Support for Developing
and Implementing
Targeted Diabetes
Prevention Campaigns in
Communities:
National Diabetes Prevention
Program Audience Assessment
Submitted by:
ICF Macro
August 2011
National Diabetes Prevention Program Audience Assessment
August 2011
1
Contents
I.
Executive Summary ............................................................................................................................ 1
II.
Introduction......................................................................................................................................... 2
Background Information ....................................................................................................................... 3
Audience Categories ........................................................................................................................ 5
Rationale for the Message Concepts ................................................................................................ 6
Research Objectives.............................................................................................................................. 7
Methodology ......................................................................................................................................... 7
Schedule of Focus Groups and IDIs ................................................................................................ 8
Audience Segmentation and Screening Criteria .............................................................................. 8
Recruitment ...................................................................................................................................... 9
Participant Demographics—Focus Groups.................................................................................... 10
III. Findings ............................................................................................................................................... 13
Findings for the Unaware Consumer Focus Group ............................................................................ 13
Consumer Knowledge About Prediabetes ..................................................................................... 13
Attitudes and Beliefs About Prediabetes ....................................................................................... 13
Definition of Prediabetes ............................................................................................................... 14
Screening for Prediabetes .............................................................................................................. 15
National Diabetes Prevention Program............................................................................................... 15
Program Description ...................................................................................................................... 15
Consumers’ Willingness to Participate in the Program ................................................................. 16
Unaware Concept Discussion ............................................................................................................. 17
Concept Preference ........................................................................................................................ 20
Notable Differences and Similarities Among Cities ........................................................................... 20
Lessons Learned From Unaware Group ............................................................................................. 20
Recommendations for Unaware Consumers ....................................................................................... 21
Findings for the Aware Consumer Focus Group ................................................................................ 21
Consumer Knowledge About Prediabetes ..................................................................................... 21
Attitudes and Beliefs About Prediabetes ....................................................................................... 22
Definition of Prediabetes ............................................................................................................... 22
Screening for Diabetes ................................................................................................................... 23
National Diabetes Prevention Program............................................................................................... 23
Program Description ...................................................................................................................... 23
Consumers’ Willingness to Participate in the Program ................................................................. 24
Aware Concept Discussion ................................................................................................................. 24
Concept Preference ........................................................................................................................ 27
Notable Differences and Similarities Among Cities ........................................................................... 27
Lessons Learned From Aware Group ................................................................................................. 27
Recommendations for Aware Consumers .......................................................................................... 28
Findings for the Diagnosed Consumer Focus Group .......................................................................... 28
Consumer Knowledge About Prediabetes ..................................................................................... 28
Attitudes and Beliefs About Prediabetes ....................................................................................... 29
Definition of Prediabetes ............................................................................................................... 30
Screening for Prediabetes .............................................................................................................. 30
National Diabetes Prevention Program............................................................................................... 30
Program Description ...................................................................................................................... 30
Consumers’ Interest in and Willingness to Participate in the Program.......................................... 31
Diagnosed Concept Discussion .......................................................................................................... 32
Concept Preference ........................................................................................................................ 34
Notable Differences and Similarities Among Cities ........................................................................... 35
Lessons Learned From Diagnosed Group........................................................................................... 35
Recommendations............................................................................................................................... 35
Findings for the Family and Friends Focus Group ............................................................................. 36
Audience’s Knowledge About Prediabetes.................................................................................... 36
Attitudes and Beliefs About Prediabetes ....................................................................................... 36
Definition of Prediabetes ............................................................................................................... 37
National Diabetes Prevention Program............................................................................................... 37
Program Description ...................................................................................................................... 37
Behavioral Intention....................................................................................................................... 39
Notable Differences and Similarities Among Cities ........................................................................... 40
Lessons Learned From Family and Friends ........................................................................................ 40
Recommendations............................................................................................................................... 41
Differences and Similarities Among Unaware, Aware, and Diagnosed Consumers and Family and
Friends Segments ................................................................................................................................ 41
Consumer Knowledge About Prediabetes ..................................................................................... 41
Attitudes and Beliefs About Prediabetes ....................................................................................... 41
Definition of Prediabetes ............................................................................................................... 41
Screening for Prediabetes .............................................................................................................. 42
National Diabetes Prevention Program Description ........................................................................... 42
Consumers’ Willingness to Participate in the Program ................................................................. 42
Concept Preference ........................................................................................................................ 42
Creative Materials ............................................................................................................................... 43
Tag Lines ....................................................................................................................................... 43
YMCA (Y) Flyer ........................................................................................................................... 43
Findings for Primary Care Physicians IDIs ........................................................................................ 43
Physician Knowledge About Prediabetes ...................................................................................... 44
Attitudes and Beliefs About Prediabetes ....................................................................................... 44
Screening for Diabetes ................................................................................................................... 45
National Diabetes Prevention Program............................................................................................... 46
Behavioral Intention....................................................................................................................... 47
Concept Discussion ............................................................................................................................ 49
Concept Preference ........................................................................................................................ 52
Lesson Learned ................................................................................................................................... 52
Recommendations............................................................................................................................... 52
Findings for the Health Care Providers Focus Groups ....................................................................... 53
Consumer Knowledge About Prediabetes ..................................................................................... 53
Definition of Prediabetes ............................................................................................................... 53
Attitudes and Beliefs About Prediabetes ....................................................................................... 54
National Diabetes Prevention Program............................................................................................... 55
Behavioral Intention....................................................................................................................... 57
Health Care Provider Concept Discussion .......................................................................................... 58
Concept Preference ........................................................................................................................ 61
Notable Differences and Similarities Among Cities ........................................................................... 61
Lessons Learned From Health Care Providers Groups....................................................................... 61
Recommendations............................................................................................................................... 62
Notable Differences and Similarities Among Physicians and other Health Care Providers............... 62
Knowledge About Prediabetes ....................................................................................................... 62
Attitudes and Beliefs About Prediabetes ....................................................................................... 62
National Diabetes Prevention Program............................................................................................... 62
Behavioral Intention....................................................................................................................... 63
Concepts Preference....................................................................................................................... 63
Appendix A: Focus Groups and In-depth Interview Schedules
Appendix B: Participant Screeners
Appendix C: Informed Consent Form
Appendix D: Moderator Guides
Appendix E: Creative Pieces
I. Executive Summary
The Centers for Disease Control and Prevention (CDC) contracted with ICF Macro to conduct a
series of focus groups and in-depth interviews (IDIs) to build CDC’s understanding of
consumers’ and health care providers’ knowledge and perceptions of prediabetes and to better
understand factors that will contribute to the successful utilization of the National Diabetes
Prevention Program.
The following audience segments were recruited for the focus groups: consumers unaware of
their risk for prediabetes, consumers aware of their risk for prediabetes but have not been
screened and have done little or nothing to minimize their disease risk, consumers diagnosed
with prediabetes who have done little or nothing to prevent diabetes; family and friends of
people at risk for or diagnosed with prediabetes; and health care providers who provide medical
services to people at risk for or diagnosed with prediabetes. IDIs were conducted with primary
care physicians.
Knowledge and perceptions of prediabetes varied among consumer groups, including family and
friends. In general, participants had not heard of the term and did not have a clear understanding
of the disease. All consumer groups wanted more information about prediabetes—its definition,
risk factors, and information on how to get screened. Consumers expressed concerns over the
lack of information and urgency from their health care providers about prediabetes.
All health care provider groups, including the primary care physicians, were familiar with
prediabetes. Some noted a universal, clinical definition was needed. In contrast to consumer
feedback, health care providers reported speaking regularly with their patients about prediabetes.
Once provided with a definition, the majority of participants in the consumer groups said they
considered prediabetes a critical and serious issue. Participants classified it as critical due to the
number of persons affected, its complications, and the opportunity to prevent the progression to
diabetes. These findings were not consistent with family and friend participants’ responses, who
felt that prediabetes was an important issue, but not a strong enough one to be considered critical.
While participants among the aware and diagnosed groups considered diabetes critical, they
admitted their actions were not congruent with their perceptions as they were not practicing
lifestyle habits to prevent diabetes. Prediabetes is a critical issue for providers.
When discussing the National Diabetes Prevention Program, the majority of participants across
all groups noted program benefits, but expressed concerns such as the time commitment required
and the cost. Despite the challenges the program length presented for some, participants across
all groups wanted more information about the program, including costs, insurance coverage,
session topics, and background and training of the lifestyle coaches. Family and friends
expressed a willingness to speak with their loved ones about the program; health care providers
stated a willingness to refer their patients to the program. Both groups needed more detailed
information about the program before promoting it. Most family, friends, and providers felt they
could make a difference in the lives of people with prediabetes, but said ultimately it is up to the
person to make the necessary lifestyle choices and changes.
Consumer groups (unaware, aware, and diagnosed), health care providers, and primary care
physicians were given message concepts and asked to rate them on their ability to move the
reader to action. Each concept emphasized a different element as it related to prediabetes and
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August 2011
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participants were asked to identify the preferred persuasive technique. Consumer concepts
emphasized the seriousness of prediabetes, urgency of prediabetes, self-efficacy, and successful
program experience through a personal testimony. Provider concepts included the seriousness
and urgency of prediabetes, program efficacy, and program support via an authoritative
recommendation.
Among unaware and aware participants, the majority of the participants indicated that the
concept emphasizing the seriousness of diabetes was their preferred persuasive style. The
preferred approach among diagnosed participants was the concept emphasizing self-efficacy—
“what you can do.” Responses to the concepts were varied among health care providers. In
Birmingham, Ala., the preferred concept emphasized the seriousness of prediabetes; for Tulsa,
Okla., and Washington, D.C., the concept highlighting the program’s efficacy resonated
best. Program efficacy was definitively the preferred persuasive technique among physicians.
Behavioral intentions for all groups were highly favorable. Most consumer participants were
very interested in learning more about the program. Several mentioned wanting to specifically
learn about the classroom structure, the various topics discussed during the sessions, the types of
exercises, and ways for program participants to stay motivated outside the classroom. Family and
friends also wanted to learn more, but reiterated concerns around the length of the program and
limitations around their ability to directly impact participant behavior. Health care providers and
physicians expressed strong support for the program, as well as their willingness to refer patients
and distribute program materials.
The findings from the focus groups and IDIs are outlined in detail in the following pages. They
reveal gaps in knowledge about prediabetes, perceived program challenges, potential motivators,
message concept preferences, and suggestions for language and graphic elements.
Recommendations for each audience group will follow at the end of each section.
II. Introduction
CDC recently announced the rollout of the National Diabetes Prevention Program, designed to
bring evidence-based, structured lifestyle interventions for preventing type 2 diabetes to
communities nationwide. Diabetes is a chronic disease that affects nearly 26 million Americans.
But, more than three times that number—79 million—are projected to have prediabetes, a
condition that, if not managed, can lead to the development of diabetes in 3 to 5 years.
Prediabetes is an urgent public health issue that carries health risks of its own, including heart
disease and stroke, even if it never progresses to diabetes.
Reaching people with and at high risk for developing prediabetes with effective health messages
and calls to action will support local attempts to populate the program. Participant recruitment
and retention are critical factors in the success of the program and its ultimate goal of staving off
the looming wave of diabetes. Identifying facilitators and barriers to sustained program
engagement is necessary to inform communication strategies and health messages.
Understanding the dynamics and roles of health care providers and support networks can further
strengthen the program’s ability to assist participants in achieving and maintaining
individualized program goals.
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The purpose of the formative evaluation was to gather data from people at risk for and diagnosed
with prediabetes and those who support and influence them. Information gathered through focus
groups and IDIs was used to direct the development of a Web-based toolkit to support the efforts
of health care providers, community-based organizations, and Diabetes Prevention and Control
Programs (DPCPs). Additionally, information from the formative evaluation served to enhance
and expand resources for people with prediabetes participating in the National Diabetes
Prevention Program.
Information gleaned from these target audiences will continue to inform CDC about what types
of communication strategies, concepts, and messages will best motivate people to get screened
for diabetes and to enroll in and complete a lifestyle intervention program if diagnosed with
prediabetes.
Background Information
CDC conducted literature reviews, an environmental scan, phone interviews, and online
assessments to better understand the characteristics of people with or at risk for prediabetes and
their behavioral practices as they relate to diabetes prevention. Findings from these preliminary
activities served to help identify audience segments for the focus groups, information gaps, and
possible approaches for motivating people at high risk for prediabetes to be screened and for
those diagnosed with prediabetes to participate in the National Diabetes Prevention Program.
The following is a brief overview of the activities conducted.
CDC conducted three literature reviews. The aim of the first literature review was to obtain
information about community-based programs that have been developed to promote lifestyle
interventions for people with prediabetes. Specific focus was on prediabetes programs that
required screening for referral or entry, where those screenings occurred, and what target
populations were reached. Seven programs were reviewed in depth, most of them based upon the
Diabetes Prevention Program. Other studies were examined as well for relevant results.
Findings illuminated two important factors, first, successful diabetes prevention screenings serve
as motivational alerts to participants, creating the knowledge that they are at risk for diabetes and
sensitizing them to the commitment required to participate in a program.
The second finding revealed that successful community-based interventions must address
barriers to participation (time and cultural values specifically), identify the participants most
likely to benefit from participating in a lifestyle program, provide adequate intensity to keep
individuals actively participating, and partner with the right organizations (specifically churches,
YMCA).
The second literature review was conducted to locate existing research on people at risk for
diabetes in order to better understand who they are; what they need and want to change in terms
of their physical activity, eating, and weight control behavior; and incentives and barriers to
changing these behaviors. This review also explored motivators and barriers for people at risk for
diabetes (and other chronic diseases) to get screened.
Findings identified that people at risk usually have poor lifestyle habits (sedentary habits, poor
diet, poor weight management) and often have difficulty changing these behaviors for the long
term. Barriers to behavior changes were found to be low level of prediabetes awareness, lack of
health insurance, food economics (healthy foods may cost more), low literacy, language barriers,
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individuals’ often overestimating their health status, poor psychosocial attitudes (lower selfefficacy lessens the probability of lasting behavior change), and chronic stress or depression.
Financial incentives were not proven to work long term based on this literature review, but the
findings identified other factors motivating behavior change. Motivators identified were the
initial screening itself, increasing readiness to change (knowledge of family history of disease
increased intention), creating culturally influenced interventions that consider the language
barrier and cultural factors (modesty, stigma), and increasing self-efficacy.
The third literature review investigated attitudes and behaviors of health care providers related to
prediabetes. Literature was searched to examine what is known about provider attitudes and
practices about screening for prediabetes and diabetes, including asymptomatic patients. Also
reviewed were the barriers and incentives for health care providers to screen for prediabetes and
to refer at-risk patients to lifestyle intervention programs. Two main barriers identified as
specific to prediabetes were providers’ lack of knowledge about the risk factors for prediabetes
and limited time spent with patients. Due to the limited amount of literature available on provider
attitudes on prediabetes, the search was expanded to explore provider attitudes concerning other
chronic diseases.
Findings indicated that physician assumptions about patients were a barrier to screening,
diagnosis, management, and treatment of prediabetes, diabetes, and other chronic conditions.
Physicians based assumptions on perceived socioeconomic resources, lack of patient motivation
to comply with medical recommendations, resistance among family members, comorbid
conditions (chronic pain, anxiety, depression), and limited English proficiency.
Another finding revealed that physician compliance with clinical practice guidelines and
evidence-based recommendations for screening, diagnosis, management, and treatment of
prediabetes, diabetes, and other chronic conditions was relatively poor. Low compliance was due
to lack of knowledge or lack of belief in the guidelines, frustration concerning
treatment/management efficacy if complications occur despite best efforts, the difficulty and
tedium that may be associated with blood glucose control, lack of trained support personnel, and
patient nonadherence. Research did not indicate that financial incentives improved physician
adherence to quality standards for diabetes and other chronic conditions.
In addition to the literature reviews, CDC analyzed survey data from Porter Novelli HealthStyles
2009 and Porter Novelli ConsumerStyles 2009. This comprehensive review of the survey data
provided an in-depth view into people at high risk for diabetes and people diagnosed with
prediabetes. Specifically, the review provided demographic information, their self-reported
health status, level of effort in terms of physical activities and leisure activities, use of health care
services, and their most trusted sources for health information.
To further inform the development of appropriate communication strategies and message
concepts for testing, CDC conducted a series of four different online assessments with health
care providers; key stakeholders, including DPCP staff; and people with prediabetes.
Five health care providers were asked to provide their thoughts on the barriers they would
encounter in referring patients to a lifestyle program. Three DPCPs provided program insights
and information about the resources that are needed to reach patients diagnosed with prediabetes.
Finally, six people with or at risk for prediabetes were asked about their knowledge of
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prediabetes, their willingness to make lifestyle changes, and what language would appeal to them
and motivate them to participate in a lifestyle program.
The results from the online assessments with health care providers revealed a consensus that
patients at risk for or diagnosed with prediabetes would greatly benefit by participating in a
lifestyle intervention program. However, health care providers noted potential barriers that may
exist that pose challenges for providers wanting to refer their patients to a program. These
barriers included the lack of willingness from patients to participate, location and convenience of
the program for patients, and a lack of knowledge from providers on available programs.
DPCPs who participated in the online assessment emphasized the need to actively engage
primary care physicians and clinicians in the recruitment process by encouraging providers to
talk with their patients and invite their peers to participate in the program. DPCPs stated that
having materials to promote the program is critical to increasing public awareness and program
enrollment.
The respondents at risk for developing diabetes said they were willing to make lifestyle changes
in order to avoid getting diabetes, and most were willing to participate in a 16-week program to
learn how to make the appropriate lifestyle changes to prevent the onset of the diabetes.
Audience Categories
Preliminary findings confirmed that people at risk for diabetes are not a homogeneous group.
Individuals in these target audiences are at different stages of behavioral change,
precontemplation, contemplation, and preparation.1,2 Because they are at different stages, it was
essential that strategies and messages developed by CDC address the various readiness levels of
people to be screened for prediabetes and, if appropriate, their readiness to engage in and
complete a lifestyle intervention program.
As a result, consumer audiences participating in the focus groups were segmented into three
categories: 1) those unaware of their risk for prediabetes, 2) those aware of their risk, and 3)
those diagnosed with prediabetes. Recruitment criteria were developed such that all
participants—even those unaware of their risk—met some risk factors for developing
prediabetes. People with a confirmed diagnosis of diabetes were excluded.
To ensure that the individuals recruited were appropriately segmented into one of the three
categories or excluded from participating, screening criteria included questions that gauged the
persons’ level of knowledge and awareness of prediabetes, their risk factors, their self-reported
health status, and their level of effort in terms of physical activities.
The unaware group included individuals who were not aware of prediabetes or their personal risk
for developing diabetes. The aware group comprised individuals who had some knowledge about
the risk factors for prediabetes and their personal risk for developing the disease. However,
despite this information, none had been screened nor were they actively engaging in behaviors to
reduce their risk for developing diabetes. The diagnosed group comprised individuals who had
1
Biuso, T. J., Butterworth, S., Linden, A. A. (2007). Conceptual framework for targeting prediabetes with lifestyle, clinical, and behavioral
management interventions. Disease Management (10), 6-15.
2
Serrano, E., Leiferman, J., Dauber, S. (2007). Self-efficacy and health behaviors toward the prevention of diabetes among high risk individuals
living in Appalachia. Journal of Community Health (32), 121-133.
National Diabetes Prevention Program Audience Assessment
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been told by a health care provider that they had prediabetes. As with the aware group, the
diagnosed group was not actively engaging in any behaviors to reduce the risk for developing
diabetes.
Using this segmentation strategy allowed CDC to examine the specific needs of these different
consumer groups in its effort to determine whether tailored messages should be developed for
each of these segments and if different communication strategies would need to be employed.
Rationale for the Message Concepts
The message concepts developed were a result of extensive work done in which CDC examined
the theoretical and empirical literature in health communication and behavior change. Four
possible approaches were identified. Message concepts to be tested with the three consumer
categories, family members and friends of people with prediabetes, and health care providers
included emphasizing the seriousness of prediabetes, the urgency of addressing one’s risk as it
relates to prediabetes, and the person’s ability to prevent diabetes as illustrated through selfefficacy and personal testimony of someone with prediabetes. The approach used for the three
consumer groups did not vary, but language based on diagnosis status did. Findings from the
literature review indicate that there is stronger intention to undergo screening if an individual
feels vulnerable to the disease3. Concept 1 emphasized the seriousness of prediabetes and the
negative effects that could result by not managing this stage of the disease. Concept 1
highlighted the serious health consequences of diabetes, such as blindness and stroke, to create a
sense of vulnerability.
Literature findings, Styles data, and interviews indicated that some individuals do not feel an
urgency to get screened for diabetes. To test whether this approach would effectively translate
into consumer messages, Concept 2 placed an emphasis on the urgency of managing prediabetes
by stating a specific timeframe within which to take action to prevent the development of
diabetes.
Background findings also found that to overcome behavior change barriers among these groups,
it is necessary to improve self-efficacy and increase readiness to change.4,5 Concept 3 focused on
patient self-efficacy by using empowering language and outlined specific behavior changes that
one could make to prevent diabetes. This concept affirmed that the power to prevent diabetes
was within the individual.
Last, preliminary activities demonstrated that people relate to personal experiences shared by
others who had made the lifestyle changes they would need to make. The personal testimony
approach was used in Concept 4 to motivate and encourage individuals to talk to their health care
providers.
3
Jacobsen, P. B., Lamonde, L. A., Honour, M., Kash, K., Hudson, P. B., Pow-Sang, J. (2004). Relation of family history of prostate cancer to
perceived vulnerability and screening behavior. Psycho-Oncology (13), 80-85.
4
Biuso, T. J., Butterworth, S., Linden, A. A. (2007). Conceptual framework for targeting prediabetes with lifestyle, clinical, and behavioral
management interventions. Disease Management (10), 6-15.
5
Serrano, E., Leiferman, J., Dauber, S. (2007). Self-efficacy and health behaviors toward the prevention of diabetes among high risk individuals
living in Appalachia. Journal of Community Health (32), 121-133.
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There was a fifth concept developed that also focused on a testimony but highlighted family
history as a risk factor. Due to time constraints and poor reception from the participants, concept
five was only tested in Washington, D.C.; CDC discontinued the testing of concept five in the
remaining two cities.
Research Objectives
CDC contracted with ICF Macro to conduct a series of focus groups and IDIs to build CDC’s
understanding of consumers’ and health care providers’ knowledge and perceptions of
prediabetes and to better understand factors that contribute to the successful use of the National
Diabetes Prevention Program. The following information was collected:

Consumers’ perceived benefits, challenges, and motivators associated with participating
in a long-term diabetes prevention program.

Consumers’ perceived benefits, challenges, and motivators associated with supporting
someone participating in a long-term diabetes prevention program.

Health care providers’ perceived benefits and challenges to screening and referring
patients to a long-term diabetes prevention program.

Consumer behavioral intentions as they relate to participating in/supporting someone in a
year-long diabetes prevention program.

Health care provider behavioral intentions as they relate to referring to and actively
promoting a year-long diabetes prevention program.

Participant feedback and reactions to message concepts, persuasive techniques, and
taglines.
Methodology
Focus group methodology was chosen for this project as a research technique offering
exploratory, formative, and information-rich data. Focus group discussions are beneficial for
exploring respondent awareness, behavior, concerns, beliefs, experiences, motivation, operating
practices, and intentions related to a particular topic and sub-issues. Focus groups are particularly
useful for generating an in-depth understanding of issues, since a skilled moderator can amplify
individual responses through group comments or individual feedback. In addition, the moderator
can follow up or probe certain tangents or views that were unanticipated in the design of the
moderator’s guide, often yielding new information or additional nuances of existing information.
Despite its many advantages, focus group methodology is not without limitations. The selection
of focus group participants is not based upon randomization or other population representative
methods. Findings from focus group discussions are not quantitative, nor can they be generalized
to the target population as a whole.
ICF Macro conducted a series of 15 focus groups in March 2011 (OMB No. 0920-0572). Each
focus group included up to 10 participants and lasted approximately 90 minutes. All groups were
recorded. A professional moderator led the group discussions, and CDC staff observed each
group. To gather feedback from a racially and ethnically diverse group of participants with
different backgrounds and socioeconomic levels, the focus groups were held in three
geographical locations: Birmingham, AL; Tulsa, OK; and Washington, D.C.
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Several factors were taken into consideration in determining focus group locations. The three
cities were selected based on CDC’s 2007 findings that highlighted diabetes prevalence in the
United States by state. During that review, the top 10 states with the highest incidence and
prevalence of diabetes were identified. Given these findings and the need to represent both urban
and rural settings, as well as the need for and availability of a readily accessible, professional
market research firm that could recruit and host the focus groups, these three sites were chosen.
In addition to the 15 focus groups, nine in-depth telephone interviews were conducted with
primary care physicians who provide medical services to people at risk for and diagnosed with
prediabetes during February and March 2011. The interviews lasted approximately 60 minutes.
A trained ICF Macro staff member conducted each of the interviews. All interviews were
recorded.
Schedule of Focus Groups and IDIs
The location, date, time and target audience for each focus group and IDI can be found in
Appendix A.
Audience Segmentation and Screening Criteria
The following five audience segments were recruited for the focus groups: (1) Consumers
unaware of their risk for prediabetes, (2) Consumers aware of their risk for prediabetes, (3)
Consumers diagnosed with prediabetes, (4) Family and friends of people at risk for or diagnosed
with prediabetes, and (5) Health care providers who provide medical services to people at risk
for or diagnosed with prediabetes. The following list is an overview of the criteria used to screen
each segment (see Appendix B for participant screeners).
Consumers

Participants must be age 45 or older.

Participants in general should be of diverse gender, race/ethnicity, and level of income
(low or middle income).

Participants must not be current or former employees of CDC.

Participants were segmented into one of the following three groups:
o Unaware: People who are not aware of prediabetes or their risk for prediabetes.
o Aware: People who are aware that they may be at risk for developing prediabetes.
They have not been screened and have done little or nothing to minimize their disease
risk.
o Diagnosed: People who have been diagnosed with prediabetes. They have done little
or nothing to prevent diabetes.
 Participants represented a mix of household incomes, including low ($30,000 or less) and
middle ($31,000 to $65,000).
Family and Friends

Participants must be age 18 or older.
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
Participants must be friends or family members of someone at risk for developing or
diagnosed with prediabetes.

