Understanding the patients’ experience in Primary Technology Enhanced Care Home HbA1c Testing (PTEC HAT) programme - A Qualitative Study

Understanding the patients’ experience in Primary Technology Enhanced Care Home HbA1c Testing (PTEC HAT) programme - A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Understanding the patients’ experience in Primary Technology Enhanced Care Home HbA1c Testing (PTEC HAT) programme - A Qualitative Study Kah Pieng Ong, Elya Chen, Evonne Oh, Eng Sing Lee, Wern Ee Tang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4461158/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Oct, 2025 Read the published version in BMC Primary Care → Version 1 posted 4 You are reading this latest preprint version Abstract Background Diabetes mellitus related healthcare expenditure is expected to rise drastically as the incidence of diabetes associated comorbidities increase. Hence, it is vital to maintain ideal glycaemia for patients with diabetes to reduce the risk of diabetic complications. Given the strong predictive value for diabetes complications, HbA1c remains the gold standard test to monitor glycaemic control in contemporary clinical practice. HbA1c is recommended to be measured between quarterly to six monthly, depending on the level of patient’s glycaemic control. There is growing positive evidence that supports the use of innovative telemedicine to monitor and manage patients with diabetes. Telemedicine has particularly played a crucial role in efforts against the COVID-19 pandemic. PTEC HAT pilot programme is developed by MOH Office of Healthcare transformation (MOHT) to implement telemonitoring care to low-risk patients with type 2 diabetes mellitus (T2DM) in the community through National Healthcare Group (NHG) Polyclinics collaboration. It is intended to empower low-risk patients to manage their T2DM care independently and maintain their follow-up with the healthcare team by telemonitoring. Through PTEC HAT, eligible patients will be able to replace their three to six monthly interim paired HbA1c test and physical polyclinic visits with home HbA1c tests and teleconsultations, saving them up to three visits to polyclinic per year while getting their glycaemic control telemonitored by the healthcare team. This qualitative study is conducted as part of the evaluation of the pilot implementation of PTEC HAT programme. It aims to explore the experiences of low-risk patients with T2DM who participated in PTEC HAT programme, and to identify the enablers and barriers of using various PTEC HAT components. Methods Patients referred by healthcare team were selected via purposive sampling and invited via telephone. Individual semistructured in-depth interviews were conducted with 12 patients. The interviews were audio-recorded and transcribed verbatim. The results generated from thematic analysis were presented in the form of rich descriptions. The nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability (NASSS) framework was used as the conceptual framework for the topic guide and guided the analysis framework. The emergent results were categorised into the enablers and barriers further grouped into themes. Results The identified enablers and barriers were grouped into themes. For the enablers, patient found the coaching by healthcare team and the access to supporting materials (video tutorial and user guide) useful in encouraging them to complete PTEC HAT programme. Patients accepted PTEC HAT as a suitable telemonitoring programme to maintain care for low-risk T2DM, especially during the pandemic. In term of technology component, patients liked the proactive reminder for home HbA1c testing by the in-app chatbot and the advantage of completing review through teleconsultation. Patients felt rewarded as the reading could be generated instantaneously using the home HbA1c test and the flexibility to perform the home HbA1c test at any preferred time was another great value. The patients also valued the convenience of teleconsultation following home HbA1c test, which saved time and reduced clinic visits. Patient characteristic which enabled successful participation included a reasonable level of digital literacy, prior experience with health monitoring, absence of needle phobia and strong intrinsic motivation. The barriers identified included tedious storage and preparation of the HbA1c self-test kit in addition to the prolonged onboarding process. The three to six months’ gap between onboarding and conducting the actual home HbA1c testing was reported to be challenging for patients to recall the required steps. Other key barriers included issues with syncing the home HbA1c reading to mobile app via the Bluetooth device. The concerns of high cost associated with the PTEC HAT programme had also resulted in a negative impact on patients’ acceptability and lowered their perceived value. Last, low digital literacy, needle phobia and lack of motivation were identified as the barriers at patient level to affect PTEC HAT programme. Conclusion Patients reported that home HbA1c monitoring under PTEC HAT was a useful alternative to routine care. The patients' experience with PTEC HAT varied with their exposure to health monitoring and health literacy. Findings from this study can provide insights to improve the design of other similar telehealth initiatives and enhance widespread adoption, scale-up, spread and sustainability of home HbA1c monitoring. Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Diabetes mellitus continues to move up the ranks as one of the leading causes of disability and years of life lost, indicating a global transition in disease patterns toward noncommunicable diseases 1 . It is one of the common chronic diseases in Singapore, with the age standardised prevalence rate of 7.9% 2 . With an ageing population, Singapore is projected to have up to one million individuals with diabetes by 2050. It has been reported that the healthcare expenditure will rise drastically as the future incidence of diabetes related comorbidities increase 3 . It is vital to achieve and maintain glycaemia as close as possible to its ideal range to reduce the risk of diabetic complications, adverse cardiovascular outcomes and mortality 4 , 5 , 6 . HbA1c results from glycation, a reaction that involves posttranslational modification of haemoglobin A by the nonenzymatic covalent binding of glucose to the N-terminal valine of the β-globin chain 7 . Low intraindividual biological variability, the stability of the analyte and the independence of results to the prandial status were the most pronounced advantages of HbA1c over plasma glucose. Hence, it remains the gold standard test to monitor glycaemic control in clinical practice 8 , especially for low risk patients with type 2 diabetes mellitus (T2DM) 20 . The HbA1c test is traditionally performed at the laboratory located within a clinic or healthcare institution. The American Diabetes Association recommends measuring HbA1c at least twice a year in patients who are meeting treatment goals and quarterly in patients whose therapy has changed or have suboptimal glycaemic control, given its strong predictive value for diabetes complications 9 . There is growing positive evidence that supports the use of innovative technology, such as telemedicine, to monitor and manage patients with diabetes 10 , 11 , 12 , 13 . Telemedicine has particularly played a crucial role in efforts against the COVID-19 pandemic, with its unique ability to minimise physical physician-patient contact, thereby breaking infection chains, as well as its ability to optimise healthcare system capacity during demand surges 14 . In Singapore, there is a significant level of willingness to take up telemedicine among the diabetes patients in polyclinics, though 52.2% of them felt that they will be willing after hearing positive reports 15 . Numerous recent qualitative studies have focused on the patients’ perception of using telehealth for T2DM management, as well the factors for supporting primary care physician engagement with patient mobile app for T2DM self-management. The studies have yielded mixed result 16 , 17 , 18 . In recent years, there have been newer approved HbA1c self-test kits available in the market but there is no study describing the deployment of these devices in published literature. PTEC HAT programme is developed by MOHT and collaborated with NHG Polyclinics to implement telemonitoring care to low-risk patients with T2DM in the community. Low-risk patients are patients who do not require self-blood glucose monitoring (SBGM) or continuous glucose monitoring (CGM), without insulin treatment, without active titration of medication and/or with low risk of hypoglycaemia. The PTEC HAT system, as illustrated in Fig. 1 , consists of HbA1c self-test kit, optional blood pressure (BP) machine for patients with coexisting hypertension and a mobile app on the patients’ smartphone (with in-app chatbot and multimedia educational materials access). It is intended to empower low-risk patients with T2DM to manage their condition independently and maintain their follow-up with the healthcare team by telemonitoring. By participating in PTEC HAT, eligible patients will be able to replace their three to six monthly interim paired HbA1c test and physical polyclinic visits with home HbA1c tests and teleconsultations. The frequency of home HbA1c test and teleconsultation will be determined by the reviewing doctor during the polyclinic visit following the annual diabetes panel test. This allows patients to save up to three visits to polyclinic per year while getting their glycaemic control telemonitored by the healthcare team. The PTEC HAT care plan is illustrated in Fig. 2 . Upon enrolment, the patients will be trained by the healthcare team to perform home HbA1c tests. They will be issued a Bluetooth enabled test kit called A1CNow + and other resources, namely, the video tutorial and guidebook to bring home. The A1cNow + test kits require refrigerator storage. When it is due to perform the home HbA1c test, the patients will receive an in-app chatbot reminder notification on their mobile app. Patients need to take out the A1CNow + from the refrigerator and thaw it. The patients are required to follow 12 steps to complete the home HbA1c test, as illustrated in Fig. 3 . Then, the A1cNow + Bluetooth device will synchronise the reading to the mobile app. While patients can keep track of their HbA1c reading from home, the reading will also be transmitted to the healthcare team at NHG Polyclinics. Patients will be followed up via tele-consultation. Timely medical interventions will be provided for any abnormal HBA1c reading. The patients will subsequently be reminded to perform home HbA1c testing and submit their readings at regular intervals, until their next scheduled appointment for annual diabetes panel tests and face-to-face consultation at the polyclinic. This qualitative study is conducted as part of the evaluation of the pilot implementation of PTEC HAT programme. At the time of conducting this qualitative research, the PTEC HAT programme will be the first to embed home HbA1c testing into telemonitoring for low-risk patients with T2DM. It aims to explore the experiences of low-risk patients with T2DM who completed PTEC HAT programme, and to identify the enablers and barriers of using various PTEC HAT components. METHODS Setting This qualitative research was conducted as part of the evaluation process of the pilot implementation of PTEC HAT programme. Following the roll-out of PTEC Home BP Monitoring programme 19 , the PTEC HAT system, which employed similar technological supports, was piloted in NHG Polyclinic between July 2021 and September 2022. NHG Polyclinics is part of the National Healthcare Group, which serves a population of 1.5 million in Singapore’s Central North region. The seven existing polyclinics are Ang Mo Kio Polyclinic, Geylang Polyclinic, Kallang Polyclinic, Hougang Polyclinic, Toa Payoh Polyclinic, Woodlands Polyclinic and Yishun Polyclinic. The NHG Polyclinic is a one stop centre for primary care needs, which provides management of acute conditions, chronic disease management, women’s health and family planning, childhood immunisation and developmental assessment, health promotion/disease prevention, allied health services (dietetic, psychology, physiotherapy, podiatry, medication management, financial counselling, medical social service, lab and diagnostic service) and dental care. Theoretical Framework This study was guided by the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) theoretical framework 20 to develop the interview guide and to conduct thematic analysis. The NASSS framework was developed to study unfolding technology programmes in real-time and particularly to identify and manage their emergent uncertainties and interdependencies 20 . It is one of the most comprehensive framework to predict the success of technology-supported health and social care programmes, and consists of evaluating the challenges across seven domains: 1) the condition, 2) the technology, 3) the value proposition, 4) the adopter system including staff, patient, and caregiver(s), 5) the healthcare organisation(s) including attention to the work of implementation and adaptation, 6) the wider context (institutional and societal), and last, 7) the interaction between domains and adaptation of technology programme over time. Sampling and Recruitment Process The inclusion criteria for PTEC HAT were: (a) age: 21–80 years old, (b) T2DM patients with HbA1c ≤ 8% (c) no diabetes complication or other condition(s) that require more than the usual three to four visits to NHG polyclinic per year, (d) smartphone is supported by PTEC HAT. The pilot implementation of PTEC HAT excluded patients (a) with cognitive impairment, (b) who were pregnant, (c) with preexisting anaemia of any cause, (d) with a history of ischaemic heart disease, congestive heart failure, stroke, transient ischaemic attack, atrial fibrillation and renal impairment, (e) with complications or target organ damage or complex medical conditions e.g. Parkinson’s disease, dementia, etc., (f) who were on active titration of medication such as angiotensin converting enzyme inhibitors/angiotensin-receptor blockers, and (g) who were concurrently participating in another clinical study or programme involving a novel therapeutic drug/device, at any time during the study period. Patients who participated in PTEC HAT programme, with successful transmission of their home HbA1c reading and received teleconsultation, were then referred by their primary healthcare team to the study team. The study team then contacted the patients for their interest and availability to participate in a semistructured individual in-depth interview to share their experiences on PTEC HAT programme. Eligible patients were purposively sampled to achieve variation in age groups, ethnicity and gender. The principal investigator, coinvestigators or trained study team members then confirmed patients' eligibility, explained the study and obtained written informed consent. Sufficient time was provided to the patients to consider participation and the voluntary nature of the research participation was emphasised. Informed consent was obtained from the participant before the start of any research procedures. Data Collection Data were collected in the form of individual in-depth interviews between April and July 2022 remotely through Zoom video conference. The patients were advised to find a private room for the virtual interview. The interviews took place via Zoom video conference and lasted between 60 to 90 minutes. Patients’ sociodemographic information, diabetes and medication history were collected at the start of the interview via an interviewer-administered questionnaire. This was followed by a semistructured interview conducted by the principal investigator and observed by study team member(s). An interview guide was designed with reference to literature and discussion among the research team members. Please refer to Table 1 for more details. Table 1 Interview Guide Domain Sample Question Experience of learning to do home HbA1c test 1. Please share your experience of learning and using the self HbA1c test. 2. What do you think of the coaching done by the care manager? 