title: Efficacy of a computerized simulation in promoting walking in individuals with diabetes.
abstract: BACKGROUND
  Regular walking is a recommended but underused self-management strategy for individuals with type 2 diabetes mellitus (T2DM).
  
  
  OBJECTIVE
  To test the impact of a simulation-based intervention on the beliefs, intentions, knowledge, and walking behavior of individuals with T2DM. We compared two versions of a brief narrated simulation. The experimental manipulation included two components: the presentation of the expected effect of walking on the glucose curve; and the completion of an action plan for walking over the next week. Primary hypotheses were (1) intervention participants' walking (minutes/week) would increase more than control participants' walking, and (2) change in outcome expectancies (beliefs) would be a function of the discrepancy between prior beliefs and those presented in the simulation. Secondary hypotheses were that, overall, behavioral intentions to walk in the coming week and diabetes-related knowledge would increase in both groups.
  
  
  METHODS
  Individuals were randomly assigned to condition. Preintervention measures included self-reported physical activity (International Physical Activity Questionnaire [IPAQ] 7-day), theory of planned behavior-related beliefs, and knowledge (Diabetes Knowledge Test). During the narrated simulation we measured individuals' outcome expectancies regarding the effect of exercise on glucose with a novel drawing task. Postsimulation measures included theory of planned behavior beliefs, knowledge, and qualitative impressions of the narrated simulation. The IPAQ 7-day was readministered by phone 1 week later. We used a linear model that accounted for baseline walking to test the main hypothesis regarding walking. Discrepancy scores were calculated between the presented outcome and individuals' prior expectations (measured by the drawing task). A linear model with an interaction between intervention status and the discrepancy score was used to test the hypothesis regarding change in outcome expectancy. Pre-post changes in intention and knowledge were tested using paired t tests.
  
  
  RESULTS
  Of 65 participants, 33 were in the intervention group and 32 in the control group. We excluded 2 participants from analysis due to being extreme outliers in baseline walking. After adjustment for baseline difference in age and intentions between groups, intervention participants increased walking by 61.0 minutes/week (SE 30.5, t(58 = 1.9, )P = .05) more than controls. The proposed interaction between the presented outcome and the individual's prior beliefs was supported: after adjustment for baseline differences in age and intentions between groups, the coefficient for the interaction was -.25, (SE 0.07, t(57 = -3.2, )P < .01). On average participants in both groups improved significantly from baseline in intentions (mean difference 0.66, t(62 = 4.5, )P < .001) and knowledge (mean difference 0.38, t(62 = 2.4, )P = .02).
  
  
  CONCLUSIONS
  This study suggests that a brief, Internet-ready, simulation-based intervention can improve knowledge, beliefs, intentions, and short-term behavior in individuals with T2DM.
authors.affiliation: George E Whalen Salt Lake City Veterans Affairs Healthcare System, IDEAS center, Salt Lake City, UT, USA. bryan.gibson@utah.edu
authors.forename: Bryan
authors.initials: B
authors.lastname: Gibson
authors.forename: Robin L
authors.initials: RL
authors.lastname: Marcus
authors.forename: Nancy
authors.initials: N
authors.lastname: Staggers
authors.forename: Jason
authors.initials: J
authors.lastname: Jones
authors.forename: Matthew
authors.initials: M
authors.lastname: Samore
authors.forename: Charlene
authors.initials: C
authors.lastname: Weir
mesh_terms: D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000032:analysis; D016022:Case-Control Studies; D003198:Computer Simulation; D003920:Diabetes Mellitus / Q000503:physiopathology* / Q000523:psychology; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion; D006801:Humans; D008297:Male; D008875:Middle Aged; D011795:Surveys and Questionnaires; D016138:Walking
chemical_list: D001786:Blood Glucose