Synthesized findings of effect of HITs on HbA1c and cardiovascular risk factors among diabetes patients.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
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In particular, the aim of providing this content, among others, is to provide skills in the form of basic skills related to the freedom of graduates to be able to work independently. It is suggested that students will be able to apply entrepreneurship theory to work experience in this learning process. Besides, the expected education imposes further emphasis on the mastery of certain fields of work which are essentially carried out in academic units. Its essence, entrepreneurship education in its vocational schools has been carried out by “development units” in various fields of study/expertise programs. Even so, the viability of real entrepreneurship research in vocational schools also varies greatly in terms of success. The number of entrepreneurs in a country could be seen as a reflection about whether or not a country is developing, since by getting more entrepreneurs in that country entirely, there would be many independent businesses in the form of large corporate entities and small and medium-sized businesses. This would have an impact on the increase and wide opening of the number of jobs, which in turn raises the level of the country’s economy. It has not happened in our beloved country of Indonesia. Indonesia’s mental entrepreneurship is still weak. That is demonstrated by a limited number of entrepreneurs with independent companies. There are still a lot of people who are still uncertain about getting a job every year. Government Regulation No 29 of 1990, Article 3(2), in the context of the vocational schools’ goals, must therefore include:
Join the job market and be able to cultivate a professional mindset within the framework of company and management skills.
Able to include career, be able to compete, and be able to establish within the scope of business and management.
Become a middle-level workforce to meet the present and future needs of the corporate sector and industry in terms of market share and management.
Be active, resilient, and innovative people.
As a result, vocational school graduates are actively trained to reach the field of employment either by career ladders to become middle-level employees or to become single, self-employed, or entrepreneurial. First, this paper will outline the goals and growth of Indonesia’s Vocational High School, relevant government policies. Secondly, the implementation of entrepreneurship education through apprenticeship programs, the implementation of apprenticeship programs, and assessment.
The level of education is the stage of education defined based on the level of student progress, the goals to be accomplished and the skills to be developed. Formal education in Indonesia covers primary education, secondary and higher education. Each level has a specific age range and period of education. Indonesia has completed 12 years of compulsory education. Twenty years of compulsory education must, therefore, be the standard of primary education consisting of 6 years of primary school or equivalent and 3 years of junior high school or equivalent. For now, though, the upper secondary school is taken up to 3 years and is generally conducted up to 4 years for higher education (S1) (Figure 1).
Formal education level in Indonesia (source: [
Primary education is the basic curriculum to be pursued during the first nine years of school and consists of a six-year primary school education system and a three-year junior secondary school educational program. Primary education takes the form of elementary school (SD) and junior high school (SMP). Primary education is the beginning of children’s education, as it teaches children to read properly, develop their math and reasoning skills. Primary literacy aims to lay the foundations for intelligence, knowledge, maturity, good character, and capacity to live independently and pursue further education. To attempt to achieve primary education goals, a teacher’s position to the learning process is required to ensure that students have consistency between cognitive, emotional, and psychomotor skills.
Secondary education is an extension of primary education. This form of secondary education is a secondary school (SMA), madrasah aliyah (MA), vocational school (SMK), and vocational madrasah aliyah (MAK) or other similar types. The general aim of secondary education is to improve comprehension, knowledge, personality, moral strength, and the ability to live independently and engage in further education. While the general aim of vocational secondary education is to improve intellect, knowledge, personality, moral strength, and ability to live independently and pursue further education in compliance with their vocational training.
Higher education is an extension of secondary school education. Higher education is no longer carried in schools but universities. Including a variety of diplomas, bachelor, master, doctoral and specialized programs organized by universities. Higher education institutions are required to provide education, research, and community services. At this level, students are required to be more active in practicing/directly involved in each learning activity, because the ultimate goal of this level of education is that students are expected to be human beings who are useful to others. Higher education institutions may organize academic, vocational programs.
Entrepreneurship is ultimately a creative and imaginative way of thinking that is used as a framework, tools, and driving force, goals and strategies, and tips to deal with the challenges of life. According to Agus Wibowo’s statement, entrepreneurship is the ability to merge existing expertise, innovation, and opportunities. Entrepreneurs are people who know how to take risks, are imaginative, inventive, never give up, and are willing to cope with opportunities properly [2]. Entrepreneurship is a mindset, a spirit, and a capacity to build something new that is very important and useful, both for oneself and for others [2, 3]. Entrepreneurship is a mental attitude and a soul that is often active or productive, motivated, innovative, creative, humble, and seeks to increase income for its company. While entrepreneurs are people who are willing to take advantage of opportunities to grow their businesses, intending to improve their lives.
Entrepreneurship is a creative and imaginative ability that is used as a framework, tips, and tools to find growth opportunities [4]. Creative and creative processes typically begin with the creation of ideas and concepts to create something new and special. Creativity is the ability to develop new ideas and ways of solving problems and finding opportunities (thinking new things). Innovation is the desire to apply ingenuity to solve problems and discover ways (to do new things). Emigawaty added that the cycle of entrepreneurship is beginning with challenges [4]. Ideas, motivation, and ability to take the initiative, which is nothing but fresh thinking and constructive action, should arise from the challenges.
Vocational education is education that incorporates, matches, and teaches people to have working habits to be able to join and expand the world of work (industry) so that they can be used to better their lives. National Education System Law (UUSPN) No. 20 of 2003 Article 15 states that vocational education is secondary education which prepares students, in particular, to work in certain fields [1]. Vocational education is associated with grooming an individual for employment and enhancing the development of a future workforce. This involves different forms of schooling, training, or further development to prepare someone to join or continue working in a legal role. Vocational education is certainly part of the national education program, which intends to train workers who have skills and expertise following the requirements of job requirements and who are able to strengthen their capacity by embracing and adapting to technological developments.
