meter. An electric signal

is generated by the flux of the glucose reaction when a glucose strip is inserted is inserted into

the glucometer. The glucometer is calibrated such that the number appearing in its digital readout

is proportional to the strength of the electrical current: The higher the glucose level in the

sample, the higher the reading, (Michael Strano, the Charles and Hilda Roddey Associate

Professor of Chemical Engineering at Massachusetts Institute of Technology).

Using the glucometer for periodic tests plays an important role in the diabetic’s treatment plan.

The complications of diabetes arise as a result of the blood sugar levels getting out of the safe

range, being able to identify such periods and intervening appropriately can, in theory, reduce the

negative effects of the disease, which can result in complications such as heart disease,

blindness, limb amputation, and kidney failure, (Jensen, 2011).

25
2.11.3 Android smartphone

Google developed Android; a mobile operating system based on the Linux kernel and designed

primarily for touchscreen mobile devices such as smartphones and tablets. The user interface of

Android is based mainly on direct manipulation, using touch signals that loosely correspond to

real-world actions, such as swiping, tapping and pinching, to control on-screen objects, along

with a virtual keyboard for text input. Apart from touchscreen devices, Google has developed

Android Auto for cars, Android TV for televisions, and Android Wear for wrist watches as well

and each of them has a specialized user interface. (Wikipedia).

Figure 2.3: Android smartphone

26
2.11.4 Blood glucose tracker application

Blood Glucose Tracker is an application developed by Little Bytes. The application makes it

simple to keep and analyze blood glucose levels in an easily accessible place, your Android

phone or tablet!

The current version has:

- Basic blood sugar recordings by time and event; example: before breakfast, before dinner,

after lunch.

- Sorting history by event type / tag.

- Tags (helps to keep track of outcomes and effects of exercise, types of food, etc.)

- Units in mg/dl or mmol/l (US or International units).

- Input numbers with your keyboard or an on-screen number pad that is convenient

- Statistics (averages per week, per month, etc)

- Automatic Android backup & restore: You don’t lose data when you get a new phone

- Manual backup & restore: Data can be saved to a file on your phone or favorite cloud service

for later import.

- Share your data: email an html version of your captured data directly from your phone to

your doctor or share it to Google Drive or Dropbox for safe keeping.

- Notepad: take notes throughout the day. subsequent blood sugar readings which you record

can be added to the notes for you.

-HBA1c results: HBA1c test results can be entered for safe-keeping and analysis

- Daily reminders: You get a notification at a time you specify every day.

- Android Wear support: Reply to reminders by speaking your blood sugar into your smart

watch.

27
- Targets: Target low and high blood sugar levels can be entered.

- Cloud sync: You can sync data a cloud service and keep all of your devices up to date.

- Medication tracking: Medication can be tracked blood sugar readings.

28
Figure2.4: Android application

29
 CHAPTER THREE

MATERIALS AND METHODS

3.1 Study site

The Trust Hospital in Accra was used as the study area and diabetic patients who attend Out

Patient Clinic were used for the study. The Trust Hospital which is a subsidiary of Social

Security and National Insurance Trust (SSNIT) is located in Accra and has three hospitals and

six clinics located in the Accra - Tema metropolis. There is a Specialist Hospital, General

Hospital and Obstetrics, Gynaecology and Paediatric Hospital all located in Osu. The clinics are

Trust clinic Tema, Trust clinic Sakumono, Trust clinic Adenta, Trust clinic Dome, Trust clinic

Dansoman and Trust clinic, SSNIT Pension house. Diabetic clinics as well as other Specialist

clinics are run in all the nine facilities.

3.2 Study Design

A randomized controlled trial was used for the study. It involved 20 people diagnosed with
diabetes type 1, type 2 or gestational diabetes. The study was to evaluate the impact of the
Glucometer, Blood glucose tracker system and the mobile phone in the treatment and
management of diabetes patients.

3.3 Target Population

The target population for this study is patients diagnosed with type 1, type 2 or gestational

diabetes at the Trust hospital and are twenty (20) years and above.

30
3.3.1 Inclusion criteria

Patients who use glucometers to monitor their disease and are willing to take part in the study

3.3.2 Exclusion criteria

Patients who are not using glucometers and/or those who are not willing to take part in the study.

3.4 Sampling method

A simple random sampling method was used to derive study respondents. A total of twenty

patients aged 20 years and above with diabetes were recruited for the trial study. Ten (10)

Patients with access to glucometers were chosen at random (Experimental group), another set of

10 patients who do not have access to glucometers were also selected (Control group).

3.5 Instrumentation

The following instruments were used for gathering information from patients;

 Glucometers for reading blood glucose levels,

 Android mobile phones

 Blood glucose tracker application which was installed on the phones of participants in the

pilot project for monitoring patient parameters.

 Patient information/bio data form

31
3.5.1 Participant information form

A structured questionnaire as referenced in Appendix A was administered to participants to

document study participants, demographic characteristics.

3.6 Data collection

Diabetic patients visit the Health facility to see the doctor once every three months or when

they need to fill their prescriptions. The blood sugar of patients are checked only when they

visit the Health facility. This study was carried out using two sets of participants; those who

use glucometers (Experimental) and those who did not use glucometers (Control).

A form was filled by each participant to gather information on their demographic factors as

well as other information that is relevant such as weight, HBA1c values, initial fasting blood

glucose levels and medications, form of exercises, foods taken in and whether they have any

complications such as high cholesterol levels, cardiovascular disease, retinopathy, neuropathy

and hypertension.

Control Group

Participants in the control group were diabetic patients who visited the health facility for

management and treatment of their disease and did not have personal glucometers for checking

their blood glucose at home.

