Transcript Use of Internet-Based Diabetes Self

Use of Internet-Based Diabetes
Self-Management Education:
Emmi Solutions
Esther Pak
MPH Candidate ‘11
March 29, 2011
The Diabetes Epidemic
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23.6 million (7.8%)
diabetics in the US
10.4% adults in Philadelphia
with diagnosed diabetes
7th leading cause of death
Diabetes increases the risk of complications:
cardiovascular disease, renal disease, neuropathy,
amputation, retinopathy, etc.
Key to controlling one’s diabetes: adherence to
recommended management behaviors
CDC: Diabetes Data and Trends, 2007
Emmi Solutions
3 diabetes computer modules:
◦ Type 2 Diabetes
◦ Checking Your Blood Sugar
◦ Injecting Insulin
Engages patients with interactive media, text and
images, narrated to simulate a one-on-one
conversation/counseling session with the
viewer.
Question
How effective and feasible are Emmi Solution’s diabetes self-management
education modules among adult type 2 diabetics at the Jefferson Family
Medicine Associates (JFMA)?
Question
How effective and feasible are Emmi Solution’s diabetes self-management
education modules among adult type 2 diabetics at the Jefferson Family
Medicine Associates (JFMA)?
Aims
1.
To evaluate the effectiveness of these modules by assessing the change
in patients’ diabetes-specific self-efficacy and their intent to perform
preventive behaviors.
1. Self Efficacy: Health Belief Model
2. Intent to Change: Theory of Reasoned Action/Theory of Planned
Behavior
Question
How effective and feasible are Emmi Solution’s diabetes self-management
education modules among adult type 2 diabetics at the Jefferson Family
Medicine Associates (JFMA)?
Aims
1.
To evaluate the effectiveness of these modules by assessing the change
in patients’ diabetes-specific self-efficacy and their intent to perform
preventive behaviors.
2.
To determine whether the Emmi program is an acceptable method of
diabetes education for patients at JFMA by assessing the self-reported
satisfaction of the modules, and the variability of satisfaction by age,
gender, or education.
Methods: Patient Recruitment
Patients aged 18 and over
 Approached at weekly Diabetes Information and
Support for Your Health (DISH) sessions in JFMA
 Informed consent obtained verbally
◦ Information about study and participant’s involvement
◦ Risks, benefits, costs
◦ Completely voluntary nature of study
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Methods: Survey Tools (1)
Communication Technology Survey
 To assess whether, and how, the population uses
“new media technology”
◦ Computer access and literacy
◦ Cell phone and text messaging use
◦ Methods used to obtain health information
 Distributed at 3 individual DISH classes to a total
of 23 patients
 One-time completion survey
Methods: Survey Tools (2)
Pre-Test Survey
Total 25 patients. Recruited from DISH sessions.
Diabetes-related knowledge, attitudes, and behavior prior to watching an Emmi video.
Emmi Modules
Complete one 20-minute module of choice (Diabetes Type 2, Checking Blood Glucose, or
Injecting Insulin)
Post-Test Survey & Interview
5-7 minute interview conducted prior to post-test survey.
Satisfaction and self-rated difficulty and usefulness of the program.
Changes in diabetes-related knowledge, attitudes, and intent to change behavior.
