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Perspectives of diabetes prevention program coordinators in socioeconomically disadvantaged communities: implementation optimization

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Perspectives of diabetes prevention program coordinators in socioeconomically disadvantaged communities: implementation optimization

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Perspectives of Diabetes Prevention Program Coordinators in Socioeconomically
Disadvantaged Communities: Implementation Optimization
by
Nina Marie Woolfolk

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

May 2022

© Copyright by Nina Marie Woolfolk 2022
All Rights Reserved

The Committee for Nina Marie Woolfolk certifies the approval of this Dissertation

Courtney Malloy
Eric Canny
Kimberly Hirabayashi, Committee Chair

Rossier School of Education
University of Southern California
2022

iv
Abstract
Diabetes is the 7th leading cause of death in the United States. It is a largely preventable disease
that affects 37 million or 11.3% individuals. Type 2 diabetes (T2D) represents 90% to 95% of
diabetes. Additionally, 96 million or 33% of adults have prediabetes. Diabetes is a devastating
disease that disproportionately affects individuals with lower educational attainment and income
levels, widening health disparities. There is substantial evidence that lifestyle modification
programs that increase physical activity and eating nutritious food could prevent or delay T2D by
58%, and for adult 60 years or older by 71%. In 2010, the Centers for Disease and Prevention
(CDC) established the National Diabetes Prevention Program (National DPP), which ensures
adherence to evidence-based standards for community-based lifestyle change programs known as
CDC-recognized DPP. The purpose of this study was to examine best/promising practices to
improve the implementation of CDC-recognized DPPs in socioeconomically disadvantaged
communities. A qualitative research design used semi-structured interviews to better understand
the practice problem from the perspective of DPP program coordinators, who are instrumental in
implementing the program. The findings showed that the participants identified several practices
that support and encourage patients to establish health-promoting behaviors to prevent or delay
T2D. Notably, the participants recognized the bidirectional influence among the individual, the
health care professional, and social determinants that supported the individual to perform this
critical behavior. Future research should explore replicating this study in different regions of the
United States to determine geographical-specific best/promising practices to prevent or delay
T2D.

v
Dedication
To my children. The best part of me is being your mother. Le’Wayne, my son, God blessed me
with you for 26 years. There is not a second in the day where I do not feel blessed for our time
together. I love you and will see you again. Ashley, we have experienced great losses over the
years, yet we have each other. My prayer is that our bond grows and you feel my love. I have
loved you; I love you, and you will always be my first love.

vi
Acknowledgements
Praise God for carrying me and sometimes dragging me through my doctoral journey. He
and I know the uncertainty and the obstacles along the way. “For I know the plans I have for
you,” declares the LORD, “plans to prosper you, and not to harm you, plans to give you hope,
and a future.” Jeremiah 29:11
I want to recognize Dr. Kimberly Hirabayashi for your masterful mindfulness and
insufferable ability to know what works best. I always felt that you were in my corner – making
me reach and work for the best I had to give. Thank you, Dr. Courtney Malloy, for
recommending a turnabout in my proposal presentation that mirrored my philosophy of
appreciating the ‘haves’ more than the ‘have-nots.’ It made my dissertation authentically me. Dr.
Eric Canny - nothing but priceless since Day 1. I desired this program because I wanted to see
what else I had to offer. Through your encouragement, patience, guidance, and attention to
detail, I now know my value and believe in the contributions that I can offer whomever or
whatever I choose.
Special thanks to my classmates who added so much to this experience in ways that,
without them, there would not be the growth I have experienced. Honorable mention to all the
individuals who dedicate themselves to supporting diabetes prevention, especially the
participants of this study who gave their time, and shared their insights.

vii
Table of Contents
Abstract ........................................................................................................................................... iv
Dedication ........................................................................................................................................ v
Acknowledgements ........................................................................................................................ vi
List of Tables .................................................................................................................................. ix
List of Figures .................................................................................................................................. x
List of Abbreviations ...................................................................................................................... xi
Chapter One: Introduction to the Study ........................................................................................... 1
Context and Background of the Problem ............................................................................ 2
Purpose of the Project and Research Questions .................................................................. 5
Importance of the Study ...................................................................................................... 6
Overview of Theoretical Framework and Methodology ..................................................... 8
Definitions ........................................................................................................................... 9
Organization of the Dissertation .......................................................................................... 9
Chapter Two: Literature Review ................................................................................................... 11
Prediabetes ......................................................................................................................... 11
Incidence and Prevalence of T2D ...................................................................................... 13
Conceptual Framework ..................................................................................................... 31
Summary ............................................................................................................................ 32
Chapter Three: Methodology ........................................................................................................ 33
Research Questions ........................................................................................................... 33
Overview of Design ........................................................................................................... 33
Credibility and Trustworthiness ........................................................................................ 38
Ethics ................................................................................................................................. 39
Chapter Four: Findings .................................................................................................................. 40

viii
Participants ........................................................................................................................ 40
Research Question 1 .......................................................................................................... 42
Research Question 2 .......................................................................................................... 54
Research Question 3 .......................................................................................................... 61
Summary ............................................................................................................................ 66
Chapter Five: Recommendations .................................................................................................. 68
Discussion of Findings ...................................................................................................... 68
Recommendations for Practice .......................................................................................... 70
Limitations and Delimitations ........................................................................................... 77
Recommendations for Future Research ............................................................................. 78
Conclusion ......................................................................................................................... 79
References ..................................................................................................................................... 81
Appendix: Interview Protocol ..................................................................................................... 105

ix
List of Tables
Table 1: Description of Participants’ Professional Background, DPP Setting, and Population
Demographics 41
Table A1: Interview Questions 106

x
List of Figures
Figure 1: Percentage of DPP Participants Retained by Racial/Ethnic Group Through Week 18 4
Figure 2: Percentage of DPP Participants Retained by Age Group through Week 18 5

xi
List of Abbreviations
AHRQ Agency for Healthcare Research and Quality
ADA American Diabetes Association
CDC Centers for Disease Control and Prevention
CMS Center for Medicare and Medicaid Services
COVID-19 Coronavirus 2019
DHHS Department of Health and Human Services
DPP Diabetes Prevention Program
DPRP Diabetes Prevention Recognition Program
DSMES Diabetes Self-Management Education and Support Services
GDP Gross Domestic Product
HP Healthcare Professionals
IGT Impaired Glucose Tolerance
IFG Impaired Fasting Glucose
NIH National Institute of Health
National DPP National Diabetes Prevention Program
OECD Organization for Economic Cooperative and Development
PC Program Coordinator
T2D Type 2 Diabetes
SDOH Social Determinants of Health
SCT Social Cognitive Theory

1

Chapter One: Introduction to the Study
Type 2 Diabetes (T2D) is a largely preventable disease. Yet, 37 million or 11.3% of
adults in the United States have diabetes, and 90%–95% of adults have T2D (Centers for Disease
Control and Prevention [CDC], 2021d). Additionally, 96 million or over 33% of adults had
prediabetes (CDC, 2021e). Individuals who develop prediabetes are up to 50% more likely to
progress to T2D within five to 10 years; however, it can be reversed (CDC, 2021e; National
Institute Diabetes and Digestive and Kidney Diseases, 2018). Smoking tobacco, eating an
unhealthy diet, and physical inactivity are risk factors that can be modified to prevent or delay
T2D (Towne et al., 2017). Several landmark studies found that lifestyle modifications that
consisted of increased physical activity and healthy eating could prevent or delay T2D (Diabetes
Prevention Research Group [DPRG], 2002, 2009). Based on the findings from these studies,
CDC established the National Diabetes Prevention Program (National DPP) in 2010 to address
the burdensome impact of prediabetes and T2D (CDC, 2019c).
Despite the evidence that lifestyle modifications are effective preventative strategies for
developing T2D, barriers to improved health outcomes, particularly for individuals with the
highest risks, remain (Hill-Briggs et al., 2021). T2D is disproportionately higher in
socioeconomically disadvantaged communities (Hill-Briggs et al., 2021). Lower educational
attainment, decreased income level, and rural geographical locations are associated with an
increased risk for T2D (Beckles & Chou, 2016). The problem of practice examined in this study
concerned health disparities affecting individuals with T2D and low socioeconomic status in the
United States. The purpose of this dissertation was to examine best/promising practices to
improve the implementation of DPPs in socioeconomically disadvantaged communities for
individuals at risk for T2D.
2

Context and Background of the Problem
The National DPP partners with public and private organizations to provide access to
lifestyle modification programs for individuals with prediabetes or at risk for developing T2D
(CDC, 2018f). The lifestyle modification programs are based on behavioral research that
demonstrates how positive social networks influence healthy behaviors (Strom & Egede, 2012).
They offer support groups led by specialty-trained lifestyle coaches who educate individuals with
prediabetes about eating healthier, increasing physical activity, and reducing stress (CDC,
2021d).
In 2010 with the inception of the National DPP, the CDC established the Diabetes
Prevention Recognition Program (DPRP; CDC, 2018f). The DPRP provides information to
individuals about the locations and performance of community-based lifestyle change programs
known as CDC-recognized diabetes prevention programs (DPP; CDC, 2018f). The DPRP is
committed to increasing access to DPPs in socioeconomically disadvantaged communities to
promote health equity (CDC, 2018f). The 2021 CDC diabetes prevention recognition standards
and operating procedures (DPRP Standards) outline the requirements to operate as a DPP.
Since the establishment of the National DPP, there have been concerted efforts to provide
continuing support to lifestyle modification programs. In 2015, The Community Prevention
Services Task Force concluded that there was strong evidence to support lifestyle modification
programs’ efficacy to prevent or delay T2D (CDC, 2018d). In 2016, the Institute for Clinical and
Economic Review found that CDC-recognized DPPs provided a health benefit (CDC, 2018d). In
2017, the CDC funded 12 cooperative agreements with state and local health departments to
offer DPPs in socioeconomically disadvantaged communities (CDC, 2018d).
3

Despite these efforts, access to preventative services among socioeconomically
disadvantaged communities is distinctively apparent. In 2018, the Centers for Medicare and
Medicaid Services (2021) expanded coverage to its beneficiaries through a no-cost Medicare
DPP. The initial evaluation of the Medicare DPP for April 2018 to December 2019 identified
that 2,248 Medicare beneficiaries participated (CDC, 2021c). The report also identified a
disparity among patients’ racial/ethnic groups, gender, and educational attainment (CDC, 2021c).
The majority of them had some college (53.5%), were women (74%), and were White (75%;
CDC, 2021c). Black (7.4%); Hispanic (2.9%) and Asian (2.1%) were significantly
underrepresented groups (CDC, 2021c). Further, Cannon et al. (2018) conducted a retrospective
review of 41,203 individuals enrolled in a DPP from January 2012 to February 2017 and found
retention gaps in program completion among racial/ethnic groups, as shown in Figure 1. Cannon
and colleagues also found a retention gap among age groups, as shown in Figure 2.

4

Figure 1
Percentage of DPP Participants Retained by Racial/Ethnic Group Through Week 18

5

Figure 2
Percentage of DPP Participants Retained by Age Group through Week 18

Purpose of the Project and Research Questions
The purpose of this dissertation was to examine best/promising practices to improve the
implementation of DPPs in socioeconomically disadvantaged communities for individuals at risk
for T2D. The following research questions guided this study:
1. What organizational/environmental strategies are DPPs implementing to address
participants’ beliefs and behaviors in delaying or preventing T2D?
2. What resources are needed to maintain or improve DPP outcomes?
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3. How are DPPs addressing the challenges of offering services during the COVID-19
pandemic?
Importance of the Study
This problem of practice is important to address because the public health and economic
implications related to the burden of diabetes extend to all individuals in the United States.
Diabetes is the seventh leading cause of death in the United States and is also one of the costliest
chronic diseases (CDC, 2020b; Yang et al., 2018). The mortality rate for individuals with
diabetes is 60% higher than for those without diabetes (CDC, 2020b). Individuals with diabetes
are also at the greatest risk for adult-onset blindness, kidney failure, heart disease, stroke, and
lower limb amputation (CDC, 2020b). Individuals with diabetes are at higher risk for breast,
colon, liver, and uterine cancers and have higher rates of dementia and Alzheimers (CDC,
2020a).
Healthcare expenditure related to diabetes comprised 25% of all healthcare costs in the
United States, including hospital care, medications and supplies, and physician office visits
(Yang et al., 2018). In 2019, the U.S. consumed 16.8% of its gross domestic product (GDP) on
health care, while the average expenditure for other high-income countries in the Organization
for Economic Cooperative and Development (OECD) was 8.8% (OECD, 2021). Additionally,
there is a 10-year gap in life expectancy between the top 100 most socioeconomically
disadvantaged and the top 100 most socioeconomically advantaged, 72.3 years and 82.3 years,
respectively (University of Michigan, 2020).
Projections for diabetes-related healthcare costs are expected to worsen. Healthcare
expenditures are projected to reach 19.4% of GDP by 2027, including a 48% increase from 2019
in out-of-pocket costs to individuals (Sisko et al., 2019). In the U.S., households are sufficiently
7

impacted with the equivalent of 530,000 bankruptcies filed each year due to medical expenses or
loss of work related to illness (Himmelstein et al., 2019). In 2030, the Institute for Alternative
Futures projects that 54% of adults will have diabetes, and the economic burden may increase to
$622B, which is a 53% increase from 2015 dollars (Rowley et al., 2017).
Health disparities related to socioeconomic status remain a significant barrier to quality
and equitable healthcare treatment (Towne et al., 2017). Identifying health disparities of the
socioeconomic disadvantaged would decrease the burden of diabetes in the U.S. healthcare
system (Towne et al., 2017). To decrease the disease burden for higher-risk racial/ethnic
populations, interventions that consider cultural, social, and biological factors and lifestyle
modifications should be implemented to treat and manage T2D (Aguayo-Mazzucato et al.,
2019). Successfully implemented DPPs have demonstrated positive outcomes in reducing T2D
when individuals complete the program (Ely et al., 2017).
The COVID-19 pandemic has resulted in further urgency to promote best/promising
practices to decrease the burden of diabetes. According to the CDC, diabetes (30%) is the second
most common underlying condition in COVID-19 deaths nationwide, preceded by
cardiovascular disease (32%; Stokes et al., 2020). Health statistics identify that individuals with
T2D experience more severe complications, with one in five patients admitted for COVID-19
needing mechanical ventilator support within 7 days of admission and death occurring by Day 28
of admission (American Diabetes Association [ADA], 2021a; Wargny et al., 2021). Several
emerging studies have identified that there is also evidence of a bidirectional relationship
between COVID-19 and T2D; however, further research is needed to determine the duration of
diabetes post-infection (Al-Aly et al., 2021; Ayoubkan et al., 2021; Bornstein et al., 2020). It is
8

