DISSEMINATION OF DIABETES PREVENTION INTERVENTION IN THE COMMUNITY: DEVELOPMENT AND IMPLEMENTATION OF A SURVEY FOR

LIFESTYLE COACHES WORKING IN THE TRENCHES

by

Anna Elizabeth Gongaware

BA, Allegheny College, 2014

Submitted to the Graduate Faculty of

Epidemiology

Graduate School of Public Health in partial fulfillment

of the requirements for the degree of

Master of Public Health

University of Pittsburgh

2016

ii

UNIVERSITY OF PITTSBURGH

GRADUATE SCHOOL OF PUBLIC HEALTH

This essay is submitted

by

Anna Elizabeth Gongaware

on

April 27, 2016

and approved by

Essay Advisor:Nancy W. Glynn, PhD ______________________________________Assistant ProfessorDepartment of EpidemiologyGraduate School of Public HealthUniversity of Pittsburgh

Essay Reader:Mary Kaye Kramer, DrPh ______________________________________Assistant ProfessorDepartment of EpidemiologyGraduate School of Public HealthUniversity of Pittsburgh

Essay Reader:Elizabeth Felter, DrPH ______________________________________Visiting Assistant ProfessorDepartment of Behavioral and Community Health SciencesGraduate School of Public HealthUniversity of Pittsburgh

iii

Copyright © by Anna Elizabeth Gongaware

2016

ABSTRACT

In the U.S., approximately 78.6 million adults are categorized as obese and over 29

million have type 2 diabetes. The high prevalence of these conditions is a pressing public health

issue. The Diabetes Prevention Program (DPP), a research study funded by the National Institute

of Health (NIH), demonstrated that type 2 diabetes could be prevented or delayed through weight

loss and physical activity. To provide this lifestyle intervention education in the community

setting, the Diabetes Prevention Program Group Lifestyle Balance Program (DPP-GLB) was

adapted from the DPP. This program, delivered by trained lifestyle coaches, has been shown to

successfully reduce diabetes and cardiovascular risk factors for at-risk adults. Coaches are

trained by the Diabetes Prevention Support Center (DPSC), which also offers support for these

coaches as they deliver the program in their own settings across the nation. The purpose of this

project was to contact these trained coaches in order to 1) track implementation of the DPP-GLB

program in the community, 2) improve training, and 3) enhance DPSC support for delivery of

the program in the community. A team effort was utilized to create a survey that was distributed

to the DPSC network of over 2,000 trained DPP-GLB coaches. Survey content was adapted

from a previously used DPSC survey, and was transferred from the SurveyMonkey program to

the Qualtrics system. This 52-question survey was sent via email to 1,509 active members of the

iv

Nancy W. Glynn, PhD

DISSEMINATION OF DIABETES PREVENTION INTERVENTION IN THE

COMMUNITY: DEVELOPMENT AND IMPLEMENTATION OF A SURVEY FOR

LIFESTYLE COACHES WORKING IN THE TRENCHES

Anna Elizabeth Gongaware, MPH

University of Pittsburgh, 2016

DPSC coach network and gathered information about the effectiveness of training workshops,

implementation of GLB in the community, challenges of program execution, and support needed

for the coaches. From a public health perspective, the data collected will improve diabetes

prevention efforts through improvement in the delivery of the DPP-GLB program.

v

TABLE OF CONTENTS

1.0 INTRODUCTION.........................................................................................................1

1.1 OBESITY..............................................................................................................1

1.2 TYPE 2 DIABETES.............................................................................................3

1.3 DIABETES INTERVENTION PROGRAMS...................................................6

1.4 BARRIERS TO PROGRAM IMPLEMENTATION.......................................9

1.5 PUBLIC HEALTH SIGNIFICANCE..............................................................11

2.0 OBJECTIVES.............................................................................................................12

3.0 METHODS..................................................................................................................13

3.1 SURVEY FOR COACHES...............................................................................13

3.2 DATA ANALYSIS..............................................................................................14

4.0 RESULTS....................................................................................................................15

5.0 DISCUSSION..............................................................................................................25

APPENDIX A – SURVEY QUESTIONS..................................................................................30

BIBLIOGRAPHY........................................................................................................................43

vi

LIST OF TABLES

Table 1. Questions were deleted or added to the previously-used survey for DPP-GLB coaches.

.......................................................................................................................................................13

Table 2. Professional affiliations among survey respondents who served as DPP-GLB coaches.16

Table 3. Geographical location of survey respondents who served as DPP-GLB coaches...........17

Table 4. Military affiliations of survey respondents who served as DPP-GLB coaches...............18

Table 5. Location of DPP-GLB programs and percent of respondents that reported each location.

.......................................................................................................................................................19

Table 6. Marketing/recruitment methods used to recruit participants into DPP-GLB programs..19

Table 7. Average attendance of DPP-GLB participants................................................................20

Table 8. Percentage of DPP-GLB participants who reached at least the 5% weight loss goal by

six months......................................................................................................................................20

Table 9. Reasons that coaches are not currently offering the DPP-GLB program........................21

Table 10. Summary of ranked barriers to program implementation as perceived by DPP-GLB

coaches...........................................................................................................................................22

Table 11. Rating of how well DPP-GLB training prepared coaches for implementing the

program..........................................................................................................................................23

vii

1.0 INTRODUCTION

Obesity and diabetes are serious health conditions that lead to negative complications for

many people. Fortunately, there are risk factors that can be modified to reduce the effects on

health. The Diabetes Prevention Program is an intervention program that was developed to help

individuals lose weight and lower their risk for diabetes. This program began in the clinical trial

phases and has been successfully implemented in the community through the Group Lifestyle

Balance program. Group coaches are trained by a central organization, the Diabetes Prevention

Support Center at the University of Pittsburgh. The center has trained over 2,000 individuals,

and has an active network of 1,509 coaches. These coaches were asked to participate in a survey

to examine barriers to program implementation to facilitate improvements in program delivery

and community dissemination.

1.1 OBESITY

Obesity is a common health condition faced by many Americans. Many factors can lead

to excess weight including diet, physical inactivity, a person’s environment, genetics,

pharmaceuticals, health conditions, and age (NHLBI, 2012a). Often, this imbalance is

determined by an equation of energy consumed by an individual versus energy expended

1

(NHLBI, 2012a). Having a chronic surplus of calories consumed compared to those used in

physical activity and daily life functions can lead to added weight (NHLBI, 2012a).

Body mass index (BMI) is a standard equation used to estimate a person’s body fat and

weight category (CDC, 2015a). Although used as a common indicator of fat due to the

straightforward and inexpensive nature of the measurement, the formula has weaknesses due to

its reliance solely on a person’s height and weight (CDC, 2015a). Obesity in adults is

specifically defined as having a BMI of at least 30 kg/m2 (Ogden, Carroll, Kit, & Flegal, 2014).