Blood glucose readings were taken from participants in the control group each time they

visited the Health facility to see the doctor or refill their prescriptions and recorded over the

period of three months. Glycated Haemoglobin (HBA1c) values were estimated for each

participant at the beginning of the study. Participants were monitored over the period of the

32
study each time they visited the Health facility findings recorded as shown in Appendix B for

each participant and the monthly average blood glucose is shown in table 3.1 below:

TABLE 3.1

MONTHLY AVERAGE GLUCOSE READING (mmol/l) FOR PARTICIPANTS WITHOUT ‘APP’ (CONTROL)

PARTICIPANT ID AGE SEX MONTH 1 MONTH 2 MONTH 3

N01 55 M 6.4 7.2 7.8

N02 82 F 8.1 11.4 6.4

N03 59 F 9.5 9.9 9.5

N04 41 F 11.6 11.6 13.7

N05 85 M 11.4 14.1 11.8

N06 65 F 6.5 11.1 6.6

N07 48 F 12.8 8.0 9.8

N08 75 F 7.0 6.1 6.7

N09 46 F 14.9 11.0 9.6

N10 58 M 6.9 9.7 7.2

HBA1c values were estimated for each participant in this group at the end of the study period

and recorded. Initial and end point HBA1c values are shown in table 3.2 below:

33
 TABLE 3.2

GLYCATED HAEMOGLOBIN (HBA1c) FOR PARTICIPANTS WITHOUT 'APP' (Control)

PARCIPANT ID AGE SEX INITIAL HBA1c (%) POST HBA1c (%)

N01 55 M 6.40 7.60

N02 82 F 7.90 7.90

N03 59 F 8.30 10.60

N04 41 F 8.70 8.65

N05 85 M 8.80 9.80

N06 65 F 7.20 10.50

N07 48 F 10.50 11.10

N08 75 F 6.10 5.20

N09 46 F 13.30 13.40

N10 58 M 6.90 7.50

Experimental Group

Participants in this group had personal glucometers which could be used for estimating their

blood glucose at home. The initial blood glucose reading was estimated for each participant as

well as their initial HBA1c values. Each participant in the Experimental group had an “app”

known as the “blood glucose tracker” installed on their android mobile phones. The blood

glucose readings from the glucometer were saved on the “app” after each test. Blood glucose

readings were checked daily or twice a week depending on the doctors’ instructions and the

type of diabetes the participant suffers from.

Recordings were forwarded by WhatsApp or SMS to the researcher’s phone for review.

Weekly and monthly averages were estimated from the recordings over a period of 12 weeks

for each participant as shown in tables 3.3 and 3.4 below:

34
 TABLE 3.3

WEEKLY AVERAGE FASTING BLOOD GLUCOSE READINGS FOR PARTICIPANTS USING GLUCOMETERS AND 'APP' (Experimental)

PARTICIPANT ID AGE SEX WEEK1 WEEK2 WEEK3 WEEK4 WEEK5 WEEK6 WEEK7 WEEK8 WEEK9 WEEK10 WEEK11 WEEK12

G01 42 F 6.0 5.8 5.2 5.3 5.3 4.2 4.7 4.9 4.6 4.1 5.4 5.1

G02 51 F 5.9 5.5 6.4 7.2 6.8 8.7 7.6 6.0 8.6 5.7 9.1 9.5

G03 51 M 12.7 8.2 7.7 6.2 6.6 5.7 6.2 6.1 5.1 5.1 6.0 5.0

G04 53 F 9.3 9.2 8.1 7.9 6.3 7.1 7.0 7.1 8.6 6.7 9.3 8.3

G05 33 F 5.5 5.7 5.7 6.9 5.1 5.1 6.8 5.3 5.9 5.6 6.0 5.4

G06 77 F 6.1 6.8 6.7 7.3 6.8 6.3 6.6 7.3 6.5 5.5 6.1 5.3

G07 60 M 6.9 8.3 6.9 6.3 7.5 6.6 7.0 6.4 6.3 6.6 5.4 5.4

G08 61 F 6.5 10.5 6.8 6.0 6.2 3.8 5.6 6.9 5.8 6.0 4.8 5.0

G09 53 M 6.0 7.1 7.3 6.3 7.1 8.2 7.9 8.3 8.0 7.7 8.3 8.1

G10 22 M 7.7 7.3 6.9 7.0 6.5 6.9 6.6 7.2 6.9 6.7 6.5 6.1

TABLE 3.4

MONTHLY AVERAGE BLOOD GLUCOSE READINGS (mmol/l) FOR PARTICIPANTS USING GLUCOMETER AND ‘APP’ (Experimental)

PARTICIPANT ID AGE SEX MONTH 1 MONTH 2 MONTH 3

G01 42 F 5.9 4.9 4.7

G02 51 F 6.1 7.6 7.8

G03 51 M 9.5 6.2 5.7

G04 53 F 8.9 7.1 7.9

G05 33 F 5.6 6.0 5.0

G06 77 F 6.8 6.8 5.5

G07 60 M 7.1 6.9 6.2

G08 61 F 7.7 5.4 5.7

G09 53 M 6.7 7.9 8.0

G10 22 M 7.2 6.8 6.6

35
HBA1c values were estimated again for participants in the Experimental group at the end of

the study period and recorded. Initial and end point HBA1c values are shown in the table 3.5

below:

TABLE 3.5

GLYCATED HAEMOGLOBIN (HBA1c) VALUES FOR PARTICIPANTS WITH BLOOD GLUCOSE 'APP' (Experimental)

PARTICIPANT ID AGE SEX INITIAL HBA1c (%) POST HBA1c (%)

G01 42 F 6.50 5.90

G02 51 F 9.30 7.20

G03 51 M 13.40 5.50

G04 53 F 10.30 7.40

G05 33 F 10.10 6.80

G06 77 F 10.50 6.10

G07 60 M 8.10 5.80

G08 61 F 6.10 5.70

G09 53 M 10.30 6.40

G10 22 M 11.20 6.30

Post Exercise Questionnaire

Participants in the Experimental group were made to fill another questionnaire; appendix B,

after the whole exercise to evaluate their ability to use the system effectively.

36
 TABLE 3.6

Evaluating the usability, acceptance and effectiveness of the mobile ‘app’

Participant ID Ease of use of ‘App’ Acceptance of ‘App’ Effectiveness Readings by

G01 No Yes Excellent SMS

G02 No No Good Whatsapp

G03 Yes Yes Excellent App

G04 Yes Yes Good App

G05 Yes Yes Excellent App

G06 Yes Yes Excellent App

G07 Yes Yes Excellent Whatsapp

G08 No Yes Good SMS

G09 Yes Yes Excellent App

G10 Yes Yes Excellent App

3.7 Data analysis

The data collected for each participant in the experimental group as well as any interventions

done were noted and assessed. The average weekly readings were compared to see if there were

improvements in the blood glucose values at the end of the study period. HBA1c values at the

end of the study were recorded and compared to values at the beginning of the study. Participants

were given a questionnaire to answer questions and rate the application and entire process.

3.8 Validity

Data from participants that completed the entire study were used for analysis. Those who could not

complete the study were declared invalid

37
 CHAPTER FOUR

ANALYSIS OF FINDINGS AND DISCUSSION

4.1 Introduction

The study sought to ascertain the impact of the introduction of IT tools such as the glucometer,

mobile ‘app’ and the use of the phone on diabetes patient’ self-management of the disease and

how that has reflected in their glycemic control. Participants were diabetics with type 1, type 2 or

gestational diabetes aged twenty years and above.

