JMIR FORMATIVE RESEARCH

Karimi et al

Original Paper

Participants’ and Health Care Providers’ Insights Regarding a
Web-Based and Mobile-Delivered Healthy Eating Program for
Disadvantaged People With Type 2 Diabetes: Descriptive
Qualitative Study
Nazgol Karimi1, BSc, Msc; Rachelle Opie1,2, PhD; David Crawford1, PhD; Stella O’Connell1, PhD; Peter Shane
Hamblin3,4, BS, MB; Cheryl Steele5, RN, RM, Grad Cert Diabetes Education, Grad Dip Health Counselling; Kylie
Ball1, PhD
1

Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Melbourne, Australia

2Institute for Mental and Physical Health and Clinical Translation, Food & Mood Centre, Deakin University, Geelong, Australia

3

Diabetes & Endocrinology Centre, Sunshine Hospital, Melbourne, Australia

4

Department of Medicine-Western Precinct, University of Melbourne, Melbourne, Australia

5

Diabetes Education Services, Sunshine Hospital, Melbourne, Australia

Corresponding Author:
Nazgol Karimi, BSc, Msc
Institute for Physical Activity and Nutrition
School of Exercise and Nutrition Sciences
Deakin University
Building J, SENS
221 Burwood Highway, Burwood
Melbourne, VIC 3125
Australia
Phone: 61 392517310
Email: karimin@deakin.edu.au

Abstract
Background: Healthy eating is a key element of type 2 diabetes (T2D) self-management. Digital interventions offer new avenues
to reach broad audiences to promote healthy eating behaviors. However, acceptance of these interventions by socioeconomicallydisadvantaged people (eg, those with lower levels of education and income or from ethnic minority groups) has not yet been fully
evaluated.
Objective: This study aimed to investigate the acceptability and usability of EatSmart, a 12-week web-based and mobile-delivered
healthy eating behavior change support program, from the perspective of intervention participants living with T2D and healthcare providers (HCPs) involved in diabetes care.
Methods: This study used a qualitative descriptive design. Overall, 60 disadvantaged adults with T2D, as determined by receipt
of either a HealthCare Card or a pension or benefit as the main source of income, were recruited. Data from participants regarding
their experiences with and perceptions of the program and longer-term maintenance of any behavior or attitudinal changes werecollected through a web-based self-report survey with open-ended questions administered 12 weeks after baseline (54/60, 90%)and semistructured telephone interviews administered 36 weeks after baseline (16/60, 27%). Supplementary semistructured
interviews with 6 HCPs involved in diabetes care (endocrinologists, accredited practicing dietitians, and diabetes nurse educators)
were also conducted 36 weeks after baseline. These interviews aimed to understand HCPs’ views on successful and unsuccessful
elements of EatSmart as a technology-delivered intervention; any concerns or barriers regarding the use of these types ofinterventions; and feedback from their interactions with patients on the intervention’s content, impact, or observed benefits. Alldata from the surveys and interviews were pooled and thematically analyzed.
Results: In total, 5 key themes emerged from the data: program impact on food-related behaviors and routines, satisfaction withthe program, reasons for low engagement and suggestions for future programs, benefits and challenges of digital interventions,and cultural considerations. Results showed that EatSmart was acceptable to participants and contributed positively to improving

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Karimi et al

food-related behaviors. Most participants (27/43, 63%) mentioned that they enjoyed their experience with EatSmart and expressedhigh satisfaction with its content and delivery. The educational and motivational content was considered the most useful part ofthe program. Benefits discussed by intervention participants included gaining health knowledge and skills, positive changes intheir food purchasing and cooking, and eating greater quantities and varieties of fruits and vegetables. HCPs also described theintervention as beneficial and persuasive for the target audience and had specific suggestions for future tailoring of such programs.
Conclusions: The findings suggested that this digitally delivered intervention with supportive educational modules and SMS
text messages was generally appealing for both participants and HCPs. This intervention medium shows promise and could
feasibly be rolled out on a broader scale to augment usual diabetes care.
International Registered Report Identifier (IRRID): RR2-10.2196/19488(JMIR Form Res 2023;7:e37429) doi: 10.2196/37429
KEYWORDS
type 2 diabetes; healthy eating; diet; dietary intervention; low socioeconomic position; digitally delivered; mobile health; mHealth;website; mobile phone; SMS text message; qualitative descriptive

Introduction
Background
The increasing prevalence of type 2 diabetes (T2D) and therelated cost of managing this complicated disease are a major
concern worldwide [1]. T2D is particularly concerning amongpeople of low socioeconomic status, who have a higher rate ofdiabetes and diabetic complications [1]. Self-management is
integral in diabetes treatment and requires adherence to several
recommended self-care behaviors such as healthy eating, regularexercise, consistent use of medication, and self-monitoring ofblood glucose [2,3]. Adherence to self-management activities
is challenging, and research suggests that people face a myriadof barriers to doing so, including lack of skills, education, or
knowledge [4,5]. Structured diabetes self-management education
for people with T2D can improve self-management activities
and health-related outcomes, but uptake is low [6]. Previous
qualitative studies suggest that some people find face-to-faceprograms difficult to attend because of a lack of transportfacilities, timing of the courses, work or family commitments,
or a dislike of group classes [6,7]. The increasing number ofpeople affected by T2D combined with low rates of attendance
to structured education programs highlights the importance ofdeveloping new and efficient modes of delivering
self-management interventions.
Digitally delivered (eg, web- and mobile-based)
self-management interventions bypass many of the barriers toface-to-face education and hold a tremendous potential to reachmore people and enable them to play an active role in the
management of their own health [8]. These interventions offer
an opportunity to provide easy access, trusted sources of
information, and a low-cost and effective approach forsupporting self-care in primary care settings [9-11]. Furthermore,with the rapid development and diffusion of mobile technologies
among all demographic groups, these interventions can become
widely available to people from different socioeconomic
backgrounds [12]. The effectiveness of digital interventions inchanging clinical outcomes has been the subject of previous
systematic reviews, and their findings have demonstrated
improved glycemic control [13,14], diabetes knowledge,
self-efficacy, self-care, and exercise behaviors [15].
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Although these reports are encouraging, digital interventions
have not yet been sufficiently tested in disadvantaged
populations, and the mechanisms of action and optimal designof these interventions are not fully understood. There remains
insufficient evidence for the acceptability of these interventions
among people of lower socioeconomic status, their preferences,and the factors that promote their engagement over time. These
aspects need special attention as, if a digital intervention is tobe practical, it needs to be accepted, well received, anduser-friendly and satisfy the needs of the end user. The
acceptability of an intervention can bring about changes inbehavior even when medical outcomes show no changes [16,17].
EatSmart, a 12-week evidence-based, theoretically grounded,healthy eating behavior support program, was developed toaddress this gap. EatSmart was trialed in a group of vulnerable
people with T2D. This program involved a simple and practical
approach tailored to the needs of people with T2D who facebarriers to eating healthily in the context of socioeconomic
disadvantage. The feasibility and quantitative impacts of the
EatSmart program on participants’ eating behaviors are reported
separately (Karimi et al, under review). In summary, feasibility
results showed that EatSmart could successfully attract andretain the target group of disadvantaged people with T2D in thefirst 3 months while the intervention was active. The quantitative
results showed that participants demonstrated improvements invegetable and fruit consumption that were sustained over time
(1.22 servings per day increase in total vegetable and fruit intake
immediately after the intervention and 1.34 servings per day
increase in total vegetable and fruit intake at 6 months after theintervention) as well as improvements in self-efficacy andperceived barriers and enablers to healthy eating after taking
part in the intervention.
In this study, using a qualitative descriptive approach, weinvestigated the perspectives of users and health care providers(HCPs) on this program. This method helped us better
understand the nuances of intention, motivation, and triggers
to action associated with the program.

Objectives
The overall objective of this study was to explore theacceptability of the EatSmart program from the perspective of
supporting long-term behavior change and to uncover the
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components of EatSmart that participants and HCPs perceived
as most beneficial. For the purpose of this paper, we define
acceptability as whether the program was usable and satisfied
the needs and requirements of participants.
Specific objectives were to (1) explore intervention participants’views on their experience with the EatSmart program, including
reasons for engagement or nonengagement; (2) explore thelonger-term maintenance of any self-reported food-related
behavior and attitudinal changes among participants; (3) explore
HCPs’ views on successful and unsuccessful elements of
EatSmart and their views on concerns or barriers regarding
using digitally delivered interventions; and (4) examine HCPs’
feedback from their interactions with participants on theintervention’s content, long-term impact, and any observed
benefits.

Methods
DesignThis study used a qualitative descriptive approach that can
provide a comprehensive summarization, in everyday terms, of
specific events experienced by individuals [18-20]. Thisapproach allowed for an in-depth understanding of intervention
participants’ experiences with the EatSmart program, of HCPs’
views on the EatSmart program in particular, and of digitallydelivered interventions in general.