Participants in general should be of diverse gender and race/ethnicity.

Participants must not be current or former employees of CDC.
Health Care Professionals

Participants must be health care professionals (i.e., certified diabetes educators,
pharmacists, physician assistants, registered dietitians, registered nurses).

Participants in general should be of diverse gender and race/ethnicity.

Participants must not be current or former employees of CDC.
Primary Care Physicians

For IDIs, the following criteria were used to screen potential participants.

Participants must currently be primary care physicians who provide medical
services/health education to people at risk for diabetes.

Participants in general should be from different geographic locations across the United
States (i.e., Northeast, Southeast, Central, Midwest, Pacific Northwest, Southwest, and
West Coast).

Participants must not be current or former employees of CDC.
Recruitment
The focus groups took place at a professional focus group facility in each city. The following is a
list of the market research firms that hosted the focus groups:
Birmingham:
Graham & Associates
3000 Riverchase Galleria
Birmingham, AL 35244
Telephone: 205-443-5399; Fax: 205-443-5389
Tulsa:
Consumer Logic
4829 South 79th Avenue
Tulsa, OK 74145
Telephone: 918-665-3311; Fax: 918-665-3388
Washington, D.C.:
Shugoll Research
7475 Wisconsin Ave Suite 200
Bethesda, MD 20814
Telephone: 301-656-0310 ext 188; Fax: 301-657-9051
All firms recruited 12 participants for 10 to participate in each group. The recruitment firms used
the screeners provided by ICF Macro to recruit individuals from diverse backgrounds. Recruiters
in each city identified consumers, family and friends, and health care providers.
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During the screening process, the recruitment firm collected information, including the
consumer’s name, address, race/ethnicity, age, income level, and whether they were unaware or
aware of their risk for prediabetes or diagnosed with the disease. For friends and family groups,
individuals were recruited who identified as having a family member or friend at risk for
diabetes or diagnosed with prediabetes. Recruiters selected health care professionals who
identified themselves as certified diabetes educators, pharmacists, physician assistants, registered
dietitians, registered nurses and providing health services or health education to people at risk for
diabetes.
Participant names and addresses were used by the recruiting firm to schedule the groups, mail
out confirmation letters verifying participation and provide the exact date, time and location of
the focus group. The recruitment firm in each city gave participant demographic data to ICF
Macro and CDC after removing personal identifying information such as last names, phone
numbers, and addresses.
A similar approach was used for coordinating the IDIs with primary care physicians. ICF Macro
worked with Baltimore Research, a professional recruiting firm located in Baltimore, Md., to
recruit physicians. The recruitment firm identified 11 participants for 9 to be interviewed. During
the screening process, the recruitment firm collected data on the participants including name,
address, and whether he or she was a primary care physician who provided medical services to
people with or at risk for prediabetes. Baltimore Research provided ICF Macro with participant
demographic data similar to the focus groups, and all personal identifiable information was
removed.
Participant Demographics—Focus Groups
Table 1 presents demographic information on the participants by location of the focus groups.
This information was compiled from the focus group screeners.
Unaware
Consumers
Aware
Consumers
Diagnosed
Consumers
Family and
Friends
Number of Participants
29
29
28
28
Male
13
11
12
12
Female
16
18
16
16
African American
7
8
6
4
American Indian/Alaska Native
0
2
1
3
Asian
1
1
0
0
Biracial
1
0
1
1
Caucasian
10
17
11
18
Hawaiian/Pacific Islander
1
0
0
0
Hispanic/Latino
2
1
0
2
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Health Care Providers
Total Number
Number of Participants
28
Male
4
Female
24
African American
5
American Indian/Alaska Native
0
Asian
1
Biracial
1
Caucasian
19
Hawaiian/Pacific Islander
0
Hispanic/Latino
2
Protection of Human Subjects. ICF Macro’s Institutional Review Board (IRB) reviews all
research involving human subjects and ensures that such research complies with all Federal
regulations. The ICF Macro Office of Human Research Participant Protections’ review board
approved the proposed procedures and techniques for this research study.
Eligible participants were given an informed consent form when they arrived at the focus group
facility (see Appendix C). The form explained the purpose of the project and affirmed
participants’ willingness to participate. The informed consent statement also notified individuals
that their participation was voluntary, that the 90-minute discussions would be recorded and
observed by CDC staff, and that their participation and everything said during the discussion
would stay private to the extent permitted by law. The moderator also reviewed the content of
the informed consent before proceeding with the discussion.
Participants were identified only by first name throughout the recruitment and sign-in processes
and during the focus group discussion. Any personal information about participants obtained
during recruitment and/or focus group discussion (e.g., age) are associated only with the
participant’s first name and with no other personally identifying information (i.e., phone number,
address). No personally identifiable information, including names, was used in the research
findings from this research.
Conduct of the Focus Groups. Before each focus group began, the moderator talked in person
with CDC observers to review the list of attendees and determine if any potential participants
should be eliminated from the group.
All discussions were led by a moderator with extensive experience in focus group research.
Moderators used a structured moderator’s guide (see Appendix D). According to standard focus
group methodology, the moderator’s guide began with general topics before delving into more
specific topics.
The moderator’s guide included the following sections:

Welcome/ground rules
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
Perceptions of prediabetes

Discussion on the definition of prediabetes

Discussion on the National Diabetes Prevention Program

Reactions to taglines

Discussion on message concepts

Discussion on behavioral intentions regarding program
During each focus group, participants were asked several ranking questions; these questions
were taken directly out of the CDC’s Health Messages Testing System Question Bank. The
ranking was on a scale from 1 to 5, with 1 being not at all compelling/not at all
interested/strongly disagree, 3 somewhat compelling/somewhat interested/somewhat agree and 5
extremely compelling/extremely interested/strongly agree. The moderator addressed all topics
and questions in the moderator’s guide. After the discussion, but before dismissing the
participants, the moderator briefly left the discussion and asked CDC observers whether there
were any additional questions to be asked of the group participants. Upon completion of the
focus group, participants were thanked for their time and received a stipend ranging from $75 to
$125 (consumer and health care provider respectively) for their participation. All participants
received CDC educational handouts, including information on prediabetes; in addition, each was
given the website address for the National Diabetes Prevention Program.
Conduct of the IDIs. While IDIs were conducted first, an approach similar to that of the focus
groups was used. At the beginning of the interview, the moderator advised each participant that
the call was being recorded. The moderator used a structured guide; it included the following
sections:

Welcome

Perceptions of prediabetes

Discussion on the definition of prediabetes

Discussion on the National Diabetes Prevention Program

Discussion on message concepts

Discussion on behavioral intentions regarding program referrals

The primary care physicians received a $175 stipend for their participation.
Transcripts and Report Writing. The focus groups and IDIs were audio recorded and discussions
documented in detailed, word-for-word transcripts. These transcripts were used as a basis for the
report findings. The textual data in the transcripts were reviewed and coded, and the major
themes/findings were identified. Supporting comments illustrate these themes in the participants’
own words. Consistent with the qualitative nature of this analysis, no attempt was made to
quantify the number of comments made on any theme. Where appropriate, findings indicate
differences by focus group location.
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III. Findings
The results of the analysis are presented in this findings section. As with all qualitative research,
the focus is on what was said by participants and what themes emerged, and not on the number
of participants who expressed an idea. With focus group studies, in particular, the unit of analysis
is the group itself and not individual participants, so we use words like “most” or “a few” to
indicate how strongly a particular idea was voiced by the group. We also report all sides, because
one of the greatest benefits of qualitative research is the presentation of the full array of
responses from the target audience.
What Did We Want to Know From Consumers?
The purpose of the formative evaluation was to gather data from people at risk for and diagnosed
with prediabetes. Information gathered from these target audiences was used to inform CDC
about what types of communication strategies, concepts, and messages best motivate them to get
screened for diabetes and to enroll in and complete a lifestyle intervention program if diagnosed
with prediabetes.
Information gathered through focus groups and IDIs was used to direct the development of a
Web-based toolkit to support the efforts of health care providers, community-based
organizations, and DPCPs. Additionally, information from the formative evaluation conducted
served to enhance and expand resources for people with prediabetes participating in the National
Diabetes Prevention Program.
This section presents the findings by segment as well as major differences and similarities across
the three consumer segments and family and friends, and major differences and similarities
across the health care providers and physician segments.
Findings for the Unaware Consumer Focus Group
Consumer Knowledge About Prediabetes
During this portion of the focus group, the moderators in each city asked the unaware
participants if they had heard of the term prediabetes and to articulate what they knew about the
disease. The majority of the participants across all groups had not heard the term prediabetes.
One participant said, “I don’t have enough knowledge to comment on what prediabetes is.”
Another participant guessed at its definition: “Maybe it means just having to take care of your
diet?” Those who were familiar with the term prediabetes associated it with borderline diabetes
or a strong family history of diabetes. One participant stated, “Prediabetes is the tendency or
predisposition to be diabetic. If you are borderline, you are almost there.” However, even those
who were familiar with the term were unsure of its exact definition. One stated, “I want to know
the difference between prediabetes and borderline diabetes.”
Attitudes and Beliefs About Prediabetes
When asked if they strongly disagreed or agreed with the statements that prediabetes is a critical
issue and prediabetes is serious, the unaware consumers who had some knowledge about
prediabetes or experienced diabetes through friends and family members felt that prediabetes
was both a critical issue and serious. Participants indicated that having experienced the
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consequences of diabetes through relatives, combined with the fact that prediabetes can be
prevented, makes it both critical and serious. One participant said, “I think it’s critical because if
you can prevent diabetes at the prediabetes stage, that’s the time to catch it.” Another participant
shared, “Diabetes has been a problem in my family so I would agree with that [statement that
prediabetes is a critical issue].”
Those participants who did not know what prediabetes was, expressed a desire to know more
about it, the risk factors, and what to do to prevent the onset of the disease.
As discussions continued and participants learned more about prediabetes from one another,
more participants articulated that the link between prediabetes and diabetes made the disease
worrisome, critical, and serious, since the “pre” or “before” aspect of a prediabetes diagnosis
meant that the patient was still in control and, by following doctor’s instructions, the patient
could make significant life changes. The participants who ranked the statements as less critical
and serious explained that they did not yet have enough information or knowledge about what
prediabetes was to categorize it as critical or serious.
Definition of Prediabetes
After the participants in each group shared their initial thoughts about prediabetes, the moderator
provided the CDC definition of prediabetes: At least 54 million Americans over age 20 have
prediabetes. Before people develop type 2 diabetes, they usually have “prediabetes”—that
means their blood glucose levels are higher than normal, but not yet high enough to be called
diabetes. People with prediabetes are more likely to develop diabetes within 5 years, and they
are more likely to have a heart attack or stroke.
Once the moderator read the definition, there was immediate reaction among the participants.
For some participants, the definition generated more questions, and for others it created
frustration and concern about the lack of information they have received from their doctors about
prediabetes.
Several said they thought that glucose levels and other risk factors were tested and assessed at
annual doctor’s office visits, but they expressed concern that they did not know this for sure.
Some participants also expressed needing more clarification about the term “higher than normal
glucose levels” so they could know when to take action. Some participants just mentioned
needing more basic information. Specific comments were:

“I am disappointed and surprised because I always go for a yearly physical, and I
presume I’m tested annually for prediabetes, but now I don’t know. No one told me my
glucose level.”

“When I go to doctors they’re regularly checking my blood pressure, they’re regularly
checking my cholesterol, triglycerides. But I don’t think I’ve ever had a doctor say, ‘Your
sugar looks good.’ And it doesn’t seem to me that the doctor’s putting that much
emphasis on it. Or at least it’s not something that’s being communicated.”

“What is the definition of “higher than normal glucose level?”

“How do you get tested and where do you go? Clear guidelines [are needed] and what to
look for myself.”
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For a few of the unaware participants who did not originally think that prediabetes was a critical
issue, hearing the definition of prediabetes prompted them to reconsider whether prediabetes was
serious. One participant said, “Based upon that definition then, I actually would change to a five.
Strongly agree [that prediabetes is a critical issue].” Hearing “higher than normal glucose level”
and “possible onset of type 2 diabetes” were the triggers that made the participant change his
mind. Another participant mentioned, “I said 5 [strongly agree that prediabetes is a critical issue]
because of the end result. You said heart attack and stroke. It’s just that serious.” It also sparked
people’s curiosity to learn more specific things about prediabetes such as causes and symptoms.
“I would like to know how to prevent it before it happens; a better explanation of why it
develops. There’s prediabetes and then you get diabetes. So [I need] information on who is
susceptible for it.”
Screening for Prediabetes
Unaware consumers were asked if they had heard about screening for prediabetes, and the
general consensus was that they had not. The unaware group had a variety of responses as to
what screening covered. Answers included a “5-hour glucose tolerance test,” “blood tests,” “a
test conducted among pregnant women,” “a pretest where blood was drawn at intervals over a
30-day period,” and that it was part of a regular wellness screening. When asked by the
moderator if they would now like to be screened, most said they would. One participant stated,
“If you don’t get screened, you know, then you wind up with the diabetes and you don’t know it.”
Despite a willingness to be screened, participants shared several reasons why they would not be
screened for prediabetes. A few participants said they would not get screened if it were not
covered by their health insurance. The cost of screening was identified as a patient barrier to
being screened and addressing prediabetes, as was the time spent waiting in the physician’s
office. The fear of finding out that one had diabetes and the realities the diagnosis would present
were also given as reasons for not wanting to be screened. One participant stated, “It comes
down to you asking the question to your physician to test you, and a lot of times I just don’t want
to do that, I don’t know [if I have prediabetes] and I don’t want to know.” These sentiments
were shared by another participant who said, “I just don’t want to know.”
National Diabetes Prevention Program
Program Description
Participants in all three cities were read a description of the National Diabetes Prevention
Program: The National Diabetes Prevention Program is an innovative evidence-based program
recognized by the Centers for Disease Control and Prevention (CDC). CDC has taken the
important step of translating research into real-life disease prevention strategies. The program is
based on the results of a national study funded by the National Institutes of Health and CDC. It
shows that, by eating healthier, increasing physical activity, and losing a small amount of weight,
a person with prediabetes can prevent or delay the onset of type 2 diabetes by 58%.
In a structured, group setting, a trained lifestyle coach helps participants change their lifestyle by
learning about healthy eating, physical activity, and other behavior changes over the course of 16
one-hour, weekly sessions. Topics covered include eating healthfully, getting started with
physical activity, overcoming stress, and staying motivated. After the initial 16 core sessions,
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participants meet once a month, for eight months for added support to help them maintain their
progress. The National Diabetes Prevention Program is currently being piloted in select cities
around the country.
After the description was read, the participants were asked about their thoughts and opinions on
the program and their interest in it. A few participants liked the idea of the program and
recognized that it could be beneficial; however, several participants voiced concerns over the
time commitment involved. Comments included:

“I think it’s a great idea. For me, 1 hour to get myself better health wise, is worth it.”

“I think it’s a good idea, I think it’s a good program. I think it mimics some programs that
currently exist in this area. I have to concur with the other individuals there—the 16
weeks I think is too lengthy.”

“I’m not sure I’m willing to give it the time required, since 16 weeks is a big commitment
and participation would be hard because people have such busy lives.”
Consumers’ Willingness to Participate in the Program
After discussing the program’s description, the majority of the unaware participants said they
were highly interested in learning more about the program and potentially joining if they were
diagnosed with prediabetes. Participants stated:

“That word—prediabetic—that’s enough for me [to take action]. And I would take steps
to do whatever it takes to not have to take medicines, shots, go blind, and all that stuff.”

“I find it extremely interesting and informative.…Just knowing that it can be prevented,
if you catch it earlier, you can still have a good quality of life, and just knowing that you
can avoid strokes, heart attacks, and things that can cripple you, or not able to function
fully because of something that could have been prevented by changing your simple
lifestyle, eating properly and exercising and having a positive outlook on life. It’s a
different perspective, and I’m going to take charge of my life and handle the situation and
not let it handle me.”
The groups were also asked if they had questions, comments, or concerns about participating in
the program. Questions participants had about the program included wanting to know more about
the program, the cost, meeting times and locations, credibility and credentials of the coaches,
insurance coverage, convenience, and program flexibility. Concerns expressed about the
program (beyond the time commitment, as stated earlier) included conflicts with family
responsibilities, lack of transportation, and past experiences with group programs. One
participant said that lack of childcare would be a barrier. Another participant said “Maybe if they
furnished child care.” Some explained that there is often great enthusiasm at first, but after a few
weeks, people tend to drop out and stop attending. One person shared, “Probably after 6 weeks,
we’ll begin to start dropping off one by one.”
The participants suggested ways to motivate potential participants to register, including
developing a comprehensive and more persuasive program description, low or zero cost for
attendance, healthy cooking demonstrations, an online option for class participation, a shorter
program, personal testimonies/success stories from past participants, and a clearly defined
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explanation of how the program lessens the likelihood that prediabetes would develop into
diabetes. Specific suggestions were:

“I think they could cut down on some of the information put in there, like the 16 one-hour
sessions. That might turn you off.”

“I would be apt to participate if they had cooking sessions, not just tell us what to cook
and how to cook it, but actually show us and actually do hands-on with the participants.”

“Maybe if it was offered online.”

“A flexible schedule. I mean, you may not be able to make it every night, every Monday
night at 6:00. If it’s an hour program, they may offer it at multiple times.”
Unaware Concept Discussion
This part of the discussion focused on getting the participants’ feedback on four message
concepts developed to persuade adults who are unaware of their risk for prediabetes to take
action such as seeing their health care professional. The moderator explained the following to the
groups: “You will be asked to rate each statement individually on a scale from 1 to 5 as to its
ability to move you and your peers to action. One is not at all compelling and five is extremely
compelling.”
It is important to note that in the first set of focus groups conducted in Washington, D.C.,
participant responses to the concepts were primarily focused on missing details about programrelated information (such as a contact number and program location) and not the persuasive style
being employed to encourage action. Critical information CDC was seeking was how health
messages should be crafted to most effectively target key audience segments. It became evident
that modifications to the messages and how they were presented were necessary to ensure that
participants were responding to the concept and not information about the program, its content,
or its location. As a result, CDC slightly modified Concept 4 and the following was added to the
discussion instructions: After reviewing all four statements, you will be asked to select the
technique you deem most effective in its ability to move you and your peers to action, and why.
When listening to the statements, please focus on the technique (e.g., urgency, seriousness), as
the messages have yet to be fully developed.” This change was made to facilitate participants
staying focused on the persuasion technique being used and providing feedback on its ability to
move the reader to take action:
As mentioned previously, the concepts developed used four persuasion elements: Concept 1
focused on the seriousness of prediabetes, Concept 2 emphasized the urgency of prediabetes,
Concept 3 focused on participant self-efficacy, and Concept 4 presented a personal testimony.
Concept 1. Statement one emphasizes the serious health consequences of diabetes:
Prediabetes increases your risk for heart disease, stroke, and blindness. You may be at risk and not
even know it. Are you age 45 years or older and overweight? If so, see your health care provider for
more information and to find out if you need to get screened.
Most participants found this message to be compelling. What appealed to them was that it
outlined the consequences of diabetes in a clear and direct manner. The message also offered
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action steps and specific information to address with their physicians. Some participants
mentioned that “health care provider” should be changed to “doctor” since that is a more familiar
term. Specific comments were:

“It’s giving you info to take some action, the age at risk susceptible to; you can do
something about this. Take action to prevent problems down the road.”

“It’s concise. Risk for heart attack, stroke, and blindness. That’s pretty negative.”

“Very factual, right up front.”

“The first thing I see is risk for heart disease, stroke, and blindness. I mean, that’s all I
need.”

“I like the part that says heart disease, stroke, blindness. But I have a problem with ‘See
your health care provider.’ Just say, ‘See your doctor.’ ‘Health care provider’ is too
much.”
A few participants did not find this message to be compelling at all and said:

“It just seemed like one more thing that was put out there to scare the public.”

“It’s a long drawn-out message and it’s not a quick read. If I were flipping through a
magazine and saw this, I’d pass it by. There is too much text.”
Concept 2. Statement two emphasizes the urgency of prediabetes:
If you have prediabetes and do nothing, you will likely develop type 2 diabetes within 3 to 5 years.
You can turn this around. If you are age 45 years or older and overweight, see your health care
provider for more information and to find out if you need to get screened.
The majority of participants ranked this concept as somewhat compelling and felt it was
speculative. Many felt there were too many “ifs” and “maybes,” which made it lack a sense of
urgency. Designating a specific timeframe within which to act did not generate a sense of
urgency for the unaware group:

“It’s not definite; it’s filled with might and could.”

“The first one said your risk would be heart disease, stroke and blindness, which is pretty
severe. This one says, if you do nothing, you will likely get diabetes, which could mean
that you couldn’t, you might not, or you might.”

“Three to 5 years, that’s even long; it happens in 2 or less. I think you’re not putting
enough urgency to it. I have 3 to 5 years to worry about it. You have to shake them and
get their attention.”
A few participants mentioned liking the phrase “You can turn this around.” One participant said,
“What I liked about it is, ‘You can turn this around.’ So, that statement empowers the person,
and gives them an opportunity to make a change.” Another participant said “You have ‘You can
turn this around.’ Something positive in such a negative atmosphere, or negative statement. This
is positive.”
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Concept 3. Statement three emphasizes patient self-efficacy through empowerment:
If you are age 45 years or older and overweight you may be at risk for prediabetes and not know it.
By increasing your physical activity and making healthy food choices, you have the power to prevent
diabetes. See your health care provider for more information and to find out if you need to get
screened.
Most participants ranked this message as very compelling, indicating that the statement has a
positive tone and empowers the reader. Specific comments were:
 “I liked the ‘you have the power to prevent,’ because I know that if I make better choices
in my food I can do something about it; the verbiage of ‘power to prevent.’”

“[You have the power to prevent diabetes] gave me motivation to maybe do something.
It’s not just telling me that I’m predisposed and I have to learn how to live with it, I can
make choices that can give me hope that I will not have diabetes.”
 “I think that reading this, it gave me the positive outlook on wanting to do exercise, on
wanting to prevent to have diabetes.”
A few participants had mixed feelings about this message as they felt it was too general, and
others did not like the idea of having to set an appointment with their doctors to learn more about
getting screened for prediabetes. Participants said the following:

“It’s still kind of generic. The words ‘prediabetes’ and ‘diabetes’ can be interchanged.”

“I don’t understand why I need to see my doctor to increase activity and eat healthy food
choices.”

“I don’t want to have to visit my health care provider for more information about this.”

“It’s like you have to get permission to get screened.”
Concept 4. Statement four (as tested in Washington, D.C.) emphasizes personal experience through a
testimonial:
At 46 and overweight, my sister just found out she has prediabetes. I look just like my sister. I’m going
to my health care provider to get more information and to find out if I need to get screened. If you
think you may be at risk for diabetes, talk to your doctor.
This message prompted mixed reactions among the D.C. participants. Those who found it
compelling reacted to the genetic implications. “My sister is 46 and she has prediabetes. I look
like her; I’m going to the doctor right away to know.” Another participant shared, “It’s not so
much that I look like her, but that I’m related to her.” “The part about the sister appeals to me,
because the genetics, actually.” A few participants mentioned not relating to this message at all
because they don’t have sisters. “If I don’t have a sister, I don't identify with it at all.” “I look at
it and say, well, I don’t have a sister…I’m looking at it and saying, this doesn’t apply to me.”
The message was modified for testing in Tulsa and Birmingham to exclude referencing a specific
family member as some Washington, D.C., participants did not relate to the message if they did
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not have that specific family relation (i.e., sister). The testimony was rewritten and referenced a
friend to test whether that change would make it more readily relatable.
At 46 and overweight, a friend of mine was just diagnosed with prediabetes. We are about the same
age and I am heavier than I should be, so I may be at risk, too. I’m going to my health care provider
to get more information and to find out if I need to get screened. If you think you may be at risk for
diabetes, talk to your health care provider.
Most participants ranked this message as not compelling because they could not relate to it or
personalize the risk. This concept was not well received; many felt it seemed “fake” and
compared it to the types of messages advertisers use in commercials. Additionally, since it was
about a friend as opposed to a family member, many felt the call to action did not seem relevant:

“I just find it a total lack of motivation. I mean, having a friend that’s been diagnosed,
what’s that have to do with anybody?”

“If they were talking about a family member that would be better.”

“It reminds me of a commercial for an attorney. This is not personal. It’s not talking
about a specific person.”
Concept Preference
After all concepts were presented, participants were asked which message style was most likely
to persuade them to take action (i.e., seriousness, urgency, self-efficacy, or personal testimony).
Among the unaware group, the majority indicated that the concepts that highlighted the
seriousness of diabetes and having the power to prevent it were their preferred persuasive styles.
Some participants suggested joining parts of the different messages to create a more compelling
one. “It could be a combination of #1 [seriousness of prediabetes] and #3 [self-efficacy through
empowerment].”
It should be noted that although the personal testimonial came across as somewhat to not
compelling, some participants made references to the use of diabetes type 2 testimonials as a
factor showing the seriousness of prediabetes.
Notable Differences and Similarities Among Cities

Participants in Birmingham expressed concerns that “many people” cannot afford to go to
the doctor.

Participants in Birmingham had a negative reaction to the YMCA and want to see the
program offered at different places.

Participants in all three cities expressed concern about the cost of the program.

