How the Behavior Change Content of a Nationally Implemented Digital Diabetes Prevention Program Is Understood and Used by Participants: Qualitative Study of Fidelity of Receipt and Enactment

Abstract

Background The National Health Service Digital Diabetes Prevention Programme (NHS-DDPP) is a program for adults in England at risk of developing type 2 diabetes mellitus (T2DM). It is based on NHS England specifications that stipulate specific behavior change techniques (BCTs), that is, active ingredients to produce behavior change to target diet and physical activity. Now rolled out nationally, the NHS-DDPP is being delivered by 4 independent providers as a 9-month intervention via apps, educational material, and remote health coaching. To optimize effectiveness, participants need to be able to understand and use behavior change content (eg, goal setting and problem solving) of an intervention delivered to them digitally. Previous research has shown that people benefit from support to aid the understanding and use of BCTs. Objective The objectives of this qualitative study were to evaluate how participants in the NHS-DDPP understand and use BCT content, investigate how participants describe the role of health coaches in supporting their behavior change, and examine how the understanding and use of behavior change content of the NHS-DDPP varies across providers. Methods In total, 45 service users were interviewed twice by telephone at 2 to 4 months into, and at the end of, the program. Topics included participants’ understanding and use of key BCTs to support self-regulation (eg, goal setting) and the support they received via the program. Transcripts were analyzed thematically, informed by the framework method. Results Participants described their understanding and use of some behavior change content of the program as straightforward: use of BCTs (eg, self-monitoring of behavior) delivered digitally via provider apps. Participants valued the role of health coaches in supporting their behavior change through the emotional support they offered and their direct role in delivery and application of some BCTs (eg, problem solving) to their specific circumstances. Participants expressed frustration over the lack of monitoring or feedback regarding their T2DM risk within the program. Variations in the understanding and use of behavior change content of the NHS-DDPP were present across provider programs. Conclusions Health coaches’ support in delivery of key components of the program seems to be pivotal. To improve the understanding and use of BCTs in digital interventions, it is important to consider routes of delivery that offer additional interactive human support. Understanding of some self-regulatory BCTs may benefit from this support more than others; thus, identifying the optimal mode of delivery for behavior change content is a priority for future research. The NHS-DDPP could be improved by explicitly setting out the need for health coaches to support understanding of some self-regulatory BCT content such as problem solving in the service specification and amending the discharge process so that knowledge of any change in T2DM risk is available to participants.

Preventing type 2 diabetes: A research agenda for behavioural science

“…By contrast, qualitative research with service users on the NHS‐DPP revealed that understanding of some key BCT content (e.g. action planning, problem solving) was frequently poor, with many service users having little recollection of these BCTs 30,48 . This is in line with other research which typically finds that those self‐regulation techniques that are effective with younger people have much less impact with older people 49 .…”

“…29 This programme of work has found that health coaches in the digital NHS-DPP help to increase engagement, motivation and accountability for service users on the programme. 30 More research is needed to better understand the amount of health coach support required to keep users engaged in these digital programmes and how this support is best delivered (e.g. via telephone, messaging).…”

“…Research on the digital NHS‐DPP has found that people on the digital programme have increased engagement with key intervention components such as setting goals and monitoring their health behaviours when they receive interaction with a health coach associated with those components 29 . This programme of work has found that health coaches in the digital NHS‐DPP help to increase engagement, motivation and accountability for service users on the programme 30 . More research is needed to better understand the amount of health coach support required to keep users engaged in these digital programmes and how this support is best delivered (e.g.…”

“…Some BCTs appear to be well understood and suited for digital delivery without further support (e.g. self‐monitoring), but other BCTs such as goal setting, feedback and problem solving may be better understood when there is a coaching element 30 . Future research should investigate how this human element adds value, the most effective way to deliver this behaviour change support (e.g.…”

Diabetes prevention at scale: Narrative review of findings and lessons from the DIPLOMA evaluation of the NHS Diabetes Prevention Programme in England

“…Using existing data and quasi‐experimental methods we confirmed that the digital NHS DPP could achieve broadly equivalent results to the conventional model 12,38 . Replicating our earlier work, we demonstrated that digital providers faced many similar challenges in ensuring fidelity 39‐41 . We also explored decisions about taking up the digital offer and found that these were based on similar issues to the conventional format (such as self‐efficacy) as well as unique features of the digital interventions such as enhanced accessibility 42 .…”