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Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach
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Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach Raymond Boon Tar Lim a,∗ , Wei Keong Wee b , Wei Chek For b , Jayalakshmy Aarthi Ananthanarayanan b , Ying Hua Soh b , Lynette Mei Lim Goh c , Dede Kam Tyng Tham a , Mee Lian Wong a a
Health Systems & Behavioural Sciences, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore City, Singapore b Health Promotion & Preventive Care, National Healthcare Group Polyclinics, Singapore City, Singapore c Clinical Services, National University Polyclinics and National University Health System, Singapore City, Singapore
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Article history:
Aims: To assess factors associated with ever receiving prediabetes education, and to explore
Received 22 March 2019
the health education and communication needs among primary care patients with predia-
Received in revised form
betes in Singapore.
8 August 2019
Methods: A mixed methods study, consisting of a cross-sectional survey involving 433
Accepted 29 August 2019
patients with prediabetes aged 21–79, and in-depth interviews (IDIs) with 48. Multivari-
Available online xxx
able regression was used to analyse the survey results, while thematic analysis was used to analyse the IDIs.
Keywords:
Results: The prevalence of ever receiving prediabetes education was 26.6%. This was
Health education
positively associated with school education, impaired glucose tolerance, number of co-
Prediabetes
morbidities, having family or peer with diabetes, having support to reduce diabetes risk,
Primary care
confidence to self-manage prediabetes, and negatively associated with age. A common
Health communication
reason among those not receiving such education was not being referred by doctors. The
Diabetes prevention
preferred content of health communication messages were to focus on risk and prevention
Mixed methods
of diabetes, health and family, and to avoid the term ‘prediabetes’ in messages. The top 2 preferred education components were healthy eating and physical activity, and the most desired setting was the community centre. Conclusions: More efforts are needed to increase the take-up rate of prediabetes education. Polyclinic healthcare professionals could provide preliminary advice, and subsequently refer patients to community-based programmes or resources. © 2019 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.
Abbreviations: aPR, adjusted prevalence ratio; CI, confidence interval; IDIs, in-depth interviews; NHG, National Healthcare Group; PR, prevalence ratio; US, United States. ∗ Corresponding author at: Health Systems & Behavioural Sciences, Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, National University of Singapore, 12 Science Drive 2, #10-01, 117549, Singapore City, Singapore. E-mail address: [email protected] (R.B.T. Lim). https://doi.org/10.1016/j.pcd.2019.08.008 1751-9918/© 2019 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.
Please cite this article in press as: R.B.T. Lim, et al., Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.08.008
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1.
Introduction
Asia has one of the highest global rates of prediabetes progression to diabetes [1]. In a cohort involving 1376 individuals in India, 58.9% with prediabetes converted to diabetes after 9.1 years [2]. Diabetes is associated with all-cause and cardiovascular disease-related mortality [3] along with huge economic burden [4]. More than 60% of the people with diabetes live in Asia, with almost one-half in China and India [5]. Lifestyle modification remains the primary means to prevent diabetes [6]. A recent meta-analysis of 16 randomised controlled trials showed that people with prediabetes who received dietary and physical activity intervention had a lower rate of progression to diabetes after 3 years of follow-up [7]. As such, current education programmes for prediabetes typically focused on building confidence and skills for self-care, improving diet and physical activity, managing weight, and following periodic medical checks [8,9]. Despite availability of these programmes, its take-up rate remained low beyond the clinical trial setting [10–13]. For example, Hooks-Anderson reported that the uptake of diabetes education among primary care patients with prediabetes was 6.0% in the United States (US) [12]. Among the few studies on health education and communication, gaps still existed in at least 3 areas [7,12,14]. Firstly, these studies were predominantly from the West, for example, there were several publications on The Healthier You: National Health Service Diabetes Prevention Programme which was launched in England in 2016 [15–17]. Patients with prediabetes received education on healthy eating, physical activity and assistance to lose weight. A preliminary analysis showed that overweight patients have lost an average of 3.7 kg over 9 months after attending this programme [17]. More information is needed in the Asia region where most people with prediabetes and diabetes reside. In addition, the needs of those in Asia could be different from the West. Secondly, these studies either focused on health education or communication [7,11–14]. Both education and communication are important because individuals with prediabetes have no obvious symptoms or signs, and often lack understanding on their condition [18,19]. For the practitioners and policymakers, it would be useful to understand the education and communication needs of individuals with prediabetes to better plan programmes and to design messages. Thirdly, evaluation of current programmes showed that they were deliverer-centric rather than user-centric [7]. While few studies such as the Prediabetes Intervention Package in New Zealand was user-centric and considered individual sociocultural context [20], most did not conduct a prior needs assessment to understand this context to develop culturally appropriate education materials [7]. Primary care is often the first setting in the healthcare system where these individuals receive their prediabetes diagnosis, hence providers should endeavour to understand their needs [21]. More studies are required to explore these needs from the user’s perspective in this setting [7]. Like other countries in Asia, the burden of prediabetes and diabetes is high in Singapore. The prevalence of Singapore residents with prediabetes will rise steadily from 15.5% in 2010 to 24.9% in 2035 [22]. The prevalence of diabetes has also been projected to increase from 12.8% in 2014 to 22.7% in 2035 [5].
Prediabetes education is not provided free of charge within the healthcare system in Singapore. Typically, patients are referred by doctors to see a nurse educator or dietitian for prediabetes education in the public primary care setting. They would have to pay a nominal fee of US$5 to US$9. As such, the objectives of the study were to (i) assess the correlates of primary care patients with existing prediabetes who have ever received prediabetes education, and (ii) explore the health education and communication needs of primary care patients with existing prediabetes.
2.
Methods
2.1.
Study design and ethics approval
We used the mixed methods approach, comprising a crosssectional survey (quantitative phase) followed by in-depth interviews (IDIs) (qualitative phase). The study was approved by the National Healthcare Group (NHG) Domain Specific Review Board (approval certificate no. 2016/01358).
2.2.
Quantitative phase
The survey took place in 8 out of 20 polyclinics in Singapore between July 2017 to January 2018. Polyclinics are public healthcare institutions which house primary care doctors and other healthcare professionals such as nurses and dietitians etc. to provide primary care services for patients of all ages. They manage about half of the patient population with chronic illness in Singapore [23]. Being the first point of contact, polyclinic doctors treat acute conditions, manage chronic diseases and keep patients healthy through preventive measures. Polyclinic doctors lead the primary care professional team to co-ordinate patient care in a comprehensive, continuous manner, integrating with secondary and tertiary care, as necessary. Where indicated, they would refer patients to the hospitals for specialist, emergency or inpatient care. At the start of the study, these polyclinics were managed by 2 public healthcare organisations, of which 1 (NHG) agreed to participate. Out of the 9 NHG Polyclinics, 8 participated while the other one declined due to operational constraints. The inclusion criteria for participants were (i) community-dwelling patients with existing prediabetes who was a Singapore citizen or Singapore Permanent Resident aged 21–79 years, (ii) diagnosis verified by oral glucose tolerance test and diagnosis code, and (iii) currently following up at any one of the 8 polyclinics. At the time of the study, participants who had progressed to diabetes or converted back to normoglycemia based on the last laboratory test and diagnosis code were excluded.
2.3. Sampling frame, recruitment process, sample size calculation and survey questionnaire For details of these different sub-sections, please refer to Appendix A.
Please cite this article in press as: R.B.T. Lim, et al., Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.08.008
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2.4.
Assessment of dependent variable
Prediabetes education was assessed using the question, “Have you ever received any education on prediabetes before?”. This included any educational activity that patients received to better understand prediabetes, such as explanation of prediabetes, its risk factors, complications as well as lifestyle modifications to manage the condition. Participant who answered the option of “Yes” was defined as ever received prediabetes education, while those who gave the option of “No” or “Not sure” would be defined as not receiving any prediabetes education before. For participants who answered “Yes”, we also enquired the sources where they received the education.
2.5.
Assessment of independent variables
Sociodemographic factors assessed were sex, ethnicity, marital status, education level, housing type, current work status and age, along with medical history. Proximal social circle influences from family or peer, and perception of prediabetes self-management (i.e. motivation and confidence) were also assessed.
2.6.
