Massive open online course for type 2 diabetes self-management: adapting education in the COVID-19 era
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* Scott C Mackenzie
* Kirsten M Cumming
* David Garrell
* Doogie Brodie
* Lyn Wilson
* Salma Mehar
* Scott G Cunningham
* Alex Bickerton
* Deborah J Wake

## Abstract

**Introduction** Type 2 diabetes self-management education is an essential component of type 2 diabetes care that is traditionally delivered in a face-to-face setting. In response to the recent COVID-19 pandemic, innovative solutions are urgently needed, allowing provision of self-management education that can be delivered in compliance with social distancing policies. Innovations that are self-service and can deliver education efficiently at low cost are particularly appealing to healthcare providers and commissioners.

**Methods** We aimed to evaluate user uptake, dropout, acceptability, satisfaction, perceived short-term knowledge gain and health benefits/behaviour changes in relation to a free massive open online course (MOOC) in diabetes self-management education, created and delivered during the COVID-19 pandemic. This course, focusing on addressing knowledge and self-management needs for people with type 2 diabetes, made use of online interactive content including expert and patient videos, quizzes, moderated discussion boards and live social media that encouraged personal reflection and goal setting. User expectations and experiences were explored via survey-based methods. Here, we present our experience of developing the course and describe users’ experiences.

**Results** 1991 users registered interest in the course over a 2-week period, with 976 users starting the course and 640 (65.6%) users completing the course in full. Users engaged well, finding the course educational, user-friendly and motivating, demonstrating high completion rates and user satisfaction. A statistically significant (p<0.001) increase in self-reported self-management ability and health knowledge was observed among participants with type 2 diabetes.

**Discussion** MOOCs in type 2 diabetes self-management education have great potential for delivering education efficiently at scale and low cost. Although engagement can be limited by digital literacy, benefits include flexible and remote access to up-to-date, evidence-based education delivered by a multidisciplinary team of healthcare professionals.

*   diabetes mellitus
*   information science
*   endocrinology
*   delivery of healthcare
*   healthcare quality
*   access
*   and evaluation

## Introduction

The COVID-19 pandemic has transformed the world in which we live, with global consequences yet to be fully realised. The response to COVID-19 has forced healthcare services to undergo rapid restructuring, significantly reducing face-to-face contact for non-urgent medical needs.1 Routine follow-up and complications screening is being largely deferred, with a predicted impact on downstream complications occurrence. People with type 2 diabetes are at risk of poor health outcomes as a result of both COVID-19 infection2 3 and the consequent lockdown-related behavioural changes necessary to slow its spread.1 4 In order to comply with social distancing measures, face-to-face interaction between patient and healthcare professionals has been reduced. Type 2 diabetes self-management education (DSME) is recommended as part of national and international guidelines5 6 and can lead to clinically significant improvements in glycaemic control and diabetes outcomes,7 but face-to-face DSME during COVID-19 has largely ceased.

In addition to lack of access to formal healthcare professional support, social distancing and lockdown may impact on individuals’ lifestyle choices and ability to self-manage in several ways. For example, through reduced access to healthy food and exercise opportunities, reduced peer and family support and mental health deterioration through social isolation. These factors may impact on ability to self-manage and subsequent control of glycaemic and other risk factors (like weight, blood pressure and cholesterol). Although many of these factors cannot be altered by DSME, reduced DSME availability and accessibility in this period could additionally contribute to poor diabetes control.

DSME is traditionally delivered in a face-to-face individual or small group based setting. Due to COVID-19, alternative mediums for DSME delivery are urgently required. Technological solutions to DSME may play a role in providing this service. Various digital DSME interventions are available including My Diabetes My Way,8 Oviva.com, ChangingHealth.com, Livongo.com and OmadaHealth.com. Digital DSME interventions have been studied previously, generally providing a smaller and more variable improvement in glycaemic control than to face-to-face equivalents, although data are limited as DSME evaluation has lagged behind technological development.9 10 The use of digital DSME in healthcare is currently limited, and adoption has been slow due to lack of budgets, rigid procurement pathways and clinical inertia. Digital interventions have high variation in their cost due to varying degrees of reliance on human resource for online coaching, impacting on cost-effectiveness.11 