Results from the 2011-2012 National Health and Nutrition Examination Survey (NHANES)

revealed that just under 35% of American adults and approximately 17% of American children

fall under the obesity category (Ogden et al., 2014). When including both the overweight and

obese segments of the population, NHANES reported that almost 69% of adults fall within these

two categories (Ogden et al., 2014). These numbers have remained generally consistent with the

statistics from the early 2000s (Ogden et al., 2014).

Many ill-health effects can arise as a consequence of being overweight or obese such as

cardiovascular issues (stroke, hypertension, heart disease), some cancers, osteoarthritis, infertility

in women, sleep apnea, mental health issues, and type 2 diabetes (NHLBI, 2012b; Kumanyika,

Jeffery, Morabia, Ritenbaugh, & Antipatis, 2002). The former International Obesity Task Force

(now called World Obesity / Policy & Prevention) identified major causes and possible solutions

for the growing prevalence of obesity worldwide (WOPP, 2015; Kumanyika et al., 2002). One

major cause involved the shift of some cultures to calorie- or energy-dense diets that focus on

foods with higher amounts of sugars and saturated fats (Kumanyika et al., 2002). Another issue

arises when cultures become more developed and increasingly sedentary, which leads to overall

lower average calorie expenditures (Kumanyika et al., 2002). The task force strongly

2

emphasized that “societal solutions are critical, especially for the long term” (Kumanyika et al.,

2002).

There are many factors that contribute to the obesity problem in the U.S., some of which

are related to the setting in which we live. The changing food environment is one such factor

(Hill & Peters, 1998). Specifically, a growing availability of food as well as recently larger

portion sizes and higher concentrations of fat in the diet are believed to have an impact on the

obesity epidemic (Hill & Peters, 1998). In addition, humans have become increasingly sedentary

due to technological advances, reduced need for physical labor, and societal dependence on

transportation (Hill & Peters, 1998). These are difficult issues that require multiple strategies to

address.

1.2 TYPE 2 DIABETES

One condition related to obesity, type 2 diabetes, is a disease in which the body develops

insulin resistance, leading to elevated blood glucose levels (ADA, 2016a). In time, this

ineffective use of insulin leads to the onset of the disease and its symptoms (NIDDK, 2014).

Risk factors for type 2 diabetes include obesity, genetic predisposition, physical inactivity, and

age (NIDDK, 2014). While type 2 diabetes was mainly observed in middle-aged to older adults

in the past, it is being seen increasingly in younger populations (NIDDK, 2014). Other risk

factors include concentration of adipose around a person’s center, or “belly fat,” race, and having

other medical conditions such as prediabetes, cardiovascular disease, or metabolic syndrome

(NIDDK, 2014).

3

Metabolic syndrome is a condition that places individuals at higher risk for health issues

such as diabetes and cardiovascular problems (AHA, 2014). People with sedentary lifestyles,

insulin resistance, and a large waistline have a greater chance of developing metabolic syndrome

(NHLBI, 2015). This health problem affects about 34% of U.S. adults and is defined as having

three or more of the following risk factors: abdominal obesity, high blood pressure, fasting

glucose greater than 100mg/dL, high triglycerides, and low HDL cholesterol (AHA, 2014).

Certain segments of the population are at increased risk for metabolic syndrome, including

women, people with a personal family history of diabetes, and women with a history of

polycystic ovarian syndrome (NHLBI, 2015).

Type 2 diabetes can cause multiple health complications, such as neuropathy, skin

problems, kidney disease, hypertension, digestive system problems, stroke potential, and vision

problems (ADA, 2016b; ADA, 2014). Within the U.S., approximately 21 million individuals

have been diagnosed with diabetes, and another 8.1 million are thought to be undiagnosed

(ADA, 2014), representing approximately 12% of the U.S. population (CDC, 2014). As of 2014,

just over 1.4 million Americans become newly diagnosed with type 2 diabetes every year, a

statistic that has declined from the rate of almost 1.7 million new cases per year in 2010 (CDC,

2015b). During this same time window, age-adjusted incidence of diabetes for adults

(specifically ages 18-79) dropped from 8.1 to 6.6 per 1,000 population (CDC, 2015c). In regard

to distribution within the population, diabetes disproportionately affects people from varying

ethnic and racial backgrounds. American Indians and Alaskan Natives have the highest rates of

diabetes (15.9%), followed by non-Hispanic blacks (13.2%), Hispanics (12.8%), Asian

Americans (9%), and non-Hispanic whites (7.6%) (ADA, 2014).

4

Symptoms of diabetes may be mild or non-existent in some individuals, but may include

blurry vision, frequent urination, fatigue, excessive hunger or thirst, slow-healing wounds, and

numbness and tingling of extremities (ADA, 2016c). Diagnosis can be made through a variety

of medical tests that examine an individual’s level of blood glucose (ADA, 2016d), and is

defined as an A1C test result of greater than or equal to 6.5%, a Fasting Plasma Glucose test

result of greater than or equal to 126 mg/dl, or an Oral Glucose Tolerance Test result of greater

than or equal to 200 mg/dl (ADA, 2016d). If a tested individual is found to have high blood

glucose, yet their values are not high enough to be considered diabetic, their condition is

categorized as “prediabetes” (ADA, 2016d). Although having prediabetes puts an individual at

higher risk of developing type 2 diabetes, overall health and test results can be improved through

lifestyle changes such as physical activity and losing weight (ADA, 2016d).

Type 2 diabetes can be treated by a variety of pharmaceuticals including Metformin,

sulfonylureas, meglitinides, thiazolidinediones, DPP-4 inhibitors, GLP-1 receptor agonists,

SGLT2 inhibitors, and injections of insulin (Mayo Clinic Staff, 2016). These medications aim to

either intensify an individual’s sensitivity to insulin, increase their body’s insulin output, lower

blood sugar, or provide insulin to the body from an external source (Mayo Clinic Staff, 2016).

As with many other chronic conditions, diabetes can lead to increased health care costs

because of continual need for medications and treatment. In regard to economic impact, diabetes

adds approximately $245 billion between both health care costs and impact of lost productivity

(ADA, 2014). Overall costs for the average diabetes patient in the U.S. are more than double the

healthcare costs of a person without the disease (ADA, 2014).

5

1.3 DIABETES INTERVENTION PROGRAMS

Diabetes and obesity have become a significant health burden in the U.S. and throughout

the world. These disease statistics, as well as their impending health challenges and

complications, demonstrate the immense need for public health action. In the past few decades,

many successful programs have surfaced to help combat these problems.

The Diabetes Prevention Program (DPP), a National Institutes of Health funded

randomized clinical research trial, began in 1996 and involved 3,234 people in 27 centers across

the United States (DPP Research Group, 2002). Eligibility criteria defined the study population

as non-diabetic, overweight individuals with elevated glucose levels (DPP Research Group,

2002). This study randomized participants into one of three arms: 1) standard lifestyle

recommendations and placebo pills, 2) standard lifestyle recommendation and metformin

medication, or 3) behavioral lifestyle modification program (DPP Research Group, 2002). The

lifestyle modification intervention arm was completed through 16 core sessions of one-on-one

interaction between a case manager and a study participant over a six month period, followed by

post-core support (DPP Research Group, 2002). These individuals were assigned a weight loss

goal of 7% which was to be accomplished through a reduced calorie and fat diet as well as

through achievement of the physical activity goal of 150 minutes per week of moderate-intensity

physical activity (DPP Research Group, 2002).

