Screening, diagnosing and management of Pacific peoples with prediabetes in New Zealand primary healthcare clinics with high concentrations of Pacific peoples: an online survey
Julienne Faletau
A,*, Rosie Dobson
B, Vili Nosa
Band Judith McCool
AABSTRACT
Introduction. Prediabetes is a condition of elevated blood sugar levels which can increase the risk of type 2 diabetes (T2D) if not managed effectively. Prediabetes is likely to affect about 24.6% of New Zealand (NZ) adults, with estimates of 29% of the Pacific population currently living with the condition.
A prediabetes diagnosis is an opportunity for intervention from trusted primary care providers. The study aim was to describe primary healthcare clinician’s knowledge and practice regarding screening, diagnosing and management of prediabetes in Pacific patients. Methods. An online survey was conducted with current practicing primary healthcare clinicians between February and April 2021.
Eligible participants included clinicians employed in a primary healthcare clinic with over 50% of enrolled patients identified as Pacific. Results. Primary healthcare clinicians (n = 30) reported that their prediabetes screening, diagnosis and management were aligned with the NZ Ministry of Health clinical guidelines. The most common factors that prompted screening was a family history of T2D (25/30, 83%), ethnicity (24/30, 80%) weight and BMI (24/30, 80%). The initial management practices involved providing recommendations for dietary changes and physical activity (28/30, 93%) and referring patients to a diabetes prevention lifestyle change programme (16/30, 53%). Discussion. Primary healthcare clinicians are the foremost point of engagement with patients and their fāmili (family) in their health journey. Culturally appropriate tools could be useful to assist healthcare providers to communicate to a higher risk population and most clinicians rely on up to date guidelines for screening and management.
Keywords: diagnosis, management, pacific, prediabetes, primary health care, risk, screening, type 2 diabetes.
Introduction
Prediabetes is a condition of elevated blood sugar levels (HbA1c 41–49 mmol mol–1), which can increase the risk of type 2 diabetes (T2D) if not managed effectively.1,2 Prediabetes affects about 24.6% of all adults in Aotearoa New Zealand (NZ) and 29.8% of Pacific peoples.3 It is estimated that in the Auckland region alone, over 40%
of people of Māori, Pacific or Indian ethnicity aged 35–39 years have prediabetes.4,5 Pacific people who are socioeconomically disadvantaged carry a disproportionate burden of T2D. Furthermore, the increasing incidence of early onset of T2D is putting more Pacific people at risk of complications and early mortality.5–8
As the first point of contact with the healthcare system, primary care providers play a vital role influencing the trajectory of risk for people living with prediabetes.9 Primary healthcare clinicians are well placed to not only to screen people at high risk but to lead conversations and communications around diabetes ‘risk’ in ways that are culturally meaningful. The window of opportunity provided during consultations can be pivotal in a patient’s journey to making changes to reduce their risk of developing debilitating T2D.
The aim of this study was to explore primary healthcare professionals’ working with Pacific patients knowledge and practice regarding screening, diagnosing and manage- ment of prediabetes.
For full list of author affiliations and declarations see end of paper
*Correspondence to:
Julienne Faletau
Epidemiology and Biostatistics Section, School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland, M&HS Building 507;
28 Park Avenue, Grafton, Auckland, 1023, New Zealand
Email: [email protected]
Handling Editor:
Felicity Goodyear-Smith
Received: 15 February 2023 Accepted: 28 April 2023 Published: 15 May 2023
Cite this:
Faletau J et al.
Journal of Primary Health Care 2023 doi:10.1071/HC23016
© 2023 The Author(s) (or their employer(s)). Published by
CSIRO Publishing on behalf of The Royal New Zealand College of General Practitioners.
This is an open access article distributed under the Creative Commons Attribution- NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
OPEN ACCESS
Methods Study design
An online survey was conducted with registered primary healthcare professionals between February 2021 and April 2021. Ethical approval for the online survey was obtained from the Auckland Human Research Ethics Committee for 3 years on the 14th of January 2021 (Ref. AH21649).