In recent years, massive open (free) online courses (MOOCs) have grown in popularity, traditionally used by academic institutions to offer a wide range of content for wider community consumption.12 MOOCs are commonly used for continuing professional development (including healthcare professionals).13 Examples of MOOCs for direct engagement for people with diabetes or other chronic disease are however limited, and no recent evidence for their impact exists.9 MOOCs could be a mechanism to supply a low-cost, efficient and accessible solution to DSME that can be delivered in line with social distancing measures. In addition, MOOCs can provide a shared experience for many, facilitated through discussion boards and social media allowing real-time support from qualified healthcare professionals. This paper aims to share our experience of developing and delivering a MOOC for a non-homogenous learning cohort and evaluate user experience including user uptake, dropout, satisfaction, acceptability and perceived short-term health benefits.

## Materials and methods

### Developing a MOOC for type 2 DSME

A MOOC, entitled *Understanding Type 2 Diabetes*, was delivered over the 28th and 29th of April 2020. The MOOC was developed by MyWay Digital Health Ltd (MWDH) in collaboration with My Diabetes My Way,8 University of Dundee and The University of Edinburgh. The course was free and open access, available to anyone provided they had technology and internet access.

For course structure, see box 1. The course curriculum was largely aligned with material normally delivered in existing QISMET accredited14 structured DSME courses, for example, MWDH’s *My Type 2 Diabetes*,15 and similar to existing accredited face-to-face offerings (eg, Desmond16 and X-PERT Health17). The MOOC provided general DSME as well as self-management education relevant to the COVID-19 pandemic. This aimed to improve user knowledge and help users make positive behaviour changes to meet their own diabetes goals. The course used several existing resources from MWDH products but developed a distinct narrative and layout to fit the purpose and timescale of a MOOC.

Box 1 
### MOOC structure

#### Day 0: hello and welcome to understanding type 2 diabetes

*   What are we going to cover?

*   Time to set a goal
    
    *   Precourse survey.

*   Join in the conversation!

#### Day 1: why managing diabetes matters

*   Topic 1: what is type 2 diabetes?

*   Topic 2: why does managing diabetes matter?

*   Topic 3: diabetes and eyes.

*   Topic 4: diabetes and feet.

*   Topic 5: diabetes and kidneys

*   Topic 6: diabetes and mental well-being.

*   Quiz: diabetes myth buster!

*   Live social media question and answer session.

#### Day 2: taking control of type 2 diabetes

*   Topic 1: why weight matters.

*   Topic 2: eating right.

*   Topic 3: let’s get physical.

*   Topic 4: smoking and alcohol advice.

*   Topic 5: diabetes medications.

*   Topic 6: treatment targets.

*   Quiz: taking control of type 2 diabetes.

*   Topic 7: thanks for joining us!
    
    *   Postcourse survey.

*   Live social media question and answer session.

### Technical aspects

To participate and gain access to the MOOC, users were required to register an account with a username and password. This allowed users’ progress through the course to be tracked. The MOOC was developed using the LearnDash WordPress LMS plugin software, which also allowed user tracking and personalised certificates to be issued.18 The MOOC was developed in line with web content accessibility guidelines (WCAG level AA19). Content was structured in topics and was available to users in a stepwise manner ensuring progression through each topic before access to subsequent topics was granted. The programme tracked completed and incomplete sections. Users had access to the MOOC introduction (day 0) 4 days prior to the scheduled launch of day 1 and day 2 content, allowing completion of introductory steps, familiarity with the user interface and troubleshooting of any technical difficulties. Day 1 and day 2 content were released at 00:00 on each day, respectively. The course stayed live for an additional 2 days after the official end date to allow course completion.