A total of twenty (20) participants were used; ten in each group (Experimental and Control

groups). Seven males and thirteen females participated. The experimental group comprised of six

females and four males and the control group had seven females and three males. Participants

were selected by a simple random sampling. The glycated haemoglobin (HBA1c) values for each

participant was estimated at the beginning and at the end of the entire exercise. Weekly and

monthly average blood glucose values were recorded for the experimental group, while monthly

averages were recorded for the control group.

4.2 Analysis of findings

The monthly average blood glucose values for the control group were mostly high with no

significant change in values over the study period; 70% had their monthly averages greater than

(>) 7mmol/l. 60% had their highest reading in the second month with a significant drop in the

third month. This suggests that patients do not take measures such as medications, diets and

exercises prescribed for them till they are about to pay the next visit to the Health facility. The

HBA1c values increased significantly for 60% of participants in the control group after the study

period; it is an indication that the participants did not manage their disease properly. 90% of the

38
participants had their HBA1c values greater than 7.0% which is the upper limit for Diabetic

patients. At the end of the study period, one person in the control group had developed

Dyslipidaemia (High blood cholesterol levels); another was referred to the eye clinic with eye

problems; Five of them were said to have uncontrolled or poorly controlled their blood glucose

values because they did not comply to dietary advice or medication. One person was newly

diagnosed with Hypertension at the end the study period while three people developed

neuropathy. Two people were also diagnosed with osteoarthritis. In all, eight out of ten people in

the control group were diagnosed with some form of Diabetic complication by the end of the

study period.

The data collected for each participant in the experimental group as well as any interventions

done were noted and assessed. The average weekly readings were compared to see if there were

improvements in the blood glucose values at the end of the study period. HBA1c values at the

end of the study were recorded and compared to values at the beginning of the study. Participants

were given a questionnaire to answer questions and rate the application and entire process at the

end of the study period. There was a steady decrease in blood glucose values and by the fourth

week, 80% of participants had their blood glucose values below 7.0mmol/l. At the end of the

study, 70% of participants in the Experimental group had their weekly blood glucose values

properly controlled (consistently within the normal range). The monthly blood glucose values for

participants in the experimental group showed significant decrease for 70% of participants in the

experimental group with values below 7.0mmol/l. The HBA1c values for the experimental group

reduced significantly at the end of the study with 80% below 7.0%. None of the participants in

the experimental group was diagnosed with any additional Diabetic complications during or at

the end of the study period.

39
Statistical analysis was done using Paired t – tests for the experimental group using HBA1c

values before and after the exercise and the control group using HBA1c values before and after

the exercise.

Analysis was also done using independent t – test to compare the HBA1c values in both the

experimental and control groups after the exercise.

4.3 Normality testing

The choice of statistical test depended on a normality test. Presented in Table 4.1 is a Shapiro –

Wilk test of normality with p-values of 0.627 and 0.620 for the experimental group and control

groups respectively. These test results are indicative of the normality of the data, paving the way

for the adoption of Paired Test as the main statistical tool to use in determining whether or not

the intervention of providing an app for the monitoring of Blood Sugar among the experimental

units has been impactful.

40
Table 4.1: Normality Test for the Before and After Differences of the Control Group and
Experimental Group

Kolmogorov-Smirnova Shapiro-Wilk

Statistic Df Sig. Statistic Df Sig.

DControl .153 10 .200* .946 10 .620

DExperimental .129 10 .200* .946 10 .627

The Q-Q plots presented in Appendix E are graphical confirmations of the normal nature of the

“before” and “after” differences in both the experimental and control groups. Credence is learnt

to the realization of normality of owing to the closeness of the points to the lines of both Figure

4.1 and Figure 4.2 (Appendix E).

41
4.3 Statistical Analysis

4.3.1 Paired t-test: The “Before” and “After” Test Results of the Experimental and Control
Groups
Hypothesis

Hoe: There is no significant difference between the “before” and “after” measurements of HBA1c

in the experimental group.

H1e: There is a significant difference between the “before” and “after” measurements of HBA1c

in the experimental group.

Hoc: There is no difference between the “before” and “after” measurements of HBA1c in the

control group.

H1c: There is a difference between the “before” and “after” measurements of HBA1c in the

control group.

Where Hoe = Null Hypothesis of Experimental Group

H1e = Alternative hypothesis of Experimental Group

Hoc =Null hypothesis of Control Group

H1c = Alternative Hypothesis of Control Group

Significance level, α = 0.05

Decision Rule

Reject Hoe, Hoc if p<0.05

42
Table 4.2: Summary Statistics of the "Before" and "After" Measurements of HBA1c in
both Control and Experimental Groups

Std. Error
Mean N Std. Deviation Mean
Pair 1 “Before” for Experimental 9.5800 10 2.191803 0.693109
Experimental Group

"After" for Experimental 6.5527 10 0.905826 0.286447

Group

Pair 2 "Before" for Control Group 9.1550 10 2.293766 0.725352

Control
"After" for Control Group 8.4100 10 2.157905 0.682390

From Table 4.2, the mean HBA1c recordings for the “After” measurements in both the

Experimental Group and the Control Group are 6.5527% and 8.41% respectively, lower than

those of the “before” measurements in the Experimental and Control groups (9.58 and 9.155

respectively).

The significance of the lower mean HBA1c measurements presented in Table 4.2 is tested using

the paired test output in Table 4.3.

43
Table 4.3: Paired Test Results of the measurement of HBA1c in both Experimental and
Control Groups

Paired Differences
95% Confidence
Interval of the
Std. Difference
Error Sig. (2-
Mean Lower Upper T Df tailed)
Pair 1 "Before" for 0.614405 -4.417181 -1.63741 -4.927 9 0.001
Experimental Group -
"After" for Experimental
Group

Pair 2 "Before" for Control 0.341276 -1.517020 0.02702 -2.183 9 0.057

Group - "After" for
Control Group

The p-value of 0.001 for the paired test between the “Before” and “After” measurements in the

Experimental Group, below the α = 0.05 means there is enough evidence to reject the null

hypothesis and conclude that the introduction of the App for monitoring the blood glucose levels

of patients has been impactful.

However, the p-value of 0.057 for the paired test between the “Before” and “After”

measurements in the Control Group, greater than α =0.05 helps me conclude that there is not

enough statistical evidence to suggest that there is a significant difference between the “Before”

and “After” measurements of HBA1c in the control group.