Vocational education is part of the national education program, structured as a continuation of the Junior Secondary School and Madrasah Tsanawiyah:
In line with the skills, interests, and abilities to meet the needs/job opportunities that are and will be created in the community.
Vocational school graduates are trained, educated, and trained workers.
Able to engage in further education and/or respond to technological changes.
Impact as a promoter of (small or large) industrial development.
Significant decrease in unemployment and crime rates.
Economic growth and national income by income tax and value-added.
UUSPN No. 20 of 2003 Article 15 states that vocational education aims, in particular, to prepare students to work in plenty of other fields. This goal can be further transferred as follows by [1] into general objectives and precise objectives:
General Aims
As part of the vocational education system, the goals of Vocational Schools are:
Preparing students to succeed in a decent life.
Improve the students’ faith and modesty;
Preparing students to become independent and accountable individuals;
Prepare students to appreciate and acknowledge the rich cultural heritage of the people of Indonesia, and
Prepare students for a healthy lifestyle, environmental insight, knowledge, and art.
Specific Aims
Vocational schools are especially purposeful:
Prepare students to be able to work independently or to fill established positions in the business community and industry as middle-level employees, in keeping with the fields and knowledge system of their preference;
Equip students to be able to choose professions, to be versatile and to remain competitive and to be able to construct professional attitudes in areas of expertise or interest, and
Equip students with science and technology to be able to enhance themselves through higher education.
In contrast, according to the Directorate of Secondary and Vocational Education (Dikmenjur) in 2006, the SMK learning system adheres to the concept of full learning (Mastery Learning) in addition to being able to master behaviors, information, and skills to be able to function following their career. As required by competence. In addition to being able to research extensively, it is necessary to develop the overall evaluation principles:
Learning by doing (learning by actual activities or activities that provide meaningful learning experiences) is transformed into production-based learning.
Objectives of Vocational Education and Entrepreneurship Education Implications Government Regulation No 19 of 2005 on National Education Standards (SNP) Section 25 paragraph 4 implicitly notes that graduates (SMKs) are required to meet graduate-level competency requirements representing the ability of graduates to act, know-how and skills. Therefore, the learning process in educational units is carried out in an active, interactive, creative, challenging, fun, and independent manner according to self-potential, physical development, talents, and interests, as well as students’ psychology. Individualized learning (learning with emphasis on the uniqueness of each individual) with a modular program. Empirical statistics show that most vocational school graduates are not yet following customer expectations or requirements of stakeholders.
Graduates tend to be “job hunters” and not many are able to work “independently” to incorporate and improve their skills (survival skills). On the other hand, the work ethic of vocational school graduates is still weak in terms of entrepreneurial thought. In accordance with Law No. 20 of 2003 on the National Education System, secondary education consists of general secondary education and vocational secondary education (Article 18, paragraph 2). Senior High School is a general education unit, while Specialized School is a specialized secondary education unit. The objective of the introduction of high school is to provide academic competence for students to pursue their higher education, while at the same time, vocational schools emphasize more on preparing students to be ready to work under certain fields. The introduction of the SMK also offers incentives for students who have the qualifications and skills to pursue professional, professional, and academic education (dual purpose).
The terms of vocational education and technology are currently being established, there are a stigma and a tendency to define vocational education and technology as an institution that seeks to prepare the workforce in accordance with the interests of students. However, there are quite many limitations related to vocational education and technology in its advancement, namely, among other things, the differing viewpoints of professionals, such as the following.
In the 1920s, Barlow [5] stated that vocational education was a means for someone to prepare and prepare for the services we need. These restrictions are very specific since the word “services” has very different definitions. Struck [5] provides another perspective on vocational education and technology, which leads to the provision of experience to students to be able to carry out work in the field. It seems that this restriction is still very common, as it does not specifically reflect the form and quality of education, both within and outside the classroom.
One form of technical and technological education, namely vocational high school technology. The educational goal is to produce students who comply with the intermediate level work requirements as interpreters or technicians in compliance with other forms of vocational training. Therefore, the management of the learning cycle is more oriented towards the incorporation of vocational skills theory and practice, which refers to the intermediate level of work requirements required by the industrial environment. The presence of an imbalance between what is created by educational institutions and the needs of the labor market is a serious concern of the Directorate for Vocational High School Growth. This seriousness is expressed in the 100-day flagship program of the “Indonesia Bersatu” Cabinet Volume II. Processes, strategies, and action plans should be developed to resolve this mismatch in the 100-day program, in particular the education program.
In order to improve the quality of vocational school graduates, the Ministry of Education and Culture will increase industrial simulations for each vocational school. The purpose of the industrial simulation is to provide vocational students with knowledge of the working culture, the real conditions in the industry, and the mastery of technology. The creation of a cooperation model will also be carried out as a policy action plan. The relationship will be formed between vocational school, vocational higher education, and skills training with the industrial environment, including the creative sector.
This is achieved in order to improve the prospects for intermediation and apprenticeship as well as the suitability of education or training for the world of work [5]. On the other hand, the competitiveness of education can be accomplished through the growth of entrepreneurship, including technology entrepreneurs (IT entrepreneurs) through collaboration between educational institutions and the business world. By the numerous measures outlined above, it is hoped that the connection between education and jobs required by the labor market can be developed and that the unemployment rate will be reduced to the lowest level.
The idea of connection and match has essentially been implemented since the 1994s, when five PSG model schools (Jakarta, Karawang, Semarang, Surabaya, and Medan) were set up, supported by the German Technical Zuzamenarbeit (GTZ). Nevertheless, in its growth, ups and downs are induced, among other things, by the lack of a consistent partnership pattern that can lead to mutually beneficial relationships (mutual benefits). The concept of establishing a mutually beneficial relationship was initially designed to provide tax relief for manufacturing communities that have collaborated intensively with vocational schools and can report on the outcomes. It takes time and a clear political will from the Government in the process of understanding the notion. In addition to applying the principle of linkage and equivalence (link and match), the structuring of study programs or skill programs (re-engineering) is an evolution of existing fields and skill programs in all vocational schools (public and private) to meet the geographic capacity and the requirements of the job market.
