Background
Aim, research questions and objectives
-
Identify primary studies that had explored health-related behaviours in populations at risk of diabetes
-
Develop a taxonomy of these studies in terms of their epistemological assumptions and methodological approaches
-
Extract and analyse data on risk perception, health-related lifestyle changes and individual and socio-cultural influences on these
-
Synthesise findings from studies across disciplines, using seemingly conflicting data to draw out higher-order insights
-
Draw conclusions on implications for the design and refinement of diabetes prevention programmes
Methods
Choice of approach
Search strategy
Data extraction
Quality assessment
Theoretical approach
Synthesising the literature
Results
Search results
Author | Paper no | Research perspective | Study design | Study population | Theory or framework used | CASP score | CERQual score |
---|---|---|---|---|---|---|---|
1,2 | Social realist | In-depth semi-structured interviews | 10 individuals participating in intervention; focus groups with 14 clinicians | Bourdieu: habitus Giddens: agency/structure Weber: choices/chances | 9 | 1 | |
Greenhalgh 2015 [31] | 3 | Social realist | Group storytelling and in-depth narrative interviews | South Asian women with a history of GDM, 17 in focus groups and 28 individual narratives | Glass and McAtee’s axis of nested hierarchies influencing behaviours and disease risk Giddens: agency/structure Weber: choices/chances | 9 | 1 |
Jallinoja 2008 [32] | 4 | Biomedical | Structured focus groups with pre-defined questions | 30 individuals interviewed after a lifestyle intervention. | No explicit theoretical framework, though references to Giddens’s reflexivity and individuality and self-determination theory | 9 | 0.5 |
Walker 2012 [28] | 5 | Psychological | Structured focus groups | 29 people a year after a lifestyle intervention | Health action process approach (Schwarzer) | 8 | 0.5 |
Troughton 2008 [36] | 6 | Biomedical | 1:1 semi-structured interviews | 15 participants, 40% with South Asian ethnicity | Leventhal’s self-regulatory model of illness behaviour referred to in discussion but not in analysis | 8 | 0.1 |
Satterfield 2003 [35] | 7 | Biomedical | Open-ended focus groups | 235 persons from a mixed US population | None | 7 | 0.1 |
Tang 2015 [38] | 8 | Psychological | Semi-structured interviews | 23 women with a history of GDM within the last year | Health belief model | 9 | 0.5 |
Vlaar 2014 [27] | 9 | Psychological | Structured questionnaire (Likert scales) | 535 people in a randomised controlled trial on diabetes prevention | Leventhal’s self-regulatory model of illness behaviour | 9 | 1 |
Kim 2007 [24] | 10 | Psychological | Telephone or written survey | 217 women of white ethnicity with a history of GDM | Health belief model | 8 | 0.5 |
Jones 2011 [25] | 11 | Psychological | Quantitative survey with semi-structured interview | 22 women with a history of GDM within the last 7 years. | Risk perception attitude framework | 8 | 0.5 |
Morrison 2014 [33] | 12 | Biomedical | Semi-structured interviews | 20 trial participants and four family volunteers | None | 9 | 0.5 |
Penn 2015 [34] | 13 | Biomedical | Semi-structured interviews | 15 intervention participants from a South Asian ethnic group | None (theoretical domains framework used in structure coding) | 8 | 0.5 |
Kolb 2015 [26] | 14 | Psychological | 60-item multi-choice survey | 54 black or Hispanic women | Trans-theoretical model of stages of change | 8 | 1 |
Morrison 2010 [39] | 15 | Biomedical | Cross-sectional analysis of national survey | 1381 women with a history of GDM | None | 9 | 1 |
Penn 2018 [37] | 16 | Biomedical | Semi-structured interviews and focus group as part of an evaluation | 21 people with pre-diabetes undertaking DPP | None | 9 | 1 |
Key research traditions
Question | Biomedical | Psychological | Social realist |
---|---|---|---|
How has the problem been conceptualised by the authors? | Pre-diabetes is a biomedical condition that is a precursor for diabetes. | Pre-diabetes is an objective risk state. People require a perception of high risk and knowledge to change their lifestyles and reduce their diabetes risk. Social context has a role to play in changing behaviours within the individual. | Development of type 2 diabetes is a complex process influenced by multiple social, cultural and environmental factors. The term ‘pre-diabetes’ is (at least in part) a socially constructed and value-laden category that obscures these wider determinants. |
People can reduce their risk by changing their lifestyles in a prescriptive way. | |||
How has the problem been theorised? | Chronic disease develops in a linear fashion (genetic predisposition to risk state to established disease). | Psychological models of health-related behaviour (especially Leventhal’s self-regulatory model of illness behaviour and the health belief model). | Sociological models of the interaction between agency (individual behaviour and choices) and wider social influences (structure), especially Bourdieu’s notion of habitus (internal predispositions shaped by cultural experiences). |