plausible that the impact of COVID-19 on individuals with diabetes may be countered through
adherence to standards of diabetes care and participation in DPP.
Overview of Theoretical Framework and Methodology
Social cognitive theory (SCT) is the theoretical framework guiding this study (Bandura,
1978). The theory explains human behavior through the lens of triadic reciprocal determinism
(Bandura, 1978). This worldview emphasizes the bidirectional interaction among three
determinants: (a) cognition, (b) behavior, and (c) external environment (Bandura, 1978). Also,
SCT assumes that learning occurs not only through one’s actions but also by observing others,
and the performance of learned behavior through observation is conditioned on the observer’s
motivation (Wood & Bandura, 1989). Behavioral models who are competent, credible, similar,
enthusiastic, and supportive are vital in motivating the learner towards goal-directed behaviors
(Glanz, 2020).
This study offers a counter-story to the increasing prevalence of T2D through the
worldview of SCT as opposed to blaming the individual for non-compliance with health-
promoting behaviors. This study explored individual self-efficacy, the healthcare professional’s
clinical practices, and the impact of social determinants of health. Examining this practice
problem through SCT serves to identify effective strategies among the three determinants that
influence one other in preventing or delaying T2D.
I used a qualitative research design for this study. Merriam and Tisdell (2016) identified
four characteristics of qualitative research: (a) the focus is on how people construct their
perception of the world; (b) the researcher is the primary instrument for collecting and analyzing
data; (c) an inductive approach is used due to a lack of existing theory, and (d) the research
outcomes include an abundance of descriptive words and images. Interviews with program
9

coordinators (PCs) of DPPs were conducted to collect information to answer the research
questions.
Definitions
This section identifies key concepts and terms used in the field of public health to provide
the reader with an understanding of these terms as used in the context of this study.
Coronavirus 2019 (COVID-19) is a disease identified in December 2019 caused by
Severe Acute Respiratory Syndrome Coronavirus 2. Medical management supports symptoms;
however, no cure or standardized treatment is available (“COVID-19,” 2022).
Health promotion is the process of enabling people to increase control over, and improve,
their health. It moves beyond a focus on individual behavior towards a wide range of social and
environmental interventions. (World Health Organization, 2022).
Hyperglycemia, per the ADA (n.d.-a), is elevated blood glucose.
Prediabetes, according to the CDC (2021g), is a serious health condition where
hyperglycemia exists, but glucose levels are not high enough to diagnose T2D.
Socioeconomically Disadvantaged Community refers to individuals who meet two or
more of seven criteria, such as growing up in a rural area, being homeless, and being in the foster
care system (National Institutes of Health, 2018).
Type 2 Diabetes is a chronic health condition when the body cannot use blood glucose for
energy because the pancreas does not make enough insulin to drive glucose into the cells or the
body cannot adequately use the insulin produced (CDC, 2020b).
Organization of the Dissertation
This dissertation is divided into five Chapters. Chapter One provides a brief introduction
to the study. Chapter Two evaluates existing literature and its relationship to this study.
10

Additionally, Chapter Two will discuss the conceptual framework of the study. Chapter Three
describes the methodological design of the study, including data collection methods, research
questions, and my positionality. Chapter Four discusses the findings pertaining to the research
questions. Finally, Chapter Five presents recommendations for solutions to the practice problem,
the study’s limitations and delimitations, and recommendations for future research.

11

Chapter Two: Literature Review
The literature review will discuss the incidence, prevalence, and economic impact of
prediabetes and T2D in the United States. It will also examine social determinants of health
(SDOH) that affect health outcomes. Current interventions that address the prevention and
management of prediabetes and T2D will be explored. Lastly, the conceptual framework for the
study will be presented.
Prediabetes
The term “prediabetes” is not used worldwide because it can be misleading if construed
as a definitive precursor for the development of T2D (Grundy, 2012). In the 1990s, the World
Health Organization eliminated the term and replaced it with “intermittent hyperglycemia”
(Grundy, 2012). The rationale was that not every person with impaired glucose converted to
T2D; however, in 2008, the ADA reintroduced the term (Grundy, 2012). The ADA’s rationale
for reintroducing the term “prediabetes” was to heighten the sense of awareness that prevention
through intervention is a possibility (Grundy, 2012).
The accurate and timely diagnosis of prediabetes is essential to reduce its risk of
converting to T2D (Grundy, 2012). The diagnosis of prediabetes requires laboratory tests,
including impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and high
glycosylated hemoglobin (a laboratory value known as A1C; Grundy, 2012). In 2003, ADA
changed the range of IFG from 110–125 mg/dl to 100–125 mg/dl (Grundy, 2012). The ADA’s
redefinition adjusted the prevalence of IFG from 6.9% to 25.7%, or 57 million adults (Grundy,
2012). Also, IGT is a strong predictor of T2D, and the range of 140–199 mg/dl indicates
prediabetes (Grundy, 2012). The benefit of A1C is that it provides an average glucose level over
a 2–3-month period, and a value between 5.7% and 6.4% indicates prediabetes (CDC, 2019b).
12

Additionally, HbA1C is the gold standard for determining how well blood glucose is controlled
over a period of time rather than at a point in time (i.e., IFG and IGT; Grundy, 2012).
In its initial stage, prediabetes has no distinctive symptoms, leading millions of adults in
the United States to be unaware of this potentially serious health condition (CDC, 2020c). It is
estimated that of the 58% or 50 million adults who visited a primary care physician in 2010, 20.4
million had undiagnosed prediabetes (Dall et al., 2014). Further, Dall and colleagues (2014)
found that the more office visits an individual had, the least likely they would be screened for
prediabetes. Prolonged hyperglycemia damages small cells in the body and is a significant risk
factor for complications related to diabetes (Grundy, 2012). Risk factors for prediabetes include
being overweight or obese, 45 years or older, a parent or sibling with T2D, physical inactivity,
and the development of diabetes during pregnancy (CDC, 2020c).
A prediabetes diagnosis for individuals at risk due to biological or socioeconomic factors
is a pathway to preventing T2D (CDC, 2020c). In 2018, individuals with prediabetes comprised
approximately 35% of adults 18 or older in the United States (DHHS, 2020). The likelihood of
being diagnosed with prediabetes increases with age (DHHS, 2020). Of individuals with
prediabetes, 12.9% were 18 to 44 years old, 30.1% were 45 to 64 years old, and 35.9% were 65
years or older (DHHS, 2020). Further, prediabetes in men (22.2%) was slightly higher than in
women (21.5%). Based on race/ethnicity, most individuals with prediabetes were Black (31.9%),
followed by Hispanic (23.8%), Asian (21.7%), and White (18.9%; DHHS, 2020). More
individuals with prediabetes had less than a high school diploma (24.4%) than adults with at least
a high school diploma (20.1%; DHHS, 2020). The projected future trends of adults 18 years or
older with prediabetes identify that, from 2020 to 2030, the percentage of Hispanic and Asian
with prediabetes will increase by 24%, followed by Black at 7.5% (Rowley et al., 2017).
13

Incidence and Prevalence of T2D
In a May 28, 2018, press release, the CDC reported that new cases of diabetes among
adults 18 or older decreased from 1.7 million in 2008 to 1.3 million in 2017, which is the first
significant decrease in over 20 years (CDC, 2019a). The decline is partly attributable to
increased awareness and emphasis on lifestyle modifications programs and adherence to diabetes
diagnostic and screening procedures (CDC, 2019a). The trend in declining new cases of
diagnosed diabetes continued in 2018 and 2019 (CDC, 2020). In 2019, there were 1.4 million
new cases of diagnosed diabetes, which is a decline from 2018 (1.5 million new cases; CDC,
2020a, 2021d). The incidence rate from 2018 to 2019 declined for the 45- to 64-year-old group
from 9.9 to 10.1, while the 65 and older age group had a decline of 8.8 to 5.8 (CDC, 2020).
Based on race/ethnic group in this same period, there was a decline for Black (7.9 to 6.5), Asian
(7.2 to 5.0), and Hispanic (9.0 to 7.0; CDC, 2020).
Although the number of new cases has declined, there continues to be a disproportionate
disparity in diabetes based on race/ethnicity in the United States (Aguayo-Mazzucato et al.,
2019). In 2019, the prevalence of diagnosed diabetes was highest in American Indian/Alaskan
Natives (14.5%), followed by Blacks (12.1%), Hispanics (11.8%), Asians (9.5%), and Whites
(7.4%; CDC, 2022a). The disparity was also identified based on education and income level
(CDC, 2022a). Individuals with less than a high school education (13.4%) had a higher
prevalence of diagnosed diabetes than individuals with more than a high school diploma (7.1%;
CDC, 2022a). Further, income level was a strong factor in diagnosed diabetes, with individuals
whose income is less than 100% family poverty level (FPL) reaching the highest prevalence of
14.1% compared to an FPL of 100–299 (10.8%), 300–499 (7.8%), and 500% (5.6%; CDC,
2022a).
14

Obesity: Predominant Risk Factor of T2D
Obesity is linked to the development of T2D, with between 30% and 53% of newly
diagnosed individuals with T2D having a high body mass index (Cameron et al., 2021; Schnurr
et al., 2020). Obesity is also a significant risk factor for prediabetes because excess adipose tissue
or body fat generates fatty acids, which lead to hyperglycemia (Grundy, 2012). Specifically,
abdominal obesity is the key contributor to the rising prevalence of T2D in the United States
(Caspard, 2018. In the 15 years from 1999 to 2014, abdominal obesity increased by 18.7%
(Caspard, 2018). Abdominal obesity further increases the risk of T2D because fat around the
abdomen is known as visceral fat versus the less damaging, subcutaneous fat found in the rest of
the body (Harvard Medical School [HMS], 2017). Visceral fat accumulates within vital body
organs, including the pancreas and heart (HMS 2017).
Prevalence of Obesity
In the United States, the prevalence of obesity increased from 30.5% in 1999 to 42.5% in
2018 (Hales et al., 2020). The prevalence of obesity for Hispanics (47%) is higher than for Black
(46.8%), White (37.9%), and Asian (17.4%) populations (Hales et al., 2020). The most
significant difference between gender was seen among Hispanic women, who have a higher
prevalence than Hispanic men, 50.6% and 43.1%, respectively (Hales et al., 2017).
Socioeconomic factors also play a central role in obesity (Hales et al., 2017). Among all
racial/ethnic groups, obesity is lower in individuals with a college degree than those without a
degree (Hales et al., 2017). Women with a higher income had a lower prevalence of obesity than
women with lower incomes; however, there is no significant difference based on income seen in
men (Hales et al., 2017).
15

Economic Impact of T2D
The increasing cost of care for individuals with diabetes is a growing burden for the
United States (Yang et al., 2018). Further, individuals diagnosed with diabetes consume about
2.3 times more medical expenditures than those without diabetes (Yang et al., 2018). In 2017, the
direct cost of diagnosed diabetes was $237 billion, and the indirect cost was $90 billion (Yang et
al., 2018). Direct costs include inpatient medical care, emergency department and outpatient
visits, medications, supplies, and equipment w (Yang et al., 2018). Indirect costs include
increased absenteeism from work, reduced productivity while at work, inability to work because
of diabetes-related disability, and low productivity due to premature death from diabetes (Yang
et al., 2018).
Over the life course of diabetes for individuals aged 65 years or older, the cost for men
and women is about the same at $56,000 (Cannon et al., 2018). Adults between 25 and 44 years
old incur a cost of $124,700 for men and $130,800 for women (Cannon et al., 2018). Future
projected trends identify a 62% increase in total cost from $327 billion in 2017 to $622 billion in
2030 (Rowley et al., 2017). As complications increase, so does the cost of medical care.
Complications also trend higher over the same projected 10-year period, including visual
impairment (20.5%), renal failure (19.3%), and leg amputation (9.9%; Rowley et al., 2017). The
mortality rate of diabetes is projected to increase by 15.8% from 2020 to 2030 (Rowley, 2017).
These costs are primarily avoidable through evidence-based interventions that prevent diabetes
or delay disease severity over time (Seuring et al., 2015; Zhuo et al., 2014). Herman et al. (2013)
found that individuals who participated in a lifestyle modification program to prevent diabetes
resulted in a cost savings of 26% over 10 years compared to a placebo group.
16

Social Determinants of Health
The World Health Organization (2018) defines health disparities as differences in health
status or the distribution of health resources between different population groups, which arise
from the social conditions in which people are born, grow, live, work and age. In 1995, the
landmark report of the Secretary’s Task Force on Black and Minority Health (The Heckler
Report) identified diabetes as one of the major contributors to health disparities in Blacks,
Hispanics, and Native Americans (CDC, 1986). Further, The Heckler Report documented
demographic profiles, dietary practices, environmental exposures, and psychological stress as
conditions that increased disease burden in these subgroups (CDC, 1986).
The SDOH have an expansive effect on health risks and outcomes for all individuals
where there is evidence of systemic, social, economic, or environmental discrimination (CDC,
2021a). The behaviors of individuals with prediabetes or T2D towards the prevention or delay of
diabetes-related complications are directly affected by SDOH (Hill-Briggs et al., 2021). The
placed-based framework of SDOH established by Healthy People 2030 is discussed in this
literature review. It includes economic stability, education access and quality, neighborhood and
built environment, and healthcare access and quality (CDC, 2021a).
Economic Stability: Income Level
The connection between income level and health is well established in the literature.
According to a 2018 Agency for Healthcare Research and Quality (AHRQ, 2020) report on over
250 quality health measures, there continues to be a marked association between income and
health status. Individuals with higher income performed 60% better in quality health measures
than low-income individuals and 50% better than middle-income individuals. The median
income for White, Black, Asian and Hispanic households increased from 2018 to 2019 by 5.9%,
17