Intervention
EatSmart, a 12-week, multimodality-delivered healthy eatingintervention, included access to a website viewable on mobile
devices or PCs and tailored SMS text messages designed for
disadvantaged people with T2D. This intervention is describedin detail in the protocol paper [21] and summarized in thissection. The website consisted of 6 skill-based modules provided
to participants on a 2-weekly basis and that covered various
topics such as the importance of vegetable, fruit, and whole
food intake for health and diabetes; smart shopping planningand food label reading; modification of recipes by trying andincorporating new types of vegetables; improvement of cooking
skills and confidence; and a final reinforcement and summary
module. The website offered various practical activities suchas calculation of current and ideal spending on different foodgroups, internet-based shopping tours, and food preparation
videos. Over the 3-month intervention period, participants also
received 3 automated unidirectional SMS text messages per
week of various kinds: educational, motivational, and reminders
to check the website. The EatSmart intervention involved thedelivery of key behavior change techniques such asproblem-solving key barriers to healthy eating, self-monitoring
consumption, and setting goals for purchasing and consuming
key food groups.

Participants and Recruitment
The EatSmart program recruited 60 socioeconomicallydisadvantaged people with T2D aged 22 to 75 years, able toread and communicate in English, and with regular access tothe internet from 2 outpatient diabetes clinics located at Sunshine
Hospital in Victoria, Australia. Individuals who are pregnant
or breastfeeding, those with visual or hearing impairment, andhttps://formative.jmir.org/2023/1/e37429

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Karimi et al
those who had an eating disorder with special medical or dietaryrequirements, clinical depression, planned surgery, or plans forlong travel during the study period were not invited to theprogram. The inclusion and exclusion criteria have been fully
described in the study protocol [21].
A total of 90% (54/60) of the participants completed a
postintervention survey on the web or by phone with guidancefrom EatSmart researchers. Those 54 participants were sent an
invitation by mail or email containing a plain language statement
outlining study details and a consent form to complete a
poststudy telephone interview of up to 40 minutes at 36 weeks
after the baseline. Of the 54 participants, 20 (37%) consented
to interviews, with interviews continuing until data saturation
was achieved.
HCPs involved in diabetes care (including endocrinologists,
accredited practicing dietitians, and diabetes nurse educators)
at Sunshine Hospital diabetes clinics were also invited by email
to take part in a short Zoom (Zoom Video Communications) or
telephone interview or to complete a web-based survey about
the EatSmart program. The same questions were asked in eachformat (Zoom, phone, and survey). This range of participation
options was provided to maximize the number of participants
given that HCPs were dealing with the impacts of the COVID-19
outbreaks in Victoria.

Ethics Approval
Ethics approval was granted by the Western Health Low-Risk
Ethics Panel (49763, version 7, dated September 23, 2021) andthe Deakin University Human Research Committee (Human
Ethics Advisory Groups 186_2019) before conducting this study.
All participants were provided with an information sheet
explaining the project’s aim and signed a written informed
consent form before participating.

Data Collection From Intervention Participants
Data from intervention participants were collected through a
web-based self-reported survey that incorporated open-ended
questions to gather qualitative data on feedback on theintervention (the feedback survey), administered 12 weeks after
the baseline (time 2), and through semistructured telephoneinterviews administered at 36 weeks after the baseline (time 3).

Self-reported Feedback Survey
The feedback survey included 11 open-ended questions
regarding the perceived program effects, useful features of the
program, and what the intervention participants liked or disliked
about the EatSmart program (Multimedia Appendix 1).
Open-ended questions allowed respondents to provide more
information and contextual feedback and allowed researchers
to better understand the respondents’ true feelings and attitudes
about the intervention. Although the questions were primarily
qualitative, a small number of categorical and Likert-style
response questions were also included to supplement the
open-ended questions. These questions were mainly about how
useful intervention participants found the SMS text messages
and modules.
A personalized link to the web-based feedback survey was sent
by SMS text message or email to intervention participants.
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Telephone assistance from EatSmart researchers was provided
to participants who could not complete the survey alone. The
data capture and management tool REDCap (ResearchElectronic Data Capture; Vanderbilt University) [22] was used
for data collection.

Semistructured Interviews
Semistructured interviews were conducted 6 months after theintervention (36 weeks after the baseline) to provide a morecomprehensive description of the acceptability and usability ofthe program and explore longer-term maintenance of any
behavior or attitudinal changes. All interviews were conductedusing an interview guide. The interview guide was developed
based on the main study research questions and similar studies
exploring users’ experiences with digital interventions[16,23-25] and pilot-tested with 2 other researchers, whichenabled the interviewer to evaluate the interview guide andensure that the questions were relevant, clear, and effective forextracting data (Multimedia Appendix 2). The first question
invited intervention participants to speak freely and asked thefollowing: “What was your experience with the EatSmart
program?” Supplementary questions were asked during theinterviews to invite clarification and elaboration. Participantsalso answered questions about the various parts of the website,
SMS text messages, and content presented within theintervention; their perceived capability for action within theirpersonal situation; and adaptation and maintenance of any
food-related changes.

Karimi et al
The telephone interviews were conducted at a mutuallyconvenient time between October 2019 and November 2019
and were digitally audio recorded with the participants’permission. The audio recordings were then transcribed verbatim
by an independent professional transcription service. Eachtranscript was subsequently cross-checked with the audio
recording for more accuracy and deidentified by NK [26].
Intervention participants received an Aus $20 (~US $13) giftcard for their time and participation in the interviews.

Data Collection From HCPs
Data from HCPs were collected through either a semistructured
interview or a web-based survey, with the same questions posedin each format (Textbox 1). Semistructured interviews with
HCPs were conducted 36 weeks after the baseline (time 3) at amutually convenient time for both the HCP and the interviewer.
If no mutually convenient time was found, a short survey with
open-ended questions was emailed to the HCP. The Zoom
web-based platform was used for conducting, recording, andtranscribing these interviews, and Qualtrics (Qualtrics
International Inc) [27] was used for sending the survey andcollecting the responses.
All data from both surveys and interviews with intervention
participants and HCPs were pooled to generate a comprehensive
picture of postintervention experiences throughout that entire
period. These data were then imported into the NVivo software(QSR International) [28] for further analysis.

Textbox 1. Health care provider interview guide.
Main and prompting questions••

Are you aware of any of the patients who joined this program? Did you see any impact of EatSmart on improving healthy eating behaviors or
diet-related health outcomes of these patients?
•

If yes, can you please explain?

•

What do you think could be done to help maintain these healthy behaviors after the program?

•If no, what can be done to make this program more influential for patients who are on low incomes?

Do you consider EatSmart an effective digital healthy program for patients with type 2 diabetes (T2D) who are on low incomes?
•

Yes? What do you think makes a program like this effective?

•

No? what do you think makes a program like this ineffective?

•

What are the advantages of “digital healthy eating programs like EatSmart” for patients with T2D who are on low incomes?

•

What can be the barriers, challenges, or adverse effects of “digital healthy eating programs like EatSmart” for patients with T2D who are on low
incomes?

•

How do you feel this program might help your own health care or your work as a health professional?

•

How do you think this program can be improved for future use on a larger scale?
•

How do you think a program like this might need to be tailored to suit patients from different cultural groups that you work with?

Data Analysis
Descriptive statistics (mean, SD, frequency, range, andpercentages) were used to describe the sociodemographic
characteristics of the intervention participants and data fromcategorical and Likert-style questions. Place of birth wasdichotomized as “Australian born” and “other,” and education
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level was grouped as low (year 10 or lower), medium (year 12
or trade, certificate, or apprentice), and high (university degree
or higher).
The interview transcripts and open-ended survey responses werecombined and thematically analyzed following phases outlined
by Braun and Clarke [26]: immersion in the data, data coding
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to organize the data, creation of major and minor categories,
and identification of themes.
The researcher used an inductive approach to derive themes
through interpretations of the raw data. To explore various
possible interpretations of the data, a random subset of 3transcripts was independently coded by a second researcher(RSO). Both researchers then met and discussed theirinterpretations of the data, and the congruence was assessed
and found to be good. Open discussions within the researchteam resolved any discrepancies in data interpretation to reduce
researcher bias during the thematic development phase.
Researchers agreed on the final category system and accepted
it as being representative of the data. To enhance methodologicalrigor and transparency in the presentation of the methods andresults, recommendations of the COREQ (Consolidated Criteria
for Reporting Qualitative Research) [29] were followed.

Karimi et al
Owing to ethical considerations, after the interviews, no further
contact was made with program participants to obtain more
feedback.

Results
Participants

NK, who conducted the interviews, is a dietitian undertaking
research in the field of nutrition and physical activity. She waspart of the team that developed the EatSmart program; therefore,
we acknowledge that there is the potential for social desirability
bias from this interviewer. However, steps were taken to reducesocial response bias; for instance, (1) at the beginning of eachinterview, after explaining the reasons for doing this research,
it was emphasized to intervention participants and HCPs thatthe researcher was only interested in their honest thoughts andperspectives on the program and that there were no right orwrong answers, and (2) intervention participants and HCPs wereassured that no identifying information (people or organizations)would be published. Intervention participants and HCPs (apartfrom one) were not known to NK. One of the HCPs (CS) was
also a coresearcher on this study.

