Edited by: Yanwu Xu, Baidu (China), China
Reviewed by: Robin Nwankwo, University of Michigan, United States; Shihao Zhang, National University of Singapore, Singapore
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Intensive lifestyle intervention remains an effective modality to reduce diabetes incidence and delay the progression to type 2 diabetes. The primary aim of this study was to pilot-test the feasibility and acceptability of a culturally and linguistically tailored web-based DPP intervention among Chinese Americans with prediabetes living in New York City.
Thirteen Chinese American participants with prediabetes were recruited to complete a 1-year web-based Diabetes Prevention Program (DPP) lifestyle intervention. Quantitative and qualitative measures such as retention rate and data collected from web-based questionnaires and focus groups were collected and analyzed to assess study feasibility and acceptability.
Participants were receptive to the program through high engagement, retention and satisfaction. Retention rate was 85%. 92% of participants completed at least 16 sessions out of 22 sessions. Post-trial surveys indicated high satisfaction of 27.2/32 based on Client Satisfaction Questionnaire (CSQ-8) score. Participants expressed the program increased their knowledge and methods to prevent onset of type 2 diabetes such as incorporating healthy eating habits and increasing physical activities. Although not a primary outcome, there was a significant weight reduction of 2.3% at the end of month 8 of the program (
In 2022, 96 million US adults (38% of US population) were estimated to have prediabetes, and 37.3 million people had diabetes (
Leveraging the success of our team’s prior research on developing a culturally and linguistically tailored DPP curriculum using Community-Based Participatory Research and Intervention Mapping approaches (
This was a pilot study based on an adapted DPP program the research team has developed; a detailed development process of the online curriculum and protocol was published earlier (
Chinese Americans with prediabetes were recruited from New York City. A purposive sample of study participants were recruited through physician referrals and community health fairs. The inclusion criteria for study participants included Chinese Americans with prediabetes [HbA1c 39–46 mmol/mol (5.7–6.4%)], a body mass index (BMI) ≥ (22) kg/m2, Chinese speaking and a willingness/ability to provide informed consent; and accessibility to web-based tools.
Eligible participants were invited to attend an online orientation prior to the start of the intervention. During the orientation, participants were informed about the study procedures, and a signed informed consent was obtained from all study participants. They were assisted in setting up a Facebook account under a pseudonym. Participants’ weight and height for BMI and demographic survey were collected at the beginning of the study. They were provided a digital pedometer as non-monetary compensation to record their steps throughout the study. They were also provided with a user manual on how to navigate weekly modules and online homework on Facebook and Qualtrics.
The online DPP modules were housed in a private Facebook group that is accessible only to study participants and research staff; program modules were delivered as photos in the weekly/monthly posts. A typical weekly module included reading materials and two Qualtrics links for self-monitoring data collection; one for online homework and the other for food intake and step records logbook (
Summary of DPP Curriculum for Chinese Americans.
| Session | Modules in English | Modules in Chinese |
|---|---|---|
|
|
||
| 1 | Introduction to the Program | 課程介紹 |
| 2 | Get active to prevent T2 | 保持活躍，預防二型 |
| 3 | Track your activity | 記錄你的活動 |
| 4 | Eat well to prevent T2 | 食得健康，預防二型 |
| 5 | Track your food | 記錄你的飲食 |
| 6 | Get more active | 增加活動 |
| 7 | Burn more calories than you take | 少吃多動，消耗熱量 |
| 8 | Shop and cook to prevent T2 | 購物烹調，預防二型 |
| 9 | Manage Stress | 應付壓力 |
| 10 | Find time for fitness | 善用時間，活動健身 |
| 11 | Cope with triggers | 應對慣性行為 |
| 12 | Keep your heart healthy | 保持心臟健康 |
| 13 | Take charge of your thoughts | 保持正面想法 |
| 14 | Get support | 爭取支持 |
| 15 | Eat well away from home | 外出用餐，健康進食 |
| 16 | Stay motivated to prevent T2 | 積極堅持，預防二型 |
|
|
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| 17 | When weight loss stalls | 減重大計，停滯不前 |
| 18 | Take a fitness break | 多作健身運動 |
| 19 | Stay active to prevent T2 | 持續活躍，預防二型 |
| 20 | More about carbs | 了解碳水化合物了解 |
| 21 | Have healthy food you enjoy | 盡情享受，健康食物 |
| 22 | Prevent T2 for life | 預防二型，終身受用 |
As mentioned above, we also conducted two online focus groups after the 16-week core phase to refine the online program and after the 1-year intervention for program sustainability. Both focus groups were held in Cantonese and Mandarin by WL
Retention rate was used to assess level of engagement. Participants received text reminders by a lifestyle coach weekly to complete the modules and homework. Module views and completeness of online homework were collected and analyzed to assess feasibility. Retention rate was calculated based on participants who had viewed all of the 1-year modules and completed the online homework.
