Cultural adaptation of a peer-led lifestyle intervention program for diabetes prevention in India: the Kerala diabetes prevention program (K-DPP)

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

AIMS

To identify barriers and enablers that influence engagement in and acceptability of diabetes prevention programmes for people with pre-diabetes. The results will provide insights for developing strategies and recommendations to improve design and delivery of diabetes prevention programmes with enhanced engagement and acceptability for people with pre-diabetes.

METHODS

This review used a critical realist approach to examine context and mechanisms of diabetes prevention programmes. Medline, Embase, PsycInfo, Cinahl, Web of Science, Scopus and Pre-Medline were searched for English language studies published between 2000 and 2023. A quality assessment was conducted using Joanna Briggs Institute critical appraisal tools.

RESULTS

A total of 90 papers met inclusion criteria. The included studies used a variety of quantitative and qualitative methodologies. Data extracted focused on barriers and enablers to engagement in and acceptability of diabetes prevention programmes, with seven key mechanisms identified. These included financial, environmental, personal, healthcare, social and cultural, demographic and programme mechanisms. Findings highlighted diverse factors that influenced engagement in preventive programmes and the importance of considering these factors when planning, developing and implementing future diabetes prevention programmes.

CONCLUSIONS

Mechanisms identified in this review can inform design and development of diabetes prevention programmes for people with pre-diabetes and provide guidance for healthcare professionals and policymakers. This will facilitate increased participation and engagement in preventive programmes, potentially reducing progression and/or incidence of pre-diabetes to type 2 diabetes and improving health outcomes.

Strengthening research capacity of early-mid career researchers: Implementation and evaluation of the Excellence in Non-COmmunicable disease REsearch (ENCORE) program

High-quality training and networking are pivotal for enhancing the research capacity of early- to mid-career researchers in the prevention and control of non-communicable diseases. Beyond building research skills, these professionals gain valuable insights from interdisciplinary mentorship, networking opportunities, and exposure to diverse cultures and health systems. Despite the significance of such initiatives, their implementation remains underexplored. Here, we describe the implementation and evaluation of the Excellence in Non-COommunicable disease REsearch (ENCORE) program, a collaborative initiative between Australia and India that was launched in 2016 and spanned a duration of 3 years. Led by a consortium that included the University of Melbourne and leading Indian research and medical institutions, ENCORE involved 15 faculty members and 20 early-mid career researchers. The program comprised various elements, including face-to-face forums, masterclasses, webinars, a health-technology conference, and roundtable events. ENCORE successfully trained the early-career researchers, resulting in over 30 peer-reviewed articles, 36 conference presentations, and the submission of seven grant applications, three of which received funding. Beyond individual achievements, ENCORE fostered robust research collaboration between Australian and Indian institutions, showcasing its broader impact on strengthening research capacities across borders.

Consolidated guidance for behavioral intervention pilot and feasibility studies

BACKGROUND

In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences.

METHODS

To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of a well-known PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences.

RESULTS

A total of 496 authors were invited to take part in the three-round Delphi survey (round 1, N = 46; round 2, N = 24; round 3, N = 22). A set of twenty considerations, broadly categorized into six themes (intervention design, study design, conduct of trial, implementation of intervention, statistical analysis, and reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading.

CONCLUSION

We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.

Enhanced or hindered research benefits? A realist review of community engagement and participatory research practices for non-communicable disease prevention in low- and middle-income countries

INTRODUCTION

Community engagement and participatory research are widely used and considered important for ethical health research and interventions. Based on calls to unpack their complexity and observed biases in their favour, we conducted a realist review with a focus on non-communicable disease prevention. The aim was to generate an understanding of how and why engagement or participatory practices enhance or hinder the benefits of non-communicable disease research and interventions in low- and middle-income countries.

METHODS

We retroductively formulated theories based on existing literature and realist interviews. After initial searches, preliminary theories and a search strategy were developed. We searched three databases and screened records with a focus on theoretical and empirical relevance. Insights about contexts, strategies, mechanisms and outcomes were extracted and synthesised into six theories. Five realist interviews were conducted to complement literature-based theorising. The final synthesis included 17 quality-appraised articles describing 15 studies.

RESULTS

We developed six theories explaining how community engagement or participatory research practices either enhance or hinder the benefits of non-communicable disease research or interventions. Benefit-enhancing mechanisms include community members' agency being realised, a shared understanding of the benefits of health promotion, communities feeling empowered, and community members feeling solidarity and unity. Benefit-hindering mechanisms include community members' agency remaining unrealised and participation being driven by financial motives or reputational expectations.

CONCLUSION

Our review challenges assumptions about community engagement and participatory research being solely beneficial in the context of non-communicable disease prevention in low- and middle-income countries. We present both helpful and harmful pathways through which health and research outcomes are affected. Our practical recommendations relate to maximising benefits and minimising harm by addressing institutional inflexibility and researcher capabilities, managing expectations on research, promoting solidarity in solving public health challenges and sharing decision-making power.

Formative research to adapt the 'Diabetes Prevention Program- Power to Prevent' for implementation in Bamako, Mali

BACKGROUND

There are few community-level behaviors change interventions for reducing diabetes and hypertension risk in Africa, despite increasing cases of type 2 diabetes and cardiovascular diseases. Thus, this study was designed to adapt the United States Centers for Disease Control and Prevention's "Diabetes Prevention Program Power to Prevent" (DPP-P2P) for use in low-income urban communities of Bamako, Mali.

METHODS

Feedback was elicited on an initial French PowerPoint adaptation of the DPP-P2P session guidelines from stakeholders at the ministry of health, organizational partners, and medical care providers. Two community health centers in districts with high levels of diabetes or hypertension were selected to assist in developing the Malian adaptation. Focus groups were conducted with 19 community health workers (CHWs) of these centers. Based on feedback from these discussions, more graphics, demonstrations, and role plays were added to the PowerPoint presentations. The 19 CHWs piloted the proposed 12 sessions with 45 persons with diabetes or at-risk patients over a one-month period. Feedback discussions were conducted after each session, and changes in dietary and exercise habits were assessed pre and post participation in the program. This feedback contributed to finalization of a 14-session sequence.

RESULTS

The DPP-P2P session guidelines were adapted for use by low-literacy CHWs, converting the written English guidelines into French PowerPoint presentations with extensive use of pictures, role plays and group discussions to introduce diabetes, diet, and exercise concepts appropriately for the Bamako context. CHWs recommendations for a strong family-oriented program led to expanded sessions on eliciting support from all adults in the household. The 45 participants in the pilot adaptation were enthusiastic about the program. At the end of the program, there were significant increases in the frequency of daily exercise, efforts to limit fat intake, and goals for more healthy diets and exercise levels.

CONCLUSION

This study documents how an iterative process of developing the DPP-P2P adaptation led to the development of a culturally appropriate set of materials welcomed by participants and having promise for reaching the low-income, low-literacy population with or at risk for diabetes in Bamako, Mali.

Expert Perspectives on Pilot and Feasibility Studies: A Delphi Study and Consolidation of Considerations for Behavioral Interventions

Background

In the behavioral sciences, conducting pilot and/or feasibility studies (PFS) is a key step that provides essential information used to inform the design, conduct, and implementation of a larger-scale trial. There are more than 160 published guidelines, reporting checklists, frameworks, and recommendations related to PFS. All of these publications offer some form of guidance on PFS, but many focus on one or a few topics. This makes it difficult for researchers wanting to gain a broader understanding of all the relevant and important aspects of PFS and requires them to seek out multiple sources of information, which increases the risk of missing key considerations to incorporate into their PFS. The purpose of this study was to develop a consolidated set of considerations for the design, conduct, implementation, and reporting of PFS for interventions conducted in the behavioral sciences.

Methods

To develop this consolidation, we undertook a review of the published guidance on PFS in combination with expert consensus (via a Delphi study) from the authors who wrote such guidance to inform the identified considerations. A total of 161 PFS-related guidelines, checklists, frameworks, and recommendations were identified via a review of recently published behavioral intervention PFS and backward/forward citation tracking of well-know PFS literature (e.g., CONSORT Ext. for PFS). Authors of all 161 PFS publications were invited to complete a three-round Delphi survey, which was used to guide the creation of a consolidated list of considerations to guide the design, conduct, and reporting of PFS conducted by researchers in the behavioral sciences.

