A critical realist exploration of factors influencing engagement in diabetes prevention programs in rural settings
Britney McMullen
A B * , Kerith Duncanson B C D , David Schmidt C , Clare Collins B D and Lesley MacDonald-Wicks B D
A Northern New South Wales Local Health District, Lismore, NSW 2480, Australia.
B School of Health Sciences, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia.
C Health Education and Training Institute, NSW Health, St Leonards, NSW 2065, Australia.
D Food and Nutrition Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.
Australian Journal of Primary Health 29(5) 510-519 https://doi.org/10.1071/PY22256
Submitted: 8 November 2022 Accepted: 4 April 2023 Published: 1 May 2023
Abstract
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.
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.
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.
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.
Keywords: barriers, critical realism, diabetes prevention, enablers, health, prediabetes, preventive programs, rural.
References
Abbott PA, Davison JE, Moore LF, Rubinstein R (2012) Effective nutrition education for Aboriginal Australians: lessons from a diabetes cooking course. Journal of Nutrition Education and Behavior 44, 55-59.
| Crossref | Google Scholar |
Australian Bureau of Statistics (2018) Socio-economic indexes for areas (SEIFA) 2016 [Online]. Available at https://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/2033.0.55.001Main+Features12016?OpenDocument [Accessed 26 January 2023]
Australian Institute of Health and Welfare (2017) Risk factors to health [Online]. Available at https://www.aihw.gov.au/reports/risk-factors/risk-factors-to-health [Accessed 26 January 2023]
Begum S, Povey R, Ellis N, Gidlow C, Chadwick P (2022) Influences of decisions to attend a national diabetes prevention programme from people living in a socioeconomically deprived area. Diabetic Medicine 39, e14804.
| Crossref | Google Scholar |
Bethancourt HJ, Rosenberg DE, Beatty T, Arterburn DE (2014) Barriers to and facilitators of physical activity program use among older adults. Clinical Medicine & Research 12, 10-20.
| Crossref | Google Scholar |
Braun V, Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77-101.
| Crossref | Google Scholar |
Connelly J (2001) Critical realism and health promotion: effective practice needs an effective theory. Health Education Research 16(2), 115-119.
| Crossref | Google Scholar |
Davis WA, Peters KE, Makepeace A, Griffiths S, Bundell C, Grant SFA, Ellard S, Hattersley AT, Paul Chubb SA, Bruce DG, Davis TME (2018) Prevalence of diabetes in Australia: insights from the Fremantle Diabetes Study Phase II. Internal Medicine Journal 48, 803-809.
| Crossref | Google Scholar |
Delgadillo AT, Grossman M, Santoyo-Olsson J, Gallegos-Jackson E, Kanaya AM, Stewart AL (2010) Description of an academic community partnership lifestyle program for lower income minority adults at risk for diabetes. The Diabetes Educator 36, 640-650.
| Crossref | Google Scholar |
Dunbar JA (2017) Diabetes prevention in Australia: 10 years results and experience. Diabetes & Metabolism Journal 41, 160-167.
| Crossref | Google Scholar |
Evans PH, Greaves C, Winder R, Fearn-Smith J, Campbell JL (2007) Development of an educational ‘toolkit’ for health professionals and their patients with prediabetes: the WAKEUP study (Ways of Addressing Knowledge Education and Understanding in Pre-diabetes). Diabetic Medicine 24, 770-777.
| Crossref | Google Scholar |
Galaviz KI, Narayan KMV, Lobelo F, Weber MB (2018) Lifestyle and the prevention of type 2 diabetes: a status report. American Journal of Lifestyle Medicine 12, 4-20.
| Crossref | Google Scholar |
Gatewood JG, Litchfield RE, Ryan SJ, Geadelmann JDM, Pendergast JF, Ullom KK (2008) Perceived barriers to community-based health promotion program participation. American Journal of Health Behavior 32, 260-271.
| Crossref | Google Scholar |
Graziani C, Rosenthal MP, Diamond JJ (1999) Diabetes education program use and patient-perceived barriers to attendance. Family Medicine 31, 358-363.
| Google Scholar |
Hawkes RE, Cameron E, Cotterill S, Bower P, French DP (2020) The NHS Diabetes Prevention Programme: an observational study of service delivery and patient experience. BMC Health Services Research 20, 1098.
| Crossref | Google Scholar |
HealthStats NSW (2019) Diabetes prevalence in adults [Online]. Available at http://www.healthstats.doh.health.nsw.gov.au/Indicator/dia_prev_age/dia_prev_lhn [Accessed 26 January 2023]
Hostalek U (2019) Global epidemiology of prediabetes – present and future perspectives. Clinical Diabetes and Endocrinology 5, 1-5.
| Crossref | Google Scholar |
Jo Delaney L (2008) Patient-centred care as an approach to improving health care in Australia. Collegian 25, 119-123.
