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During the COVID-19 pandemic, the Internet has been a major source of information for people to keep updated with news and guidelines. However, concerns have been raised about the ‘infodemic’, which includes the overabundance of online information and the spread of misleading information. Adequate eHealth literacy skills among world citizens have therefore been emphasized as vital during the pandemic. Persons with type 2 diabetes have been at increased risk of severe outcomes of COVID-19 disease. 

This study aimed to explore online COVID-19 information acquisition experiences among persons with type 2 diabetes and varying eHealth literacy. Fifty-eight participants filled out the eHealth Literacy Scale (eHEALS), along with a qualitative questionnaire with free-text questions. Additionally, 10 participants were interviewed. Thematic analysis was applied to identify patterns in participants’ experiences. Two domains were identified: perceived challenges with online information about COVID-19, and coping strategies to manage challenges. The perceived challenges were: being exposed to information overload, dealing with conflicting information, and being strongly emotionally affected. The related coping strategies were: protecting oneself, trusting authorities, taking command, and using common sense. 

These strategies often involved triangulation of the information obtained, including participants consulting their common sense, various sources, or family and friends. This paper highlights the crucial role of authorities in delivering online information, that according to health literacy principles, is easy to access, understand, and use. Furthermore, our results reinforce the importance of diabetes nurses, as well as healthcare professionals in general, in encouraging patients to share their Internet findings, promote information from reliable sources, and deliver tailored information that suits individual needs. Because our results underline the importance of social support in eHealth literacy and the assessment of online health information, the inclusion of family and friends needs to be increasingly considered in diabetes care. Due to the small homogenous sample, the results of this study cannot be generalized. However, the reader can assess the transferability to other situations and settings based on our contextual descriptions.

Background: Globally, most countries face a common challenge by moving toward a population-based structure with an increasing number of older people living with chronic conditions such as type 2 diabetes. This creates a considerable burden on health care services. The use of digital tools to tackle health care challenges established views on traditional nursing, based on face-to-face meetings. Self-management is considered a key component of chronic care and can be defined as management of the day-to-day impact of a condition, something that is often a lifelong task. The use of a screening instrument, such as the Self-Management Assessment Scale (SMASc), offers the potential to guide primary health care nurses into person-centered self-management support, which in turn can help people strengthen their empowerment and self-management capabilities. However, research on self-management screening instruments is sparse, and no research on nurses’experiences using a digitalized scale for measuring patients’ needs for self-management support in primary health care settings has been found. Objective: This paper describes diabetes specialist nurses’ (DSNs) experiences of a pilot implementation of the SMASc instrument as the basis for person-centered digital self-management support. Methods: This qualitative study is based on observations and interviews analyzed using qualitative content analysis. Results: From the perspectives of DSNs, the SMASc instrument offers insights that contribute to strengthened self-management support for people with type 2 diabetes by providing a new way of thinking and acting on the patient’s term. Furthermore, the SMASc was seen as a screening instrument with good potential that embraces more than medical issues; it contributed to strengthening person-centered self-management support, and the instrument was considered to lead both parts, that is, DSNs and patients, to develop together through collaboration. Conclusions: Person-centered care is advocated as a model for good clinical practice; however, this is not always complied with. Screening instruments, such as the SMASc, may empower both nurses and patients with type 2 diabetes with more personalize

Background: Globally, most countries face a common challenge by moving toward a population-based structure with an increasing number of older people living with chronic conditions such as type 2 diabetes. This creates a considerable burden on health care services. The use of digital tools to tackle health care challenges established views on traditional nursing, based on face-to-face meetings. Self-management is considered a key component of chronic care and can be defined as management of the day-to-day impact of a condition, something that is often a lifelong task. The use of a screening instrument, such as the Self-Management Assessment Scale (SMASc), offers the potential to guide primary health care nurses into person-centered self-management support, which in turn can help people strengthen their empowerment and self-management capabilities. However, research on self-management screening instruments is sparse, and no research on nurses’ experiences using a digitalized scale for measuring patients’ needs for self-management support in primary health care settings has been found.

Objective: This paper describes diabetes specialist nurses’ (DSNs) experiences of a pilot implementation of the SMASc instrument as the basis for person-centered digital self-management support.

Methods: This qualitative study is based on observations and interviews analyzed using qualitative content analysis.

Results: From the perspectives of DSNs, the SMASc instrument offers insights that contribute to strengthened self-management support for people with type 2 diabetes by providing a new way of thinking and acting on the patient’s term. Furthermore, the SMASc was seen as a screening instrument with good potential that embraces more than medical issues; it contributed to strengthening person-centered self-management support, and the instrument was considered to lead both parts, that is, DSNs and patients, to develop together through collaboration.

Conclusions: Person-centered care is advocated as a model for good clinical practice; however, this is not always complied with. Screening instruments, such as the SMASc, may empower both nurses and patients with type 2 diabetes with more personalized care. Using a screening instrument in a patient meeting may also contribute to a role change in the work and practice of DSNs.

