Health and Social Development, Faculty of (Okanagan)
Health and Exercise Sciences, School of (Okanagan)
DSpace
UBCO
Braaten, Kyra
Master of Science - MSc
University of British Columbia
Rural and remote populations in Canada face health disparities that increase their risk for developing type 2 diabetes (T2D; Public Health Agency of Canada, 2011; Roche et al., 2014). Locating, accessing, and being supported in making behaviour changes in line with T2D prevention guidelines are barriers for rural and remote populations in British Columbia (Keating et al., 2011; Locke et al., 2021 & Public Health Agency of Canada, 2011). A feasible form of support that may be available to these populations is family members as most self-management activities occur at home and are within the family network. Family involvement has been shown to influence adherence to diet and exercise; two health behaviours critical for preventing T2D (Mayberry et al., 2016; Johnson et al., 2013). The aim of this project was to understand how family involvement facilitates and discourages diet and physical activity behaviours among individuals at risk of developing T2D living in rural and remote communities in British Columbia. Ten individuals (five family members and five individuals at risk of T2D) participated in separate semi-structured interviews exploring perceived supportive and unsupportive family behaviours related to diet and physical activity participation. Interviews were analyzed using the adapted Framework Method for dyadic analysis (Collaco et al., 2021) using an abductive approach. Perceived supportive and unsupportive behaviours were coded to the Theoretical Domains Framework (TDF; Michie et al., 2008) and Self and Family Management Framework (SFMF; Grey et al., 2015), and dyadic perspectives were thematically analyzed. Participants reported perceived supportive behaviours (129) and unsupportive behaviours (55). The most frequently coded TDF domains were social influence (199), and environmental context and resources (109). Motivation (114) was most frequently coded from the SFMF. Themes arising from the dyadic analysis included a need for partnership, modelling of healthy behaviours by family members, and differing views on helpful environments. These findings highlight the iv prevalence of family influence on health behaviours and suggest a need to involve family members in diabetes prevention programs. Addressing the most frequently coded domains from the TDF and concepts from the SFMF could improve the quality of family support in diet and physical activity participation leading to better health outcomes and diabetes prevention practices in rural and remote areas in British Columbia.
THE ROLE OF FAMILY SUPPORT IN PREVENTING TYPE 2 DIABETES IN RURAL AND REMOTE BRITISH COLUMBIA by Kyra Braaten B.Sc., University of Saskatchewan, 2021 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE COLLEGE OF GRADUATE STUDIES (Health and Exercise Sciences) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) August 2023 © Kyra Braaten, 2023 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis/dissertation entitled: The role of family support in preventing type 2 diabetes in rural and remote British Columbia submitted by Kyra Braaten in partial fulfillment of the requirements of the degree of Master of Science. Dr. Mary Jung, School of Health and Exercise Sciences Supervisor Dr. Kathleen Martin Ginis, School of Health and Exercise Sciences Supervisory Committee Member Dr. Chelsea Pelletier, University of Northern British Columbia Supervisory Committee Member Dr. Joan Bottorff, School of Nursing University Examiner iii Abstract Rural and remote populations in Canada face health disparities that increase their risk for developing type 2 diabetes (T2D; Public Health Agency of Canada, 2011; Roche et al., 2014). Locating, accessing, and being supported in making behaviour changes in line with T2D prevention guidelines are barriers for rural and remote populations in British Columbia (Keating et al., 2011; Locke et al., 2021 & Public Health Agency of Canada, 2011). A feasible form of support that may be available to these populations is family members as most self-management activities occur at home and are within the family network. Family involvement has been shown to influence adherence to diet and exercise; two health behaviours critical for preventing T2D (Mayberry et al., 2016; Johnson et al., 2013). The aim of this project was to understand how family involvement facilitates and discourages diet and physical activity behaviours among individuals at risk of developing T2D living in rural and remote communities in British Columbia. Ten individuals (five family members and five individuals at risk of T2D) participated in separate semi-structured interviews exploring perceived supportive and unsupportive family behaviours related to diet and physical activity participation. Interviews were analyzed using the adapted Framework Method for dyadic analysis (Collaco et al., 2021) using an abductive approach. Perceived supportive and unsupportive behaviours were coded to the Theoretical Domains Framework (TDF; Michie et al., 2008) and Self and Family Management Framework (SFMF; Grey et al., 2015), and dyadic perspectives were thematically analyzed. Participants reported perceived supportive behaviours (129) and unsupportive behaviours (55). The most frequently coded TDF domains were social influence (199), and environmental context and resources (109). Motivation (114) was most frequently coded from the SFMF. Themes arising from the dyadic analysis included a need for partnership, modelling of healthy behaviours by family members, and differing views on helpful environments. These findings highlight the iv prevalence of family influence on health behaviours and suggest a need to involve family members in diabetes prevention programs. Addressing the most frequently coded domains from the TDF and concepts from the SFMF could improve the quality of family support in diet and physical activity participation leading to better health outcomes and diabetes prevention practices in rural and remote areas in British Columbia. v Lay Summary Individuals living in rural and remote communities in British Columbia (BC) are at an increased risk for developing type 2 diabetes (T2D) and experience inadequate opportunities related to being supported in preventing this condition. A form of support that may be available to individuals living in these areas is family members. It has been shown that family members can improve diet and physical activity habits; two behaviours critical for preventing T2D. Little is known about what is considered supportive and unsupportive in terms of family involvement in diet and physical activity. This thesis conducted interviews with individuals at risk of T2D living in rural and remote communities and their family members to identify what family members do that supports, and discourages, PA participation and eating a healthy diet. Both groups shared their perceptions about how family members help and hinder when it comes to PA and diet routines when living in rural and remote areas of BC. The findings can be used in future T2D prevention programs to improve the quality of family involvement in remote and rural communities. vi Preface I declare that the composition of this dissertation is the result of my own work. I was responsible for the literature review, conception of methods, ethical application and writing of the entire thesis. In collaboration with Natalie Grieve, we were responsible for data collection and analysis. Natalie also served as a critical friend in the interpretation of the analysis. This study protocol analyzed in this work was approved by The University of British Columbia Okanagan Research Services Behavioural Research Ethics Board (H22-03232). Dr. Mary Jung was responsible for overseeing all aspects of the study including editing of the thesis. vii Table of Contents Abstract ....................................................................................................................................................... iii Lay Summary ...............................................................................................................................................v Preface ......................................................................................................................................................... vi Table of Contents ...................................................................................................................................... vii List of Tables ................................................................................................................................................x List of Figures ............................................................................................................................................. xi List of Abbreviations ................................................................................................................................ xii Acknowledgements ................................................................................................................................... xiii Chapter 1: Introduction ..............................................................................................................................1 1.1 Research and Philosophical Position .............................................................................................. 1 1.2 T2D and prediabetes in Canada ...................................................................................................... 1 1.3 T2D and prediabetes in rural and remote communities ................................................................. 2 1.4 T2D prevention .............................................................................................................................. 4 1.5 “Family” Support ........................................................................................................................... 5 1.5.1 Family influence on adherence to health behaviours .............................................................. 5 1.5.2 Family support in diabetes prevention and management ........................................................ 6 1.5.3 Family support in rural and remote areas ............................................................................... 7 1.5.4 Diabetes education and prevention interventions involving family members ........................ 8 1.6 Theoretical Frameworks ................................................................................................................. 9 1.6.1 The Self and Family Management Framework ...................................................................... 9 1.6.2 The Theoretical Domains Framework .................................................................................. 10 1.7 Gaps in the Literature ................................................................................................................... 12 1.8 Objective ...................................................................................................................................... 12 Chapter 2: Manuscript ..............................................................................................................................14 viii 2.1 Overview ...................................................................................................................................... 14 2.1.1 T2D and prediabetes ............................................................................................................. 14 2.1.2 T2D and prediabetes in rural and remote communities ........................................................ 14 2.1.3 T2D prevention ..................................................................................................................... 15 2.1.4 “Family” Support .................................................................................................................. 16 2.1.6 Theoretical Frameworks ....................................................................................................... 17 2.1.7 Objective ............................................................................................................................... 18 2.2 Methods ........................................................................................................................................ 19 2.2.1 Study Design ............................................................................................................................. 19 2.2.2 Participants ............................................................................................................................ 19 2.2.3 Interviews .............................................................................................................................. 20 2.2.4 Analysis Procedure ............................................................................................................... 21 2.2.5 Coding Process ...................................................................................................................... 21 2.2.6 Inter-rater reliability (IRR) ................................................................................................... 24 2.2.7 Demographics ....................................................................................................................... 25 2.2.8 Measures ............................................................................................................................... 