Advertisement of the course occurred via social media and email lists. Once registered, users could access functionality including viewing interactive content clustered by topic, reading and leaving comments in the moderated discussion boards, completing goal setting and free text reflections, completing precourse and postcourse surveys and taking part in quizzes. Registration also allowed summary course emails to be received. On day 1 and day 2 of the course, a 2-hour question and answer livestream was hosted via social media (Facebook and Twitter) where user questions were answered by experienced diabetes healthcare professionals. Conversation was encouraged among participants and facilitated via discussion boards on each course page, through a commentary on the live Facebook feed and through use of #understandingtype2 on social media. A personalised certificate was available to users on completion of the course.

### Evaluating a MOOC for DSME

Users who expressed interest in the course provided consent for ongoing contact related to the course. When users registered with the platform, they accepted the terms and conditions and privacy policy for use of the site that permits that user information may be used for ‘research and development… and anonymised data may be used for regional and national quality reporting’. Following completion of the postcourse survey, users were asked if they consented to ongoing contact via email to assess the impact of the course on self-reported diabetes outcomes. Formal ethical approval was not required for evaluation of the MOOC as data were collected for the purpose of service improvement.

Milestones for user progress tracking were initial registration, completion of day 1 of the MOOC and completion of day 1 and day 2 of the course. Completion rates were calculated using these milestones.

As there is an absence of published evidence relating to MOOCs for DSME, this evaluation aimed to assess user uptake, engagement, user experience and to assess the MOOC method of DSME delivery (through analysis of user satisfaction, self-reported short-term benefits and free-text comments) to aid future improvements. This was achieved through a precourse and postcourse survey (see online supplemental appendix 1 for survey questions). Users were presented with the precourse survey during the course introduction. Course progression was restricted so that users only had access to the postcourse survey after completing all prior steps of the course. Completion of the precourse or postcourse surveys was optional and non-essential for course progression or completion. Survey data were exported from GravityForms20 into Microsoft Excel.

### Supplementary data

[[bmjinnov-2020-000526supp001.pdf]](pending:yes) 

### Data analysis

Data were anonymised prior to analysis, and aggregate data were presented. Free-text responses were independently coded by two coders to mutually agreed themes identified after initial review of user responses. Where coding differed between coders, consensus was reached by discussion. Coding results are expressed as descriptive statistics. Descriptive statistics were calculated, and figures were produced using Microsoft Excel.

A pseudonymised identification number was generated for each user, and this was used to pair responses between the precourse and postcourse surveys. This was relevant for two statements that users were asked to state their agreeableness to: ‘*I know enough about my health*’ and ‘*I manage my diabetes well*’. Response options were *strongly agree*, *agree*, *neutral*, *disagree* and *strongly disagree*, and these were scored 1–5, respectively. Data were tested for normality, and as the data were not normally distributed based on a Shapiro-Wilk test (p<0.05), non-parametric tests were used. Precourse and postcourse responses were analysed using a Wilcoxon signed-rank sum test to determine if the response differed between precourse and postcourse scores. Statistical tests were performed using IBM SPSS Statistics V.25.0.

## Results

### Course progress and completion rates

1991 users registered interest in the MOOC, and 976 users started the MOOC by registering on the online platform. Of these users, 75.7% (n=739) completed day 1 and 65.6% (n=640) completed day 1 and day 2 (data collected by LearnDash). Based on data collected in the precourse and postcourse survey, the dropout rate was highest at 50.0% among family members and carers of people with diabetes, followed by 47.5% among healthcare professionals, 34.0% among people with type 2 diabetes and 31.0% among people at risk of type 2 diabetes. On an introductory step of the course, users were encouraged to introduce themselves in the comment section. The audience was composed of UK based and international users.

### Precourse survey

Six hundred and thirty-six users completed the precourse survey. A percentage of 66.5 (n=423) of users self-identified as having type 2 diabetes, 2.6% (n=29) users self-identified as being at risk of developing type 2 diabetes, 5.3% (n=34) self-identified as a family member or carer of a person with type 2 diabetes and 28.8% (n=183) self-identified as a healthcare professional.

