About one third (9) of interviewees were from healthcare or hospital settings, followed by a near equal number from community-based healthcare (5, 17%), and other types of organizations (6, 20%) (Table 2). The majority of organizations were in the initial (13, 43%) or intermediate (13, 43%) phases of delivery and held Pending/Preliminary CDC DPRP status (20, 67%). There was consistent representation across the organization size categories and geographic regions. The vast majority have National DPP participants from White (80%), Black (70%), and Hispanic/Latino (63%) racial and ethnic backgrounds. Fewer organizations reported serving Alaska Native/Native American (27%) and Asian/Pacific Islander (27%) participants in their programs. These racial and ethnic demographics reflect national-level participant data, where White, Black and Hispanic participants make up the majority of enrollees .
Representation across levels of implementation reach by organization type was also fairly consistent. In terms of years delivering the program, those in the higher reach group had delivered the program for the longest number of years, while the medium and lower reach groups included many organizations in the initial delivery phase (0–2 years). The higher reach group also tended to include those from larger organizations and more often with full DPRP recognition status.
CFIR Construct Findings
The Construct Rating Matrix provides the CFIR ratings for each inner and outer setting construct by organization interviewee grouped by implementation reach level (Fig. 1). Overall, the majority of interviewees were net positive in terms of their implementation examples across all of the constructs (Fig. 1 Interviewee Average Score). However, the interviewees in the higher reach group provided stronger (+ 2) and more instances of positive examples across all constructs related to implementation and enrollment, while the low reach group stronger (-2) and more instances of negative examples across all rated constructs. Four constructs/subconstructs (incentives & rewards, learning climate, access to knowledge & information, and patient needs & resources) were not discussed in relation to implementation reach sufficiently in the interviews to conduct the construct rating and were omitted from the matrix. The following four inner setting constructs/subconstructs were identified as distinguishing: structural characteristics, compatibility, goals & feedback, leadership engagement. No outer setting constructs were distinguishing. The following results will highlight these constructs with discussion of the thematic analysis of the coded segments and supporting quotes.
The Structural Characteristics construct is comprised of many traditional measures of context and organization characteristics (organization size, type, location, etc.). Among the interviewees, Structural Characteristics often involved discussions of organization infrastructure for the program (physical space, staff size, etc.). As this construct contains a multitude of dimensions, interviewees frequently described both positive and negative examples, resulting in many mixed ratings. This construct appears to distinguish the high and medium reach level organizations from the low reach group. In the medium and high reach levels, interviewees often discussed both the benefits and challenges of implementation related to structural characteristics. For example, this interviewee highlights how the size of the organization can both help and hinder National DPP implementation:
“So, we're a pretty big organization. […] There are pros and cons to everything. I think our size is a pro just because we have a large population, like a patient population, in which to draw from. […] One thing that can make it a barrier, though, as far as trying to get referrals and spread the word is when it's a huge organization and there's a lot going on, sometimes it is hard to get the message across when there's just so much other stuff going on.” Interviewee M2, Medium Reach, Healthcare
However, among the low reach group, the vast majority of the coded Structural Characteristics segments were rated negatively. These interviewees reported difficulties with limited infrastructure for the program, lack of staff and staff time, challenges with developing referral systems, and administrative/bureaucratic hurdles due to their organization type. For example, this interviewee from a local government agency shared the challenges involved with applying for and implementing grants for the program:
“[…] for us to start applying for a grant, we somewhere in our process have to involve the city council. And in addition to that process once the city council okays on us applying for the grant, we receive the grant. Now we have to implement that grant into the city's budget. So that becomes really tedious and becomes a really huge pain as opposed to a nonprofit.” Interviewee L9, Low Reach, Government Agency
Across all cases, the most salient dimension of the Structural Characteristics construct was organization type and how it impacted their reach to populations, available infrastructure/resources, administrative processes, and reputation in the community.
Compatibility is a subconstruct of Implementation Climate and relates to how the intervention fits within the organization and its existing workflows, systems, and services. High and medium reach groups more often yielded strong positive examples of Compatibility impacting implementation, compared to those in the low reach group. Interviewees describing positive examples of the influence of Compatibility on implementation often mentioned that their organization offered complementary programs to the National DPP (e.g., diabetes self-management, nutrition education, fitness classes, etc.). This allowed them to more easily adopt and implement the National DPP. As described by one high reach organization interviewee (Interviewee H8, High Reach, Health Insurer & Employer), “it's a nice complement and it nicely rounds out the services that we offer.”
In the strongest positive examples, interviewees shared how other programs within their organization referred program participants to the National DPP and vice versa. They also gave positive examples of how the National DPP was embedded in their workflows and systems via the electronic health records (EHR) or other referral processes, all of which supported enrollment efforts. Two high reach group interviewees described challenges introducing the National DPP into their organization systems, but by taking time to educate key leaders and staff about the program, they were able to overcome those Compatibility challenges and succeed with implementation.