Results

A total of 496 authors were invited to take part in the Delphi survey, 50 (10.1%) of which completed all three rounds, representing 60 (37.3%) of the 161 identified PFS-related guidelines, checklists, frameworks, and recommendations. A set of twenty considerations, broadly categorized into six themes (Intervention Design, Study Design, Conduct of Trial, Implementation of Intervention, Statistical Analysis and Reporting) were generated from a review of the 161 PFS-related publications as well as a synthesis of feedback from the three-round Delphi process. These 20 considerations are presented alongside a supporting narrative for each consideration as well as a crosswalk of all 161 publications aligned with each consideration for further reading.

Conclusion

We leveraged expert opinion from researchers who have published PFS-related guidelines, checklists, frameworks, and recommendations on a wide range of topics and distilled this knowledge into a valuable and universal resource for researchers conducting PFS. Researchers may use these considerations alongside the previously published literature to guide decisions about all aspects of PFS, with the hope of creating and disseminating interventions with broad public health impact.

The Development of Text Messages to Support People at Risk of Diabetes in Low-Resourced Communities: The South African Diabetes Prevention Programme

Emerging evidence suggests that the addition of text messages to standard healthy lifestyle interventions may improve the outcomes of diabetes prevention programs (DPP). This paper describes the process of developing text messages targeting behavior change in people at risk of developing diabetes in low-resourced communities as part of the South African DPP (SA-DPP). The development comprised multiple steps led by nutrition and physical activity experts. The steps included the following: (1) text message development based on the existing SA-DPP curriculum and its formative research; (2) text message evaluation for readability/understandability in terms of content, language, and quality, with 75 participants from two low-resourced areas in Cape Town; (3) text message refinement by the expert panel; (4) evaluation of the refined text messages by participants from Step 2; and (5) text bank finalization. Based on the readability survey, 37 of the 67 formulated text messages [24 of the 44 encouraged healthy eating, and 13 of the 23 promoted physical activity] were refined. Based on focused discussions with participants, seven more messages were refined to consider alternative terminology. The final text bank includes a total of 67 messages comprising topics related to fruit and vegetable consumption as well as the importance of having variety in the diet (n = 15), limiting fat intake (n = 10), avoiding sugar (n = 11), avoiding salt (n = 5), promoting fiber-rich foods (n = 1), messages promoting physical activity (n = 21), and general check-in messages (n = 4). Most of the text messages were acceptable, understandable, and largely feasible to all participants, with some of the nutrition-related messages being less feasible for participants due to their socioeconomic position. The next step is to assess the text messages in the SA-DPP intervention trial.

A stepped wedge cluster randomized trial to evaluate the effectiveness of a community leader-driven kit-based diabetes self-management education approach in improving diabetes control and care: study protocol for the DElhi Diabetes INTervention Trial (DEDINTT)

INTRODUCTION

Diabetes self-management education (DSME) helps patients self-manage their condition and improve outcomes/quality of life. However, access to DSME is limited, particularly in low-income areas. This study aims to develop a DSME training kit (EK-DIN), understand barriers to implementation, and evaluate the effectiveness and sustainability of community leader (CL)-based rollout using a stepped wedge cluster randomized trial format.

METHODS AND ANALYSIS

The mixed methods study will begin with a qualitative study to evaluate the facilitators and barriers towards CL-based DSME. The in-depth interview notes will be transcribed for thematic analysis. These results will be utilized for a stakeholder's workshop to develop the EK-DIN kit, a patient-interfacing app, and an implementation plan. Rollout will be conducted in 30 clusters in Delhi, preselected by the DEDICOM-II survey in 5 steps (6 clusters every 3 months: 2 each from each socio-economic category; randomly selected per sequence). A CL from each cluster will be trained in using the EK-DIN kit/app over 1 month. The trained CL will conduct DSME sessions among the cluster residents using the EK-DIN kits provided fortnightly for 3 months. Compliance and blood parameters data will be collected at baseline, 3 months after the intervention, and every quarter thereafter till completion. Change in HbA1c before and after the intervention will be evaluated as the primary outcome using the swCRTdesign package for R version 4.0.2 and the swSummary function. The sustainability of the effects will be evaluated using the change in quarterly parameters after intervention completion.

DISCUSSION

A positive result will set the template for a generalizable public health intervention with proven community effectiveness, sustainability, cost-effectiveness, and positive quality-of-life impact. While a negative result will require the testing of alternative approaches, it would still add substantially to existing knowledge on the subject. Given the diverse socio-cultural setting in which the trial is being proposed and the high power of the study, the results (positive or negative) should be widely applicable and have policy implications.

TRIAL REGISTRATION

CTRI/2023/07/054963. Date of Registration: 7th July 2023.

Community organization guides standardization, adaptability, and innovation: lessons from peer support in the Shanghai Integration Model

Although there is broad evidence for the value of peer support (PS) in preventing and managing diabetes and other chronic diseases, identifying approaches to stage, scale, and adapt PS interventions is a challenge. Community organization may provide a process for such adaptation of standardized PS and diabetes management to individual communities. This community organization approach was used to develop PS in 12 communities in Shanghai, China. Through a convergent mixed methods design, project records, semi-structured interviews, and an implementation assessment characterized processes of adaptation of standardized materials, examined the extent to which the program was implemented, and identified key success factors and challenges. Findings from both interviews and the implementation assessment indicated that communities adapted standardized intervention components to meet the needs of their communities and assumed responsibility for implementation of different components of the program based on their community's available capacity. Additionally, community innovations occurring as part of the project were reported and standardized for dissemination in future iterations of the program. Key success factors identified included cooperation and collaboration among varied partners within and across communities. Two challenges illustrate the resilience of the community organization model in response to COVID-19 and the need for further adaptation in rural communities. Community organization provided a useful approach to standardization, adaptation, innovation, and reporting of PS interventions for diabetes management.

A peer support program results in greater health benefits for peer leaders than other participants: evidence from the Kerala diabetes prevention program

BACKGROUND

Peer support programs are promising approaches to diabetes prevention. However, there is still limited evidence on the health benefits of peer support programs for lay peer leaders.

PURPOSE

To examine whether a peer support program designed for diabetes prevention resulted in greater improvements in health behaviors and outcomes for peer leaders as compared to other participants.

METHODS

51 lay peer leaders and 437 participants from the Kerala Diabetes Prevention Program were included. Data were collected at baseline, 12 months, and 24 months. We compared behavioral, clinical, biochemical, and health-related quality of life parameters between peer leaders and their peers at the three time-points.

RESULTS

After 12 months, peer leaders showed significant improvements in leisure time physical activity (+ 17.7% vs. + 3.4%, P = 0.001) and health-related quality of life (0.0 vs. + 0.1, P = 0.004); and a significant reduction in alcohol use (-13.6% vs. -6.6%, P = 0.012) and 2-hour plasma glucose (-4.1 vs. + 9.9, P = 0.006), as compared to participants. After 24 months, relative to baseline, peer leaders had significant improvements in fruit and vegetable intake (+ 34.5% vs. + 26.5%, P = 0.017) and leisure time physical activity (+ 7.9% vs. -0.9%, P = 0.009); and a greater reduction in alcohol use (-13.6% vs. -4.9%, P = 0.008), and waist-to-hip ratio (-0.04 vs. -0.02, P = 0.014), as compared to participants. However, only the changes in fruit and vegetable intake and waist-to-hip ratio were maintained between 12 and 24 months.

CONCLUSION

Being a peer leader in a diabetes prevention program was associated with greater health benefits during and after the intervention period. Further studies are needed to examine the long-term sustainability of these benefits.

