Year: 2012
Type: article
Abstract: Patients with diabetes often need a complex set of services and support ranging from glucose monitoring, insulin and other medication management, psychotherapy and social support, to physical activity promotion, nutrition counselling and more. To be successful, patients must not only understand their condition, but also obtain the skills and attitudes to set goals, solve problems, monitor outcomes and overcome barriers to action. Patients and clinicians need to work together so patients with diabetes can adopt and sustain the health-promoting behaviours so necessary to assure good outcomes. Information technology is transforming the way patients receive education and support and clinicians need to utilise these approaches to maximise their reach and effectiveness. Providers are increasingly expected to coordinate care for a panel of patients who live with incurable chronic conditions such as diabetes. Clinicians will have to collaborate with their patients and focus on improving their behaviours, because treating diabetes and other chronic conditions requires more than medication. Providers will need to put emphasis on supporting patients in the ongoing process of adopting and sustaining health-promoting habits. Integrating these supports into a patient's therapeutic regimen presents challenges that need to be addressed through a variety of strategies. Regrettably, given the significant time constraints of a busy medical practice, healthcare providers often do not have the time to adequately support all aspects of an effective behaviour change intervention. That is where information technology can have some of its greatest impact. This chapter will present papers in which information technology has been used to improve the quality of care for patients with diabetes, to enable clinicians to more effectively manage their patients and to help patients self-manage their diabetes. van Bastelaar KM 1,2 , Pouwer F 3 , Cuijpers P 2,4 , Riper H 5 , Snoek FJ 1,2 1 Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands, 2 Institute for Health and Care Research (EMGO Institute), VU University Medical Center, Amsterdam, The Netherlands, 3 Department of Medical Psychology and Neuropsychology, and 4 Center of Research on Psychology in Somatic diseases (CoRPS), Tilburg University, Tilburg, The Netherlands, and 5 Department of Clinical Psychology, VU University, Amsterdam, The Netherlands, Netherlands Institute of Mental Health and Addiction (Trimbos), Utrecht, The Netherlands Diabetes Care 2011; 34 : 320–5 Aims: This study was an attempt to determine whether an internet-based intervention could successfully use an approach proven effective in person [cognitive behaviour therapy (CBT), coping with depression, developed by Lewinsohn] to improve depression symptoms in depressed patients with type 1 (T1D) or type 2 (T2D) diabetes. Primary outcomes were depressive symptoms. Secondary outcomes were diabetes-specific emotional distress and glycaemic control. Methods: A total of 255 adult patients with clinical depression were randomised into the web-based intervention or to a 12-week waiting list control group. Assessments in the intervention group were scheduled after the participant completed or stopped the intervention and 1 month later. The web-based programme contained eight consecutive lessons that provided written and spoken information and videos of depressed patients explaining how they learned from the course. Coaches (certified psychologists) provided standardised concise and constructive feedback on homework assignments in <3 days. The feedback was meant to help the patient understand and apply CBT skills in their daily lives. Patients on the waiting list completed assessments 8 and 12 weeks post randomisation and were provided access to the web-based intervention 12 weeks post randomisation. Results: The web-based CBT intervention was effective in reducing depressive symptoms and reduced diabetes-specific emotional distress but had no beneficial effect on glycaemic control. Conclusions: This study demonstrated that web-based CBT can effectively lessen depressive symptoms for patients with T1D and T2D. It also demonstrated that a theory and research based in-person intervention can be successfully transformed for delivery via the internet. Comment: It is encouraging to see that clinicians, researchers and technologists are embracing the approach that takes lessons learned from the non-technology world (e.g. in-person interventions) and transforms these successful approaches into effective interventions. While somewhat discouraging, it is not surprising that no changes in diabetes control were found given the short length of the study. The next phase in the research agenda is to identify the characteristics of individuals who are most likely to benefit from this approach and to determine the cost-effectiveness of these types of interventions. This information will be key as clinicians try to bring technology-enabled interventions to the widest and most appropriate audience possible. Richardson CR 1,2 , Buis LR 3 , Janney AW 1 , Goodrich DE 2 , Sen A 1,4 , Hess ML 1 , Mehari KS 1 , Fortlage LA 1 , Resnick PJ 5 , Zikmund-Fisher BJ 6,7 , Strecher VJ 8 , Piette JD 2,6,9 1 Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA, 2 Health Services Research and Development Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA, 3 College of Nursing – Adult Health, Wayne State University, Detroit, MI, USA, 4 Department of Statistics, University of Michigan, Ann Arbor, MI, USA, 5 School of Information, University of Michigan, Ann Arbor, MI, USA, 6 Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA, 7 Department of Health Behaviour and Health Education, University of Michigan, Ann Arbor, MI, USA, 8 Center for Health Communications Research, University of Michigan, Ann Arbor, MI, USA, and 9 Michigan Diabetes Research and Training Center, University of Michigan, Ann Arbor, MI, USA J Med Internet Res 2010; 12 : e71 Aims: This randomised control trial attempted to determine if providing web-based access to other overweight adults attempting to increase their physical activity would enhance the effectiveness of a 