After following participants for an average of almost three years, the DPP found that the

lifestyle intervention group had a 58% lower incidence of diabetes compared to placebo, whereas

within the metformin group, incidence was reduced by 31% compared to the placebo group

(DPP Research Group, 2002). The lifestyle arm, in comparison to both the metformin and

placebo arms, had the greatest increase in physical activity, the lowest fasting plasma glucose

6

and glycated hemoglobin levels, as well as the greatest reduction in caloric intake, weight, and

incidence of diabetes (DPP Research Group, 2002). Because of the high success rate in diabetes

reduction, the study was terminated in 2001, a year earlier than planned in order to begin

disseminating the intervention in the community setting (DPP Research Group, 2002).

The Diabetes Prevention Support Center (DPSC) was established in 2006 by DPP

researchers at the University of Pittsburgh to translate the successful DPP lifestyle intervention

to the community (DPSC, 2016). The DPSC offers training and support for health providers for

community delivery of an adapted DPP lifestyle intervention, called the Group Lifestyle Balance

(DPP-GLB) program (DPSC, 2016). Specifically, they have conducted over 50 two-day DPP-

GLB training workshops with an active network of 1,509 DPP-GLB coaches trained across the

US and internationally (DPSC, 2016).

To bring the benefits of the DPP to the community, the curriculum was updated and

adapted in to a translational program to be delivered in a group setting (Kramer et al., 2015).

The cost of the DPP, as well as feasibility for program delivery in the community, motivated the

change from an individual, or one-on-one, delivery to a group format (Kramer et al., 2009). The

DPP-GLB program involves 22 one-hour sessions delivered by trained coaches over the course

of one year. The behavioral lifestyle intervention includes the same goals as the original DPP, to

achieve and maintain a goal of 150 minutes of physical activity per week as well as to reach a

goal of 7% weight loss (DPSC, 2016). Participants are asked to monitor their dietary intake,

physical activity, and weight for the duration of the program (Kramer et al., 2015). Several

effectiveness studies found that DPP-GLB participants lost an average of 7.4 pounds, and had

reductions in risk factors for cardiovascular disease, including decreased body mass index

(BMI), waist circumferences, cholesterol levels, blood glucose, and blood pressure (Kramer et

7

al., 2009). Another translation of DPP to a group setting was evaluated in worksites, and gave

participants the option of attending in-person sessions or watching a DVD with program contents

and telephonic coach support (Taradash et al., 2015). The DPP was also brought to an online

social network with participants receiving digital program content as well as contact with

coaches (Sepah, Jiang, & Peters, 2014).

Other translational efforts that used the DPP-GLB program included testing the lifestyle

intervention when delivered by a community health worker, in a primary care clinic, and in

different delivery modalities. The Promotora Effectiveness Versus Metformin Trial

(PREVENT-DM) is currently using community health workers to deliver DPP curriculum and

then compare outcomes to other participants who were given either metformin or placebo (Perez

et al., 2015). The target population included Latina, prediabetic women (Perez et al., 2015).

Another study called Weight Loss through Living Well (WiLLoW) transformed the DPP to a

primary care setting and used a nurse educator to deliver curriculum from the GLB (McTigue,

Conroy, Bigi, Murphy, & McNeil, 2009). The WiLLoW program clinic charged a fee for

program participants in order to cover costs that were rejected by insurance companies (McTigue

et al., 2009). Participants were followed for an average of almost 358 days and program

participants lost a more clinically-significant amount of weight compared to non-participants

(McTigue et al., 2009). The Rethinking Eating and Activity (REACT) study examined the

difference between participants who had the GLB curriculum delivered by a variety of methods

(Piatt, Seidel, Powell, & Zgibor, 2013). Methods involved identical content delivered through

either face-to-face contact, internet, DVD, and “self-selection” (participant’s choice) (Piatt et al.,

2013).

8

1.4 BARRIERS TO PROGRAM IMPLEMENTATION

Despite the importance of the role of the lifestyle coach in DPP translation efforts in the

community, there are few reports found in the literature regarding barriers to program

implementation. Based on the design of the DPP-GLB program, there are a few potential

sources of barriers or challenges that coaches might face. Specifically, such programs require a

variety of resources including meeting space for the hour-long weekly sessions, printing

capabilities for participant handouts, booklets for nutrition and activity monitoring, a reference

book to find fat and calorie content of food, as well as pedometers (Kramer et al., 2009). The

cost of training and employment of a coach to provide the program must also be considered.

During the initial creation and evaluation of the DPP-GLB program, it was estimated that to offer

the one-year DPP-GLB program, the cost would be approximately $300 for each of the DPP-

GLB participants, which covered prevention professional payment, program materials, food (for

tasting during sessions), and incentive items (Kramer et al., 2009). The Healthy Living

Partnerships to Prevent Diabetes (HELP PD) was another effort in bringing the DPP to the

community, and found a program cost of $850 per participant compared to $142 for participants

receiving the placebo, or “usual care” (Lawlor et al., 2013).

Drop-out rates were noted in many studies that examined the community-based

application of the DPP program (Jackson, 2009). In one meta-analysis, intervention programs

were held at a variety of locations including YMCAs, churches, hospitals, and worksites, which

had varying outcomes regarding weight loss and drop-out rate (Jackson, 2009). The highest

drop-out rate (43.3% at 6 months) was found in a non-randomized study in a medically

underserved population (Jackson, 2009).

9

Another study evaluated the translation of the DPP as well as another diabetes

intervention, the Healthy Living Program, to a primary care setting (Carroll et al., 2015). With a

low-income, urban study population, recruitment posed a problem due to potential participants’

job insecurity and “life issues,” as well as screening complications, time and resource intensity of

recruitment, and wait time between screening and program start (Carroll et al., 2015). Program

sites faced challenges involving use of resources, management of participant records, and staff

capabilities (Carroll et al., 2015).

Participants in a weight loss study called Be Fit, Be Well (BFBW) received self-

monitoring educational materials, pedometers, and contact with a community health worker

(Warner et al., 2013). With a targeted study population of low-income, minority participants,

researchers in BFBW overcame recruitment and retention challenges through strong

relationships with clinic staff and continuous improvement of methods based on program

progression (Warner et al., 2013).