25 2.3 Results .......................................................................................................................................... 25 2.3.1 Dyadic Summaries ................................................................................................................ 30 2.3.2 Family life in rural and remote communities ........................................................................ 34 2.3.3 Frequencies of barriers, facilitators, the SFMF, and TDF domains ...................................... 35 2.3.4 IRR ........................................................................................................................................ 38 2.3.5 DPPs involving family members .......................................................................................... 39 2.4 Discussion .................................................................................................................................... 39 2.5 Strengths ....................................................................................................................................... 42 2.6 Limitations .................................................................................................................................... 43 2.7 Future directions ........................................................................................................................... 43 ix Chapter 3: Conclusion ...............................................................................................................................48 3.1 Strengths and Limitations ............................................................................................................. 51 3.2Future Directions ........................................................................................................................... 52 3.3 Conclusion .................................................................................................................................... 53 Bibliography ...............................................................................................................................................54 Appendices ..................................................................................................................................................65 Appendix A: Semi-structured interview guides for individuals at risk of T2D and family members 65 Appendix B: Dyadic summaries ......................................................................................................... 74 Appendix C: Agreements between KB and NG during the deductive coding process ..................... 92 Appendix D: Examples of reflections categorized within Barrier and Facilitators and to the TDF and SFMF ………………………………………………………………………………………………..92 Appendix E: Rural and Remote Communities Themes .................................................................... 98 x List of Tables Table 1: Barriers and Facilitators Codes ....................................................................................... 23 Table 2: Codes for the TDF Domains and SFMF Framework ..................................................... 23 Table 3: Demographic Characteristics of Individuals at Risk of T2D: Demographic Characteristics of Family Members .............................................................................................. 26 Table 4: Demographic Characteristics of Family Members ......................................................... 28 Table 5: Frequencies of barriers and facilitators ........................................................................... 36 Table 6: Frequencies of TDF Domains/ SFMF Framework Components .................................... 37 Table 7: Kappa and PABAK for Deductive Coding ..................................................................... 38 xi List of Figures Figure 1: The Self and Family Management Framework ............................................................. 10 Figure 2: The Theoretical Domains Framework ........................................................................... 12 xii List of Abbreviations A1c: glycosylated hemoglobin APEASE: Affordability, Practicality, Effectiveness, Acceptability, Safety, and Equity BCT: behaviour change techniques BCW: Behaviour Change Wheel COM-B: Capability, Opportunity, Motivation – Behaviour model DPP: Diabetes Prevention Program KB: Kyra Braaten NG: Natalie Grieve MJ: Mary Jung T2D: Type 2 diabetes xiii Acknowledgements I respectfully acknowledge that this work was conducted on the traditional, unceded, and currently occupied territory of the Syilx nation. I am an uninvited guest on these lands with the responsibility of learning the truths about colonization to hold myself accountable, and meaningfully engage in reconciliation. Thank you to my supervisor, Dr. Jung for your invaluable mentorship and support over the last two years. I am incredibly honored to have the privilege to learn from you, and am grateful for the opportunities I have been given as a graduate student in your lab. A special thanks to my committee members, Dr. Martin Ginis and Dr. Pelletier for generously providing their expertise during my proposal meeting. Thank you to Dr. Bottorff for dedicating your time to be my university examiner. This project would not have been possible without the help of Natalie Grieve. Thank you for your dedication to this thesis and guidance throughout the course of my degree. Thank you to my family and partner for encouraging me to move out to Kelowna and continue my education at UBC-O. Your constant support means the world to me. And a final thanks to all members of the DPRG for making this experience such a positive one. I am so thankful to have spent the last two years learning with, and from such a fun and passionate group of individuals. 1 Chapter 1: Introduction 1.1 Research and Philosophical Position I acknowledge that I have not been diagnosed with prediabetes nor am I a family member of someone with prediabetes. For this reason, the results of my study will be informed by my interpretation of responses from those with lived experiences, my philosophical assumptions, the Theoretical Domains Framework (TDF), and the Self and Family Management Framework (SFMF). This study was conducted with a social constructionism philosophical position. Social constructionism emphasizes society, culture, and power relations and their role in how individuals understand and attribute meaning to their experiences (Tamminen et al., 2020). It suggests that social interactions, relationships, and experiences shape an individual’s reality, knowledge, and behaviour (Pryce et al., 2014; Tamminen et al., 2020). It assumes that realities are constantly changing based on negotiations with the social world (Pryce et al., 2014). Adoption of this approach allows researchers to explain how behaviour and individual meaning can be constructed by social interactions. In the context of this study, it will inform how diet and physical activity can be influenced by family relationships, interactions, and behaviours. 1.2 T2D and prediabetes in Canada Type 2 diabetes (T2D) is a metabolic disorder that is characterized by the body’s resistance and deficiency of insulin (Chatterjee et al. 2017). The development of T2D is associated with complications including heart disease, hypertension, kidney disease, and nerve damage (Skoglund et. al., 2022; Uusitupa et al., 2019). As a result, Canadians with T2D are over three times more likely to be hospitalized compared to the general population (Diabetes Canada, 2 2020). A T2D diagnosis can also reduce quality of life through work limitations, economic instability, and mental burden (American Diabetes Association, 2020; Ali et al., 2006). It is estimated that over 11 million Canadians are living with diabetes, with 90% having T2D (Chatterjee et al., 2017; Diabetes Canada, 2022). It is projected that by the year 2032, 30% of the population in Canada will be living with diabetes (Diabetes Canada, 2022). Nearly six million Canadians are living with prediabetes (Diabetes Canada, 2022). Prediabetes is a serious health condition in which blood glucose levels are elevated, and if left unmanaged, progresses to T2D for 70% of people affected (Tabak et al., 2012). The American Diabetes Association defines prediabetes as an HbA1c result of 5.7% to 6.4% while Diabetes Canada considers an HbA1c measurement of 6.0% to 6.4% to be prediabetes. Compared to normoglycemia, prediabetes is associated with a higher risk of cardiovascular disease, microvascular disease, and all-cause mortality (Echouffo-Tcheugui et al., 2021). Prediabetes is reversible, and therefore can be viewed as a critical stage for preventing the onset of T2D (Tabak et al., 2012). 1.3 T2D and prediabetes in rural and remote communities In Canada, rural and remote communities are associated with a high rate of T2D (Public Health Agency of Canada, 2011). Compared to those residing in urban regions, individuals living in rural and remote areas are more likely to be admitted to a hospital or emergency room as a result of diabetes complications (Roche et al., 2014). Additionally, rural Canadians are at a greater risk for developing T2D (Roche et al., 2014). There is an increased prevalence of modifiable risk factors such as physical inactivity and inadequate vegetable and fruit consumption reported in these areas (Mitura et al., 2003; Public Health Agency of Canada, 2011). 3 Compared to their urban counterparts, individuals living in rural and remote communities with, or at risk for chronic conditions often face disadvantages related to accessing and receiving healthcare. This creates challenges related to preventing, being diagnosed, and managing chronic disease (Golembiewski et al., 2022). Residents of rural regions in Canada often report that their health care needs are unmet (Mitura, et al., 2003). A lack of community programs and facilities, fewer physicians and healthcare providers, and limited access to specialists have been reported by individuals living in these areas as challenges to engaging in healthy behaviours (Disler et. al., 2020; Keating et al., 2011; Smith et al., 2016). Among rural and remote residents, the financial cost, limited time, extreme weather, travelling while ill, and delays in obtaining treatment, medication, and services are all barriers associated with distance to health services (Golembiewski et al., 2022 Disler et. al., 2020; Keating et al., 2011). The inability to maintain a continuous relationship with a trusted or established clinician familiar with their health circumstances are also reported as a challenge to receiving adequate care (Golembiewski et al., 2022). Due to small populations, an absence of privacy, and lack of culture sensitivity can also be barriers to patient-centered care in rural and remote communities (Golembiewski et al., 2022). As a result, Canadians living in rural and remote areas are less likely to take action to improve their health (Mitura et al., 2003). Rural and remote communities often lack diabetes specialists and diabetes preventive services (Keating et al., 2011; Locke et al., 2021 & Public Health Agency of Canada, 2011). This poses a unique challenge for rural and remote residents with prediabetes who are hoping to reduce their risk of developing T2D. In British Columbia, locating, accessing, and being supported in making healthy lifestyle changes that are in line with T2D prevention and management guidelines are barriers for residents living in rural areas (Locke et al., 2021). 4 1.4 T2D prevention Modifications to diet and engaging in regular physical activity can prevent or delay the progression to T2D and mitigate the complications associated with both prediabetes and T2D (Tabak et al., 2012). Regular moderate- to vigorous-physical activity can enhance beta cell function and improve insulin sensitivity for those at risk of developing T2D (Galaviz et al., 2018). Diet quality and appropriate caloric intake is also linked to improved beta cell function and reduction of risk factors such as obesity (Galaviz et al., 2018). Several large-scale trials have demonstrated that interventions targeting health behaviours such as diet and exercise can effectively prevent T2D for those diagnosed with prediabetes (Glechner et al., 2018). These diabetes prevention programs (DPPs) have shown improvements in body weight, glycemic and lipid levels (Galaviz et al., 2018). For example, in the United States DPP, 24 counselling sessions addressing diet and exercise resulted in a 58% diabetes risk reduction compared to 31% in the metformin group after three years (Knowler et al., 2002). The Diabetes Prevention Study (DPS) in Finland was a four-year intervention comprised of supervised exercise sessions and dietary counselling that showed T2D risk was also reduced by 58% (Tuomilehto et al., 2001). These laboratory-based trials were costly as they required highly qualified health care providers and were time intensive (The Diabetes Prevention Program Research Group, 2003). For these reasons, these programs are not available or replicable in rural and remote communities in British Columbia. 