Introduction
Materials and methods
Semi-structured interviews
Analysis
Results
Program characteristics
Site | Host Organization Type | Suspension Duration | Pre-COVID Delivery Mode | During COVID Delivery Mode | Pre-COVID Cohort Size | During COVID Cohort Size | Recruitment Methods | Racial/ Ethnic/Cultural Groups | Foreign-Born Participants |
---|---|---|---|---|---|---|---|---|---|
Programs that were suspended during the pandemic | |||||||||
1 | Community-Based Organization | 2 months | In-Person | Distance Learning | 40 | Increased | -Advertisements -CBO referrals -In-person outreach/flyers -Social media/Word of mouth | -Korean | 100% |
2 | Citywide Service Provider | 3 months | In-Person | Distance Learning | 20 | Decreased | -Advertisements -CBO referrals -Hospital referrals -In-person outreach/flyers | -Ecuadorian -Mexican -Salvadorian | 90% |
3 | Hospital, Out-patient | 2 months | In-Person | Distance Learning | 15 | Decreased | -Advertisements -CBO referrals -Hospital referrals -In-person outreach/flyers | -Black -Dominican -Puerto Rican -White American | 40% |
4 | Health Insurance Company | 2 years | In-Person | Still suspended (preparing distance learning) | 25 | N/A | -Advertisements -CBO referrals -In-person outreach/flyers -Word of mouth | -Black -Chinese -Dominican -Mexican -Puerto Rican -White | 50% |
Programs that were NOT suspended during the pandemic | |||||||||
5 | Faith-Based | N/A | In-Person / Distance Learning | Distance Learning | 12 | Increased | -Advertisements -In-person outreach/flyers -Physician referral -Social media/Word of mouth | -Black -Dominican -Ecuadorian -Puerto Rican | 25% |
6 | For-Profit Lifestyle Company | N/A | In-Person | Combination | 12,000 | Stayed the same | -Online recruitment platform | -Unknown | Unknown |
Programs that started during the pandemic | |||||||||
7 | Federally Qualified Health Center | Started during the pandemic | N/A | Distance Learning | N/A | N/A | -In-person outreach/flyers -Physician referral -Phone calls to newly Dx -Ads on website | -Black -Bengali -Haitian -Spanish-Caribbean -White | 20–50% |
Interviewee characteristics
Qualitative results
Going virtual, educational sessions, and materials
Lifestyle Coach B: In in-person class, they are very active [they talk about themselves and how they are really concerned about their diabetes] or their successes […] but in virtual class they just listen. It’s a little hard because they still have difficulties operating Zoom and the mute/unmute function.
Lifestyle Coach A: It’s the little things that [would keep people interested] and those we had to omit because of COVID. Given that the program would have people more engaged, [we would] take a trip to the supermarket and or farmers market [or] bring healthy snacks in for them.
Coordinator B: All of our materials are in English, some [are in] Spanish. That is a barrier not having more specific kinds of languages we don’t necessarily have materials available in Mandarin or Vietnamese.
Lifestyle Coach B: We have Brooklyn clients; we have Staten Island clients [and they access the DPP] remotely because it is a virtual classroom.
Lifestyle Coach D: A lot of these participants are somewhat tight with money and even commuting to one of the centers could be a bit of a challenge… The flexibility [of online classes allows them] to take the class during their lunch hour or while preparing meals at home.
Director C: We came into the pandemic [and] we found out that there was the option to do [the DPP] virtually. We had started doing some virtual classes already for our patients, [like] virtual yoga for free, virtual cooking classes, and we had success with attendance. [...] We were surprised that we got a good cohort, and not only that, but they were consistently coming.
Coordinator B: Especially for younger populations like it's, In full disclosure, I will say I'm a millennial in my mid-30s. I can’t imagine going to a conference room at a hospital or Y facility for an hour and a half class for a year.
Staffing and training
Lifestyle Coach E: I am a dietitian and I have a full clinic to cover. The other lifestyle coach is a nurse assistant [...] he was at a COVID floor so he couldn’t do any of this with me.
Coordinator A: Not being able to control [my] staff’s schedules, like you can’t run a program for an hour and think that’s the only time you need for the program. You need prep, you need follow up. You need to have time and [...] and they’re just not given admin time, it’s awful.
Lifestyle Coach B: It was a great teamwork and then each lifestyle coach was passionate even though it's very hard…New York city [was] hardest hit by the Covid-19, but even though we really a little bit scared to go out to meet someone in person [...] we were brave and courageous.
Coordinator A: Say we had like 15 people. Someone needs to call 15 people and say, have you used Webex or whatever platform, are you comfortable with it, because it takes so much time. [...] I think clerical type support would be the best.
