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

Introduction

Globally, an estimated 298 million people have prediabetes, a condition characterised by elevated blood glucose levels, yet not sufficiently raised to be classified as type 2 diabetes mellitus (T2DM) (Rooney et al. 2023). Although prediabetes increases the risk of developing T2DM, cardiovascular disease and stroke, nearly 90% of people with prediabetes (PWP) are unaware they have the condition (Prakoso et al. 2023). Without lifestyle changes, PWP are at high risk of developing T2DM, with 5–10% expected to develop the condition within a year, and 33% within a decade (Tabák et al. 2012; Bell et al. 2020). The global prevalence of prediabetes is rising, with projections estimating >470 million people will have the condition by 2030 (Tabák et al. 2012). In Australia, approximately 16.4% of adults have prediabetes and 4.6% have T2DM (Australian Institute of Health and Welfare 2023). In rural areas, people are 1.3 times more likely to develop T2DM, and face a mortality rate 2.2 times as high as those living in urban areas (Australian Institute of Health and Welfare 2023). With T2DM costing the Australian healthcare system an estimated A$3.4 billion per year, T2DM is a burden to individuals and healthcare systems alike, requiring ongoing medical care, and complications leading to hospitalisations and reduced quality of life (Australian Institute of Health and Welfare 2023). Given the burden of T2DM, early detection and intervention at the prediabetes stage is crucial to prevent and/or delay progression to T2DM.

General practitioners (GPs) are the primary health professionals who diagnose prediabetes. Diagnosis involves a fasting venous blood test to identify whether fasting glucose is elevated (5.6–6.9 mmol/L), an oral glucose tolerance test to identify impaired glucose tolerance (7.8–11.0 mmol/L) and/or a glycated haemoglobin test (5.7–6.4%; Bell et al. 2020). Prediabetes is a critical stage whereby lifestyle intervention can prevent and/or delay progression to T2DM. Managing prediabetes involves adopting the same lifestyle modifications recommended for people with T2DM, including improved diet, regular physical activity and reducing current weight status (Bell et al. 2020). Adherence to the Australian Dietary Guidelines is advised, and engagement in at least 210 min of moderate-intensity exercise or 125 min of vigorous-intensity exercise per week, incorporating both aerobic and resistance training, is recommended (Bell et al. 2020). Currently, no medications are approved by the Therapeutic Goods Administration for prediabetes management in Australia (Bell et al. 2020). However, medical management of prediabetes is evolving rapidly, with glucagon-like peptide-1 receptor agonists resulting in substantial, sustained weight loss, supporting individuals with obesity and prediabetes to achieve reversion to normoglycaemia (McGowan et al. 2024). T2DM prevention programs aimed at improving diet, increasing physical activity and reducing weight play an important role in concurrent, sustainable lifestyle changes. A systematic review and meta-analysis by Glechner et al. (2018), comprising 22 randomised controlled trials involving 9796 PWP, examined the efficacy of lifestyle interventions that targeted diet, physical activity and weight reduction on preventing and/or delaying progression to T2DM. Risk of developing T2DM reduced by 36% after 1 year and 54% after 3 years (Glechner et al. 2018).

GPs, nurses and allied health professionals are crucial in the diagnosis and management of prediabetes; however, gaps in knowledge and underutilisation of T2DM prevention programs are common. A systematic review that explored PWP and health professionals’ knowledge, attitudes and practices towards prediabetes found health professionals had poor knowledge about prediabetes, with between 2.8% and 42% correctly identifying the diagnostic criteria and risk factors for prediabetes. Furthermore, <36% of the health professionals considered referring their patients to T2DM prevention programs (Teoh et al. 2023). These findings highlight the need for increased education, guidance and support for health professionals to screen, diagnose, manage and refer PWP before they progress to T2DM.