Participants in all three cities noted the importance of program location and accessibility.
Lessons Learned From Unaware Group
 There are gaps in knowledge on what prediabetes is, how one is tested for it, and how it
differs from other terms, such as borderline diabetes, that participants have heard.
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 Physicians continue to be a leading and trusted source for health information; however,
participants reported not getting information about prediabetes from their health care
providers.
 Once informed about the seriousness of prediabetes, this audience segment reported
being willing to be screened.
 The length of the program was stated as a concern for many participants.
 The two concepts that were found most compelling emphasized the serious health
consequences of prediabetes and self-efficacy through empowerment. A testimonial
approach focused on the seriousness of the disease with a message of self-efficacy and
empowerment should be considered as a concept to motivate aware consumers.
 Crafting a compelling personal testimony is challenging. Finding the right individuals
with a relevant connection to the reader is critical to the message being perceived as
believable and meaningful.
 An awareness campaign is needed for the unaware group. Messages need to generate a
sense of urgency by highlighting the serious consequences of prediabetes and what can
be done to prevent it.
Recommendations for Unaware Consumers
 Messages developed to reach the unaware with information about prediabetes should
emphasize the seriousness of prediabetes. Messages that highlight the serious health
risks—such as heart disease, blindness, and stroke—may be more likely to move this
group to learn more about their risks. A testimonial approach that showcases the
seriousness of the disease is recommended.
 Promotional messages developed to reach the unaware with information about the
National Diabetes Prevention Program should empower the reader and emphasize selfefficacy as it relates to program success.
 Efforts to reach and motivate unaware consumers to learn more about their risk factors as
related to prediabetes should include health care providers.
 People who are unaware of their risk need information about prediabetes, its
complications and the importance of knowing their health status as it relates to
prediabetes.
Findings for the Aware Consumer Focus Group
Consumer Knowledge About Prediabetes
During this portion of the focus groups, the moderators in each city asked the aware participants
if they had heard the term prediabetes and to articulate what they knew about this term. The
majority of the participants had heard the term or was generally familiar with prediabetes:

“Prediabetes means that your numbers are in a range that is sliding toward diabetes.”

“It means you are insulin resistant.”
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
“My doctor told me that if I didn’t lose some weight, I would be prediabetic.”

“If you are predisposed to prediabetes you need to get the information that is out there
and cut your portions.”
Those who had not heard the term prediabetes mentioned wanting to know about prediabetes, its
risk factors, and what to do to prevent diabetes.

“I never heard that prediabetes means that I could be close to having diabetes, so I want
to know what it is.”

“…I want to know how I keep my numbers from going up. What are the preventive
measures?”

“I want to know if there is a screening tool, awareness factors, and what I should
do.”
Attitudes and Beliefs About Prediabetes
Participants were asked if they strongly disagreed or agreed with the statements that prediabetes
is a serious and critical issue. Some participants indicated that having personal experiences with
friends and relatives and seeing the consequences of diabetes makes prediabetes both critical and
serious. One participant said, “I gave it a five [strongly agreed that prediabetes is a critical issue]
because if you know what to do based on your numbers, then it’s critical if you don’t want to
have to take medications and injections. If my brother had known this he would have taken it
more seriously.”
There was also strong sentiment that if this issue affected young people, it must be acted upon.
“This [prediabetes] is an important issue because it is affecting our time, now. Children are
becoming obese and our country has to take care of this. We don’t want our kids to become
diabetic.”
The participants who ranked the statements as less critical and serious explained that, for them,
the condition “prediabetes” does not represent a major threat and, therefore, is not at a critical
level. “I work at a hospital, so when I hear the term “critical” it is very serious to me…this
doesn’t meet the criteria of critical from my point of view. Yes, it is serious, but it’s not critical.”
Another participant shared that depending on the age of an individual, the condition can be more
or less critical. “If you are 75 (years of age) maybe yes, but…you can’t say that everybody is
destined to something awful.”
There was some discussion that the name of the condition “pre” significantly minimizes its
severity. One participant said, “I’ve heard that either you have it or you don’t. There is no such
thing as prediabetes...it’s like being a little bit pregnant.”
Definition of Prediabetes
After the participants in each group shared their initial thoughts about prediabetes, the moderator
read them the CDC definition of prediabetes.
Once the moderator read the definition, participants expressed frustration that their doctors were
not providing them with information on prediabetes. One participant commented:
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
“I have a physical every year. I don’t even know if I get tested for high blood sugar. To
this day, I have never heard from my doctor that I should change my diet or what I can
change about my diet or what to eat or not eat to prevent diabetes. I have never been
educated about it.”
For a few of the aware participants who did not originally think that prediabetes was a critical or
serious issue, hearing the definition of prediabetes and the potential health complications of
diabetes prompted them to reconsider whether prediabetes was critical and serious. “When you
hear the consequences of diabetes such as losing limbs, stroke, inability to earn income, all that
scares me a lot. That definition makes it very serious.”
Screening for Diabetes
Participants were asked if they had heard about screening for diabetes, and several participants
had not. One participant said “Screening for diabetes—is that even an option? Can I be screened
for prediabetes? If I could see I was heading that way I would take action.” One participant who
said he had heard of screening stated, “Screening is when they measure your blood sugar.” In
discussing the barriers to screening, the aware consumers noted cost concerns. One participant
said, “With high deductibles on your insurance, you have to be careful. You have to make a
decision [if you can go to the doctor].”
National Diabetes Prevention Program
Program Description
Participants were given a description of the National Diabetes Prevention Program and asked
about their thoughts and opinions on the program and their interest in it. The majority of the
participants had a positive response to the National Diabetes Prevention Program and noted its
potential benefits. There was some hesitation about the program length and time commitment
involved. The feedback on the National Diabetes Prevention Program description included the
following comments:

“I think it is awesome because you are being told how to eat healthy and the importance
of being more physical. Some people need a whip for that. It is appealing and I would
participate.”

“I’m gonna sign up. It has encouragement, accountability, engagement. I’m a people
person.”

“I think it’s great to have someone take a group and have a weekly session and you have
a support system 8 months later. It sounds like Weight Watchers or Jenny Craig and that
group is your support system. If you have that system, you have motivation. To have that
support means you have someone to call and say, ‘hey, I can’t do this.’ Then your buddy
will motivate you.”

“It’s easier said than done. I need a push. I told my wife. I need guidance. If I see people
like myself, and we sort of help each other and share ideas, this will motivate me.”

“It sounds good. Will I do it? Probably not. I’m busy and I don’t go to the gym. I keep
saying I’m going to do this and that. They have to tell me that I have to go.”
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Consumers’ Willingness to Participate in the Program
The groups were asked if they had questions, comments, or concerns associated with
participating in the program and other feedback that they might have about the program and its
description. The positive feedback that emerged from this question was that working in a
supportive group setting would be an encouraging and positive experience. “I like the life coach
idea. It’s like having a personal trainer.” Participating in the program as a family or for the
benefit of the family were strong themes. “It definitely appeals to me because I tell my son I
want to live forever and I need that push. If I can motive my son, he can motivate me.” Another
participant said, “This is something we can do together, as a family. If the kids attend, then they
will keep the parents on track and ask parents why they aren’t following the program. I want to
do this for my kids.” Another stated, “I think that the fact that it’s evidence-based, and the
number—decreases the onset of diabetes by 58%—is something that, if I can prevent it or slow it
down substantially then it’s worth working this program.”
Concerns expressed about the program included time conflicts and program length, such as
“Whether I’d have the time to do 16 sessions, I don’t know. It would depend over what period of
time. If it’s, like, 1 hour a week or something, maybe.” Some were more emphatic: “The 16
weeks turns me off right away. Give me a book or show me something even in the gym. But I
won’t go.”
Participants wanted to know more about the program including cost, flexibility of the
program/replacement sessions, insurance coverage, location and convenience, program
curriculum, program goals/objectives, time of sessions, transportation and types of exercises that
will given in the classes.
Participants discussed program motivators. The following are among the things that would
motivate participants to join the program:

“Shorter timeframe.”

“Make the program available online.”

“Incentives.”

“Free classes.”

“Emphasize the group support setting.”

“My doctor has to tell me this program will prolong my life.”

“Health insurance premium will go down if I participate.”

“Scare tactics. Many people don’t have time, but a scare tactic saying that if you become
a diabetic, the chances of losing a toe or becoming blind.”

“Have Medicare/Medicaid pay for this.”
Aware Concept Discussion
This part of the discussion focused on getting the participants’ feedback on message concepts
developed to persuade adults who are aware of their risk for prediabetes to take action. The
moderator explained the following to the group: “You will be asked to rate each statement
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individually on a scale from 1 to 5 as to its ability to move you and your peers to action. One is
not at all compelling and five is extremely compelling.
Please note that in the first round of focus groups conducted in Washington, D.C., participant
responses were primarily centered on the concept structure and text of the concepts. Participants
did not capture the intended messages being delivered. Consequently, CDC made modifications
to some of the message concepts. In addition, the following was added to concept discussion
instructions, “After reviewing all four statements, you will be asked to select the technique you
deem most effective in its ability to move you and your peers to action, and why. When listening
to the statements, please focus on the technique (e.g., urgency, seriousness), as the messages
have yet to be fully developed.” This would allow for participants to stay focused on the
persuasiveness technique being used and, therefore, be in a position to provide necessary
feedback on its ability to move the reader to take action. Five concepts were tested in
Washington, D.C., and four concepts were tested in Tulsa and Birmingham.
Concept 1. Statement one emphasizes the serious health consequences of diabetes:
Prediabetes increases your risk for heart disease, stroke, and blindness. You may be at risk and not
even know it. Are you age 45 years or older and overweight? If so, see your health care provider for
more information and to find out if you need to get screened.
Most participants found this message to be extremely compelling; participants indicated it spells
out the consequences of diabetes in a very direct way. Listing the serious health conditions
caught their attention. Specific comments were as follows:

“It is so scary because it increases your risk of blindness and stroke. That is very scary.”

“When they talk about heart disease and stroke and blindness, I want to be prescreened. I
do not want this to happen to me.”

“It emphasizes the seriousness of prediabetes. I would add the word “death.” They need
to add that word. Death would move my rating to a 5 [extremely compelling].”
A few participants commented that, for them, this message was not at all compelling because
there are so many messages delivered to the public on heart disease and stroke that people are no
longer influenced by them. Consequently, it would not move them to take action. One participant
stated, “Sometimes there are so many messages about heart disease and stroke and people get
immune to it.”
Concept 2. Statement two emphasizes on the urgency of prediabetes:
If you have prediabetes and do nothing, you will likely develop type 2 diabetes within 3 to 5 years.
You can turn this around. If you are age 45 years or older and overweight, see your health care
provider for more information and to find out if you need to get screened.
Most participants ranked this message as somewhat compelling. A few participants mentioned
that it did not stress a sense of urgency. Some participants questioned the 3- to 5-year timeframe
and understood that to mean they could wait this amount of time to see if they are likely to
develop diabetes.
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
“I said three [somewhat compelling] because this is how people think. The words ‘if’ and
‘likely’ make it not as definitive. If means I am in denial. Likely makes me think of
procrastination. It doesn’t make it feel urgent.”

“The statement says what happens if you are doing nothing. But we are already doing
nothing.”
The few who found this concept to be extremely compelling mentioned that the phrase “you can
turn this around” appealed to them because it was sending a positive message and motivating
them to take action to find out whether or not they are at risk.

“You can turn this around. Something positive in a negative atmosphere or negative
statement. This is positive.”

“Well, it’s already telling you that you know you have the pre-diabetes, so you can turn it
around. So it tells you that you, at the age of 45, overweight, and you see these symptoms
up in you… maybe I’ll go get screened to see if I’m going to go further with this. Maybe
I need to check on it right now.”
Concept 3. Statement three emphasizes patient self-efficacy through empowerment:
If you are age 45 years or older and overweight you may be at risk for prediabetes and not know it.
By increasing your physical activity and making healthy food choices, you have the power to prevent
diabetes. See your health care provider for more information and to find out if you need to get
screened.
Most participants ranked this message as very compelling; participants indicated it has a positive
tone and it empowers the reader. Specific comments were as follows:

“This one is positive. It is not saying, ‘Okay, you might have this scary disease so see
doctor.’ This says, ‘You know what, if you are around this body weight you may be on
the way to diabetes and not know it.’ It says ‘Go and see your doctor to see if you are at
risk and you can do something about it.’”

“It’s based on facts. If you know this, you can deal with it and you care about yourself.”

“This one excites me at my age. It lets me know I can do something to help myself.”
A few participants did rank this message as not at all compelling. One person said it was
“boring.” Another participant said, “It is poorly written. It makes two different points in the same
paragraph without connecting. Not compelling.”
Concept 4. Statement four emphasizes personal experience through a testimonial:
At 46 and overweight, a friend of mine was just diagnosed with prediabetes. We are about the same
age and I am heavier than I should be, so I may be at risk too. I’m going to my health care provider to
get more information and to find out if I need to get screened. If you think you may be at risk for
diabetes, talk to your health care provider.
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Most participants did not relate to this message at all and did not find it compelling. Participants
felt it did not provide enough information to the reader, nor did it make a strong connection
between the reader and the person telling the story.

“There is total lack of motivation. It doesn’t give much information.”

“Not enough of a connection for me. I like using the personal connection, but this is not
my friend so I don’t care. Make it a family member and not a friend.”
The testimony-based message tested in Washington, D.C., referred to an immediate family
member having been diagnosed rather than a friend. Participants had mixed reactions to this
message, from somewhat compelling to extremely compelling, with the majority toward the
middle of the spectrum. Those without a family history of diabetes did not relate to it. Some
participants mentioned that the message was stating something they already knew and, therefore,
they did not find it too compelling. Participants had the following comments:

“I have a diabetic sister. Knowing that it is hereditary and in my family, I would take
precautionary steps and make better choices.”

“No one in my family has it [diabetes].”
Concept Preference
After all concepts were presented, aware participants were asked which concept would most
likely persuade them to take action. Participants indicated that the seriousness of diabetes is their
preferred persuasive style.
Notable Differences and Similarities Among Cities

Participants in Tulsa want to hear about the consequences of diabetes using very direct,
graphic language.

Participants in Birmingham made more frequent references to being inspired to make
healthy lifestyle changes for their children and participating in the program as a family
unit.

Participants in Birmingham participants were more likely to report lacking access to
affordable foods as a barrier to managing prediabetes.
Lessons Learned From Aware Group

There were gaps in knowledge on what prediabetes is, its seriousness, and how it differs
from borderline diabetes and diabetes.

Some participants indicated that the notion of “pre” made them feel they had time to
ignore and avoid something that seemed far into their future and a vague possibility.

Insurance deductibles, costs, and fear of being categorized as someone with a preexisting
condition might deter some aware consumers from availing themselves of the National
Diabetes Prevention Program.

The majority of aware consumers liked the group setting environment of the program and
recognized that it could be beneficial to keeping them engaged and motivated. There was
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also agreement that committing to 16 weeks would be difficult for some, regardless of
how enthusiastic they were about attending.

Participants’ interest in the National Diabetes Prevention Program ranged between being
very interested to being extremely interested in learning more about the program.
Recommendations for Aware Consumers

Messages developed to persuade those aware of their risk for prediabetes should
reference the serious complications of diabetes.

Program messages intended to reach this audience should emphasize the benefits of
participation for the patient and his/her family. Opportunities to involve family members
should be explored.

Educational efforts targeting this segment should include clear definitions of prediabetes
and diabetes and should explain what the screening process entails.

Materials developed for aware individuals should use strong definitive language and
avoid words such as “if,” “might,” and “could.”.

Program promotional materials developed targeting this segment should highlight the
supportive group environment aspects of the program.
Findings for the Diagnosed Consumer Focus Group
Consumer Knowledge About Prediabetes
The moderators in each city asked the diagnosed participants if they had heard of the term
prediabetes and to elaborate on what they knew about the condition. Less than half of
participants had heard the term. Most referenced the condition using different terminology
including this participant:

“I heard that prediabetes is the same condition as borderline diabetes.”
Some participants stated that prediabetes and diabetes were both hereditary and, therefore,
inevitable:

“I’ve watched many people in my family. All of my aunts, all of my uncles have
diabetes. It’s just very prevalent in my family. And even eating right, exercising, they
were the proper weight, everything, they still have diabetes. So I think we have a way of
trying to stave it off, but as we age, no matter what you do the disease will progress.”
Still some questioned the validity of a prediabetes diagnosis. One participant stated:

“There is no such thing as prediabetes. You have it [diabetes] or you don’t.”
Many participants in the diagnosed group deferred to their doctor’s explanation and definition of
prediabetes, as illustrated by this comment:

“My doctor refers to it as hyperglycemia,” and “I asked my doctor what it meant and he
said ‘Your sugar levels are high and you are on the road to developing it [diabetes] but
you are not there yet.’”
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Some participants indicated that their physicians warned them of an impending diabetes
diagnosis, yet there is no sense of urgency from the doctor, and, consequently, none from their
patients. One participant shared:

“My doctor told me I was borderline and I asked him what’s the magic number and he
said don’t worry about it but stay away from sweets. But I can’t stay away from cakes.”
Attitudes and Beliefs About Prediabetes
The moderators asked the groups about their attitudes and beliefs about prediabetes. The
majority of diagnosed consumers felt that prediabetes was both a critical and serious issue.
Participants were somewhat familiar with the risk factors, and a few mentioned that it was vital
to take action to prevent diabetes. Participants shared:

“So many people gloss over it (prediabetes) and don’t take it seriously enough.”

“I think it’s critical because it can kill you and it can cause blindness.”
Some participants admitted that even though they understood the serious and critical nature of
prediabetes and its consequences, they were in some level of denial.

“My mind says it’s a 5 (extremely critical and serious) but I treat it like a 2.”
A few who rated it extremely critical and serious shared that they had done so because they knew
it affected them personally:

“For me it’s critical because I have been told I have it.”
Participants who had seen first-hand the consequences of diabetes through friends and relatives
were able to articulate some of their reasons for rating prediabetes as serious and critical:

“My parents had it, my mom, she went into ketosis …”
A number of participants understood that with proper treatment and lifestyle changes, diabetes
could be controlled:

“It’s behavior driven…” and “We can help prevent it or the severity, but depending on
age and how the body reacts to it…we have a way to stave it off…” and “…for me, as
well, weight control gets the sugar levels down…”
Participants expressed disappointment with their physicians, saying that prediabetes and its
complications have been downplayed.

“It makes me irritated and angry because my doctor told me I was prediabetic for years.
He never explained to me the implications, and he should have known. He never said that
it means you should do this or that or that I should change my eating habits and exercise
more. I would have had a much stronger reaction [about my prediabetes] if I knew what
prediabetes was and have had a better understanding and made different choices. I’m as
mad as fire. He wasn’t straight with me.”
A few participants admitted that even though they had been warned and counseled by their
physicians about prediabetes and were aware of the complications, they were not practicing
healthy lifestyles and habits. Despite this knowledge, participants did not articulate any sense of
urgency in the need to alter or improve their lifestyle habits and choices.
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
I know it’s [prediabetes] critical but am I doing something about it? Maybe not, but I
don’t know why I’m not doing something about it.”

“I know why I’m not doing anything about my lifestyle habits. It’s prediabetes. It’s not
here yet. But I can get away with eating something like a hot fudge sundae.”
Definition of Prediabetes
After participants shared their initial thoughts about prediabetes, the moderator provided the
CDC definition.
The reading of the definition caused strong, negative reactions among the group members. Some
participants did not know how many people had prediabetes in the United States and how long it
takes to develop diabetes after prediabetes was diagnosed. Some of the initial comments were:

“Serious enough to pay attention.”

“I didn’t know about the heart attack and stroke.”

“I didn’t know I could develop diabetes within 5 years.”
Participants discussed the impact of diabetes on the nation and on the individual patient. One
participant said:
“It’s critical for myself and for society if 54 million have it. Trying to prevent even prediabetes is
important to do.”
Screening for Prediabetes
Since these focus groups comprised people who had been diagnosis with prediabetes, there was
no discussion of whether or not physicians and other health care providers screened these
individuals for prediabetes.
National Diabetes Prevention Program
Program Description
All participants were given a definition of the National Diabetes Prevention Program and the
majority liked the idea of this effort and recognized the program’s benefits. There was a general
and positive feeling that the program was a great alternative to living with the complications of
diabetes. One participant articulated:

“It beats 16 weeks in the hospital.”
Feedback on the National Diabetes Prevention Program description included the following
comments:

“It sounds good. It sounds like Weight Watchers where you have support from others in
the same situation you’re in, and they will help you stick with it.”

“Excellent! I would join it. Keep you motivated on what you need to eat, overcoming the
stress, etc.”

“It would be a good program if they truly explain what people don’t understand about
diabetes.”
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Concerns voiced about the program included:

“My only concern when you indicate the number of classes, you automatically think
‘How am I going to squeeze that in what I’m doing now.’ You do three and then you are
tired one night and then you missed two…The length of the program does not appeal to
me.”

“I think this program sounds lame, but the percentage of people who like to learn using
their intellect is less than 20. You’re looking at people in their 30s and 40s, so how will
you get and keep their attention with factual research? It didn’t work with cigarettes…”

“I wonder about cost.”

“It’s hard for most individuals to change their lifestyle and to be able to make time, find
the time to participate in an organized group like this.”

“I don’t want 16 hours of dreary lectures. More people would participate if we had
cooking sessions and actually do hands on with the participants. We can do this.”
Consumers’ Interest in and Willingness to Participate in the Program
After they discussed the National Diabetes Prevention Program, participants were asked whether
they would be interested in learning more about the program and what they would specifically
want to know. Most participants commented that they were extremely interested in learning more
about the program. Diagnosed participants wanted to know more about the specifics of the
program, including information on location and convenience, cost, transportation, meeting times,
criteria for enrollment, availability of daycare and babysitting, background information on the
coaches, insurance coverage, program goals and objectives, curriculum, and the types of
exercises that would be covered in the classes. Specific comments included:

“I would be interested in the cooking classes on how to prepare healthy foods that don’t
take time and don’t cost a fortune. And dealing with psychological triggers.”

“I want to learn more about lifestyle changes.”

“Some people don’t regularly visit their doctor, so how do those people get the
information about participating [in the National Diabetes Prevention Program]?”

“[I want to] find out how you really need to eat, and overcome stress.”

“It would be valuable [to have] information on what I could do to prevent it [diabetes] or
to make my life healthier.”
As discussions continued about the program, participants offered the following
recommendations and suggestions to increase the likelihood of the program’s success:

“Free classes.”

“A phone number to call for support.”

“Show how to help families learn about what to cook and how to get it.”

“Shorter timeframe.”

“Truly explain what people don’t understand about diabetes.
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
“Insurance companies [should pay for the program]. It would be beneficial for companies
to offer this to their employees.”
Since these groups were conducted with participants who had already been diagnosed with
prediabetes, the facilitators probed to determine what participants wanted to hear from their
doctors, as well as any specific information they wanted to learn from the program. Responses
included the following:

“I don’t care if it’s my doctor or the mailman is telling me, but I want the information to
be candid and authentic. If the doctor never tells me, someone else needs to. Thank God
the federal government has told me, since I’m not getting this information from my
doctor.”

“One thing I want to learn [is] how to communicate this lifestyle to the people close to
you; they can be the ‘sabotagers.’”
Diagnosed Concept Discussion
This part of the discussion focused on getting the participants’ feedback on message concepts
developed to encourage adults who have been diagnosed with prediabetes to participate in the
program. The moderator explained the following to the group: “You will be asked to rate each
statement individually on a scale from 1 to 5 as to its ability to move you and your peers to
action. One is not at all compelling and 5 is extremely compelling.”
Concept 1. Statement one emphasizes the serious health consequences of diabetes:
Prediabetes increases your risk for heart disease, stroke, and blindness. If you have been diagnosed
with prediabetes, there is a National Diabetes Prevention Program in your area that can help you
prevent diabetes. Learn more. Call 1-800-123-4567.
Most participants found this message to be compelling. Those who found it compelling noted
that it mentioned the specific, serious consequences of diabetes, and some were previously
unaware of these complications. Specific comments included:

“I wasn’t aware that prediabetes increased these other things; it’s a fear that got into me,
and I have a physical this week and I will ask about it. But listening to others, it doesn’t
say much on what the program is. I might call out of curiosity.”
“This concept moved me because it tells me that it will give me a heart attack, a stroke, or I will
go blind. If I can’t see, I consider that very serious.”

“I took this message very seriously because it does tell you the outcome of what can
happen and it explains where to go for more information.”
A few participants did not find this message to be compelling. They felt that it was not a strong
message and lacked relevant information on the program. Specific comments were:

My doctor already told me this and if I’m not compelled by him, why would you
[National Diabetes Prevention Program] telling me the same thing compel me to
change?”
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
“I gave it a 1 [not at all compelling] because I think it is missing words: ‘dramatically’
should be the second word. I think delayed and coped with should go in there because I
don’t think diabetes can be prevented.”

“It is not a strong statement.”
Concept 2. Statement two emphasizes the urgency of prediabetes:
If you have prediabetes and do nothing, you will likely develop type 2 diabetes within 3 to 5 years.
You can turn this around. There is a National Diabetes Prevention Program in your area that can
help you prevent diabetes. Learn more call 1-800-123-4567.
Most participants ranked this concept as somewhat compelling. A few participants noted that it
did not provide sufficient information on what prediabetes is. Some questioned the 3-to-5- year
timeframe and said that they understood this to mean that they could wait this amount of time to
see if they developed diabetes.

“This message is not going to move me off the couch.”

“Unless you’re already aware of the seriousness of diabetes, this doesn’t explain that. If
you think it’s like a wart on your toe, you would react in a nonchalant manner; so what if
you do nothing? If a person doesn’t comprehend what type 2 diabetes can do, this
statement misses the opportunity to explain it to people.”
A few who liked this concept commented:

“There is more information that I didn’t know.”

“This message hits home because my mom got all kinds of problems and died of
diabetes.”

“It would reach me. I am curious when I read this, and I want to know more.”
Concept 3. Statement three emphasizes patient self-efficacy through empowerment:
You have the power to prevent diabetes. If you have prediabetes, increasing your physical activity and
making healthy food choices and losing a little bit of weight can prevent you from developing the
disease. There is a National Diabetes Prevention Program in your area that can help you. Learn
more call 1-800-123-4567.
Most participants ranked this message as compelling. Participants connected to the hopeful,
upbeat, and positive tone and liked that it offered optimism and a sense of empowerment.
Specific comments were:

“Motivates you to work out and gives you the power and the main things to do.”

“If you have family members with diabetes, knowing you got the power to prevent
diabetes is compelling to me.”

“This message gives you a choice versus the other one that said to do nothing. This one
tells me there is something I can do.”
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
“Because it’s a proven fact—because these are facts, and if you believe the facts then
that’s hope right there.”
A few participants had less enthusiastic responses to this message and stated that it did not offer
any new information. Comments included:
 “It’s something you hear all the time, and so what.”

“When I read, this I think, ‘they say that about everything.’”