Analysis
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Variables
◦ Independent: Demographic profile (age, gender, race/ethnicity,
level of education, number of diabetes classes ever attended,
insurance status)
◦ Dependent: Diabetes-specific self-efficacy, satisfaction of
program, intent to change behaviors
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Quantitative analysis of effectiveness
◦ Frequency & percentage of pre- vs. post-test responses
◦ Cross-tabulation of independent and dependent variables
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Mixed methods evaluation of feasibility
◦ Quantitative analysis (see above) of post-test and
communication technology survey
◦ Qualitative analysis of interviews and observation notes: major
and minor recurring comments and feedback
Demographic Profile: Age & Gender
AGE
Mean age: 52.4 years
Minimum age: 40 years
Maximum age: 72 years
GENDER
 Communication Technology
Survey (n=22)
◦ Female: 16 (73%)
◦ Male: 6 (27%)
 Pre-, Post-Test Survey (n=25)
◦ Female: 16 (64%)
◦ Male: 9 (36%)
Demographic Profile: Education
Communication Technology Survey
(n=22)
Pre-/Post-Test Surveys (n=25)
Demographic Profile: Insurance
Communication Technology
Survey (n=22)
Pre-/Post-Test Surveys (n=25)
Demographic Profile: Race/Ethnicity
Communication Technology
Survey (n=22)
Pre-/Post-Test Surveys (n=25)
Demographic Profile:
Healthcare Utilization
In the past year, how many times
did you…
a) See a doctor or nurse for your
diabetes?
b) Go to an ER or spend the night in the
hospital because of your diabetes?
c) Get a dilated eye exam?
d) Have your feet examined for your
diabetes?
e) Have an A1c test?
Mean Response
Effectiveness: Self-Efficacy
How confident are you that you can:
 A) Exercise regularly (15-30 minutes, 4-5 times a week)?
 B) Attend your regular clinic appointments?
 C) Eat the recommended food portions?
 D) Keep food records of your meals?
 E) Treat low blood glucose?
 F) Carry quick-acting sugar for lows?
 G) Read food labels?
 H) Check your blood glucose with a monitor?
 I) Eat your meals and snacks on time?
 J) Take your diabetes pills and/or insulin at the right time?
 K) Record your blood glucose results?
 L) Take the correct dose of diabetes pills and/or insulin?
Effectiveness: Self-Efficacy
How confident are you that you can:
 A) Exercise regularly (15-30 minutes, 4-5 times a week)?
 B) Attend your regular clinic appointments?
 C) Eat the recommended food portions?
 D) Keep food records of your meals?
 E) Treat low blood glucose?
 F) Carry quick-acting sugar for lows?
 G) Read food labels?
 H) Check your blood glucose with a monitor?
 I) Eat your meals and snacks on time?
 J) Take your diabetes pills and/or insulin at the right time?
 K) Record your blood glucose results?
 L) Take the correct dose of diabetes pills and/or insulin?
Pre-test confidence
5/18 (28%)
16/18 (89%)
10/18 (56%)
6/19 (32%)
9/18 (50%)
8/18 (44%)
16/19 (84%)
12/17 (71%)
10/19 (53%)
16/18 (89%)
9/18 (50%)
17/18 (94%)
Effectiveness: Self-Efficacy
How confident are you that you can:
 A) Exercise regularly (15-30 minutes, 4-5 times a week)?
 B) Attend your regular clinic appointments?
 C) Eat the recommended food portions?
 D) Keep food records of your meals?
 E) Treat low blood glucose?
 F) Carry quick-acting sugar for lows?
 G) Read food labels?
9/18 (50%) +4
17/18 (94%) +1
12/18 (67%) +2
11/19 (58%) +5
14/18 (78%)
+5
11/18 (61%)
+3
18/19 (95%)
+2
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H) Check your blood glucose with a monitor?
I) Eat your meals and snacks on time?
J) Take your diabetes pills and/or insulin at the right time?
K) Record your blood glucose results?
L) Take the correct dose of diabetes pills and/or insulin?
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Post-test confidence; n change from non-confident to confident
14/17 (82%) +2
12/19 (63%) +2
16/18 (89%)
0
13/18 (72%) +4
17/18 (94%)
0
Effectiveness: Intent to Change
When you visit your doctor or nurse,
how often do you do these (pre) /do
you think you will do these (post)?
Mean Response
Pre-Test ( ) & Post-Test (
)
a) Make a list of questions for him or her?
b) Ask about things you don’t understand?
c) Talk about personal problems?
d) Leave your doctor or nurse, and not
understand what they told you?
never
rarely
sometimes
often
Emmi Diabetes Modules: Effective?
