title: Diabetes island: preliminary impact of a virtual world self-care educational intervention for african americans with type 2 diabetes.
abstract: BACKGROUND
  Diabetes is a serious worldwide public health challenge. The burden of diabetes, including prevalence and risk of complications, is greater for minorities, particularly African Americans. Internet-based immersive virtual worlds offer a unique opportunity to reach large and diverse populations with diabetes for self-management education and support.
  
  
  OBJECTIVE
  The objective of the study was to examine the acceptability, usage, and preliminary outcome of a virtual world intervention, Diabetes Island, in low-income African Americans with type 2 diabetes. The main hypotheses were that the intervention would: (1) be perceived as acceptable and useful; and (2) improve diabetes self-care (eg, behaviors and barriers) and self-care related outcomes, including glycemic control (A1C), body mass index (BMI), and psychosocial factors (ie, empowerment and distress) over six months.
  
  
  METHODS
  The evaluation of the intervention impact used a single-group repeated measures design, including three assessment time points: (1) baseline, (2) 3 month (mid intervention), and (3) 6 month (immediate post intervention). Participants were recruited from a university primary care clinic. A total of 41 participants enrolled in the 6 month intervention study. The intervention components included: (1) a study website for communication, feedback, and tracking; and (2) access to an immersive virtual world (Diabetes Island) through Second Life, where a variety of diabetes self-care education activities and resources were available. Outcome measures included A1C, BMI, self-care behaviors, barriers to adherence, eating habits, empowerment, and distress. In addition, acceptability and usage were examined. A series of mixed-effects analyses, with time as a single repeated measures factor, were performed to examine preliminary outcomes.
  
  
  RESULTS
  The intervention study sample (N=41) characteristics were: (1) mean age of 55 years, (2) 71% (29/41) female, (3) 100% (41/41) African American, and (4) 76% (31/41) reported annual incomes below US $20,000. Significant changes over time in the expected direction were observed for BMI (P<.02); diabetes-related distress (P<.02); global (P<.01) and dietary (P<.01) environmental barriers to self-care; one physical activity subscale (P<.04); and one dietary intake (P<.01) subscale. The participant feedback regarding the intervention (eg, ease of use, interest, and perceived impact) was consistently positive. The usage patterns showed that the majority of participants logged in regularly during the first two months, and around half logged in each week on average across the six month period.
  
  
  CONCLUSIONS
  This study demonstrated promising initial results of an immersive virtual world approach to reaching underserved individuals with diabetes to deliver diabetes self-management education. This intervention model and method show promise and could be tailored for other populations. A large scale controlled trial is needed to further examine efficacy.
authors.affiliation: Institute for Health Research and Policy and Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States.
authors.forename: Laurie
authors.initials: L
authors.lastname: Ruggiero
authors.affiliation: Institute for Health Research and Policy and Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States.
authors.forename: Ada
authors.initials: A
authors.lastname: Moadsiri
authors.affiliation: College of Nursing, Department of Biobehavioral Health Science, University of Illinois at Chicago, Chicago, IL, United States.
authors.forename: Lauretta T
authors.initials: LT
authors.lastname: Quinn
authors.affiliation: College of Nursing, Department of Health Systems Science, University of Illinois at Chicago, Chicago, IL, United States.
authors.forename: Barth B
authors.initials: BB
authors.lastname: Riley
authors.affiliation: Division of Transplant Surgery, Division of Epidemiology & Biostatistics, University of Illinois at Chicago, Chicago, IL, United States.
authors.forename: Kirstie K
authors.initials: KK
authors.lastname: Danielson
authors.affiliation: Center for Advancement of Distance Education, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States.
authors.forename: Colleen
authors.initials: C
authors.lastname: Monahan
authors.affiliation: Institute for Health Research and Policy and Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States.
authors.forename: Valerie A
authors.initials: VA
authors.lastname: Bangs
authors.affiliation: Institute for Health Research and Policy and Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, IL, United States ; Jesse Brown VA Medical Center, Chicago, IL, United States ; College of Medicine, University of Illinois at Chicago, Chicago, IL, United States.
authors.forename: Ben S
authors.initials: BS
authors.lastname: Gerber
keywords: minority group; self-management; type 2 diabetes mellitus