5 1.5 “Family” Support 1.5.1 Family influence on adherence to health behaviours While healthcare professionals and services can provide invaluable support, the demand for these services often exceeds capacity. A study conducted in Thailand showed that support from family has been shown to compliment health services in improving health outcomes (Quashie et al., 2019). A review of the literature presented multiple definitions of “family”. For this study, family support will be defined by the participants at risk of T2D. This will permit the term “family” to encapsulate the individual who the participant at risk perceives to provide the most valued and consistent support. The term “family”, for example, could encompass a variety of relationships within diverse living situations including non-biological and multi-generational family members. Family members often take an active role in an individual’s health. Older adults are most likely to have conversations about health conditions and symptoms with family members compared to any other social relationship (Gallant et al., 2003). Families often assist with transportation and accompaniment to medical appointments and communicating with healthcare providers (Schulz et al., 2020). It has been shown that family relationships share many similar characteristics to clients and their clinicians. These relationships are characterized through dependability, familiarity of condition and self-care regimens, and close continuous contact (Rosland et al., 2010; Weiss-Laxer et al., 2020). Family is considered one of the most important social relationships for influencing actions to improve health (Umberson et. al., 2010; Wang et al., 2023). They provide the immediate context that shapes the development and maintenance of health behaviours (Weiss-Laxer et al., 2020) and have been shown to strongly influence commitment to diet and exercise routines (Rosland et al., 2010; Umberson et. al., 2010). 6 Activities such as grocery shopping, preparing meals, sharing diets, and exercising are often completed with family members or within the household (Gallant et al., 2007; Warehime et al., 2020). These qualities suggest family members can be considered an asset for fostering health behaviour change and preventing T2D. 1.5.2 Family support in diabetes prevention and management Most diabetes self-management activities occur at home and within the family network (Shaw et. al., 2006). Individuals often view their family members as allies when attempting to make behaviour changes to reduce their risk of developing T2D (Skoglund et. al., 2022). Those diagnosed with prediabetes reported that family members such as spouses and children play an important role in facilitating healthy behaviour changes (Skoglund et. al., 2022). Previous studies have examined perceived facilitators and barriers to making such changes among individuals with prediabetes. It has been reported that family members’ behaviours, norms, and understanding impact attempts to engage in health behaviours such as diet and exercise (Skoglund et. al., 2022). For example, Skoglund and colleagues (2022) concluded on the basis of their meta-synthesis that a mutual understanding by individuals with prediabetes and their family members about the necessity of health behaviour change for prevention increased involvement by family members and motivated those with prediabetes to change their behaviour. Much of the literature has focused on individuals with T2D and family involvement in diabetes management. Familial support has been shown to be a determinant in self-management efforts and diabetes-related outcomes. It has been shown that there are various types of family support that can affect adherence to self-management including, but not limited to, financial, emotional, practical, instrumental or informational support (Gupta et al., 2019). Studies 7 conducted in the United States report that family behaviours can influence an individual’s self-efficacy to engage in and adhere to health behaviours (Mayberry et al., 2012; Johnson et al., 2013). Among those with T2D, supportive family involvement is associated with adherence to diet and physical activity (Mayberry et al., 2016). In contrast, in a study conducted in Norway found that non-supportive behaviours by family members such as nagging and criticism were reported to obstruct perceptions of autonomy, decrease motivation, and increase diabetes related distress (Karlsen et al., 2011). Obstructive family behaviours have also been linked to worse glycemic control (Mayberry et al., 2014). The findings of a qualitative study conducted in Norway indicate that perceived lack or absence of support from family members appears to reduce self-management efforts (Oftedal et al., 2014). 1.5.3 Family support in rural and remote areas Residents of rural areas claim that ‘close-knit communities’ such as family can support their health (Golembiewski et al., 2022). Survey data collected in Thailand indicates that the absence of family support in rural communities could result in worse health outcomes for Thai older adults (Quashie et al., 2019). Individuals who have a chronic disease living in rural regions in Uganda frequently depend on familial support as a result of inconsistent access to healthcare services (Tusibira et al., 2021). However, based on three ethnographic studies conducted in the United States, researchers concluded that family involvement both exacerbates and attenuates issues related to health disparities faced by rural citizens (Congdon et al., 2001). Both formal and informal support has been shown to facilitate self-management behaviours among individuals with T2D in rural and remote communities (Rasmussen et al., 2021). A study in an American rural underserved community found that individuals with T2D were more likely to follow a meal 8 plan and engage in regular foot care when supported by family members (Shaw et al., 2006). Limited knowledge of diabetes, and recommended health behaviours for managing diabetes can have negative implications on the effectiveness and quality of family support (Denham et al., 2007). For example, Denham and colleagues (2007) reported that families can experience problems supporting dietary routines due to partial knowledge about appropriate food choices or receiving inaccurate information about T2D management. This study also concluded from their dyadic analysis of rural Appalachian families that using a family lens when addressing diabetes management could contribute to healthy routines and subsequently result in better outcomes for individuals with T2D and their family members (Denham et al., 2007). 1.5.4 Diabetes education and prevention interventions involving family members Although research suggests that family support can promote positive health behaviours among individuals with and at risk for T2D, there are limited diabetes interventions engaging and educating family members (Fisher et al., 1998; Mayberry et al., 2012; Ross et al., 2015). Researchers conducting a review of 10 studies reporting on interventions involving family members in diabetes management, concluded there was inconsistency and lack of detail pertaining to the theoretical frameworks used, development processes and elements of these interventions (Torenholt et al., 2014. Systematic reviews that have focused on evaluating the role of family and partner support in successful interventions have shown that these programs target adherence to different self-management behaviours including glucose monitoring, medication compliance, diet, and exercise (Gupta et al., 2019). Intended outcomes of interventions involving family members include weight loss, decreased emotional distress and diabetes complications, improved glycemic levels, knowledge of the condition, and recommended behaviours (Gupta et 9 al., 2019). Family members involved have varied from spouses, parents, children, grandchildren, siblings, or close neighborhood friends (Gupta et al., 2019). Interventions designed to include family members often involve them in diabetes self-management education sessions, however, other interventions have also emphasized family problem solving, decision making, or improving support (Pamungkas et al., 2017). Further research and implementation of family interventions to improve diabetes self-management and prevent related complications has been recommended (Gupta et al., 2019). It is suggested that future interventions have flexible and adaptable delivery to accommodate the individual with T2D and their family members (Gupta et al., 2019). Rather than solely providing education, these programs are recommended to be designed to address social determinants of health, family functioning, and supportive behaviours to improve interactions (Thirsk et al., 2021). 1.6 Theoretical Frameworks 1.6.1 The Self and Family Management Framework The Self and Family Management Framework (SFMF) is a model (see Figure 1) used to guide studies addressing self and family management of chronic conditions and inform related interventions (Grey et al., 2015). The framework suggests that in most cases, self-management of a chronic condition occurs within family life and routines. It recognizes the complexity of multilevel factors and relationships that impact chronic conditions among patients and their family members. The framework aims to enhance health behaviours through identifying strategies to help individuals with chronic conditions, their families, and caregivers better understand and manage their illness (Grey et al. 2015). It can be used to support studies 10 examining facilitators, barriers, and processes of self and family management and how they may lead to distal and proximal outcomes. The framework shows that diet, physical activity, and adherence are proximal outcomes that are influenced by various barriers, facilitators, and processes. These proximal categories ultimately determine health status, health care, individual and family outcomes related the chronic condition (Grey et al. 2015). Figure 1: The Revised Self- and Family Management Framework (Grey et al., 2015) Grey, 2015, Nursing Outlook 63(2), 165. Copyright [2015] by Elsevier Inc. Reprinted with permission. 1.6.2 The Theoretical Domains Framework The Theoretical Domains Framework (TDF) synthesizes 33 theories of behaviour and behaviour change in 14 domains (see Figure 2). It was developed to inform and evaluate implementation interventions by identifying cognitive, affective, social, and environmental 11 influences of behaviour (Atkins et al., 2017). The framework can be used to analyze barriers, facilitators, and mechanisms of behaviour change (Atkins et al., 2017). The TDF is systematically linked to the Behaviour Change Wheel (BCW). The BCW is comprised of three layers; the innermost layer outlines sources of a behaviour (Capability, Opportunity, and Motivation), the middle layer contains intervention functions used to address the source of behaviour, and the outermost layer suggests policy categories through which the intervention functions can be delivered (Michie et al., 2014). Using the TDF in research can help to understand a behaviour in context and what is needed to achieve a desired outcome behaviour. Then, the BCW can be used to identify what intervention functions and policies are most likely to be effective in changing the behaviour (Michie et al., 2014). The TDF has been used in previous studies to examine self-management behaviours and dyadic relationships (specific relations between two people) of care recipients and caregivers to propose intervention approaches (Baay et al., 2019; Jeyathevan et al., 2019). 12 Figure 2: The Theoretical Domains Framework (Michie et al., 2014) Michie, 2014, The Behaviour Change Wheel: A Guide to Designing Interventions. Copyright [2014] by Silverback Publishing. 1.7 Gaps in the Literature Rural and remote communities have high rates of prediabetes yet lack resources for preventing the onset of T2D. Family members have been reported to support diabetes prevention and management practices and could be an integral support system to accommodate for these disparities. The relationship between family behaviours and preventing T2D among individuals at an increased risk in rural and remote communities has yet to be examined in Canada. 1.8 Objective The primary objective of this thesis was to explore the role of family support in the context of living with prediabetes in rural and remote areas. Semi-structured interviews were 13 conducted to understand how family behaviours impact diet and physical activity for those at risk of T2D living in rural and remote areas. The SFMF and TDF were utilized to categorize these behaviours and determine if they facilitated or discouraged diet and physical activity participation associated with T2D prevention. Additionally, a systematic abductive dyadic analysis determined contrasting and overlapping themes in perceived supportive and non-supportive family behaviours. There has been limited research using dyadic analysis in qualitative work. A study most similar to this design was by Jeyathevan and colleagues (2019) which utilized a sample of 15 dyads in a study focused on re-building relationships after spinal cord injury. Thus, we aimed for a similar sample size (15 individuals at risk of T2D and 15 family members). To address the overarching objective and the demonstrated gap in the literature, this thesis sought to understand the behaviours by family members that are perceived to impact eating behaviours and participation in physical activity among individuals at risk of T2D living in rural and remote communities. An additional aim was to learn the ways in which these behaviours impact diet and physical activity. This thesis was conducted in order to answer these research questions. The methodology, results, and implications are reported in a manuscript format in the next chapter. 14 Chapter 2: Manuscript . 