Users were asked ‘*What would you like the course to help you achieve?*’ to which 367 people with type 2 diabetes left a free-text response. See table 1 for summary of responses from people with type 2 diabetes. Among healthcare professionals who left a free-text response (n=150), 85.3% (n=128) aimed to improve their understanding of diabetes and its management for professional development purposes and 13.3% (n=20) aimed to increase their understanding of DSME available to patients online. The most common theme among those who left a free-text response and self-identified as at risk of type 2 diabetes (n=23) was reducing risk of developing type 2 diabetes (n=10). The most common theme among those who left a free-text response and self-identified a family member or carer of someone with diabetes (n=29) was to help support someone with diabetes (n=12).

View this table:
[Table 1](http://innovations.bmj.com/content/7/1/141/T1)

Table 1 
What did people with type 2 diabetes want to achieve from the massive open online course (MOOC)?

When users were asked to rank their confidence in achieving their preset goals, 65.8% (n=239/363) of users with type 2 diabetes, 90.4% (n=132/146) of healthcare professionals, 65.2% (n=15/23) of those at risk of type 2 diabetes and 96.4% (n=27/28) of family member or carer of someone with diabetes were either confident or very confident in doing so.

### Postcourse survey

Four hundred and one users completed the postcourse survey. Course satisfaction was very high, with the majority of people responding that the course was easy to use and in agreement that it had improved their knowledge, motivation, confidence, health and well-being and ability to self-manage their diabetes (figure 1). Subgroup analysis of these data did not find any noteworthy differences in agreeableness between groups, aside from an 19.5% increased proportion of healthcare professionals compared with people with diabetes being in agreement to the statement ‘My learning was enhanced by sharing information and hearing stories from other people with diabetes’.

![Figure 1](http://innovations.bmj.com/https://innovations.bmj.com/content/bmjinnov/7/1/141/F1.medium.gif)

[Figure 1](http://innovations.bmj.com/content/7/1/141/F1)

Figure 1 
Postcourse survey results summary. each question is based on 271–393 responses. Response options were a 5-point Likert-type scale including *strongly agree, agree, neutral, disagree* and *strongly disagree*. Users who self-identified as only healthcare professionals were excluded from responding to statements not relevant to them. The following statements were only analysed among participants with type 2 diabetes: ‘The course helped me set my own diabetes goals’, ‘The course motivated me to manage my diabetes’, ‘The course will help me achieve my diabetes goals’, ‘The course will improve my confidence around managing diabetes’ and ‘I will change the way I manage diabetes as a result of this course’. The following statement was only analysed among people with or at risk of type 2 diabetes: ‘The course has improved my overall health and wellbeing’.

Two hundred and three precourse and postcourse survey paired responses were available for the statement ‘*I manage my diabetes well*’ and 224 precourse and postcourse survey paired responses were available for ‘*I know enough about my health*’. For both statements, users were more agreeable following completion of the course with the median response changing from *neutral* in the precourse survey to *agree* in the postcourse survey (statistically significant for both statements at p<0.001).

Free-text responses to ‘*Is there anything you found particularly enjoyable or useful in the course?*’ were highly variable and hence not formally coded. Generalised themes included users enjoying refreshing their knowledge or learning new things about type 2 diabetes and its management, the multimedia delivery of the course content (videos, text and quizzes) and hearing stories from other people with diabetes. Free-text responses to ‘*Is there anything you feel would have improved the course?’* tended to focus on users seeking more detailed information on aspects of diabetes management. Users were asked if they had any difficulty accessing the site or resources, to which 89.0% (n=357) of users reported no specific issues. Other identified issues included video playback issues (3.5%), unfamiliarity with social media channels used (2.5%), login/registration issues (2.0%) and course navigation issues (0.7%). Two hundred and forty-four people with diabetes provided consent to be contacted in future to allow the course’s impact on diabetes outcomes to be assessed.

## Discussion

This MOOC had high retention and completion rates with 65.6% of registered users completing the course and appears to be highly appreciated by registrants. Online DSME offers increased flexibility compared with face-to-face alternatives regarding where and when users progress through course materials, which may influence engagement. Remote access to DMSE is of clear benefit during the COVID-19 pandemic, allowing users to develop skills in self-management while social distancing in line with current public health guidelines. In addition, some users may simply prefer remote access to DSME with the reduced time commitment and travel costs associated with traditional DSME.

