SOCIAL MEDIA AND GAMES AS SELF-MANAGEMENT TOOLS
FOR CHILDREN AND ADOLESCENTS WITH TYPE 1
DIABETES MELLITUS
J. Lauritzen
1,2
, E. Årsand
1,2,3
, A. Horsch
1,2,4
, L. Fernandez-Luque
1,2,5
, T. Chomutare
1,3
,
J. G. Bellika
1,2,3
, O. Hejlesen
1,2,6
and G. Hartvigsen
1,2,3
1
Department of Computer Science, University of Tromsø, Tromsø, Norway
2
Tromsø Telemedicine Laboratory, University of Tromsø, Tromsø, Norway
3
Norwegian Centre for Integrated Care and Telemedicine, University Hospital of North Norway, Tromsø, Norway
4
Institut für Medizinische Statistik und Epidemiologie, Technische Universität München, Munich, Germany
5
Northern Research Institute, Tromsø, Norway
6
Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
Keywords: Type 1 Diabetes Mellitus, Children, Adolescents, Self-management, Motivation, Education, Video games,
Computer games, Social Media, Serious games.
Abstract: INTRODUCTION: Insufficient treatment of Type 1 Diabetes Mellitus (T1DM) can cause unpleasant and
dangerous short-term complications, and disabling long-term complications. Children and adolescents are
often associated with poor blood glucose regulation and poor treatment adherence. Motivating this group
into achieving better illness knowledge, self-management and treatment adherence is difficult through
ordinary diabetes education methods, which necessitates the need for alternate methods. METHODS:
Health educational video games and social media are investigated as potential platforms for providing
diabetes education and motivation. Publications were reviewed in order to estimate clinical and personal
effects. RESULTS: 6 publications on children and adolescents’ use of health educational video games
displayed increased patients knowledge regarding their illness and treatment hereof, improved treatment
adherence and positive clinical results. Social media is identified in 2 publications as a promising platform
for online communities, where patients and next of kin can seek advise, help others and share experiences.
DISCUSSION: Video games and social media constitute platforms that children and adolescents are
familiar with, engage in and enjoy and are for diabetes educational purposes. Tromsø Telemedicine
Laboratory propose that by combining these platforms to make a social game experience that educates
children and adolescents and motivates them conduct self-management and achieve better clinical results,
thereby lowering their risk of diabetes complications.
1 INTRODUCTION
1.1 Type 1 Diabetes and Young People
Type 1 Diabetes Mellitus (T1DM) in children and
adolescents is becoming a larger concern worldwide,
with global incidence of T1DM for children
increasing 3% annually. The incidences varying
from intermediate to very high in European
countries as Sweden, Norway, Finland, and UK and
in Canada and New Zealand. T1DM is the dominant
type of diabetes in the US amongst young
people.(Dashiff, Hardeman and McLain, 2008)
The treatment of T1DM is symptomatic and
complex, with the goal of regulating food intake,
physical activity and administering insulin
(Anderson et al., 2009), in order to keep daily blood
glucose levels between 4 – 8(10) mmol/L and
HbA1c <7,0% (may vary slightly from country to
country). Due to the complexity of the treatment,
children and adolescents may not be able to
comprehend the treatment (Schilling, Knafl and
Grey, 2006), and are therefore assisted by their
parents to perform and adhere to the treatment
(Dashiff, Vance, Abdullatif and Wallander, 2009;
Lewandowski and Drotar, 2007). However, the
transition from child to adolescent has become
459
Lauritzen J., Årsand E., Horsch A., Fernandez-Luque L., Chomutare T., Bellika J., Hejlesen O. and Hartvigsen G..
SOCIAL MEDIA AND GAMES AS SELF-MANAGEMENT TOOLS FOR CHILDREN AND ADOLESCENTS WITH TYPE 1 DIABETES MELLITUS.
