‘Going the distance’: an independent cohort study of engagement and dropout among the first 100 000 referrals into a large-scale diabetes prevention program

Howarth, Elizabeth; Bower, Peter; Kontopantelis, Evangelos; Soiland‐Reyes, Claudia; Meacock, Rachel; Whittaker, William; Cotterill, Sarah

doi:10.1136/bmjdrc-2020-001835

Cited by 44 publications

(61 citation statements)

References 24 publications

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“…Early evaluations suggest that the program is successful in preventing the progression to T2DM [ 4 ]. However, there is a weakness in reach and retention in the face-to-face program (eg, younger adults and those from more deprived communities) [ 5 ], which a digital program may overcome. Digital interventions have the potential to address logistical challenges such as scheduling, travel, work, and childcare [ 6 ], and they have the capacity to offer wide-reaching and tailored support at a lower cost, both of which are important for large-scale behavior change [ 7 ].…”

Section: Introductionmentioning

confidence: 99%

Fidelity to Program Specification of the National Health Service Digital Diabetes Prevention Program Behavior Change Technique Content and Underpinning Theory: Document Analysis

Hawkes¹,

Miles²,

French³

2022

J Med Internet Res

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Background The National Health Service (NHS) Diabetes Prevention Program is a behavior change intervention for adults in England who are identified as being at high risk of developing type 2 diabetes. The face-to-face service was launched in 2016, followed by a digital service (NHS Digital Diabetes Prevention Program [NHS-DDPP]) in 2019. A total of 4 service providers were commissioned to deliver the NHS-DDPP and were required to deliver the digital service in line with a program specification detailing the key intervention content. The fidelity of the behavior change content in the digital service (ie, the extent to which the program is delivered as intended) is currently unknown. Digital interventions may allow higher fidelity as staff do not have to be trained to deliver all intervention content. Assessing fidelity of the intervention design is particularly important to establish the planned behavior change content in the NHS-DDPP and the extent to which this adheres to the program specification. This is the first known independent assessment of design fidelity in a large-scale digital behavior change intervention. Objective This study aims to assess the fidelity of the behavior change content in each of the 4 NHS-DDPP providers’ intervention designs to the full program specification. Methods We conducted a document review of each provider’s NHS-DDPP intervention design, along with interviews with program developers employed by the 4 digital providers (n=6). Providers’ intervention design documents and interview transcripts were coded for behavior change techniques (BCTs; ie, the active ingredients of the intervention) using the Behavior Change Technique Taxonomy version 1 and underpinning theory using the Theory Coding Scheme framework. The BCTs identified in each digital provider’s intervention design were compared with the 19 BCTs included in the program specification. Results Of the 19 BCTs specified in the program specification, the 4 providers planned to deliver 16 (84%), 17 (89%), 16 (84%), and 16 (84%) BCTs, respectively. An additional 41 unspecified BCTs were included in at least one of the 4 digital providers’ intervention designs. By contrast, inconsistent use of the underpinning theory was apparent across providers, and none of the providers had produced a logic model to explain how their programs were expected to work. All providers linked some of their planned BCTs to theoretical constructs; however, justification for the inclusion of other BCTs was not described. Conclusions The fidelity of BCT content in the NHS-DDPP was higher than that previously documented for the face-to-face service. Thus, if service users engage with the NHS-DDPP, this should increase the effectiveness of the program. However, given that a clear theoretical underpinning supports the translation of BCTs in intervention designs to intervention delivery, the absence of a logic model describing the constructs to be targeted by specific BCTs is potentially problematic.

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Section: Introductionmentioning

confidence: 99%

Fidelity to Program Specification of the National Health Service Digital Diabetes Prevention Program Behavior Change Technique Content and Underpinning Theory: Document Analysis

Hawkes¹,

Miles²,

French³

2022

J Med Internet Res

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“…The NHS-DPP is the largest national diabetes prevention programme globally [17] and has been delivered by four commercial providers for the first three waves of implementation between 2016 and 2019. Of the first 100,000 referrals in the NHS-DPP in 2016-2017, 56% took up a place on the programme and 34% went on to attend the recommended proportion of sessions [18]. See Hawkes et al [19] for a description of NHS-DPP programme delivery.…”

mentioning

confidence: 99%

The theoretical basis of a nationally implemented type 2 diabetes prevention programme: how is the programme expected to produce changes in behaviour?

