Ylan Liu
Senior Thesis | 2025
Title: Exploring Cultural Readiness: A Phenomenological Study of the Engagement of Vietnamese Americans in Diabetes Prevention and Self-Management Programs
Abstract
Type 2 Diabetes (T2DM) is a critical condition that is rapidly becoming an epidemic in America. Two major components leading to the increase in numbers in this country is the lifestyle people choose and the support they are offered. Due to the western centric focus for the Diabetes Prevention Program in the United States, Asian Americans are not getting the proper care for Diabetes that takes into account the cultural differences between Asian Americans and White Ameircans. Due to the disparities in diet and expectations on exercise, there is a major gap of understanding between a provider who is not aware of these cultural differences and a patient. Additionally, their priorities, whether family or other aspects of life, and social determinants of health vary drastically. There are multiple genetic influences, including the ability to produce insulin and prevent insulin resistance, fat storage, and other contributors. Based on a multitude of factors, it is difficult to provide preventative care solely based on an outdated Prevention Program. Existing diabetes prevention programs, such as the Diabetes Prevention Program (DPP) and Diabetes Self-Management Education and Support (DSMES), often fail to address the cultural, socioeconomic, and genetic factors unique to this group. This study explores the readiness of Vietnamese Americans to engage with culturally tailored diabetes prevention and self-management programs by examining their experiences, cultural beliefs, and barriers to participation. Utilizing
the Transtheoretical Model (TTM), the readiness of participants to engage in diabetes programs across five stages of change was assessed. The study involved 26 Vietnamese American participants aged 18-87, with 42% diagnosed with prediabetes and 15.4% with diabetes. Key findings revealed slight variation in readiness to engage in prevention programs or lifestyle changes, but most leaned towards hesitancy and unreadiness. Family support, accountability, culturally relevant meal plans, and flexible scheduling were identified as major motivators, while barriers included financial constraints, time limitations, language barriers, and cultural stigma. Cultural values, such as prioritizing family over personal health, and traditional dietary habits, influenced willingness to adopt healthier behaviors. The study emphasizes the need for culturally tailored interventions that consider the psychosocial factors influencing health behaviors, such as family dynamics, community networks, and traditional health practices. These insights suggest that community-based, personalized programs focusing on cultural relevance and accessibility are key to improving engagement in diabetes prevention and management among Vietnamese Americans. Further research with a larger, more diverse sample is needed to refine these interventions and address the unique needs of this population.
Introduction
The prevalence of diabetes mellitus (DM) is growing into a global burden for many individuals, families, and countries. According to the International Diabetes Federation (IDF) Diabetes Atlas, 10.5% of adults aged 20-79 were living with diabetes in 2021, with nearly half unaware of their condition. By 2045, IDF
projections indicate that approximately 1 in 8 adults around 783 million people will have diabetes (9).
This chronic condition is characterized by elevated blood glucose levels due to defects in insulin production, insulin action, or both, resulting in the development of insulin resistance. Diabetes mellitus has several ramifications including microvascular: retinopathy, nephropathy, neuropathy, and macrovascular: ischaemic heart disease, stroke, peripheral vascular disease, complications (6). It occurs in distinct forms, primarily type 1 and type 2, though other forms such as gestational diabetes and specific genetic or secondary types exist. The most common form of diabetes is Type 2 diabetes mellitus (T2DM), accounting for about 90-95% of all diabetes cases. It generally develops in adults, though an increasing number of children and adolescents are now being diagnosed due to the rise in obesity rates (11).
Numerous evidence-based interventions, such as the Diabetes Prevention Program (DPP) and Diabetes SelfManagement Education and Support (DSMES), effectively prevent and manage diabetes, reduce the risk of complications, and ultimately aim to create sustainable, healthier lifestyles. The DPP, in particular, is a year-long lifestyle intervention designed to help participants achieve a 5-7% reduction in body weight. This reduction is through dietary changes, calorie reduction, and increased physical activity to a minimum of 150 minutes per week. This program has demonstrated a 58% reduction in the incidence of T2DM, with protective effects lasting over 10 years (4). The DSMES is a program for individuals with diabetes to gain the knowledge and skills to make changes to their behavior, allowing them to better manage their diabetes and its related conditions (5).
However, the approaches of these programs have been criticized for being overly standardized, lacking the necessary adaptations for cultural differences and distinct health needs, particularly within the Vietnamese American community (15).
A staple in the diet of Vietnamese American are foods with a high glycemic index, particularly the high consumption of white rice (14). Additionally, physical activity levels among VietnameseAmerican adults tend to be lower compared to individuals from other racial or ethnic groups. This disparity may be influenced by a combination of cultural, socioeconomic, and environmental factors, including differing attitudes toward exercise, time constraints due to work or family obligations, limited access to safe and affordable spaces for physical activity, or a lack of culturally tailored health promotion programs (16). Over time, these factors contribute to weight gain and, in many cases, obesity, which further aggravates insulin resistance and the complications of diabetes.
