From Insight to Action: Using the COM-B Model to Explore Behaviour Determinants in Pre-Diabetes Programs

From Insight to Action: Using the COM-B Model to Explore Behaviour Determinants in Pre-Diabetes Programs | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Insight to Action: Using the COM-B Model to Explore Behaviour Determinants in Pre-Diabetes Programs Jane EA Lewis, Tahir Touray, Zsofia Szekeres This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7046125/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The global burden of diabetes is increasing, necessitating improved surveillance and prevention efforts. Evidence supports identifying high-risk individuals and implementing intervention programmes. Until recently, Wales lacked a nationwide, standardised support programme for individuals with pre-diabetes. Clinical data from a Welsh diabetes prevention pilot program, implemented in 2022, suggested that there was a decrease in average blood glucose levels (HbA1c) at 12-month follow-up appointments however there is limited qualitative evidence on experiences of patients identified with pre-diabetes. The aim of our study was to undertake a formative evaluation, exploring the views of adults enrolled in the two prevention programmes currently being run within one Welsh health board. Methods: This qualitative study, informed by the Capability, Opportunity, Motivation and Behaviour (COM-B) model, evaluated the experiences of participants who accessed the diabetes prevention programmes in CTM UHB. Different dimensions of experience including access to service, interactions with HCSWs and behaviour change were explored and mapped against their capability, opportunity, motivation and behaviour change. Service users were invited to take part in a focus group or one to one online or telephone interviews. There were 11 individual interviews and five focus group interviews with a total of 28 participants, from January to March 2024. Thematic analysis was used to analyse the data. The key findings, were mapped around the COM-B model. Results: The evaluation identified various factors influencing programme engagement and lifestyle changes. Psychological and physical capabilities, social and physical opportunities, and automatic and reflective motivation all played roles. Key elements included prior knowledge, supportive staff, health checks, personalised guidance, risk awareness, and personal responsibility. The findings revealed a complex interplay of factors affecting participant engagement and behaviour change. Conclusions: Based on our findings, we summarised a set of recommendations that might improve the current services being offered within the Welsh Diabetes Prevention Pilot Programmes, such as increased flexibility in delivery (out-of-hours), and availability (resources to be made available online out of hours), more frequent contact (e.g. monthly for the first 6 months), and regular health checks (e.g. HbA1c every 6 months), could improve initial uptake and sustained engagement in the programmes. Figures Figure 1 Background It has been well documented that the global burden of diabetes and prediabetes is substantial and growing(1). Diabetes UK (2), describes a ‘diabetes crisis’ here in the UK with the number of those living with diabetes, hitting an all-time high of 5 million, with 1 in 3 of those having pre-diabetes (3). Wales has been reported as having the highest prevalence of diabetes in the UK (4), equating to 1 in 13 (8%) of its population being diagnosed with this chronic disease, with over 90% of these being type 2 (2). This translates to 209,015 people living with diabetes, and an estimated 580,000 more at risk of developing it, not only causing a significant human burden but also substantially impacting the healthcare system. Currently, 1 in 6 hospital beds are occupied by someone with diabetes, and this is set to rise to 1 in 4 by 2030 (5). In addition to the human burden, estimates suggest that the direct cost to the NHS is approximately £10.7 billion each year (2021/2022 figures), covering treatment, diagnosis, and complications associated with the disease (6). Additionally, indirect costs, such as work loss and decreased productivity, are also considerable, amounting to roughly £3.3 billion(6). Therefore, enhancing pre-diabetes surveillance is vital to effectively implement diabetes prevention policies and interventions(7). The growing body of evidence provides the rationale for identifying those at higher-than-average risk for developing diabetes and providing programmes that intervene to prevent this progression. Diabetes prevention programmes have been around for >10 years, most notably the examples of large-scale international lifestyle modification programmes that have been developed in Finland (FIN D2D implemented in 2000) (8) (9) (10) (11) and the USA (US_DPP implemented in 1996) (12), in an attempt to reduce the rate of diabetes development(13). The focus of the Finland study was on body mass and obesity with designated intervention and control areas. The results showed a statistically significant reduction in mean body weight in the intervention group ( p =0.041), compared to no mean reduction in the control group. For the prevalence of obesity, both areas showed a reduction, but neither area showed a reduction in morbid obesity prevalence. The US-DPP study considered a change in lifestyle within one group, the addition of metformin in another group, and a placebo in the third group. At the 10-year follow-up, the cumulative incidence of diabetes remained lowest in the lifestyle group. In England, the Healthier You Diabetes Prevention Programme (DPP) was established in 2016 and rolled out nationally by 2020(14). As part of this initiative the Let's Prevent Diabetes Programme was established(15). This consisted of a 6-hour structured group education session, with 3-hour refresher sessions at 12 and 24 months after the initial session (15). Whilst no statistically significant change was seen between the groups as a whole, most substantial changes were observed in 29.1% of patients assigned to the intervention group who attended all the sessions (16) suggesting that long-term engagement with DPP produces the best results. The study found that those less likely to engage or attend follow-up were male, smokers, socioeconomically deprived, or physically inactive. Until recently (2022), Wales lacked a nationwide, standardised support programme for individuals with pre-diabetes. Clinical data from 2 Welsh Diabetes Prevention Pilot Programmes in two primary care clusters (North Ceredigion and Afan Valley), suggested that there was a decrease in average blood glucose levels (HbA1c), for those receiving the brief intervention, at their 12-month follow-up appointments (17). These results together with other similar evaluations strongly support the notion that DPPs could play a pivotal role in combating the rising epidemic of type 2 diabetes globally as well as within Wales. The focus of these studies, however, is on the clinical data rather than the experiences, enablers and barriers described by service users. The aim of our study was to undertake a formative evaluation, exploring the views of adults enrolled in the two prevention programmes currently being run within one Welsh health board (Cwm Taf Morgannwg University Health Board (CTM UHB)). This included barriers and facilitators to accessing the appointments, attending appointments, and interacting with a Health Care Support Worker (HCSW), changes in behaviour following their appointment, their engagement with any signposted supplementary services after the appointment, such as weight management services, and the 12-month follow-up appointment. (Details of the differences between the two approached to the DPP being delivered can be found in Additional file 1). Methods This formative evaluation was informed by the Capability, Opportunity, Motivation and Behaviour (COM-B) model, to evaluate the experiences of the diabetes prevention programmes in Cwm Taf Morgannwg University Health Board (CTM UHB). A qualitative approach was taken as it best captures participants’ accounts of their experiences regarding the Diabetes Prevention programme and the way in which they attribute meaning to their health behaviours (18). Different dimensions of experience including access to service, interactions with HCSW and behaviour change were explored and mapped against the capability, opportunity and motivation elements of the Behaviour Change Wheel (Figure 1) (31). Ethics This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from Cardiff Metropolitan University Healthcare and Food Ethics committee. Project Reference Number: Sta-8994. The study was also registered as a service evaluation with the Cwm Taf Morgannwg University Health Board Research & Development Department. Project reference number: CTM/1994/24. Sampling and recruitment The recruitment target was for four focus group discussions (two groups for each programme) to be conducted with approximately 30-40 participants divided into groups of about 6-8 participants. In total, 39 patients expressed interest in taking part but due to illness or lack of availability 27 participants were recruited. Recruitment and sampling The recruitment was conducted at the Cwm Taf Morgannwg University Health Board Dietetics Department. Participants were aged over 18 years old who received a pre-diabetes diagnosis and had undergone or were invited to an initial pre-diabetes appointment with a Health Care Support Worker (HCSW). In line with indicator of heterogeneity (19) to enhance credibility in qualitative research (1), we employed a heterogeneous purposive sampling approach to achieve a maximum-variety sample (age, socioeconomic status) and to gain a holistic understanding of the experiences by revealing shared patterns and themes that cut across cases. Recruitment of participants was supported by gatekeepers from the CTM UHB Dietetics Team, i.e., lead dietitians and HCSW. Both electronic and paper versions of the invitation, which contained participant information sheet for the study, were distributed through the gatekeepers. In addition, non-attenders who did not attend their initial pre-diabetes appointment were targeted by sending further study invitations offering a telephone interview. Eleven of those patients who were invited to take part in the study did not participate due to lack of availability for the focus groups (6 patients) or lack of response (5 patients). A £10 voucher incentive was offered to each participant in the study. Data collection methods Data was collected through focus group discussions and individual interviews capturing data from individuals enrolled on two types of implementations of the All-Wales Diabetes Prevention Programme. The data was collected between January 2024 – March 2024. We used a semi-structured interview guide covering a range of issues around experiences of the intervention programmes and prompts to elicit discussion among the participants. The discussions were guided by the exploration of experiences around the following thematic areas: accessing and attending appointments; interactions with HCSW; post-intervention behaviour change such as increased physical activity and dietary management; signposting to and engagement with support services. The interview guide was co-created by an interdisciplinary team of researchers, dietitians and public health practitioners and was piloted with a group of three patients. To compensate for the limitations or shortfalls of focus groups (20, 21), we invited a sample of up to 5 patients to participate in individual interviews. These included patients who did not engage with supplementary services after their initial appointment (particularly weight management services), who did not have a significant reduction in their HbA1c levels tested after 12 months, were invited by CTM UHB staff at their 12-months follow-up appointment. The interviews took place on-line or on the telephone depending on the accessibility of the patients and lasted roughly 30 minutes. Informed consent was obtained, in-person or online, from each participant prior to participation in the interviews. The interviews were audio-recorded and transferred to a password protected, secure university database for transcribing and analysis. Data analysis A pragmatic approach was applied to answer the research questions that informed the formative service evaluation of the diabetes prevention programme. The analysis was guided by the COM-B model (22). The data was analysed using Braun and Clarke’s six-phased reflexive thematic analysis: data familiarisation; coding; theming; reviewing themes; defining and naming themes; and producing the report (23). Anonymised data were transcribed verbatim. These transcripts were imported into NVivo (QSR International, version 12). A six-step approach to thematic analysis was performed: data familiarisation, coding of the dataset (into nodes in NVivo), identification of nodes, review and revision of nodes, interpretation of patterns across nodes and generation of emerging themes and subthemes. Two researchers (FV and ZS) independently