A Diabetes Prevention Program That Is Not Retaining Participants
A county health department runs a recognized Diabetes Prevention Program in four 12-week cohorts. Of 96 enrollees last year, 38 completed (40%); completers lost a mean 2.1% of body weight against a 5% benchmark. Sessions are Tuesdays at 10 a.m. in the department's second-floor conference room. Sixty percent of participants speak Spanish; all handouts are in English. There is no childcare, no bus route to the building, and one of the two health educators is bilingual. The state grant requires 60% completion and a mean 5% weight loss for continued funding, with a report due in 10 months. A chart review shows most dropouts occurred between sessions 3 and 5.
1. Using a planning model, diagnose why the program is failing. Where is the problem located?
Read the worked answer
Use PRECEDE–PROCEED. The behavioral/environmental diagnosis points at enabling factors far more than predisposing ones: no childcare, no transit access, a second-floor room, and a 10 a.m. weekday slot exclude working participants; 60% Spanish-speaking participants receive English-only materials with one bilingual educator.
Reinforcing factors are also thin - no social support structure, no contact after a missed session.
Predisposing factors (beliefs, self-efficacy, perceived risk) are the ones programs usually blame, but the data do not support that: attrition clusters at sessions 3–5, which is exactly when the novelty fades and logistical burdens compound. A motivation problem would produce diffuse dropout; a logistics problem produces a cluster.
Equally important: this is an implementation failure (Phase 4–5), not yet an outcome failure. Redesigning curriculum content before fixing access would spend the grant's 10 months on the wrong phase. Note also that the 2.1% figure describes completers only - the full-cohort mean is almost certainly lower, and you should say so before anyone reports it upward.
2. Prioritize three changes and specify how you would measure each.
Read the worked answer
1. Remove the logistical barrier (highest leverage). Move at least two cohorts to evening/weekend times at community sites on bus routes (library, church, school), and provide childcare or a supervised activity room. Measure: attendance by session number, completion rate by cohort/time slot, and no-show rate.
2. Deliver in the participants' language. Run Spanish-language cohorts with the bilingual educator, translate all materials, and add text/phone check-ins. Measure: completion and mean weight loss stratified by language - currently you cannot even see the disparity because it is not tracked.
3. Build reinforcement between sessions 3 and 5. Buddy pairs, a coach call within 48 hours of any missed session, and a make-up option (short video or phone session). Measure: percent of missed sessions recovered, and dropout specifically at sessions 3–5 versus baseline.
Sequence matters: fix access and language first. If completion rises but weight loss does not, the content is the next target.
3. The grant demands a mean 5% weight loss in 10 months. How do you handle that expectation honestly?
Read the worked answer
State plainly that the 5% target is a completer benchmark translated into a program requirement, and that the two are not the same. As completion rises from 40%, previously non-completing participants enter the denominator, and the mean typically falls before it improves - an improvement effort that looks like failure on the report.
Recommend: (1) report both intention-to-treat and completer analyses, with the denominator defined in advance; (2) ask the funder to accept process and intermediate outcomes as the year-one primary metrics - completion rate, sessions attended, self-reported minutes of activity, and proportion achieving ≥3% loss - with 5% as a year-two outcome; (3) strengthen the intervention enough to be credible (add an activity component, since 12 weekly sessions alone rarely produce 5%); (4) note that with no comparison group, any improvement is confounded by season, cohort, and staff changes - at minimum, stagger rollout so later cohorts serve as a concurrent comparison.
Bring the funder a revised measurement plan rather than a promise you cannot keep.