Barriers and Enablers to Maintaining Behaviour Changes Following a Lifestyle Intervention for Adults With Type 2 Diabetes

Abstract

Aim

To explore short-term barriers and enablers to maintaining behaviour changes in adults with type 2 diabetes who had completed a lifestyle behaviour change program.

Methods

Focus groups with 44 participants identified barriers and enablers at the end-of-program (n = 8 groups: anticipated); and, 1-month post-program (n = 6 groups: experienced). Thematic inductive analysis was undertaken independently by two authors, discussed, then deductively grouped according to the Capability (physical, psychological), Opportunity (physical, social), Motivation (automatic, reflective) – Behaviour (COM-B) model.

Results

Nine barriers were identified: two anticipated, one experienced, and six common to both timepoints. Key barriers related to physical capability (health ability), physical opportunity (difficulty accessing and using resources), social opportunity (unwillingness to invest in social networks), and reflective motivation (lack of internal drive). Eleven enablers were identified: all across both timepoints. Key enablers related to psychological capability (knowledge), physical opportunity (access and use of program resources), social opportunity (sense of belonging and safety within the program), automatic motivation (beliefs and awareness around perceived risk; monitoring of progress), and reflective motivation (committed to change).

Discussion

Findings suggest diabetes management programs should enable ongoing access to their resources. Investing in mechanisms to scaffold program graduates into suitable community-based activities may also be beneficial.

‘Mapping the identified themes to the COM-B model enables insights into what behaviour change approaches could be used to address the barriers’.

Background

Type 2 diabetes is a chronic condition in which the body is unable to use and/or produce insulin effectively, ¹ resulting in increased morbidity and mortality.^2,3 Globally, an estimated 537 million adults have diabetes, with projections this will reach 643 million by 2030. ⁴ In Australia, around 125 people a day are diagnosed with type 2 diabetes, and in 2021, almost 1.2 million people were living with the condition. ⁵ Age-standardised rates of type 2 diabetes in Australia are almost twice as high in those living in the lowest socioeconomic areas (5.1%) compared to the highest socioeconomic areas (2.6%). ⁵ This has led to development of both local and state strategies which aim to prevent and manage the prevalence of type 2 diabetes.

In Logan, a socioeconomically disadvantaged region in Queensland, Australia, crude rates of type 2 diabetes were recorded at 10.2% in 2018 – almost double the Queensland average of 5.6%. ⁶ The burden of disease and likelihood of dying from complications of type 2 diabetes was also much higher for those living in this area. ⁷ To address this, the Logan community health action plan was initiated, with the reduction of diabetes prevalence one of its key priority areas. ⁸ In response to these priorities, an 8-week lifestyle management program specifically for people with type 2 diabetes was developed and established. ⁹ This group-based program, delivered through an interprofessional model of allied health professionals, was developed based on the recommendations from the American Diabetes Association guidelines for facilitating behaviour change and wellbeing, ¹⁰ with nutrition, physical activity and social connection the three core pillars of the program.

One of the key factors that will impact on the success of the lifestyle management program is the extent to which participants maintain and build upon their health behaviour changes following the 8-week of supervised support. Maintenance following such diabetes self-management intervention programs is generally difficult, with declines in glycaemic management reported over time. ¹¹ However, in contrast to the evidence on the effectiveness of lifestyle programs (e.g. Ref. [11,12]), relatively little is known about barriers and enablers to maintenance, with a 2023 systematic review addressing this topic identifying only 11 articles reporting findings from 10 studies. ¹³ Through a qualitative synthesis, 28 barriers and enablers were identified across these studies. These were mapped onto five themes identified a priori: resources (e.g. competing life demands; knowledge in how to manage diabetes); environmental and social influences (e.g. weather; support from family and peers); maintenance motives (e.g. enjoyment of the self-management behaviours; identification and acceptance of the new lifestyle); self-regulation (e.g. not coping with behaviour barriers; monitoring of the behaviour by others with feedback); and, habit (e.g. making self-management behaviours a habit; conflict between existing habits and self-management recommendations). ¹³

Notably, data included in this systematic review were collected three months to three years after program completion and were primarily from studies based on retrospective accounts at a single time point. ¹³ This doesn’t necessarily capture what participants anticipate their barriers and enablers to be for maintaining change, or what the actual barriers and enablers experienced were in the short term (less than three months). Understanding short-term barriers and enablers experienced is likely important for maintaining momentum and establishing habits outside the support and accountability provided by the program. Similarly, understanding the anticipated barriers and enablers helps to determine what is most salient for participants as they transition to the post-program phase. Such information could be used to adapt programs (i.e. in the content delivered and/or the timing of when this content is delivered) to help participants problem solve these barriers and set-up these enablers prior to program completion.

