Domains from the health belief model predict enrollment in the National Diabetes Prevention Program among insured adults with prediabetes

Diabetes beliefs, perceived risk and health behaviours: an embedded mixed-methods analysis from the Richmond Stress and Sugar Study

INTRODUCTION

Efforts to increase engagement with diabetes prevention programmes largely focus on increasing diabetes awareness, with the logic that risk knowledge will motivate behaviour change. However, the salience of perceived risk as it relates to diabetes prevention is contested. The goal of this cross-sectional, embedded mixed-methods study was to examine the relationships between perceived risk, diabetes beliefs and prevention behaviours among adults at elevated risk of type 2 diabetes.

METHODS

Data come from the Richmond Stress and Sugar Study (n=125). Diabetes beliefs (ie, internal, chance, powerful others) were assessed using the Multidimensional Health Locus of Control. Preventive behaviours (eg, changing diet, exercise, tobacco, alcohol) were measured by self-report. Perceived risk of developing diabetes was measured using a probability scale (0%-100%). Logistic and Poisson regression models quantified the relationships between beliefs, behaviours and perceived risk. Qualitative themes regarding challenges and facilitators to preventive behaviours were abstracted from open-ended questions and summarised using content analysis.

RESULTS

Perceived risk of developing diabetes was low (median: 35% likelihood) and only 10% of participants had ever attended a prevention class. None of the diabetes belief domains were significantly associated with either engagement in preventive behaviours or perceived diabetes risk. Perceived diabetes risk was not associated with engagement in preventive behaviours; however, having a family history of diabetes was strongly related to perceived risk (OR: 3.35, 95% CI: 1.42 to 7.86). Qualitative facilitators and barriers of preventive behaviours reflected psychosocial factors (eg, determination, stress, preferences) and resources (eg, social support, time, overall health).

CONCLUSIONS

Perceptions of risk and health beliefs are not correlated with engagement in preventive behaviours among adults at clinically elevated risk of diabetes. Awareness campaigns may benefit from incorporating family health history information. Diabetes prevention programmes should address barriers beyond health beliefs to promote engagement in behaviour change.

Predictors of enrollment in a virtual diabetes prevention program among women veterans: a retrospective analysis

BACKGROUND

The Diabetes Prevention Program (DPP) is a nationally disseminated lifestyle intervention shown to prevent type 2 diabetes (diabetes). However, enrollment in the program remains variable. We sought to identify patient characteristics associated with enrollment in a virtual DPP program among women Veterans to inform ongoing diabetes prevention efforts.

METHODS

We conducted a retrospective analysis of 2021-2024 Department of Veterans Affairs (VA) data collected through the VA Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER) 2.0 Program, an effectiveness-implementation trial to expand access to preventative health services for women Veterans. We included women meeting DPP eligibility criteria (BMI ≥ 25 kg/m2 [or ≥ 23 if Asian] with ≥ 1 risk factor for diabetes [e.g., prediabetes]) who received care at six VA sites implementing virtual DPP. We used logistic regression to examine the association between DPP enrollment and prior use of VA preventive services for weight management or diabetes prevention including the VA MOVE! clinic, Whole Health visits, nutrition visits, weight loss medications, and/or metformin. We adjusted for sociodemographic factors, comorbidities, number of DPP recruitment contacts, and site.

RESULTS

A total of 1473 women Veterans received DPP outreach. On average, their age was 53 years (range 20-96), BMI 34 kg/m2, HbA1c 5.9%, 0.7% were Asian, 44% Black, 2% Hispanic, and 44% White. In our adjusted models, prior use of VA preventative services was not significantly associated with DPP enrollment. Younger women (OR:0.97, p = 0.002) and those who received more recruitment contacts (OR:2.63, p < 0.001), were significantly more likely to enroll in DPP. Women with housing instability were significantly less likely to enroll (OR:0.44, p = 0.029).

CONCLUSIONS

We found no difference in women Veterans' enrollment in DPP based on prior use of VA weight management and prevention services. Frequency of outreach by VA sites may increase engagement in lifestyle interventions. Virtual DPP may support engagement in preventive lifestyle interventions for diverse groups of women Veterans, as a first program or as a complement to other VA services.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05050266. Registered on 20 September 2021.

Twelve-Month Reach and Effectiveness of a University-Based Diabetes Prevention Initiative

INTRODUCTION

The University of California (UC) implemented the Diabetes Prevention Program (DPP) to address diabetes and obesity risk. This project examined the reach and effectiveness of this university-based DPP delivery approach.

METHODS

This project compared 12-month weight change among three groups of UC beneficiaries with overweight/obesity: (1) those who received invitation letters and enrolled in UC DPP, (2) those mailed invitation letters but did not enroll, and (3) those who were not mailed letters and did not enroll (controls). Using 2012-2022 EHR, administrative and DPP cohort data, an interrupted time series was conducted in 2022-2023 to compare group differences in rate of weight change.