7.9%, 10.6%, and 7.1%, respectively (Semega et al., 2020). Still, when compared to White
households, Black people earned 50% less, and Hispanics earned 30% less, while Asian
households earned 25% more (Semega et al., 2020). Despite diabetes being 17% more prevalent
in rural communities, only 38% had educational programs (CDC, 2018e; University of
Michigan, 2020). Income levels vary depending on geographical location. Regionally, the
median household income in the South was less than the Northeast, West, and Midwest by about
21%, 20%, and 10%, respectively (Semega et al., 2020). Further, the income level in rural areas
was 32% less than in metropolitan areas. In 2019, 30.4 million people in the United States lived
in poverty (Semega et al., 2020). Despite racial/ethnic or geographical differences in earnings,
income level is a significant driving force behind health disparities (Lobo et al., 2020; Woolf et
al., 2015).
Behavioral risk factors for T2D, such as unhealthy diets and physical inactivity, are
highly associated with a lower life expectancy for low-income adults than for high-income adults
(Chetty et al., 2016; Lysy et al., 2013). Adults with low-income levels within the same
racial/ethnic group self-reported fair or poor health at a rate six times higher than adults with
higher incomes in the same racial/ethnic group (Woolf et al., 2015). Chetty et al. (2016) analyzed
income and mortality data from 1999 to 2014 and found that life expectancy for men and women
in the top and bottom 1% income bracket was significantly different. Chetty and colleagues
identified that the life expectancy for men in the top income bracket was 87.3 years and 72.7 in
the low-income bracket. Further, for women in the top income bracket, life expectancy was 88.9
years, and 78.8 in the low-income bracket. The same study found that over the 15 years
analyzed, the top 5% income bracket for both men and women achieved a life expectancy of
more than 2 years longer than the bottom 5% income bracket.
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Educational Access and Quality: Educational Attainment
The connection between educational attainment and health is well established in the
literature. Adults who reach higher educational attainment are positioned to have jobs with health
and wellness benefits that improve overall health (Virginia Commonwealth University Center on
Society and Health [VCU-CSH], 2014). Education provides skills to advance careers, obtain
higher-paying jobs, reduce psychological stress, and encourage healthier behaviors (VCU-CSH,
2014). Increased earnings offer the opportunity to live in higher-income neighborhoods where it
is safer to walk and more convenient to purchase more nutritious foods (VCU-CSH, 2014).
Individuals with lower education have lower-paying jobs with fewer health benefits, increased
psychological stress, and are more susceptible to deaths of despair, including suicide and death
related to drug and alcohol excess (Case & Deaton, 2017; Sasson & Hayward, 2019).
There is an established relationship between educational attainment and life expectancy
in the United States (Sasson & Hayward, 2019; Walsemann et al., 2013). Saydah et al. (2013)
found that the all-cause mortality rate for adults 25 years old or older without a high school
diploma had a 45% increased mortality rate than those with some college experience. After
graduating from high school, each additional year of education is associated with better health
(Montez et al., 2012). Between 2012 and 2015, adults 50 years old with a bachelor’s degree and
adults 50 years old with a high school diploma self-reported excellent/very good health at 72%
and 42%, respectively (Case & Deaton, 2017). In individuals with T2D, lower educational
attainment is associated with higher mortality and increased risk of complications, including
heart attack, stroke, renal and diabetic eye disease (Blomster et al., 2017; Saydah, et al., 2013).
Saydah et al. (2013) found that the all-cause mortality rate for adults 25 years or greater adjusted
19

with variables for self-reported health status and diabetes was 25% higher for high school
graduates than individuals with some college.
Neighborhood and Built Environment: Healthy Food Consumption
The connection between where a person lives and their health and psychological well-
being is well established in the literature. Individuals who live in neighborhoods that are
statistically or perceived unsafe have decreased physical activity, self-reported lower overall
health, and experience increased depression and anxiety (Meyer et al., 2014; O’Campo et al.,
2015). O’Campo and colleagues (2015) also found that for every 10-year age increase,
individuals were more susceptible to stressors and reported even higher levels of depression.
The consumption of a healthier diet is complex and includes diet patterns, affordability,
accessibility, and knowledge and attitudes about food (McGill et al., 2015; Mozaffarian, 2016).
Individuals living in socioeconomically disadvantaged communities experience psychological
stress resulting in lower self-efficacy related to the accessibility of nutritious food (Grenen et al.,
2018. In addition to accessibility to healthy food choices, strategies to promote healthy eating
behaviors need to be addressed.
Mozaffarian et al. (2012) found that simply adding labels or icons on the front of food
packaging rather than nutritional labels on the back increased awareness of healthier food
choices. Additionally, increased prices on fast food encouraged less consumption, thereby
preventing overeating of unhealthy foods (Mozaffarian et al., 2012). In 2014, the Healthy Food
Financing Initiative was established to support job growth and access to affordable, healthy food
in socioeconomically disadvantaged areas (State of Childhood Obesity, 2020). Healthy Food
Financing Initiative has contributed to over $200 million in grants and technical assistance
towards improved health outcomes (State of Childhood Obesity, 2020). Federal, state, and local
20

governments, the food industry, health care professionals, and individuals are all stakeholders
towards improved health outcomes and decreased morbidity and mortality related to obesity in
the United States (Anderson et al., 2019; Mozaffarian, 2016).
Physical inactivity and poor dietary consumption attributable to neighborhoods that are
statistically or perceived to be unsafe can lead to obesity associated with increased mortality
from T2D and cardiovascular disease (CDC, 2021b; Kowaleski-Jones et al., 2018). Obesity is
more prevalent in rural communities (34.2%) than metropolitan areas (28.7%), with the largest
difference in the South (36.6%) and Midwest (34.2%) regions of the United States (CDC,
2018a). Public health initiatives that improve the walkability of neighborhoods and healthy food
consumption can positively impact the health of individuals in socioeconomically disadvantaged
communities (CDC, 2019).
Health Access and Quality
The lack of healthcare access is a significant barrier to improved health outcomes. Access
to health care is the prompt usage of personal health services to attain optimal health outcomes
(CDC, 2021a). Individuals who visit a healthcare professional regularly for health screenings,
diagnostics, and personalized coaching on self-care behaviors experience better health, decreased
costs for medical care, and fewer visits to the emergency room or urgent care centers (Musich et
al., 2016). Hispanics (14%), Blacks (12%), and Asians (7%) with lower income had worse
access to health care than White populations (AHRQ, 2020). Family household income below
the federal poverty rate had 21% worse access to health care than those with higher incomes
(four times the federal poverty rate; AHRQ, 2020).
There are significant benefits to accessible health care, including better blood sugar
management, which reduces diabetes-related complications (CDC, 2020a). Health care access
21

also encourages preventative services for eye exams to prevent diabetes-related blindness, which
is the leading cause of new blindness in individuals between 18 and 64 years old (CDC, 2020a).
Health Insurance Coverage. In 2019, 92% of all individuals had health insurance
coverage through public (Medicaid, Medicare, or Department of Veterans Affairs) or private
(employment-based or direct purchase) sources (Keisler-Starkey & Bunch, 2020). Between
public and private coverage, employment-based coverage (68%) was the most prevalent,
followed by Medicare (18.1%) and Medicaid (17.2%). Keisler-Starkey and Bunch (2020) found
that adults 65 and older and children under 19 are frequently eligible for public health coverage,
while 12.9% of uninsured adults between 19 and 64 depend on private sources for health
coverage. The same researchers found that Hispanics had the highest uninsured rate at 16.7%,
followed by Black (9.6%), Asian (6.2%), and White (5.2%) populations. In 2019, the uninsured
rate for those living in poverty was 15.9%, and the uninsured rate by geographical location
ranged between 3% (Massachusetts) and 18.4% (Texas; Keisler-Starkey & Bunch, 2020).
Since the passage of the Patient Protection and Affordable Care Act in 2013, there has
been a decline in the uninsured, leading to improved access to health care services (Blumberg et
al., 2018). In the South, where there was a high concentration of individuals with T2D, the
Affordable Care Act contributed to a substantial decrease in the uninsured, from 39% in 2012 to
13% in 2016 (Blumberg et al., 2018; Lob et al., 2020). Despite improved access to health care,
inequities in coverage continue to be a public health concern that needs to be addressed (Cha &
Cohen, 2020; Dickman et al., 2017). In the United States, 26.1 million or 8% of people did not
have health insurance coverage, and others were underinsured (Keisler-Starkey & Bunch, 2020).
Barriers to Health Insurance Coverage. Health insurance coverage provides entry into
the healthcare system; however, financial constraints are often a hindrance to utilizing health
22

care services (Douthit et al., 2015). High cost-sharing for out-of-pocket expenses includes co-
payments, deductibles, and insurance premiums (Douthit et al., 2015). In 2018, 14.2% of U.S.
households experienced problems paying medical-related expenses (Cha & Cohen, 2020). Black
(20.6%) experienced the most challenges, followed by Hispanic (15.6%), White (13%), and
Asian (7.1%; Cha & Cohen, 2020). Individuals with employer-based or privately purchased
health coverage experienced the largest increase in out-of-pocket health care costs compared to
low-income individuals with public health coverage (Glied & Zhu, 2020). The financial burden
on individuals is often a barrier to preventative health care services and increases emergency
room and inpatient hospital visits (Berkowitz et al., 2015; Dickman et al., 2017; Douthit et al.,
2015). The need to pay medical-related expenses is the cause of more than half of payday
lending loans that come with interest rates over 650% in some states (Center for Responsible
Lending, 2021; Nuñez et al., 2016).
Interventions to Improve Health Outcomes for T2D
Diabetes care in the United States continues to evolve through evidence-based research,
patient care advances, and policy reform (ADA, 2021b). Additionally, healthcare professionals’
adherence to evidence-based guidelines is imperative in achieving optimal health outcomes. Still,
some individuals with prediabetes may develop T2D. A supportive bridge that includes a care
continuum through this transition assists in lessening the adverse effects of this chronic disease.
Self-Care Behaviors
The goal of health-promoting, self-care behaviors for individuals with prediabetes or at
risk for diabetes is to maintain normal blood glucose levels (CDC, 2020b). Abnormal levels of
blood glucose result when the body is unable to effectively use insulin to transport blood glucose
into the cell for energy (Marquez, 2015). Unhealthy weight gain is a risk factor for T2D because
23

visceral fat releases harmful inflammatory chemicals that promote insulin-resistant cells
(Marquez, 2015). Muscle is a mediator to insulin-resistant cells because physical exercise
stimulates the transport of glucose into muscle mass without insulin and helps to improve insulin
sensitivity (Marquez, 2015). To facilitate better health outcomes for prediabetics, education on
self-care behaviors must be provided, considering an individual’s capability to understand and
implement behaviors that reduce risk factors of T2D (Cha et al., 2014).
The strongest predictors of increased physical activity are instructional guidance, real-
time feedback, enjoyment of the activity, and rewards connected to the progression of the desired
behavior (Lewis et al., 2015) Olander et al., 2013). The decreased physical activity resulted in
interventions that generalized outcomes rather than encouraging individual goal setting (Olander
et al., 2014). Technology-based interventions, such as web-based diabetes support programs and
smartphone applications, and social media platforms, such as Facebook, promote physical
activity behaviors and weight loss through personalized feedback and targeted instruction (Rollo
et al., 2016). Manganello et al., (2017) found that individuals with a lower education level
preferred technology-based interventions to receive health information and were less likely to
use search engines to obtain health information.
Self-Efficacy
Self-efficacy plays a critical role in fostering health-promoting, self-care behaviors
among individuals with T2D (Abubakari et al., 2016; Sharifirad et al., 2013). Interventions to
improve self-efficacy include positive reinforcement, goal setting, and role modeling desired
behaviors (Jiang et al., 2019). Specifically, communication of exercise progress, increasing the
duration and intensity of physical activity, and role modeling to overcome barriers positively
influenced increased self-efficacy (Rajati et al., 2014). Annesi (2019) found that implementing
24

an exercise regimen before education on nutritional intake positively affected patients’ mood,
supporting higher self-efficacy in achieving weight loss and activity goals.
Clinical predictors of increased self-efficacy include longer duration of diagnosis, Type 1
diabetes, and better glycemic control, whereas demographic predictors include higher age,
income level, education level, and good patient-physician communication (Abubakari, 2016;
D’Souza et al., 2017). Poor glycemic control in T2D is a key indicator of lower self-efficacy
(D’Souza et al., 2017). Higher self-efficacy leads to improved self-care behaviors, effective
coping skills, increased adherence to medications, and lower morbidity and mortality (Jiang et
al., 2019; Strain et al., 2014).
Health Literacy
Individuals with higher health literacy skills are four times more likely to self-report
excellent health (Rubin, 2016). Health literacy refers to how individuals find, process, and use
complex health information (U.S. Department of Health and Human Services, 2015). Health
insurance, physical activity, income level, and educational attainment are associated with a
higher level of health literacy (Rubin, 2016). Groups with lower health literacy include females
(54.2%) compared to males (57.3%); Hispanics (69.4%), Blacks (55.5%) and Whites (55.3%);
individuals with less than high school education (78.5%) compared to college graduates (41.7%);
and individuals with income less than $10,000 to $24,999 (67.1% to 72.9%) compared to
individuals with incomes $75,000 or higher (43.7%; Rubin, 2016).
The benefits of higher health literacy include higher self-efficacy to perform health-
promoting behaviors (Cha et al., 2014). Cha et al. (2014) found that people with low health
literacy skills were less likely to read food nutrition labels than people with higher health
literacy. The effects of lower health literacy for individuals with T2D include increased use of
25