Hawkes

Miles

French

2021

Int J Behav Nutr Phys Act

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Background It is considered best practice to provide clear theoretical descriptions of how behaviour change interventions should produce changes in behaviour. Commissioners of the National Health Service Diabetes Prevention Programme (NHS-DPP) specified that the four independent provider organisations must explicitly describe the behaviour change theory underpinning their interventions. The nationally implemented programme, launched in 2016, aims to prevent progression to Type 2 diabetes in high-risk adults through changing diet and physical activity behaviours. This study aimed to: (a) develop a logic model describing how the NHS-DPP is expected to work, and (b) document the behaviour change theories underpinning providers’ NHS-DPP interventions. Methods A logic model detailing how the programme should work in changing diet and activity behaviours was extracted from information in three specification documents underpinning the NHS-DPP. To establish how each of the four providers expected their interventions to produce behavioural changes, information was extracted from their programme plans, staff training materials, and audio-recorded observations of mandatory staff training courses attended in 2018. All materials were coded using Michie and Prestwich’s Theory Coding Scheme. Results The NHS-DPP logic model included information provision to lead to behaviour change intentions, followed by a self-regulatory cycle including action planning and monitoring behaviour. None of the providers described an explicit logic model of how their programme will produce behavioural changes. Two providers stated their programmes were informed by the COM-B (Capability Opportunity Motivation – Behaviour) framework, the other two described targeting factors from multiple theories such as Self-Regulation Theory and Self-Determination Theory. All providers cited examples of proposed links between some theoretical constructs and behaviour change techniques (BCTs), but none linked all BCTs to specified constructs. Some discrepancies were noted between the theory described in providers’ programme plans and theory described in staff training. Conclusions A variety of behaviour change theories were used by each provider. This may explain the variation between providers in BCTs selected in intervention design, and the mismatch between theory described in providers’ programme plans and staff training. Without a logic model describing how they expect their interventions to work, justification for intervention contents in providers’ programmes is not clear.

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“…Although we were unable to look at the outcome of DPP referrals, DPP enrollment and retention are a challenge highlighted in prior studies. 24,25 Therefore, a closed-loop system with bi-directional communication between PCPs and clinical services may help to address possible barriers to patients attending nutrition appointments or DPP sessions which may not otherwise get communicated to PCPs. Finally, a prediabetes registry would allow a practice or health system to monitor the prevalence of prediabetes, uptake of evidence-based prediabetes clinical care activities, and impact of treatment on the development of diabetes among their patients with prediabetes.…”

Section: Incident Diabetes and Factors Associated With Development Of...mentioning

confidence: 99%

Clinical Care Among Individuals with Prediabetes in Primary Care: a Retrospective Cohort Study

et al. 2022

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BACKGROUND:The incidence of diabetes in the general US population (6.7 per 1000 adults in 2018) has not changed significantly since 2000, suggesting that individuals with prediabetes are not connecting to evidence-based interventions. OBJECTIVE: We sought to describe the clinical care of individuals with prediabetes, determine patient factors associated with this care, and evaluate risk for diabetes development. DESIGN: Retrospective cohort study using linked claims and electronic health record data. PARTICIPANTS: We created a cohort of adults with prediabetes based on laboratory measures. We excluded patients with a prior history of diabetes, pregnancy in prior 6 months, or recent steroid use. MAIN MEASURES: We measured ordering and completion of clinical services targeting prediabetes management and diabetes incidence within 12 months following cohort entry. We tested the strength of the association between individuals' characteristics and outcomes of interest using bivariate and multiple logistic regression. RESULTS: Our cohort included 3888 patients with a laboratory diagnosis of prediabetes (incident or prevalent prediabetes). Within 12 months, 63.4% had repeat glycemic testing, yet only 10.4% had coded diagnoses of prediabetes, 1.0% were referred for nutrition services, and 5.4% were prescribed metformin. Most patients completed labs and nutrition visits when referred and filled metformin when prescribed. Individuals with a higher glycemic level or BMI were more likely to receive prediabetes clinical care. Six percent of individuals developed diabetes within 12 months of cohort entry and had higher glycemic levels and BMI ≥ 30 kg/m 2 . In the adjusted model, Black individuals had 1.4 times higher odds of developing diabetes than White individuals. CONCLUSIONS: Rates of prediabetes clinical care activities are low and have not improved. Strategies are urgently needed to improve prediabetes care delivery thereby preventing or delaying incident diabetes.

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‘Going the distance’: an independent cohort study of engagement and dropout among the first 100 000 referrals into a large-scale diabetes prevention program

Cited by 44 publications

References 24 publications

Fidelity to Program Specification of the National Health Service Digital Diabetes Prevention Program Behavior Change Technique Content and Underpinning Theory: Document Analysis

Fidelity to Program Specification of the National Health Service Digital Diabetes Prevention Program Behavior Change Technique Content and Underpinning Theory: Document Analysis

The theoretical basis of a nationally implemented type 2 diabetes prevention programme: how is the programme expected to produce changes in behaviour?

Clinical Care Among Individuals with Prediabetes in Primary Care: a Retrospective Cohort Study

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