Intervention development frameworks, such as the Capability, Opportunity, Motivation – Behaviour (COM-B) model ¹⁴ can help identify appropriate intervention strategies to address identified barriers and enablers. Capability refers to an individual’s physical and psychological ability to participate in an activity, including the necessary knowledge and skills to act. ¹⁴ Opportunity refers to physical and social factors outside of the individual that enable or hinder a behaviour, including environmental factors, social influences, and resources, while motivation refers to the conscious and unconscious cognitive processes that direct and drive behaviour, including habitual processes, emotional responding and analytical decision making. ¹⁴ Mapping of identified barriers and enablers to the COM-B model has been used previously, including in relation to uptake of a community-based diabetes prevention program, ¹⁵ and for maintaining healthy lifestyle changes following a diagnoses of gestational diabetes. ¹⁶ Use of COM-B in the context of anticipated and experienced barriers and enablers to maintaining behaviour change following intervention can help inform both what is working well within the intervention, as well as possible areas of intervention refinement and additional supports needed.

The aims of this qualitative study were to explore the anticipated and experienced barriers and enablers to maintaining and building on lifestyle changes following the Logan Healthy Living lifestyle management program for people with type 2 diabetes, and to subsequently map these to the domains of the COM-B model. In line with the recommendations from the systematic review, ¹³ this study also explored people’s preferences and needs regarding post-intervention support. Findings are expected to inform further program modifications – both for Logan Healthy Living and for diabetes self-management programs more broadly – to help address barriers and utilise enablers for participants to maintain behaviour change.

Methods

Study Design

This qualitative focus group study was conducted at Logan Healthy Living in Logan, Queensland. A focus group methodology was chosen for pragmatic reasons (participants attended as part of a group), as well as for the benefits of focus groups more generally, including identification of areas of consensus and diversity among participants. ¹⁷ Data are reported according to the consolidated criteria for reporting qualitative research (COREQ: see Supplemental Material 1). ¹⁸ Ethical approval for this study was granted by the Low and Negligible Risk Human Research Ethics Committee at the University of Queensland. All participants provided written, informed consent prior to enrolment.

Setting

Logan Healthy Living is an interprofessional clinic with a range of allied health services, including physiotherapy, exercise physiology, dietetics, diabetes educators, health psychology and community liaisons. It is operated by UQ Healthcare (a not-for-profit healthcare organisation) with funding from the Queensland Government through Health and Wellbeing Queensland and stakeholder support from participating organisations including The University of Queensland, Griffith University, Metro South Health, and Brisbane South Primary Health Network. It uses a student-infused model, with placement students from across the multiple allied health professions working together to provide an interdisciplinary model of care. Logan Healthy Living specialises in providing evidence-based interventions to manage and improve outcomes for individuals with various chronic diseases including type 2 diabetes. The primary offering is the lifestyle management program: a group-based lifestyle intervention providing education and supervised exercise sessions of 8 weekly 2-hour sessions. The sessions, which are grounded in the Transtheoretical model of behaviour change, ¹⁹ can be delivered by any of the allied health professionals, with behaviour change approaches used including education, goal setting, action planning, nudging and problem solving. Groups are a maximum of 10 participants, with groupings based on client availability and clinical needs (such as chronicity of diagnosis or assistance required for exercise component of program). Recharge sessions (an opportunity to reconnect and participate in follow-up assessment) are offered at 1-, 3-, 6-, 9- and 12-month post-program, with participants discharged from the service after their 12-month follow-up. Notably, the clinic location changed mid-way through data collection (February 2023) from a site on a university and hospital campus to a dedicated health and medical clinic, co-located with a transport hub and retail and food shops.

Participant Recruitment

All clients who had completed the 8-week group component of the lifestyle management program were considered eligible for this research project. Recruitment occurred at the end of the final session to understand anticipated barriers and enablers, and at the scheduled 1-month recharge follow-up to understand actual barriers and enablers experienced. Potential participants were approached by the clinic manager or clinic staff of Logan Healthy Living during their 8-week (end of program) or 1-month follow-up appointment, provided with the information sheet, and given a verbal explanation of the study by a member of the research team. All participants attending the session were approached where possible, with the selection of the group recruitment based on convenience and availability of the research team. Scheduling for the 1-month post-program assessment was based on client availability (rather than group allocation) and was driven by the service provider (rather than the research team) thus, participants were not matched across the two time points. Any participant that took part in the focus groups at both time points provided separate consent for each time point. Participants were provided with the opportunity to ask any questions and it was emphasised that participation was voluntary. Although not formally tracked, reasons for non-participation were generally based on unavailability or lack of interest.