44
4.3.2 Independent t-test between the Experimental and the Control Groups

For the purpose of this research, the dependent variable of interest is the HBA1c measurements

in both groups whist the categorical or group variable is the group the HBA1c measurement

belongs.

Hypothesis Testing

Ho: The HBA1c measurements in the Experimental and Control groups are the same

H1: The HBA1c measurements in the Experimental and Control groups are not the same

Significance level

α=0.05

Decision Rule
Reject Ho if p≤ α

Table 4.4: Summary Statistics of the "After" Measurements of HBA1c in both

Experimental and Control Groups
Group N Mean Std. Deviation Std. Error Mean

With
10 6.55130 0.64938 0.20535
App

HBA1c Final
Reading
No App 10 8.41550 2.29377 0.72535

45
The mean HBA1c measurements for the Experimental Group and Control Group are 6.551% and

8.41% respectively with an absolute mean difference of approximately 2%.

The goal of the Independent t-test results below is to establish the significance of this difference

between the Experimental and Control groups.

Table 4.5: Independent t-test Output of HBA1c "After" Measurements in both

Experimental and Control Groups

Levene's Test for t-test for Equality of Means

Equality of
Variances
F Sig. T Df Sig. (2- 95% Confidence
tailed) Interval of the
Difference

Lower Upper

Equal
variances 8.722 0.009 -3.770 18.000 0.001 -4.426 -1.259
HBA1c assumed
Final Equal
Reading variances
-3.770 10.433 0.003 -4.512 -1.172
not
assumed

The Levene’s Test results of Table 4.5 with p-value of 0.009 rejects the hypothesis of

assumption of equal variances in the two populations and as such adopts the assumption of

unequal variances.

46
Decision

The assumption of unequal variances in the two populations leaves me with the adoption of the

p-value of 0.003, less than α =0.05 and hence the conclusion is that differences in the

measurements of HBA1c that exist between the Experimental and Control groups is significant.

4.4 Post exercise questionnaire results

The Experimental group filled a questionnaire after the exercise to evaluate their ability to use

the tools effectively; All participants were satisfied with the system used; 70% were able to

record the glucose values using the mobile “app” installed on their phones. 60% were able to

forward the readings directly from the “app’, 20% forwarded readings using WhatsApp and 20%

forwarded the readings by SMS. This indicates that the majority of the participants were able to

use the system effectively.

4.5 Discussion

The results from the findings show that using the IT tools in self-managing Diabetes can

positively impact glycaemic control in the short term. The Ministry of Health (Ghana) standard

treatment guideline states the fasting blood glucose levels for diabetics as 4.0-6.0 mmol/l and

that of two-hour post-meal glucose as 4.0-8.0mmol/l. The average monthly blood glucose for

70% of participants in the experimental group was below 7.0mmol/l by the end of the exercise,

whilst the control group had 30% below 7.0mmol/l. Normal HBA1c values for diabetics as

published by American Diabetes association is <7.0%. HBA1c for the experimental group after

the exercise was below 7.00% for 80% of participants (table 3.5), whereas the control group had

10% of participants having HBA1c below 7.00% (table 3.2). Participants were able to identify

47
certain foods and activities that increased their blood glucose levels and made choices as to what

to avoid and what to eat.

Montori et al in their study conducted in 2004 yielded similar results; patients with type 1

diabetes who were poorly controlled despite receiving intensive insulin therapy sent their blood

glucose data to the care team regularly over a 6-month using a modem. The experimental group

received telephone “feedback” from a nurse within 24 hours of each transmission, and these

patients’ mean HBA1c levels decreased significantly (p = 0.03). Another study by Carroll et al.,

(2011) on the combination of a glucose meter combined with the battery pack of a cell phone for

the determination of blood glucose for type 1 diabetes had negative results. Interestingly, when

this same approach was used by Cho et al. (2009) for patients with type 2 diabetes, statistically

significant (P = 0.01) improvements in blood glucose were observed. Tkenga et al, 2014,

concluded in their study that information technology is a suitable instrument to support health

care providers to effectively manage diabetes and also assist in the prevention of diabetic

complications. Recording the blood glucose values had an impact on making personal effort to

keep the levels within limits, this reflected in the weekly average glucose values recorded for the

experimental group as shown in table 3.3. There was a significant drop in monthly blood glucose

values by the third month within the experimental group with 70% of the values falling below

7.0mmol/l. This indicates a significant improvement in blood glucose as well as HBA1c values

for participants in the experimental group as compared to those in the control group.

48
 CHAPTER 5

CONCLUSION AND RECOMMENDATION

5.1 Introduction

This study sought to ascertain the impact the introduction of IT tools such as the glucometer,

Mobile ‘app’ and the use of the phone on diabetes patients’ self-management of the disease and

how that is reflected in their glycemic control.

In Ghana most Diabetic patients visit the health facility quarterly except when they are ill or need

to refill their prescriptions and that is when they check their blood glucose levels because most

Diabetic patients do not own personal glucometers. Self-management is critical, as part of a

patient’s commitment to preventing disease complications. (American diabetes Association,

2014). Self- management of diabetes has created educational and motivational benefits for the

control and prevention of the disease. Diabetes is a major cause of adult ill health and deaths in

Ghana (de Graft Aikins et al), in 2015, 4,790 of adult deaths reported in Ghana were due to

diabetes and according to WHO World Health rankings for countries, Diabetes was at the 14th

position for the top twenty causes of death in Ghana in 2017; with 5,709 deaths caused by

Diabetes. This formed 2.71% of total deaths recorded thus making it a significant public health

issue.

49
5.2 Summary of findings

Within the group that used the tools (Experimental Group), the HBA1c final measurements

showed significant improvement and none of them was diagnosed with additional Diabetic

complications at the end of the study period.

Within the group that did not use the tools (Control Group) the HBA1c final measurements did

not show any significant improvement and 80% were diagnosed with other Diabetic

complications including hypertension, eye problems, neuropathy and dyslipidaemia by the end of

the study period.

Comparing the group that used the tools (Experimental Group) and the group that did not use the

tools (Control Group), the HBA1c final measurement in the Experimental Group was

significantly better (lower) than that of the Control Group.

5.3 Conclusion

Addressing the research questions; What is the impact of the IT-based tools, conceived for

diabetes management, on the therapy and treatment of the disease?

