Phyllis Nsiah-Kumi, MD, MPH Department of Internal Medicine Internal Medicine-Pediatrics

1. Nebraska Center for Integrative Nutrition and Metabolic Processes CoBRE Retreat October 28, 2010 - Ashland, NE “Eat This, Not That!”: Using Avatars and the Community Readiness Model to Teach Healthy Food Choices to Native American Children Phyllis Nsiah-Kumi, MD, MPH Department of Internal Medicine Internal Medicine-Pediatrics College of Medicine ~~ Health Promotion, Social and Behavioral Health College of Public Health (Courtesy)

2. Mentors Terry T.K. Huang, PhD, MPH, UNMC College of Public Health Jennifer L. Larsen, MD, UNMC College of Medicine, Associaate Vice Chancellor for Clinical Research Co-Investigators Deepak Khazanchi, PhD, UNO College of Information Science & Technology Susan Raatz, PhD, MPH, MS, United States Department of Agriculture, Grand Forks Nutrition Center, ND Ronald J. Shope, PhD, Educational Psychology, UNL Project Team

3. Two-fold risk of being • obese compared to • their white counterparts • Increased risk of pre-diabetic states in childhood and adulthood. • Increased risk of early death from cardiovascular and other causes. Obesity in Native American Children

4. Eighteen tribal nations in • Iowa • Nebraska • North Dakota • South Dakota Northern Plains Tribes

5. Prevalence of obesity in children • Parental perceptions of children’s risk of diabetes and weight related problems • Health literacy of parents • Family Health Behavior data Ponca Tribe Pilot Data

6. Type 2 Diabetes Risk in Rosebud Sioux Children (n=161) Nsiah-Kumi et al. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 10, OCTOBER 2010

7. Predictors of Pre-Diabetes/Diabetes in Rosebud Sioux Children (n=201) Nsiah-Kumi et al. Pre-diabetes in Native American Children. (In Review)

8. Socio-Ecological Model:Factors Affecting Childhood Obesity

9. University of Nebraska Medical Center Dietary Guidelines for AmericansTranslating nutritional science to community settings is essential to enhance healthy diets and weights.

10. Project Approach Phase 1 Phase 4 Phase 2 Phase 3 Community Readiness Assessment Development of Metaverse and Training Scenarios Train 8-10 yo children fr Northern Plains Tribes (n=25) Evalute impact of metaverse training program

11. University of Nebraska Medical Center Specific Aim 1 Assess readiness of participating Native American community to take action on childhood obesity and type 2 diabetes prevention using the six dimension Community Readiness Model.

12. Identify community and youth leaders • Train youth on obesity, citizenship, CRM • Key Respondent interviews • Determine community readiness Phase 1: Community Readiness Assessment

13. University of Nebraska Medical Center Dimensions of Community Readiness • 1. Community Efforts (programs, activities, • policies, etc.) • 2.Community Knowledge of the Efforts • 3.Leadership (formal and informal) • 4.Community Climate • 5.Community Knowledge About the Issue • 6.Resources Related to the Issue (people, • time, money, space, etc.)

14. University of Nebraska Medical Center Community Readiness Scoring

15. University of Nebraska Medical Center Specific Aim 2 • Develop a culturally-appropriate metaverse environment including theory-driven interactive activities and simulation(s) designed to teach healthy food choices and portion size selection (based on the • Dietary Guidelines for Americans) to Native American children.

16. Avatar Development • Environment Development • Scenario Development with feedback incorporated • Scoring System Development Phase 2: Development of Second Life Training

17. University of Nebraska Medical Center Decision-Making Training for Behavior Change • Teaching guidelines alone is not enough. • Curricula have been developed for delivery of content in classroom settings. • Decision-making skills are crucial for adoption of healthy dietary habits.

