Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned fr

1. 1 Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from a Diabetes Program at Duke University Constance M. Johnson, PhD, MS, FAAN Associate Professor Randy Brown VP, Director Virtual Heroes Division

2. 2 Diabetes Prevalence 2010 http://www.altfutures.com/diabetes2025/

3. 3 Diabetes Prevalence 2025 http://www.altfutures.com/diabetes2025/

4. 4 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.)

5. 5 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.)

6. 6 Second Life Impacts Diabetes Education and Self-Management 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

7. 7 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

8. 8 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

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

10. Over 200 Interactive Grocery Items

11. Nutritional information on each grocery item

12. 12 Immediate Feedback on Items Chosen

13. 13 Results Johnson, C., et al. (2014). JMIR Res Protoc 2014;3(2):e23)

14. Places Participants Visited in the Virtual Community Social Center Grocery 9.0% Bookstore 2.5% 2.3% Orientation 5.0% Classroom Pharmacy 48.6% 3.2% Clothing 5.6% 16.8% Gym 3.5% Restaurant 3.5%

15. 15 T-Tests for comparison of means Behavioral Outcomes *p=0.001 *p=0.036 7 *p=0.020 6 Score or Days Per Week 5 Baseline 3 Months 6 Months 4 3 2 1 0 Social Support Healthy Diet Foot Care Barrera, M., Jr., et al., Am J Community Psychol, 2002. 30(5): p. 637-54 - Diabetes Support Scale McCaul, K., R. Glasgow, and L. Schafer, Medical Care, 1987. 25(9): p. 868-881 – Outcome Expectancies Questionnaire Toobert, D.J., S.E. Hampson, and R.E. Glasgow, Diabetes Care, 2000. 23(7): p. 943-50 – Summary of Diabetes Self-Care Activities

16. Metabolic Outcomes Baseline (mean + SD) (mean + SD) 3 Months 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)

17. 17 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

18. 18 Diabetes Self-Management & Support LIVE (Learning in Virtual Environments) Funded by the NHLBI - 1 R01 HL118189-01 Applied Research Associates Study data collected and managed using REDCap

19. 19 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 Vorderstrasse, A, ….Johnson . (2105). Nursing Research November/December, 64(6):485-494

20. 20 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

21. 21 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

22. 22 Dynamic Content Attrition Personalization Social Interaction Gamification

23. 23 LIVE Site

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30. 30 Bookstore

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34. 34 Personalization

37. 37 Social Interaction

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39. 39 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 Zichermann, Cunningham, Gamification by Design

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41. •41 Scenarios

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