These individuals have a genetic predisposition to developing diabetes, even when they maintain lower BMI levels compared to other populations. This predisposition is partly linked to a phenomenon known as being "skinny fat," where an individual may appear lean outward but harbor significant amounts of visceral fat. This type of fat is stored deep within the abdomen and surrounds vital organs. Visceral fat is not merely a storage site for excess calories, but also contributes to an increased risk of Type 2 diabetes. It does so by promoting chronic inflammation and impairing the body's ability to use insulin effectively, leading to insulin resistance (7).
The development, prevalence and progression of this disease is linked to several risk factors. These include genetics, family history, age, and ethnicity, as well as lifestyle factors like physical inactivity and poor dietary habits. So in order to effectively address T2DM, it is essential to address the specific needs and circumstances of these communities.
There is currently a gap between decreasing the disease burden of T2DM and the necessary resources provided by these preventative programs to help individuals with diabetes. Despite attempts to adapt the DPP and DSMES for Vietnamese Americans, there is often a “one-size-fits-all” approach due to wide withingroup variability that results from intersections among many identities and social determinants of health factors.
The purpose of this paper is to explore and understand the varying levels of readiness among Vietnamese Americans to participate in culturally and linguistically tailored diabetes prevention and self-management programs, identifying distinct subgroups with differing readiness profiles. Through a phenomenological approach, this research aims to uncover the lived experiences, cultural beliefs, perceived barriers, and motivating factors that influence their willingness to engage in such health interventions. The findings will contribute to the development of more effective, culturally relevant health programs that address the unique needs of the Vietnamese American community and improve their overall health outcomes.
Methods
This study utilized an interpretive phenomenological design with Gadamerian Hermeneutics as its guiding methodological framework.
Transtheoretical Model Stages of Change framework
The Transtheoretical Model (TTM) Stages of Change framework is a commonly applied theoretical and clinical framework to evaluate a broad spectrum of behavioral changes and health. The purpose of TTM is to help people create an effective plan to prevent deleterious behaviors or maintain healthy ones. This study utilized the TTM to assess the varying levels of readiness among Vietnamese Americans to participate in culturally and linguistically tailored diabetes prevention and selfmanagement programs. The framework outlines five progressive stages that individuals typically move through when changing behavior: Precontemplation; Contemplation; Preparation; Action Stage; Maintenance.
The first stage, Precontemplation, highlights those who are unmotivated and are not looking for a solution to their problems. These individuals are unaware of the problem and lack insight into the consequences of their harmful behaviors. Furthermore, people in this stage often present as resistant, unready, and unwilling to change and commit to changing their behavior in the next six months. The next stage is Contemplation, characterized by awareness and acknowledgement of their problematic behaviors. Individuals in this stage begin to heavily consider change, weighing the benefits and drawbacks, and are usually open to receiving information regarding their behaviors and finding
solutions to correcting them. However, this person is uncertain about committing to taking the necessary steps towards change, remaining in a state of “Contemplation” for at least six months. The following stage is the Preparation stage. At this stage, individuals are easily able to acknowledge that a behavior is problematic and can make a commitment to correct it. They gather the appropriate information to take small initial steps to changing, and start to develop a plan of action. The Action Stage is when change happens. At this stage, individuals are expected to completely abstain from their harmful behaviors for a period fewer than six months, and have gained the confidence and willpower to continue their journey of change. They are willing to receive the necessary assistance and support, actively implementing new healthy and beneficial behaviors to modify their habits. The final stage is Maintenance, where individuals have maintained total abstinence from harmful behaviors. Individuals in this stage have become more confident in their abilities to sustain a positive and healthy lifestyle and are less likely to relapse. This stage usually lasts around 6 months to 5 years, with the expectation that they are able to resist temptation and refrain from reverting back to old habits (10).
Each stage highlights a unique phase of readiness for individuals to take steps toward change, showcasing personalized approaches to behavioral interventions. By categorizing individuals into different stages, the project identified distinct readiness profiles. This approach reveals the cultural beliefs and values, perceived barriers, and motivating factors of Vietnamese Americans that influenced engagement in these health interventions such as diabetes prevention or self-management
programs, allowing for a more nuanced understanding of their lived experiences and readiness to participate. Additionally, it will provide insight into the essential features and resources of a diabetes prevention or self-management program that influence an individual's willingness to participate. Moreover, it will illustrate any potential relationships between varying phenotypic characteristics and different levels of readiness.
Sample and Setting
The inclusion criteria included self-identification as a Vietnamese American adult (age 18 years or older) either diagnosed with prediabetes or diabetes or reporting family history of prediabetes or diabetes.
