Figure 1 shows the Steps in the development of the program. Semistructured interviews were conducted to explore enablers and barriers associated with effective Type 2 diabetes self-care, together with diabetes-related emotional challenges, requirements for additional disease management support, and suggestions for elements in an online support program. The sample comprised 13 people with Type 2 diabetes and 12 general practitioners (GPs). GPs were asked the circumstances in which they would refer patients to an online Type 2 diabetes self-management support program, and the factors that may inhibit patient referral. Results revealed that patients and GPs shared most perspectives on diabetes self-management. Both the patients with diabetes and GPs identified a need for additional informational, motivational, emotional, and social support. Suggestions for program content included self-monitoring tools, informational support, motivational assistance with improving and maintaining physical activity and diet, goal setting assistance, progress feedback, social support via a chat room and accessibility to health professionals. Detailed results are available in a separate paper [53].

The existing OnTrack Alcohol and Depression program [54] was proposed as a basis for the layout of OnTrack Diabetes, and the appropriateness of this was confirmed by a review of its structure. Motivational videos, mindfulness and relaxation audios, and information technology coding from some of the self-monitoring and program tools were adapted for use in OnTrack Diabetes.

Sources that informed the development of OnTrack Diabetes information resources and tools included the Diabetes Australia guidelines for Type 2 diabetes management [55]; National Health and Medical Research Council Physical Activity and Nutrition Guidelines for Australian Adults [56]; Optometrists Association Australia [57]; Australasian Podiatry Council [58]; Medicare Australia [59], and relevant peer-reviewed empirical literature. A nutritionist, ophthalmologist, and podiatrist were consulted to discuss proposed content.

MC compiled the obtained information and discussed proposed content inclusions with DK. The program content addressed the barriers to Type 2 diabetes self-care identified in qualitative research, and attempted to maximize enhancers. Information resources complement the program’s interactive tools and provide the impetus for goal setting and planning, while providing material that can be integrated into primary care. For example, the “My Feet Check” resource contains a diagram of feet on which the date and any changes can be marked, and a checklist to tick off symptoms that can be taken to podiatry appointments.

OnTrack Diabetes information technology programming logic is based on eXtensive Markup coding developed for OnTrack Alcohol and Depression by SE and JG. In collaboration with them, MC coded tools and guidebook pages for the site. Programming modifications and the development of new features exclusive to OnTrack Diabetes was then undertaken. The administration site was built to include functions specific to this trial, including data recording and storage, access to study measures, and a schedule of follow-up study measure reminders. A graphic designer designed the website interface, inserted relevant images, and formatted the program.

Both the information technology programmers and external observers tested OnTrack Diabetes several times for bugs, errors in functionality, and design issues.

OnTrack Diabetes then had a soft initial launch to enable further screening for bugs and tests for functionality by MC and programmers.

An endocrinologist and diabetes educator were invited to provide feedback on OnTrack Diabetes’ contents, and AH, AS, PS, and two people with Type 2 diabetes who participated in the qualitative interviews (Step 1) also reviewed the program and provided feedback.

The program content was revised in response to the reviews that were undertaken in Stage 8. Specifically, some information fact sheets were added, including on providing ideas for safe physical activity for individuals with limited physical capacity. Further, modifications were made to the program’s information technology functionality, as the reviewers had provided feedback regarding bugs that they had found while testing the site’s tools and resources.

A randomized controlled trial was commenced with potential participants registering interest on the site’s home page.

Figure 2 shows the initial screen in the program, which includes the key elements.

The “My Diary” tab provides an electronic self-monitoring record of daily goal attainments in relation to physical activity, eating, and health routines (on a sliding scale from 0% to 100%); highest and lowest blood glucose levels; and mood (on a scale from best to worst). Figure 3 shows a diary page. Entries are represented in feedback graphs that are shown under the “How I’m Doing” tab. The graphs display averages per day over the previous month, and averages per week over the previous 3 months, for each self-monitoring area. Users are encouraged to recognize correlations between the different outcomes, in order to better understand their interrelationship and how they can improve their diabetic and dysphoria control. The monitoring and feedback functions emphasize the SCT focus on goals and on the motivational effects of feedback on goal attainment.

At the top right of each screen, a “Resources” tab provides access to over 40 fact sheets and quizzes on diabetes and its management, and also to 8 mindfulness audios to guide practice sessions, which can be accessed on the computer as audios or text, or downloaded onto mobile phones in the MP3 format.

