Background
Theoretical framework
The ecological model
Aim of the meta-synthesis
Methods
Search strategy
Selection criteria
Criteria | Inclusion | Exclusion | Search Element ͣ |
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Population | • People who recently (within one year) have been screened for risk of developing type 2 diabetes and diagnosed with prediabetes detected by measuring HbA1c level or fasting plasma glucose, or with an oral glucose tolerance test [32] Note: If Studies had a mixed population of both type 2 diabetes and prediabetes, and their findings on participants with prediabetes and type 2 diabetes could be read separately. We would include their study data on prediabetes participants • People aged > 18 years and over living in a home-based environment | • People diagnosed with type 2 diabetes • Women with gestational diabetes | Prediabetic State Prediabetes Impaired fasting glucose Hyperglycaemia Glucose intolerance Insulin resistance |
Phenomenon of interest | With respect to the individual, interpersonal, and societal level: • Facilitators and barriers of initial lifestyle change • Facilitators and barriers of lifestyle change maintenance | Health behaviour change Lifestyle change | |
Setting | • The informants live in home-based environments and receive or have received support from health care providers within the community health care setting regarding lifestyle change • The informants may or may not have participated in a structured community-based lifestyle intervention program | • Studies reporting from hospital or institutional settings exclusively | Lifestyle intervention program Health behaviour intervention program |
Study design | • Studies with qualitative analysis based on data from interviewing people at risk of developing type 2 diabetes • Mixed methods studies where the qualitative results are clearly separated from the quantitative data | • Qualitative studies where no human subjects participated and studies with primarily observational methods • Studies not published in peer reviewed journals | Qualitative studies |
Time frame | • No set time frame | ||
Language | • Studies written in English and Scandinavian | • All other languages |
Quality appraisal
Author, Country | Was there a clear statement of the research? | Is a qualitative methodology appropriate? | Was the research design appropriate to address the aims of the research? | Was the recruitment strategy appropriate for the aims of the research? | Was the data collected in a way that addressed the research issue? | Has the relationship between the researcher and participants been adequately considered? | Have ethical issues been taken into consideration? | Was the data analysis sufficiently rigorous? | Is there a clear statement of the findings? | How valuable is the research/ will the results help locally? | |
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Abel et al., 2018, New Zealand [34] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10/10 |
Andersson et al., 2008, Sweden [35] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10/10 |
Coppell et al., 2017, New Zealand [36] | Y | Y | Y | Y | U | Y | U | U | Y | Y | 7/10 |
Dyer et al., 2020, USA [37] | Y | Y | Y | Y | Y | N | N | Y | Y | Y | 8/10 |
Hansen et al., 2010, Norway [38] | Y | V | Y | U | Y | N | Y | Y | Y | Y | 8/10 |
Jallinoja et al., 2008, Finland [39] | Y | Y | Y | Y | Y | N | Y | Y | Y | Y | 9/10 |
Korkiangas et al., 2011, Finland [40] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10/10 |
Kullgren et al., USA, 2015 [41] | Y | Y | Y | Y | Y | U | Y | Y | Y | Y | 9/10 |
Kuo et al., 2013, Taiwan [42] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10/10 |
Lim et al., 2020, Singapore [43] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10/10 |
Lim et al., 2019, Singapore [44] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10/10 |
Mayega et al., 2014, Uganda/ Sweden [45] | Y | Y | Y | Y | Y | U | Y | Y | Y | Y | 9/10 |
Morrison et al., 2014, Scotland [46] | Y | Y | Y | U | Y | Y | Y | Y | Y | Y | 9/10 |
Penn et al., 2008, England [47] | Y | Y | Y | Y | Y | U | Y | Y | Y | Y | 9/10 |
Strachan et al., 2018, Canada [48] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10/10 |
Bean et al.,2020 Canada [49] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10/10 |
Katangwe et al., 2020, England [50] | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | 10/10 |
Griauzde et al., 2020, USA [51] | Y | Y | Y | Y | Y | N | Y | N | U | Y | 7/10 |
Howells et al., 2021, England [52] | Y | Y | Y | Y | Y | U | Y | Y | Y | Y | 9/10 |
Wallace et al., 2021, USA [53] | Y | Y | Y | Y | Y | N | Y | U | Y | Y | 8/10 |
Data extraction and synthesis
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1) Line-by-line coding of the findings of the primary studies:Two independent reviewers performed an inductive line-by-line coding of the extracted material. New codes were generated independently of the original codes used in the primary studies. The codes were compared, and all codes that represented similarities across the primary studies and belonged to the same concept were organized into categories.
