Implementation of diabetes prevention programs in rural areas: Montana and south-eastern Australia compared

A critical realist exploration of factors influencing engagement in diabetes prevention programs in rural settings

BACKGROUND

Diabetes prevention programs are intended to reduce progression to type 2 diabetes, but are underutilised. This study aimed to explore people with prediabetes' knowledge and attitudes about prediabetes, and their perceptions about engagement in preventive programs in a rural setting. The findings will inform strategies and recommendations to increase preventive health program engagement.

METHODS

Using a qualitative approach with a critical realist methodology, semi-structured interviews were conducted with 20 rural participants with prediabetes from the Northern New South Wales Local Health District in 2021. Interviews were audio-recorded, transcribed verbatim and thematically analysed. The social-ecological model was used as a framework to interpret and action the study findings.

RESULTS

Factors that empowered participants and facilitated a desire to engage in preventive programs included knowledge about prediabetes, a high level of social support, trusting and supportive relationships with health professionals, and a strong desire not to progress to diabetes. Barriers to program engagement included low health literacy levels, limited support, negative experiences with health services, and social and physical constraints. The factors that influenced engagement with preventive health programs were mapped to an individual, interpersonal, organisational, community and policy level, which highlighted the complex nature of behaviour change and the influence of underlying mechanisms.

CONCLUSIONS

Engagement in diabetes prevention programs was dependent on individual agency factors and structural barriers, each of which related to a level of the social-ecological model. Understanding the perceptions of people with prediabetes will inform strategies to overcome multi-level barriers to preventive health program engagement in rural settings.

Using Community Health Workers to Address Barriers to Participation and Retention in Diabetes Prevention Program: A Concept Paper

Objective:

The PreventionLink of Southern Maryland is a 5-year project to eliminate barriers to participation and retention in the National Diabetes Prevention Program (DPP) lifestyle change program to prevent or delay the onset of type 2 diabetes in adults with prediabetes. This is the study to identify the obstacles to participation and retention in the DPP lifestyle change program among high burden populations and learn how CHWs have reduced the identified barriers to participation and retention for high burden populations.

Methods:

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to conduct this literature review. We have used the Scopus and PubMed, including all types of studies and peer-reviewed documents published in English between 2010 and 2020.

Results:

From 131 identified articles, 18 articles were selected for qualitative synthesis. The reviewed literature documented following as main barriers to participate in a DPP lifestyle change program: time, cost, lack of transportation, cost of transportation, commute distance, technology access, access to facilities and community programs, caregiver responsibilities, lack of health literacy and awareness, and language. CHWs can address these barriers to participation and retention, they were involved in educating and supporting roles; they worked as bridges between healthcare providers and participants and as intervention team members.

Conclusions:

Diabetes prevention program participants with social determinant risk factors who most need CHW services are unlikely to have financial resources to pay for CHW services out-of-pocket. Hence, the public and private health plans that pay for their prediabetes care should consider paying for these CHW services and there is a need to trust more to CHW and have them as a “community health teams” member.

Adoption and Appropriateness of mHealth for Weight Management in the Real World: A Qualitative Investigation of Patient Perspectives

Background

Mobile health (mHealth) interventions for weight management can result in weight loss outcomes comparable to in-person treatments. However, there is little information on implementing these treatments in real-world settings.

Objective

This work aimed to answer two implementation research questions related to mHealth for weight management: (1) what are barriers and facilitators to mHealth adoption (initial use) and engagement (continued use)? and (2) what are patient beliefs about the appropriateness (ie, perceived fit, relevance, or compatibility) of mHealth for weight management?

Methods

We conducted semistructured interviews with patients with obesity at a single facility in an integrated health care system (the Veterans Health Administration). All participants had been referred to a new mHealth program, which included access to a live coach. We performed a rapid qualitative analysis of interviews to identify themes related to the adoption of, engagement with, and appropriateness of mHealth for weight management.

Results

We interviewed 24 veterans, seven of whom used the mHealth program. Almost all participants were ≥45 years of age and two-thirds were White. Rapid analysis identified three themes: (1) coaching both facilitates and prevents mHealth adoption and engagement by promoting accountability but leading to guilt among those not meeting goals; (2) preferences regarding the mode of treatment delivery, usability, and treatment content were barriers to mHealth appropriateness and adoption, including preferences for in-person care and a dislike of self-monitoring; and (3) a single invitation was not sufficient to facilitate adoption of a new mHealth program. Themes were unrelated to participants’ age, race, or ethnicity.