The outcomes of the re-engineering structuring would benefit: (1) vocational school, because the field of expertise program designed is in line with the needs of the future of employment; (2) prospective students and parents, so they can select a field of expertise program that facilitates integration in the future of employment; (3) business and industry, as it makes it easier to find employees who suit them. The structuring of the vocational education framework approach would eventually lead to the introduction of a CBT (Curriculum Based Training) that complies with the concepts of a competency-oriented curriculum that is now being developed into a unit level curriculum (KTSP). Competence-based education and training offer, ultimately, individual learning programs.
The introduction of vocational schools will, therefore, be successful and productive where: (1) provision of appropriate teaching materials/modules in terms of number, form, and quality; (2) provision of sufficient learning time in accordance with each student’s learning pace and ability; (3) provision of learning facilities that allow classical learning in schools and industrial practices outside of school.
There are educational courses in entrepreneurship in technical schools that students will take. Entrepreneurship training courses are conducted in Class X to Class XII. The competencies offered are different for each class. Class X competencies include: (1) recognizing entrepreneurial attitudes and behaviors; (2) adopting attitudes and job habits (always trying to move forward); (3) formulating problem solutions; (4) cultivating entrepreneurial spirit; (5) creating loyalty to oneself and others; (6) taking business risks; (7) making decisions. Whereas in the same semester the competencies given include: (1) displaying an unyielding and resilient attitude; (2) handling conflicts; (3) developing a business vision and task.
For reality, entrepreneurship training courses are structured into adaptive training courses. Adaptive education and subject training is a training and subject training community that acts to educate students as individuals so that they have a broad and strong knowledge base to adopt or adapt to changes in the social climate, the economic environment and to be able to learn based on the advancement of science, technology, and art. Adaptive programs provide training courses that emphasize majorly on offering opportunities for students to learn and master the fundamental concepts and principles of science and technology that can be applied to daily life or underpin work skills. Adaptive approaches ensure that students not only understand and learn “what” and “how” a job is done, but also provide comprehension and mastery of “why” a job needs to be done.
Vocational School is one of the national education systems which strives to equip students with skills or expertise through the Dual System Education (PSG) program or whatever is often referred to as an internship. Vocational schools are introducing Technical and Vocational Education Training (TVET) in Indonesia. According to Putu Sudira [6], TVET also brings schools closer to the business environment and the industrial sector. PSG aims to sync the business community and the field of education. Vocational school in legislation No. 20 of 2003 on the National Education Framework Article 18, paragraphs 2 and 3. Vocational in secondary school is organizes vocational education that gives legitimacy to student preparation to join the workforce and establishes professional attitudes (Article 1 paragraph 2 of the Decree of the Minister of Education and Culture of the Republic of Indonesia No 323/U/1997 on the introduction of the Dual System of Education at vocational school.
Vocational schools seek to develop students’ knowledge and skills in such a way that they are ready and willing to work based on their expertise in their respective fields following graduation from secondary education. The competence of vocational school graduates will be expressed in the form of achievement as real or unidentified activities, including (a) both a strong character and a weak character. (b) The development of knowledge mastery, which is characterized by a process of knowledge that is capable of processing information (a process of understanding, know-how, and know-how). (c) Professional development (tool capacity development) characterized by adherence to protocols, punctuality, resistance to fatigue, precision, and thoroughness. (d) The creation of critical thought process skills is characterized by developing new concepts, looking at problems in new ways, and preparing for strategic problem-solving. Based on the outline of the vocational school teaching program (1993: 11A), priority is given to the adoption of the vocational school curriculum: (a) Prepare students to enter the workforce and build professional attitudes. (b) Preparing students to be able to have a career, succeed, and grow to a better standard of living. (c) Preparing a middle-level workforce to meet the present and future needs of the corporate sector and industry. (d) Prepare for graduation so that they are active people who are ready to create, adapt, and be innovative.
The internship is an absolute prerequisite for the introduction of technical education. This is the primary reason for the introduction of internships in most technical education institutions. Training may also provide tangible benefits for vocational education and training programs, such as meeting the criteria of accreditation and attempts to develop the credibility of a school. Recognition of the need to expose students to the world of industry is the biggest motivation for vocational education institutions to coordinate internship programs [7, 8]. In the meantime, for industry, there are many explanations for promoting collaboration through apprenticeship programs, including (a) Public care (b) 2.2. The interpersonal connection between industry and vocational education institutions, for example, business players, is alumni of the school concerned. (c) And get a workforce that suits your needs. According to the rules, the minimum length of the internship is three months, but in certain places, the optimal maturity is six months to one year. In summary, the apprenticeship program will be carried out in the following stages (Figure 2).