Lifestyle Coach B: In late March, we had a virtual coach meeting, so we decided to take responsibility [on]how to work with the clients. But even though the coach members are around 50 and 60 so this is why they could understand how difficult, even though they didn't know what Zoom is.
Lifestyle Coach A: The Department of Health and Mental Hygiene [have] helped us tremendously. They got us trained and I actually have [monthly meetings with] one of their workers. She helped me with the process of getting certified for Medicaid. Any time I have any issues, whenever I have to submit data to the CDC, they’re great so, they got us trained and they’re still here, helping us.
Recruitment, retention, and communication
Lifestyle Coach A: [People] couldn't get an appointment with their doctor, so they didn't remember when their last A1C was. That was a little more challenging and that's why we didn't get as many participants because we didn’t have a lot of referrals.
Lifestyle Coach C: We started with about 15 patients, it’s down to 8 now [...] I think that they’re really enjoying it, they’re coming to most of the sessions. For our clientele, there’s a bunch of different things going on in their lives, so it’s really hard for them to commit long term.
Lifestyle Coach E: We started with phone calls. I even mailed them the curriculum, and I even mailed them the health bucks because farmers markets [were] still on.
Coordinator A: I want to make sure I’m signing you up with your email address, and I want to know, “do you use your email?”. That’s just a step in the right direction towards if we needed to go virtual again, like [if I know your email] that tells me that you probably can do a Webex or other means of communication. The certified lifestyle coach, she was putting stuff in the mail all the time and it’s so laborious compared to just sending an email with attachments.
Director C: We were surprised that we got a good cohort and not only that, but they consistently are coming, and so it did show a huge difference compared to anything that we've ever tried to do in person at the clinics - so far it has been a … fortunate event.
Coordinator C: [When a physician says]“Oh, I heard you’re in the DPP and you’re doing so well.” I feel like that has really helped with retention when the doctor is involved. […] Sometimes, too, how the class gels [is important]. Some people in classes become friends and they’re like “You weren’t here last week, what happened to you?”
Lifestyle Coach D: Participation is a huge factor [to succeed] in the program. Sometimes [I] get one or two that are super shy, so I make sure to give them my direct line. [I say] Please give me a call and I will work with you every step of the way [...] I feel very passionate about this program, and I give it my all.
Director A: We are on a social media [app], you know, like all [members in our community] have [this app], Everybody is on [this app]. So, you know, like in DPP you know we have like a group of chatting room, so they were all in the chat room already, so we just have to let them know we got to start the class. Yeah, everybody was so excited, and they try to make a healthy plate and take a picture and show it. “Oh, I made this” and the coaches [would] make a comment “wow that looks good!”, “that’s beautiful!”
Data collection and tracking of body weight
Director B: That has been, ironically, one of the most challenging parts of this. Getting people used to sending in your weights and activities minutes. It’s a nightmare, and I’ve even invested in the apps where [I] personally put all the information in right after the session.
Coordinator B: The challenge is making sure we have all that data [...]. Self-reporting weight [is] our proxy for attendance. The caveat to that was obviously folks who don’t have a scale at home.
Coordinator B: There are several health insurance companies that will not accept self-reported weight, but they would accept Bluetooth scales sync to an app.
Coordinator C: [affiliated clinics] would help do free A1C tests, which was really helpful especially [since] we did them week 1 and week 16. At the very end, so people can kind of see the progress, and it was helpful with the doctors.
Funding and sustainability
Coordinator A: Before, the requirements for getting preliminary recognition was simple. It was attendance. For full recognition the weight loss requirements were so strict. So that was another reason why I didn't care to be able to bill Medicaid/Medicare because we are not going to meet [the 5% weight loss] requirement. But now that [Hb]A1C is on the table, it's something to reconsider. Currently we make zero dollars, but maybe in the future, we would.
Lifestyle Coach B: So, I really didn’t want to decline them to attend the class, because the free class sometimes the funding was provided by New York City Department of Health or as a grant from the CDC. But in that case, we didn't report the undiagnosed or their family members, but we only report [eligible participants to the CDC], but we didn't decline those people.
Director C: We collect maybe half the time and that's worth it for us. So, finances and billable hours is something I always have to be thinking about. We have been fortunate that our organization believes that investing in nutrition education is a worthy endeavor and we bill for all of our services,[including] our nutrition services from insurance companies. Sometimes they reimburse them, sometimes they don't.
Coordinator A: If we had more funding and I could be like: if you complete the program, you get a $50 [gift] card or other perks and incentives. I think it could improve show rates and completion rates.