=Paper=
{{Paper
|id=Vol-1582/9Jalil
|storemode=property
|title=Integrating Persuasive Technology to Telemedical Applications for Type 2 Diabetes
|pdfUrl=https://ceur-ws.org/Vol-1582/9Jalil.pdf
|volume=Vol-1582
|authors=Sakib Jalil,Rita Orji
|dblpUrl=https://dblp.org/rec/conf/persuasive/JalilO16
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==Integrating Persuasive Technology to Telemedical Applications for Type 2 Diabetes==
https://ceur-ws.org/Vol-1582/9Jalil.pdf
Integrating Persuasive Technology to Telemedical
Applications for Type 2 Diabetes
Sakib Jalil1, Rita Orji2
1
Discipline of Information Technology, College of Business, Law & Governance,
James Cook University, Australia
sakib.jalil@my.jcu.edu.au
2
Accessible Computing Technology Lab, McGill University, Canada
rita.orji@mail.mcgill.ca
Abstract. Type 2 Diabetes (T2D) patients need constant monitoring of food,
exercise and insulin level. Telemedical systems aid the patients in monitoring
and sending their regular blood glucose to nurses and in receiving suggestions
on food, exercise and insulin dosage, especially on food choices. This paper
presents a qualitative inquiry aimed at investigating the possibility of integrat-
ing Persuasive Technology (PT) into existing telemedical system for T2D to
promote desirable dietary and physical activity among T2D patients and how
T2D patients perceive the role of such PTs in comparison to a human persuader.
The findings show that T2D patients prefered to receive dietary recommenda-
tion and suggestions or restrictions from a PT. The T2D patients prefer to be
told what they can or cannot eat by a PT than hearing it from a human. Thus,
PTs hold significant promise of complementing existing telemedical applica-
tions to achieve desirable health outcome for T2D. However, since the motiva-
tional needs of T2D patients may differ from those of non-diabetic individuals
[12], there is a need to understand them and tailor the PT to reflect the needs
and beliefs of the T2D patients
Keywords: health, type 2 diabetes, telemedicine, clinical trial, model-driven
persuasive technology, tailoring.
1 Introduction
Type 2 Diabetes (T2D) is one of the most dangerous chronic diseases [1] where the
body essentially develops immunity to insulin; eventually this causes blood glucose
levels to alter to abnormal levels and generates complications in health of a person.
T2D has no permanent cure yet, but is managed through three parameters: food, exer-
cise and insulin. Insulin is controlled by medical professionals and requires medical
knowledge about dosage. However, food and exercise are parameters that can be di-
rectly controlled by T2D patients. Hence, regular management of blood glucose levels
through medical intervention and lifestyle adaptations, such as a changed diet and
Copyright © by the paper’s authors. Copying permitted for private and academic
purposes.
In: R. Orji, M. Reisinger, M. Busch, A. Dijkstra, A. Stibe, M. Tscheligi (eds.): Pro-
ceedings of the Personalization in Persuasive Technology Workshop, Persuasive
Technology 2016, Salzburg, Austria, 05-04-2016, published at http://ceur-ws.org
Integrating Persuasive Technology to Telemedical Applications for Type 2 Diabetes 93
increased physical exercise, has been shown to reduce complications in T2D patients
[2].
The use of technology-intervened treatments, such as Telemedicine to monitor pa-
tients from home is on the increase with chronic diseases such as T2D. Telemedicine
is the use of Information and Communication Technologies (ICT) to provide clinical
treatments over distances [2]. For a telemedicine treatment of T2D, patients generally
send regular blood glucose data to nurses or health care providers via one of the fol-
lowing devices such as phone, tablet, computer, web-based system, video-conference,
phone calls, Short Message Services (SMS), etc. [3]. A nurse or healthcare provider is
involved in T2D telemedicine treatments continuously while the technology-
intervention remains as a means of transferring data (e.g., blood glucose, blood pres-
sure) and facilitates the communication between patients and nurses. When a patient’s
blood glucose is too high, the nurse generally alerts the patient to suggest foods to be
avoided, how much insulin to be taken and exercise that could be done. Sometimes
patients’ family members remind the patients about food and exercise too. How much
the patients like to hear about food and exercise advice from their nurses or family
members remains a topical question.
