A critical realist exploration of health professionals’ perspectives on prediabetes diagnosis, management and type 2 diabetes prevention programs in a rural setting

Britney McMullen; Kerith Duncanson; David Schmidt; Clare Collins; Lesley MacDonald-Wicks

doi:10.1071/PY24214

RESEARCH ARTICLE (Open Access)

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A critical realist exploration of health professionals’ perspectives on prediabetes diagnosis, management and type 2 diabetes prevention programs in a rural setting

Britney McMullen

^A ^B ^* , Kerith Duncanson ^B ^C ^D , David Schmidt ^C ^E , Clare Collins ^D ^F Lesley MacDonald-Wicks ^F

+ Author Affiliations

- Author Affiliations

^A Mid North Coast Local Health District, Coffs Harbour, NSW 2450, Australia.

^B School of Medicine and Public Health, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia.

^C Health Education and Training Institute, NSW Health, St Leonards, NSW 2065, Australia.

^D Food and Nutrition Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW 2305, Australia.

^E School of Rural Health, University of Sydney, Dubbo, NSW 2830, Australia.

^F School of Health Sciences, College of Health Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia.

^* Correspondence to: britney.mcmullen@health.nsw.gov.au

Australian Journal of Primary Health 31, PY24214 https://doi.org/10.1071/PY24214

Submitted: 13 December 2024 Accepted: 21 July 2025 Published: 7 August 2025

© 2025 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of La Trobe University. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

Abstract

Background

People with prediabetes are at high risk of developing type 2 diabetes; therefore, diagnosing and managing this condition is critical. This qualitative study aimed to explore perspectives of health professionals with experience in prediabetes management in a rural setting about prediabetes diagnostic and management practices, to inform recommendations to improve type 2 diabetes prevention strategies and programs.

Methods

The study adopted a critical realist methodology. Nineteen health professionals from northern New South Wales, Australia, who were responsible for diagnosing and/or managing people with prediabetes were interviewed. Data were thematically analysed using a critical realist lens, then context–mechanism–outcome statements were generated and confirmed by co-authors using a discussion and reflection process.

Results

Five themes were generated from the semi-structured interviews: (1) the diagnostic dilemma; (2) care coordination and referral processes; (3) diabetes ‘waiting room’; (4) the spectrum of prediabetes management; and (5) blueprint for type 2 diabetes prevention.

Conclusions

Prediabetes is a complex condition requiring diagnosis and management by a multidisciplinary team of health professionals to delay and/or prevent progression to type 2 diabetes. Establishing clear roles and responsibilities for diagnosing and managing prediabetes, and development of strategies to improve referral to and engagement in type 2 diabetes prevention programs will improve prediabetes care and diabetes prevention in rural settings.

Keywords: barriers and enablers, critical realism, prediabetes, prevention, prevention programs, primary care, public health, rural health.

References

Australian Institute of Health and Welfare (2023) Diabetes: Australian facts. Available at https://www.aihw.gov.au/reports/diabetes/diabetes

Bell K, Shaw JE, Maple-Brown L, Ferris W, Gray S, Murfet G, Flavel R, Maynard B, Ryrie H, Pritchard B, Freeman R, Gordon BA (2020) A position statement on screening and management of prediabetes in adults in primary care in Australia. Diabetes Research and Clinical Practice 164, 108188.
| Crossref | Google Scholar |

Bhaskar R (2014) ‘The possibility of naturalism: a philosophical critique of the contemporary human sciences.’ (Routledge)

Bourke SL, Harper C, Johnson E, Green J, Anish L, Muduwa M, Jones L (2021) Health care experiences in rural, remote, and metropolitan areas of Australia. Online Journal of Rural Nursing and Health Care 21(1), 67-84.
| Crossref | Google Scholar |

Dalkin SM, Greenhalgh J, Jones D, Cunningham B, Lhussier M (2015) What’s in a mechanism? Development of a key concept in realist evaluation. Implementation Science 10, 49.
| Crossref | Google Scholar |

Ekong G, Kavookjian J (2016) Motivational interviewing and outcomes in adults with type 2 diabetes: a systematic review. Patient Education and Counseling 99(6), 944-952.
| Crossref | Google Scholar | PubMed |

Enwald HP, Kortelainen T, Leppäluoto J, Keinänen-Kiukaanniemi S, Jämsä T, Oinas-Kukkonen H, Herzig K-H, Huotari M-LA (2013) Perceptions of fear appeal and preferences for feedback in tailored health communication: an explorative study among pre-diabetic individuals. Information Research 18(3), 1-3.
| Google Scholar |

Fletcher AJ (2017) Applying critical realism in qualitative research: methodology meets method. International Journal of Social Research Methodology 20(2), 181-194.
| Crossref | Google Scholar |

Glechner A, Keuchel L, Affengruber L, Titscher V, Sommer I, Matyas N, Wagner G, Kien C, Klerings I, Gartlehner G (2018) Effects of lifestyle changes on adults with prediabetes: a systematic review and meta-analysis. Primary Care Diabetes 12(5), 393-408.
| Crossref | Google Scholar | PubMed |

Hulbert LR, Zhang X, Ng BP, Nhim K, Khan T, Cannon MJ (2022) Health care providers’ knowledge, attitudes, and practices and the association with referrals to the National diabetes prevention program lifestyle change program. American Journal of Health Promotion 36(2), 236-247.
| Crossref | Google Scholar | PubMed |

Kandula NR, Moran MR, Tang JW, O’Brien MJ (2018) Preventing diabetes in primary care: providers’ perspectives about diagnosing and treating prediabetes. Clinical Diabetes 36(1), 59-66.
| Crossref | Google Scholar | PubMed |