Upon completion of each module, participants were asked to rate the modules’ clarity on a 5-point Likert scale. They were also asked whether they considered the content culturally and linguistically appropriate on a 7-point Likert scale. Participants were further asked to provide feedback and comments and state any technical issues with each module. Finally, participants were asked to rate how likely they are willing to participate in future studies in a web-based format at the end of the intervention. To facilitate social support, an additional Facebook private discussion group was created for participants to share healthy lifestyle information and act as a support group.
At the end of the core phase, participants were asked whether they liked this online diabetes prevention program (DPP) and whether they thought this DPP program helped them engage in a healthy lifestyle such as eating healthy and/or being active with optional comments. In addition, they were asked how likely they were willing to participate future studies in web-based format. They were also encouraged to utilize self-monitoring tools (uploading meal photos and step records using the provided digital pedometer).
The Client Satisfaction Questionnaire (CSQ-8) (
To evaluate the efficacy of the online DPP curriculum, the weights of participants were obtained at baseline and self-reported weight measurements were collected at month 4, month 8, month 10 and month 12 of the intervention.
Qualitative data were collected from web-based questionnaires throughout the intervention and at the end the core phase (month 4) and maintenance phase (month 12) which contains a post intervention survey and were used to evaluate feasibility and acceptability of the intervention. Qualitative data were also collected from two focus group discussions after the 16-week core phase and after the 1-year intervention. The qualitative data were analyzed by reviewing and consolidating transcripts by the research team to summarize major themes. Specifically, analysis involved initial open coding of text, which was done by a team member (WL) independently using ATLAS.ti (RRID:SCR_022920) (
For quantitative data (e.g., multiple-choice questions), statistical analyses were performed with IBM SPSS Statistics (RRID:SCR_019096). We used descriptive statistics to summarize demographics among all study participants. Descriptive statistics were used to describe DPP feasibility and acceptability and study feasibility. Paired samples
Demographic and characteristics of study participants (
| Characteristic | |
|---|---|
| Age, mean (SD) | 66 (5.8) |
| Sex, female, ( |
11 (85) |
| Education, ( |
|
| Below high school graduate | 4 (31) |
| High school graduate | 4 (31) |
| College graduate | 3 (23) |
| Prefer not to say | 2 (15) |
| Employment status, ( |
|
| Employed Full-Time | 1 (8) |
| Employed Part-Time | 1 (8) |
| Retired | 8 (61) |
| Prefer not to say | 3 (23) |
| Household income, ( |
|
| Less than $25,000 | 3 (23) |
| $25,000–$50,000 | 2 (15) |
| $50,000–$100,000 | 1 (8) |
| Prefer not to say | 7 (54) |
| Marital status, ( |
|
| Married | 7 (54) |
| Single | 3 (23) |
| Widowed | 1 (8) |
| Prefer not to say | 2 (15) |
| Internet Access | 13 (100) |
| No. of technological devices (e.g., phone, iPad) | |
| More than 2 | 11 (85) |
During the pilot feasibility study, 19 potentially eligible participants were approached. Fifteen participants were screened to be eligible to participate the study, 13 of whom (86.7%) were enrolled into the study. Two participants were excluded due to withdrawal of the program at week 2 and after week 16 due to busy schedules and waning interest the study.
By the end of week 16 (core phase), 12 of the 13 participants viewed and completed all 16-week DPP materials. This resulted in a retention rate of 92% at week 16. And by the end of the 1-year program, 11 of the 13 participants viewed and completed all 1-year DPP materials. This resulted in a retention rate of 85% at 1-year interval. It is observed that the core phase of the intervention (Module 1–16) had a higher completion rate. The completion rate slightly declined in the maintenance phase of the intervention (Modules 17–22).