Obtaining training may be another challenge that potential coaches face. The DPSC

hosts annual, two-day trainings in Pittsburgh, Pennsylvania with a participation cost of $499

(DPSC, 2016). The American Association of Diabetes Educators also hosts a two-day training

program and charges $749 and $849 for members and non-members, respectively (AADE,

2016). The Emory Centers for Training and Technical Assistance, within Emory University,

offers similar training for $750 per attendee (Emory University, 2016). Challenges may arise

because training attendance could require travel to Pittsburgh, taking time off work, and covering

the cost of attending training. Thus, issues of budget, resources, and previously-noted drop-out

rates are potential barriers faced by coaches who are working in DPP translation efforts. It is

10

important to identify and understand these barriers in order to address them and determine

possible strategies for better facilitation of these types of programs in the community.

1.5 PUBLIC HEALTH SIGNIFICANCE

Because of the high rates of obesity and diabetes within the United States, the delivery of

diabetes prevention programs/healthy lifestyle interventions is important to reduce the impact of

these health conditions. These health issues can lead to complications, comorbidities, and

increased health care costs. An individual’s lifestyle, specifically their dietary intake and level of

physical activity, can impact their likelihood of developing such health issues. Effective diabetes

prevention programs have been created to help reduce the burden of diabetes and obesity in the

population. These programs, which started in a clinical setting, have been adapted to be

delivered to the general population by trained health providers. By understanding the barriers

that coaches face in program operation, such challenges can be addressed and reduced in order to

increase the success with DPP-GLB implementation. Ultimately, this heightened success will

lead to a reduction in public health burden due to both obesity and diabetes.

11

2.0 OBJECTIVES

The main objective of this project was to examine barriers for DPP-GLB program

implementation in the community. Additionally, this project aimed to track DPP-GLB program

delivery, improve DPP-GLB coach training, and enhance DPSC support for community program

delivery. Based on prior experience and the resources needed to implement the DPP-GLB

program, it was hypothesized that DPP-GLB coaches face barriers associated with participant

attendance and interest and/or involvement in the program.

12

3.0 METHODS

3.1 SURVEY FOR COACHES

A previously-used DPSC survey was adapted from Survey Monkey and transferred to

Qualtrics, an online survey distribution system that is provided through the University of

Pittsburgh (Appendix A). Survey content was adapted from the 2012 version based on what

information the DPSC staff needed to gather. Some questions were re-worded to be more

precise, answer options were added for some multiple choice questions, and some were removed

as per DPSC request (Table 1).

Table 1. Questions were deleted or added to the previously-used survey for DPP-GLB coaches.

Question Topic Action NotesWhen they began providing DPP-GLB Deleted ---

How they marketed the program Deleted Due to redundancy in a following question about which method was most effective.

Whether they have made program modifications Deleted

Whether they used the DPP-GLB DVD Deleted Due to the next questionreferring to how it was used

If, how, and how often post-core support was provided Deleted ---

If translations of the DPP-GLB to languages other than Spanish would be helpful to the coaches and their settings.

Deleted ---

Whether they attended the most recent DPSC training Added ---

In what ways the DPSC can be of more assistance Added ---

Additional comments or suggestions. Added ---

13

The survey was distributed via email to the DPSC’s database of 1,509 active trained

DPP-GLB coaches. There were three emails sent in total, the initial request and two reminder

emails. Specifically, the survey addressed contact information for current DPP-GLB programs,

coaches’ use of DPP-GLB within community settings, barriers or challenges of program

execution, opinions about effectiveness of training workshops, and support needed for coaches to

continue to effectively carry out their programs. As an incentive for participation, coaches who

completed the survey were entered into a raffle for a healthy cookbook. The participation goal

was to have 10-12% of surveys returned to the DPSC from the DPP-GLB coaches. Survey

contents can be found in Appendix A.

3.2 DATA ANALYSIS

Once the survey was closed to respondents, results were tabulated by the Qualtrics

system. Of the fifty-two questions included in the survey, frequency distributions were

examined for questions involving recent or past DPP-GLB implementation, recruitment methods,

common locations of programs, participant attendance, and barriers to program implementation.

14

4.0 RESULTS

The survey was submitted to the University of Pittsburgh’s IRB in September of 2015.

Modifications were requested and a re-submission occurred in October. An “Exempt” status was

granted by October 8, 2015. The original message was sent out on December 17, 2015, and two

reminder request messages were sent out on January 25 and February 29, 2016, for a total of

three e-mail contacts. The target goal for returned surveys was 10-12% for those who have valid

contact information. The survey was closed on March 13, 2016.

A total of 92 individuals (6%) began the survey, and of that number 69 (75%) completed

all questions. However, eight individuals entered the survey twice and four individuals entered

three times, which reduced the total to 61 useable responses. The data was exported from

Qualtrics to Microsoft Excel and then individuals with multiple entries were examined. Since it

is likely that the most recent entry would reflect the most up to date responses, the most recent

entry for each was kept to be used in analysis, and the others were discarded.

Respondents included coaches from a variety of professional affiliations, geographical

locations, and military associations (Tables 2, 3, and 4). A majority of respondents were

Diabetes Educators, Registered Dietitians/Nutritionists, and Registered Nurses, and the most-

recorded geographic locations were Texas and West Virginia. Eleven (15%) of respondents

were affiliated with the military, a majority of whom were contractors within the military (Table

4).

15

Table 2. Professional affiliations among survey respondents who served as DPP-GLB coaches.

Professional Affiliation Responses (n) %

Certified Diabetes Educator/Diabetes Educator 22 19Registered Dietitian/Nutritionist 19 17Registered Nurse 17 15Other 17 15Health Educator 15 13Exercise Specialist 5 4Health and Wellness Center Staff 4 4PhD, DrPH 3 3Social Worker 3 3Researcher 2 2Physician 2 2Medical Technician 1 1Physical/Occupational Therapist 1 1Psychologist 1 1Student 1 1Physician Assistant 0 0Nurse Practitioner 0 0Total 113 100

16

Table 3. Geographical location of survey respondents who served as DPP-GLB coaches.

Geographic Location Responses (n) %

Alaska 1 1Alabama 1 1Arizona 4 6Bahamas 1 1California 2 3Florida 2 3Georgia 1 1Idaho 2 3Illinois 2 3Indiana 2 3Jamaica 1 1Massachusetts 2 3Maryland 2 3Montana 1 1North Carolina 1 1New Mexico 2 3Nevada 1 1Ohio 3 4Oklahoma 1 1Ontario 1 1Pennsylvania 6 9Rio Grande do Sul 1 1Tennessee 3 4Texas 13 19Utah 1 1West Virginia 10 15Total 67 100

Table 4. Military affiliations of survey respondents who served as DPP-GLB coaches.

Military Affiliation Responses %

17

(n)Contractor 8 73Active Duty Air Force 1 9Civilian working for military 1 9Reserve 1 9Active Duty Marine 0 0Active Duty Army 0 0Active Duty Navy 0 0National Guard 0 0Government 0 0Veterans Administration Staff 0 0Other 0 0Total 11 100

Of the survey respondents, 80% have implemented a DPP-GLB program, either currently

or in the past. Approximately 18% of coaches have implemented the program once, 36% have

implemented it two to four times, and 41% have led the program ten times or more. Most of the

implementation settings included a hospital (23%), worksite (16%), community or senior center

(16%), or military primary care clinic (14%) (Table 5).

