Characteristics of participants in the first fully online National Diabetes Prevention Programme: A quantitative survey

Introduction

Type 2 diabetes is a growing global health problem which can result in serious chronic health complications for individuals and places a financial burden on health systems¹.

Diabetes prevention programmes (DPPs) are being implemented worldwide to tackle the growing problem of type 2 diabetes^2–4. High levels of participation in these programmes are essential to reduce the rates of people developing diabetes, however, a systematic review of DPPs in real world settings found low participation rates in 71% of programmes studied⁵. A 2022 systematic review and meta synthesis of factors affecting lifestyle change in people with prediabetes found the individual’s evaluation of the importance of making lifestyle changes and the presence of supportive family and programmes facilitated change⁶. Psychosocial factors (belief in the seriousness of type 2 diabetes, their elevated risk, and confidence the DPP could reduce their risk) were shown to be strongly associated with participation in a recent study examining uptake in the English NHS DPP⁷. Practical barriers such as lack of time were also found to impact participation in a 2017 systematic review of diabetes prevention in primary care⁸.

DPPs which are delivered synchronously online have been shown to address some of the barriers of face-to-face delivery while retaining effectiveness⁹. Synchronous online programmes are delivered through videoconferencing with a group of participants and educators in real time. The NHS refer to this mode of delivery as remote¹⁰ and in the US the Centre for Disease Control refers to it as distance learning¹¹. People attending such online DPPs may have different characteristics and different factors affecting their decision to participate compared to face-to-face programmes. For example, a greater proportion of men and more people of working age have been found to take part in synchronous online DPPs⁹. However, very little is known about the psychosocial factors affecting participation. A recent paper exploring participation in the NHS digital DPP had 4 interviewees who declined the digital app in favour of the synchronous online programme as they preferred the peer support provided by the group format¹⁰.

In Ireland, the Health Service Executive (HSE -national publicly funded healthcare system) piloted the National Diabetes Prevention Programme (NDPP) from June 2021 to September 2022. Prior to this there was very limited availability to short prediabetes courses that were not standardised. The Irish DPP was developed and delivered to a group synchronously online due to Covid 19 restrictions. This programme is novel and unique as the first NDPP to be developed specifically for the online format and offered exclusively online. No face-to-face version of the NDPP was available at the time. In other countries programmes were initially offered face-to-face and subsequently developed into programmes for digital or online delivery^12,13. This study aims to describe the demographic, psychosocial and health characteristics of participants in the pilot of the online NDPP in Ireland. Understanding the reasons people participate in DPPs is important to help design strategies to improve the uptake, and therefore the effectiveness, of these programmes.

Methods

This quantitative study used a postal survey for data collection. STROBE reporting guidelines were followed (Extended Data-Appendix 1). Ethical approval for the study was given by the Clinical Research Ethics Committee of the Cork Teaching Hospitals (ref: ECM 4 (n) 10/8/21).

Materials

The survey was adapted from the survey used in the evaluation of the (NHS) DPP in England⁷. The NHS survey was developed to identify factors associated with the uptake of the face-to-face DPP. The NHS survey was theory-based and included questions with established validity used in other studies where available. Adaptations to the survey for our study included using the Irish national census categories for ethnicity, using the Irish levels of education, using the full quality of life measure¹⁴ and a full health confidence measure¹⁵. As the Irish DPP is delivered entirely online, a question regarding confidence in participating in an online programme was added. Our survey was piloted prior to use with the research team, health professionals, a Patient and Public Involvement group (PPI) based at University College Cork and a university statistician was consulted. The PPI group consisted of 10 people with an interest in diabetes prevention. They advised on recruitment and the wording of questions. Based on their feedback on recruitment, the cover letters used the participant’s name rather than a generic address. Data collected included factors that could influence participation in the programme including health status, motivation to improve health, quality of life, self-efficacy, beliefs about the risk of diabetes, presence of co-morbidities as well as demographic and programme participation information (Extended Data-Appendix 2).

Survey domains

Participants and procedure

All those who attended the pilot of the NDPP for initial assessment (n=73) were sent an invitation to take part in the study, a survey, a participant information leaflet and a consent form by programme educators (Extended Data-Appendix 2, 4 - 6). For eligibility criteria for the NDPP see appendix 3. Invitations were sent by post between April and June 2022. Respondents had the opportunity to attend the programme for at least 7 months when they received the survey. A €10 voucher was offered to compensate people for the time spent completing the survey. Respondents returned the survey with the consent form directly to the researcher (CH) either via email or by post.