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2) Development of descriptive themes:Descriptive subthemes were formed through the merging and grouping of categories in an iterative process, staying close to the primary data in the included studies. The primary studies were read and reviewed by GS to ensure that the descriptive themes captured and reflected the depth of the data reported in the primary studies.
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3) Development of analytical themes:The descriptive themes were discussed in the research team in relation to the research question and organized within the main analytical themes. This was an iterative and cyclic process. In the analytical stage of the synthesis, we wanted to go beyond the descriptive findings trying to generate new understanding. After the development of the analytical themes, we related this to a higher-level theoretical framework to illuminate the central themes in the synthesis.
Meta-synthesis researchers’ background and preconceptions
Results
Literature search results
Study characteristics
Author, Country | Aim of study | Inclusion criteria | Sample | Methods | Theoretical framework | Setting and intervention |
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Abel et al., 2018, New Zealand [34] | Exploring the barriers and facilitators of making dietary improvements among participants following a dietary intervention | Adults < 70 years with newly diagnosed prediabetes (HbaA1c 41–49 mmol/mol 5.9–6.6%), BMI ≥ 25 kg/m2 and metformin not prescribed | n = 20 F = 10 M = 10 Age range: 43–69 years | Semi-structured qualitative interviews, thematic analysis | Not described | Setting: A six-month primary care nurse-delivered dietary intervention pilot; Prediabetes Intervention Package (PIP) Area for lifestyle change (intervention): To promote dietary changes |
Andersson et al., 2008, Sweden [35] | Exploring the experiences of individuals with pre-diabetes and the associated increased risk of type 2 diabetes | Prediabetic as described by WHO guidelines of 1998, including IGT/IFG -6 months after health check | n = 8 F = 5 M = 3 Age range: 30–74 years | Qualitative interviews Phenomenological hermeneutical approach | Not described | Setting: Health examination at the local health centre consisting of two visits, aim being to collect information on the general health and living conditions of the population of Skaraborg. The interviews were conducted after the health examinations Area for lifestyle change (no intervention): To promote exercise and dietary changes |
Coppell et al., 2017, New Zealand [36] | Examining the implementation and feasibility of a six-month multilevel primary care nurse-led prediabetes lifestyle intervention compared with current practice in patients with prediabetes | Adults aged ≤ 70 years, if women non-pregnant with newly diagnosed prediabetes; HbA1c 41–49 mmol or FGP 6.1–6.9 mmol/L, BMI > 25 kg/m2, and metformin not prescribed | n = 20* F = 10 M = 10 Age range: 49–65 years *A subsample of patients who had completed at six-months intervention were purposefully selected to ensure a range of demographic profiles and glycaemic outcomes | Mixed methods, convergent design, involving a 6-month pragmatic non-randomised pilot study with a qualitative process evaluation Semi-structured qualitative interviews, thematic analysis | Not described | Setting: A six-month primary care nursing-led dietary intervention for prediabetes Area for lifestyle change (intervention): To promote exercise and dietary changes |
Dyer et al., 2020, USA [37] | Assessing the impact of gender-tailoring and modality choice on a diabetes prevention program (DPP) engagement among women veterans with prediabetes | Female veterans with prediabetes (HbA1c 5.7–6.4% in prior 12 months), who were overweight or obese (BMI ≥ 24 kg/m2) | n = 15 * F = 15 Mean age: 55.5 *A subsample of participants from a larger study on diabetes prevention. The subsample participants were selected by random. Interviews were conducted at early-implementation (in person modality = 6 and online modality = 4) and post-implementation follow-up (in person modality n = 6 and online modality = 6) | Mixed method study, qualitative semi-structured telephone interviews | Not described | Setting: Tailored diabetes prevention program (DPP) implemented in a large Veteran Affairs (VA) health-care system from 2016 to 2018. Area for lifestyle change (no intervention): To promote exercise and dietary changes |
Hansen et al., 2010, Norway [38] | Identify factors that could have motivational significance for lifestyle change to facilitate the reduction of impaired glucose tolerance (IGT) and, consequently, the risk of type 2 diabetes | People with IGT according to WHO guidelines | n = 18 F = 14 M = 4 Age range: 33–69 years | Semi-structured interviews, content analysis method | Health Belief Model | Setting: An instructed, controlled, physical strength exercise program for four months at a fitness centre (2–3 times per week). Interviews were conducted after the intervention Area for lifestyle change (intervention): To promote exercise |