Following intervention completion at 12 weeks (time 2), a totalof 90% (54/60) of the intervention participants (or, in 7/54, 13%of cases, when participants were not confident in using
web-based platforms to complete the survey, carers ofintervention participants) completed the feedback survey. The
mean age of these participants was 53.6 (SD 12; range 22-75)
years; 54% (29/54) of the participants were male individuals;
and 41% (22/54) were of the participants Australian born (Table
1). A total of 36 weeks after the baseline (time 3), the data were
supplemented with in-depth qualitative phone interviews with30% (16/54) of the intervention participants. Phone interviews
with participants ranged from 25 to 55 minutes in length.
Variations in interview length were predominantly because ofparticipant availability or other commitments or contributionsof the participants, with some participants providing detailed
examples of the changes they had made after the program. Afterthe 13th interview, there were no new themes emerging.
Therefore, it was deemed that the data collection had reacheda saturation point. Data collection continued for 3 moreinterviews to confirm and ensure that there were no new themes
emerging. The characteristics of the participants who completed
the feedback survey at time 2 and those who were interviewed
at time 3 are detailed in Table 1. The mean age of participants
taking part in the interviews was 49.7 (SD 13.6; range 22-68)
years; 69% (11/16) of the participants were female individuals;
and 38% (6/16) of the participants were Australian born.

The other authors were not directly involved in the interviews
and analysis. However, they were used as a sounding board on
approximately 4 to 6 occasions, where they had the opportunity
to encourage further reflection and alternate interpretations of
the data (data coding phase and the identification of themes).

In total, 3 endocrinologists, 2 accredited practicing dietitians,
and 1 diabetes nurse educator accepted the invitation toparticipate in the study as HCPs and share their views throughinterviews (1/6, 17% of the HCPs) or a web-based survey (5/6,
83% of the HCPs).

Researcher Reflexivity

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Table 1. Sociodemographic characteristics of the intervention participants.
Characteristics of the study participantsTime 2 (n=54)

Time 3 (n=16)

Age (years), mean (SD; range)

53.6 (12; 22-75)

49.7 (13.6; 22-68)

Female25 (46)

11 (69)Male

29 (54)5 (31)

High

18 (33)7 (44)

Medium22 (41)8 (50)Low

14 (26)1 (6)Single12 (22)1 (6)De facto partnership

6 (11)

3 (19)

Married29 (54)8 (50)

Divorced

7 (13)

4 (25)

12 (7.8; 1-30)

11.1 (7.2; 1-20)

Oral diabetes medication

23 (43)1 (6)Insulin10 (19)4 (25)

Insulin and oral diabetes medication

21 (39)11 (69)Australia

22 (41)

6 (38)

Other countries

34 (63)10 (62)Sex, n (%)

Education level, n (%)

Marital status, n (%)

Diabetes duration (years), mean (SD; range)
Diabetes medication type, n (%)

Place of birth, n (%)

Emergent Themes
Five key themes emerged from the qualitative data fromintervention participants and HCPs: (1) program impact on
food-related behaviors and routines, (2) satisfaction with the
EatSmart program, (3) factors contributing to low engagement
and suggestions for future programs, (4) benefits and challenges
of digital interventions from health professionals’ viewpoint(HCPs only), and (5) cultural considerations (HCPs only).
Findings are described in the following sections withcorresponding intervention participant and HCP quotes.

Theme 1: Program Impact on Food-Related Behaviors
and Routines
Participants in the EatSmart program developed various newhealthy eating behaviors such as eating, cooking, and purchasing
greater quantities and varieties of fruits and vegetables andexplained that they maintained these changes 6 months after
completing the program.
Most intervention participants (28/54, 52%) highlighted positivechanges in their eating behaviors through practical choices.
They tried new vegetables or fruits and added more variety to
the type of vegetables they ate as side dishes or snacks.
Furthermore, they developed new skills such as setting goals
for eating a specific number of servings of vegetables per day.
Some intervention participants (7/54, 13%) also reported ahttps://formative.jmir.org/2023/1/e37429

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decrease in consumption of discretionary foods and beverages
after the program:...I minimized or stopped buying processed foods andjunk foods and fast foods and stopped drinking softdrinks, even the diet or sugarless soft drinks. Instead,I buy and cook and eat more fruits and vegetables
and portion my protein intake and drink more water.
[Participant 72, male, aged 50 years, 10 years withdiabetes, week 12]
Changes in cooking behavior by trying new cooking methods
such as steaming or adding more vegetables to dishes wereanother improvement stated by some intervention participants(12/54, 22%). To a lesser extent, some intervention participants(10/54, 19%) stated that they had created shopping lists and,while grocery shopping, they had visited the fruit and vegetablesection first, spent more time there, and bought more fruits andvegetables. Participants also talked about buying frozen andcanned fruits or vegetables when fresh items were not in season
or were expensive. In addition, there were some changes in theattitudes of EatSmart participants toward their foods and eating
behaviors. After the program, intervention participants planned
and made more informed decisions about what they wanted tocook and eat. They also became more confident and enthusiastic
about trying new types of fruits and vegetables:...I’m very aware of having some fruit and vegetables
every day where previously I would never think about
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it, if there were vegetables on the plate I’d eat thembut I wouldn’t think about, “Oh, I haven’t had any
vegetables.” And now there’s fruit in the fruit basket
and there’s vegetables in the vegetable crispers...
[Participant 2, female, aged 53 years, 12 years withdiabetes, week 36]
HCPs also perceived the program as effective in improving thefood-related behaviors of participants. A total of 50% (3/6) of
the HCPs, who had close contact with EatSmart participants,
echoed that their participants became more knowledgeable,
confident, and determined to adopt new eating habits. They feltthat their patients were keen to learn more about the effect ofdifferent food items on blood glucose levels and were eager to
try new food items.

Theme 2: Satisfaction With the EatSmart Program
Informative and motivational content, appealing web design
and usability, and acceptable intensity were 3 major categories
grouped to create the broad theme of satisfaction with the
EatSmart program.
Informative and Motivational Content
In terms of informative and motivational content, mostintervention participants (29/54, 54%) saw the educational valueof the program and stated that EatSmart increased theirconfidence and motivation to eat healthily:
It increased your knowledge about what to eat andconfidence about foods as well...Main text very useful,felt it increased her knowledge. Was very unsure
before now, just followed her traditional learning.
Now very confident about what to eat, including
serving numbers etc... [Participant 78, carer of awoman aged 58 years with diabetes for 14 years, week
12]
Intervention participants particularly liked the visualpresentation of the educational content on the website andacknowledged that the visual components made the modules
more impactful and memorable and, even 6 months after theintervention, they could still remember some of the photos andvideos. Participants also said that the visuals motivated themto read the entire module and helped them understand themessages faster.
HCPs also acknowledged that the EatSmart content wasappealing. They believed that the content was in line with theneeds of people with low income and that the simple language
and highly visual messages were the main factors contributing
to the success of this program.
Recipes
One of the main components of the EatSmart module content
that was highly appreciated by many intervention participantsand HCPs was recipes. Intervention participants indicated thatthey liked the recipes and cooking ideas, and some expressedthat they saved them for future reference:...I used to look forward to the recipes that came out
with them. Just to give them a go and as I said,
something different. Like I’d never had star fruits,
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Karimi et alactually...They were easy, and they were quick...
[Participant 7, female, aged 58 years, 6 years withdiabetes, week 36]
However, a few intervention participants (8/54, 15%)commented that the recipes were either too simple or too
complicated for them, which seemed to be related to their
existing cooking skills.
HCPs also appreciated the recipes and mentioned that when
one is hungry, time-poor, and stretched for money, processed
and fast foods can seem like the best choices; hence, introducing
easy-to-prepare, budget, and healthy meals in the EatSmart
program was useful.
Text Messages
During the 3-month intervention, participants received 36
automated SMS text messages. These messages were anothersatisfactory part of the program for most participants.
Intervention participants stated that the educational SMS text
messages were very useful and that they felt cared for and were
happy to receive them:...I liked the SMS or phone messages from Stella
informing and advising me on the best foods anddrinks to eat and how easy it is to prepare and enjoy
the varieties and food options available. As a resultof being involved with the EatSmart program I’ve lost
10 kilograms weighing from 122 kg to 112 kg today...
[Participant 72, male, aged 50 years, 10 years withdiabetes, week 12]
However, several participants (13/54, 24%) mentioned thatfewer SMS text messages per week would be more acceptable.
Web Design and Usability
Another major feature that intervention participants found
impactful for their satisfaction with the program was theuser-friendly design of the website. Many participants (18/54,
33%) appreciated that it was easy to get to the website and easy
to follow through and navigate:
it’s pretty straightforward, just scrolling down andclicking to the next page. [Participant 4, female, aged
30 years, 13 years with diabetes, week 36]
A total of 50% (3/6) of the health professionals also
acknowledged the ease of using the website even for older
patients with limited digital skills. One HCP added that the factthat the website required limited data use was also advantageous
as disadvantaged participants might not have unlimited data
access.
Program Intensity
Almost all intervention participants (47/54, 87%) deemed thelength of each module to be adequate:...I found that to be just enough. It was enough forthe information to go into my brain and stay there. I
think that if you read too much of something you missa lot. So, I think it was short and concise and to thepoint that that’s why it sort of stuck with me...
[Participant 2, female, aged 56 years, 2 years withdiabetes, week 36]
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HCPs also perceived the short length of the modules to beappropriate and enough to provide essential information. Manyintervention participants that were interviewed (13/16, 81%)
wanted the program to be extended in terms of the number ofmodules and duration in future versions. Some suggested thata 6-month program would be ideal, and some believed thatweekly modules for a period of 3 months would be better.
Overall Satisfaction
Many intervention participants (35/54, 65%) brought aboutchanges in their food-related behaviors and enjoyed theexperience with EatSmart, and more than half (27/43, 63%) ofKarimi et al
the survey respondents reported finding the EatSmart website
and SMS text messages very or extremely useful (Table 2).
Some reported that their family members also found the program
enjoyable and effective. Intervention participants wanted theprogram to continue and be expanded to more people withsimilar conditions. They believed that this program had helped
them eat healthier and make the choices that they believed would
benefit their diabetes; therefore, all interviewees (16/16, 100%)agreed that they would recommend EatSmart to other people
with T2D. All but 1 interviewee, who perceived that they alreadyhad enough knowledge, said that they would also continue their
engagement with the program if it were available for a longer
period.

