e-Health for Diabetes Self Management in Saudi Arabia: Barriers and Solutions (Preprint)
Authors: Alanazi Fuhid , Gay Valerie 
Published: February 2020

BACKGROUND

U.S. National Centre for Health Statistics defines chronic disease as any disease which lasts long, typically over three months or more (Shiel Jr, 2018). Chronic diseases long term care consisting of multiple approaches. This makes many chronic diseases amenable to self-management. One such chronic disease is diabetes.
Shrivastava, Shrivastava, and Ramasamy (2013) described Diabetes or more precisely, Diabetes mellitus (DM) as “a chronic progressive metabolic disorder characterized by hyper-glycemia mainly due to absolute (Type 1 DM) or relative (Type 2 DM) deficiency of insulin hormone. “The authors prescribe seven essential components of self-management of diabetes. These include healthy eating, being physically active, monitoring of blood sugar, compliance with medications, good problem-solving skills, healthy coping skills and risk-reduction behaviours. Clearly, all these practices may not be absolutely essential for all patients all times. Some of them may be more critical than others like closer monitoring of blood sugar when the person already has high level of blood sugar. To what extent the diabetes patients follow these seven practices and in what contexts is an important aspect.
e-health is variously defined in various sources. Eysenbach (2001) defined the term as, “e-health is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies. In a broader sense, the term characterizes not only a technical development, but also a state-of-mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve health care locally, regionally, and worldwide by using information and communication technology.”
The relevance of self-management of diabetes in Saudi Arabia arises from the fact that it is a serious demographic threat to the country. In a recent review, Abdulaziz Al Dawish, et al. (2016) cited WHO to establish that Saudi Arabia tops Middle East and is seventh in the world regarding the population affected by diabetes. Out of 7 million population, 3 million have been affected by diabetes. The rate of increase in diabetes had also been very high reaching epidemic levels. An article by Jennifer Bell in Arab News (2019) cited Colliers International, which estimates 17.9% of Saudi population affected by diabetes. In addition, about 35.4% of Saudi population is obese, which is a predisposing factor for diabetes. Translated into numbers, Saudi population in 2019 is 34.1 million and 17.9% of this will be about 6 million diabetic population and 12 million obese. Thus, Saudi Arabia needs to focus on about 20 million of its population. The Saudi Vision 2030 has targets to achieve fitness and sports participation of youth by 25%. This strategy will reduce diabetes problem also. Clearly, apart from hospital visits, these patients need to be trained to manage their diabetes problem themselves. The seven elements of diabetes self-management prescribed by Srivastava et al (2013) listed above are relevant here. The usefulness of self-management in producing positive outcomes for diabetic patients in Saudi Arabia was demonstrated by AlShareef, AlMaarik, AlGarni, AlGhamdi, and AlMutairi (2017) through a survey. However, another survey by Saad, et al. (2018) showed that only foot care and medication self-management were practised by the majority of diabetic patients. Diet control, exercise and blood glucose monitoring were not being done as a part of self-management by most of them. Since these were the factors which enhanced self-efficacy, it was low in the surveyed population. Low level of self-management practices except medication was also reported by Al Johani, Kendall, and Snider (2015) from their survey. In a review of research on self-management of diabetes in GCC countries, Al Slamah, Nicholl, Alslail, and Melville (2017) mentioned about three papers arguing for culturally relevant self-management practices. This may be an important factor in the case of strongly Islamic states like Saudi Arabia.
The foregoing discussions show that self-management practices of diabetes can produce positive outcomes for patients, but the compliance levels are low. Alsomali (2018) listed culture and religion, gender, stigma, social support, and healthcare environment and support from spouse, friends and healthcare professionals as affecting self-management of diabetes. Similar and more detailed factors at micro, meso and macro levels were identified by Alharbi (2018).
Considering e-health applications in self-management of diabetes, Aldahmash, Ahmed, Qadri, Thapa, and AlMuammar (2019) pointed out to the ability of e-health applications to reach inaccessible and remote localities. It improves access and affordability of diabetes care through self-management. Availability of internet facilities determine accessibility in rural and remote areas. Hospital visits are kept to the minimum, as patients can seek medical advice through remote access when in need, specifically urgently. This makes e-health for diabetes affordable.
The internet penetration is high in Saudi Arabia in 2018. But there are limitations to access due to social and religious cultural barriers like gender differentiation and other factors. For comparison, global access figure is 58% for 2019 (Clement, 2019). Except Africa, Asia and Lain America/Caribbean, all other regions have over 80% internet penetration as per Internet World Stats (2019). Average for Middle East is 67%. More than 90% penetration has been reported for Bahrain,	Qatar, Kuwait, Lebanon, Saudi Arabia and UAE. Thus, Saudi Arabia is well-placed when compared to many other countries in the region as well as the world. Therefore, internet access cannot be a limiting factor for e-health application for self-management of diabetes in the country.
Healthcare is treated as a right in Saudi Arabia. So, all the costs to the patients at the point of care are free for Saudi citizens and expatriates. However, increasing costs have forced a review of this issue. Privatisation and insurance schemes are considered to cover the costs to the government. A survey study by Al-Hanawi, Alsharqi, Almazrou, and Vaidya (2018) showed that some dissatisfaction over the quality of care, the availability of appointments, waiting times at the hospitals and the availability of medicines and other materials existed among the patients.
From the foregoing discussions, it is clear that diabetes and obesity are two major demographic health problems for Saudi Arabia. Self-management of diabetes by patients is partial solution to the cost burden of both patients and the country. E-health offers good scope to reduce this cost further with increased accessibility and affordability within the high internet penetration scenario of Saudi Arabia. However, there are problems and barriers at various levels for fully successful achievement of e-health. These problems need to be identified and solutions found. The aim of this systematic review was to identify and solve the problems of implementing e-health for self-management of diabetes in Saudi Arabia.