Background: Self-management is a substantial part of treatment for patients with type 2 diabetes (T2D). Modern digital technology, being small, available, and ubiquitous, might work well in supporting self-management. This study follows the process of developing a pilot implementation of an electronic health (eHealth) service for T2D self-management support in primary health care. The use of digital health, or eHealth, solutions for supporting self-management for patients with T2D is increasing. There are good examples of successful implementations that can serve as guides in the development of new solutions. However, when adding person-centered principles as a requirement, the examples are scarce.

Objective: The objective of this study was to explore challenges that could impact the design of a person-centered eHealth service for T2D self-management support. The study included data collection from multiple sources, that is, interviews, observations, focus groups, and a Mentimeter (interactive presentation with polling) survey among stakeholders, representing various perspectives of T2D.

Methods: A user-centered design approach was used to exploratively collect data from different sources. Data were collected from a workshop, interviews, and observations. The different data sources enabled a triangulation of data.

Results: Results show that user needs related to an eHealth service for person-centered T2D self-management support are multifaceted and situated in a complex context. The two main user groups, patients and diabetes specialist nurses, express needs that both diverge and converge, which indicates that critical design decisions have to be made. There is also a discrepancy between the needs expressed by the potential users and the current work practice, suggesting more attention toward changing the organization of work to fully support a new eHealth service.

Conclusions: A total of three overarching challenges—flexible access, reducing administrative tasks, and patient empowerment—each having a significant impact on design, are discussed. These challenges need to be considered and resolved through careful design decisions. Special attention has to be given to the patient user group that could greatly impact current work practice and power structures at the primary care unit. A need for further studies investigating patient needs in everyday life is identified to better support the implementation of technology that does not give specific attention to organizational perspectives but instead approach design with the patient perspective in focus.

Background: Due to an ageing, multi-diseased population, type 2 diabetes (T2D) and other chronic conditions pose a challenge for primary healthcare. To meet such challenges, primary healthcare nurses must adapt to new roles and acquire new skills regarding self-management support. eHealth and digital solutions are suggested to facilitate the increasing need for care in chronic conditions. However, how these solutions are experienced among users has not yet been sufficiently explored. To successful implement new working methods in primary healthcare, it is important to identify prerequisites and barriers that exists.

Aim: The overall aim of this thesis was to explore perceptions among primary healthcare nurses and patients about digital self-management support in T2D and also to develop and evaluate a digital screening instrument assessing individual needs for self-management support. This thesis is based on four papers. Papers I and II aimed to describe perceptions among primary healthcare nurses and persons with T2D of using eHealth services for self-management support. Paper III aimed to develop and psychometrically test a screening instrument for person-centred guidance and self-management support. Paper IV aimed to describe diabetes specialist nurses’ experiences of a pilot implementation of the instrument labelled the Self-Management Assessment Scale (SMASc) as a basis for person-centred digital self-management support.

Methods: A combined approach was used to collect and analyse data. Data in the qualitative studies were collected by means of focus group interviews (I) and individual interviews (II, IV) as well as participant observations (IV) were analysed using qualitative content analysis (I, II, IV). Quantitative data in study III were psychometrically tested. The participants in the respective studies were in Paper I primary healthcare nurses (n = 24), in Papers II and III persons with T2D (n = 11; n = 104) and in Paper IV diabetes specialist nurses (n = 5) and persons with T2D (n = 14). All data were collected in a county in northern Sweden.

Results: The overall results constituted a web of mixed experiences and feelings towards using digital self-management support. Primary healthcare nurses pronounced their ambivalence towards the digital development in healthcare (I). Patients as well had mixed feelings, but they also pronounced benefits and potentials leading to increased involvement and empowerment (II). The psychometric assessment of the screening instrument, SMASc, demonstrated high potential and promising results for clinical assessments on factors affecting self-management behaviours (III). Preliminary results suggest that the SMASc instrument is considered suitable for screening of patients’ needs for self-management support (IV). 

Conclusion: The results of this thesis suggest that digitalization needs stepwise implementation. Digital tools such as the SMASc instrument can be useful in facilitating identification of patients in need of targeted interventions. However, primary healthcare nurses must be open to discussing patients’ emotional adaptation to the disease as well as the knowledge, sometimes not evidence based, the patients may have obtained from Internet sources. Targeted self-management support including person-centred guidance is suggested to be an effective way to achieve patient.

BACKGROUND: Type 2 diabetes (T2D) is increasing as the population ages. The development of new medical treatments is promising and important, but the basic treatment remains self-management, even if adherence to lifestyle advice is low. Electronic health (eHealth) or mHealth interventions can increase empowerment among people living with T2D and may compensate for the lack of professional resources and geographical distances. The interactive self-management support (iSMS) project aims at including digital tools to support people living with T2D in their self-management and facilitating their interaction with diabetes specialist nurses (DSNs). This protocol outlines a study with the purpose of developing and evaluating an intervention where people living with T2D can increase self-efficacy and empowerment through digital self-monitoring and interaction with DSNs.