Restrictions were in place around when users could complete the course (2-day period, with additional 2 days to allow completion), in part due to limited availability of healthcare professionals for moderation of social spaces such as comment sections and social media questions. However, narrowing the access period also created more of an impetus, focus and a sense of community and excitement around the event. It also ensured a critical number of users interacting concurrently enabling social media, discussion forums and live events to work well, adding to the success of the programme. The COVID-19 pandemic has emphasised the risk of misinformation online, particularly via social media.21 The risk of diabetes self-management misinformation will grow as both the online diabetes community expands and more people turn to online advice for self-management.22 There are many reputable patient-facing information sources available in DSME; however, information in diabetes-focused social communities can be of variable quality and safety.23 A MOOC in DSME mitigates misinformation risk through provision of professional endorsed materials and enabling healthcare professional moderation of live comments/individual questions in line with accepted, evidence-based practice.

A significant proportion of users participating in the MOOC were not people with diabetes. This included healthcare professionals, people at risk of type 2 diabetes and family members or carers of people with diabetes. Bringing these groups together provides a novel vibrant learning environment. These groups are typically not invited to traditional DSME due to space limitation or concerns around patient confidentiality. An online MOOC allows an opportunity for a larger community to develop a wider understanding of type 2 diabetes in a way relevant to their personal or professional life. There is a scarcity of literature evaluating large-scale social learning environments in chronic disease self-management. MOOCs aimed at patient education are available via platforms such as FutureLearn.com or Coursera.org, yet often are developed for healthcare professional consumption. Some authors have found when evaluating MOOCs aimed at healthcare professionals that patients contribute a large proportion of their audience,24 suggesting patients are interested in this medium of education delivery.

The precourse survey was useful in establishing what users hoped to achieve through participating in the MOOC. The responses were broadly in line with the content of the course itself. The most common themes identified among users with type 2 diabetes were improving glycaemic control, followed by developing general diabetes-related understanding, dietary advice and diabetes remission. User evaluation supplied in the postcourse survey was highly positive, with most users finding the MOOC a useful, easy-to-follow learning experience that improved self-management motivation and confidence. Precourse and postcourse surveys found that user self-reported health knowledge and diabetes management improved significantly. In addition, completion rates in this MOOC (65.6%) were significantly higher than typical MOOC completion rates of 5%–10%.25 

A limitation of this initial evaluation is that it assesses only user self-reported experiences in the short-term. Although participants were asked to respond to the statement ‘*I manage my diabetes well*’ before and after the course, it is clear that many aspects of the diabetes self-management may not yet have changed. Ideally, interventions such as this should be further assessed in terms of their impact on longer term diabetes outcomes such as glycaemic control (HbA1c), blood pressure, body mass index and diabetes complications (eg, retinopathy or foot disease). Access and collation of such data from this widely dispersed user group is challenging. A key advantage of this MOOC is its scalability, and although just under 1000 users took part, we believe this number was restricted due a limited sphere of influence in advertising and a short time period (~2 weeks) between initial advertisements and MOOC launch. This MOOC focused on type 2 DSME and future work aims to develop a similar course for type 1 DSME. Experience in delivering a MOOC affords many learning opportunities, both software and content related, which will allow for streamlined development of future MOOCs, aiming for improved accessibility and user experience.

Although the potential impact of this MOOC on glycaemic control is unclear, if this MOOC had a similar impact to other type 2 DSME programmes, it may deliver a reduction in HbA1C of approximately 9 mmol/mol at 2 years.10 For a conservative estimate of the cost impact, a UK prospective diabetes study outcomes model was used that applied an average HbA1C reduction of approximately 4 mmol/mol. This results in an estimated total saving of approximately £28 000 over 2 years secondary to a reduction in events associated with diabetes and delivers an approximate return on investment of 6:1.26 While DSME has previously been shown to be cost-effective, it is unusual to demonstrate cost savings.27 It is emphasised that these figures are estimated and serve mainly to illustrate potential cost savings associated with a high-volume, low-cost mechanism of DSME delivery. We aim to gathered self-reported outcomes in the 244 people with diabetes who have consented for recontact at 3 months, which may give some indication of medium-term impact.

