A total of 12 out of 21 patients referred by the care team were interviewed. Four patients declined to be interviewed when contacted by the study team. Interviews were not conducted for the rest of the five patients as data saturation has already been achieved. The data saturation was reached at the 10th interview, with the 11th and 12th interview that further confirmed data saturation. Ten of the interviews were conducted in English, while the remaining two were in Mandarin. Interviews administered in Mandarin were transcribed verbatim and translated into English.
Patient characteristics are shown in Table 2.
Table 2
Participant characteristics | n | % |
N | 12 | |
Age, mean (± SD) | 56.58 | (± 8.52) |
Gender Male Female | 5 7 | 41.7 58.3 |
Ethnicity Chinese Indian Others | 10 1 1 | 83.3 8.3 8.3 |
Educational level ‘N’ Level/’O’ Level/NTC and below ‘A’ Level/Diploma University | 3 4 5 | 25.0 33.3 41.7 |
Marital status Single Married Divorced/Separated | 2 9 1 | 16.7 75.0 8.3 |
Employment status Full-time Part-time Unemployed & not studying | 7 2 3 | 58.3 16.7 25.0 |
Diabetes duration 0–5 years 6–10 years > 10 years | 8 3 1 | 66.7 25.0 8.3 |
On medication Yes No | 9 3 | 75.0 25.0 |
Health monitoring experience Yes No | 10 2 | 83.3 16.7 |
The mean age of patients was 56.6 years (range from 48 to 65 years) and female made up 58.3% (n = 7) of the patients interviewed. Among them, 83.3% (n = 10) of the patients were Chinese, 75% (n = 9) of the patients attained preuniversity and above education, 58.2% (n = 7) of the patients were working full-time, 66.7% (n = 8) of the patients had duration of T2DM of not more than five years, 75% (n = 9) are on diabetes medication and 83.3% (n = 10) of the patients had prior experience with using health monitoring devices.
The key findings of this study were reported in the form of rich descriptions and broadly grouped into 5 themes, which are 1) patients’ experiences on PTEC HAT, 2) remote monitoring of T2DM - patient perception, 3) technology component of PTEC HAT - patient perception, 4) value proposition of the PTEC HAT and 5) patient factor in adoption of the PTEC HAT. The findings under each theme were subcategorised into the enablers and barriers.
The Patients’ Experiences
Enablers
Coaching
‘They first demo to me how to use the set and it’s quite intuitive because it’s a one-to-one training, which is good, so at any point in time if I have a question I can always ask la.’ (Interviewee 2, Female, 52 years old)
User guide and video tutorial
‘I was quite relieved because there was an instruction pamphlet that I could follow. When I opened the mobile app, there was actually a portion that I could click for the video.’ (Interviewee 12, Female, 51 years old)
‘…the video basically refreshes everything you’ve done at the clinic during the demonstration’ (Interviewee 7, Male, 58 years old)
Barriers
Prolonged onboarding
‘They didn’t really prep me that the whole learning process was quite long. Actually I remember it take about more than an hour’ (Interviewee 12, Female, 51 years old)
Storage and preparation of the HbA1c testing kit
‘Packaging too big. Bulky.. so my wife was saying you are taking space in my fridge’ (Interviewee 7, Male, 58 years old)
‘Afraid if there’s power outage, afraid this (test kits) will spoil’ (Interviewee 1, Female, 61 years old)
‘That is a bit troublesome ah, I need to wait 1 hour, then during that 1 hour probably you are doing some stuff then after that you forgot about it. Yeah, so I don’t know whether it will affect the reading after you actually left it to thaw for more than an hour. (Interviewee 3, Female, 44 years old)
Remote Monitoring of T2DM - Patient Perception
Enablers
The patients accepted that the low-risk T2DM is a suitable medical condition for home HbA1c testing and telemonitoring through PTEC HAT programme. Patients also shared that there is potential in empowering patients for self-monitoring.
‘I believe if someone who doesn’t prick and test the blood sugar, it will be revelational for them. You can actually test and see your sugar level yourself. And then for someone who doesn’t do it they can also build their confidence that actually they should consider doing a regular (HbA1c) test.’ (Interviewee 2, Female, 52 years old)
During the COVID-19 pandemic, PTEC HAT was advantageous in ensuring continued diabetes care.