Data analysis

To ensure data accuracy, 2 researchers (CH, ROM) entered the data from the surveys separately using SPSS software and then compared the 2 datasets to check for errors. Descriptive statistics were then used to summarise the data. Men's and women’s responses are also presented separately.

Results

A total of 22 surveys were returned (30.5% response rate). One person did not sign the consent form and did not provide contact details, therefore, was excluded from the analysis. For a description of the NDPP and characteristics of those who attended the NDPP initial assessment see extended data Appendix 3 and 7.

Discussion

The aim of this study was to describe the demographic, psychosocial and health characteristics of participants in the pilot of the online NDPP in Ireland. The survey provided a unique opportunity to describe the profile of those who participated in an online DPP, and their perceptions of health and psychosocial factors that may affect participation. Findings provide a number of key insights in terms of participant characteristics. Firstly, men were well represented, secondly respondents had high levels of self-reported general health and finally they understood the seriousness of type 2 diabetes.

Those who responded to the survey were representative of the cohort (n=73) that participated in the pilot online NDPP²⁰ (Extended Data-Appendix 7). Over half the respondents in this study were men (57.1%). Men have historically been harder to reach with face-to-face DPPs²¹. In a 2018 systematic review and meta-analysis of the impact of global diabetes prevention interventions, men represented only 28.8% of the 17,272 participants²². Recent evidence indicates that a higher proportion of men attend digital DPPs (which include online programmes) than face-to-face programmes^12,23 however, little is known about the reasons why. Further research should examine why this format is more attractive to men and what facilitated participation for those who rated their confidence with an online format as low.

NDPP participants who returned the survey considered themselves to be generally in good physical and mental health. Mental health scores were slightly above the national average for Ireland (77.7/100 vs 76/100)²⁴. Reported self-efficacy was higher than those who responded to an NHS DPP survey (67.08/100 Vs 64.6/100)⁷. This is a positive finding as self-efficacy has been shown to favourably influence health behaviours such as the decision to attend digital DPPs¹⁰. While it is possible that lifestyle changes made as part of the programme could have affected these scores it is also possible that the people with poorer health who were most at risk of diabetes did not attend the programme. Efforts need to be made to ensure people most at risk are recruited to DPPs to prevent a widening of health inequities²⁵. Successful strategies to improve attendance for people from diverse backgrounds such as using an extra session before the DPP involving motivational interviewing to increase risk awareness and problem solving around barriers should be considered²⁶.

Respondents in our study understood that type 2 diabetes was a serious disease, that they were at risk of developing it and that taking part in the DPP could help them to reduce that risk. These factors have been found to be important in uptake of the NHS DPP⁷ and were found to affect motivation in a meta-synthesis of facilitators and barriers to lifestyle change in 2022⁶. It is possible that attending the programme influenced these beliefs. Further study is warranted to understand why the respondents in our study held these beliefs and if these beliefs could be encouraged in others at risk to improve participation.

Strengths and limitations

This study has several strengths. We used an existing theoretically informed validated survey and modified it through discussion with the research team, health professionals, PPI and a university statistician. This ensured that the survey was appropriate for the Irish context. The study aligns with a positive deviance approach by investigating the characteristics of people who attended the online NDPP²⁷. This allows for greater understanding of the factors affecting the implementation of a successful healthcare practice, in this case attending the NDPP. Finally, and most importantly, it provides preliminary information on the first fully online NDPP, which can be used to improve participation in further roll out of the Irish NDPP and other online DPPs in the future.

While the uptake of this survey was lower than the response to the NHS survey (31% vs 54%) the people who responded to the survey had a broad age range, a wide range of educational attainment, and there was good representation from both men and women. They may however have chosen to take part due to their positive views on the NDPP and additional insights may have been identified with a larger sample. The people attending the programme may have been the easiest to recruit, therefore further research should focus on understanding the views of those who declined to attend to improve participation in the future. Further research is also recommended with those who attended the initial assessment but did not attend further sessions to understand the factors affecting their decisions not to participate in the programme.

Conclusion

This survey provides a snapshot into the demographic, health and psychosocial factors of participants in the online NDPP in Ireland. Participant’s perceptions may indicate potentially modifiable targets to increase participation in DPPs. Further qualitative research is planned to explore these factors in greater depth.

Consent

Ethical approval for the study was given by the Clinical Research Ethics Committee of the Cork Teaching Hospitals (ref: ECM 4 (n) 10/8/21) Written informed consent to participate in the study and for findings to be published was obtained.