3. What do you think of the materials and guidebook prepared? How helpful are they? 4. [Probe] How do you think this PTEC HAT programme is different from glucose monitoring done at home? 5. Please can you elaborate more on what you’ve mentioned…? (Probing question) 6. That is interesting. Please tell me more about…. (Whenever there is new data/theme arise) Experience of the technology (smartphone HealthHarmony Apps & in-app chatbot) 1. How is your experience of learning and using the PTEC HAT smartphone HealthHarmony app? 2. How do you find the interactions with in-app chatbot under the PTEC HAT pilot programme? 3. (Probing question) Do you have any concern if you need to interact and reply to the in-app chatbot using SMS service? 4. Please share your experience with using the smartphone HealthHarmony Apps to send HbA1c results to the care team? 5. Please elaborate more on what you’ve mentioned…? (Probing question) 6. That is interesting. Please tell me more about…. (Whenever there is new data/theme arise) Experience of using the A1CNow + system at home 1. One of the key features of PTEC HAT is to perform the HbA1c test remotely, can you share your experience with me? 2. Can you share your experience with storing and preparing the A1CNow + test kit? 3. What is the result of your recent home HbA1c test? 4. Do you have any concerns about performing the HbA1c test yourself at home? What are they? 5. What challenges do you face when performing the HbA1c test at home? 6. Please can you elaborate more on what you’ve mentioned…? (Probing question) 7. Do you have any issue in pricking your finger to collect blood samples? 8. Do you encounter problems in mixing your blood sample into the blood collector? 9. Do you have an issue with inserting the cartridge into the A1CNow + device? 10. Do you have any issue in getting HbA1c result on the A1CNow + device? 11. Do you find any issue in docking the A1CNow + device into the Bluetooth dock? 12. Do you encounter any issue in transmitting HbA1c reading from the Bluetooth dock to the HealthHarmony App on smartphone? 13. I find it interesting. Can you tell me more about…? (Whenever there is new data/theme arise) The role of family/social support in PTEC HAT adoption and experience 1. How would you rate the importance of family/social support in your participation in the PTEC HAT programme? 2. How has family/social support affected your participation in the PTEC HAT programme? 3. What kind of support have you received from your family members or friends in the PTEC HAT programme? What kind of support would you like to receive from your family/friends/healthcare team in the PTEC HAT programme? Experience of teleconsultation 1. Have you received teleconsultation by the care team? 2. How do you find interacting through teleconsultation with the care team? Broad experience of PTEC HAT programme 1. Please share with me why you choose to be enrolled? 2. In general, how is your experience of the PTEC HAT pilot programme? 3. In your opinion, what type of person would likely take up the PTEC HAT programme? 4. [Probe] Do you share your diabetes condition with anyone? (ask about if they are worried about people knowing their diabetes diagnosis)? 5. Please can you elaborate more on what you’ve mentioned…? (Probing question) 6. That is interesting. Please tell me more about…. (Whenever there is new data/theme arise) Overall thoughts about PTEC HAT 1. How has PTEC HAT impacted the way you manage diabetes? 2. Please share your suggestions or recommendations on how the program can be improved? What do you think of PTEC HAT vs routine diabetes care by NHGP? Scalability, Spread & Sustainability 1. How confident are you with the HbA1c self-test result? 2. How likely are you going to continue the HbA1c self-test if PTEC HAT becomes a chargeable service? 3. How much will you expect yourself to pay for this programme? 4. Will you continue PTEC HAT if it is Medisave deductible? Final remarks 1. Do you have anything else you would like to share with me? The interviews followed the natural progression of a conversation and the questions were not necessarily covered in the stated order. The patients were given the opportunity to discuss freely based on the questions asked. Probes and follow-up questions were used throughout the interviews to facilitate discussion. The interview questions were modified over the course of the study, using an iterative process that was informed by the content of previous interviews. Each patient received an honorarium at the end of the interview. The interviews were digitally audio-recorded and transcribed verbatim with written consent from the patients. Deidentified transcripts were then used for analysis. Relevant field notes and observations were captured after each interview. The key findings were summarised and added into a Rapid Research Evaluation and Appraisal Lab (RREAL) sheet that allowed the study team to synthesise the data and revise the interview guide as the data were being collected 21 . Data Analysis Each transcript was read repetitively to ensure accurate understanding of the verbatim and the data analysis was conducted independently by the principal investigator and coinvestigator. The accuracy of the transcripts was verified against the recordings. This was performed with data collection simultaneously to enable the sorting of data into categories 22 . The investigators recognised that their clinical background and preconceptions could influence data collection and interpretation. As such, reflexivity was employed to ensure minimal bias on the data collection and analysis process. Thematic analysis was used for analysis of the data. Initial open coding was carried out using reflexive iteration. The study team regularly met up to discuss the initial codes and the differences in opinions were resolved through consensus. The enablers and barriers identified in the form of rich descriptions were mapped to the emerged themes. NVivo 12 (QSR International Pty Ltd) was used for data analysis. An excel spreadsheet was used separately by the coinvestigator, which involved generating a matrix to chart the data with the cases in rows, codes in columns and to summarise data in the cells. This qualitative study was approved by the Institutional Ethics Board (Ref No. 2021/01075). RESULTS A total of 12 out of 21 patients referred by the care team were interviewed. Four patients declined to be interviewed when contacted by the study team. Interviews were not conducted for the rest of the five patients as data saturation has already been achieved. The data saturation was reached at the 10th interview, with the 11th and 12th interview that further confirmed data saturation. Ten of the interviews were conducted in English, while the remaining two were in Mandarin. Interviews administered in Mandarin were transcribed verbatim and translated into English. Patient characteristics are shown in Table 2 . Table 2 Patient Characteristics Participant characteristics n % N 12 Age, mean (± SD) 56.58 (± 8.52) Gender Male Female 5 7 41.7 58.3 Ethnicity Chinese Indian Others 10 1 1 83.3 8.3 8.3 Educational level ‘N’ Level/’O’ Level/NTC and below ‘A’ Level/Diploma University 3 4 5 25.0 33.3 41.7 Marital status Single Married Divorced/Separated 2 9 1 16.7 75.0 8.3 Employment status Full-time Part-time Unemployed & not studying 7 2 3 58.3 16.7 25.0 Diabetes duration 0–5 years 6–10 years > 10 years 8 3 1 66.7 25.0 8.3 On medication Yes No 9 3 75.0 25.0 Health monitoring experience Yes No 10 2 83.3 16.7 The mean age of patients was 56.6 years (range from 48 to 65 years) and female made up 58.3% (n = 7) of the patients interviewed. Among them, 83.3% (n = 10) of the patients were Chinese, 75% (n = 9) of the patients attained preuniversity and above education, 58.2% (n = 7) of the patients were working full-time, 66.7% (n = 8) of the patients had duration of T2DM of not more than five years, 75% (n = 9) are on diabetes medication and 83.3% (n = 10) of the patients had prior experience with using health monitoring devices. The key findings of this study were reported in the form of rich descriptions and broadly grouped into 5 themes, which are 1) patients’ experiences on PTEC HAT, 2) remote monitoring of T2DM - patient perception, 3) technology component of PTEC HAT - patient perception, 4) value proposition of the PTEC HAT and 5) patient factor in adoption of the PTEC HAT. The findings under each theme were subcategorised into the enablers and barriers. The Patients’ Experiences Enablers Coaching ‘They first demo to me how to use the set and it’s quite intuitive because it’s a one-to-one training, which is good, so at any point in time if I have a question I can always ask la.’ (Interviewee 2, Female, 52 years old) User guide and video tutorial ‘I was quite relieved because there was an instruction pamphlet that I could follow. When I opened the mobile app, there was actually a portion that I could click for the video.’ (Interviewee 12, Female, 51 years old) ‘…the video basically refreshes everything you’ve done at the clinic during the demonstration’ (Interviewee 7, Male, 58 years old) Barriers Prolonged onboarding ‘They didn’t really prep me that the whole learning process was quite long. Actually I remember it take about more than an hour’ (Interviewee 12, Female, 51 years old) Storage and preparation of the HbA1c testing kit ‘Packaging too big. Bulky.. so my wife was saying you are taking space in my fridge’ (Interviewee 7, Male, 58 years old) ‘Afraid if there’s power outage, afraid this (test kits) will spoil’ (Interviewee 1, Female, 61 years old) ‘That is a bit troublesome ah, I need to wait 1 hour, then during that 1 hour probably you are doing some stuff then after that you forgot about it. Yeah, so I don’t know whether it will affect the reading after you actually left it to thaw for more than an hour. (Interviewee 3, Female, 44 years old) Remote Monitoring of T2DM - Patient Perception Enablers The patients accepted that the low-risk T2DM is a suitable medical condition for home HbA1c testing and telemonitoring through PTEC HAT programme. Patients also shared that there is potential in empowering patients for self-monitoring. ‘I believe if someone who doesn’t prick and test the blood sugar, it will be revelational for them. You can actually test and see your sugar level yourself. And then for someone who doesn’t do it they can also build their confidence that actually they should consider doing a regular (HbA1c) test.’ (Interviewee 2, Female, 52 years old) During the COVID-19 pandemic, PTEC HAT was advantageous in ensuring continued diabetes care. ‘PTEC HAT is really good in a situation now, because of the COVID, yeah, so if the clinic gets overcrowded, the chances of people getting infected from one another is higher, so this place is an added advantage.’ (Interviewee 9, Female, 60 years old) Barriers Many patients expressed that the interval between onboarding and performing the home HbA1c test was lengthy. The HbA1c test, unlike the routine home blood glucose test, was typically performed at three to six monthly intervals to assess diabetes control. This made testing a challenge as the steps for home HbA1c testing becomes less familiar to patients a few months after enrolment. ‘We can understand very well at that point of time. But... there is a lapse of time. When we do the actual one 6 months later...I can confirm that we will not do it well.’ (Interviewee 8, Male, 63 years old) Technology Component of PTEC HAT - Patient Perception Overall, the patients valued the technology that comes with the mobile app. They found the in-app chatbot reminder particularly useful when preparing for the home HbA1c testing. However, there were differing views about the home HbA1c testing process and the subsequent teleconsultation. Many patients spoke negatively about the data transmission via the Bluetooth device provided in the package. Enablers Patients found the in-app chatbot very helpful in reminding them to perform the home HbA1c testing on the prearranged date. In addition, patients expressed that the instructions sent out by in-app chatbot provided assurance for them to complete the home testing correctly. ‘ I think the reminder is good because uh for people who are busy like me…it helps to remind me on that day I am supposed to do this test I have to make sure I keep my time for the appointment.’ (Interviewee 9, Female, 60 years old) ‘… (the in-app chatbot) reminds you that on this day you need to do the test, remember to take out and thaw 1 hour before using it. So it is a good reminder… (It is) also an add-on to tell me that I'm doing the right thing correctly…’ (Interviewee 4, Female, 45) Barriers Home HbA1c result transmission with Bluetooth device The Bluetooth device synchronises the HbA1c result from home test kit to the mobile app, thereby minimising transcribing errors by the patients. The Bluetooth device functions by pressing on the unit to turn on and subsequently two distinctive tones are played to indicate that the device is ready to be used and after it has been successfully paired with a smartphone. However, there are no visual cues. A large majority of the patients in this qualitative study encountered failure when using the Bluetooth device to synchronise home HBA1c reading from the home testing to mobile app, which resulted in negative experience and dropped in confidence. ‘The part of transmitting result is confusing… I don’t know what does the tone sound like, so the first transmission didn’t get through. It’s a negative feeling because I’ve already pricked my finger and have the HbA1c reading, then the transmission is kind of failed… The confidence level is affected… result in certain level of stress.’ (Interviewee 2, Female, 52 years old) ‘… the final procedure is to send the data over, but since you cannot send the data over, then what you have done in front is all wasted’ (Interviewee 8, Male, 63 years old) Value Proposition of PTEC HAT Patients valued the convenience of performing the HbA1c testing at home but the perceived value depended on their employment status. Enablers The instant result generated by home HbA1c testing was rewarding. It increased the self-efficacy of the participants in improving diabetes control. ‘I will also like to see results immediately, I don’t have to wait for doctor to tell me or whoever to tell me after waiting for another 45 minutes at the clinic’ (Interviewee 7, Male, 58 years old) PTEC HAT pilot programme was found to be convenient and time-saving as it was able to reduce the number of visits to the polyclinic. ‘...I will take leave to go for medical appointment and I think it is very troublesome. So if let’s say all these could be done at home, I think it will be very useful not only for COVID but actually for ...scheduling of my work...that is why I actually thought it is very good.’ (Interviewee 6, Male, 52 years old) ‘…I think this teleconsultation...is fine...is really saving time going down to see a doctor.’ (Interviewee 3, Female, 44 years old) The flexible test date or time had additional value in ensuring adherence to perform home HbA1c testing among the patients. ‘...that’s why I prefer to continue this, Because I can... decide when I can do it: this morning, or maybe this evening or tomorrow morning’ (Interviewee 6, Male, 52 years old) Patients felt at ease having the teleconsultation as the healthcare team who contacted the patient was well-informed of their medical condition. ‘So the standard (of teleconsultation), I'll say is maintained…Experience is the same (as physical consultation).’ (Interviewee 2, Female, 52 years old) ‘She seems to know what is happening, so I feel comfortable. Not only like now we are quite used to remote (consultation), but she (also) knows what she is talking about’ (Interviewee 6, Male, 52 years old) Barriers The perceived time saved from the programme was diminished for patients with other medical conditions, which also required other tests in the clinic. ‘It doesn’t take away my time or it doesn’t save me a lot of time just because I am doing this at home.’ (Interviewee 7, Male, 58 years old) Some patients found the home HbA1c testing complex and were concerned if the programme became a chargeable service in the future. 'I think these items are expensive...It is not like that the (glucometer) strip where you test and you don't have a proper reading you can just throw away the strip and just do another prick test…because of the number of steps it requires, every step is important otherwise there is failure of the data (generation and/or transmission). So if the patient is paying for these then it’s also the concern of the patient to do it right the first time. Right?’ (Interviewee 7, Male, 58 years old) Additionally, the perceived value of PTEC HAT was dependant on the potential cost of the programme. ‘I'm hoping that maybe it (PTEC HAT) will be a bit cheaper than the actual lab test because…if the prices are the same, or if this one is a bit higher than the lab test, then they might as well go to the lab test, because people (phlebotomist) will do it for them.’ (Interviewee 12, Female, 51 years old) A patient did not think the teleconsultation was helpful but instead, saw it as a standard operating procedure (SOP) and viewed the teleconsultation to be inadequate compared to a physical consult. However, the patient was not aware of the difference between the readings obtained from SBGM and A1CNow + kit as well as the requirement to consult healthcare team in clinic polyclinic visit with every routine HbA1c testing. This could have resulted in the lower perceived value of teleconsultation. ‘…this telecommunication, teleconversation, probably is just the SOP, I think that this does not help much’ (Interviewee 8, Male, 63 years old) ‘Anyone who has medical issue will still want to seek professional advice, attention, you’ll still want to see a doctor probably, face-to-face...that is where you have more peace of mind’ (Interviewee 3, Female, 44 years old) Patient Factors in Adopting PTEC HAT The successful PTEC HAT participation provided a snapshot of the potential take-up rate if it was to become an official programme. Enablers It was found that a reasonable level of digital literacy, prior experience with blood pressure and glucometer monitoring, absence of needle phobia, and strong intrinsic motivation for self-monitoring were identified as the main factors attributing to successful PTEC HAT participation. Digital literacy ‘I'm a smartphone user so l'm able to understand... what to do, so it's after I download right…they ask me to key in some administrative stuff, and everything is I done it on the spot’ (Interviewee 4, Female, 45) The absence of needle phobia ‘I actually have no issue pricking my fingers because first of all, I've been using the glucometer myself at home as well also, so that requires a lot of pricking. ...when they told me oh, you still need to actually prick your fingers, I said it's not a problem.’ (Interviewee 3, Female, 44 years old) Intrinsic motivation and prior experience with health monitoring ‘I came to a point where I'm really concerned about my wellbeing… That I might have hypertension, so I thought this is a good way for me, checking on myself…that's why I signed up for it...there is a big correlation because people who are interested in their results then they will buy the glucometer and prick.’ (Interviewee 11, Male, 62 years old) Barriers Conversely, patients with lower level of digital literacy, needle phobia and low level of self-motivation would have a lower likelihood of overcoming challenges when interacting with the multiple components of PTEC HAT. The inadequate level of digital literacy ‘....my wife (is) bad with technology...my sister-in-law was in my house and I purposely take out these kits, ask her for help...she is more educated on technology and yet we follow all the SOP, (we) cannot get through’ (Interviewee 8, Male, 63 years old) Needle phobia ‘I'm scared of needles already. I don’t want to prick myself again’ (when the participant failed to transmit the result via Bluetooth)’ (Interviewee 12, Female, 51 years old) Lack of self-motivation ‘I don’t have much feelings about it, it’s just that I didn’t know how to at the start and then I thought I didn’t want to use it anymore’ (Interviewee 5, Female, 54 years old) DISCUSSION This study aimed to explore the experiences of low-risk patients with T2DM who participated in PTEC HAT programme, and to identify the enablers and barriers of using various PTEC HAT components. The suitable patient characteristics enabling the participation in PTEC HAT included reasonable level of digital literacy, health monitoring experience in the past, absence of needle phobia and strong intrinsic motivation. The key enablers identified for using various PTEC HAT components included the positive reinforcement with instant HbA1c generation, great value of flexibility and convenience, benefits of teleconsultation to reduce polyclinic visit and the perceived suitability low-risk T2DM for home HbA1c testing and teletemonitoring. The enablers identified to maintain patients’ motivation in completing the PTEC HAT programme included the coaching by primary care team, the support in the form of in-app chatbot reminder, as well as the user guide and video tutorial accessibility. Even though they did not broadly affect patients’ experiences, there were several barriers identified, which included the long interval between onboarding and subsequent home HbA1c testing, making challenging for patients to recall the steps, persistent issue with HbA1c result transmission with Bluetooth device, misperception on inferiority of teleconsultation, concern of potential cost of the programme and the amount of efforts needed to perform self-testing as well as unsuitable patient characteristic - low digital literacy, needle phobia and lack of motivation. The Patients’ Experiences Sander et al found that high level of uncertainty regarding the technological aspects of the health device being offered was one of the reasons for nonadoption 23 . For PTEC HAT, patients shared that there were several initiatives established to minimise the uncertainty, which enhanced this learning experience during the onboarding session. The engagement, availability of training material and support delivered during the in-person coaching provided assurance to the patients the effectiveness of the technology. The return demonstration performed in the clinic gave the patients confidence that they can repeat the testing at home without the physical assistance from the care team. The additional resources provided to them in the form of video tutorial and the user guide served as mitigating factors to perform the HbA1c testing even after three to six months posttraining. The Enablers Our findings revealed that the perceived good value by the patients as the key facilitator for PTEC HAT programme uptake. Majority of the patients recognised that telemonitoring, with technology enhanced home HbA1c testing, as a convenient alternative for the routine care in the clinic. This perceived value was dependent on the compulsion for a more flexible schedule that is associated with the patients’ occupation and the amount of free time they have. Most patients do not mind travelling down to the clinic for the regular blood test as they have other appointments to fulfil, such as vaccination, diabetic retinal photography and diabetic foot screening. However, the fact that the PTEC HAT home test is not bounded by time or place made it an attractive alternative to many who have limited free time. This is consistent with the finding of a cross sectional validation study, in which the shortening of travel and waiting times to the clinic was identified as one of the benefits of diabetes telemonitoring 24 . Another enabler that increased the acceptability is the patients’ prior experience with health monitoring like SBGM, which requires similar technical competency by the patient in obtaining the blood sample, followed by the need to feed the sample into a reader to obtain the glucose reading. A scoping review of 29 studies found that previous experience with the technology is one of the patient-level facilitators for the uptake of digital health technology 25 . Majority of the patients in our study were found to have prior experience with the health monitoring, thus making them a more empowered and motivated group. The Barriers Several patients requested to remove redundant technological features that add complexity to the whole innovation in order to improve the practical acceptability. The primary barrier that the patients faced with the technology was with the result transmission using the Bluetooth device prescribed to them. Our finding was consistent with how Torbjørnsen et al., described the usability issue of Bluetooth device hindering practical acceptability of a telecare programme 26 . Torbjørnsen’s et al.’s study was primarily to understand factors affecting a patient’s acceptability of a mobile app for diabetes self-management. It was found that one of the most valued features of the app was its ability to transfer the blood glucose data to health-care personnel using Bluetooth. However, it was also found to be one of the major usability issues, requiring frequent support to reconnect the devices, making it challenging to use. The need to send the HbA1c reading via Bluetooth device was seen as a redundant feature that resulted in negative emotions and reduced the usability of the technology. The patient’s perceived barriers echoed the findings from other studies exploring the factors impeding the acceptance of digital health technologies, namely, poor design and inoperability of the telemedicine programme 27 . Some of the patients were not aware of the fundamental difference between the readings obtained from SBGM and A1CNow + kit. This could have resulted in the lower perceived value of PTEC HAT programme and the lack of appreciation for the additional steps required by PTEC HAT to obtain the reading. This highlighted the importance of better patient education to illuminate the significance and value of HbA1c in self-management of T2DM. The low frequency of HbA1c testing was shared by the patients as another potential barrier in joining the programme. They did not see the cost-effectiveness of investing both time and money in a potentially high-cost device, that requires a certain level of technical and digital competency to operate, which will only be used two to four times a year. Therefore, these factors, as opposed to the physical visit to the clinic that provides a no-hassle-service, makes PTEC HAT less attractive to the patients. In this regard, the growth of value-based payment models may be a solution to provide incentives in implementing cost-effective, high-quality and coordinated telehealth 28 . Study Strengths and Limitations To our knowledge, this is the first qualitative study on low risk adult patients adopting telemonitoring with technology-enhanced home HbA1c test for T2DM care. The purposive sampling enabled detailed data collection from patients with various demographic profiles. The in-depth individual interviews performed until data saturation enabled comprehensive identification of interweaving enablers and barriers. The strengths of the study were enhanced by striving to achieve credibility, transferability, dependability and confirmability using Lincoln and Guba framework 29 . A few strategies were used to achieve credibility: 1) investigators maintained prolonged engagement and member-checking was carried out pro-actively during interviews and 2) investigator triangulation was carried out during the process of data analysis. In addressing transferability, the coded data was presented as thick descriptions so that the patient’s context, behaviour and experience are meaningful to the reader. To maintain dependability, records of the conduct of the study and all meetings were documented, thereby establishing a clear audit trail. Confirmability was achieved by including patients’ direct quotes in the results and reference to the literature that confirmed the interpretations in this study. This qualitative study was limited by the fact that 83.3% of the patients were Chinese, and there were no Malay participants. Therefore, this ethnicity was unrepresented. The small number of patients in PTEC HAT programme (n = 33) had also restricted the heterogeneity for purposive sampling. In addition to that, other NASSS domains such as ‘the organisation’, ‘the wider context’ and ‘the interaction between domains and adaptation over time’ were not addressed as the study team did not ask the related views in this study. The transferability of our findings to other groups of diabetes patients may be limited as this study was conducted with low-risk patients with T2DM. Future studies should focus on exploring the perspectives of the healthcare team and other stakeholders in PTEC HAT programme, in terms of the factors associated with nonadoption and the cost-effectiveness of PTEC HAT in diabetes management. CONCLUSION As telemonitoring increasingly becomes an integral part of healthcare, it is important to understand and learn from the patients’ experiences in novel technology enhanced home HbA1c telemonitoring programme for T2DM care. Based on the patients’ experiences, our qualitative study established that telemonitoring with technology enhanced home HbA1c testing is a useful alternative to routine care for low-risk patients with T2DM in primary healthcare institutions. It is not only one that is providing patients with the flexibility and convenience but also empowers patients for self-care. However, the benefit is moderated by lack of practical usability of the Bluetooth device for HbA1c result transmission, as well as concerns of possible high cost associated with the technology component for HbA1c testing that is only done a few times a year, which diminishes the value proposition. It is hoped that the knowledge gained from our study can improve the design of telehealth initiatives for patients with T2DM and possibly integrate PTEC HAT seamlessly into existing programmes for other chronic diseases, thereby enhancing the overall benefit for the patient. Abbreviations BP = Blood pressure CGM = Continuous glucose monitoring MOHT = MOH Office of Healthcare Transformation NASSS = nonadoption, abandonment, scale-up, spread and sustainability NHG = National Healthcare Group PTEC HAT = Primary Technology Enhanced Care - Home HbA1C Testing RREAL = Rapid Research Evaluation and Appraisal Lab SBGM = self-blood glucose monitoring SOP = standard operating procedure T2DM = type 2 diabetes mellitus Declarations Ethical Consideration This study received ethics approval from the NHG Domain Specific Review Board (Ref No. 2021/01075). Written informed consent was obtained from all participants prior to data collection. Competing Interests The authors declare that they have no competing interests. Funding This study is funded by NHG Polyclinics Research Fund (Ref no.: RF-2021-002). Author’s contributions All authors contributed to the conceptualisation and design of the study. Dr Kah Pieng Ong, Dr Eng Sing Lee and Ms Elya were involved in developing the interview guide. Dr Kah Pieng Ong and Ms Elya Chen conducted the interviews, analysed the data and wrote the manuscripts. Ms Elya Chen made substantial contributions in drafting the manuscripts. Dr Kah Pieng Ong, Dr Eng Sing Lee, Dr Wern Ee Tang and Dr David Wei Liang Ng were involved in revising the manuscripts. Dr Eng Sing Lee and Dr Wern Ee Tang were involved in supervising the conduct of the study. Acknowledgements The research team is thankful to get the permission from the MOHT to embark on this qualitative study, as well as the contributions of MOHT interns, Mr Cedric Koh and Ms Rachel Lim, in audio transcription and data coding. We would also like to thank Ang Mo Kio Polyclinic teamlet F, as well as research coordinator, Ms Nur Atiqah Bte Surya Akmaja for her logistic support in this study. References Khan MAB, Hashim MJ, King JK, Govender RD, Mustafa H, Al Kaabi J. Epidemiology of Type 2 Diabetes - Global Burden of Disease and Forecasted Trends. J Epidemiol Glob Health. 