What methods have been used to research the problem? | Questionnaires and semi-structured focused interviews. | Semi-structured interview and focus group studies seeking data on psychological factors (attitudes, perceptions, concerns and barriers to change or engagement). Questionnaire studies of attitudes, stage of change, self-reported behaviours, risk assessment and disease knowledge. | Interviews and ethnographic studies seeking a rich picture of how wider social and cultural influences affect individual decision-making and action. Lifestyles are viewed as social practices with cultural meaning and moral worth. |
What instruments have been used to measure key variables or influences? | Quantitative scales and questionnaires. Qualitative data from focus groups. | Quantitative scales and questionnaires. Qualitative data from focus groups. | Critical ethnography, analysis of individual narratives (e.g. of family life) and analysis of wider cultural storytelling narratives (e.g. of diaspora or oppression). |
What are the main findings? | A diagnosis of pre-diabetes is sometimes (but not always) accepted and seen positively as prompting behavioural change. | People with pre-diabetes do not always perceive themselves at high risk of developing type 2 diabetes, even when they know the risk factors. Social context has an important role to play in changing lifestyles. | Perceptions and actions are socio-culturally framed. |
Lifestyle change is possible only when (and to the extent that) the individual’s social context, culture, and material and economic situation support particular behaviours. | |||
What conclusions are drawn from the findings? | Diabetes prevention can be improved through individual lifestyle education. This should focus on improving knowledge. | Diabetes prevention can be improved through lifestyle change by increasing risk perception and knowledge. However, social context is an important determinant of individual behavioural change. | Diabetes prevention through individual lifestyle education will have limited impact unless wider socio-cultural, environmental and material influences are addressed. |
Meta-narrative 1: pre-diabetes as a biomedical condition
The pre-diabetes diagnosis
Socio-cultural influences
‘some motivation to show that one went along with the rest of the group and as the sessions ended the individual became disengaged from lifestyle change pursuit, with fading out of the novel behaviours formed during the programme.’
‘Once a week they have children all come so we feel that the food should be much nicer according to the tradition and also children don’t like ordinary vegetables they fancy food like from McDonald’s so just to compete with that kind of food we try to make our old Indo-Pakistani dishes.’
“When you go to somebody’s home and they’ve invited you in and they’ve prepared a meal for you, it’s very difficult to say, ‘I won’t eat that. I can’t eat that. I shouldn’t eat that.’” [37]
Meta-narrative 2: pre-diabetes from a psychological perspective
Pre-diabetes and risk
Socio-cultural influences
‘Trying to actually practice it [behavioural change] in my home, yeah, it’s somewhat difficult, you know, because we’re all used to this lifestyle. And it’s a major change’. [25].
‘Everything revolves around food, and a lot of native peoples, that’s their highlight of any kind of social gathering is that you’ve got to have food to celebrate’.
‘Cooking like most of all Indians do; we fry everything, deep fry everything. Fry bread, fried potatoes, and we love it. That’s what was our meal; that’s what we were raised on.’ [25]
‘You know when you grow up and you just hear about those things, you know ‘Indians get diabetes.’ … It’s pounded in my head growing up.’ [25]
‘I don’t leave the children alone with non-family members and so that is difficult because if I am not exercising with them, with me, then I feel I have really leaned on my mother a lot for sitting so I don’t want to overdo it.’ [38]
‘It’s difficult to change your own lifestyle if your partner and family don’t want to change theirs.’ [28]
‘Households needed supplies of biscuits and cakes for visitors, while savoury scones or biscuits and cheese were healthy alternatives to cake for morning tea’. [28]
Meta-narrative 3: pre-diabetes as a social realist construct
The pre-diabetes diagnosis
‘Right now, I’m just like whatever. It is just me. I am not worrying about another human being in my womb. It makes a big difference. Right now, I just need to get energy to take care of this guy right here.’ [31]
Socio-cultural influences
‘I liked it the minute I entered [the fitness club] … I cannot run on the treadmill, I only walk for like 10 min at a brisk trot.’ [29]
‘I have already exercised away much of the fat. I wake up every morning and cycle 11 km… I love it. It has become my way of life.’ [29]
‘There is peer pressure involved, you know…. When we are with friends, they do not accept a ‘no’, so you end up drinking that beer. It’s hard to lose weight’. [29]
‘I didn’t like to look at myself in the mirror; it didn’t look good with that stomach. And twice a week, I measure my circumference and my weight. I write it down in my book here.’ [29]