Statistical analysis
We obtained the prevalence of participants ever receiving prediabetes education and the components that they would prefer. Bivariate analysis between receiving education and each independent variable were carried out. Categorical variables were compared using chi-square test, ordinal variables with the Mann–Whitney U test and continuous variables with the independent-samples t test. We then evaluated the association between receiving education with each variable using mixed effects Poisson regression model accounting for clustering by polyclinic venue to obtain the crude prevalence ratio (PR) and 95% confidence interval (CI). Poisson rather than logistic regression was used, as the prevalence of ever receiving prediabetes education was more than 10% of the study population [24]. To identify the independent factors, those with crude PR of p < 0.10 were selected for multivariable analysis. A backward stepwise approach was performed to obtain the adjusted PR (aPR) and 95% CI, where only variables with p ≤ 0.05 were included in the final model. All statistical analyses were performed using STATA version 15.0 (Stata Corp, College Station, TX).
2.7.
Qualitative phase
From the 433 survey participants, 48 underwent IDIs from September 2017 to April 2018. Maximum variation sampling strategy was used to recruit a purposive sample from diverse backgrounds based on age, sex and whether they have ever received prediabetes education. The interview was conducted using a topic guide prepared a priori (Appendix B). This was available in English, Mandarin and Malay, and were pilot tested before study commencement. The guide consisted of open-ended questions to explore reasons for not receiving prediabetes education as well as preferred (i) health communication message contents, (ii) communication channels, (iii) subcomponents of healthy eating education, (iv) subcom-
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ponents of physical activity education, and (v) setting for the education programme. The interview was conducted in the participant’s preferred language and was audio recorded with consent. All interviews were conducted by the first and seventh authors to ensure consistency. Duration lasted from 30 min to an hour. Data saturation was reached.
2.8.
Qualitative data analysis
The interviews were transcribed verbatim and checked for accuracy against the recordings. Interviews in Mandarin and Malay were translated into English before transcription. These were then imported into NVivo 11.0 and coded line-by-line. We carried out thematic data analysis using the inductive approach to elicit emergent themes or unexpected findings. The data analysis process was guided by the 6-step procedure from Braun and Clarke 2006 [25]. This involved reading and re-reading through the transcripts to become familiar with the data. The initial codes were then generated by the first and seventh authors independently before coming together to compare the codes. Any discrepancy was resolved through discussion involving all team members and the codebook was finalised. The codes were then categorised and condensed into preliminary subthemes and themes by the same 2 authors independently. Several meetings were held to review, define and name the subthemes and themes. Any discrepancy was again resolved by group discussion.
3.
Results
3.1.
Quantitative phase results
A total of 648 responded out of 948 whom we approached. Of the 648, 433 agreed to take part, giving a participation rate of 66.8%. There was no significant difference between those who participated compared to those who did not in terms of sex, age and ethnicity. Participants mirrored the total NHG Polyclinic patient pool with prediabetes in sex, marital status and age. Table 1 shows the survey participant characteristics according to those who had received prediabetes education versus those who did not. The prevalence of participants who had ever received prediabetes education was 26.6%. Majority of them received the education in polyclinics (74.6%), while others received theirs from community-based programmes (14.9%), online sources and books (4.3%), mass media such as television and radio (2.6%), workplace programmes (1.8%) and hospitals (1.8%). Of note, 49.2% of the participants did not perceive themselves to be at risk for diabetes. Table 2 shows the crude and adjusted PR of factors associated with receiving prediabetes education. On multivariable analysis, the prevalence of prediabetes education was positively associated in those with secondary (aPR 1.42; 1.17–1.72) and post-secondary education (aPR 1.45; 1.05–1.99), those with impaired glucose tolerance (aPR 1.47; 1.05–2.05), number of co-morbidities (aPR 1.08; 1.02–1.14), those with family or peer with diabetes (aPR 1.47; 1.09–1.98), received family or peer support to reduce diabetes risk (aPR 1.54; 1.06–2.24), moderate (aPR 1.74; 1.03–2.93) and high (aPR 1.97; 1.30–2.99) confidence to self-manage prediabetes, as well as negatively associated
Please cite this article in press as: R.B.T. Lim, et al., Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.08.008
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Table 1 – Comparison of sociodemographic characteristics, medical history, proximal social circle influences and perception of prediabetes self-management for those who had received prediabetes education and those who did not. Characteristic
Did not receive prediabetes education (n = 318)
Received prediabetes education (n = 115)
p Value*
Sociodemographic characteristics Sex Female Male
Number (%) 155 (48.7) 163 (51.3)
56 (48.7) 59 (51.3)
0.99
Ethnicity Chinese Malay Indian Others
258 (81.1) 33 (10.4) 22 (6.9) 5 (1.6)
91 (79.1) 17 (14.8) 7 (6.1) 0 (0)
0.34
Marital status Single Married
43 (13.5) 275 (86.5)
17 (14.8) 98 (85.2)
0.74
Highest education level No formal education/primary Secondary Post-secondary
109 (34.3) 130 (40.9) 79 (24.8)
24 (20.9) 51 (44.3) 40 (34.8)
0.02
Housing typea 1–3 room public housing 4–5 room public housing Executive flat/private property
67 (21.2) 189 (59.8) 60 (19.0)
14 (12.2) 71 (61.7) 30 (26.1)
0.06
Current work status Currently working Not working
176 (55.3) 142 (44.7)
69 (60.0) 46 (40.0)
0.39
Age in years, mean (SD)
62.4 (8.8)
60.7 (7.7)
0.03
Medical history Type of prediabetes Impaired fasting glycaemia Impaired glucose tolerance
182 (57.2) 136 (42.8)
49 (42.6) 66 (57.4)
0.007
Years with prediabetes, mean (SD)
2.1 (2.3)
2.0 (2.1)
0.99
Number of co-morbidities, median (IQR)b
2.0 (1.0–2.0)
2.0 (1.0–2.0)
0.18
Proximal social circle influences Family or peer with prediabetes No Yes
283 (89.0) 35 (11.0)
94 (81.7) 21 (18.3)
0.05
Family or peer with diabetes No Yes
146 (45.9) 172 (54.1)
35 (30.4) 80 (69.6)
0.004
Received family or peer support to reduce diabetes risk 275 (86.5) No 43 (13.5) Yes
83 (72.2) 32 (27.8)
0.001
Perception of prediabetes self-management Motivation to self-manage prediabetes Low Moderate High
55 (17.3) 74 (23.3) 189 (59.4)
11 (9.6) 31 (26.9) 73 (63.5)
0.13
Confidence to self-manage prediabetes Low Moderate High
46 (14.5) 74 (23.3) 198 (62.2)
7 (6.1) 25 (21.7) 83 (72.2)
0.04
All figures in the table referred to frequency (column percentage) unless otherwise indicated. Contained missing number (housing type, 2). b The list of co-morbidities included chronic diseases commonly encountered in the primary care setting in Singapore such as hypertension, lipid disorders, stroke, heart disease, kidney disease, gout, asthma, cancer, arthritis etc. ∗ The p-values were computed using 2 test or Fisher Exact test (whichever appropriate) for categorical variables, ordinal variables with the Mann–Whitney U test, and two-sample t-test for continuous variables. a
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Table 2 – Crude and adjusted prevalence ratio (PR) of sociodemographic characteristics, medical history, proximal social circle influences and perception of prediabetes self-management associated with receiving prediabetes education. Characteristic
Crude PR (95% CI)
Adjusted PRc (95% CI)
Sociodemographic characteristics Sex Female Male
Referent 1.00 (0.76–1.32)
0.94 (0.70–1.27)
Ethnicity Chinese Malay Indian
Referent 1.30 (0.85–2.00) 0.93 (0.41–2.08)
1.14 (0.79–1.63) 0.78 (0.40–1.51)
Marital status Single Married
Referent 0.93 (0.68–1.26)
0.94 (0.65–1.35)
Highest education level No formal education/primary Secondary Post-secondary
Referent 1.56 (1.28–1.91) 1.86 (1.28–2.72)
1.42 (1.17–1.72)d 1.45 (1.05–1.99)d
Housing typea 1–3 room public housing 4–5 room public housing Executive flat/private property
Referent 1.58 (0.98–2.54) 1.93 (0.94–3.96)
1.51 (0.89–2.59) 1.70 (0.80–3.60)
Current work status Currently working Not working
Referent 0.87 (0.71–1.07)
0.97 (0.74–1.28)
Age in years
0.98 (0.97–0.99)
0.99 (0.98–0.99)d
Medical history Type of prediabetes Impaired fasting glycaemia Impaired glucose tolerance
Referent 1.54 (1.08–2.19)
1.47 (1.05–2.05)d
Years with prediabetes
0.99 (0.94–1.04)
0.99 (0.93–1.04)
Number of co-morbidities
1.08 (1.00–1.16)
1.08 (1.02–1.14)d
Proximal social circle influences Family or peer with prediabetes No Yes
Referent 1.50 (0.94–2.40)
1.41 (0.85–2.35)
Family or peer with diabetes No Yes
Referent 1.64 (1.19–2.27)
1.47 (1.09–1.98)d
Received family or peer support to reduce diabetes risk No Yes
Referent 1.84 (1.37–2.47)
1.54 (1.06–2.24)d
Perception of prediabetes self-management Motivation to self-manage prediabetes Low Moderate High
Referent 1.77 (1.08–2.89) 1.67 (1.18–2.37)
1.34 (0.68–2.64) 0.83 (0.50–1.37)
Confidence to self-manage prediabetes Low Moderate High
Referent 1.91 (1.22–3.00) 2.24 (1.57–3.19)
1.74 (1.03–2.93)d 1.97 (1.30–2.99)d
b
e
a b c
d e
Contained missing number (housing type, 2). Ethnicity under “Other” not included as there was none who received prediabetes education. The aPR of the variables that were not significant at the 5% level was obtained by incorporating that particular variable in the final multivariable model. These variables were significant at the 5% level and were included in the final multivariable model using the backward stepwise approach. The list of co-morbidities included chronic diseases commonly encountered in the primary care setting in Singapore such as hypertension, lipid disorders, stroke, heart disease, kidney disease, gout, asthma, cancer, arthritis etc.