Table 2. Results of the closed-ended questions from the postintervention feedback survey (N=54).
Survey question

Participants, n (%)

Have you changed the way you buy, cook, or eat food after taking part in the EatSmart program? (n=54)
Do not know

7 (13)

No

12 (22)Yes

35 (65)

How useful did you find the website? (n=43)
Not at all useful

1 (2)Slightly useful

6 (14)

Moderately useful

9 (21)

Very useful

6 (14)

Extremely useful21 (49)How useful did you find the phone messages? (n=49)
Not at all useful

1 (2)Slightly useful

4 (8)Moderately useful

12 (24)

Very useful

8 (16)

Extremely useful24 (49)Theme 3: Factors Contributing to Low Engagement and
Suggestions for Future Programs
Overview
Most intervention participants (27/43, 63%) expressedsatisfaction with EatSmart and viewed it as a valuable program.
Nevertheless, our data showed that not all of them visited all
the modules and read all the SMS text messages (data presented
in Karimi et al, under review). The reasons mentioned weregrouped into the following four categories: (1) sociocultural
factors such as lack of time because of long working hours orfamily responsibilities; (2) psychological factors such as apathy,
lethargy, and perception of inability to use the phone orcomputer to visit the website; (3) difficulties in accessing theinternet during some stages of the intervention; and (4)dissatisfaction with the content.
Concerning dissatisfaction with the content, some intervention
participants (7/54, 13%), particularly those who had had T2D
for a long period, believed that the program did not offer
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anything new to them and just reiterated what they alreadyknew. They highlighted the need for further or more advanced
information than that provided in the program. Although someof these participants felt that there was little new information,
they nevertheless considered that EatSmart was helpful as itprovided healthier food options or reinforced their previous
knowledge. In addition, 4% (2/54) of the participants perceived
that the program content contradicted their previous nutritional
beliefs or their culture; therefore, they were reluctant to read orfollow the recommendations:...some things contradicted her thoughts about
diabetes. Thought the website (was) associated withwestern medicine and doctors, so this put her off
reading more... [Participant 82, carer of a woman
aged 44 years with diabetes for 14 years, week 12]
Suggestions for Future Programs
Several suggestions were made on how to enhance the program.
Intervention participants believed that the program could be
improved with greater tailoring to individual needs; more
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advanced diabetes-specific information; more recipes; and morefeatures, such as a web-based discussion board.
In the design of EatSmart, all participants received the same setof basic and essential nutrition-related skills and informationnecessary for managing T2D. This was done to maximize theusability of the program for participants with very little
knowledge of the relationship between food and diabetes.
However, some participants (10/54, 19%) noted that people atdifferent stages of diabetes have different needs in establishingor changing eating behaviors, and they looked for informationthat was relevant to the complications that they faced. Therefore,
they requested more detailed diabetes-specific information suchas the carbohydrate content of different fruits and vegetables,
best drink choices, and low-carbohydrate diets. A participantsuggested that future programs would be more beneficial if they
included some dietary advice for people who struggle withdifferent conditions at the same time, for example, diabetes andarthritis.
Furthermore, intervention participants described the desire tohave recipes that accommodated varying characteristics andcircumstances, such as different cooking skill levels, foodpreferences (eg, vegetarianism), and families’ food preferences.
They desired more traditional recipes or techniques toincorporate more vegetables into traditional foods fromparticular cultures. The inclusion of low-carbohydrate, “quick
and easy” recipes that are suitable for working women wasanother suggestion made for future programs:...I liked the recipes there; they were simple and easy
to prepare. But maybe add more traditional recipes(Indian foods) or show how we can improve our
traditional foods and make them healthier by adding
vegetables... [Participant 13, male, aged 68 years, 20
years with diabetes, week 36]
Although participants highlighted the benefits of an automatic
web-based program, a complementary theme was identified inwhich the importance of support from others (HCPs, peers withlived experience, or other people with similar conditions) was
expressed. Several participants who were interviewed (8/16,
50%) suggested adding a web-based forum or discussion board
where they could share their problems or experiences with otherparticipants or the research team.
HCPs also recommended some improvements in content toincrease the efficacy of EatSmart or future similar programs.
They specified the need to discuss the common food- andbudget-related problems of disadvantaged people with diabetes
on the website. One HCP advised the addition of content on
how having a healthy diet can help patients save money by
preventing diabetes complications and their related medical
expenses.
Similar to the participants, HCPs also spoke of the importanceof introducing more affordable recipes using commonly
available nutritious foods:...Use examples of foods that are readily available
and affordable recipes of popular foods prepared ina healthy way. Information regarding carbohydrates
in popular “unhealthy” food, when they may be able
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Karimi et al
to have them and how much exercise needed to offset
it Regular updates on new recipes etc... [HCP 5,
endocrinologist, week 36]

Theme 4: Benefits and Challenges of Digital
Interventions From HCPs’ Viewpoint
The digital environment was seen by all the HCPs (6/6, 100%)
as a promising platform to deliver support and informationneeded by people with diabetes. They acknowledged that manyof their patients, especially the younger ones, were alreadyengaged with digital technologies, and some were interested inreceiving digitally delivered health programs. HCPs believedthat digital interventions could provide an important adjunct totheir routine medical care, facilitate the delivery of support andeducation, and save consultation time:...Well, I think, having that program to refer people
to, it’s something they can take home and do after
because often in a consultation you don’t have timeto go through everything that you’d like to cover, but
if you can cover some essentials in the consultationand then give that program to the patient to say look,
you can take time at your convenience go through at
your own pace, the different parts of the program andthen, if you’ve got questions at our next consultation
we could discuss those and reinforce anything thatneeded to be reinforced... [HCP 6, credentialed
diabetes educator, week 36]
HCPs also emphasized that this mode of program is affordable,“free,” and easily accessible and, in addition to making the rightinformation available at the right time and in the correct form,
can help patients save on travel time.
Although digital interventions were acknowledged to simplify
the transmission of essential information to patients, some HCPs
(2/6, 33%) articulated concerns about the reliability of thematerials and stressed the importance of providing up-to-dateevidence-based information. In total, 50% (3/6) of the HCPs
also expressed unease about information being misinterpreted
by patients, which may cause harm to them. One HCP
emphasized that these programs needed to be introduced only
by HCPs and as an adjunct to their care after the first visit:
Another adverse effect can be a misunderstanding
about the serving sizes. You tell them to eat two servesof fruits and five serves of vegetables, but they may
think the more the better so overeat different fruits.
Because of this, I suggest the introduction of thisprogram should be after the first session with adietitian. They need to learn the basics first, then stepby step learn new information. [HCP 2, accredited
practicing dietitian, week 36]
Another concern of HCPs was the possibility that participants
might overlook the role of the health care team afterparticipating in these programs. A total of 50% (3/6) of thehealth professionals talked about the perceived detrimental
effects on the health professional-patient relationship with theadvent of health-related digital technologies and shifting thecontrol of information from the health care team to digitalprograms. HCPs argued that, regardless of advances in digital
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Karimi et alinterventions, these programs provide general information rather
than customized recommendations for the special needs ofpatients; thus, the need for communication between healthprofessionals and patients should not be neglected.

a behavior is important for producing intention to change. Thisis regulated by forethought, in which people guide their actions
by considering anticipated future behaviors and their effects.
Over time, forethought contributes to increase self-efficacy [30].

Theme 5: Cultural Considerations

Similar results were reported by Arora et al [31], Moussa et al[32], Porter et al [33], and Ruggiero et al [34], who exploredthe effects of different kinds of digital interventions on
food-related behaviors of disadvantaged people with T2D. Thesestudies found positive intervention effects on nutritional
knowledge, diabetes knowledge, self-efficacy, and nutritional
behavior.