Procedures and Data Collection

The focus groups took place on-site at Logan Healthy Living, with two members of the research team attending each of the focus groups, and the clinic manager also in attendance for most sessions. Following consent, but prior to starting the focus groups, participants were asked to complete a brief questionnaire to understand the characteristics of those taking part in terms of their age, sex, and employment. Of note is that consent was not obtained to access any data collected as part of standard service delivery of the lifestyle management program, including diabetes status and activity and nutrition levels before and following the program. To minimise participant burden, these questions were not asked again for participants taking part in this research study.

A semi-structured interview guide (Supplemental Materials 2 and 3) was then used to guide discussions, with all focus groups audio-recorded and field notes taken. The guide was developed based on key questions jointly identified by the research team and the clinic team. Questions probed on barriers and enablers relating to the three pillars of the program, namely, physical activity, nutrition, and social connection. End-of-program (EoP) questions focussed on anticipated barriers and enablers, while questions at 1-month post-program (1M-PP) asked about those experienced. Participants were also asked to comment on the use of sharing wearable (e.g. Fitbit) data and program-led social connection activities (e.g. Facebook groups; social meet-ups) as potential program-led options to support maintenance. All participants were encouraged to contribute to the conversation and non-verbal cues were used to encourage input, with interviews ranging from 24-57 minutes duration. Immediately following each focus group, the research team and clinic manager reflected on the discussions regarding common themes identified and actionable items that could be addressed as part of ongoing quality improvement. Data collection occurred from June 2022 to November 2023. Participants could take part in both focus groups; however, for pragmatic and logistical reasons, including that the 1M-PP assessment included participants from a mix of original groups (i.e. it was not just the same group from the EoP), this was not a focus of the study. Data collection continued until saturation was deemed to have been reached at both time points, as determined by the research team through the post-focus group discussions and reflections. Saturation was considered from both a data perspective and in terms of ensuring the participant sample was reflective of those that attended the Logan Healthy Living service.

Research Team

Each focus group was supervised or led by female university academics, both of whom are trained researchers (PhD) with extensive experience (>10 years) in qualitative data collection. The study was also used to upskill university students in qualitative methods, with students (undertaking a clinical exercise physiology undergraduate qualification or a medicine postgraduate qualification) included on the ethics, attending data collection, and participating in the post-focus group reflections. The lead researcher introduced themselves and the team at the start of session, including their qualifications and the aims of the research. No relationship existed between the clients and the research team prior to the study commencement; however, the senior research team do have a strong connection with Logan Healthy Living and are responsible for the evaluation of the lifestyle management program.

Data Analysis

Audio data were transcribed (https://Rev.com) then reviewed by three research members: two of whom had been involved in the interviews and one who had not. A thematic analysis process was undertaken, with analyses initially conducted independently to formulate draft themes via inductive coding, then collaboratively with other team members to refine prominent themes and subthemes related to barriers and enablers at each time point.^20,21 Reflections from the research team involved in data collection were documented and discussed with members of the team not involved in the data collection to understand potential bias. ²¹ The identified themes across the two time points were then synthesised and finalised, with participant quotes used to illustrate identified themes. Themes that were identified by multiple participants across multiple focus groups were identified as key themes. All identified themes were then deductively mapped through discussion with the team according to the domains of capability (physical, psychological), opportunity (physical, social), and motivation (automatic, reflective), in line with the COM-B model of behaviour change. ¹⁴ Participant preferences and needs in relation to suggestions about program-led post-intervention support options were also described.

Due to the anonymity of the participants, it was not possible to examine individual-level changes over time for the three participants who attended groups at both timepoints. Transcripts were not returned to participants for comment and participants did not provide feedback on the findings. However, at the conclusion of the data collection, a series of knowledge translation posters (‘you said, we listened’) were displayed within the clinic reporting on the findings and the impact on clinic operations and client experience.

Results

Eight focus groups at end-of-program and six at 1-month post-program were conducted, with a total of 44 unique participants (two to seven participants in each focus group). There was a total of 27 participants in the end-of-program groups and 20 participants in the 1-month post-program groups, with three participants taking part in both interviews. Participants were aged between 48 to 83 years (mean [SD] 66.4 [8.5] years), and there were approximately equal numbers of females (53.5%) and males (46.5%). Seven participants (16%) indicated they did some form of work, with four (9%) working full time.

The themes that were identified relating to anticipated and experienced barriers and enablers to maintaining lifestyle changes, then mapped to the COM-B components are shown in Table 1 (barriers) and Table 2 (enablers). In total, nine barriers (four key) were identified, with two anticipated only, one experienced only, and six both anticipated and experienced. A total of eleven enablers (six key) were identified, with all identified across both time points. Access and use of physical resources, particularly those available at Logan Healthy Living, was identified as both a barrier and an enabler, depending on the participants’ availability and proximity to the clinic. Further details are below.

