Tag Archives: WIC

Women in Control: Real and Virtual World Healthcare Intervention

We’ve just wrapped up our NIH-funded experiment, using virtual worlds for health behavior change and patient education.  The Women in Control study, out of Boston University Medical Center, was a year-long research program to test a virtual world versus real world-delivered diabetes healthcare intervention.  The program’s subjects were Boston area Black women, between the ages of 40 and 60, who suffer from out of control type 2 diabetes (T2DM).  The Co-Principal Investigators,  John Wiecha, MD, MPH and Milagros C. Rosal, PhD, designed an intriguing study with a talented team. The eight-week health behavior program was an adaptation of a CDC program called The Power to Prevent. One hundred women in the greater Boston area participated. Subjects were randomly assigned to one of two groups – those who engaged in weekly 90-120 minute sessions in the virtual world of Second Life and those who did so in face-to-face meetings at Boston Medical Center.

Our research questions: How feasible is the use of a virtual world for this purpose? And will subjects in the virtual world program demonstrate similar impact at study-end on health behaviors as subjects in the real world, as measured by patient activity levels; dietary patterns; adherence to diabetes medications; and improvements in metabolic and anthropometric indicators (hemoglobin a1c values, body mass index, and blood pressure)?

We are still churning the data and analyzing our results, so stay tuned for future posts and publications, but we do have this 4-minute video (beautifully compiled by Ariella Furman, Framed in 3D) that gives you a feel for the study and the impact on the subjects.

You can also read past blog posts on the study here and here.

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Finding the Balance: Direct Instruction and Exploration

Learning involves a little bit of dancing

Finding the most effective balance between direct instruction and discovery learning is a tricky business. We just finished the first group computer and Second Life training in our Women in Control study (Drs. John Wiecha and Milagros Rosal, Co-PIs), and I have to confess that, despite all of our careful planning and design, that particular fulcrum turned out to be pretty darned illusive.   There were nine women in this first group (three more groups to come) – all of them with type 2 diabetes, new to computers, and definitely new to Second Life.  Our job? To get them up and running on their brand new laptops, and comfortable in the virtual world of Second Life.  The challenge is made all the more daunting by the fact that the women in our study are not computer literate and most of them have a fourth-grade reading level.

Each subject in our portion of the controlled study receives a new Macbook computer and a 4G wireless device which will allow them to join their diabetes healthcare group sessions, from home, in the virtual world (the control group will participate in face-to-face sessions at Boston Medical Center).  They will meet online, as a group, once per week, for the next eight weeks, with nurse educators, to learn about their disease and how to manage it.  In order to get them up to speed for the group sessions, we conduct two face-to-face computer training workshops.  The first introduces them to their new laptop, shows them how to assemble their modem and connect to the internet, and get familiar with the keyboard, mouse, and interface.  The second workshop introduces them to Second Life.  In advance of the training, we set up their SL accounts, create and cloth their avatars, and configure their interface (set favorites and preferences).  So, when they first fire up Second Life, they arrive in a configured “home” and meet the avatar that bears their name.  Lessons abound…

*  A passive introduction to SL (project SL up onto a screen, dim the lights, and give them a basic tour) at the end of the first computer training really helped.  “Just sit back and relax, you don’t have to do anything right now, just enjoy.” You could see them visibly relax after the tension of figuring out USB cable connections and learning the significance of new terms like “modem”, “space bar”, “application”, and “return key”.  I kept the initial tour to just the basics – my avatar waved to them, walked around a bit, sat down, stood up, and then flew (“Oooohh!!!”) over the area that will be their new virtual “home”.

* We break the training into two successive sessions – it’s too much to swallow all at once.  Ideally, it would be three sessions.  Almost everything our subjects are learning is completely new to them  – it’s overwhelming.

* Modeling the fabulous instructional comics made by my colleague, Liz Dorland, I created very simple tutorial comics (sample: Talk.WIC) that review the basics of talking, moving, and finding objects in inventory.  I kept to one page per skill, used very simple language, and printed them out. These went over very well.

Example comic tutorial

* Our subjects identify with their avatars very quickly.  Evidence of this….one who walked into the water, “Yikes! I don’t want her to get wet!”  Two who bumped into each other, “Watch where you’re stepping, girl!”  One who didn’t like her look, “How do I change these clothes, I look awful.”  And as we prepared to shut down, “Where should I put her?  She needs a house to sleep in.”