OBJECTIVE

The aim of this systematic review was to find out how e-health applications can benefit self-management of diabetes in Saudi Arabia. Barriers and solutions was the focus. Google Scholar was searched using the topic as the search term. The search yielded 20 usable papers which were listed and described briefly and then categorised according to the topic of the paper and direction of findings.
Mobile-enabled e-health applications was found promising in most papers. However, many barriers at various levels and in various contexts need to be overcome for its successful implementation. Integration of patient records at national level, training of those operating and maintaining the system, improving internet connectivity and speed to reach even the remote areas are some basics to be addressed. Education of patients through knowledge creation and management using social networks in mobile phones, registered nurses or community-level trained educators is a pre-requisite to introduction of mobile-enabled e-health here. Cultural aspects like Ramadan fasting and other religious observations need to be researched further. Obesity, diabetes of type 1 and type 2 among children can be addressed using social robots. But parents also need to be educated. Mobile-enabled self-management of diabetes by women during pregnancy also needs further research.

METHODS

Google Scholar was used as the search engine. The topic itself was used as the search term to collect literature from five web pages each for three different time frames. Only works in English language were collected. Abstracts have been included if they contained useful information. There is no definite period for search. But generally articles older than 2005 were not favoured. Only research articles on Saudi Arabia were selected. This search strategy yielded 20 usable papers. These papers are listed and briefly described below. Then they have been categorised in various ways to derive findings and conclusions.

RESULTS

1. An intelligent mobile application for diabetes management and educational system for patients in Saudi Arabia with type 2 diabetes, SAED, was developed by Alotaibi, Istepanian, Sungoor, and Philip (2014). It has a patient/healthcare component and an intelligent diabetes management component. The first of these has two units, one for the patient and the other for diabetes specialist unit. In the intelligent management system, there is a database module, an intelligent decision support based on fuzzy logic, an SMS reminder module and a diabetes education module. Stored clinical data like test results, medication and other interventions, along with the decision support system, facilitates monitoring and recommending suitable interventions by clinicians as and when required. Trials to validate the system were to be undertaken. The SAED system was validated for its effectiveness in reducing HbA1C levels in a pilot trial by Alotaibi, Istepanian, and Philip (2016).
2. A six month study on feasibility of mobile messages to control type 1 diabetes in children by Bin-Abbas, Jabbari, Al-Fares, El-Dali, and Al-Orifi (2014) showed a small reduction in blood sugar glucose level. In the trial, parents of 200 children were sent daily information and weekly interaction messages were sent to the parents. The knowledge of parents about diabetes and its management improved due to this effort. Such mobile messaging serves as useful intervention between clinical visits.
3. A high percentage of youngsters favoured application of mobile technologies and social networking for diabetes self-management in the studies of Alanzi, Istepanian, Philip, and Sungoor (2014).
4. Although there was no significant impact of screen size of mobile phone on the comprehension of content of diabetes related information, small screens reduced the speed of reading the contents. This finding was reported by Alghamdi, Yunus, and Househ (2013).
5. The barriers associated with implementation of e-health initiatives were discussed by Almuayqil, Atkins, and Sharp (2015) Absence of systems to connect health information systems available at various levels to integrate at national level was one. Lack of technical and computer skills to use design and use health information systems was the second. Absence of guidelines on using health information records and poor maintenance of networks and computers, slow connections and old terminals were included here. Human barriers of negative perceptions of healthcare professionals about technologies, lack of trust towards computer-based solutions consisted of the third barrier. Cultural barriers stand in the way of virtual contact in favour of physical contact. The possibility of medication safety due to lack of communication or miscommunication is another barrier. Communication gaps among healthcare institutions and limited use of technology to compensate for illegible prescriptions are also included in this barrier. High cost of transferring paper records into digital records is another barrier. Security and privacy problems of internet is a major barrier. To solve this problem, the authors proposed a knowledge management and knowledge discovery.
6. In a follow-up paper, a detailed study using surveys of citizens, healthcare professionals and IT specialists led to ranking of e-health barriers by Almuayqil, Atkins, and Sharp (2016). The citizen’s ranking of barriers is reproduced in Fig 1.