How can self-management of the disease improve diabetes short-term outcomes? the findings

have addressed the purpose of the study because there was a significant improvement of blood

glucose and HBA1c levels for the experimental group as compared to the control group. HBA1c

values dropped significantly. This shows that using IT based tools to assist in the management of

diabetes is effective and gives short term positive outcomes in terms of controlling blood glucose

levels. It also shows that diabetic patients can be monitored at home to help them achieve normal

50
blood glucose levels hence reduce emergency room visits and complications associated with

diabetes as well as reduce the burden on Health professionals and Healthcare facilities.

5.4 Recommendations

The system should be adopted for use in the self-management of Diabetes to reduce

complications suffered from poor management of the disease.

Diabetic patients must be encouraged to use glucometers and education on their effective use

should be done by health professionals.

Health insurance schemes should assist diabetic patients acquire personal glucometers to enable

continuous monitoring of blood glucose levels.

Further research can be done to develop automatic feedback systems that will advise patients on

what to do when blood glucose levels are too high or too low.

51
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59
Young, R. J., Taylor, J., Friede, T., Hollis, S., Mason, J.M., Lee, P., Burns, E., Long, A.F.,
Gambling, T., New, J.P. and Gibson J.M. (2005), “Pro-Active Call Center Treatment Support
(PACCTS) to Improve Glucose Control in Type 2 Diabetes,” Diabetes Care, 28 (2), 278-282.

60
APPENDIX A

PARTICIPANT’S INFORMATION
1. Name……………………………………………………………ID……………………

2. Age: 18 - 30 □ 31 - 40 □ 41 - 50 □ 51 - 60 □ 60+ □

3. Sex: Male □ Female □

4. Weight………………………………………………………………………………

5. Height………………………………………………………………...............................

6. Diabetes Type

Type 1□ Type 2 □ Gestational □

7. Time since Diagnosis…………………………………………………….

8. Any complications? Tick appropriate

Hypertension □ Cardiovascular disease □ Cerebrovascular disease □

Neuropathy □ .Dyslipidaemia □

9. Profession/Occupation……………………………………………………………….
10. Socioeconomic status:

Low income □ Middle income □ High income □

11. Body mass Index…………………….

12. Frequency of Healthcare facility visits

Weekly □ Bimonthly □ Monthly □ Quarterly □ Others □

13. Distance to hospital

1 - 5km □ 6 -10km □ 11 - 15km □ 15 - 20km □ 20+km □

14. Travel time to the hospital

0 - 1hr □ 1 -2hr □ 2 - 3hrs □ 3+hrs □

15. Current knowledge or use of ICT

61
 Internet □ Personal computer □ Smart phones □ Glucometers □

16. Do you use any form of Information technology to monitor the disease?

Yes □ No □

If yes, what was its effect after a specified period?

…………………………………………………………………………………

17. Diets taken

Breakfast…………………………………………………………………………

Lunch……………………………………………………………………………

Dinner………………………………………………………………………………

18. Do you exercise? Yes □ No □

If yes, how?

……………………………………………………………………………………

19. Smoking? Yes □ No □

20. Footcare? Yes □ No □

Blood Glucose…………………………………………………………………………..

HBA1c…………………………………………………………………………………

Blood Pressure…………………………………………………………………………..

Date…………………………………………………………………………………….

HBA1c after three months......................................Blood glucose.................................

Date............................................................................................................................

62
APPENDIX B: Data for Participants in Control group

Table B1

PATIENT IDN01
DOCTOR

AGE 55
SEX MALE
HBA1c 6.40% PRE
BP 120/66
TYPE 2 MONTHLY AERAGE
DIAGNOSED 2014 1 6.4
2 7.2
DATE BLOOD SUGAR MMOL/L 3 7.8
20/12/17 6.4
18/1/18 7.2
22/2/18 7.8

22/12/17 7.60% POST

Table B2

PATIENT ID
DOCTOR N02
AGE 82
SEX FEMALE
WEIGHT 78KG
TYPE 2
BP 156/83
HBA1c 7.90% PRE MONTHLY AVERAGE
DIAGNOSED 2015 1 8.1
2 11.4
DATE BLOOD SUGAR MMOL/L 3 6.4
18/12/17 8.1
15/1/18 11.4
22/2/18 6.4

HBA1c 7.90% POST

63
Table B3

PATIENT ID N03
DOCTOR
AGE 59
SEX FEMALE
WEIGHT 85kg
HBA1c 8.30% PRE 8.40% POST
BP 139/88 MONTHLY AVERAGE
TYPE 2 1 9.5
DIAGNOSED 2004 2 9.9
3 9.5
DATE BLOOD GLUCOSE MMOL/L
1/12/2017 9.5
4/1/2018 7.5
18/1/18 12.3
10/2/2018 10.2
8/3/2018 9.5

HBA1c 10.60% POST

Table B4

PATIENT ID N04
AGE 41
SEX FEMALE
WEIGHT90.2
HBA1c 8.70% PRE
BP 183/110 MONTHLY AVERAGE
TYPE 2 1 11.6
DIAGNOSED 2012 2 11.6
3 13.7
DATE BLOOD SUGAR MMOL\L
1/12/2017 17.6

4/1/2018 11.6
30/1/18 11.6
10/3/2018 13.7

64
Table B5
PATIENT ID N05
DOCTOR

AGE 85
SEX MALE
WEIGHT 61kg
HBA1c 8.80% PRE MONTHLY AVERAGE
BP 97/57 1 11.4
TYPE 2 2 14.1
DIEDAGNOS 19 YEARS 3 11.8

DATE BLOOD SUGAR mmol/l

7/12/2017 11.4
7/1/2018 21
8/1/2018 19.6
9/1/2018 18.1
22/2/18 11.8

HBA1c 9.80%

Table B6
PATIENT ID N06
DOCTOR

AGE 65
SEX FEMALE
WEIGHT 79kg
HBA1c 7.20% PRE
BP 134/74 MONTHLY AVERAGE
TYPE 2 1 6.5
DIAGNOSED 2014 2 11.1
3 6.6
DATE BLOOD SUGAR mmol/l
11/12/2017 6.5
10/1/2018 9.2
24/1/18 13
22/2/18 6.6

HBA1c 9.80% POST

65
Table B7
PATIENT ID N07
DOCTOR

AGE 48
SEX F
WEIGHT
HBA1c 10.50% PRE
BP 148/89 MONTHLY AVERAGE
TYPE 2 1 12.8
DIAGNOSED 2015 2 8
3 9.8
DATE BLOOD SUGAR mmol/l
5/12/2017 12.8
15/1/2018 16.8
22/2/2018 8
22/3/2018 9.8

