Showcases the development of a global visual language to communicate self management of type 2 diabetes. The emojifit library has been developed by D'Arcy Ellis for the App. The evidence based goal setting and lifestyle planning tool emojifit Diabetes has been developed by Prof Timothy Skinner and Prof Isabelle Skinner with assistance for the App design from Barbara White of Charles Darwin University. Emojis cover the broad range of risk factors, complications and actions for diabetes self management.

1. Putting Prevention into the Hands of
People with Type 2 Diabetes
Prof Timothy Skinner Charles Darwin University
Prof Isabelle Skinner CDU, Decision Support Analytics
D’Arcy Ellis, Charles Darwin University
Barbara White, Charles Darwin University
Helen Mitchell, Diabetes WA

2. Diabetes around the world

3. Diabetes around the world

5. Darwin

11. Emojifit Library

12. Gardening

13. Cycling

14. Heart Disease

15. Stroke

16. Kidney Disease

17. Eye Health

18. Eye Health

19. Sexual Health

20. Erectile Dysfunction

21. Depression

22. Confidence Scale

23. Twitter Facebook Apple Google
Emojifit

24. Play the video

25. Transcript- Putting Prevention into the Hands of People with Type 2 Diabetes
Isabelle Skinner
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Monday was world diabetes day, which celebrated 125 years since the invention of Insulin.
This lifesaving drug has helped millions of people with type 1 diabetes around the world.
Diabetes is a disease that occurs when the organ, the pancreas, stops producing insulin, or
when the insulin that is produced can’t be used by the body to regulate the level of sugar in
the blood.
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In 2015 type 2 diabetes was the fastest growing chronic disease in the world. The
International diabetes federation estimated that 1 in 11 adults had diabetes, that is 415
million people globally, with ½ of those people undiagnosed.
It is also estimated that 12% of global health expenditure was spent on diabetes, that is a
staggering 675 Billion USD. Despite this, 75% of people with diabetes live in low and middle
income countries and have poor access to diabetes care.
Why so much money? Too much sugar in the blood causes damage to large blood vessels
and small blood vessels. Left untreated, the effects can be severe and tragic causing
blindness, kidney failure, stroke, heart attacks, sexual health problems and lower limb
amputation. In 2012 the World Health Organisation estimated that 2.2 million deaths
globally were attributed to high blood sugar. But the real tragedy is that type 2 diabetes is
largely preventable and can be managed using inexpensive actions. Such as what and how
much we eat, how much we move, taking the medications to reduce blood sugar and having
regular screening for complications.
Sounds easy right. Well wrong. People develop diabetes over a lifetime. They often go
undiagnosed for a long period of time with the symptoms of fatigue, diet failures, and self-
loathing leading to loss of confidence in being able to make the changes needed. For many
people by the time they are diagnosed with diabetes they feel helpless and trapped in a
body that is expanding in girth and failing them.

26. There is hope though. Evidence based interventions that promote self-monitoring,
understanding of actual risk factors and setting and achieving small lifestyle goals one at a
time work.
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Our challenge has been to translate one of these effective programs, the DESMOND
program which has helped more than 200,000 people in the UK, Netherlands, Australia and
New Zealand into an App that can be used to assist people who have limited access to a
trained diabetes educator. And to help all people with type 2 diabetes with ongoing self-
monitoring.
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We come from the Northern Territory in Australia. Known mostly for its pristine wilderness,
extreme heat and dangerous animals. But it is also home to 72,000 Indigenous people
making up 30% of the Territory’s population, many of whom live in remote and isolated
towns and villages and speak their native languages. Some of these communities have in
excess of 30 % prevalence of type 2 diabetes and. Access to health services is limited and
people often rely on the Royal Flying Doctor Service in times of emergency. Type 2 diabetes
rarely presents as an emergency and many people with diabetes have poorly controlled
blood sugar levels and consequently they suffer long term complications such as end stage
kidney disease which is up to 30 times the national average. However, mobile phone
coverage in remote communities is ubiquitous and most people have access to a smart
phone.

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Emojifit diabetes is an mHealth app designed to assist people with type 2 diabetes. It goes
beyond clinical measures of blood glucose monitoring for insulin titration, risk identification,
to helping people identify diabetes distress and depression work on their confidence to
achieve the goals they set for themselves.
Emojifit diabetes enables the user to securely share their plans with their health care team
and gain support as they work on achieving their goals. It is an information source and on
the go support system with tailor made reminders built into 4 week plans.
People develop diabetes over the course of a lifetime, there is no quick fix for type 2
diabetes. Helping people to persevere and build willpower as they build confidence in their
abilities is an evidence based approach to self-management.
In the process of developing the app we middle aged health care professionals fell into the
trap of making things complicated and very wordy, so we engaged a communication
designer and a software engineer.
The challenge was to translate a successful evidence based face to face program that was
delivered to groups to one that would stand alone on a mobile phone and be understood by
people with limited English and limited health literacy. Professor Tim Skinner, the designer
of the DESMOND program had a range of resources that had been developed for the
program and these concepts needed to be included such as categorising risk, identifying
complications that are of most concern to the person with diabetes and developing scales to
measure diabetes distress, wellbeing and confidence. There was also the issue of
communicating clearly in a cross cultural context.
Let me hand you over to D’Arcy