HCPs highlighted that food practices can be affected by cultural
identity and, therefore, it is important to consider culturaldifferences in both the intervention content and design.
In terms of content, HCPs suggested the addition of more diverse
food items and recipes to the website that cater to different
ethnic and cultural backgrounds. One of the health professionals
emphasized that participants from different ethnic backgrounds
are probably familiar with how to cook their traditional foods.
Hence, it is valuable that, instead of merely providing therecipes, the program shows them how to make their traditional
foods healthier by, for example, adding more affordable
vegetables. Another HCP also suggested covering different foodbeliefs such as vegetarianism along with cultural considerations:...It would be good to have some that specified thedifferent cultural groups or different eating beliefs
like even one for vegans one for vegetarians thatmight not even be about their particular ethnic
culture, but it could be just about their beliefs aroundfood... [HCP 6, credentialed diabetes educator, week
36]
Regarding technical design, all HCPs suggested translating thewebsite to languages other than English so that it can be usable
by non-English speakers. In addition, HCPs suggested using
culturally familiar elements for specific ethnic groups, forinstance, incorporating pictures and videos of people of theirown nationalities into the design of websites.

Discussion
Principal Findings
The findings showed that a digitally delivered intervention withsupportive and educational modules and SMS text messages
improved healthy eating and was accepted by people withdiabetes who were socioeconomically disadvantaged. The study
also found that HCPs generally held positive views of digitalprograms in promoting healthy eating behaviors and had specificsuggestions for tailoring such programs, including to culturalgroups.

Changes in Food-Related Behavior
EatSmart targeted nutritional knowledge as well as promoting
positive mindsets toward healthy eating (ie, self-efficacy).
Participants reported an increase in their nutritional knowledge
and confidence in improving their eating behaviors. Moreover,many perceived that the program had led them to eat more
vegetables and fruits. These changes were confirmed by HCPs
who had direct contact with the participants.
These changes may have been brought about by the intervention
material, increasing participants’ intentions and forethought
about improving their eating behaviors. Bandura [30] proposedthat providing information about a behavior or cues to perform
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Program Intensity
Many EatSmart participants (32/54, 59%) perceived thefrequency of the modules to be appropriate, although a few(13/54, 24%) were dissatisfied with the number of SMS text
messages per week. Previous evidence suggests that more
frequent contact from an intervention is associated with greater
effects on behavior change, whereas, by contrast, SMS text
messages sent too frequently can elicit negative reactions andresult in disengagement or adverse outcomes [25,35]. For
example, Horner et al [35] found that intervention participants
with T2D who received physical activity–related SMS text
messages twice daily for 6 months developed negative feelings
about the program and started avoiding or ignoring messages.
That study and others [25,36,37] found that participantsquestioned the intrusiveness of receiving frequent SMS text
messages. It remains unclear how digital interventions candeliver accurate and timely information at a sufficient intensity
without unfavorable effects on participants’ engagement. Somestudies have indicated that patient preferences for the numberof SMS text messages may depend on the message type. A large
and varied SMS text message database can improve participant
engagement as opposed to frequent messages with similar
content, which can cause boredom or indifference [25,38].
Updating delivery frequency according to participant preferences
after regular check-ins may also help negate the negative
feelings that result from frequent SMS text messages [39].

Engagement With the EatSmart Program and Directions
for Future Programs
Participants reported good engagement with different
components of EatSmart in general, which attests to the overall
acceptability of the program. However, almost half (23/43, 53%)of the participants reported not fully engaging with allcomponents. Some participants (7/54, 13%) suggested that theywould have preferred more detailed diabetes-specificinformation or more customized information as the basic content
and familiarity with the content were the main reasons for theirlower engagement. Many previous studies [6,40-45] havediscussed patients’ perceptions of having sufficient knowledge
as main reasons for lower engagement or nonattendance todiabetes education programs. Horigan et al [6] have suggested
that many people are simply rejecting educational opportunities
without fully understanding what is involved and what theymight gain from attending and that, if all aspects of diabetes
education were explained to participants, it might increase
engagement [6]. In a study by Temple and Epp [42], whennoncompleters were given more information about the
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JMIR FORMATIVE RESEARCH
intervention, many said that they would be willing to complete
or expressed a wish to learn more.
In this study, lower engagement and suggestions for moreadvanced content mainly came from participants with a longer
diabetes duration. Similarly, other studies have shown that
program satisfaction and uptake were lower among people who
had a longer diabetes duration, with newly diagnosed
participants more likely than others to complete the course[7,46]. This suggests that, although diabetes self-management
education and support should be offered to everyone with T2D,
people who are newly diagnosed should be specifically targetedin the first year following diagnosis, and more advanced andspecifically tailored programs should be designed for people
with a longer diabetes duration.
A 2017 review of diabetes education programs [6] stated that
there are a multitude of other reasons why people with diabetes
may have lower engagement with digital interventions, including
the nonprioritization of health interventions, lack of enthusiasm,
and the belief that they would not benefit, contributing to poor
uptake and completion. Our study results also corroborate thesefindings.
In the EatSmart program, both intervention participants and
HCPs expressed high satisfaction with the recipes and videos
of food preparation within the intervention, and one of thesuggestions made to improve the program was adding moresimilar materials to the website, such as more recipes
incorporating affordable foods. This finding highlights theimportance of direct instruction and observational learning ininterventions with this target group. Observational learning
involves people observing a behavior conducted by others andthen replicating those actions. This is often exhibited through“modelling” of behaviors. Modeling provides individuals withthe skills and strategies to adopt and maintain behaviors [47].
The positive effect of modeling on improving diabetes
self-management among people from different sociocultural
backgrounds has been reported in previous studies[32,34,48-51].
Intervention participants also suggested adding more interactive
features such as a web-based forum or a discussion board toprovide opportunities to interact with other people with diabetes
or HCPs in a way that is anonymous and convenient. This
demonstrates the importance of delivering social support, which
is an effective technique for behavior change. The facilitationof social support in electronic health programs has been shownto increase health outcomes above and beyond programs without
this feature (Hales et al [52]). Evidence has demonstrated thatbeing a member of a web-based diabetes forum resulted in better
engagement with programs and improved glucose control,
reduced HbA1c levels, and improved dietary choices and led
to a better understanding and increased confidence in managing
diabetes [6,34,53]. However, a qualitative study showed negative
attitudes toward peer support in health promotion programs[54]. The authors of this UK study expressed the need to further
investigate how to foster engaging and enjoyable social support
environments in interventions [54]. Further importantconsiderations regarding web-based forums are the additional
ongoing cost and resources required to host the forums andhttps://formative.jmir.org/2023/1/e37429

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Karimi et al
ensure their safety, maintain the currency and relevancy of theinformation presented there, and moderate the discussion
between participants [55]. Previous research has also indicatedthat providing a high level of support from HCPs is more
important for people of low socioeconomic status, who often
have lower health literacy, material resources, and self-efficacy
to cope with the complex burden of self-care [54].

HCPs’ Perspectives on the Benefits and Challenges ofDigital Interventions
Our findings showed that EatSmart was well received among
HCPs as it was felt to be both feasible and sustainable to support
their patients from a workload standpoint. Consistent withprevious studies [55-58], HCPs in this study stated that the useof digital platforms is a promising method to improve patientagency and empowerment by providing disease-related
knowledge and education, provided that concerns about
patient-HCP contact and reliability of information wereaddressed. HCPs also acknowledged that, rather than relying
on occasional in-clinic interactions, digital interventions havethe potential to benefit health care by overcoming constraints
because of limited clinician time and inability to provide
meaningful interventions at the most appropriate time.
Furthermore, in line with previous literature [13,53,59-61], theymentioned that digital interventions can broaden the availabilityof services through ease of access, reducing health careinequities and increasing cost-effectiveness through prevention
and self-management.
In this study, HCPs expressed some concern about the possible
negative effects of digital interventions on routine clinical careand patient-HCP interactions. However, the current literaturesuggests that such educational and behavior change platforms
hold value to patients by facilitating improvements incommunication with HCPs and enabling a level of understandingthat supports shared decision-making in clinics [62].
Furthermore, appointment reminders can be added to theseinterventions to encourage session attendance with HCPs.
Another element of concern for HCPs was related to thereliability and appropriateness of the content of digitalinterventions, which may limit their use in clinical care. This
concern has been similarly expressed in previous studies [55],which noted that poorly designed health and medical apps havethe potential to harm the users. Gurupur et al [63] discussed
that many readily available low-cost health apps are not basedon evidence from research and that such apps may provide
incorrect information. To address this concern, efforts need tobe made to ensure that digitally delivered diabetes programs
are evidence based, theory driven, quality assured, and regularly
audited for necessary updates to content.