16-week web-based physical activity promotion programme. Methods: Sedentary adults with at least one of body mass index > 25 kg/mm2, T2D or coronary artery disease were enrolled in a 16-week web-enabled intervention that provided four intervention components: uploading pedometers, step-count feedback, individually assigned and gradually incrementing step-count goals, and individually tailored motivational messages. Participants were instructed to wear their pedometers every day while awake and to log in at least once a week to view tailored messages and updated goals. Study subjects were randomised to have no additional online elements or access to a web-based community that focused on providing social support, encouraging social modelling of successes, and facilitating use of non-community components of the intervention. To promote sociability, participants were encouraged to post self-introductions, and research staff posted their own self-introductions. In addition, research staff posted open-ended questions encouraging participants to post messages modelling self-regulation strategies such as overcoming barriers and describing successes. Posts about pedometers, goals and graphs encouraged participants to pay attention to the non-online community components of the intervention. To generate more activity, contests were run with small rewards such as water bottles or bumper stickers for posting content. Assessments were done on all study subjects on entry and at the end of the intervention. Results: A total of 324 subjects participated in the study; 70 were randomised to the activity website alone and 254 to the activity website plus the online community site. Both arms significantly increased their average daily steps between baseline and the end of the intervention period, but there were no significant differences in increase in step-counts between the two arms. The percentage of completers was 13% higher in the online community arm than the no online community arm (online community arm 79%, no online community arm 66%, p = 0.02). In addition, online community arm participants remained engaged in the programme longer than no online community arm participants [hazard ratio 0.47, 95% confidence interval (CI) 0.25–0.90, p = 0.02]. Participants with lower baseline social support posted more messages to the online community (p < 0.001) and viewed more posts (p < 0.001) than participants with higher baseline social support. Conclusion: Adding online community features to an internet-mediated walking programme did not increase average daily step-counts but did reduce participant attrition. Participants with low baseline social support used the online community features more than those with high baseline social support. Thus, online communities may be a promising approach to reducing attrition from online health behaviour change interventions, particularly in populations with low social support. The authors suggest three possible mechanisms by which participation in an online community might impact programme attrition and step-counts. Increased social support: Social support (defined as the structure and quality of social relationships) can improve health outcomes by improving adherence to healthy behaviours and by impacting emotions and mood. Social modelling: The experiences of others, including the barriers they have overcome and the successes they have achieved, can serve as inspirational models. Reading the posts of others enables vicarious learning. Increased intervention website exposure: Online communities can provide engaging and dynamic content that increases return visits and encourages use of non-online community components including self-regulation components such as goal setting, feedback and tailored motivational messages. Comment: I chose this study to demonstrate that there are ways to thoughtfully investigate the impact of 'new technologies' on patient behaviours and outcomes. It is all the rage to add technology-enabled social networking to any intervention that moves … or gets patients to move. The real challenge is how to quickly study these innovations to see if the additional approach brings real value. This is made all the more difficult since whatever technology one studies is probably obsolete by the time the rigorous research study is completed and published. That is why we need to continue to increase our understanding of the core principles through which technology can have a positive impact on patient behaviours and outcomes. Ramadas A 1 , Quek KF 1 , Chan CK 1 , Oldenburg B 2 1 School of Medicine and Health Sciences, Monash University Sunway Campus, Petaling Jaya, Malaysia, and 2 Department of Epidemiology and Preventive Medicine, Monash University Clayton Campus, Wellington Road, Clayton, VA, Australia Int J Med Inform 2011; 80 : 389–405 Aims: The authors state that prior to this review it was known that (1) behavioural and self-monitoring interventions could assist T2D prevention and management effort; and (2) websites are a feasible medium for the delivery of behaviour interventions. The authors' aim was to analyse the state-of-the-evidence that web-based interventions can improve outcomes for patients with T2D. Methods: A systematic literature review of English language papers published between 2000 and June 2010 was performed looking for papers (1) that describe exchange of information via the website between a healthcare provider and an individual with T2D; (2) that intervene in physical activity, nutrition, self-monitoring or weight loss; (3) that use a randomised controlled trial or quasi-experimental designs; (4) in which outcome measures include behaviour changes or biomarkers related to T2D. Results: Twenty articles describing 13 different studies were found to meet the criteria and were the subject of this review. Constant tracking progress of participants, goal-setting, personalised coaching, interactive feedback and online peer support groups were some of the successful approaches which were applied in e-interventions to manage T2D. A strong theoretical background, use of other technologies and longer duration of intervention were proved to be successful strategies. As well, the use of other