Internship adoption batch (source: [
The prerequisites for the completion of the internship [9] include: (a) the department at school must be in keeping with the area of jobs in industrial apprenticeship location. (b) Schools must ensure that the definition of internships to be introduced complies with Regulation. (c) Schools must set industry standards for the location of apprenticeships. Evaluation practices must be seen as part of the growth of all businesses, schools, and students. In particular, internships are also supposed to be a feedback platform. Therefore, evaluations should be carried out regularly, not only at the end of the industrial working cycle, but even once a month, for example. Bon and Eschborn [9] listed a variety of items that were evaluated, including the achievement of the internship participants is consistent with the objectives set for the internship. (a) Creation of technical competence. (b) Creation of non-technical competencies (soft skills and attitudes) focused, in particular, on the goals of competence. (c) Quality according to job requirements and client commitment. (d) Another capacity of the participants. According to Duc in Billet [10], “The contribution of the student is linked to the various ways in which internship guidance can be given or not depending on the context in which they are trained.” In our study of vocational education in the Swiss VET dual program, observations find workplaces where spontaneous types of instruction are much more common than others, or where vocational trainers respond easily and enthusiastically to assist requests. Conversely, we often identified firms where contested modes of instruction were the prevailing pattern of interaction and staff fought for knowledge and became a valid teacher. In particular, the requirements given to students can differ from one background to another [11]. This degree of high contextual variability is an essential challenge for practice-based learning models, as it greatly undermines overall performance. The introduction of the PSG is carried out in phases at SMK, to ensure the quality and efficacy of coaching, as well as allow the process of improving the PSG to take place. In other words, the adoption of this initial stage is a trial that is often accompanied by constant evaluation and review, and, in effect, it is expected that the principle and application of the PSG, which is legitimately solid and in line with the school, will be formulated. The distribution of the adoption of the PSG in schools will be decided by the readiness of the vocational school concerned, in particular, the readiness to develop cooperative ties with industry or companies to become partner institutions.
The internship is part of a vocational curriculum that aims to prepare students’ skills or abilities in a specific field in order to be able to work. Through the apprenticeship training course, students are prepared to face the true world of life, both through the mindset, the job is done, and the actual working environment. It is expected that the graduates of this apprenticeship program will be better qualified mentally and in their abilities to succeed in the real work environment.
Via internships, students are required (1) to experience the working climate in the world of work directly, (2) to acquire work experience, including expertise, skills, work attitudes and character-based values that emerge from industrial culture, (3) to know the real working environment in the world of work, (4) to know the working processes of the business (products, labor, discipline, values of work), (5) contrasting the knowledge and skills acquired at school with the knowledge and skills acquired during the internship in industry, (6) acquiring the most recent knowledge from the internship, (7) applying the principles of attitudes and character, knowledge and skills acquired at the internship, and (8) getting stronger soft skills in terms of motivation, communication, freedom.
The introduction of the internship has similar features to the apprenticeship program as provided for in Regulation No 36 of 2016 of the Minister of Labor of the Republic of Indonesia on the implementation of the Domestic Apprenticeship, which states that the apprenticeship is stipulated as part of the vocational training system that is carried out in an integrated manner between the training. Directly under the direction and supervision of teachers or staff who are more knowledgeable in the manufacturing process of products and/or services within the business, intending to acquire those skills or expertise.
Diabetes is the fastest growing chronic condition worldwide. The prevalence of people with type 2 diabetes (T2D) is growing in each country [1]. Diabetes is also the seventh leading cause of deaths in the world. Around 1.6 million people died due to diabetes in 2016 [1]. Higher blood glucose levels also caused an additional 2.2 million deaths, by increasing the risks of cardiovascular and other complications such as kidney disease, blindness, neuropathy, and limb amputation [2, 3, 4]. Successful glycemic control can prevent and reduce these complications. However, to maintain optimal glycemic control requires ongoing monitoring and treatment, which can be costly and challenging [5]. Advances in health information technologies (HITs) have introduced approaches that support effective and affordable health-care delivery and education. Technologies in mobile, computer, e-mail, and Internet approaches have shown evidence in enhancing chronic disease management including diabetes management, via supporting provider decision-making (through electronic risk assessment, alerts, guidelines, formularies, and prescribing) and facilitating patient self-management (through risk communication, Web portals, telemedicine, e-mailing, and secure messaging) [6, 7, 8]. In this chapter, we summarized the current findings on HITs in managing T2D, especially on glycemic control and CVD risks management. In addition, we discussed limitations in the current research in this area and implications for future research. Further, we presented challenges of applying HITs in T2D management in the real-world context and suggested steps to move forward.
\nHITs include a broad range of technologies, electronic tools, applications, or systems that provide patient care, information, recommendations, or services for promotion of health and health care [9]. The advantages of using HITs in health care have been well documented [10, 11, 12, 13]. They have the potential to empower patients and support a transition from a role in which the patient is the passive recipient of care services to an active role in which the patient is informed, has choices, and is involved in the decision-making process [10]. They are also designed to promote communication and relationships between clinicians and patients and overcome geographical barriers and logistical inconvenience when seeking health-care services [11]. In the realm of chronic disease management, a variety of technologies have shown their positive effects. For examples, electronic health record system provides reminders at the point of care for providers to identify high-priority clinical areas for patients with complex chronic illness [14]; telemonitoring system provides asthma patients with continuous individualized help in the daily routine of asthma self-care [12]; Web-based applications increase knowledge, problem-solving skills, and social support via an interactive system for patients with cancers [13]; mobile technology devices such as personal digital assistants (PDAs) and cellular phones enable additional resources to care and change the location of care; and mobile phone short message service (SMS) were able to remind patients of scheduled visits, deliver test results, and monitor side effects of treatment [15, 16, 17]. The HIT-enabled self-care keeps evolving and attempts to address more challenging health-care issues, such as diabetes management where patients need comprehensive information and ongoing guidance as they work to develop a diverse knowledge and skills.