Cultural Considerations
EatSmart shows promise in delivering the essential knowledge
and skills necessary to eat healthily. However, engaging withthis program can still be challenging for many ethnic minority
groups because of socioeconomic, linguistic, and culturalbarriers. HCPs in this study emphasized the critical importanceof tailoring the content and design of digital interventions to fit
the cultural identity of patients. Previous studies andmeta-analysesoftechnology-based
interventions
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JMIR FORMATIVE RESEARCH[13,25,33-35,64-67] have emphasized the importance ofcustomizing the interventions in a way that meets the culturaland linguistic needs of the target population. However, studies
on the effect of interventions that address these needs haveproduced mixed results. For instance, Arora et al [31] foundimprovements in eating habits and medication adherence but
not in glycemic control; Moussa et al [32] found improvements
in knowledge, self-care behaviors, and glycemic control; andWayne et al [68] found improvements in glycemic control but
not in self-care behaviors.
Tailoring program content to culture or language may be more
complicated, costly, and time-intensive to implement but may
make it more persuasive, salient, and useful. Further researchshould be conducted on how to execute precise tailoring andcustomization on a cost-effective basis and what types of
personalization will result in more persuasive cues.

Strengths and Limitations
The strengths of this study included the qualitative approach,which enabled us to gather rich data about participants’experiences with the EatSmart program and HCPs’ insights on
successful or unsuccessful elements of EatSmart. These data
were based on responses from 54 participants of different ages,
education, occupations, living arrangements, and marital
statuses, which is a relatively large and demographically varied
sample for a qualitative study. The complementary one-on-one
interviews with participants and HCPs allowed for triangulationof the data to gather richer descriptive insights. Exploring theperspectives of both patients and HCPs was a further strength.
Other strengths included the application of Social Cognitive
Theory to both the intervention design and the consideration of
the results, which allowed us to make a theoretically informedinterpretation of the qualitative data.
Despite the study strengths, our results should be interpretedwith consideration of the following limitations. First, thefindings regarding HCPs’ perspectives are limited by their small
number. This may have limited the variability in responses andprecluded comparing results across different HCPs or
disciplinary backgrounds. However, all the health professionals
involved (6/6, 100%) had extensive experience in providing
services to vulnerable patients and were aware of the special
needs of these groups. Second, this study was conducted in
English, limiting some participants (with English as their second
language) regarding precisely expressing their opinions andelaborating on their ideas. It was also conducted in a
metropolitan area and so generalizability to those in rural or
remote areas is unknown. Moreover, another possible limitation

Karimi et al
to the generalizability of results might be the limited access todigital technologies by people experiencing severesocioeconomic disadvantage, such as those who are homeless.
However, Australia has a high diffusion of mobile technologies
among all demographic groups, and the digital divide isshrinking steadfastly, with currently nearly 9 out of 10 adults
owning a smartphone [69]. A further limitation was our inability(because of the ethical limitations) to invite people who were
offered the program but did not register to take part in it or those
who withdrew from the program to take part in interviews.
Interviewing these people could have helped us better
understand why some people are not willing to use phone- or
web-based structured programs or were unsatisfied with theprogram. Finally, people with T2D and HCPs who chose to takepart in the study interviews may have been a particularly
motivated group who had a positive experience with EatSmart.

Conclusions
The findings indicate that EatSmart, a behaviorally focused
nutrition intervention, was generally appealing tosocioeconomically disadvantaged people with T2D and showedpromise in terms of promoting healthy eating behaviors andincreases in vegetable and fruit consumption that were sustained
over time. HCPs also found this intervention beneficial andpersuasive for the target audience.
We identified specific objective elements of the intervention,such as informative content, appealing design, and acceptable
intensity of the program. The web and text content was foundto be engaging and provided an appropriate source of knowledge
and psychosocial support for people with diabetes. On the basisof Social Cognitive Theory, we conceptualized that knowledge
increased the self-efficacy of participants and was used by themto make and maintain changes in food-related behaviors.
Improvements for future studies were identified, including
tailoring to the frequency of contact preferences, existingknowledge, and cultural background, as well as enhanced
opportunities for social support and verbal communication.
If specific adaptations are made, the intervention could feasibly
be rolled out on a broader scale as an inexpensive adjunct toroutine clinical care to promote healthy eating and diabetes
self-management among vulnerable populations. More work is
required to make digital interventions more appropriate forpeople from different cultural backgrounds. Future studies are
required to investigate whether increased customization results
in increased engagement of more disadvantaged participants
and improved health outcomes.

Acknowledgments
This work was supported by a Diabetes Australia Research Program grant and the Institute for Physical Activity and Nutrition
at Deakin University. The authors gratefully acknowledge the time and effort contributed by the participants.

Authors' Contributions
Each named author contributed to conducting the underlying research and drafting the manuscript.

Conflicts of Interest
None declared.
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Karimi et alMultimedia Appendix 1
Postintervention feedback survey.
[DOCX File , 16 KB-Multimedia Appendix 1]

Multimedia Appendix 2Interview questions for intervention participants.
[DOCX File , 19 KB-Multimedia Appendix 2]

References
1.
2.

3.

4.

5.
6.
7.

8.

9.

10.

11.

12.

13.

14.

15.
16.

17.

Roglic G. WHO Global report on diabetes: a summary. Int J Noncommunicable Diseases 2016;1(1):3-8.
Lie SS, Karlsen B, Graue M, Oftedal B. The influence of an eHealth intervention for adults with type 2 diabetes on thepatient-nurse relationship: a qualitative study. Scand J Caring Sci 2019 Sep;33(3):741-749. [doi: 10.1111/scs.12671][Medline: 30866066]
Nelson LA, Coston TD, Cherrington AL, Osborn CY. Patterns of user engagement with mobile- and web-delivered self-careinterventions for adults with T2DM: a review of the literature. Curr Diab Rep 2016 Jul;16(7):66 [FREE Full text] [doi:10.1007/s11892-016-0755-1] [Medline: 27255269]
Kirkman MS, Rowan-Martin MT, Levin R, Fonseca VA, Schmittdiel JA, Herman WH, et al. Determinants of adherence
to diabetes medications: findings from a large pharmacy claims database. Diabetes Care 2015 Apr;38(4):604-609 [FREEFull text] [doi: 10.2337/dc14-2098] [Medline: 25573883]
García-Pérez LM, Alvarez M, Dilla T, Gil-Guillén V, Orozco-Beltrán D. Adherence to therapies in patients with type 2
diabetes. Diabetes Ther 2013 Dec;4(2):175-194 [FREE Full text] [doi: 10.1007/s13300-013-0034-y] [Medline: 23990497]
Horigan G, Davies M, Findlay-White F, Chaney D, Coates V. Reasons why patients referred to diabetes education programmes
choose not to attend: a systematic review. Diabet Med 2017 Jan;34(1):14-26. [doi: 10.1111/dme.13120] [Medline: 26996982]
Poduval S, Marston L, Hamilton F, Stevenson F, Murray E. Feasibility, acceptability, and impact of a web-based structured
education program for type 2 diabetes: real-world study. JMIR Diabetes 2020 Jan 06;5(1):e15744 [FREE Full text] [doi:10.2196/15744] [Medline: 31904580]
Joiner K, Nam S, Whittemore R. Lifestyle interventions based on the diabetes prevention program delivered via eHealth:a systematic review and meta-analysis. Prev Med 2017 Jul;100:194-207 [FREE Full text] [doi: 10.1016/j.ypmed.2017.04.033][Medline: 28456513]
Gatwood J, Shuvo S, Ross A, Riordan C, Smith P, Gutierrez ML, et al. The Management of Diabetes in Everyday Life
(MODEL) program: development of a tailored text message intervention to improve diabetes self-care activities among
underserved African-American adults. Transl Behav Med 2020 Feb 03;10(1):204-212. [doi: 10.1093/tbm/ibz024] [Medline:
30794316]
Burner E, Lam CN, DeRoss R, Kagawa-Singer M, Menchine M, Arora S. Using mobile health to improve social support
for low-income latino patients with diabetes: a mixed-methods analysis of the feasibility trial of TExT-MED + FANS.
Diabetes Technol Ther 2018 Jan;20(1):39-48 [FREE Full text] [doi: 10.1089/dia.2017.0198] [Medline: 29227155]
Wang J, Cai C, Padhye N, Orlander P, Zare M. A behavioral lifestyle intervention enhanced with multiple-behavior
self-monitoring using mobile and connected tools for underserved individuals with type 2 diabetes and comorbid overweightor obesity: pilot comparative effectiveness trial. JMIR Mhealth Uhealth 2018 Apr 10;6(4):e92 [FREE Full text] [doi:10.2196/mhealth.4478] [Medline: 29636320]
Fallon M, Spohrer K, Heinzl A. Deep structure use of mHealth: a social cognitive theory perspective. In: Proceedings ofthe 27th European Conference on Information Systems (ECIS). 2019 Presented at: 27th European Conference on Information
Systems (ECIS); Jun 8-14, 2019; Stockholm & Uppsala, Sweden.
Pal K, Eastwood SV, Michie S, Farmer AJ, Barnard ML, Peacock R, et al. Computer-based diabetes self-management
interventions for adults with type 2 diabetes mellitus. Cochrane Database Syst Rev 2013 Mar 28(3):CD008776 [FREE Fulltext] [doi: 10.1002/14651858.CD008776.pub2] [Medline: 23543567]
Greenwood DA, Gee PM, Fatkin KJ, Peeples M. A systematic review of reviews evaluating technology-enabled diabetes
self-management education and support. J Diabetes Sci Technol 2017 Sep 31;11(5):1015-1027 [FREE Full text] [doi:10.1177/1932296817713506] [Medline: 28560898]
Pereira K, Phillips B, Johnson C, Vorderstrasse A. Internet delivered diabetes self-management education: a review. Diabetes
Technol Ther 2015 Jan;17(1):55-63. [doi: 10.1089/dia.2014.0155] [Medline: 25238257]
Torbjørnsen A, Ribu L, Rønnevig M, Grøttland A, Helseth S. Users' acceptability of a mobile application for persons with
type 2 diabetes: a qualitative study. BMC Health Serv Res 2019 Sep 06;19(1):641 [FREE Full text] [doi:10.1186/s12913-019-4486-2] [Medline: 31492176]
Jalil S, Myers T, Atkinson I. A meta-synthesis of behavioral outcomes from telemedicine clinical trials for type 2 diabetes
and the Clinical User-Experience Evaluation (CUE). J Med Syst 2015 Mar 13;39(3):28. [doi: 10.1007/s10916-015-0191-9][Medline: 25677954]

