Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from a Diabetes Program at Duke University

Supporting Chronic Disease Management in a Virtual

Environment: The Lessons Learned from a Diabetes

Program at Duke University

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Constance M. Johnson, PhD, MS, FAANAssociate Professor

Randy BrownVP, Director Virtual Heroes Division

Diabetes Prevalence 2010

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http://www.altfutures.com/diabetes2025/

Diabetes Prevalence 2025

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http://www.altfutures.com/diabetes2025/

Diabetes

• Metabolic control reduces morbidity

& mortality (DCCT, Diabetes Control and Complications Trial: The effect of

intensive treatment of diabetes on the development and progression of

long-term complications in insulin-dependent diabetes mellitus.

New England Journal of Medicine, 1993. 329: p. 977-986)

• Individuals with T2DM provide 99% of their own care (Funnell, M.M. and R.M. Anderson, Patient empowerment: a look back, a look ahead. Diabetes Educ, 2003. 29(3): p. 454-8.)

– Self-management (diet, exercise, glucose testing, etc.)

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Diabetes Self-Management Internet Interventions

• Potential for cost-effective Internet interventions – Not produced large effects on behavioral and

metabolic outcomes (Jackson, C.L., et al., A systematic review of interactive computer-assisted technology in diabetes care. Interactive information technology in diabetes care. J Gen Intern Med, 2006. 21(2): p. 105-10.; Yu, et al., Systematic review and evaluation of web-accessible tools for management of diabetes and related cardiovascular risk factors by patients and healthcare providers. J Am Med Inform Assoc. 2012 Jul-Aug;19(4):514-22. doi: 10.1136/amiajnl-2011-000307.)

– Most Internet interventions are “flat” with asynchronous communication

– Lack of usability, real-time feedback, and theoretical foundation with comprehensive evaluation (El-Gayar, et al., A systematic review of IT for diabetes self-management: are we there yet? Int J Med Inform. 2013 Aug;82(8):637-52. doi: 10.1016/j.ijmedinf.2013.05.006.)

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Johnson, C., et al. (2014). International Journal of Virtual Communities and Social Networking ,5(3), 68-80, July-September2014.

Funded by the National Library of Medicine: 1 R21 LM010727-01

Second Life Impacts Diabetes Education and Self-Management

SLIDES Aims

• Primary aim: To assess its feasibility and acceptability

• Secondary aim: To determine the preliminary effects of participation in the SLIDES intervention on: – (1) metabolic control (HbA1c levels, blood pressure

and body mass index) – (2) potential psychosocial mediating variables

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Study Sample

• Participants with Type 2 Diabetes• 21 - 75 years old• Computer and Internet literate • No severe diabetes related complications

or late stage chronic disease

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Multidimensional Data• Quantitative data

– Movement, interactions with objects & other participants, proxemics

– Time spent in the site, frequency of log-ins– Survey data – knowledge, self-management

behaviors, self-efficacy, perceived support

• Qualitative data– Observational data, voice, text, email, forum, focus

groups

• Visual data – Photos and videos

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DCCT, NEJM, 1993, 329:977-986. – Diabetes Knowledge ScaleBarrera, M., Jr., et al., Am J Community Psychol, 2002. 30(5): p. 637-54 - Diabetes Support ScaleMcCaul, K., R. Glasgow, and L. Schafer, Medical Care, 1987. 25(9): p. 868-881 – Outcome Expectancies QuestionnaireToobert, D.J., S.E. Hampson, and R.E. Glasgow, Diabetes Care, 2000. 23(7): p. 943-50 – Summary of Diabetes Self-Care Activities

Over 200 Interactive Grocery Items

Nutritional information on each grocery item

Immediate Feedback on Items Chosen

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Results

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Johnson, C., et al. (2014). JMIR Res Protoc 2014;3(2):e23)

2.3%2.5%

3.2%

5.6%

3.5%

3.5%

9.0%

5.0%48.6%

16.8%

Social Center

Gym

Grocery

Pharmacy

Clothing

Classroom

Orientation

Bookstore

Restaurant

Places Participants Visited in the Virtual Community

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T-Tests for comparison of means

Social Support Healthy Diet Foot Care0

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2

3

4

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6

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Behavioral Outcomes

Baseline3 Months6 Months

Sco

re o

r D

ays

Per

Wee

k

*p=0.020

*p=0.036*p=0.001

Barrera, M., Jr., et al., Am J Community Psychol, 2002. 30(5): p. 637-54 - Diabetes Support ScaleMcCaul, K., R. Glasgow, and L. Schafer, Medical Care, 1987. 25(9): p. 868-881 – Outcome Expectancies QuestionnaireToobert, D.J., S.E. Hampson, and R.E. Glasgow, Diabetes Care, 2000. 23(7): p. 943-50 – Summary of Diabetes Self-Care Activities