Inclusion criteria
The inclusion criteria stipulated that participants must:
1. Be a current registered healthcare professional.
2. Work in a primary healthcare provider where at least 50% of their enrolled patients were of Pacific ethnicity.
3. Understand English.
4. Be able to provide informed consent.
Procedures
Participants were recruited through email invitations distrib- uted through existing mailing lists and networks, including General Practitioners (GP) and nurse associations, and via the University of Auckland Faculty of Medical and Health Sciences mailing list. Information about the study was included in the participant information sheet attached to the email invitation. Potential participants had the opportu- nity to ask questions by contacting the research team directly.
If participants agreed to participate, they visited the online survey webpage, provided electronic consent and completed screening questions to confirm eligibility to participate.
Survey design
The Qualtrics web-based survey tool was used to host the questionnaire. The questionnaire included both closed and open-ended questions to explore knowledge and practice
regarding screening, diagnosing and management of pre- diabetes. Questions were adapted from two existing survey questionnaires developed by Tseng and colleagues to describe primary healthcare doctors’ knowledge and prac- tice regarding (1) knowledge of risk factors that should prompt prediabetes screening and laboratory criteria for diagnosing prediabetes, and (2) management practices.10,11 Questions were adapted to ensure appropriateness to the NZ context and to focus specifically on prediabetes (not other types of diabetes). Demographic information including eth- nicity, age, gender and role in the clinic were also collected.
The questionnaire also explored communication of risk to patients with prediabetes and perspectives on a prediabetes risk communication visual tool not presented in this paper.
The questionnaire was pretested with healthcare profes- sionals and revised before being finalised. No internal reli- ability testing was undertaken. Part one of the survey collected demographic information, clinic practice and experience. Part two (a) contained the knowledge and prac- tice of screening, diagnosing and management of pre- diabetes questions. Parts two (b) and (c) of the survey are not included in this short report.
Statistical analysis
Completed questionnaire data were exported into Microsoft Office Excel for descriptive quantitative analyses, including means, standard deviation and proportions using SPSS Statistics 26. Qualitative open-ended responses were ana- lysed using an inductive thematic approach to identify themes and patterns in the data.
Results
There were 46 entries to the survey website; 30 people completed the survey, giving a completion rate of 65%.
Table 1 presents the demographic characteristics of the sample. Most of the respondents identified as a Pacific ethnicity (24/30, 80%) and almost half of the participants were GPs (14/30, 47%). Twenty-seven percent (8/30) of the participants indicated that during the week, 40–50% of patients that presented to the clinic had prediabetes.
Screening practices
Table 2 presents the factors that prompt participants to screen for diabetes, with the most common factors being a family history of diabetes (25/30, 83%), followed by ethni- city (Māori, Pacific and South-Asian) (24/30, 80%) and weight (BMI >25 kg m–2) (24/30, 80%).
Tests ordered to screen for prediabetes
Respondents identified that HbA1c (26/30, 87%) was the standard test they would order to screen for prediabetes.
WHAT GAP THIS FILLS
Evidence that Pacific primary care providers are highly adept at using established guidelines for practice, but culturally relevant tools relevant for Pacific people are lacking.
What is already known: Pacific people have a higher preva- lence of prediabetes which is a risk factor for the development of T2Ds. Primary care providers play a vital role in caring, and influencing the trajectory of risk, for people living with prediabetes.
What this study adds: This paper provides important infor- mation on primary healthcare professional’s (including nurses, doctors, and allied healthcare professionals) knowledge of screening, diagnosing and management of prediabetes of Pacific patients in New Zealand.
B
A smaller proportion of respondents indicated that they would order a fasting blood glucose (7/30, 23%), the 2-h oral glucose tolerance test (4/30, 13%) and non-fasting blood glucose (3/30, 10%) test.
The diagnostic values and measurements used to identify prediabetes
Almost all respondents (25/30, 83%) specified that an HbA1c result ranging from 41 to 49 mmol mol–1 was the diagnostic value and measurement they would use to iden- tify prediabetes. However, two respondents indicated they would also use an HbA1c greater than 48 or greater than 49 mmol mol–1 to identify patients with prediabetes. Three respondents reported that they would use a fasting glucose test (6.1–6.9 mmol L–1), glucose tolerance test and fasting venous glucose (>6.0 mmol L–1) test instead.
Management practices
Most respondents reported that the initial management approach that they would undertake if a patient had pre- diabetes would involve recommendations on diet changes and physical activity (28/30, 93%), followed by referring the patient to a diabetes prevention lifestyle change pro- gramme (16/30, 53%) and nutritionist (7/30, 23%). There were four participants (13%) who reported that they would start the patient immediately on metformin.