Implementation of non-insulin-dependent diabetes self-management education (DSME) in LMICs: a systematic review of cost, adoption, acceptability, and fidelity in resource-constrained settings

Background

Type II diabetes (T2D), is a serious health issue accounting for 10.7% of mortality globally. 80% of cases worldwide are found in low- and middle-income countries (LMIC), with rapidly increasing prevalence. Diabetes-self management education (DSME) is a cost-effective program that provides at-risk individuals with the knowledge and skills they need to adopt lifestyle changes that will improve their health and well-being. This systematic review examined the application of DSME in LMICs and identified the corresponding implementation results (cost, fidelity, acceptance, and adoption) associated with successful implementation in low-resource settings.

Methods and analysis

The available research on T2D and the use of DSME in LMIC were systematically searched for using six electronic databases (PubMed, Embase, Cochrane, Web of Science, Google Scholar, PAIS, and EBSCO Discovery) between the months of October and November of 2022. The articles that met the search criteria were subsequently imported into EndNote and Covidence for analysis. The Cochrane RoB methodology for randomized trials was used to evaluate the risk of bias (RoB) in the included studies. A narrative synthesis was used to summarize the results.

Results

A total of 773 studies were imported for screening, after 203 duplicates were removed, 570 remained. Abstract and title screenings resulted in the exclusion of 487 articles, leaving 83 for full-text review. Following a full-text review, 76 articles were excluded and seven were found to be relevant to our search. The most common reasons for exclusion were study design (n = 23), lack of results (n = 14), and wrong patient population (n = 12).

Conclusion

Our systemic review found that DSME can be an acceptable and cost-effective solution in LMIC. While we intended to analyze cost, adoption, acceptability, and fidelity, our investigation revealed a gap in the literature on those areas, with most studies focusing on acceptability and cost and no studies identifying fidelity or adoption. To further evaluate the efficacy of DSME and enhance health outcomes for T2D in LMICs, more research is needed on its application.

Systematic Review Registration

osf.io/7482t.

The long-term effects of Kerala Diabetes Prevention Program on diabetes incidence and cardiometabolic risk: a study protocol

INTRODUCTION

India currently has more than 74.2 million people with Type 2 Diabetes Mellitus (T2DM). This is predicted to increase to 124.9 million by 2045. In combination with controlling blood glucose levels among those with T2DM, preventing the onset of diabetes among those at high risk of developing it is essential. Although many diabetes prevention interventions have been implemented in resource-limited settings in recent years, there is limited evidence about their long-term effectiveness, cost-effectiveness, and sustainability. Moreover, evidence on the impact of a diabetes prevention program on cardiovascular risk over time is limited.

OBJECTIVES

The overall aim of this study is to evaluate the long-term cardiometabolic effects of the Kerala Diabetes Prevention Program (K-DPP). Specific aims are 1) to measure the long-term effectiveness of K-DPP on diabetes incidence and cardiometabolic risk after nine years from participant recruitment; 2) to assess retinal microvasculature, microalbuminuria, and ECG abnormalities and their association with cardiometabolic risk factors over nine years of the intervention; 3) to evaluate the long-term cost-effectiveness and return on investment of the K-DPP; and 4) to assess the sustainability of community engagement, peer-support, and other related community activities after nine years.

METHODS

The nine-year follow-up study aims to reach all 1007 study participants (500 intervention and 507 control) from 60 randomized polling areas recruited to the original trial. Data are being collected in two phases. In phase 1 (Survey), we are admintsering a structured questionnaire, undertake physical measurements, and collect blood and urine samples for biochemical analysis. In phase II, we are inviting participants to undergo retinal imaging, body composition measurements, and ECG. All data collection is being conducted by trained Nurses. The primary outcome is the incidence of T2DM. Secondary outcomes include behavioral, psychosocial, clinical, biochemical, and retinal vasculature measures. Data analysis strategies include a comparison of outcome indicators with baseline, and follow-up measurements conducted at 12 and 24 months. Analysis of the long-term cost-effectiveness of the intervention is planned.

DISCUSSION

Findings from this follow-up study will contribute to improved policy and practice regarding the long-term effects of lifestyle interventions for diabetes prevention in India and other resource-limited settings.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry-(updated from the original trial)ACTRN12611000262909; India: CTRI/2021/10/037191.

Adapting and Developing A Diabetes Prevention Intervention Programme for South Africa: Curriculum and Tools

The South African Diabetes Prevention Programme (SA-DPP) is a lifestyle intervention targeting individuals at high risk of developing type 2 diabetes mellitus (T2DM). In this paper we describe the mixed-method staged approach that was used to develop and refine the SA-DPP intervention curriculum and the appropriate tools for local resource-poor communities. During the preparation phase, existing evidence on similar DPP interventions was reviewed, focus group discussions with individuals from the target population were conducted as part of a needs assessment, and experts were consulted. The curriculum booklet, a participant workbook and facilitator workbook were developed, and the content was evaluated by experts in the field. The design and layout of the booklet and workbooks needed to be culturally and contextually appropriate. The printed material was evaluated for readability and acceptability by participants of the target population; based on their feedback, the design and layout were refined and the printed material was translated. The suitability of the intervention was tested in a pilot study; based on feedback from the participants and facilitator, the curriculum was revised where needed and finalised. Through this process a context specific intervention and printed materials were developed. A complete evaluation of this culturally relevant model for T2DM prevention in South Africa is pending.

The suitability, acceptability, and feasibility of a culturally contextualized low-calorie diet among women at high risk for diabetes mellitus in Kerala: a mixed-methods study

Background

Nutritional therapy has been conventionally recommended for people with prediabetes as a method to delay or halt progression to type 2 diabetes mellitus (T2DM). The extensive diversity in food culture and habits in India pose a challenge in devising a uniform low-calorie diet plan. Though there are a number of studies related to different diet therapies, there exists limited evidence on culturally contextualized low-calorie diet plans and their process in India. The objective of the study is to test the suitability, acceptability, and feasibility of a culturally contextualized low-calorie diet among women with high risk for T2DM in Kerala.

Method

We employed a four-stage equal-status sequential design for this study. Firstly, in-depth interviews (n = 10) were conducted to understand the modifiable and non-modifiable components of the usual diet for diabetes prevention. Secondly, we developed a low-calorie diet plan (1500 kcal per day) based on the local preferences and availability. Thirdly, we piloted the diet plan among 18 individuals in the community to know its acceptability. Fourthly, in-depth interviews were done (n = 4) among pilot participants to understand the feasibility of pursuing it through facilitators and barriers to implementing the diet plan.

Results

Low-calorie diet plan was suitable for this setting as the burden of diabetes is very high and the diet plan had dietary components similar to the usual diet. Though participants had an intrinsic motivation to follow a healthy lifestyle, several systemic challenges such as the high cost of healthy foods options (fruits and vegetables), rice addiction, and food preferences driven by peer pressure act as hurdles.

Conclusion

Apart from culturally contextualizing the low-calorie diet, it is important that complementary strategic measures such as reorientation of the public distribution system and subsidizing fruit and vegetable production and cost are required for the suitability, acceptability, and feasibility of implementation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13410-022-01134-8.

Application of the Theoretical Framework of Acceptability to assess a telephone-facilitated health coaching intervention for the prevention and management of type 2 diabetes

Background

Lifestyle interventions focusing on diet and physical activity for the prevention and management of type 2 diabetes have been found effective. Acceptance of the intervention is crucial. The Theoretical Framework of Acceptability (TFA) developed by Sekhon et al. (2017) describes the multiple facets of acceptance: Affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs and self-efficacy. The aims of this study were to develop and assess the psychometric properties of a measurement scale for acceptance of a telephone-facilitated health coaching intervention, based on the TFA; and to determine the acceptability of the intervention among participants living with diabetes or having a high risk of diabetes in socioeconomically disadvantaged areas in Stockholm.

Methods

This study was nested in the implementation trial SMART2D (Self-management approach and reciprocal learning for type 2 diabetes). The intervention consisted of nine telephone-facilitated health coaching sessions delivered individually over a 6-month period. The acceptability of the intervention was assessed using a questionnaire consisting of 19 Likert scale questions developed using Sekhon’s TFA. Exploratory factor analysis (EFA) was performed.

