My health for life - PRINCIPLES OF CO-DESIGN IN AN ALLIANCE TO PREVENT TYPE 2 DIABETES

THE CONTEXT
Launching the 5th report card on the health of Queenslanders in 2014, Queensland’s Chief Health Officer Dr Jeannette Young said “There can be no health silos… prevention programs and services are needed for a new world…’’

THE RESPONSE
Diabetes Queensland responded to this call. In 2016 it forged an alliance with five not-for-profit organisations and seven primary health care networks, and entered into a partnership arrangement with the State Government of Queensland.

The common goal: work within a contracted, collaborative framework to target those in the population most at risk of developing chronic disease, such as type 2 diabetes, heart disease and stroke.

Purpose: Reverse the trends. (E.g. lifestyle interventions can reduce T2 diabetes incidence up to 60% and improve community knowledge and awareness about chronic disease and modifiable risk factors.

The result: My health for life, an integrated risk assessment and behaviour modification program, launched this year backed by $27 million in funding by the Queensland government to 2020. Target 10,000 completers.

The program was built around a strong governance framework and a solid evidence base. This is the journey so far…   

THE HEALTHIER QUEENSLAND ALLIANCE
•	Diabetes Queensland - leadership role. Responsibility for program management, intervention and design, ICT and social marketing, including engagement
•	Heart Foundation - GP and health professional engagement
•	Stroke Foundation - Risk assessment and pharmacy engagement
•	Seven primary health care networks - Commonwealth-funded – GP and health professional engagement at the local level
•	The Aboriginal and Torres Strait Islander Health Council - advocacy and design
•	The Ethnic communities Council of Queensland - advocacy & delivery.   

CREATING ALLIANCE FOUNDATION
•	Formal program structure -  foundation documentation agreed at the outset
•	Development supported by management consultants in the initial set-up, in conjunction with an Alliance executive steering committee 
•	Program structure and documentation approved by funder (Queensland Health) prior to service commencement
•	Program principles based on mutual respect, transparency, communication and accountability 
•	Ongoing monitoring, reporting and management across the Alliance by Program Management Office –  active governance and decision making through series of key committees (E.g. Steering Group, Operational Management Committee, Risk Committee and Clinical Reference Group) and “stream’’ leads.

EVIDENCE BASE  
Qualitative and quantitative research:
•	48 % target population don’t see themselves at risk of chronic disease – rate their own risk as low as 4.5 out of 10. Rate personal risk of T2 diabetes 3.9 out of 10 - the severity of diabetes as 7.2
•	The program holds appeal - want access to health professionals and personalisation  – not a one-fit approach
•	Many feel that being a healthier version of themselves is more achievable and sustainable than being extremely healthy 
•	Are concerned about their health and wellbeing, particularly their ability to lose weight 
•	The benefits of healthy change not known or immediately recognisable
•	77% worry it is too late to make changes
•	Entrenched attitudes and behaviours – see themselves as time poor and fear failure

Co-design:
Co-design is the practice of true collaboration and takes traditional engagement and consultation to the next level by involving the end-user in the overall design and development of initiatives, policies and programs.  
How we used it:
•	To challenge Alliance thinking – in program development and to be open to outside views
•	It encouraged the Alliance to critically analyse health programs built on a “we know best’’ basis and resist the desire to do the same
•	With the help of “participants’’ the Alliance was able to test assumptions and define the hallmarks of an effective prevention program  
•	It stripped away preconceived ideas about the target population and ensured the final  design reflected their needs and wants
How we did it:
•	Recruited members of the community from a single geographic area who would have been eligible for the program
•	Recruited them by undertaking risk assessments in shopping centres and through local health professionals, including the pharmacy environment
•	Those who met the eligibility criteria were then invited to take part in a process over several weeks to explore their views on healthy lifestyle programs and contribute to the design of a proposed program
•	The co-design spanned two months in late 2016. The final program rolled out in April 2017
•	Interestingly, some of these participants were among the first people to enrol in the program.

