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For people living with diabetes in low- and middle-income countries, access to education and support can depend as much on geography, income and health system stability as on clinical need. Mobile health is often presented as a way to narrow that gap. In Lebanon, the question is more urgent: Can mobile health and digital tools help sustain diabetes care when the health system around them is under immense pressure?
That question was at the centre of a presentation by Dr Ola Sukkarieh, an International Diabetes Federation (IDF) Senior Fellow from Lebanon and Associate Professor of Nursing at the American University of Beirut, during a recent IDF Fellows Virtual Roundtable, From insights to impact: driving change in global diabetes care. Her work examined the practical challenges of running a randomised controlled trial on mobile health for diabetes self-management education in a low- and middle-income setting. But its significance goes beyond the design of a study. It offers a window into what happens when digital diabetes care meets the realities of economic crisis, conflict, displacement and overstretched health services.
Lebanon has faced years of overlapping crises: financial hardship, the Covid-19 pandemic, the Beirut port explosion, recent conflict and refugee arrivals. These pressures have disrupted health services and reshaped daily life for many people living with type 2 diabetes. In this context, diabetes care can easily compete with more immediate concerns: safety, income, transport, food access and family responsibilities. Education and self-management support remain essential, but their delivery needs to align with people’s everyday lives.
Dr Sukkarieh’s study explored whether diabetes self-management education could be delivered through mobile devices. The intervention used WhatsApp video calls, a familiar and low-cost platform, to connect people living with diabetes with a diabetes educator.
The research was developed in two phases. The first used qualitative interviews to understand the views, needs and expectations of people living with diabetes. This groundwork helped the research team refine the intervention before moving into the trial phase.
The second phase was designed as a single blind randomised controlled trial. Participants completed baseline assessments, including blood glucose and lipid profiles, body mass index, blood pressure and waist circumference.. They also completed surveys on diabetes knowledge, diabetes fatalism, behaviour change, social support and self-efficacy.
They were then assigned to one of two groups. One group received eight diabetes self-management education sessions through WhatsApp video calls with a diabetes educator. The other received usual care. Follow-up assessments were planned at three and six months, using the same clinical and survey measures collected at baseline.
Lebanon has faced years of overlapping crises. These pressures have disrupted health services and reshaped daily life for many people living with type 2 diabetes.
At the heart of the intervention was a person-centred approach supported by motivational interviewing. This matters. Diabetes education is not simply a matter of giving information and expecting behaviour to change.
Self-management is shaped by confidence, trust, culture, affordability, family responsibilities and the pressures of everyday life. A person may know what is recommended but still face barriers that make it difficult to follow those recommendations.
The study found that participants clearly appreciated the intervention’s personalised and culturally tailored approach. This suggests that people may still see such programmes as relevant and worthwhile, even when wider pressures limit their impact on behaviour. That distinction matters. In mobile health trials in low- and middle-income countries, an intervention can be acceptable to participants without necessarily producing measurable behavioural change.
Dr Sukkarieh’s work recognised people living with diabetes as active partners in their own care. In a setting where daily priorities may shift suddenly because of economic or social instability, that distinction is crucial. Mobile health, in this context, is not just a delivery channel. It is a test of whether care can be made more flexible, more reachable and more responsive to people’s circumstances.
One of the strongest lessons from Lebanon is that health innovation cannot be separated from context.
Mobile health may reduce travel time, lower costs and improve access to healthcare professionals. For underserved communities, it may help address some of the inequities that prevent safe and effective diabetes management. But digital access alone is not enough.
The Lebanon study also showed why pilot work matters. The qualitative phase allowed the research team to listen before intervening. In settings where local evidence is limited, this is not optional. It is part of responsible implementation.
The research also exposed the pressures that shape whether studies can be delivered at all. Approvals, staffing shortages, laboratory processes, budget constraints and stakeholder engagement all affected the study. Recruitment was more difficult than expected, requiring the team to expand beyond the original site and engage primary healthcare centres.
These are not minor administrative details. They determine whether evidence can be generated, whether interventions can be sustained and whether successful programmes can eventually be scaled.
Self-management is shaped by confidence, trust, culture, affordability, family responsibilities and the pressures of everyday life.
Randomised controlled trials are often seen as a strong method for evaluating health interventions. But Dr Sukkarieh’s report points to a wider challenge: trials do not take place in ideal conditions.
In countries affected by conflict, displacement, economic instability or sudden disruption, maintaining the structure of a trial can be difficult. Religious observances, insecurity, transport barriers and abrupt changes in people’s priorities may all influence participation.
This does not weaken the value of research. It shows why research must be designed with enough flexibility to reflect real life. In low- and middle-income countries, where health systems may already be under strain, implementation is not a final step after evidence has been produced. It is part of the evidence itself.
The Lebanon experience reinforces a clear message: mobile health programmes must be designed with people living with diabetes, not only for them. They must also reflect the conditions in which care is delivered, including workforce capacity, funding, infrastructure and social realities.
The lessons from Lebanon sit within a larger global shift. Mobile diabetes care is already taking many forms, from WhatsApp-based education sessions and SMS support to app-based coaching, continuous glucose monitoring education and connected tools that help people track glucose, physical activity and self-management needs.
But Dr Sukkarieh’s report helps bring the discussion back to the ground. The real question is not whether digital tools exist. It is whether they can be trusted, accessed, supported and integrated into care.
This is where policy becomes relevant. The European Diabetes Forum roadmap underpins the support mobile applications can provide to people living with diabetes in tracking their condition and supporting more informed, data-driven decisions by healthcare professionals. It also stresses the need for user-centred apps, best-practice access pathways and the integration of high-quality apps into health systems.
That policy direction reinforces one of the central lessons from Lebanon: mobile health cannot succeed as a stand-alone tool. It needs regulation, quality standards, professional support and clear routes into care. Without these, digital tools risk widening inequity rather than reducing it.
The same principle applies to newer digital and AI-enabled tools in diabetes care. Innovation must be guided by safety, fairness, transparency, accountability and equitable access. For settings such as Lebanon, these are not abstract policy concerns. They affect whether digital care can be used safely, sustained over time and trusted by the communities it is meant to serve.
The lessons from Lebanon sit within a larger global shift. Mobile diabetes care is already taking many forms.
Dr Sukkarieh’s work in Lebanon shows that mobile health has real potential to expand diabetes self-management education, especially in settings where health systems are under pressure. But it also shows that technology is only one part of the answer.
Programmes need cultural relevance, health system support, responsible governance and a commitment to equity. They must account for the realities of people’s lives, from transport and cost to trust, family responsibilities and service disruption.
For global diabetes care, the implications are meaningful. Digital health is often presented as a solution to access barriers. The Lebanon experience suggests a more cautious conclusion: digital health can help, but only when it is designed around people and embedded in systems that can support it.
The question is not simply how to bring diabetes care online. It is about ensuring that digital care reaches the people who need it most, in ways that respect their lives, their communities, and their right to continued support.
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