Conversely, in strong negative examples of Compatibility, interviewees struggling to implement the National DPP described how it was different from the typical services and programs provided by their organization and was not embedded into their current systems.
"We have to force it to fit. Do I feel like it -- I feel like it needs to be a part of the entire process, like if someone's coming in for one particular service they should be screened for being at risk of having Type 2 Diabetes. And we've done it, but it's only been during specific times and then it goes away. […] So I would love to see it more integrated into all of the programs. " – Interviewee L7, Low Reach, Government Agency
Across all reach levels there were some additional themes related to Compatibility. A commonly voiced complaint was how time consuming and burdensome the data reporting to the CDC DPRP is compared to other evidence-based interventions implemented at their organizations. Lastly, in a few cases, interviewees shared that their organization had a large number of chronic disease programs and this created challenges for staff to remember to refer to the National DPP. While complementary programs was a strength for some, it was also possible for the National DPP to get buried and forgotten when so many programs were available.
Goals & Feedbackis a subconstruct of Implementation Climate and refers to the degree to which goals are clearly communicated, acted upon, and fed back to staff, as well as the alignment of that feedback with goals. We asked interviewees to discuss how enrollment goals (target number of participants to recruit each year) set by them or leaders at their organization impacted their implementation efforts. This construct was distinguishing among reach groups by the presence and communication of enrollment goals. The majority of the high implementation organizations (n = 9, 82%) had formal enrollment goals set by organization leadership or the program coordinator. In comparison, only four (40%) of the medium and three (33%) low reach interviewees reported having enrollment goals.
Overall, interviewees did not provide many details on how enrollment goals impact implementation, but when they did it was very clear how goals facilitate enrollment. One high reach group interviewee described how goals motivate the staff to increase their referrals and enrollment,
“[…] we always have a goal, an enrollment goal. So we always reach the goal and we have a waiting list. There's always a waiting list and as I said, that's something that we're very proud of. […] it's nice to have the number, I like numbers. Tell me what you want, I'll go for that number.”– Interviewee H3, High Reach, Community-Based Healthcare
For organizations that did not have formal enrollment goals, interviewees mentioned other goals such as achieving CDC DPRP recognition status, billing Centers for Medicare & Medicaid Services (CMS)/becoming a Medicare DPP supplier, training their staff to implement the program, general diabetes prevention in their communities, or focusing on the retention of their current cohorts first before attempting to enroll more participants. One interviewee from a medium reach organization said because their focus is on establishing a process for billing CMS, they are not concerned about enrollment and prefer a small cohort at the moment.
Multiple interviewees that currently did not have enrollment goals said they were interested in setting formal enrollment goals. In some cases, interviewees had their own personal enrollment goals, not set by their leadership or organization. While the interviews focused on pre-COVID-19 implementation, a few interviewees mentioned how COVID-19 had disrupted their implementation and therefore currently enrollment goals were not a priority.
Leadership Engagement is a subconstruct of Readiness for Implementation and refers to the commitment, involvement, and accountability of leaders and managers with the implementation of the program. This construct appeared numerous times throughout most interviews. While the majority of interviewees simply said they have “support” from their leadership, when asked to describe this support in terms of Leadership Engagement their examples varied greatly. Examples of Leadership Engagement included: leadership being aware of all program activities and events, making presentations to promote the program, connecting with other organization leaders/partners for the program, facilitating internal organization processes (e.g. board approvals, system establishment) for the program, obtaining resources including adequate staffing for the program, and providing the program for free to organization employees.
Leadership Engagement was a distinguishing construct as high and medium reach cases had more strong positive examples of Leadership Engagement compared to the low reach cases. High and medium reach interviewees also more often connected Leadership Engagement with positive examples of successful enrollment efforts and growing the infrastructure for the program.
“Our leadership has been great […] I'll just give an example when we were going to be Medicare suppliers or applying for Medicare reimbursement. […] And because we had physicians on our board and people that knew about the program, they knew about the process even with Medicare we really had buy-in there because they were able to explain it […] So they really came together and got everybody on board and we were able to get those numbers and submit the application.” – Interviewee H6, High Reach, Community-Based Organization
Low reach groups had more mixed experiences with this construct. Leadership was described as not being engaged enough; not doing enough to understand the program, and taking a “hands off” approach. One interviewee described this as a gap in leadership knowledge about the National DPP:
“[…] I think leadership -- just to actually sit down and know -- understand the program a little bit better and understanding the goals that are attached to it and understanding the work that's needed to get done. That's it. I think that's where the gap comes in.”– Interviewee 8, Low Reach, Government Agency
The key message from all interviewees across reach levels was that Leadership Engagement is highly desired and appreciated when available. Leadership support and knowledge of the program was discussed as a strong facilitator in implementing and scaling the program.