Table 5. Location of DPP-GLB programs and percent of respondents that reported each location.

Program Location Responses (n) %

Hospital 10 23

18

Worksite 7 16Community or Senior Center 7 16Military Setting – Primary Care Clinic 6 14Other 6 14Out-patient Hospital Clinic 3 7Primary Care Practice 3 7Fitness Center/YMCA 1 2Military Setting – Health and Wellness Center 1 2Military Setting – Endocrinology Practice 0 0Church 0 0School/College/University 0 0Insurance Provider 0 0Total 44 100

In regard to recruitment, the methods deemed most effective included word of mouth,

flyers, and recommendation by physician or other health care provider (Table 6).

Table 6. Marketing/recruitment methods used to recruit participants into DPP-GLB programs.

Marketing Method Responses (n) %

Word of mouth 27 21Flyers 25 20Physician/Health care provider 21 17Newspaper 10 8Email 9 7Newsletter 8 6Health fairs 6 5Direct mailing 6 5Other 6 5Social media (Facebook, Twitter, etc.) 4 3Telephone 3 2Did not market 2 2TV advertisement 0 0Total 127 100

Out of 43 respondents to the question on finances, 35 reported charging a fee to

participants, and 16 reported that over 75% of their programs were funded through grants or

research funds. One coach noted that “Tricare,” the health insurance provided by the U.S.

Military, covers costs, but was otherwise unsure of specifics. Another coach listed “Caresource”

19

as third party reimbursement, but also noted that the participant in question paid $50 to cover

material costs.

Attendance of program sessions varied, but 63% of respondents stated that more than

50% of their participants attended at least half of the core DPP-GLB sessions (Table 7).

Table 7. Average attendance of DPP-GLB participants.

Average Attendance Responses (n) %

Less than 25% 2 525% - 49% 6 1450% - 74% 13 3075% - 100% 14 33Not sure 8 19Total 55 100

Percentages of participants who reached at least 5% weight loss at the six months varied

across groups. Most coaches (30%) were unsure of the percentage, and 26% of coaches reported

that between 10-24% of participants reached this goal (Table 8).

Table 8. Percentage of DPP-GLB participants who reached at least the 5% weight loss goal by six months.

Percent Who Reached Goal Responses (n) %

0% - 9% 3 710% - 24% 11 2625% - 49% 4 950% - 74% 7 1675% - 100% 5 12Not sure 13 30Total 43 100

Coaches provided a variety of reasons for not currently offering the DPP-GLB program

(Table 9). Many indicated that they were unable to recruit or felt a lack of community interest,

as well as having a lack of time, funding, and staffing. The “other” option had the majority of

responses. When asked to specify, most responses involved a form of “Not applicable”

20

(specifically due to starting a program soon, have plans to start in the near future, and currently

implementing the program), as well as needing a refresher or having the program implemented

by a different part of their organization. Similar responses were provided when asked why they

felt it unlikely that they will provide the program in the future, and included a change in job

position, lack of eligible or interested participants, lack of funding, and needing a refresher or

training for new coaches.

Table 9. Reasons that coaches are not currently offering the DPP-GLB program.

Reasons Responses (n) %

Other 14 26Unable to recruit or lack of community interest 8 15Lack of time 6 11Not confident participants would commit to length of program 5 9

Lack of funding 4 8Lack of staffing 4 8Lack of supervisor interest 3 6Feel unprepared 2 4Job responsibilities have changed 2 4Attending DPSC training for other reasons 2 4Lack of meeting space 1 2Using different DPP curriculum 1 2Deployment 1 2Feel program is not needed 0 0Inability to earn RVUs 0 0Total 53 100

When asked about barriers and how they affected the administration and/or effectiveness

of the program, challenges were rated on a scale of 1-3: 1 indicates “Not a barrier,” 2 indicates a

“Minor barrier,” and 3 indicates a “Major barrier.” Averages of these ratings were taken by

weighting the tally of scores in each rating category, and dividing by the total number of ratings

for that question (excluding the “Not applicable” scores). The most common challenges were

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participant drop-out and participant motivation with mean responses of 2.19 and 2.12,

respectively, which suggests that these items are slightly more than “minor barriers” (Table 10).

The barriers with the next highest ranking of impact were time and inadequate meeting space,

with mean responses of 1.61 and 1.55, which equate to between “Not a barrier” and a “Minor

barrier.” The lowest-ranking barriers and their mean responses were language-related challenges

(1.10), inadequate preparation for program delivery (1.12), and parking or transportation (1.28),

which all equate to either “Not a barrier” or just slightly more than “Not a barrier.”

Table 10. Summary of ranked barriers to program implementation as perceived by DPP-GLB coaches.

Barrier Not a Barrier

Minor Barrier

Major Barrier

Total Responses Mean

Participant drop out 8 18 16 42 2.19Participant motivation 8 21 13 42 2.12Lack of time 19 19 3 41 1.61Inadequate meeting space 23 12 5 40 1.55Lack of funding 26 10 5 41 1.49Inclement weather 22 15 2 39 1.49Lack of organizational support 26 12 4 42 1.48Lack of trained available staff 29 11 1 41 1.32Parking/transportation issues 29 9 1 39 1.28Inadequate preparation for DPP-GLB delivery

36 5 0 41 1.12

Language barriers 36 4 0 40 1.10* Barriers were ranked with the following values: 1=Not a barrier; 2=Minor barrier; 3=Major barrier.

The survey also evaluated the value of DPSC’s training for new DPP-GLB coaches.

When asked to rate how well DPP-GLB training prepared them for implementing the program,

respondents could answer on a scale of Very Well to Very Poor (Table 11). When values of

ratings were weighted by response and averaged, each topic had a mean of less than two points.

This indicates that responses averaged between “Very Well” and “Well” for all topics of the

training. The following question asked for components of training that coaches felt were

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missing. Responses included: wanting to learn more about the behavior component, physical

activity, ethnic diversity, and budgeting. Some felt that role playing and increased opportunity

for discussion or feedback would improve the program.

Table 11. Rating of how well DPP-GLB training prepared coaches for implementing the program.

Question Very Well (n) Well (n) Fair (n) Poor (n) Very

Poor (n) Mean

Implementing in the local setting 21 26 11 0 0 1.83Leading group sessions 20 30 5 0 1 1.79Behavioral component 25 24 8 1 0 1.74Nutrition component 23 29 6 0 0 1.71Physical activity component 26 24 7 0 0 1.67Evidence and rationale for the GLB program 37 19 2 0 0 1.40

* Mean score is calculated by averaging responses based on the following scale: 1=Very Well; 2=Well;

3=Fair; 4=Poor; 5=Very Poor.

