BACKGROUND
FROM EFFICACY TO BROADER UPTAKE OF LIFESTYLE INTERVENTION PROGRAMS FOR DIABETES PREVENTION IN FINLAND AND AUSTRALIA
Program phases | GOAL Program (Finland) | Greater Green Triangle Diabetes Prevention Program (GGT DPP, Australia) |
---|---|---|
Awareness of the problem and possible solutions (2001–2002) | The Development Program for the Prevention and Care of Diabetes (DEHKO 2000–2010) is initiated and coordinated by the National Diabetes Association. | Australia’s National Health and Medical Research Council releases guidelines on diabetes prevention |
Regionally and locally, the social welfare and health care leaders in Päijät-Häme identify chronic disease prevention as a major community goal. | ||
GOAL Program for Good Aging in Lahti is established to address high mortality and prevalence of lifestyle-related disease. | ||
Planning (2002–2003) | Funding from Academy of Finland for the GOAL Lifestyle Implementation Trial (GOAL LIT) to prevent T2DM in the municipalities of Päijät-Häme region | Australian Department of Health and Ageing funds GGT University Department of Rural Health to implement a diabetes prevention program, based on the Finnish GOAL program, in three rural settings in southeastern Australia. |
A planning group is formed with local representatives of relevant professionals to adapt FinDPS. | Project builds on existing collaborations and regular exchanges between senior GGT staff (James Dunbar, Director) and senior researchers from Finland National Public Health Institute. Dr. Laatikainen on sabbatical from Finland sets up GGT DPP. | |
Program is designed based on health psychology theories and national diet and physical activity recommendations | GTT DPP is adapted from the GOAL LIT program to Australian conditions. | |
Materials are developed and selected. | ||
Implementation (2003–2004) | Thirty municipal health care professionals are trained to use the program, and one dietician is hired to support them. | One dietician and four nurses are employed and trained to run the program. |
The GOAL LIT is implemented with 36 lifestyle counseling groups. | The GTT DPP is implemented with some 30 groups across three intervention sites. | |
Evaluation (2006–2011) | Data are collected for 3- and 12-month and 3-year follow-ups. | Data are collected for 3- and 12-month follow-ups. |
Maintenance (2006–) | Encouraged by positive experiences, municipal health care sector seeks to maintain the program and takes over funding of the program dietician. | Results presented by Australian–Finnish team to Council of Australian Governments and Department of Health and Ageing |
Training program is further developed to cover gaps identified with already trained facilitators and to provide improved training for new facilitators. | ||
The GOAL Current Care Guideline Implementation Trial (CCG) is started to develop multi-professional prevention processes including lifestyle counseling. | ||
Based on results from GOAL LIT and CCG trials, lifestyle management guidelines are developed by regional health care with the FINDRISC test as screening instrument and group-based lifestyle counseling as the recommended intervention. | ||
Ongoing outcome evaluation after research phase enabled by recording of lifestyle change data in the electronic patient register | ||
Diffusion | Growing interest towards the program outside Finland (Australia, Malaysia, India) | Council of Australian Governments (COAG) commits AUD $200 million to future diabetes prevention programs throughout the country |
Interest within Finland starts to grow in 2010. Uptake of the program by several new regions | Diabetes Australia Victoria allocated funding to implement a further adaptation of the GOAL LIT and the GGT DPP, renamed as the Life! program, for 25,000 Victorian residents aged 50+ years in metro and rural areas identified at high risk for diabetes over the next 4 years | |
Social marketing of the program | ||
Orientation and training of allied health professionals to become program facilitators |
From efficacy to broader uptake in Finland
From efficacy to broader uptake in Australia
KEY ELEMENTS INVOLVED IN THE DEVELOPMENT, IMPLEMENTATION, AND EVALUATION OF EACH PROGRAM
GOAL Lifestyle Implementation Trial | GGT Diabetes Prevention Program | |
---|---|---|
Setting | ||
Health care system | - Public primary health care centers (organized by municipalities) | - General practice is federally funded with general practices voluntarily grouped into divisions, but community health centers are funded by the states and territories. |
Organizations | ||
Leaders | - National Public Health Institute | - Greater Green Triangle University Department of Rural Health, Flinders and Deakin Universities |
Strategic regional partners | - Päijät-Häme Social and Health Care District | - Limestone Coast, Otway and West Vic Divisions of General Practice, Wimmera Health Care Group |
- University of Helsinki, Palmenia Centre for Continuing Education | ||
Strategic national partners | - UKK Institute for Health Promotion | - Department of Health and Ageing, Office of the Victorian Premier (COAG) |
Operational partners | - Public health care sector and sports and recreation sector in the municipalities of Päijät-Häme | - General practices in Hamilton, Horsham, and Mount Gambier. |