2.1 Overview 2.1.1 T2D and prediabetes Nearly six million Canadians are currently living with prediabetes (Diabetes Canada, 2022). Prediabetes is a serious condition in which blood glucose levels are elevated, and if left unmanaged, progresses to type 2 diabetes (T2D) in up to 70% of people affected (Tabak et al., 2012). A T2D diagnosis can reduce quality of life as a result of work limitations, economic instability and mental burden, (American Diabetes Association, 2020; Ali et al., 2006) and have associated complications including cardiovascular disease and neuropathy (Skoglund et. al., 2022; Uusitupa et al., 2019). It is projected that by the year 2032, 30% of the Canadian population will have diabetes (Diabetes Canada, 2022). To mitigate the onset of T2D, prediabetes must be viewed as a critical stage for prevention (Tabak et al., 2012). 2.1.2 T2D and prediabetes in rural and remote communities In Canada, rural and remote communities are associated with high rates of prediabetes and T2D (Public Health Agency of Canada, 2011). Physical inactivity and inadequate vegetable and fruit consumption are modifiable risk factors prevalent among these populations (Mitura et al., 2003; Public Health Agency of Canada, 2011). Individuals living in rural and remote communities often face challenges related to preventing, being diagnosed, and managing chronic conditions (Golembiewski et al., 2022). In British Columbia, locating, accessing, and being supported in making healthy lifestyle changes that are in line with T2D prevention and management guidelines are barriers for residents in rural areas (Locke et al., 2021). As a result of 15 these disparities, rural and remote Canadians may be less likely to take action to improve their health (Mitura et al., 2003). 2.1.3 T2D prevention Engaging in regular physical activity and eating a healthy diet can prevent or delay the progression of T2D and mitigate associated complications (Tabak et al., 2012). For those at risk of developing T2D, moderate to vigorous exercise, diet quality, and appropriate caloric intake can reduce risk factors such as obesity (Galaviz et al., 2018). Several large-scale trials have demonstrated that interventions targeting health behaviours such as diet and exercise can effectively prevent T2D for those diagnosed with prediabetes (Glechner et al., 2018). For example, in the United States, the Diabetes Prevention Program (DPP) showed that participants receiving an intervention compromised of diet and exercise counselling resulted in a diabetes risk reduction of 58% compared to 31% in the group receiving the leading pharmaceutical drug treatment for prediabetes 3 years post-intervention (Knowler et al., 2002). The Diabetes Prevention Study in Finland also achieved a diabetes risk reduction of 58% following a four-year intervention that delivered supervised exercise sessions and dietary counselling (Tuomilehto et al., 2001). While these DPPs have demonstrated improvements in clinical outcomes such as body weight, glycemic, and lipid levels, (Galaviz et al., 2018), these laboratory-based trials were costly due to their length and delivery through highly qualified health care providers (The Diabetes Prevention Program Research Group, 2003). For these reasons, these programs are not available or replicable in rural and remote communities in British Columbia. 16 2.1.4 “Family” Support While healthcare professionals and services can provide invaluable support, the demand for these services often exceeds capacity. Support from family members has been shown to compliment health services in improving health outcomes among older adults (Quashie et al., 2019). A review of the literature presented multiple definitions of “family”. For this study, family support will be defined by the participants at risk of T2D. This will permit the term “family” to encapsulate those who provide the most valued and consistent support as perceived by the recipient of this support. The term “family”, for example, could encompass a variety of relationships within diverse living situations including non-biological and multi-generational family members. Family members can be considered a critical support system for diabetes prevention as they provide the immediate context that shapes the development, maintenance and commitment to health behaviours including diet and physical activity (Weiss-Laxer et al., 2020). Individuals diagnosed with prediabetes report that family members such as spouses and children play an important role in facilitating health behaviour changes (Skoglund et. al., 2022). This may be especially important among rural and remote populations lacking other support systems, such as healthcare providers, fitness facilities, and health programs in the community. It has been suggested the absence of family support in rural communities could result in worse health outcomes for older adults (Quashie et al., 2019). While it has been demonstrated that family support can encourage diet and exercise behaviours for individuals at risk of developing T2D, there are limited T2D diabetes interventions involving family members (Fisher et al., 1998; Mayberry et al., 2012; Ross et al., 2015). Among interventions that do exist for individuals with a diagnosis of T2D, most address 17 diabetes management through family education sessions (Pamungkas et al., 2017). However, there are some interventions designed to emphasize family problem solving, decision making, or improving support (Pamungkas et al., 2017). Interventions involving family members in diabetes management have been reported to lack consistency and detail pertaining to theoretical frameworks, development, and program elements (Torenholt et al., 2013). Further research and implementation of family interventions to improve diabetes self-management and prevent related complications are recommended (Gupta et al., 2019). It is suggested that in future these interventions have flexible and adaptable delivery to accommodate the participant as well as their family members (Gupta et al., 2019). Rather than just providing education, these programs have been encouraged to address social determinants of health, family functioning, and supportive behaviours to improve family interactions (Thirsk et al., 2021). 2.1.6 Theoretical Frameworks The Self and Family Management Framework (SFMF) is a model that outlines multilevel factors and relationships that impact individuals with chronic conditions and their family members (Grey et al., 2014). It suggests that in most cases, self-management of a chronic condition and respective outcomes occur within family life and routines. The framework outlines facilitators, barriers, and processes of self and family management and how they may lead to distal and proximal outcomes (Grey et al., 2014). The Theoretical Domains Framework (TDF) was developed to inform and evaluate implementation interventions by identifying cognitive, affective, social, and environmental influences of behaviour (Atkins et al., 2017). The framework outlines 33 theories in 14 domains that can be used to analyze barriers, facilitators, and mechanisms of behaviour change (Atkins et 18 al., 2017). It is systematically linked to the Behaviour Change Wheel (BCW) which is comprised of three layers; the innermost layer outlines sources of a behaviour (Capability, Opportunity, and Motivation), the middle layer contains intervention functions used to address the source of behaviour, and the outermost layer suggests policy categories through which the intervention functions can be delivered (Michie et al., 2014). The TDF can help to understand a behaviour in context before using the BCW to identify intervention functions and policies that are most likely effective in changing the behaviour (Michie et al., 2014). The TDF has been used in previous studies to examine self-management behaviours and dyadic relationships, representing specific relations between two people, of care recipients and caregivers to propose intervention approaches (Baay et al., 2019; Jeyathevan et al., 2019). 2.1.7 Objective The primary objective of this thesis was to explore the role of family support in the context of living with prediabetes in rural and remote areas. Semi-structured interviews were conducted to understand how family behaviours influence diet and physical activity participation for those at risk of T2D living in rural and remote areas. The SFMF and TDF was utilized to categorize these behaviours and determine if they facilitated or discouraged healthy eating and physical activity. Additionally, a systematic abductive dyadic analysis determined contrasts and overlaps in perceived supportive and non-supportive family behaviours. Research Questions: What behaviours by family members are perceived to impact diet and physical activity participation among individuals with prediabetes living in rural and remote communities? In what ways do these family behaviours influence physical activity and nutrition behaviours of the individual at risk of T2D?? 19 2.2 Methods 2.2.1 Study Design Semi-structured interviews with individuals at risk of developing T2D and family members were conducted to explore the relationship between family behaviours and diabetes prevention practices in rural and remote communities. KB interviewed all individuals at risk of T2D and NG interviewed all family members in separate interviews over the phone or on a video conferencing platform at a time that was most convenient for participants. All interviews were audio-recorded and transcribed verbatim in Otter (Version 3.27.0, 2023) and imported to NVivo (Release 1.7.1, 2022) and excel for qualitative analysis. 2.2.2 Participants Participants at risk of T2D and their family members were recruited from January 2023 to May 2023. Eligible participants were individuals living in rural and remote communities in British Columbia and at risk of developing T2D determined through one of the following means: a) a haemoglobin A1c value between 5.7-6.4% b) an American Diabetes Association risk assessment score indicating an increased risk (>5). Rural and remote communities were determined using criteria from British Columbia’s Rural Practice Subsidiary Agreement (BC Ministry of Health, 2022) and Health System Strategy (BC Ministry of Health, 2013). Eligible family members were those considered to provide valued and consistent support to the individual at risk of T2D, and had regular contact with the individual at risk of T2D. Both members of the dyad provided written informed consent prior to scheduling interviews. Ten participants (five dyads) were recruited through local adverting, social media, and the Small Steps for Big Changes diabetes prevention program in Oliver, Prince George and Vanderhoof. 20 2.2.3 Interviews The interview guides were created using the SFMF and the TDF, and informed by interview guides from similar studies that examined chronic disease prevention or management in dyadic relationships (Appendix A). Interviews focused on diet, physical activity, and adherence to these behaviours due to its criticality in preventing T2D. Questions were created based on the SFMF outlined facilitators, barriers and processes shown to determine proximal outcomes such as diet, physical activity and adherence. The 19 domains of the TDF were also used to understand the context of diet and physical activity behaviours. Questions were developed to understand how family members might influence these behaviours within the context of remoteness and rurality. The guides were piloted on a Diabetes Prevention Research Group (DPRG) research assistant and updated based on feedback prior to interviewing participants. Interviews were conducted over the phone or on Zoom depending on participant preference. Individuals at risk of developing T2D and their family members were interviewed separately to capture both individual and dyadic perspectives. Members of each dyad were interviewed by different researchers (KB and NG) to ensure that interviewers were not influenced by a previous informant. This approach is used to help interviewees feel an additional safeguard of secrecy when revealing information about their relationship with their family member (Eisikovits et al., 2010). Pseudonyms were used to keep participant’s responses anonymous and identifiable details were removed from the presentation of data. All interviews were audio recorded using Zoom, transcribed using Otter.ai, and imported to NVivo R1 software for qualitative analysis. 21 2.2.4 Analysis Procedure Analysis of the interviews was guided by the Adapted Framework for Dyadic Analysis (Collaco et al., 2021); a tool founded upon Framework method (Gale et al., 2013) with adapted and additional stages for analyzing both individual and dyadic perspectives. This method is a systematic approach to analyzing and categorizing qualitative data into themes through a systematic process of summarization (Collaco et al., 2021). These frameworks were used to develop a richer understanding of the relationship between the individual at risk of T2D and their family member, their shared and differing perspectives, and the impact that their behaviours have on one another. An abductive approach was used for data analysis. The SFMF and TDF were used to guide deductive analysis and interpretation of the interviews. At the same time, inductive identification of overlaps and contrasts in the individual and dyadic narratives were identified and themes and sub-themes were generated. Themes were also generated for narratives explaining how living in rural and remote communities contextualize family involvement in health behaviours. Using abductive analysis allowed for summarization of research findings to the SFMF and TDF, but also provided opportunity for unanticipated responses that did not align with either of the frameworks. 