Please cite this article in press as: R.B.T. Lim, et al., Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.08.008
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Fig. 1 – Components of health education programme that patients with prediabetes would prefer.
Table 3 – Participant characteristics for the in-depth interviews. Characteristic
N = 48
Sociodemographic characteristics Sex Female Male
Number (%) 24 (50.0) 24 (50.0)
Ethnicity Chinese Malay Indian
37 (77.1) 6 (12.5) 5 (10.4)
Age in years, mean (SD)
59.8 (9.1)
Ever received prediabetes education No Yes
30 (62.5) 18 (37.5)
All figures in the table referred to frequency (column percentage) unless otherwise indicated.
with age (aPR 0.99; 0.98 – 0.99). Fig. 1 shows the components of health education programme that patients with prediabetes would prefer. The top 2 components were healthy eating (62.3%) and physical activity (60.4%).
3.2.
Qualitative phase results
Table 3 shows the IDI participant characteristics.
3.3.
Reasons for not receiving prediabetes education
Several reasons were cited by participants who had never received prediabetes education. The common ones included not being referred for education by doctors, no time to receive education due to other pressing commitments like work and family, not aware or lack of information on where they could seek education, perceived no benefits from receiving education, did not feel at risk of diabetes, and have not experienced any negative consequences of prediabetes yet. Other reasons included not willing to pay for education, satisfaction with
current blood sugar control, satisfaction with own prediabetes knowledge, and have not accepted their prediabetes diagnosis.
3.4. Preferred health communication message contents (Fig. 2a) Participants’ views were different according to whether they had ever received prediabetes education in the following aspects. Those who had received prediabetes education preferred that the message focused on diabetes, e.g. emphasising the personalised risk of diabetes, “You must emphasise the risk of getting diabetes if someone with prediabetes does not control his diet and does not engage in any exercise. This is especially so for people who do not know their risk or if they feel that they are low risk. The message should indicate the risk of getting diabetes in a year’s time.” (AMK 054, 67 years old Chinese male). For some, they preferred to see messages emphasising complications of diabetes, “Diabetes is a serious illness, can lead to complications like leg amputations, so it’s important to highlight diabetes is no joke.” (AMK 063, 60 years old Chinese female). For others, it was to emphasis the high medical costs, “You have to emphasis the high cost of having diabetes, and that taking care of your health also means taking care of your pocket.” (TPY 039, 56 years old Chinese male). In contrast, participants who had never received prediabetes education expressed that the message should avoid labelling, “When you want to design public messages for those with prediabetes, I would urge you all to be more sensitive with the term [prediabetes] used, the surrounding people will see and label, ’this group has illness’, so this will make people with prediabetes feel uncomfortable.” (CCK 039, 55 years old Chinese male). Both groups of participants however shared similar views in the following aspects. The first was to focus on promoting prevention. These messages could (i) promote healthy eating, “You have to promote healthy eating and point out that in Singapore a lot of people are not eating too healthily. In your message, you can encourage people to eat all foods in moderation.” (WDL 019, 65 years old Malay male); (ii) promote physical activity, “The message needs to reinforce the value of being physically active. Talk about the various advantages of exercising, for example can lose weight in a healthy way.” (WDL 056, 55 years old Malay female); (iii)
Please cite this article in press as: R.B.T. Lim, et al., Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.08.008
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c
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d
Fig. 2 – (a) Themes and subthemes pertaining to preferred health communication message contents. (b) Preferred communication channels. (c) Themes and subthemes pertaining to subcomponents of healthy eating education. (d) Themes and subthemes pertaining to subcomponents of physical activity education.
promote screening, “We have health screening for various cancers. But I don’t think a lot of people know that there is also screening available for diabetes. Therefore, I think in your message, you should talk about screening for diabetes.” (TPY 004, 24 years old Chinese male); and (iv) emphasise that diabetes can be prevented, “Talk about diabetes prevention, for example mention that diabetes can be
prevented, and give examples of how a person can do that.” (AMK 007, 68 years old Chinese female). The second was on emphasising the family, “You need to bring in the family in your messaging. Something about living healthy for your family, for your grandchildren. If you tell them you keep healthy so that you can enjoy a more meaningful life with your
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family, that will help.” (AMK 075, 56 years old Chinese female). The third was on emphasising health, “The main message should be that all of us aspire to have a healthy body, as health is wealth. With a healthy body, then you can live life to the fullest.” (YIS 002, 57 years old Malay female).
3.5.
Preferred communication channels (Fig. 2b)
All participants regardless of their prediabetes education status reported more than one source of preferred communication channel. For face-to-face channels, most participants particularly those who had never received prediabetes education preferred their primary care providers to actively refer them for education, “The staff at the polyclinic such as the doctors can provide us some basic information on prediabetes, after that they should take the initiative to refer us for further education.” (AMK 078, 60 years old Indian female). Another common preference was peer educators, “Get people of the same background to spread the message, people who also have prediabetes. It would be easier for us to identify and learn from them.” (BBK 008, 65 years old Chinese female). Other face-to-face channels included celebrities, religious leaders, management from workplaces and members of parliaments. For non-face-to-face channels, these were TV, radio, newspapers, phone call and text, pamphlets, public transport and neighbourhood advertisements. There was a greater preference for traditional media than new ones such as online portal and social media. While some were keen to access information online, others were also concerned whether they have the skills or means to access them.
3.6. Preferred subcomponents of healthy eating education (Fig. 2c) Both groups of participants had largely similar views on this. Participants would like to be taught certain knowledge on healthy eating. For example, what is a healthy diet, “All of us have different definitions of a healthy diet. Perhaps it will be good if you can let us know the guidelines and the recommendations of a healthy diet.” (CCK 001, 56 years old Chinese female), and the consequences of eating unhealthily, “You see people just fixate on sugar, probably because of diabetes. But sugar is just one component of an unhealthy diet, you need to educate us on other components, such as how fatty food can also be harmful.” (AMK 097, 58 years old Chinese female). Participants would also want to be taught specific skills on healthy eating. One preference was on how to read food labels, “Sometimes when I go to the supermarket, I do see the labels, but I don’t know how to read them, and I don’t know how to differentiate between healthy and unhealthy food.” (WDL 068, 55 years old Malay female), while another was how to eat out more healthily, “How to eat out in a healthier way and to choose outside food more wisely, I think this is an important skill for people who don’t usually cook at home to learn.” (HOU 041, 46 years old Indian female). Others expressed preference such as how to evaluate personal diet, “Teaching us how to look at our plate, evaluate if this is healthy or am I getting enough fruits or veggie, am I getting enough wholegrains.” (TPY 004, 24 years old Chinese male), and how to prepare healthy food, “There should be cooking demonstrations where you teach recipes on healthy food.