Results

Ratings from 49 participants (19 with type 2 diabetes and 30 at high risk of developing diabetes) in ages 38–65 were analyzed. The EFA on the acceptability scale revealed three factors with acceptable reliabilities: affective attitude (alpha 0.90), coherence and understanding (alpha 0.77), perceived burden (alpha 0.85), explaining 82% of the variance. Positive affect and coherence had high median scores and small variance. Median score for perceived burden was low, but with significant variance due to younger individuals and those at high risk reporting higher burden.

Conclusions

The telephone-facilitated health coaching intervention was perceived as acceptable by the study population using a questionnaire based on Sekhon’s TFA, with a wider variation in perceived burden seen among high risk and younger participants.

Non-pharmacological interventions for the prevention of type 2 diabetes in low-income and middle-income countries: a systematic review of randomised controlled trials

OBJECTIVE

Diabetes poses serious health threats and economic burdens to patients, especially in low-income and middle-income countries (LMICs). This systematic review searches for non-pharmacological interventions for the prevention of type-2 diabetes mellitus (T2DM) among patients who are non-diabetic and pre-diabetic from LMICs.

SETTINGS

LMICs.

PARTICIPANTS

Adult population aged over 18 years without having diabetes.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome is to measure the change in the incidence of T2DM. The secondary outcome is to measure changes in glycated haemoglobin (HbA1c) level, weight/body mass index (BMI), fasting glucose level and 2-hour glucose from baseline of the included randomised controlled trials.

METHODS

This review has been conducted following the standard systematic review guidelines. A total of six electronic databases including MEDLINE, Embase, the Cochrane Library, Web of Science, ClinicalTrials.gov and International Clinical Trials Registry Platform were searched in February 2021 using a comprehensive search strategy.Two sets of independent reviewers performed screening, risk of bias (ROB) assessment using the Cochrane ROB tool and data extraction. Narrative coalescence of selected articles was demonstrated using tables. No meta-analysis was performed due to the lack of homogenous intervention strategies and study settings.

RESULT

A total of five studies were included for the review with a combined population of 1734 from three countries. Three of the studies showed a significant reduction in T2DM incidence after the intervention of physical training and dietary modifications. Four of the studies also demonstrated a significant reduction of different secondary outcomes like weight, BMI, fasting and 2-hour plasma glucose and HbA1c. All the studies demonstrated a low ROB in most of the bias assessment domains with some unclear results in allocation concealments.

CONCLUSIONS

Emphasising non-pharmacological interventions for T2DM prevention can improve health outcomes and lessen the economic burdens, which will be of paramount importance in LMICs.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42020191507.

Effectiveness and implementation of a lifestyle modification intervention for women with isolated impaired fasting glucose: Study protocol for a hybrid type 2 study in Kerala, India

Background: Isolated impaired fasting glucose (i-IFG) constitutes a major group in the prediabetic spectrum among Indians, and thus it is imperative to identify effective diabetes prevention strategies. This study aims to evaluate the effects of an intensive community-based lifestyle modification program on regression to normoglycemia among women with i-IFG, compared to a control group at 24 months. The study also aims to evaluate the implementation of the intervention, via both process and implementation outcomes. Methods: We will use a hybrid design (Effectiveness-implementation hybrid type 2 trial) to test the effectiveness and implementation of the lifestyle modification intervention. Effectiveness is evaluated using a randomized controlled trial among 950 overweight or obese women, aged 30 to 60 years, with i-IFG on an oral glucose tolerance test in the Indian state of Kerala. The intervention involves an intensive lifestyle modification program through group and individually mentored sessions using behavioural determinants and behavioural change techniques.  The intervention group will receive the intervention for a period of 12 months and the control group will receive general health advice through a health education booklet. Data on behavioural, clinical, and biochemical measures will be collected using standard methods at 12 and 24 months. The primary outcome will be regression to normoglycemia at 24 months, as defined by the American Diabetes Association criteria. Discussion: This study will provide the first evidence on the effects of lifestyle interventions on regression to normoglycemia in people with i-IFG among Indians. CTRI registration: CTRI/2021/07/035289 (30/07/2021).

Implementation of a diabetes prevention program within two community sites: a qualitative assessment

Background

Despite numerous translations of diabetes prevention programs, implementation evaluations are rarely conducted. The purpose of this study was to examine the implementation process and multilevel contextual factors as an evidence-based diabetes prevention program was implemented into two local community organization sites to inform future scale-up. To build the science of implementation, context and strategies must be identified and explored to understand their impact.

Methods

The program was a brief-counseling diet and exercise modification program for individuals at risk of developing type 2 diabetes. A 1-year collaborative planning process with a local not-for-profit community organization co-developed an implementation plan to translate the program. A pragmatic epistemology guided this research. Semi-structured interviews were conducted with staff who delivered the program (n = 8), and a focus group was completed with implementation support staff (n = 5) at both community sites. Interviews were transcribed verbatim and thematically analyzed using a template approach. The consolidated framework for implementation research (CFIR) is a well-researched multilevel implementation determinant framework and was used to guide the analysis of this study. Within the template approach, salient themes were first inductively identified, then identified themes were deductively linked to CFIR constructs.

Results

Implementation strategies used were appropriate, well-received, and promoted effective implementation. The implementation plan had an impact on multiple levels as several CFIR constructs were identified from all five domains of the framework: (a) process, (b) intervention characteristics, (c) outer setting, (d) inner setting, and (e) individual characteristics. Specifically, results revealed the collaborative 1-year planning process, program components and structure, level of support, and synergy between program and context were important factors in the implementation.

Conclusion

This study offers insights into the process of implementing a community-based diabetes prevention program in two local sites. Successful implementation benefited from a fully engaged, partnered approach to planning, and subsequently executing, an implementation effort. The CFIR was a useful and thorough framework to evaluate and identify multilevel contextual factors impacting implementation. Results can be used to inform future implementation and scale-up efforts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00258-6.

SMART2D-development and contextualization of community strategies to support self-management in prevention and control of type 2 diabetes in Uganda, South Africa, and Sweden

Type 2 diabetes (T2D) and its complications are increasing rapidly in low- and middle-income countries, as well as among socioeconomically disadvantaged populations in high-income countries. Support for healthy lifestyle and self-management is paramount but not well implemented in health systems, and there is need for knowledge on how to design and implement interventions that are contextualized and patient centered and address special needs of disadvantaged population groups. The SMART2D project implements and evaluates a lifestyle and self-management intervention for participants recently diagnosed with or being at increased risk for T2D in rural communities in Uganda, an urban township in South Africa, and socioeconomically disadvantaged urban communities in Sweden. Our aim was to develop an intervention with shared key functions and a good fit with the local context, needs, and resources. The intervention program design was conducted in three steps facilitated by a coordinating team: (a) situational analysis based on the SMART2D Self-Management Framework and definition of intervention objectives and core strategies; (b) designing generic tools for the strategies; and (c) contextual translation of the generic tools and their delivery. This article focuses on community strategies to strengthen support from the social and physical environment and to link health care and community support. Situational analyses showed that objectives and key functions addressing mediators from the SMART2D framework could be shared. Generic tools ensured retaining of functions, while content and delivery were highly contextualized. Phased, collaborative approach and theoretical framework ensured that key functions were not lost in contextualization, also allowing for cross-comparison despite flexibility with other aspects of the intervention between the sites. The trial registration number of this study is ISRCTN11913581.

Cultural Considerations for the Adaptation of a Diabetes Self-Management Education Program in Cotonou, Benin: Lessons Learned from a Qualitative Study

Background: Type 2 diabetes (T2D) poses a disproportionate burden on Benin, West Africa. However, no diabetes intervention has yet been developed for Benin’s contexts. This study aimed to explore specific cultural beliefs, attitudes, behaviors, and environmental factors to help adapt a diabetes self-management program to patients with T2D from Cotonou, in southern Benin. Methods: Qualitative data were collected through focus group discussions (FDGs) involving 32 patients with T2D, 16 academic partners, and 12 community partners. The FDGs were audio-recorded, transcribed verbatim from French to English, and then analyzed thematically with MAXQDA 2020. Results: Healthy food was challenging to obtain due to costs, seasonality, and distance from markets. Other issues discussed were fruits and vegetables as commodities for the poor, perceptions and stigmas surrounding the disease, and the financial burden of medical equipment and treatment. Information about local food selections and recipes as well as social support, particularly for physical activity, were identified, among other needs. When adapting the curriculum, gender dynamics and spirituality were suggested. Conclusions: The study demonstrates the need for culturally sensitive interventions and a motivation-based approach to health (spiritual and emotional support). It also lays the groundwork for addressing T2D contextually in Benin and similar sub-Saharan African countries.

