NHS Diabetes Prevention Programme in England: formative evaluation of the programme in early phase implementation

Innovative solution or cause for concern? The use of continuous glucose monitors in people not living with diabetes: A narrative review

AIMS

Continuous glucose monitors (CGMs) have expanded their scope beyond indicated uses for diabetes management and are gaining traction among people not living with diabetes (PNLD). CGMs track in time glucose levels and are proposed as tools for the early detection of abnormal glucose and a potential solution for its normalisation through behavioural change, particularly, diet personalisation and motivation of physical activity. This becomes relevance given the growing incidence of metabolic conditions, such as type 2 diabetes mellitus (T2DM). Clinical guidelines, however, do not recommend CGMs in contexts outside type 1 diabetes (T1DM) or insulin-treated T2DM. Therefore, there is a visible disconnect between the indicated and real-world usage of these medical devices. While the commercial market for CGMs in PNLD is expanding rapidly, a comprehensive and evidence-based evaluation of the devices' utility in this population has not been done. Therefore, this review aims to formulate a working model for CGM utility in PNLD as proposed by the 'health and wellness' market that advertises and distributes it to these individuals.

METHODS

We aim to critically analyse the available research addressing components of the working model, that is (1) detection of abnormal glucose; (2) behavioural change, and (3) metabolic health improvement.

RESULTS

We find a lack of consistent and high-quality evidence to support the utility of CGMs for these purposes. We identify significantly under-reserved areas including clinical benchmarks and scoring procedures for CGM measures, device acceptability, and potential adverse effects of CGMs on eating habits in PNLD. We also raise concerns about the robustness of available CGM research.

CONCLUSION

In the face of these research gaps, we urge for the commercial claims suggesting the utility of the device in PNLD to be labelled as misleading. We argue that there is a regulatory inadequacy that fuels 'off-label' CGM distribution and calls for the strengthening of post-market clinical follow-up oversight for CGMs. We hope this will help to avert the continued misinformation risk to PNLD and 'off-label' exacerbation of health disparities.

Transferability of the NHS low-calorie diet programme: A qualitative exploration of factors influencing the programme's transfer ahead of wide-scale adoption

INTRODUCTION

Although behavioural interventions have been found to help control type 2 diabetes (T2D), it is important to understand how the delivery context can influence implementation and outcomes. The NHS committed to testing a low-calorie diet (LCD) programme designed to support people living with excess weight and T2D to lose weight and improve diabetes outcomes. Understanding what influenced implementation during the programme pilot is important in optimising rollout. This study explored the transferability of the NHS LCD Programme prior to wider adoption.

METHODS

Twenty-five interviews were undertaken with stakeholders involved in implementing the LCD programme in pilot sites (health service leads, referring health professionals and programme deliverers). Interviews with programme participants (people living with T2D) were undertaken within a larger programme of work, exploring what worked, for whom and why, which is reported separately. The conceptual Population-Intervention-Environment-Transfer Model of Transferability (PIET-T) guided study design and data collection. Constructs of the model were also used as a deductive coding frame during data analysis. Key themes were identified which informed recommendations to optimise programme transfer.

RESULTS

Population: Referral strategies in some areas lacked consideration of population characteristics. Many believed that offering a choice of delivery model would promote acceptability and accessibility of the eligible population.

INTERVENTION

Overall, stakeholders had confidence in the LCD programme due to the robust evidence base along with anecdotal evidence, but some felt the complex referral process hindered engagement from GP practices.

ENVIRONMENT

Stakeholders described barriers to accessing the programme, including language and learning difficulties. Transferability: Multidisciplinary working and effective communication supported successful implementation.

CONCLUSION

Referral strategies to reach underrepresented groups should be considered during programme transfer, along with timely data from service providers on access and programme benefits. A choice of delivery models may optimise uptake. Knowledge sharing between sites on good working practices is encouraged, including increasing engagement with key stakeholders.

Promoting lifestyle changes in patients with prediabetes from African-Caribbean backgrounds in the United Kingdom

OBJECTIVES

Diabetes is a non-communicable disease where the patient's glucose level in the blood is too high. Diabetes is prevalent among ethnic minority groups in the United Kingdom (UK). Type 2 diabetes is a major cause of premature mortality in England. Unfortunately, the lifestyle of these minority groups has become a barrier to diabetes healthcare treatment. The timely intervention of programmes targeting risk factors associated with diabetes may reduce the prevalence of diabetes among these ethnic minority groups. This review critically explores and identifies barriers that hinder specific African-Caribbean groups from accessing diabetes healthcare and how nurses can promote lifestyle changes in patients with prediabetes from African-Caribbean backgrounds.

DESIGN

An extended literature review (ELR). The process consisted of a search of key databases and other nursing and public health journal articles with the keywords defined in this extended review (prediabetes, diabetes, lifestyle of Afro-Caribbean). Thematic analysis is then applied from a socio-cultural theoretical lens to interpret the selected articles for the review.

RESULTS

Three main barriers were identified: (a) the strong adherence to traditional diets, (b) a wrong perception about diet management and (c) 'Western medication' as a key barrier that hinders effective diabetes management in ethnic minorities, including the African-Caribbean in the UK.

CONCLUSION

To address these barriers, it is important for policymakers to prioritise well-tailored interventions for African-Caribbean groups as well as support healthcare providers with the requisite capacity to provide care.

Test and Treat for Prediabetes: A Review of the Health Effects of Prediabetes and the Role of Screening and Prevention

The term prediabetes describes blood glucose levels above the normal range but below the threshold to diagnose type 2 diabetes. Several population health initiatives encourage a test and treat approach for prediabetes. In this approach, screening and identification of individuals with prediabetes should be followed by prompt referral to structured lifestyle modification programs or pharmacologic interventions that have been shown to prevent or delay the progression to type 2 diabetes in clinical trials. Here we provide a critical review of evidence for this test and treat approach by examining health outcomes associated with prediabetes and the availability and effectiveness of lifestyle modification approaches that target prediabetes. We also describe current limitations to the reach and uptake of evidence-based treatment options for prediabetes. Finally, we highlight lessons learned from identifying and labeling other preconditions to consider challenges and opportunities that may arise with increasing awareness of prediabetes as part of routine preventive care.

Quasi-experimental evaluation of a nationwide diabetes prevention programme

Diabetes is a leading cause of morbidity, mortality and cost of illness1,2. Health behaviours, particularly those related to nutrition and physical activity, play a key role in the development of type 2 diabetes mellitus3. Whereas behaviour change programmes (also known as lifestyle interventions or similar) have been found efficacious in controlled clinical trials4,5, there remains controversy about whether targeting health behaviours at the individual level is an effective preventive strategy for type 2 diabetes mellitus6 and doubt among clinicians that lifestyle advice and counselling provided in the routine health system can achieve improvements in health7-9. Here we show that being referred to the largest behaviour change programme for prediabetes globally (the English Diabetes Prevention Programme) is effective in improving key cardiovascular risk factors, including glycated haemoglobin (HbA1c), excess body weight and serum lipid levels. We do so by using a regression discontinuity design10, which uses the eligibility threshold in HbA1c for referral to the behaviour change programme, in electronic health data from about one-fifth of all primary care practices in England. We confirm our main finding, the improvement of HbA1c, using two other quasi-experimental approaches: difference-in-differences analysis exploiting the phased roll-out of the programme and instrumental variable estimation exploiting regional variation in programme coverage. This analysis provides causal, rather than associational, evidence that lifestyle advice and counselling implemented at scale in a national health system can achieve important health improvements.

A qualitative evaluation of the national rollout of a diabetes prevention programme in England

BACKGROUND

The National Health Service Diabetes Prevention Programme (NHS DPP) was commissioned by NHS England in 2016 and rolled out in three 'waves' across the whole of England. It aims to help people with raised blood glucose levels reduce their risk of developing type 2 diabetes through behaviour change techniques (e.g., weight loss, dietary changes and exercise). An independent, longitudinal, mixed methods evaluation of the NHS DPP was undertaken. We report the findings from the implementation work package: a qualitative interview study with designated local leads, responsible for the local commissioning and implementation of the programme. The aim of the study was to explore how local implementation processes were enacted and adapted over time.