Figure 1. Citizen's ranking of barriers to e-health in Saudi Arabia (Almuayqil, Atkins, & Sharp, 2016).
According to the ranking b citizens, connectivity of information systems ranked first. Human barriers related to negative perceptions, lack of trust in the new system and resistance to change were ranked second. Financial barriers was the third, mainly related to utilising electronic systems of healthcare.
The ranking by healthcare professionals is reproduced in Fig 2.

Figure 2. Ranking of barriers of e-health by healthcare professionals in Saudi Arabia (Almuayqil, Atkins, & Sharp, 2016).
The mean values of ratings by health professionals did not cross 3.5 for any variable. Connectivity of information systems was again ranked one, leading to the conclusion that they do not use e-health for their patients. They also unable to view, update or disseminate EHRs and laboratory test results of patients from other hospitals visiting them. Cultural barriers were also identified by healthcare professionals. Security and privacy was ranked third by them.
The ranking by IT specialists is reproduced in Fig 3. IT professionals ranked medication safety as top barrier, followed by financial barriers. Connectivity of internet systems was only ranked third. Their own technical skills were ranked fourth.

Figure 3. Ranking of e-health barriers in Saudi Arabia by IT specialists (Almuayqil, Atkins, & Sharp, 2016).
7. An e-health literacy scale (SeHL) was developed by Zakaria, et al. (2018) to facilitate self-management of chronic diseases like diabetes. Four key aspects of e-health literacy were identified for measurement of e-health literacy and implementation of strategies to enhance e-health literacy of chronic patients. These four were use of technology/media, information-seeking, usefulness and confidence.
8. Based on survey and interviews, Alotaibi M. M. (2015) concluded that there is high level of support from youngsters for use of mobile technology for effective management and health awareness of fasting diabetes in Saudi Arabia. The study was done during Ramadan time. Thus, cultural congruence was ensured in this study.
9. Asiri (2015) recognised diabetic education programmes for diabetic patients to manage their problems better to reduce complications and thereby reduce costs. PHCs can play an active role in this respect through their registered nurses. The author proposed an educational plan for PHC centres in the southern region to meet this objective of Saudi Arabia.
10. An innovative social robotics system for diabetes management and educational system for diabetic children in Kingdom of Saudi Arabia was proposed by Alotaibi and Choudhury (2015). The system made use of Aisoy1 v5 robot applicable in mobile health technologies. The system was aimed improve the diabetes type 1 management by empowering them with relevant knowledge about diabetes and its management and to create awareness among them.
11. A mobile information and education system for gestational diabetes was proposed by Alotaibi and Albalawi (2018). It integrates the patient information and ongoing interventions and their outcomes with the already available information on the topic, so that continuous contextual updating happens. The framework is to be tested trough randomized controlled trials on a wide scale in Saudi Arabia.
12. Alanzi T. (2018) identified lack of mHealth expertise and human shortage, inadequacies of funding and infrastructure investments, legal, privacy standardization and regulatory obstacles, health care organizational and bureaucracy problems, as barriers of implementing m-health for self-management of diabetes.
13. Inadequate functional health literacy, overall effective self-care affected by depressed mood were noted from the survey results by Almigbal, et al. (2019). However, functional health literacy was not associated with self-management. Functional health literacy was significantly influenced by age, gender, educational level, employment status and level of the depressive symptoms were significantly.
14. Alwin Robert, et al. (2016) noted that over the last two decades, there was a 500% increase in the expenses in healthcare and treatment of diabetes in Saudi Arabia. In 2014, out of the total health care budget of SR180 billion, about 25 billion (13.9%) was spent on diabetic care alone. To mitigate the situation, a comprehensive epidemic control program using multidisciplinary approach needs to be stringently enforced. The authors identified rising prevalence rate of diabetes and its pre-conditions, increasing prevalence among children and younger population, lifestyle risks, obesity and delayed diagnosis as the major challenges of implementing effective diabetes control programmes. The same obstacles are relevant in self-management and e-health applications for self-management.
15. The knowledge creation model, Socialization, Externalisation, Combination and Internalisation (SECI) facilitates interaction of tacit and explicit knowledge by applying the four conversion modes implied in the model. Almuayqil, Atkins, and Sharp (2017) proposed a framework to support diabetic patients and healthcare professionals to enable self-manage by patients. It has two components: data mining and the SECI model integrated suitable for this purpose.
16. Mashi, et al. (2019) found from a survey that health literacy level was high among Saudi diabetes patient, but it was not used for effective glycaemic control.
17. Similar to the social robotics system for children for diabetes management and education (Alotaibi & Choudhury, 2015), a social robotics system for obesity management for children was also proposed by Alotaibi M. (2018).
18. Abdullah (2018) tried to identify predictors of Saudi female diabetic patients’ intention to use smartphones for self-management of diabetes. Performance expectancy, effort expectancy, social influence and patient-centred factors were tested as likely predictors. The results showed that Saudi female diabetic patients were using and intended to use smartphones in future also for self-management of the disease. Current use influenced their intention for future use. Only effort expectancy was a significant predictor of intention to use smartphones in future.
19. Combining Theory of Planned Behaviour and Technology Acceptance Model, AlBar and Hoque (2018) examined the factors influencing patient acceptance of e-health services in Saudi Arabia. Perceived usefulness and perceived ease of use strongly influenced attitude towards e-health. Attitude and subjective norm highly influenced patient behavioural intention to use e-health services. On the other hand, perceived behavioural control did not affect patient behavioural intention to use e-health services. These findings may be applicable in the case of e-health applications for self-management of diabetes also.
20. A systematic review by Alotaibi M. (2017) revealed the usefulness of social robots to improving the diabetic management and awareness among Saudi children.
Some trends
Topics of the selected papers
Some interesting trends were observable in the selected papers. A large majority of papers dealt with mobile/smart phones applications as e-health tools. The trend of papers virtually meant that e-health means m-health. More trends on the topics of the papers are given in Table 1.
Table 1. Topics dealt by the selected papers. Numbers given in the references are the item numbers in the brief description of the papers. EH-e-health, SM-smartphone/mobile. FHL-Functional Health Literacy.
Topic	Number	References
Mobile/smartphone	6	1,2, 3, 4, 8, 11
Problems/challenges/barriers/obstacles/factors/predictors of e-health or smartphone applications	7	5 EH, 6EH, 12SM, 13FHL, 14EH, 18SM, 19EH
e-health literacy measuring	2	7, 16, 18
Education through RNs in PHCs	1	9
Social robotics for children	3	10, 17, 20
Knowledge creation and management	1	15