Most users found the MOOC easy to use and did not report technical difficulties, although it is likely that this self-selected group have a high level of digital literacy. Digital alternatives to traditional DSME rely on technology, internet access and internet skills that are not universal.28 Awareness of this digital inequality is important, particularly if digital solutions to DSME are to displace face-to-face interventions in future.

## Conclusion

Online DSME shows great promise, and MOOCs have potential to provide social learning in a structured, accessible and engaging manner. MOOCs are highly efficient and likely cost-effective, with low healthcare resource requirements per user, enabling release of staff for frontline duties. Further understanding of the impact of a MOOC on diabetes outcomes is warranted. However, the highly positive user feedback and completion suggests that high-quality DSME need not be sacrificed in the COVID-19 era.

## Acknowledgments

The work was supported by National Health Service colleagues around the UK. We would also like to acknowledge the support of the wider MyWay Digital Health Ltd (MWDH) team in supporting technical work and course marketing.

## Footnotes

*   Contributors DJW conceived the study and supervised development of the massive open online course (MOOC). SCM and KMC led the development of the MOOC and performed the data analysis. All authors contributed to revision and development of the MOOC content. DG performed economic analysis. SCM drafted the manuscript. All authors revised the manuscript and approved the final version.

*   Funding This work was funded by MWDH.

*   Competing interests SCM, KMC, DG, DB and SGC are employees of MWDH. DJW and SGC are cofounders and shareholders of MWDH.

*   Patient consent for publication Not required.

*   Provenance and peer review Not commissioned; externally peer reviewed.

*   Data availability statement Pseudonymised data available on reasonable request.

*   Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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## References

1.   Wake DJ , Gibb FW , Kar P , et al . Endocrinology in the time of COVID-19: remodelling diabetes services and promoting innovation.. Eur J Endocrinol 2020;1.
    
    

2.   Fang L , Karakiulakis G , Roth M . Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir Med 2020;8:e21.[doi:10.1016/S2213-2600(20)30116-8](http://dx.doi.org/10.1016/S2213-2600(20)30116-8) pmid:http://www.ncbi.nlm.nih.gov/pubmed/32171062 
    
    [PubMed](http://innovations.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjinnov%2F7%2F1%2F141.atom) 

3.   Williamson EJ , Walker AJ , Bhaskaran K , et al . OpenSAFELY: factors associated with COVID-19 death in 17 million patients. Nature 2020;8.
    
    

4.   Xue T , Li Q , Zhang Q , et al . Blood glucose levels in elderly subjects with type 2 diabetes during COVID-19 outbreak: a retrospective study in a single center. Medrxiv 2020.
    
    

5.  National Institute for Health and Care Excellence. Type 2 diabetes in adults: management, 2019. Available: [https://www.nice.org.uk/guidance/ng28/](https://www.nice.org.uk/guidance/ng28/) [Accessed 10 May 2020].
    
    

6.   Davies MJ , D'Alessio DA , Fradkin J , et al . Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American diabetes association (ADA) and the European association for the study of diabetes (EASD). Diabetologia 2018;61:2461–98.[doi:10.1007/s00125-018-4729-5](http://dx.doi.org/10.1007/s00125-018-4729-5) pmid:http://www.ncbi.nlm.nih.gov/pubmed/30288571 
    
    [PubMed](http://innovations.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjinnov%2F7%2F1%2F141.atom) 

7.   Chrvala CA , Sherr D , Lipman RD . Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Patient Educ Couns 2016;99:926–43.[doi:10.1016/j.pec.2015.11.003](http://dx.doi.org/10.1016/j.pec.2015.11.003) pmid:http://www.ncbi.nlm.nih.gov/pubmed/26658704 
    