https://formative.jmir.org/2023/1/e37429

XSL• FO
RenderX

JMIR Form Res 2023 | vol. 7 | e37429 | p. 13(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
18.
19.
20.

21.

22.

23.

24.

25.

26.
27.
28.
29.

30.
31.

32.
33.
34.

35.

36.

37.
38.

39.

40.

Kim H, Sefcik JS, Bradway C. Characteristics of qualitative descriptive studies: a systematic review. Res Nurs Health 2017
Feb 30;40(1):23-42 [FREE Full text] [doi: 10.1002/nur.21768] [Medline: 27686751]
Lambert V, Lambert C. Qualitative descriptive research: an acceptable design. Pacific Rim Int J Nursing Res
2012;16(4):255-256.
Willis D, Sullivan-Bolyai S, Knafl K, Cohen M. Distinguishing features and similarities between descriptive
phenomenological and qualitative description research. West J Nurs Res 2016 Sep;38(9):1185-1204. [doi:10.1177/0193945916645499] [Medline: 27106878]
Karimi N, Crawford D, Opie R, Maddison R, O'Connell S, Hamblin PS, et al. EatSmart, a web-based and mobile healthyeating intervention for disadvantaged people with type 2 diabetes: protocol for a pilot mixed methods intervention study.
JMIR Res Protoc 2020 Nov 06;9(11):e19488 [FREE Full text] [doi: 10.2196/19488] [Medline: 33155571]
Harris P, Taylor R, Minor B, Elliott V, Fernandez M, O'Neal L, REDCap Consortium. The REDCap consortium: building
an international community of software platform partners. J Biomed Inform 2019 Jul;95:103208 [FREE Full text] [doi:10.1016/j.jbi.2019.103208] [Medline: 31078660]
Moyano D, Morelli D, Santero M, Belizan M, Irazola V, Beratarrechea A. Perceptions and acceptability of text messaging
for diabetes care in primary care in Argentina: exploratory study. JMIR Diabetes 2019 Mar 18;4(1):e10350 [FREE Fulltext] [doi: 10.2196/10350] [Medline: 30882362]
Bartlett YK, Newhouse N, Long HA, Farmer AJ, French DP. What do people with type 2 diabetes want from a brief
messaging system to support medication adherence? Patient Prefer Adherence 2019;13:1629-1640 [FREE Full text] [doi:10.2147/PPA.S217843] [Medline: 31686789]
Udoko AN, Graff J, Ransone S, Coday M, Gatwood JD, Bailey JE. Characteristics of health-related text messages preferredby medically underserved African-American patients with diabetes. Cureus 2019 Sep 24;11(9):e5743 [FREE Full text][doi: 10.7759/cureus.5743] [Medline: 31723504]
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006 Jan;3(2):77-101. [doi:10.1191/1478088706qp063oa]
Qualtrics homepage. Qualtrics. URL: https://www.qualtrics.com [accessed 2021-10-01]
Jackson K, Bazeley P. Qualitative Data Analysis with NVivo. London: Sage Publications; 2013.
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist forinterviews and focus groups. Int J Qual Health Care 2007 Dec;19(6):349-357. [doi: 10.1093/intqhc/mzm042] [Medline:
17872937]
Bandura A. Human agency in social cognitive theory. Am Psychol 1989 Sep;44(9):1175-1184. [doi:10.1037/0003-066x.44.9.1175] [Medline: 2782727]
Arora S, Peters AL, Agy C, Menchine M. A mobile health intervention for inner city patients with poorly controlled diabetes:
proof-of-concept of the TExT-MED program. Diabetes Technol Ther 2012 Jun;14(6):492-496. [doi: 10.1089/dia.2011.0252][Medline: 22524591]
Moussa M, Sherrod D, Choi J. An e-health intervention for increasing diabetes knowledge in African Americans. Int J Nurs
Pract 2013 Sep 01;19 Suppl 3:36-43. [doi: 10.1111/ijn.12167] [Medline: 24090296]
Porter SJ, Chapman-Novakofski KM, Scherer JA. Your guide to diet and diabetes: web-based diabetes education tailored
to Hispanics. J Nutr Educ Behav 2009;41(5):374-376. [doi: 10.1016/j.jneb.2009.04.003] [Medline: 19717123]
Ruggiero L, Moadsiri A, Quinn LT, Riley BB, Danielson KK, Monahan C, et al. Diabetes island: preliminary impact of avirtual world self-care educational intervention for African Americans with type 2 diabetes. JMIR Serious Games
2014;2(2):e10 [FREE Full text] [doi: 10.2196/games.3260] [Medline: 25584346]
Horner GN, Agboola S, Jethwani K, Tan-McGrory A, Lopez L. Designing patient-centered text messaging interventions
for increasing physical activity among participants with type 2 diabetes: qualitative results from the text to move intervention.
JMIR Mhealth Uhealth 2017 Apr 24;5(4):e54 [FREE Full text] [doi: 10.2196/mhealth.6666] [Medline: 28438728]
Kannisto KA, Koivunen MH, Välimäki MA. Use of mobile phone text message reminders in health care services: a narrative
literature review. J Med Internet Res 2014 Oct 17;16(10):e222 [FREE Full text] [doi: 10.2196/jmir.3442] [Medline:
25326646]
Holtz B, Lauckner C. Diabetes management via mobile phones: a systematic review. Telemed J E Health 2012
Apr;18(3):175-184. [doi: 10.1089/tmj.2011.0119] [Medline: 22356525]
Job JR, Spark LC, Fjeldsoe BS, Eakin EG, Reeves MM. Women's perceptions of participation in an extended contact text
message-based weight loss intervention: an explorative study. JMIR Mhealth Uhealth 2017 Feb 27;5(2):e21 [FREE Fulltext] [doi: 10.2196/mhealth.6325] [Medline: 28242595]
Alkhaldi G, Modrow K, Hamilton F, Pal K, Ross J, Murray E. Promoting engagement with a digital health intervention(HeLP-diabetes) using email and text message prompts: mixed-methods study. Interact J Med Res 2017 Aug 22;6(2):e14[FREE Full text] [doi: 10.2196/ijmr.6952] [Medline: 28829328]
Schäfer I, Pawels M, Küver C, Pohontsch NJ, Scherer M, van den Bussche H, et al. Strategies for improving participationin diabetes education. A qualitative study. PLoS One 2014 Apr 14;9(4):e95035 [FREE Full text] [doi:10.1371/journal.pone.0095035] [Medline: 24733428]

https://formative.jmir.org/2023/1/e37429

XSL• FO
RenderX

Karimi et al

JMIR Form Res 2023 | vol. 7 | e37429 | p. 14(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
41.
42.
43.
44.
45.

46.
47.
48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

58.

59.

60.

61.