Participants were primarily recruited through community organizations with established connections or access to a broad network of Vietnamese Americans. These organizations included churches, temples, civic organizations, community engagement events, and health clinics. A purposive sampling strategy was employed to ensure diverse representation of voices, including variation in age, gender, and socioeconomic status, while also guaranteeing that the data collected would provide deep insights specifically about the Vietnamese American community (1). Due to the difficulty of reaching this population because of its specific characteristics, snowball sampling was applied, utilizing current research participants to refer to other prospective participants who may be interested or eligible. Additionally, one focus group was conducted with a cohort of Vietnamese American older adults who had attended the DPP within one year prior. Participants were nominally compensated with a $50 Amazon gift card (1).
The goal of sampling was to reach a data saturation to the stage at which further data collection no longer contributed additional insight, and enough information has been gathered to answer the research question effectively.
Data Collection
Once participants have confirmed study eligibility, they were sent a Qualtrics link with an investigator-developed demographic questionnaire. Participants were also given the option for a face-to-face interviewer-guided completion of the demographic questionnaire in either English or Vietnamese.
Further qualitative data was collected through semistructured interviews using questions found in the Appendix. The interview contained open-ended questions to encourage participants to expand upon their thoughts, feelings and beliefs related to diabetes management and how their culture and identity as a Vietnamese American influences their views and standpoints. The interviews were conducted in Vietnamese or English, depending on the participant's preference, to ensure comfort and clarity. Each interview was audio-recorded and transcribed verbatim.
Data Analysis: Interpretive Phenomenological Design with Gadamerian Hermeneutics
Gadamer’s iterative and dialogical approach to a structured six-stage process for data analysis emphasizes the importance of understanding the meaning of the data within its historical and cultural context, and as researchers, recognizing how our biases and perspectives influence interpretation. The cyclical aspect of
this process, the “hermeneutic circle” of analysis, where each step is understood in relation to the whole and vice versa, allows for a deeper and richer understanding.
Following the steps of Gadamer’s approach, the research team began with immersion by thoroughly reviewing the interview transcripts, collecting important quotes and details that were discussed, and categorizing them. Specifically, the research group focuses on the participant’s DM knowledge, the complication of DM and its potential invisibility (a patient’s unawareness of their disease and its symptoms), their urgency to act or lack of, and any influencers, values or challenges the participant has faced with T2DM. This allowed us to gain a deep understanding of the participants' narratives and to help identify key themes and patterns.
Data analysis involved a thematic coding (or abstraction) process, in which the research team created a framework based on recurring themes identified by participants. This included both inductive and deductive coding, with some themes emerging directly from the data and others informed by existing literature. For example, the team used the TTM stages of change as a base of our framework. After discussing initial codes, the team reached consensus on key themes that reflected participants' experiences.
This was then followed by synthesis and theme development, where the findings were then synthesized into narratives that highlighted the diverse perspectives of participants while preserving their individual voices. Each narrative included direct quotes for authenticity. The analysis also considered the intersectionality of cultural beliefs, gender roles, and socio-
economic factors impacting participants' engagement in diabetes prevention programs.
The stage for illumination and illustration of phenomena involved linking existing literature to the themes and reconstructing interpretations into stories. The research team examined the literature for what was known about recommendations for healthy eating and physical activity recommendations to match them with the stages of readiness for self-directed lifestyle changes. Furthermore, the stages of readiness were also analyzed for family members of participants.
In the final stage of integration and critique, the research team critically examined and reflected upon their preconceptions and biases during routine debriefing sessions to ensure that the participants’ perspectives were not overshadowed by those of the researchers. This reflective practice created a more balanced interpretation of the narratives, allowing for a richer analysis that centered on the participants' voices. This holistic approach aimed to uncover the barriers and motivators affecting Vietnamese Americans in diabetes management.
Results
The Qualtrics investigator-developed demographic questionnaire conducted by Dr. Tam Nguyen and her research team, showed that participants (n=26) were adults between 18 to 87 years old. The majority of participants were female (69.2%; n=18). Several participants were diagnosed with prediabetes (42.3%; n=11), while only four participants were diagnosed with diabetes (15.4%). The remaining participants had not been diagnosed with prediabetes or diabetes, and others are at risk per family history of prediabetes or diabetes or personal history of gestational diabetes (42.3%; n=11). More than one-third of the sample only had a high school diploma or lower level of education (38.5%; n=10). Less than half the participants reported having good or excellent spoken and written English proficiency (46.2% or n=12 and 38.5% or n=10, respectively), and nearly one-quarter (23.1%; n=6) reported needing support in understanding health literature. The narratives of the participants reveal a complex interplay of cultural beliefs, values, and behaviors that influence their readiness to engage in a DPP or DSMES program and lifestyle changes. The four major themes that emerged were: (1) levels of readiness characterized by stages of change, (2) key motivating factors for engagement in DPP or DSMES programs, (3) key barriers to engagement in diabetes programs, (4) cultural beliefs and values, and (5) essential features of DPP/DSME programs.