On the other hand, a significant advantage that Persuasive Technologies (PT) pos-
sesses over regular technologies is the ability to persuade users without having a hu-
man persuader’s involvement and/or interaction with the users [4]. Thus, PT can offer
greater anonymity for a human persuader. In case of T2D management, PT has great
promises to help to manage two of the three parameters (food and exercise) of T2D
management. However, since the motivational needs of T2D patients may differ from
those of non-diabetic individuals [12], there is a need to tailor the PT to reflect the
needs and beliefs of the T2D patients. This paper presents results from investigating
T2D patients’ perception of the role of a PT versus the role of a human persuader in
T2D management. All our participants are T2D patients who use an in-home monitor-
ing telemedicine device and officially enrolled in a clinical trial.
2 Background
Food and exercise are the two parameters that are very crucial for T2D management
and patients can directly control them. T2D patients’ motivational needs differ from
non-diabetic individuals in several ways. For T2D patients, healthy eating and regular
exercise is a requirement as they are necessary for T2D management unlike non-
diabetic patients who may adopt healthy eating and regular exercise for health promo-
tion and disease prevention purposes. T2D patients are required to eat healthy nutri-
tious meals by choosing foods that help stabilize blood glucose and need to control
their portion of food. Excessive blood glucose causes hyperglycemia that may result
into stroke, heart failure, nerve and eye disease. Extremely low blood glucose causes
hypoglycemia that may result into sweating, dizziness, fainting, etc. Therefore, T2D
patients’ motivational needs are very different to non-diabetic individuals, whose
motivational needs could be weight loss and general health promotion and improve-
94 Integrating Persuasive Technology to Telemedical Applications for Type 2 Diabetes
ment. T2D patients’ motivational needs for food control arise to avoid fatal health
conditions. In terms of exercise T2D patients are required to stay fit and burn exces-
sive blood glucose due to insulin intolerance, while for non-diabetic individuals the
motivation for exercise could be to reach certain fitness goals.
PTs, which are designed to promote desirable behavior, have been shown to be ef-
fective at motivating behavior in various domains including healthy eating and physi-
cal activities [16,17]. Research has also shown that PTs can be used to increase en-
gagement, adoption, and adherence to certain task including medication adherence
[5], oral hygiene [6], and physical activity [7]. Similarly, strategies to design effective
PT to motivate healthy behavior among individuals have been thoroughly researched
[8], where tailoring through personalization and culturally-relevant design guidelines
[9] proved significant.
With respect to T2D specific PT design, an experiment consisting of daily persua-
sive text message and a weekly tailored newsletter was shown to be effective for T2D
patients on two participants [10]. The daily text messages sent to the subject were
fresh and were limited in number. Although the persuasive text message support sys-
tems have shown promise as means of motivating adherence to insulin therapy in
adolescent diabetics [11], it is not clear that text messages could be used to motivate
increased physical activity and healthy eating for T2D patients. More specifically, as
a research community we do not have a good understanding of how PT can be incor-
porated into technology-enabled therapy for T2D patients to motivate desirable physi-
cal activity and healthy eating behavior. Persuasive interaction design may be espe-
cially fundamental to achieving high motivation in the context of individuals with
T2D. However, since their motivational needs may differ from those of non-diabetic
individuals [12], there is a need to tailor the PT to reflect the needs and beliefs of the
T2D patients.