coded the data set and then compared their coding. At each stage of the process, discussion among three team members (TT, FV and ZS) resolved any discrepancies to produce an analysis of the barriers and engagement to behaviour change and engagement in the All Wales Diabetes Prevention Programme (AWDPP). The results presented in the form of themes were described using illustrative quotes from participants. The three researchers (TT, FV and ZS) then discussed and refined each theme and subtheme and classified into the coding framework which comprised of 3 main organising themes and six subcomponents of the COM-B model (Figure 1). The themes and subthemes were mapped out according to the components of the COM-B model. Results Twenty-seven participants took part in the study (mean age = 65 years, range 47-75). Participants took part in interviews over the telephone (N = 11) or participated in focus groups in person (N = 16) , according to their choice. Table 1 presents the demographics of participants purposively sampled to participate. There was an uneven distribution across those who had engaged with the DPP (completed, attended or dropped out (n=26)) and those who had not (declined and waiting (n=1)) due to lack of responses from patients who haven’t engaged with the programmes. Table 1 Participant characteristics (N = 27) Average age 65 years old Age range 47-75 Sex 17 female, 10 male Number of months since starting the programme All-Wales Diabetes Prevention Programme (Merthyr, Pyle) 5.5 months (range 1-15) WISE (Aberdare and others) 4.9 months (range 1-12) Results of the mapping exercise highlighted the main themes that revolved around participants’ motivation from the point they knew about the pre-diabetes diagnosis, the support that they received in the diabetes prevention programme and their challenges and the way they implemented sustainable lifestyle changes in their everyday life. Details for these finding can be found in Additional file 2. Two main themes emerged after the iterative process of analysis: Getting to know about the condition and Factors of engagement in the programme. The Factors of engagement theme were mapped out under Capability, ‘physical’ (e.g. physical skills) or ‘psychological’ (e.g. knowledge) ability to perform the behaviour; Opportunity ‘physical’ (e.g. Resources) or ‘social’ (e.g. interpersonal influences) and Motivation, ‘reflective’ (e.g. beliefs about what is good or bad) or ‘automatic’ (e.g. processes involving wants and needs). Table 2 presents the main themes and subthemes grouped under the categories of the COM-B model. Table 2 The main themes and subthemes Themes COM-B area Subthemes Getting to know about the condition – The first reaction Factors of engagement in the programme Capability Psychological Previous knowledge and experience with diabetes Learning about positive lifestyle behaviour Barriers to change Physical Physical ability and previous active lifestyle Opportunity Social Supportive staff Family support Social barriers to making change Physical Health checks and follow-up appointments Programme content and resources Motivation Automatic Unconflicted change The social network Reflective Need for change Taking ownership Getting to know about the condition Participants reported various reactions and life circumstances at the point when they found out about their pre-diabetes. Many participants expressed shock or surprise after receiving the letter while others felt “relief” as suddenly they found the explanation for their ongoing symptoms of “ fatigue, sleepiness or lack of energy” . This first reaction to the diagnosis was likely to influence readiness and motivation to change. Participants often expressed that they would not think that they had elevated blood sugar level until they were diagnosed as such, and they highlighted the importance and the necessity of getting to know about their condition early and to have the DPP available for them. Factors of engagement in the programme (A) Capability Psychological Capabilities Three subthemes were identified as psychological capabilities: Previous knowledge and experience with diabetes, learning about positive lifestyle behaviour and barriers to change. Previous knowledge and experience with diabetes influenced participants' perception of the pre-diabetes diagnosis that had an extended effect on their readiness to engage with the programme. Those participants who had an insight in the prognosis and life of people with diabetes, for example in their family or while working in healthcare setting, reported that after receiving the letter about the pre-diabetes diagnosis they wanted to take actions straight away to avoid diabetes. But for me, like I said, because I was a nurse and worked with people with diabetes and I know that the difficulties that you can have, you know the illnesses, it's definitely changed, changed my lifestyle. And because they said by next year, I could be possibly type 2 diabetes, and I didn't want to go down that road. (Telephone Interview, Female participant, 47 years old, WISE programme) Others had little knowledge about the diabetes and its consequences before their initial appointment and most of them had difficulty to understand the different ways of measuring blood sugar levels. Like until you're actually have it, you don't really know anything about it. That sounds ignorant, I suppose, but yeah. You hear of type 1 and Type 2. And until it actually comes to your door, you don't really look any further, don't you? Until it affects you personally. (Focus group, Female participant, 60 years old, Merthyr) Learning about positive lifestyle behaviour helped participants take actions towards implementing changes in their eating and exercise habits. The new knowledge about healthy eating gained during the first meeting with the Healthcare Support Worker (HCSW) or the Lifestyle Coach or the Foodwise programme, enabled them to make healthier choices. Younger and middle-aged participants often reported that they took on the opportunity of Exercise Referral and started to go to the gym or joined an exercise class. Internet was often reported as a source of information through credible resources, like the NHS or Diabetes UK website but some participants reported using Instagram or other non-evidence-based resources as well. Overall, participants felt that their knowledge improved after engaging with the programme. For most, eating habits was the first thing to change by becoming more aware of the different food groups, portion sizes, meal planning guided by the Eatwell visual guide, or the surprising sugar content of processed foods. Some of the following examples demonstrate how participants become more aware about the content of their meals: I never really looked at the sugar content of anything. I always looked at the calorie counts. My go-to was like a skinny whip or something like that and they’re quite high in sugar….. So, it's sort of like changing your mindset. (Telephone interview, Male participant, 53 years old, WISE programme) The useful advice given to them at the first meeting and on the Foodwise sessions enabled them to take small achievable steps making a difference to their perception of the “sacrifices” they had to take, for example one of the older women participants said: You know, I'm 70 years of age, don’t want to go on a diet, and she [HCSW] said, well, no, it's not like that really. And I can see that I can still have most of the things I like, yeah, I just gotta be sensible in how much I put on my plate. (Telephone interview, Male participant, 70 years old, Pyle) Barriers to change , especially resistance and circumstances, hindered participants' ability to engage with the programme and follow the recommendations. For example, an older male participant reported being retired and the enjoyment of eating made it difficult for him to make changes in their eating habits. We're retired, you know, we've got you fill the day by doing the things you enjoy. For me, those seem to involve food. So that's always a challenge. And we're in our 60s, we've eaten this way for 60 years, to suddenly change is quite difficult, you know, brought up by parents who went through the war, who you can't leave anything on your plate because it's waste. As I say, a lifetime of wrong habits. (Focus group, Female participant, 62 years old, Pyle) Physical Capabilities Co-morbidities such as heart conditions, arthritis and mental health problems hold some participants back from attending appointments and making healthier choices in eating and activities. Because of my arthritis. If I walk, I'm in pain. The flare up doesn't help. It's like Pilates, I tried and the next day I was in pain, you know? So, I just want to find something that I can do. (Focus group, Female participant, 63 years old, Pyle) Physical ability and previous active lifestyle , on the other hand, was a key enabler for engaging the exercise referral programme or increasing the physical activity level. Also, some participants reported improvement in their physical abilities since they have lost weight which helped them to gain confidence and adhere to exercise. (B) Opportunities Social Opportunities The social influences of programme uptake and lifestyle changes were the supportive staff members, the family and social circles of participants. Supportive staff were a prominent subtheme as all participants reported positive relationships and felt the support and compassion, they received from the HCSWs, or life coaches, had a positive impact on their motivation. The relaxed approach, non-judgemental attitude, empathy, tailored advice and practical tips were some of the most often mentioned facilitators within the programmes that enabled participants to learn and implement healthier habits. Participants valued the expertise and honesty of support staff, who acted as role models and provided informed guidance and practical advice tailored to individual needs. Participants agreed that “it doesn’t have to be your GP” who talked to them about their pre- diabetes status and lifestyle behaviour but a knowledgeable and supportive healthcare practitioner. He’s [lifestyle coach] good in a way that he directs because he does it without me realising that he's actually influencing me. Because I was eating the right foods, was just eating too much. I mean, and he, he suddenly sort of said, well, how much when you have fruit and nuts on your cereal, how much do you have? (Focus group, Aberdare, Male participant, 53 years old, WISE programme) Participants’ experiences during the consultation(s) depicted the nonjudgemental and compassionate communication style of the staff members that fostered trust, enabling participants to feel comfortable discussing their health concerns, feeling responsible for their own health. Oh, she was lovely. She was really helpful. Really easy-going, down to Earth. Didn't sort of push anything on who just went through everything with you. (Telephone interview, Female participant, 75 years old, Wise programme) The two-way dialogic nature of the interactions between the participants and the HCSWs, rather than a monologic approach, further strengthened the trust between the HCSWs and the participants. Family support was another important domain that facilitated lifestyle change. Close family members who had a direct influence on behaviour change were critical to help participants maintain healthier portion control or reduced sugar level. For example, some participants attended the Foodwise programme together with their spouse who could then modify the content of home-cooked meals or motivate them if they were struggling with mental health problems. He was pleased that I was going to make changes that would not only affect me but affect him as well. And we do. We've cut down on portion size. You know, when there are two of you together. It it's quite nice. (Focus group, Male participant, 63 years old, Pyle) Gentle nudge, encouragement or reinforcement of achievements received from relatives and friends were also facilitators to keep up with regular exercise. Social influences from the wider community around the participants acted as barriers for some participants. They shared challenges in social situations, for example when eating out or at work, to say no to temptations or choose healthy options from the menu. One of the ladies who I work…loves to bake cakes and baked Welsh cakes yesterday. And even though I've said to them, you know, I'm trying to lose weight, they said “Just that corner one, you'll be fine…” She was practically literally trying to force it down. Oh, how can I say not so? It's so difficult and I did. I gave in. (Telephone interview, Female participant, 63 years old, Pyle) Physical Opportunities The health checks, follow-up appointments and programme content and resources were important components that facilitated engagement . Health checks and follow-up appointments were highlighted as important facilitators to ‘ keep on track’ with lifestyle changes, Participants, engaged with the WISE programme, expressed the view that such checks, including annual blood tests and frequent consultations with health care support workers (HCSWs), are crucial for staying informed about their health status. Participants, engaged in the other type of prevention programme, who didn’t have opportunity for regular meetings identified a need for more frequent interactions, at least blood test twice a year, to prevent health deterioration and to keep themselves accountable. Participants also suggested integration of self-administered health checks that they could complete at home. Programme content and resources were found appropriate with the right level of information and practical advice that had positive impact on participants and helped them take a proactive approach to manage their health. And I’ve learned a lot from it, you know. Things creep up on you in life, and you don’t even realise it. It’s been an eye-opener for me and I welcome anything that will help me, and to control it and keep it under level. (Focus group, Female participant, 71 years old, Aberdare) Participants valued the tailored recommendations, such as portion control tips, dietary adjustments and fitting more physical activity within the busy schedule. The Foodwise programme and additional cooking course with visual aids, such as the Eatwell plate and food models, provided interactive learning experiences and better understanding of the impact and importance of implementing healthy eating habits. Participants highlighted the value of peer learning experiences during group programmes, suggesting that interactions with fellow participants contribute to their understanding and motivation. The information was brilliant, really good. I read it all, still have the thing [Eatwell Plate] on my fridge. It was all very informative and clear. (Focus group, Female participant, 63 years old, Pyle) The Exercise referral scheme was only taken up by those who had confidence in their physical ability and found an exercise offer that suited their preference. The reasons why participants did not engage with the scheme were physical disability, dislike of leisure centre environment or group programmes, and preferring flexible time for exercise or outdoor activities. Most participants increased the time spent on walking instead of taking up the exercise referral scheme offer. Some who had other physical or mental health conditions (for example arthritis, cardiovascular disease, depression) expressed a need for tailored programmes that address specific health conditions. The quotes illustrate participants' challenges with finding suitable exercise options within referral programmes. I went to the meeting about [ERS] but they weren't able to offer me something that I knew I would participate in. I knew I wouldn't go to the gym. I have no interest in sitting on a on an exercise bike. And I asked could I you know was there some swimming element or aqua-aerobics. But there was nothing that they could offer me. (Focus group, Female participant, 62 years old, Pyle) The participants mentioned some areas where the programme could be improved, for example, improving the promotion of programmes in the community (for example Foodwise and Exercise Referral), having regular consultations and blood tests, and being able to access support or resources outside of regular hours, indicating a need for flexibility in programme delivery, especially for individuals with mental health problems and comorbidities. Some participants expressed disappointment about the approach how they were informed about the pre-diabetes diagnosis. as it was ‘ shocking’ to them, and they would have preferred a healthcare professional calling them or informing them in person. (C) Motivation while reflective motivation relates to processes of conscious goal setting and evaluation of the potential benefits and consequences of the desired behaviours. Automatic Motivation Automatic motivation and its sub-themes relate to impulses or reflex behaviours determined by external factors that influenced health behaviour. Unconflicted change, drawing on the Conflict Model of Decision Making, this subtheme was identified as the recognition of the risks of progressing from prediabetes to type 2 diabetes if current behaviours were continued and little or no risks of such progression if change was adopted. Participants described many automatic processes that encouraged them to attend appointments and participate in the additional parts of the programmes. I suppose it’s because i really don’t want diabetes 2. I’d rather be eating a healthier diet for a number of reasons. Now I got it, I look at recommended diets….and what's on my plate at any particular time. (Telephone interview, Male participant, 60 years old, Pyle) There were emotional aspects to this motivation. Many of the participants described their reaction to the diagnosis as “shocking” or “surprising”. These reactions ignited the intention for action. The reactions, coupled with the immediate desire for health improvement and the desire for longevity and spending more time with loved ones encouraged the decision to participate in the prevention programmes and adopt healthy behaviours. There was a feeling that not doing so could lead not only to diabetes but also to early separation from loved ones. One study participant described this as: For other participants, receiving the letter about the pre-diabetes diagnosis while felt “relief” as suddenly they found the explanation for their ongoing symptoms of “ fatigue, sleepiness or lack of energy” . Participants often expressed that they would not think that they had elevated blood sugar level until they were diagnosed as such, and they highlighted the importance and the necessity of getting to know about their condition early and to have the DPP available for them. The social network of the participants played an important role in their motivation (or otherwise) to participate in the programmes and subsequent behaviour change. For example, some participants had comorbidities (physical ailments like osteoporosis) that could limit their capabilities for behaviour change in relation to exercise. However, the prevention programmes and a supportive social network particularly the immediate family who engaged in the desired activities served as a positive reinforcement for behaviour change and health improvement. Reflective Motivation Need for change was identified due to the diagnosis of being at risk of developing type 2 diabetes having evoked reflexivity among the participants. It made them think about their current situation and what could be done to effect changes and achieve positive outcomes. The programme enhanced these reflective processes and led to the desire and the decisions to change behaviour. This underscores the benefits of diabetes prevention through identifying raised blood glucose and engagement in diabetes prevention programmes. So, you know, the programme has made me having that discussion as maybe kick started me and I thought no, come on now, you know. Yeah, you need to make changes now. (Telephone interview, Male participant, 61 years old, Pyle) Some of the participants said that they used to engage in physical activity. However, they were physically inactive at the time of the diagnosis. As they reflected on this, they became cognisant of the need to change and therefore determined to revert to their previous active lifestyle. I made my mind up to do something about it, I didn’t wanna take medication or anything, and I've always trained but gone through a period when I wasn't training, be back to training and cutting out… I was overweight, I wasn't training and, you know, made me realise I needed to go back to where I was. (Telephone interview, Male participant, 60 years old, Pyle) Taking ownership was expressed by many participants. They believed that the prevention of diabetes was their personal responsibility, and they should take ownership of the responsibility. The lifestyle changes associated with the diagnosis were described by participants as challenging (for example, abstaining from behaviours they had engaged in for decades) and having a significant impact on their views about life. Being honest with themselves and accepting their responsibility positively influenced readiness and proactivity to engage with the programme following the pre-diabetes diagnosis. The engagement with the healthcare team was important in promoting the sense of taking ownership and responsibility for action. When initially contacted, some participants felt ‘cynical’ about the programmes, considering them as some meaningless ‘tick box exercises’ and had no desire to participate. However, through engagement with the team: My mind was changed completely…I started to lose weight, and started to, improve and feel better, and I'm now actually reducing medication I've been on for 20 years because of the improvements. So yes, I think we've [participant and the lifestyle coach] done a cracking job. (Focus group, Male participant, 69 years old, Aberdare) In describing how the healthcare team contributed to enhancing the sense of ownership and responsibility and eventually the decision to take action, a participant says: When she spoke to, strangely enough, after she's spoken to me and we had a good chat about things, I came out of there and I decided I have got to do something and I'm going to do something about it. (Focus group, Female, 62 years old, Pyle) This finding, i.e. taking ownership, highlights the importance of knowing one’s status and being equipped with the required knowledge and skills could contribute to enabling individuals to have control over their lives and prevent the progression to diabetes. Discussion Participants described how the above factors influenced their ability to implement lasting changes in long-standing habits. The most reported health behaviour changes involving dietary adjustments, such as reducing sugar and carbohydrate intake, controlling portion sizes, cutting down on snacks, eliminating sugar in hot drinks, making healthier menu choices when dining out, avoiding bakery shops, and limiting the availability of sweets at home. Additionally, many participants increased their physical activity by incorporating regular exercise or walking into their routines. While some found it challenging to make sudden changes in all unhealthy eating habits or maintain consistent exercise throughout the year, most were able to achieve sustained improvements in certain areas of their health behaviours. These positive changes were supported by consultations, personalised practical advice from HCSWs and Lifestyle Advisors, or participation in the Foodwise course. Overall, the participants were empowered by the easily understandable information given to them, the small achievable targets and the nonjudgemental compassionate communication style of the healthcare professionals. Similarly to Jokar's study( 24 ), our findings highlight the importance of a multilevel approach in addressing barriers to self-care in individuals with pre-diabetes. This supports our suggestion that interventions should not only focus on individuals but also consider broader systemic and social influences to enhance self-care behaviours. Our findings also emphasised the need for healthcare providers to understand patient needs and tailor interventions accordingly. Like Troughton's study ( 15 ), our research suggests that personalised approaches are necessary to influence perceptions and improve engagement in self-care behaviours. In agreement with Twohig ( 13 ), our findings also recognises that while a diagnosis of prediabetes might be a motivating factor, sociocultural and environmental barriers can hinder individuals from making sustained lifestyle changes. Both studies stress the need for supportive environments to facilitate effective engagement with diabetes prevention programmes. This study was not without limitations. The project completion time given was 3 months. Whilst the wider team were instrumental in supporting the recruitment of participants, this short turn-around time did limit the opportunity to recruit a larger sample of service-users. The length of programme engagement time that service-users had from their initial brief intervention to their participation was relatively short. Some participants had not had their follow-up appointment as originally planned. There is the potential for this to impact on the sustained engagement time of participants and therefore not allow any comparison with other national and international DPP publications which report on > 2 years duration. Conclusion Based on the current literature and the qualitative findings presented in this report we summarised a set of recommendations that might improve the current services being offered within the DPPs (Table 3 ). Overall, your findings reinforce the necessity of a comprehensive, patient-centred approach that considers individual, healthcare, and societal influences in improving prediabetes self-care behaviours. Table 3 Recommendations from the literature and the findings of this study Specific recommendations from the literature • Face-to-face diabetes prevention programme with regular contact yields better clinical outcomes; for those with recognised barriers, consider