Table 1. Stages of Readiness for Change. Participants 19 through 26 were given a focus group interview and stages of readiness were determined for each group.
Mean = 74.87
HS or less (5), prefer not to answer (2), some college (1)/retired (7), not answer (1) F (7), M (1)/Good (3), fair poor (5) Maintenance Maintenance
Theme #1: Levels of Readiness Characterized by Stage of Change
Two major levels of readinesses were identified: (1) readiness to participate in a formal, traditional DPP/DSMES program and (2) readiness for self-directed lifestyle behavior changes, as shown in Table 1 for stages of readiness of interviewed participants and the family members with diabetes or prediabetes that were discussed.
The analysis of levels of readiness, characterized by the TTM stages of change model, revealed a spectrum of engagement among participants. The Focus Group participants were in the maintenance stage for both readiness to attend a DPP and readiness for lifestyle behavior changes. The Focus Group participants noted their commitment to regular exercise and healthier dietary choices
stemming from what they learned in diabetes prevention programs. For example, Participant 26 reported walking 30 minutes every day, even when she is sick. Participant 20 also reports walking routinely and states that even extreme weather is not a deterrent to exercise since she will instead use her exercise equipment at home. Related to healthier dietary choices, Participant 25 reported using the MyPlate method and fills two-thirds of her plate with vegetables, eats more fruit, and eats less fried foods. A few of the Focus Group participants reported eating oatmeal for breakfast. Participants 20 and 25 note that they are now used to their new diets and state that eating healthily has become a habit.
Of the remaining 6 participants who had prediabetes, half of the participants (n=3) were in the precontemplation stage of readiness for attending the formal DPP. Of the three participants who had prediabetes in the DPP precontemplation stage, only Participant 1 was in the action stage of change for recommended lifestyle changes for diet and exercise. Participant 1 felt that she has a good handle on her prediabetes and did not currently have a desire to participate in a DPP program.
Other than those Focus Group participants, half of the participants (n=3) with prediabetes were in the action stage of readiness for lifestyle changes.
Those in the precontemplation stage displayed little awareness of the need for personal change, often waiting for a crisis to act. In contrast, participants in the preparation stage were actively seeking ways to implement small health changes. For instance, Participant 9 shared, “I’ve started mixing brown rice with white rice to ease into healthier eating.”
Theme #2: Key Motivating Factors for Engagement in the Diabetes Prevention and Management Programs
Family and accountability emerged as powerful driving forces for many participants, underscoring the significant emotional and social support that influences their health-related decisions. For instance, Participants 1, 2, and 10 all highlighted the essential role that family played in their health journeys, noting that the encouragement and support from loved ones often acted as a foundation for their commitment to personal well-being.
Participant 9 succinctly expressed this sentiment, stating, “My family pushes me to be healthier; I can’t let them down.” This remark suggests that the sense of responsibility to family members not only provided motivation but also acted as a strong source of accountability. The desire to not disappoint family members seemed to be a powerful emotional driver, creating a sense of obligation to prioritize health.
In addition to familial support, practical incentives were noted by several participants as a key factor in bolstering their motivation to engage in health programs. Participants 2, 6, and 12 specifically mentioned that incentives, such as meal plans that cater to cultural preferences and tangible rewards like gift cards, could significantly increase their likelihood of participating in and adhering to health programs. The inclusion of culturally relevant meal plans was particularly important, as it demonstrated a level of personalization that aligned with participants’ unique needs and preferences, making the health program feel more accessible and appealing. As Participant 2 explained, “Incentives help make it feel worth the effort.” This statement reflects the idea that small, thoughtful rewards can provide both practical value and emotional
encouragement, reinforcing participants’ commitment to making healthier choices.
Theme #3: Key Barriers to Engagement in Diabetes Programs
The key barriers identified included financial and time constraints, as highlighted by participants 1, 3, and 14. Many expressed the difficulty of prioritizing health amidst work commitments and financial struggles, often stating that these challenges make it hard to engage in prevention programs. Participant 6 remarked, “Finding time to take care of myself feels impossible when I’m working multiple jobs just to get by.”
Cultural stigma and a lack of health awareness also emerged as barriers. Participants 3, 5, and 14 noted that without a diagnosis or visible signs of illness, there is often little urgency to engage in health programs. As Participant 5 explained, “In our culture, we avoid talking about illness until it’s a crisis.”
The language and literacy barriers faced by older generations further hinder engagement in diabetes prevention efforts, as noted by participants 8, 10, and 18. The complexity of health information and the inability to communicate effectively in English can prevent individuals from fully understanding their health needs.