Table 1.

Themes Identified Related to Barriers to Maintaining Health Behaviour Changes Anticipated at the End-Of-Program (EoP) and Experienced at 1-Month Post-program (1M-PP) Mapped to the COM-B Model Components.

COM-B	Themes Identified	Example Quotes
Capability
Physical	Impaired or limited physical ability (EoP, 1M-PP)	‘I can’t go swim in the pool, because I suffer with incontinence. You’re not allowed to go in the pool. There’s a lot that I can’t do’. (EoP)
Psychological	Poor mental health (EoP, 1M-PP)	‘It’s very difficult to try to keep on top of everything when loneliness sets in and you don’t want to go out’. (EoP)
	Poor behaviour regulation (EoP, 1M-PP)	‘The way I eat, that is very, very hard still to change and knowing that it takes two months to form a habit after the education here, that’s a long way away’ (EoP)
	Lack of knowledge/poor retention of knowledge (1M-PP)	‘And I’ve been very slack about actually studying enough to get my brain around it’. (1M-PP)
Opportunity
Physical	Difficulties in accessing and using resources to maintain change (EoP, 1M-PP)	‘No, I have to volunteer for dole… So, it restricts me. Like when they were saying they had extra sessions here we could come to, most of them were days that I couldn’t come’. (1M-PP)
Social	Unwillingness to invest in social networks (EoP)	‘Not inclined to get involved in social activities outside the group, or outside anywhere. Once the group’s finished. That’s it. For me anyway’. (EoP)
	Loss of support from clinic (EoP, 1M-PP)	‘Now you’ve got to go out to do it yourself without the social aspect, without the backup, without the students’ (EoP)
	Social pressure and expectations (EoP)	‘Our generation was raised where we weren’t allowed to leave anything on your plate’ (EoP)
Motivation
Reflective	Lack of internal drive (EoP, 1M-PP)	‘I’ve never been one to just be motivated to get up and do it on my own. That would be my first-step challenge, probably, keep the programme going, keep my exercise programme going’. (EoP)

EoP: End of Program. 1M-PP: One-month post-program. Note: all themes observed at both timepoints (EoP; 1M-PP), key themes are highlighted.

Table 2.

Enablers to Maintaining Health Behaviour Changes Mapped to the COM-B Model Components

COM-B	Theme Identified	Example Quote
Capabilit y
Psychological	Increased knowledge, awareness and skills	‘I know what I’ve got to do. I know what foods I’ve got to eat and what I can eat and what I can’t, and I know what structure’s there to keep the diet into place. So that’s pretty good’. (EoP)
	Maintaining healthy routines	I think when I’m organised it’s good… you have time and you do all the things (1M-PP)
Opportunity
Physical	Ability to access and use clinic resources	‘It’s cheaper here… I know the people here and I know [name] really good… They won’t let me do anything wrong. I’ve got a lot of injuries in my body’. (EoP)
	Access and use of a wide range of resources outside of the clinic	The council run community things, quite a few community things at the community hall just near the library, right next to the council chambers. (EoP)
Social	Sense of belonging and safety provided by clinic	‘I’m just talking about if you go to a normal gym and that then you get bullies there, that go to those type of gyms… the Centre sort of filters out the bullies. And it’s got nice safe environment to do what we have to do, without being harassed’. (1M-PP)
	Expanding positive social connections	‘I’ve enrolled in another gym with a friend that I made here, so it’s opened up my life hugely, both socially and physically and mentally’. (EoP)
Motivation
Automatic	Beliefs and awareness around perceived risk	‘Well, the choice is if I don’t exercise or take an interest, my health will go backwards, my knees will deteriorate, diabetes will spiral out of control, I’d go blind, lumps cut out of my toes off and things like that’ (EoP)
	Monitoring progress	‘It really is a good motivational thing to have praise and people that do show an interest’. (EoP)
	Positive self-efficacy	‘I just look at healthy all the time now. And they had a burrito bowl and I’d never had one. So I got one… and I thought "well I can do this at home." And it makes me feel happy that I’m doing the right thing with what I’m putting in. And it reflects everywhere in my life now’. (1M-PP)
	Enjoyment of self-management	‘I really, really enjoy the times that we’ve done, and that routine that we have. Knowing that coming here to meet the people and also knowing how far you’ve progressed as well’. (1M-PP)
Reflective	Committed to positive change	‘Come rain or snow, I was going to come and do something for myself today, and I’m so glad I did’. (1M-PP)

EoP: End of Program. 1M-PP: One-month post-program. Note: all themes observed at both timepoints (EoP; 1M-PP), key themes are highlighted.