Findlay-White F, Slevin M, Carey M, Coates V. "What's the point?": understanding why people with type 2 diabetes decline
structured education. Clin Diabetes 2020 Apr;38(2):166-175 [FREE Full text] [doi: 10.2337/cd19-0030] [Medline: 32327889]
Temple B, Epp D. Evaluation of a diabetes education program's non-attendees: the program response. Can J Diab 2009
Jan;33(4):375-380. [doi: 10.1016/s1499-2671(09)34007-1]
Rafique G, Shaikh F. Identifying needs and barriers to diabetes education in patients with diabetes. J Pak Med Assoc 2006
Aug;56(8):347-352 [FREE Full text] [Medline: 16967784]
Schäfer I, Küver C, Wiese B, Pawels M, van den Bussche H, Kaduszkiewicz H. Identifying groups of nonparticipants intype 2 diabetes mellitus education. Am J Manag Care 2013 Jun;19(6):499-506 [FREE Full text] [Medline: 23844710]
Gucciardi E, Chan VW, Lo BK, Fortugno M, Horodezny S, Swartzack S. Patients’ perspectives on their use of diabetes
education centres in Peel-Halton region in Southern Ontario. Can J Diab 2012 Aug;36(4):214-217. [doi:10.1016/j.jcjd.2012.07.009]
Poduval S. Online Structured Education for People Newly Diagnosed with Type 2 Diabetes. London: UCL (University
College London); 2019.
Bandura A, McClelland D. Social Learning Theory. Hoboken, New Jersey, United States: Prentice Hall; 1977.
Burgermaster M, Gajos K, Davidson P, Mamykina L. The role of explanations in casual observational learning about
nutrition. In: Proceedings of the 2017 CHI Conference on Human Factors in Computing Systems. 2017 Presented at: CHI'17: CHI Conference on Human Factors in Computing Systems; May 6 - 11, 2017; Denver Colorado USA.
Diker A, Cunningham-Sabo L, Bachman K, Stacey J, Walters L, Wells L. Nutrition educator adoption and implementationof an experiential foods curriculum. J Nutr Educ Behav 2013;45(6):499-509 [FREE Full text] [doi:10.1016/j.jneb.2013.07.001] [Medline: 23958208]
Nauta H, Spil T. Change your lifestyle or your game is over: the design of a serious game for diabetes. In: Proceedings ofthe 2011 IEEE 1st International Conference on Serious Games and Applications for Health (SeGAH). 2011 Presented at:2011 IEEE 1st International Conference on Serious Games and Applications for Health (SeGAH); Nov 16-18, 2011; Braga,
Portugal.
Madden M, Tomsik P, Terchek J, Navracruz L, Reichsman A, Clark T, et al. Keys to successful diabetes self-management
for uninsured patients: social support, observational learning, and turning points: a safety net providers' strategic alliancestudy. J National Med Assoc 2011 Mar;103(3):257-264 [FREE Full text] [doi: 10.1016/s0027-9684(15)30292-3]
Hales S, Turner-McGrievy GM, Wilcox S, Fahim A, Davis RE, Huhns M, et al. Social networks for improving healthy
weight loss behaviors for overweight and obese adults: A randomized clinical trial of the social pounds off digitally (Social
POD) mobile app. Int J Med Inform 2016 Oct;94:81-90. [doi: 10.1016/j.ijmedinf.2016.07.003] [Medline: 27573315]
Mayberry LS, Lyles CR, Oldenburg B, Osborn CY, Parks M, Peek ME. mHealth interventions for disadvantaged andvulnerable people with type 2 diabetes. Curr Diab Rep 2019 Nov 25;19(12):148 [FREE Full text] [doi:10.1007/s11892-019-1280-9] [Medline: 31768662]
Dennison L, Morrison L, Conway G, Yardley L. Opportunities and challenges for smartphone applications in supporting
health behavior change: qualitative study. J Med Internet Res 2013 Apr 18;15(4):e86 [FREE Full text] [doi:10.2196/jmir.2583] [Medline: 23598614]
Shaw T, McGregor D, Brunner M, Keep M, Janssen A, Barnet S. What is eHealth (6)? Development of a conceptual modelfor eHealth: qualitative study with key informants. J Med Internet Res 2017 Oct 24;19(10):e324 [FREE Full text] [doi:10.2196/jmir.8106] [Medline: 29066429]
Willcox JC, van der Pligt P, Ball K, Wilkinson SA, Lappas M, McCarthy EA, et al. Views of women and health professionals
on mHealth lifestyle interventions in pregnancy: a qualitative investigation. JMIR Mhealth Uhealth 2015 Oct 28;3(4):e99[FREE Full text] [doi: 10.2196/mhealth.4869] [Medline: 26510886]
Aweko J, De Man J, Absetz P, Östenson CG, Swartling Peterson S, Mölsted Alvesson H, et al. Patient and provider dilemmasof type 2 diabetes self-management: a qualitative study in socioeconomically disadvantaged communities in Stockholm.
Int J Environ Res Public Health 2018 Aug 22;15(9):1810 [FREE Full text] [doi: 10.3390/ijerph15091810] [Medline:
30135373]
Wang J, Chu C, Li C, Hayes L, Siminerio L. Diabetes educators' insights regarding connecting mobile phone- and wearable
tracker-collected self-monitoring information to a nationally-used electronic health record system for diabetes education:
descriptive qualitative study. JMIR Mhealth Uhealth 2018 Jul 26;6(7):e10206 [FREE Full text] [doi: 10.2196/10206][Medline: 30049667]
Poole ES. HCI and mobile health interventions: how human-computer interaction can contribute to successful mobile healthinterventions. Transl Behav Med 2013 Dec;3(4):402-405 [FREE Full text] [doi: 10.1007/s13142-013-0214-3] [Medline:
24294328]
Rollo ME, Aguiar EJ, Williams RL, Wynne K, Kriss M, Callister R, et al. eHealth technologies to support nutrition andphysical activity behaviors in diabetes self-management. Diabetes Metab Syndr Obes 2016;9:381-390 [FREE Full text][doi: 10.2147/DMSO.S95247] [Medline: 27853384]
Heitkemper EM, Mamykina L, Travers J, Smaldone A. Do health information technology self-management interventions
improve glycemic control in medically underserved adults with diabetes? A systematic review and meta-analysis. J Am
Med Inform Assoc 2017 Sep 01;24(5):1024-1035 [FREE Full text] [doi: 10.1093/jamia/ocx025] [Medline: 28379397]

https://formative.jmir.org/2023/1/e37429

XSL• FO
RenderX

Karimi et al

JMIR Form Res 2023 | vol. 7 | e37429 | p. 15(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
62.
63.
64.

65.

66.
67.
68.

69.

Karimi et al

Rowland SP, Fitzgerald JE, Holme T, Powell J, McGregor A. What is the clinical value of mHealth for patients? NPJ Digit
Med 2020;3:4 [FREE Full text] [doi: 10.1038/s41746-019-0206-x] [Medline: 31970289]
Gurupur VP, Wan TT. Challenges in implementing mHealth interventions: a technical perspective. Mhealth 2017;3:32[FREE Full text] [doi: 10.21037/mhealth.2017.07.05] [Medline: 28894742]
Wayne N, Perez DF, Kaplan DM, Ritvo P. Health coaching reduces HbA1c in type 2 diabetic patients from alower-socioeconomic status community: a randomized controlled trial. J Med Internet Res 2015 Oct 05;17(10):e224 [FREEFull text] [doi: 10.2196/jmir.4871] [Medline: 26441467]
Mayberry LS, Berg CA, Harper KJ, Osborn CY. The design, usability, and feasibility of a family-focused diabetes self-care
support mHealth intervention for diverse, low-income adults with type 2 diabetes. J Diabetes Res 2016;2016:7586385[FREE Full text] [doi: 10.1155/2016/7586385] [Medline: 27891524]
Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol
Rev 2010;32:56-69 [FREE Full text] [doi: 10.1093/epirev/mxq004] [Medline: 20354039]
Fjeldsoe BS, Marshall AL, Miller YD. Behavior change interventions delivered by mobile telephone short-message service.
Am J Prev Med 2009 Feb;36(2):165-173. [doi: 10.1016/j.amepre.2008.09.040] [Medline: 19135907]
Wayne N, Ritvo P. Smartphone-enabled health coach intervention for people with diabetes from a modest socioeconomic
strata community: single-arm longitudinal feasibility study. J Med Internet Res 2014 Jun 06;16(6):e149 [FREE Full text][doi: 10.2196/jmir.3180] [Medline: 24907918]
Mobile Nation 2019. Deloitte Access Economics. 2019. URL: https://www2.deloitte.com/content/dam/Deloitte/au/Documents/
Economics/deloitte-au-economics-mobile-nation-2019-080419.pdf [accessed 2022-01-20]

Abbreviations
COREQ: Consolidated Criteria for Reporting Qualitative Research
HCP: health care provider
REDCap: Research Electronic Data Capture
T2D: type 2 diabetes

Edited by A Mavragani; submitted 20.02.22; peer-reviewed by E Burner, M Maviso; comments to author 23.05.22; revised version
received 06.06.22; accepted 06.06.22; published 04.01.23
Please cite as:
Karimi N, Opie R, Crawford D, O’Connell S, Hamblin PS, Steele C, Ball K
Participants’ and Health Care Providers’ Insights Regarding a Web-Based and Mobile-Delivered Healthy Eating Program for
Disadvantaged People With Type 2 Diabetes: Descriptive Qualitative StudyJMIR Form Res 2023;7:e37429
URL: https://formative.jmir.org/2023/1/e37429
doi: 10.2196/37429
PMID: 36598815©Nazgol Karimi, Rachelle Opie, David Crawford, Stella O’Connell, Peter Shane Hamblin, Cheryl Steele, Kylie Ball. Originallypublished in JMIR Formative Research (https://formative.jmir.org), 04.01.2023. This is an open-access article distributed under
the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, isproperly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as wellas this copyright and license information must be included.

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