Overall, participants reported that the weekly modules were clear and understandable. Based on a 5-point Likert scale, module 3 on Track Your Activity, module 8 on Shop and Cook to Prevent T2 and module 15 on Eat Well Away from Home were reported as most clear and understandable (mean score of 4.6 ± 0.5), while module 2 on Get Active to Prevent T2 as least clear and understandable (mean of 4.0 ± 1.3). Most of the modules were considered culturally and linguistically appropriate (6.0 ± 0.9) based on 7-point Likert scale. Out of 11 respondents who completed the 1-year program, seven (64%) reported that they are likely/very likely to participate in future studies in web-based format. For social support, only two participants (15%) used the private discussion group created in Facebook and shared exercise video.
The program was well-received by the participants. All (100%) of the respondents reported that they liked the online DPP and agreed this program helped them engage in a healthy lifestyle. The self-monitoring tools were highly accepted by the participants as 12 of 13 (92%) participants utilized the features to upload three days’ of meal photos and step records 12 or more weeks. Participants were also quite satisfied with the program as the average intervention satisfaction CSQ-8 score was 27.2 ± 2.5 on a range of 8–32.
Using paired
Mean weight change over 1 year.
| Weight, kg (mean ± SD) | Weight change from baseline Mean (95% CI) | % | |
|---|---|---|---|
| Baseline | 63.4 ± 11.4 | – | – |
| Month 1 | 63.2 ± 11.6 | 0.28 (−0.15, 0.70) | −0.44 |
| Month 2* | 62.8 ± 11.2 | 0.64 (0.01, 1.27) | −1.00 |
| Month 3* | 62.4 ± 11.3 | 1.00 (0.30, 1.70) | −1.58 |
| Month 4* | 62.3 ± 11.5 | 1.13 (0.34, 1.91) | −1.78 |
| Month 8* | 63.4 ± 11.4 | 1.45 (0.23, 2.68) | −2.29 |
| Month 10* | 63.5 ± 11.1 | 1.30 (0.04, 2.56) | −2.00 |
| Month 12 | 63.8 ± 11.9 | 1.03 (−0.46, 2.52) | −1.62 |
*
Eleven participants joined focus group 1 at the end of the core phase intervention, and 10 participants participated in focus group 2 at the end of 1 year program. The thematic summary of the focus group findings on the feasibility and acceptability of the online DPP program are outlined below.
In terms of usability, several participants reported that they encountered difficulties in the first 2 weeks of the program due to low online literacy (for example, one participant stated
Participants also shared different opinions on food intake record. Some participants expressed that they learned the My Plate method from DPP to keep track of a balanced meal and portion sizes. Many expressed that it was difficult for them to record their intake at each meal because in Chinese culture meals are often shared in family style without individual portions, making portion sizes difficult to track. Here are two common sentiments:
Although the majority of the participants expressed that the digital pedometer was a great tool to keep track of physical activity, surprisingly, many preferred using their own phone over a pedometer. One participant stated that
The social support group on Facebook demonstrated low participation with only 2 participants posting videos and commented in the private discussion group. Participants expressed that they were not familiar with the features of Facebook and would be familiar with texting software popular among Chinese immigrants such as WeChat.
Consistent with quantitative findings shown earlier, focus group findings also illustrated that participants generally were highly receptive to the web-based 1-year program. Most participants shared the same experiences of learning more in-depth information about preventing progression of type 2 diabetes and they liked recording diet and physical activity using photos and digital pedometer.