regular online resources and contact. • To help manage costs associated with face-to-face contact, consider mentorship with diabetes volunteers with lived experience to help run sessions (train the trainer). • Ensure QA measures are in place to confirm equity for all enrolled, consistent success outcomes are generated (e.g. engagement; weight loss; HbA1c) and evaluate cost-effectiveness. General recommendations from the literature • To enhance the translation of diabetes prevention programmes into real-world settings, more comprehensive reporting of programme elements to evaluate their practical value are recommended. • Detailed reporting on the four key PIPE Matric Framework components (Penetration, Implementation, Participation, Effectiveness), can offer valuable insights and promote wider adoption of Type 2 Diabetes prevention programmes. • Standardising outcome reporting and criteria for translational diabetes prevention programmes in real-world settings can improve consistency and comparability across Wales. Specific recommendations from the qualitative findings • To improve and monitor the methods of signposting to supplementary services and to promote these services more broadly in order to enable all patients being informed about these supplementary services (for example, Foodwise, cooking course, Exercise referral scheme group activities). • To offer more regular consultations in person, online or over the phone and facilitate self-monitoring of weight, diet, exercise via apps or in paper depending on patients’ needs/preferences. • To offer blood tests at six months for all patients. • To offer a wider range of options for accessing support or resources outside of regular hours, to provide flexibility for those patients who have barriers to engage with components of the programme. • To offer more personalized guidance within the programme for those who have mental health or other long-term health conditions. • To allow and recommend patients to involve their trusted family members or friends when they access the services or implementing lifestyle changes in a way that suits their needs (for instance, attend Foodwise course together, exercise or cook together, etc). • To incorporate more elements of peer support within the programme through group components and volunteers with lived experiences. Abbreviations HbA1c - glycated haemoglobin COM-B model - Capability, Opportunity, Motivation and Behaviour model CTM UHB – Cwm Taff Morgannwg University Health Board FIN-D2D – Diabetes Prevention Program in Finland US-DPP study – US Diabetes Prevention Program DPP – Diabetes Prevention Program HCSW - Health Care Support Worker AWDPP - All Wales Diabetes Prevention Programme Declarations Ethics: Ethical approval was obtained from Cardiff Metropolitan University Healthcare and Food Ethics committee. Project Reference Number: Sta-8994. The study was also registered as a service evaluation with the Cwm Taf Morgannwg University Health Board Research & Development Department. Project reference number: CTM/1994/24. Consent for publication: All participants were asked to complete a written consent form before taking part in this study. This included consent to use anonymous quotes for publication purposes. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests Funding: The funding for this study was secured through Cwm Taff Morgannwg University Health Board Service Enhancement Department’s competitive tendering process. Authors' contributions: JL carried out the literature synthesis, analysed the data and contributed to writing this paper. TT contributed to thematic analysis of the qualitative data and to the writing of this paper. SZ contributed to participant recruitment, focus group data collection, thematic analysis of the qualitative, data and the writing of this paper. Acknowledgements: The researchers wish to express their sincere gratitude to the CTM UHB team for their invaluable support in participant recruitment and for providing appropriate facilities for the focus group interviews. 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Hex N, MacDonald R, Pocock J, Uzdzinska B, Taylor M, Atkin M, et al. Estimation of the direct health and indirect societal costs of diabetes in the UK using a cost of illness model. Diabet Med. 2024;41(9):e15326. Rooney MR, Fang M, Ogurtsova K, Ozkan B, Echouffo-Tcheugui JB, Boyko EJ, et al. Global Prevalence of Prediabetes. Diabetes Care. 2023;46(7):1388-94. Saaristo T, Peltonen M, Keinänen-Kiukaanniemi S, Vanhala M, Saltevo J, Niskanen L, et al. National type 2 diabetes prevention programme in Finland: FIN-D2D. Int J Circumpolar Health. 2007;66(2):101-12. Wikström K, Lindström J, Tuomilehto J, Saaristo TE, Helakorpi S, Korpi-Hyövälti E, et al. National diabetes prevention program (DEHKO): awareness and self-reported lifestyle changes in Finnish middle-aged population. Public Health. 2015;129(3):210-7. Tuomilehto J, Uusitupa M, Gregg EW, Lindström J. Type 2 Diabetes Prevention Programs—From Proof-of-Concept Trials to National Intervention and Beyond. Journal of Clinical Medicine. 2023;12(5):1876. Salopuro TM, Saaristo T, Oksa H, Puolijoki H, Vanhala M, Ebeling T, et al. Population-level effects of the national diabetes prevention programme (FIN-D2D) on the body weight, the waist circumference, and the prevalence of obesity. BMC Public Health. 2011;11:350. Knowler WC, Fowler SE, Hamman RF, Christophi CA, Hoffman HJ, Brenneman AT, et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet. 2009;374(9702):1677-86. Twohig H, Hodges V, Mitchell C. Pre-diabetes: opportunity or overdiagnosis? Br J Gen Pract. 2018;68(669):172-3. Torjesen I. NHS England rolls out world’s first national diabetes prevention programme. BMJ. 2016;352:i1669. Gray LJ, Troughton J, Khunti K, Davies MJ. Let's Prevent Diabetes: from idea to implementation. Practical Diabetes. 2017;34(2):55-7. Twohig H, Hodges V, Mitchell C. Pre-diabetes: opportunity or overdiagnosis? British Journal of General Practice. 2018;68(669):172-3. Thatcher R, Gregory N, Cheung WY, Dunseath GJ, Parsons SN, Goodwin M, et al. Brief lifestyle interventions for prediabetes in primary care: a service evaluation. BMC Prim Care. 2022;23(1):45. Joshi H. Social Research Methods (4th Edition) by Alan Bryman, Oxford University Press, New Delhi, 2012, Pages 766, Price Rs. 825. New Delhi: Foundation for Organizational Research and Education (FORE); 2015. p. 77. Burke MJ, Hoppe EJ. Qualitative Literacy: A Guide to Evaluating Ethnographic and Interview Research: By Mario Luis Small and Jessica McCrory Calarco. Oakland, CA: University of California Press, 2022, 240 pp., $85.00 (hardcover), $24.95 (paperback), ISBN: 9780520390669. Washington: Routledge; 2024. p. 67-8. Belzile JA, Öberg G. Where to begin? Grappling with how to use participant interaction in focus group design. Qualitative Research. 2012;12(4):459-72. Kidd PS, Parshall MB. Getting the Focus and the Group: Enhancing Analytical Rigor in Focus Group Research. Qualitative Health Research. 2000;10(3):293-308. Michie S, Whittington C, Hamoudi Z, Zarnani F, Tober G, West R. Identification of behaviour change techniques to reduce excessive alcohol consumption. Addiction. 2012;107(8):1431-40. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative research in sport, exercise and health. 2019;11(4):589-97. Jokar M, Zandi M, Ebadi A, Momenan AA, Rostamkhani M. Barriers and facilitators of self-care in adults with pre-diabetes: a directed qualitative content analysis. BMC Health Services Research. 2025;25(1):332. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1Commonalitiesanddifferencesbetweentwoapproach.docx Additionalfile2FocusandInterviewSchedule.docx Additionalfile3MapofthemesandsubthemesguidedbytheCOMBmode.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7046125","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":491541732,"identity":"84a03403-3705-46f3-8bfe-1a3a29511f48","order_by":0,"name":"Jane EA Lewis","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYBACxgYGxgMMDBIM/CAej4EcP1xKArcWBrAWyQawFmMgzYxfCwgcABEGIJKHgQgtzO3NDw58bLOwNz5++NmHNwUGErrt/QcYftQwJM5swOGwnmMGB2e2SSRuO5NmPHOOgYGE2ZnDIFGGxNm4/DIjweAw7zaJBLMbDMbMPAZ/6sxuJDMw8DYwJM7DpWX+8w+H/26TsDeewf4ZqAVoy/3HDIx/8WmZwWNwmHGbBOMGCR5jiJYbzAzMIFtwOqwnp+Bg7z+JxBlncooZIX5JNjgsc0zCGJf3DduPb3zw40ydPX/78c0Mb/4AtRw/+PDhmxob2RkHcGjBatQBfBEpj1NmFIyCUTAKRgEMAACplVwKo+1sKwAAAABJRU5ErkJggg==","orcid":"","institution":"Cardiff Metropolitan University","correspondingAuthor":true,"prefix":"","firstName":"Jane","middleName":"EA","lastName":"Lewis","suffix":""},{"id":491541736,"identity":"53086f86-3dee-4940-b443-75c26fe5d2ce","order_by":1,"name":"Tahir Touray","email":"","orcid":"","institution":"Cardiff Metropolitan University","correspondingAuthor":false,"prefix":"","firstName":"Tahir","middleName":"","lastName":"Touray","suffix":""},{"id":491541738,"identity":"08dc3243-69c8-4018-ab6e-17dc98763e64","order_by":2,"name":"Zsofia Szekeres","email":"","orcid":"","institution":"Cardiff Metropolitan University","correspondingAuthor":false,"prefix":"","firstName":"Zsofia","middleName":"","lastName":"Szekeres","suffix":""}],"badges":[],"createdAt":"2025-07-04 11:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7046125/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7046125/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87818164,"identity":"14d1ecdd-d4ff-460c-a6af-de2378e917ec","added_by":"auto","created_at":"2025-07-29 10:29:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":346631,"visible":true,"origin":"","legend":"\u003cp\u003eThe Behaviour Change Wheel framework - Reproduced with permission from Michie et al, 2012\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7046125/v1/43e3556780a44edaea32eae5.png"},{"id":90571420,"identity":"cf94813f-789e-40c5-aaaf-76eaf1d5c9ed","added_by":"auto","created_at":"2025-09-04 08:32:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1167273,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7046125/v1/b500a58d-e586-46a3-83f2-d77f0dc6c3aa.pdf"},{"id":87817137,"identity":"49dc7dc1-eb55-4dc5-b23a-b1a7d49042ac","added_by":"auto","created_at":"2025-07-29 10:21:35","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25151,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1Commonalitiesanddifferencesbetweentwoapproach.docx","url":"https://assets-eu.researchsquare.com/files/rs-7046125/v1/201da8a67d66e2e8b9a6e758.docx"},{"id":87817135,"identity":"08a7e28d-b7c6-42bc-ab6b-57e73b9319ce","added_by":"auto","created_at":"2025-07-29 10:21:35","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":28274,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2FocusandInterviewSchedule.docx","url":"https://assets-eu.researchsquare.com/files/rs-7046125/v1/fcba3793d27c38392e2dd2ec.docx"},{"id":87818725,"identity":"444e18bf-a0e8-4f39-b382-fe732ef5abbe","added_by":"auto","created_at":"2025-07-29 10:37:35","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":161325,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3MapofthemesandsubthemesguidedbytheCOMBmode.docx","url":"https://assets-eu.researchsquare.com/files/rs-7046125/v1/551cdd2afc1173ed8763af95.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Insight to Action: Using the COM-B Model to Explore Behaviour Determinants in Pre-Diabetes Programs","fulltext":[{"header":"Background","content":"\u003cp\u003eIt has been well documented that the global burden of diabetes and prediabetes is substantial and growing(1).\u0026nbsp;Diabetes UK\u0026nbsp;(2), describes a \u0026lsquo;diabetes crisis\u0026rsquo; here in the UK with the number of those living with diabetes, hitting an all-time high of 5 million, with 1 in 3 of those having pre-diabetes\u0026nbsp;(3). \u0026nbsp;Wales has been reported as having the highest prevalence of diabetes in the UK\u0026nbsp;(4), equating to 1 in 13 (8%) of its population being diagnosed with this chronic disease, with over 90% of these being type 2\u0026nbsp;(2). This translates to 209,015 people living with diabetes, and an estimated 580,000 more at risk of developing it, not only causing a significant human burden but also substantially impacting the healthcare system. \u0026nbsp;Currently, 1 in 6 hospital beds are occupied by someone with diabetes, and this is set to rise to 1 in 4 by 2030\u0026nbsp;(5). \u0026nbsp;In addition to the human burden, estimates suggest that the direct cost to the NHS is approximately \u0026pound;10.7 billion each year (2021/2022 figures), covering treatment, diagnosis, and complications associated with the disease\u0026nbsp;(6). \u0026nbsp;Additionally, indirect costs, such as work loss and decreased productivity, are also considerable, amounting to roughly \u0026pound;3.3 billion(6). Therefore, enhancing pre-diabetes surveillance is vital to effectively implement diabetes prevention policies and interventions(7). \u0026nbsp;The growing body of evidence provides the rationale for identifying those at higher-than-average risk for developing diabetes and providing programmes that intervene to prevent this progression.