Conclusions

In a study assessing real-world use of mHealth in a group of middle-aged and older adults, we found that—despite free access to mHealth with a live coach—most did not complete the registration process. Our findings suggest that implementing mHealth for weight management requires more than one information session. Findings also suggest that focusing on the coaching relationship and how users’ lives and goals change over time may be an important way to facilitate engagement and improved health. Most participants thought mHealth was appropriate for weight management, with some nevertheless preferring in-person care. Therefore, the best way to guarantee equitable care will be to ensure multiple routes to achieving the same behavioral health goals. Veterans Health Administration patients have the option of using mHealth for weight management, but can also attend group weight management programs or single-session nutrition classes or access fitness facilities. Health care policy does not allow such access for most people in the United States; however, expanded access to behavioral weight management is an important long-term goal to ensure health for all.

Primary healthcare in rural areas: access, organization, and health workforce in an integrative literature review

Primary healthcare is essential for dealing with the iniquities marking rural and remote territories. The concept of rurality is somewhat imprecise, and rural health policies in Brazil are insufficient. A review of the international literature can foster better understanding of the strategies developed in central rural health issues. The article's objective was to identify and analyze the challenges in access, organization of healthcare, and health workforce in primary care in rural areas. An integrative literature review was performed to search for scientific articles published from 2000 to 2019 in the Cochrane and MEDLINE databases and specific rural health journals. The search yielded 69 articles, categorized as addressing access, organization of healthcare, or health workforce. The findings' main themes were analyzed. Articles classified as access presented the following central themes: geographic aspects, patients' needs to travel for care, and access to hospital and specialized services. Articles on organization of healthcare dealt with structure and inputs, functioning of health services, and community-based management. Health workforce featured healthcare workers' profiles and roles and factors for their attraction/retention. Crosscutting issues in strengthening access, organization of healthcare, and health workforce in rural areas were community action, outreach/visiting models, communication/information technologies, access to care, and professional training/development. The review provides a comprehensive understanding of primary care in rural health to promote equity for rural populations.

Implementing internet- and tele-based interventions to prevent mental health disorders in farmers, foresters and gardeners (ImplementIT): study protocol for the multi-level evaluation of a nationwide project

BACKGROUND

Farmers are a vulnerable population for developing depression or other mental health disorders due to a variety of risk factors in their work context. Beyond face-to-face resources, preventive internet- and tele-based interventions could extend available treatment options to overcome barriers to care. The German Social Insurance Company for Agriculture, Forestry and Horticulture (SVLFG) implements several guided internet- and mobile-based interventions and personalised tele-based coaching for this specific target group provided by external companies within a nation-wide prevention project for their insured members. The current study aims to evaluate the implementation process and to identify determinants of successful implementation on various individual and organisational levels.

METHODS

The current study includes two groups of participants: 1) insured persons with an observable need for prevention services, and 2) staff-participants who are involved in the implementation process. The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework and the Consolidated Framework for Implementation Research (CFIR) will be used to track and evaluate the implementation process. A mixed-method approach will provide insights on individual and organizational level (e.g. degree of normalization, readiness for change) and helps to identify determinants of successful implementation. In-depth insights on experiences of the participants (e.g. acceptance, satisfaction, barriers and facilitating factors of intervention use) will be yielded through qualitative interviews. Focus groups with field workers provide insights into barriers and facilitators perceived during their consultations. Furthermore, intervention as well as implementation costs will be evaluated. According to the stepwise, national rollout, data collection will occur at baseline and continuously across 24 months.

DISCUSSION

The results will show to what extent the implementation of the internet- and tele-based services as a preventive offer will be accepted by the participants and involved employees and which critical implementation aspects will occur within the process. If the implementation of the internet- and tele-based services succeeds, these services may be feasible in the long-term.

TRIAL REGISTRATION

German Clinical Trial Registration: DRKS00017078 . Registered on 18.04.2019.

Implementation of Physical Activity Interventions in Rural, Remote, and Northern Communities: A Scoping Review