Jallinoja et al., 2008, Finland [39] | Exploring whether the individual is seen as capable of autonomously seeking a healthier lifestyle or is dependent on external control and support | Individuals with increased risk of type 2 diabetes but not diagnosed with diabetes | n = 30 F = 17 M = 13 Age range: 52–65 years The focus groups consisted of three weight-reducers’ interview groups (5 women, 10 men) and three weight-gainers’ interview groups (12 women, 3 men) | Focus groups Discourse analysis | Not described | Setting: The participants had 1 ½ years earlier participated in a group-based counselling program: GOAL (Good Aging in Lahti Region), a type 2 diabetes prevention program (8-month duration) Area for lifestyle change (intervention): To promote exercise and dietary changes |
Korkiangas et al., 2011 [40] | Describing motivators and barriers of exercise among adults with a high risk of type 2 diabetes | Individuals who had either scored 15 points or more or 12 points or more on the diabetes risk test with an increased risk of work disability or elevated FGT or IGT in an oral glucose tolerance test within the last 12 months | n = 74 F = 33 M = 41 Mean age: 49 years | Focus groups, inductive content analysis Video conferences and face-to-face groups (data obtained from taped video conferences only) | Not described | Setting: Six-month follow up study on the effectiveness and feasibility of activating counselling methods and video conferences in dietary group counselling Area for lifestyle change (intervention): To promote exercise |
Kullgren et al., 2015, USA [41] | Examining the frequency of, facilitators of, and barriers to prevent type 2 diabetes among employees found to have pre-diabetes during a workplace screening | Individuals who had FBG measurements of 100 to 125 mg/dl | n = 40* F = 29 M = 11 Age range: 41–57 *A subsample of participants from a larger study on diabetes prevention. The subsample participants were selected by purposive sampling with regard to whether they followed the recommendations or not | Mixed methods observational study Semi-structured telephone interviews | Not described | Setting: Follow up study on university employees (n = 82) who were found to have prediabetes during a workplace screening. After three months two groups were compared: 1) Participants attempting weight loss who have gotten at least 150 min of moderate physical activity since the screening or participating in a DPP or 2) have not carried out any of these recommendations after screening Area for lifestyle change (no intervention): To promote exercise and dietary changes |
Kuo et al., 2013, Taiwan [42] | Exploring the experiences of people with prediabetes in relation to their engagement in exercise | Adults over 18 years with IFG, experience with exercise | n = 20 F = 11 M = 9 Age range: 38–66 Mean age: 52.3 | In-depth semi-structured interviews Grounded theory | Not described | Participants were interviewed after health consultations Area for lifestyle change (no intervention): To promote exercise |
Publication from 2020:Assessing factors associated with meeting the recommendation of at least 150 min of moderate/vigorous physical activity weekly and exploring facilitators and barriers related to the exercise behaviour among primary care patients with prediabetes in Singapore Publication from 2019: Assessing factors associated with fulfilling the healthy plate recommendation and exploring reasons for the dietary behaviour among primary care patients with prediabetes in Singapore | Community dwelling patients aged 21–79 years with existing prediabetes, diagnosis verified by oral glucose tolerance test (OGTT) and diagnosis code, and currently following up at any of the eight polyclinics | n = 48* F = 24 M = 24 Age range: 21–79 years *A subsample of participants from a larger study on diabetes prevention. Maximum variation sampling strategy was used to recruit a purposive subsample of participants from diverse backgrounds, based on the criteria of sex and whether they reported meeting the “My healthy Plate” recommendation | Mixed methods In depth interviews, thematic data analysis (Braun and Clarke) | Social ecological model (SEM) framework | Setting: Recruited from nine NHG (National Health Care Group) polyclinics in Singapore, health consultations | |
Mayega et al., 2014, Uganda/ Sweden [45] | Assessing perceptions about type 2 diabetes and lifestyle change among people afflicted with or at high risk of the disease in a low-income setting in Iganga, Uganda | Three glycaemic categories: Suspected diabetes type 2: FPG as ≥ 7.0 mmol/l, suspected prediabetes as an FPG of 6.1–6.9 mmol/l and obesity as BMI > 30 kg/m2 | n = 96 F = 47 M = 47 Age 35–60 years | Focus group discussions, content analysis Ethnographic approach | Not described | Setting: The study was conducted in the Iganga-Mayuge Health and Demographic Surveillance Site (HDSS) in eastern Uganda Area for lifestyle change (no intervention): To promote exercise and dietary changes |