2020 Mar;10(1):107-111. doi: 10.2991/jegh.k.191028.001. PMID: 32175717; PMCID: PMC7310804. Ministry of Health, Singapore. Result from government five-year “Was against diabetes” effort. 2022 Jan 10 [cited 2022 Dec 27]. Available from https://www.moh.gov.sg/news-highlights/details/result-from-government's-five-year-war-against-diabetes-effort/#:~:text=Hence%2C%20while%20the%20recent%20National,the%20same%20period%20at%207.9%25. Mark Tan KW, Dickens BSL, Cook AR Projected burden of type 2 diabetes mellitus-related complications in Singapore until 2050: a Bayesian evidence synthesis BMJ Open Diabetes Research and Care 2020;8:e000928.doi: 10.1136/bmjdrc-2019-000928 Nathan DM; DCCT/EDIC Research Group. The diabetes control and complications trial/epidemiology of diabetes interventions and complications study at 30 years: overview. Diabetes Care. 2014;37:9–16. UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34) Lancet. 1998;352:854–865. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359:1577–1589. Lenters-Westra E, Schindhelm RK, Bilo HJ, Slingerland RJ. Haemoglobin A1c: Historical overview and current concepts. Diabetes Res Clin Pract. 2013;99:75–84. Krhač M, Lovrenčić MV. Update on biomarkers of glycemic control. World J Diabetes. 2019 Jan 15;10(1):1-15. doi: 10.4239/wjd.v10.i1.1. PMID: 30697366; PMCID: PMC6347654. American Diabetes A. 6. Glycemic targets: standards of medical care in diabetes-2018. Diabetes Care 2018;41(Suppl 1):S55e64. Greenwood DA, Gee PM, Fatkin KJ, Peeples M. A Systematic Review of Reviews Evaluating Technology-Enabled Diabetes Self-Management Education and Support. JDiabetes Sci Technol. 2017 Sep;11(5):1015-1027. doi:10.1177/1932296817713506. Epub 2017 May 31.PMID: 28560898; PMCID: PMC5951000. Huang Z, Tao H, Meng Q, Jing L. Effects of telecare intervention on glycemic control in type 2 diabetes: a systematic review and meta-analysis of randomized controlledtrials. Eur J Endocrinol. 2015;172(3):93–101. Lee PA, Greenfield G, Pappas Y. The impact of telehealth remote patient monitoring on glycemic control in type 2 diabetes: a systematic review and meta-analysis of systematic reviews of randomised controlled trials. BMC Health Serv Res. 2018 Jun 26;18(1):495. doi:10.1186/s12913-018-3274-8. PMID: 29940936; PMCID: PMC6019730. Lee JY, Lee SWH. Telemedicine Cost-Effectiveness for Diabetes Management: A Systematic Review. Diabetes Technol Ther. 2018 Jul;20(7):492-500.doi: 10.1089/dia.2018.0098. Epub 2018 May 29. PMID: 29812965. Lai SH, Tang CQ. Telemedicine and COVID-19: beyond just virtual consultations–the Singapore experience. Bone & Joint Open. 2020 Jun 6;1(6):203-4. Sin, D.Y.E., Guo, X., Yong, D.W.W. et al. Assessment of willingness to Tele-monitoring interventions in patients with type 2 diabetes and/or hypertension in the public primary healthcare setting. BMC Med Inform Decis Mak 20 , 11 (2020). https://doi.org/10.1186/s12911-020-1024-4 Lee PA, Greenfield G, Pappas Y. Patients' perception of using telehealth for type 2 diabetes management: a phenomenological study. BMC Health Serv Res. 2018 Jul 13;18(1):549. doi: 10.1186/s12913-018-3353-x. PMID: 30005696; PMCID: PMC6045870. Turnbull S, Lucas PJ, Hay AD, Cabral C. Digital Health Interventions for People With Type 2 Diabetes to Develop Self-Care Expertise, Adapt to Identity Changes, and Influence Other's Perception: Qualitative Study. J Med Internet Res. 2020 Dec 21;22(12):e21328. doi: 10.2196/21328. PMID: 33346733; PMCID: PMC7781797. Ayre J, Bonner C, Bramwell S, McClelland S, Jayaballa R, Maberly G, McCaffery K. Factors for Supporting Primary Care Physician Engagement With Patient Apps for Type 2 Diabetes Self-Management That Link to Primary Care: Interview Study. JMIR Mhealth Uhealth. 2019 Jan 16;7(1):e11885. doi: 10.2196/11885. PMID: 30664468; PMCID: PMC6352005. Ministry of Health, Singapore. Investing in enablers and infrastructure to support healthcare transformation. 2022 March 9 [cited 2022 Dec 27]. Available from https://www.moh.gov.sg/news-highlights/details/investing-in-enablers-and-infrastructure-to-support-healthcare-transformation Greenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A'Court C, Hinder S, Fahy N, Procter R, Shaw S. Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies. J Med Internet Res 2017;19(11):e367. Vindrola-Padros, Cecilia and Chisnall, Georgia and Polanco, Natalia and Vera San Juan, Norha, Iterative Cycles in Qualitative Research: Introducing the RREAL Sheet as an Innovative Process. Available at SSRN: https://ssrn.com/abstract=4162797 or http://dx.doi.org/10.2139/ssrn.4162797 Sandelowski M,Barroso J. Classifying the Findings in Qualitative Studies. Qualitative Health Research. 2003;13(7):905-923.doi:10.1177/1049732303253488 Sanders, C., Rogers, A., Bowen, R. et al. Exploring barriers to participation and adoption of telehealth and telecare within the Whole System Demonstrator trial: a qualitative study. BMC Health Serv Res 12, 220 (2012). https://doi.org/10.1186/1472-6963-12-220 Muigg D, Duftschmid G, Kastner P, Modre-Osprian R, Haluza D. Telemonitoring readiness among Austrian diabetic patients: A cross-sectional validation study. Health Informatics J. 2020 Dec;26(4):2332-2343. doi: 10.1177/1460458219894094. Epub 2020 Feb 12. PMID: 32046567. Whitelaw, S., Pellegrini, D. M., Mamas, M. A., Cowie, M., & Van Spall, H. G. (2021). Barriers and facilitators of the uptake of digital health technology in cardiovascular care: a systematic scoping review. European Heart Journal-Digital Health, 2(1), 62-74. Torbjørnsen, A., Ribu, L., Rønnevig, M. et al. Users’ acceptability of a mobile application for persons with type 2 diabetes: a qualitative study. BMC Health Serv Res 19, 641 (2019). https://doi.org/10.1186/s12913-019-4486-2 Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: A systematic review. J Telemed Telecare. 2018 Jan;24(1):4-12. doi: 10.1177/1357633X16674087. Epub 2016 Oct 16. PMID: 29320966; PMCID: PMC5768250. Andrès E, Talha S, Jeandidier N, Meyer L, Hajjam M, Hajjam A. Telemedicine in chronic diseases: the time of maturity with telemedicine 2.0 in the setting of chronic heart failure and diabetes mellitus! Curr Res Diabetes Obes J. 2018;6:1–4. Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park, CA: Sage Publications, 1985 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Oct, 2025 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 28 May, 2024 Editor assigned by journal 25 May, 2024 Submission checks completed at journal 25 May, 2024 First submitted to journal 22 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4461158","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":307610543,"identity":"b71c5b9b-a579-40fd-bb42-0a10847601a6","order_by":0,"name":"Kah Pieng 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2","display":"","copyAsset":false,"role":"figure","size":9907912,"visible":true,"origin":"","legend":"\u003cp\u003ePTEC HAT Care Plan\u003c/p\u003e","description":"","filename":"Figure2PTECHATCarePlan.png","url":"https://assets-eu.researchsquare.com/files/rs-4461158/v1/13d484c6d79919a81a2c4596.png"},{"id":58078220,"identity":"da68abdd-638f-4aa9-a841-c1e9619e0399","added_by":"auto","created_at":"2024-06-10 22:55:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":15559124,"visible":true,"origin":"","legend":"\u003cp\u003eSteps for Home HbA1c Test and Result Submission\u003c/p\u003e","description":"","filename":"Figure3StepsforHomeHbA1cTestandResultSubmission.png","url":"https://assets-eu.researchsquare.com/files/rs-4461158/v1/5f0433d80d29b514441f8b38.png"},{"id":93957258,"identity":"962709e6-d1fc-450d-9b2c-6686aaaaf9cd","added_by":"auto","created_at":"2025-10-20 16:13:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":70878817,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4461158/v1/95c9da8b-6aba-4ddd-a9eb-85c732b618df.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding the patients’ experience in Primary Technology Enhanced Care Home HbA1c Testing (PTEC HAT) programme - A Qualitative Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDiabetes mellitus continues to move up the ranks as one of the leading causes of disability and years of life lost, indicating a global transition in disease patterns toward noncommunicable diseases\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. It is one of the common chronic diseases in Singapore, with the age standardised prevalence rate of 7.9%\u003csup\u003e2\u003c/sup\u003e. With an ageing population, Singapore is projected to have up to one million individuals with diabetes by 2050. It has been reported that the healthcare expenditure will rise drastically as the future incidence of diabetes related comorbidities increase\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. It is vital to achieve and maintain glycaemia as close as possible to its ideal range to reduce the risk of diabetic complications, adverse cardiovascular outcomes and mortality\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHbA1c results from glycation, a reaction that involves posttranslational modification of haemoglobin A by the nonenzymatic covalent binding of glucose to the N-terminal valine of the β-globin chain\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Low intraindividual biological variability, the stability of the analyte and the independence of results to the prandial status were the most pronounced advantages of HbA1c over plasma glucose. Hence, it remains the gold standard test to monitor glycaemic control in clinical practice\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, especially for low risk patients with type 2 diabetes mellitus (T2DM)\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. The HbA1c test is traditionally performed at the laboratory located within a clinic or healthcare institution. The American Diabetes Association recommends measuring HbA1c at least twice a year in patients who are meeting treatment goals and quarterly in patients whose therapy has changed or have suboptimal glycaemic control, given its strong predictive value for diabetes complications\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere is growing positive evidence that supports the use of innovative technology, such as telemedicine, to monitor and manage patients with diabetes\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Telemedicine has particularly played a crucial role in efforts against the COVID-19 pandemic, with its unique ability to minimise physical physician-patient contact, thereby breaking infection chains, as well as its ability to optimise healthcare system capacity during demand surges\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. In Singapore, there is a significant level of willingness to take up telemedicine among the diabetes patients in polyclinics, though 52.2% of them felt that they will be willing after hearing positive reports\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Numerous recent qualitative studies have focused on the patients\u0026rsquo; perception of using telehealth for T2DM management, as well the factors for supporting primary care physician engagement with patient mobile app for T2DM self-management. The studies have yielded mixed result\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. In recent years, there have been newer approved HbA1c self-test kits available in the market but there is no study describing the deployment of these devices in published literature.\u003c/p\u003e \u003cp\u003e PTEC HAT programme is developed by MOHT and collaborated with NHG Polyclinics to implement telemonitoring care to low-risk patients with T2DM in the community. Low-risk patients are patients who do not require self-blood glucose monitoring (SBGM) or continuous glucose monitoring (CGM), without insulin treatment, without active titration of medication and/or with low risk of hypoglycaemia. The PTEC HAT system, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, consists of HbA1c self-test kit, optional blood pressure (BP) machine for patients with coexisting hypertension and a mobile app on the patients\u0026rsquo; smartphone (with in-app chatbot and multimedia educational materials access). It is intended to empower low-risk patients with T2DM to manage their condition independently and maintain their follow-up with the healthcare team by telemonitoring. By participating in PTEC HAT, eligible patients will be able to replace their three to six monthly interim paired HbA1c test and physical polyclinic visits with home HbA1c tests and teleconsultations. The frequency of home HbA1c test and teleconsultation will be determined by the reviewing doctor during the polyclinic visit following the annual diabetes panel test. This allows patients to save up to three visits to polyclinic per year while getting their glycaemic control telemonitored by the healthcare team.