‘PTEC HAT is really good in a situation now, because of the COVID, yeah, so if the clinic gets overcrowded, the chances of people getting infected from one another is higher, so this place is an added advantage.’ (Interviewee 9, Female, 60 years old)
Barriers
Many patients expressed that the interval between onboarding and performing the home HbA1c test was lengthy. The HbA1c test, unlike the routine home blood glucose test, was typically performed at three to six monthly intervals to assess diabetes control. This made testing a challenge as the steps for home HbA1c testing becomes less familiar to patients a few months after enrolment.
‘We can understand very well at that point of time. But... there is a lapse of time. When we do the actual one 6 months later...I can confirm that we will not do it well.’ (Interviewee 8, Male, 63 years old)
Technology Component of PTEC HAT - Patient Perception
Overall, the patients valued the technology that comes with the mobile app. They found the in-app chatbot reminder particularly useful when preparing for the home HbA1c testing. However, there were differing views about the home HbA1c testing process and the subsequent teleconsultation. Many patients spoke negatively about the data transmission via the Bluetooth device provided in the package.
Enablers
Patients found the in-app chatbot very helpful in reminding them to perform the home HbA1c testing on the prearranged date. In addition, patients expressed that the instructions sent out by in-app chatbot provided assurance for them to complete the home testing correctly.
‘ I think the reminder is good because uh for people who are busy like me…it helps to remind me on that day I am supposed to do this test I have to make sure I keep my time for the appointment.’ (Interviewee 9, Female, 60 years old)
‘… (the in-app chatbot) reminds you that on this day you need to do the test, remember to take out and thaw 1 hour before using it. So it is a good reminder… (It is) also an add-on to tell me that I'm doing the right thing correctly…’ (Interviewee 4, Female, 45)
Barriers
Home HbA1c result transmission with Bluetooth device
The Bluetooth device synchronises the HbA1c result from home test kit to the mobile app, thereby minimising transcribing errors by the patients. The Bluetooth device functions by pressing on the unit to turn on and subsequently two distinctive tones are played to indicate that the device is ready to be used and after it has been successfully paired with a smartphone. However, there are no visual cues.
A large majority of the patients in this qualitative study encountered failure when using the Bluetooth device to synchronise home HBA1c reading from the home testing to mobile app, which resulted in negative experience and dropped in confidence.
‘The part of transmitting result is confusing… I don’t know what does the tone sound like, so the first transmission didn’t get through. It’s a negative feeling because I’ve already pricked my finger and have the HbA1c reading, then the transmission is kind of failed… The confidence level is affected… result in certain level of stress.’ (Interviewee 2, Female, 52 years old)
‘… the final procedure is to send the data over, but since you cannot send the data over, then what you have done in front is all wasted’ (Interviewee 8, Male, 63 years old)
Value Proposition of PTEC HAT
Patients valued the convenience of performing the HbA1c testing at home but the perceived value depended on their employment status.
Enablers
The instant result generated by home HbA1c testing was rewarding. It increased the self-efficacy of the participants in improving diabetes control.
‘I will also like to see results immediately, I don’t have to wait for doctor to tell me or whoever to tell me after waiting for another 45 minutes at the clinic’ (Interviewee 7, Male, 58 years old)
PTEC HAT pilot programme was found to be convenient and time-saving as it was able to reduce the number of visits to the polyclinic.
‘...I will take leave to go for medical appointment and I think it is very troublesome. So if let’s say all these could be done at home, I think it will be very useful not only for COVID but actually for ...scheduling of my work...that is why I actually thought it is very good.’ (Interviewee 6, Male, 52 years old)
‘…I think this teleconsultation...is fine...is really saving time going down to see a doctor.’ (Interviewee 3, Female, 44 years old)
The flexible test date or time had additional value in ensuring adherence to perform home HbA1c testing among the patients.
‘...that’s why I prefer to continue this, Because I can... decide when I can do it: this morning, or maybe this evening or tomorrow morning’ (Interviewee 6, Male, 52 years old)
Patients felt at ease having the teleconsultation as the healthcare team who contacted the patient was well-informed of their medical condition.
