Perceived Benefits and Barriers to the Diabetes Prevention Program

Objective: Diabetes prevention interventions have a proven positive efect on health outcomes. he goal of this project is to understand the factors that motivate and deter people with prediabetes from utilizing evidence-based education programs, such as the Diabetes Prevention Program (DPP). Research Design and Methods: Formative research was conducted among program facilitators, health providers who care for diabetes patients, and patients living with prediabetes to generate an in-depth understanding of perceptions of the program. he methodology included a mixed methods approach. A total of 97 interviews and 5 focus groups were conducted with health providers, program facilitators, and patients. An online survey was administered to 50 patients with prediabetes. Results: All three populations agreed the DPP aided in implementing lifestyle changes and preventing the onset of type 2 diabetes, and the classes provided a positive experience for support, in-depth discussion, and opportunities for learning how to make lifestyle changes. However, while the overall beneits of the program were expressed, there were barriers noted by all populations that afect program utilization and physician referrals. General lack of knowledge, cost of the program, and the signiicant time commitment necessary to complete the program were barriers discussed. Conclusions: he Diabetes Prevention Program is successful in helping individuals with prediabetes make positive lifestyle changes. he lack of knowledge about the program, however, is a deterrent for utilization. Creation of a social marketing campaign based on the indings from this research will aim to increase healthcare provider referrals to the DPP.


INTRODUCTION
Prediabetes is indicated by elevated blood glucose levels that are below the clinical range for a diabetes diagnosis, but above 100mg/dl [1].If left untreated, poorly managed, or undiagnosed, prediabetes can lead to serious health complications [1].Close to 57 million adults in the U.S. and approximately one in four U.S. adults over 20 years old are categorized as pre-diabetic or at risk for developing type 2 diabetes [2].
Prediabetes and diabetes present a signiicant challenge for individuals, communities, and healthcare systems.Diabetes can result in debilitating complications like kidney disease, cardiovascular disease, blindness, and amputations [1].As of 2012, the healthcare costs associated with diabetes are $176 billion annually and diabetes contributes to $69 billion in loss of productivity in the workplace [1].With the rise of newly diagnosed diabetes cases and an increase of prediabetes, eforts focusing on the prevention of diabetes and diabetes complications have emerged in community-based settings across the nation.
he Diabetes Prevention Program (DPP) is an efort to combat the rising numbers of prediabetes.It began as a multisite research study funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) comparing a dietary and physical activity intervention with oral anti-diabetic medication as a means of preventing the onset of diagnosed diabetes among individuals at high risk for developing diabetes [3]. he results of the study indicated that those participants who experienced modest weight loss through lifestyle intervention lowered their diabetes risk more signiicantly than participants receiving oral medications (58% versus 31%) [4].Additionally, the study found that lifestyle intervention was highly efective in all subgroups of age, gender, and ethnicity.his research became the model for the National Diabetes Prevention Program (NDPP) that includes education on diet, physical activity, and behavior modiication.he behavioral goals of the program are to eat less fat and fewer calories and exercise for a total of 150 minutes a week in order to lose 7 percent of their body weight and maintain that loss. he year-long program targets individuals at high risk for developing type 2 diabetes.Eligibility for the program is determined using the following metrics: the Centers for Disease Control  he NDPP partners with non-proit organizations and private insurance companies to provide and expand oferings of the DPP across the United States.It has recognized several grantee organizations that provide the program through their memberships and local programs: American Association of Diabetes Educators, American Health Insurance Plans, Black Women's Health Exchange, National Association of Chronic Disease Directors, Optum Healthcare Solutions/Diabetes Prevention and Control Alliance, and the YMCA of the USA. he American Medical Association (AMA) is collaborating with the NDPP in an attempt to prevent the progression of prediabetes by addressing risk factors and developing new approaches to reduce diabetes [5].his aligns with the AMA's goal of improving health outcomes in cardiovascular disease and type 2 diabetes due to the detrimental impact on patients nationally and the increased costs on the healthcare system. he YMCA of the USA has been an active partner in this efort by providing the program in YMCA locations.he ultimate goal of these partnerships is to increase the number of referrals of adults who have prediabetes to this evidence-based program.

Formative Research Objectives
Despite evidence that lifestyle intervention can reduce the incidence of diabetes, and despite evidence that this reduction is applicable to the diverse population of the U.S., participation in the DPP is less than desired.he Research goal of this formative research is to understand the factors that motivate and deter people with prediabetes from utilizing evidence-based education programs.he population of interest is isolated to the state of Florida, since the research was partially funded through a grant from the Florida Department of Health.Results from this research will be used to create a multi-faceted intervention to increase health provider referral to these programs and develop other materials needed to increase DPP program utilization.