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe PTEC HAT care plan is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Upon enrolment, the patients will be trained by the healthcare team to perform home HbA1c tests. They will be issued a Bluetooth enabled test kit called A1CNow\u0026thinsp;+\u0026thinsp;and other resources, namely, the video tutorial and guidebook to bring home. The A1cNow\u0026thinsp;+\u0026thinsp;test kits require refrigerator storage. When it is due to perform the home HbA1c test, the patients will receive an in-app chatbot reminder notification on their mobile app. Patients need to take out the A1CNow\u0026thinsp;+\u0026thinsp;from the refrigerator and thaw it. The patients are required to follow 12 steps to complete the home HbA1c test, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Then, the A1cNow\u0026thinsp;+\u0026thinsp;Bluetooth device will synchronise the reading to the mobile app. While patients can keep track of their HbA1c reading from home, the reading will also be transmitted to the healthcare team at NHG Polyclinics. Patients will be followed up via tele-consultation. Timely medical interventions will be provided for any abnormal HBA1c reading. The patients will subsequently be reminded to perform home HbA1c testing and submit their readings at regular intervals, until their next scheduled appointment for annual diabetes panel tests and face-to-face consultation at the polyclinic.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThis qualitative study is conducted as part of the evaluation of the pilot implementation of PTEC HAT programme. At the time of conducting this qualitative research, the PTEC HAT programme will be the first to embed home HbA1c testing into telemonitoring for low-risk patients with T2DM. It aims to explore the experiences of low-risk patients with T2DM who completed PTEC HAT programme, and to identify the enablers and barriers of using various PTEC HAT components.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eThis qualitative research was conducted as part of the evaluation process of the pilot implementation of PTEC HAT programme. Following the roll-out of PTEC Home BP Monitoring programme\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, the PTEC HAT system, which employed similar technological supports, was piloted in NHG Polyclinic between July 2021 and September 2022. NHG Polyclinics is part of the National Healthcare Group, which serves a population of 1.5\u0026nbsp;million in Singapore\u0026rsquo;s Central North region. The seven existing polyclinics are Ang Mo Kio Polyclinic, Geylang Polyclinic, Kallang Polyclinic, Hougang Polyclinic, Toa Payoh Polyclinic, Woodlands Polyclinic and Yishun Polyclinic. The NHG Polyclinic is a one stop centre for primary care needs, which provides management of acute conditions, chronic disease management, women\u0026rsquo;s health and family planning, childhood immunisation and developmental assessment, health promotion/disease prevention, allied health services (dietetic, psychology, physiotherapy, podiatry, medication management, financial counselling, medical social service, lab and diagnostic service) and dental care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eTheoretical Framework\u003c/h2\u003e \u003cp\u003eThis study was guided by the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) theoretical framework\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e to develop the interview guide and to conduct thematic analysis. The NASSS framework was developed to study unfolding technology programmes in real-time and particularly to identify and manage their emergent uncertainties and interdependencies\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. It is one of the most comprehensive framework to predict the success of technology-supported health and social care programmes, and consists of evaluating the challenges across seven domains: 1) the condition, 2) the technology, 3) the value proposition, 4) the adopter system including staff, patient, and caregiver(s), 5) the healthcare organisation(s) including attention to the work of implementation and adaptation, 6) the wider context (institutional and societal), and last, 7) the interaction between domains and adaptation of technology programme over time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSampling and Recruitment Process\u003c/h2\u003e \u003cp\u003eThe inclusion criteria for PTEC HAT were: (a) age: 21\u0026ndash;80 years old, (b) T2DM patients with HbA1c\u0026thinsp;\u0026le;\u0026thinsp;8% (c) no diabetes complication or other condition(s) that require more than the usual three to four visits to NHG polyclinic per year, (d) smartphone is supported by PTEC HAT. The pilot implementation of PTEC HAT excluded patients (a) with cognitive impairment, (b) who were pregnant, (c) with preexisting anaemia of any cause, (d) with a history of ischaemic heart disease, congestive heart failure, stroke, transient ischaemic attack, atrial fibrillation and renal impairment, (e) with complications or target organ damage or complex medical conditions e.g. Parkinson\u0026rsquo;s disease, dementia, etc., (f) who were on active titration of medication such as angiotensin converting enzyme inhibitors/angiotensin-receptor blockers, and (g) who were concurrently participating in another clinical study or programme involving a novel therapeutic drug/device, at any time during the study period.\u003c/p\u003e \u003cp\u003ePatients who participated in PTEC HAT programme, with successful transmission of their home HbA1c reading and received teleconsultation, were then referred by their primary healthcare team to the study team. The study team then contacted the patients for their interest and availability to participate in a semistructured individual in-depth interview to share their experiences on PTEC HAT programme. Eligible patients were purposively sampled to achieve variation in age groups, ethnicity and gender. The principal investigator, coinvestigators or trained study team members then confirmed patients' eligibility, explained the study and obtained written informed consent. Sufficient time was provided to the patients to consider participation and the voluntary nature of the research participation was emphasised. Informed consent was obtained from the participant before the start of any research procedures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eData were collected in the form of individual in-depth interviews between April and July 2022 remotely through Zoom video conference. The patients were advised to find a private room for the virtual interview. The interviews took place via Zoom video conference and lasted between 60 to 90 minutes. Patients\u0026rsquo; sociodemographic information, diabetes and medication history were collected at the start of the interview via an interviewer-administered questionnaire. This was followed by a semistructured interview conducted by the principal investigator and observed by study team member(s).\u003c/p\u003e \u003cp\u003eAn interview guide was designed with reference to literature and discussion among the research team members. Please refer to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for more details.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterview Guide\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSample Question\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience of learning to do home HbA1c test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. Please share your experience of learning and using the self HbA1c test.\u003c/p\u003e \u003cp\u003e2. What do you think of the coaching done by the care manager?\u003c/p\u003e \u003cp\u003e3. What do you think of the materials and guidebook prepared? How helpful are they?\u003c/p\u003e \u003cp\u003e4. [Probe] How do you think this PTEC HAT programme is different from glucose monitoring done at home?\u003c/p\u003e \u003cp\u003e5. Please can you elaborate more on what you\u0026rsquo;ve mentioned\u0026hellip;? (Probing question)\u003c/p\u003e \u003cp\u003e6. That is interesting. Please tell me more about\u0026hellip;. (Whenever there is new data/theme arise)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience of the technology (smartphone HealthHarmony Apps \u0026amp; in-app chatbot)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. How is your experience of learning and using the PTEC HAT smartphone HealthHarmony app?\u003c/p\u003e \u003cp\u003e2. How do you find the interactions with in-app chatbot under the PTEC HAT pilot programme?\u003c/p\u003e \u003cp\u003e3. (Probing question) Do you have any concern if you need to interact and reply to the in-app chatbot using SMS service?\u003c/p\u003e \u003cp\u003e4. Please share your experience with using the smartphone HealthHarmony Apps to send HbA1c results to the care team?\u003c/p\u003e \u003cp\u003e5. Please elaborate more on what you\u0026rsquo;ve mentioned\u0026hellip;? (Probing question)\u003c/p\u003e \u003cp\u003e6. That is interesting. Please tell me more about\u0026hellip;. (Whenever there is new data/theme arise)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience of using the A1CNow\u0026thinsp;+\u0026thinsp;system at home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. One of the key features of PTEC HAT is to perform the HbA1c test remotely, can you share your experience with me?\u003c/p\u003e \u003cp\u003e2. Can you share your experience with storing and preparing the A1CNow\u0026thinsp;+\u0026thinsp;test kit?\u003c/p\u003e \u003cp\u003e3. What is the result of your recent home HbA1c test?\u003c/p\u003e \u003cp\u003e4. Do you have any concerns about performing the HbA1c test yourself at home? What are they?\u003c/p\u003e \u003cp\u003e5. What challenges do you face when performing the HbA1c test at home?\u003c/p\u003e \u003cp\u003e6. Please can you elaborate more on what you\u0026rsquo;ve mentioned\u0026hellip;? (Probing question)\u003c/p\u003e \u003cp\u003e7. Do you have any issue in pricking your finger to collect blood samples?\u003c/p\u003e \u003cp\u003e8. Do you encounter problems in mixing your blood sample into the blood collector?\u003c/p\u003e \u003cp\u003e9. Do you have an issue with inserting the cartridge into the A1CNow\u0026thinsp;+\u0026thinsp;device?\u003c/p\u003e \u003cp\u003e10. Do you have any issue in getting HbA1c result on the A1CNow\u0026thinsp;+\u0026thinsp;device?\u003c/p\u003e \u003cp\u003e11. Do you find any issue in docking the A1CNow\u0026thinsp;+\u0026thinsp;device into the Bluetooth dock?\u003c/p\u003e \u003cp\u003e12. Do you encounter any issue in transmitting HbA1c reading from the Bluetooth dock to the HealthHarmony App on smartphone?\u003c/p\u003e \u003cp\u003e13. I find it interesting. Can you tell me more about\u0026hellip;? (Whenever there is new data/theme arise)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe role of family/social support in PTEC HAT adoption and experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. How would you rate the importance of family/social support in your participation in the PTEC HAT programme?\u003c/p\u003e \u003cp\u003e2. How has family/social support affected your participation in the PTEC HAT programme?\u003c/p\u003e \u003cp\u003e3. What kind of support have you received from your family members or friends in the PTEC HAT programme?\u003c/p\u003e \u003cp\u003eWhat kind of support would you like to receive from your family/friends/healthcare team in the PTEC HAT programme?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExperience of teleconsultation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. Have you received teleconsultation by the care team?\u003c/p\u003e \u003cp\u003e2. How do you find interacting through teleconsultation with the care team?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBroad experience of PTEC HAT programme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. Please share with me why you choose to be enrolled?\u003c/p\u003e \u003cp\u003e2. In general, how is your experience of the PTEC HAT pilot programme?\u003c/p\u003e \u003cp\u003e3. In your opinion, what type of person would likely take up the PTEC HAT programme?\u003c/p\u003e \u003cp\u003e4. [Probe] Do you share your diabetes condition with anyone? \u003cem\u003e(ask about if they are worried about people knowing their diabetes diagnosis)?\u003c/em\u003e\u003c/p\u003e \u003cp\u003e5. Please can you elaborate more on what you\u0026rsquo;ve mentioned\u0026hellip;? (Probing question)\u003c/p\u003e \u003cp\u003e6. That is interesting. Please tell me more about\u0026hellip;. (Whenever there is new data/theme arise)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall thoughts about PTEC HAT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. How has PTEC HAT impacted the way you manage diabetes?\u003c/p\u003e \u003cp\u003e2. Please share your suggestions or recommendations on how the program can be improved? What do you think of PTEC HAT vs routine diabetes care by NHGP?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScalability, Spread \u0026amp; Sustainability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. How confident are you with the HbA1c self-test result?\u003c/p\u003e \u003cp\u003e2. How likely are you going to continue the HbA1c self-test if PTEC HAT becomes a chargeable service?\u003c/p\u003e \u003cp\u003e3. How much will you expect yourself to pay for this programme?\u003c/p\u003e \u003cp\u003e4. Will you continue PTEC HAT if it is Medisave deductible?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal remarks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. Do you have anything else you would like to share with me?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e The interviews followed the natural progression of a conversation and the questions were not necessarily covered in the stated order. The patients were given the opportunity to discuss freely based on the questions asked. Probes and follow-up questions were used throughout the interviews to facilitate discussion. The interview questions were modified over the course of the study, using an iterative process that was informed by the content of previous interviews. Each patient received an honorarium at the end of the interview. The interviews were digitally audio-recorded and transcribed verbatim with written consent from the patients. Deidentified transcripts were then used for analysis. Relevant field notes and observations were captured after each interview. The key findings were summarised and added into a Rapid Research Evaluation and Appraisal Lab (RREAL) sheet that allowed the study team to synthesise the data and revise the interview guide as the data were being collected\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eEach transcript was read repetitively to ensure accurate understanding of the verbatim and the data analysis was conducted independently by the principal investigator and coinvestigator. The accuracy of the transcripts was verified against the recordings. This was performed with data collection simultaneously to enable the sorting of data into categories\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. The investigators recognised that their clinical background and preconceptions could influence data collection and interpretation. As such, reflexivity was employed to ensure minimal bias on the data collection and analysis process. Thematic analysis was used for analysis of the data. Initial open coding was carried out using reflexive iteration. The study team regularly met up to discuss the initial codes and the differences in opinions were resolved through consensus. The enablers and barriers identified in the form of rich descriptions were mapped to the emerged themes.\u003c/p\u003e \u003cp\u003eNVivo 12 (QSR International Pty Ltd) was used for data analysis. An excel spreadsheet was used separately by the coinvestigator, which involved generating a matrix to chart the data with the cases in rows, codes in columns and to summarise data in the cells.