technologies such as mobile phones has been proved to improve compliance with an intervention. Conclusion: Web-based interventions have demonstrated some level of favourable outcomes, provided they are further enhanced with proper e-research strategies. Comment: This review furthers the conclusion that well designed and thoughtfully implemented interventions have the potential to generate long-term behaviour change and improve outcomes for patients with T2D. Not surprisingly, certain key elements associated with a positive impact are very similar to what has been shown to work when patients participate in face-to-face interventions. Go figure … people are people no matter how they get their support. Technology is not going to change human nature. At its best it will make education and support more scalable and affordable for large numbers of patients. Anderson-Bill ES 1 , Winett RA 1 , Wojcik JR 2 1 Center for Research in Health Behaviour, Department of Psychology, Virginia Tech, Blacksburg, VA, USA, and 2 Exercise Science Program, Department of Physical Education, Sports and Human Performance, Winthrop University, Rock Hill, SC, USA J Med Internet Res 2011; 13 : e28 Aims: This study attempts to increase the understanding of the characteristics of web-based users of a weight loss intervention to provide guidance regarding the development of effective, theory-based online behaviour change interventions. It focused on the influence of social support, self-efficacy, outcome expectations and self-regulation. Methods: The demographic, behavioural and psychosocial characteristics of web-health users recruited for an online social cognitive theory (SCT) based nutrition, physical activity and weight gain prevention intervention, the Web-based Guide to Health (WB-GTH), were examined. Study subjects were directed to the WB-GTH site by advertisements through online social and professional networks and through print and online media. Participants were screened, consented and assessed with demographic, physical activity, psychosocial and food frequency questionnaires online (taking a total of about 1.25 h); they also kept a 7-day log of daily steps and minutes walked. Results: From 4700 visits to the site, 963 web users consented to enrol in the study: 83% were female, mean age 44.4 years, 91% white, 61% college graduates; median annual household income was US$85,000. Daily step-counts were in the low active range and overall dietary measures were poor. The web-health users had good self-efficacy and outcome expectations for health behaviour change; however, they perceived little social support for making these changes and engaged in few self-regulatory behaviours. Perceived social support and use of self-regulatory behaviours were strong predictors of physical activity and nutrition behaviour. Web users' self-efficacy was also a good predictor of healthier levels of physical activity and dietary fat but not of fibre, fruits and vegetables. Social support and self-efficacy indirectly predicted behaviour through self-regulation, and social support had indirect effects through self-efficacy. Conclusions: Results suggest web-health users visiting and participating in online health interventions will probably be middle-aged, well educated, upper middle class women whose detrimental health behaviours put them at risk of obesity, heart disease, some cancers and diabetes. The success of internet physical activity and nutrition interventions may depend on the extent to which they lead users to develop self-efficacy for behaviour change, and the extent to which these interventions help them garner social support for making changes. Success of these interventions may also depend on the extent to which they provide a platform for setting goals, planning, tracking and providing feedback on targeted behaviours. Comment: This study of a self-selected population of users of a particular web-based programme demonstrated that, for educated, affluent, middle income, sedentary US women with poor nutrition habits, particular components can make a difference in outcomes. While this finding is of interest and perhaps helpful if one is building an intervention for the same target population, I included this paper more to show how research findings can be based on the specifics of a particular intervention. Of course the users of this web-based programme were of a particular demographic with particular needs generating unique conclusions. I assume that is the target population used in the creation and marketing of the programme. Unfortunately, from a logistics and cost-to-produce and implement perspective, every intervention needs to be created for a particular target population and ideally should be able to modify what the user experiences based on the user's characteristics (age, gender, ethnicity, readiness to change, psychological state, preferred style of learning, degree of social support etc.) and performance over time (met goals, specific outcomes obtained etc.). Skip Rizzo A, Lange B, Suma EA, Bolas M Institute for Creative Technologies, University of Southern California, Playa Vista, CA, USA J Diabetes Sci Technol 2011; 5 : 256–64 Aims: This paper was an introduction to the field of clinical virtual reality and its ability to increase calorie expenditure as a way to help overweight individuals lose weight to improve health. Methods: The authors present their personal opinions with reference to the virtual reality literature about the type, effectiveness and potential use of clinical virtual reality. Results: The convergence of advances in virtual reality enabling technologies with a growing body of clinical research and experience has fuelled the evolution of the discipline of clinical virtual reality. This paper provides a brief overview of methods for producing and delivering virtual reality environments that can be accessed by users for a range of clinical health conditions. This includes interactive digital games and new forms of natural-movement-based interface devices (exergaming). Children using currently available exergames expend significantly more energy than sedentary activities (equivalent to a brisk walk). These activities currently do not