Nine participants (9/30, 30%) described that their man- agement of patients with prediabetes involves enlisting the help of health coaches, diabetes nurse specialists and com- munity workers of Pacific descent to educate and discuss management plans. One respondent described they would meet with the patient and their family members to create a health plan and provide Pacific-specific nutrition advice and access to physical activity support. Others reported educat- ing the patient on prediabetes aetiology, their risk, cardio- vascular risk, progression to T2D and the importance of lifestyle changes.
We have an on-site community health worker who is Pacific and provides Pacific specific nutrition food, edu- cation and support. (Respondent #19, Nurse, Cook Island Māori)
I highlight the importance of making lifestyle changes especially to achieve a healthy weight and also give recommendations on healthy eating and the benefits of regular exercise. (Respondent #23, Doctor, Samoan)
Repeating blood tests with newly diagnosed patients with prediabetes
In newly diagnosed patients with prediabetes, 37% (11/30) of the participants recorded that they would repeat a Table 1. Demographics of survey respondents (n = 30).
Variable Category n (%)
Gender Female 21 (70%)
Male 9 (30%)
Age (in years) 15–29 years 6 (20%)
30–44 years 14 (46%) 45–64 years 8 (27%) 65–74 years 2 (7%)
Ethnicity Pacific people 24 (80%)
European 2 (7%)
Asian 2 (7%)
Māori 1 (3%)
Other 1 (3%)
Role General Practitioner 14 (47%)
Nurse 10 (33%)
Health Coach 3 (10%)
Other 3 (10%)
The proportion of patients with prediabetes that present to the clinic in a week
<20 8 (27%)
20–30 8 (27%)
30–40 4 (13%)
40–50 8 (27%)
Did not answer 2 (6%)
Table 2. Factors that prompt primary healthcare professionals to screen for prediabetes (n = 30).
Risk Factor Yes, n (%)
Family history of diabetes 25 (83%)
Weight and BMI > 25 kg m–2 24 (80%)
Ethnicity (Māori, Pacific and South-Asian ethnicity) 24 (80%)
Age 23 (77%)
Evidence of prediabetes on prior testing 23 (77%)
History of gestational diabetes 22 (73%)
Cardiovascular disease 21 (70%)
Increased blood pressure 19 (63%)
Increased lipid levels 17 (57%)
Women with polycystic ovarian syndrome 16 (53%)
Smoking status 13 (43%)
Physical activity level 9 (30%)
Other 6 (20%)
I do not routinely screen for prediabetes 4 (13%)
C
patient’s blood test every 3 months. Twenty-three percent (7/30) indicated they would repeat blood tests every 6 months. Two respondents (2/30, 6%) indicated they would follow up to review the patient’s lifestyle and weight before repeating blood tests.
Discussion
The aim of this study was to describe primary healthcare professionals’ knowledge and practice of screening for, diagnosing and managing prediabetes for their Pacific pop- ulations. Respondents indicated that a family history of T2D, weight and ethnicity were the three risk factors taken into consideration when opting to screen for pre- diabetes. Most of the respondents deemed management of prediabetes essential, including encouraging diet changes and physical activity to reduce the risk of T2D and refer- ring patients to a diabetes prevention lifestyle change pro- gramme. This is in line with the evidence for lifestyle changes in the treatment of prediabetes.12–14 An objective measure of this impact is in HbA1c levels and on percep- tions of health and wellbeing.
Primary healthcare professionals in this study followed standard screening processes, using appropriate diagnostic tools to identify risk. The challenge is translating this diag- nosis into the support patients need to motivate them to change, be it individual or collective fāmili based support.
Prediabetes is a controversial diagnosis, but the potential for early intervention is important.15–17 In earlier work, we found a low level of understanding about the condition in Pacific patients previously diagnosed with prediabetes, with some believing it was inevitable they would then develop T2D and therefore making changes was pointless.18
The patient and healthcare professional relationship in primary care is one that is unique. The communication approach and interaction between the patient and health- care professional shapes subsequent disease-related percep- tions, self-management and health promoting behaviours.19 A prediabetes diagnosis can be daunting, presenting chal- lenges to the individual and the fāmili in terms of compre- hending the implications of elevated risk of chronic disease.