2.2.5 Coding Process After transcribing the interviews, transcripts and reflective notes were re-read. A table of overarching themes was created by KB using an inductive process in the dyadic analysis. First, 22 transcripts were reviewed and coded for experiences that encompassed both members of the dyad. Once compiled into a table, dyadic summaries were created for each code so that it reflected both individual and dyadic perspectives. These summaries were then reviewed to construct overarching themes and sub-themes (see Appendix B). A table was also created for themes derived inductively that were specific to family involvement in rural and remote communities. During data collection, all participants gave context about living in rural and remote communities that was found to influence family behaviours. During the development of these tables, meetings were held twice with NG who served as a critical friend in this analytic process. During the deductive portion of analysis, transcripts of the individual at risk of T2D and their family members were coded separately by two researchers (KB and NG). Family member behaviours mentioned in the transcripts were identified and coded as: facilitator (a family behaviour that was perceived by the interviewee to encourage healthy eating and/or physical activity), barrier (a family behaviour that was perceived by the interviewee to discourage healthy eating and/or physical activity), both a barrier and facilitator (a family behaviour that was perceived by the interviewee to both encourage and discourage healthy eating and/or physical activity), neither a barrier or a facilitator (a family behaviour that did not have enough context to be categorized as a barrier or facilitator; see Table 1). Through a deductive process, identified family behaviours were then double coded by KB and NG using the TDF domains and facilitators, barriers, and processes of the SFMF (see Appendix D). After independently coding, a comparison query was run within NVivo to identify disagreements between coders. A consensus meeting between KB and NG took place where discrepancies were discussed by KB and NG and resolved by coming to an agreement on a final 23 code for each disagreement. MJ was invited as a third reviewer when needed to reach a consensus. These meetings occurred after independently coding supportive and unsupportive behaviours, and again after coding to the TDF and the SFMF. Table 1: Barriers and Facilitators Codes Code Barriers and facilitators 1 Barrier 2 Facilitator 3 Both a barrier and facilitator 4 Neither a barrier or a facilitator Table 2: Codes for the TDF Domains and SFMF Framework Code TDF domains and SFMF concepts 1 Knowledge 2 Skills 3 Social/profession role and identify 4 Beliefs about capabilities 5 Optimism 6 Beliefs about consequences 7 Reinforcement 8 Intentions 9 Goals 24 Code TDF domains and SFMF concepts 10 Memory, attention, and decision processes 11 Environmental context and resources 12 Social influences 13 Emotion 14 Behavioural regulation 15 Motivation 16 Life patterns 17 Health status 18 Healthcare system 19 Focus on illness needs 20 Living with the condition 21 Health Beliefs 2.2.6 Inter-rater reliability (IRR) Interrater reliability (IRR) was manually calculated using Cohen’s kappa and PABAK. Three rounds of calculating IRR occurred; the first round took place after the first initial interview, the second round was at a ‘halfway point’ when both reviewers had coded 50% of the data, and the third round took place when all deductive coding had been finished. During these rounds, coders met to discuss any potential differences and clarify coding. 25 2.2.7 Demographics Participants were asked in the interviews to report their age, sex, gender, ethnicity, highest level of education completed, marital status, household income, and where they currently reside. 2.2.8 Measures Frequencies of codes for barriers, facilitators, TDF domains (Michie et al., 2014), and SFMF constructs (Grey et al., 2017) were calculated in this analysis. Frequencies were also stratified by family members and individuals at risk of T2D. 2.3 Results Ten interviews were conducted with five dyads; five individuals at risk of T2D, and five family members (three spouses/partners, one sibling, one parent). Of those at risk of developing T2D, 40% identified as women and 60% identified as men, and 100% of family members identified as women. All dyads had frequent contact with one and other and 60% of individuals lived together in the same household. The mean age of participants was 61.9 + 8.3 years. All demographic results can be seen in Table 3 and Table 4. Interviews lasted between 33 minutes to 2 hours. To secure anonymity, identifiable details were removed from quotations, and the pronouns “they” and “them” replaced pronouns used in the interviews. 26 Table 3: Demographic Characteristics of Individuals at Risk of T2D Sample characteristic Frequency Valid Percent Age (in years) 40-49 1 20% 50-59 0 0% 60-69 4 80% 70-79 0 0% Total 5 100% Biological sex Female 2 40% Male 3 60% Total 5 100% Gender Woman 2 40% Man 3 60% Total 5 100% Marital Status Married 3 60% Widow/Widower 1 20% Single 1 20% Total 5 100% Education Level Less than high school 0 0% 27 Sample characteristic Frequency Valid Percent High school or GED 1 20% Trades certification 0 0% College diploma 2 40% University undergraduate degree 2 40% Total 5 100% Annual household income $0-$24,999 0 0% $25,000-$49,999 1 20% $50,000-74,999 2 40% $75,000-$99,999 1 20% $100,000-$124,999 1 20% Missing 0 0% Total 5 100% 28 Table 4: Demographic Characteristics of Family Members Sample characteristic Frequency Valid Percent Age (in years) 40-49 0 0% 50-59 1 20% 60-69 3 60% 70-79 1 20% Total 5 100% Biological sex Female 5 100% Male 0 0% Total 5 100% Gender Woman 5 100% Man 0 0% Total 5 100% Marital Status Married 5 100% Widow/Widower 0 0% Divorced 0 0% Single 0 0% Total 5 100% Relationship to individual with T2D 29 Sample characteristic Frequency Valid Percent Spouse/partner 3 60% Parent 1 20% Child 0 0% Sibling 1 20% Total 5 100% Education Level Less than high school 0 0% High school or GED 0 0% Trades certification 1 20% College diploma 3 60% University undergraduate degree 1 20% University graduate degree 0 0% Total 5 100% Annual household income $0-$24,999 0 0 $25,000-$49,999 0 0 $50,000-74,999 3 60% $75,000-$99,999 1 20% $100,000-$124,999 0 0 Missing 1 20% Total 5 100% 30 2.3.1 Dyadic Summaries While probed about both supportive and unsupportive behaviours, individuals at risk of developing T2D and their family members spoke in depth about perceived supportive behaviours by family members that impacted physical activity participation and eating a healthy diet. Surprisingly, very few unsupportive behaviours were captured in these dyadic summaries. There were three themes (with subsequent sub-themes) constructed by KB and NG from the dyadic analysis that were perceived to impact health behaviours of individuals at risk of T2D: 1) Partnership of the dyad: reflecting on the collaborative effort to engage in healthy behaviours; 2) modelling from family members; describing the health behaviours engaged in, and clinical outcomes experienced by family members that impact the motivation of those at risk of developing T2D; and 3) attitudes of the dyad; reflecting similar and differing health beliefs and values between members of the dyad that impact engagement in health behaviours. Partnership Both individuals at risk of developing T2D and their family members described that engagement in health behaviours was facilitated by mutual interest and a collaborative commitment to physical activity and healthy eating. For example, one of the participants at risk of T2D shared how their partner supports them in eating a healthy diet: By eating what I do, by understanding the impact of what I eat, how critical it is for me, and supporting me, being there. You know, really, making sure I'm doing the right thing. I'm driven to do it, but fully supported not just by my partner but by my kids as well. (Pat) 31 This individual’s partner also viewed their commitment to the same diet to be a supportive behaviour: “I think, you know, the way that I help now, is that I have committed to having the same diet as my partner.” (Sally) This dyadic summary reflects partnership by showing that both individuals in the dyad believe that understanding and committing to the same, healthy diet facilitates healthy eating for the individual at risk of developing T2D. Dyads acknowledged that the probability of adherence is greatly influenced by the willingness of family members to accompany individuals at risk of T2D in the same type of physical activities. Family members’ lack of involvement in physical activity was considered to be unsupportive and was reported in situations where the individuals at risk of T2D lived alone. This theme also recognized that while working as a team to engage in physical activity and eating a healthy diet, being together can also make it easier to succumb to unhealthy behaviours. Participants also described that learning about health together and sharing educational resources can be a facilitator. The importance of reciprocity in relationships was highlighted. It was expressed in multiple dyadic summaries that while it is important for family members to support those at risk of developing T2D, it is important that these family members are also receiving support. It was acknowledged that encouraging healthy behaviours is not necessarily one-sided, and that often each member of the dyad would offer support to one another at different times. Modelling Modelling of healthy behaviours by family members was described as a means to encourage both physical activity participation and adherence to a healthy diet for individuals at risk of developing T2D. For example, one individual at risk of T2D explained that they 32 encouraged a particular family member to participate in the study interview because they viewed them as a role model: “I have chosen a family member who I would like to be like, that I admire, and I think they set the bar.” (Sharon) Their family member also recognized their role in modelling healthy behaviours to support the individual at risk of T2D: “Luckily, we were in contact frequently. Yeah. And because they are in a smaller demographic area they are on their own. So I guess I'm their mentor, their encouragement.” (Patricia) In this summary, both individuals agree that the family member’s modelling of positive health behaviours motivates the individual at risk of T2D. Conversely, dyadic summaries suggested that family members that did not model healthy behaviours were perceived as unsupportive to the individuals at risk of developing T2D. Modelling also captured comparisons made to the health status of family members and its impact on motivation to engage in healthy behaviours. Some individuals reported that observing other family members’ poor health outcomes motivated them to engage in physical activity and eating a healthy diet to avoid similar consequences. Cultural traditions modelled by family members and passed on through generations seemed to negatively influence diet and physical activity choices by creating habits and preferences that support cultural identities among those at risk of developing T2D. Attitudes The dyadic analysis also showed similar and differing attitudes in regard to what was considered supportive and unsupportive when attempting to encourage diet and physical activity. Summaries revealed that sometimes members of the dyad had differing views on physical environments that supported healthy behaviours. In these situations, it was considered unhelpful for the individual 33 at risk of T2D to have conflicting perspectives with their family member. In some dyadic relationships there was inconsistency between members’ beliefs on the degree of family involvement that is considered supportive. Multiple dyads agreed that autonomy among individuals at risk of T2D is not only important, but ultimately determines behaviour. Attitudes also included recognizing that as a family member attempting to support their loved one, it is important to refrain from judgment and criticism. For example, this participant at risk of T2D describes their view on how their family member supports healthy eating: And I think my partner often will point out or will... we might have a conversation about different food choices and so forth, just in a general way, and give viewpoints or information on what would be the optimal, without judging if I want to have an extra cookie or whatever. Get that we have limitations, right. We do what we want kind of thing. So I think just having an interest in trying to eat healthfully without being on a strict regime. (Dan) Their family member explained their perspective on encouraging a healthy diet: I think being respectful and helpful to somebody that's trying to improve is important. Like, I do think it's important, like if I was not eating well, for somebody to check in with me. But I guess it's respecting that balance and making sure that you're trying to model and understand what somebody's going through and be helpful without being judgmental. (Amanda) This dyadic summary shows that both individuals perceive that while having conversations about health is important, it is also important to respect balance and refrain from being judgmental 34 about every choice being made by the individual at risk of T2D. See Appendix B for the complete version with themes and their corresponding subthemes. 