emergency services and hospital care, decreased ability to take medications as prescribed, and
increased mortality related to poor glycemic control (Doubova et al., 2019). Given the increasing
complexity of the U.S. healthcare system and health information, Healthy People 2030 identified
health literacy as a priority in improving health and well-being for all (Office of Disease
Prevention and Health Promotion, n.d.).
Health Care Professionals
Conflicting health priorities and attitudes between physicians and patients contribute to
poor health outcomes related to diabetes prevention and management (Harris et al., 2018; Strain
et al., 2014). Strain and colleagues (2014) surveyed 337 physicians and 652 adults with diabetes.
They found that physicians recalled discussing the importance of reducing the risk of
cardiovascular disease, recognizing signs of abnormally low blood sugar, and risk of death. In
contrast, patients were most concerned with the risk for blindness, and only 37% were concerned
with complications from diabetes. Harris et al. (2018) found that when health care professionals
encouraged patients to participate in diabetes-related educational courses, their attendance rate
was higher than patients who were not encouraged by a health care professional. Holt et al.
(2013) conducted a study of 8,596 adults in 17 countries. They found that when physicians
perceive the patient does not mitigate risk factors, physicians often feel overwhelmed and
frustrated and attribute suboptimal self-care behaviors as the primary contributor to poor
glycemic control. In effect, the path of the non-compliant patient shifts the responsibility from
the physician to the patient. Holt and colleagues also found that physicians avoid addressing
behavior change or inquiring about emotional concerns due to a lack of knowledge or
unwillingness to manage psychosocial issues.
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Support for Diabetes Distress
The burden of chronic disease management increases the risk of mental health conditions
in individuals with diabetes (CDC, 2018c; Owens-Gary et al., 2019). Individuals with diabetes
are up to 50% more likely to be depressed, and up to 50% also have diabetes distress consisting
of feelings of worry, stress, and difficulty coping with diabetes (CDC, 2018c). People with
diabetes, depression, and diabetes distress have worse health outcomes, including poor glycemic
control, decreased quality of life, higher complication rates, higher mortality, and increased
healthcare cost (Owens-Gary et al., 2019). The COVID-19 pandemic has resulted in an
escalation of diabetes distress. Since the COVID-19 pandemic, diabetes distress has increased
because individuals are worried about the effects of COVID-19 due to their diabetes, being
characterized as a high-risk group, and not being able to manage diabetes should a diagnosis
occur (Joensen et al., 2020). The achievement of improved health outcomes is through a
collaboration between health care professionals and patients and is based on shared goals, an
individualized, evidence-based care plan, and considering the whole person, including
physiological and psychosocial needs (Strain et al., 2014).
Standards of Diabetes Care
Since 1989, the ADA’s standards of medical care in diabetes have provided evidence-
based, clinical practice recommendations for the care of diabetes, general treatment goals, and
tools to evaluate quality care (ADA, 2021c). These standards emphasize patient-centered care
that is responsive to and respectful of individual preferences, needs, and values. The healthcare
professional’s role in establishing a collaborative, individualized plan of care to encourage hope
and engagement is critical for optimal patient outcomes (ADA, 2021c). The standards of care
recommend annual screening of prediabetics for the development of T2D and referrals to DPPs
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as a proactive approach to prevent or delay T2D (ADA, 2021c). There is much evidence that the
standards of medical care improve health outcomes (Khunti et al., 2013). Still, health
professionals sometimes delay intensifying treatment and postpone timely screening and referrals
to supportive services (Khunti, 2013; Lavoie et al., 2017). Diabetes-related complications, lower
life expectancy, and preventable adverse health outcomes result from untimely care and
treatment (Khunti, 2013; Okemah et al., 2018).
Clinical Inertia
Clinical inertia refers to the reluctance or inability of health care professionals to
incorporate evidence-based clinical guidelines in the prevention, management, and treatment of
diabetes (Rushforth et al., 2016; Zafar et al., 2015). The clinical inertia of health care
professionals is well-documented (Gembillo et al., 2021, Khunti et al., 2018; Rushforth et al.,
2016). Holt et al. (2013) surveyed over 4,700 health care professionals, including physicians,
diabetes specialists, and nurses. They found that inadequate medical training and reimbursement
for healthcare professionals contributed to clinical inertia. Other determinants of clinical inertia
included the healthcare professional’s lack of self-efficacy in initiating the frequent updates to
clinical practice guidelines and role ambiguity among physicians, nurses, and diabetes specialists
(Rushforth et al., 2016; Zafar et al., 2015). The healthcare professionals’ low expectations that
their patients would adhere to treatment recommendations were cited as additional causes of
clinical inertia (Rushforth, 2016; Strain et al., 2014). In socioeconomically disadvantaged
communities, clinical inertia is compounded by the lack of trustworthiness that historically
marginalized individuals feel towards their health care professionals (Read et al., 2021).
Culturally competent health care professionals who consider the uniqueness of their patients
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support the delivery of care that promotes better adherence to treatments, an increased perception
of quality care, and better patient health outcomes (Henderson et al., 2018).
Despite the mounting best practice guidelines, new medicines, and treatment tools, health
care professionals are hesitant to advance a patient’s care plan when goals are not achieved
(ADA, n.d.-b). The ADA defines therapeutic inertia as a provider’s delay in adding or changing
a patient’s care plan when treatment goals are not met (ADA, n.d.-b). The care plan includes
medications, diabetes education, nutrition therapy, exercise, and emotional support (ADA n.d.b).
Khunti et al. (2013) found in a retrospective review of 81,573 patients with T2D that despite
long-standing, impaired glycemic control of greater than seven years, an escalation of treatment
to insulin was delayed. The ADA (n.d.-b) launched the Overcoming Therapeutic Inertia initiative
due to fewer than 50% of people with T2D achieving the target HbA1C goal of 7%. The
initiative recommends that healthcare professionals schedule diabetes-only appointments to
address diabetes distress and SDOH to address therapeutic inertia (ADA, n.d.-b).
Diabetes Prevention and Management Program
Over the past 30 years, the ADA has built upon its criteria for quality diabetes education
for individuals with diabetes (ADA, 2021c. Researchers found that diet and exercise reduced the
incidence of T2D by 58% after 3 years (71% for adults over 60 years old) and 34% after a 10-
year follow-up (Herman et al., 2013; DPRG, 2002). Global studies supported these findings,
including the China Da Qing Diabetes Prevention Study, which found that diet and exercise
reduced the incidence of T2D by 38% after 6 years and 43% after a 20-year follow-up (Li et al.,
2008; Pan et al., 1997). The Finnish Diabetes Prevention Study Group found that diet and
exercise reduced the incidence of T2D by 58% after 3 years and 38% after a 10-year follow-up
(Lindstrom et al., 2012; Tuomilehto et al., 2011).
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National Diabetes Prevention Program
Four years after implementing the National DPP, Ely et al. (2017) conducted a
descriptive analysis of patient’s attendance, weight loss, and physical activity minutes for over
14,000 adults who participated in the year-long National DPP. The analysis found that the
average attendance was 14 sessions, 35.5% of patients met the 5% weight loss goal, and 41.8%
met the 150 minutes per week goal. A correlation between the number of sessions attended and
the percent of body weight loss (i.e., each additional session plus 30 additional minutes of
physical activity resulted in a 0.3% weight loss) identified that patients’ intensity and duration
were significant factors in the program’s success (Ely, 2017). However, it was noted that after 6
months in the program, attendance dropped, and only 43% of patients completed the program
(Ely, 2017). Alternative DPP instructional formats include mobile-based and self-directed or
web-based programs administered by primary care clinics, which demonstrate up to 7% of
weight loss success (Kim et al., 2019; Ma et al., 2013). Alternative platforms may better serve
individuals with prediabetes who struggle with transportation limitations, childcare availability,
or work-hour demands (Kim, 2019).
National DPP Program Coordinators
The PC oversees DPPs, implements and facilitates daily operations, trains staff, and
submits and monitors program data to ensure DPRP Standards are achieved (CDC, 2018b).
Essential attributes of a PC include facilitating groups, knowledge of principles of behavior
change, and the ability to provide quality assurance. Additional skills include building a network
of referral sources, advocating for lifestyle change programs, marketing and publicity, and
engaging with payers for reimbursement (CDC, 2018b). The PC is also responsible for patient
engagement and retention to meet the performance goal required for continued CDC recognition
30

(CDC, 2018b). Barriers to patient retention include class location, convenient class times,
transportation limitations, childcare availability, physician referrals, and commitment to self-care
activities (Ackermann & O’Brien, 2020; Rehm et al., 2017).
Diabetes Self-Management Education and Support Services
The DPPs establish effective self-care behaviors before developing T2D, which is
beneficial to the long-term management and prevention of complications related to this chronic
disease. Since 2006, the National Standards for Diabetes Education and Support Standards have
provided evidence-based guidelines to improve outcomes for individuals with diabetes (ADA,
2021c; Beck et al., 2017). Given the average adult with diabetes visits their primary care
physician less than 2 hours each year, diabetes self-management education and support
(DSMES) services are an important adjunct to help individuals learn effective problem-solving
skills (Beck, 2017). Education and support include knowledge and skills about taking medication
correctly, monitoring blood sugar levels, and coping with the stress of managing a chronic
disease (Lin et al., 2017). Technology-enabled models of care, such as e-health tools, online
support groups, and virtual health care provider visits, have extended the availability of DSMES
services; however, coverage challenges remain a concern (Chrvala et al., 2016; Greenwood et al.,
2017).
Health insurance coverage for DSMES is limited to 10 hours during the first year and 2
hours in subsequent years of the first diagnosis (Chrvala et al., 2016). The likelihood of the
availability of services decreased in counties with a higher number of uninsured or an
educational attainment level of high school education or less, with only 38% of rural counties
with DSMES services (Rutledge et al., 2017). Chrvala et al. (2016) found through a systematic
review of 118 DSMES services that individuals who received greater than 10 hours of services
31

reduced their all-cause mortality risk by 70.3%. In 2010, 57.4% of adults with diabetes received
DSMES services, and between 2011 and 2012, 6.8% of privately insured, newly diagnosed
adults with diabetes received DSMES services within the first year of onset (Li et al., 2014).
Forty-one states require private insurance coverage of DSMES; however, barriers to coverage
include preauthorization, cost-sharing to providers and patients, lack of access, lower income,
and lack of transportation (CDC, 2018). While there is sufficient evidence supporting the
benefits of DSMES services, referrals by primary care physicians were only 67% (Mehta et al.,
2017).
Conceptual Framework
Social cognitive theory (SCT) is the worldview that guides this study’s conceptual
framework. The theory emphasizes the bidirectional interaction among the three determinants:
(a) cognition, (b) behavior, and (c) external environment (Bandura, 1978). The key theoretical
principle of SCT is that it explains human behavior through the lens of triadic reciprocal
determinism (Bandura, 1978). The theory assumes individuals learn through behavioral models,
learning occurs through reinforcements, and goals direct behavior (Bandura, 1978).
Health literacy is foundational to higher self-efficacy because health literacy represents
the comprehension of complex health information (Office of Disease Prevention and Health
Promotion, n.d.). As individuals better understand and use health information, their level of self-
efficacy improves (Swoboda et al., 2017). A higher self-efficacy empowers individuals to
perform lifestyle modifications to prevent or delay T2D (Cha et al., 2014; D’Souza et al., 2017).
The lifestyle coach’s role in effectively communicating among cultures to encourage and engage
patients promote retention and positive health outcomes (ADA, 2021c). The disproportionate
health disparity among the socioeconomically disadvantaged in the United States is influenced
32

by race/ethnicity, income level, and educational attainment, and the results are poorer health care
outcomes (Saydah, 2013). Bridging health disparities precipitation by SDOH supports the
individual’s ability to adopt lifestyle modifications to improve their health outcomes (Hill-Briggs
et al., 2021). Health promotion is achieved when the individuals are confident, encouraged, and
supported. DPPs provide an educational and social platform for individuals with prediabetes to
receive the knowledge, encouragement, and tools needed to prevent or delay T2D (CDC, 2021d).
Summary
The literature review presented research findings identifying the growing prevalence of
prediabetes and T2D, particularly for the socioeconomically disadvantaged. Further, SDOH
related to income level, educational attainment, healthy food consumption, and access to quality
health care were presented in the context of how SDOH influences health outcomes. Finally,
evidence-based interventions aimed at preventing or delaying T2D contributed to understanding
current strategies available to individuals with prediabetes or T2D.

33

Chapter Three: Methodology
The purpose of this study was to examine best/promising practices to improve the
implementation of DPPs in socioeconomically disadvantaged communities for individuals at risk
for T2D. This chapter will discuss the study’s methodological approach, research setting, and
potential influences on the data based on the researcher’s positionality. Participant sampling
criteria and recruitment are examined, and the logistics and analysis of the data are presented.
This chapter will next outline strategies that maximized the credibility and trustworthiness of the
study and identify ways in which I ensured responsibility to the participants as mandated by the
institutional review board (IRB).
Research Questions
1. What organizational/environmental strategies are DPPs implementing to address
participants’ beliefs and behaviors in delaying or preventing T2D?
2. What resources are needed to maintain or improve DPP outcomes?
3. How are DPPs addressing the challenges of offering services during the COVID-19
pandemic?
Overview of Design
This study used a qualitative research design. Merriam and Tisdell (2016) identified four
characteristics of qualitative research: a focus on how people construct their perception of the
world; the researcher as the primary instrument for collecting and analyzing data; use of an
inductive approach due to the lack of existing theory; and the outcome of the research includes
an abundance of descriptive words and images. Interviews were the primary source of data. This
inquiry strategy aligned with the study because it assisted in understanding the perspectives of
participants who implement DPPs.
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Research Setting
The CDC’s national registry lists 1880 recognized DPPs that provide year-long learning
in person, online, distance learning, or a combination of the modalities (CDC, n.d.; CDC,
2018b). In-person patients are in a classroom, and those who attend online sessions do so by
connecting through an electronic device like a computer or smartphone, and distance learning
patients attend sessions through videoconferencing or conference calls (CDC, 2018). Essential
staff for DPPs includes lifestyle coaches responsible for teaching program sessions and PCs who
serve as program ambassadors, data collectors, and hire, train, and support lifestyle coaches
(CDC, 2018b). In smaller organizations, the PCs may also serve as lifestyle coaches; however,
there may be several lifestyle coaches and PCs in larger DPPs (CDC, 2018b).
Through a series of program requirements identified in the DPRP Standards, DPPs
transition from pending, preliminary, to full recognition status (CDC, 2018b). Pending status
requires submitting an application, using a CDC-approved approved curriculum, and offering 22
lifestyle change sessions over 1 year (CDC, 2018b). Preliminary status includes pending status
requirements and retention of five or more patients at the end of 1 year (CDC, 2018b). Full status
is achieved upon meeting preliminary status and evidence that 60% of patients meet one of the
following outcomes: an average weight loss of 5% or an average weight loss of 4% and 150
minutes of physical activity per week or a 0.2% reduction in HbAIC (CDC, 2018b). All three
categories require the submission of the patients’ body weight and minutes of physical activity
every 6 months (CDC, 2018b).
In California, there are 143 CDC-recognized DPPs. Thirty-four are in low-income zip
codes based on the Health Resources and Services Administration (HRSA) database of low-
income zip codes (CDC, n.d.; HRSA, 2020). I contacted DPPs utilizing publicly retrievable
35

email addresses and phone numbers on the CDC website (CDC, n.d.). When a PC responded, an
interview was scheduled until 10 interviews took place. I confirmed with each PC that their DPP
served low-income areas and had achieved full recognition status from DPRP. The setting
selection identified was appropriate to address the research questions because the DPP sites
serviced geographical areas that were socioeconomically disadvantaged. The DPPs that achieved
full status have demonstrated evidence of risk reduction for the development of T2D. The PC
was chosen as the participant for this study because the role was directly responsible for
implementing DPP; therefore, the PC could best address the research questions. In this study,
implementation refers to the planning, coordination, and control of tasks, time, financial and
human capital for services offered by DPPs.
The Researcher
Identifying and mitigating researcher bias is essential in qualitative research because data
is at risk of misinterpretation surrounding the participant’s intent (Merriam & Tisdell, 2016). I
am a middle-aged, Black female who has served as a healthcare professional in several acute
care hospitals for 20 years. This position has offered a first-hand account of the adverse patient
outcomes of poorly controlled and undermanaged diabetes, particularly within
socioeconomically disadvantaged communities. As a health care colleague and as part of a
historically marginalized racial group, my positionality may have positively affected establishing
rapport with the participants. Building rapport based on shared knowledge fosters an authentic
interaction that creates an accepting atmosphere where experiences, attitudes, and feelings are
freely expressed in the interview (Patton, 2002).
Further, my ethnicity may promote an empathic understanding of barriers to health equity
that disproportionately affect socioeconomically disadvantaged communities. Blacks are more
36

likely to delay needed treatments due to distrust, mismatch, or misunderstanding of instructions
from healthcare providers that are not of the same race (Eastman, 2002). Thirty-two percent of
Blacks have experienced discrimination when receiving health care and 22% avoid medical care
for fear of discrimination (Robert Wood Johnson Foundation, 2017). On the other hand, the
assumption that participants would develop a kinship with me based on the stated positionalities
may not have been fruitful. A variance that could have created bias is my limited exposure to
services in a community setting of DPPs compared to the more well-versed inpatient acute care
hospital setting. I will attempt to mitigate the potential bias by listening to learn new knowledge
from the participants’ perspectives. According to Patton (2002), qualitative interviewing should
assume that only the participants can provide information on their feelings, thoughts, and
intentions. To ensure high-quality data, I held responsibility for creating an environment that
encouraged participants to comfortably and honestly share their experiences (Patton, 2002). An
effective strategy to establish trust is maintaining neutrality by incorporating role-playing and
presupposition within the interview questions (Patton, 2002).
Data Sources
The source of data in this study was semi-structured interviews. Researchers can collect
high-quality data from semi-structured interviews because probing questions can be asked to
clarify responses or gain additional information from the participants (Johnson & Christensen,
2014). A further strength of interviews is that they can reduce interviewer bias and facilitate the
organization and analysis of the data (Patton, 2002). I developed the interview questions to align
with one or more research questions. The interview questions were a vehicle for eliciting the
participants’ knowledge, feelings, and opinions about the research questions.
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Participants
This study used a nonprobability sampling method, specifically purposive sampling.
Purposeful sampling in qualitative research attempts to understand practice problems versus
generalize findings to a population (Merriam & Tisdell, 2016). Participant criteria included
serving as a PC in a full-status DPP located in a low-income zip code and the availability to
interview within the date range of data collection identified below under data collection
procedures. Chapter Four includes a description of the 10 participants.
Instrumentation
The interview protocol was semi-structured. Each question was created to collect
participant insight to understand the research questions better. The questions were based on
questions that improve the likelihood of the interviewer asking clear questions that solicit
relevant responses from the interviewee. Appendix A presents the interview protocol used in the
study.
Data Collection Procedures
To recruit study participants, I prepared a one-paragraph introductory email. The email
contained information concerning my background, the purpose of the study, and the estimated
duration of the interview. The email also described the process to ensure participant
confidentiality. Finally, the email offered the availability of a phone conversation for recruits to
ask additional questions before setting an appointment for the interview. The introductory email
informed recruits about an incentive of a $25 Amazon gift card for agreeing to participate in the
interview. I sent the gift card to each participant after the interview was completed. Once the
interview was confirmed, I sent a calendar invite as a reminder.
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The interviews were conducted through a teleconferencing platform: Zoom. The duration
of the interviews ranged from 35 to 120 minutes, with an average of 47 minutes. I conducted
interviews from October 7 through November 18, 2021. The transcription application of Rev
Meeting Assistant was used to transcribe interviews. The quality of the data was influenced by
the interpersonal relationships between interviewee and interviewer (Johnson & Christensen,
2014). I was flexible with locations and schedules. Prioritizing rapport, neutrality, and a trusting
relationship increases the effectiveness of the interview (Johnson & Christensen, 2014).
Data Analysis
Maxwell (2013) stated that data should be analyzed after each interview and between
writing the research paper. For interviews, data analysis began during data collection. I wrote
analytic memos after each interview. I also documented memos that included thoughts, concerns,
and initial conclusions about the data. Throughout the data collection period, I coded the
interviews. Open coding was utilized in the first analysis phase, looking for empirical codes and
applying a priori codes from the conceptual framework. The second analysis phase consisted of
empirical and prior codes aggregated into analytic/axial codes. The third data analysis phase
identified pattern codes and themes emerging from the conceptual framework and research
questions.
Credibility and Trustworthiness
To promote credibility and trustworthiness, member checks, triangulation, and a detailed
audit trail help the reader to buy into the research findings (Merriam & Tisdell, 2016). In this
study, I asked clarifying questions throughout the interviews to minimize misinterpretation of
participant responses (Merriam, 2016). Each participant answered each interview question
presented. Triangulation was achieved through the compilation and reconciliation of member
39