Morrison et al., 2014, Scotland [46] | Exploring the reasons for enrolling in, experiences participating in, and reasons for remaining in a family-based, cluster randomized controlled trial of a dietitian-delivered lifestyle modification intervention aiming to reduce obesity in South Asians at high risk of developing diabetes | Waist size ≥ 90 cm for men and ≥ 80 cm for women; IGT (i.e., fasting plasma glucose of < 7 mmol/l and, following a standard OGTT, a 2 h plasma glucose of 7.8–11.0 mmol/l) IFG (i.e., plasma fasting glucose of 6.1–6.9 mmol/l); no previous diagnosis of diabetes | n = 20* F = 7 M = 13 Age not described *A subsample of participants from a larger study on diabetes prevention. The subsample participants were selected by purposive sampling, ensuring diversity, within the trial population by sex, ethnicity, faith, group, geographical location (Glasgow and Edinburgh) and whether they were allocated to the intervention or control group | Narrative interviews, thematic analysis | Not described | Setting: A complex dietitian-led dietary-based and physical activity-based intervention for reducing obesity and preventing type 2 diabetes mellitus in people of Indian and Pakistani origin at a high risk of developing diabetes living in Scotland over a three-year period Area for lifestyle change (intervention): To promote exercise and dietary changes |
Penn et al., 2008, England [47] | Understanding the experience of participants who maintained behaviour change aiming to inform future interventions. Exploring the dimensions of achieving and maintaining lifestyle change | At trial, first recruit: > 40 years, Caucasians with BMI > 25 and IGT diagnosed based on two OGTTs | n = 15 F = 7 M = 8 Age range: 47–74 | Semi-structured interviews, content analysis, framework approach Empirical phenomenology approach | Not described | Setting: A study nested from the European Diabetes Prevention Study (EDIPS); intervention was individual motivational interviewing (three-month interval) aiming to reduce total food energy and fat intake and increasing activity. Exploring experiences of the participants 3–5 years after Area for lifestyle change (intervention): To promote exercise and dietary changes |
Strachan et al., 2018, Canada [48] | Exploring how people from a small Canadian city diagnosed with prediabetes react emotionally to their diagnosis | Between 18 and 65 years old, diagnosed with prediabetes according to the ADA (2016): HbA1c = 5.7%-6.4% (n = 20) or ADA risk-questionnaire indicating increased risk (> 5 = 1) within the past year | n = 21* F = 18 M = 3 Age range: 47–65 years *A subsample of participants from a larger study on diabetes prevention. The subsample participants were selected by random | Semi-structured interviews, inductive thematic analysis (Braun and Clarke) | Not described | Setting: The study was part of a larger project where people with prediabetes participated in a 3‐week community‐based lifestyle intervention in Western Canada, “Small Steps for Big Changes Program (SSB)”. Participants were interviewed prior to involvement in the intervention Area for lifestyle change (intervention): To promote exercise and dietary changes |
Bean et al., 2020, Canada [49] | Two-fold purpose of the study: a) Profiling patterns of women’s perceived PA journey over one year in those who engaged in Small Steps for Big Changes (SSBC) and b) understanding strategies used to engage in and maintain PA | Participants were a) between 18- and 65-years old b) able to read and speak English, c) identify as a woman, d) have prediabetes (glycated haemoglobin 5.7% to 6.4%), and e) have completed SSBC | n = 14* F = 14 Age range: 48–63 Mean age: 60.07 *A subsample of participants from a larger study on diabetes prevention who were female and eligible for SSBC participation, were invited to participate in the qualitative sub study | Qualitative semi-structured interviews, face-to-face and telephone interviews Trajectory approach coupled with a deductive-inductive thematic analysis (Braun and Clarke) | Not described | Setting: The study is a follow-up to a three-week community-based diabetes prevention program in Canada; Small Steps for Big Changes (SSBC) Participants were interviewed at baseline, during and after the intervention Area for lifestyle change (intervention): To promote exercise and dietary changes |
Katangwe et al., 2020, England [50] | Exploring factors influencing engagement with the National Health Service (NHS) DPP and the role of community pharmacies (CP) in diabetes prevention | Eligible patients for referral: individuals 18 years or over with HbA1c blood test results within the pre-diabetes range (42–47 mmol/mol [6.0–6.4%]) in the last 12 months | n = 16* F = 9 M = 7 Mean age: 68.4 *A subsample of participants from a larger study on diabetes prevention were purposively sampled from the questionnaire respondents for follow-up semi-structured interviews (n = 10) and a focus group (n = 6) | Explanatory sequential mixed method design Focus groups and semi-structured interviews (telephone) Thematic analysis (Braun and Clarke) | COM- B approach, theoretical model for identifying key factors influencing desired behaviours | Setting: Individuals were invited to participate in the NHS DPP in order to lower their risk of developing T2D. In the interview study sample, three had attended the program, three had completed the program, three were waiting, two had dropped out, and five had declined Area for lifestyle change (intervention): To promote exercise and dietary changes |