28. D’Arcy Ellis
So, as Isabelle has mentioned already in Australia many of the people and communities
most affected by diabetes also face a range of challenges in accessing the vital medical and
educational services needed to manage their diabetes, this is due in part to their remote
location but another key factor is low English literacy levels. So in order to meet the needs
of our users it was important not only to build an effective evidence based app but also to
translate the information in this app to a format that was cross culturally accessible.
This was initially a daunting problem, but with some research it became clear that there was
a readily available, if not slightly surprising solution, emojis. Emojis are now considered an
official language, and the language is relatively new, started in 1999 by a Japanese man
named Shigataka Kurita while working for the mobile carrier DoCoMo to send pictures back
and forth without using much data. Today there are now more than 1800 registered emojis
used to express a vast range of meanings, from the simple and silly to the complex and
nuanced.
Our team saw emojis as a possible opportunity to solve the difficult problem of
communicating a wide range of complex information to our users in a way that was flexible
enough to accommodate both cultural differences and a limited level of English literacy. To
do this however it was necessary for me to then design a new vocabulary of medical and
diabetes specific emojis ranging from appropriate dietary choices, to physical exercise,
disease, risk factors, related medical conditions, medication and more, this a small sample
selection of some of the emojis designed for the initial demo, with more to come in future.

29. Due to emoji’s potential for assisting apps to more easily transfer between languages and
scale more effectively by smoothing inter-cultural communication issues by supplementing
written text, we thought it would be worthwhile highlighting some of the design challenges
we faced and how these were resolved so as to give you an insight into the process.
Our users are from a broad range of demographics, different ages, races, genders and body
types, from the research we conducted we found that our users did not respond as
positively to depictions of people that were different to themselves, this presents an
obvious problem; how can you possibly depict every demographic without having many
different emojis for the same activity and even if you did do this how would you present
these options for the user to choose in an intuitive and user friendly way without endless
menus and customisations? The solution we came up with was to avoid depicting culturally
and physically identifying features of the human body where at all possible, for example
when designing emojis to depict physical activities and exercise we chose to depict the
accessories used for these activities rather than the bodies performing them.
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In this case gardening and cycling.
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But it is easy to imagine how this would apply to activities such as fishing, tennis or football
for example.
While emojis are often thought of as being cute cartoons it is important that they are
considered first and foremost as communication tools and as such they need to be
appropriate for the context in which they are deployed. In this case many of these emojis
are describing serious medical conditions and risk factors so it is vital they are not seen to
trivialise either the users or the health condition.
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For example, when depicting heart disease drawing the obvious love heart shape does not
convey the serious nature of this condition, our research pointed to the use of anatomical
drawings being more emotionally affective in this case. Similarly, when communicating a
stroke or kidney disease using depictions of actual brain
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and kidneys was also found to be most effective amongst the trial users.

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This is not to say that all medical conditions should be depicted in a graphic way as this can
cause high levels of diabetes distress and anxiety. For example, when I first designed the
emoji to depict loss of vision caused by damage to the blood vessels at the back of the eye
using an anatomical organ it did not go down well with the trial users at all.
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Too macabre they said, understandable really, this underlines the vital importance of
consultation, user feedback and group testing.
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So I went back to the drawing board to design a new emoji, this time in a more
approachable way, showing the use of an opthalmascope to test for blood vessel damage
rather than the blood vessels themselves.
Using emoji’s in the context of medicine can also present a range of unique design
problems, sometimes it’s not possible for reasons of decency, culture or religion to depict
medical conditions directly at all, for example sexual health, neither a depiction of the
organs affected or the physical activities involved were appropriate. However, both women
and men suffer from complications due to small blood vessel disease associated with
diabetes. Women have difficulty with arousal and men experience problems with erections.
However, in this case these issues were overcome using older cultural tropes and symbolic
language.
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For general sexual health I provided a generic image based on the road sign for no entry and
a traditional love heart, this was well received in the trial group but it was suggested a
separate emoji was required for erectile dysfunction specifically.
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to do this I modified the universal symbol for male. So far both have been well received and
easily understood in the Australian context, however the risk with more abstract symbology
like these is that they may not be well understood globally, again further testing will be
needed to understand the extent of this phenomenon.

31. Finally, depictions of emotions and moods, this is probably the easiest application of emoji’s
and can be leveraged to depict conditions such as depression.
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But can also be used to gauge user feedback or provide quantifiable and valuable in app
communication tools such as a confidence scale for the users 4 week plans.
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The challenge of creating a universal language has in part been overcome with emojis but
like all languages it is evolving and each group has their own dialects Apple, Google, Twitter,
Facebook and now Emojifit. Some are more successful than others but all of them are only
useful if they connect directly and intuitively with the user. To achieve this clever design is
necessary but consultation and collaboration is vital.
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We have finished the demo and are now testing it with users. We hope to launch the App
on the Apple iTunes store early in the new year. To keep up with our progress please follow
us on the Emojifit Diabetes Facebook page. Thank you.