Abstract
The prevalence of diabetes in Indonesia increased from 10.9% in 2018 to 11.7% in 2023. Over 90% of the diabetes cases are type 2 diabetes (T2D), which is primarily driven by modifiable risk factors, such as unhealthy diets, reduced physical activity levels, and obesity. Given that T2D causes severe health complications and economic burden, its primary prevention is pivotal. Evidence has shown that the risk of T2D can be reduced through lifestyle modification. In Indonesia, there is currently limited evidence of an effective community-based diabetes prevention program focused on sustained lifestyle modification, with most existing programs prioritising screening rather than prevention. Therefore, this PhD project aimed to develop a T2D prevention program. It began with a baseline study that described the dietary and activity patterns of adults in Bandung City. The findings of this study helped identify the target participants and the modifiable dietary and physical activity behaviours to be targeted. The next phase was the intervention development study, which used a co-design approach guided by the Behaviour Change Wheel (BCW). The co-design approach enabled collaboration between the researcher, target participants, and relevant stakeholders, ensuring that their views and preferences were incorporated throughout the intervention development. Meanwhile, the BCW, incorporating Capability, Opportunity, and Motivation-Behaviour (COM-B) and Theoretical Domain Frameworks (TDF), allowed a systematic theory-based development process to encourage behaviour change. The final phase was the evaluation study, which evaluated the acceptability of the developed intervention among target participants and stakeholders. The stakeholders included staff from the Bandung Health Office and Community Health Centres who are responsible for non-communicable disease prevention.
The dietary and activity patterns were assessed using a cross-sectional survey of 204 adults from 10 selected community units in Bandung City (Baseline study). Dietary intake was measured using two 24-hour food recalls (one weekday and one weekend). Dietary habits were measured using a study-specific questionnaire. The target behaviours were derived from the baseline survey. The findings revealed that low consumption of fruits (22.5%) and vegetables (35.8%), frequent intake of deep-fried foods (33.8%), sugary drinks (35.3%), and snacks (35.3%), distracted eating (38.7%), and low levels of physical activity (38.6%) were highly prevalent. These behaviours were associated with increased risk of T2D. The baseline study also found a high prevalence (60.3%) of overweight, obesity, and abdominal obesity, particularly among individuals aged 35-50 years. Based on these findings, the target behaviours of the intervention were to increase consumption of fruits and vegetables, reduce intake of deep-fried foods, sugary drinks, and snacks, improve mindful eating, and increase physical activity levels. This intervention thus targeted adults aged 35 to 50 years with overweight, obesity, and/or abdominal obesity.
The intervention development study followed the three stages and seven steps of the BCW, utilising focus group discussions, interviews, and a co-design workshop as data collection methods. In total, 31 target participants from two selected sub-districts and 20 stakeholders participated. After identifying target participants and behaviours from the baseline study, the next step was to determine barriers to target behaviours. Key barriers included insufficient knowledge, poor behavioural regulation, financial constraints, lack of time, high accessibility and affordability of unhealthy foods, early life habits and cultural norms, low confidence, and low prioritisation. These were addressed through the intervention functions of education, training, persuasion and modelling, delivered using behaviour change techniques such as providing information about health consequences, demonstrating behaviours, giving instructions, using credible sources, action planning, and verbal persuasion. Target participants preferred face-to-face group meetings and remote delivery via videos uploaded to YouTube. The final intervention, named Bandung Cegah Diabetes (diabetes prevention in Bandung), consisted of two group meetings and eight modules containing 17 videos.
The developed intervention was evaluated for its acceptability from the perspectives of both target participants and stakeholders. Acceptability among target participants was evaluated using a mixed-methods study design combining a survey and qualitative interviews, while stakeholder acceptability was evaluated using a cross-sectional online survey. A total of 33 target participants from two sub-districts completed the four-week Bandung Cegah Diabetes program and participated in the survey and interviews. The findings indicated high acceptability, with participants reporting improved knowledge and practical recommendations for healthier lifestyles. They also suggested improvements related to content, interactivity, and program continuity. A total of 32 stakeholders completed the online survey, and all agreed that the intervention was acceptable, feasible for delivery as designed, and capable of strengthening T2D prevention efforts. Future studies could focus on refining this intervention and assessing its effectiveness.
This thesis demonstrates that a diabetes prevention program can be systematically developed using a co-design approach combined with a theory-informed model, in close collaboration with target participants and relevant stakeholders. The co-design process enabled the intervention to be shaped around the needs, preferences, and contextual realities of the target population, rather than relying on a one-size-fits-all approach. Importantly, this approach enhanced the acceptability of the intervention for both community members and stakeholders, highlighting the value of participatory and theory-driven methods in developing a feasible and contextually appropriate diabetes prevention program.