The Science of Diabetes Self-Management and Care2023, Vol. 49(6) 493 –511© The Author(s) 2023
Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/26350106231208153journals.sagepub.com/home/tde
Abstract
Purpose: The purpose of this systematic review was to determine if the use of gaming (gamification) among persons with type 2 diabetes improves diabetes self-management behaviors and diabetes outcomes.
Methods: A systematic review was conducted using electronic databases including MEDLINE, Embase, Web of Science, and CINAHL. Studies reporting on the impact of gaming on at least 1 of the Association of Diabetes Care and Education Specialists self-care behaviors (ADCES7) were included.
Results: The review included 9 studies, 8 of which were of strong/high quality. Five of the self-care behaviors were addressed in at least 1 of the included studies. However, taking medications and problem solving were not reported in any of the studies. Physical activity and self-efficacy or quality of life (healthy coping) were the most frequently reported ADCES7 behaviors. Six of the studies used A1C as an outcome measure, with a reduction reported in all the studies except 1.
Conclusion: Type 2 diabetes affects a person holistically, necessitating a range of self-care behaviors to effectively manage the chronic condition. Novel gaming interventions may improve coping mechanisms, lifestyle behaviors, medication engagement, and monitoring of risks and problems, all of which are essential in facilitating optimal diabetes self-management.
Type 2 diabetes (T2DM) affects 422 million persons worldwide.1 In 2021, over 37 million people were diagnosed with diabetes, and 95% had T2DM.2 Diabetes is the seventh leading cause of death in the United States.3 Following diagnosis of diabetes ongoing attainment of glycemic targets is necessary in order to prevent complications related to diabetes. Gregg et al4 reported a resurgence in diabetes complications, indicating that a decrease in preventive care may have been associated with these finding. One of the primary resources utilized to assist in the attainment of glycemic targets is diabetes self-management education (DSME). Świa˛toniowska et al5 recognized DSME as a “preventive activity.”5 DSME involves the transfer of knowledge and addressing and supporting behavioral change to improve clinical and health-related outcomes. The outcome of DSME is “behavior change,” which is evaluated based on the Association of Diabetes Care and Education Specialists (ADCES) framework (ADCES7) that includes these behaviors: healthy coping, healthy eating, being active, taking medication, monitoring, reducing risk, and problem solving.6 Diabetes self-management behaviors are known to positively impact overall glycemic outcomes. The findings from an international online survey study conducted by Adu et al7 revealed that an enabler of DSME was a desire to prevent complications and the use of technology. The barriers included frustrations with the chronic nature of the diabetes, financial constraints, environmental and work factors, and unrealistic expectations.7
Recent studies have shown a benefit in using gaming/gamification in improving self-management behaviors.8,9 Gaming/gamification involves the use of game design elements to engage patients in health promotion efforts.10 Gamification may involve competition to further enhance engagement.11 Gaming involves the use of technology, such as smartphones, video games(ing), and virtual environments. The utilization of apps on smartphones to engage the patient in self-care behaviors is also a form of gaming that is used. However, a recent study by Gong et al12 reported that people with diabetes want apps that cover a variety of content, are interactive, and provide emotion and psychological support. Video gaming (active video gaming or exergaming) requires active physical movement to play.13 Virtual environments provide a way in which patients can engage in realistic settings to receive health information, social support, and education while developing new skills.14 Gamification uses technology as an educational tool and offers the patient a “fun” way to engage in the acquisition of knowledge while addressing and supporting behavioral change.
Several systematic reviews have been done evaluating the use of gaming to improve knowledge and self-management15 among pediatric patients with asthma, cancer, and type 1 diabetes (T1DM); games and health education in persons with T1DM and T2DM16; gaming applications in cardiovascular disease17; and diabetes gamification among people with T1DM and T2DM18 with reported improvement in knowledge and self-management. Recently, Kaihara et al19 reported on their systematic review and meta-analysis of randomized control trials (RCTs) utilizing gamification to improve “glycemic control.” However, there have been no recent systematic reviews evaluating the impact of gaming/gamification on diabetes self-management behaviors and glycemic outcomes among adults with T2DM. The purpose of this systematic review was to determine if the use of gaming (gamification) among adults with T2DM improves diabetes self-management behaviors and diabetes outcomes.