DOI: 10.5220/0003874104590466
In Proceedings of the International Conference on Health Informatics (HEALTHINF-2012), pages 459-466
ISBN: 978-989-8425-88-1
Copyright
c
 2012 SCITEPRESS (Science and Technology Publications, Lda.)

synonymous with decreasing treatment quality and
adherence (Waller, Eiser, Heller, Knowles and Price,
2005; Piazza-Waggoner et al., 2008). A study in the
UK show that only 14-20% of children and young
people reach the goal of HbA1c <7,5% (Christie et
al., 2009).
Poor treatment quality can result in short-term
complications for the patient, such as
aggressive/violent behaviour, confusion, discomfort,
anxiety and in extreme cases coma (Boyle and
Zrebiec, 2007) possibly resulting in brain damage or
even death, if the patient is not helped (Cryer, Davis
and Shamoon, 2003). Over time, insufficient
treatment also increases the risk of long-term
complications such as blindness, kidney disease,
neuropathies, amputations and elevated risk of heart
attack and stroke (DCCT, 1993). It is therefore
important to teach children with T1DM from young
age about their disease, what affects it, and how to
treat it. An early understanding of the condition, its
treatment and motivation to adhere to the treatment
may result in better glycaemic control and lowered
risk of short- and long-term complications.
The poor results of today’s diabetes self-care for
this group necessitate different methods of patient
education. This statement is supported by Waller et
al. (2005) in an analysis of 62 published papers on
the topic of psychosocial and educational
interventions for youths with T1DM. Waller et al.
find the designs presented in the 62 papers to be
poor and were unable to establish guidelines for
appropriate education methods for young people
based on these papers. The research community thus
has a challenge of identifying alternative methods
for educating children and adolescents with T1DM
that also motivates them to perform better self-
management and increased adherence to healthy
treatment regimes.
1.2 New Potential Platforms
for Delivering Diabetes Education
One method of educating and motivating children
and adolescents with T1DM could be through the
use video games. This media has over the years
become one of the most popular forms of
entertainment media (DeShazo, Harris and Pratt,
2010), and is engaged in by almost all teenagers
(Lenhart et al., 2008) and approximately 60% of
kids in the US aged 6 and above (Lieberman, 2001).
A report made in 2005 by Roberts, Foehr and
Rideout (2005) found that of the children and
adolescents playing video games, 8-10 year olds on
average spend 65 minutes daily playing video
games, 52 minutes daily on average for the 10-14
year olds and 33 minutes daily on average for the
15-18 year olds. These findings support that video
games is a medium that children and adolescents are
familiar with, enjoy and engage in, and therefore
constitute an obvious platform for delivering health
related information and education.
Social media constitutes another potential
platform for delivering diabetes education to
children and adolescents, due to its widespread and
popularity. The largest social media website as of
autumn 2011 is Facebook, with over 800 million
active users (FaceBook Official, 2011) and 20.6% of
these listed and being under 18 years of age (Inside
Network, 2011). This media makes it possible to
reach and interact with larger groups of patients,
who share the same interests. Social media should
therefore also be considered a highly relevant media
and investigated with focus on usage in health and
diabetes related contexts.
A new popular trend for children and adolescents
are video games available for free on social media
web sites such as Facebook, where casual gameplay
is combined with social media where players interact
and build communities dedicated to said games. This
combination of video games and social media
constitute a potentially more desirable platform for
educating and motivating children and adolescents
for better self-management and treatment adherence.
It is therefore important to investigate what could
make social games successful and existing projects
on the use of social games in patient health care.
In this paper, we present an alternative approach
to traditional diabetes education of children and
adolescents with T1DM. We propose to combine
video games and social media, media which children
and adolescents are familiar with, engage in and
enjoy, with diabetes education. Using existing
literature, the hypothesis that video games and social
media can be used for health care purposes are each
supported, and game design success criteria for a
serious/educational game for children and
adolescents are identified. The goal is to develop an
educational video game, with social media interface
for children and adolescents with T1DM. The game
will utilize the captivating and motivating elements
of existing successful social games and elements
described in literature. The social game experience
is intended to challenge the player to learn and
improve self-management and treatment adherence,
by performing virtual diabetes care, partaking in
quizzes of diabetes related knowledge and
competing with other players, using their own
treatment data. All content will be based on quality
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460

assured sources, acknowledged guidelines, diabetes
modelling software and will be approved by experts.
