Implementation of a group-based diabetes prevention program within a healthcare delivery system

Abstract

Background Group-based Diabetes Prevention Programs (DPP), aligned with recommendations from the Centers for Disease Control and Prevention, promote clinically significant weight loss and reduce cardio-metabolic risks. Studies have examined implementation of the DPP in community settings, but less is known about its integration in healthcare systems. In 2010, a group-based DPP known as the Group Lifestyle Balance (GLB) was implemented within a large healthcare delivery system in Northern California, across three geographically distinct regional administration divisions of the organization within 12 state counties, with varying underlying socio-demographics. The regional divisions implemented the program independently, allowing for natural variation in its real-world integration. We leveraged this natural experiment to qualitatively assess the implementation of a DPP in this healthcare system and, especially, its fidelity to the original GLB curriculum and potential heterogeneity in implementation across clinics and regional divisions. Methods Using purposive sampling, we conducted semi-structured interviews with DPP lifestyle coaches. Data were analyzed using mixed-method techniques, guided by an implementation outcomes framework consisting of eight constructs: acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. Results We conducted 33 interviews at 20 clinics across the three regional administrative divisions. Consistencies in implementation of the program were found across regions in terms of satisfaction with the evidence base (acceptability), referral methods (adoption), eligibility criteria (fidelity), and strategies to increase retention and effectiveness (sustainability). Heterogeneity in implementation across regions were found in all categories, including: the number and frequency of sessions (fidelity); program branding (adoption); lifestyle coach training (adoption), and patient-facing cost (cost). Lifestyle coaches expressed differing attitudes about curriculum content (acceptability) and suitability of educational level (appropriateness). While difficulties with recruitment were common across regions (feasibility), strategies used to address these challenges differed (sustainability). Conclusions Variation exists in the implementation of the DPP within a large multi-site healthcare system, revealing a dynamic and important tension between retaining fidelity to the original program and tailoring the program to meet the local needs. Moreover, certain challenges across sites may represent opportunities for considering alternative implementation to anticipate these barriers. Further research is needed to explore how differences in implementation domains impact program effectiveness.

Consolidated guidance for behavioral intervention pilot and feasibility studies

“…Studies investigating setting or context are useful for the identification of whether an intervention is appropriate or feasible to deliver for a given setting [50][51][52][53]. This allows for understanding uncertainties about the setting and how differences across settings may influence implementation [54][55][56][57]. In some situations, where an existing intervention is adapted to be delivered in a different setting, understanding how the intervention interacts with the new context becomes a key feasibility outcome to evaluate.…”

A systematic review of the mechanisms influencing engagement in diabetes prevention programmes for people with pre‐diabetes

“…Tables 3, 4 summarise the 90 studies included in the analysis. From these, 36 studies dealt with barriers and enablers to engagement in diabetes prevention progr ammes [21][22][23][24][27][28][29][30][31][32][33][35][36][37][38][39][42][43][44][45][51][52][53][54][56][57][58]64,68,73,88,92,94,97,98,103 (Table 3), 65 studies with programme acceptability 16,[24][25][26][27][28]33,34,37,40,41,43,44,[46]…”

“…Conversely, participants who felt confused and uncertain at diagnosis were less likely to participate. 28,36,42 Aujla et al 24 found that people who declined to participate in a diabetes prevention programme were unsure about whether they were at risk of type 2 diabetes. This was supported by Joachim-Célestin et al, 36 whereby health information and referral to a diabetes prevention programme from a health professional prompted enrolment.…”

Feasibility and Effectiveness of a Worksite-Weight-Loss Program for Cancer Prevention among School-District Employees with Overweight and Obesity

“…However, participant retention in the program varies by age, race/ethnicity [26], and other behavioral, psychological, and structural factors [27]. Thus, there is a need to consider adaptations and modifications to the program to identify strategies to improve retention and effectiveness [26], as well as alternative modes of implementation/program delivery to overcome barriers [28]. The Vibrant Lives program adapted the DPP program for virtual, light-touch delivery using print materials sent via email, text messages, group challenges, and weight and activity trackers, to improve retention and successful weight loss.…”