Päijät-Häme Social and Health Care District | - National Public Health Institute of Finland | |
- University of Helsinki, Palmenia Centre for Continuing Education | ||
Research partners | - National Public Health Institute | - Greater Green Triangle University Department of Rural Health |
- University of Helsinki, Palmenia Centre for Continuing Education | - Flinders and Deakin Universities | |
- Monash University, Australia | - The University of Melbourne | |
- University of Konstanz, Germany | ||
Funding | ||
Development | - Academy of Finland, Program for Health Promotion | - Department of Health and Ageing |
- Uebergang Foundation | ||
Implementation | - Municipalities of Päijät-Häme | - Greater Green Triangle University Department of Rural Health, assisted by a Finn on sabbatical leave from the National Public Health Institute of Finland |
- Päijät-Häme Social and Health Care District | ||
Evaluation | - Academy of Finland, Program for Health Promotion | - Greater Green Triangle University Department of Rural Health assisted by the National Public Health Institute of Finland |
- Social Insurance Agency | ||
- Ministry of Social Affairs and Health | ||
Target population | ||
Demographics | - Women and men (3:1) | - Women and men (7:3) |
- Age 50–65 years | - Age 40–75 years | |
- Ethnicity: Finnish (white) | - Predominantly Anglo Celtic Australian, (>95%), | |
- Socioeconomic status: educational level as in same-aged general population; retired and unemployed overrepresented | - Similar to the same-aged general population | |
- Rural, semi-urban, and urban communities | - Rural, semi-urban, and urban but not metropolitan communities | |
Type 2 diabetes mellitus (T2DM) risk | - Moderate or higher risk for T2DM (FINDRISC ≥12) | - Moderate or higher risk for T2DM (FINDRISC ≥12) |
- Glycemic status: NGT (74%), IGT (26%) | - Glycemic status: normal glucose values, 65.9%; impaired glucose values, 34.1% | |
Program elements | ||
Theoretical basis | Health Action Process Approach (Schwarzer and Fuchs, 1996) | Same |
Motivational theories (Deci and Ryan, 1985) | ||
Key components | Improved knowledge on T2DM based on materials | Same |
Improved knowledge on healthy diet and health-enhancing physical activity based on Finnish national guidelines | ||
Self-efficacy in healthy diet and physical activity | ||
Self-regulation (goal setting, planning, and self-monitoring) in healthy diet and physical activity | ||
Adoption and maintenance | ||
Materials | Program structure including session contents and materials for self-regulation and self-efficacy developed by the GOAL group | Same, but program materials required language and cultural translation from Finnish to English, and adaptation to ensure alignment with Australian national physical activity and dietary guidelines. |
Information leaflets and materials for self-regulation (e.g., nutrition tests) from relevant nongovernment organizations | ||
Delivery | Group counseling with six 2-h sessions | Same, except for facilitation by study nurses solely employed for the purpose |
Delivery by public health nurses and physiotherapists employed by the municipalities as part of their routine work | ||
A dietician supporting delivery during one session, employed by the program | ||
Municipal sports and recreation office supporting delivery during one session | ||
Training | A 2.5-day training program delivered by GOAL group and specialists from the regional central hospital | Two-day training program delivered by Dr. Laatikainen from the National Public Health Institute of Finland |
DISCUSSION
Country | Program | Key points of exchange |
---|---|---|
India | Kerala Diabetes Prevention Program | Strong exchange between program implementers and researchers from Kerala, Finland, Australia, and USA to conduct a large implementation trial of diabetes prevention in Kerala, India. This trial is funded for 2011–2015, and there is a strong Advisory Group of potential champions from elsewhere in India who will be able to lead future “scaling up” elsewhere in India. |
Malaysia | Malaysian Diabetes Prevention Program | An ongoing exchange is being undertaken between university researchers and health service delivery organizations in Kuala Lumpur to develop, implement, and evaluate a culturally tailored program that has been adapted from Finland and Australia. |
Sri Lanka | Pilot implementation projects | Funding has been obtained from US National Institutes of Health (Millennium Promise Award) by Program Directors from Australia, Malaysia, Sri Lanka, India, and USA to conduct training and capacity building with trainees from Sri Lanka, Malaysia, and India to address NCDs, including diabetes. A number of the research projects being undertaken by trainees will adapt and test diabetes prevention strategies in these three countries. This will help establish a focus on diabetes prevention in Sri Lanka. |
China | Pilot implementation projects | Provisional agreement has been reached to initiate some pilot implementation projects in Beijing by cultural tailoring and adaptation of program from Australia. |
South Africa | N/A | Exchanges are just beginning between researchers from Australia and researchers and program implementers in South Africa. |