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Positive change in participants’ self-efficacy and intent to
change diabetes-maintenance behaviors.
◦ More pronounced changes in those predisposed to lower
confidence: older, less educated individuals. These two groups
had the greatest changes between pre- and post-test.
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Post-test interviews:
◦ “…The [narrator’s voice] was like a conversation, so it made me
want to listen and take it seriously.”
◦ “I learned new information, like checking your blood sugar in the
morning, afternoon, and evening. I plan to implement these new
tips immediately.”
Feasibility: Use of Technology
Communication Technology Survey
 Computer use
◦ 18 of 23 respondents (78%) used computers
◦ 3 of the 5 that did not use computers planned on learning how
◦ 19 of 22 respondents (86%) could find a computer to use when
they wanted to (most common locations: at home, at work)
◦ Majority can use the Internet: 17 get onto Internet; 15 can copy,
download, or print files from the Internet, write/send emails, and
use the Internet to find health information
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Cellphone use
◦ 20 of 23 respondents (87%) owned a cell phone
◦ 16 of 23 (70%) had sent and received text messages
◦ 17 of 23 (74%) were willing to receive health information or
reminders on his or her cellphone
Feasibility: Self-reported Satisfaction
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Did this program answer questions you would have
called your doctor/nurse to talk about?
◦ 18/20 answered “Yes”
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How helpful was this program for…
(Not helpful – A little helpful – Helpful – Very helpful)
◦ Helping you understand how to manage your diabetes? 18/20
answered “Very Helpful”
◦ Giving you useful information? 18/20 answered “Very Helpful”
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How easy was this program to understand? (Very hard;
A little hard; Fairly easy;Very easy)
◦ 23/25 answered “Very Easy”
Post-Test Interview
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9 of 25 had never used a computer before (All above
the mean age of 52.4 years).
◦ After brief tutorial on computer use, 8 proceeded through
entire program without additional assistance.
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15 of 25 mentioned their positive response to the
personable tone of the narrator: “felt like a
conversation”; “made me feel more comfortable”; “…so
I wanted to listen and take it seriously”
7 of 25 wanted additional printouts and information; 4
asked for note-taking material
3 asked to watch a second module.
Emmi Diabetes Modules: Feasible?
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Surprisingly high percentage of the population knew
how to use computers
◦ For the computer-illiterate, a simple “crash course” on
computers and mouse control seemed to be adequate to
successfully navigate through the program without help.
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High level of interest in program and positive feedback
◦ “I wish I’d been shown this [program] when I first got diagnosed
with diabetes [in 2005]! It would’ve helped me take [my
diabetes] seriously.”
◦ “This would greatly benefit older patients...[because it’s] so easy
to just sit and watch.”
Limitation
◦ Patient population from DISH classes: potential bias
from knowledge and behavioral influence that may
have been learned from these classes
 Cross-tabulated: Attended 0-2 diabetes classes vs. 3+ diabetes
classes.
 From a veteran diabetes education class attendee: “This is
very, you know, unlike [other classes I have been to]; this is
one on one.You can gather more knowledge compared to
other programs; it was a little easier because you sit and listen
one on one.”
Recommendations
◦ More help for the computer illiterate
◦ To better see the differences (self-efficacy, intent to
change, satisfaction of program) among various
demographic groups, increase the total n of the study.
 Differences between variables will be more pronounced and
can be analyzed for statistical significance.
 Can tailor program recommendations to specific groups, e.g.
older versus younger populations.
◦ Analyze responses for each module separately
◦ Home study of program: assess effectiveness and
feasibility when participants complete it on their own
time and at a location of their choosing.
Special thanks to…
Dr. Sarfaty
Dr. Diamond
Dr. Brawer
JFMA SEPA Group
Emmi Solutions
DISH Staff and Patients