The recipes must use healthy food that’s cheap, easy to prepare, and tasty.” (WDL 011, 71 years old Chinese male).
3.7. Preferred subcomponents of physical activity education (Fig. 2d) The views of participants on this were largely similar regardless of their prediabetes education status. For physical activity education, participants would like to be given certain knowledge. For example, what is considered physical activity, “You have to tell people what is exactly exercise, what type of exercises are considered physical activity.” (AMK 078, 60 years old Indian female), and the benefits of physical activity, “Let us know the advantages of the common types of exercise and how that would benefit our body. For example, the benefits of swimming, what does it do to the body. If you’re doing yoga, what are the advantages. This is so that each of us know what exercise to pick for ourselves.” (AMK 097, 58 years old Chinese female). Participants would also want to be taught specific skills on physical activity. One preference was on how to evaluate personal physical activity level, “Most people do exercise in the wrong way. Better to get trainers to teach us how to assess our physical activity level, and whether we are doing it correctly or not.” (YIS 005, 57 years old Malay female), and another was on how to be more physically active, “You should incorporate a component to teach us how to be more physically active, share with us ideas on how to incorporate exercise in our daily lives.” (TPY 009, 75 years old Chinese male). Others expressed preference on how to exercise for the elderly, “Right now, the exercises that are recommended appear to be more appropriate for the young and middle aged, so I don’t know whether these are suitable for the elderly too. You might want to teach the elderly specifically how to exercise.” (AMK 075, 56 years old Chinese female), and how to exercise for people with certain medical issues, “A lot of times we don’t know what kind of exercises we can do, what is appropriate for people like us with knee pain.” (HOU 041, 46 years old Indian female).
3.8.
Preferred setting for the education programme
Participants gave various suggestions on the preferred venue for the education programme, such as community centres, polyclinics, hospitals, shopping malls, parks and hawker centres. Almost all participants (regardless of their prediabetes education status) expressed that community centre was their most preferred venue.
4.
Discussion
This study found a low prevalence of primary care patients who have ever received education on prediabetes, along with factors associated with receiving the education. The qualitative results also revealed several gaps in health education and communication needs of these patients. Polyclinic doctors and primary care patients have contributed to this low prevalence of education as reflected in our IDIs, consistent with the findings of other studies. Doctors seldom discuss prediabetes or refer these patients for education due to various reasons such as heavy patient load, poor understanding on prediabetes, lacking the skills or confidence to counsel these
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patients on prediabetes [8,26]. Individuals with prediabetes seldom actively seek education due to various reasons such as lack of awareness, not being informed on the availability of such educational programmes, not willing to pay or travel far to receive education [27]. Our participants were generally receptive to receiving more education and have indicated that they would like to be taught on healthy eating and physical activity. To increase the take-up rate of education programmes, one strategy would be to train primary care doctors so that they could initiate conversations on prediabetes during their encounters with these patients. If this is not possible within the busy primary care setting, they should direct these patients to nurse educators, or even refer to community resources. Another strategy would be to extend the education from the primary care setting to the community [28]. This aligned with our finding where participants most preferred community-based programmes. In countries such as Singapore where there are community aggregate areas (e.g. community centres), these could be used to hold the health education programmes. Specific skills such as how to cook healthy food as well as how to exercise for the elderly and those with medical issues could also be demonstrated in these places. In addition, the family or peer could be involved when these programmes are held in the community. The family is often regarded as the basic societal unit in Asia [29] and is influential in the self-management of a chronic illness such as diabetes [30]. Similarly, peer support is also effective in improving health behaviours in disease management including diabetes [31]. While prediabetes might not be as complex as diabetes, our survey and IDI results have revealed the preference for greater family and peer involvement. As such, they could potentially be engaged as agents of change and the education programme be promoted as a family/peer bonding activity. Our proportion (49.2%) of participants who did not perceive themselves to be at risk for diabetes was comparable to other studies where the prevalence varied from 28.4% to 74.0% [32–34]. This discordance between perceived and actual risk indicates an unrealistic optimism concerning diabetes [35]. Convincing these patients to adopt healthier behaviours would be difficult if they believe they are not susceptible to diabetes or less susceptible than others. Our findings have indicated a clear need to enhance risk communication in diabetes prevention, particularly among this subgroup. There are 2 general approaches to this: (i) probability-based where numerical information regarding the probability of a given risk occurring are presented (e.g. risk score of having diabetes), and (ii) contextualised-based where informational context to understand and interpret a given risk are provided (e.g. information on prevalence, causes and complications of diabetes) [36]. Both have been highlighted by participants in our IDIs as preferred message contents. Primary care professionals should take these into account when they counsel individuals with prediabetes. Similarly, policymakers and health promoters need to be aware of these when designing public health messages on diabetes prevention. Participants specifically pointed out that health messages should avoid the term ‘prediabetes’ to avoid labelling. While the American Diabetes Association has endorsed this terminology, World Health Organisation and International Diabetes
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Federation have discouraged its use [37]. Although this might be a useful way to indicate the seriousness of the condition, there have been concerns on its use in health education materials and messages [14,38,39]. This is particularly for individuals without any knowledge on the condition, those with anxiety about future complications, and those with low perceived self-efficacy [37]. Instead of focusing on the preventability of progression to diabetes, and the need for lifestyle change, there is the concern that these individuals would focus on the label itself [14,38,39]. Future studies could assess the impact of the use of this term in health education materials and messages. Moreover, our participants have expressed that messages should emphasise on prevention rather than on medical treatment. Other studies have also called for more attention on the action that individuals should take to prevent diabetes [14,38,39], such as promotion of healthy diet and physical activity or screening, rather than on “medicalisation” as highlighted by our participants. This study has some limitations. Firstly, during the qualitative phase, we did not show the transcript to the participants to confirm whether their responses had been accurately documented. Despite this, the interviewers regularly “check back” with the participants to ascertain that their responses were rightfully understood. Secondly the sole reliance on selfreported data may have resulted in social desirability bias. However, this was expected to be minimal given the steps taken to reduce this bias described in Appendix A. Thirdly, causal relationships could not be inferred from the crosssectional study (quantitative component). Fourthly, we could not differentiate whether these patients were actively seeking or passively receiving education based on the question assessing prediabetes education. We also did not examine referral rate by doctors and their reasons for non-referral, hence future studies could explore this. Despite this, there were various strengths. This was one of the very few studies to adopt a mixed methods approach in understanding the health education and communication needs among primary care patients at high risk of diabetes. This approach enabled triangulation as some of the correlates in the quantitative analysis were also recurrent themes in the qualitative analysis. The IDI findings have also helped us to better understand their needs. Data saturation was also reached for the qualitative analysis. Although the study sample was not generalisable to all individuals with prediabetes in Singapore, the sample was largely representative of the total NHG Polyclinic patient pool with prediabetes since it mirrored this population in sex, marital status and age. More needs to be done to fill the gaps in health education and communication needs of primary care patients with prediabetes in Singapore. Polyclinic healthcare professionals could provide preliminary advice, and subsequently refer patients to community-based programmes or resources.
Funding The study was funded through the War on Diabetes seed funding, Saw Swee Hock School of Public Health, National University of Singapore. The funding committee did not play a role in the design, conduct or analysis of the study nor in the drafting of this manuscript.
Please cite this article in press as: R.B.T. Lim, et al., Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.08.008
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Conflict of interest [13]
The authors state that they have no conflict of interest. [14]
Acknowledgements The authors would like to thank Zheng Kang Lum, Alwyn Ng, Michelle Tan, Qiao Jing Lee, Siti Wan, Wei Liang Tan, Erica Lim and Clifford Lok for their contribution to the study, as well as the Public Health Translational Team of the Saw Swee Hock School of Public Health for their inputs to the study.
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Appendix A. Supplementary data [17]
Supplementary material related to cle can be found, in the online doi:https://doi.org/10.1016/j.pcd.2019.08.008.