RESULTS

Among 6,231 beneficiaries (132 UC DPP aware enrollees, 1,750 DPP aware non-enrollees, 4,349 controls), UC DPP enrollees were older (mean age 49), mostly women (76%), and more diverse (33% Asian, 8% Black, 20% Hispanic, 4% Multi/Other). Over 12 months of follow-up, UC DPP enrollee postenrollment rate of weight loss was -0.68 lbs./month. UC DPP enrollees had significantly greater weight change from pre- to post-enrollment than DPP aware non-enrollees (adjusted Δ-1.02 vs. Δ-0.07 lbs./month, difference= -0.95, p<0.001). Weight change among all participants who received letters with/without DPP enrollment was similar to controls.

CONCLUSIONS

UC DPP reached a diverse group and was effective for weight loss at 12-month follow-up. However, UC DPP invitation letters to raise prediabetes and DPP awareness were not associated with significant weight change in the absence of DPP enrollment. University-based approaches to DPP delivery are effective and may enhance reach of DPP among at-risk adults.

Healthcare utilization among informal caregivers of older adults in the Ashanti region of Ghana: a study based on the health belief model

BACKGROUND

Existing global evidence suggests that informal caregivers prioritize the health (care) of their care recipients (older adults) over their own health (care) resulting in sub-optimal health outcomes among this population group. However, data on what factors are associated with healthcare utilization among informal caregivers of older adults are not known in a sub-Saharan African context. Guided by the Health Belief Model (HBM), the principal objective of this study was to examine the association between the dimensions of the HBM and healthcare utilization among informal caregivers of older adults in the Ashanti Region of Ghana.

METHODS

Data were extracted from a large cross-sectional study of informal caregiving, health, and healthcare survey among caregivers of older adults aged 50 years or above (N = 1,853; mean age of caregivers = 39.15 years; and mean age of care recipients = 75.08 years) in the Ashanti Region of Ghana. Poisson regression models were used to estimate the association between the dimensions of the HBM and healthcare utilization among informal caregivers of older adults. Statistical significance of the test was set at a probability level of 0.05 or less.

RESULTS

The results showed that 72.9% (n = 1351) of the participants were females, 56.7% (n = 1051) were urban informal caregivers and 28.6% (n = 530)  had no formal education. The results further showed that 49.4% (n = 916) of the participants utilized healthcare for their health problems at least once in the past year before the survey. The final analysis showed a positive and statistically significant association between perceived susceptibility to a health problem (β = 0.054, IRR = 1.056, 95% CI = [1.041-1.071]), cues to action (β = 0.076, IRR = 1.079, 95% CI = [1.044-1.114]), self-efficacy (β = 0.042, IRR = 1.043, 95% CI = [1.013-1.074]) and healthcare utilization among informal caregivers of older adults. The study further revealed a negative and statistically significant association between perceived severity of a health problem and healthcare utilization (β= - 0.040, IRR = 0.961, 95% CI= [0.947-0.975]) among informal caregivers of older adults. The results again showed that non-enrollment in a health insurance scheme (β= - 0.174, IRR = 0.841, 95% CI= [0.774-0.913]) and being unemployed (β= - 0.088, IRR = 0.916, 95% CI= [0.850-0.986]) were statistically significantly associated with a lower log count of healthcare utilization among informal caregivers of older adults.

CONCLUSION

The findings of this study to a large extent support the dimensions of the HBM in explaining healthcare utilization among informal caregivers of older adults in the Ashanti Region of Ghana. Although all the dimensions of the HBM were significantly associated with healthcare utilization in Model 1, perceived barriers to care-seeking and perceived benefits of care-seeking were no longer statistically significant after controlling for demographic, socio-economic and health-related variables in the final model. The findings further suggest that the dimensions of the HBM as well as demographic, socio-economic and health-related factors contribute to unequal healthcare utilization among informal caregivers of older adults in the Ashanti Region of Ghana.

Uptake, retention, and outcomes of the National Diabetes Prevention Program by enrollee characteristics and program type

AIMS

To describe National Diabetes Prevention Program (NDPP) uptake, retention, and outcomes by enrollee characteristics and program type.

METHODS

We studied 776 adult University of Michigan employees, dependents, and retirees with prediabetes and overweight or obesity who enrolled in one of four CDC-recognized NDPPs at no out-of-pocket cost. Programs included 1) an in-person classroom-based program led by certified diabetes educators in an endocrinology outpatient clinic; 2) an in-person classroom-based program led by trained peer instructors in community settings; 3) an in-person fitness-focused program led by trained lifestyle coaches; and 4) an online digital program led by personal health coaches with virtual group meetings. Data from the insurer and surveys were analyzed.

RESULTS

Older individuals with hypertension and cardiovascular disease were more likely to enroll in classroom-based programs. Program time, location, and perceived focus on diet or physical activity influenced program selection. Retention, weight loss, and physical activity were greater among enrollees in in-person classroom-based programs. Changes in blood pressure, lipid levels, self-rated health, and health-related quality-of-life did not differ by program, nor did Type 2 diabetes mellitus incidence.

CONCLUSIONS

Individuals with prediabetes who enrolled in a NDPP achieved health benefits regardless of the type of program they chose.