Barriers to Maintaining Behaviour Change

Overall, the key themes that were identified as barriers to maintaining change were related to participants’ physical capability to undertake the activities due to their health, difficulties in accessing and using physical resources to maintain their changes, and their lack of internal motivation, with these themes identified at both time points (Table 1). At the end-of-program focus groups, there was also a general unwillingness to invest in social networks, both in the ones started during the program and outside of the program. Other barriers anticipated by some participants at the end of the program included social pressures related to expectations and cultural norms, while at 1-month, knowledge (poor retention of/lack of) was identified as an additional barrier for some participants. These themes are described further below, grouped according to the COM-B model components.

Capability Barriers

One barrier was mapped to physical capability: impaired or limited physical ability. This key barrier was identified as a common theme at both time points. Barriers noted related to the instability of their condition, injuries, fatigue, illness, and co-morbid conditions that impacted on their choice of activities and their ability and capacity to participate.

Three themes were mapped to psychological capability: poor mental health (EoP, 1M-PP); poor behavioural regulation (EoP, 1M-PP); and, lack of knowledge/poor retention of knowledge (1M-PP). In terms of poor mental health, many participants identified that they felt lonely at times, with some indicating they also battled depression. Some identified these conditions as a barrier to maintaining their self-management. Poor behavioural regulation was identified as a barrier at both time points, with some participants anticipating barriers relating to the loss of routine and accountability that had been provided by the weekly lifestyle management program, the ‘power of old, unhealthy habits’, and the time required to establish healthy habits. At 1-month, a few identified that they hadn’t yet established these healthy routines. Lack of knowledge was also identified at 1-month as barrier, with some participants stating they had found it difficult to remember all the information about self-management they had learnt during the program, though they didn’t specify which information they found difficult to retain. A few participants also mentioned difficulty finding information to inform their decision making around participation in community-based activities, which then impacted on their willingness to try new activities.

Opportunity Barriers

Difficulties in accessing and using resources to maintain change was the only barrier mapped to physical environment opportunities. Participants lives were often complex and impacted by multiple external factors including cost-of-living, housing insecurity, caring responsibilities, and work commitments. These external factors, including the instability of them, were identified at both time points as a key barrier for participants to be able to access and use resources to help them maintain changes. Some participants identified that the time they had dedicated to commit to the program over 8-week was not sustainable due to other commitments. Time constraints were particularly pertinent for those who were still working, where the relatively limited opening hours of the gym (during working hours only; initially only a few hours a week but increasing across the duration of the data collection), and the commute time required, were seen as barriers to continuing to attend regularly. Some also had caring responsibilities which impacted on their time availability. Additional barriers to accessing the resources available through Logan Healthy Living were identified at 1-month, including the costs of the open gym (relative to other options), transportation to and from the gym (both the costs and the time required), and technical failures relating to the exercise prescription mobile App used by the clinic. Financial barriers were identified as an anticipated barrier to accessing and using resources outside of the clinic at the end-of-program focus groups. These costs were considered both directly, in terms of gym attendance, and also indirectly, in terms of the transport costs to get there.

‘Plus it cost a lot of money, and you're on a pension, you don't have extra money. We are below the breadline’. (EoP)

Three of the identified barriers were mapped to opportunities relating to the social environment. A key barrier, identified only at the end-of-program focus groups, was an unwillingness to invest in a social network. Specifically, when probed about their social connections, many participants during the end-of-program interviews identified that they did not have a strong support network outside of the program, though they did not necessarily see this as a barrier. There was a general unwillingness to invest in building social connections outside of the program, despite many participants valuing these social interactions during the 8-week group program. For some, they didn’t perceive the need or value in investing in new relationships. One person did not want to make new connections as they did not want to experience any more grief of friends dying, while a few raised health concerns relating to meeting new people, given increased risk of contracting infections such as COVID.

Other barriers identified that related to social environment opportunities were loss of support from the clinic, and perceptions around social pressure and expectations. The loss of regular support and associated accountability that had been provided through the lifestyle management program (from staff, students and peers) was primarily identified as an anticipated barrier for some participants though a few also noted this reduced accountability during the 1-month groups. Social pressure and expectations were identified as an anticipated barrier for some participants, particularly around maintaining nutritional changes. Christmas was highlighted as a potentially difficult time, while others highlighted cultural norms and expectations as anticipated barriers.