METHODS

We conducted a telephone interview study across two time-points. Twenty-four semi-structured interviews with local leads across 19 sampled case sites were undertaken between October 2019 and January 2020 and 13 interviews with local leads across 13 sampled case sites were conducted between July 2020 and August 2020. Interviews aimed to reflect on the experience of implementation and explore how things changed over time.

RESULTS

We identified four overarching themes to show how implementation was locally enacted and adapted across the sampled case sites: 1. Adapting to provider change; 2. Identification and referral; 3. Enhancing uptake in underserved populations; and 4. Digital and remote service options.

CONCLUSION

This paper reports how designated local leads, responsible for local implementation of the NHS DPP, adapted implementation efforts over the course of a changing national diabetes prevention programme, including how local leads adapted implementation during the COVID-19 pandemic. This paper highlights three main factors that influence implementation: the importance of facilitation, the ability (or not) to tailor interventions to local needs and the role of context in implementation.

Achieving behavior change at scale: Causal evidence from a national lifestyle intervention program for pre-diabetes in the UK

There remains widespread doubt among clinicians that mere lifestyle advice and counseling provided in routine care can achieve improvements in health. We aimed to determine the health effects of the largest behavior change program for pre-diabetes globally (the English Diabetes Prevention Programme) when implemented at scale in routine care. We exploited the threshold in glycated hemoglobin (HbA1c) used to decide on program eligibility by applying a regression discontinuity design, one of the most credible quasi-experimental strategies for causal inference, to electronic health data from approximately one-fifth of all primary care practices in England. Program referral led to significant improvements in patients' HbA1c and body mass index. This analysis provides causal, rather than associational, evidence that lifestyle advice and counseling implemented in a national health system can achieve important health improvements.

Knowledge in Motion: A Comprehensive Review of Evidence-Based Human Kinetics

This comprehensive review examines critical aspects of evidence-based human kinetics, focusing on bridging the gap between scientific evidence and practical implementation. To bridge this gap, the development of tailored education and training programs is essential, providing practitioners with the expertise and skills to effectively apply evidence-based programs and interventions. The effectiveness of these programs in improving physical fitness across all age groups has been widely demonstrated. In addition, integrating artificial intelligence and the principles of slow science into evidence-based practice promises to identify gaps in knowledge and stimulate further research in human kinetics. The purpose of this review is to provide researchers and practitioners with comprehensive information on the application of scientific principles in human kinetics. By highlighting the importance of evidence-based practice, this review is intended to promote the adoption of effective interventions to optimize physical health and enhance performance.

Does recruiting patients to diabetes prevention programmes via primary care reinforce existing inequalities in care provision between general practices? A retrospective observational study

BACKGROUND

Primary care plays a crucial role in identifying patients' needs and referring at-risk individuals to preventive services. However, well-established variations in care delivery may be replicated in this prevention activity.

OBJECTIVE

To examine whether recruiting patients to the English NHS Diabetes Prevention Programme via primary care reinforces existing inequalities in care provision between practices, in terms of clinical quality, accessibility and resources.

METHODS

We generated annual practice-level counts of referrals across the first 4 years of the programme (June 2016 to March 2020). These were linked to 15 indicators of practice clinical quality, access and resources measured during 2018/19. We used random effects Poisson regressions to examine associations between referrals and these indicators, controlling for practice and population characteristics, for 6871 practices in England.

RESULTS

On average, practices made 3.72 referrals per 1000 population annually and rates varied substantially between practices. Referral rates were positively associated with the quality of clinical care provided. A 1 SD higher level of achievement on Quality and Outcomes Framework diabetes indicators was associated with an 11% (95% CI: 8% to 14%) higher referral rate. This positive association was consistent across all five clinical quality indicators. There was no association between referral rates and accessibility, overall payments or staffing. Associations between referrals and receiving different supplementary payments over the core contract were mixed, with 8%-11% lower referral rates for some payments but not for others.

CONCLUSION

Recruiting patients to diabetes prevention programmes via primary care reinforces existing inequalities between general practices in the clinical quality of care they provide. This leaves patients registered with practices providing lower quality clinical care even more disadvantaged. Providing additional support to lower quality practices or using alternative recruitment methods may be necessary to avoid differential engagement in prevention programmes from widening these variations and potential health inequalities further.

Assessing and ensuring fidelity of the nationally implemented English NHS diabetes prevention programme: lessons learned for the implementation of large-scale behaviour change programmes

Background

Health services interventions are typically more effective in randomised controlled trials than in routine healthcare. One explanation for this ‘voltage drop', i.e. reduction in effectiveness, is a reduction in intervention fidelity, i.e. the extent to which a programme is implemented as intended. This article discusses how to optimise intervention fidelity in nationally implemented behaviour change programmes, using as an exemplar the National Health Service Diabetes Prevention Programme (NHS-DPP); a behaviour change intervention for adults in England at increased risk of developing Type 2 diabetes, delivered by four independent provider organisations. We summarise key findings from a thorough fidelity evaluation of the NHS-DPP assessing design (whether programme plans were in accordance with the evidence base), training (of staff to deliver key intervention components), delivery (of key intervention components), receipt (participant understanding of intervention content), and highlight lessons learned for the implementation of other large-scale programmes.

Results

NHS-DPP providers delivered the majority of behaviour change content specified in their programme designs. However, a drift in fidelity was apparent at multiple points: from the evidence base, during programme commissioning, and on to providers’ programme designs. A lack of clear theoretical rationale for the intervention contents was apparent in design, training, and delivery. Our evaluation suggests that many fidelity issues may have been less prevalent if there was a clear underpinning theory from the outset.

Conclusion

We provide recommendations to enhance fidelity of nationally implemented behaviour change programmes. The involvement of a behaviour change specialist in clarifying the theory of change would minimise drift of key intervention content. Further, as loss of fidelity appears notable at the design stage, this should be given particular attention. Based on these recommendations, we describe examples of how we have worked with commissioners of the NHS-DPP to enhance fidelity of the next roll-out of the programme.

Using health economic modelling to inform the design and development of an intervention: estimating the justifiable cost of weight loss maintenance in the UK

BACKGROUND

There is a need to develop cost-effective weight loss maintenance interventions to prolong the positive impact of weight loss on health outcomes. Conducting pre-trial health economic modelling is recommended to inform the design and development of behavioural interventions. We aimed to use health economic modelling to estimate the maximum cost per-person (justifiable cost) of a cost-effective behavioural weight loss maintenance intervention, given an estimated intervention effect for individuals with: i) a Body Mass Index (BMI) of 28 kg/m2 or above without diabetes and ii) a diagnosis of type 2 diabetes prescribed a single non-insulin diabetes medication.

METHODS

The School for Public Health Research Diabetes prevention model was used to estimate the lifetime Quality-adjusted life year (QALY) gains, healthcare costs, and maximum justifiable cost associated with a weight loss maintenance intervention. Based on a meta-analysis, the estimated effect of a weight loss maintenance intervention following a 9 kg weight loss, was a regain of 1.33 kg and 4.38 kg in years one and two respectively compared to greater regain of 2.84 kg and 5.6 kg in the control group. Sensitivity analysis was conducted around the rate of regain, duration of effect and initial weight loss.

RESULTS

The justifiable cost for a weight loss maintenance intervention at an ICER of £20,000 per QALY was £104.64 for an individual with a BMI of 28 or over and £88.14 for an individual with type 2 diabetes. Within sensitivity analysis, this varied from £36.42 to £203.77 for the former, and between £29.98 and £173.05 for the latter.

CONCLUSIONS

Researchers developing a weight loss maintenance intervention should consider these maximum justifiable cost estimates and the potential impact of the duration of effect and initial weight loss when designing intervention content and deciding target populations. Future research should consider using the methods demonstrated in this study to use health economic modelling to inform the design and budgetary decisions in the development of a behavioural interventions.