\nA growing research attention has been given to evaluate HITs’ impact on diabetes management, including the primary management goal, glycemic status, and major complications such as cardiovascular conditions. Previous reviews on this subject suggested that HITs have the potential to improve these disease outcomes [18, 19, 20, 21, 22, 23]. However, effect size is specific to the main outcome; glycated hemoglobin (HbA1c) varied between studies with reported mean difference ranging from −0.20 to −0.57% [19, 20, 21, 22, 23]. Table 1 presented the synthesized findings from the latest systematic reviews. Heitkemper et al. searched randomized control trials (RCTs) that studied the effect of HITs on HbA1c among medically underserved patients [21]. In this meta-analysis of 10 eligible trials, HITs were associated with significant HbA1c reduction at 6 months (pooled standardized difference in mean: −0.36, 95% CI −0.53, −0.19) with diminishing but still significant effect at 12 months (pooled standardized difference in mean: −0.27, 95% CI −0.49, −0.04). The authors also performed analyses by HIT type including computer software without Internet (n = 2), cellular/automated telephone (n = 4), Internet-based (n = 4), and telemedicine/telehealth (n = 3). The Internet-based interventions demonstrated the greatest reduction in HbA1c at both 6 months (pooled standardized difference in mean: −0.50, 95% CI −0.69, −0.32) and 12 months (pooled standardized difference in mean: −0.87, 95% CI −1.58, −0.21). Cellular and automated telephone interventions showed the smallest reduction. In Tao and colleagues’ systematic review on consumer-centered HITs, they identified a significant pooled reduction of −0.31 (95% CI −0.38, −0.23) in HbA1c from 18 RCTs [18]. Similarly, Alharbi et al. also found HITs were associated with a statistically significant reduction in HbA1c levels (mean difference: −0.33%, 95% CI −0.40, −0.26%) [19]. In addition, Alharbi and colleagues found studies focusing on electronic self-management systems demonstrated the greatest reduction in HbA1c (−0.50%), followed by those with electronic medical records (−0.17%), an electronic decision support system (−0.15%), and a diabetes registry (−0.05%) [19]. Faruque et al. identified 11 RCTs with specific focus on effect of telemedicine [20]. Telemedicine refers to the use of telecommunications to deliver health services, expertise, and information on glycemic control [20]. In this study, the authors demonstrated a significant reductions in HbA1c all three follow-up periods (mean difference at ≤3 months: −0.57%, 95% CI −0.74, −0.40%, at 4–12 months: −0.28%, 95% CI −0.37, −0.20%, and at >12 months: −0.26%, 95% CI −0.46, −0.06%). In another meta-analysis that specially focused on telemedicine, Marcolino and colleagues found telemedicine was associated with a statistically significant and clinically relevant decline in HbA1c level compared to control (mean difference = −0.44%, 95% CI −0.61, −0.26%) [22]. Pal et al. examined the effect of computer-based intervention in self-management in adults with T2D. The authors found modest effect associated with the interventions (mean difference: −0.2%, 95% CI −0.4, −0.1%) [24]. Liang et al. assessed the effect of mobile phone intervention on glycemic control in diabetes self-management and found a significant common reduction of HbA1c (mean difference: −0.5%, 95% CI −0.3, −0.7%) among 22 trials over a median follow-up of 6 months [23].
\nAuthor, year | \nObjective and intervention(s) under review | \nInclusion criteria | \nSample | \nHbA1c reduction (absolute difference in means) | \nHbA1c reduction (standardized difference in means and Hedges’ g) | \nCVD risk factor assessment | \nIntervention period | \nHIT subgroup analysis | \nMajor limitations | \n
---|---|---|---|---|---|---|---|---|---|
Yoshida et al., 2018 [33] | \nEvaluating of effect of HITs on T2D glycemic control in general T2D patients, including mobile phone-based HITs, Web-based HITs, short message/text, and other HITs | \nRCTs conducted from 1946 to December 2017 | \n34 RCTs (40 estimation points); 3983 participants with T2D | \n−0.65% (95% CI −0.99, −0.64%) | \nStandard mean difference: −0.57 (95% CI −0.71, −0.43); Hedges’ g: −0.56 (95% CI −0.70, −0.43) | \nA separate analysis focusing on CVD risk factors is upcoming | \n2–12 months | \nMobile phone-based approaches [Hedges’ g = −0.66 (95% CI −0.88, −0.45)]; SMS/text [Hedges’ g = −0.63 (95% CI −1.07, −0.19)]; Web-based [Hedges’ g = −0.48 (95% CI −0.65, −0.30)] | \nDid not provide analysis at different time points | \n
Heitkemper et al., 2017 [21] | \nEvaluating of effect of HIT self-management interventions on glycemic control in medically underserved adults with diabetes, including computer software without Internet, cellular/automated telephone, Internet-based HITs, and telemedicine/telehealth | \nRCTs conducted from 2000 to 2015 | \n10 RCTs; 3257 medically underserved adults with diabetes | \nNot reported | \nStandard mean difference: −0.36, 95% CI −0.53, −0.19 at 6 months and −0.27, 95% CI −0.49, −0.04 at 12 months | \nNo | \nUp to 12 months | \nInternet-based HITs (standard mean difference = −0.50, 95% CI −0.69, −0.32 at 6 months and −0.87, 95% CI −1.58, −0.21 at 12 months); cellular/automated telephone HITs (standard mean difference = −0.26, 95% CI −0.49, −0.03 at 6 months and not significant at 12 months); telehealth (standard mean difference = −0.37, 95% CI −0.68, −0.06 at 6 months and not significant at 12 months) | \nExternal validity issue (only focused on a specific patient group); mixed participants with type 1 and 2 diabetes | \n
Tao et al., 2017 [18] | \nEvacuating of effect of consumer-oriented HITs in diabetes management | \nRCTs conducted up until July 2016 | \n18 RCTs; participants in trials ranged from 14 to 1382 | \nNot reported | \nStandard mean difference: −0.31, 95% CI −0.38, −0.23; glycemic control was significant at intervention duration of 3, 6, 8, 9, 12, 15, 30, and 60 months | \nNo | \nUp to 60 months | \nNot reported | \nLumped all types of HITs into analysis; mixed participants with type 1 and 2 diabetes | \n