‘So the standard (of teleconsultation), I'll say is maintained…Experience is the same (as physical consultation).’ (Interviewee 2, Female, 52 years old)
‘She seems to know what is happening, so I feel comfortable. Not only like now we are quite used to remote (consultation), but she (also) knows what she is talking about’ (Interviewee 6, Male, 52 years old)
Barriers
The perceived time saved from the programme was diminished for patients with other medical conditions, which also required other tests in the clinic.
‘It doesn’t take away my time or it doesn’t save me a lot of time just because I am doing this at home.’ (Interviewee 7, Male, 58 years old)
Some patients found the home HbA1c testing complex and were concerned if the programme became a chargeable service in the future.
'I think these items are expensive...It is not like that the (glucometer) strip where you test and you don't have a proper reading you can just throw away the strip and just do another prick test…because of the number of steps it requires, every step is important otherwise there is failure of the data (generation and/or transmission). So if the patient is paying for these then it’s also the concern of the patient to do it right the first time. Right?’ (Interviewee 7, Male, 58 years old)
Additionally, the perceived value of PTEC HAT was dependant on the potential cost of the programme.
‘I'm hoping that maybe it (PTEC HAT) will be a bit cheaper than the actual lab test because…if the prices are the same, or if this one is a bit higher than the lab test, then they might as well go to the lab test, because people (phlebotomist) will do it for them.’ (Interviewee 12, Female, 51 years old)
A patient did not think the teleconsultation was helpful but instead, saw it as a standard operating procedure (SOP) and viewed the teleconsultation to be inadequate compared to a physical consult. However, the patient was not aware of the difference between the readings obtained from SBGM and A1CNow + kit as well as the requirement to consult healthcare team in clinic polyclinic visit with every routine HbA1c testing. This could have resulted in the lower perceived value of teleconsultation.
‘…this telecommunication, teleconversation, probably is just the SOP, I think that this does not help much’ (Interviewee 8, Male, 63 years old)
‘Anyone who has medical issue will still want to seek professional advice, attention, you’ll still want to see a doctor probably, face-to-face...that is where you have more peace of mind’ (Interviewee 3, Female, 44 years old)
Patient Factors in Adopting PTEC HAT
The successful PTEC HAT participation provided a snapshot of the potential take-up rate if it was to become an official programme.
Enablers
It was found that a reasonable level of digital literacy, prior experience with blood pressure and glucometer monitoring, absence of needle phobia, and strong intrinsic motivation for self-monitoring were identified as the main factors attributing to successful PTEC HAT participation.
Digital literacy
‘I'm a smartphone user so l'm able to understand... what to do, so it's after I download right…they ask me to key in some administrative stuff, and everything is I done it on the spot’ (Interviewee 4, Female, 45)
The absence of needle phobia
‘I actually have no issue pricking my fingers because first of all, I've been using the glucometer myself at home as well also, so that requires a lot of pricking. ...when they told me oh, you still need to actually prick your fingers, I said it's not a problem.’ (Interviewee 3, Female, 44 years old)
Intrinsic motivation and prior experience with health monitoring
‘I came to a point where I'm really concerned about my wellbeing… That I might have hypertension, so I thought this is a good way for me, checking on myself…that's why I signed up for it...there is a big correlation because people who are interested in their results then they will buy the glucometer and prick.’ (Interviewee 11, Male, 62 years old)
Barriers
Conversely, patients with lower level of digital literacy, needle phobia and low level of self-motivation would have a lower likelihood of overcoming challenges when interacting with the multiple components of PTEC HAT.
The inadequate level of digital literacy
‘....my wife (is) bad with technology...my sister-in-law was in my house and I purposely take out these kits, ask her for help...she is more educated on technology and yet we follow all the SOP, (we) cannot get through’ (Interviewee 8, Male, 63 years old)
Needle phobia
‘I'm scared of needles already. I don’t want to prick myself again’ (when the participant failed to transmit the result via Bluetooth)’ (Interviewee 12, Female, 51 years old)
Lack of self-motivation
‘I don’t have much feelings about it, it’s just that I didn’t know how to at the start and then I thought I didn’t want to use it anymore’ (Interviewee 5, Female, 54 years old)