Griauzde et al., 2020, USA [51] | 1) Estimating weight change from a low-carbohydrate diabetes prevention programme (LC-DPP) and 2) evaluating the feasibility and acceptability of a LC-DPP. General experiences with the intervention as well as specific barriers and facilitators of VLCD adherence were specifically explored | (1) Overweight (BMI ≥ 25 kg/m2), (2) haemoglobin A1c (HbA1c) between 5.7% and 6.4% drawn within six months of the study start date, (3) willingness to participate in group-base class, and (4) ability to engage in at least light physical activity | n = 14* F = 8 M = 6 Mean age: 58.7 *A subsample of participants was recruited from the dietary intervention, sampling not described | Mixed methods sequential explanatory study design Single arm pilot study Qualitative semi-structured interviews | Not described | Setting: Primary care clinic within a large academic medical centre in the USA. An evidence based, low-fat dietary intervention to teach participants to follow a very low carbohydrate diet (VLCD). Participants attended 23 group-based classes over one year. The participants were interviewed at six (n = 13) and 12 months (n = 12) Area for lifestyle change (intervention): To promote dietary changes |
Howells et al., 2021, England [52] | Exploring how individuals with prediabetes understand biomedical definitions of risk and the extent to which they resist them, as this reframing of risk could have implications for engagement with the NHS DPP | High-risk patients defined as prediabetic via a blood glucose test (HbA1c level 42–47 mmol/mol) and who had received their prediabetes diagnosis within the last 12 months | n = 43* F = 20 M = 23 Mean age: 60 *Seven general practices were purposively selected to recruit participants (based on a range of factors, including deprivation scores, ethnic diversity and their approach to informing their patients about diabetes risk). From these, all eligible at-risk patients were invited to have consultations audio-recorded and to also participate in in-depth interviews | Qualitative mixed methods: observational study (audio recorded consultations), and individual in-depth interviews Grounded theory approach | Not described | Setting: In the context of a national diabetes prevention program, the setting of this study is the primary care consultation where data was drawn from individual interviews and observations Area for lifestyle change (no intervention): To promote exercise and dietary changes |
Wallace et al., 2021, USA [53] | Understanding how Latinos with prediabetes attempted to slow T2D progression and how stress affected their engagement in these behaviours | (1) 20 years of age or older; (2) born in a Spanish-speaking Latin American or Caribbean country; 3) doctor confirmed prediabetes diagnosis (haemoglobin A1c range 5.7–6.4%) or elevated fasting glucose reading 100–125 mg/dL in past year, and (4) received medical care in the health system in the past year | n = 20 F = 14 M = 6 Age range: 22–72 Mean age: 51 | Qualitative semi-structured interviews | Not described | Setting: Participants were interviewed after having been diagnosed with prediabetes, following participants’ medical appointments Area for lifestyle change (intervention): To promote exercise and dietary changes |
Quality assessment
Thematic synthesis of the qualitative studies
Intervention (structured lifestyle intervention program) | No intervention | |||||||
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Main theme | Subthemes | Exercise and diet | Exercise | Diet | Exercise and diet | Exercise | Diet | Number of studies |
Individuals’ evaluation of the importance of initiating lifestyle change | The impact of the awareness and perception of risk when diagnosed with prediabetes | [38] | [34] | [4] | 15 | |||
The internal struggle in the process of lifestyle change | [44] | 18 | ||||||
The importance of internal motivation and positive health feedback | [38] | [41] | [44] | 12 | ||||
Strategies and coping mechanisms for maintaining lifestyle changes | The motivation in making plans and setting goals | [38] | [43] | [44] | 15 | |||
Knowledge and skills in mastering lifestyle change maintenance | [43] | [44] | 15 | |||||
The significance of supportive relations and environments in initiating and maintaining lifestyle change | Family as allies for change and the importance of support from health care providers and peers | [44] | 17 | |||||
The motivation of external monitoring in maintaining lifestyle change | [40] | [44] | 14 | |||||