Theme #4: Cultural Beliefs and Values
Cultural beliefs and values significantly shape the readiness of Vietnamese Americans to engage in diabetes prevention and management programs. A key aspect of these beliefs is the emphasis on familial responsibility, where participants frequently indicated that taking care of family members often takes precedence over personal health. Participant 5 noted, “I have to
prioritize my family; my health comes second,” highlighting the cultural norm of prioritizing familial needs over self-care. This strong sense of duty can lead to neglecting personal health needs, particularly when it comes to seeking preventive care.
Community influence was another critical factor impacting health decisions. Participants 2, 7, and 15 discussed how family and community values strongly affect their engagement in health programs. This is particularly true for older generations who often rely on communal and faith-based support to encourage participation in preventive care. Participant 2 stated, “Without my family’s support, I wouldn’t even consider changing my diet.”
The "crisis-oriented" approach to health-seeking behavior is another critical cultural factor. Many participants expressed that they typically seek medical help only when faced with significant health issues or crises. As Participant 12 observed, “In our culture, we only go to the doctor when something is seriously wrong.” This belief in endurance and self-sufficiency often delays necessary preventive care and can result in late diagnoses and complications, particularly for conditions like diabetes.
Stigma surrounding health discussions further complicates the willingness to engage in health programs. Participants pointed out that many older adults feel embarrassed to talk openly about their health conditions, a sentiment echoed by Participant 10, who stated, “It’s hard for my parents to discuss their health issues; they see it as a weakness.” This stigma is often exacerbated by historical trauma stemming from experiences like the Vietnam War, which has instilled a reluctance to openly address health concerns. Participant 12 noted, “The trauma from our past
influences how we approach health today; we carry that weight with us.”
Dietary norms also play a significant role in health priorities. Traditional practices, such as a high consumption of rice and sugary foods, are deeply ingrained in Vietnamese culture. Participant 1 articulated this challenge, saying, “Rice is a staple in our diet; it’s hard to change that habit.” Participant 11 emphasized, “We can’t abandon rice or that lifestyle surrounding rice,” highlighting the struggle of balancing traditional eating habits with the need for healthier choices.
Additionally, the concept of “nhau,” which refers to drinking alcohol while consuming unhealthy foods, was noted by Participants 1 and 14. They emphasized how such habits are common during family gatherings, reinforcing the difficulty of altering these cultural practices. Participant 14 remarked, “Drinking with meals is part of our culture; it’s hard to change that.”
Financial constraints and busy lifestyles further exacerbate these challenges. Many participants expressed that their long working hours and multiple jobs leave little room for healthfocused activities. Participant 18 illustrated this, stating, “I want to exercise, but I just don’t have the time with work and the kids.” This prioritization of economic stability over self-care underscores the need for programs that are flexible and accommodating to the demanding lives of Vietnamese Americans.
Ultimately, these cultural beliefs and values, intertwined with familial responsibilities and societal pressures, profoundly impact the readiness of Vietnamese Americans to participate in diabetes prevention and management programs. Acknowledging
these dimensions is essential for developing effective, culturally tailored interventions that resonate with the community's unique experiences and challenges.
Theme #5: Essential Features of Diabetes Prevention or SelfManagement Programs
The essential features of diabetes prevention and selfmanagement programs, as identified by participants, included the need for cultural relevance and flexibility. Participants 1, 3, and 14 emphasized the importance of dietary advice that aligns with traditional Vietnamese preferences. As 3 noted, “If it’s not relevant to our culture, we won’t stick with it.” Moreover, flexible timing and formats were highly valued; participants 2, 5, and 9 preferred virtual options to accommodate their busy lifestyles.
Programs should be community-based, culturally sensitive, and led by individuals who understand Vietnamese culture and language. Participants prefer programs that are engaging and provide practical, actionable information. Incorporating incentives and making sessions interactive can enhance engagement.
The topic of health monitoring devices also garnered mixed responses. Participants 1, 2, and 17 expressed openness to wearable devices like a FitBit or continuous glucose monitors if they were easy to use. However, Participant 10 voiced a strong aversion to commitment, stating, “I don’t want to wear something that tracks me all the time; it feels burdensome.” The Focus Group revealed divided opinions, with concerns over data privacy weighing heavily on some individuals. “I don’t trust who will see my health data,” shared a participant from the group.
In summary, the findings reflect a rich tapestry of cultural beliefs, challenges, and motivations that inform the readiness of Vietnamese Americans to engage in diabetes prevention and management programs. These insights highlight the importance of culturally tailored approaches that address the unique needs and values of this community.
Discussion
Type 2 Diabetes Mellitus affects 11.4% of Asian Americans, resulting in numerous health complications and is a “silent killer” as the fifth leading cause of death in this population (3). Although Asian Americans experience a higher increase in prediabetes and T2DM prevalence compared to other ethnic groups, efforts to address this growing health crisis are often hindered by language limitations, low health literacy, restricted access to healthcare and technology, cultural attitudes toward diet, exercise and disease, and family and community influences (2). Among underrepresented Vietnamese Americans, there is a critical need to understand the key motivators and distractors to adopting healthier lifestyle changes. By applying the TTM, the readiness of participants to engage in DPP or similar programs to change behaviors was examined. This understanding will inform future adaptations of culturally sensitive behavioral health interventions tailored to the unique needs of Vietnamese American individuals.
