Engagement with a nationally-implemented digital behaviour change intervention: Usage patterns over the 9-month duration of the National Health Service Digital Diabetes Prevention Programme

Exposure to behaviour change techniques and self-management tasks in a nationally-implemented digital intervention for type 2 diabetes self-management: Analysis of usage data

BACKGROUND

'Healthy Living' is an online self-management intervention for people living with type 2 diabetes rolled out across England from 2019. It was based on the 'HeLP-Diabetes' intervention which demonstrated effectiveness in a randomised controlled trial. However, it is unclear how much people are exposed to intervention content outside of a trial setting.

PURPOSE

To analyse exposure to behaviour change techniques and self-management content in routine usage.

METHODS

Anonymous usage data was obtained for all registered Healthy Living users between May 2020 and September 2023, and linked with previously coded behaviour change technique and self-management content of 895 Healthy Living webpages.

RESULTS

N = 42,689 users registered for a Healthy Living account, of whom n = 27,422 activated it, and n = 19,137 (69.8%) accessed some intervention content. The median number of times users (n = 19,137) were exposed to self-regulatory behaviour change techniques across the intervention was 0 (IQR: 0,0), apart from 'Self-monitoring of outcome(s) of behaviour' (median: 1, IQR: 0,1). Fewer than 30% of users were exposed to behaviour change techniques present after the first section of the curriculum. The median frequency of user (n = 19,137) exposure to medical self-management tasks was 11 (IQR: 4,32), emotional self-management tasks was 4 (IQR: 1,7), and role self-management tasks was 0 (IQR: 0,1).

CONCLUSIONS

This is the first analysis to quantify engagement with behaviour change techniques and self-management tasks in a 'real-world' digital type 2 diabetes self-management programme. Future work needs to identify how to encourage usage of key material in online interventions, for example, by allowing users greater flexibility to access content they wish to engage with.

Service users' experiences of, and engagement with, a nationally implemented digital diabetes prevention programme

OBJECTIVES

Type 2 diabetes mellitus (T2DM) may be prevented by promoting weight loss through adopting healthier behaviours (e.g., improved diet and increased physical activity). In 2016, the National Health Service (NHS) in England introduced a 9-month face-to-face T2DM prevention intervention, delivered by four independent providers. Since 2019, the NHS Digital Diabetes Prevention Programme (NHS-DDPP) was offered to increase accessibility of the programme. This research aimed to understand how service users engaged with, and experienced using the NHS-DDPP.

DESIGN

Qualitative interviews.

METHOD

Semi-structured interviews were conducted with service users (n = 45) who took part in one of the four NHS-DDPP providers' programmes and transcribed verbatim. Transcripts were thematically analysed using a framework approach.

RESULTS

Two overarching themes were produced: 'Personalized Guidance' and 'Path to Success'. Service users valued having health coach support, which provided personalized guidance throughout the programme, alongside access to different app features to suit their needs (e.g., educational content, tracking health behaviours, group support). Service users described self-monitoring, feedback from their health coach and support from their social circle as helpful towards changing their health behaviours. This enabled them to visualize their progress and provided accountability.

CONCLUSION

Service users emphasized how human contact alongside this digital behaviour change programme improved their experiences and engagement with the programme. Digital health interventions could consider how to better incorporate support from health coaches, friends and family to help users in making behavioural changes. Future digital health interventions should consider how best to harness non-digital elements to promote behaviour change.

Effectiveness of Different Intervention Modes in Lifestyle Intervention for the Prevention of Type 2 Diabetes and the Reversion to Normoglycemia in Adults With Prediabetes: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Lifestyle interventions have been acknowledged as effective strategies for preventing type 2 diabetes mellitus (T2DM). However, the accessibility of conventional face-to-face interventions is often limited. Digital health intervention has been suggested as a potential solution to overcome the limitation. Despite this, there remains a significant gap in understanding the effectiveness of digital health for individuals with prediabetes, particularly in reducing T2DM incidence and reverting to normoglycemia.

OBJECTIVE

This study aimed to assess the effectiveness of different intervention modes of digital health, face-to-face, and blended interventions, particularly the benefits of digital health intervention, in reducing T2DM incidence and facilitating the reversion to normoglycemia in adults with prediabetes compared to the usual care.

METHODS

We conducted a comprehensive search in 9 electronic databases, namely MEDLINE, Embase, ACP Journal Club, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Clinical Answers, Cochrane Methodology Register, Health Technology Assessment, and NHS Economic Evaluation Database through Ovid, from the inception to October 2024. This review included randomized controlled trials (RCTs) that studied the effectiveness of lifestyle interventions in adults with prediabetes. The overall intervention effect was synthesized using a random-effects model. The I² statistic was used to assess heterogeneity across the RCTs. We performed a subgroup analysis to explore the effectiveness of digital health, face-to-face, and blended interventions compared with the control group, which received usual care.