2 METHOD AND MATERIALS
2.1 Literature Review
Existing literature on the use of video games for
health educational and motivational purposes was
examined, in order to determine whether this
approach was usable for children and adolescents
with T1DM and to determine factors that made
existing healthcare educational video games
successful. The use of social media, in patient health
related contexts, was also studied in the literature
review to determine the usefulness of this media.
The literature review did however not include
literature describing educational games with social
media interface for people with T1DM, since it was
not possible to identify any publications this subject.
The literature search was conducted in PubMed,
using the following search enquiries and MeSH
terms: Diabetes, Type 1 Diabetes Mellitus, Chronic
Illness, Adherence, Self-care, Video Games, Serious
Games, Computer Games, Educational Games,
Social Media, Social Network, Facebook, MySpace,
Children, Adolescents, Motivation.
All literature matching the search criteria
underwent abstract reading, in order to determine
relevance for this project. Papers not available in
English were not included, nor were publications
from which only the abstract could be obtained.
Papers focusing solely on improving the diabetes
care abilities of the parents/legal guardians of the
child/adolescent with T1DM were also excluded
from the literature discussed in this review. Review
papers were accepted in the literature search.
The results of the literature search were divided
into clinical effect studies of serious games and
social media and studies which identified success
criteria for serious games, e.g. how to make the
gameplay appeal to the player and keep them
motivated for playing.
In total, 8 papers were identified that fulfilled the
established literature criteria. Of these 8, 2 papers
addressed the use of social media and 6 papers,
including review papers addressed health related
video games for children and adolescents.
2.2 Analysis of Popular Social Games
In order to determine the success of current popular
games on the social networking site Facebook, we
examined the different elements of these games.
Games that were chosen include FarmVille, Simply
Hospital and educational games/mind training games
such as Word Challenge and quizzes. Games that
promote gambling, contains violence, sexual content
or games that require a fee/paid subscription to play
were excluded from the study.
3 RESULTS
The results of the identified studies and the review
papers are presented in two sub-sections, addressing
the clinical outcome of the studies and the identified
success criteria for serious games.
3.1 Clinical Effects of using Serious
Games and Social Media
Research by Lieberman (2001) estimates the effect
of using serious games in a group of children and
adolescents with T1DM compared to a control
group. After 6 months, the intervention group
showed a reduction in diabetes related
urgent/emergency visits of 77%, whereas no change
was detected in the control group. The study also
reports that the children in the intervention group
show improved knowledge about their health and
awareness of the risk factors of their illness, better
daily self-care and –monitoring, increased
confidence about self-care as well as improved
attitude towards prevention and better
communication between child, parent and clinicians.
Baranowski, Buday, Thompson and Baranowski
(2008) made a review of 27 scientific publications
about 25 serious games for promoting health related
behaviour changes, including diet-change games,
physical activity change games, for people with
disabilities and games for children with asthma and
diabetes. The review shows that the majority of the
publications demonstrate positive changes in patient
health, as a result of engaging in serious games.
A review of 11 diabetes video games targeting
people with T1DM, 10 of these targeting children
with T1DM using a problem solving approach in
their games, showed an increase in the players’
knowledge, adherence to self-care and clinical
outcomes (DeShazo et al., 2010).
Other studies show that using video games for
health educational purposes can yield positive
results, such as improving treatment adherence,
knowledge of disease and improved clinical
outcome for children with Type 2 Diabetes Mellitus
and obesity (Thompson et al., 2007) and
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adolescents/young adults with cancer (Kato, Cole,
Bradlyn and Pollock, 2008).
