JMIR Publications

ABSTRACT

Background:

Chinese Americans experience a high prevalence of prediabetes and face barriers to engaging in diabetes prevention programs. In 2023-2024, we conducted a pilot randomized controlled trial of the Integrating Cultural Aspects into Diabetes Education (INCLUDE) program, a culturally and linguistically tailored mobile health (mHealth) diabetes prevention intervention among Chinese Americans at risk for diabetes in New York City.

Objective:

This qualitative study aimed to identify barriers and facilitators to engagement in the INCLUDE program.

Methods:

As part of the INCLUDE trial, we conducted post-intervention interviews with 25 participants from the intervention arm at the 3-month follow-up (end of intervention) between February and December 2024. Participants completed either focus groups (4 groups; n=20; 4-7 participants per group) or one-on-one in-depth interviews (n=5). Semi-structured interviews explored participants’ perceptions of INCLUDE, barriers and facilitators to engagement, and recommendations for improvement. Interviews were audio-recorded, transcribed verbatim, and coded by three team members using a combined deductive and inductive thematic approach.

Results:

Participants had a mean age of 53.6 years (SD 12.3). Most were women (20/25; 80%) and reported speaking English less than very well (24/25; 96%). Approximately half had less than a high school education (14/25; 56%) and annual household income below US $25,000 (12/25; 48%). Six major facilitators of engagement were identified. Participant-level facilitators included: (1) motivation to prevent diabetes, (2) trust in community organizations, and (3) perceived gains from participation, such as increased knowledge, skills, confidence, and improvements in health behaviors and outcomes. Intervention-level facilitators included: (4) culturally and linguistically concordant content, (5) accessibility through digital delivery, and (6) personalized guidance and human support through community health worker coaching calls. Three primary barriers were identified: (1) time constraints limiting participation in coaching calls, (2) unmet needs related to produce delivery, including freshness, cultural relevance, and pick-up logistics, and (3) insufficient support for translating knowledge into sustained behavior change. Participants provided recommendations to strengthen the program, including more actionable dietary guidance, additional home-based physical activity options, shorter or alternative coaching formats, and more flexible, tailored produce delivery approaches.

Conclusions:

INCLUDE was well received among Chinese Americans at risk for diabetes. Engagement was supported by culturally tailored content, accessible digital delivery, personalized guidance and human support, and recruitment through trusted community partnerships. Future research should focus on addressing identified barriers to optimize diabetes prevention efforts and promote engagement in this underserved population. Clinical Trial: ClinicalTrials.gov NCT05492916; https://clinicaltrials.gov/study/NCT05492916