Existing interventions for people with diabetes generally involve group or individual counseling for self-management education and support [1-3]. The use of technology to collect data through the internet to manage disease is increasing; many such studies focus on diabetes, including monitoring glucose or vital signs through mobile apps or websites, messaging reminders through email or SMS text messaging for self-care skills, and improving emotional status [4-8]. In recent years, mobile phones have become an increasingly important platform for the delivery of health interventions; they can be used to help individuals manage their health and disease condition [9-13]. Web-based structured integrated care has been employed by several research teams to provide information for diabetes education, record blood glucose readings, and provide personal feedback [14-16]. Many mobile apps have been developed for diabetes care. Better outcomes were observed for mobile apps that provided 2-way communication between people with diabetes and their health care team [17,18]. However, most of these interventions require the development of a structured website or a diabetes-specific mobile app; these are not translated into many languages, which limits their universal use [19].

Currently, 53% of adults age 65 and older use the Internet in Taiwan [20], and one third of older persons who are online use social networking sites such as Facebook, LinkedIn, and LINE, which were listed as age-friendly apps in 2012 [21]. Some traditional technologies (eg, telephones, video game consoles) have been utilized to conduct health-related interventions. New technologies such as exoskeleton human body posturizers [22], the Nintendo Wii console [23], and virtual reality gaming [24] have also been investigated to assist older people in improving their balance and have been shown to decrease both the fear of falling and the number of falls. For diabetes control apps in Taiwan, the National Health Insurance program developed an internet platform called My Health Bank. My Health Bank provides patients’ medical records over the past 3 years; patients can use it to record their own health data, such as BMI and blood test results, including fasting plasma glucose, hemoglobin A1_c (HbA_1c), and lipid profiles. Physicians can quickly understand their patients’ physical condition, treatment status, and medical examinations through this app [25]. Moreover, many studies have explored the use of new technologies such as websites or mobile apps to help with disease or health management, such as smoking cessation [26,27], medication management [28], and prevention of excessive gestational weight gain and associated maternal and child health consequences [29]. However, few existing studies have focused on the effects of existing, freely available communication apps (eg, Facebook Messenger, LINE, WhatsApp Messenger) among middle-aged and older adults; therefore, the effectiveness of social networking interventions to address the health issues of middle-aged and older adults is not certain. One of the most age-friendly and easy-to-use social network applications is known as LINE; it does not restrict the learning pace, time, or space of learners, and users also benefit from the interaction in this mobile app [30]. In addition, information about diabetes self-management can be easily transmitted through text messages, photographs, and short videos to enable people to use this information in daily life. LINE is one of the most popular apps for social communication in Taiwan [31]. However, whether this tool can be employed in self-management education and support to help older adults manage their diabetes is unknown.

According to the American Association of Diabetes Educators (AADE), 7 behavioral indicators [4] are critical to enhancing the self-care abilities of people with diabetes and to helping them reach their optimal goal of glycemic control through education and various support resources. These indicators, called the AADE7 Self-Care Behaviors, are (1) healthy eating, (2) being active, (3) monitoring, (4) taking medication, (5) problem solving, (6) reducing risks, and (7) healthy coping. The results of one study indicated that most diabetes apps do not adhere to more than 2 AADE7 self-care behavior guidelines [32]. Therefore, the aims of this study were to test 3 intervention modes that were developed based on the AADE7 self-care behavior guidelines, including mobile-based, telephone-based, and usual care interventions. We compared the impact of the mobile-based, telephone-based, and usual care interventions on diabetes-related distress, depressive symptoms, and glycemic control in middle-aged and older adults living in the community. We also compared the degrees of acceptance within the 3 groups to determine which subgroup experienced the most effects.

This study was a 3-arm quasiexperimental design. We recruited participants aged ≥50 years with type 2 diabetes through a medical chart review. Exclusion criteria were people with renal dysfunction (creatinine ≥1.5 milligrams per deciliter) or who were receiving dialysis treatment. People who were diagnosed with dementia, cognitive impairment, or major depression were also excluded. We recruited our participants from the endocrine and family medicine clinics of a medical center in Southern Taiwan. Informed consent was obtained at the Ministry of Science and Technology, and the study was approved by the National Cheng Kung University Hospital Institutional Review Board (No. A-ER-102-425).

