Summary
Changing Health’s intervention programme to prevent Type 2 diabetes combines new technology and behavioural change experts to encourage people to make long term, positive lifestyle changes. It has been adopted as part of the Healthier You NHS Diabetes Prevention Programme (DPP). The NHS provides face-to-face, structured education and support, but its approach cannot be tailored to individual needs. The solution is a personalised, digital programme using comprehensive research in metabolism, diabetes and behavioural science. It combines bespoke, one-to-one lifestyle coaching (delivered over the phone), with a customisable course of structured diabetes education (delivered via an app). People at risk of diabetes learn how they can fit simple lifestyle changes into their lives and receive personalised support. Each participant sets goals based on their ability to change at any one time and can call on a dedicated lifestyle coach for support or just to chat about their health.
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Innovation
Most people at risk of Type 2 diabetes know they need to change their lifestyles, but they are stuck with unhealthy habits. They need to know how to move away from habitual behaviours and sustain positive lifestyle choices, over the long term and as part of their daily routines. This new programme is underpinned by the Health Action Process Approach (HAPA). This separates behaviour change into two stages: the formation of an intention to change (motivation) and the subsequent planning and acting on that intention (volition). Behaviour change techniques (BCTs) then target the different psychological processes that translate an intent to behave into action. Crucially for facilitating long term, sustainable behaviour change, the HAPA model acknowledges that behaviours that are years or decades old are not going to change overnight. Equally, most people see some early success in changing their behaviour, then fall back, so relapse management is at the heart of the HAPA. It gives people the skills to re-engage and, ultimately, become their own lifestyle coach. A six-month trial of the programme by North West London Collaboration of CCGs in 2018 measured the impact of the programme on diabetes health outcomes. Users saw a Patient Activation Measure (PAM) score increase of 10 points, on average, over the course of the programme, equating to a 20% increase in medication adherence and a 20% decrease in hospitalisations. Coaching delivery is critical to users’ success. Each coach is trained in the most effective behavioural change techniques, rooted in psychology. The programmes are designed not to replace traditional, face-to-face education, but to widen access and improve uptake.
Method
Participants were recruited via the website (www.changinghealth.com), which was publicised in the BBC1 TV documentary ‘How to Stay Young’. The 149 people who began the programme received access to the 12-month programme, comprising an app with six structured education modules, including animations, articles and interactive exercises focused on lifestyle modifications through diet and physical activity. The app also allowed participants to log their weight, take pictures of their meals and tag them green or red (healthy or unhealthy), track their steps and book appointments with their lifestyle coach. The coaches had access to the user data to tailor their client conversations. The primary focus was weight loss, based on the participant’s reported weight at months three, six, nine and 12. Since clinically-significant weight loss has a more meaningful impact on health, the percentage of participants achieving 3% and 6% weight loss at each time point was also assessed. Other outcomes measured included participants’ reported changes in diet and physical activity, quality of life and diet. Uptake of the app, completion of the structured education programme and use of the coaching element were also reviewed. All participant-reported outcomes were assessed using online surveys. Implementation measures were based on app usage data extracted from the database.
Results
Participants lost an average of 2.5kg at three months, 3.3kg at six months, 3.6kg at nine months and 4.5kg at 12 months. This trend of slow, but sustained, weight loss is a reflection of the design of the programme, which encourages individuals to make small but ongoing changes to their behaviour. 43% of participants achieved ≥3% weight loss at three months, increasing to 60% at six months and 63% at nine months, before reducing slightly to 56% at 12 months. A total of 25% of participants achieved ≥6% weight loss at three months, with 36% at six months, 34% at nine months, before reducing slightly to 28% at 12 months. In terms of uptake, 89% of participants downloaded the app (79% of whom completed the learning modules) and 53% accessed the coaching element by booking an appointment with their lifestyle coach. In terms of behaviour change, 91% of respondents at month 12 reported that they had made healthy changes to their diet and 85% reported increased physical activity, while 92% were satisfied with the coaching and 82% said they would recommend it. These learnings can now be applied in an NHS context at scale through the DPP.
Sustainability and Spread
Changing Health has partnered with Ingeus, a provider of face-to-face diabetes support, to offer the prevention programmes at scale in Lancashire and South Cumbria (STP), Hampshire and the Isle of Wight (STP), and The Black Country (STP). Using the Progressive Web App (PWA) means it can be accessed on any device with an internet connection and delivered at scale. It also allows improvements based on user feedback and can customise the learning programmes into multiple languages. It has had approval for the NHS Apps Library and QISMET accreditation. It is also providing Type 2 diabetes management programmes across 30 clinical commissioning groups (CCGs) and will partner NHS England in the first nationwide rollout of digital Type 2 diabetes management support, targeting 600,000 people. Results were shared with around 6,000 healthcare professional and service user followers on social media, as well as in the media and at conferences.
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