Digital Behavior Change Interventions for the Prevention and Management of Type 2 Diabetes: Systematic Market Analysis

BACKGROUND

Advancements in technology offer new opportunities for the prevention and management of type 2 diabetes. Venture capital companies have been investing in digital diabetes companies that offer digital behavior change interventions (DBCIs). However, little is known about the scientific evidence underpinning such interventions or the degree to which these interventions leverage novel technology-driven automated developments such as conversational agents (CAs) or just-in-time adaptive intervention (JITAI) approaches.

OBJECTIVE

Our objectives were to identify the top-funded companies offering DBCIs for type 2 diabetes management and prevention, review the level of scientific evidence underpinning the DBCIs, identify which DBCIs are recognized as evidence-based programs by quality assurance authorities, and examine the degree to which these DBCIs include novel automated approaches such as CAs and JITAI mechanisms.

METHODS

A systematic search was conducted using 2 venture capital databases (Crunchbase Pro and Pitchbook) to identify the top-funded companies offering interventions for type 2 diabetes prevention and management. Scientific publications relating to the identified DBCIs were identified via PubMed, Google Scholar, and the DBCIs' websites, and data regarding intervention effectiveness were extracted. The Diabetes Prevention Recognition Program (DPRP) of the Center for Disease Control and Prevention in the United States was used to identify the recognition status. The DBCIs' publications, websites, and mobile apps were reviewed with regard to the intervention characteristics.

RESULTS

The 16 top-funded companies offering DBCIs for type 2 diabetes received a total funding of US $2.4 billion as of June 15, 2021. Only 4 out of the 50 identified publications associated with these DBCIs were fully powered randomized controlled trials (RCTs). Further, 1 of those 4 RCTs showed a significant difference in glycated hemoglobin A_1c (HbA_1c) outcomes between the intervention and control groups. However, all the studies reported HbA_1c improvements ranging from 0.2% to 1.9% over the course of 12 months. In addition, 6 interventions were fully recognized by the DPRP to deliver evidence-based programs, and 2 interventions had a pending recognition status. Health professionals were included in the majority of DBCIs (13/16, 81%,), whereas only 10% (1/10) of accessible apps involved a CA as part of the intervention delivery. Self-reports represented most of the data sources (74/119, 62%) that could be used to tailor JITAIs.

CONCLUSIONS

Our findings suggest that the level of funding received by companies offering DBCIs for type 2 diabetes prevention and management does not coincide with the level of evidence on the intervention effectiveness. There is considerable variation in the level of evidence underpinning the different DBCIs and an overall need for more rigorous effectiveness trials and transparent reporting by quality assurance authorities. Currently, very few DBCIs use automated approaches such as CAs and JITAIs, limiting the scalability and reach of these solutions.

Effect of dietary fat intake and genetic risk on glucose and insulin-related traits in Brazilian young adults

PURPOSE

The development of metabolic diseases such as type 2 diabetes (T2D) is closely linked to a complex interplay between genetic and dietary factors. The prevalence of abdominal obesity, hyperinsulinemia, dyslipidaemia, and high blood pressure among Brazilian adolescents is increasing and hence, early lifestyle interventions targeting these factors might be an effective strategy to prevent or slow the progression of T2D.

METHODS

We aimed to assess the interaction between dietary and genetic factors on metabolic disease-related traits in 200 healthy Brazilian young adults. Dietary intake was assessed using 3-day food records. Ten metabolic disease-related single nucleotide polymorphisms (SNPs) were used to construct a metabolic-genetic risk score (metabolic-GRS).

RESULTS

We found significant interactions between the metabolic-GRS and total fat intake on fasting insulin level (Pinteraction = 0.017), insulin-glucose ratio (Pinteraction = 0.010) and HOMA-B (Pinteraction = 0.002), respectively, in addition to a borderline GRS-fat intake interaction on HOMA-IR (Pinteraction = 0.051). Within the high-fat intake category [37.98 ± 3.39% of total energy intake (TEI)], individuals with ≥ 5 risk alleles had increased fasting insulin level (P = 0.021), insulin-glucose ratio (P = 0.010), HOMA-B (P = 0.001) and HOMA-IR (P = 0.053) than those with < 5 risk alleles.

CONCLUSION

Our study has demonstrated a novel GRS-fat intake interaction in young Brazilian adults, where individuals with higher genetic risk and fat intake had increased glucose and insulin-related traits than those with lower genetic risk. Large intervention and follow-up studies with an objective assessment of dietary factors are needed to confirm our findings.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40200-021-00863-7.

Healthcare Voucher Scheme for Screening of Cardiovascular Risk Factors: A Population-Based Study

The present study aimed to evaluate the factors associated with unwillingness to join a healthcare voucher scheme for screening of cardiovascular risk factors in a Chinese population. We conducted a telephone survey by random selection of 1200 subjects who were aged 45 years or above in Hong Kong. We collected data on their attitude, perception, and perceived feasibility of a healthcare voucher scheme. The overall rates of having received at least one type, two types, and all three types of screening tests are 81.1%, 80.7%, and 79.3%, respectively. Younger individuals (aOR = 0.338, p = 0.004), those of a higher educational level (aOR = 1.825, p = 0.006), being employed (aOR = 3.030, p = 0.037), and lower perception of screening as beneficial (aOR = 0.495, p < 0.001) were significantly associated with no regular screening for at least one medical condition. The overall rate of willingness to join the voucher scheme (among those aged ≥ 45) is 83.7%. Male sex (aOR = 2.049, p = 0.010) and absence of family history of cardiovascular disease (aOR = 0.362, p = 0.002) are independent predictors of unwillingness to join. Our findings highlighted the significance of sex and family history on screening of cardiovascular factors. These constructs and independent predictors identified provide evidence-based formulation and implementation targeted screening strategies that enhance the screening rate of the three cardiovascular risk factors.

Trends in type 2 diabetes mellitus disease burden in European Union countries between 1990 and 2019

This observational study aimed to assess trends in type 2 diabetes mellitus (T2DM) disease burden in European Union countries for the years 1990–2019. Sex specific T2DM age-standardised prevalence (ASPRs), mortality (ASMRs) and disability-adjusted life-year rates (DALYs) per 100,000 population were extracted from the Global Burden of Disease (GBD) Study online results tool for each EU country (inclusive of the United Kingdom), for the years 1990–2019. Trends were analysed using Joinpoint regression analysis. Between 1990 and 2019, increases in T2DM ASPRs were observed for all EU countries. The highest relative increases in ASPRs were observed in Luxembourg (males + 269.1%, females + 219.2%), Ireland (males + 191.9%, females + 165.7%) and the UK (males + 128.6%, females + 114.6%). Mortality trends were less uniform across EU countries, however a general trend towards reducing T2DM mortality was observed, with ASMRs decreasing over the 30-year period studied in 16/28 countries for males and in 24/28 countries for females. The UK observed the highest relative decrease in ASMRs for males (− 46.9%). For females, the largest relative decrease in ASMRs was in Cyprus (− 67.6%). DALYs increased in 25/28 countries for males and in 17/28 countries for females between 1990 and 2019. DALYs were higher in males than females in all EU countries in 2019. T2DM prevalence rates have increased across EU countries over the last 30 years. Mortality from T2DM has generally decreased in EU countries, however trends were more variable than those observed for prevalence. Primary prevention strategies should continue to be a focus for preventing T2DM in at risk groups in EU countries.

A simulation study of the economic and health impact of a diabetes prevention programme in Ireland

AIMS

Type 2 diabetes is a major public health issue that has a large effect on society including its health and social services. The aims of this paper are to generate a projection of the number of cases and explore the potential impact of a preventive intervention targeted at people with pre-diabetes on disease prevalence, complications, mortality and cost.

METHODS

A Markov simulation model of diabetes and pre-diabetes in Ireland, for the period 1991 to 2036, was generated based on international epidemiological data. The simulation was calibrated with the available Irish data on the prevalence of pre-diabetes, diabetes and diabetic complications. The economic and health impact of a hypothetical nationwide preventive intervention programme, which reduces the incidence by a factor consistent with the international literature, was estimated under three scenarios of alternative effectiveness and uptake.