Motivation Barriers

A lack of internal drive was identified at both time points, with this barrier mapped to the COM-B component of reflective motivation. Here, it was identified that some participants did not believe they had the ability, capability or internal drive to maintain change, with motivation a struggle for them. The fear of a lack of progress in their measurements was also seen as a potential barrier for a small number of participants.

‘Cause if in a month’s time my measurements are a whole lot worse, that might kill my motivation altogether. I might just go home and throw up my hands and go, “Wasn’t worth it, can’t do it.”’ (EoP)

No barriers relating to automatic motivation were identified.

Enablers for Maintaining Behaviour Change

The key themes that were identified as enablers for maintaining behaviour change were: the ongoing ease of access and use of the clinic resources; the sense of belonging and safety provided by clinic; the beliefs and awareness around the perceived risk (on health; on finances) for not maintaining the changes; monitoring progress; increased knowledge, awareness and skills; and, commitment to positive change. Other enablers were: maintaining healthy routines; access to and use of a wide range of resources and supports outside of the clinic; expanding positive social connections; positive self-efficacy; and, enjoyment of self-management. All eleven enablers were identified at both time points.

Capability Enablers

In terms of psychological capability, the knowledge, awareness and skills participants had gained through the program was identified as a key enabler for maintaining change. Participants felt they had the knowledge and skills in self-management as well as the confidence to make sustainable and informed choices. They were able to apply the knowledge they had gained in the program throughout their daily life, empowering their self-management. Creating and maintaining a healthy routine through, for example, embedding incidental activity into the day and doing preferred activities was also identified as an enabler for maintaining changes. At one month, many participants had established a routine of attending the open gym available at Logan Healthy Living on at least a weekly basis. No enablers relating to physical capability were identified.

Opportunity Enablers

In terms of physical opportunity, the ongoing ability to access and use the clinic resources at Logan Healthy Living (open gym, exercise prescription mobile App, health professionals) was a critical enabler for maintaining change. The high level of care provided by the Logan Healthy Living clinicians and clinical placement students was noted by some participants in reference to the perceived lack of care or time provided by their general practitioner. They appreciated the time and attention they received at the clinic and credited that to their ongoing success in maintaining their diet and physical activity changes. Some also highlighted the program was affordable and accessible, as well as flexible to their scheduling needs. A few also noted that the resistance training equipment at the clinic (which would automatically adjust load for the participant) to be an enabler as they didn’t have to remember how to adjust the weights. At one month, some participants highlighted the exercise prescription mobile App provided by the clinic as an enabler for maintaining their physical activity changes, noting the prompts to be a good reminder to do their exercises as well as continue their activities outside of the clinic gym. Another enabler related to physical opportunity was the access and use of several other resources beyond those provided by the clinic, which were identified by participants as an important facilitator to help them maintain change. These included: taking part in local and affordable community activities; using free gym equipment in parks; doing their physical activity in a shopping centre (where it was unaffected by weather and mentally stimulating); accessing the exercise classes and facilities (e.g. pool) where they were living; using government-funded transport options; and using technology such as wearables and Apps. Some participants also acknowledged time as a resource now available to them.

A key enabler relating to social environment opportunities was the sense of belonging and safety provided had at Logan Healthy Living. For some, it was one of their few/only social connections and was seen to help combat feelings of isolation and loneliness that many participants experienced.

‘I live on my own, a pretty quiet lifestyle. My grandchildren, all the family live in [X]. And they all work, so I don't get to see them all that much. So this is my home, this is the only activity I have, is coming here’. (1M-PP)

Participants found the clinic to be a safe and trusted environment. Many had complex health needs and highlighted the access to the expertise available at Logan Healthy Living (something they observed wasn’t available in other gyms) as an enabler for them to continue to exercise. Many participants commented on the non-judgemental, caring and positive supportive environment at Logan Healthy Living, where they felt safe and understood by both staff and other participants. This was in contrast to their actual and/or perceived experience of commercial gyms where they felt out of place and uncomfortable. Another theme identified related to social environment opportunities was expanding positive social connections. Reducing feelings of loneliness and isolation was a key driver for some participants to make new connections. Some participants had also invested in building new connections beyond the program, including socially and through the community. This included walking groups in the neighbourhood, hosting exercise sessions in the pool, and taking part in community events.

Motivation Enablers

Two key enabling themes identified that were mapped to automatic motivation were beliefs and awareness around perceived risk and monitoring progress. Specifically, an increased awareness and ownership of the consequences of their health condition, both health and financial, was a strong motivator for maintaining and building change for many participants. Similarly, the repeated measurement of health outcomes, and associated tracking and feedback of progress provided as part of the program and follow-up, was identified as a strong enabler for maintenance for many participants. At 1-month participants were further motivated by the progress they had made since program completion as these changes were considered to have been made on their own without the more intense support provided by the program. Other enabling themes identified by some participants that mapped to automatic motivation were: positive self-efficacy, where participants expressed confidence in their ability to self-manage their condition and saw this as an enabler to help them maintain and build on the changes they had achieved; and, enjoyment of the activities and feeling rewarded and encouraged to continue by the Logan Healthy Living community.