The literature search identified two studies
reviewing the usage of Facebook by children and
adolescents, for diabetes related concerns. The
research, published in 2010 evaluates the content of
diabetes communities on Facebook. The findings
show that patients with diabetes, their family and
friends use Facebook as a forum, in which they
share experiences with others, give treatment
advices and ask questions and receive feedback
about diabetes related matters (Greene, Choudhry,
Kilabuk and Shrank, 2010). Another study by
Farmer et al. argues that younger patients become
able to share and compare experiences with others,
gain new knowledge about the disease and discuss
side effects of their treatment with others (Farmer,
Bruckner Holt, Cook and Hearing, 2009).
Of the reviewed literature, none displayed any ill
effects of children and adolescents using either
serious games or social media for healthcare related
purposes.
3.2 Success Criteria for Serious Games
In the study by Lieberman (2001), two games were
designed and implemented, one for children with
asthma and one for children with T1DM. The study
identified the following 7 elements as motivating
factors for improving health behaviour (Lieberman,
2001): (1) Having an attractive role model who
demonstrates appropriate self-care; (2) Being able to
customize the self-care regimen of the players’
character to match that of their own; (3) Tests of the
player’s self-care and preventive skills; (4) Supportive
and informative feedback on choices the player makes
in the game; (5) Having a log for the player’s
character, containing the same elements that the
player’s own log has, e.g. medication, activity etc.; (6)
Supporting two-player gameplay; and (7) being able
to choose game languages (Lieberman, 2001).
The review by Baranowski et al. (2008) also
identifies elements to help improve a serious game,
by analysing the recommendations in the literature.
Baranowski et al. define two different approaches,
which potentially promotes health behaviour change
based on their literature: (1) Make behaviour change
a process of playing the game, e.g. having goals; and
(2) Implementing behaviour change concepts into
the story of the game.
Hsu, Lee and Wu (2005) mention 6 fun factors in
action games: (1) Novelty and powerfulness, (2)
appealing presentation, (3) interactivity, (4)
challenging, (5) sense of control, and (6) rewarding.
3.3 Review of Game Mechanics in
Popular Social Games on Facebook
Utilizing the knowledge established in the literature
review of video game elements, social media and
factors that help make a serious game successful, it
was possible to identify three characteristics of the
social games and quizzes analysed in this paper:
(1) The games involve learning skills and
planning actions/activities to achieve the best results.
This can include planning the most cost-effective
crop and when to plow, seed and harvest at a virtual
farm or how to coordinate the work-shifts,
maintenance and research at a virtual hospital. In
order to progress or achieve better results quicker
and cheaper, the player must actively learn the
different aspects of the game mechanics and learn to
plan ahead.
(2) The games are popular and keep being
played, because they reward the player, which is
supported by the findings of Hsu et al. (2005).
Players are given virtual rewards for their
achievements, e.g. mastering a certain skill/crop or
learning to perform a new medical procedure. These
rewards can be shared on the players Facebook
profile for others to see, e.g. “Thomas mastered fly-
fishing at level 3” or “Susan is building a new
radiology unit”.
The rewards mechanics and progress motivates
the player to keep playing and doing better and
receiving new rewards. This can motivate others to
do better and can build a community, where new
less experienced players seek advice from the more
experienced players with much routine and
knowledge about the game and its mechanics, as
supported by Greene et al. (2010).
(3) The games also use status sharing for other
purposes, such as challenging other Facebook users
or to ask them for their aid, e.g. “John beat your
record at Crazy Taxi. Click to try to reclaim your
throne” or “Alex’ crops need fertilizer. Click to go
to Alex farm and help out”.
(1) and (2) motivates the player to do better in
his/her game, by addressing other players’ desire to
compete with the new record holder, about being the
better farmer, physician or others. (3) addresses the
other players’ desire to help others, by offering them
to help out a person, which will benefit the player in
need of help and also the player helping, who can
see how helping made a difference, and potentially
receive a reward for being helpful.