This survey found that management of patients with prediabetes involves enlisting the help of health coaches, diabetes nurse specialists and community workers of Pacific descent to educate and discuss management plans. Actively having an interprofessional team approach is helpful when working with Pacific peoples.
Importantly, it is vital that primary healthcare profes- sionals understand that Pacific peoples have deeply con- nected cultural expectations of serving others before self which may contravene individual behaviour change inter- ventions.20–23 Cultural traditions and religious obligations are important considerations in explanation for what has been referred to as ‘non-compliance’ in behaviour change to
improve health outcomes.20,21,24,25 Furthermore, where people live affects what they eat. Food environments that prioritise commercial over public health interests contribute to maintain unhealthy diets and poor eating behaviours, and for Pacific peoples, it is a result of acculturation to NZ society and the impact of socio-environmental and socio- cultural determinants.24,26 For lifestyle changes to occur, the social determinants of health that negatively impact our Pacific peoples’ health outcomes need to be addressed.
Understanding primary healthcare professionals’ methods of communication to Pacific patients with prediabetes and vice versa would essentially be beneficial for both patient and healthcare professional in the long run.
Finally, it is important to note that although this is a small sample, with potential response bias given the close network of Pacific primary care providers, it nonetheless provides valuable evidence of current clinical practice for screening and managing prediabetes by Pacific for Pacific.
The measures used in the questionnaire were generated for this survey, they were pilot tested for readability, but inter- nal reliability analyses were not conducted.
Conclusion
Primary healthcare providers are key players in the detec- tion and management of prediabetes. The majority surveyed in this study work in alignment with best practice guidelines and are playing a critical role in supporting Pacific people with prediabetes. Under Te Whatu Ora Health NZ, there is a call for greater emphasis on people centred care. With Pacific people bearing a greater burden of prediabetes our primary healthcare workforce need support to build compe- tency in culturally tailored approaches to communicate the risk of T2D.
Supplementary material
Supplementary material is available online.
References
1 New Zealand Society for the Study of Diabetes. Type 2 Diabetes Management Guidelines. Prediabetes. 2020. Available at https://
t2dm.nzssd.org.nz/Section-98-Prediabetes
2 World Health Organization. Classification of Diabetes Mellitus.
Geneva: World Health Organization; 2019. Available at https://
www.who.int/publications/i/item/classification-of-diabetes-mellitus 3 Coppell KJ, Mann JI, Williams SM, et al. Prevalence of diagnosed
and undiagnosed diabetes and prediabetes in New Zealand: findings from the 2008/09 Adult Nutrition Survey. N Z Med J 2013;
126(1370): 23–42.
4 Ministry of Health. Pre-diabetes: Risk Factor Management.
Wellington: Ministry of Health; 2016.
5 Chan WC, Lee M (AW). Update on Diabetes prevalence in 2019 based on laboratory results in the Auckland Metropolitan Region (from TestSafe). Auckland: Counties Manukau Health; 2020.
D
6 Atlantis E, Joshy G, Williams M, et al. Diabetes among Māori and other ethnic groups in New Zealand. In: Dagogo-Jack S, editor.
Diabetes Mellitus in Developing Countries and Underserved Communities. Switzerland: Springer International; 2017.
pp. 165–190.
7 Kukkady S, Kool B, Emma S, et al. The Prevalence of Diabetes Mellitus and Retinopathy among Pacific Peoples Residing in South Auckland, New Zealand. Integr Obes Diabetes 2017; 3(1): 1–6.
doi:10.15761/IOD.1000167
8 Warin B, Exeter DJ, Zhao J, et al. Geography matters: the preva- lence of diabetes in the Auckland Region by age, gender and ethni- city. N Z Med J 2016; 129(1436): 25–37.