2.3.2 Family life in rural and remote communities Participants suggested many ways in which family support is unique in rural and remote communities in comparison to larger centers. Multiple individuals suggested that because there is less time spent commuting within a city, those living in rural and remote communities have more time to spend with their family. Some participants also reported that rural and remote community members have expectations that family members have the responsibility of supporting each other in health behaviours. For example, this participant described: I live with my family member… And like, for example, people would often make comments that I should be caring for them and provide them with the food that they need to be healthy and what not…So I would say that's different in rural communities, because people who know me are telling me well, you should tell your family member to do that.(CL) Participants frequently mentioned characteristics of living in rural or remote communities. Some of the context given about living in these areas were found to influence family behaviours. A common facilitator to engaging in healthy behaviours was accessibility in rural and remote communities. This included access to trails and lakes that encouraged physical activity, and local farms and residential gardens that promoted healthy eating. It was often reported that family members would accompany individuals at risk of T2D in outdoor activities, gardening, and purchasing food from local farms. However, most residents in rural and remote communities also reported that lack of access was also a barrier to participation in physical activity and eating a healthy diet. Most of the communities that participants resided in lacked 35 recreational facilities and grocery stores limiting their opportunities for exercise and nutritious food options. Among these reported barriers, adaptability was frequently mentioned among dyads living in these areas. Participants mentioned multiple attempts to build their own gym and eat what is provided by the land. Many participants reported their dependence on the internet for health education and appointments with healthcare providers stating that family members help seek out health information or diet education online. However, for some, the internet was not accessible and consequently they were not able to obtain health information. Limited social opportunities were considered a barrier to engaging in physical activity. Participants described that due to smaller populations, there is less diversity in group activities offered, and the interests among community members. As a result, individuals at risk of T2D are often dependent on their family members for social support when participating in physical activity. For example, one participant stated: I think there is a difference because you end up relying on each other… I could go up for a ski and meet up with a group of people from within our club, a lot easier (in the city), versus here if I want to go for a ski, it's my partner and me, or just me. (Dan) See Appendix E for more detail about themes related to rural and remote characteristics affecting family involvement and support in diet and physical activity behaviours. 2.3.3 Frequencies of barriers, facilitators, the SFMF, and TDF domains A descriptive overview of the 10 interviews showed that facilitators were coded more frequently (129 times) than barriers (55 times). Less frequent codes were both a barrier and a facilitator (14 times) and neither a barrier or a facilitator (16 times). Stratification of the data between individuals at risk of T2D and family members revealed that family members were 36 more likely to report barriers (31) than those at risk of T2D (24), and that both groups reported a similar number of facilitators (66 and 63 respectively). The most common TDF domains coded were social influences (199), environmental context and resources, (109), beliefs about consequences (71), and intentions (70). These TDF domains were also the most frequent among family members while reinforcement (35) was more frequently coded than beliefs about consequences among individuals at risk of T2D (24). Similar to the TDF, environment and resources (109) were the most frequently coded components of the SFMF for both family members and those at risk of developing T2D. Motivations (114), a domain not included in the TDF, was also one of the most frequently coded components by both groups. See Tables 5 and 6 for more detailed information about frequencies of barriers and facilitators, the TDF, and the SFMF codes. Table 5: Frequencies of barriers and facilitators Code Barrier/Facilitator At risk of T2D Family member Total Frequency 1 Barrier 24 31 55 2 Facilitator 63 66 129 3 Both a barrier and a facilitator 9 5 14 4 Neither a barrier or a facilitator 9 7 16 37 Table 6: Frequencies of TDF Domains/ SFMF Framework Components Code TDF domains At risk of T2D Family member Total Frequency 1 Knowledge 28 28 56 2 Skills 24 17 41 3 Social/profession role and identify 28 15 43 4 Beliefs about capabilities 22 8 30 5 Optimism 17 7 24 6 Beliefs about consequences 24 47 71 7 Reinforcement 35 17 52 8 Intentions 35 35 70 9 Goals 6 7 13 10 Memory, attention, and decision processes 25 23 48 11 Environmental context and resources 53 56 109 12 Social influences 96 103 199 13 Emotion 15 19 34 14 Behavioural regulation 18 20 38 15 Motivation 47 67 114 16 Life patterns 6 7 13 17 Health status 11 18 29 18 Healthcare system 7 5 12 38 Code TDF domains At risk of T2D Family member Total Frequency 19 Focus on illness needs 13 10 23 20 Living with the condition 10 13 23 21 Health Beliefs 33 36 69 2.3.4 IRR Extracted content from participants’ transcripts were included in Cohen’s kappa and PABAK calculations following independent coding by KB and NG of barriers and facilitators, the TDF domains and SFMF components. Calculations indicate substantial agreement (Landis et al., 1977) between coders for barriers and facilitators (Cohens kappa =0.72, PABAK =0.85) and the TDF domains and SFMF components (Cohens kappa= 0.68, PABAK =0.78). IRR is reported in Table 7. Table 7: Kappa and PABAK for Deductive Coding Codification Kappa PABAK Barriers and facilitators KB/NG 0.72 0.85 TDF/SFMF KB/NG 0.68 0.78 39 2.3.5 DPPs involving family members All participants agreed that there is a need to involve family members in diabetes prevention programs. Responses from both individuals at risk of developing T2D and family members determined that partnership, education, and personalization were important components of family participation within DPPs. Partnership reflected participants’ desire to do physical activity simultaneously, learn together about T2D prevention, and consult each other about ways to integrate healthy behaviours into their daily lives. It was suggested that these programs provide education to both individuals at risk of T2D and their family members about how to reduce their risk in ways that are easily digested by the general population. Multiple individuals also recommended that DPPs involving family members be personalized by providing information and activities that can be adapted to various abilities and environments. Participants suggested resources that could be important for the delivery of these programs in rural and remote communities such as access to gym facilities and adequate staffing. These findings highlighted the need for careful consideration and adaptations made to urban DPPs to successfully implement DPPs in rural or remote communities in British Columbia. 2.4 Discussion The current study aimed to understand what behaviours by family members are perceived to impact adherence to diet and physical activity among individuals at risk of developing T2D living in rural and remote communities. A second aim was to determine the ways in which these behaviours impact participation in physical activity and eating a healthy diet. The abductive analysis demonstrated that family members engage in both supportive and unsupportive behaviours that influence diet and physical activity among those at risk of T2D. Three themes 40 were identified from the dyadic analysis that were of impact to these health behaviours: partnership, modelling, and attitudes of the dyad. While most of the literature has focused on family involvement in behaviours to self-manage a diagnosis of T2D, these findings are in congruence with the few studies that have identified supportive and unsupportive family behaviours among those attempting to reduce their risk of T2D. These findings extend on those of prior studies by offering the perspective of family members on their own behaviours in addition to those at risk of T2D. Our results show that family behaviours emulating partnership encourage physical activity and healthy eating for those at risk of developing T2D. Similarly, Wang and colleagues concluded on the basis of reports from participants with prediabetes in this qualitative meta-synthesis that joint family participation can enhance self-management of health behaviours for those with prediabetes (Wang et al., 2023). Our findings expand on this notion by suggesting that these family behaviours may be increasingly important in rural and remote communities where there are less reported social opportunities for improving diet and physical activity routines. Family members modelling positive health behaviours was shown to motivate individuals at risk of T2D to engage in similar activities. Interestingly, both good and poor health outcomes experienced by family members were perceived to encourage diet and physical activity adherence. In congruence with other qualitative studies, poor health outcomes such as a diagnosis of T2D experienced by family members, can prompt individuals at risk of T2D to think and engage in preventive measures (Wang et al., 2023). In contrast, the findings of a related meta-synthesis indicate that family members demonstrating good health can also motivate individuals at risk of T2D through accountability, the desire to have similar outcomes, and reduce potential burden within the family context that the development of T2D may cause 41 (Skoglund et al., 2022). We expand on previous research by demonstrating that family members also recognize their role in being a positive role model and the impact it has on those at risk of T2D. These results also support previous qualitative research exploring cultural traditions and habitual practices passed on through family generations, with findings of perceived negative influence on diet behaviours by both members of the dyad (Skoglund et al., 2022). Overlaps and contrasts were frequently seen in the dyadic summaries in regard to attitudes about health behaviours. Similar attitudes, such as recognizing the importance of autonomy, and respecting balance seemed to support individuals in diabetes prevention efforts. Differing health perspectives and views on helpful environments were frequently noted between members of the dyad and can have a negative impact on health behaviours. Identification of these differences in attitudes is important because it may reflect misunderstanding between the individuals at risk and their family members. Fostering mutual understanding of the necessity of change has been identified as an important factor leading to increased positive family involvement in T2D prevention efforts including encouraging engagement in regular exercise and eating a healthy diet (Skoglund et al., 2023). Results from deductive coding to the TDF and SFMF found that the most frequently identified domains were social influences and environmental context and resources. Intervention functions and BCTs that align with these domains should be considered when designing DPPs for individuals at risk of T2D and their family members. These findings from both analyses suggest that because of their influence on health behaviours, family members play a critical role in T2D prevention among those at risk in rural and remote communities in British Columbia. 42 2.5 Strengths To the best of our knowledge this is one of the first studies to provide insight on family support and diabetes prevention practices among those at risk of T2D in rural and remote communities. The frequency of supportive behaviours by family members identified in this analysis suggest the beneficial impact family members can have on T2D prevention. This study allows an opportunity for individuals living in rural and remote communities in British Columbia to speak about perceived family support in the context of eating a healthy diet and participating in physical activity. A further strength of this research is focussing on rural and remote locations who have been traditionally ignored in the development and implementation of DPPs. Existing literature suggests that in addition to considering the experiences and perspectives of those with prediabetes, future studies should seek to understand the opinions of family members of these individuals (Wang et al., 2023). Performing a dyadic analysis offered insight into individual and group meanings, as well as contrasts and overlaps between perspectives (Eisikovits & Koren, 2010). This method of triangulation provided a holistic lens of supportive and unsupportive behaviours engaged in by family members that affect diabetes prevention efforts. Further, gaining insight from the individual at risk of T2D, and their family members, could improve the design of DPP’s involving both members of the dyad. Studies examining family involvement in T2D prevention are often conducted with spouses and other immediate family members (Hingle et al., 2019; Soltero et al., 2018). It has been suggested that future work consider cultural differences and global changes when defining family (Torenholt et al., 2013). The definition of family used for this study allowed for more diversity and inclusion amongst cultures and environments as it could encompass a variety of relationships within diverse living situations. This allowed us to learn about the importance of 43 family involvement outside of the immediate family context or household and its criticality in remote and rural communities. 