3 Method
We conducted a qualitative study to understand T2D patient’s perception and attitude
towards PT in comparison to a human persuader. This study was conducted in parallel
with a research project called Clinical User-experience Evaluation (CUE) of T2D
patients. The CUE project studied T2D patients’ uses and interactions of an in-home
diabetes-monitoring device in a telemedicine clinical trial in Townsville region of
Australia [13]. The telemedicine clinical trial was conducted by Townsville-Mackay
Medicare Locals (TMML) while the CUE project was an independent study. The
CUE project and the original clinical trial used a non-persuasive in-home monitoring
device.
In the telemedicine clinical trial, T2D patients were using an in-home monitoring
device to send blood glucose data to nurses and receive medical advice through
phone. The in-home monitoring device these patients used consisted of a tablet with
Integrating Persuasive Technology to Telemedical Applications for Type 2 Diabetes 95
11-inch screen, a glucometer and a sphygmomanometer, which would upload the
patients’ blood glucose and blood pressure automatically to an online system. The
patients received phone calls from nurses about food, exercise and insulin doses.
Some patients received consultation via phone 2 times a week while other patients
received consultation via phone once every 2 weeks, depending on the severity of
their diabetic conditions. In addition, patients’ family members were also involved in
their diabetes management.
This study involved six T2D patients (Table 1) of the CUE project. Participation
to this study was voluntary. All patients are computer literate Caucasians and were
given pseudonyms for privacy reasons.
Table 1. Patient Information
Patient pseudonyms Sex Age Diagnosed with
T2D (years)
Zach M 70 10+
Vince M 66 10+
Bill M 64 20
Heidi F 60 25
Serena F 55 2
Pete M 53 1
The entire fieldwork was done one-on-one. Each patient was visited individually
in his/her own home. The study presented a scenario to each patient in non-technical
language. The scenario described a persuasive technology integrated into their exist-
ing telemedicine system for T2D that would provide a patient with a choice of foods
he can eat that day and suggested portion, based on his recent blood glucose reading
from the telemedicine system. The system would also list foods the patients should
avoid and could send reminders to keep them motivated. The current device would
provide patients with types of physical exercise that he could perform based on his
recent blood glucose. It will remind him to exercise and will encourage and inspire
him throughout the day.
Next, each patient was asked to explain his/her thoughts about such an application
and to compare it to a human persuader. The questions asked - “If PT features (as
described in the scenario) were to recommend and encourage you about food and
exercise instead of a human, how would you feel?” followed by “How helpful would
the PT features for food and exercise be for you?” The patients often referred to the
nurses or some family member as their human persuaders. The answers were audio-
recorded and transcribed. Note that we were not allowed to show the patients any
interfaces due to ethical restrictions.
This study assumes that for the insulin dosage, the patients will still receive in-
structions from the nurses in their telemedicine in-home monitoring device. The per-
96 Integrating Persuasive Technology to Telemedical Applications for Type 2 Diabetes
suasive features to motivate about food and exercise would be integrated into the
existing system while the nurses would control insulin dosage.
4 Findings and Discussion
The patients provided interesting feedback concerning the idea of integrating a per-
suasive application to existing telemedical systems to help motivate them to meet
their healthy dietary and physical activities requirement inline with each T2D patients
needs and capabilities.
4.1 PT for Healthy and Appropriate Dietary Intake among T2D Patients
Most of the T2D patients found the use of the PT for motivating health dietary intake
and recommending appropriate diet in line with their individual T2D need, very inter-
esting and showed enthusiasm. Bill, a 64-year old male said he would not like to hear
from his wife or other people about the food that he can or cannot take, especially the
fact that he cannot take some of the foods he like. He mentioned “battered fish” being
one of his favorite foods, which he has to consume sparingly due to his diabetes. Yet,
he does consume “battered fish” and he stated he would prefer to hear what he can eat
or cannot eat, or the results of eating “battered fish” from a PT. “I prefer an app tell-
ing me than a human. You know I like eating fish, battered fish. My blood sugar will
just go through the roof if I had battered fish.”