In a previous study, we explored the perspectives of PWP in northern New South Wales (NNSW) to better understand knowledge, attitudes and perceptions about prediabetes and engagement in T2DM prevention programs. The findings highlighted a range of barriers and enablers that influenced program engagement and behaviour change, illustrating the complex nature of prediabetes diagnosis and management, and T2DM prevention in a rural setting (McMullen et al. 2023). This study recommended further research exploring rural health professionals’ perspectives about prediabetes. Despite the high prevalence of prediabetes, limited research exists on how rural health professionals diagnose and manage the condition, and whether prediabetes management differs compared with metropolitan areas. This study seeks to address that gap by exploring rural health professionals’ perspectives on prediabetes diagnosis, management, and ways to improve referral to, and engagement in, T2DM prevention programs. The findings will inform diagnostic and management practices, and recommendations to strengthen T2DM prevention programs in rural areas.

Methods

Results

A total of 74 clinicians were invited to participate in the study. Of these, 21 initially agreed to participate, but two later declined. Semi-structured interviews were conducted with 19 health professionals (14 female and five male), including five dietitians, five exercise physiologists, three GPs, three pharmacists, two clinical nurse specialists and one practice nurse. Four participants were also diabetes educators. Most (16/19) participants had >10 years clinical experience. Seven participants worked in the public health sector, 11 were employed in the private sector and one worked across both sectors. Most participants (17/19 and 16/19) reported between 0–10 prediabetes consults per month and 0–40 diabetes consults per month, respectively. During these consults, more participants reported spending a higher percentage of time (≥50%) focusing on diabetes (14/19) compared with prediabetes (8/19) (see Table 1). Five themes and six CMO statements were generated, as shown in Table 2.

Discussion

Using a critical realist approach, this study described health professionals’ perspectives on the diagnosis and management of prediabetes, and the factors influencing referral to, and engagement in, T2DM prevention programs in a rural setting. The five themes generated from semi-structured interviews with health professionals were: (1) the diagnostic dilemma; (2) care coordination and referral processes; (3) diabetes ‘waiting room’; (4) the spectrum of prediabetes management; and (5) blueprint for T2DM prevention. Based on these findings, six CMO statements were synthesised, which informed the structure of the following discussion. These statements highlight how specific contexts (C) interact with underlying mechanisms (M) to produce particular outcomes (O), and provide a deeper understanding of the complexity surrounding prediabetes diagnosis, management and T2DM prevention.

The first CMO statement highlights the lack of role clarity in the diagnosis and management of prediabetes. For health professionals in public and primary healthcare settings in NNSW (C), lack of clarity surrounding roles and responsibilities in the diagnosis and management of prediabetes (M), including inconsistent use of diagnostic practices, leads to missed opportunities for early intervention, and confusion among PWP about their condition (O). This finding is consistent with descriptions by PWP in the same rural setting who reported GPs either did not specifically diagnose prediabetes or provided unclear diagnoses with limited guidance, information or referrals (McMullen et al. 2023). Clear and consistent diagnosis of prediabetes by GPs is important and valued. A study by Somerville et al. (2020) highlighted people with T2DM would have preferred to be made aware of their prediabetes diagnosis sooner, allowing time to make proactive lifestyle changes (Somerville et al. 2020). GPs play an important and influential role in screening, diagnosing and referring PWP to prevention programs.

It is important to consider the generalist nature of rural practice, where health professionals manage a broad range of conditions, and prediabetes is less frequently the primary diagnosis or reason for referral compared with other chronic diseases. This may contribute to the low prioritisation of prediabetes diagnosis and management observed among GPs. Although barriers to healthcare access in rural areas compared with metropolitan areas are well-documented (Mullan et al. 2023), these challenges are also common across other chronic diseases and risk factors (Mazumdar et al. 2021). The striking, consistently reported and differentiating factor with prediabetes was the extent to which it was not addressed as directly or consistently as it could be, highlighting an important opportunity for change in both clinical practice and policy. In our current study most health professionals felt it was the GP’s role to diagnose prediabetes; however, one GP did not consider prediabetes a diagnosable condition. The variability of attitudes towards prediabetes and how this impacts motivation to diagnose and manage the condition was evident in a study by Kandula et al. (2018). Of 15 primary care providers interviewed, approximately 50% viewed prediabetes diagnosis as an opportunity to educate and motivate patients. The remainder of participants felt it was a waste of time or were wary of diagnosing prediabetes in the presence of other health conditions (Kandula et al. 2018). Furthermore, a quantitative study that surveyed 1248 physicians in the US to determine the relationship between attitudes towards prediabetes and screening or treatment practices, found physicians with a positive attitude were more likely to follow recommended guidelines for screening, diagnosing and managing prediabetes (Mainous et al. 2016).