# Participation in DPP versus modified DPP/Self-management program:
The TTM-based mapping of individual participant levels of engagement has been shown to aid in constructing targeted
diabetes self-management programs (10). Depending on the stage of readiness, understanding which services can motivate each participant to make positive behavioral changes helps optimize limited healthcare resources. This study examines how participants respond to the traditional Centers for Disease Control and Prevention (CDC) translated DPP, a flexible modified DPP, and the use of wearable health feedback devices (Fitbit, Whoop, CGM, Apple phone). Nearly half of the participants (42.3%; n=?) reported confidence in using computers, while more than half (61.6%; n=?) reported confidence in using smartphones.
Differ by age
A recent review of diabetes prevention interventions shows that the mean age of participants in the DPP was 60 years old and skewed towards older ages. However, the cost effectiveness and potential of lifestyle intervention is greatest with a younger cohort of 45 years old or less. Youthful age engagement and intervention can prevent the progression of prediabetes onto diabetes and serious health complications. Recruiting and retaining people between 18 and 60 years of age has been more challenging than recruiting and retaining older people into the DPP. Understanding barriers to recruiting and retaining a younger cohort of people into the diabetes prevention program is essential and is the reason for targeting participants who were 18 to 60 years of age in our focus group study.
The major obstacles for middle-aged participants (between the ages of 45 to 55) to invest in health promoting initiatives are financial and time constraints. This group places lower priority on their own health along with emphasis on work commitment and
earning a living to support the family. Contrast this to (older retirees) with higher self-care interest and more time to engage in the rigorous yearlong DPP program and to (young age) generation focus on better work-life balance. Healthy eating and lifestyle choices can be both costly and time consuming to start and maintain. Nonetheless, younger Vietnamese American cohorts expressed motivation to consider flexible diabetes preventive selfmanagement programs.
Differ by education/Socioeconomics
Awareness of and knowledge of T2DM and its complications have propelled participants to act. Our study demonstrated individuals in the different readiness stages interested in enrolling in a DPP program varies across educational backgrounds.
Empowering people to take control of their health and explore options depends largely on access to health care resources and technology. Those whose socioeconomics allow more advanced alternatives find traditional DPP less attractive and are more open to a flexible less time demanding self-management program utilizing diverse educational platforms. Innovative selfmonitoring interventions such as wearable health devices, Fitbit, Whoop, CGM, Apple phone, that provide real-time feedback on health state are likely available to more health-educated and affluent VA. There is promising data that this self-monitoring feedback can lead to a sense of confidence and control, building “self-efficacy”, and coupled with TTM can enhance progress (5). But as noted by few participants, older Vietnamese Americans may
resist change due to entrenched habits or skepticism of new methods.
The focus group study recruited participants living in Massachusetts, where there is universal health coverage. Despite the amplified access to health-related resources, the DPP is still a relatively unknown and underused community program by both health care providers and participants.
Differ by DM: Having T2DM, PreDM, Family risk factors
A great number of Vietnamese Americans are impacted by T2DM, either being prediabetic or T2DM or having family with the condition. The proximity to T2DM and its health consequences forces involvement in managing this chronic disease that can alter/hinder quality of life. The study group comprises a diverse cohort of participants with diabetes providing insights into their experience as a prediabetic and living with T2DM and those with high risk as prediabetes and family history. The readiness for healthy life choices should vary among T2DM risk groups, but the study shows that the majority of participants, in regards to readiness- DPP/DSME are in the Pre-contemplation (n=8) or Contemplation (n=6), with only one individual in Maintenance, despite having prediabetes or T2DM.
Changes in health behaviors are most transformative to those “at risk” for T2DM, but providers have not put emphasis on education or treatment. A review of 16,713 outpatients at Cleveland clinic revealed that 80% of patients with new prediabetes never receive referral or treatment (17). Although there is limited disparity data in Asians, it is suggested that fewer marginalized Vietnamese Americans patients would have received
T2DM preventive recommendation from their healthcare providers.
