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Adequate self-management is the cornerstone of type 2 diabetes treatment, as people make the majority of daily treatment measures and health decisions. The increasing prevalence of type 2 diabetes mellitus (T2DM) and the complexity of diabetes self-management demonstrate the need for innovative and effective ways to deliver self-management support. eHealth interventions are promoted worldwide and hold a great potential in future health care for people with chronic diseases such as T2DM. However, many eHealth interventions face high dropout rates. This led to our interest in the experiences of participants who dropped out of an eHealth intervention for adults with T2DM, based on the Guided Self-Determination (GSD) counseling method.
In this study, we aimed to explore experiences with an eHealth intervention based on GSD in general practice from the perspective of those who dropped out and to understand their reasons for dropping out. To the best of our knowledge, no previous qualitative study has focused on participants who withdrew from an eHealth self-management support intervention for adults with T2DM.
A qualitative design based on telephone interviews was used to collect data. The sample comprised 12 adults with type 2 diabetes who dropped out of an eHealth intervention. Data were collected in 2016 and subjected to qualitative content analysis.
We identified one overall theme: “Losing motivation for intervention participation.” This theme was illustrated by four categories related to the participants’ experiences of the eHealth intervention: (1) frustrating technology, (2) perceiving the content as irrelevant and incomprehensible, (3) choosing other activities and perspectives, and (4) lacking face-to-face encounters.
Our findings indicate that the eHealth intervention based on GSD without face-to-face encounters with nurses reduced participants’ motivation for engagement in the intervention. To maintain motivation, our study points to the importance of combining eHealth with regular face-to-face consultations. Our study also shows that the perceived benefit of the GSD eHealth intervention intertwined with choosing to focus on other matters in complex daily lives are critical aspects in motivation for such interventions. This indicates the importance of giving potential participants tailored information about the aim, the content, and the effort needed to remain engaged in complex interventions so that eligible participants are recruited. Finally, motivation for engagement in the eHealth intervention was influenced by the technology used in this study. It seems important to facilitate more user-friendly but high-security eHealth technology. Our findings have implications for improving the eHealth intervention and to inform researchers and health care providers who are organizing eHealth interventions focusing on self-management support in order to reduce dropout rates.
eHealth interventions are promoted worldwide and hold a great potential in future health care for people with chronic diseases such as type 2 diabetes mellitus (T2DM). However, many eHealth interventions face adoption problems and high dropout rates [
Diabetes is a chronic disease affecting an estimated 415 million people worldwide. Most of them have T2DM and its prevalence is rapidly increasing [
Secure messaging is an eHealth technology that facilitates personal and interactive communication between health care providers and patients. A systematic review of participatory Web-based interventions found that asynchronous communication tools such as secure messaging was experienced as particularly useful for self-management support [
As a response to the need for effective and theory-based interventions for people with T2DM, we adapted the self-management support intervention Guided Self-Determination (GSD) for T2DM [
Some eHealth interventions show dropout rates of up to 80% [
Dropout and nonuse are thus major challenges in eHealth interventions, including those offering self-management support and personalized feedback. This makes it imperative to explore experiences of such interventions among people who drop out. To the best of our knowledge, no previous study has conducted qualitative interviews with participants who dropped out of an eHealth counseling intervention designed to support self-management for people with T2DM. The aim of this study was therefore to explore experiences with the eHealth intervention based on GSD from the perspectives of those who dropped out and to provide insight into their reasons.
Overview of the Guided Self-Determination counseling for adults with type two diabetes and the reflection sheets.
Consultations | Focus | Reflection sheets |
The first session at the GPa’s office | Preparing for subsequent consultations | Invitation to work together |
eConsultation 1 | Your life with diabetes | RSc1a. Important events and periods in your life |
eConsultation 2 | Focus for change | RS 2a. Room for diabetes in your life |
eConsultation 3 | Work with changes | RS 3a. Clarification of challenge in your life with diabetes |
eConsultation 4 | Changes in daily life | RS 4a. Blood glucose self-monitoring and your reasons for self-monitoring |
aGP: general practitioner.
bHbA1c: glycosylated hemoglobin.
cRS: reflection sheet.
The secure messaging service was provided by the portal MinJournal. The secure messaging system at the portal demands login with electronic identification (BankID), providing the highest level of security (security level 4). Norwegian law requires this for Web-based sensitive information transfer, such as asynchronous communication between patients and health care personnel. This platform is already in use in Norwegian health care.
We used a qualitative design and collected data by means of individual telephone interviews with participants who withdrew from the GSD eHealth intervention.