In the mobile-based group, participants were required to own a mobile device and to be capable of using the mobile device (n=49). Participants who did not have a mobile device and access to the internet at home were randomized to either the telephone-based interview group (n=91) or the usual care group (n=91).

Each group was provided with diabetes-related self-care information and provided with emotional support through usual care. In the mobile-based intervention group, in addition to the participants’ usual care, we used a communication app called LINE to send multimedia messages about diabetes self-management for 12 weeks. LINE is a free instant communication service. In Taiwan, over 90% of people install LINE on their mobile devices [33]. LINE users can set up their own accounts using their telephone number or email address and can link with friends by telephone number or LINE ID. When the participants were ready to join our study, we checked their telephone number or LINE ID and linked it to our research account, and a welcome message was sent to the individual accounts of the participants. The research team verified whether the messages we sent to each individual account were marked as “read.” The participants were also able to interact with our research team by LINE. Messages were sent 3 times a week, and the participants received an average of 5 messages per week. Structural diabetes health education modules were developed according to AADE7 guidelines. We included 6 of the behavioral indicators in our messages: healthy eating (eg, how to select appropriate food and observe amounts of sweeteners); being active (eg, suitable ways to exercise and precautions related to exercise); monitoring (eg, the standard glucose values before and after a meal); taking medication (eg, what to do if they forgot to take their medicine); (5) problem solving (eg, how to relax and search for health information); and (6) reducing risk (eg, foot care skills). The topics of the weekly messages are shown in Textbox 1 and sample messages are shown in Multimedia Appendix 1.

In the telephone-based intervention group, the participants received 3-4 phone calls lasting 30-60 minutes each from a diabetes health educator. The first call explored the participant’s diet, sleep habits, exercise level, and blood glucose control as well as their general and diabetes-specific health conditions. The people with diabetes were asked to talk about their feelings and lifestyle changes after they were diagnosed with diabetes. The goal was to understand their daily routines, thoughts, worries, related feelings, and behavior. According to the baseline assessment, in the second and subsequent phone calls, the assistants asked the participants to discuss self-care problems related to diabetes and their feelings about the disease in addition to the AADE7 modules. The usual care group received a routine intervention for people with diabetes in hospital, where the participants received 5-10 minutes of usual care (including a nutrition consultation, exercise guidance, medication, and other self-care skills related to diabetes) once every 3 months by family medicine physicians in family medicine outpatient departments and by certified diabetes educators at diabetic health education clinics.

We collected data on the health conditions of the patients, such as the year they were diagnosed with diabetes, body weight, height, anti-diabetic therapy, and recent HbA_1c levels through a medical chart review. We reviewed the medical record data related to complications such as diabetic foot, hypertension, and stroke. We also collected self-reported data about sociodemographic characteristics, health behavior, and psychological well-being. Sociodemographic factors included age, sex, education, ethnicity, and marital status. The educational levels were divided into 6th grade and below, grades 7-12, and grades 13 and above. The options in the ethnicity category were Taiwanese, mainlander, Hakka, and aborigine. The possible answers to the question on marital status were widowed, married and living with spouse, and other (divorced, separated, or unmarried). The health behavior variables included the frequency and time of exercise, dietary habits, tobacco use, alcohol use, and the amount of alcohol consumed. These data were collected at baseline and after the intervention.

Diabetes-specific emotional distress was measured using the Problem Areas in Diabetes (PAID) scale. It contains 20 questions; each question describes a problem that a person with diabetes may have. The PAID scale uses a 5-point item scale: 1=Not a problem, 2=Minor problem, 3=Moderate problem, 4=Somewhat serious problem, and 5=Serious problem. A higher PAID score indicates greater emotional distress related to diabetes. The total scale of PAID is 0-100, and the commonly used cutoff score of ≥40 was used to indicate elevated levels of diabetes-specific emotional distress [34].

Depressive symptoms were measured with the Center for Epidemiological Studies Depression Scale (CES-D), which is a self-reported questionnaire. The CES-D contains 20 questions. It has been found to have good validity and reliability for different races and ages [35]. In the pretest, we used the brief CES-D. The brief CES-D contains 10 questions on a 4-point scale to classify the depression status of older persons in the most recent week, with possible answers of “not at all,” “usually,” and “always.” The short-form CES-D scale ranges from 0-30, with a higher CES-D score indicating a higher level of depression. The cutoff scores for depressive symptoms were ≥16 for the full-length questionnaire and ≥10 for the 10-item version for older adults [36,37].