\u003c/p\u003e\n\u003cp\u003eDiabetes prevention programmes have been around for \u0026gt;10 years, most notably the examples of large-scale international lifestyle modification programmes that have been developed in Finland (FIN D2D implemented in 2000) (8) (9) (10) (11) and the USA (US_DPP implemented in 1996) (12), in an attempt to reduce the rate of diabetes development(13). \u0026nbsp;The focus of the Finland study was on body mass and obesity with designated intervention and control areas. \u0026nbsp;The results showed a statistically significant reduction in mean body weight in the intervention group (\u003cem\u003ep\u003c/em\u003e=0.041), compared to no mean reduction in the control group. \u0026nbsp;For the prevalence of obesity, both areas showed a reduction, but neither area showed a reduction in morbid obesity prevalence. \u0026nbsp;The US-DPP study considered a change in lifestyle within one group, the addition of metformin in another group, and a placebo in the third group. At the 10-year follow-up, the cumulative incidence of diabetes remained lowest in the lifestyle group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn England, the \u003cem\u003eHealthier You\u003c/em\u003e Diabetes Prevention Programme (DPP) was established in 2016 and rolled out nationally by 2020(14). \u0026nbsp;As part of this initiative the \u003cem\u003eLet\u0026apos;s Prevent Diabetes\u003c/em\u003e Programme was established(15). \u0026nbsp;This consisted of a 6-hour structured group education session, with 3-hour refresher sessions at 12 and 24 months after the initial session (15). Whilst no statistically significant change was seen between the groups as a whole, most substantial changes were observed in 29.1% of patients assigned to the intervention group who attended all the sessions (16) suggesting that long-term engagement with DPP produces the best results. \u0026nbsp; The study found that those \u003cem\u003eless\u003c/em\u003e likely to engage or attend follow-up were male, smokers, socioeconomically deprived, or physically inactive. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUntil recently (2022), Wales lacked a nationwide, standardised support programme for individuals with pre-diabetes. \u0026nbsp;Clinical data from 2 Welsh Diabetes Prevention Pilot Programmes in two primary care clusters \u0026nbsp;(North Ceredigion and Afan Valley), suggested that there was a decrease in average blood glucose levels (HbA1c), for those receiving the brief intervention, at their 12-month follow-up appointments (17). \u0026nbsp; These results together with other similar evaluations strongly support the notion that DPPs could play a pivotal role in combating the rising epidemic of type 2 diabetes globally as well as within Wales. \u0026nbsp;The focus of these studies, however, is on the clinical data rather than the experiences, enablers and barriers described by service users.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe aim of our study was to undertake a formative evaluation, exploring the views of adults enrolled in the two prevention programmes currently being run within one Welsh health board (Cwm Taf Morgannwg University Health Board (CTM UHB)). This included barriers and facilitators to accessing the appointments, attending appointments, and interacting with a Health Care Support Worker (HCSW), changes in behaviour following their appointment, their engagement with any signposted supplementary services after the appointment, such as weight management services, and the 12-month follow-up appointment. (Details of the differences between the two approached to the DPP being delivered can be found in Additional file 1).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis formative evaluation was informed by the Capability, Opportunity, Motivation and Behaviour (COM-B) model, to evaluate the experiences of the diabetes prevention programmes in Cwm Taf Morgannwg University Health Board (CTM UHB). A qualitative approach was taken as it best captures participants\u0026rsquo; accounts of their experiences regarding the Diabetes Prevention programme and the way in which they attribute meaning to their health behaviours (18). Different dimensions of experience including access to service, interactions with HCSW and behaviour change were explored and mapped against the capability, opportunity and motivation elements of the Behaviour Change Wheel (Figure 1) (31).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from Cardiff Metropolitan University Healthcare and Food Ethics committee. Project Reference Number: Sta-8994. The study was also registered as a service evaluation with the Cwm Taf Morgannwg University Health Board Research \u0026amp; Development Department. Project reference number: CTM/1994/24.\u003c/p\u003e\n\n\u003cp id=\"_Toc165935252\"\u003e\u003cstrong\u003eSampling and recruitment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe recruitment target was for four focus group discussions (two groups for each programme) to be conducted with approximately 30-40 participants divided into groups of about 6-8 participants. In total, 39 patients expressed interest in taking part but due to illness or lack of availability 27 participants were recruited. \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eRecruitment and sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe recruitment was conducted at the Cwm Taf Morgannwg University Health Board Dietetics Department. Participants were aged over 18 years old who received a pre-diabetes diagnosis and had undergone or were invited to an initial pre-diabetes appointment with a Health Care Support Worker (HCSW). In line with indicator of heterogeneity (19) to enhance credibility in qualitative research (1), we employed a heterogeneous purposive sampling approach to achieve a maximum-variety sample (age, socioeconomic status) and to gain a holistic understanding of the experiences by revealing shared patterns and themes that cut across cases. Recruitment of participants was supported by gatekeepers from the CTM UHB Dietetics Team, i.e., lead dietitians and HCSW. Both electronic and paper versions of the invitation, which contained participant information sheet for the study, were distributed through the gatekeepers. In addition, non-attenders who did not attend their initial pre-diabetes appointment were targeted by sending further study invitations offering a telephone interview. Eleven of those patients who were invited to take part in the study did not participate due to lack of availability for the focus groups (6 patients) or lack of response (5 patients). A \u0026pound;10 voucher incentive was offered to each participant in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was collected through focus group discussions and individual interviews capturing data from individuals enrolled on two types of implementations of the All-Wales Diabetes Prevention Programme. The data was collected between January 2024 \u0026ndash; March 2024. We used a semi-structured interview guide covering a range of issues around experiences of the intervention programmes and prompts to elicit discussion among the participants. The discussions were guided by the exploration of experiences around the following thematic areas: accessing and attending appointments; interactions with HCSW; post-intervention behaviour change such as increased physical activity and dietary management; signposting to and engagement with support services. The interview guide was co-created by an interdisciplinary team of researchers, dietitians and public health practitioners and was piloted with a group of three patients.\u003c/p\u003e\n\u003cp\u003eTo compensate for the limitations or shortfalls of focus groups (20, 21), we invited a sample of up to 5 patients to participate in individual interviews. These included patients who did not engage with supplementary services after their initial appointment (particularly weight management services), who did not have a significant reduction in their HbA1c levels tested after 12 months, were invited by CTM UHB staff at their 12-months follow-up appointment. The interviews took place on-line or on the telephone depending on the accessibility of the patients and lasted roughly 30 minutes. Informed consent was obtained, in-person or online, from each participant prior to participation in the interviews. The interviews were audio-recorded and transferred to a password protected, secure university database for transcribing and analysis.\u003c/p\u003e\n\n\u003cp id=\"_Toc165935254\"\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA pragmatic approach was applied to answer the research questions that informed the formative service evaluation of the diabetes prevention programme. The analysis was guided by the COM-B model (22). The data was analysed using Braun and Clarke\u0026rsquo;s six-phased reflexive thematic analysis: data familiarisation; coding; theming; reviewing themes; defining and naming themes; and producing the report (23). \u003c/p\u003e\n\u003cp\u003eAnonymised data were transcribed verbatim. These transcripts were imported into NVivo (QSR International, version 12). A six-step approach to thematic analysis was performed: data familiarisation, coding of the dataset (into nodes in NVivo), identification of nodes, review and revision of nodes, interpretation of patterns across nodes and generation of emerging themes and subthemes. Two researchers (FV and ZS) independently coded the data set and then compared their coding. At each stage of the process, discussion among three team members (TT, FV and ZS) resolved any discrepancies to produce an analysis of the barriers and engagement to behaviour change and engagement in the All Wales Diabetes Prevention Programme (AWDPP). The results presented in the form of themes were described using illustrative quotes from participants. The three researchers (TT, FV and ZS) then discussed and refined each theme and subtheme and classified into the coding framework which comprised of 3 main organising themes and six subcomponents of the COM-B model (Figure 1). The themes and subthemes were mapped out according to the components of the COM-B model.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty-seven participants took part in the study (mean age = 65 years, range 47-75). Participants took part in interviews over the telephone \u003cem\u003e(N = 11)\u003c/em\u003e or participated in focus groups in person \u003cem\u003e(N = 16)\u003c/em\u003e, according to their choice. Table 1 presents the demographics of participants purposively sampled to participate. There was an uneven distribution across those who had engaged with the DPP (completed, attended or dropped out (n=26)) and those who had not (declined and waiting (n=1)) due to lack of responses from patients who haven\u0026rsquo;t engaged with the programmes.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eParticipant characteristics (N = 27)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eAverage age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e65 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eAge range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e47-75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e17 female, 10 male\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eNumber of months since starting the programme\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eAll-Wales Diabetes Prevention Programme (Merthyr, Pyle)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e5.5 months (range 1-15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 369px;\"\u003e\n \u003cp\u003eWISE (Aberdare and others)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 264px;\"\u003e\n \u003cp\u003e4.9 months (range 1-12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eResults of the mapping exercise highlighted the main themes that revolved around participants\u0026rsquo; motivation from the point they knew about the pre-diabetes diagnosis, the support that they received in the diabetes prevention programme and their challenges and the way they implemented sustainable lifestyle changes in their everyday life. \u0026nbsp;Details for these finding can be found in Additional file 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo main themes emerged after the iterative process of analysis: Getting to know about the condition and Factors of engagement in the programme. The Factors of engagement theme were mapped out under Capability, \u0026lsquo;physical\u0026rsquo; (e.g. physical skills) or \u0026lsquo;psychological\u0026rsquo; (e.g. knowledge) ability to perform the behaviour; Opportunity \u0026lsquo;physical\u0026rsquo; (e.g. Resources) or \u0026lsquo;social\u0026rsquo; (e.g. interpersonal influences) and Motivation, \u0026lsquo;reflective\u0026rsquo; (e.g. beliefs about what is good or bad) or \u0026lsquo;automatic\u0026rsquo; (e.g. processes involving wants and needs). Table 2 presents the main themes and subthemes grouped under the categories of the COM-B model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eThe main themes and subthemes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOM-B area\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 359px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubthemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 