One enabling theme was mapped to reflective motivation, which was committed to positive change. The deliberate prioritisation of self-management (for some, the first time they had prioritised their own health) and committing to the changes through setting goals and action plans, was identified as an important enabler for maintaining changes. Participants expressed a strong desire to maintain their health and remain independent.

Feedback on Potential Program-Led Options to Support Maintenance

Wearable Devices

The research team explored the concept with participants of providing a wearable device (e.g. Fitbit) as part of the program, with participants sharing their activity data with the clinical team to enable ongoing, tailored support following the program. Many participants already owned a wearable and used it for self-monitoring. Some expressed initial hesitancy, with data privacy concerns and a fear of negative feedback from the clinical team (if not meeting goals). However, when the opportunity was posed as a way to allow the clinic team to check-in and celebrate successes, the feedback was generally supportive of the concept, with some viewing it as a way to maintain accountability.

Facebook

Participants were generally receptive of using the Logan Healthy Living Facebook page to increase social connection but did not see the need for a page specific for their group. Many were comfortable in sharing their accomplishments through Facebook if used appropriately. Relatively few were currently active with the existing Facebook page. Desire was expressed for more educational and motivational material on the Facebook pages.

Other options suggested to increase social connections, such as organised walking groups and coffee catch-ups were generally dismissed by participants. However, there were suggestions for a more active role from the clinic in helping participants engage with the community, including in helping participants understand whether the activities offered within the community were suitable. Participants were also supportive of a monthly email from the clinical team.

Discussion

This study explored the anticipated and experienced barriers and enablers to maintaining and building on lifestyle changes following the Logan Healthy Living lifestyle management program for type 2 diabetes, as well as potential program-led options to support maintenance. Overall, nine barriers and eleven enablers were identified, with these then mapped onto the COM-B model. The strongest enabler that was identified across the focus groups at both time points related to the opportunities (both physical and social) provided by Logan Healthy Living. Many participants had strong internal motivation and were committed to maintaining their changes. For most, the clinic was a place of safety, trust and belonging: a feeling some hadn’t experienced from other gyms and/or health services. The key barriers primarily related to external barriers to achieving these desired changes, including health, time and financial constraints. Collectively, these findings highlight the importance of having a flexible and low cost/no cost mechanism for clients to continue to access resources beyond the formal duration of the program.

In general, the barriers and enablers observed in this study were similar to those identified through the systematic review by Carvalho and colleagues. ¹³ The current study adds to this literature by examining both anticipated barriers and enablers, as well as those experienced in the short term. Common barriers to this study and the review included those related to self-regulation, resource access, social influences, competing demands and concurrent health problems. Common enablers were access to appropriate and affordable support post-intervention (both physical and social), habit formation, and fear of negative health outcomes (named in the current study as beliefs and awareness around perceived risk). Unlike findings from the review, ¹³ barriers related to weather were only mentioned by a few participants (likely reflective of the temperate climate in which the data were collected).

A novel finding from this study was the unwillingness of many participants to invest in building their social support network at the end of the intervention, despite acknowledging that they enjoyed and valued the social support experienced during the program. Notably, this theme was not identified at the 1-month focus groups. Although unable to be determined given the anonymity of respondents, this is potentially because those who were unwilling to expand their social networks did not return for their 1-month follow-up. For those with chronic disease, having strong and varied social networks, including connections to community and volunteer groups, has been shown to support self-management ability (including maintenance of behaviour over time) and better physical and mental wellbeing. ²² Conversely, loneliness increases risk of morbidity and all-cause mortality. ²³ Given that social connection is one of the three core pillars of the lifestyle management program, the focus groups also sought participant feedback and suggestions on a range of possible clinic-led options to support ongoing connections. Participants were generally receptive to using clinic-led social media sites (such as Facebook) to increase connection. They also suggested the page could include educational material (which could help to address the knowledge barrier identified by some participants at one month) and motivational material (which could help address barriers relating to low internal drive). It was also suggested that the clinic could more actively link participants into suitable community activities, and Logan Healthy Living is now exploring the possibilities of investing in a social prescribing community link worker. Investing in resources to explicitly support social prescribing may not only enhance social connections, but also help scaffold program participants to maintain their self-management outside of the clinic setting (thus freeing up limited resources for new participants).