“Most of it is about your eating habits and we [already] know that.”
Concept 4. Statement four emphasizes personal experience and success through a testimonial:
“My doctor told me I have prediabetes and then he told me about a program in my community that
would help keep me from getting diabetes. At first, I wasn’t too sure. But I am so glad that I went! The
classes teach me about lifestyle changes that even I can make to be healthier. Now I feel great and my
doctor has even noticed the difference. You can prevent diabetes, too. If you have prediabetes, find
out about the National Diabetes Prevention Program in your area. Call 1-800-123-1234.”
Most participants ranked this message as compelling. Specific comments were:
 “It’s a good message. It’s a testimonial showing it helped her.”

“The patient got information from his doctor, followed the advice, and then saw results.
That’s what I liked about this concept.”
A few participants ranked this concept as not at all compelling and thought it sounded like a
commercial. Those who did not like this concept felt it could be enhanced if they knew the
patient was an actual National Diabetes Prevention Program participant. Comments included:
 “You see this person on TV and you say, ‘this is an actor and not real.’”

“I don’t trust my doctors so I don’t trust this concept.”

“The whole thing sounds too good to be true.”
The testimony-based message concept tested in Washington, D.C., referred to a family member
having been diagnosed rather than a friend. The diagnosed participants ranked this concept as not
at all compelling. Most of the participants agreed that the concept would not motivate a reader as
they felt it did not provide any meaningful information other than a phone number. Participants
commented:
 “The two sentences have no relationship to each other. It goes nowhere.”

“You have to read too many words before you get into the info, and it doesn’t address the
potential of lifestyle, just genetics.”

“The first line gives you hope and then it goes nowhere.”
Concept Preference
After all concepts were presented, participants discussed which one would most likely persuade
them to take action. The preferred technique for the diagnosed participants was self-efficacy
through empowerment (Concept 3). The phrase “You have the power…” resonated with this
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group. A few participants mentioned combining the language from each of the statements. For
example, one participant suggested combining sections of the “what you can do” concept with
the personal testimony concept. The participant said: “I like the combination of these two
concepts. I want to know about this power through a testimonial.”
Notable Differences and Similarities Among Cities

Stress was a strong theme among the Washington, D.C., participants. They noted the
impact of stress on disease in general and prediabetes and diabetes in particular.

Participants in Tulsa and Birmingham preferred the message concept that emphasized
self-efficacy; the Washington, D.C., participants preferred the personal testimony.

Concerns about the cost of the program were expressed in all three cities.

Participants in all three cities expressed concern about the lack of information on
prediabetes they are receiving from their doctors.
Lessons Learned From Diagnosed Group

The diagnosed participants noted repeatedly that they are not receiving adequate
information about prediabetes and its seriousness from their health care providers.

Despite rating prediabetes as both serious and critical, participants noted their behaviors
in managing their prediabetes were not consistent with this knowledge.

Many of the diagnosed participants had never heard that prediabetes may progress into
diabetes within 3 to 5 years.

Although many diagnosed participants were aware of the risk factors for diabetes, they
did not realize that stroke and heart disease were complications of prediabetes.
Recommendations

Efforts are needed to introduce the term prediabetes and its relation to other commonly
used terms such as borderline diabetes.

Messages about prediabetes developed to reach the diagnosed must be differentiated from
other diseases and conditions with similar complications. Messages need to be heard
about the myriad of health messages.

Messages created to encourage and increase program participation should emphasize selfefficacy and empower the reader. Program messages intended to reach this audience
using personal testimonies should include actual program participants.

People in the diagnosed segment of the population are impressed by and attracted to the
concept of having access to a trained life coach. This aspect of the program should be
underscored.

Messages should not assume that consumers who have been diagnosed fully understand
prediabetes, its progression, or its complications.

Messages developed referencing the 3 to 5 years within which prediabetes progresses into
diabetes must be crafted to ensure they communicate a sense of urgency.
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
Messages and materials should be developed targeting health care providers to support
and encourage their efforts in explaining prediabetes and its seriousness to their patients.
Findings for the Family and Friends Focus Group
Audience’s Knowledge About Prediabetes
The degree of knowledge about prediabetes varied among cities. Participants in Birmingham,
had the least knowledge of prediabetes compared to Washington, D.C., and Tulsa; the majority
had not even heard about it. Half of the group in Tulsa and the majority in Washington, D.C.,
had heard of prediabetes and had some knowledge of its definition.
Attitudes and Beliefs About Prediabetes
Participants across groups strongly agreed that prediabetes is a serious issue but not all agreed to
it being a critical issue. For some the fact that prediabetes is a “pre” condition makes it less
critical. The fact that diabetes can still be prevented further contributed to this sentiment:

“As far as critical issues, type 1 and type 2 are critical issues, because you already have it.
So, I don’t think [prediabetes] is necessarily [critical] at that point. It’s important but it’s
not critical.”
Another participant said:

“When I think of ‘critical,’ I think of very bad. And prediabetes—they don’t have to get
to the critical level. If you prevent it by exercising, eating healthy. There’s ways to
prevent it.”
However the fact that prediabetes is preventable is what made it a critical issue for those who did
agree with prediabetes being critical:

“The reason I would choose 5 [strongly agree that prediabetes is a critical issue] is
because I assume, and I could be wrong, that it is preventable. Therefore, it would be that
much more important to focus on it—before it becomes diabetes.”

“I would strongly agree because it’s preventable. ‘Cause if you catch it early you're more
likely to prevent it.”
Participants in all three groups felt that they could and would help a family member or friend at
risk or diagnosed with prediabetes to make lifestyle changes by providing information and
encouraging them to make healthy lifestyle choices. Most did express, however, that ultimately,
it is the individual who will need to take action. Others expressed their willingness to help but
felt limited since they are not health care professionals. Participants shared:

“People have to be willing to change their lifestyle. It’s a matter of changing their
lifestyle. You can give them the information, but unless they change their diet,
incorporate exercise and rest, there will probably be very few results.”

“I feel like I can [help] to a point, but there’s that point of view just you’re not the
doctor”

“You can kind of tell people what you think is going on with them and that you could
help get [them] screened, but some people just think that they know everything and they
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refuse unless they see it in the media or they see it from someone with a higher level of
education than just me.”
Participants also said that they would address prediabetes with a friend or loved one if they felt
they had enough information about it:

“If I was trying to talk them into going [to the doctor] I would want the information in
hand so I could pretty much have proof of what I’m saying to talk them into it.”

“And especially if you have facts and information. When you present the information to
them, tell them why it is important and how you can help. They’re more likely to listen.”
Definition of Prediabetes
The definition of prediabetes that was shared with the participants sparked curiosity about
causes, symptoms, risk factors, and treatment. Comments were:

“It’s important to find out how to prevent it.”

“How do you get it?”

“How much of it is hereditary rather than diet?”

“What [do you] pay attention to?”
Specific words and data within the definition also caused reactions among the participants. The
number of Americans who have prediabetes, the timeframe in which prediabetes progresses into
diabetes, and the complications was new information for almost all participants and raised
concerns:

“It’s a very large number of people out there with prediabetes that probably don’t even
know it.”

“I think it was the within 5 years of being diagnosed is when you can get it, because I
think that I’m at a young age and if I get it in the next few years then I’ve only got five
years to basically turn it around before I could have diabetes.”

“After hearing the word ‘stroke,’ I think you can change your attitude about eating
healthy, exercising, maybe getting out and walking.”
National Diabetes Prevention Program
Program Description
Participants were given the description of the National Diabetes Prevention Program and then
asked to comment on the program. They were asked about their willingness to talk to and
encourage a friend or family member at risk or diagnosed with prediabetes to attend. The
program description prompted mixed reactions from group participants. In Birmingham and
Tulsa, the majority of the participants thought it was a good idea and found the program to be
appealing.

“I think it’s wonderful, because people are more willing to do something as a group than
they would be to do as an individual.”
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
“I think it’s important. Education is a great thing, because most people will go to their
doctor. The doctor will say, ‘You have diabetes.’ Or, ‘You have prediabetes. You need to
do this.’ But they don’t really tell you how to do it or provide you with the support and
motivation that you can get from a program like this. Especially meeting with other
people.”
One aspect participants felt important and of benefit to the participants was the “post-program,”
monthly, maintenance sessions:

“I think one of the main things that would really help is making it a long term, make it
consistent, not doing a one-time thing where maybe for one day you feel motivated and
then the week after you forget about it. It’s consistent every week. I think the 16 weekly
sessions and then the monthly follow up—making it long-term will help.”

“I think that it’s also good that even after the 16 weeks they continue to give them
support and make sure they’re staying on the right track. Because a lot of people after
they get finished with the program, they slack off and go back to the same lifestyle. But if
you got continual support, then that helps create that change of mindset, so you’ll be able
to do it on your own without somebody else telling you to do it.”
The group members in Washington, D.C., expressed skepticism about the program working.

“Don’t waste my tax dollars trying to change people’s bad habits.”

“I think that 16 hours of instruction is not enough. There are so many influences in our
culture and this is just a drop in the bucket.”
A few participants across the groups felt that the program should target a younger audience:

“Adults have habits that have already been established. If we implement this program at
the Head Start level, we have a chance of this working, because it’s best if you train
young children. But for adults, you’re not going to change their habits.”

“The younger this program reaches people, the better.”
Participants across all groups were willing to talk to their loved ones about the National Diabetes
Prevention Program. However, they again stressed the fact that it depends on the individuals
themselves to make the necessary changes.

“I was just going to say you’ve got to want to change, you’ve got to get it in your head
that this is what you’ve got to do, you know. That’s the first step in anything.”
As the discussions about the program continued, the moderators probed for more information
about how participants would promote the program to family and friends with prediabetes.
Participants noted the need to be supportive, highlight the benefits of the program, as well as the
negative consequences that diabetes can have not only for the individual, but for the whole
family.

“I would tell them how much they mean to me and how much I need them in my life and
that I want them around a long time.”

“I’d say ‘Look, this is the cold fact of the matter. It’s not going to be fun and it’s not
going to be easy, but think of the way you’re going to suffer if you don’t deal with it.”
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
”[Emphasize] the fact that it can happen to people in your household. Say, for instance, if
you’re living a certain lifestyle and your children are there, more than likely you make it
worse for them as they become adults because they’re used to that lifestyle.”
Participants in Tulsa emphasized that doctors should use fear tactics and speak graphically to
their patients. They felt the focus should be on the serious and severe complication of diabetes
rather than on prediabetes.

“I’m a firm believer in tough love. They [doctors] need to speak straight over and tell
them about how bad it can be in the end. Forget about telling them what it’s going to be
like in the beginning. Just tell them how deathly bad it can be at the end, maybe that’d be
enough to open some eyes.”
Several participants said that there needs to be more information on prediabetes for the family
members. Doctors were considered the key source for this information.

“I think the doctors really should give out more information. I think there’s just not
enough information given to families about it so that they can learn about the changes
and things that are needed and necessary to prevent it.”
Behavioral Intention
Participants were asked how confident they were that their loved one would enroll in and
complete the 16-week program and the 8-month maintenance period. Although the majority of
the participants in Tulsa and Birmingham reacted positively to the program description, many of
the respondents were not confident that a family member or friend would complete the program
mostly because they felt there is a lack of awareness to the disease and, therefore, people believe
the disease is not serious enough to be acted upon. One participant shared:

“I think it’s pretty unlikely people are going to do it. I have friends that they just lie to
themselves. I sit and I watch them eat and they lie to themselves. And that’s—everybody
that I’m around—that’s the way it is. My sister’s a full blown diabetic. She absolutely
drives me crazy. As far as I’m concerned, she’s committing suicide, slowly and you have
to sit and watch her and I talk and they get irate with me. They don’t want to hear what
you have to say about it.”

“In my experience people don’t take things seriously until it is serious. Until they are
about to be directly affected in a big way and a doctor tells them, ‘You either stop doing
this or else.’ I could tell a relative or a friend but they’re in denial, they’ll have all these
excuses. So I don’t think the commitment would be there to stay motivated to a 16 onehour weekly sessions.”
Participants were asked possible motivators to encourage their friends and relatives to join and
complete the program. One participant suggested setting rewards after reaching certain levels in
the program.

“Just giving them something positive to look forward to. The idea of ‘When I finish this I
got this to look forward to.’”
Another motivator participants across all three cities suggested incorporating was a ‘buddy
system.’ This would enable family and friends to accompany and support the participants
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throughout the whole program. Many mentioned that if the whole family is not involved, it will
be harder for the individual to be successful. One participant shared:

“I’d probably invite them to go with me. I'd probably go and be an example and
especially with this particular friend I’m thinking about, she would never go if I was just
talking to her.”
Other motivating factors mentioned by participants included:

“It needs to be free.”

“If they were also doing cooking classes, showing people how they could eat healthier.”

“If you want to convince somebody, you show them the cost of the disease.”

“I think maybe the doctors are going to have to start pushing a little, you know, put it out
there with their patients so they can talk with them about [the program] and put it in their
minds how serious it [prediabetes] is.”
Participants across all groups also mentioned needing more information before they could
promote the program to their friends or relatives. Program information needed included the cost,
class times, locations, the type and structure of the classes, and background information about
the coaches.
Notable Differences and Similarities Among Cities

Participants in Birmingham had the least knowledge of prediabetes.

Participants in Washington, D.C., were the most skeptical about the program’s ability to
be successful.

Participants in Tulsa recommended that the seriousness of the diabetes, as opposed to
prediabetes, should be conveyed using fear tactics and emphasizing the most serious
complications of the disease.

Given disease and program information, participants across all cities were willing to talk
to their loved ones about prediabetes and the National Diabetes Prevention Program.

Participants across all cities recognized the limitations on their abilities to impact their
family and friends’ behavior choices.
Lessons Learned From Family and Friends

Knowledge about prediabetes varied widely among participants from some completely
unaware of the disease to a few fully understanding what prediabetes entails.

The fact that this condition is at the “pre” stage makes it a serious but not critical issue.

Family and friends of individuals at risk or diagnosed with prediabetes are willing to
support the National Diabetes Prevention Program by sharing information, being
encouraging, and attending class sessions.

The view held by many participants that prediabetes is not a serious condition is an
impediment to disease management and program participation.
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
Family and friends of people at risk for or diagnosed with prediabetes consider family
involvement integral to the individual’s success in the program.

Family and friends of individuals at risk for or diagnosed with prediabetes would want
specific information on prediabetes to enable them to provide adequate and appropriate
support.
Recommendations

Friends and relatives can be used as catalysts for individuals needing to manage
prediabetes. A limited number of materials specifically for family and friends of
individuals at risk for or diagnosed with prediabetes should be developed providing
detailed information about prediabetes and tips on how to support their loved one.

Materials need to emphasize the seriousness of prediabetes, its prevalence, and
complications.

Basic information about prediabetes is needed by this segment.

Opportunities to integrate family and friends into the program should be identified and
implemented as appropriate.
Differences and Similarities Among Unaware, Aware, and Diagnosed
Consumers and Family and Friends Segments
Consumer Knowledge About Prediabetes

The term prediabetes was unfamiliar to the majority of the participants across all groups,
including the diagnosed.

Borderline diabetes was a more familiar term than prediabetes across all segments.

All participants across all segments expressed a desire to know more about the
prediabetes, its risks factors, and how to prevent the onset of diabetes.
Attitudes and Beliefs About Prediabetes

Across all segments, most participants agreed with prediabetes being a critical issue,
especially those participants who had experienced diabetes through friends and relatives.

Family and friends found prediabetes to be serious but not critical as they felt that the fact
that it is a “pre” condition means that it may or may not happen and, therefore, it is not
critical.

Participants diagnosed with prediabetes, despite having some knowledge of the risks and
complications of the disease and acknowledging it as critical, lacked a sense of urgency
in managing it.
Definition of Prediabetes

The definition of prediabetes sparked a sense of concern and urgency among the majority
of the unaware and family and friends participants.
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
For the aware and diagnosed, the definition of prediabetes caused negative reactions and
frustration, especially towards their doctors. They voiced that doctors were not relaying
the urgency of the disease.
Screening for Prediabetes

A great number of the unaware and aware participants had not heard about screening for
prediabetes.

Cost and lack of insurance coverage was mentioned by unaware and aware participants as
a barrier to getting screened.

Unaware participants also mentioned the fear of finding out that they had prediabetes and
dealing with the diagnosis as a barrier to getting screened.
National Diabetes Prevention Program Description

The majority of participants across all segments liked the concept of the program and
recognized its benefits.

Common concerns and potential barriers to participating in the program, among all
segments, included program length, time commitment involved, cost, and lack of
insurance coverage.
Consumers’ Willingness to Participate in the Program

The majority of the participants across all segments expressed the willingness of
participating in the program; however, they would first need detailed information about it
to make a final decision.

Besides cost and insurance, information requested by all segments included program
curriculum, goals and objectives, background on coaches, and times and location.

Participants across all segments emphasized that the program needs to be “hands-on,”
“fun,” and “interactive” rather than lecture-based classes.

The majority of the aware and diagnosed participants liked the lifestyle coach feature in
particular.

The aware participants liked the support group element of the program.
Concept Preference

The preferred persuasive style for the majority of the unaware and aware participants
emphasized the seriousness of prediabetes.

The preferred persuasive style for the diagnosed segment was self-efficacy through
empowerment. The words “you have the power” resonated with this group.
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Creative Materials
Tag Lines
Participants in the consumer and family and friends groups were asked to review and rate two
taglines: “Live Well. Stay Well.” and “Healthy Habits. Healthy Life.” Participants use a scale of
1-5, where 1 was not at all compelling and 5 was extremely compelling.

The majority of participants across all segments selected “Healthy Habits. Healthy Life”
as the preferred tagline. However, it was rated towards the “somewhat compelling to not
compelling” side of the scale as they felt that healthy habits do not always lead to a
healthy life. Some of the comments included:
o “In terms of for what they’re [CDC] trying to do, and prevent disease and promote
health, obviously there’s no question that ‘Healthy Habits. Healthy Life.’ is more
geared towards the subject that we’re talking about.”
o
“I like the healthy habits one because to me it’s more proactive. It’s doing
something, it’s more the doing. Living well could be thought of differently by
different people. Healthy habits means it’s more proactive. To me [“Healthy Habits.
Healthy Life”] is more clear.”
YMCA (Y) Flyer
Participants were asked to review and provide feedback on a diabetes prevention program flyer
developed by the Y.6 Groups in Birmingham and Tulsa were asked to share their thoughts and
opinions about the content and layout of the flyer. Note that, due to a shortage of time, the Y
flyer was not tested in Washington, D.C. The following is a brief summary of findings from
participants in Birmingham and Tulsa.

The majority of participants across all segments reacted positively to the flyer, most
specifically to the program description.

One common element of concern was cost. Participants noted this could become a barrier
for individuals even wanting to inquire about the program as some associate the Y with
being expensive.

Participants in Birmingham had a negative reaction towards the Y. They want to see the
program being offered at different venues.

Recommended changes among all segments included incorporating images that reflect
different races, and ethnicities as well as age ranges.
Findings for Primary Care Physicians IDIs
Recruiting for physicians is a challenge given their work schedules and availability to
participate in focus groups. To allow for a more successful response rate, IDIs were conducted
with primary care physicians. The following section presents findings from these interviews.
6
The Y Flyer can be found in Appendix E. We also tested a creative piece with one consumer group in Washington, D.C. (also in Appendix E).
This flyer was not well-received by participants. After the first round of testing, the flyer was not tested in Birmingham or Tulsa.
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Physician Knowledge About Prediabetes
Participants were asked about their general knowledge of prediabetes. All were familiar with the
term “prediabetes.” However, when asked how they define prediabetes, all eight physicians
interviewed provided varying responses. Specific comments include:

“I think of prediabetes as somebody with an A1C that is not as high as high as a diabetic
patient. What I mean by that is 6.5 or less or rather 6.4 or less. Six point five is the cut off
line for diabetes these days and the low limit for that, it kind of depends on the
laboratories. Sometimes I see normal quoted range for non diabetic patient anywhere
from 5 to 6. I mean 5.6 or less to 5.8 or less.”

“I would say a fasting glucose of between 100 to 125.”

“A person with [high] blood sugar usually between 105 and 128 and a slightly elevated
A1C.”

“Prediabetes is not exactly diabetes, but it is a pre-stage of diabetes where the blood sugar
is between 110 and 150. And the A1C is more than seven.”
Attitudes and Beliefs About Prediabetes
When asked if they strongly disagree or agree that prediabetes is a critical issue, all participants
agreed that prediabetes is a critical issue. Several participants acknowledge that prediabetes is
critical issue among the communities that they serve and that many people have prediabetes or
are at risk.

“It is. It is critically important. I see them a lot. I want to say I see them every day in my
practice, and I see a lot of medical conditions in my practice and, unfortunately for the
patients, it’s very common. And, understand where I practice there’s especially pretty
high diabetes compared to the national average.”

“I do [think prediabetes is critical]. Well, I just think that it gives us some warning that
the patient … a lot of these patients will go on to get diabetes unless they make some
changes. And diabetes is a very serious disease…and so, is prediabetes, because it can
make a difference, if you can change these people’s, you know, lives in the other
direction.”

“Extremely. I mean, diabetes is, and the fact that there are millions and millions of people
you know who are in that prediabetes or risk category, I mean, it’s already been an
explosion of diabetes, so I can only imagine what the next 10 to 20 years are going to be
like.”

“Yes, because I think if it’s not addressed with either diet, exercise, or maybe even a mild
drug program, it will go on to full diabetes in a relatively short time.”

“Yes. Well, again if they don’t get diagnosed, a lot of times they’ll go for several years
before they start getting, you know, symptomatic. And the disease itself of course can be
life-altering or even, you know, more critically it can be life ending if it’s not diagnosed
and treated in a prompt period of time.”

“Yes, it’s perhaps not surprising that I see a lot of prediabetes patients on their way to
become diabetic if not treated, if not monitored or if not intervened. And as we all know,
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diabetes or even prediabetes is an extremely important factor in predicting mortality and
morbidity in terms of risks of, most importantly, cardiovascular diseases and a host of
other problems too.”
When asked if they feel as though they can make a difference in patients’ lives as it relates to
prediabetes, the majority of the participants agreed that they can. Many providers shared that
they do take the time to counsel and advise their patients who are at risk or diagnosed with
prediabetes to make lifestyle changes. Comments included:

“Yes, I have done that. I’ve been in clinical practice now 20 years, and I’ve certainly had
patients who were on the verge, or at risk, who did make changes, and did result in not
developing, or at least not yet developing type 2 diabetes. There is the ability to
intervene.”

“In general, I really try to make a difference and really spend time talking about lifestyle
changes for these patients.”

“If I see that they have prediabetes or, you know, even trending towards that I bug them a
lot about weight loss, trying to exercise, to start walking, et cetera. Because most people
don’t really know. If they go for a short walk they think they’ve walked a lot. So, you
know, they need to kind of build up. And it’s very hard for people to start.”
Physicians identified barriers they encounter when working their patients to encourage them to
manage prediabetes. Physicians mentioned a lack of patient motivation and a lack of patient
knowledge or awareness of the seriousness of prediabetes as barriers. Other comments included:

“Yes, I do talk to my patients. However, if a patient lives in a household where they’re
not concerned about their health, especially parents and they don’t care, so that’s a
barrier.”

“We work on diet and we’ll talk about diet and exercise all the time, and patients are very
interested, but then I see them a few months later, and then it will be the same old stuff
all over again.”
Screening for Diabetes
When participants were asked if they screen for prediabetes, all respondents indicated that they
do screen their patients for prediabetes. When asked what factors they consider when screening
someone for prediabetes, participants responded that they review the following:

Weight

Family history of diabetes

Fasting blood sugar

Impaired glucose tolerance

Acanthosis nigricans on patient’s neck7
7
According to CDC, Acanthosis nigricans (AN) is a skin problem often found on the neck, axilla, groin, and other flexural areas. Literally, AN
means thick, coarse, and dark. Scientists once thought AN was associated with conditions such as polycystic ovarian syndrome, but recently, they
have found that AN is a marker for high levels of insulin.
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
Irregular periods or infertility in women

History of thyroid disease

Blood pressure

Obesity
Participants were asked if they experience any barriers to screening people for prediabetes.
Several respondents mentioned lack of insurance and patients not showing up for appointments.
One participant said, “Well the fact that they don’t come to doctor, that’s it neglect.” Other
comments included:

“Sometimes the patients don’t have insurance.’’

“If patients don’t show up for appointments, if patients don’t want to get their blood
drawn or checked—those are the biggest barriers for screening.”

“You know, once I have them in the office, it’s not an issue. Of course, sometimes
getting people into the office who may need to be in here for annual checkups, or
biannual checkups, or if a symptom develops or concern about weight, they’re not always
willing to come because their co-pay has gone up or their company’s changed insurance
plans.”

“I guess one of the main barriers is financial. If people come in without insurance, one of
the barriers would be the cost to doing blood work on these patients. So cost is one factor.
Lack of insurance, of course, is another factor.”

“Sometimes they don't want to probe into whether they have an abnormal blood group
glucose level, and I think cost is probably the most significant barrier.”
National Diabetes Prevention Program
Participants were given the description of the National Diabetes Prevention Program and asked
about their thoughts and opinions of the program and their willingness to screen high risk
patients and refer those patients with prediabetes to a diabetes prevention program. The program
description prompted positive reactions from the physicians. Most agreed that it would be
feasible for them to screen and refer their patients to the program. A few mentioned that as long
the referral process was easy and not labor intensive, they did not anticipate having difficulties
referring patients.
 Well, as long as the paperwork was pretty straightforward, it would be pretty easy. I
mean if it was a one-page form that we fax somewhere that would be pretty
straightforward.”

In a program like that, that might be a comprehensive review of what typical activity to
do and what things to eat and maybe other stuff too. I’m sure that’d be pretty valuable.
And so as long as it was not time-consuming and laboring; hence, it would be pretty good
and pretty easy.”

“Well, I think with staff education, which would be important, particularly my medical
assistant, but yes, even the front desk. And with reasonably adequate materials to hand
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out as well as locations they can go for, whether it’s classes and exercise programs at the
YMCA or local hospitals and so forth.”