Throughout the training sessions I could feel the constant push and pull of how much to instruct versus giving time and space to explore on their own. We think of didactic instruction as the most efficient method (pack it all in) for teaching complex information to a large group. In a budget-strapped grant such as ours, with a large population (100 subjects), time is of the essence.  But we also know that exploration and discovery are keys to learning that sticks and a better overall experience for the learner.  This idea is reinforced by a study, recently published in the journal Cognition, by Elizabeth Bonawitz (UC Berkeley) and Patrick Shafto (University of Louisville), where four and five-year olds visiting a museum were divided into four groups with four pedagogically different introductions to a novel toy.  The toy had many “hidden” interactive elements in the toy (squeakers, musical panels, lights). Group 1 received a full-on demonstration.  The experimenter with Group 2 pretended she was interrupted in the midst of her demonstration, suggesting that she didn’t finish demonstrating all that the toy could do.  Group three’s demonstrator pretended that she’d discovered something the toy did by accident.  And in Group four, the toy was simply given to the children with the comment, “Wow, see this toy? Look at this!” and then the demonstrator left the room.  After the various introductions, the children were left with the toy and allowed to play. All of the interactions were videotaped and later analyzed.  The results were crystal clear – the less direct instruction received, the longer the children played with and explored the toy.  And it wasn’t just time spent on task, the fourth group (the group given less instruction) tried out more actions on the toy.  In other words, direct instruction seemed to dampen the learners’ motivation for exploration and self discovery.

But how to balance that experimental truth against the fact that these adult learners have absolutely no context for this new world they are exploring?  Their low literacy, limited experience with computers, and negligible understanding of the internet would cripple open exploration and only lead to frustration. For this program, we’ve settling on a hybrid model – a blend of direct instruction, followed by periods of exploration. What some refer to as guided inquiry. For example, we show them the gesture panel in Second Life, ask them to click on it, and then stop talking – indicating a gap in the “class” for exploration.  We lead their avatars to an interactive dance floor, show them how to access the choser panel, and then stop talking – indicating another gap.  The audio recordings of the training sessions reveal a rhythmic swell and lowering of sound, almost like a musical score, that trace the pattern of these “gaps”.  The noise level gets loud and raucous during the exploration times then quietly hums during the direct instruction times.  I’m coming around to understand that the chaotic noise level is, in part, a measure of success. But it is omportant to recognize that these learners (and most of us, for that matter) need both.  They need context, shape, and guidance — and they need to explore and follow what interests them.

Designing sessions this way involves mental adjustments on the part of the instructors. For example, we must get used to a reduced emphasis on “covering the content”.  One has to let go of anxiety over topics left out or diminishing time to “get to” key concepts. We are learning to measure success by the learners’ enthusiasm for the experience.  If they end the session feeling like it was fun, that this virtual world was intriguing and they wanted to get in there again to play around, then the training session was a success. But that doesn’t mean that we don’t have a plan for the skills they must master in order to be succesful. Fortunately, we’ve built into the instructional design later opportunities for the learners to scoop up specific skills missed in front end training, if needed.

I have to say that my favorite moment of the training was when they first logged into SL and saw their avatar rez in front of them.  “Ooooh!  There she is!”  These moments, when their delight and fascination over this completely foreign world, are contagious.

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Women In Control: The Theoretical Framework

"Women in Control" Theoretical Framework

This graphic is the theoretical framework for our NIH-funded Women in Control project.  I’ve blogged about this project previously here and here, but to briefly recap, this is a health behaviors program intended for African-American women with uncontrolled type 2 diabetes mellitus (T2DM).  We are currently recruiting 120 T2DM patients in the Boston area as study participants.  Half the subjects will participate in the health education program in traditional, face-to-face sessions conducted at Boston Medical Center while the other half will participate in the same curriculum from the comfort of their own homes, in the virtual world of Second Life.  All study participants will be given a laptop computer and those in the virtual world experimental group will receive hands-on training to familiarize them with Second Life.

Our research question is:

Will subjects in the virtual world program demonstrate greater impact at study-end on health behaviors than subjects in the real world, as measured by patient activity levels: calories consumed; adherence to prescribed medication regime; and decrease trends in overall disease indicators (hemoglobin a1c values, body mass, LDL, and blood pressure)?

For the last six months, the project team has been building the curriculum, planning (and building) the Second Life activities, refining the materials, plotting the recruitment procedures, and clarifying the desired outcomes for the intervention.