Compared with urban centers, rural, remote, and northern communities face substantial health inequities and increased rates of noncommunicable disease fuelled, in part, by decreased participation in physical activity. Understanding how the unique sociocultural and environmental factors in rural, remote, and northern communities contribute to implementation of physical activity interventions can help guide health promotion policy and practice. A scoping review was conducted to map literature describing the implementation of physical activity interventions in rural, remote, and/or northern communities. Databases MEDLINE, PsycINFO, EMBASE, CINAHL, and SPORTDiscus were searched using a predetermined search strategy. Outcomes of interest included community demographics, program characteristics, intervention results, measures of implementation, and facilitators or barriers to implementation. A total of 1672 articles were identified from a search of databases, and 8 from a targeted hand search. After screening based on inclusion and exclusion criteria, 12 articles were summarized in a narrative review. Prominent barriers to physical activity program implementation included transportation, lack of infrastructure, sociocultural factors, and weather. Facilitators of program success included flexibility and creativity on the part of the implementation team, leveraging community relationships, and shared resources. Few papers reported on traditional implementation outcomes such as fidelity, dose, and quality. There is a lack of rigorous implementation evaluations of physical activity interventions delivered in rural, remote, or northern communities. Positive aspects of rural life, such as social cohesion and willingness to share resources, appear to contribute to successful program implementation.

Challenges to Introducing Integrated Diabetes Care to an Inner-Regional Area in South Western Sydney, Australia

Introduction

Diabetes care often requires collaboration between general practitioners, allied health professionals, nurses, and/or medical specialists. This study aimed to describe the establishment of an integrated diabetes prevention and care approach in an area with limited access to primary and secondary care, and the challenges faced in its initial development.

Description

A qualitative research approach to identify challenges was taken. Data included meeting minutes, observational data and reports involving local clinical and non-clinical stakeholders from June 2016- December 2018 and were thematically analysed.

Discussion

Key challenges were low patient attendance in general practice, healthcare professional time, low participation at health promotion activities/peer support groups and diabetes education reflecting a low priority among people with and at risk of diabetes. Coordination between services remained a challenge.

Conclusion

This study highlights the need to integrate new diabetes services with existing health activities in the community and the importance of allowing flexibility and regular contact with local healthcare professional and community to encourage their involvement. Regular meetings with the funders, internal and external stakeholders are key for sustainability and to adapt programmes to the local situation. Further work is needed to identify and implement strategies to overcome these challenges.

Geographic and Social Factors Associated With Chronic Disease Self-Management Program Participation: Going the "Extra-Mile" for Disease Prevention

Introduction

We examined geographic and social factors associated with participation in the Chronic Disease Self-Management Program (CDSMP) and the Diabetes Self-Management Program (DSMP) implemented at 144 sites in Illinois.

Methods

Programs were delivered by trained facilitators, once per week, during 6 weeks to 1,638 participants aged 50 or older. Of the 1,638 participants, we included in our analysis 1,295 participants with complete geographic information and baseline data on demographic characteristics, health history, and health behaviors. We assessed the following program data: program type (CDSMP or DSMP), workshop location, class size, and number of sessions attended by participants. We geocoded each participant’s home address, classified the home address as rural or urban, and calculated the distance traveled from the home address to a workshop. We used linear and logistic regression analyses to examine the associations between participant and program factors with number of sessions attended and odds of program completion by whether participants lived in an urban or rural county.

Results

Average program attendance was 4.2 sessions; 71.1% (1,106 of 1,556) completed 4 or more sessions. Most participants enrolled in CDSMP (59.6% [954 of 1,600]), but DSMP had greater completion rates. Less than 7% (85 of 1,295) of our sample lived in a rural county; these participants had better completion rates than those living in urban counties (89.4% [76 of 85] vs 75.6% [890 of 1,178]). Traveling shorter distances to attend a workshop was significantly associated with better attendance and program completion rates among urban but not rural participants. The number of sessions attended was significantly higher when class size exceeded 16 participants. Not having a high school diploma was significantly associated with lower levels of attendance and program completion.

Conclusion

Participation in CDSMP and DSMP was associated with distance traveled, program type, class size, and education. Increasing participation in self-management programs is critical to ensure participants’ goals are met.

Standardized Follow-Ups Lower HbA1c in Adults With Type 2 Diabetes Living in a Rural Community: A Pilot Study

Aim:

To implement and evaluate the use of a standardized process, which includes the teach-back method for follow-up among patients with type 2 diabetes in rural health care settings in order to reduce glycosylated hemoglobin A1c (HbA1c) in adults with diabetes.

Background:

It remains unclear whether or not controlled patient follow-up among patients with type 2 diabetes between office visits (at 3-month intervals) is effective in reducing their HbA1c.

Method:

This study recruited 12 participants from a rural health family practice in Northern Illinois to participate in a pretest–posttest study to evaluate if close patient follow-up with reinforced education was effective in helping patients reduce their HbA1c.

Results:

The preintervention for HbA1c and postintervention HbA1c mean difference was found to be statistically significant. The HbA1c level decreased from preintervention to postintervention (p < .05). Further, the mean and standard deviation from the preintervention for HbA1c and postintervention HbA1c were used to calculate an effect size using Cohen’s d found that there was a medium to large effect size d = .67. The change in HbA1c levels was of clinical significance as well as statistical significance.