“Yes, I think it would be feasible. Again, similar to what we’re doing already with
existing diabetics trying to get them into a diabetes education program if they’ve been
newly diagnosed, or if they’re transitioning to insulin, or they’ve fallen off the wagon in
one way or another. I mean, I could see this being feasible, as long as we have ready
access to the materials right there.”
Participants noted that cost will be an important, determining factor in program participation for
many of their patients. Other comments included:

“I would just have them [patients] lined up. I would love it. Yes, I would definitely use
that [the program] and I think it would be outreach to pediatricians and primary care
providers in the community. And certainly if it were free, you know, people would go for
it and take their kids.”

“I think it should not be too difficult [to refer patients]. We are very dear to what is
prevention medicine in the office. I think I will be able to convince a patient that this is
an important program and, as long as it does not cost them a lot of money, if it costs any,
there should be no problem.”
Participants were asked what information they would need to know about the program before
referring their patients. The type of information requested included the following:

Location

Contact phone number for patient use

Insurance requirements

Detailed program description

Type of physical exercise conducted in the class—especially for older adults

Transportation/accessibility to program location

Cost

Monitoring—Are there physicians/health care professionals monitoring program
participants?

Process for referring patients to the program
Behavioral Intention
When participants were asked if they would be interested in receiving information on the
National Diabetes Prevention Program, they were extremely interested. Participants specifically
wanted to receive more information on the cost of program for their patients and details about
program curriculum. Specific comments were:

“I’d say I’d be at a 10 [extremely interested]. I’d be very interested.”

Yes, depending on cost of the program for my patients.”

“I am interested, specifically about what’s involved in the program.”
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
“Yes, very interested. I really spend my whole day talking about this stuff [diabetes
prevention] and it’s to everybody. I have a big thyroid practice; the patients are
overweight too and they’re worried about getting diabetes and asking ‘what do I do?’”

“Yes, because we have a YMCA pretty close to us. It’s actually brand new, and it looks
like it has a great facility. If it was in that facility—or there’s a couple other facilities that
are similar to YMCA, although they’re not exactly YMCA—that were to offer the
program, I think that it could potentially do a really good job. I know education about diet
and exercise can only help a person, and those sure are [good motivators] to get involved
in referring to patient programs like that.”
If there was a website available for physicians to get information on the program, the participants
noted the following:

Brochures

Background information on the program

Program materials to distribute to patients

Information on program instructors
Physicians were asked if they had any program recommendations. Suggestions offered included:
advertising about program on the state medical board bulletin, websites, and mailings. A few
participants mentioned two different approaches, such as financial incentives for physicians
referring patients to lifestyle program and conducting IDIs with physicians to inform them about
the program. Comments included:

“I think that letting them [physicians] know basically that there is this new program that
is going to be coming out in whatever manner, shape, or form they can do it, whether it’s
through the, you know, websites, or mailings, or TV advertisements, or whatever way.
Just…through these types of interviews, you’re doing here with me, you know, is very
helpful.”

“I think, yes, as far as for physicians’ standpoint, I think mass mailing is one way, or
CDC probably had enough strings to pull to get them on a Medical Board of California,
the bulletin. Physicians get it quarterly several times a year. The bulletin from Medical
Board of California or in other states and every physician gets them.”

“You’re going to capture attention, particularly primary care physicians,’ as things evolve
forward with so-called pay for performance, and accountable care organizations, and a lot
of the other ideas that have been out there to tame the monster that is health care. I am
involved in one organization that promotes and rewards higher quality practice of
medicine and one of the areas is diabetes, and having diabetic patients at goal in terms of
their hemoglobin A1C, and their cholesterol numbers, and their blood pressures, and so
forth, to reduce the risk of the complications, like heart attacks, and strokes, and so forth.
Financial incentives are financial incentives, and they bring out performance. If you’re
part of an ‘accountable care’ organization, and you’re saving the organization money
because you’re keeping prediabetics from being diabetics, there’s going to be incentives.”
Health care providers were asked about their willingness to become a “physician champion.” The
interviewer explained to the participant that the role would entail referring patients to the
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National Diabetes Prevention Program, presenting information about the program to their
colleagues, and encouraging other health care providers to screen and refer their diagnosed
patients to the program. Most participants seemed eager to participate in this effort. However,
respondents stated that they would need to have additional information about the program and
the exact duties and expectations of this role before committing to participate as a physician
champion. One participant said:

“Yes, I would participate. I’d want to know more about the program. What exactly the
program is and then, where the locations are. It’d be nice to know if they’ve done any
outcomes as to what their program has actually done with real patients.”
Concept Discussion
This part of the discussion focused on getting the participants’ feedback on four message
concepts developed to persuade providers to take action by screening and referring their patients
to a program. The moderator explained the following to the individual: “You will be asked to rate
each statement individually on a scale from 1 to 5 as to its ability to move you and your peers to
action. One is not at all compelling and five is extremely compelling. After reviewing all four
statements, you will be asked to select the technique you deem most effective in its ability to move
you and your peers to action, and why. When listening to the statements, please focus on the
technique (i.e., urgency, seriousness), as the messages have yet to be fully developed.”
Concept 1. Statement one emphasizes the urgency of screening for prediabetes:
Prediabetes, if not addressed early, will develop into type 2 diabetes within 3 to 5 years. Don’t miss
this window of opportunity to prevent diabetes. Screen your patients now so they can take steps to
reduce their risk of diabetes. There is a National Diabetes Prevention Program in your area to help
those who test positive for prediabetes.
Overall, participants found this concept to be compelling. Most agreed that it was a strong
statement because it is straightforward. A few commented that, by stating the 3- to 5-year
timeframe, it created a sense of urgency. Other comments included:
 “I like it because of the clause where it says it will develop into diabetes in 3 to 5 years.
I’m one of those people who don’t like to beat around the bush. I think it’s more direct
and it’s not scary but, you know, it certainly is true. And it also stresses that there is help
now.”

“I’d like the wording that…about prediabetes that’s not addressed early will develop into
type 2 within 3 to 5 years and give them, you know, a sense of urgency you know that
you do something right now you can help prevent a patient from developing diabetes.”

“I think it’s pretty good. I think it underscores the need to treat prediabetes. It probably
could even be a more impressive statement than that. Overall, I think it’s a good
statement.”

“It makes it sound very important to do it quickly, and I think that that is motivating.”
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Concept 2. Statement two emphasizes the seriousness of prediabetes:
Prediabetes increases a person’s risk for heart disease, stroke, and blindness. Screen your high risk patients for prediabetes. There is a diabetes prevention program in your area to help those
who test positive.
Overall, participants ranked this concept between somewhat compelling to extremely
compelling. A common response was that it does not provide physicians with new information; it
includes facts that doctors already know or should know. Therefore, the concept would not
motivate them. One participant mentioned that, as a physician, threatening people with possible
health condition is not an effective way of communication even if they have diabetes. Comments
included:
 “It’s sort of the future risk of something. It just isn’t the here and now you know. For
example, I don’t find threatening people with going blind in the future very helpful even
if they are diabetic today.”

“We’re inundated with all these comments about ‘do this, do that’ and once you start
seeing the litany of heart disease, stroke, blindness; we tend to speed read this type of
information. I already know this information. It looks like an introduction to a drug fact
sheet.”

“Physicians know that diabetes can lead to heart disease, the blindness, and kidney
disease.”

“I already kind of know about the risks. And it doesn’t give me enough information to get
me all excited and motivated.”
For those who found it to be extremely compelling, comments included:
 “It’s short, succinct. In the first sentence it immediately tells the reader that prediabetes,
it’s not just something, you know, that it is benign.”

“I think this is extremely compelling. Those three things that you had mentioned are the
ones that are the targets for uncontrolled diabetes.”
Concept 3. Statement three emphasizes program efficacy in preventing diabetes:
The Diabetes Prevention Program study found that people with prediabetes who completed a 16-week
lifestyle intervention program were 58% less likely to develop type 2 diabetes than the control group.
Screen your high-risk patients for prediabetes. There is a diabetes prevention program in your area to
help those who test positive.
Participants rated this concept very compelling. For these participants, the statistical information
and the program length caught their attention. They found the concept motivating. A few of the
physicians suggested adding more information on the study to make the message more
persuasive. Comments included:

“Well, now I’m getting, like, lots of specifics. And I feel I’m very motivated. Sixteen
weeks seems like a very reasonable amount of time. Fifty-eight percent less likely is also
a really good number. So, again, it makes me more motivated to refer.”
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
“It talks about the 16 week, you know, lifestyle intervention. That’s important. And also
58% is pretty good.”

“The only thing is every single doctor who reads that is going to say, ‘Well, how long
was your study,’ for follow-up, you know. If you’re going to be quoting actual ‘58% less
likely’ then you have to finish it and put in, you know, the study lasted 2 years and, you
know, and everybody will have a bunch of questions about that.”

“I think physicians would want a little more information if you’re … if you’re saying
58%. You know, they’re going to say, you know, how many years was the study and, you
know, what was…what was the average BMI and how old were the people?”

“I like it that the program is so effective, according to the statistics. I mean 58% less
likely, those are pretty good statistics.”
“I think that the first part comes on really well. It gives you that statistic….We tend to always look at
things that are more data-oriented. It’s accurate, succinct, gets you to the point, which is ‘Well, what do
you want me to do about this 58%? Oh, get them to a program.’ So it’s well written.”
Concept 4. Statement four presents a scientific recommendation:
The American College of Endocrinology and American Association of Clinical Endocrinologists
recommends that high-risk patients be screened for prediabetes. Risk factors include the following:
family history of diabetes, cardiovascular disease, being overweight, sedentary lifestyle, and
previously identified impaired fasting glucose or impaired glucose tolerance.
Screen your high-risk patients for prediabetes. There is a diabetes prevention program in your area to
help those who test positive.
Participants did not find this statement to be compelling. Several respondents expressed that the
message was too long and redundant. A common response among respondents was “doctors
already know this information.” A few commented that a statement coming from a scientific or
authoritative organization was not relevant and would not persuade them to take action.
Comments included:

“I think most physicians know the risk factors for diabetes. So, it’s kind of redundant. It’s
not forceful enough for me.”

“It’s not as exciting. Too wordy. Not enough really specific information. These are things
that I already know.”

“I think doctors should already know this.”

“It's too long. If you’re trying to make the point, that whole first line between American
College of Endocrinology and American Association of Clinical Endocrinologists is too
cumbersome.”

“The first sentence about the American College of Endocrinology, the American
Association for Endocrinologists that does not matter to me.”
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Concept Preference
After all four message concepts were presented, the physicians were asked which concept would
mostly likely persuade them to screen and refer patients to the program. The majority of
physicians selected program efficacy as their preferred persuasive style. A couple of participants
suggested incorporating parts from Concept 2 (seriousness of prediabetes) with Concept # 3
(program efficacy).

“I would try to incorporate the heart disease, stroke and blindness thing which would
make it [more compelling].”
Lesson Learned

Physicians were familiar with prediabetes.

Physicians are willing and extremely interested in counseling their patients on
prediabetes and how to prevent diabetes. However, they recognize that it also takes
willingness from the patients to want to make lifestyle changes.

Physicians are willing to screen their patients. However, they recognize that there are
patient barriers to screening such as lack of insurance and missed appointments.

Physicians want statistics.

The credentials of course instructors is important to physicians.

Physicians are interested in referring patients to the National Diabetes Prevention
Program. However, before they screen and refer, they want specific information on the
program. Physicians wanted specific information on the cost to their patients, locations,
and program efficacy.

Physicians preferred messages that focused on program efficacy. They do not want
messages that include facts that they already know.
Recommendations

Messages developed to persuade physicians to screen and refer patients should focus on
the efficacy of the program.

Materials developed to educate health care providers about the National Diabetes
Prevention Program should include detailed program information, including curriculum
content and instructor qualifications.

Messages for physicians need to address common barriers, such as referencing that the Y
has scholarships for those that don’t have insurance to help cover costs, etc.

Program activities that involve physicians—such as referring patients to the program and
completing other necessary program paperwork—cannot be labor or time intensive.

Develop promotional materials for physicians that include strategies for promoting the
program to their patients.

Program messages need to be short and succinct, yet include statistical information where
possible.
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Findings for the Health Care Providers Focus Groups
The focus groups with health care providers specifically included those professionals who
identified themselves as certified diabetes educators, pharmacists, physician assistants,
registered dieticians and registered nurses. The focus groups conducted with these individuals
did not include physicians.
Consumer Knowledge About Prediabetes
Participants in all three groups were asked about their general knowledge of prediabetes. All
participants acknowledge having heard the term and the majority made reference to the A1C
levels being higher than normal and that diet and exercise are recommended as treatment.
However, the way health care providers explained prediabetes to their patients varied widely.
Responses included:

“I explain to my patients that prediabetes means that your numbers are abnormal but
they’re not high enough to say you have diabetes, and they’re not low enough to say you
don’t have diabetes. I also explain to them that we can go back to the normal range, but
once they hit that diabetes range, we can’t go back. We want to stop them before they get
there.”

I’ve used the hemoglobin A1C range. If you’re in this range you’re considered to have
prediabetes. You are more at risk for developing diabetes, so now is the time to change
your lifestyle so that you can prevent progressing into diabetes.”

“If you make some changes in the way that you eat and you exercise you can prevent the
progression to diabetes if you’re diagnosed with prediabetes.”
Definition of Prediabetes
Once participants started discussing the term prediabetes, several expressed the feeling that this
can be a confusing term for patients and that there also seems to be no clear, standard definition.
Several participants mentioned how there are inconsistencies when referring to A1C levels to
determine prediabetes. Comments included:

“What confuses me is that there doesn’t seem to be a universal agreement as to what
prediabetes is. I would love to have a definition. But I have patients who come in all the
time who say, ‘I’ve been told by my primary care provider that I’m prediabetic.’ I ask
them for their definition. They have a lot of times no idea. So, I would love to have a
little bit more of a consensus among the health care providers in terms of what does that
term mean.”

“I’ve heard a lot of people say that prediabetes is not diabetes yet. I’m a diabetes
educator, so, of course, that concerns me a lot because a lot of people think that if they
have prediabetes, that they don’t have to worry about it yet. I tell people that prediabetes
is diabetes. It’s just the very earliest stages of it.”

“It’s actually a very fine line. There’s not a lot of demarcation between prediabetes and
diabetes because what they say is if your fasting [blood sugar level] is 125 or less, you
have prediabetes. If your fasting is 125 or higher your diabetic. So, it’s conflicting.”
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
“Many times for one person it may be an A1C of 6 and for another person it may be an
A1C of 7, which to me it’s diabetes.”

“I will say I like prediabetes better than borderline, which is what they used to call it. I
think the word borderline is even more confusing to people than prediabetes because
prediabetes says, ‘This is right before I’m about to get diabetes.’ Borderline—I’m not
sure what that would mean to a patient.”
Participants in each of the groups were then provided with the CDC definition of prediabetes and
all seemed to agree with it. Participants in Birmingham questioned the A1C levels in the
definition and mentioned that the actual range for prediabetes is 5.7 to 6.4, which are those stated
by the American Diabetes Association:
Definition of prediabetes: Prediabetes occurs when a person’s blood glucose levels are
higher than normal but not high enough for a diagnosis of diabetes (Fasting blood glucose
[100–125 mg/dl] or A1C of 6–6.5%). Diagnosis of prediabetes includes impaired fasting
glucose (IFG) or impaired glucose tolerance (IGT) and is a significant risk factor for type
2 diabetes. In fact, before people develop type 2 diabetes, they almost always have
prediabetes. Studies show that most people with prediabetes develop type 2 diabetes
within 5 years.
Attitudes and Beliefs About Prediabetes
When asked to rate if “prediabetes is a critical issue” on a scale of strongly agree to strongly
disagree, all participants agreed prediabetes was a critical issue. The two main reasons given as
to why they strongly believe prediabetes is critical were the fact that diabetes can be prevented,
and the fact that the prevalence to diabetes is increasing within our society. Specific comments
included:

“I also think it’s a critical issue because at the level that we call prediabetes people can
manage their health in such a way that they have very little risk of ever experiencing the
complications that go along with diabetes. Once we get to the diabetes phase we know
that we’re just managing to slow that process down. So, for me the whole idea of
prevention ever getting to that point is what’s most critical.”

“Because that is a good time for people to find out that they have a blood sugar disorder
and they can begin to do something about it.”

“The incidence of diabetes is at epidemic proportions, and if we can stop the progression
to type 2 diabetes, that’s great. So if we get it to them when they’re motivated and get
them started on the right track we can make a big impact on the long-term cost of
diabetes to our whole society, and pain and suffering.”

“I’m a dietitian, and I’ve been doing nutrition counseling for a number of years. But I
would definitely say in the last 5 or 6 years it’s an explosion of people that have been
coming to see me just for prediabetes as a preventative.”
When asked if they feel as though they can make a difference with prediabetes, the majority of
the participants felt they could. Many of the providers expressed that they do take the time to
counsel and advise their patients who are at risk or diagnosed with prediabetes to make lifestyle
changes. However, ultimately, it is up to that individual to decide whether they are going to
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make the necessary changes. Some participants mentioned patient barriers they encounter when
talking with their patients about lifestyle changes. These included:

Lack of motivation

Stress

Cost associated with maintaining a healthy lifestyle

Patient beliefs
Participants also mentioned that patients do not feel that prediabetes is not a serious or critical
condition and, therefore, is not an urgent health issue. Specific comments were:

“I think it’s more up to the patient but it can work when I tell them. However, I can’t
make them do it, exercise, dieting, etc. I don’t have that much control.”

“I can make a difference by helping them [the patients] determine what motivates them to
be healthier and finding the spark to set a goal and reach a goal.”

“It also has to do with economic/financial means. Some of my patients who are not so
well-off and can only afford medications.”

“I hear that all the time. They [patients] say the doctor doesn’t know what he’s doing, the
test was wrong—I had one tell me ‘they took it from the wrong vein.’ So, I try really hard
but it takes a lot. I get ignored.”
Participants also mentioned some of the barriers they see with respect to identifying and
eventually screening those at high risk for prediabetes. Among the barriers mentioned were a
lack of clear guidelines on screening procedures, the limited amount of time patients actually
spend with physicians, and socioeconomic barriers including insurance coverage, “episodic
care,” transportation, and childcare support. Specific comments included:

“There’s always been a lot of controversy about when you should check your [patients’]
blood sugars.”

“When you see a primary care physician, the maximum time they can spend with you is
only like two minutes. You cannot do much in two or three minutes.”

“I think before you even get to the provider’s office, there are socioeconomic barriers.
Because some of the groups of people in this culture that are the highest at risk for
prediabetes and diabetes, don’t have insurance or don’t have a cultural perspective which
allows them to even think about looking for that possibility.”

“Even if you find someone at a health fair with an elevated sugar, again there’s that social
barrier. They’ll say, ‘Well, what should I do now?’ They may not have a primary care.
They may not have insurance. So, they can’t follow up on it.”
National Diabetes Prevention Program
Participants were given the description of the National Diabetes Prevention Program and queried
on their thoughts and opinions of the program and their willingness to screen and refer patients at
risk or diagnosed with prediabetes to attend a diabetes prevention program.
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The program description prompted positive reactions from the health care professionals. The
majority said they would consider referring their patients to the program. They liked the
supportive, group-like setting and felt that the monthly follow-up was important. Some of the
comments were:

“I would tell all my patients with prediabetes about this program.”

“It’s an awesome idea.”

“I would want to find out where it’s going on and let people know about it. People can
have incredible results. I believe in this program and I think it’s great.”

“It would motivate me [to refer a patient to the program] because one thing that bothers
me about doing a one or two hour class is that there’s no follow-up. This would really be
good for someone that was motivated.”

“Sounds good, but I can think of people that won’t be too motivated. People who join
will have awesome results.”

“I like the lifestyle coach. I have diabetes on both sides of my family. This would
motivate me.”
Although the description of the program caught the interest of the health care professionals, and
it was generally well received, participants had questions and concerns about it. Some of the
more patient-focused issues included the program length, a person’s willingness to commit to the
16 sessions, and the cost of the program. Participants in each of the groups agreed that, if
insurance did not cover the cost or if the program was not free, cost would be a barrier for many
of their patients. Comments included:

“It’s hard to expect people to make those 16 sessions.”

“It seems like a lot of time. The length might be a challenge. One hour is good.”

“I would refer people to the program but I’m not sure if they would make the time
commitment.”

“Some would commit but so many are not insured or they have transportation issues or
Medicaid/Medicare and that is a big barrier.”

“I wish insurance can cover that [the program]. It would be great for that period of time.”

“If this program is not free that is a huge barrier.”
Participants in each location stressed the fact that before they would refer a patient to the
program, they would need to have specific information about it. Information needs included:

Class times

Locations

Accessibility

Cost

Insurance coverage/eligibility

Type and structure of the classes
National Diabetes Prevention Program Audience Assessment
August 2011
P a g e | 56

Type of exercises recommended

Information on the developer of the curriculum

Cultural appropriateness of the curriculum

Background of class instructors

Professional training received by the instructors

Definition of a lifestyle coach

Referral process (provider and self-referrals)

Strategies for promoting the program

Availability of an informational hotline

Availability of patient education materials
Behavioral Intention
When participants were asked if they would be interested in receiving information on the
National Diabetes Prevention Program, all were interested, most were extremely interested.
Participants discussed their preferences for receiving program information. These included:

E-mail

One-on-one or group presentations

Health-related conferences

Publications

Magazines

Social media, such as blogs

Website
Participants noted if there was a website available for health care professionals, they would like
the following tools available on that site:

Materials for download for use with their patients

Educational materials to complement what is taught in the program

Tip sheets

Program brochure
Health care providers were asked about their willingness to become a “health care provider
champion.” The moderators explained that the role would entail referring patients to the National
Diabetes Prevention Program, presenting information about the program to their colleagues, and
encouraging other health care providers to screen and refer their patients to the program. Most
participants agreed that it seemed feasible, and they would be willing to try being a physician
champion. However, some raised concerns about the time commitment; some noted being
uncomfortable advising other doctors to use the program. Participants stated that they would
National Diabetes Prevention Program Audience Assessment
August 2011
P a g e | 57
need to have additional information about the duties and expectations of a physician champion
before committing to participate. Specific comments and questions were:

“I would want to know the time commitment.”

“Time is a constraint.”

“Would I get paid?”

“I feel uncomfortable telling doctors what to do.”

“I don’t mind presenting a program but you were saying encouraging them to start having
their patients screened. If that’s what I’m meant to do, I would feel uncomfortable. I
would have no problem suggesting the program. ”
Health Care Provider Concept Discussion
This part of the discussion focused on getting the participants’ feedback on four message
concepts developed to persuade health care providers to screen their high risk patients and to
support the National Diabetes Prevention Program. The moderators explained the following:
“You will be asked to rate each statement individually on a scale from 1 to 5 as to its ability to
move you and your peers to action. One is not at all compelling and 5 is extremely compelling.
After reviewing all four statements, you will be asked to select the technique you deem most
effective in its ability to move you and your peers to action, and why. When listening to the
statements, please focus on the technique (e.g., urgency, seriousness), as the messages have yet
to be fully developed.”
Concept 1. Statement one emphasizes the urgency of screening for prediabetes:
Prediabetes, if not addressed early, will develop into type 2 diabetes within 3 to 5 years. Don’t miss
this window of opportunity to prevent diabetes. Screen your patients now so they can take steps to
reduce their risk of diabetes. There is a National Diabetes Prevention Program in your area to help
those who test positive for prediabetes.
Overall, participants did not find this to be a strong or compelling message. Several participants
commented that it did not convey a sense of urgency and therefore would not cause them to take
action to screen and refer patients to the National Diabetes Prevention Program. A common
response was that the facts being presented were not new and that it was information that health
care professionals already know. Comments included:

“It doesn’t sound urgent.”

“This statement is very passive and matter of fact.”

“This message is not strong enough.”

“Been there done that, heard it before, move on.”

“It’s not that compelling, we all know this, but ‘don’t miss this window of opportunity’—
it’s just not strong enough.”
National Diabetes Prevention Program Audience Assessment
August 2011
P a g e | 58
Concept 2. Statement two emphasizes the seriousness of prediabetes:
Prediabetes increases a person’s risk for heart disease, stroke, and blindness. Screen your high-risk
patients for prediabetes and, for those who test positive, refer them to the National Diabetes
Prevention Program in your area.
Concept 2 received mixed responses. In Birmingham and Tulsa, the health care providers felt
that this message conveyed the seriousness of prediabetes. The list of complications and the
phrase—“Screen your high-risk patients for prediabetes” caught the groups’ attention.
Comments included the following:

“It is much more urgent sounding.”

“It reminds you of the complications associated with diabetes.”

“People don’t look at this as they should. We need to be reminded about it. There’s no
redundancy in this message.”

“I like the way it points out to screen our high-risk patients.”

“Right after it talks about the complications, it tells you to refer your patients. It’s a
directive.”

“I like that it says refer your patients.”
In Washington, D.C., this concept was seen as neither strong nor compelling. A few described
the concept as generic. One participant said, “Interchange this message with any other disease
name. We’ve heard all this before.” Another participant felt that the message lacked specific
information on how much prediabetes increases a person’s risk for developing the listed
complications. Other comments included:

“It’s very generic. Nothing new here to make you want to do anything.”

“This message does not have a punch. It’s the same message we always hear about risks.”

“I want to hear specific numbers. How much does it increase the risk? By how much can
they reduce the risk?”

“If you tell people about a program you also have to be able to give them specific
information and details. This concept needs a follow-up statement. This is not giving any
positive information.”
Concept 3. Statement three emphasizes program efficacy in preventing diabetes:
The Diabetes Prevention Program study found that people with prediabetes who completed a 16-week
lifestyle intervention program were 58% less likely to develop type 2 diabetes than the control group.
Screen your high-risk patients for prediabetes, and refer those who test positive to the National
Diabetes Prevention Program in your area. It works!
Overall, participants across all three groups had positive reactions to this concept. Most agreed
that emphasizing the program efficacy was a good approach. The statistical information and the
National Diabetes Prevention Program Audience Assessment
August 2011
P a g e | 59
fact that it was evidence-based caught the attention of the group participants. Comments included
the following:

“It mentions their lifestyle and you see numbers about success. I like the way it is
worded. That would catch my attention.”

“I ranked it a four [with 5 being extremely compelling] because it mentions that 58%
would develop type 2—that’s a high percentage.”

“The stats grab my attention as a health care professional.”

“It says right off [that] the diabetes prevention program gives you results.”

“Is it worth my time to introduce this program? Well with this statistic, it’s worth it.”