A systematic review was conducted to identify, synthesize, and critically analyze the existing peer-reviewed literature on the use of virtual gaming to improve diabetes self-management behaviors and diabetes outcomes in patients with T2DM. The study protocol was registered with the National Institute for Health Research, International Prospective Register of Systematic Reviews (PROSPERO—Registration No. CRD42022299559).
Studies were included in this review if (1) they were original research studies (RCTs or quasi-experimental studies); (2) they were conducted among adults with T2DM; (3) they examined a gaming intervention via online environment, virtual system, video game, or smartphone technology; or (4) they evaluated at least 1 of the diabetes mellitus self-management behaviors (diet, exercise, medications, blood glucose monitoring, healthy coping, social support, doctors’ visits). The criteria for exclusion were as follows: (1) focused exclusively on children or adolescent populations (ie, mean age < 18 years), (2) were not available in English, (3) were literature reviews or systematic reviews, (4) centered on T1DM, or (e) was conducted using virtual reality.
A medical librarian from the Texas Medical Center Library developed searches for the Ovid MEDLINE, Embase, Web of Science, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases to identify articles that were published from January 2013 to April 2022. The goal was to capture the most recent research articles regarding the effects of gamification on diabetes self-management behaviors to update the evidence on the topic. Search terms used to identify articles for “type 2 diabetes mellitus” were combined with search terms that encompassed “games” in each database (Table 1). Beginning in April 2022, the preliminary search was conducted in Ovid MEDLINE. Upon the research team’s approval, the main search was finalized in Ovid MEDLINE on May 12, 2022, and then translated to Ovid MEDLINE, Embase, Web of Science, and CINAHL on May 19, 2022. In addition to the robust database search strategies, references found in the retrieved articles were reviewed to conduct a comprehensive search of the literature. A combined total of 346 articles were identified. After removal of duplicates and screening of abstracts and full text, 9 studies were included in the review (see Figure 1).
Abstracts from the 4 databases were imported to EndNote20 citation manager and de-duplicated for review on May 19, 2022, and then uploaded to Covidence,20 which helped to expedite the initial screening of abstracts and titles independently by the research team members. Covidence is a web-based collaboration software platform that streamlines the production of systematic and other literature reviews.20
Several meetings were conducted among all the reviewers to discuss discrepancies and build consensus for final inclusion of the articles. Abstracts of all articles were screened, and full-text copies of potentially relevant articles were reviewed. Three authors independently screened all the articles for eligibility using the inclusion and exclusion criteria. Data from each research article were organized into data extraction tables to facilitate systematic comparisons among the studies. Data synthesis led to a comprehensive portrayal of the research question, “What is the effect of virtual environment gaming on diabetes self-management behaviors and diabetes outcomes among patients with T2DM?” The search strategy and retrieved articles and abstracts were reviewed by the 3 researchers independently on 2 occasions to ensure adequate sampling.
The quality of each study was evaluated using the Joanna Briggs Institute (JBI) critical appraisal criteria for RCTs or quasi-experimental studies.21 Each question was scored to determine whether the criterion was met with options of yes (score of 1), no (score of 0), unclear (unscored), or not applicable (unscored). Total quality scores were calculated by adding all individual scores and dividing them by the number of items scored. Total scores of below 60%, between 60% and less than 80%, and 80% or higher were evaluated as low, medium, and high quality, respectively.
The identified 9 studies were examined for publication year, design, sample, sample size, sample characteristics, type of gaming (app, board game, virtual environment, etc), key variables, and key findings as changes in self-care behaviors.
The effects of gaming interventions in adults with T2DM were examined utilizing the holistic ADCES behaviors framework of diabetes care (ADCES7).6 The ADCES7 behaviors include (1) healthy coping, which entails maintaining a positive outlook on diabetes self-management; (2) healthy eating, which describes a routine of eating nutrient-dense meals; (3) being active, defined as engaging in any regular physical activity; (4) taking medication, which involves engaging in the prescribed treatment plan; (5) monitoring, which includes assessing glucose level, activity, and food intake to make decisions; (6) problem solving, such as finding solutions to assist in diabetes selfmanagement; and (7) reducing risks, which involves adopting habits to reduce complications associated with diabetes. The primary glycemic outcome of interest was hemoglobin A1C (A1C). Data in this systematic review were evaluated using constant comparison analysis.
