The Values and Research that Underpin emojifit® Diabetes

Professor Timothy Skinner- Charles Darwin University, Decision Support Analytics

Using the best available research and clinical evidence, we have developed a mobile App for people with Type 2 Diabetes to assist with the lifestyle changes that are needed to reduce the risk of complications caused by the physiological and psychological effects of un-managed Type 2 Diabetes. We believe our role is to help people with diabetes make informed choices about how to manage their diabetes. We see our role as using available technologies to help people make sense of the abundant and often apparently contradictory information about Type 2 Diabetes.
Our goal is to help people make choices about their diabetes that are consistent with their own individual values, goals, concerns, abilities and resources.  
Research has shown there is no one right way to manage Type 2 Diabetes; and that successful self-management occurs when each person works out their own plan and is supported to stick with it. 
Our aim is to help people find their own path to manage their diabetes by providing a tool that will enable people to set their own diabetes management plan, get the support they want, and succeed one step at a time.

Key Features of emojifit® Diabetes
emojifit® Diabetes is designed to help people with Type 2 Diabetes make choices on how they wish to focus their efforts for managing their diabetes. We have structured the App so that users are taken through series of decisions, or choices about their diabetes. The App takes users from identifying which complication they are most concerned or worried about, to creating a specific individualised plan. This process is, as far as we know, unique in the diabetes App space. We know this process works, as structured self-management has been extensively tested by Prof Skinner and the team including for the DESMOND program for individuals newly diagnosed with Type 2 Diabetes [1,2] .

emojifit® Diabetes has been developed to focus people with diabetes on a small number of action plans. People with Type 2 Diabetes are usually given a long list of things they are told they need to do, or change to manage their diabetes: eat less fat, eat less saturated fat, eat more fibre; eat less salt, and the list goes on. For most people, it is not possible to do all the things they are told they need to do. So they do few if any at all. This means the diabetes does not get managed; and people feel even more concerned about the future. emojifit® Diabetes helps people identify initially only one focus for their diabetes management. Making one change, and keeping that going for a period of four weeks will have a real benefit for people’s diabetes. So emojifit® Diabetes helps people determine where they are likely to achieve progress on the outcomes that are most important to them.

Evidence Based 
There are a large number of Apps currently available for people with Type 2 Diabetes. The majority of these Apps are focused on blood glucose monitoring. Whilst blood glucose monitoring plays an important part in diabetes, it is not the only risk factor for diabetes complications. For many complications, the research suggests that managing other risk factors, such as cholesterol, blood pressure and depression are more important than blood glucose [3,4,5] . Similarly, we know that not all the dietary changes you can make impact equally on the different risk factors. Changing some aspects of our diet has more impact on blood glucose, whilst other changes may have more impact on cholesterol. We have designed emojifit® Diabetes to use this research evidence to inform the decision options users have. In this way, users only have to choose from options that we know will help them reach their goals, rather than try and work through the mass of information available themselves.

Type 2 diabetes is a demanding condition to manage. It is challenging for people with diabetes to try to manage the lifestyle changes to address all of the different risk factors for complications. The changes that people wish to make can often conflict with the habits and preferences that have developed over a lifetime. So putting these changes into place and sustaining them requires support. We have built into emojifit® Diabetes the ability for people to share their plans for managing their diabetes with friends and family, through Facebook. This enables people to safely let others know what they are trying to achieve, and enable others to support them in their decision-making.

There is a substantial mass of evidence that demonstrates when we actively monitor our progress, or actions, we are far more likely to achieve our goals and realize our action plans [6,7,8] . This is commonly referred to as self-monitoring. That is, we actively enter data, write it down, or put a coin in a jar to track what we have done. The key is that we self-monitor. When we use Apps, or pedometers to track what we do, we are often not engaged in the act. This is not self-monitoring but technology tracking. So we have designed emojifit® Diabetes so that you can easily monitor your progress and achievements. You need to enter the data saying you have done each action that you planned to do. We have deliberately prevented automated tracking and data logging into the App from other Apps on the phone, or other devices as we wish users to self-monitor. Self-monitoring is a key tool to achieving our goals.  

What theories have we used to design how it works?
The emojifit® Diabetes team have used two theories to inform the development of the App: Social Learning/Cognitive Theory and Self-Determination Theory. Whilst there are many theories that are relevant and share similar concepts/ processes and make similar inferences on how best to support someone; we have restricted ourselves to these two for parsimony and their congruency with the underpinning philosophy and values.