“I like it, statistics are helpful, and the term prediabetes, for some it’s known as
borderline so it’s putting the term out.”

“This is evidence-based.”
It should be noted that several group members in Birmingham and Tulsa mentioned that, even
though they felt that this concept was strong and compelling, it needed to be shortened. Some
described the message as “long” and “wordy.” Others commented that the phrase “It works!” be
removed. Other comments included:

“Too wordy and it loses me.”

“It does not jump out at me. So many words, it seems like blah blah blah.”

“I don’t like the ‘It works!’ at the end. Seems too cheesy.”
Concept 4. Statement four presents an authoritative recommendation:
The American College of Endocrinology recommends that high-risk patients be screened for
prediabetes. Prediabetes, if not addressed, will develop into type 2 diabetes within 3 to 5 years,
however people with prediabetes who completed a 16-week lifestyle intervention program were
58% less likely to develop type 2 diabetes than the control group. Screen your high-risk patients
for prediabetes, and refer those who test positive to the National Diabetes Prevention Program in
your area.
Concept 4 received mixed responses. For some participants, the fact that it cited a
recommendation from the American College of Endocrinology was appealing. A few
participants commented that the numbers and facts presented in the message caught their
attention. Comments include the following:

“I like it because they mentioned the American College of Endocrinology. That caught
my attention.”

“I like facts and figures.”

“It’s a good message. Gives you statistics.”

“I like it. It makes me more interested knowing it came from the ACE.”

“I gave it a four because of the ACE, and I like numbers. That number persuades me.”
National Diabetes Prevention Program Audience Assessment
August 2011
P a g e | 60

“I like the authoritative nature of the ACE and it says refer, and it does not sound like a
commercial.”
Alternatively, some group members found this message to be too long and wordy:

“This is too wordy. Someone pressed for time is not going to read this all the way
through, like a doctor. It’s even longer than concept three.”

“Too many numbers. Where it comes from doesn’t really impress me. Too much to
read.”

“It’s a great thing to have because for the primary care doctors having that reminder is
helpful, but I also think there’s too much in there.”

“It’s a good resource, but it’s too lengthy. I like the shorter and sweeter messages.
Doctors don’t have too much time to read this.”
Concept Preference
After all four concepts were presented, the participants were asked which one would most likely
persuade them to take action. The majority of health care providers preferred the message
emphasis on program efficacy (Concept 3). However, in Birmingham, the preferred technique
was the seriousness of prediabetes (Concept 2).
Notable Differences and Similarities Among Cities

Participants in Tulsa and Birmingham voiced more concerns about the program’s cost
and insurance coverage than their Washington, D.C., counterparts.

Health care providers in Washington, D.C., and Tulsa preferred program efficacy as a
persuasive technique, while health care providers in Birmingham felt emphasizing the
seriousness of prediabetes was more impactful.

Health care providers across locations considered prediabetes a critical issue.

Health care providers across locations are willing to refer patients to the National
Diabetes Prevention Program.
Lessons Learned From Health Care Providers Groups

Health care providers felt that they could make a difference in the lives of their patients
with prediabetes; however, barriers such as lack of patient motivation and time
constraints limit what they are able to do.

Health care providers want program information for themselves as well as for patients.

Health care providers need detailed information about the program in order to refer their
patients.

Health care providers noted costs, lack of insurance coverage, and program accessibility
as potential patient barriers to program participation.

Program efficacy needs to be conveyed to health care providers through statistics and
quantifiable program results.
National Diabetes Prevention Program Audience Assessment
August 2011
P a g e | 61
Recommendations

Materials developed to educate health care providers about the National Diabetes
Prevention Program should include detailed program information such as curriculum
content and instructor qualifications.

Promotional messages designed to encourage participation of health care providers
should incorporate statistics and highlight program efficacy.

Materials developed to educate health care providers about the National Diabetes
Prevention Program should include detailed program information such as curriculum
content and instructor qualifications.

Messages targeting health care providers need to be short and succinct.

Messages should be delivered through a combination of channels, including professional
organizations, medical publications, medical websites, health-related conferences, and
blogs.
Notable Differences and Similarities Among Physicians and other Health Care
Providers
Knowledge About Prediabetes

Health care providers and physicians are familiar with the term “prediabetes”.

Health care providers noted wanted a ‘universal definition’ of prediabetes.
Attitudes and Beliefs About Prediabetes

Both health care providers and physicians acknowledged prediabetes as a critical issue
among the communities they serve.

Health care providers and physicians felt that they could make a difference in their
patients’ lives as it relates to prediabetes.

Both health care providers and physicians noted patient barriers and challenges they
encounter with respect to identifying and screening people at risk for prediabetes.
Barriers included lack of insurance and patients not showing up for appointments.

Health care providers mentioned that there is a lack of clear guidelines on screening
procedures.
National Diabetes Prevention Program

The National Diabetes Prevention Program was well received by both audiences. Many
were enthusiastic about the having a lifestyle program to which they could refer their
patients with prediabetes.

Before referring, both health care providers and physicians stressed a need to have more
information about the program. Specifically, they want the following information:
o Class times
National Diabetes Prevention Program Audience Assessment
August 2011
P a g e | 62
o Locations
o Accessibility (public transportation)
o Contact information
o Cost
o Insurance coverage /eligibility
o Type and structure of the classes
o Types of physical exercises conducted in the classes
o Monitoring—are there physicians/health care professionals monitoring program
participants?
o Referral process
o Health care professionals had some concerns about the program. They questioned the
length of the program and a person’s willingness to commit to the program and said
that cost implications will deter many of their patients from participating.
Behavioral Intention

Health care providers and physicians are very interested in receiving information about
the National Diabetes Program.

If a website were available for health care professionals and physicians, they would like
to offer the following tools:
o Printed materials to give to their patients
o Educational materials to coincide with what is taught in the program
o Tip sheets
o Brochures describing the program
o Health care providers and physicians expressed interest in becoming “health care
provider/physician champions.” However, both audiences stated that before
committing to this effort, they would need to have additional information about the
duties and expectations for this role. Specifically, they want to know about the time
commitment and if financial incentives are offered.
Concepts Preference
 The preferred message concept for both health care providers and physicians was
program efficacy. Participants liked the statistical information and the fact that the
program is evidence-based.
National Diabetes Prevention Program Audience Assessment
August 2011
P a g e | 63
APPENDIX A:
FOCUS GROUP AND IN-DEPTH
INTERVIEW SCHEDULES
Focus Group Schedule
Date
Time
Group
Washington, D.C.
March 14, 2011
5:45 p.m.-7:00 p.m.
Health Care Providers
March 14, 2011
7:30 p.m.-9:00 p.m.
Family and Friends
March 15, 2011
4:00 p.m.-5:30 p.m.
Unaware
March 15, 2011
5:45 p.m.- 7:00 p.m.
Aware
March 15, 2011
7:30 p.m.- 9:00 p.m.
Diagnosed
Birmingham, AL
March 23, 2011
6:00 p.m.-7:30 p.m.
Unaware
March 23, 2011
8:00 p.m.-9:30 p.m.
Aware
March 24, 2011
11:00 a.m.-12:30 p.m.
Family and Friends
March 24, 2011
6:00 p.m.-7:30 p.m.
Health Care Providers
March 24, 2011
8:00 p.m.-9:30 p.m.
Diagnosed
Tulsa, Okla.
March 23, 2011
6:00 p.m.-7:30 p.m.
Unaware
March 23, 2011
7:45 p.m.-9:15 p.m.
Aware
March 24, 2011
4:30 p.m.-6:00 p.m.
Family and Friends
March 24, 2011
6:15 p.m.-7:45 p.m.
Health Care Providers
March 24, 2011
8:00 p.m.-9:30 p.m.
Diagnosed
Washington, D.C.
March 14, 2011
5:45 p.m.-7:00 p.m.
Health Care Providers
March 14, 2011
7:30 p.m.-9:00 p.m.
Family and Friends
March 15, 2011
4:00 p.m.-5:30 p.m.
Unaware
March 15, 2011
5:45 p.m.- 7:00 p.m.
Aware
March 15, 2011
7:30 p.m.- 9:00 p.m.
Diagnosed
1
Birmingham, AL
March 23, 2011
6:00 p.m.-7:30 p.m.
Unaware
March 23, 2011
8:00 p.m.-9:30 p.m.
Aware
March 24, 2011
11:00 a.m.-12:30 p.m.
Family and Friends
March 24, 2011
6:00 p.m.-7:30 p.m.
Health Care Providers
March 24, 2011
8:00 p.m.-9:30 p.m.
Diagnosed
Tulsa, Okla.
March 23, 2011
6:00 p.m.-7:30 p.m.
Unaware
March 23, 2011
7:45 p.m.-9:15 p.m.
Aware
March 24, 2011
4:30 p.m.-6:00 p.m.
Family and Friends
March 24, 2011
6:15 p.m.-7:45 p.m.
Health Care Providers
March 24, 2011
8:00 p.m.-9:30 p.m.
Diagnosed
Schedule for In-depth Interviews
Date
Time
Target audience
Location of
respondent
February 28, 2011
8:00 p.m.-9:00 p.m.
Primary Care Physician
Albuquerque, NM
March 1, 2011
2:00 p.m.-3:00 p.m.
Primary Care Physician
Jefferson City, MO
March 1, 2011
5:00 p.m.-6:00 p.m.
Primary Care Physician
Pittsburgh, PA
March 1 2011
7:00 p.m.-8:00 p.m.
Primary Care Physician
Bakersfield, CA
March 2, 2011
11:00 a.m.-12:00 p.m.
Primary Care Physician
Pacific Palisades, CA
March 3, 2011
3:00 p.m.-4:00 p.m.
Primary Care Physician
Wynnewood, PA
March 8, 2011
12:00 p.m.-1:00 p.m.
Primary Care Physician
Tacoma, WA
March 9, 2011
1:00 p.m.-2:00 p.m.
Primary Care Physician
Conyers, GA
March 17, 2011
11:00 a.m.-12:00 p.m.
Primary Care Physician
Longwood, FL
2
APPENDIX B:
PARTICIPANT SCREENERS
Form Approved
OMB No. 0920-0572
Exp. Date 11/30/11
Support for Developing and Implementing
Targeted Diabetes Prevention Campaigns
in Communities: Prediabetes Focus Group
Screener for Consumers
Date of screen: _________________
Recruitment Criteria








Each group should consist of 8–12 adults (aged 45 and older).
Each group should comprise a mix of people from different racial and ethnic
backgrounds.
Each group should include a mix of individuals with low and middle household incomes.
Only one member of the same family can participate in any group.
Persons who work/have worked for or who have family who are employed by the
Centers for Disease Control and Prevention (CDC) shall be excluded.
Participants should not have participated in a focus group or other qualitative research
study in the past 6 months.
Eligible participants will be placed into one of three groups:
o
Group A—Unaware: People who are not aware of prediabetes or their risk for
prediabetes.
o
Group B—Aware: People who are aware that they may be at risk for developing
prediabetes. They have not been screened and have done little or nothing to
minimize their disease risk.
o
Group C—Diagnosed: People who have been diagnosed with prediabetes. They
have done little or nothing to prevent diabetes.
Participants in Birmingham and Tulsa will receive $75 as incentive; participants in
Washington, D.C., will receive $85.
Focus Group Schedule
Date
Time
Participants
Location
Facility
TBD
TBD
 Adults unaware of prediabetes
 Adults aware of risk of prediabetes
 Adults diagnosed with prediabetes
District of Columbia
metropolitan area
Shugoll
Research
Screener for Consumers
February 2, 2011
1
TBD
TBD
TBD
TBD






Adults unaware of prediabetes
Adults aware of risk of prediabetes
Adults diagnosed with prediabetes
Adults unaware of prediabetes
Adults aware of risk of prediabetes
Adults diagnosed with prediabetes
Birmingham,
Alabama
Graham &
Associates
Tulsa, Oklahoma
Consumer
Logic
Research
General Notes




Participants will receive healthy snacks.
Each focus group will last approximately 90 minutes.
Each focus group will be audiotaped.
Participant identity will remain confidential; only first names will be used in the focus
group.
Introduction
Hello. My name is
. I’m calling from [subcontractor name]. We are conducting a
research project for the Centers for Disease Control and Prevention on informing consumers
about the National Diabetes Prevention Program. Your participation will help us to tailor
promotional materials being developed by CDC. If selected, you will receive $___ to
compensate for your time and travel. [Note to recruiter: participants in Birmingham and
Tulsa will receive $75 as incentive; participants in Washington, D.C., will receive $85.]
Gender: [Note person’s gender. Not an exclusion criteria; recruit a mix of males and
females.]

Female

Male
1. May I ask you a few questions to see if you are eligible to participate in this study?

Yes
[continue]

No
[terminate]
2. Are you 45 years of age or older?

Yes
[continue]

No
[terminate]
3. Have you participated in a focus group within the past 6 months?

Yes
[terminate]

No
[continue]
Screener for Consumers
February 2, 2011
2
4. Have you or a member of your immediate family ever worked for the Centers for Disease
Control and Prevention?

Yes
[terminate]

No
[continue]
5. What is your household income? [Note to recruiter: Recruit a mix of low and middle
income levels.]
Birmingham
Tulsa
 35K or less [continue]
 36K–65K [continue]
 65K or more [terminate]
 30K or less [continue]
 31K–65K [continue]
 65K or more [terminate]
Washington, D.C.
 30K or less [continue]
 31K–70K [continue]
 70K or more [terminate]
[Note to recruiter: Respondents will be segmented into one of the three groups below. Do
not read the categories to the respondent. Begin reading at question number 6.]
o
Group A—Unaware: People who are not aware of prediabetes or their risk for
prediabetes.
o
Group B—Aware: People who are aware that they may be at risk for developing
prediabetes. They have not been screened and have done little or nothing to
minimize their disease risk.
o
Group C—Diagnosed: People who have been diagnosed with prediabetes. They
have done little or nothing to prevent diabetes.
6. Have you ever heard of prediabetes?

Yes
[continue]

No
[continue]
7. What is your height? [Note to recruiter: Write down the response on the line below].
________
[continue]
Based on the response, locate the height given on the table below. Ask the person if he or she
weighs more than the weight in pounds that is given directly to the right of the height. [For
example, if the response is “5 feet 6 inches,” you would ask, “Do you weigh more than
167 pounds?”]

Yes
[continue]

No
[terminate]
Screener for Consumers
February 2, 2011
3
At-Risk Weight Chart
Height
4’10”
4’11”
5’0”
5’1”
5’2”
5’3”
5’4”
5’5”
5’6”
5’7”
5’8”
5’9”
5’10”
5’11”
6’0”
6’1”
6’2”
6’3”
6’4”
Weight in
Pounds
129
133
138
143
147
152
157
162
167
172
177
182
188
193
199
204
210
216
221
8. How likely are you to develop type 2 diabetes in the next 5 years?

Very likely [continue to question 9]

Not likely [skip to question 10]

Don’t know [respondent qualifies for Group A—Unaware; skip to question 12]
9. Have you ever been screened or taken a blood test to find out if you have diabetes?

Yes
[continue]

No
[skip to question 10]
10. Have you ever been told by a health care provider that you are at risk for diabetes or that
you have prediabetes?

Yes
[skip to question 11a]

No
[terminate]
11. Using the following scale, how would you rate your current level of effort to prevent
diabetes?
Screener for Consumers
February 2, 2011
4

No current effort [respondent qualifies for Group B—Aware; skip to question12]

Little effort
[respondent qualifies for Group B—Aware; skip to question12]

Great effort
[terminate]
11a. Using the following scale, how would you rate your current level of effort to prevent
diabetes?

No current effort [respondent qualifies for Group C—Diagnosed; continue to
question 12]

Little effort
[respondent qualifies for Group C—Diagnosed; continue to
question 12]

Great effort
[terminate]
12. What is your racial/ethnic background?

African American [continue]

American Indian or Alaska Native [continue]

Asian
[continue]

Caucasian
[continue]

Hispanic/Latino
[continue]

Native Hawaiian or other Pacific Islander [continue]

Biracial
[continue]
If the participant qualifies:
We would like to invite you to participate in a focus group with 8–10 other participants. This
focus group is being sponsored by CDC and consists of a discussion with other consumers. The
discussion will last about 90 minutes. Your participation and everything you say during the
discussion will remain confidential. Your name will not be used in any results from this research.
You will receive $__ for participating in this group.
The discussion will take place at ________________________________________
on ____________at _____a.m./p.m. We are inviting only a few people, so it is very important
that you notify us as soon as possible if you are unable to attend. Please call [name of
recruiter] at [telephone number] if you become unable to participate.
Will you be available to participate at this time?

Yes
[continue]

No
[terminate]
Termination Script: I’m sorry, but we are currently looking for people who fit a different
profile. Thank you for your time and interest in this research.
Screener for Consumers
February 2, 2011
5
I would like to send you a confirmation letter. The letter will include the date, time, and location
of the focus group. Please share your mailing address and a phone number so that I can send
you this confirmation letter.
Name: ______________________________________
Address: _________________________________________________________
City: _______________________
State: _________ ZIP:
Phone: _______________________
Cell phone: __________________
E-mail: _______________________
Fax: ________________________
Date of focus group: __________________
Time: ________________
Thank you very much. I appreciate you taking time to talk to me.
Screener for Consumers
February 2, 2011
6
Form Approved
OMB No. 0920-0572
Exp. Date 11/30/11
Support for Developing and Implementing
Targeted Diabetes Prevention Campaigns
in Communities: Family/Friends Focus
Group Screener
Date of screen: _________________
Recruitment Criteria






Each group should consist of 8–12 adults (aged 18 and older) who are
friends/family members of people at risk for or diagnosed with prediabetes.
Each group should comprise a mix of people from different racial and ethnic
backgrounds.
Members of the same family cannot participate in the same group.
Persons who work/have worked for or who have family who are employed by
the Centers for Disease Control and Prevention (CDC) shall be excluded.
Participants should not have participated in a focus group or other qualitative
research study in the past 6 months.
Participants in Birmingham and Tulsa will receive $75 incentive; participants
in Washington, D.C. will receive $85.

Focus Group Schedule
Date
Time
Participants
Location
Facility
TBD
TBD
Family and friends
of people at risk
for/with prediabetes
District of
Columbia
metropolitan
area
Shugoll Research
TBD
TBD
Family and friends
of people at risk
for/with prediabetes
Birmingham,
Alabama
Graham &
Associates
TBD
TBD
Family and friends
of people at risk
for/with prediabetes
Tulsa,
Oklahoma
Consumer Logic
Research
Screener for Family and Friends
February 2, 2011
1
General Notes




Participants will receive refreshments.
Each focus group will last approximately 90 minutes.
Each focus group will be audiotaped.
Participant identity will remain confidential; only first names will be used.
Introduction
Hello. My name is
. I’m calling from [Subcontractor Name]. We are conducting
a discussion groups for the Centers for Disease Control and Prevention to better
understand how to inform health care providers about the National Diabetes Prevention
Program, a diabetes prevention lifestyle program. Your participation will help us to tailor
promotional materials that are being developed by CDC. If selected, you will receive
$___ to compensate you for your time and travel. [Note to recruiter: participants in
Birmingham and Tulsa will receive $75 as incentive; participants in Washington,
D.C., will receive $85.]
1.
2. May I ask you a few questions to see if you are eligible to participate in the
discussion group?

Yes [continue]

No [terminate]
3. Are you 18 years of age or older?

Yes [continue]

No [terminate]
4. Have you participated in a focus group within the past 6 months?

Yes [terminate]

No [continue]
5. Have you or a member of your immediate family ever worked for the Centers
for Disease Control and Prevention?

Yes [terminate]

No [continue]
Screener for Family and Friends
February 2, 2011
2
6. Has anyone in your family or one of your friends ever been told by a health care
provider that he/she is at risk for diabetes?
 Yes  Respondent qualifies continue to question 9

No [continue]
7. Has anyone in your family or one of your friends ever been told by a health care
provider that he/she has prediabetes?

Yes  Respondent qualifies continue to question 9

No [ terminate]
8. What is your racial/ethnic background?

African American [continue]

American Indian or Alaska Native [continue]

Asian [continue]

Biracial [continue]

Caucasian [continue]

Hispanic/Latino [continue]

Native Hawaiian or other Pacific Islander[continue]
If the participant qualifies:
We would like to invite you to participate in a focus group with 8–10 other participants.
This focus group is being sponsored by CDC and consists of a discussion with other
consumers. The discussion will last about 90 minutes. Your participation and everything
you say during the discussion will remain confidential. Your name will not be used in
any results from this research. You will receive $75 for participating in this group.
The discussion will take place at ________________________________________
on ____________at _____a.m./p.m. We are inviting only a few people, so it is very
important that you notify us as soon as possible if you are unable to attend. Please call
(insert name of recruiter) at (insert telephone number) if you become unable to
participate.
Will you be available to participate at this time?

Yes [continue]

No [terminate ]
Termination Script: I’m sorry, but we are currently looking for people who fit a
different profile. Thank you for your time and interest in this project.
Screener for Family and Friends
February 2, 2011
3
I would like to send you a confirmation letter. The letter will include the date, time, and
location of the focus group. Please share your mailing address and a phone number so
that I can send you this confirmation letter.
Name: ______________________________________
Address: _________________________________________________________
City: _______________________
State: _________ ZIP:
Phone: _______________________
Cell phone: __________________
E-mail: _______________________
Fax: ________________________
Date of focus group: __________________
Time: ________________
Thank you very much. I appreciate you taking time to talk to me.
Screener for Family and Friends
February 2, 2011
4
Form Approved
OMB No. 0920-0572
Exp. Date 11/30/11
Support for Developing and Implementing
Targeted Diabetes Prevention Campaigns
in Communities: Health Care Provider
Focus Group Screener
Date of screen: _________________
Recruitment Criteria
 Each group should consist of 8–12 participants who are health care providers.
 Each group should comprise a mixed group of health care providers (i.e., certified
diabetes educators, pharmacists, physician assistants, registered dieticians, registered
nurses).
 Each group should be made up of a mix of male and female participants from different
racial and ethnic backgrounds.
 Persons who work/have worked for or who have family who are employed by the
Centers for Disease Control and Prevention (CDC) shall be excluded.
 Participants should not have participated in a focus group or other qualitative research
study in the past 6 months.
 Each participant will receive $125 as incentive.
Focus Group Schedule
Date
Time
Participants
Location
Facility
March 14,
2011
TBD

Shugoll Research
March 24,
2011
TBD





District of
Columbia
metropolitan
area
Graham &
Associates
March 24,
2011
TBD





Birmingham,
Alabama
Tulsa, Oklahoma
Consumer Logic
Research
Screener for Physician IDI’s
February 2, 2011




Certified diabetes
educators
Pharmacists
Physician assistants
Registered dieticians
Registered nurses
Certified diabetes
educators
Pharmacists
Physician assistants
Registered dieticians
Registered nurses
Certified diabetes
educators
Pharmacists
Physician assistants
Registered dieticians
Registered nurses
1
General Notes




Participants will receive refreshments.
Each focus group will last approximately 90 minutes.
Each focus group will be audiotaped.
Participant identity will remain confidential; only first names will be used.
Introduction
Hello. My name is
. I’m calling from [Subcontractor Name]. We are conducting
discussion groups for the Centers for Disease Control and Prevention to better understand how
to inform health care providers about the National Diabetes Prevention Program, a diabetes
prevention lifestyle program. Your participation will help us to tailor promotional materials that
are being developed by CDC. If selected, you will receive $ 125 to compensate you for your
time and travel.
May I ask you a few questions to see if you are eligible to participate in this discussion group?

Yes [continue]

No [terminate]
Have you participated in a focus group within the past 6 months?

Yes[terminate]

No[continue]
Have you or a member of your immediate family ever worked for the Centers for Disease
Control and Prevention?

Yes [terminate]

No [continue]
What type of health care provider are you? [Note to recruiter: recruit a mix of healthcare
providers]

Administrative support staff [terminate]

Certified diabetes health educator [continue]

Registered nurse or nurse practitioner [continue]

Pharmacist [continue]

Physician assistant [continue]

Registered dietician [continue]

Other [specify]__________________ [terminate]
Do you provide services or education to adults at risk for diabetes?

Yes [continue]

No [terminate]
Screener for Physician IDI’s
February 2, 2011
2
Note gender:
 Male [continue]

Female [continue]
Which best describes the type of facility at which you work? (Check all that apply)
 Private clinical practice [continue]

Community clinic [continue]

Community health care center

Hospital—Inpatient [continue]

Hospital—Outpatient [continue]

Research institute/university [continue]

Other: ________________ [continue]
[continue]
If participant qualifies:
We would like to invite you to participate in a focus group with 8–10 other participants. This
focus group is being sponsored by CDC and consists of a discussion with other health care
professionals about diabetes prevention. The discussion will last about 90 minutes. Your
participation and everything you say during the discussion will remain confidential. Your name
will not be used in any results from this project. You will receive $125 for participating in this
group.
The discussion will take place at ________________________________________on
____________at _____a.m./p.m.
Will you be available to participate at this time?