checks and the literature review to establish data alignment to answer the study’s research
questions. An audit trail provided rich detail of the interview environment, specific dates and
times of each interview, and my reflections to mitigate bias in the study’s findings (Merriam,
2016).
Ethics
Before conducting the interviews, the study received IRB approval. An information sheet
presented to the participants ensured they were aware of the purpose of the study, could ask
questions, and provided a voluntary agreement to be interviewed (Hicks, 2019). The interview
protocol explicitly informed them of their option to stop at any time. To ensure the
confidentiality of the data and the participants, I used an encrypted, password-protected file to
store the data and assigned each participant a code name to ensure anonymity. After each
interview, I transcribed the data using a contracted service. According to Bogdan and Biklen
(2007), the benefits of personally transcribing the interview recording versus outsourcing include
reliving the experience and creating a better understanding of the data. Transcription services
provide accurate transcription in editable formats with expedited turnaround times (i.e., Rev
speech-to-text services). Upon receipt of each transcribed recording, I reviewed the data against
the content of the audit trail to relive the encounter. I also reviewed the Zoom recordings of each
interview at least twice.

40

Chapter Four: Findings
The purpose of this study was to examine best/promising practices to improve the
implementation of DPPs in socioeconomically disadvantaged communities. The semi-structured
interviews with PC of DPPs provided insight into this study’s research questions. This chapter
provides a description of the participant’s professional background, DPP setting, and population
demographic. Next, this chapter will answer the research questions and summarize those
findings.
Participants
There were 10 participants in this study, as shown in Table 1. Seven were female, and
three were male. Their racial/ethnic backgrounds were as follows: seven White, two Latino, and
one Black. Three participants stated they either had diabetes or were at risk for developing T2D.
Nine held an educational degree or background in a health-related field that contributed to their
current administrative role. The participants’ duration of health-related professional experience
ranged from 5 to over 20 years. The DPP settings were faith-based, not-for-profit, charitable, and
private organizations with one consortium of tribal governments and one healthcare organization.
Nine participants validated that their client population was low-income adults 18 years old or
older. One DPP provided only one session in a low-income community but planned to expand in
the future. Among the DPPs, there was more female than male patients, nearly 80% female to
20% male. The racial/ethnic group was Latino, White, Black, American Indian/Alaska Native,
and Asian/Pacific Islander.

41

Table 1
Description of Participants’ Professional Background, DPP Setting, and Population
Demographics
Pseudonym Professional background DPP setting Population
characteristics
Alice Certified diabetes educator A consortium of
Tribal Governments
American
Indian/Alaska
Native, Latino, White
Barry Public health and mental
hygiene, and organic
farms
Faith-based
organization
Latino, Black, White
Connie Certified health education
specialist, Former health
care executive
Not-for-profit, private
organization
Latino, Asian/Pacific
Islander, Black,
White
Dave Dramatic arts professional,
public speaker, lifestyle
coach
Faith-based
organization
Latino, White, Black
Ellen Health and wellness coach,
lifestyle coach
Faith-based
organization
Latino, Black, White
Frank Information technology,
health care, law
enforcement
Healthcare
organization
Latino, Asian/Pacific
Islander, Black,
White
Gloria Health and wellness;
Certified health coach
Not-for-profit,
charitable
organization
White, Latino
Helen Project manager, grant-
writer
Not-for-profit,
charitable
organization
White, Latino
Irene Grant manager, lifestyle
coach
Not-for-profit,
charitable
organization
Latino
Janet Special education educator,
lifestyle coach
Not-for-profit, private
organization
White, Latino, Black

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Research Question 1
The first research question asked, “What organizational/environmental strategies are
DPPs implementing to address participants’ beliefs and behaviors in delaying or preventing
T2D?” The first research question aimed to identify approaches the participants believed were
best/promising practices that impacted an individual’s decision to participate in the DPP. Several
themes emerged from the interviews: (a) build cultural competence, (b) understand the
psychology of food, (c) engage in social networks, (d) address clinical inertia, and (e) build self-
efficacy.
Build Cultural Competence
Five participants believed that each community was different and required a deliberate
approach to understanding members’ cultural needs. Further, they recognized that staff members
who shared similar life experiences with community members uniquely understood their
challenges. Dave relayed how essential cultural competence was to DPPs: “Getting to know each
participant and really getting to know both their culture, how they’re currently living has
become, I think, instrumental in delivering this program.” Connie recalled when DPPs were
introduced into the field of diabetes prevention:
There was this great program that’s going to be community-based organizations, is going
to be your community health workers and your peer educators. After that came national
organizations who may have the staff, they may have the resources, but their lifestyle
coaches don’t necessarily live in that community. So, while yes, they can be a lifestyle
coach, but they may not understand the needs of the patient who may be struggling. I just
think it’s important to have lifestyle coaches who are a part of the population so that
there’s more inclusion and diversity.
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Connie shared a practice used in her DPP that characterizes her commitment to ensuring
inclusion and diversity: “Sometimes, we step back and say, maybe this person is not the right
person for this particular cohort. Maybe there is someone who can co-lead who is a member of
the community.” She shared a practice used in her DPP that characterizes her commitment to
ensuring inclusion and diversity:
Our program identifies community ambassadors who are really engaged in their own
health and wellness and want to support their peers. People are comfortable because it’s
someone like them. They could be the same racial/ethnic background or seniors
recruiting seniors.
Dave provided an example of reflecting on the best approach to a church whose congregation
was primarily African American:
I’m a White guy going into that community with the life I’ve lived doesn’t necessarily
lend itself well to not to generalize the way that they’ve lived, but the fact that they’re in
a community of churches and the fact that they’re primarily African American, I think
it’s important to have somebody who has more knowledge to that culture than I do.
Understand the Psychology of Food
Findings from the interviews identified that food was very personal and aroused pleasant
feelings among their patients. Five participants shared that patients struggled to change their
unhealthy food choices to more nutritious food because of their cultural or familial connection
with food. They found that food was grounded in cultural norms for their patients and was a
significant part of their identity. Social gatherings, such as graduation and wedding ceremonies,
funerals, or weekend barbecues, commonly had food at the center. Frank, who is Mexican,
shared a personal example: “My sister-in-law’s Filipino, and they’re very similar in Mexican
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culture. It’s all about food. Is it a gathering? It’s about food. You never show up to their house
without food. It’s very insulting if you do.” Two participants also spoke about food connections
based on fond childhood memories, making changing food habits difficult to implement. Irene
offered insight into the difficulty some patients had with changing food habits:
This is all they’ve known. So to tell somebody to make this dish without this, but that’s
how their mom used to make it. Like, it’s not so easy for them to just change that habit
really quickly. So, that’s really the hard part of just pinpointing what to do and what from
your childhood and your habits that you can change.
Strategies to address this form of connection to food included dissecting the
psychological effect of food and adapting food choices that were healthier and reminiscent of
favorite food recipes. Barry incorporated “food talk” into his DPP sessions to understand why
people ate unhealthy foods: “Trying to come at it from a stress, mental health place can be just as
effective as trying to say, no, you can’t eat that because it’s bad for you.” Connie established
creative ways to hold on to food traditions by incorporating food challenges that involved
substituting healthy ingredients for favorite food recipes. She shared a food activity used in her
DPP: “In groups of two or three, they’ll get the weekly grossly circular to see how many healthy
meals they can make with $20. They have a book with calories, fat grams, or carbs, and they
would create healthy meals.”
Four participants understood that some food patterns required support beyond the DPP’s
ability. In this scenario, case managers, social workers, or psychotherapists provided more
extensive counseling about food choices. Additionally, the DPP would refer patients to their
healthcare provider to address complicated aspects of unhealthy eating. Connie shared an
example of a patient who struggled with “emotional eating:”
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We had a young woman who weighed over 300 pounds, and she shared with her lifestyle
coach that she had a lot of issues with emotional eating. We asked our psychotherapists to
talk with her, and she did have two sessions with her, and then, of course, she referred her
to her own provider for support. She’s still in the program right now, but she hasn’t lost a
lot of weight, but we recognize that she needs additional support. For that particular
patient, we had four different team members support her.
Ellen described her DPP’s intake procedure for identifying patients who may need supplemental
support to help them succeed in the program:
At the beginning of the program, we administer a depression and anxiety assessment. If
somebody scores high, we refer them to mental health services. If we notice in classes or
in the one-on-ones that people are exhibiting signs of depression or severe anxiety, we’ll
give it again, or we’ll talk to them if they want referrals to therapists. In one of our other
programs, the social workers are 2nd-year graduate students, and so they’re allowed to do
counseling. So at one point, we offered counseling to our DPP patients, and a lot of them
used it. That was really popular for people who didn’t want to go through their insurance
and do formal therapy.
Two participants identified the importance of approaching patients about their unhealthy
eating patterns in a way that preserved their dignity. Frank shared insight about the consequence
of approaching individuals negatively. “Food can be a shameful thing because it is like you’re
telling them what they do as a result and part of their norm is wrong. Shaming them then means
you’re shaming their family.” Frank’s lifestyle coaches educate individuals about how to make
healthier food choices. He shared an example:
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We had a patient who was so excited about a smoothie they made with a juicer. They put
in apples, oranges, bananas, and a little bit of kale with lemon. We said, that’s great, but
next time, try not juicing it because you’re losing the good fiber. We don’t try to shame
them but suggest another option.
Promote Social Engagement
The strong impact of social connections on patient engagement was a finding that
resonated among all the participants. Seven of them identified how establishing a safe space for
open communication helped build patient relationships. They describe the importance of the
patients openly sharing their challenges with other group members and staff actively listening to
learn about their life patterns and demands. Ellen explained the critical impact of social
connections: “The whole beauty of DPP is the social interaction. That’s what keeps people
coming back. So, it’s the interaction with the [lifestyle] coach. It’s the interaction with each
other.” Irene expanded on the importance of having compassionate staff who encouraged
relationships among patients:
We are very good at making sure we have a lot of people that are very empathetic. They
listen and make sure that they’re very responsive inside and outside of classroom time.
That’s been a huge strategy for us. When it comes down to it, they’re there for the
meetings, but they all build relationships among themselves. I think having those people
that can foster relationships between the group has been our biggest success.
Five participants described how their DPP used the check-in approach to build social
connections. The check-in served apart from the program’s curriculum. It was a time when
individuals freely shared their struggles and successes and supported one another. Barry
elaborated, “The conversation that we have on the side of class is, I would say, equally important
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for engagement.” Helen discussed the importance of allowing the space for individuals to share
and support each other:
It’s important to acknowledge when patients are not able to accomplish what they intend.
Maybe they work late, or their schedule was crazy. As a group or to the individual, we
ask for suggestions on how to meet these challenges.
Barry described his DPP’s process for the check-in:
We have a check-in with everybody. Almost like AA, where anyone can say what
they’ve been struggling with for the week, why they may have overindulged, had too
much ice cream, whatever. It’s a great way for them to kind of share because everyone’s
in the same boat.
Three participants discussed how their DPP integrated challenges in their group meetings
to encourage social engagement around food choices. Connie’s DPP had an activity called
“Living on $5 a Day,” where patients received weekly grocery circulars and, as a group, created
a grocery list of affordable healthy food. Dave also shared a food activity his DPP used to
increase engagement among patients: “We would take trips to the grocery store together to
challenge them. They’ve got 15 minutes to shop in a healthy way. We want to recreate the stress
of shopping for a family or when you have a time constraint.”
Address Clinical Inertia
There is an imperative for increased understanding of DPPs by health care professionals
who are a critical element in supporting patients to perform health-promoting behaviors. Helen
expressed how important it was for health care providers to utilize DPPs: “Spreading awareness
then offering a solution [DPP] because there is no other solution in our country right now.”
Three participants believed that healthcare professionals poorly understood DPPs. Barry’s DPP
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had more than 50 community partners, including clinics and hospitals; however, patients were
expected to be referred to his DPP but did not meet eligibility criteria. He explained, “We’ve
been having problems with some of the community partners because they refer people because
they are overweight and want to eat healthier, but we have to tell them about [CDC] criteria.”
Three participants described their approach to obtaining criteria-based referrals from healthcare
professionals. Alice stated, “I try to get the providers to refer patients to me when they are in
their offices.” Irene recalled that her predecessor was active in the community by “hitting the
pavement” to meet regularly with different hospitals and clinics to solicit referrals and provide
education about the DPP.
Gloria expressed her concern that underdeveloped provider-patient relationships inhibit
the patient’s success in the program.
I don’t think they’ve done a lot in terms of helping the patients be successful in the
program. I don’t think they see them frequently enough. I think it’s just they don’t have
time to sit with patients a lot and ask them how it’s going and that kind of thing.
The healthcare professional’s role to encourage hope and engagement was identified as a
critical component in the patient’s success in the DPP. Gloria described the favorable outcomes
for the patient when there was a supportive relationship with their health provider. “The people
that I had that were really successful, their doctors were like praising them so much. They came
back and told me how thrilled their physicians were at the progress they’ve made.”
All participants shared that family and friends, staff members, and other people
connected with the services offered by DPP served as a bountiful resource for referrals. They
identified that this practice had been the most reliable source of referrals for enrollment. Six
participants shared that encouraging patients to bring their caregiver or spouse to the meetings
49