RESULTS

From an initial 7868 records retrieved from 9 databases, we identified 54 articles from 31 RCTs. Our analysis showed that face-to-face interventions demonstrated a significant 46% risk reduction in T2DM incidence (risk ratio [RR] 0.54, 95% CI 0.47-0.63; I²=43%; P<.001), and a 46% increase in the reversion to normoglycemia (RR 1.46, 95% CI 1.11-1.91; I²=82%; P=.006), when compared with the control group. On the other hand, digital health interventions, compared with the control group, were associated with a 12% risk reduction in T2DM incidence (RR 0.88, 95% CI 0.77-1.01; I²=0.6%; P=.06). Moreover, the blended interventions combining digital and face-to-face interventions suggested a 37% risk reduction in T2DM incidence (RR 0.63, 95% CI 0.49-0.81;I²<0.01%; P<.001) and an 87% increase in the reversion to normoglycemia (RR 1.87, 95% CI 1.30-2.69; I²=23%; P=.001). However, no significant effect on the reversal of prediabetes to normoglycemia was observed from the digital health interventions.

CONCLUSIONS

Face-to-face interventions have consistently demonstrated promising effectiveness in both reductions in T2DM incidence and reversion to normoglycemia in adults with prediabetes. However, the effectiveness of digital health interventions in these areas has not been sufficiently proven. Given these results, further research is required to provide more definitive evidence of digital health and blended interventions in T2DM prevention in the future.

TRIAL REGISTRATION

PROSPERO CRD42023414313; https://tinyurl.com/55ac4j4n.

Supporting the Individualized Use of Digital Tools in Community Mental Health: The Technology Specialist Pilot Study

This pilot study evaluated the feasibility of the technology specialist intervention, which assists clients in achieving mental health recovery and well-being goals via existing digital tools in a real-world community mental health setting. Thirteen adult clients with serious mental illness and their providers completed baseline, 3-, and 6-month assessments, including goal setting, self-efficacy, activation, and acceptability measures, along with weekly ecological momentary assessments. Clients selected goals and corresponding tools, used the tools steadily, and showed improvement in activation and self-efficacy. Most participating clients (82%, n = 9) and providers (80%, n = 8) found the intervention acceptable. These preliminary findings show that the technology specialist intervention is promising and warrants further testing.

Framework Development for Reducing Attrition in Digital Dietary Interventions: Systematic Review and Thematic Synthesis

BACKGROUND

Dietary behaviors significantly influence health outcomes across populations. Unhealthy diets are linked to serious diseases and substantial economic burdens, contributing to approximately 11 million deaths and significant disability-adjusted life years annually. Digital dietary interventions offer accessible solutions to improve dietary behaviors. However, attrition, defined as participant dropout before intervention completion, is a major challenge, with rates as high as 75%-99%. High attrition compromises intervention validity and reliability and exacerbates health disparities, highlighting the need to understand and address its causes.

OBJECTIVE

This study systematically reviews the literature on attrition in digital dietary interventions to identify the underlying causes, propose potential solutions, and integrate these findings with behavior theory concepts to develop a comprehensive theoretical framework. This framework aims to elucidate the behavioral mechanisms behind attrition and guide the design and implementation of more effective digital dietary interventions, ultimately reducing attrition rates and mitigating health inequalities.

METHODS

We conducted a systematic review, meta-analysis, and thematic synthesis. A comprehensive search across 7 electronic databases (PubMed, MEDLINE, Embase, CENTRAL, Web of Science, CINAHL Plus, and Academic Search Complete) was performed for studies published between 2013 and 2023. Eligibility criteria included original research exploring attrition in digital dietary interventions. Data extraction focused on study characteristics, sample demographics, attrition rates, reasons for attrition, and potential solutions. We followed ENTREQ (Enhancing the Transparency in Reporting the Synthesis of Qualitative Research) and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and used RStudio (Posit) for meta-analysis and NVivo for thematic synthesis.

RESULTS

Out of the 442 identified studies, 21 met the inclusion criteria. The meta-analysis showed mean attrition rates of 35% for control groups, 38% for intervention groups, and 40% for observational studies, with high heterogeneity (I²=94%-99%) indicating diverse influencing factors. Thematic synthesis identified 15 interconnected themes that align with behavior theory concepts. Based on these themes, the force-resource model was developed to explore the underlying causes of attrition and guide the design and implementation of future interventions from a behavior theory perspective.

CONCLUSIONS

High attrition rates are a significant issue in digital dietary interventions. The developed framework conceptualizes attrition through the interaction between the driving force system and the supporting resource system, providing a nuanced understanding of participant attrition, summarized as insufficient motivation and inadequate or poorly matched resources. It underscores the critical necessity for digital dietary interventions to balance motivational components with available resources dynamically. Key recommendations include user-friendly design, behavior-factor activation, literacy training, force-resource matching, social support, personalized adaptation, and dynamic follow-up. Expanding these strategies to a population level can enhance digital health equity. Further empirical validation of the framework is necessary, alongside the development of behavior theory-guided guidelines for digital dietary interventions.