Conclusion:

The use of a standardized process for patient follow-up as part of routine management of type 2 diabetes appears to have had a clinically as well as statistically significant impact in reducing HbA1c levels.

Diet modification challenges faced by marginalized and nonmarginalized adults with type 2 diabetes: A systematic review and qualitative meta-synthesis

Objectives Diet modification is an important part of the prevention and treatment of type 2 diabetes, but sustained dietary change remains elusive for many individuals. This paper describes and interprets the barriers to diet modification from the perspective of people with type 2 diabetes, paying particular attention to the experiences of people who experience social marginalization. Methods A systematic review of primary, empirical qualitative research was performed, capturing 120 relevant studies published between 2002 and 2015. Qualitative meta-synthesis was used to provide an integrative analysis of this knowledge. Results Due to the central role of food in social life, dietary change affects all aspects of a person's life, and barriers related to self-discipline, emotions, family and social support, social significance of food, and knowledge were identified. These barriers are inter-linked and overlapping. Social marginalization magnifies barriers; people who face social marginalization are trying to make the same changes as other people with diabetes with fewer socio-material resources in the face of greater challenges. Discussion A social-ecological model of behavior supports our findings of challenges at all levels, and highlights the need for interventions and counseling strategies that address the social and environmental factors that shape and sustain dietary change.

Review Strategies to Recruit and Retain Rural Patient Participating Self-management Behavioral Trials

Self-management plays a vital role in improving health outcomes and reducing costs in patients with cardiovascular disease (CVD) and associated risk factors. Based on existing studies, rural residents with CVD and/or risk factors show low engagement in self-management behaviors. Due to low participation in behavioral intervention trials, the most promising mechanism to promote self-management among rural populations is unknown. In turn, the purpose of this article is to review the evidence that supports strategies to recruit and retain rural patients to participate in behavioral intervention trials aimed to promote self-management of CVD and its risk factors. This review is expected to assist researchers in identifying effective solutions to overcome barriers in the recruitment and retention processes when conducting intervention research studies on the self-management of CVD in rural communities.

A Conceptual Framework for Barriers to the Recruitment and Retention of Rural CVD Participants in Behavior Intervention Trials

BACKGROUND

Rural residents diagnosed with cardiovascular disease (CVD) or with CVD-related risks are underrepresented in behavioral intervention trials based on an extensive review of published studies. The low participation rate of rural residents weakens both the internal and external validity of published studies. Moreover, compared to urban residents, limited research exists to describe the unique barriers that limit the participation of rural residents in behavioral intervention trials.

OBJECTIVE

The purpose of this review is to identify a conceptual framework (CF) underpinning common barriers faced by rural CVD patients to enroll in behavioral intervention trials.

METHODS

We conducted a literature review using several electronic databases to obtain a representative sample of research articles, synthesized the evidence, and developed a CF to explain the barriers that may affect the research participation rate of rural residents with CVD or related risks.

RESULTS

We found our evidence-based CF well explained the barriers for rural CVD patients to take part in behavioral intervention trials. Besides contextual factors (i.e. patient, community and research levels), other common factors impacting rural patients' intent to enroll are lack of awareness and understanding about behavioral trials, limited support from their healthcare providers and social circles, unfavorable attitudes, and the lack of opportunity to participating research.

CONCLUSION AND IMPLICATION OF RESULT

The findings demonstrate the evidence-based model consisting of interlinked multi-level factors may help our understanding of the barriers encountered by rural CVD patients participating interventions to promote behavioral change. The implication for researchers is that identifying and developing strategies to overcome the barriers precedes conducting studies in rural communities.

Reducing episodes of diabetic ketoacidosis within a youth population: a focus group study with patients and families

Background

Diabetic ketoacidosis (DKA) is the most common cause of morbidity and mortality for youth with type 1 diabetes mellitus (T1DM). This article reports qualitative data from focus groups with youth and parents of youth with T1DM on the barriers that they identify to DKA prevention and resources that may aid youth better manage their diabetes.

Methods

Four focus groups were held in three communities, two rural and one urban, in the Canadian province of Newfoundland and Labrador (NL) with adolescents and parents of youth with diabetes. Open-ended questions focused on knowledge of DKA, diabetes education, personal experiences with DKA, barriers to diabetes self-management, situations which put them at risk for DKA and resources that could be developed to aid youth in preventing DKA.