was successful. This inclusion provided significant support for the person enrolled and opened a
window of opportunity to market DPP services to others who may be at risk for T2D. Janet
shared her DPP’s research on the benefits of couples attending together. “There was some data
that we compiled on that, that the success rate skyrocketed for our couples that attended together
because they were helping each other.” Frank described a common situation at his DPP where
they encouraged caregivers to attend the meeting as support for their patients:
A lot of times, we have a husband who doesn’t even know his own cell phone number.
The wife does, and the wife is there, and he’s the diabetic. So, we really encourage them
to be there if they’re more the caregiver. Getting the other family, if they don’t have
diabetes involved, we’re very big on it.
Connie’s strategy to obtain referrals to her DPP was to ask her patients if they have family
members or friends with whom they want to share diabetes prevention information. She stated
that “a lot of our patients have family members who have prediabetes. We keep an archive of
flyers that we can mail and are just hoping that when the next class comes about, that person
might be interested in joining”
Build Self-Efficacy
Three participants recognized that an individual’s readiness and commitment to change
were factors that impacted their level of self-efficacy. Ellen’s DPP used motivational
interviewing to “meet people where they are” She identified the importance of diagnosing an
individual’s capacity and desire for change as a starting point for establishing health-promoting
behaviors. Ellen believes that a detriment of the National DPP curriculum is that it does not
allow for growth progression:
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The one fault of the DPP is to stay recognized. You have to meet weight loss goals. We
were able to get the A1C down a lot, but we couldn’t always get the weight down. A lot
of our patients get frustrated because they’re supposed to lose 5% to 7% of their body
weight and when someone might sign up for this class. They might not be there yet. You
know, so the program recognition portion of it, which is what you need for
reimbursement or to be evidence-based, it doesn’t meet people where they are. It starts
with the ground running.
Each participant emphasized the importance of incremental goal setting to build
confidence among their patients in making lifestyle modifications. They shared that mastering
experiences or accomplishing a small win accumulated to become lifelong changes for better
health. Irene verbalized this concept further by stating, “Any little minor change is a major for
us. When someone goes to the gym one time a week rather than not going at all. When someone
stops eating candy after 10 pm.” Additionally, Frank shared a success story about a significant
change that occurred in a relatively short period:
We have had patients come here with an A1C at 13.5, and within three or four months,
we’ve seen it drop down to 6.5 to 5.3. We start showing them how to eat, how to diet,
how exercise is important.
Six participants emphasized recognizing the progress made towards set goals and
obstacles their patients encountered on their journey to improved health. Three participants
discussed the importance of life events that may challenge their client’s resilience. Irene shared,
“In times like this, we recognize that sometimes progress is not something you can see, but
sometimes it’s something you feel, and all progress is growth.” She also shared a strategy used in
her DPP:
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It’s good to recognize that they might be going through something, and they probably
have been pushing themselves really hard, and they’re still not seeing the results they
would like. When I know somebody is in that same state. I’ll talk about it in general to
the class and recognize that they are all doing hard work, and sometimes it’s not
something you can see, but sometimes it’s something you feel. As long as you are feeling
better about yourself, you guys are doing amazing. The only strategies I have in that
sense are being direct about it and talking to people.
Janet shared how her DPP recognized the progress of their patients who may not lose weight but
achieve other outcomes:
We’ll see a patient who will be incorporating all these lifestyle change goals and
sometimes just doesn’t lose the weight, so we have a differentiator. We send them
measuring tape and do waist and arm circumference measurements. Some people may
not lose a lot of weight, but they lose inches, and so we’re able to give them praise for
that as well.
The Impact of Lower Health Literacy Among Generations
Three participants recognized that increasing health literacy through education led to
better health outcomes. Connie contextualized the importance of health literacy: “Education is
what helps us to achieve literacy, right? If we don’t receive the education, then we’re not going
to grow, and our lifestyle will not be as healthy as it could be. And then it goes down
generations.” Dave also commented on the importance of education to increase low health
literacy:
So, it’s [diabetes] just a history that we have to try to do our best to change and reverse it,
and a lot of folks had not been exposed to education. So, it became a passion for me to
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ensure that I could reach out and help as many of my fellow community members so that
they could gain the knowledge that they would need to live a healthier life.
Three participants spoke about the intergenerational trauma observed in patients and the
potential negative impact on health outcomes. They provided examples of patients who believed
that another family member’s adverse health outcome would also be their own. The trauma
evoked a feeling of ‘helplessness’ for patients on whether T2D was preventable. Alice recalled a
conversation with the daughter of a Native American woman:
There wasn’t even that thought of any steps that could help them because they’re destined
to be diabetic on dialysis and lose limbs. I realize that’s the theme that unfortunately
happens to a lot of families, especially the Native population. That they’ve gone to
destiny to have diabetes and being out of control and losing their sight or losing a limb or
being on dialysis. So, you know, you gotta be prepared to figure out. Do you think you
can capture that person early enough to give them that hope of small change? That they
don’t have to be like the rest of their family members and go down that path because that
seems pretty much the theme that goes through a lot of them, certainly the Native
families, at least here.
Gloria explained the issue in her community, which is primarily Hispanic: “Some
cultures see it as a punishment. They don’t realize it’s something that can be treated. They just
feel like it is what it is, and that’s the way you have to deal with it.” Alice shared how her DPP
approached patients’ who may have low health literacy. She described her DPP’s approach to
instilling hope in their patients:
You just have to get to the person’s level of learning. I have really understood lately that
there’s still people that can’t read enough for you. Give them a handout, and they really
53