A summary of the characteristics of the studies that met inclusion/exclusion criteria are outlined in Table 2. Initially, 6 RCTs10,11,22-24 were included, but the study by Joshi et al25 was excluded due to low quality. Thus, our review included 5 RCTs10,11,22-24 and 4 quasi-experimental studies.13,26-28 The articles were published between 2013 and 2021. Among these 9 studies, 1370 participants were enrolled with sample sizes ranging from 10 to 456. Four of the studies were conducted in the United States, 2 each were conducted in Switzerland and Germany, and 1 was conducted in Australia. The gaming platforms/methods used in the included studies were virtual environment,27 smartphone games,11,22,23 video games,13,24,28 and online games.11,26
The quality of the articles was assessed using the JBI critical appraisal tools. Of the 6 RCTs,10,11,22-24 4 were determined to be of high quality, 1 was of medium quality, and 1 was of low quality25 and therefore excluded. All 4 quasi-experimental studies were found to be of high quality (Table 3). Based on the JBI Grades of Recommendation and Levels of Evidence,29 the 6 RCTs10,11,22-24 were judged as 1c and given a grade A recommendation. All 4 highquality quasi-experimental studies were rated as 2d and given a grade A recommendation (Table 3).
Five of the self-care behaviors were addressed in at least 1 of the included studies. However, taking medications and problem solving were not reported in any of the studies (Table 4).
Six studies examined changes in self-reported efficacy or quality of life.11,13,24,26-28 Three studies assessed the use of exercise video games. One study used a virtual environment, which facilitated diabetes self-management and support.27 Two studies used online games, 1 of which used a point scoring system to promote competition and community.11,26
Video games. In the 3 studies that evaluated healthy coping using exercise video games, 2 found no difference in participants’ self-reported quality of life after 4 weeks28 and 8 weeks of intervention, while a study by Kempf and Martin24 found a significant increase in reported quality of life by 2.4 + 12.9% (P = .03), increase in subjective wellbeing by 8.6 + 19.4% (P < .001), and a reduction in diabetes-related impairment of 5.2 + 13.2% (P < .001) after 12 weeks (about 3 months) of video game intervention.
Virtual environment. Likewise, in a virtual environment, Johnson et al27 found that participants reported an increase in self-efficacy from neutral to moderate at baseline (mean = 3.89, SD = 0.81) to moderate at 3 months (mean = 4.45, SD = 0.67) and then significantly (P = .02) toward high at 6 months (mean = 4.64, SD = 0.39).
Online gaming. Both studies that assessed online games found nonsignificant improvement in self-efficacy measures using the).11,26 Cuevas et al26 reported that diabetes-related self-efficacy increased from a preintervention mean score of 23 (SD = 11.2) to a postintervention mean score of 32.2 (SD = 1.4) after 8 weeks (about 2 months) of game-like online intervention. Kerfoot et al11 found that a 6-month team-based diabetes self-management education online game improved empowerment measured by DES-SF (+ 1.7; 95% CI, 0.7-2.7; P = .010) compared with those who did not participate in the online game.
Two of the 9 studies (22%) discussed healthy eating.
Virtual environment. Johnson et al27 used a virtual environment and indicated that there was an improvement in eating habits at 3 and 6 months, but these changes were not significant.
Online gaming. Cuevas and Carter26 reported that using an online game-like intervention increased dietary adherence from 3 to 5 days a week.
Eight studies examined the use of games to promote physical activity.10,13,22,24,26-28 Three of the 8 studies involved the use of exercise video games.13,24,28 One study created a virtual environment, which facilitated diabetes selfmanagement and support.16 One study used an online game-like intervention.26 Two studies evaluated the use of a smartphone game.22,23 One study involved a digital game, which used a point-scoring system to foster competition and collaboration.10
Video games. In the 3 studies that evaluated exercise video games, 2 found significant changes in physical activity. According to Kempf and Martin,24 participants reported a significant increase in their physical activity by 10 + 10% (P < .001) during the 12-week study period of using the video game Wii Fit Plus. Participants also reported an increase in their overall physical activity that persisted beyond their involvement in the video game.24 Likewise, Senior et al28 found that playing the Nintendo Wii tennis video game twice a week for 4 weeks increased moderate physical activity time from 300 (0-2800) metabolic equivalent (MET) minutes in a week to 2559 (734-5560; P = .04) and increased total physical activity time from 1272 (300-3592) MET minutes in a week to 2940 (1176-7910; P < .01). In a study by Huang et al,13 aerobic endurance measured by the YMCA 3-minute Step Test remained the same after participants played an exercise video game on Xbox Kinect and/or Nintendo Wii twice a week for 8 weeks (about 2 months).
