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Supporting Chronic Disease
Management in a Virtual
Environment: The Lessons
Learned from a Diabetes
Program at Duke Univer...
Diabetes Prevalence 2010
http://www.altfutures.com/diabetes2025/
Diabetes Prevalence 2025
http://www.altfutures.com/diabetes2025/
Diabetes
• Metabolic control reduces morbidity
& mortality
(DCCT, Diabetes Control and Complications Trial: The effect of
...
Diabetes Self-Management Internet
Interventions
• Potential for cost-effective Internet interventions
– Not produced large...
Johnson, C., et al. (2014). International Journal of Virtual Communities and Social Networking ,5(3), 68-80, July-Septembe...
SLIDES Aims
• Primary aim: To assess its feasibility and
acceptability
• Secondary aim: To determine the preliminary
effec...
Study Sample
• Participants with Type 2 Diabetes
• 21 - 75 years old
• Computer and Internet literate
• No severe diabetes...
Multidimensional Data
• Quantitative data
– Movement, interactions with objects & other
participants, proxemics
– Time spe...
Over 200 Interactive Grocery Items
Nutritional
information
on each
grocery item
Immediate Feedback on Items Chosen
Results
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
Book...
T-Tests for comparison of means
Social Support Healthy Diet Foot Care
0
1
2
3
4
5
6
7
Behavioral Outcomes
Baseline
3 Month...
Metabolic Outcomes
Baseline
(mean + SD)
3 Months
(mean + SD)
6 Months
(mean + SD)
Weight (lbs) 217.5 + 45.1 215.6 + 45.7 2...
Discussion
• Allows experiential learning
• Synchronous communication – people feel
like they are really there
• Shown to ...
Diabetes Self-Management & Support
LIVE (Learning in Virtual Environments)
Funded by the NHLBI - 1 R01 HL118189-01
Applied...
Purpose of the Study
To determine whether participation in LIVE
which incorporates real-time diabetes self-
management tra...
Design
• Multi-site RCT with longitudinal repeated
measures design
• 220 participants
– 110 randomized to LIVE
– 110 rando...
Design
• First three months
– Diabetes education classes twice per week
– Participants to log-in twice per week & use Fitb...
Attrition
Dynamic Content
Social Interaction
Gamification
Personalization
LIVE Site
Bookstore
Personalization
Social Interaction
Gamification
• Include rewards for achievement
– Potential to produce behavior change
• Skill Points
– Assigned to specifi...
Scenarios
Badges/Scores/Tickets/Rank
Badge and Name
Encouraging Participants to Use Fitbit
Leaderboards
Results To Date
Control (n = 84) LIVE (n = 73)
White Some College $50 - 69K
0
10
20
30
40
50
60
70
80
90
100
58 56
29
46
25
41
55 52
30
34...
Conclusion
• Usability – site is easy to use
– Learnability, memorability, satisfaction
• Engagement
– Dynamic content
– G...
www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary
INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS
Virtual Hero...
www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary
INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS
Virtual Worl...
www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary
INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS
Diabetes LIV...
www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary
INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS
Key Reusable...
www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary
INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS
Diabetes LIV...
www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary
INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS
Diabetes LIV...
www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary
INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS
Diabetes LIV...
www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary
INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS
Questions?
C...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from...
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Constance Johnson & Randy Brown - Supporting Chronic Disease Management in a Virtual Environment: The Lessons Learned from a Diabetes Program at Duke University

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Randy Brown, VP, Virtual Heroes Division Manager, ARA
Constance Johnson, Associate Professor and Senior Research Faculty in the Center for Nursing Research, Duke University School of Nursing

This presentation was given at the 2016 Serious Play Conference, hosted by the UNC Kenan-Flagler Business School.

Since little is known about the efficacy of health interventions in a VE, this study, conducted by Duke and Virtual Heroes, constitutes an innovative step in exploring how this type of environment can be suused to facilitate self-management behaviors in those with chronic diseases, in this case, diabetes. This program has good potential to improve care in an easily disseminated model that promotes cost-effective resource utilization.

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

  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. 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
  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. 10. Over 200 Interactive Grocery Items
  11. 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. 14. 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
  15. 15. T-Tests for comparison of means Social Support Healthy Diet Foot Care 0 1 2 3 4 5 6 7 Behavioral Outcomes Baseline 3 Months 6 Months ScoreorDaysPerWeek *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 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. 16. Metabolic Outcomes Baseline (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)
  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. Attrition Dynamic Content Social Interaction Gamification Personalization
  23. 23. LIVE Site
  24. 24. Bookstore
  25. 25. Personalization
  26. 26. Social Interaction
  27. 27. 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
  28. 28. Scenarios
  29. 29. Badges/Scores/Tickets/Rank
  30. 30. Badge and Name
  31. 31. Encouraging Participants to Use Fitbit
  32. 32. Leaderboards
  33. 33. Results To Date
  34. 34. Control (n = 84) LIVE (n = 73) White Some College $50 - 69K 0 10 20 30 40 50 60 70 80 90 100 58 56 29 46 25 41 55 52 30 34 20 25 LIVE Control Average Duration of Diabetes = 10.9 years Average Age = 58.5 years old
  35. 35. Conclusion • Usability – site is easy to use – Learnability, memorability, satisfaction • Engagement – Dynamic content – Gamification – Social interaction • Personalization – Relate to their avatar
  36. 36. www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS Virtual Heroes Division of ARA  Game Studio founded in 2004  Located in Raleigh NC and Orlando FL  Acquired by ARA in 2009
  37. 37. www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS 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
  38. 38. www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS Diabetes LIVE Virtual World Access
  39. 39. www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS 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
  40. 40. www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS Diabetes LIVE Virtual World Districts Lobby Reflection Garden Plaza Food Court
  41. 41. www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS Diabetes LIVE In-World Discussions
  42. 42. www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS Diabetes LIVE Virtual World Demo
  43. 43. www.ara.com © 2016 Applied Research Associates, Inc. ARA Proprietary INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS Questions? Constance M. Johnson, PhD, FAAN Associate Professor O: 919.684.9332 M: 832-444-9370 Constance.johnson@duke.edu Randy Brown VP, Director Virtual Heroes Division O: 919.747.7603 M: 919.593.0928 Rbrown@ara.com

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