RESEARCH DESIGN AND METHODS
A mixed methods approach was utilized combining qualitative and quantitative data collection and analysis.Speciically, an exploratory design was used, where indings from the qualitative analysis guided the survey design for the quantitative analysis.

Participant Recruitment
Participants were recruited for this research in multiple ways.Health Professional and Program Facilitator recruitment occurred through email and phone calls for interviews and focus groups.Researchers began with a database of professional contacts and used snowball sampling to increase recruitment eforts.Patient recruitment occurred in person.Patient recruitment was the inal phase of the research and research team members had already established relationships with the program facilitators to receive permission to recruit patient participants from active programs.

Qualitative Methodology
A semi-structured interview guide was developed to aid researchers in developing an understanding of how DPP programs are implemented and to explore the perceptions of program beneits and barriers.A total of 97 interviews and 5 focus groups were conducted.Sixty-nine interviews with healthcare professionals and program facilitators were carried out, and 28 patient interviews were conducted.Informed consent was signed or verbally agreed upon by the interviewees prior to each interview.Information about the minimal risks associated with their involvement with this research study was discussed as per the Institutional Review Board (IRB) guidelines.All study procedures were reviewed and approved by the University of South Florida IRB.

Participants
Program Facilitators are those that work within accredited and non-accredited diabetes prevention programs.hese people include those that are administrators of programs and/or class facilitators.
Healthcare Professionals are those that are qualiied to provide clinical care to patients.he professionals interviewed work in multiple discipline areas, from general practice, pharmacy, internal medicine, obstetrics, and nursing.
Patients are those who have participated in the DPP programs.Patient characteristics varied among all interviewed.Income level, age, race/ethnicity, and health insurance status were mixed between all patients interviewed.

Qualitative Data Analysis
As interviews were conducted, codes were generated based on project goals and themes that emerged from the interviews. he codebook was modiied through the use of the Constant Comparative Method throughout the coding process to accurately relect all ideas represented.hree researchers coded all of the transcripts and compared/revised codes until 100% inter-rater agreement was achieved.Interviews and focus groups continued until thematic saturation was achieved with each target audience.

Survey Participant Recruitment
Survey participants were recruited through the research team's professional contact database, as well as from panels purchased from Survey Monkey. he panels were specifically designed to match the research objectives for each group: Healthcare Providers and DPP Patients.DPP Patients were provided surveys by DPP Program Facilitators with whom the research team had received permission.

Quantitative Methodology
Survey data was gathered through the use of survey panels from Survey Monkey.Survey participants were all over the age of 18, could read English language, and were either people with diabetes in the state of Florida, or healthcare providers in the state of Florida.All survey participants had access to a computer and were able to respond to a Survey Monkey link. he surveys were created with language that was speciic to each population: healthcare providers and patient groups.Healthcare professionals were queried about their perceptions of DPP utility, beneits and risks of referral to DPP, and the perceived beneit of DPP when considering patient outcomes and experiences.Patients were queried about their overall impression of DPP, as well as their speciic experiences.

Healthcare Providers
In total, 251 healthcare providers (65% males) were surveyed on their experiences with diabetes prevention education programs.Of those healthcare providers, 46% were primary care physicians, 19% were in internal medicine, and the remainder held various job titles including endocrinologist, OB-GYN, registered nurse, dietician, pharmacist, psychologist, and physician's assistant.Of these healthcare providers, 23% were certiied diabetes educators, but all who participated treated patients with either diabetes or prediabetes.Forty-four percent of providers had been practicing for over 20 years, 31% between 11-20 years, 20% between 5-10 years, and 5% practicing less than ive years.

DPP Patients
Patients (n=50) who participated in a Diabetes Prevention Program in Florida completed a survey describing the experiences in their program.Respondents' ages ranged from 34-80 years with the mean age being 58.7 years (SD=11.30).Participants (35% males) had a racial background of 83% white and 6% African American.Regarding educational background, 56% had completed or at least attended some college, and 28% had completed or at least attended graduate school.All participants had some form of health insurance; 58% of respondents had health insurance through either their employer's plan or their spouse's employer's plan.Other forms of health insurance included Medicare (38%), Medicaid (4%), the Health Insurance Marketplace Plan, military/veteran beneits, were self-insured, or were covered under their parent's plan.