Self-Determination Theory was proposed by Richard Ryan and Edward Deci [9,10,11] and is about motivation. It had six mini-theories contained within it. Primarily, for the purposes of this App development, we are interested in the contrasts between intrinsic and extrinsic motivation, and how these different sources of motivational energy influence our behavior. Extrinsic motivation refers to when we do things for external rewards such as: money, promotion, praise. In comparison, intrinsic motivation refers to when we do things for their own sake; for their own enjoyment, or they serve our basic needs for autonomy, competence and relatedness. The more we choose to do things for intrinsic over extrinsic reasons, the more likely we are to follow through and enact that choices in our day to day life.
Albert Bandura initially articulated his theory Social Learning Theory in the 1960 and 70s and adapted it further in the 1980s to become Social Cognitive Theory [12,13,14] . There are many facets to the full theory, at the core of which is the concept of self-efficacy. Self-efficacy is the belief that you can undertake an action or behavior in the face obstacles or barriers that life may throw at you. Many researchers translate this concept as confidence in our every day language. This concept is one of the most important in our understanding of social behavior, and as a result much of Bandura’s work and ideas on the concept of self-efficacy have been included in nearly all other theories and models that attempt to understand, explain and change people social and health behavior. One of the unique features of Bandura’s work is his articulation of how self-efficacy is developed and also undermined. This theorises on how to promote self-efficacy, and in turn increase the chance someone will be able to do the things they want to, is what we have used to inform this App design.  

We have predominantly focused on the value of mastery experiences in developing some sense of confidence and ability. That is, the value that succeeding, even at small steps, has in increasing a person’s sense that they can affect the course of their diabetes. Thus the App breaks the development of a management plan into small sequential steps. The App asks the user to decide how big or small their goals will be. The App also puts a check in place to see if the plan may be too hard. It is better to build on small successes, than to fail in our efforts. That is why we have the confidence scale as a check to see if success is likely. If not, the App encourages users to adapt their plan for success. 

  1. Skinner TC, Carey ME, Cradock S, Daly H, Davies MJ, Doherty Y, Heller S, Khunti K, Oliver L, on behalf of the DESMOND Collaborative. Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND): Process Modelling of Pilot Study. Patient Education Counselling 2006; 64:369–377
  2. Davies MJ, Heller S, Skinner TC, Campbell MJ, Carey ME, Cradock S, Dallosso HM, Daly H, Doherty Y, Eaton S, Fox C, Oliver L, Rantell K, Rayman G, Khunti K. On behalf of the Diabetes Education and Self Management for Ongoing and Newly Diagnosed Collaborative. Effectiveness of a structured group education programme on individuals newly diagnosed with Type 2 diabetes: A cluster randomised controlled trial of the DESMOND programme. British Medical Journal 2008; 336: 491 – 495
  3. UKPDS Study Group. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS: 23) BMJ 1998;316:823
  4. Elley et al. Derivation and Validation of a New Cardiovascular Risk Score for People With Type 2 Diabetes. The New Zealand Diabetes Cohort Study. Diabetes Care. 2010 Jun; 33(6): 1347-1352.
  5. Rodriguez-Poncelas et al. Comparison of different vascular risk engines in the identification of type 2 diabetes patients with high cardiovascular risk BMC Cardiovascular Disorders 2015;15:121. 
  6. Lim S, O’Reilly S, Behrens H, Skinner TC, Ellis I, Dunbar J.A. Effective strategies for weight loss in postpartum women: a systematic review and meta-analysis. Obesity Reviews. 2015 16(11) 972-987. 
  7. Butryn ML, Phelan S, Hill JO, Wing RR. Consistent self- monitoring of weight: a key component of successful weight loss maintenance. Obesity (Silver Spring). 2007; 15: 3091–3096. 
  8. Michie S, Abraham C, Whittington C, McAteer J, Gupta S. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychol 2009; 28: 690–701. 
  9. Deci, E. L., & Ryan, R. M. The empirical exploration of intrinsic motivational processes. In L. Berkowitz (Ed.), Advances in experimental social psychology. New York: Academic. 1980; 13: 39–80.
  10. Deci, E. L., & Ryan, R. M. Intrinsic motivation and self-determination in human behavior. New York: Plenum. 1985.
  11. Deci, E. L., & Ryan, R. M. A motivational approach to self: Integration in personality. In R. Dienstbier (Ed.),Nebraska symposium on motivation: Perspectives on motivation Lincoln: University of Nebraska Press 1991;38:237-288.
  12. Bandura, A. Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. 1977.
  13. Bandura, Albert. Social Foundations of Thought and Action. Englewood Cliffs, NJ: Prentice-Hall. 1985. ISBN 978-0138156145.
  14. Bandura, A. Self-efficacy: The exercise of control. New York: Freeman. 1996.

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