The final question of the survey provided space for coaches to write additional

comments, suggestions, or thoughts regarding the program and/or the DPSC. Fifteen coaches

used this space to provide input, and responses often involved how they felt it was a good/great

program that accomplishes its goals. Quotes include “Love the program and am looking forward

to expanding it in our community!” “It is a wonderful program” and “I found the training overall

I attended in Pittsburgh was excellent.” One coach stated interest in the DPSC despite not

knowing what the organization is, and another noted having trouble getting other staff members

(who attended the DPSC training) involved. This posed a problem for that coach due to an

overload of work, tight schedule, and a complication of site funding. A comment was submitted

asking about “update classes” for coaches already providing the DPP-GLB program and another

noted interest in the online program.

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5.0 DISCUSSION

The survey for DPP-GLB coaches was administered over a period of three months with a

total of 92 overall responses and 61 complete and useable responses, after accounting for

duplicate and blank entries. Out of the DPP-GLB current contact list of 1,509 coaches, the total

of 61 responses equates to a response rate of 4.04%, which was lower than the targeted rate.

Commonly noted barriers included participant drop-out, participant motivation, lack of time, and

inadequate meeting space. Frequent program locations included hospitals, worksites, and

military primary care clinics, and methods of recruitment reported as most effective were word

of mouth, flyers, and physician recommendation.

At the present time information regarding implementation barriers for DPP translation is

lacking; however, some literature does exist regarding barriers to delivery of similar health and

wellness programs in the community. For example, one wellness program in Los Angeles

reported difficulty with participant recruitment and retention (Yancey et al., 2006), which is also

reflected in the current DPP-GLB coach survey through the question regarding why coaches are

not currently offering a program. The inability to recruit was among the most frequently selected

answers for this question, along with a lack of confidence that participants would commit to the

program’s length of time. Poor participation, a possible indicator of retention, was similarly

noted in the survey results as a “participant motivation” barrier. The Los Angeles program also

found that poor participation was specifically thought to be an effect of limited resources or

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ability of groups to host programs rather than a lack of interest (Yancey et al., 2006). This,

however, is not mirrored in the DPP-GLB survey results. Lack of funding, organizational

support, meeting space, and trained staff were ranked between 1.32 and 1.61 on the barrier scale,

indicating that they were either slightly more than “Not a barrier” or slightly less than “A minor

barrier.”

Although participant motivation and drop-out were ranked highly on the list of barriers,

attendance seemed to be a strong point for many coaches. Of survey respondents, 63% reported

having more than 50% of their participants attend at least half of the core DPP-GLB sessions.

Only 19% reported not knowing their program’s attendance rates. Participant weight seemed to

be less well-documented, and 30% of coaches were unsure what percentage of their participants

reached the targeted weight loss goal. More than a quarter (23%) reported that 10-24% of

participants reached the goal, and 16% reported that 50-74% reached the goal. The weight loss

results did not reveal an overall pattern, so no trend could be identified.

The DPSC training was generally well received by coaches, some of whom commented

that they “loved” the program and were looking forward to bringing it to their community.

When asked how well the training prepared them for certain aspects of the program, all topics

averaged scores between “Very Well” and “Well.” The topic with the highest ranking

(indicating room for improvement) was implementation in the local setting. In contrast, the topic

with the lowest ranking (indicating that they felt the best prepared in that area) was surrounding

the evidence and rationale for the DPP-GLB program.

In regard to survey implementation, studies have found that electronic surveys provide

higher response rates compared to surveys that are sent through the postal service (Kiernan,

Kiernan, Oyler, & Gilles, 2005). Although the DPP-GLB survey did not have a mailed, paper

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survey to compare response rates, the emailed DPP-GLB survey for coaches was very low (with

61 respondents from a contact list of 1,509 coaches). Due to resource availability, mailed and

face-to-face surveys are not feasible for the DPP-GLB survey’s purposes. Similar to an

Australian university’s study, reminder emails may have increased responses, and the potential

of winning the healthy cookbook raffle may have provided additional incentive to participate in

the survey (Nulty, 2008).

Limitations of the survey largely surround its response rate. Although the Diabetes

Prevention Support Center has a contact list of 1,509 DPP-GLB coaches in its network, only 61

individuals completed the survey. Furthermore, twelve individuals started or completed the

survey two or three times. The overall low response rate indicates the lack of generalizability of

survey data and requires replication to ensure that the population of DPP-GLB coaches is

appropriately represented. Specifically, the limited number of responders from a restricted

number of sectors suggests that the data should be evaluated with caution. A majority of

respondents were from Texas and West Virginia (19 and 15%, respectively), whereas the next

most common state was Pennsylvania with 9% of respondents. Almost a quarter (23%) held

their programs in a hospital location, and 15% of respondents were affiliated with the military in

some capacity. Of those within the military, almost three quarters (73%) were contractors, and a

majority of coaches reported careers of diabetes educators, dietitians/nutritionists, and registered

nurses. If there are differences in barriers faced by each sector, program location, geographic

location, or professional affiliation of coaches, then their responses will reflect these

dissimilarities and will not be representative of the DPP-GLB coach network as a whole. These

associations and potential differences of the small group of respondents limit the data’s

generalizability.

26

Response rate may be affected by multiple factors. Specifically, response bias may have

an effect in that coaches may be more likely to complete the survey if they are currently leading

a DPP-GLB program, have had successful groups in the past, or have a higher interest level in

health care topics. Individuals may be less likely to complete the survey if they took the DPP-

GLB training course or led a group in the distant past, or have since moved careers and are no

longer in a related field. Coaches may or may not be paid to lead the program, which could

provide incentive if they are able to complete the survey while at work. Additionally, the survey

was only offered via email, which excludes coaches who do not have email or access to the

internet.

The survey for DPP-GLB coaches had strengths in that it aimed to capture barriers faced

by DPP-GLB coaches. The survey was originally designed to gather an understanding of the

experiences of DPP-GLB coaches in the community and to determine what challenging aspects

of program implementation might lead to limited success of the program and of the individual

participants. Although a small percentage of the coach network responded to the survey request,

the results provided some insight to what coaches experience in terms of barriers to survey

implementation. The survey also provides feedback about the DPSC training, information which

can be used to improve future training workshops.

The next steps involve determining how to distribute the survey more effectively to

improve the overall response rate. Surveys can be administered in many forms, ranging from

mailed paper copies, telephone calls, in-person interviews, or online surveys. The advancement

of computers, tablets, and smartphones increases the opportunity and ease for survey

implementation due to the ability of the target audience to access the internet from almost any

location as well as the decreased need for personnel and physical paper copies to conduct in-

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person surveys and mailed surveys. The online method was used for the DPP-GLB coaches

survey due to the vast number of trained coaches in the network and resource efficiency.

Although reminder emails were sent to the coaches and an incentive raffle was provided, the

final response rate did not meet the desired value. The exploration of other survey

implementation methods would be determined by the availability of DPSC resources (both time

and tangible resources), although alternative approaches may be unrealistic due to the

widespread geographical locations of the network coaches.