Metabolic OutcomesBaseline (mean + SD)

3 Months (mean + SD)

6 Months (mean + SD)

Weight (lbs) 217.5 + 45.1 215.6 + 45.7 208.5 + 43.8

BMI (kg/m2 ) 37.4 + 7.8 37.2 + 8.2 36.15 + 8.3

Systolic BP (mmHg)

131 + 13.0 130 + 14.5 130 + 10.5

Diastolic BP (mmHg)

75 + 10.8 75 + 11.2 78 + 9.4

HbA1c (%) 7.6 + 1.3 7.1 + 1.2 6.9 + 1.3

Johnson, C., et al. (2014). Feasibility and preliminary effects of a virtual environment for adults with type 2 diabetes: Pilot study. JMIR Res Protoc 2014;3(2):e23)

Discussion• Allows experiential learning • Synchronous communication – people feel

like they are really there• Shown to be a feasible and useful platform

for patients and educators/clinicians• Scalability – multiple, geographically

widespread users assisted by relatively few educators/professionals

• Social interaction is making the difference

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Diabetes Self-Management & Support LIVE (Learning in Virtual Environments)

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Funded by the NHLBI - 1 R01 HL118189-01Applied Research Associates Study data collected and managed using REDCap

Purpose of the Study

To determine whether participation in LIVE which incorporates real-time diabetes self-management training and support will be associated with positive changes in health behaviors and metabolic outcomes in adults with T2D as compared to traditional education and support in a website

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Vorderstrasse, A, ….Johnson . (2105). Nursing Research November/December, 64(6):485-494

Design• Multi-site RCT with longitudinal repeated

measures design• 220 participants

– 110 randomized to LIVE– 110 randomized to Control group - website

• Determine effects on diet, physical activity, self-efficacy, diabetes knowledge, social support, HbA1c, BP, BMI, lipid panels, waist circumference at baseline, 3, 6, 12, and 18 months

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Design• First three months

– Diabetes education classes twice per week– Participants to log-in twice per week & use Fitbit– Surveys at baseline and three months

• Last nine months– Diabetes education classes twice per week– Participants to log-in at will & use Fitbit– Surveys at six and twelve months

• 18 month follow-up surveys

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Attrition

Dynamic Content

Social Interaction

Gamification

Personalization

LIVE Site

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Bookstore

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Personalization

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Social Interaction

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Gamification

• Include rewards for achievement – Potential to produce behavior change

• Skill Points– Assigned to specific activities– Assign points to using Fitbit

• Redeemable Points– Clothing– Play games

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Zichermann, Cunningham, Gamification by Design

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Scenarios

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Badges/Scores/Tickets/Rank

Badge and Name

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Encouraging Participants to Use Fitbit

Leaderboards

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Results To Date

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Control (n = 84) LIVE (n = 73)

White Some College $50 - 69K0

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30

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60

70

80

90

100

58 56

29

46

25

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55 52

3034

2025

LIVEControl

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Average Duration of Diabetes = 10.9 yearsAverage Age = 58.5 years old

Conclusion

• Usability – site is easy to use– Learnability, memorability, satisfaction

• Engagement – Dynamic content– Gamification– Social interaction

• Personalization – Relate to their avatar

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INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS

Virtual Heroes Division of ARAGame Studio founded in 2004 Located in Raleigh NC and Orlando FLAcquired by ARA in 2009



Virtual Worlds, Simulations, Serious Games

• We create content via these technologies:• PC/Mac through downloads

• Streaming to a Browser (HTML5/Plug-ins)

• Mobile Devices

• Cloud-based platforms

• We create:• Individual, self-paced learning

• Instructor-facilitated team training

• 24/7/365 open virtual worlds



Diabetes LIVE Virtual World Access



Key Reusable Platform Elements

Data-Driven Platform (Duke Nursing databases)

Full local infrastructure control (Duke servers)

Customized/Simplified user interfaces

Duke Instructor-led in-world educational sessions

Scriptable Quests with Quest Generator interface on-line

Significant back-end statistics tracking and analytics

Fully recorded 3D in-world information/training sessions

Awards/Gamification system is also data-driven



Diabetes LIVE Virtual World Districts

LobbyReflection Garden

PlazaFood Court



Diabetes LIVE In-World Discussions



Diabetes LIVE Virtual World Demo



Questions?

Constance M. Johnson, PhD, FAANAssociate Professor

O: 919.684.9332M: 832-444-9370

[email protected]

Randy BrownVP, Director Virtual Heroes Division

O: 919.747.7603M: 919.593.0928

[email protected]

Health & Medicine

Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from a Diabetes Program at Duke University