Barriers to and Facilitators of Participant Engagement in a Multi-level Intervention for Type 2 Diabetes and Food Insecurity

Context: Type 2 Diabetes (T2D) impacts 35 million Americans. A considerable body of research indicates higher prevalence among racial/ethnic minorities and low-income adults. Adults with T2D often face unmet social needs, such as food insecurity, compounding the challenges associated with their engagement in disease management interventions.

Objective: To explore participants’ barriers to and facilitators of engagement in a multilevel, cross-sector clinical trial designed to address social needs and improve health-related outcomes for individuals with T2D experiencing food insecurity.

Study Design and Analysis: Semi-structured qualitative interviews (n=20) were conducted with a purposive sample of trial participants at intervention end (i.e., their 3-month endpoint visit). Interviews were transcribed and a deductive-dominant approach to thematic analysis was employed in line with a priori process evaluation constructs.

Setting: Ambulatory clinics (e.g., family medicine, general internal medicine, endocrinology) at an urban academic medical center in the Midwest.

Population Studied: Adults (≥18 years) who receive care at an affiliated clinic, screen positive for food insecurity, have a T2D diagnosis, and an A1c level > 7.5%.

Intervention: LINK is a randomized controlled 2x2 factorial trial testing the effect of 2 distinct interventions on A1c: a 6-week culinary and nutrition education class and community referrals to address unmet social needs. All participants are referred to receive free produce (“standard of care”).

Outcome Measures: Themes regarding barriers to and facilitators of engagement.

Results: Social and economic factors, such as housing instability and limited income, presented significant barriers to management of T2D and intervention engagement. Transportation and scheduling challenges also hindered engagement. Despite these barriers, participants were motivated by the opportunity to learn more about diabetes management and to support others struggling with the disease, and perceived the intervention to be impactful in shifting their behavioral awareness and A1c.

Conclusions: Despite the complex interplay of reported barriers, participants were motivated to engage in the LINK study for the sake of their own health and—notably—the health of others’. These findings may inform the strategic design and marketing of multi-level interventions like those included in LINK.