Virtual environment. In the virtual environment study by Johnson et al,27 physical activity outcomes did not show statistically significant changes at 3 months (0.00; P = 1.00) or 6 months (−0.76; P = .46) compared with baseline activity levels.
Smartphone. A 24-week smartphone game intervention was associated with significant improvements in physical activity and intrinsic motivation for exercise.22,23 In the intervention group, participants’ daily physical activity increased on average by 3998 steps (SD = 1293), while in the control group, it increased on average by 939 steps (SD = 1156). Between the 2 groups, there was an adjusted difference of 3128 more steps per day in favor of the intervention group in terms of the increase in daily physical activity (95% CI, 2313-3943; P < .001).22 With an adjusted difference of changes in motivation for exercise of 8.15 points (95% CI, 0.90-15.39; P = .03) between the 2 groups, intrinsic physical activity motivation significantly increased by an average of 6.39 points (SD 4.19; P < .001) in the intervention group and decreased by an average of 1.94 points (SD 16.46; P = .62) in the control group.23
Patel et al10 examined a yearlong digital gaming intervention with several social incentive components that used points and levels to foster competition, collaboration, or support. Compared with the control group, the gaming intervention with support increased steps per day from an average 4353 at baseline to 4909 at 3 months and at 1 year (503 steps; P = .01), and gaming with competition also increased physical activity from an average of 4681 steps per day at baseline to 5257 at 3 months and at 1 year (606 steps; P = .003). Participants who received gaming with collaboration experienced a modest increase in physical activity from a mean of 4122 steps/day at baseline to 4385 steps/day at 3 months but no significant change at 1 year (280 steps; P = .16) compared with the control group of an average of 4410 steps/day at baseline and 4221 at 3 months. In the gaming with support and collaboration groups, the mean number of daily steps significantly declined from the first 6 months to the last 6 months of the study (–423 steps, P = .003 and –394 steps, P < .001, respectively); however, in the gaming with competition group, physical activity did not decrease (–143 steps; P = .23). The mean daily steps for the control group also did not change significantly (–43 steps; P = .60). Although gaming with collaboration and support was effective, only gaming with competition produced sustained impacts.10
Online gaming. Additionally, in an 8-week online game-like intervention, Cuevas and Carter26 reported an increase in physical activity from 1 day per week to 3 days per week.
Two (22%) of the studies26,27 reported on monitoring.
Virtual environment. In their study using a virtual environment, Johnson et al27 noted that although blood glucose monitoring increased over the 6-month study period, the increase was not statistically significant.
Online gaming. Cuevas and Carter26 found that their online game-like intervention resulted in an increase in glucose monitoring among participants from 1 day per week to 3 days per week.
Five of the studies evaluated the impact of gaming on reducing risk.10,13,23,24,27
Virtual environment. In their virtual environment study, Johnson et al27 found that on average, participants lost 9.1 pounds from baseline to 6 months. They also reported that performance of foot care improved from a mean of 3.68 days per week (SD, 2.08) to a mean of 6.17 days per week (SD, 1.54) by 6 months.
Smartphone. Two of the studies used smartphone-based gaming.10,23 Participants in all arms of the study by Patel et al10 experienced a decrease in mean weight from baseline to 6 months, and at 12 months, all groups had a significant decrease in mean weight (control: 2.0 kg; gaming with support: 3.6 kg; gaming with collaboration: 3.4 kg; and gaming with competition: 2.9 kg). Among those in the study by Höchsmann et al,23 total body mass decreased in both the intervention (−2.5 kg) and control groups (−0.9 kg), with no change in skeletal muscle mass.
Video games. Risk-reducing behaviors were evaluated in 2 of the video-game-based studies. Kempf and Martin24 reported significant reductions in weight and body mass index (BMI) among participants in the control and intervention groups. They also reported a reduction in systolic and diastolic blood pressure in both groups, a reduction in total cholesterol, and an increase in high-density lipoprotein in both groups. In their study, Huang et al13 reported no significant change in weight, BMI, or body fat percentage. They did report a decrease in diastolic blood pressure; however, these changes were not statistically significant. Of note, they also reported an increase in muscle strength on lower extremity flexion and extension on the left and right extremity and increased muscle strength in the left upper extremity with a decrease on the right. Furthermore, flexibility increased as well, but these changes were not statistically significant.