Key learnings
•	Programs needs to be flexible and personalised
•	Goal setting-approach more appealing than a content-based program  
•	Basic health and nutrition knowledge in easy “small bites’’
•	Storytelling resonates
•	Social support is important – this point was also reflected in the formative market research
•	Need for social connections  
•	Need for sensitive and positive engagement
•	Want maintenance support after program completion
•	“Look feel and tone’’ of program information and resources important – positive, friendly and easy to understand
•	Need for motivation – participants looking for motivation, wanting to understand it better and seeking tips and support

PROGRAM
Eligibility   
•	Program targets Queenslanders at high risk of developing type 2 diabetes, heart disease or stroke. Criteria for eligibility:
•	Adults > 45 with an AUSDRISK score of ≥15 (12 as of 2018). Absolute CVD risk score of ≥15% or blood pressure reading of ≥160 systolic and/or diastolic ≥100.
•	People of Aboriginal or Torres Strait Islander descent > 18 + with an AUSDRISK  ≥15; Absolute CDV score of 15%or blood pressure reading of 160 systolic and/or diastolic ≥100
•	18+ in a workplace setting with AUSDRISK score of ≥15 (12 as of 2018); Absolute CDV score of 15% or blood pressure reading of 160 systolic and/or diastolic ≥100
•	Adults 18+ with pre-existing conditions including history of gestational diabetes mellitus; familia hypercholesterolemia; high blood pressure or high blood cholesterol
•	Pre-diabetes diagnosed by IGT and FGT 

To check eligibility
•	Dedicated free telephone line 
•	Visit myhealthforlife.com.au where they can also do an online health check 
•	Talk to their GP, supporting pharmacist, or health professional.

 PROGRAM SNAPSHOT
•	Free
•	Delivered by qualified health professionals in local areas 
•	Involves six sessions over six months, and maintenance for a further months 
•	First session a personalised one-on-one appointment
•	Choice of phone coaching or small groups
•	Workplace program also available
•	Works in partnership with other health professionals 

RESULTS SO FAR
•	More than 270 program completers and still counting
•	50 contracted providers and 150 facilitators delivering the program for the Alliance
•	Self-reported behaviour and attitudinal change already occurring with some participants reporting weight loss of more than 10 kilos, increased physical activity and increased wellbeing
•	Phone coaching launched mid-year – almost 30% opting for phone coaching at this time and growing
•	A workplace program currently being piloted with expressions of interest already received from other interested organisations
•	Adapted program for both rural and urban Aboriginal and Torres Strait Islander people in development for 2018
•	Adapted program for  the culturally and linguistically diverse, including Arabic, Vietnamese, Pacific Islander and Chinese participants, to go live early 2018 
•	By April 2018 the program will be fully available across Queensland 
•	Successful negotiation to include pre-diabetes as part of the eligibility criteria and acceptance of people 45+ with an AUSDRISK score of 12 or more effective from 2018
•	Looking at new strategies to “feed the pipeline’’ amid changing political landscapes, changing pharmacy environment and emerging health priorities, issues and opportunities.


REFERENCES
The online health check includes the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) and a number of additional questions to help you better understand your health. AUSDRISK has been developed by the Baker IDI Heart and Diabetes Institute for the Australian, State and Territory Governments to help you find out about your risk of developing type 2 diabetes in the next 5 years.

ACKNOWLEDGEMENTS
This work has been funded by the Queensland Government.
The authors gratefully acknowledge the collaboration that has incurred in the development and the implementation across the Healthier Queensland Alliance and the Queensland Government and program stakeholders.

CONTACT
Diabetes Queensland
Michelle Trute, CEO Diabetes Queensland
Adjunct Associate Professor : Griffith University
E: michellet@diabetesqld.org.au
Twitter.com/michelletrute
www.diabetesqld.org.au

“My Health for LIFE!” Principles of co-design in an alliance to prevent type 2 diabetes