The relationship between common mental disorders and incident diabetes among participants in the Kerala Diabetes Prevention Program (K-DPP)

This study aims to describe the prevalence of depression and anxiety among a population sample of people at high risk for type 2 diabetes in Kerala, India, and examine the relationship between depressive symptoms, anxiety, and incident Type 2 Diabetes Mellitus (T2DM) over a two-year period. We used data from the Kerala Diabetes Prevention Program, a cluster-randomized controlled trial for diabetes prevention among 1007 high-risk individuals. The prevalence of depression and anxiety were estimated using the 9-item Patient Health Questionnaire and the Generalized Anxiety Disorder 7-item scale, respectively. We calculated proportions for depression and anxiety and performed generalized estimating equations (GEE) to examine the relationship between baseline mental health status and incident T2DM. The prevalence of depression and anxiety at baseline were 7.5% and 5.5%, respectively. Compared with those reporting none/low symptoms, the odds ratio for incident diabetes was 1.07 (95% CI 0.54–2.12) for participants with moderate to severe depression and 0.73 (95% CI 0.23–2.28) for participants with moderate to severe anxiety, after adjusting for potential confounders. Our findings suggest that the prevalence of depression and anxiety were higher than those previously reported in the general population in India. However, among this sample of community-based adults at high risk of developing T2DM, the presence of moderate to severe depression and/or anxiety symptoms was not significantly associated with the risk of developing T2DM.

Trial registration: Australia and New Zealand Clinical Trials Registry ACTRN12611000262909. Registered 10 March 2011.

The effect of a cluster-randomized controlled trial on lifestyle behaviors among families at risk for developing type 2 diabetes across Europe: the Feel4Diabetes-study

BACKGROUND

This study investigated the effect of the Feel4Diabetes-intervention, a 2-year multilevel intervention, on energy balance-related behaviors among European families at risk for developing type 2 diabetes. Intervention effects on self-reported physical activity, sedentary behavior and eating behaviors were investigated across and within the participating countries: Belgium, Finland, Greece, Spain, Hungary and Bulgaria.

METHODS

Families were recruited through schools, located in low socio-economic status areas. In total, 4484 families at risk for developing type 2 diabetes were selected using the FINDRISC-questionnaire. Parents' and children's energy balance-related behaviors data were collected by questionnaires at three time points (baseline, mid- and post intervention). Families assigned to the intervention group were invited to participate in a 2-year school-, community-, and family-based intervention to promote a healthier lifestyle, including counseling sessions (first intervention year) and text messages (second intervention year). Families assigned to the control group received standard care, including medical check-up results and recommendations and tips regarding a healthy lifestyle. To assess the intervention-effects, Mixed Models were conducted using the R-Package "lmer "with R v3.2.

RESULTS

Significant intervention effects were found on a certain number of families' lifestyle behaviors. Significant favorable intervention effects were detected on parents' water consumption and consumption of fruit and vegetables, and on children's consumption of sweets and moderate-to-vigorous physical activity. Analyses by country revealed significant favorable intervention effects on water consumption and on moderate-to-vigorous physical activity in Belgian parents and on fruit and vegetable consumption among Belgian children, on sweets consumption among Spanish parents and children, and on moderate-to-vigorous physical activity among Finnish children. Unfavorable intervention effects were found on the consumption of soft drinks and sugar-containing juices among Hungarian children and parents, while when examining the intervention effects for the overall population and per country, 10 from the 112 investigated outcome variables were improved in the intervention group compared to the control group (9%).

CONCLUSIONS

The Feel4Diabetes-intervention managed to improve a certain number of targeted lifestyle behaviors while the intervention was not effective on a large number of targeted lifestyle behaviors. The findings of the current study are encouraging, but further research is needed on how we can further improve effectiveness of lifestyle interventions to prevent type 2 diabetes in families at risk.

TRIAL REGISTRATION

The Feel4Diabetes-study is registered with the clinical trials registry http://clinicaltrials.gov , ID: 643708.

Effects of a lifestyle intervention on cardiovascular risk among high-risk individuals for diabetes in a low- and middle-income setting: Secondary analysis of the Kerala Diabetes Prevention Program

We aimed to examine whether a lifestyle intervention was effective in reducing cardiovascular disease (CVD) risk in individuals at high-risk of developing diabetes in a low- and middle-income setting. The Kerala Diabetes Prevention Program was evaluated by a cluster-randomized controlled trial (2013-2016) of 1007 individuals (aged 30-60 years) at high-risk for diabetes (Indian Diabetes Risk Score ≥ 60 and without diabetes) in Kerala state, India. Sixty polling areas in Kerala were randomized to intervention or control groups by an independent statistician using a computer-generated randomization sequence. Participants from 30 intervention communities received a 12-month structured peer-support lifestyle intervention program involving 15 group sessions and linked community activities, aimed at supporting and maintaining lifestyle change. The primary outcome for this analysis was the predicted 10-year CVD risk at two years, assessed using the Framingham Risk Score. The mean age at baseline was 46.0 (SD: 7.5) years, and 47.2% were women. Baseline 10-year CVD risk was similar between study groups. The follow-up rate at two years was 95.7%. The absolute risk reduction in predicted 10-year CVD risk between study groups was 0.69% (95% CI: 0.09% to 1.29%, p=0.024) at one year and 0.69% (95% CI: 0.10% to 1.29%, p=0.023) at two years. The favorable change in CVD risk with the intervention condition was mainly due to the reduction in tobacco use (change index: -0.25, 95% CI: -0.42 to -0.09). Our findings suggest that a community-based peer-support lifestyle intervention could reduce CVD risk in individuals at high-risk of developing diabetes in India. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry ACTRN12611000262909.

Cost-effectiveness of a lifestyle intervention in high-risk individuals for diabetes in a low- and middle-income setting: Trial-based analysis of the Kerala Diabetes Prevention Program

BACKGROUND

Data on the cost-effectiveness of lifestyle-based diabetes prevention programs are mostly from high-income countries, which cannot be extrapolated to low- and middle-income countries. We performed a trial-based cost-effectiveness analysis of a lifestyle intervention targeted at preventing diabetes in India.

METHODS

The Kerala Diabetes Prevention Program was a cluster-randomized controlled trial of 1007 individuals conducted in 60 polling areas (electoral divisions) in Kerala state. Participants (30-60 years) were those with a high diabetes risk score and without diabetes on an oral glucose tolerance test. The intervention group received a 12-month peer-support lifestyle intervention involving 15 group sessions delivered in community settings by trained lay peer leaders. There were also linked community activities to sustain behavior change. The control group received a booklet on lifestyle change. Costs were estimated from the health system and societal perspectives, with 2018 as the reference year. Effectiveness was measured in terms of the number of diabetes cases prevented and quality-adjusted life years (QALYs). Three times India's gross domestic product per capita (US$6108) was used as the cost-effectiveness threshold. The analyses were conducted with a 2-year time horizon. Costs and effects were discounted at 3% per annum. One-way and multi-way sensitivity analyses were performed.

RESULTS

Baseline characteristics were similar in the two study groups. Over 2 years, the intervention resulted in an incremental health system cost of US$2.0 (intervention group: US$303.6; control group: US$301.6), incremental societal cost of US$6.2 (intervention group: US$367.8; control group: US$361.5), absolute risk reduction of 2.1%, and incremental QALYs of 0.04 per person. From a health system perspective, the cost per diabetes case prevented was US$95.2, and the cost per QALY gained was US$50.0. From a societal perspective, the corresponding figures were US$295.1 and US$155.0. For the number of diabetes cases prevented, the probability for the intervention to be cost-effective was 84.0% and 83.1% from the health system and societal perspectives, respectively. The corresponding figures for QALY gained were 99.1% and 97.8%. The results were robust to discounting and sensitivity analyses.

CONCLUSIONS

A community-based peer-support lifestyle intervention was cost-effective in individuals at high risk of developing diabetes in India over 2 years.

TRIAL REGISTRATION

The trial was registered with Australia and New Zealand Clinical Trials Registry ( ACTRN12611000262909 ). Registered 10 March 2011.

Prevalence of hypertension and diabetes morbidity among adults in a few urban slums of Bangalore city, determinants of its risk factors and opportunities for control - A cross-sectional study

Introduction:

In World Health Organization's(WHO) South-East Asia region(SEAR), India accounts for >2/3rd of total deaths due to non-communicable diseases(NCD). Annually, NCDs account for ~60% of all deaths in India. Apart from the known risk factors, an individual's physical environment, behavioral and biological susceptibility are known to associated with NCDs. Social factors tend to create barriers for accessing healthcare among the poor people.

Objectives:

i)To screen and diagnose hypertension and diabetes among individuals aged >30 years, and its associated risk factors such as obesity and tobacco consumption. ii) To deliberate on the social determinants influencing this survey, and suggest suitable recommendations for the National Programme for prevention and control of Cancer, Diabetes, Cardiovascular disease and Stroke (NPCDCS).

Methods:

As a component of NPCDCS, the present survey was conducted in a few urban slums of Bangalore city during 2010. The collaborators for the conduct of this survey include the Ministry of health and family welfare, Director of health and family welfare services and Medical colleges in Bangalore city.

Results:

In our study, we found a prevalence proportion of 21.5% for hypertension, 13.8% for diabetes and 30.4% were co-morbid with both the diseases. Consumption of tobacco(any form) was present in 5.1% of the study subjects, overweight among 32.4% and obesity among 20.0%. The study population comprises 18.96% of the source, and the main reason for inadequate utilization was lack of Programmatic awareness.

Conclusion:

NPCDCS program needs to conceptualize the relevant social factors which determine access to screening and diagnostic healthcare services, including behavior change initiatives. For Program effectiveness, changes at the level of healthcare system need to adopted.

Obtaining evidence base for the development of Feel4Diabetes intervention to prevent type 2 diabetes - a narrative literature review

BACKGROUND

Feel4Diabetes was a school and community based intervention aiming to promote healthy lifestyle and tackle obesity for the prevention of type 2 diabetes among families in 6 European countries. We conducted this literature review in order to guide the development of evidence-based implementation of the Feel4Diabetes intervention. We focused on type 2 diabetes prevention strategies, including all the phases from risk identification to implementation and maintenance. Special focus was given to prevention among vulnerable groups and people under 45 years.

METHODS

Scientific and grey literature published between January 2000 and January 2015 was searched for relevant studies using electronic databases. To present the literature review findings in a systematic way, we used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. A complementary literature search from February 2015 to December 2018 was also conducted.

RESULTS

The initial review included 27 studies with a follow-up ≥12 months and 9 studies with a follow-up ≥6 months and with a participant mean age < 45 years. We found out that interventions should be targeted at people at risk to improve recruiting and intervention effectiveness. Screening questionnaires (primarily Finnish Diabetes Risk Score FINDRISC) and blood glucose measurement can both be used for screening; the method does not appear to affect intervention effectiveness. Screening and recruitment is time-consuming, especially when targeting lower socioeconomic status and age under 45 years. The intervention intensity is more important for effectiveness than the mode of delivery. Moderate changes in several lifestyle habits lead to good intervention results. A minimum of 3-year follow-up seemed to be required to show a reduction in diabetes risk in high-risk individuals. In participants < 45 years, the achieved results in outcomes were less pronounced. The complementary review included 12 studies, with similar results regarding intervention targets and delivery modes, as well as clinical significance.

CONCLUSION

This narrative review highlighted several important aspects that subsequently guided the development of the Feel4Diabetes high-risk intervention. Research on diabetes prevention interventions targeted at younger adults or vulnerable population groups is still relatively scarce. Feel4Diabetes is a good example of a project aiming to fill this research gap.

TRIAL REGISTRATION

clinicaltrials.gov NCT02393872, registered 20th March 2015.

Adaptations and patient responses to behavioral intervention components in a depression-focused chronic disease care model implemented in India

Integrated care models offer one approach to treat patients with chronic multimorbidity. However, because these models consist of multiple components designed to provide individualized care, they should be adapted to best meet the needs of patients in diverse settings. This paper presents qualitative and quantitative data from a realist process evaluation embedded in the INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study to uncover what worked, for whom, how, and in what circumstances. We aimed to examine adaptations made to a care coordinator-led behavioral intervention, and how patients responded to adaptations, through a secondary analysis of these data. A purposive sample of 62 patients and 3 care coordinators were recruited based on their involvement with the INDEPENDENT care model across two clinics. Patients were interviewed and surveyed about their experiences in the care model and care coordinators were interviewed about their experiences implementing intervention components. Interview data were coded for reported modifications in intervention content, tools, and delivery; then, these adaptations were categorized by how they served to enhance implementation in the Indian context. Adaptations made in the delivery of this care model served two functions: (a) to improve health promotion communication between care coordinators and patients and (b) to improve patient engagement. Patients' expressed needs were consistent with what care coordinators perceived. Patients were satisfied with adaptations designed to improve intervention fit for local contexts. Study findings demonstrate that adapting components of an integrated care model can enhance patient satisfaction and engagement with behavioral interventions.

Scale-up of the Kerala Diabetes Prevention Program (K-DPP) in Kerala, India: implementation evaluation findings

The cluster-randomized controlled trial of the Kerala Diabetes Prevention Program (K-DPP) demonstrated some significant improvements in cardiometabolic risk factors and other outcomes. We aimed to refine and improve K-DPP for wider implementation in the Kerala state of India. The specific objectives of the scale-up program were (a) to develop a scalable program delivery model and related capacity building in Kerala and (b) to achieve significant improvements in cardiometabolic risk factors in the target population. A total of 118 key trainers of a large women’s organization trained 15,000 peer leaders in three districts of Kerala. Each of these peer leaders was required to deliver 12 monthly sessions to ~25 people, reaching an estimated total of 375,000 adults over 12 months. We evaluated the number of sessions conducted, the participation of men, and program reach. We also assessed the effectiveness of the program in a random sample of 1,200 adults before and after the intervention and performed a biochemical evaluation on a subsample of 321. Of the 15,222 peer leaders who were trained, 1,475 (9.7%) returned their evaluation forms, of which, 98% reported conducting at least 1 session, 88% ≥6 sessions, and 74% all 12 sessions. Tobacco use among men reduced from 30% to 25% (p = .02) and alcohol use from 40% to 32% (p = .001). Overall, mean waist circumference reduced from 89.5 to 87.5 cm (p &lt; .001). Although there were some study shortcomings, the approach to scale-up and its implementation was quite effective in reaching a large population in Kerala and there were also some significant improvements in key cardiometabolic risk factors following the 1 year intervention.

Development of a Living Lab for a Mobile-Based Health Program for Korean-Chinese Working Women in South Korea: Mixed Methods Study

BACKGROUND

Korean-Chinese (KC) women make up the largest group of female migrants in South Korea. To prevent and manage chronic diseases in middle-aged KC women working full time, it is necessary to develop health promotion programs that utilize an online platform because such a platform would allow individuals to participate in health promotion interventions at their convenience.

OBJECTIVE

This study aimed to develop a living lab for a mobile-based health (LLm Health) program focused on improving the physical activity and cultural adaptation of KC women workers.