567px;\"\u003e\n \u003cp\u003eGetting to know about the condition \u0026ndash; The first reaction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 567px;\"\u003e\n \u003cp\u003eFactors of engagement in the programme\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCapability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ePsychological\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 359px;\"\u003e\n \u003cp\u003e\u003cem\u003ePrevious knowledge and experience with diabetes Learning about positive lifestyle behaviour\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eBarriers to change\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ePhysical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 359px;\"\u003e\n \u003cp\u003e\u003cem\u003ePhysical ability and previous active lifestyle\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOpportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eSocial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 359px;\"\u003e\n \u003cp\u003e\u003cem\u003eSupportive staff\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eFamily support\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSocial barriers to making change\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003ePhysical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 359px;\"\u003e\n \u003cp\u003e\u003cem\u003eHealth checks and follow-up appointments\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eProgramme content and resources\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMotivation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eAutomatic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 359px;\"\u003e\n \u003cp\u003e\u003cem\u003eUnconflicted change\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eThe social network\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eReflective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 359px;\"\u003e\n \u003cp\u003e\u003cem\u003eNeed for change\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eTaking ownership\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eGetting to know about the condition\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported various reactions and life circumstances at the point when they found out about their pre-diabetes. \u0026nbsp;Many participants expressed shock or surprise after receiving the letter while others felt \u003cem\u003e\u0026ldquo;relief\u0026rdquo;\u0026nbsp;\u003c/em\u003eas suddenly they found the explanation for their ongoing symptoms of \u0026ldquo;\u003cem\u003efatigue, sleepiness or lack of energy\u0026rdquo;\u003c/em\u003e. This first reaction to the diagnosis was likely to influence readiness and motivation to change. Participants often expressed that they would not think that they had elevated blood sugar level until they were diagnosed as such, and they highlighted the importance and the necessity of getting to know about their condition early and to have the DPP available for them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFactors of engagement in the programme\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(A) Capability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePsychological\u0026nbsp;Capabilities\u003c/p\u003e\n\u003cp\u003eThree subthemes were identified as psychological capabilities: Previous knowledge and experience with diabetes, learning about positive lifestyle behaviour and barriers to change.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePrevious knowledge and experience with diabetes\u003c/em\u003e\u003c/strong\u003e influenced participants\u0026apos; perception of the pre-diabetes diagnosis that had an extended effect on their readiness to engage with the programme. Those participants who had an insight in the prognosis and life of people with diabetes, for example in their family or while working in healthcare setting, reported that after receiving the letter about the pre-diabetes diagnosis they wanted to take actions straight away to avoid diabetes.\u003c/p\u003e\n\u003cp\u003eBut for me, like I said, because I was a nurse and worked with people with diabetes and I know that the difficulties that you can have, you know the illnesses, it\u0026apos;s definitely changed, changed my lifestyle. And because they said by next year, I could be possibly type 2 diabetes, and I didn\u0026apos;t want to go down that road. (Telephone Interview, Female participant, 47 years old, WISE programme)\u003c/p\u003e\n\u003cp\u003eOthers had little knowledge about the diabetes and its consequences before their initial appointment and most of them had difficulty to understand the different ways of measuring blood sugar levels.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLike until you\u0026apos;re actually have it, you don\u0026apos;t really know anything about it. That sounds ignorant, I suppose, but yeah. You hear of type 1 and Type 2. And until it actually comes to your door, you don\u0026apos;t really look any further, don\u0026apos;t you? Until it affects you personally. (Focus group, Female participant, 60 years old, Merthyr)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLearning about positive lifestyle behaviour\u003c/em\u003e\u003c/strong\u003e helped participants take actions towards implementing changes in their eating and exercise habits. The new knowledge about healthy eating gained during the first meeting with the Healthcare Support Worker (HCSW) or the Lifestyle Coach or the Foodwise programme, enabled them to make healthier choices. Younger and middle-aged participants often reported that they took on the opportunity of Exercise Referral and started to go to the gym or joined an exercise class. Internet was often reported as a source of information through credible resources, like the NHS or Diabetes UK website but some participants reported using Instagram or other non-evidence-based resources as well. Overall, participants felt that their knowledge improved after engaging with the programme. For most, eating habits was the first thing to change by becoming more aware of the different food groups, portion sizes, meal planning guided by the Eatwell visual guide, or the surprising sugar content of processed foods. Some of the following examples demonstrate how participants become more aware about the content of their meals:\u003c/p\u003e\n\u003cp\u003eI never really looked at the sugar content of anything. I always looked at the calorie counts. My go-to was like a skinny whip or something like that and they\u0026rsquo;re quite high in sugar\u0026hellip;.. So, it\u0026apos;s sort of like changing your mindset. (Telephone interview, Male participant, 53 years old, WISE programme)\u003c/p\u003e\n\u003cp\u003eThe useful advice given to them at the first meeting and on the Foodwise sessions enabled them to take small achievable steps making a difference to their perception of the \u003cem\u003e\u0026ldquo;sacrifices\u0026rdquo;\u003c/em\u003e they had to take, for example one of the older women participants said:\u003c/p\u003e\n\u003cp\u003eYou know, I\u0026apos;m 70 years of age, don\u0026rsquo;t want to go on a diet, and she [HCSW] said, well, no, it\u0026apos;s not like that really. And I can see that I can still have most of the things I like, yeah, I just gotta be sensible in how much I put on my plate. (Telephone interview, Male participant, 70 years old, Pyle)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBarriers to change\u003c/em\u003e\u003c/strong\u003e, especially resistance and circumstances, hindered participants\u0026apos; ability to engage with the programme and follow the recommendations. For example, an older male participant reported being retired and the enjoyment of eating made it difficult for him to make changes in their eating habits.\u003c/p\u003e\n\u003cp\u003eWe\u0026apos;re retired, you know, we\u0026apos;ve got you fill the day by doing the things you enjoy. For me, those seem to involve food. So that\u0026apos;s always a challenge. And we\u0026apos;re in our 60s, we\u0026apos;ve eaten this way for 60 years, to suddenly change is quite difficult, you know, brought up by parents who went through the war, who you can\u0026apos;t leave anything on your plate because it\u0026apos;s waste. As I say, a lifetime of wrong habits. (Focus group, Female participant, 62 years old, Pyle)\u003c/p\u003e\n\u003cp\u003ePhysical Capabilities\u003c/p\u003e\n\u003cp\u003eCo-morbidities such as heart conditions, arthritis and mental health problems hold some participants back from attending appointments and making healthier choices in eating and activities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBecause of my arthritis. If I walk, I\u0026apos;m in pain. The flare up doesn\u0026apos;t help. It\u0026apos;s like Pilates, I tried and the next day I was in pain, you know? So, I just want to find something that I can do. (Focus group, Female participant, 63 years old, Pyle)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePhysical ability and previous active lifestyle\u003c/em\u003e\u003c/strong\u003e, on the other hand, was a key enabler for engaging the exercise referral programme or increasing the physical activity level. Also, some participants reported improvement in their physical abilities since they have lost weight which helped them to gain confidence and adhere to exercise.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(B) Opportunities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSocial Opportunities\u003c/p\u003e\n\u003cp\u003eThe social influences of programme uptake and lifestyle changes were the supportive staff members, the family and social circles of participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSupportive staff\u0026nbsp;\u003c/em\u003e\u003c/strong\u003ewere a prominent subtheme as all participants reported positive relationships and felt the support and compassion, they received from the HCSWs, or life coaches, had a positive impact on their motivation. The relaxed approach, non-judgemental attitude, empathy, tailored advice and practical tips were some of the most often mentioned facilitators within the programmes that enabled participants to learn and implement healthier habits. Participants valued the expertise and honesty of support staff, who acted as role models and provided informed guidance and practical advice tailored to individual needs. Participants agreed that \u003cem\u003e\u0026ldquo;it doesn\u0026rsquo;t have to be your GP\u0026rdquo;\u0026nbsp;\u003c/em\u003ewho talked to them about their pre- diabetes status and lifestyle behaviour but a knowledgeable and supportive healthcare practitioner.\u003c/p\u003e\n\u003cp\u003eHe\u0026rsquo;s [lifestyle coach] good in a way that he directs because he does it without me realising that he\u0026apos;s actually influencing me. Because I was eating the right foods, was just eating too much. I mean, and he, he suddenly sort of said, well, how much when you have fruit and nuts on your cereal, how much do you have? (Focus group, Aberdare, Male participant, 53 years old, WISE programme)\u003c/p\u003e\n\u003cp\u003eParticipants\u0026rsquo; experiences during the consultation(s) depicted the nonjudgemental and compassionate communication style of the staff members that fostered trust, enabling participants to feel comfortable discussing their health concerns, feeling responsible for their own health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOh, she was lovely. She was really helpful. Really easy-going, down to Earth. Didn\u0026apos;t sort of push anything on who just went through everything with you. (Telephone interview, Female participant, 75 years old, Wise programme)\u003c/p\u003e\n\u003cp\u003eThe two-way dialogic nature of the interactions between the participants and the HCSWs, rather than a monologic approach, further strengthened the trust between the HCSWs and the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFamily support\u003c/em\u003e\u003c/strong\u003e was another important domain that facilitated lifestyle change. Close family members who had a direct influence on behaviour change were critical to help participants maintain healthier portion control or reduced sugar level. For example, some participants attended the Foodwise programme together with their spouse who could then modify the content of home-cooked meals or motivate them if they were struggling with mental health problems.\u003c/p\u003e\n\u003cp\u003eHe was pleased that I was going to make changes that would not only affect me but affect him as well. And we do. We\u0026apos;ve cut down on portion size. You know, when there are two of you together. It it\u0026apos;s quite nice. (Focus group, Male participant, 63 years old, Pyle)\u003c/p\u003e\n\u003cp\u003eGentle nudge, encouragement or reinforcement of achievements received from relatives and friends were also facilitators to keep up with regular exercise.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocial influences\u0026nbsp;\u003c/em\u003e\u003c/strong\u003efrom the wider community around the participants acted as barriers for some participants. They shared challenges in social situations, for example when eating out or at work, to say no to temptations or choose healthy options from the menu.