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4 DISCUSSION
The use of serious games for children and adolescents
are recommended in several scientific publications,
which also identifies positive clinical outcome of
these systems (Baranowski et al., 2008; DeShazo et
al., 2010; Kato et al., 2008; Lieberman, 2001;
Thompson et al., 2010; Thompson, Baranowski and
Buday, 2010; Thompson et al., 2007). Despite these
positive results, some studies agree that more research
is needed, about what makes a game successful and
what specifically initiates the player to make a change
in their behaviour concerning their condition
(Baranowski et al., 2008; Thompson et al., 2010;
Thompson, et al., 2010b).
The popularity of video games and potential
clinical outcomes suggest utilizing a video game
approach to prepare children and adolescents with
T1DM for handling their disease unsupervised,
which will become necessary eventually, as they
grow older. The clinical applications for social
media in T1DM and the general popularity of this
media also suggest this as a potential platform for
T1DM education.
The authors believe that the success of each
media could be combined to form more effective
and helpful diabetes education applications. This
could be in form of a diabetes-oriented game that
utilizes addictive casual game-play, combined with a
reward/achievement system and a social media
interface for interacting, helping and competing with
other players. The patient outcome of this could be
better insight into their condition, improvement of
self-management and increased adherence to their
treatment.
Such games could also appeal to youths without
T1DM, and thus increase the general insight in the
population about T1DM, how it is treated and how
to react in a situation where a person with T1DM
requires help, e.g. in case of severe hypoglycaemia.
We propose a video game that lets the player
engage in four different types of mini games of
different nature:
1. Counselling: The player takes the role of
an adviser/diabetes nurse/specialist.
2. Avatar: A part where the player follows
and controls a person with T1DM for a virtual
day/week
3. Mixed reality: Players enter their own
blood glucose values, physical parameters, nutrition
data, etc. The player is thus actively taking part in
the game and competes with the artificial avatars
(see pt.2) and other physical players, about being
better regulated.
4. Quiz: Through answering different quiz
the player is educated in diabetes treatment.
4.1 Counselling
In this part of the game, the player will take the role
of a diabetes nurse/specialist/adviser, who helps
patients on a daily basis. Each patient will present a
different situation/problem that they need help with.
The player will be able to see recent blood glucose
measurements, dietary information, ask the patient
questions, and based on this, give advice to the
patient. Based on the actions performed, the player
will be rewarded points and achievements and the
virtual patients will be either happy or unsatisfied
with the help they received. The points and
achievements received can be posted on a leader
board and to the players Facebook account, and it
can be shared with other people playing the game.
4.2 Avatar
In this part of the game, the player is assigned a
virtual person with T1DM. The player will follow
the person for a virtual day/week and have control of
when the person measures their blood glucose, eats,
administer insulin and is physically active. After the
virtual period is over, the player will see how well
they did in applying treatment to the virtual person
with T1DM and receive points and achievements
based on their performance. Their point score and
achievements for this part of the game can also be
shared via Facebook.
4.3 Mixed Reality
When the player has learned to compete with the
avatar, he/she will get the opportunity to actively
take part in the game with his or her own data. In a
mixture of avatars and real user/players, the players
can compete with each other as well as the avatars,
about being better regulated. This requires that the
metabolism models and other physical models,
which avatars are based on, should be as realistic as
possible. As for the avatar module, the point score
and achievements for this can be shared via
Facebook.
4.4 Quiz
This part will consist of quick quizzes with
predefined multiple-choice answers. Players will be
presented with various questions about T1DM. This
could vary from “What to do in this situation?”,
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“Why is it important to …”. Other questions could
be “Guess the next blood glucose value” and
“Complete the blood glucose curve”. In the latter,
the player will be presented with picture of a blood
glucose development curve plus food and insulin
intake. The player could have three pictures to
choose from, which each shows a different outcome.
The player is asked to select the correct one.