General practice was chosen as an applicable intervention site because general practitioners (GPs) and registered nurses working with GPs are primarily responsible for health care for T2DM in Norway. The GSD eHealth intervention was delivered in addition to regular care. Regular care consists of structured annual consultations with a GP and nurse, as well as recommended routine measurement of glycosylated hemoglobin (HbA1c) and consultations with a GP every 3-4 months, or individually adapted [
The aim of the GSD intervention was to support diabetes self-management. The participants answer questions on reflection sheets, and the themes addressed are then discussed with the nurse [
In this study, 4 trained nurses experienced in diabetes care at general practices delivered the GSD eHealth intervention over 12 to 35 weeks from August 2015 to April 2016. To establish a relationship, the nurse and patients initially met face-to-face at the GPs office. The nurse explained the aim of the GSD counseling, how to work with the reflection sheets (
Overall, 18 people invited by nurses at 4 general practices in southwestern Norway agreed to participate in the GSD eHealth intervention. However, 13 of these 18 eventually left the intervention. The nurses who conducted the intervention invited the participants who had dropped out to take part in telephone interviews with a researcher. One person declined and 12 agreed.
Data were collected through telephone interviews in the spring of 2016. Telephone interviews are useful for collecting qualitative data and are considered less time- and energy-consuming for participants than face-to-face interviews [
The transcribed interviews were subjected to qualitative content analysis as described by Graneheim and Lundman [
The Norwegian Regional Committee for Medical and Health Research Ethics (REK west No.2015/60) approved the study. All participants signed a written consent form and were guaranteed anonymity and the right to withdraw from the study at any time.
Participant characteristics are presented in
Dropout graph.
Participant characteristics.
Demographics | All 18 participants recruited to the intervention | The 13aparticipants who dropped out of the intervention | |
Women (n) | 4 | 2 | |
Men (n) | 14 | 11 | |
Mean age (years, range) | 55 (42-73) | 57 (44-73) | |
Mean HbA1cb (%, range) | 7.3 (5.8-10.0) | 7.1 (5.8-10.0) | |
Median diabetes duration (years, range) | 9 (2-15) | 9 (2-15) | |
Alone | 4 | 3 | |
With family | 14 | 10 | |
Higher education >4 years | 1 | 0 | |
Higher education <4 years | 6 | 4 | |
Upper secondary education | 8 | 6 | |
Primary school | 3 | 3 | |
Working full-time | 15 | 10 | |
Retirement pensioner | 2 | 2 | |
Receiver of disability benefit | 1 | 1 | |
Diet | 4 | 4 | |
Oral or other medications | 11 | 7 | |
Insulin | 3 | 2 |
a12 were interviewed in this study.
bHbA1c: glycosylated hemoglobin.
The analysis resulted in identification of one theme related to experiences of the participants who dropped out of the GSD eHealth intervention: losing motivation for intervention participation. This theme described how motivation for participating in the intervention was influenced by some discouraging experiences. It was based on four categories: (1) frustrating technology, (2) perceiving the content as irrelevant and incomprehensible, (3) choosing other activities and perspectives, and (4) lacking face-to-face encounters. These categories are presented below and illustrated with quotations to facilitate transparency of interpretation. The quotations are attributed to the participants [P1-P12] to demonstrate their experiences and opinions.
This category focuses on how participants felt frustrated by the technology used in this eHealth intervention. Initially, participants reported being receptive to participating in the GSD eHealth intervention. They valued the time and resource-saving potential of electronic communication with their nurse. However, they described difficulties in navigating the Web page due to errors with the portal and perceived the Web solution as time-consuming and tiring:
There was just too much trouble with it (the web page). In the end, I just gave up trying. Had it only been easier...
Participants stated that it was cumbersome to download and save the PDFs before filling out the reflection sheets. They would have preferred completing the reflection sheets directly on the Web page. Participants also experienced Web page errors, for instance downtime, login problems, alerts from the firewall that it was an insecure Web page (which it was not), or that the nurse had not received the messages they sent. Some described being irritated and frustrated by technological problems. They pointed out that the Web solution bothered them when they were unable to send secure messages:
I answered the questions and tried to send, but it did not send. I tried several times, and I could not do it. This made the whole thing stressful for me...I bothered myself with it because I did not understand it and was not able to send anything. It was a bit silly, but it bothered me a lot, that I didn’t get it...I feel like those kinds of things could be manageable, those forms, sending them. So I don’t know what it was with this web page, why it didn’t work.
Although most participants experienced some challenges with the Web solution, some considered the problems minor. They said having to resend undelivered messages and change the browser to access the Web page were acceptable difficulties in an eHealth intervention.