The perception that prediabetes is less serious than T2DM and other chronic conditions leads to unclear or inconsistent approaches to diagnosis and treatment. Our findings reiterate McKinlay et al. (2022), who reported GPs and nurses did not perceive prediabetes to be a priority compared to other health conditions, and trivialised or did not provide a diagnosis (McKinlay et al. 2022). Low prioritisation of prediabetes leads to a cycle where it is unclearly diagnosed, ineffectively communicated with patients and not managed with the urgency it requires. To improve early detection and management of prediabetes, it needs to be recognised and managed as an independent, priority health condition.

The second CMO statement addresses the impact of perceived urgency and prioritisation of prediabetes. Perceived lower urgency and low prioritisation of prediabetes diagnosis and management (M) among health professionals in primary care settings in NNSW (C) leads to prediabetes being overlooked until it progresses to T2DM (O). Public health diabetes services in NNSW do not accept referrals for prediabetes due to large volumes of referrals for type 1 and 2 diabetes. Therefore, prediabetes is predominantly managed in the primary care sector.

In Australia, CDMPs are provided by GPs for people with chronic conditions to access five Medicare-subsidised sessions with an allied health professional per year. Notably, prediabetes is not listed as a chronic condition under CDMPs, which impacts health professionals’ ability to effectively manage prediabetes and PWP to access affordable allied health services. If PWP are allocated a CDMP, it is usually for coexisting chronic conditions. These barriers are consistent with another study by Somerville et al. (2021), whereby PWP did not qualify for a CDMP without comorbidities. This was considered to minimise the seriousness of prediabetes, and make it challenging for primary care providers to offer subsidised early intervention. Prediabetes is an under-recognised and under-prioritised condition across both metropolitan and rural contexts (Teoh et al. 2023). However, these issues are likely compounded in rural areas, where healthcare disparities, such as reduced service availability, workforce shortages and limited access to specialist care, further exacerbate challenges in the diagnosis and management of prediabetes (Mazumdar et al. 2021). Listing prediabetes as an eligible condition for CDMPs would increase its recognition as an important, standalone condition, and support primary care providers to efficiently and effectively refer PWP to affordable allied health services for earlier, structured intervention.

The third CMO statement highlights the importance of multidisciplinary collaboration in the management of prediabetes. For health professionals in public and primary care settings in NNSW (C), working collaboratively to manage prediabetes (M) leads to increased adoption of lifestyle changes among PWP (O). Although management approaches varied somewhat between health professions, most reported using similar treatment approaches for both prediabetes and T2DM, which aligns with current recommendations (Bell et al. 2020). Some allied health professionals felt frustrated that GPs prioritised prescribing medications, such as glucagon-like peptide-1 receptor agonists, to manage overweight before encouraging PWP to make lifestyle changes. These medications can be effective for weight loss (McGowan et al. 2024); however, medication combined with lifestyle changes results in sustained weight loss (Wilding et al. 2021). Support for PWP to make lifestyle changes requires a collaborative approach whereby multidisciplinary health professionals work as a team to provide specific expertise and holistic care (Bell et al. 2020). Consistent across multiple studies, health professionals play an important role in assisting PWP to make lifestyle changes by providing education, guidance, behaviour change counselling and support. For example, a systematic review that synthesised facilitators and barriers for lifestyle change in PWP highlighted most participants reported healthcare professionals played a key role in encouraging and supporting lifestyle change due to increased trust and accountability (Skoglund et al. 2022). This highlights the importance of health professionals motivating and educating PWP to make lifestyle changes. However, it is common for PWP to have low health literacy levels and consequently limited understanding of their condition and how to manage it, which was reported by health professionals in this study and others (Luo et al. 2020).