Yes [continue]

No [terminate]
Termination Script: I'm sorry, but we are currently looking for people who fit a different
profile. Thank you for your time and interest in this project.
I would like to send you a confirmation letter. The letter will include the date, time, and location
of the focus group. Please share your mailing address and a phone number so that I can send
you this confirmation letter.
Name: ______________________________________
Address: _________________________________________________________
City: _______________________
Screener for Physician IDI’s
February 2, 2011
State: _________ ZIP:
3
Phone: _______________________
Cell phone: __________________
E-mail: _______________________
Fax: ________________________
Date of focus group: __________________
Time: ________________
We are inviting only a few people, so it is very important that you notify us as soon as possible if
you are unable to attend. Please call (insert name of recruiter) at (insert telephone number)
if you become unable to participate.
Thank you very much. I appreciate you taking time to talk to me.
Screener for Physician IDI’s
February 2, 2011
4
Form Approved
OMB No. 0920-0572
Exp. Date 11/30/11
Support for Developing and Implementing
Targeted Diabetes Prevention Campaigns
in Communities: Screener for Physician
In-depth Telephone Interviews
Date of screen: _________________
Recruitment Criteria
 Recruit 11-physicians for 9 to participate.
 Recruit physicians that provide physicians that provide medical services/health
education to people at risk for diabetes.
 Recruit primary care physicians and endocrinologist.
 Recruit physicians from different geographic locations across the US (i.e.
Northeast, Southeast, Central, Midwest, Pacific Northwest, Southwest and West
coast).
 Persons who work/have worked for or who have family who are employed by the
Centers for Disease Control and Prevention (CDC) shall be excluded.
 Participants should not have participated in a focus group or other qualitative
research study in the past 6 months.
 Primary Care Physicians will receive $175 incentive.
Focus Group Schedule
Date
TBD
Time
Participants
Location
Facility
TBD

Conducted over
the phone by
ICF Macro staff
Baltimore
Research
Primary Care
Physicians
General Notes



Each phone interview will last approximately 60 minutes.
Each phone interview will be audiotaped.
Participant identity will remain confidential; only first names will be used.
Screener for Physician IDI’s
February 2, 2011
5
Introduction
Hello. My name is
. I’m calling from [Subcontractor Name]. We are conducting
a series of in-depth phone interviews for the Centers for Disease Control and
Prevention to better understand how to inform physicians about the National Diabetes
Prevention Program, a diabetes prevention lifestyle program. Your participation will help
us to tailor promotional materials that are being developed by CDC. If selected, you will
receive $ ____ to compensate you for your time. [Note to recruiter: incentives- $175
for Primary Care Physicians]
May I ask you a few questions to see if you are eligible to participate in the phone
interview?

Yes [continue]

No [terminate]
Have you participated in a focus group or other qualitative research study within the
past 6 months?

Yes[terminate]

No[continue]
Have you or a member of your immediate family ever worked for the Centers for
Disease Control and Prevention?

Yes [terminate]

No [continue]
What type of physician are you? [Note to recruiter: recruit PCPs]

Primary Care Physician [continue]

Other [specify]__________________ [terminate]
Do you provide medical services or health education to adults at risk for diabetes?

Yes [continue]

No [terminate]
Note gender:
 Male [continue]

Female [continue]
Which best describes the type of facility at which you work? (Check all that apply)
Screener for Physician IDI’s
February 2, 2011
6

Private clinical practice [continue]

Community clinic [continue]

Community health care center [continue]

Hospital—Inpatient [continue]

Hospital—Outpatient [continue]

Research institute/university [continue]

Other: ________________ [continue]
If participant qualifies:
We would like to invite you to participate in a brief in-depth phone interview. This
interview is being sponsored by CDC. The discussion will last about 60 minutes. Your
participation and everything you say during the discussion will remain confidential. Your
name will not be used in any results from this project. You will receive $___ for
participating in this discussion.
The discussion will take place on ____________at _____a.m./p.m.
Will you be available to participate at this time?

Yes [continue]

No [terminate]
Termination Script: I'm sorry, but we are currently looking for people who fit a
different profile. Thank you for your time and interest in this project.
I would like to send you a confirmation letter. The letter will include the date, and time of
the phone interview. Please share your mailing address and a phone number so that I
can send you this confirmation letter.
Name: ______________________________________
Address: _________________________________________________________
City: _______________________
State: _________ ZIP:
Phone: _______________________
Cell phone: __________________
E-mail: _______________________
Fax: ________________________
Date of focus group: __________________
Time: ________________
Screener for Physician IDI’s
February 2, 2011
7
We are inviting only a few people, so it is very important that you notify us as soon as
possible if you are unable to participate. Please call (insert name of recruiter) at
(insert telephone number). Thank you very much. I appreciate you taking time to talk
to me.
Screener for Physician IDI’s
February 2, 2011
8
APPENDIX C:
INFORMED CONSENT FORM
Form Approved
OMB No. 0920-0572
Exp. Date 11/30/11
INFORMED CONSENT
March 14, 2011
ICF Macro is conducting a series of discussions on behalf of the Centers for Disease Control
and Prevention (CDC) to increase the public’s awareness about diabetes and to get your ideas
and feedback on messages that are being developed to communicate important information
about diabetes prevention.
You have been invited to participate in a 90 minute discussion with other participants. A report
of from the discussions will be prepared by ICF Macro for CDC. Before you agree to join in this
discussion, please review and consider the conditions listed below:


Participation in this group discussion is completely voluntary.
Any questions you have about this project will be answered before the group
discussion begins.

The discussion will be audio taped.

There will be a staff from CDC and ICF Macro observing the discussion.

We ask you to avoid using your last name during the discussion.

Your name will not be used in any reports about this group and no quotes will be
attributed to you.

You may choose not to answer questions that you do not want to answer.

You may choose to leave the group at any time for any reason.

You will receive $___ to compensate you for your time.
Your signature below indicates that you understand the conditions stated above and agree to
participate in this group.
Signature _______________________________________
Witness _______________________________________
Date
_______________________________________
APPENDIX D:
MODERATOR GUIDES
Form Approved
OMB No. 0920-0572
Exp. Date 11/30/11
Support for Developing and Implementing
Targeted Diabetes Prevention Campaigns in
Communities: Adults Unaware of Their Risk
for Prediabetes Focus Group Moderator
Guide
Welcome and Introductions
Good morning/afternoon. My name is _______________ and I will be your moderator
for this session. I am employed by a management consulting firm located just outside of
the District of Columbia. Right away, I want to let everyone know that I’m not a medical
professional, and I am not an expert on diabetes. I am a trained focus group moderator.
I want to hear your honest opinions about the topics we will discuss today. There are no
right or wrong answers to the questions I’m going to ask. Please just relax and enjoy the
discussion.
Please keep in mind that your participation in this discussion is completely voluntary. If
for any reason you wish to leave the discussion, you may.
Ground Rules
Before we begin, I’d like to review some ground rules for today’s discussion. Ground
rules are our guidelines for operating so that we can complete our task in a manner that
is respectful of everyone and provides all of you with the opportunity to express your
thoughts safely and confidentially.

You have been invited here to offer your views and opinions.

Everyone’s participation is important.

Please speak one at a time and avoid side conversations.

Again, there are no right or wrong answers.

Please use your first names only during the discussion.
It’s okay to be critical. I want to hear your views and opinions about whether
you like or dislike something you see or hear.
This session will be audiotaped. This allows us to capture everything that is
being said today, and we will include the information in a report to our client.
Unaware Adults Moderator Guide
1
There are people behind the glass observing the discussion.
All of your answers will be confidential, so feel free to say exactly what is on
your mind. Nothing will be attributed to any particular person in our report.
If anyone needs to use the restroom, they are located [specify]. There is no
need to stop the discussion.
You may excuse yourself from the conversation at any time for any reason.
Lastly, please turn off the ringers on your cell phones.
Icebreaker—Introduction
Let’s begin by finding out a little bit about each of you. Please tell everyone your first
name and tell us what you enjoy doing during your free time. As I mentioned, my name
is __________ and I enjoy __________. Let’s begin on my left and move around the
table.
Note to moderator: Thank participants after the introductions.
Topic 1—General Understanding
We’re here today because my client wants to increase the public’s awareness about
diabetes prevention. I will ask you some questions and show you some graphics. I want
your candid discussion and to get your ideas and feedback on these materials that are
being developed as part of a nationwide diabetes prevention program.
Are there any questions before we get started?
Topic 2—Prediabetes [Urgency]
Today, we are going to be talking about prediabetes. For purposes of our group
discussion, I want to give you a definition of prediabetes.
Note to moderator: Read definition out loud to the group and tape it to the wall.
Definition of prediabetes: At least 54 million Americans over age 20 have prediabetes.
Before people develop type 2 diabetes, they usually have “prediabetes”—that means
their blood glucose levels are higher than normal, but not yet high enough to be called
diabetes. People with prediabetes are more likely to develop diabetes within 5 years,
and they are more likely to have a heart attack or stroke.
Now that we have read the definition of prediabetes, I would like to get your thoughts on
a statement.
Unaware Adults Moderator Guide
2
1. On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5
indicates that you strongly agree, please tell me the number which indicates
how much you agree or disagree with the following statement:
I think that prediabetes is a critical issue.
Note to moderator: Record each participant’s number on a flip chart.
o Probe:
 Why do you agree? Or why do you disagree?
Topic 3—Screening
2. Have you heard about screenings for diabetes?
Topic 4—The National Diabetes Prevention Program [Efficacy]
Note to moderator: Read the description of the CDC National Diabetes Prevention Program
and tape it to the wall.
The National Diabetes Prevention Program is an innovative evidence-based program
recognized by the Centers for Disease Control and Prevention (CDC). CDC has taken
the important step of translating research into real-life disease prevention strategies.
The Program is based on the results of a national study funded by the National
Institutes of Health and CDC. It shows that, by eating healthier, increasing physical
activity, and losing a small amount of weight, a person with prediabetes can prevent or
delay the onset of type 2 diabetes by 58%.
In a structured, group setting, a trained lifestyle coach helps participants change their
lifestyle by learning about healthy eating, physical activity, and other behavior changes
over the course of 16 one-hour, weekly sessions. Topics covered include eating
healthfully, getting started with physical activity, overcoming stress, and staying
motivated. After the initial 16 core sessions, participants meet once a month, for eight
months for added support to help them maintain their progress. The National Diabetes
Prevention Program is currently being piloted in select cities around the country.
3. What do you think of this idea?
4. Is this an appealing message?
5. If you were to find out that you have prediabetes, does this message make you want
to do anything?
6. Where would this information need to be so that you would pay attention to it?
o Probe:
 Health care provider
 Pharmacist
 Internet
Unaware Adults Moderator Guide
3


Family members or friends
Other
Topic 5—Taglines
Now I would like to show you two taglines. I will show you each tagline separately. Once
you have carefully reviewed each tagline, I’d like to get your thoughts and opinions.
Note to moderator: Present the first tagline:

Show each person the tagline.

Ask the participants to read the statement silently.

Read the statement aloud in a moderate and clear voice.

Ask participants:
7. What is the main idea that this message “Healthy Habits. Healthy life.” Is
trying to get across, in your own words?
8. Do you like the way it is written?
o Probe:
 Do you like the tone, language, style? Is it easy to read?
(Collect everyone’s paper before passing out the second tagline.)
Note to moderator: Present the second tagline:

Show each person the second tagline.

Ask the participants to read the statement silently.

Read the statement aloud in a moderate and clear voice.

Ask participants:
9. What is the main idea that this message “Live well. Stay well.” is trying to get
across, in your own words?
10. Do you like the way it is written?
o Probe:
 Do you like the tone, language, style? Is it easy to read?
11. Now that you have seen all of these messages, which one catches your
attention the most? Why?
12. Which one is most inspiring or motivating for you personally? Why?
Unaware Adults Moderator Guide
4
13. Do you think one is more appealing than the other?
o Probe:
 Which one? What about that one makes it more appealing?
Topic 6— Concept Discussion
I will read five separate statements to you. You will be asked to rate each statement on
a scale of one to five as to its ability to move you to action. One is not at all compelling
and five is extremely compelling. Please keep in mind that each statement is based on
the fact that if you are 45 years of age or older and overweight, you may be at risk for
prediabetes.
Note to moderator: Read each concept out loud and have the participants rate each
statement. Write down on a flip chart each participant’s response.

This statement emphasizes the seriousness of prediabetes:
o Prediabetes increases your risk for heart disease, stroke, and blindness.
You may be at risk and not even know it. Are you age 45 years or older,
and overweight? If so, see your health care provider for more information
and to find out if you need to get screened.

This statement emphasizes what can happen if you do nothing.
o If you have prediabetes and do nothing, you will likely develop type 2
diabetes within three to five years. You can turn this around. If you are age
45 years or older, and overweight, see your health care provider for more
information and to find out if you need to get screened.

This statement emphasizes what you can do.
o If you are age 45 years or older, and overweight you may be at risk for
prediabetes and not know it. By increasing your physical activity and
making healthy food choices, you have the power to prevent diabetes.
See your health care provider for more information and to find out if you
need to get screened.

Personal experience
“At 46 and overweight, a friend of mine was just diagnosed with prediabetes. We
are about the same age and I am heavier than I should be, so I may be at risk
too. I’m going to my health care provider to get more information and to find out if
I need to get screened. If you think you may be at risk for diabetes, talk to your
health care provider.”
Unaware Adults Moderator Guide
5
Topic 7—Behavioral Intention
So far we have only talked about prediabetes and the National Diabetes Prevention
Program. Now, I would like to get your thoughts and opinions on your willingness to take
action to prevent diabetes.
Note to moderator: Take a vote by having participants raise their hands. Count the
number of hands for each response. Participants may vote only once.
14. On a scale from 1 to 10, where 1 is not at all interested and 10 is extremely
interested, how interested are you in learning more about the National
Diabetes Prevention Program?
Note to moderator: Go around the room and have each participant provide a response
out loud.
15. After participating in this discussion group, do you plan to get screened for
prediabetes?
o Probe:

Why or why not?
Topic 8— Creative Materials Discussion
Note to moderator: if time permits, test the following creative piece.
Now I would like to get your feedback on a creative piece that has been developed.
Please note they are not the final products, these are mock ups.
Moderator:
 Show participants the Y flyer
 Give each participant a hard color copy of the flyer.
 Ask the questions below.
16. Is this an appealing message?
o Probe:
 What makes the message appealing or unappealing?
17. Are there words or phrases in the flyer that you think are particularly attention
–getting or appealing?
18. How do you feel about the images used in this concept? Are they engaging?
Why or why not?
19. If you saw or heard this message, would it get your attention? Why or why
not?
20. What would you think of having the logo of an organization you
recognize/trust?
Unaware Adults Moderator Guide
6
False Close
Tell participants that you are going to speak with observers to see whether they have
any follow-up questions. Leave the room to check with observers.
Closing
On behalf of CDC, I wish to thank all of you for your participation today. Please stop at
the front desk to pick up your incentive. Thank you.
Unaware Adults Moderator Guide
7
Form Approved
OMB No. 0920-0572
Exp. Date 11/30/11
Support for Developing and Implementing
Targeted Diabetes Prevention Campaigns in
Communities: Adults Aware of Their Risk
for Prediabetes Focus Group Moderator
Guide
Welcome and Introductions
Good morning/afternoon. My name is _______________ and I will be your moderator
for this session. I am employed by a management consulting firm located just outside of
the District of Columbia. Right away, I want to let everyone know that I’m not a medical
professional, and I am not an expert on diabetes. I am a trained focus group moderator.
I want to hear your honest opinions about the topics we will discuss today. There are no
right or wrong answers to the questions I’m going to ask. Please just relax and enjoy the
discussion.
Please keep in mind that your participation in this discussion is completely voluntary. If
for any reason you wish to leave the discussion, you may.
Ground Rules
Before we begin, I’d like to review some ground rules for today’s discussion. Ground
rules are our guidelines for operating so that we can complete our task in a manner that
is respectful of everyone and provides all of you with the opportunity to express your
thoughts safely and confidentially.

You have been invited here to offer your views and opinions.

Everyone’s participation is important.

Please speak one at a time and avoid side conversations.

Again, there are no right or wrong answers.

Please use your first names only during the discussion.

It’s okay to be critical. I want to hear your views and opinions about whether
you like or dislike something you see or hear.

This session will be audiotaped. This allows us to capture everything that is
being said today, and we will include the information in a report to our client.
Aware Adults Moderator Guide
1

There are people behind the glass observing the discussion.

All of your answers will be confidential, so feel free to say exactly what is on
your mind. Nothing will be attributed to any particular person in our report.

If anyone needs to use the restroom, they are located [specify]. There is no
need to stop the discussion.

You may excuse yourself from the conversation at any time for any reason.

Lastly, please turn off the ringers on your cell phones.
Icebreaker—Introduction
Let’s begin by finding out a little bit about each of you. Please tell everyone your first
name and tell us what you enjoy doing during your free time. As I mentioned, my name
is __________ and I enjoy __________. Let’s begin on my left and move around the
table.
Note to moderator: Thank participants after the introductions.
Topic 1—General Understanding
We’re here today because my client wants to increase the public’s awareness about
diabetes prevention. I will ask you some questions and show you some graphics. I want
your candid discussion and to get your ideas and feedback on these materials that are
being developed as part of a nationwide diabetes prevention program.
Are there any questions before we get started?
Topic 2—Prediabetes [Urgency]
Today, we are going to be talking about prediabetes. For purposes of our group
discussion, I want to give you a definition of prediabetes.
Note to moderator: Read definition out loud to the group and tape it to the wall.
Definition of prediabetes: At least 54 million Americans over age 20 have prediabetes.
Before people develop type 2 diabetes, they usually have “prediabetes”—that means
their blood glucose levels are higher than normal, but not yet high enough to be called
diabetes. People with prediabetes are more likely to develop diabetes within 5 years,
and they are more likely to have a heart attack or stroke.
Now that we have read the definition of prediabetes, I would like to get your thoughts on
a statement.
Aware Adults Moderator Guide
2
1. On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5
indicates that you strongly agree, please tell me the number which
indicates how much you agree or disagree with the following statement:
I think that prediabetes is a critical issue.
Note to moderator: Record each participant’s number on a flip chart.
o Probe:
 Why do you agree? Or why do you disagree?
Topic 3—The National Diabetes Prevention Program
Note to moderator: Read the description of the CDC National Diabetes Prevention
Program and tape it to the wall.
The National Diabetes Prevention Program is an innovative evidence-based program
recognized by the Centers for Disease Control and Prevention (CDC). CDC has taken
the important step of translating research into real-life disease prevention strategies.
The Program is based on the results of a national study funded by the National
Institutes of Health and CDC. It shows that, by eating healthier, increasing physical
activity, and losing a small amount of weight, a person with prediabetes can prevent or
delay the onset of type 2 diabetes by 58%.
In a structured, group setting, a trained lifestyle coach helps participants change their
lifestyle by learning about healthy eating, physical activity, and other behavior changes
over the course of 16 one-hour, weekly sessions. Topics covered include eating
healthfully, getting started with physical activity, overcoming stress, and staying
motivated. After the initial 16 core sessions, participants meet once a month, for eight
months for added support to help them maintain their progress. The National Diabetes
Prevention Program is currently being piloted in select cities around the country.
2. What do you think of this idea?
3. Is this an appealing message?
4. If you were to find out that you have prediabetes, does this message make
you want to do anything?
o Probe:

Does this motive you to take action?
5. Who do you think would be a good spokesperson to convince you to join
the National Diabetes Prevention Program?
6. Who in your household might be against trying this? Why?
7. Doctors are interested in what they can say to motivate patients to
participate in a lifestyle program to prevent diabetes. What is your advice
to them? That is, what should doctors tell people if they want them to
participate in the National Diabetes Prevention Program?
Aware Adults Moderator Guide
3
8. Where would this information need to be/come from so that you would pay
attention to it?
Probe:
 Health care provider
 Pharmacist
 Internet
 Family members or friends
 Other
Topic 4—Taglines
Now I would like to show you two taglines. I will show you each tagline separately. Once
you have carefully reviewed each tagline, I’d like to get your thoughts and opinions.
Note to moderator: Present the first tagline:
 Show each person the tagline.
 Ask the participants to read the statement silently.
 Read the statement aloud in a moderate and clear voice.
 Ask participants:
9. What is the main idea that this message “Healthy habits. Healthy life.” is
trying to get across, in your own words?
10. Do you like the way it is written?
Probe:
 Do you like the tone, language, style? Is it easy to read?
(Collect everyone’s paper before passing out the second tagline.)
Note to moderator: Present the second tagline:
 Show each person the second tagline.
 Ask the participants to read the statement silently.
 Read the statement aloud in a moderate and clear voice.
 Ask participants:
11. What is the main idea that this message “Live well. Stay well.” is trying to
get across, in your own words?
12. Do you like the way it is written?
o Probe:
 Do you like the tone, language, style? Is it easy to read?
Aware Adults Moderator Guide
4
13. Now that you have seen all of these massages, which one catches your
attention the most? Why?
Topic 5— Concept Discussion
I will read five separate statements to you. You will be asked to rate each statement on
a scale of one to five as to its ability to move you to action. One is not at all compelling
and five is extremely compelling. Please keep in mind that each statement is based on
the fact that if you are 45 years of age or older and overweight, you may be at risk for
prediabetes.
Note to moderator: Read each concept out loud and have the participants rate each
statement. Write down on a flip chart each participant’s response.

This statement emphasizes the seriousness of prediabetes:
o Prediabetes increases your risk for heart disease, stroke, and blindness.
You may be at risk and not even know it. Are you age 45 years or older,
and overweight? If so, see your health care provider for more information
and to find out if you need to get screened.

This statement emphasizes what can happen if you do nothing.
o If you have prediabetes and do nothing, you will likely develop type 2
diabetes within three to five years. You can turn this around. If you are age
45 years or older, and overweight, see your health care provider for more
information and to find out if you need to get screened.

This statement emphasizes what you can do.
o If you are age 45 years or older, and overweight you may be at risk for
prediabetes and not know it. By increasing your physical activity, making
healthy food choices, and losing a small amount of weight, you have the
power to prevent diabetes. See your health care provider for more
information and to find out if you need to get screened.

Personal experience
o “At 46 and overweight, a friend of mine was just diagnosed with
prediabetes. We are about the same age and I am heavier than I should
be, so I may be at risk too. I’m going to my health care provider to get
more information and to find out if I need to get screened. If you think you
may be at risk for diabetes, talk to your doctor.”
Topic 6—Behavioral Intention
Aware Adults Moderator Guide
5
So far we have only talked about prediabetes and the National Diabetes Prevention
Program. Now, I would like to get your thoughts and opinions on your willingness to take
action to prevent diabetes.
Note to moderator: Take a vote by having participants raise their hands. Count the
number of hands for each response. Participants may vote only once.
14. On a scale from 1 to 10, where 1 is not at all interested and 10 is
extremely interested, how interested are you in learning more about the
National Diabetes Prevention Program?
Note to moderator: Go around the room and have each participant provide a response
out loud.
15. After participating in this discussion group, do you plan to get screened for
prediabetes?
o Probe:

Why or why not?
Topic 7— Creative Materials Discussion
Note to moderator: if time permits, test the following creative piece.
Now I would like to get your feedback on a creative piece that has been developed.
Please note they are not the final products, these are mock ups.
Moderator:



Show participants the Y flyer
Give each participant a hard color copy of the flyer
Ask the questions below.
16. Is this an appealing message?
o Probe:
 What makes the message appealing or unappealing?
17. Are there any words or phrases in the flyer that you think are particularly
attention –getting or appealing?
18. How do you feel about the images used in this concept? Are they
engaging? Why or why not?
19. If you saw or heard this message, would it get your attention? Why or why
not?
Aware Adults Moderator Guide
6
20. What would you think of having the logo of an organization you
recognize/trust?
False Close
Tell participants that you are going to speak with observers to see whether they have
any follow-up questions. Leave the room to check with observers.
Closing
On behalf of CDC, I wish to thank all of you for your participation today. Please stop at
the front desk to pick up your incentive. Thank you.
Aware Adults Moderator Guide
7
Form Approved
OMB No. 0920-0572
Exp. Date 11/30/11
Support for Developing and Implementing
Targeted Diabetes Prevention Campaigns in
Communities: Adults Diagnosed With
Prediabetes Focus Group Moderator Guide
Welcome and Introductions
Good morning/afternoon. My name is _______________ and I will be your moderator
for this session. I am employed by a management consulting firm located just outside of
the District of Columbia. Right away, I want to let everyone know that I’m not a medical
professional, and I am not an expert on diabetes. I am a trained focus group moderator.
I want to hear your honest opinions about the topics we will discuss today. There are no
right or wrong answers to the questions I’m going to ask. Please just relax and enjoy the
discussion.
Please keep in mind that your participation in this discussion is completely voluntary. If
for any reason you wish to leave the discussion, you may.
Ground Rules
Before we begin, I’d like to review some ground rules for today’s discussion. Ground
rules are our guidelines for operating so that we can complete our task in a manner that
is respectful of everyone and provides all of you with the opportunity to express your
thoughts safely and confidentially.

You have been invited here to offer your views and opinions.

Everyone’s participation is important.

Please speak one at a time and avoid side conversations.

Again, there are no right or wrong answers.

Please use your first names only during the discussion.

It’s okay to be critical. I want to hear your views and opinions about whether
you like or dislike something you see or hear.

This session will be audiotaped. This allows us to capture everything that is
being said today, and we will include the information a report to our client.

There are people behind the glass observing the discussion.
Diagnosed Adults Moderator Guide
1

All of your answers will be confidential, so feel free to say exactly what is on
your mind. Nothing will be attributed to any particular person in our report.

If anyone needs to use the restroom, they are located [specify]. There is no
need to stop the discussion.

You may excuse yourself from the conversation at any time for any reason.