RESULTS

The estimated number of people over 40 years of age with type 2 diabetes in Ireland is projected to increase from 216,000 in 2020 to 414,000 in 2036. A prevention programme, based on the NHS Diabetes Prevention Programme, is estimated to result in a reduction of between 2000 (0.5%) and 19,000 (4.6%) in the number of prevalent cases of diabetes in 2036 resulting in substantial health and quality of life benefits.

CONCLUSIONS

A wide range of initiatives with uncertain outcomes will be required to reduce the impact of obesity and type 2 diabetes. A diabetes prevention programme seems likely to be worth pursuing as one element of this set of initiatives.

The effects of structure, process and outcome incentives on primary care referrals to a national prevention programme

Despite widespread use, evidence is sparse on whether financial incentives in healthcare should be linked to structure, process or outcome. We examine the impact of different incentive types on the quantity and effectiveness of referrals made by general practices to a new national prevention programme in England. We measured effectiveness by the number of referrals resulting in programme attendance. We surveyed local commissioners about their use of financial incentives and linked this information to numbers of programme referrals and attendances from 5170 general practices between April 2016 and March 2018. We used multivariate probit regressions to identify commissioner characteristics associated with the use of different incentive types and negative binomial regressions to estimate their effect on practice rates of referral and attendance. Financial incentives were offered by commissioners in the majority of areas (89%), with 38% using structure incentives, 69% using process incentives and 22% using outcome incentives. Compared to practices without financial incentives, neither structure nor process incentives were associated with statistically significant increases in referrals or attendances, but outcome incentives were associated with 84% more referrals and 93% more attendances. Outcome incentives were the only form of pay-for-performance to stimulate more participation in this national disease prevention programme.

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

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.

Early economic evaluation of an intervention to improve uptake of the NHS England Diabetes Prevention Programme

BACKGROUND

Despite reported increases in referral numbers, a large proportion of those with prediabetes still decline participation in the NHS England Diabetes Prevention Programme (NDPP). The aim of this study was to explore whether investment in interventions to improve uptake of the programme has the potential to be cost-effective.

METHODS

An early cost-utility analysis was conducted using a Markov model parameterized based on secondary data sources. We explored different uptake scenarios and the impact that this had on the maximum allowable intervention price based on cost-effectiveness at the UK NICE willingness to pay threshold of £20,000 (US$ 25,913). Value of information analyses were conducted to explore the potential value of further research to resolve uncertainty at each uptake level.

RESULTS

As uptake levels increase, the maximum allowable intervention price and overall expected value of removing decision uncertainty increases. For 5 percentage and 50 percentage points increase in uptake levels, the maximum allowable intervention price is £41.86 (US$ 54.23) and £418.59 (US$ 542.34) per person, and the overall expected value of removing decision uncertainty are £361,818,839 (US$ 468,786,625) and £1,468,712,316 (US$ 1,902,921,063) respectively.

CONCLUSION

There is headroom for investment in interventions that improve uptake to the NDPP, thereby allowing the programme itself to be delivered in a manner that remains cost-effective.

Is the NHS Diabetes Prevention Programme Intervention Delivered as Planned? An Observational Study of Fidelity of Intervention Delivery

Background

The NHS Diabetes Prevention Programme (NHS-DPP) has been delivered by four commercial organizations across England, to prevent people with impaired glucose tolerance developing Type 2 diabetes. Evidence reviews underpinning the NHS-DPP design specification identified 19 Behavior Change Techniques (BCTs) that are the intervention “active ingredients.” It is important to understand the discrepancies between BCTs specified in design and BCTs actually delivered.

Purpose

To compare observed fidelity of delivery of BCTs that were delivered to (a) the NHS-DPP design specification, and (b) the programme manuals of four provider organizations.

Methods

Audio-recordings were made of complete delivery of NHS-DPP courses at eight diverse sites (two courses per provider organization). The eight courses consisted of 111 group sessions, with 409 patients and 35 facilitators. BCT Taxonomy v1 was used to reliably code the contents of NHS-DPP design specification documents, programme manuals for each provider organization, and observed NHS-DPP group sessions.

Results

The NHS-DPP design specification indicated 19 BCTs that should be delivered, whereas only seven (37%) were delivered during the programme in all eight courses. By contrast, between 70% and 89% of BCTs specified in programme manuals were delivered. There was substantial under-delivery of BCTs that were designed to improve self-regulation of behavior, for example, those involving problem solving and self-monitoring of behavior.

Conclusions

A lack of fidelity in delivery to the underlying evidence base was apparent, due to poor translation of design specification to programme manuals. By contrast, the fidelity of delivery to the programme manuals was relatively good. Future commissioning should focus on ensuring the evidence base is more accurately translated into the programme manual contents.

The Fidelity of Training in Behaviour Change Techniques to Intervention Design in a National Diabetes Prevention Programme

Background

The National Health Service Diabetes Prevention Programme (NHS-DPP) is a behavioural intervention for people identified as high risk for developing type 2 diabetes that has been rolled out across England. The present study evaluates whether the four commercial providers of the NHS-DPP train staff to deliver behaviour change technique (BCT) content with fidelity to intervention plans.

Method

One set of mandatory training courses across the four NHS-DPP providers (seven courses across 13 days) was audio-recorded, and all additional training materials used were collected. Recordings and training materials were coded for BCT content using the BCT Taxonomy v1. BCTs and depth of training (e.g. instruction, demonstration, practice) of BCT content was checked against providers’ intervention plans.

Results

Ten trainers and 78 trainees were observed, and 12 documents examined. The number of unique BCTs in audio recordings and associated training materials ranged from 19 to 44 across providers, and staff were trained in 53 unique BCTs across the whole NHS-DPP. Staff were trained in 66% of BCTs that were in intervention plans, though two providers trained staff in approximately half of BCTs to be delivered. The most common way that staff were trained in BCT delivery was through instruction. Training delivery style (e.g. experiential versus educational) varied between providers.

Conclusion

Observed training evidences dilution from providers’ intervention plans. NHS-DPP providers should review their training to ensure staff are trained in all key intervention components, ensuring thorough training of BCTs (e.g. demonstrating and practicing how to deliver) to enhance BCT delivery.

A digital lifestyle behaviour change intervention for the prevention of type 2 diabetes: a qualitative study exploring intuitive engagement with real-time glucose and physical activity feedback

BACKGROUND

Mobile health technologies have advanced to now allow monitoring of the acute physiological responses to lifestyle behaviours. Our aim was to explore how people engaged with real-time feedback on their physical activity and glucose levels over several weeks.

METHODS

Semi-structured interviews with 26 participants (61.5% female, 56.6 years) at moderate-to-high risk of developing type 2 diabetes were conducted. Interviews were completed after participants took part in an intervention comprising a flash glucose monitor (Freestyle Libre) and a physical activity monitor (Fitbit Charge 2). Purposive sampling ensured representation of ages, genders and group allocations.

RESULTS

Inductive thematic analysis revealed how individuals intuitively used, interpreted and acted on feedback from wearable technologies. Six key themes emerged: triggers of engagement with the technologies, links between behaviour and health, lack of confidence, changes to movement behaviours, changes to diet and barriers to lifestyle behaviour change.

CONCLUSIONS

Our findings demonstrate that accessing behavioural and physiological feedback can increase self-awareness of how lifestyle impacts short-term health. Some participants noticed a link between the feedback presented by the two devices and changed their behaviour but many did not. Training and educational support, as well as efforts to optimize how feedback is presented to users, are needed to sustain engagement and behaviour change. Extensions of this work to involve people with diabetes are also warranted to explore whether behavioural and physiological feedback in parallel can encourage better diabetes self-management.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN17545949 , 12/05/2017, prospectively registered.