9 Ministry of Health. Primary Health Care. 2020. Available at https://
www.health.govt.nz/our-work/primary-health-care
10 Tseng E, Greer RC, O’Rourke P, et al. Survey of primary care providers’ knowledge of screening for, diagnosing and managing prediabetes. J Gen Intern Med 2017; 32(11): 1172–1178.
doi:10.1007/s11606-017-4103-1
11 Tseng E, Greer RC, O’Rourke P, et al. National survey of primary care physicians’ knowledge, practices, and perceptions of pre- diabetes. J Gen Intern Med 2019; 34(11): 2475–2481.
doi:10.1007/s11606-019-05245-7
12 Abel S, Whitehead LC, Coppell KJ. Making dietary changes follow- ing a diagnosis of prediabetes: a qualitative exploration of barriers and facilitators. Diabet Med 2018; 35(12): 1693–1699.
doi:10.1111/dme.13796
13 Beulens JWJ, Rutters F, Rydén L, et al. Risk and management of pre- diabetes. Eur J Prev Cardiol 2019; 26(2): 47–54. doi:10.1177/
2047487319880041
14 Whitehead L, Glass CC, Abel SL, et al. Exploring the role of goal setting in weight loss for adults recently diagnosed with pre- diabetes. BMC Nurs 2020; 19(1): 67. doi:10.1186/s12912-020- 00462-6
15 Shaw J. Diagnosis of prediabetes. Med Clin North Am 2011; 95(2):
341–352. doi:10.1016/j.mcna.2010.11.012
16 Yudkin JS. “Prediabetes”: are there problems with this label? Yes, the label creates further problems! Diabetes Care 2016; 39(8):
1468–1471. doi:10.2337/dc15-2113
17 Vas PRJ, Alberti KG, Edmonds ME. Prediabetes: moving away from a glucocentric definition. Lancet Diabetes Endocrinol 2017; 5(11):
848–849. doi:10.1016/S2213-8587(17)30234-6
18 Faletau J, Nosa V, Dobson R, et al. Falling into a deep dark hole:
Tongan people’s perceptions of being at risk of developing type 2 diabetes. Health Expect 2020; 23: 837–845. doi:10.1111/hex.13056 19 Hong Y-R, Jo A, Cardel M, et al. Patient-provider communication
with teach-back, patient-centered diabetes care, and diabetes care education. Patient Educ Couns 2020; 103(12): 2443–2450.
doi:10.1016/j.pec.2020.05.029
20 Muimuiheata S. Food practices and diabetes management: the lived experience of Tongan people with Type 2 Diabetes Mellitus in New Zealand. Doctor of Health Sciences Thesis, Auckland University of Technology, Auckland, New Zealand; 2021.
21 Akbar H, Radclyffe CJT, Santos D, et al. “Food is our love language”:
using Talanoa to conceptualize food security for the Māori and Pasifika diaspora in South-East Queensland, Australia. Nutrients 2022; 14(10): 2020. doi:10.3390/nu14102020
22 Akbar H, Gallegos D, Anderson D, et al. Deconstructing type 2 diabetes self-management of Australian Pacific Islander women:
using a community participatory research and talanoa approach.
Health Soc Care Community 2021; 30(5): 1988–1999. doi:10.1111/
hsc.13580
23 Bassett SF, Holt EAL. New Zealand resident Tongan peoples’ health and illness beliefs and utilisation of the health care system. Pac Health Dialog 2002; 9(1): 40–47.
24 Mavoa HM, McCabe M. Sociocultural factors relating to Tongans’
and Indigenous Fijians’ patterns of eating, physical activity and body size. Asia Pac J Clin Nutr 2008; 17(3): 375–384.
25 Barnes L, Moss-Morris R, Kaufusi M. Illness beliefs and adherence in diabetes mellitus: a comparison between Tongan and European patients. N Z Med J 2004; 117(1188): 1–9.
26 Pauuvale AF, Vickers MH, Pamaka S, et al. Exploring the retail food environment surrounding two secondary schools with predomi- nantly Pacific populations in Tonga and New Zealand to enable the development of mapping methods appropriate for testing in a classroom. Int J Environ Res Public Health 2022; 19(23): 15941.
doi:10.3390/ijerph192315941
Data availability. The data that support this study will be shared upon reasonable request to the corresponding author.
Conflicts of interest. All authors have no conflicts of interest to declare.
Declaration of funding. This research was funded by the Health Research Council Pacific PhD Scholarship.
Acknowledgements. The authors thank all primary healthcare professionals who took part in the survey during the COVID19 pandemic.
Author affiliations
AEpidemiology and Biostatistics Section, School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland, M&HS Building 507;
28 Park Avenue, Grafton, Auckland, 1023, New Zealand.
BPacific Health Section, School of Population Health, Faculty of Medical and Health Sciences, The University of Auckland, M&HS Building 507; 28 Park Avenue, Grafton, Auckland, 1023, New Zealand.
E