HBA1c 11.10% POST

Table B8
PATIENT ID N08
DOCTOR
AGE 75
SEX F
WEIGHT 75 kg
DIAGOSED 2015
MONTHLY AVERAGE
HBA1c 6.10% PRE 1 7
BP 139/77 2 6.1
TYPE 2 3 6.7
DATE BLOOD SUGAR mmol/l
16/12/17 13.3
20/1/18 7
6/2/2018 6.1
8/3/2018 6.7

HBA1c 5.20% POST

66
Table B9
PATIENT ID N09
DOCTOR

AGE 46
SEX F
WEIGHT 84.7KGS MONTHLY AVERAGE
HBA1c 13.30% PRE 1 14.9
BP 118/79 2 11
TYPE 2 3 9.6
DIAGNOSED 10 YEARS GESTATIONAL

DATE BLOOD GLUCOSE mmol/L

13/11/2017 13.3
21/12/17 16.4
24/12/17 13.3
4/1/2018 16
4/2/2018 9.6
15/3/18 5.4

HBA1c 13.40% POST

Table B10
PATIENT ID N10
DOCTOR
AGE 58
SEX M
SEX 76 kg
DIAGNOSED 2016
MONTHLY AVERAGE
HBA1c 6.90% PRE 1 6.9
BP 135/67 2 9.7
TYPE 2 3 7.2

DATE BLOOD SUGAR mmol/l 3 MONTH AVEREAGE

6/12/2017 6.9
15/1/2018 12.9
22/1/18 6.5
12/2/2018 7.2

HBA1c 7.50% POST

67
APPENDIX C: Data collected for experimental group

Table C1
PATIENT ID G01
DOCTOR ABANKWA

AGE 42
SEX FEMALE
WEIGHT
HBA1c 6.50% PRE 5.90% POST
BP
TYPE GESTATIONAL
DIAGNOSED 3 MONTHS
READINGS BY SMS AVERAGES

DATE BLOOD SUGAR

2HPPmmol/L(FAST)
1HPL 2HPL 2H PS wk FBSmmol/l2hpp 1hpl 2hpl 2hps
12/12/2017 6.6 1 6 8.6 7.4 7.6 7.9
13/12/2017 5.9 9.7 7.6 6.6 8.5 2 5.8 7.5 5.4 9 8
16/12/2017 5.4 7.5 7.2 8.5 7.3 3 5.2
21/12/2017 5.7 7.5 5.4 8.2 8.5 4 5.3 9.8 7.8 8.7 7.5
24/12/2017 5.8 7.2 9.7 7.5 5 5.3 8.7 6.7 10.2
3/1/2018 5.3 9.8 7.8 8.7 9.5 6 4.2 6.7 7.8 9.5
4/1/2018 5.2 7 4.7 8.4 5.9
13/1/2018 5.3 8.7 6.7 10.2 8 4.9
21/1/2018 4.2 6.7 7.8 7.4 9 4.6 7 6.5 8.1
27/1/2018 4.7 8.4 5.9 10 4.1
5/2/2018 4.6 7 6.5 8.1 11 5.4
9/2/2018 5.2 12 5.1
12/2/2018 4.1
19/2/18 5.4 MONTHLY AVERAGE
22/2/18 5.6 1 5.9 8.1 6.4 8.3 8
27/2/18 5 2 4.9 8.4 6.8 8.3 9
2/3/2018 4.80% 3 4.7 7 8.1
5/3/2018 5.1
3 MONTH AVERAGE
4.7 7.8 6.6 8.3 8.3

68
Table C2
READINGS BY TEXT
AGE 51
SEX FEMALE
WEIGHT 72.6 kg
HBA1c 9.30% PRE 7.20% POST
BP 133/89
TYPE 2
AVERAGES
WEEKLY AVERAGES FBS (mmol /lPBFAST
) P SUP
DATE BLOOD SUGAR
TIME
mmol
P BREAKFAST
/L P SUPPER 1 5.9 6.8
12/12/2017 6 2 5.5 8.5 6.3
13/12/2017 5.7 3 6.4 7.4 6.4
14/12/2017 5.7 4 7.2 7.3 8.8
15/12/2017 4.7 4.7 6.5 5 6.8 8.3
16/12/2017 6.3 6 6 8.7
17/12/2017 6 7.8 7 7.6 8.1
18)12/2017 5.2 8 6 7.4
20/12/2017 5.6 6.3 9 8.6 8.8
21/12/2017 5.6 5.8 10 5.7
23/12/207 7.2 11.2 11 9.1
25/12/2017 5.5 12 9.5
27/12/207 6.8 7.8 6.4 13 9.3
29/12/2017 5.2 5.8
30/12/2017 7.8 8.2
31/12/2017 7.2 6.8 MONTHLY AVERAGES
3/1/2018 7.1 7.8 10.8 1 6.1
4/1/2018 6.8 7.7 2 7.6
5/1/2018 7.6 3 7.8
6/1/2018 5.8 6.7 8.7
7/1/2018 11.2 3 MONTH AVERAGE 7.2mmol/l
8/1/2018 7.8 8.3 10.7
9/1/2018 6.8
11/1/2018 6.8 10.2
12/1/2018 6.5
16/1/2018 6.2 12
18/1/2018 8.7
21/1/2018 10.1
22/1/2018 7.5
23/1/2018 7.2 7.1
25/1/2018 7.7
26/1/2018 9.9 9.7
27/1/2018 6.7 7.8
28/1/2018 6.1

69
Table C3
PATIENT ID G03
DOCTOR ASAMOAH
AGE 51
SEX MALE
WEIGHT 80kg
HBA1c 13.40% PRE 5.50% POST
BP 130/75
TYPE 2
DIAGNOSED Dec-17
READINGS BY APP