18. Metaverses are immersive 3D virtual worlds (VWs) in which people interact as avatars with each other and with software agents, using the metaphor of the real world but without its physical limitations. • Second Life is among the most common. Metaverses

19. University of Nebraska Medical Center Virtual Worlds • Computer based • Available via internet • 3 dimensional recreation of “reality” • Visual • Static • Motion • Audio

21. Presence Questionnaire • Mean total score: 134.67 + 15.62 (max – 224) • Min/Max: 121/157 • Mean item score: 4.27 out of 7 • Summary of identified themes • Realistic scenario • For right now “good as it gets” • Gives sense of home visit • Inconsistencies (in environment) • Modern house – too many broken windows • Furniture too nice for run down neighborhood • Clutter in real homes is much worse • Too many homes with water damage UNO/CON Pilot Results

22. Nearly unlimited freedom. Highly adapatable. • Can design and integrate content with engaged learning. • Experiment with decision-making safely in the virtual world. • Health related information exchange and teaching can occur with this type of educational delivery. • Successful transfer to the real world of skills practiced in a virtual environment. Benefits of avatars for skills training

23. My Second Life Avatar – Pink Lapis

24. 8-10 year olds from Northern Plains Tribes (n=25) will complete Second Life training. • Training scenarios will include food choices in: • Home • School • Community event • Restaurant Phase 3: Second Life Training Program Implementation

25. Source: Davis, A., Owens, D., Murphy, J., Khazanchi, D. and Zigurs, I. (2009, February). "Avatars, People, and Virtual Worlds: Foundations for Research in Metaverses." Journal of the Association for Information Systems, Volume 10, Issue 2 , Article 2, pp. 90-117. Conceptual Model for Metaverse Research

26. University of Nebraska Medical Center Specific Aim 3 • Evaluate the impact of metaverse-based decision-making training on: • Knowledge of Dietary Guidelines for Americans • Metaverse-based food choices and real-world choices • Anthropometric and biomarkers related to childhood obesity and cardiovascular disease risk over time

27. University of Nebraska Medical Center Targeted Behavior(s)/Guideline Recommendations: • a.) increasing water consumption • b.) decreasing SSB consumption • c.) decreasing intake of fatty foods • d.) increasing fruit and vegetable consumption, • e.) decreasing portion size.

28. Second Life Test Scenarios • Food and Beverage Logs • Pre-post DGA knowledge testing • Focus Groups Phase 4: Evaluation of Decision-Making Skills and Second Life Experience

29. University of Nebraska Medical Center Anthropometric and biomarker dataPre-post-6mos-12mos • Height, weight, BMI percentile, waist circumference, blood pressure • hsCRP • Glucose • Insulin • Lipids

30. Use of Second Life, as a platform for learning simulations through role plays with the intent to improve the development of decision-making. • No web-based, metaverse-based trainings focused on teaching this type of decision-making currently exist. • The impact of using 3D environments such as virtual worlds that integrate theory-driven pedagogy to teach effective decision-making to younger children is not very well studied. Innovation

32. University of Nebraska Medical Center

33. Percentage of Overweight or Obese Children: 2003* Source: The National Survey of Children's Health.

34. Percentage of Overweight or Obese Children: 2005* Source: The National Survey of Children's Health.

35. Percentage of Overweight or Obese Children: 2007* Source: The National Survey of Children's Health.

36. Percentage of Overweight or Obese Children: 2003, 2005, and 2007 2003 2005 2007 Source: The National Survey of Children's Health.

37. Dietary Guidelines for Americans GRAINS VEGETABLES FRUITS OILS MILK MEAT & BEANS Translating nutritional science to community settings is essential to enhance healthy diets and weights.

38. University of Nebraska Medical Center Hypothesis 1 • Community readiness to address the issue of childhood obesity and type 2 diabetes prevention can be improved using avatar-based decision making training.

39. A culturally-appropriate metaverse environment including interactive activities and simulation(s) can teach healthy food choices and portion size selection (based on the Dietary Guidelines for Americans) to Native American youth and can help them translate these skills into their real world decision-making. Hypothesis 2

40. University of Nebraska Medical Center Games, Simulations and Virtual Worlds Games Simulations Use rigorously structured scenarios carefully designed to develop specific competencies that can be directly transferred into the real world. • Fun, engaging activities usually used purely for entertainment, but they may also allow people to gain exposure to • a particular set of tools, motions, or ideas.

41. University of Nebraska Medical Center Virtual Worlds • Multiplayer (and often massively multiplayer), 3D persistent social environments with easy-to-access building capabilities. They share with games and simulations the 3D • environment, but they do not have the focus on a particular goal, such as advancing to the next level or successfully navigating the scenario.