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne of the ladies who I work\u0026hellip;loves to bake cakes and baked Welsh cakes yesterday. And even though I\u0026apos;ve said to them, you know, I\u0026apos;m trying to lose weight, they said \u0026ldquo;Just that corner one, you\u0026apos;ll be fine\u0026hellip;\u0026rdquo; She was practically literally trying to force it down. Oh, how can I say not so? It\u0026apos;s so difficult and I did. I gave in. (Telephone interview, Female participant, 63 years old, Pyle)\u003c/p\u003e\n\u003cp\u003ePhysical Opportunities\u003c/p\u003e\n\u003cp\u003eThe health checks, follow-up appointments and programme content and resources were important components that facilitated engagement\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHealth checks and follow-up appointments\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003ewere highlighted as important facilitators to \u0026lsquo;\u003cem\u003ekeep on track\u0026rsquo;\u003c/em\u003e with lifestyle changes, Participants, engaged with the WISE programme, expressed the view that such checks, including annual blood tests and frequent consultations with health care support workers (HCSWs), are crucial for staying informed about their health status. Participants, engaged in the other type of prevention programme, who didn\u0026rsquo;t have opportunity for regular meetings identified a need for more frequent interactions, at least blood test twice a year, to prevent health deterioration and to keep themselves accountable. Participants also suggested integration of self-administered health checks that they could complete at home.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eProgramme content and resources\u003c/em\u003e\u003c/strong\u003e were found appropriate with the right level of information and practical advice that had positive impact on participants and helped them take a proactive approach to manage their health.\u003c/p\u003e\n\u003cp\u003eAnd I\u0026rsquo;ve learned a lot from it, you know. Things creep up on you in life, and you don\u0026rsquo;t even realise it. It\u0026rsquo;s been an eye-opener for me and I welcome anything that will help me, and to control it and keep it under level. (Focus group, Female participant, 71 years old, Aberdare)\u003c/p\u003e\n\u003cp\u003eParticipants valued the tailored recommendations, such as portion control tips, dietary adjustments and fitting more physical activity within the busy schedule. The Foodwise programme and additional cooking course with visual aids, such as the Eatwell plate and food models, provided interactive learning experiences and better understanding of the impact and importance of implementing healthy eating habits. Participants highlighted the value of peer learning experiences during group programmes, suggesting that interactions with fellow participants contribute to their understanding\u0026nbsp;and motivation.\u003c/p\u003e\n\u003cp\u003eThe information was brilliant, really good. I read it all, still have the thing [Eatwell Plate] on my fridge. It was all very informative and clear. (Focus group, Female participant, 63 years old, Pyle)\u003c/p\u003e\n\u003cp\u003eThe Exercise referral scheme was only taken up by those who had confidence in their physical ability and found an exercise offer that suited their preference. The reasons why participants did not engage with the scheme were physical disability, dislike of leisure centre environment or group programmes, and preferring flexible time for exercise or outdoor activities. Most participants increased the time spent on walking instead of taking up the exercise referral scheme offer. Some who had other physical or mental health conditions (for example arthritis, cardiovascular disease, depression) expressed a need for tailored programmes that address specific health conditions. The quotes illustrate participants\u0026apos; challenges with finding suitable exercise options within referral programmes.\u003c/p\u003e\n\u003cp\u003eI went to the meeting about [ERS] but they weren\u0026apos;t able to offer me something that I knew I would participate in. I knew I wouldn\u0026apos;t go to the gym. I have no interest in sitting on a on an exercise bike. And I asked could I you know was there some swimming element or aqua-aerobics. But there was nothing that they could offer me. (Focus group, Female participant, 62 years old, Pyle)\u003c/p\u003e\n\u003cp\u003eThe participants mentioned some areas where the programme could be improved, for example, improving the promotion of programmes in the community (for example Foodwise and Exercise Referral), having regular consultations and blood tests, and being able to access support or resources outside of regular hours, indicating a need for flexibility in programme delivery, especially for individuals with mental health problems and comorbidities. Some participants expressed disappointment about the approach how they were informed about the pre-diabetes diagnosis. as it was \u0026lsquo;\u003cem\u003eshocking\u0026rsquo;\u0026nbsp;\u003c/em\u003eto them, and they would have preferred a healthcare professional calling them or informing them in person.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(C) Motivation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ewhile reflective motivation relates to processes of conscious goal setting and evaluation of the potential benefits and consequences of the desired behaviours.\u003c/p\u003e\n\u003cp\u003eAutomatic Motivation\u003c/p\u003e\n\u003cp\u003eAutomatic motivation and its sub-themes relate to impulses or reflex behaviours determined by external factors that influenced health behaviour.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eUnconflicted change,\u0026nbsp;\u003c/em\u003e\u003c/strong\u003edrawing on the Conflict Model of Decision Making, this subtheme was identified as the recognition of the risks of progressing from prediabetes to type 2 diabetes if current behaviours were continued and little or no risks of such progression if change was adopted. Participants described many automatic processes that encouraged them to attend appointments and participate in the additional parts of the programmes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI suppose it\u0026rsquo;s because i really don\u0026rsquo;t want diabetes 2. I\u0026rsquo;d rather be eating a healthier diet for a number of reasons. Now I got it, I look at recommended diets\u0026hellip;.and what\u0026apos;s on my plate at any particular time. (Telephone interview, Male participant, 60 years old, Pyle)\u003c/p\u003e\n\u003cp\u003eThere were emotional aspects to this motivation. Many of the participants described their reaction to the diagnosis as \u0026ldquo;shocking\u0026rdquo; or \u0026ldquo;surprising\u0026rdquo;. These reactions ignited the intention for action. The reactions, coupled with the immediate desire for health improvement and the desire for longevity and spending more time with loved ones encouraged the decision to participate in the prevention programmes and adopt healthy behaviours. There was a feeling that not doing so could lead not only to diabetes but also to early separation from loved ones. One study participant described this as:\u003c/p\u003e\n\u003cp\u003eFor other participants, receiving the letter about the pre-diabetes diagnosis while felt \u003cem\u003e\u0026ldquo;relief\u0026rdquo;\u0026nbsp;\u003c/em\u003eas suddenly they found the explanation for their ongoing symptoms of \u0026ldquo;\u003cem\u003efatigue, sleepiness or lack of energy\u0026rdquo;\u003c/em\u003e. Participants often expressed that they would not think that they had elevated blood sugar level until they were diagnosed as such, and they highlighted the importance and the necessity of getting to know about their condition early and to have the DPP available for them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe social network\u003c/em\u003e\u003c/strong\u003e of the participants played an important role in their motivation (or otherwise) to participate in the programmes and subsequent behaviour change. For example, some participants had comorbidities (physical ailments like osteoporosis) that could limit their capabilities for behaviour change in relation to exercise. However, the prevention programmes and a supportive social network particularly the immediate family who engaged in the desired activities served as a positive reinforcement for behaviour change and health improvement.\u003c/p\u003e\n\u003cp\u003eReflective Motivation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNeed for change\u003c/em\u003e\u003c/strong\u003e was identified due to the diagnosis of being at risk of developing type 2 diabetes having evoked reflexivity among the participants. It made them think about their current situation and what could be done to effect changes and achieve positive outcomes. The programme enhanced these reflective processes and led to the desire and the decisions to change behaviour. This underscores the benefits of diabetes prevention through identifying raised blood glucose and engagement in diabetes prevention programmes.\u003c/p\u003e\n\u003cp\u003eSo, you know, the programme has made me having that discussion as maybe kick started me and I\u0026nbsp;thought no, come on now, you know. Yeah, you need to make changes now. (Telephone interview, Male participant, 61 years old, Pyle)\u003c/p\u003e\n\u003cp\u003eSome of the participants said that they used to engage in physical activity. However, they \u0026nbsp;were physically inactive at the time of the diagnosis. \u0026nbsp;As they reflected on this, they became cognisant of the need to change and therefore determined to revert to their previous active lifestyle.\u003c/p\u003e\n\u003cp\u003eI made my mind up to do something about it, I didn\u0026rsquo;t wanna take medication or anything, and I\u0026apos;ve always trained but gone through a period when I wasn\u0026apos;t training, be back to training and cutting out\u0026hellip; I was overweight, I wasn\u0026apos;t training and, you know, made me realise I needed to go back to where I was. (Telephone interview, \u0026nbsp;Male participant, 60 years old, Pyle)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTaking ownership\u003c/em\u003e\u003c/strong\u003e was expressed by many participants. They believed that the prevention of diabetes was their personal responsibility, and they should take ownership of the responsibility. The lifestyle changes associated with the diagnosis were described by participants as challenging (for example, abstaining from behaviours they had engaged in for decades) and having a significant impact on their views about life.\u003c/p\u003e\n\u003cp\u003eBeing honest with themselves and accepting their responsibility positively influenced readiness and proactivity to engage with the programme following the pre-diabetes diagnosis. The engagement with the healthcare team was important in promoting the sense of taking ownership and responsibility for action. When initially contacted, some participants felt \u0026lsquo;cynical\u0026rsquo; about the programmes, considering them as some meaningless \u0026lsquo;tick box exercises\u0026rsquo; and had no desire to participate. However, through engagement with the team:\u003c/p\u003e\n\u003cp\u003eMy mind was changed completely\u0026hellip;I started to lose weight, and started to, improve and feel better, and I\u0026apos;m now actually reducing medication I\u0026apos;ve been on for 20 years because of the improvements. So yes, I think we\u0026apos;ve [participant and the lifestyle coach] done a cracking job. (Focus group, Male participant, 69 years old, Aberdare)\u003c/p\u003e\n\u003cp\u003eIn describing how the healthcare team contributed to enhancing the sense of ownership and responsibility and eventually the decision to take action, a participant says:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWhen she spoke to, strangely enough, after she\u0026apos;s spoken to me and we had a good chat about things, I came out of there and I decided I have got to do something and I\u0026apos;m going to do something about it. (Focus group, Female, 62 years old, Pyle)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis finding, i.e. taking ownership, highlights the importance of knowing one\u0026rsquo;s status and being equipped with the required knowledge and skills could contribute to enabling individuals to have control over their lives and prevent the progression to diabetes.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eParticipants described how the above factors influenced their ability to implement lasting changes in long-standing habits. The most reported health behaviour changes involving dietary adjustments, such as reducing sugar and carbohydrate intake, controlling portion sizes, cutting down on snacks, eliminating sugar in hot drinks, making healthier menu choices when dining out, avoiding bakery shops, and limiting the availability of sweets at home. Additionally, many participants increased their physical activity by incorporating regular exercise or walking into their routines.