METHODS

We used a mixed methods design. Living lab principles were factored into the LLm Health program, including the use of multiple methods, user engagement, multistakeholder participants, real-life settings, and cocreation. The program was developed using the 4 steps of the intervention mapping method: needs assessment, setting of objectives, identification of intervention strategies, and intervention design. Needs assessment was conducted through a literature review, focus group interviews with a total of 16 middle-aged KC women, and an online survey related to health promotion of migrant workers given to 38 stakeholders. KC middle-aged women participated in the early stages of program development and provided the idea of developing programs and mobile apps to enhance physical activity and acculturation. The mobile app developed in the program was validated with the help of 12 KC women and 4 experts, including 3 nursing professors and a professor of physical education. They were asked to rate each item based on content, interface design, and technology on a 4-point scale using a 23-item Smartphone App Evaluation Tool for Health Care.

RESULTS

The LLm Health program comprised a 24-week walking program using Fitbit devices, the mobile app, and social cognitive interventions. The mobile app contained 6 components: a step counter, an exercise timer, an online chat function, health information, level of cardiovascular risk, and health status. The cultural aspects and lifestyles of KC women were accommodated in the entire process of program development. The content validity of the mobile app was found to be 0.90 and 0.96 according to the 12 KC women and 4 experts, respectively.

CONCLUSIONS

The mobile app was found to be valid and acceptable for KC women. The living lab approach was a useful strategy for developing a culturally adaptive LLm Health program for KC women workers, leading to their active participation in the overall research process, including needs assessment, program composition, and pre-evaluation.

Prevalence of risk factors of non-communicable diseases in Kerala, India: results of a cross-sectional study

OBJECTIVE

To estimate the prevalence of non-communicable disease (NCD) risk factors in Kerala.

DESIGN

A community-based, cross-sectional survey.

PARTICIPANTS

In 2016-2017 a multistage, cluster sample of 12 012 (aged 18-69 years) participants from all 14 districts of Kerala were studied.

MAIN OUTCOME MEASURES

NCD risk factors as stipulated in the WHO's approach to NCD risk factors surveillance were studied. Parameters that were studied included physical activity score, anthropometry, blood pressure (BP), and fasting blood glucose (FBG) and morning urine sample to estimate dietary intake of salt.

RESULTS

The mean age was 42.5 years (SD=14.8). Abdominal obesity was higher in women (72.6%; 95% CI 70.7 to 74.5) compared with men (39.1%; 95% CI 36.6 to 41.7), and also higher among urban (67.4%; 95% CI 65.0 to 69.7) compared with rural (58.6%; 95% CI 56.6 to 60.5) residents. Current use of tobacco and alcohol in men was 20.3% (95% CI 18.6 to 22.1) and 28.9% (95% CI 26.5 to 31.4), respectively. The estimated daily salt intake was 6.7 g/day. The overall prevalence of raised BP was 30.4% (95% CI 29.1 to 31.7) and raised FBG was 19.2% (95% CI 18.1 to 20.3). Raised BP was higher in men (34.6%; 95% CI 32.6 to 36.7) compared with women (28%; 95% CI 26.4 to 29.4), but was not different between urban (33.1%; 95% CI 31.3 to 34.9) and rural (29.8%; 95% CI 28.3 to 31.3) residents. Only 12.4% of individuals with hypertension and 15.3% of individuals with diabetes were found to have these conditions under control. Only 13.8% of urban and 18.4% of rural residents did not have any of the seven NCD risk factors studied.

CONCLUSION

Majority of the participants had more than one NCD risk factor. There was no rural-urban difference in terms of raised BP or raised FBG prevalence in Kerala. The higher rates of NCD risk factors and lower rates of hypertension and diabetes control call for concerted primary and secondary prevention strategies to address the future burden of NCDs.

Strengthening Noncommunicable Disease Research Capacity and Chronic Disease Outcomes in Low- and Middle-Income Countries in South Asia: Implementation and Evaluation of the ASCEND Program

This article describes the design, outcomes, challenges, and lessons learned from the ASian Collaboration for Excellence in Non-Communicable Disease (ASCEND) program, implemented between 2011 and 2015 in India, Sri Lanka, and Malaysia. The program involved a blended-delivery model, incorporating online and face-to-face training, mentoring, and supervision of trainees' research projects. Evaluation data were collected at baseline, 6, 12, 18, and 24 months. Intended outcomes, lessons, and challenges were summarized using a logic model. During the program period, 48 participants were trained over 2 cohorts in June 2011 and 2012. The trainees published 83 peer-reviewed articles between 2011 and 2015. Additionally, 154 presentations were given by trainees at national and international conferences. Underutilization of the online learning management system was an important challenge. Utilizing a combination of intensive face-to-face and online learning and mentoring of early career researchers in low- and middle-income countries has great potential to enhance the research capacity, performance, and outputs.

Using a RE-AIM framework to identify promising practices in National Diabetes Prevention Program implementation

BACKGROUND

The National Diabetes Prevention Program (National DPP) is rapidly expanding in an effort to help those at high risk of type 2 diabetes prevent or delay the disease. In 2012, the Centers for Disease Control and Prevention funded six national organizations to scale and sustain multistate delivery of the National DPP lifestyle change intervention (LCI). This study aims to describe reach, adoption, and maintenance during the 4-year funding period and to assess associations between site-level factors and program effectiveness regarding participant attendance and participation duration.

METHODS

The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to guide the evaluation from October 2012 to September 2016. Multilevel linear regressions were used to examine associations between participant-level demographics and site-level strategies and number of sessions attended, attendance in months 7-12, and duration of participation.

RESULTS

The six funded national organizations increased the number of participating sites from 68 in 2012 to 164 by 2016 across 38 states and enrolled 14,876 eligible participants. By September 2016, coverage for the National DPP LCI was secured for 42 private insurers and 7 public payers. Nearly 200 employers were recruited to offer the LCI on site to their employees. Site-level strategies significantly associated with higher overall attendance, attendance in months 7-12, and longer participation duration included using self-referral or word of mouth as a recruitment strategy, providing non-monetary incentives for participation, and using cultural adaptations to address participants' needs. Sites receiving referrals from healthcare providers or health systems also had higher attendance in months 7-12 and longer participation duration. At the participant level, better outcomes were achieved among those aged 65+ (vs. 18-44 or 45-64), those who were overweight (vs. obesity), those who were non-Hispanic white (vs. non-Hispanic black or multiracial/other races), and those eligible based on a blood test or history of gestational diabetes mellitus (vs. screening positive on a risk test).

CONCLUSIONS

In a time of rapid dissemination of the National DPP LCI the findings of this evaluation can be used to enhance program implementation and translate lessons learned to similar organizations and settings.

Participant recruitment into a community-based diabetes prevention trial in India: Learnings from the Kerala Diabetes Prevention Program

Background

Data on participant recruitment into diabetes prevention trials are limited in low- and middle-income countries (LMICs). We aimed to provide a detailed analysis of participant recruitment into a community-based diabetes prevention trial in India.

Methods

The Kerala Diabetes Prevention Program was conducted in 60 polling areas (electoral divisions) of the Neyyatinkara taluk (subdistrict) in Trivandrum district, Kerala state. Individuals (age 30–60 years) were screened with the Indian Diabetes Risk Score (IDRS) at their homes followed by an oral glucose tolerance test (OGTT) at community-based clinics. Individuals at high-risk of developing diabetes (IDRS score ≥60 and without diabetes on the OGTT) were recruited.

Results

A total of 1007 participants (47.2% women) were recruited over nine months. Pilot testing, personal contact and telephone reminders from community volunteers, and gender matching of staff were effective recruitment strategies. The major recruitment challenges were: (1) during home visits, one-third of potential participants could not be contacted, as they were away for work; and (2) men participated less frequently in the OGTT screening than women (75.2% vs. 84.2%). For non-participation, lack of time (42.0%) was most commonly cited followed by ‘I am already feeling healthy’ (30.0%), personal reasons (24.0%) and ‘no benefit to me or my family’ (4.0%). An average of 17 h were spent to recruit one participant with a cost of US$23. The initial stage of screening and recruitment demanded higher time and costs.

Conclusions

This study provides valuable information for future researchers planning to implement community-based diabetes prevention trials in India or other LMICs.

Trial registration

Australia and New Zealand Clinical Trials Registry: ACTRN12611000262909.