Based on our previous research on user preferences concerning Web program formats [60], modules in OnTrack Diabetes are available in any order and at any time, using the tabs shown under the “Journey Map” at the right hand side of Figure 2. All of the tools within the program are also available at any time under the respective tabs at the top of the screen. However, users are advised to apply the strategies in a module for at least a couple of weeks before working on another, and the natural order of the program (by clicking “next”) leads them through a logical sequence of resources and skills.

The overall program (“My Journey”) contains five modules (“signposts”), which each includes a series of interactive tools. Tools are preceded by “guidebook” screens, which inform them about the tool and its relevance to diabetes. All tools produce a printable summary page, which can later be reviewed under the tab “What I’ve Done” at the top of the screen. In advertisement-length videos, actors illustrate key concepts such as reconceptualizing a problem. Users with low bandwidth Web connections can access the script of these videos. Throughout the program, written material is kept below a secondary school (Year 7) reading level, to maximize accessibility for users with limited education.

As shown on the right side of Figure 2, the program has five signposts or modules: (1) “Keeping Active and Feeling Great”, (2) “Eating Well and Feeling Healthy”, (3) “Health Routines”, (4) “Thinking Well and Feeling Fine”, and (5) “Keeping OnTrack”. All but the last two have two sections. The first section of signposts on activity, diet, and medical regimens, asks users to select potential behavioral strategies, to imagine undertaking one, consider and image advantages of that action (Figure 4 shows this), and consider strategies to address potential barriers. Self-efficacy is boosted by a consideration of past relevant successes, and a detailed stepwise plan is formulated, including the timing of those steps and a consideration of sources of potential social support (Figure 5 shows this).

The second section of each signpost (“More on...”) contains tools that assist with making behavioral changes routine. For example, users can plan to add incidental and short bursts of activity to their week, as well as longer physical activity sessions, and specify the times and days that they will do them. It also includes a problem-solving tool [61] to assist with overcoming challenges to reaching users’ personalized goals. This tool can also be used to solve other problems, including threats to emotional well-being.

Users are asked to focus on practicing the skills learned in each section for 1-2 weeks before moving forward in the program. In the meantime they are encouraged to log on to the site regularly to self-monitor, use resources, undertake, and revisit tools as needed. The signpost “Keeping OnTrack” provides support while aiming to support the maintenance of progress. It focuses on moving on from past maladaptive behaviors and maintaining positive, new beginnings in the broader context of the individual’s life. Users are asked to evaluate positive changes since starting the program without losing sight of other life goals (eg, education, travel).

There are four self-administered quizzes that enable users to evaluate their participation in diabetes self-care activities [62], mood [63], physical activity participation [64], and fat and fiber intake [65]. Self-screening enhances early recognition of distress and depression [66,67], which are important foci for ongoing assessment in diabetes patients [6], and commonly remain undetected in primary care [68]. Participants receive instantaneous, automated feedback on their results via the program, which provides a brief description of what their score indicates about how they have doing in each of the above areas.

Information resources on a number of Type 2 diabetes-related areas are included as printable fact sheets within the program. Specifically, information and resources are provided in the areas of: (1) general Type 2 diabetes information; (2) hyper- and hypo-glycaemia; (3) weight management; (4) physical activity guidelines and steps to increasing physical activity; (5) nutritional guidance including reading nutrition labels, counting carbohydrates, sugars, the glycaemic index and glycaemic load, protein, fats, fiber, dairy, salt intake, and alcohol; (6) eye care; (7) foot care; and (8) erectile dysfunction. Information sheets detail the roles of each primary care professional to diabetes management and include Web addresses to relevant organizations that allow a search for primary care professionals within any area of Australia to be performed.

The “Resources” section also contains mindfulness audios that provide spoken instructions on performing various forms of mindfulness (eg, mindfulness meditation and mindfulness of pleasure). Users are encouraged to listen to the audios on their computer or download them to an MP3 player for use offline. Guidebook pages throughout the program refer users to the most relevant mindfulness resources to each area. Inclusion of these resources is based on evidence regarding the deleterious effects of stress on glycaemic control and its tendency to increase susceptibility to dysphoria and diabetes-specific distress. Users are trained to mitigate worrying thoughts by meditative practice.

Brief videos that feature role models on key health-related and behavior change areas (eg, alcohol modification, physical activity) are also included, and provide vicarious experience.