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Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach Raymond Boon Tar Lim a,∗ , Wei Keong Wee b , Wei Chek For b , Jayalakshmy Aarthi Ananthanarayanan b , Ying Hua Soh b , Lynette Mei Lim Goh c , Dede Kam Tyng Tham a , Mee Lian Wong a a
Health Systems & Behavioural Sciences, Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore City, Singapore b Health Promotion & Preventive Care, National Healthcare Group Polyclinics, Singapore City, Singapore c Clinical Services, National University Polyclinics and National University Health System, Singapore City, Singapore
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aims: To assess factors associated with ever receiving prediabetes education, and to explore
Received 22 March 2019
the health education and communication needs among primary care patients with predia-
Received in revised form
betes in Singapore.
8 August 2019
Methods: A mixed methods study, consisting of a cross-sectional survey involving 433
Accepted 29 August 2019
patients with prediabetes aged 21–79, and in-depth interviews (IDIs) with 48. Multivari-
Available online xxx
able regression was used to analyse the survey results, while thematic analysis was used to analyse the IDIs.
Keywords:
Results: The prevalence of ever receiving prediabetes education was 26.6%. This was
Health education
positively associated with school education, impaired glucose tolerance, number of co-
Prediabetes
morbidities, having family or peer with diabetes, having support to reduce diabetes risk,
Primary care
confidence to self-manage prediabetes, and negatively associated with age. A common
Health communication
reason among those not receiving such education was not being referred by doctors. The
Diabetes prevention
preferred content of health communication messages were to focus on risk and prevention
Mixed methods
of diabetes, health and family, and to avoid the term ‘prediabetes’ in messages. The top 2 preferred education components were healthy eating and physical activity, and the most desired setting was the community centre. Conclusions: More efforts are needed to increase the take-up rate of prediabetes education. Polyclinic healthcare professionals could provide preliminary advice, and subsequently refer patients to community-based programmes or resources. © 2019 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.
Abbreviations: aPR, adjusted prevalence ratio; CI, confidence interval; IDIs, in-depth interviews; NHG, National Healthcare Group; PR, prevalence ratio; US, United States. ∗ Corresponding author at: Health Systems & Behavioural Sciences, Saw Swee Hock School of Public Health, National University of Singapore, Tahir Foundation Building, National University of Singapore, 12 Science Drive 2, #10-01, 117549, Singapore City, Singapore. E-mail address: [email protected] (R.B.T. Lim). https://doi.org/10.1016/j.pcd.2019.08.008 1751-9918/© 2019 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.
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1.
Introduction
Asia has one of the highest global rates of prediabetes progression to diabetes [1]. In a cohort involving 1376 individuals in India, 58.9% with prediabetes converted to diabetes after 9.1 years [2]. Diabetes is associated with all-cause and cardiovascular disease-related mortality [3] along with huge economic burden [4]. More than 60% of the people with diabetes live in Asia, with almost one-half in China and India [5]. Lifestyle modification remains the primary means to prevent diabetes [6]. A recent meta-analysis of 16 randomised controlled trials showed that people with prediabetes who received dietary and physical activity intervention had a lower rate of progression to diabetes after 3 years of follow-up [7]. As such, current education programmes for prediabetes typically focused on building confidence and skills for self-care, improving diet and physical activity, managing weight, and following periodic medical checks [8,9]. Despite availability of these programmes, its take-up rate remained low beyond the clinical trial setting [10–13]. For example, Hooks-Anderson reported that the uptake of diabetes education among primary care patients with prediabetes was 6.0% in the United States (US) [12]. Among the few studies on health education and communication, gaps still existed in at least 3 areas [7,12,14]. Firstly, these studies were predominantly from the West, for example, there were several publications on The Healthier You: National Health Service Diabetes Prevention Programme which was launched in England in 2016 [15–17]. Patients with prediabetes received education on healthy eating, physical activity and assistance to lose weight. A preliminary analysis showed that overweight patients have lost an average of 3.7 kg over 9 months after attending this programme [17]. More information is needed in the Asia region where most people with prediabetes and diabetes reside. In addition, the needs of those in Asia could be different from the West. Secondly, these studies either focused on health education or communication [7,11–14]. Both education and communication are important because individuals with prediabetes have no obvious symptoms or signs, and often lack understanding on their condition [18,19]. For the practitioners and policymakers, it would be useful to understand the education and communication needs of individuals with prediabetes to better plan programmes and to design messages. Thirdly, evaluation of current programmes showed that they were deliverer-centric rather than user-centric [7]. While few studies such as the Prediabetes Intervention Package in New Zealand was user-centric and considered individual sociocultural context [20], most did not conduct a prior needs assessment to understand this context to develop culturally appropriate education materials [7]. Primary care is often the first setting in the healthcare system where these individuals receive their prediabetes diagnosis, hence providers should endeavour to understand their needs [21]. More studies are required to explore these needs from the user’s perspective in this setting [7]. Like other countries in Asia, the burden of prediabetes and diabetes is high in Singapore. The prevalence of Singapore residents with prediabetes will rise steadily from 15.5% in 2010 to 24.9% in 2035 [22]. The prevalence of diabetes has also been projected to increase from 12.8% in 2014 to 22.7% in 2035 [5].
Prediabetes education is not provided free of charge within the healthcare system in Singapore. Typically, patients are referred by doctors to see a nurse educator or dietitian for prediabetes education in the public primary care setting. They would have to pay a nominal fee of US$5 to US$9. As such, the objectives of the study were to (i) assess the correlates of primary care patients with existing prediabetes who have ever received prediabetes education, and (ii) explore the health education and communication needs of primary care patients with existing prediabetes.
2.
Methods
2.1.
Study design and ethics approval
We used the mixed methods approach, comprising a crosssectional survey (quantitative phase) followed by in-depth interviews (IDIs) (qualitative phase). The study was approved by the National Healthcare Group (NHG) Domain Specific Review Board (approval certificate no. 2016/01358).
2.2.
Quantitative phase
The survey took place in 8 out of 20 polyclinics in Singapore between July 2017 to January 2018. Polyclinics are public healthcare institutions which house primary care doctors and other healthcare professionals such as nurses and dietitians etc. to provide primary care services for patients of all ages. They manage about half of the patient population with chronic illness in Singapore [23]. Being the first point of contact, polyclinic doctors treat acute conditions, manage chronic diseases and keep patients healthy through preventive measures. Polyclinic doctors lead the primary care professional team to co-ordinate patient care in a comprehensive, continuous manner, integrating with secondary and tertiary care, as necessary. Where indicated, they would refer patients to the hospitals for specialist, emergency or inpatient care. At the start of the study, these polyclinics were managed by 2 public healthcare organisations, of which 1 (NHG) agreed to participate. Out of the 9 NHG Polyclinics, 8 participated while the other one declined due to operational constraints. The inclusion criteria for participants were (i) community-dwelling patients with existing prediabetes who was a Singapore citizen or Singapore Permanent Resident aged 21–79 years, (ii) diagnosis verified by oral glucose tolerance test and diagnosis code, and (iii) currently following up at any one of the 8 polyclinics. At the time of the study, participants who had progressed to diabetes or converted back to normoglycemia based on the last laboratory test and diagnosis code were excluded.
2.3. Sampling frame, recruitment process, sample size calculation and survey questionnaire For details of these different sub-sections, please refer to Appendix A.
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2.4.
Assessment of dependent variable
Prediabetes education was assessed using the question, “Have you ever received any education on prediabetes before?”. This included any educational activity that patients received to better understand prediabetes, such as explanation of prediabetes, its risk factors, complications as well as lifestyle modifications to manage the condition. Participant who answered the option of “Yes” was defined as ever received prediabetes education, while those who gave the option of “No” or “Not sure” would be defined as not receiving any prediabetes education before. For participants who answered “Yes”, we also enquired the sources where they received the education.
2.5.
Assessment of independent variables
Sociodemographic factors assessed were sex, ethnicity, marital status, education level, housing type, current work status and age, along with medical history. Proximal social circle influences from family or peer, and perception of prediabetes self-management (i.e. motivation and confidence) were also assessed.
2.6.
