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.

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

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

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. 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. 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. 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. 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. 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. Immediate Feedback on Items Chosen

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

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. 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. 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. 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. 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. 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. 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. 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. Attrition
Dynamic Content
Social Interaction
Gamification
Personalization

23. LIVE Site

30. Bookstore

34. Personalization

37. Social Interaction

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

41. Scenarios

51. Badges/Scores/Tickets/Rank

52. Badge and Name

53. Encouraging Participants to Use Fitbit

54. Leaderboards

55. Results To Date

56. 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

57. 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 ARA

Game Studio founded in 2004

Located in Raleigh NC and Orlando FL

Acquired by ARA in 2009

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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

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INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS
Diabetes LIVE Virtual World Access

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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

62. 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

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INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS
Diabetes LIVE In-World Discussions

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INNOVATIVE SOLUTIONS TO COMPLEX PROBLEMS
Diabetes LIVE Virtual World Demo

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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