Strengths and Limitations
This study has several strengths. These strengths include the 3-group design ensuring an active comparison group; well-balanced baseline characteristics between groups, suggesting successful randomization; a high retention rate at the primary end point of 3 months; and a preplanned blinded analysis.The study also has limitations. First, the uptake of the interventions was suboptimal (eg, 29.3% of those in the app group never accessed the app). Consistent with the pragmatic nature of the trial, participants were required to install the app themselves, but phone assistance was offered to those who needed it. This process might have influenced uptake of the app, particularly among participants with limited digital literacy. Low engagement with the intervention could explain the lack of effect on the primary outcome, even if the app itself was potentially effective. However, our per-protocol analyses did not support this notion. In addition, given the lack of consensus on outcome measures for self-management behavior,