    [CrossRef](http://innovations.bmj.com/lookup/external-ref?access_num=10.1016/j.pec.2015.11.003&link_type=DOI) 
    
    [PubMed](http://innovations.bmj.com/lookup/external-ref?access_num=26658704&link_type=MED&atom=%2Fbmjinnov%2F7%2F1%2F141.atom) 

8.   Cunningham SG , Wake DJ , Waller A , et al . My diabetes my way: an electronic personal health record for diabetes. Br J Diabetes Vasc Dis 2013;13:143–9.[doi:10.1177/1474651413493336](http://dx.doi.org/10.1177/1474651413493336) 
    
    [CrossRef](http://innovations.bmj.com/lookup/external-ref?access_num=10.1177/1474651413493336&link_type=DOI) 

9.   Greenwood DA , Gee PM , Fatkin KJ , et al . A systematic review of reviews evaluating technology-enabled diabetes self-management education and support. J Diabetes Sci Technol 2017;11:1015–27.[doi:10.1177/1932296817713506](http://dx.doi.org/10.1177/1932296817713506) pmid:http://www.ncbi.nlm.nih.gov/pubmed/28560898 
    
    [PubMed](http://innovations.bmj.com/lookup/external-ref?access_num=28560898&link_type=MED&atom=%2Fbmjinnov%2F7%2F1%2F141.atom) 

10.  Steinsbekk A , Rygg Lisbeth Ø , Lisulo M , et al . Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis. BMC Health Serv Res 2012;12:213. [doi:10.1186/1472-6963-12-213](http://dx.doi.org/10.1186/1472-6963-12-213) pmid:http://www.ncbi.nlm.nih.gov/pubmed/22824531 
    
    [CrossRef](http://innovations.bmj.com/lookup/external-ref?access_num=10.1186/1472-6963-12-213&link_type=DOI) 
    
    [PubMed](http://innovations.bmj.com/lookup/external-ref?access_num=22824531&link_type=MED&atom=%2Fbmjinnov%2F7%2F1%2F141.atom) 

11.  McNamee P , Murray E , Kelly MP , et al . Designing and undertaking a health economics study of digital health interventions. Am J Prev Med 2016;51:852–60.[doi:10.1016/j.amepre.2016.05.007](http://dx.doi.org/10.1016/j.amepre.2016.05.007) pmid:http://www.ncbi.nlm.nih.gov/pubmed/27745685 
    
    [PubMed](http://innovations.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjinnov%2F7%2F1%2F141.atom) 

12.  Breslow L , Pritchard DE , DeBoer J , et al . Studying learning in the worldwide classroom research into edX’s first MOOC. Res Pract Assessment 2013;8:13–25.
    
    

13.  Liyanagunawardena TR , Williams SA . Massive open online courses on health and medicine: review. J Med Internet Res 2014;16:e191. [doi:10.2196/jmir.3439](http://dx.doi.org/10.2196/jmir.3439) pmid:http://www.ncbi.nlm.nih.gov/pubmed/25123952 
    
    [CrossRef](http://innovations.bmj.com/lookup/external-ref?access_num=10.2196/jmir.3439&link_type=DOI) 
    
    [PubMed](http://innovations.bmj.com/lookup/external-ref?access_num=25123952&link_type=MED&atom=%2Fbmjinnov%2F7%2F1%2F141.atom) 

14. QISMET. Qismet: home, 2020. Available: [https://www.qismet.org.uk/](https://www.qismet.org.uk/) [Accessed 16 May 2020].
    
    

15. MyWay Digital Health. My type 2 diabetes, 2020. Available: [https://elearning.mydiabetes.com/courses/my-type-2-diabetes/](https://elearning.mydiabetes.com/courses/my-type-2-diabetes/) [Accessed 16 May 2020].
    
    

16. Desmond, 2020. Available: [https://www.desmond-project.org.uk/](https://www.desmond-project.org.uk/) [Accessed 16 May 2020].
    
    

17. X-PERT health, 2020. Available: [https://www.xperthealth.org.uk/](https://www.xperthealth.org.uk/) [Accessed 16 May 2020].
    