One suggestion to increase survey response rate is to mention the upcoming survey at the

annual DPSC two-day training workshops, or to provide the link at each workshop and allow the

survey to be continuous instead of only open for a short time. Additionally, more reminder

emails at closer time intervals may help increase the response rate. Although hard copy methods

may be becoming outdated, there may be coaches who do not regularly check email and thus

may have been missed during the time the survey was available. This may prompt consideration

of the option of sending hard copies to coaches, resources permitting.

Results of this year’s survey will be given to the Diabetes Prevention Support Center, to

be used as they see fit. The survey may be continued in the future to gather information about

the barriers faced by DPP-GLB coaches and improvement of the annual training. This will

enable the DPSC to maintain up-to-date records of current DPP-GLB programs as well as

contact information for the active coaches. Access to this information will enable the DPSC to

improve upon future DPP-GLB coach trainings and increase support and resources to overcome

program implementation barriers. Enhancing coaches’ abilities to successfully carry out the

programs needs to be priority to benefit future program participants and reduce the public health

burden of both obesity and diabetes.

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Appendix A– SURVEY QUESTIONS

Group Lifestyle Balance Coaches

Q1 Please provide your name, current address, e-mail, and phone number below so that the Diabetes Prevention Support Center (DPSC) has the most up-to-date information on file. Your information will not be shared or used for other purposes. NOTE: If you would prefer to complete the evaluation anonymously, please enter "none" in the text boxes where appropriate.

NameCompanyAddress 1Address 2City/TownState/ProvinceZIP/Postal CodeCountryEmail AddressPhone Number

Q2 Is the contact information provided for home or work? Home Work Do not wish to provide contact information

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Q3 Please indicate your professional affiliation (check all that apply). Certified Diabetes Educator/Diabetes Educator Exercise Specialist Health and Wellness Center (HAWC) Staff Health Educator Medical Technician Nurse Practitioner PhD, DrPH Physical Therapist/Occupational Therapist Physician Physician Assistant Psychologist Registered Dietitian/Nutritionist Registered Nurse Researcher Social Worker Student Other (please specify) ____________________

Q4 Are you currently affiliated with the military? Yes No

Answer If Are you currently affiliated with the military? Yes Is SelectedQ5 What is your military affiliation? Active Duty Air Force Active Duty Army Active Duty Marine Active Duty Navy Civilian working for military Contractor Government National Guard Reserve Veterans Administration Staff Other (please specify) ____________________

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Q53 Did you complete Diabetes Prevention Program (DPP) Group Lifestyle Balance (GLB) training between 2012 and 2015? Yes NoIf No Is Selected, Then Skip To Since attending the GLB training work...

Q6 How well do you feel the Group Lifestyle Balance (DPP-GLB) training workshop prepared you for implementation of the DPP-GLB program in each of the following categories?

Very Well Well Fair Poor Very Poor

Evidence and rationale for the GLB program

Nutrition Component

Physical Activity Component

Behavioral Component

Leading Group Sessions

Implementing in the Local Setting

Q7 Considering the DPP-GLB training that you received, please describe any components that were lacking or could have been improved upon:

Q8 Please provide your primary reason(s) for attending the DPP-GLB training workshop (check all that apply). Leadership identified need for diabetes prevention or weight loss program Planning to implement the DPP-GLB program at my site Personal interest in topic Obtainment of continuing education or school credit Involved in research project using DPP-GLB program Other (please specify) ____________________

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Q9 To date, have you implemented the DPP-GLB program in any capacity (either currently or in the past)? Yes NoIf No Is Selected, Then Skip To Please provide the reason(s) below th...

Q10 When did you begin providing the DPP-GLB program? (If you are not sure, please approximate.)

Date (MM/DD/YYYY)

Q11 When did you conclude your most recent DPP-GLB program? Within the past 3 months 3-6 months ago 6-9 months ago 9-12 months ago 1-2 years ago Over 2 years ago

Q12 Please indicate the settings in which you have implemented the DPP-GLB program (check all that apply). Church Community or Senior Center Fitness Center/YMCA Hospital Insurance Provider Military Setting - Endocrinology Practice Military Setting - Health and Wellness Center (HAWC) Military Setting - Primary Care Clinic Out-patient Hospital Clinic Primary Care Practice School/College/University Worksite Other (please specify) ____________________

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Q13 Which of the following marketing methods have you found to be most effective in recruiting participants (check all that apply). Did not market DPP-GLB program Direct mailing E-mail Flyers Health fairs Newsletter Newspaper Social media (Facebook, Twitter, etc.) Telephone Through physician/health care provider TV advertisement Word of mouth Other (please specify) ____________________

Q15 What general eligibility criteria is used for participant enrollment in the DPP-GLB program? BMI > 25 kg/m2 and pre-diabetes BMI > 25 kg/m2 and the metabolic syndrome BMI > 25 kg/m2, pre-diabetes, and/or the metabolic syndrome BMI > 25 kg/m2 and other risk factors (not specifically pre-diabetes and/or the metabolic

syndrome) BMI > 25 kg/m2 only BMI > 25 kg/m2 and large waist measurement Large waist measurement only Other (please specify) ____________________ None

Q16 Please describe the mode you have utilized for delivery of the DPP-GLB Program (check all that apply). One year, DPP-GLB curriculum delivered via face-to-face group meetings One year, DPP-GLB curriculum delivered via DVD with coach support One year, DPP-GLB curriculum delivered via face to face group meetings and/or DVD 12 session core only delivered via face to face group meetings 12 session core only delivered via DVD with coach support 12 session core only delivered via face to face group meetings and/or DVD Other (please specify) ____________________

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Q17 Have you made any modifications to the DPP-GLB program? Yes (if yes, please describe) ____________________ No

Q18 Since the time that you began providing the DPP-GLB program, how many times have you personally delivered the program (either individually or team-taught, including programs that you are currently providing)? 1 time 2-4 times 5-9 times 10 or more times Not sure

Q19 If you are part of a group DPP-GLB delivery system, i.e., hospital health insurer, etc., approximately how many times has the program been delivered within a system? I am not part of a group delivery system 1-5 6-20 21-50 51-100 100+ Not sure

Q20 What is the TOTAL number of participants who have taken part in your DPP-GLB program(s)? 1-10 11-20 21-50 51-100 100+ Not sure

Q21 On average, what percentage of participants attend at least half of the core DPP-GLB sessions? Less than 25% 25% - 49% 50% - 74% 75% - 100% Not sure

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Q22 Other than weight and physical activity, which are collected at each DPP-GLB session, please indicate the clinical outcome measures that are/were collected for GLB participants (check all that apply). Fasting glucose Fasting lipid profile HbA1c Height Waist circumference Other (please specify) ____________________

Q23 Please indicate at what time points these measures are/were collected (check all that apply). Baseline 3 months 6 months 9 months 12 months Other (please specify) Do not collect any additional measures.

Q24 Please indicate what type of database you maintain (if none, please indicate).