DATE BLOOD SUGAR

TIMEMMOL/L (FBS) AVERAGES
12/12/2017 12.4 7:57AM WEEK FBSmmol/l)
post meal(2hr)
13/12/2017 16.7 7:45AM 1 12.7
14/12/2017 11.2 9:09AM 2 8.2
15/12/2017 10.4 8:39AM 3 7.7
18)12)2017 8.6 9:43 AM 4 6.2
19/12/2017 9.1 5 6.6
20/12/2017 8.5 9:43 AM 6 5.7
21/12/2017 8.4 9:38 AM 7 6.2
22/12/2017 7.4 9:59 AM 8 6.1
23/12/2017 7.1 10:17 AM 9 5.1
25/12/2017 7.7 9:36 AM 10 5.1 6.5
26/12/2017 7.6 9:58 AM 11 6
27/12/2017 7.6 9:50 AM 12 5 7.2
29/12/2017 7.7 9:34 AM
2/1/2018 6.2 8:57 AM monthly average
3/1/2018 6.3 9:37 AM 1 9.5
4/1/2018 6.3 8:50 AM 2 6.2
5/1/2018 6.5 3 5.7 6.9
6/1/2018 5.6
8/1/2018 7.1 3 month average 7.1
9/1/2018 7.3
11/1/2018 6.2
12/1/2018 6.4
13/1/2018 6.1
15/1/2018 6.1
17/1/2018 5.7
20/1/2018 5.3
22/1/2018 6.7
24/1/2018 5.8
26/1/2018 5.8

70
Table C4

PATIENT ID G04
DOCTOR

AGE 53
SEX FEMALE
WEIGHT 85
HBA1c 10.30% PRE 7.43% POST
BP 127/78
TYPE 2 AVERAGES
DIAGNOSED 2003 WEEKLY AVERAGES FBS(MMOL/L)
POST MEALS
READINGS BY APP 1 9.3 8.7
2 9.2
DATE BLOOD SUGAR
TIMEMMOL/LP SUPPER 3 8.1
13/12/2017 9.6 7:12 AM 4 7.9
15/12/2017 8.9 7:22 AM 5 6.3
17/12/2017 8 8.7 6 7.1 7.4
19/12/2017 9.9 7 7 9.7
21/12/2017 8.1 10.2 8 7.1
23/12/2017 8.2 9 8.6
26/12/2017 10.7 P BFAST 10 6.7
27/12/2017 8.1 11 9.3 Patient short of medicine
29/12/2017 7.5 12 8.3
1/1/2018 6.8
4/1/2018 8.9 Monthly average
8/1/2018 5.9 1 8.9
10/1/2018 6 2 7.1
13/1/2018 7.1 3 7.9
15/1/2018 8.5
17/1/2018 6.9 7.4 3 month average 8
19/1/2018 5.8
20/1/2018 5.8 7.4
22/1/2018 6 7.6 P BREAKFAST
24/1/2018 6.2 9.7
27/1/2018 5.9 10.2
29/1/2018 6.5 9.3

71
Table C5
PATIENT ID G05
DOCTOR LARYEA
AGE 33
SEX FEMALE
WEIGHT 93 kg
HBA1C 10.10% PRE 6.80% POST
BP 120/70
TYPE 1
DIAGNOSED 27 YEARS
READINGS BY APP
AVERAGES
DATE BLOOD SUGAR
TIMEmmol/L
PRE SUPPER AFTER SUPPER
WEEKLY FBS(mmol/l)B SUP P SUP
13/12/2017 6 7:30 AM 1 5.5 8.7 9.8
14/12/2017 5.6 7:04 AM 5.8 9.8 2 5.7 8.3 8
15/12/2017 4.8 8:45 AM 3 5.7 8.9
16/12/2017 4.9 11.5 4 6.9 8.8
18/12/2017 5.9 6:17 AM 11.5 4.3 5 5.1
19/12/2017 6.1 7:06 AM 9.1 6 5.1
20/12/2017 5.7 6:30 AM 10.5 7 6.8
21/12/2017 5.8 7:20 AM 5.2 8 5.3
22/12/2017 5.4 9 5.9
23/12/2012 6 8:36 AM 10 5.6
24/12/2017 5.1 6.9 11 6
25/12/2017 6 8.1 12 5.4
26/12/2017 3.1 12.6 10.9 13 4.7
27/12/2017 6.1 7:10 AM
28/12/201 7.9 8.2 MONTHLY AVERAGE
29/12/217 5.4 10.2 1 5.6
30/12/2017 5.8 2 6
31/12/2017 5.6 11.7 3 5
1/1/2018 6.6
2/1/2018 7.2 3 MONTH AVERAGE 5.5
3/1/2018 7.9 10.7
4/1/2018 6.1 12.9
5/1/2018 6.6
6/1/2018 7
7/1/2018 9.3 6.9
8/1/2018 5.9 12.6
9/1/2018 5.2
10/1/2018 5.7 9.7
11/1/2018 4.8
12/1/2018 4.5
13/1/2018 5.1
14/12018 4.6
15/1/2018 4.3 9.6

72
Table C6

PATIENT ID G06
DOCTOR ASAMOAH
DIAGNOSED 1998
READINGS BY APP/TEXT
AGE 77
SEX FEMALE
WEIGHT
HBA1c 10.50% PRE 6.1% POST AVERAGES
BP WEEKLY AVE
TYPE 2 WEEK FBS(mmol/l)
1 6.1
DATE BLOOD SUGAR mmol/L fasting 2 6.8
27/12/2017 6.5 3 7.3
30/12/2017 6.1 4 6.8
2/1/2018 6.9 5 6.3
4/1/2018 6.6 6 6.6
8/1/2018 7.6 7 7.3
11/1/2018 6.9 8 6.5
15/1/2018 7 9 5.5
18/1/2018 6.5 10 6.1
22/1/2018 6.1 11 5.3
25/1/2018 6.1 12 5.2
27/1/2018 6.6
29/1/2018 6.7
1/2/2018 6.3 MONTHLY AVERAGE
3/2/2018 6.8 1 6.8
6/2/2018 7.1 2 6.8
9/2/2018 7.4 3 5.5
12/2/2018 6.4
13/2/18 6.7 3 MONTH AVERAGE 6.4
16/2/18 6.3
20/2/18 4.9
23/2/18 6
26/2/18 5.7
1/3/2018 6.4

73
Table C7

PATIENT ID G07
DOCTOR ASAMOAH
DIAGNOSED 2007
READINGS BY SMS
AGE 60
SEX MALE
WEIGHT 80 kg
HBA1c 8.10% PRE 5.80% POST
BP 133/82
TYPE 2
AVERAGES
DATE BLOOD SUGAR mmol/L WEEKLY
28/12/2017 7.8 WEEK FBS(mmol/l)
30/12/2017 6.6 1 6.9
3/1/2018 8.3 2 8.3
8/1/2018 7.4 3 6.9
11/1/2018 6.4 4 6.3
15/1/2018 6.4 5 7.5
19/1/2018 6.2 6 6.6
22/1/2018 7.5 7 7
29/1/2018 6.6 8 6.4
1/2/2018 6.5 9 6.3
6/2/2018 7.3 10 6.6
9/2/2018 6.7 11 5.4
12/2/2018 6.8 12 6.3
16/2/18 6
19/2/2018 5.6 MONTHLY AVERAGE
23/2/18 7 1 7.1
27/2/18 6.5 2 6.9
3/3/2018 6.7 3 6.2
5/3/2018 5.4
16/3/18 6.3 3 MONTH AVERAGE 6.7