Lifestyle intervention in individuals with impaired glucose regulation affects Caveolin-1 expression and DNA methylation

Aims: We investigated whether a lifestyle intervention could influence expression and DNA methylation of diabetes-related genes in patients with impaired glucose regulation (IGR), the results were compared to bariatric surgery, considering it an intensive change. Methods: Twenty participants with IGR had adipose tissue biopsy and blood collected pre- and post-lifestyle (6 months) intervention; 12 obese patients had subcutaneous fat taken before and after bariatric surgery. RNA/DNA was extracted from all samples and underwent qPCR. DNA was bisulphite converted and 12 CpG sites of Caveolin-1 (CAV1) promoter were pyrosequenced. Results: lifestyle intervention resulted in opposite direction changes in fat tissue and blood for CAV1 expression and DNA methylation and these changes were correlated between tissues, while no significative differences were found in CAV1 expression after bariatric surgery. Conclusions: Our findings suggest a role for CAV1 in modulating adipocyte function as a consequence of lifestyle changes, as exercises and diet. These results may provide insights into new therapeutic targets for diabetes prevention.

The NHS Diabetes Prevention Programme: an observational study of service delivery and patient experience

BACKGROUND

The NHS Diabetes Prevention Programme (NHS-DPP) is a nine-month, group-based behavioural intervention for adults in England at risk of developing Type 2 diabetes. Four independent providers were commissioned to deliver versions of the NHS-DPP, in line with NHS England specifications. This observational study maps NHS-DPP delivery in routine practice against the NHS specification, and compares service delivery with observed patient experiences.

METHODS

Researchers observed service delivery across eight complete NHS-DPP courses (118 sessions, median 14 sessions per course), consenting 455 participants (36 staff, 398 patients, 21 accompanying persons). Key features of NHS-DPP delivery were described using the Template for Intervention Description and Replication (TIDieR) framework. Researchers wrote detailed field notes during each session, including observations of patient experience. Field notes were content analysed; instances of positive and negative experiences were labelled and grouped into categories. Researchers used a novel method of comparing observed patient experiences to variations in programme delivery.

RESULTS

Delivery broadly followed NHS England's specification and the plans set out by providers. Deviations included the scheduling and larger group sizes in some sessions. There was variation in the type and format of activities delivered by providers. Positive patient experiences included engagement, satisfaction with the programme, good within-group relationships and reported behavioural changes. Negative experiences included poor scheduling, large groups, and dissatisfaction with the venue. Where more interactive and visual activities were delivered in smaller groups of 10-15 people with good rapport, there were generally more instances of positive patient experiences, and where there were structural issues such as problems with the scheduling of sessions, poor venues and inadequate resources, there tended to be more negative patient experiences.

CONCLUSIONS

Addressing issues that we have identified as being linked to negative experiences with the NHS-DPP could increase uptake, reduce patient drop-out and increase the overall effectiveness of the programme. In particular, modifying structural aspects of the NHS-DPP (e.g. reliable session scheduling, reducing group sizes, enough session resources) and increasing interaction appear particularly promising for improving these outcomes.

Influences on NHS Health Check behaviours: a systematic review

Background

National Health Service Health Checks were introduced in 2009 to reduce cardiovascular disease (CVD) risks and events. Since then, national evaluations have highlighted the need to maximise the programme’s impact by improving coverage and outputs. To address these challenges it is important to understand the extent to which positive behaviours are influenced across the NHS Health Check pathway and encourage the promotion or minimisation of behavioural facilitators and barriers respectively. This study applied behavioural science frameworks to: i) identify behaviours and actors relevant to uptake, delivery and follow up of NHS Health Checks and influences on these behaviours and; ii) signpost to example intervention content.

Methods

A systematic review of studies reporting behaviours related to NHS Health Check-related behaviours of patients, health care professionals (HCPs) and commissioners. Influences on behaviours were coded using theory-based models: COM-B and Theoretical Domains Framework (TDF). Potential intervention types and behaviour change techniques (BCTs) were suggested to target key influences.

Results

We identified 37 studies reporting nine behaviours and influences for eight of these. The most frequently identified influences were physical opportunity including HCPs having space and time to deliver NHS Health Checks and patients having money to adhere to recommendations to change diet and physical activity. Other key influences were motivational, such as beliefs about consequences about the value of NHS Health Checks and behaviour change, and social, such as influences of others on behaviour change. The following techniques are suggested for websites or smartphone apps: Adding objects to the environment, e.g. provide HCPs with electronic schedules to guide timely delivery of Health Checks to target physical opportunity, Social support (unspecified), e.g. include text suggesting patients to ask a colleague to agree in advance to join them in taking the ‘healthy option’ lunch at work; Information about health consequences, e.g. quotes and/or videos from patients talking about the health benefits of changes they have made.

Conclusions

Through the application of behavioural science we identified key behaviours and their influences which informed recommendations for intervention content. To ascertain the extent to which this reflects existing interventions we recommend a review of relevant evidence.

Use of dental practices for the identification of adults with undiagnosed type 2 diabetes mellitus or non-diabetic hyperglycaemia: a systematic review

AIM

Type 2 diabetes is a growing global challenge. Evidence exists demonstrating the use of primary care (non-hospital based) dental practices to identify, through risk assessments, those who may be at increased risk of type 2 diabetes or who may already unknowingly have the condition. This review aimed to synthesize evidence associated with the use of primary care dental services for the identification of undiagnosed non-diabetic hyperglycaemia or type 2 diabetes in adults, with particular focus on the pick-up rate of new cases.

METHOD

Electronic databases were searched for studies reporting the identification of non-diabetic hyperglycaemia/type 2 diabetes in primary care dental settings. Returned articles were screened and two independent reviewers completed the data-extraction process. A descriptive synthesis of the included articles was undertaken due to the heterogeneity of the literature returned.

RESULTS

Nine studies were identified, the majority of which utilized a two-stage risk-assessment process with risk score followed by a point-of-care capillary blood test. The main barriers cited were cost, lack of adequate insurance cover and people having previously been tested elsewhere. The pick-up rate of new cases of type 2 diabetes and non-diabetic hyperglycaemia varied greatly between studies, ranging from 1.7% to 24% for type 2 diabetes and from 23% to 45% for non-diabetic hyperglycaemia, where reported.

CONCLUSION

This review demonstrates that although it appears there may be benefit in using the dental workforce to identify undiagnosed cases of non-diabetic hyperglycaemia and type 2 diabetes, further high-quality research in the field is required assessing both the clinical and cost effectiveness of such practice. (Prospero Registration ID: PROSPERO 2018 CRD42018098750).

Does the design of the NHS Diabetes Prevention Programme intervention have fidelity to the programme specification? A document analysis

AIMS

To assess fidelity of the Healthier You: NHS Diabetes Prevention Programme (NHS-DPP), a behavioural intervention for people in England at high risk of developing type 2 diabetes, to the specified programme features.

METHODS

Document analysis of the NHS-DPP programme specification, including National Institute for Health and Care Excellence (NICE) PH38 diabetes prevention guidance. This was compared with the intervention design (framework response documents and programme manuals) from all four independent providers delivering the NHS-DPP. Documents were coded using the Template for Intervention Description and Replication framework (describing service parameters) and the Behaviour Change Technique Taxonomy v1.

RESULTS

Providers demonstrated good fidelity to service parameters of the NHS-DPP. The NHS-DPP specification indicated 19 unique behaviour change techniques. Framework responses for the four providers contained between 24 and 32 distinct behaviour change techniques, and programme manuals contained between 23 and 45 distinct behaviour change techniques, indicating variation in behaviour change content between providers' intervention documents. Thus, each provider planned to deliver 74% of the unique behaviour change techniques specified, and a large amount of behaviour change content not mandated.

CONCLUSIONS

There is good fidelity to the specified service parameters of the NHS-DPP; however, the four providers planned to deliver approximately three-quarters of behaviour change techniques specified by the NHS-DPP. Given that behaviour change techniques are the 'active ingredients' of interventions, and some of these techniques in the programme manuals may be missed in practice, this highlights possible limitations with fidelity to the NHS-DPP programme specification at the intervention design stage.

A systematic review of recruitment strategies and behaviour change techniques in group-based diabetes prevention programmes focusing on uptake and retention

BACKGROUND

Many countries worldwide have developed diabetes prevention programmes (DPPs) that involve lifestyle modification. Research has shown that uptake and retention of DPPs are important and by exploring recruitment strategies and behaviour change techniques (BCTs) used, factors that are most effective in promoting uptake and retention can be identified.