reach the level of intensity that would match playing the actual sport, nor do they deliver the recommended daily amount of exercise for children. Conclusions: These results provide some support for the use of digital exergames using the current state of technology as a complement to, rather than a replacement for, regular exercise. This may change in the future as new advances in novel full-body interaction systems for providing vigorous interaction with digital games are expected to drive the creation of engaging low-cost interactive game based applications designed to increase exercise participation in persons at risk for obesity. Comment: See the end of the next paper for combined comments. Kahol K Human Machine Symbiosis Laboratory, School of Biological and Health Systems Engineering, Center for Sustainable Health, BioDesign Institute, Arizona State University, Tempe, AZ, USA J Diabetes Sci Technol 2011; 5 : 293–300 Aims: To highlight the opportunities for game-based diabetes management to help individuals adopt and sustain health programme behaviours and to describe an integrative gaming designed to activities physical and cognitive skills through a game-based Methods: The authors review how games can health and behavioural can (1) with (2) help (4) clinicians to of patients through online of game (4) provide engaging environments to and be to proper The authors work in of these to identify the opportunities and challenges of Results: can provide environments that a patient's and and dynamic provide a and and disease A as a motivational that enables a user to activities such as and While the activities in the users wear that can and measures These measures drive the game and are and on a A integrative gaming is and are Conclusions: diabetes management approaches are as an effective to help patients with diabetes adopt and sustain healthy behaviours. The is and researchers to games for the with and drive the games with different types of The of the for engaging and the user for the Clinicians can use the to in a Comment: These two overview papers similar and are included to the a of what is about to interventions – in person or technology-enabled – with engaging users over of all to games and to have exercise that is Integrating gaming activities a behaviour change intervention has the potential to the intervention. To be able to have these activities a theory-based and approach would improve delivery of effective patient and behaviour change and improve long-term outcomes. B, Health Center, Veterans Medical Center, USA J Care 2010; Aims: To describe the US Veterans Health experience with to their identify outcomes and provide for other systems in providing Methods: The authors performed a literature and papers published between 2000 and of intervention that focused on health outcomes. Results: The is the and most healthcare in the USA and includes medical and more than the challenges the is providing healthcare services to an increasingly population, of are of with disease and in where to is the on an with – – for more than a the has healthcare delivery These the of in large healthcare in support of (1) chronic disease management, (2) health delivery through and and (3) through medical information was found to be when ongoing of patient symptoms is as in chronic disease care (e.g. for or health to enhance patient access to healthcare and provides access to patient medical Conclusions: has been a focus for health delivery has been used to monitoring, medical information and intervention to higher associated with patients. The of interventions for the of patient and the ongoing technology of patients and providers are challenges to Comment: the US Veterans Health has demonstrated that it is one of the in the effective use of technology to improve patient care and patient outcomes. Of the is a with Of course large are to change … we what the has been able to should of – that, with the and individuals can make a real difference when are and are made , , H 4 , , J , 6 , 1 , 1 , 3 , KS 3 , 7 , 1 Department of Medical University 2 Department of Internal Medicine, University 3 Department of Internal Medicine, University College of Medicine, 4 School of Health, USA, 5 Department of University 6 Department of Internal Medicine, and 7 Research Institute, Diabetes Care 2011; 34 : Aims: To determine if patients with T2D will have outcomes while using a mobile based intervention. Methods: The authors a controlled clinical trial patients = Participants were assigned to receive care = to the glucose = or to the healthcare group = The to an medical in which medical are given through the patient's mobile Patients receive a with a that results to a the are to the an the Clinical and messages by mobile The was the of patients < at 6 Results: 6 of the mean level was significantly from to (p < 0.001) in the group and from to (p = in the with to (p = in the control group. The of patients with < was in the in the group and in the control group (p < Conclusions: The glycaemic control with than and care and may provide effective and diabetes management in patients with T2D. Comment: See the combined at the end of the next Department of Medicine and of Institute and of Medical and Medical Med 2011; : Aims: To the effect of mobile interventions on glycaemic control in patients with diabetes. Methods: The authors papers from through 2010 in which the study (1) use of mobile phones for diabetes (2) mean of and for intervention group or the mean difference in between intervention and (3) had one of the study randomised controlled trial (e.g. or medical controlled trial or controlled The authors a systematic review and of the papers to the effect of mobile use on glycaemic control in diabetes Results: A total of were for the review. The of mobile intervention the included with of use of the internet and in-person support in to use was not of the mobile intervention were with of support provided for self-monitoring and glucose of exercise and medication
Author: Neal Kaufman
Institution: University of California, Los Angeles
Language: English
Subfield: Endocrinology, Diabetes and Metabolism
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W1584108365