Statistical analysis
We obtained the prevalence of participants ever receiving prediabetes education and the components that they would prefer. Bivariate analysis between receiving education and each independent variable were carried out. Categorical variables were compared using chi-square test, ordinal variables with the Mann–Whitney U test and continuous variables with the independent-samples t test. We then evaluated the association between receiving education with each variable using mixed effects Poisson regression model accounting for clustering by polyclinic venue to obtain the crude prevalence ratio (PR) and 95% confidence interval (CI). Poisson rather than logistic regression was used, as the prevalence of ever receiving prediabetes education was more than 10% of the study population [24]. To identify the independent factors, those with crude PR of p < 0.10 were selected for multivariable analysis. A backward stepwise approach was performed to obtain the adjusted PR (aPR) and 95% CI, where only variables with p ≤ 0.05 were included in the final model. All statistical analyses were performed using STATA version 15.0 (Stata Corp, College Station, TX).
2.7.
Qualitative phase
From the 433 survey participants, 48 underwent IDIs from September 2017 to April 2018. Maximum variation sampling strategy was used to recruit a purposive sample from diverse backgrounds based on age, sex and whether they have ever received prediabetes education. The interview was conducted using a topic guide prepared a priori (Appendix B). This was available in English, Mandarin and Malay, and were pilot tested before study commencement. The guide consisted of open-ended questions to explore reasons for not receiving prediabetes education as well as preferred (i) health communication message contents, (ii) communication channels, (iii) subcomponents of healthy eating education, (iv) subcom-
3
ponents of physical activity education, and (v) setting for the education programme. The interview was conducted in the participant’s preferred language and was audio recorded with consent. All interviews were conducted by the first and seventh authors to ensure consistency. Duration lasted from 30 min to an hour. Data saturation was reached.
2.8.
Qualitative data analysis
The interviews were transcribed verbatim and checked for accuracy against the recordings. Interviews in Mandarin and Malay were translated into English before transcription. These were then imported into NVivo 11.0 and coded line-by-line. We carried out thematic data analysis using the inductive approach to elicit emergent themes or unexpected findings. The data analysis process was guided by the 6-step procedure from Braun and Clarke 2006 [25]. This involved reading and re-reading through the transcripts to become familiar with the data. The initial codes were then generated by the first and seventh authors independently before coming together to compare the codes. Any discrepancy was resolved through discussion involving all team members and the codebook was finalised. The codes were then categorised and condensed into preliminary subthemes and themes by the same 2 authors independently. Several meetings were held to review, define and name the subthemes and themes. Any discrepancy was again resolved by group discussion.
3.
Results
3.1.
Quantitative phase results
A total of 648 responded out of 948 whom we approached. Of the 648, 433 agreed to take part, giving a participation rate of 66.8%. There was no significant difference between those who participated compared to those who did not in terms of sex, age and ethnicity. Participants mirrored the total NHG Polyclinic patient pool with prediabetes in sex, marital status and age. Table 1 shows the survey participant characteristics according to those who had received prediabetes education versus those who did not. The prevalence of participants who had ever received prediabetes education was 26.6%. Majority of them received the education in polyclinics (74.6%), while others received theirs from community-based programmes (14.9%), online sources and books (4.3%), mass media such as television and radio (2.6%), workplace programmes (1.8%) and hospitals (1.8%). Of note, 49.2% of the participants did not perceive themselves to be at risk for diabetes. Table 2 shows the crude and adjusted PR of factors associated with receiving prediabetes education. On multivariable analysis, the prevalence of prediabetes education was positively associated in those with secondary (aPR 1.42; 1.17–1.72) and post-secondary education (aPR 1.45; 1.05–1.99), those with impaired glucose tolerance (aPR 1.47; 1.05–2.05), number of co-morbidities (aPR 1.08; 1.02–1.14), those with family or peer with diabetes (aPR 1.47; 1.09–1.98), received family or peer support to reduce diabetes risk (aPR 1.54; 1.06–2.24), moderate (aPR 1.74; 1.03–2.93) and high (aPR 1.97; 1.30–2.99) confidence to self-manage prediabetes, as well as negatively associated
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Table 1 – Comparison of sociodemographic characteristics, medical history, proximal social circle influences and perception of prediabetes self-management for those who had received prediabetes education and those who did not. Characteristic
Did not receive prediabetes education (n = 318)
Received prediabetes education (n = 115)
p Value*
Sociodemographic characteristics Sex Female Male
Number (%) 155 (48.7) 163 (51.3)
56 (48.7) 59 (51.3)
0.99
Ethnicity Chinese Malay Indian Others
258 (81.1) 33 (10.4) 22 (6.9) 5 (1.6)
91 (79.1) 17 (14.8) 7 (6.1) 0 (0)
0.34
Marital status Single Married
43 (13.5) 275 (86.5)
17 (14.8) 98 (85.2)
0.74
Highest education level No formal education/primary Secondary Post-secondary
109 (34.3) 130 (40.9) 79 (24.8)
24 (20.9) 51 (44.3) 40 (34.8)
0.02
Housing typea 1–3 room public housing 4–5 room public housing Executive flat/private property
67 (21.2) 189 (59.8) 60 (19.0)
14 (12.2) 71 (61.7) 30 (26.1)
0.06
Current work status Currently working Not working
176 (55.3) 142 (44.7)
69 (60.0) 46 (40.0)
0.39
Age in years, mean (SD)
62.4 (8.8)
60.7 (7.7)
0.03
Medical history Type of prediabetes Impaired fasting glycaemia Impaired glucose tolerance
182 (57.2) 136 (42.8)
49 (42.6) 66 (57.4)
0.007
Years with prediabetes, mean (SD)
2.1 (2.3)
2.0 (2.1)
0.99
Number of co-morbidities, median (IQR)b
2.0 (1.0–2.0)
2.0 (1.0–2.0)
0.18
Proximal social circle influences Family or peer with prediabetes No Yes
283 (89.0) 35 (11.0)
94 (81.7) 21 (18.3)
0.05
Family or peer with diabetes No Yes
146 (45.9) 172 (54.1)
35 (30.4) 80 (69.6)
0.004
Received family or peer support to reduce diabetes risk 275 (86.5) No 43 (13.5) Yes
83 (72.2) 32 (27.8)
0.001
Perception of prediabetes self-management Motivation to self-manage prediabetes Low Moderate High
55 (17.3) 74 (23.3) 189 (59.4)
11 (9.6) 31 (26.9) 73 (63.5)
0.13
Confidence to self-manage prediabetes Low Moderate High
46 (14.5) 74 (23.3) 198 (62.2)
7 (6.1) 25 (21.7) 83 (72.2)
0.04
All figures in the table referred to frequency (column percentage) unless otherwise indicated. Contained missing number (housing type, 2). b The list of co-morbidities included chronic diseases commonly encountered in the primary care setting in Singapore such as hypertension, lipid disorders, stroke, heart disease, kidney disease, gout, asthma, cancer, arthritis etc. ∗ The p-values were computed using 2 test or Fisher Exact test (whichever appropriate) for categorical variables, ordinal variables with the Mann–Whitney U test, and two-sample t-test for continuous variables. a
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Table 2 – Crude and adjusted prevalence ratio (PR) of sociodemographic characteristics, medical history, proximal social circle influences and perception of prediabetes self-management associated with receiving prediabetes education. Characteristic
Crude PR (95% CI)
Adjusted PRc (95% CI)
Sociodemographic characteristics Sex Female Male
Referent 1.00 (0.76–1.32)
0.94 (0.70–1.27)
Ethnicity Chinese Malay Indian
Referent 1.30 (0.85–2.00) 0.93 (0.41–2.08)
1.14 (0.79–1.63) 0.78 (0.40–1.51)
Marital status Single Married
Referent 0.93 (0.68–1.26)
0.94 (0.65–1.35)
Highest education level No formal education/primary Secondary Post-secondary
Referent 1.56 (1.28–1.91) 1.86 (1.28–2.72)
1.42 (1.17–1.72)d 1.45 (1.05–1.99)d
Housing typea 1–3 room public housing 4–5 room public housing Executive flat/private property
Referent 1.58 (0.98–2.54) 1.93 (0.94–3.96)
1.51 (0.89–2.59) 1.70 (0.80–3.60)
Current work status Currently working Not working
Referent 0.87 (0.71–1.07)
0.97 (0.74–1.28)
Age in years
0.98 (0.97–0.99)
0.99 (0.98–0.99)d
Medical history Type of prediabetes Impaired fasting glycaemia Impaired glucose tolerance
Referent 1.54 (1.08–2.19)
1.47 (1.05–2.05)d
Years with prediabetes
0.99 (0.94–1.04)
0.99 (0.93–1.04)
Number of co-morbidities
1.08 (1.00–1.16)
1.08 (1.02–1.14)d
Proximal social circle influences Family or peer with prediabetes No Yes
Referent 1.50 (0.94–2.40)
1.41 (0.85–2.35)
Family or peer with diabetes No Yes
Referent 1.64 (1.19–2.27)
1.47 (1.09–1.98)d
Received family or peer support to reduce diabetes risk No Yes
Referent 1.84 (1.37–2.47)
1.54 (1.06–2.24)d
Perception of prediabetes self-management Motivation to self-manage prediabetes Low Moderate High
Referent 1.77 (1.08–2.89) 1.67 (1.18–2.37)
1.34 (0.68–2.64) 0.83 (0.50–1.37)
Confidence to self-manage prediabetes Low Moderate High
Referent 1.91 (1.22–3.00) 2.24 (1.57–3.19)
1.74 (1.03–2.93)d 1.97 (1.30–2.99)d
b
e
a b c
d e
Contained missing number (housing type, 2). Ethnicity under “Other” not included as there was none who received prediabetes education. The aPR of the variables that were not significant at the 5% level was obtained by incorporating that particular variable in the final multivariable model. These variables were significant at the 5% level and were included in the final multivariable model using the backward stepwise approach. The list of co-morbidities included chronic diseases commonly encountered in the primary care setting in Singapore such as hypertension, lipid disorders, stroke, heart disease, kidney disease, gout, asthma, cancer, arthritis etc.