Retention and outcomes of National Diabetes Prevention Program enrollees and non-enrollees with prediabetes: The University of Michigan experience

AIMS

To evaluate retention and outcomes of insured adults with prediabetes who enrolled or did not enroll in National Diabetes Prevention Programs (NDPPs).

METHODS

Between 2015 and 2019, 776 University of Michigan employees, dependents, and retirees with prediabetes and overweight or obesity enrolled in one-year NDPPs.

RESULTS

Enrollees attended a median of 18 sessions. Median retention was 38 weeks. Retention was associated with older age, greater initial weight loss, and physical activity. At both 1- and 2-years, body mass index, triglycerides, and HbA1c were significantly improved among enrollees. After adjusting for age group, sex, and race, the odds of developing diabetes based on HbA1c ≥6.5 % was 40 % lower at 1-year and 20 % lower at 2-years, and the odds of self-reported diabetes was 57 % lower at 1-year and 46 % lower at 2-years in enrollees compared to non-enrollees. Enrollees who disenrolled before completing the core curriculum had higher odds and enrollees who completed the NDPP had lower odds of developing diabetes that non-enrollees.

CONCLUSIONS

In this population with prediabetes, NDPP retention was generally good, risk factors were improved, and diabetes was delayed or prevented for up to two years.

Influences on Patient Uptake of and Engagement With the National Health Service Digital Diabetes Prevention Programme: Qualitative Interview Study

BACKGROUND

Digital diabetes prevention programs (digital-DPPs) are being implemented as population-based approaches to type 2 diabetes mellitus prevention in several countries to address problems with the uptake of traditional face-to-face diabetes prevention programs. However, assessments of digital-DPPs have largely focused on clinical outcomes and usability among those who have taken them up, whereas crucial information on decision-making about uptake (eg, whether a user downloads and registers on an app) and engagement (eg, the extent of use of an app or its components over time) is limited. Greater understanding of factors that influence uptake and engagement decisions may support large-scale deployments of digital-DPPs in real-world settings.

OBJECTIVE

This study aimed to explore the key influences on uptake and engagement decisions of individuals who were offered the National Health Service Healthier You: Digital Diabetes Prevention Programme (NHS-digital-DPP).

METHODS

A qualitative interview study was conducted using semistructured interviews. Participants were adults, aged ≥18 years, diagnosed with nondiabetic hyperglycemia, and those who had been offered the NHS-digital-DPP. Recruitment was conducted via 4 providers of the NHS-digital-DPP and 3 primary care practices in England. Interviews were conducted remotely and were guided by a theoretically informed topic guide. Analysis of interviews was conducted using an inductive thematic analysis approach.

RESULTS

Interviews were conducted with 32 participants who had either accepted or declined the NHS-digital-DPP. In total, 7 overarching themes were identified as important factors in both decisions to take up and to engage with the NHS-digital-DPP. These were knowledge and understanding, referral process, self-efficacy, self-identity, motivation and support, advantages of digital service, and reflexive monitoring. Perceptions of accessibility and convenience of the NHS-digital-DPP were particularly important for uptake, and barriers in terms of the referral process and health care professionals' engagement were reported. Specific digital features including health coaches and monitoring tools were important for engagement.

CONCLUSIONS

This study adds to the literature on factors that influence the uptake of and engagement with digital-DPPs and suggests that digital-DPPs can overcome many barriers to the uptake of face-to-face diabetes prevention programs in supporting lifestyle changes aimed at diabetes prevention.

Health Beliefs Associated With Metformin Use Among Insured Adults With Prediabetes

OBJECTIVE

To use the framework of the Health Belief Model (HBM) to explore factors associated with metformin use among adults with prediabetes.

RESEARCH DESIGN AND METHODS

We analyzed survey data from 200 metformin users and 1,277 nonmetformin users with prediabetes identified from a large, insured workforce. All subjects were offered the National Diabetes Prevention Program (DPP) at no out-of-pocket cost. We constructed bivariate and multivariate models to investigate how perceived threat, perceived benefits, self-efficacy, and cues to action impacted metformin use and how demographic, clinical, sociopsychological, and structural variables impacted the associations.

RESULTS

Adults with prediabetes who used metformin were younger and more likely to be women and to have worse self-rated health and higher BMIs than those with prediabetes who did not use metformin. Those who used metformin were also more likely to be aware of their prediabetes and to have a personal history of gestational diabetes mellitus or a family history of diabetes. After consideration of perceived threat, perceived benefits, self-efficacy, and cues to action, the only independent predictors of metformin use were younger age, female sex, higher BMI, and cues to action, most specifically, a doctor offering metformin therapy.

CONCLUSIONS

Demographic and clinical factors and cues to action impact the likelihood of metformin use for diabetes prevention. Perceived threat, perceived benefits, and self-efficacy were not independently associated with metformin use. These results highlight the importance of patient-centered primary care and shared decision-making in diabetes prevention. Clinicians should proactively offer metformin to patients with prediabetes to facilitate effective diabetes prevention.