Some factors were identified as both barriers and enablers, in particular, the ability to access and use the clinic resources and monitoring of progress. While most found the ongoing access to the clinic resources to be a key enabler, the limited opening hours (relative to gyms open 24/7), the location, and the costs were seen as barriers for some. Similarly, while most found the measurement and ongoing monitoring provided by the clinic a motivator, for others the fear of failure and of letting people down was seen as potentially de-motivating. Knowledge was primarily seen as an enabler; however, some participants highlighted that they couldn’t remember all the information provided through the program. Collectively, this highlights the need for an individualised approach for maintenance support, which includes understanding of how participant needs may change over time.

Mapping the identified themes to the COM-B model enables insights into what behaviour change approaches could be used to address the barriers. For example, to address the barrier regarding physical capability, participants can access the expertise at the clinic to guide them on how to modify their activities. Given this resource is already available, the intervention might be raising awareness of this opportunity. Though most themes could be categorised according to a sub-component of the COM-B model, some were a mix of the elements. For example, some of the enablers to maintain behaviour were due to social opportunities, while psychological capability impacted on capacity to take part in the opportunities available. This reflects the hypothesised interactions and feedback loops between the components of the model, where opportunity and capability can influence motivation, and behaviour can alter motivation, capability and opportunity. ¹⁴ Notably, due to the anonymity of responses within the group (as well as across time), we were unable to unpack if and how these various components were interacting with each other. For example, unless it was within a single quote, we did not know how physical capability impacted on a participants’ access to the opportunities (both physical and social). Future research tracking individuals across time will help to further elucidate these interactions and their impact on maintenance. The five scheduled follow-up assessments following the lifestyle management program (1-, 3-, 6-, 9-, 12-month post intervention) provides an ideal opportunity to achieve this. These scheduled appointments will also help understand the stability of perceived barriers and enablers over time. Further, these check-ins provide the opportunity for tailoring of maintenance support; noting that this opportunity is currently only available for those that can attend these check-ins.

Key strengths of this study are the collection of data at two time points. This enabled understanding of what participants anticipated to be barriers and enablers, as well as their actual experiences, providing insights into the stability of these factors over time. Given that participants took part in the focus groups immediately following an action planning session on how to identify barriers and enablers and problem solve barriers, the data collected also provides insights into the salience of these discussions. Such information will help inform refinements to the program sessions. A key limitation is the generalisability of the findings, with participants recruited from a single clinic. However, it is important to consider barriers and enablers unique to a community for effective delivery and incorporation into participants’ diabetes management strategies. ²⁴ Notably, Logan is highly ethnically and culturally diverse; however, although shown to be relevant for understanding adherence, ²⁵ these factors were not captured in the context of these anonymous focus groups. Future research, using one-on-one interviews, could explore the impact of ethnicity and culture on barriers and enablers to maintenance in this community.

Another limitation was that the 1-month group was recruited from those participants who attended the follow-up session. This is likely to miss people who are experiencing significant barriers to attending. As all data collection occurred during work hours, it is also likely to bias recruitment to those no longer working, as evidenced by only seven (of 44) participants currently employed. In a similar study from Finland, work related factors including stress, fatigue and lack of time was indicated as a significant barrier to adherence to lifestyle changes. ²⁶ Future research could deliberately recruit those with these additional time barriers (i.e. work; caring commitments) to understand barriers and enablers in this group. The presence of the clinic manager in the focus groups may have influenced responses. Similarly, two of the study team are involved in the broader evaluation of the lifestyle management program, which may have impacted on their analyses. To minimise these potential impacts, coding was done independently by two coders, with generated themes then discussed and resolved with a third coder not involved in the program evaluation, as well as with the broader team (not including the clinic manager). As the recruitment was reliant on scheduling organised by the service delivery provider, the study did not deliberately try and recruit the same participants at each time point, with only three (of 44) participants taking part at both time points. Findings from the two timepoints should be interpreted in this context, rather than considered as within-person changes. Future research could use individual interviews, and the scheduled follow-up assessment points, to understand individual-level changes in barriers and enablers across time.

Conclusions

In conclusion, findings from these focus groups highlight the importance of enabling ongoing connection to the resources and supports provided by lifestyle management programs to help participants maintain and build upon their behaviour changes. Deliberate investment in building and maintaining social connections is likely required.

Ethical Statement

Ethical Approval

Ethical approval for this study was granted by the Low and Negligible Risk Human Research Ethics Committee at the University of Queensland on the 8^th August, 2022 (2022/HE000671).

ORCID iDs

Genevieve N. Healy https://orcid.org/0000-0001-7093-7892

Lucy Campbell https://orcid.org/0009-0008-2230-9718