Quantitative Data Analysis
Survey responses were collected electronically from Survey Monkey and analyzed using Excel and SPSS (v.22).In order to investigate possible sub-population characteristics in each target audience, several key demographic variables were examined for interactions with evaluation and opinion questions on the surveys using Pearson Chi-Squared Tests for Independence (χ 2 ).Chi-square estimates the probability that the association between variables is a result of random chance or sampling error by comparing the actual distribution of responses with the expected distribution of responses [6].When relevant, data were segmented and compared using Analysis of Variance techniques (ANOVA F-tests).his analytical technique aims to determine whether variables are related to each other by comparing the diferences between three or more subgroups and the variance on the same variable within each of the subgroups [6].Peer Support he community-based format allows for group education that results in powerful peer support.All of the facilitators in the study described how the dynamics of the group format created a sense of accountability and encouragement for participants.he development of peer support was made possible by the long-term format of the program.

Long-term Format
Meeting regularly for a year allowed for relationships to develop and for behavior change to be reinforced.For facilitators, this is a hallmark of the DPP.Ironically, the long-term format of the program was perceived by some new participants as a barrier, but once participants began the program they valued the extended time frame, even asking for the program to continue past the original year commitment.

Flexible Program
A inal signiicant beneit is the lexibility of administering the program.he program requirements are lexible enough to allow for programs to operate in a variety of community settings including YMCA facilities, health department locations, community centers, libraries, churches, and workplaces. he use of trained lay facilitators was reported as a strength of the program and would allow for easier expansion of programs.

Professional Perspectives
Providers reported several beneits of DPP including communal support, ease of information, and the convenient location of the educational venue.Some providers acknowledged the healthy lifestyle component of the program to be a viable success and motivating component in reaching diabetes prevention goals.For example, a family medicine physician said, "What I like the most about the DPP is that they talk about nutrition but also have a holistic approach.It focuses on obesity and healthy weight with the help of a healthy diet."Additionally, an internal medicine physician stated:

Benefits of DPP: Patient Perspectives
Patients participating in DPP programs indicated communal support and an encouraging environment are beneicial and assist in their eforts toward diabetes prevention.A female participant provided the comment, "It's a feeling of everybody having something in common.I feel comfortable here talking, because I know everybody understands, probably, what I'm going through.I understand what you're going through." he comfort and ease of the program was also highlighted as a beneit of the curriculum.For example, one participated said, "I like the simplicity of just dealing with one thing.If I worry about fat grams, and I worry about it good enough, I will come in and will have lost some weight.hat works for me."

Barriers to the DPP: Program Facilitator Perspectives
Cost he implementation costs for organizations to ofer DPP classes is an important consideration for future policy decisions.Program facilitators discussed cost barriers in two contexts.hey described the investment costs necessary to run the program and the need for insurance coverage to relieve patient inancial burden.For programs, there are several operational costs including staf salaries, data tracking software, cost of materials, incentives, and purchasing supplemental materials like nutrition books.
Program facilitators also reported that participant costs impede recruitment and success in the DPP.While some programs ofer reduced rate or free access to the DPP due to grants or special coverage, these ofers are not long-term solutions.Without insurance coverage many participants are unable to aford the program.One program facilitator said, "he biggest problem is seeing that population that has no insurance, or their insurance doesn't cover for them to come to class."

Content
he content of the DPP curriculum is described as outdated.For example, a program facilitator stated, "Because you can't change the curriculum, one of the barriers we see from our coordinators is that the curriculum is not up to date.hey haven't changed it since whenever they wrote it in the '90s."here is also a reported lack of cultural competency.For example, the curriculum is ofered in English and Spanish, but there were no ethnic dishes used as examples in the curriculum.his can make it challenging to engage diverse groups.

Content
Patients felt that the program curriculum was a bit "too basic" at times and more techniques or education were needed.

Cost
Additionally, the cost of the program and insurance coverage could possibly cause patients to reconsider participating in the program.For example, a female participant said, "his sounds fantastic, but is it going to cost me because my insurance is not going to it?"

