Barriers and Facilitators to Real-world Implementation of the Diabetes Prevention Program in Large Healthcare Systems: Lifestyle Coach Perspectives

Abstract

Background

Group-based lifestyle change programs based on the Diabetes Prevention Program (DPP) are associated with clinically significant weight loss and decreases in cardiometabolic risk factors. However, these benefits depend on successful real-world implementation. Studies have examined implementation in community settings, but less is known about integration in healthcare systems, and particularly in large, multi-site systems with the potential for extended reach.

Objective

To examine the barriers and facilitators to successful DPP implementation in a large multi-site healthcare system.

Design

Semi-structured interviews, based on the RE-AIM framework, were conducted in person for 30–90 min each.

Participants

Past and present DPP lifestyle coaches in the healthcare system identified using purposive sampling.

Approach

Thematic analysis of qualitative data to identify key factors influencing the success of DPP implementation. An iterative consensus process was used to model the relationships among factors.

Key Results

We conducted 33 interviews across 20 clinic sites serving 12 counties. Participants described six key factors as potential barriers or facilitators to implementation, including (1) Broader Context, including the surrounding physical and sociodemographic context; (2) Institutional Context, including finances, infrastructure, and personnel; (3) Program Provision, including curriculum, administration, cost, goals, and visibility; (4) Recruitment Process, including screening and referrals; (5) Lifestyle Coaches, including their characteristics, behaviors, and morale; and (6) Cohort, including group attrition/retention and interpersonal dynamics. These factors were both highly interconnected in their impact on implementation and widely variable across sites within the healthcare system, as illustrated in our multi-level conceptual framework.

Conclusions

This study identified key factors that could serve as barriers or facilitators in the implementation of DPP in large healthcare systems, from the perspective of lifestyle coaches. With further examination, the conceptual model presented here may be used for planning and managing the implementation of group-based behavioral interventions in these settings.

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Data Availability

The dataset, which includes participants’ transcripts, is not publicly available due to confidentiality policies.

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Funding

Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health under Award Number R18DK110739. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Corresponding author

Correspondence to Kristen M. J. Azar RN, BSN, MSN/MPH.

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The authors declare that they do not have a conflict of interest.

Consent for Publication

All participants provided written consent before participating in the study, which included consent to publish anonymous quotes from individual participants.

Disclaimer

This was an investigator-initiated study by Sutter Health Research. No sponsor or funding source had a role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.

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Halley, M.C., Petersen, J., Nasrallah, C. et al. Barriers and Facilitators to Real-world Implementation of the Diabetes Prevention Program in Large Healthcare Systems: Lifestyle Coach Perspectives. J GEN INTERN MED 35, 1684–1692 (2020). https://doi.org/10.1007/s11606-020-05744-y

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KEY WORDS

  • real-world
  • Diabetes Prevention Program
  • implementation
  • semi-structured interviews