Q25 Please rate the following barriers as to how much they affected the administration and/or effectiveness of your program:

Not a barrier Minor barrier Major barrier N/A

Inadequate preparation for DPP-

GLB delivery

Lack of organizational support

Participant drop out

Lack of time

Inclement weather

Language barriers

Lack of trained available staff

Lack of funding

Inadequate meeting space

Parking/transportation

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issues

Participant motivation

Q26 Please indicate any significant barriers to implementation that were not included above:

Q27 In general, what percentage of your participants reach at LEAST a 5% weight loss at 6 months? 0% - 9% 10% - 24% 25% - 49% 50% - 74% 75% - 100% Not sure

Q28 Have you utilized the DPP-GLB DVD (Initial 12 Session Core)? Yes No

Answer If Have you utilized the GLB DVD (12 Session Core)? Yes Is SelectedQ29 How have you utilized the DPP-GLB DVD? (Check all that apply.) DPP-GLB DVD is utilized for make-up sessions. Participants attend group sessions to watch the DVD Participants complete each session individually Participants complete some of the sessions individually and some of the sessions in a group

meeting Other (please specify) ____________________

Q33 What percentage of the DPP-GLB programs that you have provided were funded through grant and/or research funds? 0% 1% - 25% 26% - 50% 51% - 75% 76% - 100% Not sure

36

Q34 Please indicate a response regarding charging a fee for the program: A fee is charged to take part in the DPP-GLB program (please specify amount).

____________________ No fee is charged for the program.

Answer If Please indicate a response regarding charging a fee for the program: No fee is charged for the program Is SelectedQ35 Since you do NOT charge a fee for this program, how are the costs of the DPP-GLB program covered? (If not sure, please enter "not sure" in the box.)

Q36 Have you been able to obtain third-party/insurance reimbursement for DPP-GLB program delivery? Yes No

Answer If Have you been able to obtain third-party reimbursement for GLB program delivery? Yes Is SelectedQ37 Please describe the third party reimbursement you have received:

Q38 The DPSC is interested in keeping our list of current DPP-GLB programs up to date. Please respond regarding current programs being offered: I am currently offering the DPP-GLB program. I am not currently offering the DPP-GLB program.If I am currently offering the... Is Selected, Then Skip To Is your program and contact informati...

Q40 Is your program and contact information the same as what you entered at the beginning of the survey? Yes No

37

Q39 Please provide the reason(s) below that you have not or are not currently offering the DPP-GLB program: (Check all that apply.) Attended the training workshop for reasons other than DPP-GLB program implementation Deployment Feel program is not needed Feel unprepared for DPP-GLB implementation Inability to earn RVUs Lack of funding for program Lack of interest from supervisor Lack of meeting space Lack of staffing Lack of time My job responsibilities have changed such that I am not able to provide the program Not confident participants would commit to the length of the program Unable to recruit participants or lack of community interest Using a different DPP curriculum Other (please specify) ____________________If Attended the training works... Is Selected, Then Skip To How likely is it that you will provid...If Deployment Is Selected, Then Skip To How likely is it that you will provid...If Feel program is not needed Is Selected, Then Skip To How likely is it that you will provid...If Feel unprepared for GLB imp... Is Selected, Then Skip To How likely is it that you will provid...If Inability to earn RVUs Is Selected, Then Skip To How likely is it that you will provid...If Lack of funding for program Is Selected, Then Skip To How likely is it that you will provid...If Lack of interest from super... Is Selected, Then Skip To How likely is it that you will provid...If Lack of meeting space Is Selected, Then Skip To How likely is it that you will provid...If Lack of staffing Is Selected, Then Skip To How likely is it that you will provid...If Lack of time Is Selected, Then Skip To How likely is it that you will provid...If My job responsibilities hav... Is Selected, Then Skip To How likely is it that you will provid...If Not confident participants ... Is Selected, Then Skip To How likely is it that you will provid...If Unable to recruit participants Is Selected, Then Skip To How likely is it that you will provid...If Using a different DPP curri... Is Selected, Then Skip To How likely is it that you will provid...If Other (please specify) Is Selected, Then Skip To How likely is it that you will provid...If Other (please specify) Is Not Empty, Then Skip To How likely is it that you will provid...

38

Q41 Please enter your Group Lifestyle Balance Program location and contact information.NameCompanyAddress 1Address 2City/TownState/ProvinceZIP/Postal CodeCountryEmail addressPhone number

Q42 Please enter the name of a contact person for your DPP-GLB program.

Q43 Would you like your DPP-GLB program and contact information listed on the DPSC website? Yes No

Q44 How likely is it that you will provide the DPP-GLB program within the next year? Very Likely Likely Unlikely Very UnlikelyIf Likely Is Selected, Then Skip To The DPSC website includes a password ...If Very Likely Is Selected, Then Skip To The DPSC website includes a password ...

Q45 Please indicate the primary reason you feel it is unlikely that you will provide the DPP-GLB program in the upcoming year: Administration is not interested/supportive Feel the DPP-GLB program is too labor intensive I am not interested in providing the program I will be deploying Lack of eligible/interested participants Lack of funding Lack of space to hold program My job position has changed Previous attempt at GLB implementation was not successful Other (please specify) ____________________

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Q46 The DPSC website includes a password protected Health Professionals Portal that is available only to those who have completed DPP-GLB training, and contains support materials for program implementation. Please provide your response below regarding the DPSC website Health Professionals Portal. I have not accessed the DPSC website Health Professionals Portal. I have not accessed the DPSC website Health Professionals Portal because I need a

username and password. I have accessed the DPSC website Health Professionals Portal and found it to be useful. I have accessed the DPSC website Health Professionals Portal and found it was NOT useful.

Q47 The DPSC is committed to meeting your DPP-GLB program implementation needs. Please let us know of any additional ways that we might be of assistance to you or what resources would be of value.

Q48 The Centers for Disease Control and Prevention Diabetes Prevention Recognition Program (CDC-DPRP) has been developed to recognize organizations that have shown their ability to effectively deliver a lifestyle change intervention program (lifestyle intervention) to prevent type 2 diabetes.Do you plan to apply or have you already applied to the CDC-DPRP using the DPP-GLB program curriculum? Yes. If yes, please provide the date (or planned date) of application for DPRP

(MM/DD/YYYY). ____________________ NoIf Yes. If yes, please provid... Is Selected, Then Skip To Would you and/or your organization ha...

Q49 Please indicate the reason(s) you do not plan to apply for CDC-DPRP using the DPP-GLB curriculum: (Check all that apply.) Do not feel DPRP is important to our organization Do not intend to provide the DPP-GLB program Do not understand DPRP instructions Have applied to the DPRP using a curriculum other than DPP-GLB Plan to apply to DPRP at some point in the future but not sure when Process for application to the DPRP is too complicated Was not aware of the DPRP Other (please specify) ____________________

Q50 Would you and/or your organization have interest in an online DPP-GLB program for your participants? Yes No Maybe

40

Q52 Please add any additional comments, suggestions or thoughts regarding the DPP-GLB program and/or the DPSC.

41

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