\u003c/p\u003e \u003cp\u003eThis qualitative study was approved by the Institutional Ethics Board (Ref No. 2021/01075).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 12 out of 21 patients referred by the care team were interviewed. Four patients declined to be interviewed when contacted by the study team. Interviews were not conducted for the rest of the five patients as data saturation has already been achieved. The data saturation was reached at the 10th interview, with the 11th and 12th interview that further confirmed data saturation. Ten of the interviews were conducted in English, while the remaining two were in Mandarin. Interviews administered in Mandarin were transcribed verbatim and translated into English.\u003c/p\u003e \u003cp\u003ePatient characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, mean (\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e(\u0026plusmn;\u0026thinsp;8.52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.7\u003c/p\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003cp\u003eChinese\u003c/p\u003e \u003cp\u003eIndian\u003c/p\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.3\u003c/p\u003e \u003cp\u003e8.3\u003c/p\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational level\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u0026lsquo;N\u0026rsquo; Level/\u0026rsquo;O\u0026rsquo; Level/NTC and below\u003c/p\u003e \u003cp\u003e\u0026lsquo;A\u0026rsquo; Level/Diploma\u003c/p\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003cp\u003e33.3\u003c/p\u003e \u003cp\u003e41.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSingle\u003c/p\u003e \u003cp\u003eMarried\u003c/p\u003e \u003cp\u003eDivorced/Separated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003cp\u003e75.0\u003c/p\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFull-time\u003c/p\u003e \u003cp\u003ePart-time\u003c/p\u003e \u003cp\u003eUnemployed \u0026amp; not studying\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003cp\u003e16.7\u003c/p\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes duration\u003c/b\u003e\u003c/p\u003e \u003cp\u003e0\u0026ndash;5 years\u003c/p\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.7\u003c/p\u003e \u003cp\u003e25.0\u003c/p\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOn medication\u003c/b\u003e\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.0\u003c/p\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHealth monitoring experience\u003c/b\u003e\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.3\u003c/p\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean age of patients was 56.6 years (range from 48 to 65 years) and female made up 58.3% (n\u0026thinsp;=\u0026thinsp;7) of the patients interviewed. Among them, 83.3% (n\u0026thinsp;=\u0026thinsp;10) of the patients were Chinese, 75% (n\u0026thinsp;=\u0026thinsp;9) of the patients attained preuniversity and above education, 58.2% (n\u0026thinsp;=\u0026thinsp;7) of the patients were working full-time, 66.7% (n\u0026thinsp;=\u0026thinsp;8) of the patients had duration of T2DM of not more than five years, 75% (n\u0026thinsp;=\u0026thinsp;9) are on diabetes medication and 83.3% (n\u0026thinsp;=\u0026thinsp;10) of the patients had prior experience with using health monitoring devices.\u003c/p\u003e \u003cp\u003eThe key findings of this study were reported in the form of rich descriptions and broadly grouped into 5 themes, which are 1) patients\u0026rsquo; experiences on PTEC HAT, 2) remote monitoring of T2DM - patient perception, 3) technology component of PTEC HAT - patient perception, 4) value proposition of the PTEC HAT and 5) patient factor in adoption of the PTEC HAT. The findings under each theme were subcategorised into the enablers and barriers.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eThe Patients\u0026rsquo; Experiences\u003c/h2\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eEnablers\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section4\"\u003e \u003ch2\u003eCoaching\u003c/h2\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;They first demo to me how to use the set and it\u0026rsquo;s quite intuitive because it\u0026rsquo;s a one-to-one training, which is good, so at any point in time if I have a question I can always ask la.\u0026rsquo; (Interviewee 2, Female, 52 years old)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eUser guide and video tutorial\u003c/h2\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I was quite relieved because there was an instruction pamphlet that I could follow. When I opened the mobile app, there was actually a portion that I could click for the video.\u0026rsquo; (Interviewee 12, Female, 51 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;the video basically refreshes everything you\u0026rsquo;ve done at the clinic during the demonstration\u0026rsquo; (Interviewee 7, Male, 58 years old)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eBarriers\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eProlonged onboarding\u003c/h2\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;They didn\u0026rsquo;t really prep me that the whole learning process was quite long. Actually I remember it take about more than an hour\u0026rsquo; (Interviewee 12, Female, 51 years old)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStorage and preparation of the HbA1c testing kit\u003c/h2\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;Packaging too big. Bulky.. so my wife was saying you are taking space in my fridge\u0026rsquo; (Interviewee 7, Male, 58 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;Afraid if there\u0026rsquo;s power outage, afraid this (test kits) will spoil\u0026rsquo; (Interviewee 1, Female, 61 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;That is a bit troublesome ah, I need to wait 1 hour, then during that 1 hour probably you are doing some stuff then after that you forgot about it. Yeah, so I don\u0026rsquo;t know whether it will affect the reading after you actually left it to thaw for more than an hour. (Interviewee 3, Female, 44 years old)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eRemote Monitoring of T2DM - Patient Perception\u003c/h2\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eEnablers\u003c/h2\u003e \u003cp\u003eThe patients accepted that the low-risk T2DM is a suitable medical condition for home HbA1c testing and telemonitoring through PTEC HAT programme. Patients also shared that there is potential in empowering patients for self-monitoring.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I believe if someone who doesn\u0026rsquo;t prick and test the blood sugar, it will be revelational for them. You can actually test and see your sugar level yourself. And then for someone who doesn\u0026rsquo;t do it they can also build their confidence that actually they should consider doing a regular (HbA1c) test.\u0026rsquo; (Interviewee 2, Female, 52 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDuring the COVID-19 pandemic, PTEC HAT was advantageous in ensuring continued diabetes care.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;PTEC HAT is really good in a situation now, because of the COVID, yeah, so if the clinic gets overcrowded, the chances of people getting infected from one another is higher, so this place is an added advantage.\u0026rsquo; (Interviewee 9, Female, 60 years old)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eBarriers\u003c/h2\u003e \u003cp\u003eMany patients expressed that the interval between onboarding and performing the home HbA1c test was lengthy. The HbA1c test, unlike the routine home blood glucose test, was typically performed at three to six monthly intervals to assess diabetes control. This made testing a challenge as the steps for home HbA1c testing becomes less familiar to patients a few months after enrolment.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;We can understand very well at that point of time. But... there is a lapse of time. When we do the actual one 6 months later...I can confirm that we will not do it well.\u0026rsquo; (Interviewee 8, Male, 63 years old)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eTechnology Component of PTEC HAT - Patient Perception\u003c/h2\u003e \u003cp\u003eOverall, the patients valued the technology that comes with the mobile app. They found the in-app chatbot reminder particularly useful when preparing for the home HbA1c testing. However, there were differing views about the home HbA1c testing process and the subsequent teleconsultation. Many patients spoke negatively about the data transmission via the Bluetooth device provided in the package.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eEnablers\u003c/h2\u003e \u003cp\u003ePatients found the in-app chatbot very helpful in reminding them to perform the home HbA1c testing on the prearranged date. In addition, patients expressed that the instructions sent out by in-app chatbot provided assurance for them to complete the home testing correctly.\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026lsquo;\u003c/b\u003e \u003cem\u003eI think the reminder is good because uh for people who are busy like me\u0026hellip;it helps to remind me on that day I am supposed to do this test I have to make sure I keep my time for the appointment.\u0026rsquo; (Interviewee 9, Female, 60 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip; (the in-app chatbot) reminds you that on this day you need to do the test, remember to take out and thaw 1 hour before using it. So it is a good reminder\u0026hellip; (It is) also an add-on to tell me that I'm doing the right thing correctly\u0026hellip;\u0026rsquo; (Interviewee 4, Female, 45)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eBarriers\u003c/h2\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eHome HbA1c result transmission with Bluetooth device\u003c/h2\u003e \u003cp\u003eThe Bluetooth device synchronises the HbA1c result from home test kit to the mobile app, thereby minimising transcribing errors by the patients. The Bluetooth device functions by pressing on the unit to turn on and subsequently two distinctive tones are played to indicate that the device is ready to be used and after it has been successfully paired with a smartphone. However, there are no visual cues.\u003c/p\u003e \u003cp\u003eA large majority of the patients in this qualitative study encountered failure when using the Bluetooth device to synchronise home HBA1c reading from the home testing to mobile app, which resulted in negative experience and dropped in confidence.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;The part of transmitting result is confusing\u0026hellip; I don\u0026rsquo;t know what does the tone sound like, so the first transmission didn\u0026rsquo;t get through. It\u0026rsquo;s a negative feeling because I\u0026rsquo;ve already pricked my finger and have the HbA1c reading, then the transmission is kind of failed\u0026hellip; The confidence level is affected\u0026hellip; result in certain level of stress.\u0026rsquo; (Interviewee 2, Female, 52 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026lsquo;\u0026hellip;\u003c/b\u003e \u003cem\u003ethe final procedure is to send the data over, but since you cannot send the data over, then what you have done in front is all wasted\u0026rsquo; (Interviewee 8, Male, 63 years old)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eValue Proposition of PTEC HAT\u003c/h2\u003e \u003cp\u003ePatients valued the convenience of performing the HbA1c testing at home but the perceived value depended on their employment status.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eEnablers\u003c/h2\u003e \u003cp\u003eThe instant result generated by home HbA1c testing was rewarding. It increased the self-efficacy of the participants in improving diabetes control.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I will also like to see results immediately, I don\u0026rsquo;t have to wait for doctor to tell me or whoever to tell me after waiting for another 45 minutes at the clinic\u0026rsquo; (Interviewee 7, Male, 58 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePTEC HAT pilot programme was found to be convenient and time-saving as it was able to reduce the number of visits to the polyclinic.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;...I will take leave to go for medical appointment and I think it is very troublesome. So if let\u0026rsquo;s say all these could be done at home, I think it will be very useful not only for COVID but actually for ...scheduling of my work...that is why I actually thought it is very good.\u0026rsquo; (Interviewee 6, Male, 52 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;I think this teleconsultation...is fine...is really saving time going down to see a doctor.\u0026rsquo; (Interviewee 3, Female, 44 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe flexible test date or time had additional value in ensuring adherence to perform home HbA1c testing among the patients.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;...that\u0026rsquo;s why I prefer to continue this, Because I can... decide when I can do it: this morning, or maybe this evening or tomorrow morning\u0026rsquo; (Interviewee 6, Male, 52 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003ePatients felt at ease having the teleconsultation as the healthcare team who contacted the patient was well-informed of their medical condition.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;So the standard (of teleconsultation), I'll say is maintained\u0026hellip;Experience is the same (as physical consultation).\u0026rsquo; (Interviewee 2, Female, 52 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;She seems to know what is happening, so I feel comfortable. Not only like now we are quite used to remote (consultation), but she (also) knows what she is talking about\u0026rsquo; (Interviewee 6, Male, 52 years old)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eBarriers\u003c/h2\u003e \u003cp\u003eThe perceived time saved from the programme was diminished for patients with other medical conditions, which also required other tests in the clinic.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;It doesn\u0026rsquo;t take away my time or it doesn\u0026rsquo;t save me a lot of time just because I am doing this at home.\u0026rsquo; (Interviewee 7, Male, 58 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome patients found the home HbA1c testing complex and were concerned if the programme became a chargeable service in the future.\u003c/p\u003e \u003cp\u003e \u003cem\u003e'I think these items are expensive...It is not like that the (glucometer) strip where you test and you don't have a proper reading you can just throw away the strip and just do another prick test\u0026hellip;because of the number of steps it requires, every step is important otherwise there is failure of the data (generation and/or transmission). So if the patient is paying for these then it\u0026rsquo;s also the concern of the patient to do it right the first time. Right?\u0026rsquo; (Interviewee 7, Male, 58 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAdditionally, the perceived value of PTEC HAT was dependant on the potential cost of the programme.