might take it, but they don’t know how to read it. So, you’ve got to somehow, without
making that person feel uncomfortable, try to figure out what their learning curve is so
that you can do the best job you can educating. And that’s where all the teach-back is
really important.
Two participants spoke about education events held in their community to increase
knowledge about T2D. Helen’s DPP holds education events to provide information and
encourage program enrollment:
We’re doing an event in November, Let’s Talk Prediabetes, [to] let people come and get
to ask a nutritionist questions, you get to ask a physician questions, ask questions about
the program. So, really designed to make people aware of what prediabetes is and why
you want to catch it early and then hopefully get them into our program as well.
In summary, the participants emphasized the importance of cultural competency to
understand each community’s unique challenges. The lack of economic stability of individuals
who live in low-income communities required an adeptness of their unique struggles to engage
patients to embark on their health promotion journey to prevent or delay T2D. Individuals need
support in navigating their obstacles to achieve greater self-efficacy to perform health-promoting
behaviors. Health literacy was identified as a critical element to build self-efficacy. Participants
implemented strategies to create an attractive environment that motivated and engaged patients
toward health promotion by forming connections through shared life experiences, creating a safe
space where patients learn from one another, and adapting treasured recipes with healthier food
choices.
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Research Question 2
The second research question asked, “What resources are needed to maintain or improve
DPP outcomes?” The aim was to identify what participants’ needed to continue their status as a
CDC-recognized DPP. The themes that emerged from the interview are (a) improved retention,
(b) support for lifestyle coaches, (c) leveraging community partnerships, and (d) resources for
sustainable funding.
Improve Retention
Four participants identified that retention was most difficult around the program’s fourth
to the 6-month mark. At the 6-month mark, the group sessions transitioned from weekly to
monthly. Janet described the factors that affected her DPP’s retention:
The most attrition is after six months. I feel like we set that initial goal of 5%–7% weight
loss, and a lot of people think, okay, at Month 6, they’re pretty close to hitting it or hitting
it, and then it’s very hard to retain after that.
Four participants discussed strategic retention approaches to encourage patients to
complete the DPP. Dave provided an example of how his DPP structured an incentive to align
with physical activity goals: “I’ve learned that if I don’t give those outright at the beginning, but
I say, hey, in our fourth week, we’re talking about tracking. I’m going to give you a Fitbit.
Suddenly everybody’s showing up more often.” Frank spoke about how his DPP used incentives
to engage and retain his patients:
To keep them engaged, one of the things we got from the churches here, they gave us
about 300 books about diabetes. So, we give it as a reward at the end. Not at the
beginning. At the end, like a package, like, “Hey, if you stay through the classes, we got
this great book.” We just have to advertise.
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Interestingly, three participants mentioned that retention was improved more from their
patients’ anticipation of receiving the incentive than actual receipt of the item. Dave provided an
example of how creating anticipation helped retention:
I’ve learned that if I don’t give incentives outright at the beginning, but I say, hey, in our
fourth week when we’re talking about activity tracking, I’m going to give you a Fitbit,
then suddenly everybody’s showing up more often.
Gloria found that informing patients at the start of the program that they would receive a free
gym membership encouraged them to continue in the program:
Around Week 5 or 6 in the program, we offer patients a free gym membership, but a lot
of them don’t use it. Yet, when they sign up for the DPP, that’s like one of the reasons
they sign up is because they’re going to get this membership. It’s like in their head, it’s a
great incentive, but they just never come to use it. It is interesting.
Support for Lifestyle Coach
All participants identified that the role of the lifestyle coach was a critical element in
retaining patients in the program. Helen provided insight into the direct influence that the
lifestyle coach has on patients’ success in the DPP: “So, we can recruit all day long and get
people there. I think you have the [lifestyle] coaches that help them reach their goal. I think
getting good coaches is huge.” Dave has integrated his lifestyle coaches throughout the planning
structure of his DPP. The coaches are invited to attend the program’s steering, operations,
research, and coaching committee meetings. Five participants found that the lifestyle coach
affected important aspects of their program, including patient engagement, group interactions,
and program retention. Ellen found that their retention rate was connected to the effectiveness of
their lifestyle coaches. “Some coaches have a retention of 70% to 90%, and then other ones have
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a 50%. You’ve got to make sure the coaches are engaged and committed because some of ours
weren’t, and it showed in the attendance.” Additionally, Frank identified that it was essential for
lifestyle coaches to possess the ability to relate to patients. He believed that this “relatability”
was essential for improved patient experience and offered advice for recruiting lifestyle coaches.
Make sure that you have people who are able to talk to someone on a personal level. You
don’t want to ever have somebody in there that feels like they know much more than the
person in the class. You want to have somebody that’s just relatable or somebody that is
truly there to help everybody out, not just feel like they have all the information in the
world to give out to them.
Two participants spoke about their efforts to reduce burnout of their lifestyle coaches to
reserve their resilience. Dave planned to schedule retreats for his coaches to address the issue of
burnout: “Have a retreat for coaches. I just want to keep an eye on them for burnout.” Frank had
introduced the messaging application of WhatsApp in his DPP to support the prevention of
burnout of his lifestyle coaches.
It’s great because it’s just a text app. They don’t have your phone number. Just has your
name. You can make yourself private, and you can even have it shut off the text. It’s been
working great because now the coaches don’t feel overwhelmed because it’s not going
home with them. So we have to also look at that. You have to look at how your
employees are being taken care of as well because it can be overbearing at times.
Leverage Community Partnerships
All participants found that local partnerships with businesses and public health agencies
were essential in supporting individuals to achieve program success. The partnerships included
community churches, charitable organizations, and public health services. The partnerships
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addressed disparities related to social or economic conditions that influenced health outcomes.
Examples of supplemental services included transportation vouchers, free nutritious food, and
necessities for their children, such as diapers or childcare. Frank described the importance of
addressing the patients’ needs:
We tell people to follow up with your endocrinologist and everything else. And they’re
like, I don’t know what that is. So, I really don’t care about my medications. I really
don’t care about my disease process. I got to get home and pay my bills. I have no ride. I
have no insurance. I have no this or that. And you’re like, well, what can I do? So, it
really opened us up to realize that there are a lot of resources out there that could help our
patients who are dealing with issues other than diabetes.
Frank shared an example of how access to a diaper bank allowed an individual to rejoin
the program: “One patient wasn’t attending anymore because she was having trouble getting
diapers. The United States has diaper banks. So, I found them a diaper bank where they can go
and pick up diapers for free.” Irene shared an example of ways her DPP helped individuals
overcome access barriers:
I have had patients who have had some social determinants of health barriers, and we
provided transportation vouchers for them to get to class, and that was significant and
really assisted in their program’s success because they were allowed to attend. Also, for a
few other patients, we provided complimentary childcare while they attended class.
Ellen shared how she worked with community partners to find a variety of resources for patients
in her DPP: “If they needed a doctor, a place to exercise, or anything they couldn’t figure out for
themselves, our navigators would help them. Through our community partners, we were able to
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access just all kinds of different things.” Barry shared a unique aspect of his DPP that partners
with a church to provide free produce to patients experiencing food insecurities:
If they need food, we can always provide them with produce that we can get them if
they’re having trouble, like, “Oh, I couldn’t buy produce this week. I couldn’t eat healthy
this week because I needed to pay rent.” So, we could provide them with like 20, 30
pounds of food. We’re unique in that way. We have other programs besides DPP that we
can leverage.
Connie routinely collaborates with site coordinators at senior housing apartment complexes to
foster an alignment between their need to bring programs to their residents and the DPP’s need to
enroll members. She described how this partnership worked:
In senior apartment complexes, there’s, in most cases, a coordinator who oversees
activity. So, our key is to establish that relationship with that coordinator, and that
coordinator has to, for example, bring programs to the residents. And we’ve worked
closely with them to help us to get the residents of their particular building engaged in
our classes.
Resources for Sustainable Funding
All participants expressed concern regarding continued funding, which they used for
operational expenses such as salaries, market program services, and support for data collection
and entry for required reports. Eight participants shared that they relied solely on grants to fund
their DPP. Four participants shared their difficulty in finding replacement funding for expiring
grants. Ellen shared the challenges in her DPP with obtaining funding: “We have two grants, and
they’re both ending. So, we have applied for several grants. Nobody wants to fund the program
delivery, which is interesting because reimbursement is very difficult.”
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Two participants shared how earmarked grants allowed for the expansion of DPP.
Services beyond the essential expenses. They credited their additional services as important to
the growth of their DPPs. Ellen grew the number of lifestyle coaches through a special grant she
received: “Through the grant, I was trained as a master trainer. So, now I’ve trained. I want to
say. Say. Around. 30 or 40 coaches”. Connie shared patients’ feedback regarding a grant that
supported post-program success:
We work with the patients to create an action plan. It’s a physical activity and an action
plan for nutrition. At the end of the six months, we’re hoping that they will achieve and
complete that action plan. It seems to really go off very well, and folks really enjoy it.
Three of the DPPs discussed developing partnerships with local businesses to provide support
services at no cost to their program. The businesses included universities, local libraries, and the
city government. These relationships included doctoral students to help with data entry and
social work students who required community health care volunteers’ hours as part of their
graduation requirement. Frank shared how he bartered with another organization to provide
services for his DPP.
That’s why we have community health workers that’s not even on our payroll. We just
coordinate with them. But because we coordinate, we get them a little office here and a
desk, and we’re like, “Here, you can work here.” We have meetings with them like,
“Hey, this is what we’re doing. How’s your program going? Hey, we got nursing
students.” We can have them make calls to the Spanish-speaking community and keep
them engaged.
Ellen shared how her DPP collaborated with students:
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Health coaches getting their masters need coaching hours to sit for the national board
exam. So we had people who were having trouble getting jobs in health coaching, and so
they just needed the experience to put on their resume. We have a mix of interns and
volunteers and people that have either sat for the exam, can’t get a job, or they need to sit
for the exam, and they need the 50 coaching sessions. So, they’re able to get that through
our program.
Federal Reimbursement
Reimbursement through Medicaid DPP was particularly challenging for five participants
who explored this funding option. Helen described the experience as “the hoops, the hoopla, the
things we would have to go through to be Medicare-approved just wasn’t worth what we would
get paid from Medicare.” She recognized a possible benefit for DPPs who could run 20–30
classes at a time versus the two concurrent classes that her DPP offered each month. Connie
shared her challenge with obtaining funding:
I’ve found that at our state-level diabetes program here in California acknowledges that
there are only three organizations that have been able to provide the Medi-Cal diabetes
prevention program and get reimbursed. My question to them was, “So, if there’s only
three organizations that can be reimbursed, and we are one of them, then can you please
help us with funding to continue our program?” So, no, there’s not a lot of support, or
there hasn’t been support for our funding.
Connie also shared that in 2020, the CDC released funds for DPP to the state, who in turn
released funds to the counties; however, “The money went to nutrition workshops and the like
that support diabetes prevention but lacked strategic efforts to fund DPPs that are actually on the
ground doing the work.” Ellen is currently collaborating with a DPP in another state who has
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received Medicaid reimbursement. In return, she shared her DPPs capacity to research program
outcome measures. Janet shared her DPP current position on pursuing approval as a Medicare
DPP:
Medicare does have a second-year payment plan now for Medicare patients. We haven’t
instilled that yet, but that is something we’re looking into, to providing a second year of
support. The biggest concern is payment. They’re not offering a very high payment for
year two, and it’s performance-based, so that makes it hard sometimes to meet those
performance metrics. Yeah, definitely something we’re looking at in the future,
especially if Medicare is raising their payment structure for it.
In summary, patient retention presented a common challenge among participants.
Economic instability adversely influenced their ability to complete the year-long program. At
times, DPPs partnered with local businesses and religious or academic institutions to provide
transportation vouchers, free nutritious food, and necessities for their children, like diapers and
childcare, to address their patients’ needs. These partnerships enabled patients to participate in
program services. Additionally, the role of the lifestyle coach was directly related to retention
rates. Relatable, empathetic, and compassionate lifestyle coaches had better retention rates. The
participants’ need for sustainable funding was another concern since a high reliance on grant
funding emerged. The application process to obtain federal reimbursement was complex, and the
deterrent was the low reimbursement rate. Strategies to secure supplemental funding included
collaborating with DPPs in other states who received federal reimbursement.
Research Question 3
The third research question asked, “How are DPPs addressing the challenges of offering
services during the COVID-19 pandemic?” The aim was to identify how participants addressed
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the challenges that faced their DPP from the COVID-19 pandemic. The themes that emerged
from the interviews were to leverage technology and capitalize on increased awareness of health
needs.
Leverage Technology
Before the COVID-19 pandemic, nine DPPs offered only in-person classes held in off-
site locations, such as libraries, schools, churches, and hospitals. When California’s shelter-in-
place mandate took effect, many of these off-site locations were no longer available. Since CDC
offered online and distance learning in addition to in-person classes, six participants chose to
meet the challenge of the shelter-in-place mandate by transitioning to online learning using
Zoom. While the Zoom meetings allowed for the continuation of group sessions, there were
strengths and barriers to using online learning for their patients. Barry shared the difficulty his
DPP experienced with supporting patients during the pandemic:
It’s been really hard during the pandemic to get people to stay on track because you’re
not with them in person every single day or every single week. So, when we did go back
to in-person a couple of months ago, we saw notable decreases in weight and adherence
to like the diet plan because I think there’s just more accountability when you have
classes in person.
Frank shared the initial resistance from patients and their ultimate acceptance of using Zoom:
We had a lot of patients dropping out, and it was all due to just them having to adjust.
Some cultures like more in-person versus camera. Classes were filled to the brim. We
didn’t have enough chairs. And we did Zoom, and it was different. The technology, they
get frustrated with it. They didn’t want to deal with it, and so it’s been hard with the
Zoom. It’s been working, but it’s been hard to retain a lot of our patients because of it.
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Now that COVID’s getting relaxed, we’re able to retain our patients a little bit longer.
We’re hoping that when classes open up, we’ll be able to get them because now they got
used to Zoom. Now, they’re like, “Well, I don’t know if I want to come into class.”
Connie also noted a retention concern when her program changed to a virtual format:
COVID came in, and we had to stop the class. So, then we decided to translate that over
to a digital class where we actually have an app. So, they [patients] would access the app
and read the materials. That didn’t work well. Of the 12 plus, we were down to maybe
seven.
Ellen shared the challenge of effective problem-solving in a virtual format:
Some of our coaches that we’re in person, we’re able to have common activities. So, they
would have a dance party, or they would, you know, go on a walk before class or things
like that. Virtually, it’s a little difficult because you kinda just have to help them problem
solve the barriers and then have them set the goal and then kind of see what happened.
While DPPs made the necessary adjustment to a virtual format, three participants realized the
impact that virtual classes had on social interactions among patients when in-person sessions
resumed. Dave shared the variance in his DPP:
I will say the convenience of Zoom while it provided us with, you know, that hiccup of
getting used to it. People really like it. It’s just been really convenient for them. With that
said, I prefer in person. I think there’s a way to speak to each other where we’re not
interrupting and cutting each other off.
Barry also expressed the social benefit of returning to in-person group sessions: “So, they’re
excited to be back, and it’s just like a more genial atmosphere. They talk more amongst each
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other. They encourage each other. They like being in person better, especially for class
participation.”
Web-based applications provided an additional method for continuing DPP services
during the pandemic. Five participants described their use of Facebook, Instagram, organization-
based community forums, and free texted-based applications like WhatsApp or Slack. Two of
them described strategies that ensured the success of their web-based applications, including the
availability of technical support, ease of use, and content variability. Janet described the
importance of technical support for patients:
With the virtual program, definitely having a very responsive tech support team is crucial
because you definitely don’t want the app crashing, and people can’t have access when
they need to log in to complete activity minutes, log their meals, and communicate with
their coach. It’s essential that you have the app working.
Barry’s DPP encouraged health-promoting behaviors through text messaging. “We’re on the
phone with each other through text or through Slack or WhatsApp, and we’re encouraging
everybody to eat healthy that way.”
Three participants attempted to use technology to expand services but met resistance.
Alice described her challenge with using technology in that her community members use prepaid
phones and their numbers change frequently. Connie discussed the transition of technology for
seniors in her program: “We post on Facebook. We’ve posted on Instagram. I’d say more than
60% of our patients are seniors, and not a lot of our seniors are on Facebook.” Helen shared an
unexpected challenge from when her DPP incorporated Facebook to engage patients during the
pandemic:
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So, we do have a Facebook group for the patients. I think six of the 10 patients opted in.
We made it a very optional group. And some of it felt politically charged to decide
whether they were joining the group or not or wanted to be on Facebook or not. Really
one or two patients are posting or sharing much on that Facebook page.
Capitalize on Increased Awareness of Health Needs
Six participants shared feedback from their patients regarding news media reports that
people with chronic diseases are more prone to adverse outcomes if infected with COVID-19.
The feedback centered on an increased desire to prevent or delay T2D. Since the pandemic, these
six participants observed a shift in how individuals with prediabetes approach their health.
Connie described a transformational change in her patients since the pandemic: “Their interests
have increased because that’s all we’ve heard on TV. If you have diabetes, you’re more
susceptible to COVID. So, folks were more likely to be engaged and want to understand more
about preventing diabetes.” Dave observed an increased connection among his patients. He
stated that “people feel more connected and bonded because they’re all going through the same
thing.” Janet noticed that patients have been more responsive to emails and referred other family
members and friends to the program. Irene noticed that individuals were more engaged with the
DPP:
People have been extra motivated, and COVID-19 has been a reason for them to want to
jump on and join the program. I’ve had long conversations with people who really put
things in perspective. I need to get my health in line because of not wanting to have
bigger medical issues with COVID-19 now than in the past.
While all participants have recognized the increased desire of individuals with
prediabetes to improve their health, they continue to identify ways to best support these
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individuals beyond providing health or program information. Alice shared the resistance of
people in her community to getting the COVID-19 vaccine and the challenges of having one of
the highest rates of COVID-19 in California:
Many are being more cautious about getting the virus, but there is a good chunk of one or
two of the tribes that did not even want to get the vaccine. In our community, we were,
like, the lowest area in California for a long time with low cases of COVID. Then, all of a
sudden, we were the highest rate of COVID because there was a big chunk of patients,
not just Native patients but quite a few pockets that just did not want to take the vaccine,
So we’re trying to recover from that right now.
In summary, participants identified that the pandemic created a shift in how their DPPs
were delivered, from in-person to online. The use of Zoom supported the continuation of DPP
services; however, they expressed that patients initially struggled with adapting to an online
platform. The pandemic also created a shift in the behaviors of individuals with prediabetes.
They wanted more knowledge about health promotion and were more receptive to learning about
the services offered by DPPs. The media advertised the disproportionate health outcomes for
individuals based on their socioeconomic level. This increased awareness about the worsened
outcome of COVID-19 for individuals with chronic diseases increased camaraderie among
patients who shared in their desire to prevent or delay T2D.
Summary
This chapter has provided insights shared by PC of CDC-recognized DPPs to improve
these programs’ implementation in socioeconomically disadvantaged communities. These
findings identified the cognitive, behavioral, and external environmental influences of human
behavior that influence the health outcomes of individuals with prediabetes. Based on these
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findings, the next chapter will present five recommendations for practice changes that other
DPPs may implement to succeed.
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Chapter Five: Recommendations
This chapter presents four recommendations based on the findings in Chapter 4. The
recommendations support the PC of DPPs in socioeconomically disadvantaged communities.
Administrators of other program delivery services may also benefit from the recommendations
provided
Discussion of Findings
This study aimed to examine best/promising practices to improve the implementation of
DPPs in socioeconomically disadvantaged communities. The findings identified in Chapter Four
align with this study’s conceptual framework and literature review. The conceptual framework
identified the bidirectional interaction among the individual’s self-efficacy, the lifestyle coach,
and the SDOH that impact an individual’s ability to perform health-promoting behaviors. DPPs
provide education and social support that inspire individuals to make lifestyle modifications that
prevent or delay T2D. The findings presented in Chapter Four align with this study’s conceptual
framework and literature review in four ways:
1. The COVID-19 pandemic has created a sense of urgency to make healthier lifestyle
choices among individuals with prediabetes.
2. Self-efficacy to perform health-promoting behaviors is increased through positive
reinforcement.
3. Public and private community partnerships are essential in bridging health disparities
in socioeconomically disadvantaged communities; and
4. The lifestyle coach’s relationship with patients positively influences goal-directed
behaviors and program retention.
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The COVID-19 pandemic triggered a sense of urgency among individuals with
prediabetes to improve their health (Joensen et al., 2020). Participants interviewed identified a
renewed interest in diabetes prevention among individuals with prediabetes that included a
transformational change towards attitudes and beliefs concerning prevention interventions
precipitated by their concerns about disease progression. This study’s literature review aligned
with this finding, identifying that diabetes distress had worsened because of the disparity of
health outcomes for individuals with diabetes who contracted COVID-19. (Joensen et al., 2020;
Owens-Gary et al., 2019).
Participants discussed the importance of providing patients with praise and
encouragement for their accomplishments. This study’s literature review found that self-efficacy
was improved when individuals received positive reinforcement (Jiang et al., 2019). Individuals
with higher self-efficacy better participated in health-promoting behaviors (Cha et al., 2014).
Nezami et al. (2017) found that increased eating self-efficacy and physical activity self-efficacy
led to improvements in weight control behaviors and actual weight loss.
Participants identified the importance of addressing their patient’s unmet social and
economic conditions to recruit and retain patients. Participants also expressed concern regarding
the financial constraints of DPPs who relied on grant funding to meet daily operational needs.
Partnerships with public and private businesses enhanced supplemental program activities that
participants believed were crucial to the continuous engagement of patients. This study’s
literature review supported the need to address disparities in SDOH, which resulted in poorer
health outcomes for individuals with prediabetes (CDC, 2021a). Addressing the community’s
health needs requires businesses, faith-based organizations, health insurers, and other
stakeholders to close health disparities induced by social and economic conditions (CDC, 2015)
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Participants identified that the lifestyle coach was influential in patient engagement,
group interactions, and retention rates. Further, participants recognized that relatable and
committed lifestyle coaches helped patients reach their goals. The findings align with this study’s
literature review that goal setting was a strong predictor of achieving the desired behavior (Lewis
et al., 2016; Olander et al., 2014). Strong relationships between health coaches and patients are
instrumental in making healthier lifestyle choices (Thom et al., 2016). Additionally, as
individuals demonstrate success in achieving their goals, their self-efficacy increases (Swoboda
et al., 2017).
Recommendations for Practice
The recommendations in this chapter present a recruitment tactic for DPPs and address
the determinants of health promotion to prevent or delay T2D as illustrated in this study’s
conceptual framework, namely: Self-efficacy, SDOH, and the lifestyle coach.
Recommendation 1: Expand Recruitment Efforts in the Era of COVID-19
Six participants identified that the COVID-19 pandemic had created a renewed interest in
diabetes prevention among individuals with prediabetes. This interest signaled a motivation to
increase their knowledge, and higher education leads to improved health outcomes (VCU-CSH,
2014 ). The evidence of this interest included the participant’s observations that patients had
developed increased responsiveness to program marketing initiatives and the creation of bonds
between patients who developed a heightened sense of urgency in preventing T2D due to
COVID-19. This study’s literature review supported the imperative among individuals with
prediabetes, given their susceptibility to worsened outcomes from COVID-19 compared to
individuals without chronic diseases.
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The strategy that participants used to capitalize on the increased interest in diabetes
preventative measures centered on recruitment efforts, including
● Soliciting referrals from family, friends, or program staff who were familiar with the
benefits of the program;
● Distributing mailers to homes in the community;
● Providing marketing material at informational events held in clinics or hospitals; and
● Raising diabetes awareness among family members by inviting the patient’s relatives
to attend meetings regardless of enrollment in the program.
DPPs can partner with health insurers and employers who provide coverage benefits to
expand recruitment efforts. Each is instrumental to health promotion because of its impact on the
access and affordability of DPP services, particularly in socioeconomically disadvantaged
communities (CDC, 2021f; Hill-Briggs et al., 2021). The National DPP Coverage Toolkit is a
website that provides resources to community stakeholders about entities that cover CDC-
recognized DPPs as a benefit. The toolkit includes a list of commercial health plans and public
and private employers that provide coverage by geographical location. The list of employers is
from public schools, universities, and localities with public employee coverage. The toolkit also
includes coverage resources from state Medicaid, Medicare, and Medicare Advantage plan
members.
Recommendation 2: Build Self-Efficacy in Performing Health-Promoting Behaviors
A benefit of higher self-efficacy is an increased ability to perform health-promoting
behaviors that prevent or delay T2D (Cha et al., 2014). Participants identified that developing
their patient’s health literacy was essential to building self-efficacy. Health literacy is the
capacity to understand and use health information to make informed decisions for better
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outcomes (Office of Disease Prevention and Health Promotion, 2015). This recommendation
might be particularly relevant for low-income populations, given individuals with less education
or income less have lower health literacy (Rubin, 2016).
Socioeconomically disadvantaged communities have a disproportionately lower level of
health literacy (CDC, 2022b). This study’s literature review identified that when individuals lack
the necessary health literacy to adopt healthy behaviors, they have poorer health outcomes. DPPs
must evaluate the patient’s readiness and commitment to learning as a baseline to grow health
literacy. Three participants used motivational interviewing to gauge their patient’s capacity to
perform health-promoting behaviors to prevent or delay T2D.
The recommendations on improving self-efficacy include:
• Implementing goal setting and establishing positive reinforcement;
• Enhancing the health provider and patient relationship
• Identifying Intergenerational Influence on Health Promotion
The participant’s practice of goal setting through incremental changes increased self-
efficacy among patients. The participants recognized that it was significant for the patient’s
continuation in the program to acknowledge change regardless of whether they achieved the
CDC outcomes of weight loss, physical activity, or HA1C reduction. This type of positive
reinforcement played an essential role in building the patient’s self-efficacy. The concept of
progress as a ‘feeling’ of achievement served to help patients find the motivation to engage in
program activities. The participants identified that it was also essential to recognize when
progress took other forms that did not completely fulfill CDC outcomes, such as changing
unhealthy food patterns or reducing body circumferences rather than losing a prescribed amount
of body weight.
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The relationships that patients established with their health care professionals affected
their level of self-efficacy toward performing health-promoting behaviors. One of the
participants noted that role ambiguity and time seemed to be a factor in the healthcare
professional’s capacity to form supportive relationships with their patients. The practices
participants employed to promote DPP services included visiting medical offices to obtain
patient referrals during scheduled appointments, meeting with healthcare professionals at the
clinics or hospitals where they work, and holding informational meetings to explain how lifestyle
modifications prevent or delay T2D.
A lower self-efficacy toward preventing or delaying T2D is carried throughout
generations and can lead to poorer health outcomes (D’Souza et al., 2017; Sauder & Ritchie,
2021). Participants described this phenomenon as intergenerational trauma, prevalent in the
Hispanic and Indigenous racial/ethnic groups. Participants focused interventions on improving
health literacy through education. They sought to dispel the patient’s belief that T2D was
unpreventable and offered them hope for improved health outcomes. Interventions to increase
self-efficacy and counter intergenerational trauma include teaching patients how to modify
behaviors within the demands of their daily life patterns, make nutritious meals within financial
constraints, and increase physical activity in unsafe neighborhoods.
The CDC Health Literacy website is a recommended resource to improve health literacy
for patients in DPPs. The Understanding Your Audience guide provides users with resources to
help navigate their patient’s unique learning needs based on culture or age. The site offers
validated health literacy assessment tools to establish a baseline for learning. The Visual
Communications platform has hyperlinks to health-related images that support written or spoken
messages. The CDC recognizes an organizational component to improving an individual’s health
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literacy. Organizational literacy is “the degree to which organizations equitably enable
individuals to find, understand, and use information and services to inform health-related
decisions and actions for themselves and others” (CDC, 2022b). DPPs can model educational
material from the Federal Plain Language Guidelines to ensure educational material is
universally understood because health information can be complex for any individual.
Recommendation 3: Establish Community Partnerships to Address SDOH and the
Sustainability of Program Delivery Services
All participants agreed that community partnerships are instrumental to the successful
implementation of DPPs. In particular, individuals in low-income communities are more likely to
have food and housing insecurities or live in unsafe neighborhoods, which inhibit their ability to
practice health-promoting behaviors to prevent or delay T2D (Charkhchi et al., 2018; Meyer et
al., 2014). The participants of this study identified partnerships that supplied basic goods and
services to assist patients in need. Supplementing income disparities through partnerships was a
strategy among all the participants. The literature review identified the importance of addressing
SDOH to motivate behavioral changes toward the delay or prevention of T2D (Hill-Briggs et al.,
2021).
The recommendation for establishing community partnerships includes
● Securing Resources to Address SDOH Disparities
● Creating Mutual Alliances
● Establishing partnerships to Support Program Sustainability
To attain resources for their patients who were experiencing economic instability, the
participants reached out to the local chapter of the National Diaper Bank for patients who could
not afford diapers. These charitable organizations provided complimentary childcare during
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group meetings and offered patients referrals for free cellular phones collected by the mental
health department during a phone drive. Transportation vouchers supplied by public health
agencies enabled patients to attend group meetings.
The participants also developed mutual alliances with students who needed volunteer
hours to complete a graduation requirement. Social worker students provided free counseling to
patients and health care coach students who performed as lifestyle coaches. Senior housing
complexes were another example of an alliance whereby the complex received a source of
activities for its members, and the DPP gained patient referrals.
The partnerships supported the long-term viability of DPPs by bridging the financial gap
left by dwindling grant funding or arduous federal reimbursement programs. The supplemental
services provided by these partnerships included academic institutions that provided doctoral
students who conducted data collection and data entry required to maintain CDC recognition as a
full-status DPP. Hospitals and clinics offered free office space for DPPs to conduct group
meetings and hold marketing events.
Participants in this study found that partnership served to narrow the bridge of health
disparities in low-income communities by augmenting access barriers related to the unmet needs
of their patients. DPPs should seek to assimilate the best practice of forming partnerships to
motivate their patients to perform health-promoting behaviors that prevent or delay T2D. The
reciprocal causative relationship within SCT among the individual, behavior, and the external
environment is evident in this practice.
The CDC Community Health Improvement (CHI) Navigator website provides
community stakeholders with resources to improve health in their communities (CDC, 2015).
CDC’s holistic approach includes four key areas that influence health outcomes: socioeconomic
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(40%), behavior (30%), clinical care (20%), and physical environment (10%; CDC, 2015). The
CHI offers a database of interventions that address socioeconomic factors and the physical
environment affecting health outcomes (CDC, 2015). It also provides exemplars of community
partnerships that work together to maximize strategic efforts to meet communities’ needs (CDC,
2015).
Recommendation 4: Ensure Competencies of Lifestyle Coaches to Promote Retention
The participants identified that the role of the lifestyle coach was essential to patient
engagement and retention in the DPP. The coaches’ ability to deliver culturally competent
support and create engaging group interactions were attributes of skilled lifestyle coaches cited
by participants. According to SCT, behavioral models who are competent, credible, similar,
enthusiastic, and supportive are vital in motivating the learner towards goal-directed behaviors
(Glanz, 2020). This finding was consistent with the literature review, which found that health
outcomes were improved when individuals trusted their health care professionals (Henderson et
al., 2018).
The recommendations on how to ensure the competencies of lifestyle coaches include
● Maximizing Connections based on the Shared Life Experiences with Community
Members;
● Identifying Cultural Competence concerning Food Choice;
● Encouraging Social Engagement
The participants identified that the trustworthiness of lifestyle coaches was enhanced
when they shared similar life experiences of patients in the DPP. They utilized community
ambassadors or staff who mirrored the racial/ethnic or age group to help build the patient’s trust
that DPP services were beneficial. The participants identified that it was important for lifestyle
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coaches to understand the unique needs of the community they served, including the cultural
influence of food choices and environmental conditions that limited physical activity.
It is important to recognize that in Hispanic and Asian cultures, food can be a positive,
familiar component shared in celebratory settings rather than a harmful habit formed from
unfortunate life events. Lifestyle coaches must explore why participants make unhealthy food
choices rather than shaming them for choices that often evoke favorable memories. As one of the
participants mentioned, shaming is counterproductive for creating health-promoting behaviors.
Lifestyle coaches also need to understand SDOH, such as unsafe neighborhoods that
prevent outdoor physical activity. When participants identified that their patients were
experiencing barriers to physical activity outdoors, they suggested ways to exercise in the home
or during the commute to work. They also leaned on group members to support each other. The
lifestyle coaches provided patients with a time to check in with one another before or after group
meetings. During the check-in conversations, patients encouraged each other and provided
suggestions on overcoming barriers to lifestyle modifications.
In summary, the recommendations presented in this chapter identified that DPPs should
factor in the individuals’ readiness to practice health-promoting behaviors, and organizations
need to address the social and environmental influences that promote health-promoting behavior.
People with prediabetes need support to improve their health outcomes. Interventions aimed at
the multitude of influences of health promotion are more likely to improve health outcomes in
socioeconomically disadvantaged communities.
Limitations and Delimitations
This section will outline the limitations and delimitations of this study to consider when
reviewing the findings. A limitation of this study was the small sample of 10 participants. The
78