    

18. LearnDash, 2020. Available: [https://www.learndash.com/](https://www.learndash.com/) [Accessed 9 May 2020].
    
    

19. WC3. Web content accessibility guidelines (WCAG) overview, 2020. Available: [https://www.w3.org/WAI/standards-guidelines/wcag/](https://www.w3.org/WAI/standards-guidelines/wcag/) [Accessed 16 May 2020].
    
    

20. Gravity. Gravity forms, 2020. Available: [https://www.gravityforms.com/](https://www.gravityforms.com/) [Accessed 9 May 2020].
    
    

21.  Kouzy R , Abi Jaoude J , Kraitem A , et al . Coronavirus goes viral: quantifying the COVID-19 misinformation epidemic on Twitter. Cureus 2020;12:e7255.[doi:10.7759/cureus.7255](http://dx.doi.org/10.7759/cureus.7255) pmid:http://www.ncbi.nlm.nih.gov/pubmed/32292669 
    
    [PubMed](http://innovations.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjinnov%2F7%2F1%2F141.atom) 

22.  Hilliard ME , Sparling KM , Hitchcock J , et al . The emerging diabetes online community. Curr Diabetes Rev 2015;11:261–72.[doi:10.2174/1573399811666150421123448](http://dx.doi.org/10.2174/1573399811666150421123448) pmid:http://www.ncbi.nlm.nih.gov/pubmed/25901500 
    
    [CrossRef](http://innovations.bmj.com/lookup/external-ref?access_num=10.2174/1573399811666150421123448&link_type=DOI) 
    
    [PubMed](http://innovations.bmj.com/lookup/external-ref?access_num=25901500&link_type=MED&atom=%2Fbmjinnov%2F7%2F1%2F141.atom) 

23.  Litchman ML , Walker HR , Ng AH , et al . State of the science: a scoping review and gap analysis of diabetes online communities. J Diabetes Sci Technol 2019;13:466–92.[doi:10.1177/1932296819831042](http://dx.doi.org/10.1177/1932296819831042) pmid:http://www.ncbi.nlm.nih.gov/pubmed/30854884 
    
    [PubMed](http://innovations.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjinnov%2F7%2F1%2F141.atom) 

24.  Wake DJ . The future of diabetes education. Practical Diabetes 2019;36:196–200.[doi:10.1002/pdi.2245](http://dx.doi.org/10.1002/pdi.2245) 
    
    

25.  Davis D , Jivet I , Kizilcec RF . Follow the successful crowd: raising MOOC completion rates through social comparison at scale. Proceedings of the seventh international learning analytics & knowledge conference; Mar 13, 2017:454–63.
    
    

26.  Cunningham SG , Stoddart A , Wild SH . Cost-effectiveness of an online education platform and diabetes personal health record: analysis over 10 years. Poster presented at the International diabetes Federation conference, Korea, 2019.
    
    

27.  Boren SA , Fitzner KA , Panhalkar PS , et al . Costs and benefits associated with diabetes education: a review of the literature. Diabetes Educ 2009;35:72–96.[doi:10.1177/0145721708326774](http://dx.doi.org/10.1177/0145721708326774) pmid:http://www.ncbi.nlm.nih.gov/pubmed/19244564 
    
    [CrossRef](http://innovations.bmj.com/lookup/external-ref?access_num=10.1177/0145721708326774&link_type=DOI) 
    
    [PubMed](http://innovations.bmj.com/lookup/external-ref?access_num=19244564&link_type=MED&atom=%2Fbmjinnov%2F7%2F1%2F141.atom) 
    
    [Web of Science](http://innovations.bmj.com/lookup/external-ref?access_num=000263699100006&link_type=ISI) 

28.  Hargittai E , Piper AM , Morris MR . From Internet access to Internet skills: digital inequality among older adults. Univers Access Inf Soc 2019;18:881–90.[doi:10.1007/s10209-018-0617-5](http://dx.doi.org/10.1007/s10209-018-0617-5)