Similarly, Serena is a 55-year old female and lives with her university going son.
Serena specifically mentioned that she would prefer PT to provide her with food
guidelines. According to her, hearing food advice from nurses does not feel very
good. She said that people can tell her what not to eat, but she still can eats it. At this
point Serena was seen to respond with emotion to say that she can eat what she wants
even if a human says she cannot. “An app. Someone tells me I can't; I can (signs of
strong assertion in her voice). So an app far better.”
Zach a 74-year old male showed similar preferences for a PT. Zach said he would
not like to go through series of conversations to convince his wife about his food
choices. He does not want to justify and be answerable to his wife about what he eats.
“The gizmo-referring to PT (Zach broke into laughter). You don’t like your wife to nag
you and she doesn’t like you to nag. The gizmo can nag as much as it can”
Other patients Vince, Heidi and Pete also expressed similar interests in having a
PT to advice about their food choices as opposed to a human persuader or informer.
Pete provided a positive argument for PT. Pete mentioned that just by looking at his
blood glucose readings every morning and evening, he started to be conscious of his
food intake. He has lost 13 kg of bodyweight in 5 months from this practice. So Pete
think that a PT targeted at healthy eating would benefit him more in comparison to the
Integrating Persuasive Technology to Telemedical Applications for Type 2 Diabetes 97
simple non-persuasive telemedicine technology. This finding suggests that T2D pa-
tients may trust and adhere to feedbacks provided by PT than that from human. This
is contrary to Orji et al [14] who found that some people might not be open to receiv-
ing feedback and praise from a system. This highlights the need to tailor PT to indi-
vidual’s inclinations and suggests indeed that T2D patients may be different.
One patient, Bill additionally pointed out the importance of triggers in the PT.
Surprisingly, none of the patients had any experience about PT before the study and
was not given any information about PT design while the study was conducted. Yet,
Bill described PTs as having a trigger that would help in prompting behavior. In Bill’s
words: “if you have that app, you need that app to have jumped out at you. You know
sort of like make a sound or something …” This supports the concept of triggers in the
theory of PT [4].
Serena, in addition, mentioned that besides being on the clinical trial of the in-
home monitoring telemedicine technology, she was using her iPad to look for applica-
tions that could help her with making better food choices. She said she received food
advice from the nurses in the clinical trial, but wanted to see all the details of the food
choices, the nutrition, and the calories because the nurses only guided about food. She
wanted concrete food choices to stay healthy with T2D. Serena and her son had done
extensive search of applications on App Store of Apple Inc. After having tried many
current applications, she suggested that the PT could include information for T2D
patients such as, GI (glycemic index), nutritional value as opposed to just asking for
body weight, an important need for T2D patients.
4.2 PT for Promoting Physical Activity among T2D Patients
Even though the patients were asked about a PT for food and exercise, very few pa-
tients spoke about PT for exercise specifically. There could be two possible reasons
for this. First, it was hard for them to perceive how a PT can motivate them to exer-
cise since this study was scenario based and therefore requires the patients to imagine
the applications without the use of any interfaces or mock-ups. Second, the patients
perhaps were not involved in physical activity for diabetes management. They may
not believe that physical activity is a significant contributor to the overall health of
T2D patients. They probably placed more emphasis on food because they believe that
food have a direct relationship with T2D.
Pete a 53-year old male said he could not see the PT helping with physical activity
as it could for healthy eating choices. “But not so much about the exercise because I
know what to do about the exercise and what I have gotta do.”
In conclusion, these preliminary findings show that PT can be an effective tool for
T2D self-management by promoting healthy eating and physical activity among pa-
tients. Patients have positive beliefs and perception about PT in general. However, for
98 Integrating Persuasive Technology to Telemedical Applications for Type 2 Diabetes
PT to be really effective, they need to be tailored to capture the unique needs, motiva-
tions, and capabilities of the T2D patients.