OBJECTIVES

This review aims to identify recruitment strategies of group-based DPPs that are associated with high uptake and common BCTs associated with high retention.

METHODS

Papers were identified with a systematic literature search. Programmes that were predominantly group-based and involved lifestyle modification and in which uptake and/or retention could be determined, were included. Intervention details were extracted, recruitment strategies and BCTs identified, and response, uptake and retention rates were calculated.

RESULTS

A range of recruitment strategies were used making it difficult to discern associations with uptake rates. For BCTs, all programmes used a credible source, 81% used instruction on how to perform a behaviour and 71% used goal setting (behaviour). BCTs more commonly found in high retention programmes included problem-solving, demonstrating the behaviour, using behavioural practice and reducing negative emotions.

CONCLUSIONS

Recommendations include that DPPs incorporate BCTs like problem-solving and demonstrating the behaviour to maximise retention.

Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach

AIMS

To assess factors associated with ever receiving prediabetes education, and to explore the health education and communication needs among primary care patients with prediabetes in Singapore.

METHODS

A mixed methods study, consisting of a cross-sectional survey involving 433 patients with prediabetes aged 21-79, and in-depth interviews (IDIs) with 48. Multivariable regression was used to analyse the survey results, while thematic analysis was used to analyse the IDIs.

RESULTS

The prevalence of ever receiving prediabetes education was 26.6%. This was positively associated with school education, impaired glucose tolerance, number of co-morbidities, having family or peer with diabetes, having support to reduce diabetes risk, confidence to self-manage prediabetes, and negatively associated with age. A common reason among those not receiving such education was not being referred by doctors. The preferred content of health communication messages were to focus on risk and prevention of diabetes, health and family, and to avoid the term 'prediabetes' in messages. The top 2 preferred education components were healthy eating and physical activity, and the most desired setting was the community centre.

CONCLUSIONS

More efforts are needed to increase the take-up rate of prediabetes education. Polyclinic healthcare professionals could provide preliminary advice, and subsequently refer patients to community-based programmes or resources.

Stakeholders' perceptions and experiences of the National Health Service diabetes prevention programme in England: qualitative study with service users, intervention providers and deliverers, commissioners and referrers

BACKGROUND

The National Health Service diabetes prevention programme in England, (NHS DPP) aims to identify people at high risk of type 2 diabetes (T2D) and offer them a face-to-face, group-based, behaviour change intervention for at least 9 months. The NHS DPP was rolled out in phases. We aimed to elicit stakeholders' perceptions and experiences of the factors influencing implementation of, and participation in, the programme during the development phase.

METHODS

Individual, semi-structured telephone interviews were conducted with 50 purposively sampled stakeholders: service users (n = 20); programme commissioners (n = 7); referrers (n = 8); and intervention deliverers (n = 15). Topic guides were structured using a pragmatic, theory-informed approach. Analysis employed the framework method.

RESULTS

We identified factors that influenced participation: Risk communication at referral - stakeholders identified point of referral as a window of opportunity to offer brief advice, to provide an understanding of T2D risk and information about the programme; Perceived impact of the NHS DPP - service users highlighted the positive perceived impact on their behaviour change, the peer support provided by participating in the programme, the option to involve a relative, and the 'knock on' effect on others. Service users also voiced disappointment when blood test results still identified them at high risk after the programme; and Behavioural maintenance - participants highlighted the challenges linked to behavioural maintenance (e.g. discontinuation of active support). Factors influencing implementations were also identified: Case finding - stakeholders suggested that using community involvement to identify service users could increase reach and ensure that the workload was not solely on GP practices; Adaptability: intervention deliverers acknowledged the need to tailor advice to service users' preferences and needs; Accountability - the need to acknowledge who was responsible for what at different stages of the NHS DPP pathway; and Fidelity - stakeholders described procedures involved in monitoring service users' satisfaction, outcome data collection and quality assurance assessments.

CONCLUSIONS

The NHS DPP offers an evidence-informed behavioural intervention for T2D prevention. Better risk communication specification could ensure consistency at the referral stage and improve participation in the NHS DPP intervention. Cultural adaptations and outreach strategies could ensure the NHS DPP contributes to reducing health inequalities.

Integrated health and care systems in England: can they help prevent disease?

Objectives

Over the past 12 months, there has been increasing policy rhetoric regarding the role of the National Health Service (NHS) in preventing disease and improving population health. In particular, the NHS Long Term Plan sees integrated care systems (ICSs) and sustainability and transformation partnerships (STPs) as routes to improving disease prevention. Here, we place current NHS England integrated care plans in their historical context and review evidence on the relationship between integrated care and prevention. We ask how the NHS Long Term Plan may help prevent disease and explore the role of the 2019 ICS and STP plans in delivering this change.

Methods

We reviewed the evidence underlying the relationship between integrated care and disease prevention, and analysed 2016 STP plans for content relating to disease prevention and population health.

Results

The evidence of more integrated care leading to better disease prevention is weak. Although nearly all 2016 STP plans included a prevention or population health strategy, fewer than half specified how they will work with local government public health teams, and there was incomplete coverage across plans about how they would meet NHS England prevention priorities. Plans broadly focused on individual-level approaches to disease prevention, with few describing interventions addressing social determinants of health.

Conclusions

For ICSs and STPs to meaningfully prevent disease and improve population health, they need to look beyond their 2016 plans and fill the gaps in the Long Term Plan on social determinants.

Implementing a national diabetes prevention programme in England: lessons learned

Background

Type 2 diabetes mellitus is preventable through lifestyle intervention. Diabetes prevention programmes (DPPs) aim to deliver prevention-based behaviour change interventions to reduce incidence. Such programmes vary from usual primary care in terms of where, how, and by whom they are delivered. Implementation is therefore likely to face new commissioning, incentive and delivery challenges. We report on the implementation of a national DPP in NHS England, and identify lessons learned in addressing the implementation challenges.

Methods

In 2017/18, we conducted 20 semi-structured telephone interviews covering 16 sampled case sites with the designated lead(s) responsible for local implementation of the programme. Interviews explored the process of implementation, including organisation of the programme, expectations and attitudes to the programme, funding, target populations and referral and clinical pathways. We drew on constant comparative methods to analyse the data and generate over-arching themes. We complemented our qualitative data with a survey focused on variation in the financial incentives used across sites to ensure usual primary care services recruited patients to new providers.

Results

We identified five over-arching areas of learning for implementing this large-scale programme: 1) managing new providers; 2) promoting awareness of services; 3) recruiting patients; 4) incentive payments; and 5) mechanisms for sharing learning. In general, tensions appeared to be caused by a lack of clear roles/responsibilities between hierarchical actors, and lack of communication. Both local sites and the national NHS coordination team gained experience through learning by doing. Initial tensions with roles and expectations have been worked out during implementation.

Conclusions

Implementing a national disease prevention programme is a major task, and one that will be increasingly faced by health systems globally as they aim to adjust to demand pressures. We provide practical learning opportunities for the wider uptake and sustainability of prevention programmes. Future implementers might wish to define clear responsibilities for each actor prior to implementation, ensure early engagement with new providers, offer mechanisms/forums for sharing learning, generate evidence and provide advice on incentive payments, and prioritise public and professional awareness of the programme.

Users' experiences of a pragmatic diabetes prevention intervention implemented in primary care: qualitative study

OBJECTIVES

To explore service-user and provider experience of the acceptability and value of the Let's Prevent Diabetes programme, a pragmatic 6-hour behavioural intervention using structured group education, introduced into primary care practice.

DESIGN

Qualitative interview-based study with thematic analysis.

SETTING

Primary care and community.

PARTICIPANTS

Purposeful sample of 32 participants, including 22 people at high risk of diabetes who either attended, defaulted from or declined the intervention; and 10 stakeholder professionals involved in implementation.