2.6 Limitations Unsupportive behaviours were less frequently reported by participants of this study. A limitation of dyadic analysis was revealed in the recruitment process of this study when individuals at risk of T2D expressed interest in participating but did not have a family member that they considered to provide them with support. These individuals were deemed ineligible because there was no way to conduct the dyadic analysis without the participation of a family member. It is also possible that individuals who did not feel supported by their family members to engage in healthy behaviours refrained from reaching out to participate in this study. As a result, unintentional selection bias may have occurred, precluding insights about unsupportive behaviours from surfacing. A second limitation is that we did not reach our intended sample size. This may have implications as having more participants may have resulted in different themes and sub-themes identified in the interviews. A sample of only 5 dyads impacted our ability to reach a diverse sample of the population in British Columbia. 2.7 Future directions Our findings allowed for an initial mapping of the TDF to identify appropriate intervention functions that were in alignment with most frequently coded domains. Future research should continue this rigorous process and could expand on these findings by applying the APEASE criteria (Affordability, Practicality, Effectiveness, Acceptability, Safety, and 44 Equity; Michie et al., 2014) to identified intervention functions and their corresponding BCTs for the design of, and adaptations to DPPs involving family members. Furthermore, knowledge translation strategies to communicate perceived supportive and unsupportive behaviours to family members should be examined and implemented to successfully disseminate the knowledge gained to the general public so it can be used to guide future behaviours and decisions made by family members. Perspectives from individuals at risk of T2D who may not have a family member to participate would be a valuable next step in future research exploring the role of familial support. While they may not be included in a dyadic analysis, their perspectives on the absence of family involvement and non-supportive behaviours could further inform influences on prevention and self-management efforts of T2D and other chronic conditions. All family members that participated in this study identified as women. Future work should examine gender-related differences in family involvement and work to understand how interventions could be tailored to family members based on gender roles and preferences. Since culture and structural determinants have been shown to influence health behaviours, this should also be addressed in future research. 2.8 Implications Study findings are in line with previous literature suggesting that involving family members in DPPs can promote adoption, maintenance, and adherence to health behaviours for individuals at risk of T2D. Participants of this study suggested that partnership, education, and personalization be components of DPPs in rural and remote communities. Partnership was a 45 theme identified in the dyadic summaries that can support diet and physical activity behaviours among those at risk of developing T2D. This aligns with Skoglund and colleague’s recent meta-synthesis, which suggested that participants can benefit from having the opportunity to share their experiences, exchange ideas, and motivate each other (Skoglund et al., 2022). Joint family participation in DPPs could also promote the health of the supporting family member as well. Suggestions by participants for educational components are in line with recent qualitative research stating that family participation in diabetes prevention education can foster mutual understanding of the criticality of diet and exercise and encourage completion of self-management goals (Wang et al., 2023). Dyadic components such as diet and exercise education and motivational skills training suggested by participants in this study have also been previously recommended for programs focusing on self-management of T2D (Gupta et al., 2019). Differing attitudes was a common theme among dyads in this study that affected diabetes prevention practices. This could be addressed by providing education and fostering a mutual understanding between the individual at risk and their family member. Personalization reflected the need for intervention components to be tailored to the unique needs and abilities of each participant. Ensuring that programs are personalized could also foster autonomy. It was reported by multiple dyads that adapting recommendations surrounding engagement in diet and exercise behaviours to rural and remote community realities was already something practiced by individuals at risk of T2D and their family members. Previous researchers have discussed the need for family-based interventions to be founded on theoretical constructs (Pamungkas et al., 2017; Torenholt et al., 2013). Our study provides a preliminary foundation based on the TDF that could be used to develop interventions or adapt existing DPPs to include family members. The TDF domains most frequently coded in 46 both members of the dyad were social influences and environmental context and resources. An initial mapping of these domains to the BCW suggests that the most appropriate intervention functions are environmental restructuring, modelling, and enablement - all of which correspond with the policy categories of service provision, environmental and social planning, and legislation. Interestingly, modelling by family members was a prominent theme in the dyadic analysis that facilitated physical activity and healthy diet behaviours. Interventions that support family members in these health behaviours may assist in reducing the risk of developing T2D. For example, a DPP that encourages families to model diet choices and exercise that is in line with T2D prevention could address the TDF domain of social influences through a service provision. A DPP that fosters dyadic conversations about ways to engage in recommended health behaviours that is appropriate to circumstances of those living in rural and remote communities could be a way of addressing the environmental context and resources domain through environmental and social planning. From the SFMF’s outlined barriers and facilitators, the results of this study suggest that among individuals at risk of developing T2D and their family members living in rural and remote communities in BC, resources, the environment, and motivation have the most prominent impact on diet, physical activity, and adherence. It could be effective to focus on addressing these concepts from the framework in future interventions that are delivered to both members of the dyad. For example, for DPPs that expand into rural and remote communities in BC, the design of intervention components that involve family members and target such domains and themes to change family behaviours should be considered as a strategy to sustaining health behaviours among individuals at risk of T2D. For example, interventions that provide individuals at risk of T2D and their family members with instrumental or educational resources that assist in 47 diabetes prevention practices could increase the likelihood of physical activity engagement and healthy eating behaviours. DPPs using motivational interviewing informed techniques among the individuals at risk of T2D and the family members could be an effective way to elicit behaviour changes. 48 Chapter 3: Conclusion Rural and remote populations in Canada face health disparities that increase their risk for developing T2D (Public Health Agency of Canada, 2011; Roche et al., 2014). Locating, accessing, and being supported in making behaviour changes in line with T2D prevention guidelines are barriers for rural and remote populations in British Columbia (Keating et al., 2011; Locke et al., 2021 & Public Health Agency of Canada, 2011). A feasible form of support that may be available to these populations is family members since most self-management activities occur at home and are within the family network. Family is considered one of the most important social relationships for influencing actions to improve health (Umberson et. al., 2010; Wang et al., 2023). They provide the immediate context that shapes the development and maintenance of health behaviours (Weiss-Laxer et al., 2020) and have been shown to strongly influence commitment to diet and exercise routines (Rosland et al., 2010; Umberson et. al., 2010). This study identified supportive and unsupportive behaviours by family members that were perceived to influence participation in physical activity and adherence to a healthy diet among individuals at risk of T2D living rural and remote communities in BC. Separate, semi-structured interviews with individuals at risk of developing T2D living in rural and remote communities and their family members were analyzed using an abductive approach guided the by the adapted Framework for dyadic analysis (Collaço et al., 2021). Identified family behaviours were coded deductively using the TDF (Michie et al., 2014) and the SFMF (Grey et al., 2017) and inductively analyzed for themes in dyadic summaries. Three prominent themes were generated from the dyadic summaries: 1) partnership, 2) modelling, and 3) attitudes. Partnership reflected a mutual interest and a collaborative commitment to physical activity and healthy eating. Both members of the dyad acknowledged 49 that this joint participation in healthy behaviours facilitated adherence for those at risk of developing T2D. Family members that modelled healthy behaviours and good health status were perceived to motivate individuals to engage in diabetes prevention practices. In contrast, dyads also agreed that family members who demonstrated poor health status or developed chronic conditions motivated individuals to reduce their risk through diet and physical activity routines. Individuals at risk of T2D and their family members shared some similar attitudes that positively influenced health behaviours of those at risk. Some dyads presented differing views on helpful environments and the degree of desired family involvement in self-management which could negatively influence health behaviours. All participants mentioned characteristics of living in rural or remote environments that contextualized the behaviours that families did engage in and how family support might differ in these communities compared to larger centers. This included the degree of time spent with family, community member expectations, and barriers and facilitators to diet and physical activity. It was found that family support is unique in these areas as individuals at risk of T2D may rely more heavily on family members for social support as a result of these rural and remote characteristics. Taken together, these findings suggest that involving family members in DPPs delivered to individuals living in rural and remote communities could be a critical strategy for implementation. The existing literature also discusses the need for a clear understanding of the theoretical basis needed to effectively involve family members in these programs (Pamungkas et al., 2017; Torenholt et al., 2013). Our study provides a preliminary foundation based on the TDF that could be used to develop interventions or adapt existing DPPs to include family members. The most commonly identified SFMF and TDF domains were social influences and environmental context 50 and resources. This suggests that interpersonal processes, circumstances of the environment, and available resources were most frequently reflected in the family behaviours that influence diet and physical activity. Environmental restructuring, modelling, and enablement are associated interventions functions that could be used in future implementation of family components to DPPs (Michie et al., 2014). Dyads also made suggestions about ways to involve family members in DPPs that are in congruence with some intervention functions and themes from the analyses. Recommendations included promoting partnership, providing dyadic education, and personalizing the delivery of the intervention the individual at risk of T2D. Results of this study including the perceived supportive behaviours such as joint participation and modelling are in line with existing literature (Wang et al., 2023; Skokglund et al., 2022). Our findings extend on the results of previous research by providing dyadic perspectives, additional supportive and unsupportive family behaviours that influence diet and physical activity, and a lens that is situated in remoteness and rurality. It has been recommended that to improve future family interventions focusing on T2D self-management, behaviours and functioning of the entire family must be addressed (Torenholt et al., 2013). The methods used in this study attempt to understand interpersonal processes through identification of perceived supportive and unsupportive behaviours from individual and dyadic perspectives. Understanding behaviours engaged in by family members that support diet and physical activity can help to inform DPPs that work to elicit such behaviours among family members. 