Some participants did not see the content of the GSD as tailored to their needs and expectations for a diabetes self-management intervention. They expressed that they lost interest after reading some of the first issues raised in the reflection sheets because they could not familiarize themselves with these issues and did not consider the content relevant to their diabetes. As one participant noted:
I felt as if some constellations were made that I could not familiarize myself with. I live a completely normal life really; it’s just the food, and the blood glucose level that makes me attend to it. But I have managed to adapt to the situation. And I keep adapting more gradually...I felt that it didn’t suit me.
The participants who reached the third eConsultation worked with reflection sheets intended to stimulate people to reflect on their goals and diabetes self-management behaviors. However, the purpose of these reflection sheets was described as difficult to understand:
When I came to “dynamic problem-solving” I started losing interest. I wondered: what do you want here? What method is this? I did not understand the purpose behind the form.
Moreover, some of the participants stated that they did not fully understand what the intervention entailed when they signed up for it. Three of them said that they would prefer being able to send messages in free text to their nurse on their own schedule, instead of participating in a structured counseling intervention.
This category concerns the participants’ narratives of more important priorities in their lives than the GSD eHealth intervention. Examples were other illnesses that needed more attention and other personal or work-related responsibilities. Daily life consisted of many complex tasks and commitments:
I am quite busy. I work full time and I really like to read. I have so much reading material, and I am active in politics as well. I have so much to read, so that just going online and having to spend much time there...It took too much of my time. Therefore, I felt it was a bit like...I didn’t like that so much. I felt it took too much time.
Going on the Web and engaging in the GSD eHealth intervention seemed to be considered less important than other matters requiring their attention, and the participants therefore chose to minimize their engagement with it:
It was the required time that did it. Some of the questions also, but that was not the main reason. It was more that it became a bit too much on top of everything else, having to sit down and spend time there, and remember to send and, yeah...There was too much else that had to be paramount somehow. Therefore, I simply had to downgrade it.
Choosing not to focus on diabetes was also mentioned. Being uncomfortable with the issues raised in the reflection sheets or feeling pathologized by the demanding questions were articulated. Wanting to focus on living their life illustrates this perspective:
Because I feel healthy, and I do not want to be sick. But I am sick. Therefore I do have to look after it in the long run. But there is something in my head that I can’t seem to get right...I have a diagnosis, but I do not run around being sick. I can explain some of this. My diet is what is wrong, or my life situation towards it (the diabetes). But I want to live as well. There is a limit there somewhere
This category concerns the experience of lack of dialogue and a preference for face-to-face encounters with their nurse:
I would miss sitting down, see each other, and talk to each other. Because I’m not so into all the electronic communication. I really like to sit down and see the person I’m talking to.
Meeting the nurse in person was emphasized as a motivating experience. One participant felt more obligated to try to reduce HbA1c, for example, when communicating with the nurse in person. Participants also stated that answering questions verbally was easier than writing down the answers, and that they would rather speak with the nurse in their regular consultations with the nurse. The following quotation illustrates this preference:
I think it is a lot better to sit and talk with her (the nurse) right in front of me. You know, and then we can discuss things and talk a little bit like that...And if there is any misunderstanding we can ask when we’re sitting right next to each other.
In addition, having eConsultations without a scheduled appointment with the nurse was considered less binding than regular health consultations:
It was allocating the time to it I had problems with...Although committing to answer, it does not have the same “disciplining” effect that one gets by meeting up at the doctor's office.
At the same time, some participants emphasized that written messages could improve communication with the nurse by enabling carefully considered answers. They valued the ability to read and reflect upon the questions before answering:
The information you are able to provide about your health condition is much more thorough and better over the internet, when you sit and think through what you are going to answer and how to answer and that kind of thing. Than meeting up at the GPs office.
Some of the participants insisted that they were accustomed to electronic and written communication. They appreciated the potential benefits of digital communication in health care, and some of them even preferred it, given they had the need for it. They mentioned that asynchronous digital communication could be time- and resource-saving. A combination of eHealth and regular encounters with the nurse was suggested as preferable when conducting the GSD, compared with merely written communication via secure messages.
This study provides insight into experiences with an eHealth intervention based on GSD from the perspective of those who dropped out and into their reasons for dropping out. Our findings indicate that the GSD eHealth intervention without face-to-face encounters influenced the participants’ motivation for the intervention negatively and resulted in dropout. Other factors that diminished their motivation pertained to choosing other activities and perspectives in their lives, perceiving the content as irrelevant, and the technology as frustrating. We discuss these findings considering earlier research and in relation to the dimensions of autonomy, relatedness, and competence proposed by the SDT as important to develop and maintain autonomous motivation.