No studies reported on taking medications according to prescribed treatment plans as an outcome measure.
No studies reported on problem solving as an outcome measure.
The effects of gaming interventions on glycemic outcomes differed across the 6 research studies that examined changes in A1C.10,11,13,23,24,27 Three studies reported a significant improvement in A1C, 2 showed a nonsignificant reduction in A1C, and another found no changes in A1C. Two of the 6 studies targeted patients with diabetes who had A1C targets for inclusion (>8%10 and > 58 mmol/mol11 at baseline, respectively), whereas the other studies did not have this restriction.
Video games. In the 2 studies that evaluated A1C using exercise video games, Kempf and Martin24 found that the A1C level decreased significantly from 7.1 + 1.3% to 6.8 + 0.9% (P = .0002) after participants in the intervention group received a Wii Fit Plus and were instructed to play it for at least 30 minutes a day for 12 weeks (about 3 months), while Huang et al13 found that playing an active video game for 16 sessions over 8 weeks on an Xbox Kinect and/or Nintendo Wii nonsignificantly reduced participants’ A1C from 7.5% to 7.1%.
Virtual environment. Smilarly, in a virtual environment study that facilitated diabetes self-management, Johnson et al27 reported a decrease in A1C from 7.51% at baseline (SD, 1.15%) to 6.92% (SD, 1.37%) after 6 months. Although not statistically significant, it was considered clinically significant.
Smartphone. Also, in a 1-year gamification intervention to achieve step goals and weight loss targets, Patel et al10 showed that A1C significantly decreased in the competition group (from 9.7% at baseline to 8.8% at 6 months and 8.7% at 12 months) and in the control group (from 9.5% at baseline to 8.8% at 6 and 12 months). Regular feedback and goal setting were provided to participants through digital devices in the control group. Last, Höchsmann et al23 showed that a 24-week individualized smartphone game intervention focused on physical activity did not change participants’ A1C (remained at 6.2%) over the study period.
Online games. Furthermore, both of the digital game studies using point-scoring systems found significant improvements in A1C levels. Kerfoot et al11 reported that those who participated in a team-based online game experienced significantly higher reductions in A1C over the 12-month study period compared with those who did not participate in the game (−8 mmol/mol vs −5 mmol/mol; P = .048).
Healthy coping. Four studies found favorable effects in promoting healthy coping strategies by playing a video game24 or online games11,26 or using a virtual environment.27 The positive benefits of gaming coupled with increased social support suggest that identifying effective gaming interventions in people with diabetes may present opportunities for tailored therapies. Our findings are consistent with a previous review supporting the use of gamification in increasing perceptions of positive emotions, self-efficacy, and motivation.30 Given that psychosocial factors influence coping mechanisms and well-being, studies should consider a holistic approach based on individual psychosocial risk factors to promote positive physical and psychosocial health outcomes in people with diabetes. Efforts should be made to assess and manage the psychosocial aspects of diabetes in clinical practice to promote healthy coping behaviors and improve quality of life in this population.
Healthy eating. Two studies found a positive impact on healthy eating using a virtual environment27 and online gaming.14 Several studies showed that gamification was an effective method to improve knowledge about nutrition, weight management, and intention to follow a healthy diet.9,31,32 However, studies should evaluate improvements in weight, BMI, waist circumference, and percentage of body fat maintained over time in persons with T2DM. When counseling individuals with T2DM, one must emphasize that meal planning and healthy eating plus physical activity, when combined with glucose-lowering medications, can lead to an optimal glucose-lowering effect in addition to other health benefits.
Being active. One of the self-care behaviors, being active by engaging in any regular physical activity, was improved by engaging in gaming via smartphone,10,13,22-24,26-28 a virtual environment,27 and online.26 These findings were consistent with those of other studies using diabetes self-management apps incorporating behavior change techniques and gamification to engage in and improve physical activity in adults with T2DM.33 This information can be used by clinicians to make safe and effective recommendations for integrating physical activity/exercise into self-management plans for individuals with diabetes or at risk for its development. Diabetes Care and Education Specialists (DCESs) play an important role in informing, motivating, and supporting all individuals, including those with T2DM, in their efforts to make positive lifestyle changes for improved health. Advice about physical activity is an essential lifestyle recommendation and should be offered at an appropriate level based on careful evaluation of patients’ ability to exercise. Patients should also be provided all the necessary exercise guidelines and resources established by recognized sources to ensure the appropriateness, accuracy, and safety of physical activity recommendations. Being competitive may serve as a motivator to continue to stay active in this population.