Based on how the player answered the questions,
points and achievements will be given, which can be
shared on Facebook and a leader board. The player,
if they beat someone’s record, can issue a challenge
to other players, challenging them to beat the new
record.
4.5 Scenario Materials
The scenarios for the four parts of the game will be
based on actual data from a current study of 30
T1DM patients and textbook material on T1DM and
through simulations, using the DIASnet Blood
Glucose simulation algorithm, developed in a
research project at the University of Aalborg,
Denmark (Cavan, Everett, Plougmann and Hejlesen,
2003; Hejlesen, Plougmann and Cavan, 2000).
Researchers and clinical personal must approve all
scenarios.
4.6 Pitfalls of using Social Games as a
Platform for Diabetes Education
Despite the literature displaying positive results and
suggesting use of video games and social media as
platforms for patient health care related projects,
there are potentially pitfalls with using these media.
Publications on serious games generally display
the effects of these when being actively used in
studies, but not whether these games are able to
compete with commercially available games. It is
important to consider this competition, since a
serious game will not be played, or they are played
at lower frequency, once the study is over, thus
lowering their usefulness. When designing serious
games, the competition comes from game companies
with larger budgets, more experience and
manpower, an established name and fan base and a
professional marketing section. It should therefore
be considered to change the target audience in this
project to not include adolescents that have the high
standards of commercial games, but children aged 7-
12 that are more likely to accept simpler casual
games, such as social games. The game(s) should
therefore be designed and developed with focus on
resembling and competing with simpler casual social
games.
Social media are suggested as a beneficial
platform in T1DM related projects and the project
group did not encounter any ill effects. There is
however a concern of the quality and correctness of
the content shared in social media. This is a relevant
concern, since it is often the community itself that
provides the content, often with no review from health
care professionals or specialists. Incorrect information
and wrongful recommendations can therefore occur,
which potentially poses a risk of patient hazards. In
order to include social media in patient focused
projects, it is therefore necessary to define and control
the type and content of user-to-user communication
and interaction, if any. Having no restrictions could
result in presence of information that could potentially
be harmful for patients.
5 CONCLUSION AND FUTURE
WORK
Children and adolescents with T1DM constitute a
group that often experience insufficient treatment
regimens. In order to improve knowledge of this
group about their condition, their treatment and
motivate them to improve treatment adherence, an
alternate method of providing diabetes education is
required. Health educational video games have
shown improved treatment knowledge and clinical
results in children and adolescents with T1DM and
other chronic diseases, and social media is shown to
be a promising platform for forming communities,
for patients with diabetes and their family and next
of kin. This recently initiated project at Tromsø
Telemedicine Laboratory currently focuses on
combining video games and social media, into
T1DM educational video games with social media
interface for children and adolescents with T1DM.
These games will through different gameplay
educate and motivate the player to learn about their
condition and to improve their treatment and
treatment adherence, and thus potentially help this
group avoid short- and long-term diabetes
complications.
In order to avoid potential pitfalls of video games
and social media for the presented use case, future
work includes additional in-depth studies and
analysis of video game design for children and
design of social games for children. One or more
serious social games will be designed for one or
multiple platforms. The video game(s) will be based
on scientific literature search, game development
literature, in cooperation with diabetes nurses and -
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specialists, children and adolescents with T1DM and
potentially interest groups such as the Danish and
Norwegian Diabetes Association.
The project will evaluate clinical outcome of
children and adolescents with T1DM using serious
video games with social media interface. HbA1c
will be measured before and after use of the
game(s), to determine any improvements. Personal
experiences and outcomes for children/adolescents
and their close families will also be examined, by
conducting interviews with participating children
and adolescents and their families.
The project will be conducted over a period of 3
years as a PhD-study (2012-2015), aiming to
contribute in the field of serious gaming and
diabetes self-management.
ACKNOWLEDGEMENTS
This work was supported by the Centre for
Research-based Innovation, Tromsø Telemedicine
Laboratory, Norwegian Research Council Grant No.
174934.
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