The fourth CMO statement focuses on the role of person-centred care in supporting behaviour change among PWP. When health professionals in public and primary care settings in NNSW (C) adopt a person-centred approach (M), long-term behaviour change is more likely to occur (O). A key motivator for behaviour change identified by health professionals in this current study was fear of developing T2DM and other complications, which is common among PWP (McMullen et al. 2023). Providing health information to educate PWP about their condition, including how to manage it and risk of developing T2DM, plays an important role in initiating behaviour change. However, the way in which this information is delivered and framed can impact motivation to change (Enwald et al. 2013). Being diagnosed with prediabetes can be distressing and fear inducing, which can motivate change; however, according to self-determination theory, motivation arising from fear is less likely to result in long-term behaviour change (Ryan and Deci 2000). Training in motivational interviewing for health professionals who manage PWP and adopting a person-centred approach are effective strategies to enhance patient engagement and promote long-term behaviour change (Ekong and Kavookjian 2016).

The fifth CMO statement focuses on how awareness of referral pathways enhances care coordination for prediabetes. For health professionals in NNSW (C), increased awareness of referral pathways (M) will lead to more consistent referrals of PWP to allied health professionals and T2DM prevention programs (O). Allied health professionals in the current study received low levels of referrals from GPs for prediabetes compared with T2DM. Furthermore, when referrals were made, important information was often missing, such as pathology results, which made efficient management of prediabetes challenging. These findings are consistent with Montee et al. (2022), who surveyed 121 GPs from Reunion Island to better understand their knowledge, attitudes and practices towards prediabetes care, and found only 19% of GPs referred PWP to a dietitian. Although participants rarely discussed rurality explicitly, the limitations they described, such as a lack of access to programs specifically for PWP in their region, reflect challenges commonly experienced in rural settings (Bourke et al. 2021). Despite the known effectiveness of existing T2DM prevention programs, health professionals in the current study reported low awareness of and referrals to T2DM prevention programs. Nearly all health professionals interviewed were unaware of existing T2DM prevention programs, and consequently did not refer.

Low referral rates of PWP to T2DM prevention programs is a common issue exacerbated due to unclear referral processes, limited time during consultations and uncertainty about program effectiveness. In a cross-sectional study with 1503 health professionals, only 15.2% referred PWP to the National Diabetes Prevention Program; however, health professionals were 36% more likely to make referrals when they were familiar with the program, and 49.1% more likely to refer when they knew the program’s availability (Hulbert et al. 2022). Therefore, increased awareness of existing programs through promotion, education and information on program availability is essential.

The final CMO statement highlights key factors that influence referral to, and engagement in, T2DM prevention programs. In NNSW (C), PWP are more likely to be referred to and engage with diabetes prevention programs (O) when these programs are free or low-cost, culturally appropriate, flexible, group-based, regularly promoted, led by multidisciplinary health professionals and incentivised (M), addressing key barriers around cost, accessibility and relevance. There are examples of effective established programs for other health conditions to serve as models. For example, the Good Living with Osteoarthritis is an education and exercise program for people with hip and/or knee osteoarthritis that effectively reduces pain intensity, and improves knee and health-related quality of life. Similarly, Diabetes Education and Self-Management for Ongoing and Newly Diagnosed is a free or low-cost group education program for people with T2DM that is delivered by a multidisciplinary team of health professionals. It flexibly offers a single full-day session or shorter self-paced sessions, both face-to-face and online, adopts a person-centred approach and encourages friends or family to attend to boost social support. In a study by Miller et al. (2020), 233 participants attended a Diabetes Education and Self-Management for Ongoing and Newly Diagnosed program in regional Western Australia, and reported enhancements in their skills, knowledge and confidence to self-manage T2DM (Miller et al. 2020). This demonstrates the feasibility and viability of implementing well-designed T2DM prevention programs. It also highlights the need for PWP to have access to T2DM management programs given the similar management guidelines for both conditions.

Implications

Conclusion

Prediabetes is a serious and complex condition, but currently lacks consistent diagnosis or management by a collaborative, multidisciplinary team of health professionals. Improved consensus around health professionals’ roles and responsibilities in diagnosing and managing prediabetes are needed, but will rely on advocacy for prediabetes to be listed as a qualifying condition in CDMPs. T2DM prevention programs are effective in delaying and/or preventing progression to T2DM, so a concerted and collaborative effort to enhance and promote these programs is vital. Improved resourcing for multidisciplinary health professionals to optimally manage PWP, in parallel to enhancement of group-based prevention programs, will improve prediabetes care and outcomes in rural settings.

Supplementary material

Supplementary material is available online.