Monitoring. One14 of the 2 studies evaluating blood glucose monitoring showed a positive impact on monitoring in that participants increased their monitoring from 1 day to 3 days per week.
Reducing risk. Contrary to the findings of the study conducted by Arnaez et al,8 which showed that among adults, gaming was associated with obesity, our review revealed that gaming was associated with weight loss, lowering of blood pressure and cholesterol levels, and increased frequency of foot exams among participants in all 5 of the studies that reported on this self-care behavior.10,13,22,24,27 Although the changes in the study by Huang et al13 were not significant, Kempf and Martin24 and Höchsmann et al23 reported a positive change in both the intervention and control groups.
Glycemic outcomes. Most studies showed improvements in glycemic outcomes, except for a 24-week smartphone gaming intervention focused on physical activity, where participants’ A1C stayed at 6.2%.10 This lack of change may be due to the baseline A1C being at a desired level, making further improvements unlikely. Various exercise video games had varying effects on participants’ glycemic outcomes, with some people experiencing significant improvements and others experiencing only minor improvements. However, those who participated in scorebased, competitive online games considerably improved their A1C levels.10,11 In a recent systematic review, 2 studies that explored educational games for children with diabetes did not show improvements in A1C levels.34 Findings suggest that games that encourage competition by employing points or other scoring mechanisms may be more likely to have a greater impact. Although most of the gaming interventions were effective at improving participants’ A1C outcomes, the game’s design and level of competition may affect achieving glycemic improvements in this population. Future research must consider the factors that influence the effectiveness of games in improving glycemic outcomes to inform the design and implementation of gaming interventions.
A strength of this review is that it includes only studies conducted among adults with T2DM. Also, the ADCES7 framework was used as the lens through which to evaluate the study findings. However, many of the included studies lacked diversity in terms of age, gender, and ethnicity and had small samples and short durations, which limits the generalizability of the findings. For example, in lower-income populations, participants may not be able to afford smartphones or have access to high-speed Internet and may experience barriers to gaming interventions. Additionally, the gaming modalities and outcome measures used in the included studies were highly varied, further hampering the ability to make appropriate comparisons. Several studies examined the effect of gaming on “glycemic control.” However, there were many potential confounding variables due to minimal information regarding participants’ diabetes duration, metabolic factors, glycemic level, and diabetes medications. Finally, due to the constantly evolving gaming industry, new gaming technologies must be adapted to appeal to the demographics of people with diabetes to determine the sustainability and effectiveness of gaming interventions in improving diabetes self-management behaviors and outcomes. Future research studies are needed to determine the long-term effect of gamification on the health parameters of patients with T2DM.
This review demonstrates that gamification is a promising way to support patients with diabetes to improve their self-management behaviors. Although different gaming modalities have been found to be beneficial, those that include competition (teams, leaderboards, etc) have the most significant impact. With the emergence and subsequent reliance on mobile technology, novel game-based platforms have been integrated with developing personalized diabetes self-management plans through lifestyle behavior modification, medication engagement, and monitoring of risks and problems. Ideally, these game-based interventions can promote long-term engagement in diabetes self-care behaviors. Gamification offers the advantages of enhancing patient care without face-to-face contact and with flexible timing, thereby reducing transportation time and cost for patients with T2DM. Virtual gaming also provides a novel way for the DCES to engage with patients to provide education and assess the attainment of knowledge.
Lara Ouellette, MLS, research and instruction librarian.
None.
Veronica Joyce Brady https://orcid.org/0000-0002-9755-3482
From Department of Research, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, Texas (Dr Brady); and Department of Undergraduate Studies, Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, Texas (Dr Mathew Joseph, Dr Ju).
Corresponding Author:Veronica Brady, Cizik School of Nursing, The University of Texas Health Science Center at Houston, 6901 Bertner Ave, Suite 567E, Houston, TX 77030, USA.Email: veronica.j.brady@uth.tmc.edu