Health promoting options and facilitating surroundings for lifestyle change | [40] | [34] | [43] | [44] | 14 |
Theme 1: The individual’s evaluation of the importance of initiating lifestyle change
The impact of the awareness and perception of risk when diagnosed with prediabetes
There’s a big element of worry . . . like I’m on the train and I can’t stop it. You get that worry of ‘are you going to be able to stop this from getting worse?’ . . . like ‘whoa, what’s going on here?’ . . . I don’t want to become diabetic, that would be my main concern, I don’t want what comes with that. [48]
The internal struggle in the process of lifestyle change
How am I going to do this? It seems so overwhelming. I know I should ideally lose a hundred pounds to get back to…my ideal weight, but it seems like such an insurmountable mountain to climb that why even try? [48]
Sometimes I get very angry at myself because I don’t have the self-control to say: ‘stop eating that and go and exercise.’ Typically, I intend to do it, but then I feel anxious and I go and eat a pastry or something like that. Then after I feel terrible and I start thinking, how is it possible that I cannot get over this stress? [53]
I think there’s always a risk, I think there’s always some sort of risk, but it’s a very . . . I put it really on the backburner. If you think of priorities, it’s falling downstairs or tripping over, and I do try and eliminate risk. This is why I’ve started off with this Pilates teacher, which is definitely making me more aware of balance. Diabetes, it doesn’t worry me particularly. [52]
The importance of internal motivation and positive health feedback
So, when you go outside to exercise, you feel the sunshine, you breathe in the fresh air, your body will then be good. It is for our wellbeing. [43]
Theme 2: Strategies and coping mechanisms for maintaining lifestyle change
I established a goal. I force myself to run three laps no matter how sluggish I feel. . . If I run today, I feel that I have paid attention to my health and I feel at peace. [39]
From Monday to Friday, I’m working . . . then Saturday and weekend I need to run errands for my children, my husband, and on top of that there is the housework. I also need to spend some time to visit my parents. Time is very important to me, I have so many duties and roles to fulfil, my first priority is always my family. [43]
Knowledge and skills in mastering lifestyle change maintenance
. . . my cooking is all standard, you add the oil, the salt, and the sauce. But if you ask me to cook healthy food, like reduce the oil, reduce the salt, don’t use the sauce, then I don’t know how to cook already. Also, I have been cooking white rice all my life, now you tell me change to brown or red rice, I don’t know how to cook, how to make it tasty like white rice. [44]
It wasn’t stop this, stop that. It was cut down on this, cut down, little steps. . .The favourite saying is ‘little steps.’ And that’s probably one of the most helpful sayings I’ve ever heard. Not trying to do it in a week or two weeks, or two months or three months. It’s over a period of time, you know? [34]
Theme 3: The significance of supportive relations and environments in initiating and maintaining lifestyle change
Family as allies for change and the importance of support from health care providers and peers
My children will say, ‘mom that’s salty, don’t eat’ or you know, they will say ‘this is too fat, don’t eat’, you know what I mean? They will remind me and keep a look-out on my diet. [44]
My whole family eats white rice since young, it has become a habit, a culture in us. Now say change to brown rice, not easy, it takes time for us to adjust to the new taste of brown rice. [44]
It was the way she encouraged me, how she uplifted me. I am so grateful . . . So, I think having the right people at the forefront there just to open you up, you know, and acknowledging where I am at. [34]
The motivation of external monitoring in maintaining lifestyle change
I have a Fitbit that makes it easier, because I like to challenge myself to make sure I get my steps every day. So, lots of times, I’ll get home in the evening and I’ll see them at 9000 steps, and I’ll like go out and walk up and down the driveway. [41]
I must not just settle with reducing carbohydrates, but I must, as we say, document it. I had a friend that believed that, for everything you did, you had to keep a record of it and said, ‘It’s like sports; if you don’t keep a record, you’re only practicing. [53]
The availability of health promoting options and facilitating surroundings
Look, the barrier to those goal settings is budget, you know . . . So, when you see on TV people saying they’re eating unhealthily, what they’re doing, what we’re doing is we’re eating to a budget planned to survive for the week.... So, don’t go telling poor people ‘you’re going to get diabetes if you eat this and this and this’; so we want you to eat this food, but it’s too expensive for you to buy, you know. [36]