\u003c/p\u003e\u003cp\u003eWhile some found it challenging to make sudden changes in all unhealthy eating habits or maintain consistent exercise throughout the year, most were able to achieve sustained improvements in certain areas of their health behaviours. These positive changes were supported by consultations, personalised practical advice from HCSWs and Lifestyle Advisors, or participation in the Foodwise course.\u003c/p\u003e\u003cp\u003e Overall, the participants were empowered by the easily understandable information given to them, the small achievable targets and the nonjudgemental compassionate communication style of the healthcare professionals.\u003c/p\u003e\u003cp\u003eSimilarly to Jokar's study(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), our findings highlight the importance of a multilevel approach in addressing barriers to self-care in individuals with pre-diabetes. This supports our suggestion that interventions should not only focus on individuals but also consider broader systemic and social influences to enhance self-care behaviours. Our findings also emphasised the need for healthcare providers to understand patient needs and tailor interventions accordingly. Like Troughton's study (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), our research suggests that personalised approaches are necessary to influence perceptions and improve engagement in self-care behaviours. In agreement with Twohig (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), our findings also recognises that while a diagnosis of prediabetes might be a motivating factor, sociocultural and environmental barriers can hinder individuals from making sustained lifestyle changes. Both studies stress the need for supportive environments to facilitate effective engagement with diabetes prevention programmes.\u003c/p\u003e\u003cp\u003eThis study was not without limitations. The project completion time given was 3 months. Whilst the wider team were instrumental in supporting the recruitment of participants, this short turn-around time did limit the opportunity to recruit a larger sample of service-users.\u003c/p\u003e\u003cp\u003eThe length of programme engagement time that service-users had from their initial brief intervention to their participation was relatively short. Some participants had not had their follow-up appointment as originally planned. There is the potential for this to impact on the sustained engagement time of participants and therefore not allow any comparison with other national and international DPP publications which report on \u0026gt;\u0026thinsp;2 years duration.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBased on the current literature and the qualitative findings presented in this report we summarised a set of recommendations that might improve the current services being offered within the DPPs (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Overall, your findings reinforce the necessity of a comprehensive, patient-centred approach that considers individual, healthcare, and societal influences in improving prediabetes self-care behaviours.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRecommendations from the literature and the findings of this study\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eSpecific recommendations from the literature\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Face-to-face diabetes prevention programme with regular contact yields better clinical outcomes; for those with recognised barriers, consider regular online resources and contact.\u003c/p\u003e\u003cp\u003e\u0026bull; To help manage costs associated with face-to-face contact, consider mentorship with diabetes volunteers with lived experience to help run sessions (train the trainer).\u003c/p\u003e\u003cp\u003e\u0026bull; Ensure QA measures are in place to confirm equity for all enrolled, consistent success outcomes are generated (e.g. engagement; weight loss; HbA1c) and evaluate cost-effectiveness.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGeneral recommendations from the literature\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; To enhance the translation of diabetes prevention programmes into real-world settings, more comprehensive reporting of programme elements to evaluate their practical value are recommended.\u003c/p\u003e\u003cp\u003e\u0026bull; Detailed reporting on the four key PIPE Matric Framework components (Penetration, Implementation, Participation, Effectiveness), can offer valuable insights and promote wider adoption of Type 2 Diabetes prevention programmes.\u003c/p\u003e\u003cp\u003e\u0026bull; Standardising outcome reporting and criteria for translational diabetes prevention programmes in real-world settings can improve consistency and comparability across Wales.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSpecific recommendations from the qualitative findings\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; To improve and monitor the methods of signposting to supplementary services and to promote these services more broadly in order to enable all patients being informed about these supplementary services (for example, Foodwise, cooking course, Exercise referral scheme group activities).\u003c/p\u003e\u003cp\u003e\u0026bull; To offer more regular consultations in person, online or over the phone and facilitate self-monitoring of weight, diet, exercise via apps or in paper depending on patients\u0026rsquo; needs/preferences.\u003c/p\u003e\u003cp\u003e\u0026bull; To offer blood tests at six months for all patients.\u003c/p\u003e\u003cp\u003e\u0026bull; To offer a wider range of options for accessing support or resources outside of regular hours, to provide flexibility for those patients who have barriers to engage with components of the programme.\u003c/p\u003e\u003cp\u003e\u0026bull; To offer more personalized guidance within the programme for those who have mental health or other long-term health conditions.\u003c/p\u003e\u003cp\u003e\u0026bull; To allow and recommend patients to involve their trusted family members or friends when they access the services or implementing lifestyle changes in a way that suits their needs (for instance, attend Foodwise course together, exercise or cook together, etc).\u003c/p\u003e\u003cp\u003e\u0026bull; To incorporate more elements of peer support within the programme through group components and volunteers with lived experiences.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHbA1c - glycated haemoglobin\u003c/p\u003e\n\u003cp\u003eCOM-B model - Capability, Opportunity, Motivation and Behaviour model\u003c/p\u003e\n\u003cp\u003eCTM UHB \u0026ndash; Cwm Taff Morgannwg University Health Board\u003c/p\u003e\n\u003cp\u003eFIN-D2D \u0026ndash; Diabetes Prevention Program in Finland\u003c/p\u003e\n\u003cp\u003eUS-DPP study \u0026ndash; US Diabetes Prevention Program\u003c/p\u003e\n\u003cp\u003eDPP \u0026ndash; Diabetes Prevention Program\u003c/p\u003e\n\u003cp\u003eHCSW - Health Care Support Worker\u003c/p\u003e\n\u003cp\u003eAWDPP - All Wales Diabetes Prevention Programme\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics:\u003c/strong\u003e Ethical approval was obtained from Cardiff Metropolitan University Healthcare and Food Ethics committee. Project Reference Number: Sta-8994. The study was also registered as a service evaluation with the Cwm Taf Morgannwg University Health Board Research \u0026amp; Development Department. Project reference number: CTM/1994/24. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e All participants were asked to complete a written consent form before taking part in this study. \u0026nbsp;This included consent to use anonymous quotes for publication purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The funding for this study was secured through Cwm Taff Morgannwg University Health Board Service Enhancement Department\u0026rsquo;s competitive tendering process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions: \u003c/strong\u003eJL carried out the literature synthesis, analysed the data and contributed to writing this paper. \u0026nbsp;TT contributed to thematic analysis of the qualitative data and to the writing of this paper. \u0026nbsp;SZ contributed to participant recruitment, focus group data collection, thematic analysis of the qualitative, data and the writing of this paper. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements: \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe researchers wish to express their sincere gratitude to the CTM UHB team for their invaluable support in participant recruitment and for providing appropriate facilities for the focus group interviews.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlliance N. 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Grappling with how to use participant interaction in focus group design. Qualitative Research. 2012;12(4):459-72.\u003c/li\u003e\n\u003cli\u003eKidd PS, Parshall MB. Getting the Focus and the Group: Enhancing Analytical Rigor in Focus Group Research. Qualitative Health Research. 2000;10(3):293-308.\u003c/li\u003e\n\u003cli\u003eMichie S, Whittington C, Hamoudi Z, Zarnani F, Tober G, West R. Identification of behaviour change techniques to reduce excessive alcohol consumption. Addiction. 2012;107(8):1431-40.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative research in sport, exercise and health. 2019;11(4):589-97.\u003c/li\u003e\n\u003cli\u003eJokar M, Zandi M, Ebadi A, Momenan AA, Rostamkhani M. Barriers and facilitators of self-care in adults with pre-diabetes: a directed qualitative content analysis. BMC Health Services Research. 2025;25(1):332.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7046125/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7046125/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The global burden of diabetes is increasing, necessitating improved surveillance and prevention efforts. Evidence supports identifying high-risk individuals and implementing intervention programmes. Until recently, Wales lacked a nationwide, standardised support programme for individuals with pre-diabetes. Clinical data from a Welsh diabetes prevention pilot program, implemented in 2022, suggested that there was a decrease in average blood glucose levels (HbA1c) at 12-month follow-up appointments however there is limited qualitative evidence on experiences of patients identified with pre-diabetes. The aim of our study was to undertake a formative evaluation, exploring the views of adults enrolled in the two prevention programmes currently being run within one Welsh health board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This qualitative study, informed by the Capability, Opportunity, Motivation and Behaviour (COM-B) model, evaluated the experiences of participants who accessed the diabetes prevention programmes in CTM UHB. Different dimensions of experience including access to service, interactions with HCSWs and behaviour change were explored and mapped against their capability, opportunity, motivation and behaviour change. Service users were invited to take part in a focus group or one to one online or telephone interviews. There were 11 individual interviews and five focus group interviews with a total of 28 participants, from January to March 2024. Thematic analysis was used to analyse the data. The key findings, were mapped around the COM-B model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The evaluation identified various factors influencing programme engagement and lifestyle changes. Psychological and physical capabilities, social and physical opportunities, and automatic and reflective motivation all played roles. Key elements included prior knowledge, supportive staff, health checks, personalised guidance, risk awareness, and personal responsibility. The findings revealed a complex interplay of factors affecting participant engagement and behaviour change.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Based on our findings, we summarised a set of recommendations that might improve the current services being offered within the Welsh Diabetes Prevention Pilot Programmes, such as increased flexibility in delivery (out-of-hours), and availability (resources to be made available online out of hours), more frequent contact (e.g. monthly for the first 6 months), and regular health checks (e.g. HbA1c every 6 months), could improve initial uptake and sustained engagement in the programmes.\u003c/p\u003e","manuscriptTitle":"From Insight to Action: Using the COM-B Model to Explore Behaviour Determinants in Pre-Diabetes Programs","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-29 10:21:30","doi":"10.21203/rs.3.rs-7046125/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"553dbc18-527a-4be1-91d1-eca9887a7984","owner":[],"postedDate":"July 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-04T08:24:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-29 10:21:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7046125","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7046125","identity":"rs-7046125","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}