small sample may hinder the generalizability of results to other DPPs that do not share the same
characteristics. Another limitation was the condensed time for data collection, which occurred
directly before the winter holidays and during the resurgence of the COVID-19 pandemic.
Access to participants was hindered based on the timing of data collection and the inability to
perform in-person interviews, which may have been preferred rather than virtually.
Delimitations of the study included the qualitative study design, which does not allow for
the findings to be generalizable to a larger group of DPPs. The choice to only select full-status
recognized DPPs was also a delimitation. The inclusion of preliminary and pending status DPPs
may have allowed for a better understanding of best/promising practices along the continuum to
full-status recognition. Additionally, the limited geographical area narrowed the examination of
best/promising practices, as SDOH vary based on geographic region. The subjectivity of the
interview questions was also a delimitation of this study. The diversity of the participants’
professional backgrounds may have influenced their responses to the questions. The exclusion of
the lifestyle coaches’ perspective was also a delimitation of this study. It became apparent that
lifestyle coaches were instrumental to successful program retention during data collection.
Through their direct interaction with patients, the lifestyle coach was positioned to better
understand the patient’s social and economic conditions in which they lived. The awareness of
SDOH barriers was fundamental in low-income communities because unmet needs hindered the
patient’s ability to engage in DPP services.
Recommendations for Future Research
This section will provide three recommendations for future exploration based on this
study’s findings. Additionally, it will provide a recommendation for further exploration from the
perspective of DPP attendants who could not complete the program due to external
79

environmental influences. The first recommendation relates to the study’s delimitation regarding
a narrower geographical scope to the Western region of the United States. A similar inquiry of
best/promising practices in the Northeast, Southeast, Southwest, and Midwest regions of the
United States would provide interesting comparative data. This data might also be helpful to
DPPs within those regions because they share cultural norms specific to that region.
The second recommendation relates to the study’s delimitation regarding the role of the
lifestyle coach in DPPs. Based on interview data, the lifestyle coach has a significant impact on
the retention of patients in the program. A mixed-method approach to identify best/promising
practices to retain patients in DPPs in socioeconomically disadvantaged communities could help
improve retention rates. The data collection method would consist of semi-structured interviews
with lifestyle coaches and examining retention rates from each DPP cohort they led.
The third recommendation is to replicate the study using a larger sample size of 30
participants. The larger sample size can help to verify the consistency of findings better. Lastly, a
qualitative study to gain insights from the perspective of former DPP attendants from low-
income communities who did not complete the program would provide data that could identify
contributions of attrition related to SDOH. This information could guide PCs on proportioning
limited resources to fill the greatest needs.
Conclusion
The practice problem addressed in this study was the health disparities of individuals
with T2D in socioeconomically disadvantaged communities. This study discussed the interplay
among the individual, their social and economic determinants of health, and the health care
professional’s role in supporting the patient’s application of health-promoting behaviors that
prevent or delay T2D. Further, the study presented recommendations for best/promising
80

practices identified through interviews with PCs in CDC-recognized DPPs located in
socioeconomically disadvantaged communities.
Although T2D is preventable, it requires collaborative efforts from key stakeholders who
share in the individual’s journey towards health promotion. Socioeconomically disadvantaged
communities with the most apparent health disparities are in critical need of federal, state, and
local alliances to address barriers associated with SDOH. Healthcare and education access and
quality, economic stability, and food and housing insecurities are social and environmental
determinants of health, or supportive interventions are needed to support the individual better.
Diabetes prevention is more than just telling someone to eat less.

81

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Appendix: Interview Protocol
Hi [Name of Participant here]. I very much appreciate the opportunity to meet with you
today and have been very excited about our interview. The purpose of my study is to examine
best/promising practices to improve the implementation of DPPs in socioeconomically
disadvantaged communities. Our interview will help to better understand from your role’s
perspective about what organizational/environmental strategies are DPPs implementing to
address participants’ beliefs and behaviors in the delaying or preventing T2D; What resources
needed to maintain or improve DPP outcomes? and How are DPPs address the challenges of
offering services during the COVID-19 pandemic? With your permission, I would like to record
our interview and take a few hand-written notes so that I can refer back to it later for points of
clarification. To protect your confidentiality and anonymity, please know that the recording will
not be uploaded to a cloud-based application but remain on my desktop which is password-
protected. Do I have your permission to record and take notes? [PAUSE FOR ANSWER]. Thank
you [Name of Participant here]. Also, if at any time you would like to stop the interview, not
answer a question, or pause the recording, let me know. What’s most important is that you feel
comfortable throughout our interview together. Your time is very valuable to me so are you
ready to begin the interview

106

Table A1
Interview Questions
1. Please tell me about your professional background in your field.
2. Please describe the demographics (age, gender, racial/ethnicity, SES) of the
participants you primarily serve.
3. Tell me a little about your program goals beyond the target outcomes to meet CDC
DPP recognition
4. What would you say are the most effective strategies your organization has
implemented to achieve these outcomes?
5. What collaborative strategies with healthcare providers increase referrals to DPPs?
6. How are community-based stakeholders engaged in supporting participants’ success in
the program?
7. What funding sources have you been able to secure to promote the mission of the
program?
8. What activities or strategies do you implement to help increase the engagement of
participants in eating healthier and increasing physical activity?
9. Please describe any innovative or technology-based strategies you have implemented to
foster retention of participants while they are in the program
10. What are strategies that have been implemented to promote the mental well-being of
participants who have expressed a lack of confidence in their ability to complete the
program?
11. What initiatives or strategies have you implemented to promote maintenance of weight
loss and continued physical activity beyond the 1-year duration of the program?
12. During the pandemic, what are barriers (i.e. transportation or scheduling) that may
have affected the participants’ access to the DPP?
13. Since the pandemic (March 2020), how has public or private (employers, healthcare
professionals, health insurers) support for DPPs changed or affected the services
offered?
14. Individuals with chronic diseases such as diabetes are at higher risk for severe
complications if they have COVID-19. Since the pandemic, have you seen that
participants’ beliefs and behaviors about preventing or delaying diabetes through
lifestyle changes have changed?
15. Suppose I was a new PC implementing a DPP, what advice would you give me to
achieve the level of success that you’ve seen with your program?
107

Conclusion of the interview
Thank you [Name of Participants here] your insights have been extremely enlightening in
better understanding how the DPP has implemented best/promising practices in offering services
to individuals at risk for T2D. If I have any further questions, would it be okay to email you?
[PAUSE FOR RESPONSE]. Thank you again for your time.

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Asset Metadata

Creator Woolfolk, Nina Marie (author)

Core Title Perspectives of diabetes prevention program coordinators in socioeconomically disadvantaged communities: implementation optimization

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2022-05

Publication Date 04/27/2022

Defense Date 03/30/2022

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag best practice,Diabetes,diabetes prevention program,disadvantaged communities,health disparities,implementation,lifestyle change program,OAI-PMH Harvest,socioeconomically disadvantaged

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hirabayashi, Kimberly (committee chair), Canny, Eric (committee member), Malloy, Courtney (committee member)

Creator Email woolfolk_1@yahoo.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111136631

Unique identifier UC111136631

Document Type Dissertation

Format application/pdf (imt)

Rights Woolfolk, Nina Marie

Type texts

Source 20220428-usctheses-batch-934 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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