The majority of the participants preferred online learning over in-person classes as online classes allow flexibility with their schedules. For example,
Participants also revealed that the COVID-19 pandemic helped them achieve healthier eating habits. For example, they reduced their frequency of eating out and learned how to eat healthier. Many also learned making a shopping list before going to the grocery store: “
Participants also provided valuable insights to improve the program, including technical issues such as allowing participants to revisit their homework and saving unfinished surveys to prevent repetitive work. In regard to programmatic issues, the majority of participants preferred bi-weekly sessions over monthly sessions in the maintenance phase. As one participant put it:
This pilot study demonstrated feasibility and acceptability of the translated DPP curriculum delivered through a web-based format. To our knowledge, this is the first feasibility study assessing a web-based DPP using a culturally and linguistically appropriate curriculum among Chinese Americans with prediabetes. The program was well perceived with 85% of study participants completing all 22 modules (16 core weekly modules plus six-monthly modules) and homework over 1-year. The high level of engagement is consistent with other feasibility studies that delivered digital diabetes prevention programs. For example, a study conducted a telehealth-adapted DPP at a senior center for 6 weeks demonstrated 80% attendance rate and 75% retention rate, which had a similar retention rate with our study (
The web-based DPP was highly acceptable and was rated as useful. Participants reported overall satisfaction based on usability and content. They expressed the language in the curriculum was culturally and linguistically appropriate. This is in line with our previous studies using a translated DPP curriculum for an in-person DPP (
Our study, although not powered to detect significant changes in weight and lacking a comparison group, showed that there was significant weight reduction at month 2 (−1%), month 3 (−1.58%), month 4 (−1.78%), month 8 (−2.29%) and month 10 (−2%) when compared to baseline. This small, yet significant result demonstrated that the culturally and linguistically tailored web-based DPP shows promising effects on weight loss, especially during the core phase. Moreover, although the standard DPP recommends a 7% weight loss goal, evidence showed that there were variations by race in achieving this goal. (
Standard DPP program offers monthly maintenance sessions (
Despite the high engagement in our DPP program, the low utilization of the social support group on Facebook suggested that online social support interaction seemed to contribute little to program completion and satisfaction. Our participants stated the major reason of not utilizing the discussion group was because they were not familiar with the features of Facebook. We also suspect that participants viewed the social support group as an optional activity. For example, a family-based adolescent substance abuse prevention program with high engagement using Facebook as an additional support also encountered challenges in involving participants to interact online (
Several features distinguish our web-based DPP from other traditional DPPs. First, our pilot web-based DPP successfully delivered the contents of a 1-year DPP intervention asynchronously without the need of participants to attend in-person classes often seen in traditional DPPs. The flexibility of time may have contributed to a higher participation rate which has also been shown in other web-based DPPs when compared to in-person DPPs (
There are several strengths of this feasibility study, including offering an online diabetes prevention program for a rapidly growing minority population, testing the feasibility of the program for a full 1-year that includes core and post-core modules, and collecting both quantitative and qualitative outcomes. Nonetheless, our study has several limitations. First, this is a pilot study with a very small sample size and findings are only generalizable to people who are highly engaged. Second, features such as built-in messages or feedback loops were limited in the current online version. The lack of a fully automated function may impact its feasibility as an asynchronous online curriculum. Third, we were able to collect only self-reported weights post-intervention due to the COVID-19 pandemic, which may contribute to errors and biases in weight outcomes. Furthermore, due to funding constraints, we were not able to collect blood samples to obtain objective measures such as A1c from study participants.
In summary, this study demonstrated feasibility and acceptability through engagement, satisfaction and significant weight reduction for delivering an online diabetes prevention program among Chinese Americans with prediabetes. Recommendations for improvements for future studies include enhancing communications between lifestyle coaches and participants by sending automated messages regularly, finding other means to promote social support discussions; and adding automated feedback loops to enhance the functionality of online programs. In addition, replication of these findings in a larger study is warranted.
The original contributions presented in the study are included in the article/
The studies involving human participants were reviewed and approved by Institutional Review Board of Hunter College, City University of New York. The patients/participants provided their written informed consent to participate in this study.
M-CY conceptualized the study, drafted the focus group discussion guides, interpreted the findings, drafted the manuscript outline, and contributed to the writing of the manuscript. WL assisted in facilitating focus group discussion, transcribing focus group texts, and reviewing transcripts, helped interpret the findings, and contributed to the writing of the manuscript. CK, MH-R, H-JT, LH, GM, and JW-R provided feedback to the focus group discussion guides and reviewed and provided feedback to drafts of the manuscript. All authors contributed to the article and approved the submitted version.
This research was funded by PSC-CUNY Award # 61707–0049 and NIH/NIGMS award # 5SC3GM131949–02 (PI: M-CY) and, in part, by City University of New York Interdisciplinary Research Grant 2022–2023 #8020905–26 (PI: MH-R), TUFCCC/HC Regional Comprehensive Cancer Health Disparity Partnership, Award # U54 CA221704(5) from NIH/NCI (Contact PIs: GM and Ogunwobi) and by the NY-Regional Center for Diabetes Research l (grant # DK111022), which supported the effort of JW-R. The contents of this manuscript are the responsibility of the authors and do not necessarily represent the official views of the NIGMS/NIH. NCI/NIH or NIDDK/NIH.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
The authors would like to thank the staff at the Chinese Community Partnership for Health of the New York Presbyterian-Lower Manhattan Hospital for assisting in recruitment and focus group preparation.
The Supplementary material for this article can be found online at: