Background
Methods
PHASE 1: Needs assessment
PHASE 2: Formulation of program objectives
PHASE 3: Program adaptation and development
PHASE 4: Piloting the program and its delivery
PHASE 5: Refinement and active implementation
Results
PHASE 1: Needs assessment
PHASE 2: Formulation of program objectives
Program Objectives | Participant learning and environmental change objectives | Theory- and evidence-based determinants as per the Health Action Process Approach [47] | Behavior change techniques as per Michie et al.’s Taxonomy v1 [48] (BCT number) | Feasible and culturally acceptable strategies to enhance engagement and implementation |
---|---|---|---|---|
1. Increase the consumption of fruit, vegetables and fibre 2. Reduce intake of carbohydrates with high glycaemic index and total and saturated fats 3. Increase physical activity 4. Reduce tobacco use with emphasis on chewing tobacco 5. Reduce alcohol consumption, particularly among men 6. Set realistic goals and associated targets for weight loss and other lifestyle risks 7. Improve sleep | Participant learning objective • Increase awareness of the risk factors of T2DM • Improve risk perception on T2DM • Improve self-efficacy in making lifestyle changes Environmental change objective • Enhance peer support for behavior change • Enhance household / family support for behavior change • Enhance neighborhood and community support • Facilitate opportunities for healthy life style with collaboration at group-community level. | • Outcome expectations • Risk perception • Self-efficacy • Action planning • Coping planning | • Goal setting (behavior) (BCT #1.1), action planning (BCT #1.4) and review of behaviour goal(s) (BCT #1.7) e.g. participants are assisted to set realistic behavioral goals and prompted to detail a plan of how they will achieve it. The goals are reviewed within the sessions. • Instruction on how to perform a behaviour (BCT #4.1) e.g. experts advised and up-skilled participants in yoga classes and kitchen garden development • Information about health consequences (BCT #5.1) e.g. information is provided in the DPES sessions and small group sessions on diabetes and potential complications • Problem solving/coping planning (BCT #1.2) e.g. barriers to physical activity and healthy eating are discussed and planned for throughout the small group sessions • Social support (practical) (BCT #3.2), social support (general) (BCT #3.1), and social support (emotional) (BCT #3.3) e.g. inclusion of family members and peer-based intervention is designed to enhance social support | Individual-level • Educational sessions that focus on ‘modifiable’ determinants of risk on diabetes • Provide information on the risk factors of T2DM • Sessions scheduled in local neighborhoods (e.g. a reading room or anganwadi) according to work, family and other cultural needs of participants • Inclusion of strategies to attract more male participation Interpersonal-level • Group-based delivery/ peer-support • Inclusion of family members in the K-DPP sessions • Provide information on the dietary and physical activity targets for individuals as well as family members • Enabling ongoing peer and social support, with family members and friends of participants • Kitchen gardening training and seeds • Forming of walking groups • Yoga training sessions Community-level • Community mobilization activities • Forming partnerships with community stakeholders and organizations • Clearing of walking paths with peer group and community members |
PHASE 3: Program adaptation and development
Behavior change techniques
Strategies to enhance engagement
Intervention model and delivery
PHASE 4: Piloting the program and its delivery
Identified challenge | Strategies adopted | Modifications made |
---|---|---|
Low education level of the participants. The majority of the participants (n = 18) had no formal education, with the highest level of education being 11 years of schooling. | Simplify intervention materials to assist understanding of individuals with lower literacy levels. | Intervention materials were modified with additional pictures to support understanding of text-based information. Additional group-based activities were planned to be incorporated into the sessions to facilitate story-telling and oral language based learning. |
Low participation level of male participants. | Recruit male peer-leaders that can encourage male participants to attend. Ensure sessions are run during convenient times for working males. | Male peer-leaders were recruited in addition to the female peer-leaders. Sessions were organised during the evening and on weekends to enhance male participation. |
Perceived relevance of T2DM prevention, with priority given to control and management of T2DM | A strong link between prevention and disease management needed to be established to make the program relevant for the participants. Program content (intervention materials and sessions) needed to be modified to sensitize participants on the need for diabetes prevention amongst themselves and their families and to include information on diabetes management. More community awareness on prevention programs was required. | An additional educational session, Diabetes Prevention Education Session (DPES 1), was incorporated into the program. DPES 1 provided an introduction to understanding Type 2 diabetes and its risk factors. This session stressed the similarity of strategies for primary and secondary prevention, and addressed misconceptions and role of lifestyle modification. The original diabetes education session became a sequel to DPES 1. This session, DPES 2, focused on the modifiable risk factors for diabetes prevention. The session took a deeper view on the specifics of healthy lifestyle behaviors, diet, physical inactivity, tobacco and importance of sleep. We also included “Diabetes Management” as an additional topic into the small group sessions to link diabetes management with prevention strategies, and thereby to increase perceived relevance of the program among participants. |
Perceived relevance of T2DM prevention
Readability of resource materials
Attendance of male participants
PHASE 5: Refinement and active implementation
Engagement (0-2 months) | Preparation and adoption of changes (3-5 months) | Adoption and maintenance of changes (6-12 months) | Community empowerment (>9 months) | |
---|---|---|---|---|
Overall objective | • Increasing willingness to participate • Rapport building • Establishing personal relevance • Increasing awareness of T2DM prevention and K-DPP | • Increasing personal relevance • Preparing for changes | • Increasing self-efficacy • Making and assessing changes on personal and family level | • Assessing and sustaining changes on personal and family level • Supporting community change |
K-DPP Components | • Recruitment of LRPs • Small group sessions (1-2) • DPES 1 • Peer-leaders selection and training | • Small group sessions 3-5 • Pre- and post-session telephone contact with PLs and LRPs • DPES II • PLs training | • Small group sessions 6-12 • Pre- and post-session telephone contact with PLs and LRPs • Extra-curricular activities (yoga training, kitchen garden cultivation, etc.)Workshops for PL and LRP and support for planning extra-curricular activities in the community (E.g. healthy snack preparation, sports, painting competition on behavior change themes) | • Linkage with other services for health care and promotion • Linkage with other community organizations |
Peer Leader (PL) | • Selection, • Commitment | • PL leader skill-building and support for self-efficacy • Benefits of being a PL | • Supporting PL self-efficacy and perception of benefits • Enabling and promoting peer support among peer-leaders | • Supporting peer-leader self-efficacy, autonomy and perception of benefits. • Promoting linkages with community organisations. |
Participants (and family) | • Recruitment • Retention: participatory methods and benefits from participation (for participant and family) | • Building peer support and self-efficacy in behavior change in participant and family | • Promoting maintenance of peer support and behavior change • Supporting participants in becoming change agents in their families | • Promoting maintenance of peer support and behavior change in participant and family • Supporting participants in becoming change agents in their community |
Community | • Increasing community awareness of K-DPP • Encouraging community support of K-DPP | • Encouraging community support of K-DPP | • How can K-DPP groups support health in their communities: extra-curricular activities and linkages with community organizations | • Support for community rollout |