Type 2 diabetes prevention policy and practice: a multimethod qualitative study exploring the perspectives of patients, clinicians, and policy makers

Introduction There are broadly two approaches to type 2 diabetes prevention. ‘Population’ approaches which target structural influences, and ‘high-risk’ approaches which focus on identifying individuals at risk of type 2 diabetes and encouraging lifestyle change. There is a paucity of evidence on how people respond to pre-diabetes and evaluations of high-risk approaches have shown limited effects in women, deprived and diverse groups. Despite this, there is relatively little focus on the structural drivers of ill health. Aims To understand the impact of pre-diabetes policies from different stakeholder perspectives. Objectives 1. Explore the perspective of primary care teams; how they deliver the pre-diabetes diagnosis and manage the condition. 2. Explore what pre-diabetes means to people and how this influences their lifestyle choices. 3. Explore policymakers’ perspectives and understand why individualist health promotion policies dominate the policy agenda. Methods 1. Three focus groups with primary care practice teams. 2. In depth case studies with people diagnosed with pre-diabetes. 3. Semi-structured interviews with commissioners and policymakers. A thematic analysis was undertaken applying critical social science perspectives; Bourdieu’s Theory of Practice and Shiffman and Smith’s framework for determining political priorities to the data. Findings Pre-diabetes was largely framed as a biomedical diagnosis by all participant groups. GP practices and policymakers were tasked with individual-level monitoring with little power to address population-level influences due to the distribution of funding and power. Participants with pre-diabetes whose social-cultural backgrounds did not align with health promotion messages reported difficulties changing lifestyles. Disrupting social norms posed risks to social positioning, cultural belonging and relationship building. This risk was greater than a future type 2 diabetes risk. Structural influences determined whether participants could eat well and exercise. Conclusion Type 2 diabetes prevention strategies reflect our strongly neoliberal political context, placing the responsibility on individuals to reduce their type 2 diabetes risk with limited emphasis on addressing structural influences on health. Individuals who sustain lifestyle change, are those whose ‘habitus’ aligns with these interventions, have the capital to enact change, and live in communities which facilitate health promoting practices.