| Crossref | Google Scholar |
Katangwe T, Family H, Sokhi J, Kirkdale CL, Twigg MJ (2020) The community pharmacy setting for diabetes prevention: a mixed methods study in people with ‘pre-diabetes’. Research in Social and Administrative Pharmacy 16, 1067-1080.
| Crossref | Google Scholar |
Kilkkinen A, Heistaro S, Laatikainen T, Janus E, Chapman A, Absetz P, Dunbar J (2007) Prevention of type 2 diabetes in a primary health care setting. Interim results from the Greater Green Triangle (GGT) Diabetes Prevention Project. Diabetes Research and Clinical Practice 76, 460-462.
| Crossref | Google Scholar |
Laatikainen T, Dunbar JA, Chapman A, Kilkkinen A, Vartiainen E, Heistaro S, Philpot B, Absetz P, Bunker S, O’Neil A, Reddy P, Best JD, Janus ED (2007) Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting: Greater Green Triangle (GGT) Diabetes Prevention Project. BMC Public Health 7, 249.
| Crossref | Google Scholar |
Luo H, Chen Z, Bell R, Rafferty AP, Gaskins Little NR, Winterbauer N (2020) Health literacy and health behaviors among adults with prediabetes, 2016 behavioral risk factor surveillance system. Public Health Reports 135, 492-500.
| Crossref | Google Scholar |
McLeroy KR, Bibeau D, Steckler A, Glanz K (1988) An ecological perspective on health promotion programs. Health Education Quarterly 15, 351-377.
| Crossref | Google Scholar |
Miller CK, Weinhold KR, Marrero DG, Nagaraja HN, Focht BC (2015) A translational worksite diabetes prevention trial improves psychosocial status, dietary intake, and step counts among employees with prediabetes: a randomized controlled trial. Preventive Medicine Reports 2, 118-126.
| Crossref | Google Scholar |
Mirzaei M, Aspin C, Essue B, Jeon Y-H, Dugdale P, Usherwood T, Leeder S (2013) A patient-centred approach to health service delivery: improving health outcomes for people with chronic illness. BMC Health Services Research 13, 251.
| Crossref | Google Scholar |
NSW Health (2022) Northern NSW – local health districts [Online]. Available at https://www.health.nsw.gov.au/lhd/Pages/nnswlhd.aspx [Accessed 26 January 2023]
Oladele D, Clark AM, Richter S, Laing L (2013) Critical realism: a practical ontology to explain the complexities of smoking and tobacco control in different resource settings. Global Health Action 6, 19303.
| Crossref | Google Scholar |
Penn L, Ryan V, White M (2013) Feasibility, acceptability and outcomes at a 12-month follow-up of a novel community-based intervention to prevent type 2 diabetes in adults at high risk: mixed methods pilot study. BMJ Open 3, e003585.
| Crossref | Google Scholar |
Reddy P, Hernan AL, Vanderwood KK, Arave D, Niebylski ML, Harwell TS, Dunbar JA (2011) Implementation of diabetes prevention programs in rural areas: Montana and south-eastern Australia compared. Australian Journal of Rural Health 19, 125-134.
| Crossref | Google Scholar |
Schaefer I, Kuever C, Wiese B, Pawels M, van den Bussche H, Kaduszkiewicz H (2013) Identifying groups of nonparticipants in type 2 diabetes mellitus education. The American Journal of Managed Care 19, 499-506.
| Google Scholar |
Shawley-Brzoska S, Misra R (2018) Perceived benefits and barriers of a community-based diabetes prevention and management program. Journal of Clinical Medicine 7, 58.
| Crossref | Google Scholar |
Somerville M, Ball L, Sierra-Silvestre E, Williams LT (2019) Understanding the knowledge, attitudes and practices of providing and receiving nutrition care for prediabetes: an integrative review. Australian Journal of Primary Health 25, 289-302.
| Crossref | Google Scholar |
Somerville M, Burch E, Ball L, Williams LT (2020) ‘I could have made those changes years earlier’: experiences and characteristics associated with receiving a prediabetes diagnosis among individuals recently diagnosed with type 2 diabetes. Family Practice 37, 382-389.
| Crossref | Google Scholar |
Tabák AG, Herder C, Rathmann W, Brunner EJ, Kivimäki M (2012) Prediabetes: a high-risk state for diabetes development. The Lancet 379, 2279-2290.
| Crossref | Google Scholar |
Thankappan KR, Sathish T, Tapp RJ, Shaw JE, Lotfaliany M, Wolfe R, Absetz P, Mathews E, Aziz Z, Williams ED, Fisher EB, Zimmet PZ, Mahal A, Balachandran S, D’Esposito F, Sajeev P, Thomas E, Oldenburg B, Gregg E (2018) A peer-support lifestyle intervention for preventing type 2 diabetes in India: a cluster-randomized controlled trial of the Kerala Diabetes Prevention Program. PLoS Medicine 15, e1002575.
| Crossref | Google Scholar |
World Health Organization (2021) Obesity and overweight [Online]. Available at https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight [Accessed 26 January 2023]