TRIAL REGISTRATION

PROSPERO CRD42024512902; https://tinyurl.com/3rjt2df9.

Improving retrospective intervention descriptions: Lessons learned from research on type 2 diabetes programmes in the United Kingdom and the Republic of Ireland

In recent years, multiple countries worldwide have implemented behavioural interventions within national healthcare systems. Describing the content of these interventions is critical to improve their implementation, replication, and effectiveness, as well as to advance behavioural science. Tools, such as the Behaviour Change Technique Taxonomy, can enhance the quality of intervention description and reporting. As interventions are frequently developed without the use of such tools, retrospective coding of existing interventions to accurately characterise their content is becoming more common. However, the use of these tools for retrospective coding poses various challenges, the discussion of which has been neglected to date. This commentary discusses the challenges encountered when retrospectively describing the content of five nationally implemented programmes for type 2 diabetes in the United Kingdom and the Republic of Ireland and suggests recommendations to tackle these challenges. We present important methodological, practical, and ethical considerations for researchers to reflect on, relevant to the retrospective description of existing interventions. Specifically, we discuss (i) the importance of positive relationships and collaboration with intervention stakeholders, (ii) the practical and ethical considerations when analysing the content of implemented interventions, (iii) the independence of research teams and the potential for misclassification of intervention content, and (iv) the challenges associated with the analysis of intervention content using behavioural science tools. There is a growing demand for more robust approaches to address the methodological, practical, and ethical challenges associated with such studies. The present commentary describes key issues to be considered by research teams, as well as concrete recommendations to improve the retrospective characterisation of intervention content.

Experiences of online group support for engaging and supporting participants in the National Health Service Digital Diabetes Prevention Programme: A qualitative interview study

OBJECTIVES

The National Health Service Digital Diabetes Prevention Programme is a nine-month behavioural intervention for adults in England at risk of type 2 diabetes. This qualitative study aimed to explore how service users engaged with the group support available within the programme.

METHODS

The majority of participants (n = 33), all service users, were interviewed twice via telephone, at 2-4 months into the programme, and at the end of the programme at 8-10 months. Semi-structured interviews covered participants' experiences of online group support functions and how such groups served as a route of support to aid participants' behavioural changes. Data were analysed using manifest thematic analysis.

RESULTS

The majority of participants valued the format of closed group chats, which provided an interactive platform to offer and receive support during their behaviour change journey. However, engagement with group chats reduced over time, and some participants did not find them useful when there was a lack of common interests within the group. Health coaches helped to promote engagement and build rapport among participants within the group chats. Participants reported mixed experiences of discussion forums.

CONCLUSIONS

Programme developers should consider how to optimise online group support to help service users make behavioural changes, in terms of format, participant composition and use of health coach moderators. Further research is required to better understand who might benefit most from 'group chat' or 'discussion forum' support. Health coach moderation of online support groups is likely to facilitate engagement.

Design and Early Use of the Nationally Implemented Healthier You National Health Service Digital Diabetes Prevention Programme: Mixed Methods Study

BACKGROUND

The Healthier You National Health Service Digital Diabetes Prevention Programme (NHS-digital-DPP) is a 9-month digital behavior change intervention delivered by 4 independent providers that is implemented nationally across England. No studies have explored the design features included by service providers of digital diabetes prevention programs to promote engagement, and little is known about how participants of nationally implemented digital diabetes prevention programs such as this one make use of them.

OBJECTIVE

This study aimed to understand engagement with the NHS-digital-DPP. The specific objectives were to describe how engagement with the NHS-digital-DPP is promoted via design features and strategies and describe participants' early engagement with the NHS-digital-DPP apps.

METHODS

Mixed methods were used. The qualitative study was a secondary analysis of documents detailing the NHS-digital-DPP intervention design and interviews with program developers (n=6). Data were deductively coded according to an established framework of engagement with digital health interventions. For the quantitative study, anonymous use data collected over 9 months for each provider representing participants' first 30 days of use of the apps were obtained for participants enrolled in the NHS-digital-DPP. Use data fields were categorized into 4 intervention features (Track, Learn, Coach Interactions, and Peer Support). The amount of engagement with the intervention features was calculated for the entire cohort, and the differences between providers were explored statistically.

RESULTS

Data were available for 12,857 participants who enrolled in the NHS-digital-DPP during the data collection phase. Overall, 94.37% (12,133/12,857) of those enrolled engaged with the apps in the first 30 days. The median (IQR) number of days of use was 11 (2-25). Track features were engaged with the most (number of tracking events: median 46, IQR 3-22), and Peer Support features were the least engaged with, a median value of 0 (IQR 0-0). Differences in engagement with features were observed across providers. Qualitative findings offer explanations for the variations, including suggesting the importance of health coaches, reminders, and regular content updates to facilitate early engagement.

CONCLUSIONS

Almost all participants in the NHS-digital-DPP started using the apps. Differences across providers identified by the mixed methods analysis provide the opportunity to identify features that are important for engagement with digital health interventions and could inform the design of other digital behavior change interventions.