74
Table C8

PATIENT ID G08
DOCTOR ASAMOAH
DIAGNOSED 2017
READINGS BY APP/TEXT
AGE 61
SEX FEMALE
WEIGHT 82kg
HBA1c 6.10% PRE 5.70% POST
BP
TYPE 2
AVERAGES
DATE BLOOD SUGAR mmol/l FBS WEEKLY AVERAGE
24/12/2017 6.5 WEEK FBS(mmol/l
27/12/2017 10.6 1 6.5
8/1/2018 5.5 2 10.5
11/1/2018 6.5 3 6.8
16/1/2018 6.2 4 6
22/1/2018 6 5 6.2
26/1/2018 3.8 11:30 AM 6 6
6/2/2018 5.6 7 3.8
14/2/2018 7.8 8 5.6
17/2/18 5.9 9 6.9
19/2/18 5.9 10 5.8
23/2/18 5.6 11 6
27/2/18 6 12 4.8
3/3/2018 4.8 13 5
6/3/2018 4.8
9/3/2018 5.2 MONTHLY AVERAGE
1 7.7
2 5.4
3 5.7

3 MONTH AVERAGE 6.3

75
Table C9

PATIENT ID G09
DOCTOR
DIAGNOSED 2016
READINGS BY APP
AGE 55
SEX MALE
WEIGHT
HBA1c 10.30% PRE 6.40% POST
BP 132/80
TYPE 2

DATE BLOOD SUGAR mmol/l AVERAGES

30/12/2017 6 B BREAKFAST WEEKLY AVERAGES
2/1/2018 7 B BREAKFAST WEEK FBS(mmol/l)
5/1/2018 7.1 B. BREAKFAST 1 6
9/1/2018 6.9 B BREAKFAST 2 7.1
11/1/2018 7.6 B BREAKFAST 3 7.3
16/1/2018 6.9 4 6.3
18/1/2018 5.6 5 7.1
23/1/2018 6.8 6 8.2
25/1/2018 7.4 7 7.9
30/1/2018 8.4 8 8.3
1/2/2018 8.9 9 8
2/2/2018 7.3 10 7.7
6/2/2018 7.5 11 8.3
8/2/2018 8.3 12 8.1
13/2/18 9.6
15/2/18 6.9
20/2/18 8.1 MONTHLY AVERAGE
22/2/18 7.9 1 6.7
27/2/18 7.6 2 7.9
1/3/2018 7.7 3 8
6/3/2018 7.8 NO MEDICATION
8/3/2018 8.8 3 MONTH AVERAGE 7.5
13/3/18 7.8
15/3/18 8.4

76
Table C10

PATIENT ID G10
DOCTOR
DIAGNOSED 2006
READING BY APP
AGE 22
SEX MALE
WEIGHT
HBA1c 11.20% PRE 6.30% POST
BP 118/60
TYPE 1

DATE BLOOD SUGAR MMOL/L AVERGES

30/12/2017 7.3 B BREAKFAST 6.4 P SUP WEEKLY AVERAGES
31/12/2017 7.1 B BREAKFAST 6.5 P SUP WEEK FBS(mmol/l)post meals
1/1/2018 6.8 B BREAKFAST 1 7.7 6.5
8/1/2018 7.8 B B 9.3 P SUP 2 7.3 9.3
10/1/2018 6.7 B BREAKFAST 8.6 P SUP 3 6.9 9.2
11/1/2018 7.0 B BREAKFAST 9.8 P SUP 4 7 8.1
16/1/2018 6.8 B BREAKFAST 9.4 P SUP 5 6.5 8.9
18/1/2018 7.2 B BREAKFAST 6.7 P SUP 6 6.9 10
25/1/2018 6.5 B BREAKFAST 8.9 P SUP 7 6.6 8.8
31/1/2018 6.9 B BREAKFAST 10 P SUP 8 7.2 9
5/2/2018 6.3 B BREAKFAST 8.4 P SUP 9 6.9 8.7
9/2/2018 6.8 B BREAKFAST 9.1 P SUP 10 6.7 8.7
12/2/2018 7.3 B BREAKFAST 9.6 P SUP 11 6.5 8
17/2/18 7.0 B BREAKFAST 8.3 P SUP 12 6.1 7.8
22/2/18 6.9 B BREAKFAST 8.7 P SUP
27/2/18 6.8 B BREAKFAST 8.9 P SUP MONTHLY AVERAGES
3/3/2018 6.6 B BREAKFAST 8.5 P SUP 1 7.2
5/3/2018 6.7 B BREAKFAST 8.1 P SUP 2 6.8
10/3/2018 6.5 B BREAKFAST 8.2 P SUP 3 6.6
11/318 6.4 B BREAKFAST 7.8 P SUP
14/3/18 6 B BREAKFAST 7.7 P SUP 3 MONTH AVERAGES6.9
16/3/18 6.2 B BREAKFAST 7.8 P SUP

77
APPENDIX D

POST EXERCISE QUESTIONNAIRE

Participant ID: ……………………………………………

1. How often could you use the system successfully? Rate it;

i.Excellent □ ii.Good □ iii. Fair □ iv. Poor □

2. Were you able to use the ‘App’ with ease?

i. Yes □ ii. No

3. Evaluate the options and designs of the ‘App’

i. Excellent □ ii. Good □ iii. Fair □ iv. Poor □

4. Did the exercise motivate you to control your blood glucose levels?

i. Yes □ ii. No □

5. Did feedbacks help you in the management of your disease?

i. Yes □ ii. No □

6. Kindly tell me how you feel about the entire exercise of using the mobile phone and ‘App’ to

monitor your blood glucose levels.

………………………………………………………………………………………………………

……………………………………………………………………………………………………....

7. Would you want to continue using the ‘App’ and recommend it to others?

i. Yes □ ii. No □

78
APPENDIX E: Normality plots for the Experimental and Control groups

The Q-Q Plot of the Difference in HBA1c for the Before and After Measurements in the
Experimental Group

79
The Q-Q Plot of the Difference in HBA1c for the Before and After Measurements in the Control
Group

80