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I'm hoping that maybe it (PTEC HAT) will be a bit cheaper than the actual lab test because\u0026hellip;if the prices are the same, or if this one is a bit higher than the lab test, then they might as well go to the lab test, because people (phlebotomist) will do it for them.\u0026rsquo; (Interviewee 12, Female, 51 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eA patient did not think the teleconsultation was helpful but instead, saw it as a standard operating procedure (SOP) and viewed the teleconsultation to be inadequate compared to a physical consult. However, the patient was not aware of the difference between the readings obtained from SBGM and A1CNow\u0026thinsp;+\u0026thinsp;kit as well as the requirement to consult healthcare team in clinic polyclinic visit with every routine HbA1c testing. This could have resulted in the lower perceived value of teleconsultation.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026hellip;this telecommunication, teleconversation, probably is just the SOP, I think that this does not help much\u0026rsquo; (Interviewee 8, Male, 63 years old)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;Anyone who has medical issue will still want to seek professional advice, attention, you\u0026rsquo;ll still want to see a doctor probably, face-to-face...that is where you have more peace of mind\u0026rsquo; (Interviewee 3, Female, 44 years old)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003ePatient Factors in Adopting PTEC HAT\u003c/h2\u003e \u003cp\u003eThe successful PTEC HAT participation provided a snapshot of the potential take-up rate if it was to become an official programme.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eEnablers\u003c/h2\u003e \u003cp\u003eIt was found that a reasonable level of digital literacy, prior experience with blood pressure and glucometer monitoring, absence of needle phobia, and strong intrinsic motivation for self-monitoring were identified as the main factors attributing to successful PTEC HAT participation.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eDigital literacy\u003c/h2\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I'm a smartphone user so l'm able to understand... what to do, so it's after I download right\u0026hellip;they ask me to key in some administrative stuff, and everything is I done it on the spot\u0026rsquo; (Interviewee 4, Female, 45)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eThe absence of needle phobia\u003c/h2\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I actually have no issue pricking my fingers because first of all, I've been using the glucometer myself at home as well also, so that requires a lot of pricking. ...when they told me oh, you still need to actually prick your fingers, I said it's not a problem.\u0026rsquo; (Interviewee 3, Female, 44 years old)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eIntrinsic motivation and prior experience with health monitoring\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003e\u0026lsquo;I came to a point where I'm really concerned about my wellbeing\u0026hellip; That I might have hypertension, so I thought this is a good way for me, checking on myself\u0026hellip;that's why I signed up for it...there is a big correlation because people who are interested in their results then they will buy the glucometer and prick.\u0026rsquo; (Interviewee 11, Male, 62 years old)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eBarriers\u003c/h2\u003e \u003cp\u003eConversely, patients with lower level of digital literacy, needle phobia and low level of self-motivation would have a lower likelihood of overcoming challenges when interacting with the multiple components of PTEC HAT.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eThe inadequate level of digital literacy\u003c/h2\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;....my wife (is) bad with technology...my sister-in-law was in my house and I purposely take out these kits, ask her for help...she is more educated on technology and yet we follow all the SOP, (we) cannot get through\u0026rsquo; (Interviewee 8, Male, 63 years old)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eNeedle phobia\u003c/h2\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I'm scared of needles already. I don\u0026rsquo;t want to prick myself again\u0026rsquo; (when the participant failed to transmit the result via Bluetooth)\u0026rsquo; (Interviewee 12, Female, 51 years old)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003eLack of self-motivation\u003c/h2\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I don\u0026rsquo;t have much feelings about it, it\u0026rsquo;s just that I didn\u0026rsquo;t know how to at the start and then I thought I didn\u0026rsquo;t want to use it anymore\u0026rsquo; (Interviewee 5, Female, 54 years old)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study aimed to explore the experiences of low-risk patients with T2DM who participated in PTEC HAT programme, and to identify the enablers and barriers of using various PTEC HAT components. The suitable patient characteristics enabling the participation in PTEC HAT included reasonable level of digital literacy, health monitoring experience in the past, absence of needle phobia and strong intrinsic motivation. The key enablers identified for using various PTEC HAT components included the positive reinforcement with instant HbA1c generation, great value of flexibility and convenience, benefits of teleconsultation to reduce polyclinic visit and the perceived suitability low-risk T2DM for home HbA1c testing and teletemonitoring. The enablers identified to maintain patients\u0026rsquo; motivation in completing the PTEC HAT programme included the coaching by primary care team, the support in the form of in-app chatbot reminder, as well as the user guide and video tutorial accessibility. Even though they did not broadly affect patients\u0026rsquo; experiences, there were several barriers identified, which included the long interval between onboarding and subsequent home HbA1c testing, making challenging for patients to recall the steps, persistent issue with HbA1c result transmission with Bluetooth device, misperception on inferiority of teleconsultation, concern of potential cost of the programme and the amount of efforts needed to perform self-testing as well as unsuitable patient characteristic - low digital literacy, needle phobia and lack of motivation.\u003c/p\u003e\n\u003ch3\u003eThe Patients’ Experiences\u003c/h3\u003e\n\u003cp\u003eSander et al found that high level of uncertainty regarding the technological aspects of the health device being offered was one of the reasons for nonadoption\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. For PTEC HAT, patients shared that there were several initiatives established to minimise the uncertainty, which enhanced this learning experience during the onboarding session. The engagement, availability of training material and support delivered during the in-person coaching provided assurance to the patients the effectiveness of the technology. The return demonstration performed in the clinic gave the patients confidence that they can repeat the testing at home without the physical assistance from the care team. The additional resources provided to them in the form of video tutorial and the user guide served as mitigating factors to perform the HbA1c testing even after three to six months posttraining.\u003c/p\u003e \u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003eThe Enablers\u003c/h2\u003e \u003cp\u003eOur findings revealed that the perceived good value by the patients as the key facilitator for PTEC HAT programme uptake. Majority of the patients recognised that telemonitoring, with technology enhanced home HbA1c testing, as a convenient alternative for the routine care in the clinic. This perceived value was dependent on the compulsion for a more flexible schedule that is associated with the patients\u0026rsquo; occupation and the amount of free time they have. Most patients do not mind travelling down to the clinic for the regular blood test as they have other appointments to fulfil, such as vaccination, diabetic retinal photography and diabetic foot screening. However, the fact that the PTEC HAT home test is not bounded by time or place made it an attractive alternative to many who have limited free time. This is consistent with the finding of a cross sectional validation study, in which the shortening of travel and waiting times to the clinic was identified as one of the benefits of diabetes telemonitoring\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAnother enabler that increased the acceptability is the patients\u0026rsquo; prior experience with health monitoring like SBGM, which requires similar technical competency by the patient in obtaining the blood sample, followed by the need to feed the sample into a reader to obtain the glucose reading. A scoping review of 29 studies found that previous experience with the technology is one of the patient-level facilitators for the uptake of digital health technology\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Majority of the patients in our study were found to have prior experience with the health monitoring, thus making them a more empowered and motivated group.\u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003eThe Barriers\u003c/h2\u003e \u003cp\u003eSeveral patients requested to remove redundant technological features that add complexity to the whole innovation in order to improve the practical acceptability. The primary barrier that the patients faced with the technology was with the result transmission using the Bluetooth device prescribed to them. Our finding was consistent with how Torbj\u0026oslash;rnsen et al., described the usability issue of Bluetooth device hindering practical acceptability of a telecare programme\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Torbj\u0026oslash;rnsen\u0026rsquo;s et al.\u0026rsquo;s study was primarily to understand factors affecting a patient\u0026rsquo;s acceptability of a mobile app for diabetes self-management. It was found that one of the most valued features of the app was its ability to transfer the blood glucose data to health-care personnel using Bluetooth. However, it was also found to be one of the major usability issues, requiring frequent support to reconnect the devices, making it challenging to use. The need to send the HbA1c reading via Bluetooth device was seen as a redundant feature that resulted in negative emotions and reduced the usability of the technology. The patient\u0026rsquo;s perceived barriers echoed the findings from other studies exploring the factors impeding the acceptance of digital health technologies, namely, poor design and inoperability of the telemedicine programme\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSome of the patients were not aware of the fundamental difference between the readings obtained from SBGM and A1CNow\u0026thinsp;+\u0026thinsp;kit. This could have resulted in the lower perceived value of PTEC HAT programme and the lack of appreciation for the additional steps required by PTEC HAT to obtain the reading. This highlighted the importance of better patient education to illuminate the significance and value of HbA1c in self-management of T2DM.\u003c/p\u003e \u003cp\u003eThe low frequency of HbA1c testing was shared by the patients as another potential barrier in joining the programme. They did not see the cost-effectiveness of investing both time and money in a potentially high-cost device, that requires a certain level of technical and digital competency to operate, which will only be used two to four times a year. Therefore, these factors, as opposed to the physical visit to the clinic that provides a no-hassle-service, makes PTEC HAT less attractive to the patients. In this regard, the growth of value-based payment models may be a solution to provide incentives in implementing cost-effective, high-quality and coordinated telehealth\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec39\" class=\"Section2\"\u003e \u003ch2\u003eStudy Strengths and Limitations\u003c/h2\u003e \u003cp\u003eTo our knowledge, this is the first qualitative study on low risk adult patients adopting telemonitoring with technology-enhanced home HbA1c test for T2DM care. The purposive sampling enabled detailed data collection from patients with various demographic profiles. The in-depth individual interviews performed until data saturation enabled comprehensive identification of interweaving enablers and barriers.\u003c/p\u003e \u003cp\u003eThe strengths of the study were enhanced by striving to achieve credibility, transferability, dependability and confirmability using Lincoln and Guba framework\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. A few strategies were used to achieve credibility: 1) investigators maintained prolonged engagement and member-checking was carried out pro-actively during interviews and 2) investigator triangulation was carried out during the process of data analysis. In addressing transferability, the coded data was presented as thick descriptions so that the patient\u0026rsquo;s context, behaviour and experience are meaningful to the reader. To maintain dependability, records of the conduct of the study and all meetings were documented, thereby establishing a clear audit trail. Confirmability was achieved by including patients\u0026rsquo; direct quotes in the results and reference to the literature that confirmed the interpretations in this study.\u003c/p\u003e \u003cp\u003eThis qualitative study was limited by the fact that 83.3% of the patients were Chinese, and there were no Malay participants. Therefore, this ethnicity was unrepresented. The small number of patients in PTEC HAT programme (n\u0026thinsp;=\u0026thinsp;33) had also restricted the heterogeneity for purposive sampling. In addition to that, other NASSS domains such as \u0026lsquo;the organisation\u0026rsquo;, \u0026lsquo;the wider context\u0026rsquo; and \u0026lsquo;the interaction between domains and adaptation over time\u0026rsquo; were not addressed as the study team did not ask the related views in this study. The transferability of our findings to other groups of diabetes patients may be limited as this study was conducted with low-risk patients with T2DM. Future studies should focus on exploring the perspectives of the healthcare team and other stakeholders in PTEC HAT programme, in terms of the factors associated with nonadoption and the cost-effectiveness of PTEC HAT in diabetes management.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAs telemonitoring increasingly becomes an integral part of healthcare, it is important to understand and learn from the patients\u0026rsquo; experiences in novel technology enhanced home HbA1c telemonitoring programme for T2DM care. Based on the patients\u0026rsquo; experiences, our qualitative study established that telemonitoring with technology enhanced home HbA1c testing is a useful alternative to routine care for low-risk patients with T2DM in primary healthcare institutions. It is not only one that is providing patients with the flexibility and convenience but also empowers patients for self-care. However, the benefit is moderated by lack of practical usability of the Bluetooth device for HbA1c result transmission, as well as concerns of possible high cost associated with the technology component for HbA1c testing that is only done a few times a year, which diminishes the value proposition. It is hoped that the knowledge gained from our study can improve the design of telehealth initiatives for patients with T2DM and possibly integrate PTEC HAT seamlessly into existing programmes for other chronic diseases, thereby enhancing the overall benefit for the patient.