Number of Influencers for Adopting health changes:
Vietnamese Americans have cultural imprints that create both barriers and opportunities to adopt healthy preventive habits. Aside from public health efforts against infections and injuries, the preventive medicine combating chronic diseases is still evolving in Vietnam (12). Patients seek medical attention when they suffer from symptoms or complications of an illness. This low emphasis on chronic illness prevention and primary care contributes to the “invisibility” of T2DM and delays in diagnosis and advancement of prediabetes and T2DM interventions. Furthermore, the profound stigma within the Vietnamese Americans community to openly discuss health and complications remains a major challenge. With widespread culturally relevant social media, there is an appreciation for education on healthy lifestyles. Projects to implement educational campaigns in Vietnamese media channels (e.g., ethnic radio, TV, and newspapers) can raise awareness about diabetes prevention and management and highlight success stories from within the community to normalize discussions about health. But some popular social news about health that Vietnamese Americans listen to can propagate “unchecked” information.
Who and what motivates participants to move across stages of commitment to healthy habits varies among individuals. Family and community influence play a pivotal role in health decisions for Vietnamese Americans. Family is significantly involved in health decisions but can also perpetuate unhealthy habits such as shared unhealthy meals involving “nhau” a Vietnamese term that means
to drink and eat for no reason. Community-based programming with family-focused DPP workshops where entire households learn about healthier cooking, portion control, and physical activity can succeed in promoting family health changes.
Many Vietnamese Americans are part of tight-knit religious communities, often revolving around communal meals. Catholicism and Buddhism help guide some Vietnamese Americans daily lives and social gatherings. Religious institutions, cultural practices, and community gatherings shape health behaviors. This social network was used to design programs that partner with churches, temples, and social clubs to host health fairs, screenings, and wellness workshops. Designing culturaltailored public health programs that bring DPP and selfmanagement projects into the community where participants socialize will foster trust therefore better engagement and sustainability.
Traditional Vietnamese cuisine is carbohydrate-rich, which can exacerbate diabetes risk. There is an astounding statement that “rice” and “sweet desserts/fruits” are integral to Vietnamese Americans. To create culturally sensitive Vietnamese meals, it is necessary to collaborate with local Vietnamese chefs or dietitians to modify traditional recipes to include lower glycemic index alternatives while maintaining familiar flavors.
Study Limitations
This research, however, is subject to several limitations. In this study, one major issue that may compromise the significance of this study and should be addressed by further research to appropriately illustrate the impact of T2DM on the Vietnamese
American community is the small sample size, misrepresenting and underestimating the devastation of T2DM. There are many causes for this limitation, but most notably, the cause of this is due to the difficulties in recruiting ethnic minority research participants, such as Vietnamese Americans. Historically, researchers have encountered numerous challenges to assessing and recruiting from researchers have historically encountered challenges to accessing and recruiting those from underrepresented groups. So recruiting participants for health research programs like the DPP is hindered by a range of participant-level, practical, psychological, and systemic barriers. Individual factors include time constraints, transportation issues, linguistic mismatches, fear and mistrust of research, and a lack of awareness about the opportunity to participate. Additionally, poor communication about research and a lack of understanding of cultural differences among ethnic minority groups exacerbate these challenges. Systemic barriers include institutionalized racism, the absence of ethnically diverse researchers, and research designs that fail to align with community values. The DPP faces particular obstacles, such as limited public awareness, low perceived risk, stigma related to weight judgment, and denial of health risks. These are compounded by competing health priorities, psychological barriers like fear of failure and low motivation, and logistical issues, including inadequate referrals from healthcare providers, insufficient marketing, and cultural distrust. These factors collectively contribute to the difficulty in engaging diverse and underserved populations in prevention programs. (8)
Another significant limitation of implementing the DPP is that hospitals and patients often prefer medication and immediate
pharmacological treatments that stabilize their health over lifestyle intervention programs for managing T2DM. Medications provide immediate and measurable outcomes, which are essential in acute care settings where rapid stabilization of patients' health is a priority. In contrast, the DPP emphasizes long-term lifestyle changes, which require ongoing patient effort and participation an approach that may not align with the short-term goals of hospital care and patient expectations. Moreover, hospitals face constraints such as limited resources, including trained personnel, time, and funding, which can make it challenging to allocate support for programs like the DPP. Insurance structures and reimbursement policies also tend to favor medications over intensive lifestyle interventions, further limiting the feasibility of such programs. Finally, hospitalized patients often present with complex, multifaceted health issues, making it difficult to prioritize lifestyle interventions over immediate pharmacological treatments that address urgent needs. (15)
Additionally, a lot of this information is self-reported and therefore subject to biases such as social desirability, recall inaccuracies, and misinterpretation of health-related behaviors. Self-reported data may not always reflect actual adherence to lifestyle changes, dietary habits, or engagement in physical activity, potentially affecting the reliability of the study's findings. Future research should consider incorporating objective measures, such as biomarkers, continuous glucose monitoring (CGM) data, or wearable activity trackers, to provide more accurate assessments of behavioral and physiological changes.
There was also a lack of long-term follow-up data to assess the sustained impact of the DPP on participants’ health outcomes.