Faruque et al., 2017 [20] | \nEvaluating of effect of telemedicine on glycemic control, including broad forms of electronic forms communication. | \nRCTs conducted from 1946 to November 2015 | \n111 RCTs; 23,648 participants with diabetes | \n−0.57% (95% CI −0.74, −0.40%) at ≥3 months; −0.28% (95% −0.37, −0.20%) at 4–12 months; −0.26% (95% −0.46, −0.06%) at >12 months | \nNot reported | \nNo | \n3–68 months | \nThe effect was the greatest in trials where providers used Web portals or text messaging to communicate with patients [mean difference: −0.35% (95% −0.56, −0.14) and −0.28% (95% CI −0.52, −0.14)] at 4–12 months | \nMixed participants with type 1 and 2 diabetes | \n
Alharbi et al., 2016 [19] | \nEvaluating of effect of HITs in glycemic control in T2D patients. HITs included Web-based approaches, telephone-based system, mobile phone-based system, and telemedicine | \nRCTs conducted up until July 2016 | \n32 RCTs; 40,454 participants with T2D | \n−0.33%, (95% CI −0.40, −0.26) | \nNot reported | \nNo | \n3–36 months | \nElectronic self-management systems [mean difference: −0.50% (95% CI −0.67, −0.43%)]; EHR [mean difference: −0.33% (95% CI −0.40, −0.26%)]; electronic decision support system [mean difference: −0.15% (95% CI −0.34, −0.16%)]; diabetes registry [mean difference: −0.05% (95% CI −0.15, −0.19%)] | \nDid not provide analysis at different time points | \n
Pal et al., 2014 [24] | \nEvaluating computer-based interventions in self-management in T2D patients. Intervention delivered via clinics, the Internet, and mobile phone | \nRCTs conducted up until November 2011 | \n16 RCTs; 3578 participants with T2D | \n−0.2% (95% CI −0.4, −0.1%) | \nNot reported | \nYes. Did not find improvement of blood pressure, lipids, or weight due to interventions | \n8 weeks to 12 months | \nMobile phone intervention (mean difference: −0.5%, 95% CI −0.3, −0.7) | \nDid not provide analysis at different time points | \n
Marcolino et al., 2013 [22] | \nEvaluating of effect of telemedicine on diabetes care | \nRCTs conducted up until April 2012 | \n13 RCTs; 4207 participants with diabetes | \n−0.44% (95% CI −0.61, −0.26%) | \nNot reported | \nYes. Only found telemedicine was associated with reduction in LDL (−6.6 mg/dL, 95% CI −8.3, −4.9 mg/dL) | \n6–18 months | \nNot reported | \nMixed participants with type 1 and 2 diabetes; did not provide analysis at different time points | \n
Liang et al., 2010 [23] | \nEvaluating of effect of mobile phone intervention for diabetes on glycemic control | \nRCTs conducted from January 2010 to February 2010 | \n22 trials including 11 RCTs and 11 non-RCTs; 1657 participants with diabetes | \n−0.5% (95% CI −0.3, −0.7%) | \nNot reported | \nNo | \n3–12 months | \nNot reported | \nLumped nonrandomized and randomized trials together into evaluation | \n
Synthesized findings of effect of HITs on HbA1c and cardiovascular risk factors among diabetes patients.
Many of review studies including those mentioned above have shed light on the effect of HITs in glycemic control. However, these studies often included limited number of trials [21], lack of adherence to standard quantitative methods [25], inadequate attention to heterogeneity across studies [26], lumped nonrandomized and randomized trials together into evaluation [19, 23, 25, 27, 28, 29], mixed participants with type 1 or type 2 diabetes into analysis [18, 22, 25, 27, 28, 29], or restricted searching criteria to a particular patient population or a specific type of HIT [27, 30, 31, 32]. To address these limitations and to verify if and how much HITs impact glycemic control, Yoshida and colleagues recently conducted a meta-analysis to examine the most current state of evidence from RCTs concerning the effect of HITs on HbA1c reduction among patients with T2D [33]. From an analysis of 34 eligible studies (40 estimates) identified from multiple databases from January 1946 to December 2017, the study reported that introduction of HITs to standard diabetes treatment resulted in a statistically reduced HbA1c. The absolute mean difference in HbA1c pre- and postintervention between intervention and control group was −0.65% (95% CI −0.99, −0.64%). The pooled reduction (standardized difference in means) of HbA1c was −0.57 (95% CI −0.71, −0.43) (Figure 1). In addition, Yoshida et al. also found the reduction was significant across each of the four types of HIT interventions (i.e., mobile phone-based, Web-based technologies, SMS/text, or others) under review, with mobile phone-based approaches generating the largest effects [pooled reduction was −0.67 (95% CI −0.90, −0.45)] followed by SMS/text [−0.64 (95% CI −1.09, −0.19)], and Web-based [−0.48 (95% CI −0.65, −0.30)] [33].
\nPooled reduction of HbA1c due to HITs. Adopted from the study of Yoshida et al [
HITs also have significant clinical impact in reducing HbA1c among patients with T2D. It is reported that every 1% decrease in HbA1c over a 10-year period is associated with a risk reduction of 21% for diabetes-related death and 37% of microvascular complications [34]. This reduction results from HIT interventions may be bigger than effects of many targeted pharmacological therapies. Oral antidiabetic agents reduced HbA1c levels of 0.5–1.25%, with thiazolidinedione and sulfonylureas showing the best reduction (1–1.25%) [35]. Biguanide reduced HbA1c by 1.0–2.0%; dipeptidyl peptidase 4 (DPP-IV) inhibitor, 0.5–0.8%; GLP-1 agonists, 0.5–1.5%; and TZD, 0.5–1.4% [36]. It is questionable that the effects on HbA1c yielded from the HIT trials were a mixed product of both HITs and standard diabetes care including medication adherence and lifestyle modifications. This concern was addressed in the systematic review of Yoshida et al. [33]. The authors conducted a subset analysis of 18 studies that exclusively compared the outcome between a combined HITs and standard care intervention group vs. standard care control group. The effect size estimated from this analysis was −0.63 (Hedges’ g: −0.63 95% CI −0.84, −0.42), which is attributable to HIT tools in addition to the usual care [33]. This result suggests that HITs are the key to the effectiveness rather than tools or components of these trials. Additionally, pharmacotherapies often use motivated patients’ sample and they cannot generate their full effects without patients’ adherence to treatment and persistence in usage [33]. In this sense, HITs may add additional value in the effectiveness by addressing challenges in adherence of a pharmacological therapy or of behavioral interventions.
