How to improve the prevention and self-management of type 2 diabetes in real-world settings

Abstract

Type 2 Diabetes Mellitus (T2DM) is recognised as one of the most challenging public health problems of the 21st century with the number of people with T2DM rapidly increasing worldwide. While the efficacy of interventions in preventing and improving T2DM outcomes has been well established, there has generally been quite poor uptake, implementation and translation in populations, particularly in Low and Middle-Income Countries (LMICs). This thesis aims to evaluate the implementation of behavioural interventions for the prevention and self-management of T2DM and to identify the key factors required to improve their uptake in real-world settings.

This Ph.D. thesis includes a systematic review of real-world diabetes prevention programs implemented in the last 15 years as well as a comprehensive implementation evaluation of two cluster randomised controlled trials: 1) the Kerala Diabetes Prevention Program (K-DPP), India and 2) the Australasian Peers for Progress – Diabetes Project (AusPfP-DP), Australia. This thesis utilises two existing evaluation frameworks (RE-AIM and PIPE) and has developed a novel evaluation logic model to identify the provider-, participant- and community-level factors that are most relevant for the successful implementation of real-world diabetes programs. The provider-level factors are further investigated.

The systematic review identified that program intensity plays a major role in weight loss outcomes. However, low-intensity interventions that have high uptake—both in terms of good coverage of invitees and their willingness to accept the invitation—can still have considerable impact in lowering diabetes risk in a population, even when effectiveness in weight loss is low or moderate.

The findings from the implementation evaluation of K-DPP demonstrated that the intervention was feasible and acceptable in changing lifestyle behaviours in high-risk individuals. The intervention was delivered as per protocol and there was high adherence to the intended design and delivery of the intervention by peer leaders. The communities’ trust in the local partnering institute and the commitment of the local political leaders were important in facilitating the high uptake of the program.

The findings of the implementation evaluation of AusPfP-DP show that peer support programs are feasible, acceptable and can be used to supplement treatment for patients motivated to improve behaviours related to diabetes. However, program planners need to focus on the participation component in designing future programs.

Finally, the use of the two evaluation frameworks allowed a comprehensive evaluation of a diabetes prevention and self-management program, from the provider-, participant-, community- and public health- perspectives.

The research contained in this Ph.D. thesis highlights several important findings required to improve the uptake and wider implementation of diabetes prevention and self-management lifestyle interventions in real-world settings. Future implementation research needs to identify effective recruitment and program implementation strategies for targeting both reach and program participation. Rigorous evaluation should be a central feature of the implementation of prevention and self-management programs. More rigorous reporting of program components is needed to evaluate programs to assess the practical value of the diabetes interventions.