Results

There were 19 participants (14 parents and 5 youth). Participants identified factors which increased their risk of DKA as difficulty in distinguishing cases of DKA from other illnesses; variations in diabetes education received; information overload about their condition; the long period from initial diagnosis, when most education about the condition was received; and stress regarding situations where youth are not in the direct care of their parents. Participants from rural areas reported geographical isolation and lack of regular access to specialist health care personnel as additional barriers to better diabetes management.

Conclusions

The project identified barriers to DKA prevention for youth which were not previously identified in the medical literature, e.g., the stress associated with temporary guardians, risk of information overload at initial diagnosis and the long period from initial diagnosis when most diabetes education is received. Families from rural areas do report additional burdens, but in some cases these families have developed community supports to help offset some of these problems. Mobile and online resources, educational refreshers about DKA, concise resources for teachers and other temporary guardians, and DKA treatment kits for parents may help improve diabetes management and prevent future episodes of DKA.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1358-7) contains supplementary material, which is available to authorized users.

Comparison of two methods for assessing diabetes risk in a pharmacy setting in Australia

Background

Since 2007, the Australian Know your numbers (KYN) program has been used in community settings to raise awareness about blood pressure and stroke. In 2011, the program was modified to include assessment for type 2 diabetes risk. However, it is unclear which approach for assessing diabetes risk in pharmacies is best. We compared two methods: random (non-fasting) blood glucose testing (RBGT); and the Australian type 2 diabetes risk assessment tool (AUSDRISK); according to 1) identification of ‘high risk’ participants including head-to-head sensitivity and specificity; 2) number of referrals to doctors; and 3) feasibility of implementation.

Methods

117 Queensland pharmacies voluntarily participated and were randomly allocated to RBGT and AUSDRISK or AUSDRISK only. Although discouraged, pharmacies were able to change allocated group prior to commencement. AUSDRISK is a validated self-administered questionnaire used to calculate a score that determines the 5-year risk of developing type 2 diabetes. AUSDRISK (score 12+) or RBGT (≥5.6 mmol/I) indicates a high potential risk of diabetes. Median linear regression was used to compare the two measures. Staff from 68 pharmacies also participated in a semi-structured interview during a site visit to provide feedback.

Results

Data were submitted for 5,483 KYN participants (60% female, 66% aged >55 years, 10% history of diabetes). Approximately half of the participants without existing diabetes were identified as ‘high risk’ based on either RBGT or AUSDRISK score. Among participants who undertook both measures, 32% recorded a high RBGT and high AUSDRISK. There was a significant association between RBGT and AUSDRISK scores. For every one point increase in AUSDRISK score there was a half point increase in RBGT levels (coefficient 0.55, 95% CI: 0.28, 0.83). Pharmacy staff reported that AUSDRISK was a simple, low cost and efficient method of assessing diabetes risk compared with RBGT, e.g. since management of sharps is not an issue.

Conclusions

In a large, community-based sample of Australians about half of the participants without diabetes were at ‘high risk ‘of developing diabetes based on either AUSDRISK or RBGT results. AUSDRISK was considered to be an acceptable method for assessing the risk of diabetes using opportunistic health checks in community pharmacies.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1227) contains supplementary material, which is available to authorized users.

Integration of chronic disease and disability and health state programs in Montana

This paper describes the strategies used in one state, Montana, to improve the health of individuals at risk for or living with chronic conditions associated with disability. These strategies demonstrate capacity to intervene at individual and environmental levels, and reveal opportunities for public health professionals to collaborate with independent living and long term care partners. In this paper we attempt to outline some of the challenges inherent in these collaborations and suggest strategies to overcome them.

The Treatment of Comorbid Anxiety in a Male With Poorly Controlled Diabetes in a Very Remote Primary Health Care Service

Rural Australians are shown to have poorer health and mental-health outcomes compared with their metropolitan counterparts, particularly for diabetes. Individuals with diabetes often meet criteria for comorbid mental-health conditions, such as anxiety and depression. Psychological treatment, as an adjunct to medical care, for individuals with diabetes is shown to improve overall health and wellbeing. This article describes a 38-year-old male who was referred to a very remote primary health care service by his diabetes educator for strategies to reduce work-related stress and improve his diabetes mismanagement. Mindfulness-based cognitive behavior therapy techniques were used, over six sessions, in the context of a rural and very remote community. Pre- and post-intervention measures showed a reduction in anxiety, distress, and improvement in his perception of his quality of life. Clinical implications for psychological treatment of diabetes and comorbid mental-health issues in rural and remote communities are discussed.