\nT2D is commonly accompanied by cardiovascular complications. Adults with diabetes have a 77–87% prevalence of hypertension, a 74–81% prevalence of elevated low-density lipoprotein cholesterol (LDL), and a 62–67% prevalence of obesity [37]. Cardiovascular disease (CVD) is recognized as the most frequent cause of morbidity and mortality in patients with diabetes, causing up to 70% of all deaths in this patient group [2]. Type 2 diabetes (T2D) confers an approximate twofold elevation of CVD risk, equivalent to that of a previous myocardial infarction [3, 38]. In light of CVD burden in those with diabetes, the management of modifiable CVD risk factors, including hypertension, dyslipidemia, and obesity, is critical to minimizing the risk of macrovascular complications as well as death of diabetes. Yet, the implementation of preventive strategies to CVD among individuals with T2D is often not adequate [39, 40, 41] and less than half of patients who visit their care provider meet recommended levels for blood pressure (BP) and lipids [42]. Innovative approaches such as HITs are needed to facilitate CVD risk factor management among patients with T2D.
\nIn the context of cardiovascular care among general populations, HITs were documented to offer numerous benefits and have been associated with improvements in the measurement and monitoring of heart health, including risk factors such as BP, arrhythmia, cholesterol, and weight, as well as the implementation of guideline-based decision support for providers [43]. However, CVD outcomes are usually secondary and less described compared to glycemic status in T2D management trials [26, 44]. Furthermore, many review studies examining HITs’ effect in diabetes management often overlooked CVD outcomes [26, 44] or include insufficient sample size or limited CVD parameters for analysis [22, 24]. In the study by Marcolino et al., only 13 studies were included in the final analysis, within which 8 studies assessed the effect on SBP, 7 on DBP, and 5 on LDL [22]. No effects of telecommunication and information technologies were seen on SBP and DBP. They did, however, find a statistically significant reduction on LDL (−6.6 mg/dL, 95% CI −8.3, −4.9 mg/dL) associated with the technologies evaluated. They were not able to perform analysis on weight outcome, because only two studies assessed the effect of HITs on weight and both studies demonstrated a nonsignificant reduction on weight. In the systematic review by Pal et al., among 11 RCTs included in their final analysis, 5 studies looked into changes in BP (only 1 showed improvement in BP), 7 reported changes in BMI or weight (5 were combined in a meta-analysis), and 10 measured serum lipids (7 were combined in a meta-analysis) [24]. The overall pooled effect did not reach statistical significance for all of these outcomes [24].
\nThe current research on the effect of HITs in diabetes management has several limitations. First of all, the published trials often do not provide protocols for studies [45]. There is also lack of information on the theoretical bases of the interventions, and whether the HIT interventions are accompanied by other pharmaceutical or lifestyle therapies in their publications. As these HIT interventions are main therapeutic agents, it would be beneficial to explicitly prescribe interventions for trials and state the active components (behavior-change techniques), dose (frequency and intensity of interactions), route (mode of delivery), and duration of treatment [45]. There is also a need to clarify other ingredients in the intervention such as medication, standard care from health professionals, so that the major role of the HITs to the effectiveness of the interventions can be estimated, separating the effects from usual care and treatment [33].
\nAdditionally, intervention periods in published trials are short (most trials under 1 year) [33] and few systematic reviews provided effect estimation by length of follow-up. Studies by Tao et al. and Heitkemper et al. showed that HITs’ effect on glycemic control was diminishing as the interventions proceeded [18, 21]. It is not clear whether intervention effect and compliance with the HIT interventions would sustain in the long term. Misuse or nonuse of technological support is a common problem in disease management, which greatly affects patient’s outcomes. There is also lack of focus on cardiovascular health assessments in HIT interventions for diabetes management. We only found two systematic reviews that discussed CVD outcomes in addition to glycemic control. Because very few trials included cardiovascular risk factor evaluations, the synthesized findings were modest (Table 1). As we discussed earlier, because CVD causes major morbidity and mortality among T2D patients, designing and evaluating HITs for diabetes management should include cardiovascular health indicators. Further, many review studies only reported standardized difference in means [18, 21], which may be less intuitive to patients who care the absolute changes (i.e., mean difference) in outcomes (e.g., HbA1c) due to an intervention. Moreover, it remains unclear whether there are harms associated with the intervention. It has been reported that people may suffer from negative consequences of excessive self-monitoring by finding it uncomfortable, intrusive, and unpleasant [46, 47]. Studies found patients with diabetes who self-monitor their own blood glucose concentration did not benefit from increased glycemic control but rather found their disease more intrusive [48]. The interaction between a HIT device and a patient can be complex, and further studies need to consider these in more detail. Further, whether the interventions would be cost-effective if it required significant health professional support in a long-run has not been documented well in the literature [33, 49]. Additional research with more time points of follow-up is warranted to maximize data to inform the compliance with the HITs, long-term impact on health outcomes, to look for evidence of harms and to determine the cost-effectiveness in the intervention [49]. Studies with CVD risk factor assessments and absolute outcome measurement are also needed.