Diabetes prevention and management require continuous effort, and without longitudinal studies, it is challenging to determine whether initial behavioral changes translate into lasting improvements in metabolic health. Future studies should prioritize extended follow-up periods to evaluate the program’s long-term efficacy and identify factors influencing sustained engagement. Furthermore, this study aimed to provide insights into the Vietnamese American community, the findings may not be fully generalizable to all Vietnamese Americans due to regional, socioeconomic, and generational differences. Variability in acculturation levels, healthcare access, and cultural perceptions of diabetes may lead to differing health behaviors and intervention responses. Expanding research efforts to include diverse subpopulations and geographical regions can help develop more tailored and inclusive diabetes prevention strategies. Despite these limitations, this study contributes valuable knowledge on the challenges and opportunities in implementing culturally tailored diabetes prevention programs. Addressing these barriers through community engagement, improved recruitment strategies, and structural healthcare reforms can enhance the accessibility and effectiveness of diabetes prevention efforts within the Vietnamese American community.
Conclusion
The findings of this study underscore the critical role of culturally relevant and community-based approaches in enhancing the diabetes prevention and self-management programs for Vietnamese Americans. By recognizing the interplay of cultural beliefs, values, and motivators, interventions can be better aligned with the individuals’ lived realities and readiness to engage. These insights offer a foundation for precision health research focused on developing customized interventions that address the diverse needs and health profiles of Vietnamese Americans, with an emphasis on human-centered design.
Psychosocial phenotyping offers a promising pathway for advancing diabetes prevention among Vietnamese Americans by analyzing measurable behaviors, psychological traits, and social factors. This approach enables health professionals to create personalized interventions that resonate with the lived experiences of individuals and unique challenges in managing diabetes. Effective phenotyping requires a deep understanding of the health behaviors of the community, demographics, and social determinants, helping to identify specific patterns that guide tailored interventions. Focusing on psychosocial characteristics, rather than superficial cultural markers, promotes more effective and sustainable self-management.
Future efforts should explore the role of family dynamics, community networks, and traditional health practices in shaping health behaviors, while testing and refining culturally sensitive interventions. Longitudinal studies will be critical for assessing the long-term effectiveness of these holistic approaches. Expanding research to include various subgroups within the Vietnamese
Americans population can help identify specific barriers and facilitators to diabetes management leading to more effective and culturally responsive health interventions. Addressing these challenges requires increasing awareness, offering flexible and culturally tailored programs, providing incentives, and building trust through community partnerships and targeted outreach. By adopting a multidimensional approach that incorporates cultural, behavioral, and technological strategies, future research and public health initiatives can drive meaningful progress in reducing diabetes disparities within the Vietnamese American community. Ultimately, a comprehensive, culturally informed framework will not only improve diabetes outcomes but also serve as a model for addressing chronic disease prevention and management in other immigrant and minority populations.
Acknowledgements
I am deeply grateful to Dr. Tam Nguyen for the opportunity to contribute to this research and for her invaluable mentorship in expanding my understanding of diabetes and prevention programs. Her guidance and expertise have been instrumental in shaping my research skills and appreciation for community-based healthcare interventions. I also sincerely appreciate Dr. Nguyen and her research team for their support and for providing essential data, including information from the Qualtrics investigator-developed demographic questionnaire and the focus group. Their contributions were crucial in ensuring the depth and accuracy of this study. This project is truly meaningful as it advances research while directly benefiting the Vietnamese American community by
addressing critical health disparities through culturally tailored interventions.
Appendix
Appendix A: interview questions
1) To start us off, can you all share how you are currently managing your health as a person with pre-diabetes?
2) Can we go around the room and share how long we’ve had pre-diabetes?
a) Optional follow-up: how did you find out you have pre-diabetes?
3) Did your healthcare provider give you any suggestions or resources on how to manage your pre-diabetes?
4) Did any of your providers recommend enrolling in a diabetes prevention program? Or have you ever heard about the diabetes prevention program?
a) Clarify/define the program: The diabetes prevention program– or DPP, is a one-year program that helps participants sustain a healthy lifestyle to manage their pre-diabetes. This includes support in weight management and physical activity. As part of this program, participants meet in weekly group sessions that are facilitated by a health coach for the first 6 months. After that, the group meets once a month for the last 6 months.
i) Can you see the benefits of this?
ii) Do you think this is feasible?
5) One main component of the DPP is weight management and healthy eating. Can you share a time when eating healthy was a challenge for you?
a) Optional follow-up: Can I ask, what did you eat yesterday?
6) Another main component of the DPP is regular physical activity. Can you share a time when engaging in physical activity was hard for you?
a) Optional follow-up: Can you give us an example of the physical activity you did this past week?
7) Our diabetes prevention program takes about a year. How do you feel about engaging in a long-term program to prevent diabetes like that?
8) For our particular project, we want participants to wear Fitbits or continuous glucose to monitor and measure how much physical activity they get. How interested would you be in wearing those devices?
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