4.3 Discussion and future of telemedicine devices for T2D management
Telemedicine technologies are currently designed ad-hoc. The particular in-home
monitoring device used in the clinical trial, where the CUE project was conducted,
was simply a digital version of the regular T2D management, in the traditional way.
The traditional way of T2D management consists of patients recording their blood
glucose data and diet in a hand written diary and then meeting nurses or doctors every
90 days. With the in-home monitoring device, the patients’ data are regularly sent to
the nurses and feedback on health is received more frequently. However, PT can sig-
nificantly benefit telemedicine in-home monitoring devices. T2D patients require
constant motivation to make adequate food choices and avoid high GI food. T2D
patients are also recommended to do certain amount of physical activity to remain
healthy.
Opportunely, recent Model-driven Persuasive Technology (MPT) research [8] has
demonstrated with large-scale studies how to effectively use persuasion strategies to
motivate healthy eating choice. MPT research [9,14] showed that tailoring PTs with
the right categories of users showed positive outcomes in the users for healthy food
choice. Telemedicine in general, and especially telemedicine devices for T2D can
incorporate the MPT to tailor PT for T2D patients based on their needs, motivations,
and individual characteristics. Our findings from the interviews of T2D patients in the
CUE project in this paper showed that patients perceive the importance of PT to mo-
tivate them to adopt a healthy eating behavior. The findings also showed that the pa-
tients prefer a PT in comparison to a human persuader.
T2D patients have higher carbohydrate cravings such as sweetened foods [15].
T2D does not have a permanent cure. Patients have to manage it on a daily basis with
the right food choice and exercise. Telemedicine for T2D and MPT researchers can
work hand-in-hand together to create technologies that help the patients on a daily
basis instead of simply collecting and sending blood glucose data to nurses from pa-
tients. Incorporating tailored persuasive strategies in the existing device used in the
clinical trial promises to create a positive and compelling persuasive experience that
will promote desirable changes among T2D patients.
This study has several limitations. It is a side study of the CUE-project and thus it
did not have a strong focus on the design and development of a PT. This study simply
explores the promises of PT in telemedical systems for T2D. This study is a first step
towards exploring if regular T2D patients in a clinical trial using a non-persuasive
telemedicine in-home monitoring device can perceive the benefits of a PT. Again, the
dual aspect of the system – having nurses administer the insulin dosage and having
PT help with food and exercise may affect the patients. We hope to investigate that as
part of our future work.
Integrating Persuasive Technology to Telemedical Applications for Type 2 Diabetes 99
5 Conclusion
Diabetes is an epidemic worldwide and telemedical in-home monitoring systems fa-
cilitate T2D management by replacing hospital visits. However, T2D telemedical
systems are failing to harness the full potential of the devices. By integrating Persua-
sive Technology (PT) features to existing telemedical systems, they will benefit T2D
patients who struggle hard to control their daily food intake.
This paper presents insights from a qualitative inquiry of T2D patients with re-
spect to the possibility of integrating PTs to existing telemedical systems as opposed
to a non-PT solution. All patients were T2D diagnosed patients and were enrolled in a
telemedicine clinical trial. The patients use a simple, non-persuasive in-home moni-
toring device to send blood glucose data over to the nurses and receive feedback. Our
findings reveal that patients perceive the whole idea of integrating PT to telemedical
applications to help them meet their dietary and physical activity need as positive. In
fact, they would prefer to receive dietary recommendations and suggestions from a
PT, as opposed to a human persuader such as a nurse or family member. This results
show that PTs hold great potential for T2D patients and in the area of telemedical
systems. PT techniques can easily be integrated into to existing telemedical in-home
monitoring devices (such as the one in this study) to increase their effectiveness.
Acknowledgements. Special thanks go to TMML, Trina Myers and Ian Atkinson
who were part of the CUE-project and to a grant of James Cook University that sup-
ported the CUE-project.
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