Koopmans E, Schiller DC (2022) Understanding causation in healthcare: an introduction to critical realism. Qualitative Health Research 32(8-9), 1207-1214.
| Crossref | Google Scholar | PubMed |

Luo H, Chen Z, Bell R, Rafferty AP, Gaskins Little NR, Winterbauer N (2020) Health literacy and health behaviors among adults with prediabetes, 2016 behavioral risk factor surveillance system. Public Health Reports® 135(4), 492-500.
| Crossref | Google Scholar | PubMed |

Mainous AG, Tanner RJ, Scuderi CB, Porter M, Carek PJ (2016) Prediabetes screening and treatment in diabetes prevention: the impact of physician attitudes. The Journal of the American Board of Family Medicine 29(6), 663-671.
| Crossref | Google Scholar | PubMed |

Mazumdar S, Bagheri N, Chong S, McRae IS, Jalaludin B, Girosi F (2021) Diabetes and the use of primary care provider services in rural, remote and metropolitan Australia. Rural and Remote Health 21(3), 5844.
| Crossref | Google Scholar |

McGowan BM, Bruun JM, Capehorn M, Pedersen SD, Pietiläinen KH, Muniraju HAK, Quiroga M, Varbo A, Lau DCW (2024) Efficacy and safety of once-weekly semaglutide 2· 4 mg versus placebo in people with obesity and prediabetes (STEP 10): a randomised, double-blind, placebo-controlled, multicentre phase 3 trial. The Lancet Diabetes & Endocrinology 12(9), 631-642.
| Crossref | Google Scholar | PubMed |

McKinlay E, Hilder J, Hood F, Morgan S, Barthow C, Gray B, Huthwaite M, Weatherall M, Crane J, Krebs J, Pullon S (2022) Uncertainty and certainty: perceptions and experiences of prediabetes in New Zealand primary care–a qualitative study. Journal of Primary Health Care 14(2), 138-145.
| Crossref | Google Scholar | PubMed |

McMullen B, Duncanson K, Schmidt D, Collins C, MacDonald-Wicks L (2023) A critical realist exploration of factors influencing engagement in diabetes prevention programs in rural settings. Australian Journal of Primary Health 29(5), 510-519.
| Crossref | Google Scholar | PubMed |

Miller VM, Davies MJ, Etherton-Beer C, McGough S, Schofield D, Jensen JF, Watson N (2020) Increasing patient activation through diabetes self-management education: outcomes of DESMOND in regional Western Australia. Patient Education and Counseling 103(4), 848-853.
| Crossref | Google Scholar | PubMed |

Montee N, Anthony N, Collet A, Franco J-M, Marimoutou C, Leruste S, Nobecourt E (2022) Knowledge, attitudes and practices regarding prediabetes among general practitioners in Reunion Island. Diabetes Epidemiology and Management 6, 100048.
| Crossref | Google Scholar |

Mullan L, Armstrong K, Job J (2023) Barriers and enablers to structured care delivery in Australian rural primary care. Australian Journal of Rural Health 31(3), 361-384.
| Crossref | Google Scholar | PubMed |

Prakoso DA, Mahendradhata Y, Istiono W (2023) Family involvement to stop the conversion of prediabetes to diabetes. Korean Journal of Family Medicine 44(6), 303-310.
| Crossref | Google Scholar | PubMed |

Rooney MR, Fang M, Ogurtsova K, Ozkan B, Echouffo-Tcheugui JB, Boyko EJ, Magliano DJ, Selvin E (2023) Global prevalence of prediabetes. Diabetes Care 46(7), 1388-1394.
| Crossref | Google Scholar | PubMed |

Ryan RM, Deci EL (2000) Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist 55(1), 68-78.
| Crossref | Google Scholar | PubMed |

Skoglund G, Nilsson BB, Olsen CF, Bergland A, Hilde G (2022) Facilitators and barriers for lifestyle change in people with prediabetes: a meta-synthesis of qualitative studies. BMC Public Health 22(1), 553.
| Crossref | Google Scholar |

Somerville M, Burch E, Ball L, Williams LT (2020) ‘I could have made those changes years earlier’: experiences and characteristics associated with receiving a prediabetes diagnosis among individuals recently diagnosed with type 2 diabetes. Family Practice 37(3), 382-389.
| Crossref | Google Scholar | PubMed |

Somerville M, Ball L, Chua D, Johnson T, Williams S, Williams LT (2021) How do healthcare providers support people with prediabetes to eat well? An in-depth, mixed-methods case study of provider practices. Australian Journal of General Practice 50(7), 497-504.
| Crossref | Google Scholar | PubMed |

Tabák AG, Herder C, Rathmann W, Brunner EJ, Kivimäki M (2012) Prediabetes: a high-risk state for diabetes development. The Lancet 379(9833), 2279-2290.
| Crossref | Google Scholar |

Teoh KW, Ng CM, Chong CW, Bell JS, Cheong WL, Lee SWH (2023) Knowledge, attitude, and practice toward pre-diabetes among the public, patients with pre-diabetes and healthcare professionals: a systematic review. BMJ Open Diabetes Research & Care 11(1), e003203.
| Crossref | Google Scholar |

Wilding JPH, Batterham RL, Calanna S, Davies M, Van Gaal LF, Lingvay I, McGowan BM, Rosenstock J, Tran MTD, Wadden TA, Wharton S, Yokote K, Zeuthen N, Kushner RF, for the STEP 1 Study Group (2021) Once-weekly semaglutide in adults with overweight or obesity. The New England Journal of Medicine 384(11), 989.
| Crossref | Google Scholar |