Our findings indicate that participants missed face-to-face encounters with the nurse when communicating asynchronously via secure messages in the GSD eHealth intervention. They stated that they found it easier to discuss a variety of issues with the nurse and avoid misunderstandings when meeting face-to-face. Secure messages may have advantages for patient-nurse communication, such as efficient communication at convenient points of time in addition to the ability to think about the message before replying. However, our findings show the importance of acknowledging the drawbacks of written communication, such as the lack of nonverbal communication and the inability to ask immediate follow-up questions. Earlier research has demonstrated that support provided by clinicians via email enhanced adherence in eHealth interventions [
This could relate to the SDT, which proposes that a sense of relatedness is essential for motivation [
Moreover, our findings suggest that the current eHealth intervention was seen as less important when the participants had to engage in it on their own time and had no standing appointment with the nurse. This could reflect that asynchronous Web-based health consultations are regarded as less obligatory than regular health consultations with a scheduled appointment. This adds to findings from a recent study suggesting that planning for human support and interaction could be essential to upkeep motivation and use of digital interventions [
Our findings indicate that participants had commitments that required more attention than diabetes and the GSD eHealth intervention. This was illustrated by narratives of other illnesses or daily responsibilities and competing life demands that required focus and reduced their motivation for participation. According to the SDT, the value people place on various activities affects their motivation [
Patients’ perspective of “wellness-in-the foreground” has been addressed in the shifting perspectives model, describing that people with chronic illness varies their attention of their disease [
Some participants did not see the relevance of the structured reflection sheets in the GSD eHealth intervention as relevant to them. This matter relates to the discussion of the consequences for motivation when an activity is not perceived as valuable enough and could indicate that the current intervention, with its complex aspects and delivery method, is not suitable for all participants. These findings can have two possible explanations. First, the reflection sheets address aspects of people’s lives and emotions which may differ from what the participants are accustomed to and what they expect from communication with their nurse. The patients are asked to reflect on their challenges and make a plan for ideal problem solving (
Previous research addresses technical problems as a continuous challenge in eHealth interventions resulting in high dropout rates [
The findings from this study may serve as a basis for future research aimed at broadening our understanding of the dynamics of withdrawing from eHealth interventions. However, generalizations from this small and situational study are not possible, nor are they intended. Out of 13 participants who dropped out of the intervention, 12 agreed to be interviewed. Although this could be considered a small sample, it is a strength of this study that most of the participants who dropped out were willing to be interviewed. The semistructured interview guide allowed the participants to express their genuine experiences, providing rich data. As the interviewer had no relationship with the participants, the participants might have felt more comfortable being candid. However, we cannot rule out the possibility that the nuances of face-to-face interaction are lost so that misleading information may not be detected [
A limitation that should be mentioned was the uneven gender distribution of the participants in this study. Initially, 14 men and 4 women were included, of which only 10 men and 2 women were interviewed. In relative terms, more men than women withdrew from the intervention. eHealth interventions may be used and experienced differently by men and women. A systematic literature review argues that there are gender differences in needs, preferences, and Web-based communication styles when engaging in Web-based health communication [
Our findings indicate that the eHealth intervention based on GSD without face-to-face encounters with nurses reduced participants’ motivation for engagement in the intervention. To maintain motivation, our study points to the importance of combining eHealth with regular face-to-face consultations. Our study also shows that the perceived benefit of the GSD eHealth intervention intertwined with choosing to focus on other matters in complex daily lives are critical aspects in motivation for such interventions. This indicates the importance of giving potential participants tailored information about the aim, the content, and the effort needed to remain engaged in complex intervention so that eligible participants are recruited. Finally, motivation for engagement in the eHealth intervention was influenced by the technology used in this study. It seems important to facilitate more user-friendly but high-security eHealth technology. Our findings have implications for improving the eHealth intervention and to inform researchers and health care providers who are organizing eHealth interventions focusing on self-management support, in order to reduce dropout rates.
general practitioners
Guided Self-Determination
glycosylated hemoglobin
portable document format
self-determination theory
type 2 diabetes mellitus
This study was conducted as a collaboration between Western Norway University of Applied Sciences and the University of Stavanger. It was funded by a grant from the Norwegian Research Council (Project No. 221065), University of Stavanger, and Western Norway University of Applied Sciences, Norway.
The authors would like to specially thank the patients participating in the study. In addition, we express our gratitude to the four study nurses and the involved general practices for recruiting the patients and conducting the intervention.
SSL, BK, MG, and BO developed the study design. ERO contributed to the recruitment of participants and data collection. SSL performed the data collection, transcription, the tentative data analysis, and drafted the first version of the manuscript. BK, MG, and BO contributed to the data analysis. All authors contributed in editing the manuscript, and all authors contributed and agreed to the final draft of the article.
None declared.