As Table 1 shows, 6 papers dealt directly with mobile phone or smartphone as e-health tool, often termed as m-health. An additional two papers dealt with problems and challenges related to m-health. Together, out of 20 papers, 8 (40%) were m-health related. Papers dealing with e-health mostly dealt with problems and challenges. There were 4 such papers. Three papers dealt with functional health literacy, FHL. Out of these, two were related to its measurement and one was related to factors affecting FHL. Thus, only seven papers dealt with e-health topics. Social robotics for diabetes education of children was the subject of three papers, all led by a single author. One of these was a review. Only one paper dealt with knowledge creation and management, although as said above, three papers measured FHL, which is a product of knowledge creation and management.
Direction of findings
Some problems affect generalisability and identifying common trends via meta-analysis of quantitative data across the papers, as discussed below. Instead, a simple method of categorising the direction of the overall finding has done in Table 2. It answers the question: Does this paper support or reject e-health applications for self-management of diabetes as an effective method to control diabetes in Saudi population. It can be seen that 11 out of 20 papers are positive towards e-health as a self-management tool for diabetes and more so, with mobile/smartphone applications. Negative findings are related to challenges and barriers for e-health. Once these problems are solved, e-health becomes positive for self-management of diabetes. Three papers just described some aspects and hence could not be categorised either way. So, they were grouped as No Trend papers.
Table 2. Direction of findings for e-health applications in self-management. Problems, challenges and barriers are categorised as negative direction. Predictors are positive.
Direction of findings	References	Number of papers
Positive	2, 3, 4, 7, 8, 9, 10, 17, 18, 19, 20	11
Negative	5, 6, 12, 13, 14, 16	6
No trend	1, 11, 15	3

CONCLUSIONS

The reviewed papers clearly show that mobile-enabled e-health systems for diabetes self-management will be the most effective and efficient route. But before doing that, the patients need to be educated through direct approach, mobile applications and social networking through mobile phones. Internet connectivity and speed need to be improved to reach even remote locations. Other infrastructures need to be provided. Patient information scattered in different provider units at different places need to be integrated at national level. People involved in operating and maintaining the system need to be trained. All the problems, challenges and barriers need to be removed.
Researches on problems and challenges need to focus on solutions rather than just identification. Need for further research on education of children through social robotics along with education of their parents is highlighted. Apart from Ramadan, the impact of other religious practices on adaptation of diabetes self-management need to be researched. Two other aspects needing attention of researchers are: type 1 diabetes self-management among children and self-management of diabetes by women during pregnancy. The question to be answered may be: How smartphone enabled e-health can serve these two purposes.