\nMoreover, it is unknown which populations will benefit the most from the HIT intervention as the current research in HITs has not always directly engaged diverse end users. There are also many questions surrounding the “digital divide” in HITs use, where the access, usability, and effectiveness of diabetes technologies are divided by users’ age, education, computer literacy, culture, and affluence [49]. These issues highlight the importance of engaging more research to design, test, and implement HITs for diverse patients with diabetes.
\nWhile features of HITs can expand patients’ ability in diabetes management and the results from the existing research showed their positive effects on outcomes of HbA1c and CVD risk factors, many of these applications described above have so far been explored predominantly within clinical trials rather than a real-world context. For those that have been widely used in real health-care setting, such as electronic patient record system; both health-care providers and patients have reported difficulties for engagement [50]. Multiple sources of tension contribute to these barriers (Table 2).
\nBarriers | \nPossible solutions | \n
---|---|
Validity and reliability | \n\n
| \n
Privacy and security | \n\n
| \n
Adaptability | \n\n
| \n
Barriers of using HITs in the real-world context and possible solutions.
First of all, the reliability and validity of some HITs is concerning. For example, many manufacturers market their products under the premise that they will help in improving health, but they often do not provide empirical evidence to support the effectiveness of their products [51]. Recent comparisons between different wearable devices for tracking physical activities yielded large heterogeneity in accuracy [52, 53]. The medical apps market also showed the similar discrepancy [54]. Lack of reliability is a serious obstacle that needs to be addressed before a HIT could be considered for medical use. Moreover, whether technological designs incorporated evidence-based guidelines is questionable [55]. It is reported that features of diabetes management apps on the online market did not cover evidence-based recommendations. A recent study evaluated 137 diabetes management apps from two major app stores (iTunes and Google Play) and compared the features with the American Association of Diabetes Educators (AADE) Self-Care Behavior guidelines. The author found an unbalanced feature development of current diabetes management apps. Few apps provided features supporting problem solving, reducing risks, and healthy coping, which are critical for user engagement and successful diabetes self-management [56].
\nSecondly, the privacy and security of personal data generated by HITs remains problematic. Users of these devices or technologies usually do not own the data; rather, data may be collected and stored by the manufacturers [51]. While some companies are willing to share user’s “anonymizing” data via a simple distortion or removal of identifying features, these techniques do not provide adequate levels of anonymity and are not sufficient to prevent identity fraud [57]. Moreover, some devices are easily to be hacked as a result of various communication technologies that aid the transfer of data between the devices and smartphones. It has been reported that wireless digital pacemakers and glucose pumps are vulnerable to cyberattacks [58].
\nFurther, even in relatively widely adopted HIT systems, such as the electronic patient records system, there are still many unfilled promises due to lack of interoperability between systems, difficult-to-use interface, and lack of consideration on patients’ backgrounds [50]. In the United States, for example, the patient records systems are not designed to talk to each other [59]. Until now, health-care providers have had little incentive to acquire or develop interoperable systems [50]. As a result, the current electronic health records do not allow a patient or provider to access needed health information anywhere at any time. Additionally, many clinicians are reluctant to invest the considerable time and effort to master difficult-to-use technology, which hindered the anticipated productivity gains of HITs [59]. Moreover, there are limited data collection on patient backgrounds, such as race/ethnicity, language preference, and health literacy in the patient records systems [49]. Lack of this set of data could cause fragmented care delivery and lead to patients’ misunderstanding of provider instruction and lose trust in the medical system [49].
\nTo transform HITs a real asset for diabetes care, further steps need to be considered (Table 2). First is to create a simple regulatory framework that does not suppress innovation but helps HITs, especially some wearable devices and apps become valid in the context of their health-oriented value [51]. A risk-based classification that promotes innovation, protects patient safety, and avoids regulatory duplications has recently been proposed [60]. As part of this model, the U.S. Food and Drug Administration jurisdiction covers higher-risk medical apps [61]. The National Health Service in the United Kingdom adopts similar pathway with their regulatory framework for mobile apps, which can be classified as “medical devices” by Medicines and Health Products Regulatory Agency [61].
\nA simple and powerful guide is also needed to transform the HIT system, especially the electronic patient records system. Health data stored in one system should be readily retrievable by others, subject to patient consent [50, 62]. For true interoperability, standardization must be achieved across three dimensions: how messages are sent and received; the structure and format of the information; and terms used within these dimensions [50]. HITs should also facilitate the work of clinicians by providing a system that is intuitive to use and without extensive retraining. Easy-to-use HIT systems not only will increase the productivity of providers but also will be safer [50].
\nAdditionally, HIT systems need to include automated and standardized categories for a patient background (e.g., race/ethnicity, language), facilitate communication among multiple providers and patients, and tailor to the needs of diverse populations [9]. Moreover, a genuine partnership should be fostered between patients and health-care providers through the use of HITs. Engagement can range from patients being simply better informed to individuals themselves being dynamically engaged in the HIT management, giving feedbacks about the HIT interventions, and even controlling who has access to their data [62, 63]. Furthermore, future technologies developed for diabetes management should incorporate balanced features from creditable guidelines to better support changing self-management behaviors of people with diabetes.
\nOverall, the current evidence shows that HITs have favorable impact on glycemic control and CVD risk management among patients with T2D. Future studies should examine the long-term effects of HITs and their cost-effectiveness, potential harms, and test and verify their effectiveness in glycemic control and other important health indicators such as CVD risk factors, among diverse populations. HITs may be valuable tools in enhancing human health and well-being overall. However, their advances also pose challenges in aspects of validity and reliability, patients’ privacy, security, and engagement. These issues need to be addressed before a broader implementation of HITs in the real-world setting.
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