Healthcare Provider Perceptions of DPP Programs
A key inding from the survey data is that only 51% (128/250) reported referring patients with prediabetes to DPP programs.A little over half of the respondents (55%; 138/250) felt that DPP programs are helpful to their patients with 53% (132/249) stating that they were "very satisied" or "satisied" with DPP programs.
When asked to rank what aspects of the DPP they like best, HCPs reported the highest ranking factor as "dietary education" (30%; 78/257), followed by "peer support" (25%; 64/257), "group setting" (18%; 46/257), and "lifestyle coach/non-professional leader" (15%; 39/257).Two barriers were equally reported as being primary barriers to referring prediabetes patients to DPP programs, "patients' lack of interest" and "cost for patients due to lack of insurance coverage" (28%; 68/244 for each).Research lack of "motivation to attend" as the greatest barrier for engagement.Participants, program facilitators, and HCPs all expressed during interviews the beneits of the long-term format in that it allows for incremental lifestyle change.he nutritional and physical components praised by HCPs are presented in a slow, progressive format that allows for ease of information comprehension which is appreciated by participants who fear being overwhelmed.Additionally, the extended length of the program allows participants to build relationships and provide communal, peer support.
Participants disclosed during interviews their joy of being able to openly share their feelings and the struggles they experience making lifestyle changes with others who truly understand.Program facilitators also relected on the power of peer support for fostering accountability and encouragement among participants.
Finally, the lexibility built into the DPP was recognized by program facilitators, HCPs, and participants as one of the program's strengths.he program enables classes to be taught in a variety of community settings, allowing for the creation of convenient times and locations.
Given the beneits of the program, 90% of survey respondents reported an overall positive impression of their experience participating in the DPP.Unfortunately, the lack of knowledge about the DPP is a barrier that must be overcome to increase utilization of this evidence-based program.

CONCLUSION
Findings in this formative research study provide evidence that the Diabetes Prevention Program is successful in helping individuals with prediabetes make positive lifestyle changes and attain better health management.Healthcare providers, program facilitators, and patients/participants all believe the DPP provides individuals with support and the opportunity to learn essential skills for healthy living.However, while the overall beneits of the program were expressed, there were barriers to program utilization noted by all populations.Cost of the program and the signiicant time commitment necessary to complete the programs were two barriers that were discussed on numerous occasions.While those barriers are at a macro-level, the large barrier present, the lack of knowledge about the programs, is something that can be addressed and would create signiicant impact.

LIMITATIONS
his study is limited by use of convenience sampling and a limited time frame.

Figure 1 :
Figure 1: and Prevention (CDC) Prediabetes Screening Test, BMI measurement over 24, fasting glucose test indicating prediabetes, and over 18 years of age. he implementation of the NDPP Recognition Program sets program delivery standards of Diabetes Prevention Programs to assure idelity and quality in programs throughout the United States.Local organizations ofering DPP programs can submit applications for recognition including proposed curriculum and available organizational resources.he applications are reviewed and ofered "pending status" while initiating programs and collecting participant outcomes data.If programs are able to meet benchmarks, "full recognition status" is awarded.he review process is free of charge for organizations and usually takes 2-3 years.Local recognized programs beneit in reputation from the CDC seal of approval.he CDC sponsors trainings for "lifestyle coaches."Lifestyle coaches are encouraged to attend CDC sponsored trainings by the Diabetes Training and Technical Assistance Center (DTTAC) and partner organizations that deliver approved curriculum.Additionally, the standardized program provides technical assistance and support to assure idelity, capacity, and sustainability.

Table 1
Incremental Lifestyle ChangeAccording to program facilitators, the evidence-based curriculum is a primary strength of the program.hegoal of the program is systematic behavior change that is targeted incrementally. he incremental steps taken in the program were perceived as beneicial for participants who may be overwhelmed by major lifestyle changes happening quickly.Another program facilitator stated:From a lifestyle change, I think for a lot of these folks one at a time was plenty.'Let'sstart here; let's just look at what you're eating.Start documenting.It doesn't matter what you eat, just put it on a pad of paper.hen start looking at your fat grams.Now we've got two things.'hen we slowly added more.It was so easy.It wasn't too much for them.

Table 3
Results from the survey data demonstrate that only about half of healthcare providers refer patients to the DPP, which may be in part due to the lack of awareness and knowledge about the program.Additionally, providers reported during interviews that they question the credibility of the program since classes are not led by medical professionals, and 29% of survey respondents reported being unaware of what is actually taught in the DPP classes.

WHAT WOULD MAKE LIVING WITH PREDIABETES EASIER?
Results of this study highlight two signiicant indings.First, there is a general lack of awareness of the Diabetes Prevention Program among patients and healthcare providers.hose who heard of the program had limited knowledge of what the DPP entails and how to ind a local program.Second, participation in the DPP aids in better health management, lifestyle change, and diabetes prevention.hese indings emphasize the need to increase knowledge and awareness of the programs ofered in local communities.