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Fig. 1 – Components of health education programme that patients with prediabetes would prefer.
Table 3 – Participant characteristics for the in-depth interviews. Characteristic
N = 48
Sociodemographic characteristics Sex Female Male
Number (%) 24 (50.0) 24 (50.0)
Ethnicity Chinese Malay Indian
37 (77.1) 6 (12.5) 5 (10.4)
Age in years, mean (SD)
59.8 (9.1)
Ever received prediabetes education No Yes
30 (62.5) 18 (37.5)
All figures in the table referred to frequency (column percentage) unless otherwise indicated.
with age (aPR 0.99; 0.98 – 0.99). Fig. 1 shows the components of health education programme that patients with prediabetes would prefer. The top 2 components were healthy eating (62.3%) and physical activity (60.4%).
3.2.
Qualitative phase results
Table 3 shows the IDI participant characteristics.
3.3.
Reasons for not receiving prediabetes education
Several reasons were cited by participants who had never received prediabetes education. The common ones included not being referred for education by doctors, no time to receive education due to other pressing commitments like work and family, not aware or lack of information on where they could seek education, perceived no benefits from receiving education, did not feel at risk of diabetes, and have not experienced any negative consequences of prediabetes yet. Other reasons included not willing to pay for education, satisfaction with
current blood sugar control, satisfaction with own prediabetes knowledge, and have not accepted their prediabetes diagnosis.
3.4. Preferred health communication message contents (Fig. 2a) Participants’ views were different according to whether they had ever received prediabetes education in the following aspects. Those who had received prediabetes education preferred that the message focused on diabetes, e.g. emphasising the personalised risk of diabetes, “You must emphasise the risk of getting diabetes if someone with prediabetes does not control his diet and does not engage in any exercise. This is especially so for people who do not know their risk or if they feel that they are low risk. The message should indicate the risk of getting diabetes in a year’s time.” (AMK 054, 67 years old Chinese male). For some, they preferred to see messages emphasising complications of diabetes, “Diabetes is a serious illness, can lead to complications like leg amputations, so it’s important to highlight diabetes is no joke.” (AMK 063, 60 years old Chinese female). For others, it was to emphasis the high medical costs, “You have to emphasis the high cost of having diabetes, and that taking care of your health also means taking care of your pocket.” (TPY 039, 56 years old Chinese male). In contrast, participants who had never received prediabetes education expressed that the message should avoid labelling, “When you want to design public messages for those with prediabetes, I would urge you all to be more sensitive with the term [prediabetes] used, the surrounding people will see and label, ’this group has illness’, so this will make people with prediabetes feel uncomfortable.” (CCK 039, 55 years old Chinese male). Both groups of participants however shared similar views in the following aspects. The first was to focus on promoting prevention. These messages could (i) promote healthy eating, “You have to promote healthy eating and point out that in Singapore a lot of people are not eating too healthily. In your message, you can encourage people to eat all foods in moderation.” (WDL 019, 65 years old Malay male); (ii) promote physical activity, “The message needs to reinforce the value of being physically active. Talk about the various advantages of exercising, for example can lose weight in a healthy way.” (WDL 056, 55 years old Malay female); (iii)
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c
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d
Fig. 2 – (a) Themes and subthemes pertaining to preferred health communication message contents. (b) Preferred communication channels. (c) Themes and subthemes pertaining to subcomponents of healthy eating education. (d) Themes and subthemes pertaining to subcomponents of physical activity education.
promote screening, “We have health screening for various cancers. But I don’t think a lot of people know that there is also screening available for diabetes. Therefore, I think in your message, you should talk about screening for diabetes.” (TPY 004, 24 years old Chinese male); and (iv) emphasise that diabetes can be prevented, “Talk about diabetes prevention, for example mention that diabetes can be
prevented, and give examples of how a person can do that.” (AMK 007, 68 years old Chinese female). The second was on emphasising the family, “You need to bring in the family in your messaging. Something about living healthy for your family, for your grandchildren. If you tell them you keep healthy so that you can enjoy a more meaningful life with your
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family, that will help.” (AMK 075, 56 years old Chinese female). The third was on emphasising health, “The main message should be that all of us aspire to have a healthy body, as health is wealth. With a healthy body, then you can live life to the fullest.” (YIS 002, 57 years old Malay female).
3.5.
Preferred communication channels (Fig. 2b)
All participants regardless of their prediabetes education status reported more than one source of preferred communication channel. For face-to-face channels, most participants particularly those who had never received prediabetes education preferred their primary care providers to actively refer them for education, “The staff at the polyclinic such as the doctors can provide us some basic information on prediabetes, after that they should take the initiative to refer us for further education.” (AMK 078, 60 years old Indian female). Another common preference was peer educators, “Get people of the same background to spread the message, people who also have prediabetes. It would be easier for us to identify and learn from them.” (BBK 008, 65 years old Chinese female). Other face-to-face channels included celebrities, religious leaders, management from workplaces and members of parliaments. For non-face-to-face channels, these were TV, radio, newspapers, phone call and text, pamphlets, public transport and neighbourhood advertisements. There was a greater preference for traditional media than new ones such as online portal and social media. While some were keen to access information online, others were also concerned whether they have the skills or means to access them.
3.6. Preferred subcomponents of healthy eating education (Fig. 2c) Both groups of participants had largely similar views on this. Participants would like to be taught certain knowledge on healthy eating. For example, what is a healthy diet, “All of us have different definitions of a healthy diet. Perhaps it will be good if you can let us know the guidelines and the recommendations of a healthy diet.” (CCK 001, 56 years old Chinese female), and the consequences of eating unhealthily, “You see people just fixate on sugar, probably because of diabetes. But sugar is just one component of an unhealthy diet, you need to educate us on other components, such as how fatty food can also be harmful.” (AMK 097, 58 years old Chinese female). Participants would also want to be taught specific skills on healthy eating. One preference was on how to read food labels, “Sometimes when I go to the supermarket, I do see the labels, but I don’t know how to read them, and I don’t know how to differentiate between healthy and unhealthy food.” (WDL 068, 55 years old Malay female), while another was how to eat out more healthily, “How to eat out in a healthier way and to choose outside food more wisely, I think this is an important skill for people who don’t usually cook at home to learn.” (HOU 041, 46 years old Indian female). Others expressed preference such as how to evaluate personal diet, “Teaching us how to look at our plate, evaluate if this is healthy or am I getting enough fruits or veggie, am I getting enough wholegrains.” (TPY 004, 24 years old Chinese male), and how to prepare healthy food, “There should be cooking demonstrations where you teach recipes on healthy food.
