Published on in Vol 11 (2023)

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Authors’ Reply: Methodological Considerations for a Diabetes Family-Based eHealth Intervention

Authors’ Reply: Methodological Considerations for a Diabetes Family-Based eHealth Intervention

Authors’ Reply: Methodological Considerations for a Diabetes Family-Based eHealth Intervention

Authors of this article:

Yuheng Feng1 Author Orcid Image ;   Xiaohong Li1 Author Orcid Image

Letter to the Editor

Department of Health Policy and Management, School of Public Health, Fudan University, Shanghai, China

Corresponding Author:

Xiaohong Li, PhD

Department of Health Policy and Management

School of Public Health

Fudan University

PO Box 177, 130 Dong’ an Road



Phone: 86 13918213586


We greatly appreciate the authors’ interest and comments [1] on our eHealth family-based intervention program [2]. We hope that our responses are beneficial to the article’s readership.

It is a common phenomenon that patients with type 2 diabetes mellitus (T2DM) have poor glucose control [3]. Clinical inertia, including physician related, health care system related, and patient related, is the main reason [4]. Our study developed an eHealth family-based intervention program, which decreased patient-related inertia. We interviewed endocrinologists and community physicians and found that physician and health care inertia existed. Some patients with T2DM with very poor glucose control failed to visit tertiary or secondary hospitals to adjust their medication.

Changes in self-care activities were not substantial. There are two possible reasons. First, most patients with a long disease course had baseline self-care activities that were better than patients with a short disease course. So it was difficult to substantially enhance self-care activities. Second, the intervention intensity was not very high because we aimed to develop a generalizable labor-saving intervention model. Although differences were not substantial, it indicates that the eHealth family-based intervention program is effective.

The general diet and blood sugar test had the most significant effect on changes in hemoglobin A1c (HbA1c). During the intervention implementation, family members mainly concentrated on how to help patients with T2DM maintain a healthy diet. Regarding glucose self-monitoring, family members can help them test regularly for the glucose status and prompt them to follow the physician’s suggestion.

According to the National Standard for Basic Public Health Services, community physicians need to follow up with patients registered in the community system once every 3 months. Our patients were recruited from this system. The frequency of doctor visits in the control group was the same as in the intervention group.

Due to workforce deficiencies in community health centers caused by the COVID-19 outbreak, we did not adjust oral medication or insulin. However, treatment changes should be monitored carefully. More detailed information could better explain how the intervention influenced the patients’ glucose control.

We considered baseline HbA1c levels as a covariable. The covariance analysis indicated that patients with T2DM with worse baseline HbA1c levels get better intervention effectiveness, similar to Brož et al’s [5] study, which indicates that priorities should be given to patients with T2DM and poorer glucose control.

To reduce the physician-based and health care–based inertia, measures targeted toward the health care system and physicians should be implemented. Future studies could be focused on physician-based and health care–based factors. More attention could be paid to the mechanism of improving the referral system and community physicians’ skills based on the medical alliance modes [6]. The feedback mechanism of two-way referral also should be improved, which will help the community physicians know whether patients with T2DM follow suggestions and provide targeted health education to those who do not follow suggestions.

Conflicts of Interest

None declared.

  1. Brož Y, Campbell MD, Krollová P, Michalec J. Comment: methodological considerations for a diabetes family-based eHealth intervention. JMIR Mhealth Uhealth. 2023;11:e48652. [FREE Full text] [CrossRef]
  2. Feng Y, Zhao Y, Mao L, Gu M, Yuan H, Lu J, et al. The effectiveness of an eHealth family-based intervention program in patients with uncontrolled type 2 diabetes mellitus (T2DM) in the community via WeChat: randomized controlled trial. JMIR Mhealth Uhealth. Mar 20, 2023;11:e40420. [FREE Full text] [CrossRef] [Medline]
  3. Brož J, Janíčková Žďárská D, Urbanová J, Brabec M, Doničová V, Štěpánová R, et al. Current level of glycemic control and clinical inertia in subjects using insulin for the treatment of type 1 and type 2 diabetes in the Czech Republic and the Slovak Republic: results of a multinational, multicenter, observational survey (DIAINFORM). Diabetes Ther. Oct 2018;9(5):1897-1906. [FREE Full text] [CrossRef] [Medline]
  4. Reach G, Pechtner V, Gentilella R, Corcos A, Ceriello A. Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus. Diabetes Metab. Dec 2017;43(6):501-511. [FREE Full text] [CrossRef] [Medline]
  5. Brož J, Janíčková Ždárská D, Štěpánová R, Kvapil M. Addition of basal insulin to oral antidiabetic agents in patients with inadequately controlled type 2 diabetes leads to improved HbA1c levels: metabolic control, frequency of hypoglycemia, and insulin titration analysis as results of a prospective observational study (BALI Study). Diabetes Ther. Apr 2019;10(2):663-672. [FREE Full text] [CrossRef] [Medline]
  6. Cai Y, Wen C, Tang L, Liu P, Xu Y, Hu S, et al. Exploration and consideration of the medical alliance modes. Iran J Public Health. Aug 2018;47(8):1160-1165. [FREE Full text] [Medline]

HbA1c: hemoglobin A1c
T2DM: type 2 diabetes mellitus

Edited by T Leung; This is a non–peer-reviewed article. submitted 25.08.23; accepted 30.08.23; published 18.09.23.


©Yuheng Feng, Xiaohong Li. Originally published in JMIR mHealth and uHealth (, 18.09.2023.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.