OBJECTIVE: To develop and evaluate a person-centered iSMS intervention in primary health care for people with T2D in addition to their usual diabetes care.

METHODS: This study is a 12-month, 3-armed, nonblinded randomized controlled trial (RCT), which will be conducted in 6 primary health care centers (HCCs) in northern Sweden. Eligible participants will be randomized to either an intervention group (n=46), a control group (n=46), or an external group (n=46) for comparison. The intervention group will receive the mobile app, and the control group will receive a minimal intervention (diabetes brochure) and the usual standard of care. Changes in glycated hemoglobin (HbA_1c) will be the primary outcome measure.

RESULTS: This trial is currently open for recruitment. The first results are expected to be submitted for publication in Autumn 2019.

CONCLUSIONS: This study, with its focus on iSMS, will provide insights regarding suitable ways to promote and develop a person-centered intervention. If successful, the intervention has the potential to become a model for the provision of self-management support to people with T2D.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/10250.

Aim: To develop and psychometrically test the Self‐Management Assessment Scale (SMASc), a screening instrument for person‐centred guidance and self‐management support of persons with type 2 diabetes (T2D).

Background: T2D is a common and globally increasing chronic condition. Improved self‐management is a vital and integral component of diabetes care to prevent complications from poorly managed diabetes. For diabetes nurses to better understand persons with diabetes experienced challenges and needs regarding self‐management and further for persons with T2D to take an active role in managing their condition, an instrument measuring this is needed.

Design: Instrument development and psychometric testing of the content and construct validity, factor structure and reliability.

Method: The SMASc was psychometric tested on a sample of participants (September 2017–November 2017) with a confirmed diagnosis of T2D (N = 104).

Results: Psychometric findings were satisfactory and supported the scale´s reliability. Cronbach's alpha, CVI and goodness‐of‐fit were acceptable.

Conclusion: Self‐Management Assessment Scale is a short validated screening instrument, which can indicate possible barriers for self‐management that ought to be approached during the conversation between the person with T2D and the primary healthcare nurses. Therefore, it is a promising instrument to be used to facilitate person‐centred guidance and to improve self‐management of people living with T2D.

Background: Digital health services are increasing rapidly worldwide. Strategies to involve patients in self-monitoring of type 2 diabetes (T2D) on a daily basis is of crucial importance, and there is a need to optimize the delivery of care such as self-management support. Digitalized solutions have the potential to modify and personalize the way in which people use primary health services, both by increasing access to information and providing other forms of support at a distance. It is a challenge to integrate core values of person-centered care into digitalized health care services.

Objective: The objective of this study was to describe perceptions of using electronic health (eHealth) services and related technologies for self-management support among people with T2D treated in Swedish primary health care.

Methods: This is a qualitative study based on interviews analyzed using qualitative content analysis conducted among people diagnosed with T2D.

Results: Findings suggest that the participants had mixed feelings regarding the use of digital health services for self-management support. They experienced potentials such as increased involvement, empowerment, and security, as well as concerns such as ambivalence and uncertainty.

Conclusions: Digital health services for self-management are easily accessible and have the potential to reach a wide population. However, targeted training to increase digital skills is required, and personalized devices must be adapted and become more person-centered to improve patients’ involvement in their own care.

BACKGROUND: Nurses have expressed doubts about the ongoing digitalisation of Swedish primary health care. Given the potential role of eHealth in primary health care, including supporting interactive self-management for people with chronic conditions, it is important to highlight nurses' experiences. This study is part of a larger project aimed at implementing person-centred interactive self-management support (iSMS) in primary health care.

AIM: The aim of this study was to describe Swedish primary healthcare nurses' perceptions of using digital eHealth systems and services to support patient self-management.

METHODS: Focus group interviews were conducted with primary healthcare nurses (n = 20). The interview transcriptions were analysed using qualitative content analysis.

RESULTS: Three themes emerged from the content analysis: caregiving in the midst of digital chaos; a lack of overview and control in daily work; and mixed feelings towards digitalisation. Each theme was subdivided into three subthemes.

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: The results of this study provide insight into a number of concerns that stand in the way of success when it comes to the implementation and use of digital technology. If nurses are to adapt to the new policies and practices that accompany the current digitalised development in Swedish primary health care, the concept of a nurse's traditional work role needs to be amended in terms of the scope of work tasks and established views of traditional nursing. The study also highlights the need for more research to enable eHealth systems/services to be designed to fulfil multiple requirements. The digitised systems should be a tool for achieving good quality self-management support as well as giving the primary healthcare nurses adequate resources to support patients' self-management while still maintaining the values associated with person-centred care.