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBP = Blood pressure\u003c/p\u003e\n\u003cp\u003eCGM = Continuous glucose monitoring\u003c/p\u003e\n\u003cp\u003eMOHT = MOH Office of Healthcare Transformation\u003c/p\u003e\n\u003cp\u003eNASSS = nonadoption, abandonment, scale-up, spread and sustainability\u003c/p\u003e\n\u003cp\u003eNHG = National Healthcare Group\u003c/p\u003e\n\u003cp\u003ePTEC HAT = Primary Technology Enhanced Care - Home HbA1C Testing\u003c/p\u003e\n\u003cp\u003eRREAL = Rapid Research Evaluation and Appraisal Lab\u003c/p\u003e\n\u003cp\u003eSBGM = self-blood glucose monitoring\u003c/p\u003e\n\u003cp\u003eSOP = standard operating procedure\u003c/p\u003e\n\u003cp\u003eT2DM = type 2 diabetes mellitus\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Consideration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethics approval from the NHG Domain Specific Review Board (Ref No. 2021/01075). Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is funded by NHG Polyclinics Research Fund (Ref no.: RF-2021-002).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conceptualisation and design of the study. \u0026nbsp; Dr Kah Pieng Ong, Dr Eng Sing Lee and Ms Elya were involved in developing the interview guide. Dr Kah Pieng Ong and Ms Elya Chen conducted the interviews, analysed the data and wrote the manuscripts. Ms Elya Chen made substantial contributions in drafting the manuscripts. Dr Kah Pieng Ong, Dr Eng Sing Lee, Dr Wern Ee Tang and Dr David Wei Liang Ng were involved in revising the manuscripts. Dr Eng Sing Lee and Dr Wern Ee Tang were involved in supervising the conduct of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team is thankful to get the permission from the MOHT to embark on this qualitative study, as well as the contributions of MOHT interns, Mr Cedric Koh and Ms Rachel Lim, in audio transcription and data coding. We would also like to thank Ang Mo Kio Polyclinic teamlet F, as well as research coordinator, Ms Nur Atiqah Bte Surya Akmaja for her logistic support in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKhan MAB, Hashim MJ, King JK, Govender RD, Mustafa H, Al Kaabi J. Epidemiology of Type 2 Diabetes - Global Burden of Disease and Forecasted Trends. J Epidemiol Glob Health. 2020 Mar;10(1):107-111. doi: 10.2991/jegh.k.191028.001. PMID: 32175717; PMCID: PMC7310804.\u003c/li\u003e\n\u003cli\u003eMinistry of Health, Singapore. Result from government five-year \u0026ldquo;Was against diabetes\u0026rdquo; effort. 2022 Jan 10 [cited 2022 Dec 27]. Available from https://www.moh.gov.sg/news-highlights/details/result-from-government\u0026apos;s-five-year-war-against-diabetes-effort/#:~:text=Hence%2C%20while%20the%20recent%20National,the%20same%20period%20at%207.9%25.\u003c/li\u003e\n\u003cli\u003eMark Tan KW, Dickens BSL, Cook AR Projected burden of type 2 diabetes mellitus-related complications in Singapore until 2050: a Bayesian evidence synthesis BMJ Open Diabetes Research and Care 2020;8:e000928.doi: 10.1136/bmjdrc-2019-000928\u003c/li\u003e\n\u003cli\u003eNathan DM; DCCT/EDIC Research Group. 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PMID: 30697366; PMCID: PMC6347654.\u003c/li\u003e\n\u003cli\u003eAmerican Diabetes A. 6. Glycemic targets: standards of medical care in diabetes-2018. Diabetes Care 2018;41(Suppl 1):S55e64.\u003c/li\u003e\n\u003cli\u003eGreenwood DA, Gee PM, Fatkin KJ, Peeples M. A Systematic Review of Reviews Evaluating Technology-Enabled Diabetes Self-Management Education and Support. JDiabetes Sci Technol. 2017 Sep;11(5):1015-1027. doi:10.1177/1932296817713506. Epub 2017 May 31.PMID: 28560898; PMCID: PMC5951000.\u003c/li\u003e\n\u003cli\u003eHuang Z, Tao H, Meng Q, Jing L. Effects of telecare intervention on glycemic control in type 2 diabetes: a systematic review and meta-analysis of randomized controlledtrials. Eur J Endocrinol. 2015;172(3):93\u0026ndash;101.\u003c/li\u003e\n\u003cli\u003eLee PA, Greenfield G, Pappas Y. The impact of telehealth remote patient monitoring on glycemic control in type 2 diabetes: a systematic review and meta-analysis of systematic reviews of randomised controlled trials. BMC Health Serv Res. 2018 Jun 26;18(1):495. doi:10.1186/s12913-018-3274-8. PMID: 29940936; PMCID: PMC6019730.\u003c/li\u003e\n\u003cli\u003eLee JY, Lee SWH. Telemedicine Cost-Effectiveness for Diabetes Management: A Systematic Review. Diabetes Technol Ther. 2018 Jul;20(7):492-500.doi: 10.1089/dia.2018.0098. Epub 2018 May 29. PMID: 29812965.\u003c/li\u003e\n\u003cli\u003eLai SH, Tang CQ. Telemedicine and COVID-19: beyond just virtual consultations\u0026ndash;the Singapore experience. Bone \u0026amp; Joint Open. 2020 Jun 6;1(6):203-4.\u003c/li\u003e\n\u003cli\u003eSin, D.Y.E., Guo, X., Yong, D.W.W. \u003cem\u003eet al.\u003c/em\u003e Assessment of willingness to Tele-monitoring interventions in patients with type 2 diabetes and/or hypertension in the public primary healthcare setting. \u003cem\u003eBMC Med Inform Decis Mak\u003c/em\u003e 20\u003cstrong\u003e, \u003c/strong\u003e11 (2020). https://doi.org/10.1186/s12911-020-1024-4\u003c/li\u003e\n\u003cli\u003eLee PA, Greenfield G, Pappas Y. Patients\u0026apos; perception of using telehealth for type 2 diabetes management: a phenomenological study. BMC Health Serv Res. 2018 Jul 13;18(1):549. doi: 10.1186/s12913-018-3353-x. PMID: 30005696; PMCID: PMC6045870.\u003c/li\u003e\n\u003cli\u003eTurnbull S, Lucas PJ, Hay AD, Cabral C. Digital Health Interventions for People With Type 2 Diabetes to Develop Self-Care Expertise, Adapt to Identity Changes, and Influence Other\u0026apos;s Perception: Qualitative Study. J Med Internet Res. 2020 Dec 21;22(12):e21328. doi: 10.2196/21328. PMID: 33346733; PMCID: PMC7781797.\u003c/li\u003e\n\u003cli\u003eAyre J, Bonner C, Bramwell S, McClelland S, Jayaballa R, Maberly G, McCaffery K. Factors for Supporting Primary Care Physician Engagement With Patient Apps for Type 2 Diabetes Self-Management That Link to Primary Care: Interview Study. JMIR Mhealth Uhealth. 2019 Jan 16;7(1):e11885. doi: 10.2196/11885. PMID: 30664468; PMCID: PMC6352005.\u003c/li\u003e\n\u003cli\u003eMinistry of Health, Singapore. Investing in enablers and infrastructure to support healthcare transformation. 2022 March 9 [cited 2022 Dec 27]. Available from https://www.moh.gov.sg/news-highlights/details/investing-in-enablers-and-infrastructure-to-support-healthcare-transformation\u003c/li\u003e\n\u003cli\u003eGreenhalgh T, Wherton J, Papoutsi C, Lynch J, Hughes G, A\u0026apos;Court C, Hinder S, Fahy N, Procter R, Shaw S. Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies. J Med Internet Res 2017;19(11):e367.\u003c/li\u003e\n\u003cli\u003eVindrola-Padros, Cecilia and Chisnall, Georgia and Polanco, Natalia and Vera San Juan, Norha, Iterative Cycles in Qualitative Research: Introducing the RREAL Sheet as an Innovative Process. Available at SSRN: https://ssrn.com/abstract=4162797 or http://dx.doi.org/10.2139/ssrn.4162797\u003c/li\u003e\n\u003cli\u003eSandelowski M,Barroso J. Classifying the Findings in Qualitative Studies. Qualitative Health Research. 2003;13(7):905-923.doi:10.1177/1049732303253488\u003c/li\u003e\n\u003cli\u003eSanders, C., Rogers, A., Bowen, R. et al. Exploring barriers to participation and adoption of telehealth and telecare within the Whole System Demonstrator trial: a qualitative study. BMC Health Serv Res 12, 220 (2012). https://doi.org/10.1186/1472-6963-12-220\u003c/li\u003e\n\u003cli\u003eMuigg D, Duftschmid G, Kastner P, Modre-Osprian R, Haluza D. Telemonitoring readiness among Austrian diabetic patients: A cross-sectional validation study. Health Informatics J. 2020 Dec;26(4):2332-2343. doi: 10.1177/1460458219894094. Epub 2020 Feb 12. PMID: 32046567.\u003c/li\u003e\n\u003cli\u003eWhitelaw, S., Pellegrini, D. M., Mamas, M. A., Cowie, M., \u0026amp; Van Spall, H. G. (2021). Barriers and facilitators of the uptake of digital health technology in cardiovascular care: a systematic scoping review. European Heart Journal-Digital Health, 2(1), 62-74.\u003c/li\u003e\n\u003cli\u003eTorbj\u0026oslash;rnsen, A., Ribu, L., R\u0026oslash;nnevig, M. et al. Users\u0026rsquo; acceptability of a mobile application for persons with type 2 diabetes: a qualitative study. BMC Health Serv Res 19, 641 (2019). https://doi.org/10.1186/s12913-019-4486-2\u003c/li\u003e\n\u003cli\u003eScott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: A systematic review. J Telemed Telecare. 2018 Jan;24(1):4-12. doi: 10.1177/1357633X16674087. Epub 2016 Oct 16. PMID: 29320966; PMCID: PMC5768250.\u003c/li\u003e\n\u003cli\u003eAndr\u0026egrave;s E, Talha S, Jeandidier N, Meyer L, Hajjam M, Hajjam A. Telemedicine in chronic diseases: the time of maturity with telemedicine 2.0 in the setting of chronic heart failure and diabetes mellitus! Curr Res Diabetes Obes J. 2018;6:1\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eLincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park, CA: Sage Publications, 1985\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4461158/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4461158/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDiabetes mellitus related healthcare expenditure is expected to rise drastically as the incidence of diabetes associated comorbidities increase. Hence, it is vital to maintain ideal glycaemia for patients with diabetes to reduce the risk of diabetic complications. Given the strong predictive value for diabetes complications, HbA1c remains the gold standard test to monitor glycaemic control in contemporary clinical practice. HbA1c is recommended to be measured between quarterly to six monthly, depending on the level of patient\u0026rsquo;s glycaemic control. There is growing positive evidence that supports the use of innovative telemedicine to monitor and manage patients with diabetes. Telemedicine has particularly played a crucial role in efforts against the COVID-19 pandemic. PTEC HAT pilot programme is developed by MOH Office of Healthcare transformation (MOHT) to implement telemonitoring care to low-risk patients with type 2 diabetes mellitus (T2DM) in the community through National Healthcare Group (NHG) Polyclinics collaboration. It is intended to empower low-risk patients to manage their T2DM care independently and maintain their follow-up with the healthcare team by telemonitoring. Through PTEC HAT, eligible patients will be able to replace their three to six monthly interim paired HbA1c test and physical polyclinic visits with home HbA1c tests and teleconsultations, saving them up to three visits to polyclinic per year while getting their glycaemic control telemonitored by the healthcare team. This qualitative study is conducted as part of the evaluation of the pilot implementation of PTEC HAT programme. It aims to explore the experiences of low-risk patients with T2DM who participated in PTEC HAT programme, and to identify the enablers and barriers of using various PTEC HAT components.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients referred by healthcare team were selected via purposive sampling and invited via telephone. Individual semistructured in-depth interviews were conducted with 12 patients. The interviews were audio-recorded and transcribed verbatim. The results generated from thematic analysis were presented in the form of rich descriptions. The nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability (NASSS) framework was used as the conceptual framework for the topic guide and guided the analysis framework. The emergent results were categorised into the enablers and barriers further grouped into themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe identified enablers and barriers were grouped into themes. For the enablers, patient found the coaching by healthcare team and the access to supporting materials (video tutorial and user guide) useful in encouraging them to complete PTEC HAT programme. Patients accepted PTEC HAT as a suitable telemonitoring programme to maintain care for low-risk T2DM, especially during the pandemic. In term of technology component, patients liked the proactive reminder for home HbA1c testing by the in-app chatbot and the advantage of completing review through teleconsultation. Patients felt rewarded as the reading could be generated instantaneously using the home HbA1c test and the flexibility to perform the home HbA1c test at any preferred time was another great value. The patients also valued the convenience of teleconsultation following home HbA1c test, which saved time and reduced clinic visits. Patient characteristic which enabled successful participation included a reasonable level of digital literacy, prior experience with health monitoring, absence of needle phobia and strong intrinsic motivation. The barriers identified included tedious storage and preparation of the HbA1c self-test kit in addition to the prolonged onboarding process. The three to six months\u0026rsquo; gap between onboarding and conducting the actual home HbA1c testing was reported to be challenging for patients to recall the required steps. Other key barriers included issues with syncing the home HbA1c reading to mobile app via the Bluetooth device. The concerns of high cost associated with the PTEC HAT programme had also resulted in a negative impact on patients\u0026rsquo; acceptability and lowered their perceived value. Last, low digital literacy, needle phobia and lack of motivation were identified as the barriers at patient level to affect PTEC HAT programme.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePatients reported that home HbA1c monitoring under PTEC HAT was a useful alternative to routine care. The patients' experience with PTEC HAT varied with their exposure to health monitoring and health literacy. Findings from this study can provide insights to improve the design of other similar telehealth initiatives and enhance widespread adoption, scale-up, spread and sustainability of home HbA1c monitoring.\u003c/p\u003e","manuscriptTitle":"Understanding the patients’ experience in Primary Technology Enhanced Care Home HbA1c Testing (PTEC HAT) programme - A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-10 22:55:34","doi":"10.21203/rs.3.rs-4461158/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-28T08:45:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-25T11:11:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-25T11:11:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2024-05-22T13:13:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"40f02f2c-084f-4c41-b2e3-704a3294bbc2","owner":[],"postedDate":"June 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-20T16:10:32+00:00","versionOfRecord":{"articleIdentity":"rs-4461158","link":"https://doi.org/10.1186/s12875-025-03034-2","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2025-10-13 15:58:37","publishedOnDateReadable":"October 13th, 2025"},"versionCreatedAt":"2024-06-10 22:55:34","video":"","vorDoi":"10.1186/s12875-025-03034-2","vorDoiUrl":"https://doi.org/10.1186/s12875-025-03034-2","workflowStages":[]},"version":"v1","identity":"rs-4461158","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4461158","identity":"rs-4461158","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}