Leveraging Technology & Theory to Increase Readiness for and Enrollment in the National Diabetes Prevention Program: A Demonstration Project

Summary:  View help for Summary In the United States, approximately 96 million people have prediabetes, and more than 80% are not aware that they do. Without intervention, many of those adults will develop type 2 diabetes within 5 years. Participation in the National Diabetes Prevention Program (National DPP) Lifestyle Change Program (LCP) can reduce that risk by as much as 58-71%. While progress has been made scaling the National Diabetes Prevention Program (DPP), innovative strategies are urgently needed to increase engagement. This implementation evaluation leveraged and combined technology, behavior change theory, and community-based participatory design approaches to develop, deploy, and evaluate a 6-month, bilingual, tailored text-message delivered program (bRIght communities/comunidades bRIllantes) to increase: 1) readiness to engage in key behaviors for diabetes prevention; 2) engagement in services that address unmet social needs to reduce barriers to participation; and 3) readiness to enroll in the DPP. bRIght communities relied on a systematic approach to integrating best practices of behavior change science organized around the Transtheoretical Model of Behavior Change (the TTM). The TTM is an intentional model of behavior change that frames readiness to change as a continuum that includes five stages of change: 1) Precontemplation—not yet ready; 2) Contemplation—getting ready; 3) Preparation—ready; 4) Action—recently adopted a new behavior; and 5) Maintenance—adopted a behavior more than six months ago and is feeling more confident about sustaining it.

Funding Sources:  View help for Funding Sources Centers for Disease Control and Prevention, Division of Diabetes Translation

Subject Terms:  View help for Subject Terms diabetes; prediabetes; diabetes prevention; behavior change

Geographic Coverage:  View help for Geographic Coverage Rhode Island

Time Period(s):  View help for Time Period(s) 2022 – 2023

Collection Date(s):  View help for Collection Date(s) 2022 – 2023

Universe:  View help for Universe prediabetic individuals, 18 years or older in Rhode Island

Data Type(s):  View help for Data Type(s) survey data

Collection Notes:  View help for Collection Notes Study design:
bRIght communities was divided into 10-day text message sessions that included assessment questions related to the specific focus of that session.  

During Session 1, users were asked about their current daily consumption of fruit and vegetables. Based on responses, the tailoring software then asked end users to respond to a stage of change algorithm to assess their stage of readiness to consume 4.5 cups of fruits and vegetables (the recommendation from the Dietary Guidelines for Americans). Users then received tailored feedback matched to their stage of change, followed by a question about their level of self-efficacy (confidence) for eating 4.5 cups of fruit and vegetables each day. Responses to that question triggered feedback based on level of self-efficacy and stage of change. Any user in a pre-action stage of change (i.e., Precontemplation, Contemplation, or Preparation) was asked about food insecurity or transportation concerns. End users classified as having food insecurity were provided with immediate zip code-matched community resources to help close that gap. Similarly, anyone who endorsed that transportation was a barrier was provided with immediate feedback about regional transportation resources. User’s responses to this session were used to queue 30 days of tailored text message tips matched to their level of readiness consume sufficient fruit and vegetables and the specific constellation of unmet social needs they were experiencing (if any).  

During Session 2 (Day 10), users were asked to self-report their weekly minutes of physical activity. Similar to the previous session, users were then asked about their readiness to engage in regular physical activity (i.e., 150 minutes of moderate physical activity per week). They received immediate stage-matched feedback followed by a self-efficacy question and feedback on confidence. Any user in a pre-action stage of change (i.e., Precontemplation, Contemplation, or Preparation) who endorsed concerns about perceived neighborhood safety or childcare presenting a barrier to being physically activity was given feedback and regional resources to address those concerns. Individuals were also asked about their readiness to quit smoking. Tailored feedback based on readiness to quit was presented to any current or former smoker. Up to 30 days of tailored text messages were then queued to be sent based on a cadence that was determined by their stage of change. For those with one or both unmet social needs, messages about community-based resources were interspersed with the tailored messages designed to promote stage progress for physical activity.  

During Session 3 (Day 20), individuals were presented with a brief, validated measure of resilience (the Resilience Evaluation Measure-3). Feedback on resilience-boosting strategies was provided to all end users. Individuals who had been told by a doctor that they have prediabetes or who were at risk based on the Prediabetes Risk Screening Test were provided with information about the National DPP and asked about their past or current participation. Those who have never participated or who had previously dropped out were then asked about their readiness to and confidence for participating in the National DPP. Immediate feedback based on stage of change and confidence was presented in conjunction with a zip-code matched referral to the geographically closest National DPP and the state Community Health Network. Tailored messages based on readiness to participate were then queued up for 30 days and sent on a schedule set based on stage of change.  

The logic and decision rules of the system allowed the cycles of three sessions to recur every thirty days. Users were invited to complete up to 18 sessions over a 6-month period.  Six months post-enrollment, 273 participants completed an online follow-up survey. For those participants (n=273), their “last” available data is from the 6-month final follow-up evaluation. For those that did not complete the follow-up evaluation, their “last” available data is from their last session completed of bRIght communities (if they did at least 2 sessions from the same focus).

Response Rate:  View help for Response Rate The response rate was 63.3% for those completing the 6-month follow-up survey.

Sampling:  View help for Sampling A statewide, multi-channel recruitment strategy was implemented from May-October, 2022 to recruit 432 community members who received up to 6 months of tailored text messages designed to increase their readiness for adequate fruit and vegetable intake and physical activity; determine prediabetes risk; increase readiness for the National DPP among those at risk; and provide zip-code matched resources to address unmet social needs.   Users were ineligible to participate if they: 1) were under 18 years of age, 2) had been previously diagnosed with diabetes, or 3) were pregnant or unsure.

Collection Mode(s):  View help for Collection Mode(s) other; web-based survey

Unit(s) of Observation:  View help for Unit(s) of Observation Individuals