Public health and health systems: implications for the prevention and management of type 2 diabetes in south Asia

Many non-communicable chronic diseases, including type 2 diabetes, are highly prevalent, costly, and largely preventable. The prevention and management of type 2 diabetes in south Asia requires a combination of lifestyle changes and long-term health-care management. However, public health and health-care systems in south Asian countries face serious challenges, including the need to provide services to many people with inadequate resources, and substantial between-population and within-population inequalities. In this Series paper, we explore the importance and particular challenges of public health and health systems in south Asian countries (Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka) with respect to the provision of culturally appropriate lifestyle modification to prevent and manage diabetes, especially in resource-poor settings. Effective primary prevention strategies are urgently needed to counter risk factors and behaviours preconception, in utero, in infancy, and during childhood and adolescence. A concerted focus on education, training, and capacity building at the community level would ensure the more widespread use of non-physician care, including community health workers. Major investment from governments and other sources will be essential to achieve substantial improvements in the prevention and management of type 2 diabetes in the region.

Reduced expression of microRNA-199a-3p is associated with vascular endothelial cell injury induced by type 2 diabetes mellitus

The aim of the present study was to investigate the function and mechanism of action of microRNA (miRNA or miR)-199a-3p in vascular endothelial cell injury induced by type 2 diabetes mellitus (T2DM). A total of 36 patients with T2DM (26 males and 10 females; mean age, 52.5±7.0 years) and 20 healthy subjects (10 males and 10 females; mean age, 55.6±4.5 years) were included in the present study. Peripheral blood samples were obtained from all participants and total RNA was extracted Reverse transcription-quantitative polymerase chain reaction was performed to determine the expression of miR-199a-3p. Following the transfection of human umbilical vein endothelial cells (HUVECs) with a negative control (NC) miRNA or miR-199a-3p mimics, cell proliferation was assessed using a Cell Counting kit-8 assay. Cell migration was investigated using Transwell assays and flow cytometry was performed to detect the apoptosis of HUVECs. HUVECs were infected with Ad-GFP-LC3B and laser-scanning confocal microscopy was performed to observe autophagosomes in HUVECs. Western blotting was used to measure the expression of proteins associated with autophagy and the phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT)/nuclear factor (NF)-κB signaling pathway. MiR-199a-3p was downregulated in peripheral blood from patients with T2DM compared with healthy subjects. Transfection with miR-199a-3p mimics promoted the proliferation and migration of HUVECs. However, miR-199a-3p overexpression inhibited the apoptosis of HUVECs. MiR-199a-3p facilitated HUVEC autophagy by affecting autophagy-associated signaling pathways. Furthermore, miR-199a-3p regulated the biological functions of HUVECs via the PI3K/AKT/NF-κB signaling pathway. The results of the present study suggest that miR-199a-3p expression was reduced in patients with T2DM compared with healthy subjects and may be associated with vascular endothelial cell injury. In addition, miR-199a-3p promoted the proliferation, migration and autophagy of HUVECs, potentially by regulating the PI3K/AKT/NF-κB signaling pathway. Therefore, miR-199a-3p may function as protector of vascular endothelia.

A group-based lifestyle intervention for diabetes prevention in low- and middle-income country: implementation evaluation of the Kerala Diabetes Prevention Program

BACKGROUND

While several efficacy trials have demonstrated diabetes risk reduction through targeting key lifestyle behaviours, there is a significant evidence gap in relation to the successful implementation of such interventions in low- and middle-income countries (LMICs). This paper evaluates the implementation of a cluster randomised controlled trial of a group-based lifestyle intervention among individuals at high-risk of developing type 2 diabetes mellitus (T2DM) in the state of Kerala, India. Our aim is to uncover provider-, participant- and community-level factors salient to successful implementation and transferable to other LMICs.

METHODS

The 12-month intervention program consisted of (1) a group-based peer-support program consisting of 15 sessions over a period of 12 months for high-risk individuals, (2) peer leader (PL) training and ongoing support for intervention delivery, (3) diabetes education resource materials and (4) strategies to stimulate broader community engagement. The evaluation was informed by the RE-AIM and PIPE frameworks.

RESULTS

Provider-level factors: Twenty-nine (29/30, 97%) intervention groups organised all 15 sessions. A 2-day PL training was attended by 51(85%) of 60 PLs. The PL handbook was found to be 'very useful' by 78% of PLs. Participant-level factors: Of 1327 eligible individuals, 1007(76%) participants were enrolled. On average, participants attended eight sessions. Sixty-eight percent rated their interest in group sessions as 'very interested', and 55% found the group sessions 'very useful' in making lifestyle changes. Inconvenient time (43%) and location (21%) were found to be important barriers for participants who did not attend any sessions. Community-level factors: Community-based activities reached to 41% of the participants for walking groups, 40% for kitchen garden training, and 31% for yoga training. PLs were readily available for support outside the sessions, as 75% of participants reported extracurricular contacts with their PLs. The commitment from the local partner institute and political leaders facilitated the high uptake of the program.

CONCLUSION

A comprehensive evaluation of program implementation from the provider-, participant- and community-level perspectives demonstrates that the K-DPP program was feasible and acceptable in changing lifestyle behaviours in high-risk individuals. The findings from this evaluation will guide the future delivery of structured lifestyle modification diabetes programs in LMICs.

TRIAL REGISTRATION

Trial registration: Australia and New Zealand Clinical Trials Registry ACTRN12611000262909 . Registered 10 March 2011.

A peer-support lifestyle intervention for preventing type 2 diabetes in India: A cluster-randomized controlled trial of the Kerala Diabetes Prevention Program

BACKGROUND

The major efficacy trials on diabetes prevention have used resource-intensive approaches to identify high-risk individuals and deliver lifestyle interventions. Such strategies are not feasible for wider implementation in low- and middle-income countries (LMICs). We aimed to evaluate the effectiveness of a peer-support lifestyle intervention in preventing type 2 diabetes among high-risk individuals identified on the basis of a simple diabetes risk score.

METHODS AND FINDINGS

The Kerala Diabetes Prevention Program was a cluster-randomized controlled trial conducted in 60 polling areas (clusters) of Neyyattinkara taluk (subdistrict) in Trivandrum district, Kerala state, India. Participants (age 30-60 years) were those with an Indian Diabetes Risk Score (IDRS) ≥60 and were free of diabetes on an oral glucose tolerance test (OGTT). A total of 1,007 participants (47.2% female) were enrolled (507 in the control group and 500 in the intervention group). Participants from intervention clusters participated in a 12-month community-based peer-support program comprising 15 group sessions (12 of which were led by trained lay peer leaders) and a range of community activities to support lifestyle change. Participants from control clusters received an education booklet with lifestyle change advice. The primary outcome was the incidence of diabetes at 24 months, diagnosed by an annual OGTT. Secondary outcomes were behavioral, clinical, and biochemical characteristics and health-related quality of life (HRQoL). A total of 964 (95.7%) participants were followed up at 24 months. Baseline characteristics of clusters and participants were similar between the study groups. After a median follow-up of 24 months, diabetes developed in 17.1% (79/463) of control participants and 14.9% (68/456) of intervention participants (relative risk [RR] 0.88, 95% CI 0.66-1.16, p = 0.36). At 24 months, compared with the control group, intervention participants had a greater reduction in IDRS score (mean difference: -1.50 points, p = 0.022) and alcohol use (RR 0.77, p = 0.018) and a greater increase in fruit and vegetable intake (≥5 servings/day) (RR 1.83, p = 0.008) and physical functioning score of the HRQoL scale (mean difference: 3.9 score, p = 0.016). The cost of delivering the peer-support intervention was US$22.5 per participant. There were no adverse events related to the intervention. We did not adjust for multiple comparisons, which may have increased the overall type I error rate.

CONCLUSIONS

A low-cost community-based peer-support lifestyle intervention resulted in a nonsignificant reduction in diabetes incidence in this high-risk population at 24 months. However, there were significant improvements in some cardiovascular risk factors and physical functioning score of the HRQoL scale.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry ACTRN12611000262909.