The “intervention” consists of 3 individual sessions and 8 groups sessions for the subjects led by diabetes educators.  The intent is to produce changes in internal factors that lead to changes in behaviors and psychological states for the subjects.  The eventual, hoped-for results will be physiological improvements that ultimately lead to improved overall health and quality of life.

The diagram shown at the top of this post provides the theoretical overview of what we hope to accomplish.  The tourqouise-colored box shows the factors that could modify the intervention’s impact (e.g. low literacy levels).  The purple box displays the variables that the intervention will attempt to modify.  While we can’t make people eat more healthily or take their medications regularly, we can use tools and techniques that have been shown to help people change their behavior. The techniques we will use in this study are motivational interviewing, active learning, and the dynamics of group work.  It is our hope that these methods will help the subjects take small steps toward greater self-management of their disease.

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Reflections on Learning in Second Life

Our working Second Life working space

Last week we conducted a pilot Second Life training with two “test” subjects for our forthcoming health behaviors study, to be conducted in the virtual world of Second Life.  I’ve blogged about this project in an earlier post.  In a nutshell, this is an NIH-funded health behaviors study with African-American women who have uncontrolled diabetes type 2. The project team has finalized the curriculum, set out a plan for subject recruitment and secured the IRB approval.  My part of the project is everything to do with the subject cohort who will experience the program in Second Life.  To that end, in anticipation of the program’s start in May, we have built out the Second Life space (shown above), trained all of the educators, designed Second Life activities, and designed an SL orientation for the subjects.  It was that orientation that we tested last week.

It is unlikely that any of this program’s subjects will have virtual world experience.  In fact, for the most part, our subjects will not have all that much computer experience.  So we will start with

Spiral Theas, my avatar

the basics.  Their orientation consists of two, two-hour in-person sessions. The first one is an orientation to the laptops and the wireless modem they will use for the program (Macbook laptops and Verizon USB modem devices).  At the conclusion of that first session, I take them into Second Life in what I’m thinking of as a passive, “first-look” view.  I projected my computer onto the room’s media screen, dimmed the lights, and encouraged them to just sit back and enjoy.  I logged into SL and introduced them to Spiral Theas, my avatar.  She waved.  They gasped.

Then I walked around the island, showed them how she could turn right and left, sit, dance, and even fly.  Another gasp.  Then I teleported her to Paris and cammed back to take in the full height and majesty of the Eiffel Tower.  Another gasp.  By this time our test subjects were laughing, joking, asking questions.  “When can we go in?”  “What will my avatar look like”, “Can you climb up in that Eiffel Tower?”  “Are those other people speaking French??!”

We left them there – with lots of questions and anticipation. The next two-hour session, held three days later, was going to be all about Second Life.  They came in, hooked up their laptops, and fired them up.  Without too much trouble, they all got in-world and met their avatars (that we’d prepared for them in advance).  They walked, ran, danced, and sat down.  We went over how to chat, how to speak (fiddled with headsets).  We opened the map (“oooh, it’s like looking down at the world from a plane!”).  We opened their inventory (“where are my clothes?”).  We teleported to another location.

It all went so much more smoothly than we thought it would.  They were excited, interested, and not at all intimidated by the interface or the complexity. There were some confounding gaps in their computer knowledge that tripped me up. Here’s one that took us by surprise:  When we were using local chat to send messages to each other, one of the subject’s messages appeared with no spaces between the words.  She asked me how did I get the spaces between the words and I explained that you just hit the space bar when you finished typing a word in order to advance one blank space and type the next word.  “Where’s the space bar?”.

Another had to do with physical orientation to the space.  I had thought that a projection of my laptop to the front of the room would help them – if they got lost as to what to do, they could look up on the big screen and I could demonstrate.  Instead, they kept referring to the big screen over their own, smaller screen and getting very confused about their “view”.  After a few minutes of this confusion, I disconnected my laptop.  They were then able to focus on their own screens and seemed relieved.  Less to manage.

The navigational task that they found the most challenging were (not surprisingly) controlling their camera view.  We made a program decision to not have a mouse with the computers and rely instead on the track pad.  We figured that since these subjects did not have much in the way of computer experience, learning to use a mouse would be just as much of a task as learning to use a track pad and then we’d have one less appliance to worry about.  The track pad is a bit tricky (one finger or two?  swipe or drag?) but the element that caught me by surprise was that one of the subjects had longish fingernails and it was much harder for her to use because of them.

By far and away, my favorite quote of the session from one of the subjects was, “Well, I can’t dance in real life, but I can dance in Second Life!”

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