DOI: 10.3886/e199601v1
title: Leveraging Technology & Theory to Increase Readiness for and Enrollment in the National Diabetes Prevention Program: A Demonstration Project

description: 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.
description: Response Rates: The response rate was 63.3%
for those completing the 6-month follow-up survey.
description: 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.
description: prediabetic individuals,
18 years or older in Rhode Island.
description: other; web-based survey; <b>Study design</b>:<br>bRIght
communities was divided into 10-day text
message sessions that included assessment questions related to the specific
focus of that session.  <br><br>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). 

 
<br><br>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.


 <br><br>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. 

 
<br><br>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).