RESULTS

Participants had low prior awareness of their elevated risk and were often surprised to be offered intervention. Attenders were commonly older, white, retired and motivated to promote their health; who found their session helpful, particularly for social interaction, raising dietary awareness, and convenience of community location. However attenders highlighted lack of depth, repetition within and length of session, difficulty meeting culturally diverse needs and no follow-up as negative features. Those who defaulted from, or who declined the intervention were notably apprehensive, uncertain or unconvinced about whether they were at risk of diabetes; sought more specific information about the intervention, and were deterred by its group nature and day-long duration, with competing work or family commitments. Local providers recognised inadequate communication of diabetes risk to patients. They highlighted significant challenges for implementation, including resource constraints, and facilitation at individual general practice or locality level.

CONCLUSIONS

This pragmatic diabetes prevention intervention was acceptable in practice, particularly for older, white, retired and health-motivated people. However, pre-intervention information and communication of diabetes risk should be improved to increase engagement and reduce potential fear or uncertainty, with closer integration of services, and more appropriate care pathways, to facilitate uptake and follow-up. Further development of this, or other interventions, is needed to enable wider, and more socially diverse, engagement of people at risk. Balancing a locality and individual practice approach, and how this is resourced are considerations for long-term sustainability.

The community pharmacy setting for diabetes prevention: Views and perceptions of stakeholders

Background

Diabetes prevention programmes delay or prevent the onset of type 2 diabetes in people with pre-diabetes. To increase accessibility, national guidelines recommend delivering diabetes prevention programmes in primary care settings, including community pharmacy. This study aimed to explore the English community pharmacy setting as an option for delivering diabetes prevention services.

Methods

Two focus groups and nine semi-structured interviews were conducted with stakeholders including, community pharmacists, general practitioners and commissioners. The topic guide was framed using the COM-B theoretical model for behaviour change to elicit practitioners’ capability, opportunity and motivation to engage with providing or referring to community pharmacy diabetes prevention services. Data were analysed thematically, and barriers/facilitators mapped to the COM-B framework.

Results

Five themes were identified: ‘Pre-diabetes management and associated challenges’, ‘The community pharmacy setting’, ‘Awareness of community pharmacy services’, ‘Relationships and communication’ and ‘Delivery of community pharmacy services’. Community pharmacy was highlighted as an accessible setting for delivering screening and follow-on lifestyle interventions. Key factors for enhancing the capability of community pharmacy teams to deliver the interventions included training and appropriate use of skill mix. Delivering diabetes prevention services in collaboration with general practices was identified as key to the provision of integrated primary care services. Whilst financial incentives were identified as a motivating factor for delivery, service promotion to patients, public and healthcare professionals was perceived as crucial for enhancing engagement.

Conclusions

This research highlights a role for community pharmacy in diabetes prevention. New service models should seek to integrate community pharmacy services in primary care to facilitate patient engagement and better communication with general practices.

Understanding the diagnosis of pre-diabetes in patients aged over 85 in English primary care: a qualitative study

Background

The benefit of a “diagnosis” of pre-diabetes in very elderly patients is debated. How clinicians manage pre-diabetic blood results in these patients is unknown. This study aims to understand how clinicians are “diagnosing” older patients with pre-diabetic blood parameters.

Methods

Semi-structured interviews and focus groups with health care staff (24 total participants) were conducted in the north of England. Interviews and focus groups were recorded, transcribed and analysed thematically. A grounded theory approach was taken with the theory of candidacy being used as a sensitising concept through which questions were framed and results interpreted.

Results

There is a complex system of competing pressures that influence a clinician in deciding whether, and in what way, to inform a very elderly patient that they have pre-diabetes. The majority of clinicians adjust their management of pre-diabetes to the age and perceived risk/benefit for the patient. Whilst some clinicians choose not to inform certain patients of their blood results, many clinicians maintain, what could be seen as a somewhat paradoxical approach of labeling all older patients with pre-diabetes but downplaying the significance to the patient. The policy, organisational context, workload and professional constraints under which clinicians work, play a significant role in shaping how they deal with pre-diabetic blood results in the very elderly.

Conclusion

There has been recent acknowledgement of how policy and organisational context frames decision-making, but there is a lack of evidence on how this influences uncertainty and dilemmas in decision-making in practice. These findings add further weight for the argument that treatment burden should be included in clinical guidelines.

Referral of patients to diabetes prevention programmes from community campaigns and general practices: mixed-method evaluation using the RE-AIM framework and Normalisation Process Theory

BACKGROUND

Each year around 5-10% of people with non-diabetic hyperglycaemia will develop type 2 diabetes mellitus. Diabetes prevention is a national and global public health concern. Diabetes Prevention Programmes, which seek to identify at-risk individuals and support entry to health improvement initiatives, recognise that enhanced identification and referral of at-risk individuals is required within primary care and beyond, through community-focused prevention approaches. We report an evaluation of a demonstrator site for the NHS Diabetes Prevention Programme in the UK, which piloted an enhanced Primary Care referral programme (sampling from patients identified as at-risk from general practice databases) and a Community identification programme (sampling from the general population through opportunistic identification in community locations) in an effort to maximise participation in prevention services.

METHODS

We used mixed-methods evaluation to assess the impact of the two referral routes on participation in the Diabetes Prevention Programmes in line with the RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation and Maintenance). Individual level patient data was descriptively analysed to assess identifications and eligible referrals made in each route. Semi-structured interviews conducted with referral staff and key stakeholders were analysed using thematic analysis and informed by Normalisation Process Theory.

RESULTS

The nurse facilitated primary care referral route provided 88% of all referrals to the telephone DPP, compared to the community referral route which provided 5%, and the proportion joining the programme was higher among primary care referrals (45%) than community referrals (22%), and retention rates were higher (73% compared to 50%). The nurse-facilitated route integrated more easily into existing clinical processes. The community programme was impeded by a lack of collaborative inter-agency working which obscured the intended focus on high-risk populations despite conversion rates (numbers identified at risk who entered prevention programmes) being highest in areas of high deprivation.

CONCLUSIONS

The study demonstrates the interaction of components, with effective Adoption and Implementation necessary to support Reach. The NPT analysis demonstrated the importance of consensus around not only the need for such programmes but agreement on how they can be delivered. Future programmes should support inter-agency communication and collaboration, and focus identification efforts on areas of high-risk.

Prevention and reversal of Type 2 diabetes: highlights from a symposium at the 2019 Diabetes UK Annual Professional Conference

AIM

This symposium covers the gamut of Type 2 diabetes prevention, reversing established Type 2 diabetes, population-level delivery of weight loss programmes and personal insights into achieving and retaining substantial weight loss.

RESULTS

The NHS Diabetes Prevention Programme was launched in 2016 and rates of referral and attendance have both exceeded expectations. By March 2018, mean weight loss for completers (those attending more than 60% of sessions) was 3.2 kg reflecting considerable health benefits. Established Type 2 diabetes is now known to be a reversible condition in the early years, and the underlying mechanism is the removal of the excess fat from within liver and pancreas in these susceptible individuals. The Diabetes Remission Clinical Trial has shown that around half of a primary care population of people with Type 2 diabetes of less than 6 years' duration can be returned to non-diabetic blood glucose control which lasts at least 12 months. This raises the question of population-level intervention to achieve weight loss. The success of some mass weight loss programmes requires to be recognized. Reframing mass provision of weight loss support should be a vital part of our clinical strategy to prevent and treat Type 2 diabetes. However, the current obesogenic environment is a reality in which individuals must live. A personal account of achieving substantial and maintaining substantial weight loss provides an invaluable insight into practical problems encountered. All health professionals dealing with weight control should assimilate and reflect upon this understanding.

CONCLUSIONS

Effective prevention and long term reversal of Type 2 diabetes is feasible. The impact upon the individual must be considered during delivery of advice and support.

How do we identify people at high risk of Type 2 diabetes and help prevent the condition from developing?

AIMS

To review the evidence regarding the identification of those at high risk of Type 2 diabetes and the conceptual and clinical criteria defining high risk, the prevention or delay of onset of Type 2 diabetes through lifestyle interventions, and the evolution of evidence from efficacy trials, through effectiveness trials in real-world settings, to implementation programmes at scale.