Lastly, please turn off the ringers on your cell phones.
Icebreaker—Introduction
Let’s begin by finding out a little bit about each of you. Please tell everyone your first
name and tell us what you enjoy doing during your free time. As I mentioned, my name
is __________ and I enjoy __________. Let’s begin on my left and move around the
table.
Note to moderator: Thank participants after the introductions.
Topic 1—General Understanding
We’re here today because my client wants to increase the public’s awareness about
diabetes prevention. I will ask you some questions and show you some graphics. I want
your candid discussion and to get your ideas and feedback on these materials that are
being developed as part of a nationwide diabetes prevention program.
Are there any questions before we get started?
Topic 2—Prediabetes [Urgency]
Today, we are going to be talking about prediabetes. For purposes of our group
discussion, I want to give you a definition of prediabetes.
Note to moderator: Read definition out loud to the group and tape it to the wall.
Definition of prediabetes: At least 54 million Americans over age 20 have prediabetes.
Before people develop type 2 diabetes, they usually have “prediabetes”—that means
their blood glucose levels are higher than normal, but not yet high enough to be called
diabetes. People with prediabetes are more likely to develop diabetes within 5 years
and they are more likely to have a heart attack or stroke.
Now that we have read the definition of prediabetes, I would like to get your thoughts on
a statement.
1. On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5
indicates that you strongly agree, please tell me the number which
indicates how much you agree or disagree with the following statement:
Diagnosed Adults Moderator Guide
2
I think that prediabetes is a critical issue.
Note to moderator: Record each participant’s number on a flip chart.
o Probe:
 Why do you agree? Or why do you disagree?
Topic 3—The National Diabetes Prevention Program [Efficacy]
Note to moderator: Read the description of the CDC National Diabetes Prevention
Program and tape it to the wall.
The National Diabetes Prevention Program is an innovative evidence-based program
recognized by the Centers for Disease Control and Prevention (CDC). CDC has taken
the important step of translating research into real-life disease prevention strategies.
The Program is based on the results of a national study funded by the National
Institutes of Health and CDC. It shows that, by eating healthier, increasing physical
activity, and losing a small amount of weight, a person with prediabetes can prevent or
delay the onset of type 2 diabetes by 58%.
In a structured, group setting, a trained lifestyle coach helps participants change their
lifestyle by learning about healthy eating, physical activity, and other behavior changes
over the course of 16 one-hour, weekly sessions. Topics covered include eating
healthfully, getting started with physical activity, overcoming stress, and staying
motivated. After the initial 16 core sessions, participants meet once a month, for eight
months for added support to help them maintain their progress. The National Diabetes
Prevention Program is currently being piloted in select cities around the country.
2. What do you think of this idea?
3. Is this an appealing message?
4. Who do you think would be a good spokesperson to convince you to join the
National Diabetes Prevention Program?
5. Who in your household may be against trying this? Why?
6. Doctors are interested in what they can say to motivate patients to participate
in a lifestyle program to prevent diabetes. What is your advice to them? That
is, what should doctors tell people if they want them to participate in the
National Diabetes Prevention Program?
Topic 4—Taglines
Now I would like to show you two taglines. I will show you each tagline separately. Once
you have carefully reviewed each tagline, I’d like to get your thoughts and opinions.
Note to moderator: Present the first tagline:
 Show each person the tagline.
Diagnosed Adults Moderator Guide
3
 Ask the participants to read the statement silently.
 Read the statement aloud in a moderate and clear voice.
 Ask participants:
7. What do you think the message “Healthy habits. Healthy life.” means?
8. Do you like the way it is written?
Probe:
 Do you like the tone, language, style? Is it easy to read?
(Collect everyone’s paper before passing out the second tagline.)
Note to moderator: Present the second tagline:
 Show each person the second tagline.
 Ask the participants to read the statement silently.
 Read the statement aloud in a moderate and clear voice.
 Ask participants:
9. What do you think the message “Live well, Stay well.” means?
10. Do you like the way it is written?
Probe:
 Do you like the tone, language, style? Is it easy to read?
11. Now that you have seen all of these messages, which one catches your
attention the most? Why?
Topic 5— Concept Discussion
I will read five separate statements to you. You will be asked to rate each statement on
a scale of one to five as to its ability to move you to action. One is not at all compelling
and five is extremely compelling. Please keep in mind that each statement is based on
the fact that if you are 45 years of age or older and overweight, you may be at risk for
prediabetes.
Note to moderator: Read each concept out loud and have the participants rate each
statement. Write down on a flip chart each participant’s response


This statement emphasizes the seriousness of prediabetes.
Prediabetes increases your risk for heart disease, stroke, and blindness. If you
have been diagnosed with prediabetes, there is a National Diabetes Prevention
Program in your area that can help you prevent diabetes. Learn more. Call 1800123-4567.
This statement emphasized what can happen if you do nothing.
Diagnosed Adults Moderator Guide
4

If you have prediabetes and do nothing, you will likely develop type 2 diabetes
within three to five years. You can turn this around. There is a National Diabetes
Prevention Program in your area that can help you prevent diabetes. Learn more.
Call 1800-123-4567.
This statement emphasizes what you can do.

You have the power to prevent diabetes. If you have prediabetes, increasing your
physical activity, making healthy food choices, and losing a little bit of weight can
prevent you from developing the disease. There is a National Diabetes
Prevention Program in your area that can help you. . Learn more. Call 1800-1234567.

Testimonial
“My doctor told me I have prediabetes, and then he told me about a program in
my community that would help keep me from getting diabetes. At first, I wasn’t
too sure. But I am so glad that I went! The classes teach me about lifestyle
changes that even I can make to be healthier. Now I feel great and my doctor
has even noticed the difference. You can prevent diabetes, too. If you have
prediabetes, find out about the National Diabetes Prevention Program in your
area.” Call 1-800-123-4567.
Topic 6—Behavioral Intention
So far we have only talked about prediabetes and the National Diabetes Prevention
Program. Now, I would like to get your thoughts and opinions on your willingness to take
action to prevent diabetes.
19. On a scale from 1 to 10, where 1 is not at all interested and 10 is
extremely interested, how interested are you in learning more about the
National Diabetes Prevention Program?
Note to moderator: Go around the room and have each participant provide a response
out loud.
Topic 7— Creative Materials Discussion
Note to moderator: if time permits, test the following creative piece.
Now I would like to get your feedback on a creative piece that has been developed.
Please note they are not the final products, these are mock ups.
Moderator:



Show participants the Y flyer
Give each participant a hard color copy of the flyer.
Ask the questions below.
Diagnosed Adults Moderator Guide
5
1. Is this an appealing message?
a. Probe:
 What makes the message appealing or unappealing?
2. Are there words or phrases in the flyer that you think are particularly attention –
getting or appealing?
3. How do you feel about the images used in this concept? Are they engaging?
Why or why not?
4. If you saw or heard this message, would it get your attention? Why or why not?
5. What would you think of having the logo of an organization you recognize/trust?
False Close
Tell participants that you are going to speak with observers to see whether they have
any follow-up questions. Leave the room to check with observers.
Closing
On behalf of CDC, I wish to thank all of you for your participation today. Please stop at
the front desk to pick up your incentive. Thank you.
Diagnosed Adults Moderator Guide
6
Form Approved
OMB No. 0920-0572
Exp. Date 11/30/11
Support for Developing and Implementing
Targeted Diabetes Prevention Campaigns in
Communities: Family and Friends Focus
Group Moderator Guide
Welcome and Introductions
Good morning/afternoon. My name is _______________ and I will be your moderator
for this session. I am employed by a management consulting firm located just outside of
Washington, D.C.. I want to let everyone know that I’m not a medical professional, and I
am not expert on diabetes. I am a trained focus group moderator. I want to hear your
honest opinions about the topics we will discuss today. There are no right or wrong
answers to the questions I’m going to ask. Please just relax and enjoy the discussion.
Please keep in mind that your participation in this discussion is completely voluntary. If
for any reason you wish to leave the discussion, you may.
Ground Rules
Before we begin, I’d like to review some ground rules for today’s discussion. Ground
rules are our guidelines for operating so that we can complete our task in a manner that
is respectful of everyone and provides all of you with the opportunity to express your
thoughts safely and confidentially.

You have been invited here to offer your views and opinions.

Everyone’s participation is important.

Please speak one at a time and avoid side conversations..

Again, there are no right or wrong answers.

Please use your first names only during the discussion.

It’s okay to be critical. I want to hear your views and opinions about whether you
like or dislike something you see or hear.

This session will be audiotaped. This allows us to capture everything that is being
said today, which we will include in a report to our client.

There are people behind the glass observing the discussion.

All of your answers will be confidential, so feel free to say exactly what is on your
mind. Nothing will be attributed to any particular person in our report.
Family & Friends Guide
1

If anyone needs to use the restroom, they are located (specify). There is no need
to stop the discussion.

You may excuse yourself from the conversation at any time for any reason.

Lastly, please turn off the ringers on your cell phones.
Icebreaker—Introduction
Let’s begin by finding out a little bit about each of you. Please tell everyone your first
name, and tell us what do you enjoy doing during your free time? As I mentioned, my
name is __________ and I enjoy (fill in the blank). Let’s begin on my left and move
around the table.
Moderator: Thank participants after the introductions.
Topic 1—General Understanding
We’re here today because my client wants to increase the public’s awareness about
diabetes prevention. I will ask you some questions and share some program concepts
with you. I want your candid discussion and to get your ideas and feedback on these
pieces that are being developed as part of a nationwide diabetes prevention program.
You are here because you could support someone with prediabetes in your family or as
a friend.
Are there any questions before we get started?
Topic 2—Prediabetes [Urgency]
Today, we are going to be talking about prediabetes. For purposes of our group
discussion, I want to give you a definition of prediabetes.
Note to moderator: Read definition out loud to the group and tape definition up on the
wall.
Definition of prediabetes: At least 54 million Americans over age 20 have prediabetes.
Before people develop type 2 diabetes, they usually have "prediabetes"—that means
their blood glucose levels are higher than normal, but not yet high enough to be called
diabetes. People with prediabetes are more likely to develop diabetes within 10 years
and they are more likely to have a heart attack or stroke.
Now that we have read the definition of prediabetes, I would like to get your thoughts on
a statement.
1. On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5
indicates that you strongly agree, please tell me the number which indicates how
much you agree or disagree with each statement:
Family & Friends Guide
2
Note to moderator: Record each participant’s number on a flip chart.
I think that prediabetes is a critical issue.
o Probe:
 Why do you agree? Or why do you disagree?
I feel as though I can make a difference in helping my family member or
friend prevent diabetes.
o Probe:
 Why do you agree? Or why do you disagree?
Topic 3—The National Diabetes Prevention Program [Efficacy]
Note to moderator: Read the description of the CDC National Diabetes Prevention
Program and tape it to the wall.
The National Diabetes Prevention Program is an innovative evidence-based program
recognized by the Centers for Disease Control and Prevention (CDC). CDC has taken
the important step of translating research into real-life disease prevention strategies.
The Program is based on the results of a national study funded by the National
Institutes of Health and CDC. It shows that, by eating healthier, increasing physical
activity, and losing a small amount of weight, a person with prediabetes can prevent or
delay the onset of type 2 diabetes by 58%.
In a structured, group setting, a trained lifestyle coach helps participants change their
lifestyle by learning about healthy eating, physical activity, and other behavior changes
over the course of 16 one-hour, weekly sessions. Topics covered include eating
healthfully, getting started with physical activity, overcoming stress, and staying
motivated. After the initial 16 core sessions, participants meet once a month, for eight
months for added support to help them maintain their progress. The National Diabetes
Prevention Program is currently being piloted in select cities around the country.
2. What do you think of this idea?
3. Is this an appealing message?
4. If you were trying to influence a family member or a friend to attend a diabetes
prevention program, what would you say to them?
o Probe:

Family & Friends Guide
Would you emphasize the benefits of participating in diabetes
prevention program? What would you do to overcome barriers?
3

How likely do you think it is that you could influence your family
member or friend to participate in the National Diabetes Prevention
Program?

How likely do you think it is that your family member or friend would
participate in the National Diabetes Prevention Program?
5. Is there anything that could be changed to make it more likely that your family
member or friend would be motivated to participate?
6. Doctors are interested in what they can say to motivate patients to participate in
lifestyle program to prevent diabetes. What is your advice to them? That is, what
should doctors tell people with prediabetes if they want them to participate in the
National Diabetes Prevention Program?
Topic 4-Taglines
Now I would like to show you two taglines that I would like to get your reactions to.
Note to moderator: Present 1st tagline:




Show each person the tagline.
Ask the participants to read the statement silently.
Read the statement aloud at a moderate and clear voice
Ask participants:
7. What is the main idea that this message “Live well. Stay well.” is trying to get
across, in your own words?
8. Do you like the way it is written?
o Probe:
 Do you like the tone, language, style? Is it easy to read?
(Collect everyone’s paper before passing out the 2nd tagline)
Note to moderator: Present 2nd tagline
 Show each person the second tagline.
 Ask the participants to read the statement silently.
 Read the statement aloud at a moderate and clear voice
 Ask participants:
9. What is the main idea that this message “Healthy habits. Healthy life.” is trying to
get across, in your own words?
10. Do you like the way it is written?
o Probe:
 Do you like the tone, language, style? Is it easy to read?
Family & Friends Guide
4
11. Now that you have seen all these messages, which one catches your attention
the most? Why?
12. Which one is most inspiring or motivating? Why?
13. Do you think one is more appealing than the other?
o Probe:
 Which one? What about that one makes it more appealing?
Topic 5— Behavioral Intention
So far we have only talked about what the National Diabetes Prevention Program
messages should look like, and what words and images they should contain. Now, I
would like to get your thoughts and opinions on supporting your loved one at risk for
diabetes.
14. How likely are you to talk with your family member or a friend at risk for or
diagnosed with prediabetes to participate in the National Diabetes Prevention
Program in the next week or so?
15. On a scale of 0 to 10, where 0 is not at all confident and 10 is extremely
confident, how confident are you right now that your loved one would enroll in
and complete the 16-week program and 8 month maintenance period?
Note to moderator: go around the room and have each participant provide a
response out loud.
Topic 6— Creative Materials Discussion
Note to moderator: if time permits, test the following creative piece.
Now I would like to get your feedback on a creative piece that has been developed.
Please note they are not the final products, these are mock ups.
Moderator:
 Display the Y flyer
 Give each participant a hard copy
 Ask the following questions:
16. Is this an appealing message?
o Probe:
 What makes the message appealing or unappealing?
17. Are there words or phrases in the flyer that you think are particularly attention –
getting or appealing?
Family & Friends Guide
5
18. How do you feel about the images used in this concept? Are they engaging?
Why or why not?
19. If you saw or heard this message, would it get your attention? Why or why not?
20. What would you think of having the logo of an organization you recognize/trust?
False Close
Tell participants that you are going to speak with observers to see whether they have
any follow-up questions. Leave the room to check with observers.
Closing
On behalf of the CDC, I wish to thank all of you for your participation today. Please stop
at the front desk to pick up your incentive. Thank you.
Family & Friends Guide
6
Form Approved
OMB No. 0920-0572
Exp. Date 11/30/11
Support for Developing and Implementing
Targeted Diabetes Prevention Campaigns in
Communities: Health Care Provider Focus
Group Moderator Guide
Welcome and Introductions
Good morning/afternoon. My name is _______________ and I will be your moderator
for this session. I am employed by a management consulting firm located just outside of
the District of Columbia. Right away, I want to let everyone know that I’m not a medical
professional, and I am not an expert on diabetes. I am a trained focus group moderator.
I want to hear your honest opinions about the topics we will discuss today. There are no
right or wrong answers to the questions I’m going to ask. Please just relax and enjoy the
discussion.
Please keep in mind that your participation in this discussion is completely voluntary. If
for any reason you wish to leave the discussion, you may.
Ground Rules
Before we begin, I’d like to review some ground rules for today’s discussion. Ground
rules are our guidelines for operating so that we can complete our task in a manner that
is respectful of everyone and provides all of you with the opportunity to express your
thoughts safely and confidentially.

You have been invited here to offer your views and opinions.

Everyone’s participation is important.

Please speak one at a time and avoid side conversations.

Again, there are no right or wrong answers.

Please use your first names only during the discussion.

It’s okay to be critical. I want to hear your views and opinions about whether
you like or dislike something you see or hear.

This session will be audiotaped. This allows us to capture everything that is
being said today, and we will include the information in a report to our client.

There are people behind the glass observing the discussion.
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
All of your answers will be confidential, so feel free to say exactly what is on
your mind. Nothing will be attributed to any particular person in our report.

If anyone needs to use the restroom, they are located [specify]. There is no
need to stop the discussion.

You may excuse yourself from the conversation at any time for any reason.

Lastly, please turn off the ringers on your cell phones.
Icebreaker—Introduction
Let’s begin by finding out a little bit about each of you. Please tell everyone your first
name and tell us what you enjoy doing during your free time. As I mentioned, my name
is __________, and I enjoy __________. Let’s begin on my left and move around the
table.
Note to moderator: Thank participants after the introductions.
Topic 1—General Understanding
We’re here today because my client wants to hear your opinions about a national
lifestyle intervention program to prevent diabetes in persons at risk for developing the
disease. Health care providers can play a critical role in the program by screening
patients for prediabetes and, if results are positive, referring patients to local programs. I
will also share some program concepts with you and would like to get your ideas and
feedback on these ideas.
Are there any questions before we get started?
Topic 2—Prediabetes (Urgency)
1. Have you heard about the term “prediabetes”?
For purposes of our group discussion, I want to give you a definition of prediabetes.
Note to moderator: Read definition out loud to the group and tape the definition to the
wall.
Definition of prediabetes: Prediabetes occurs when a person’s blood glucose levels are
higher than normal but not high enough for a diagnosis of diabetes (Fasting blood
glucose [100–125 mg/dl] or A1C of 6–6.5%). Diagnosis of prediabetes includes
impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) and is a significant
risk factor for type 2 diabetes. In fact, before people develop type 2 diabetes, they
almost always have prediabetes. Studies show that most people with prediabetes
develop type 2 diabetes within 5 years.
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2. On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5
indicates that you strongly agree, please tell me the number which indicates
how much you agree or disagree with each statement:
Note to moderator: For the next two statements, go around the room and
have each participant provide a response out loud. Record each participant’s
number on a flip chart.
o I think that prediabetes is a critical issue.
Probe:

Why do you agree? Why do you disagree?
o I feel as though I can make a difference regarding prediabetes.
Probe:

Why do you agree? Why do you disagree?
Topic 3—The National Diabetes Prevention Program (Referral and Efficacy)
Note to moderator: Read definition out loud to the group and tape definition up on the
wall
The National Diabetes Prevention Program is an innovative evidence-based program
recognized by the Centers for Disease Control and Prevention (CDC). CDC has taken
the important step of translating research into real-life disease prevention strategies.
The Program is based on the results of a national study funded by the National
Institutes of Health and CDC. It shows that, by eating healthier, increasing physical
activity, and losing a small amount of weight, a person with prediabetes can prevent or
delay the onset of type 2 diabetes by 58%.
In a structured, group setting, a trained lifestyle coach helps participants change their
lifestyle by learning about healthy eating, physical activity, and other behavior changes
over the course of 16 one-hour, weekly sessions. Topics covered include eating
healthfully, getting started with physical activity, overcoming stress, and staying
motivated. After the initial 16 core sessions, participants meet once a month, for eight
months for added support to help them maintain their progress. The National Diabetes
Prevention Program is currently being piloted in select cities around the country.
3. Does this message make you want to do anything?
4. Is there anything that could be changed to make it more likely you would be
motivated to refer patients to the program?
5. Is there anything you want to know that this item does not tell you?
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6. How often, if at all, do you pick up information about health/lifestyle programs
for patients such as the National Diabetes Prevention Program?
o Probe:
 What are the sources of this information?
 Where might you seek information for the National Diabetes
Prevention Program?
Topic 4—Concept Discussion
I will read four separate statements to you. You will be asked to rate each statement on
a scale of one to five as to its ability to move you and your peers to action. One is not at
all compelling and five is extremely compelling. Each statement will provide facts about
prediabetes using a different persuasive technique. Each statement is based on the fact
that your overweight patients, age 45 and older (with a fasting blood glucose of 100-125
milligrams per deciliter or an A1C of 6.0-6.5) are at risk for prediabetes.
Note to moderator: Read each concept out loud and have the participants rate each
statement. Write down on a flip chart each participant’s response.

Statement one emphasizes the urgency of screening for prediabetes:
Prediabetes, if not addressed early, will develop into type 2 diabetes within 3
to 5 years. Don’t miss this window of opportunity to prevent diabetes. Screen
your patients now so they can take steps to reduce their risk of diabetes.
There is a National Diabetes Prevention Program in your area to help those
who test positive for prediabetes.

Statement two emphasizes the seriousness of prediabetes:
Prediabetes increases a person’s risk for heart disease, stroke, and
blindness. Screen your high-risk patients for prediabetes, and for those who
test positive, refer them to the National Diabetes Prevention Program in your
area.

Statement three emphasizes program efficacy in preventing diabetes:
The Diabetes Prevention Program study found that people with prediabetes
who completed a 16-week lifestyle intervention program were 58% less likely
to develop type 2 diabetes than the control group. Screen your high-risk
patients for prediabetes, and refer those who test positive to the National
Diabetes Prevention Program in your area. It works!

Statement four presents an authoritative recommendation:
The American College of Endocrinology recommends that high-risk patients be
screened for prediabetes. Prediabetes, if not addressed, will develop into type 2
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diabetes within 3 to 5 years, however people with prediabetes who completed a
16-week lifestyle intervention program were 58% less likely to develop type 2
diabetes than the control group. Screen your high-risk patients for prediabetes,
and refer those who test positive to the National Diabetes Prevention Program
in your area.
Topic 5—Behavioral Intention
We have talked about prediabetes and the National Diabetes Prevention Program. Now,
I would like to get some additional thoughts and opinions about the program.
7. On a scale of 1 to 10, where 1 is not at all interested and 10 is extremely
interested, how interested are you in receiving information and materials
about the National Diabetes Prevention Program?
Note to moderator: Go around the room and have each participant provide a response
out loud.
The role of a “health care provider champion of the National Diabetes
Prevention Program” entails referring patients to the program, presenting
information about the program to your colleagues, and encouraging other
health care providers to screen and refer.
8. How feasible is it that you would try to do this? Please explain.
False Close
Tell participants that you are going to speak with observers to see whether they have
any follow-up questions. Leave the room to check with observers.
Closing
On behalf of the Centers for Disease Control and Prevention, I wish to thank all of you
for your participation today. Please stop at the front desk to pick up your incentive.
Thank you.
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Support for Developing and Implementing
Targeted Diabetes Prevention Campaigns
in Communities: Physician In-Depth
Interview Questions
Date of interview___________________
Hello. My name is
. I’m calling from [Subcontractor Name]. We are conducting
interviews for the Centers for Disease Control and Prevention (CDC)to better understand how
best to inform physicians about and engage them in the National Diabetes Prevention Program,
a diabetes prevention lifestyle program for people with prediabetes. Your participation will help
us to tailor promotional materials and messages specifically for physicians by CDC. The
discussion will last about 60 minutes. Your participation and everything you say during this
discussion will be confidential. Your name will not be used in any results from this project. You
will receive $350 for your time. Let’s begin.
Prediabetes
1. How do you define prediabetes?
2.
Do you think that prediabetes is a critical issue?
If yes, why?
If no, why not?
Screening
1. Do you screen your patients for prediabetes?
a. If so, what factors do you consider in screening someone for prediabetes?
b. If not, why not?
2. What are the barriers to screening people for prediabetes?
3. What are possible motivators for physicians to screen their patients for prediabetes?
4. Are there any barriers within your office system (i.e. limited staff, technology) that would
make identifying those patients who may be at risk for prediabetes challenging?
a. How might those barriers be eliminated or minimized?
Referral
Read description of the Centers for Disease Control and Prevention’s (CDC)
National Diabetes Prevention Program: The National Diabetes Prevention Program
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January 11, 2011
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is a 16-week, science-based lifestyle program developed to prevent or delay people at
risk for diabetes from developing the disease. The program is based on the findings of
the Diabetes Prevention Program trial which showed that one of the most effective ways
to lower the risk of type 2 diabetes is through regular exercise and modest weight loss.
Currently, the program is being offered by YMCAs in a number of cities throughout the
country and will be offered by a range of organizations in many communities in the
future. There are two important roles for healthcare professionals in this program –
screening at-risk people for diabetes and, if they have prediabetes, referring them to
their local National Diabetes Prevention Program.
1. If you screened and identified your patients with prediabetes, how feasible is it for
you or your office staff to refer them to the CDC’s National Diabetes Prevention
Program, if one existed in your community? Please explain.
o What are the barriers to referring?
o Is there anything that could be changed to make it more likely you would
refer patients to the program?
2. What information would you need to know about the program for you to consider
referring patients?
o Probe:
 Is the endorsement of the Centers for Disease Control and
Prevention (CDC) meaningful to you?

If you had colleagues referring patients to the program, would that
motivate you to refer?

Where would you want to find this information?
3. Are there any barriers within your office system (i.e. limited staff, technology) that
would make referring patients diagnosed with prediabetes challenging?
Read description of the physician champion: The National Diabetes Prevention
Program will enlist the support of physicians to screen and refer patients to local
program sites and encourage the involvement of other health care providers.
Physicians who participate in this capacity will be recognized as “physician
champions.”
4. If you were offered the opportunity to serve as a “physician champion” for the
National Diabetes Prevention Program would you be interested?
o Probe:
Physician IDI Guide
January 11, 2011
2


Would knowing your peers were referring patients to the diabetes
prevention program motivate you to refer your patients to the
program?
What would make the concept of being a physician champion more
appealing?
I will read four statements to you. You will be asked to rate each statement on a scale of
one to five as to its ability to move you and your peers to action. One is not at all
persuasive and five is extremely persuasive. Each statement will provide facts about
prediabetes using a different persuasive technique. Each statement is based on the fact
that your overweight patients, age 45 and older (with a fasting blood glucose of 100-125
milligrams per deciliter or an A1C of 6.0-6.5) are at risk for prediabetes.
Note to moderator: Read each concept out loud and have the participants rate each
statement. Write down on a flip chart each participant’s response.

Statement one emphasizes the urgency of screening for prediabetes:
Prediabetes, if not addressed early, will develop into type 2 diabetes within
three to five years. Screen your patients now so steps can be taken to reduce
their risk of diabetes. Don’t miss this window of opportunity. There is a
diabetes prevention program in your area to help those who test positive for
prediabetes.

Statement two emphasizes the seriousness of prediabetes:
Prediabetes increases a person’s risk for heart disease, stroke, and
blindness. Screen your high-risk patients for prediabetes. There is a diabetes
prevention program in your area to help those who test positive.

Statement three emphasizes program efficacy in preventing diabetes:
The Diabetes Prevention Program study found that people with prediabetes
who completed a 16-week lifestyle intervention program were 58 percent less
likely to develop type 2 diabetes than the control group. Screen your high-risk
patients for prediabetes. There is a diabetes prevention program in your area
to help those who test positive.

Statement four presents a scientific recommendation:
The American College of Endocrinology and American Association of Clinical
Endocrinologists recommends that high-risk patients be screened for
prediabetes. Risk factors include the following: family history of diabetes;
cardiovascular disease; being overweight; sedentary lifestyle; and previously
identified impaired fasting glucose or impaired glucose tolerance.
Screen your high-risk patients for prediabetes. There is a diabetes prevention
program in your area to help those who test positive.
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January 11, 2011
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5. Do you feel as though you can make a difference in helping your patients prevent
diabetes?
6. Overall, on a scale from 1 to 10—where 1 is not at all interested and 10 is
extremely interested—how interested are you in supporting the National Diabetes
Prevention Program? SINGLE NUMBER RESPONSE.
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January 11, 2011
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APPENDIX E:
CREATIVE PIECES