The recipes must use healthy food that’s cheap, easy to prepare, and tasty.” (WDL 011, 71 years old Chinese male).
3.7. Preferred subcomponents of physical activity education (Fig. 2d) The views of participants on this were largely similar regardless of their prediabetes education status. For physical activity education, participants would like to be given certain knowledge. For example, what is considered physical activity, “You have to tell people what is exactly exercise, what type of exercises are considered physical activity.” (AMK 078, 60 years old Indian female), and the benefits of physical activity, “Let us know the advantages of the common types of exercise and how that would benefit our body. For example, the benefits of swimming, what does it do to the body. If you’re doing yoga, what are the advantages. This is so that each of us know what exercise to pick for ourselves.” (AMK 097, 58 years old Chinese female). Participants would also want to be taught specific skills on physical activity. One preference was on how to evaluate personal physical activity level, “Most people do exercise in the wrong way. Better to get trainers to teach us how to assess our physical activity level, and whether we are doing it correctly or not.” (YIS 005, 57 years old Malay female), and another was on how to be more physically active, “You should incorporate a component to teach us how to be more physically active, share with us ideas on how to incorporate exercise in our daily lives.” (TPY 009, 75 years old Chinese male). Others expressed preference on how to exercise for the elderly, “Right now, the exercises that are recommended appear to be more appropriate for the young and middle aged, so I don’t know whether these are suitable for the elderly too. You might want to teach the elderly specifically how to exercise.” (AMK 075, 56 years old Chinese female), and how to exercise for people with certain medical issues, “A lot of times we don’t know what kind of exercises we can do, what is appropriate for people like us with knee pain.” (HOU 041, 46 years old Indian female).
3.8.
Preferred setting for the education programme
Participants gave various suggestions on the preferred venue for the education programme, such as community centres, polyclinics, hospitals, shopping malls, parks and hawker centres. Almost all participants (regardless of their prediabetes education status) expressed that community centre was their most preferred venue.
4.
Discussion
This study found a low prevalence of primary care patients who have ever received education on prediabetes, along with factors associated with receiving the education. The qualitative results also revealed several gaps in health education and communication needs of these patients. Polyclinic doctors and primary care patients have contributed to this low prevalence of education as reflected in our IDIs, consistent with the findings of other studies. Doctors seldom discuss prediabetes or refer these patients for education due to various reasons such as heavy patient load, poor understanding on prediabetes, lacking the skills or confidence to counsel these
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patients on prediabetes [8,26]. Individuals with prediabetes seldom actively seek education due to various reasons such as lack of awareness, not being informed on the availability of such educational programmes, not willing to pay or travel far to receive education [27]. Our participants were generally receptive to receiving more education and have indicated that they would like to be taught on healthy eating and physical activity. To increase the take-up rate of education programmes, one strategy would be to train primary care doctors so that they could initiate conversations on prediabetes during their encounters with these patients. If this is not possible within the busy primary care setting, they should direct these patients to nurse educators, or even refer to community resources. Another strategy would be to extend the education from the primary care setting to the community [28]. This aligned with our finding where participants most preferred community-based programmes. In countries such as Singapore where there are community aggregate areas (e.g. community centres), these could be used to hold the health education programmes. Specific skills such as how to cook healthy food as well as how to exercise for the elderly and those with medical issues could also be demonstrated in these places. In addition, the family or peer could be involved when these programmes are held in the community. The family is often regarded as the basic societal unit in Asia [29] and is influential in the self-management of a chronic illness such as diabetes [30]. Similarly, peer support is also effective in improving health behaviours in disease management including diabetes [31]. While prediabetes might not be as complex as diabetes, our survey and IDI results have revealed the preference for greater family and peer involvement. As such, they could potentially be engaged as agents of change and the education programme be promoted as a family/peer bonding activity. Our proportion (49.2%) of participants who did not perceive themselves to be at risk for diabetes was comparable to other studies where the prevalence varied from 28.4% to 74.0% [32–34]. This discordance between perceived and actual risk indicates an unrealistic optimism concerning diabetes [35]. Convincing these patients to adopt healthier behaviours would be difficult if they believe they are not susceptible to diabetes or less susceptible than others. Our findings have indicated a clear need to enhance risk communication in diabetes prevention, particularly among this subgroup. There are 2 general approaches to this: (i) probability-based where numerical information regarding the probability of a given risk occurring are presented (e.g. risk score of having diabetes), and (ii) contextualised-based where informational context to understand and interpret a given risk are provided (e.g. information on prevalence, causes and complications of diabetes) [36]. Both have been highlighted by participants in our IDIs as preferred message contents. Primary care professionals should take these into account when they counsel individuals with prediabetes. Similarly, policymakers and health promoters need to be aware of these when designing public health messages on diabetes prevention. Participants specifically pointed out that health messages should avoid the term ‘prediabetes’ to avoid labelling. While the American Diabetes Association has endorsed this terminology, World Health Organisation and International Diabetes
9
Federation have discouraged its use [37]. Although this might be a useful way to indicate the seriousness of the condition, there have been concerns on its use in health education materials and messages [14,38,39]. This is particularly for individuals without any knowledge on the condition, those with anxiety about future complications, and those with low perceived self-efficacy [37]. Instead of focusing on the preventability of progression to diabetes, and the need for lifestyle change, there is the concern that these individuals would focus on the label itself [14,38,39]. Future studies could assess the impact of the use of this term in health education materials and messages. Moreover, our participants have expressed that messages should emphasise on prevention rather than on medical treatment. Other studies have also called for more attention on the action that individuals should take to prevent diabetes [14,38,39], such as promotion of healthy diet and physical activity or screening, rather than on “medicalisation” as highlighted by our participants. This study has some limitations. Firstly, during the qualitative phase, we did not show the transcript to the participants to confirm whether their responses had been accurately documented. Despite this, the interviewers regularly “check back” with the participants to ascertain that their responses were rightfully understood. Secondly the sole reliance on selfreported data may have resulted in social desirability bias. However, this was expected to be minimal given the steps taken to reduce this bias described in Appendix A. Thirdly, causal relationships could not be inferred from the crosssectional study (quantitative component). Fourthly, we could not differentiate whether these patients were actively seeking or passively receiving education based on the question assessing prediabetes education. We also did not examine referral rate by doctors and their reasons for non-referral, hence future studies could explore this. Despite this, there were various strengths. This was one of the very few studies to adopt a mixed methods approach in understanding the health education and communication needs among primary care patients at high risk of diabetes. This approach enabled triangulation as some of the correlates in the quantitative analysis were also recurrent themes in the qualitative analysis. The IDI findings have also helped us to better understand their needs. Data saturation was also reached for the qualitative analysis. Although the study sample was not generalisable to all individuals with prediabetes in Singapore, the sample was largely representative of the total NHG Polyclinic patient pool with prediabetes since it mirrored this population in sex, marital status and age. More needs to be done to fill the gaps in health education and communication needs of primary care patients with prediabetes in Singapore. Polyclinic healthcare professionals could provide preliminary advice, and subsequently refer patients to community-based programmes or resources.
Funding The study was funded through the War on Diabetes seed funding, Saw Swee Hock School of Public Health, National University of Singapore. The funding committee did not play a role in the design, conduct or analysis of the study nor in the drafting of this manuscript.
Please cite this article in press as: R.B.T. Lim, et al., Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.08.008
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Conflict of interest [13]
The authors state that they have no conflict of interest. [14]
Acknowledgements The authors would like to thank Zheng Kang Lum, Alwyn Ng, Michelle Tan, Qiao Jing Lee, Siti Wan, Wei Liang Tan, Erica Lim and Clifford Lok for their contribution to the study, as well as the Public Health Translational Team of the Saw Swee Hock School of Public Health for their inputs to the study.
[15]
[16]
Appendix A. Supplementary data [17]
Supplementary material related to cle can be found, in the online doi:https://doi.org/10.1016/j.pcd.2019.08.008.
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Please cite this article in press as: R.B.T. Lim, et al., Health education and communication needs among primary care patients with prediabetes in Singapore: A mixed methods approach, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.08.008