METHOD

The wide scope of this review precluded a systematic approach, therefore, we present a narrative review that highlights key themes and contemporary developments, drawing on landmark studies, previous systematic and expert reviews, and previous meta-analyses.

RESULTS

While the diagnostic thresholds for Type 2 diabetes are accepted, international consensus on whether, and how, to classify those at high risk of Type 2 diabetes has not been achieved. There is ongoing debate about which laboratory test to use and each test's corresponding inclusion threshold, about where the balance of clinical benefits and harms sit when defining thresholds, and about how affordability of subsequent preventative interventions might influence the derivation of such thresholds within any particular population. A remarkable international effort has seen the evolution of interventions for those at high risk move from efficacy trials, through effectiveness trials, to implementation at scale, and the evidence supporting each stage is reviewed.

CONCLUSIONS

To achieve healthcare system sustainability, many countries are now focusing on disease prevention. To complement population-level interventions that address the obesogenic environment, lifestyle interventions that empower individuals at high risk of Type 2 diabetes to modify this risk beneficially are now being implemented at scale.

Validation of a non-laboratorial questionnaire to identify Metabolic Syndrome among a population in central Mexico

OBJECTIVE

To determine the reliability of a non-laboratorial questionnaire, the Encuesta de Identificación de Sujetos Metabólicamente Comprometidos en Fase-I (ESF-I) for identifying Metabolic Syndrome among a population in central Mexico.

METHODS

Clinical and biochemical parameters were collected for 232 participants from 1 June 2012 - 31 August 2013. Three definitions of Metabolic Syndrome (Harmonizing, National Cholesterol Education Program Expert Panel and Adult Treatment Panel III [ATPIII], and International Diabetes Federation [IDF]) were used to allocate subjects to either the normal or Metabolic Syndrome positive (MetS+) group. The predictability of the questionnaire was determined by the Area-Under-the-Receiver-Operating Characteristic curve (AUC). Youden's index was calculated and the highest score was considered the optimal cutoff value. Cohen´s kappa (κ) was calculated to determine the level of agreement between the ESF-I questionnaire (max score: 15 based on 15 items) and Metabolic Syndrome.

RESULTS

From 53.8% - 60.7% of the participants were determined to be MetS+. The average questionnaire score was significantly higher in the MetS+ group for each definition (4.0 vs. 8.0, P < 0.05). The ESF-I questionnaire was predictive for the Harmonizing definition (AUC = 0.841, 95%CI: 0.790 - 0.892), the ATPIII definition (AUC = 0.827, 95%CI: 0.774 - 0.880), and the IDF definition (AUC = 0.836, 95%CI: 0.785 - 0.887). A cutoff value of 7 was determined for each definition; therefore, the cohort was re-categorized based on questionnaire results. There was a strong agreement between the ESF-I questionnaire and MetS (Harmonizing: accuracy = 77.6%, κ = 0.554; ATPIII: accuracy = 74.1%, κ = 0.489; IDF: accuracy = 74.6%, κ = 0.495, P < 0.001).

CONCLUSION

The ESF-I questionnaire can identify MetS+ patients, and therefore, lead to earlier diagnoses, reduced number of consultations, and lower costs with easier application.

How are health-related behaviours influenced by a diagnosis of pre-diabetes? A meta-narrative review

BACKGROUND

Several countries, including England, have recently introduced lifestyle-focused diabetes prevention programmes. These aim to reduce the risk of individuals with pre-diabetes developing type 2 diabetes. We sought to summarise research on how socio-cultural influences and risk perception affect people's behaviour (such as engagement in lifestyle interventions) after being told that they have pre-diabetes.

METHODS

Using the RAMESES standards for meta-narrative systematic reviews, we identified studies from database searches and citation-tracking. Studies were grouped according to underlying theorisations of pre-diabetes. Following a descriptive analysis, the studies were synthesised with reference to Cockerham's health lifestyle theory.

RESULTS

In total, 961 titles were scanned, 110 abstracts assessed and 35 full papers reviewed. Of 15 studies included in the final analysis, 11 were based on individual interviews, focus groups or ethnography and five on structured questionnaires or surveys. Three meta-narratives emerged. The first, which we called biomedical, characterised pre-diabetes as the first stage in a recognised pathophysiological illness trajectory and sought to intervene with lifestyle changes to prevent its progression. The second, which we called psychological, focused on the theory-informed study of the knowledge, attitudes and behaviours in people with pre-diabetes. These studies found that participants generally had an accurate perception of their risk of developing diabetes, but this knowledge did not directly lead to behavioural change. Some psychological studies incorporated wider social factors in their theoretical models and sought to address these through action at the individual level. The third meta-narrative we termed social realist. These studies conceptualised pre-diabetes as the product of social determinants of health and they applied sociological theories to explore the interplay between individual agency and societal influences, such as the socio-cultural context and material and economic circumstances. They recommended measures to address these structural influences on lifestyle choices.

CONCLUSIONS

The study of pre-diabetes to date has involved at least three research disciplines (biomedicine, psychology and sociology), which up to now have operated largely independently of one another. Behavioural science and sociology are increasing our understanding of how personal, social, cultural and economic aspects influence health-related behaviours. An interdisciplinary approach with theoretically informed multi-level studies could potentially improve the success of diabetes prevention strategies.

TRIAL REGISTRATION

Prospero Registration Number: CRD42018088609 .

Using evidence-based guidelines to inform service provision: a structured mapping exercise within the National Health Service Diabetes Prevention Programme in England

Objective

The National Health Service (NHS) in England planned a national diabetes prevention programme (NHS DPP) with phased implementation. Evidence-based guidelines and service specifications support efficient and effective translation of research into practice. We aimed to evaluate the use of a structured mapping exercise to appraise how evidence, service specification and early phase practice could inform recommendations to guide subsequent implementation of the NHS DPP.

Results

The mapping exercise facilitated comparison and appraisal of key components from different documentary sources (evidence-based NICE guidelines, service specification, and provider documents). Key components were categorised into (A) pathways into programmes, (B) intervention content (C) inequalities and (D) quality assurance and staff training. We identified where key components were the same (accordance), where they varied (discrepancies) and where they were lacking (discontinuities), across the documentary sources. For example there was discrepancy in intervention duration and discontinuity in intervention enrolment procedures. This mapping exercise was useful to compare the fidelity in translation of evidence-based guidance into service specification and programme documents, thus identifying where future service implementation might be improved. This method may be applicable for use with other health conditions where research evidence requires translation into real world population programmes.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3546-8) contains supplementary material, which is available to authorized users.

Progress of the Healthier You: NHS Diabetes Prevention Programme: referrals, uptake and participant characteristics

AIMS

To describe early progress of the Healthier You: NHS Diabetes Prevention Programme, a behavioural intervention designed to prevent or delay onset of Type 2 diabetes in people in England already identified to be at high risk, to assess numbers of referrals received by Programme providers and the proportion that attended the initial assessment, and to identify the factors associated with attendance rates.

METHODS

These analyses examine the data for referrals received between June 2016 and March 2017.

RESULTS

There were 43 603 referrals received, 16% higher than expected. Of those referred, 49% attended the initial assessment, higher than the 40% modelled uptake. Of those referred, there was no significant difference in uptake by sex (P=0.061); however, attendance per 100 000 population varied significantly by sex, age group, ethnicity and deprivation; it was significantly lower for men (P<0.001), higher as age increased (P<0.001) and higher for individuals from Asian, Afro-Caribbean, mixed and other ethnic groups compared with individuals from white European groups (P<0.001). There was significant interaction between attendance rates by ethnicity and deprivation (P<0.001) such that attendance rates were significantly higher in the most deprived quintile vs the least deprived quintile for Asian, Afro-Caribbean, mixed and other ethnic groups but not significantly different for white European ethnic groups.

CONCLUSION

The analyses show that referral numbers and percentage uptake are in excess of prior modelled values. Characteristics of attendees suggest that the programme is reaching those who are both at greater risk of developing Type 2 diabetes and who typically access healthcare less effectively.