51 3.1 Strengths and Limitations The results of this study provide separate, shared, and differing perspectives from the individuals at risk of T2D and their family members about family involvement in T2D prevention efforts. Using dyadic analysis allowed us to gather information from multiple sources about perceived supportive and unsupportive family behaviours which could be seen as a method of triangulation (Eisikovits & Koren, 2010; Hochman et al., 2020). These perspectives will help tailor future family interventions to meet the needs of both members of the dyad when integrating program elements to facilitate and improve supportive behaviours for T2D prevention. The use of separate interviews allowed each individual to respond to questions without having to consider the reaction of the other member of the dyad (Eisikovits & Koren, 2010). Utilizing a semi-structured approach respected the narratives of participants and allowed the conversation to follow topics that they perceived as the most important in regard to family behaviours and diabetes prevention practices. This study follows the recommendations of previous literature by including a theoretical framework to analyze behaviours and subsequently suggest future intervention elements (Pamungkas et al., 2017; Torenholt et al., 2013). Including two independent coders in the deductive analysis to the TDF and SFMF reduced coder bias in interpreting participant meanings and a high agreement enables confidence in the results produced (McGowan et al., 2020). Lastly, findings indicated the need for consultation and consideration of individuals living in rural and remote communities in order to develop programs that meet the needs of these populations. This study allowed the opportunity for individuals living in rural and remote communities in BC to speak about the influence of family behaviours on participation in physical activity and eating a healthy diet. These populations are typically under-represented in the development of DPPs. 52 Despite these strengths, this study is not without limitations. It is possible that an unintentional selection bias may have occurred in the recruitment process as individuals that did not perceive to have a family member providing support to them may have not participated. As a result, we could have missed key insights about unsupportive family behaviours impacting T2D prevention efforts. By not reaching our intended sample size, there was lack of diversity and may have been additional themes missed in our analysis. 3.2 Future Directions In order to address this study’s limitations, future research conducting dyadic analysis should consider eligibility criteria that allows individuals to participate without the requirement of a family member. This could help mitigate the chances of selection bias while also increasing the chances of learning about unsupportive behaviours and possibly the absence of support from family members in physical activity participation and diet adherence. Due to our sample of family members all identifying as women, research should focus on gender-related differences in supportive behaviours and involvement in health behaviour change for T2D prevention. Additionally, future work could focus on recruitment strategies to reach a more diverse sample of the population. To expand on the initial mapping of frequently identified TDF domains to the BCW, future work could apply the APEASE criteria (Affordability, Practicality, Effectiveness, Acceptability, Safety, and Equity; Michie et al., 2014) to the identified interventions functions and their BCT’s that align with the TDF domains identified to guide future adaptations and implementation of DPPs involving family members. To successfully translate these results to family members to improve the quality of support in T2D prevention practices, future research 53 should involve end-users in identifying the best knowledge translation strategies to communicate these findings. 3.3 Conclusion Including family members in DPPs is an integral part of sustaining health behaviours and ultimately preventing the development of T2D for those at risk. DPPs aimed at improving the quality of support may be especially important for individuals living in rural and remote communities that face disparities related to being supported in diabetes prevention practices. This study provides insight into behaviours engaged in by family members that are perceived to be supportive and unsupportive of health behaviours critical for diabetes prevention. These findings reflect themes, considerations, and intervention functions that should be taken into account when implementing future DPPs involving family members in rural and remote communities. 54 Bibliography Atkins, L., Francis, J., Islam, R., O’Connor, D., Patey, A., Ivers, N., Foy, R., Duncan, E. M., Colquhoun, H., Grimshaw, J. M., Lawton, R., & Michie, S. (2017). A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science, 12(1), 77. https://doi.org/10.1186/s13012-017-0605-9 Baay, S., Hemmelgarn, B., Tam-Tham, H., Finlay, J., Elliott, M. J., Straus, S., Beanlands, H., Herrington, G., & Donald, M. (2019). Understanding Adults With Chronic Kidney Disease and Their Caregivers’ Self-Management Experiences: A Qualitative Study Using the Theoretical Domains Framework. Canadian Journal of Kidney Health and Disease, 6, 205435811984812. https://doi.org/10.1177/2054358119848126 Bean, C., Dineen, T., Locke, S. R., Bouvier, B., & Jung, M. E. (2021). An Evaluation of the Reach and Effectiveness of a Diabetes Prevention Behaviour Change Program Situated in a Community Site. Canadian Journal of Diabetes, 45(4), 360–368. https://doi.org/10.1016/j.jcjd.2020.10.006 BC Office of the Provincial Health Officer. Taking the Pulse of the Population. (2019). https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/reports-publications/annual-reports/pho-annual-report-2019.pdf. Chatterjee, S., Khunti, K., & Davies, M. J. (2017). Type 2 diabetes. The Lancet, 389(10085), 2239–2251. https://doi.org/10.1016/S0140-6736(17)30058-2 Collaço, N., Wagland, R., Alexis, O., Gavin, A., Glaser, A., & Watson, E. K. (2021). Using the Framework Method for the Analysis of Qualitative Dyadic Data in Health Research. Qualitative Health Research, 31(8), 1555–1564. 55 Congdon, J. G., & Magilvy, J. K. (2001). Themes of rural health and aging from a program of research. Geriatric Nursing, 22(5), 234–238. https://doi.org/10.1067/mgn.2001.119471 Denham, S. A., Manoogian, M. M., & Schuster, L. (2007). Managing family support and dietary routines: Type 2 diabetes in rural Appalachian families. Families, Systems & Health, 25(1), 36–53. Diabetes in Canada: Facts and figures from a public health perspective. (2011). Public Health Agency of Canada. Diabetes Canada. (2021). Retrieved from https://www.diabetes.ca Diabetes Canada. (2022). Retrieved from https://www.diabetes.ca Disler, R., Glenister, K., & Wright, J. (2020). Rural chronic disease research patterns in the United Kingdom, United States, Canada, Australia and New Zealand: A systematic integrative review. BMC Public Health, 20(1), 770. https://doi.org/10.1186/s12889-020-08912-1 Echouffo-Tcheugui, J. B., & Selvin, E. (2021). Prediabetes and What It Means: The Epidemiological Evidence. Annual Review of Public Health, 42(1), 59–77. https://doi.org/10.1146/annurev-publhealth-090419-102644 Eisikovits, Z., & Koren, C. (2010). Approaches to and Outcomes of Dyadic Interview Analysis. Qualitative Health Research, 20(12), 1642–1655. https://doi.org/10.1177/1049732310376520 Fisher, L. W., Chesla, C. A., Bartz, R. J., Gilliss, C., Skaff, M. A., Sabogal, F., Kanter, R. A., & Lutz, C. P. (1998). The Family and Type 2 Diabetes: A Framework for Intervention. The Diabetes Educator, 24(5), 599–607. https://doi.org/10.1177/014572179802400504 56 Gale, N. K., Heath, G., Cameron, E., Rashid, S., & Redwood, S. (2013). Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology, 13(1), 117. https://doi.org/10.1186/1471-2288-13-117 Gallant, M. P. (2003). The Influence of Social Support on Chronic Illness Self-Management: A Review and Directions for Research. Health Education & Behavior, 30(2), 170–195. https://doi.org/10.1177/1090198102251030 Gallant, M. P., Spitze, G. D., & Prohaska, T. R. (2007). Help or Hindrance? How Family and Friends Influence Chronic Illness Self-Management among Older Adults. Research on Aging, 29(5), 375–409. https://doi.org/10.1177/0164027507303169 Galaviz, K. I., Narayan, K. M. V., Lobelo, F., & Weber, M. B. (2018). Lifestyle and the Prevention of Type 2 Diabetes: A Status Report. American Journal of Lifestyle Medicine, 12(1), 4–20. https://doi.org/10.1177/1559827615619159 Glechner, A., Keuchel, L., Affengruber, L., Titscher, V., Sommer, I., Matyas, N., Wagner, G., Kien, C., Klerings, I., & Gartlehner, G. (2018). Effects of lifestyle changes on adults with prediabetes: A systematic review and meta-analysis. Primary Care Diabetes, 12(5), 393–408. https://doi.org/10.1016/j.pcd.2018.07.003 Golembiewski, E. H., Gravholt, D. L., Torres Roldan, V. D., Lincango Naranjo, E. P., Vallejo, S., Bautista, A. G., LaVecchia, C. M., Patten, C. A., Allen, S. V., Jaladi, S., & Boehmer, K. R. (2022). Rural Patient Experiences of Accessing Care for Chronic Conditions: A Systematic Review and Thematic Synthesis of Qualitative Studies. The Annals of Family Medicine, 20(3), 266–272. https://doi.org/10.1370/afm.2798 57 Grey, M., Knafl, K., & McCorkle, R. (2006). A framework for the study of self- and family management of chronic conditions. Nursing Outlook, 54(5), 278–286. https://doi.org/10.1016/j.outlook.2006.06.004 Grey, M., Schulman-Green, D., Knafl, K., & Reynolds, N. R. (2015). A revised Self- and Family Management Framework. Nursing Outlook, 63(2), 162–170. https://doi.org/10.1016/j.outlook.2014.10.003 Gupta, L., Khandelwal, D., Lal, P. R., Gupta, Y., Kalra, S., & Dutta, D. (2019). Factors Determining the Success of Therapeutic Lifestyle Interventions in Diabetes – Role of Partner and Family Support. European Endocrinology, 15(1), 18–24. https://doi.org/10.17925/EE.2019.15.1.18 Haw, J. S., Galaviz, K. I., Straus, A. N., Kowalski, A. J., Magee, M. J., Weber, M. B., Wei, J., Narayan, K. M. V., & Ali, M. K. (2017). Long-term Sustainability of Diabetes Prevention Approaches: A Systematic Review and Meta-analysis of Randomized Clinical Trials. JAMA Internal Medicine, 177(12), 1808–1817. https://doi.org/10.1001/jamainternmed.2017.6040 Hingle, M. D., Turner, T., Going, S., Ussery, C., Roe, D. J., Saboda, K., Kutob, R., & Stump, C. (2019). Feasibility of a family-focused YMCA-based diabetes prevention program in youth: The E.P.I.C. Kids (Encourage, Practice, and Inspire Change) Study. Preventive Medicine Reports, 14, 100840. https://doi.org/10.1016/j.pmedr.2019.100840 Hochman, Y., Segev, E., & Levinger, M. (2020). Five Phases of Dyadic Analysis: Stretching the Boundaries of Understanding of Family Relationships. Family Process, 59(2), 681–694. https://doi.org/10.1111/famp.12466 58 Iphofen, R., & Tolich, M. (2018). The SAGE Handbook of Qualitative Research Ethics. SAGE Publications Ltd. Jeyathevan, G., Cameron, J. I., Craven, B. C., Munce, S. E. P., & Jaglal, S. B. (2019). Re-building relationships after a spinal cord injury: Experiences of family caregivers and care recipients. BMC Neurology, 19(1), 117. https://doi.org/10.1186/s12883-019-1347-x Johnson, M. D., Anderson, J. R., Walker, A., Wilcox, A., Lewis, V. L., & Robbins, D. C. (2013). Common dyadic coping is indirectly related to dietary and exercise adherence via patient and partner diabetes efficacy. Journal of Family Psychology, 27(5), 722–730. https://doi.org/10.1037/a0034006 Jung, M. E., Locke, S. R., Bourne, J. E., Beauchamp, M. R., Lee, T., Singer, J., MacPherson, M., Barry, J., Jones, C., & Little, J. P. (2020). Cardiorespiratory fitness and accelerometer-determined physical activity following one year of free-living high-intensity interval training and moderate-intensity continuous training: A randomized trial. The International Journal of Behavioral Nutrition and Physical Activity, 17, 25. https://doi.org/10.1186/s12966-020-00933-8 Karlsen, B., Oftedal, B., & Bru, E. (2012). The relationship between clinical indicators, coping styles, perceived support and diabetes-related distress among adults with type 2 diabetes. Journal of Advanced Nursing, 68(2), 391–401. https://doi.org/10.1111/j.1365-2648.2011.05751.x Keating, N., Swindle, J., & Fletcher, S. (2011). Aging in Rural Canada: A Retrospective and Review*. Canadian Journal on Aging / La Revue Canadienne Du Vieillissement, 30(3), 323–338. https://doi.org/10.1017/S0714980811000250 59 Knowler, W. C., Barrett-Connor, E., Fowler, S. E., Hamman, R. F., Lachin, J. M., Walker, E. A., Nathan, D. M., & Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The New England Journal of Medicine, 346(6), 393-403. https://doi.org/10.1056/NEJMoa012512 Landis, J. R., & Koch, G. G. (1977). The Measurement of Observer Agreement for Categorical Data. Biometrics, 33(1), 159–174. https://doi.org/10.2307/2529310 Lindström, J., Peltonen, M., Eriksson, J. G., Ilanne-Parikka, P., Aunola, S., Keinänen-Kiukaanniemi, S., Uusitupa, M., Tuomilehto, J., & for the Finnish Diabetes Prevention Study (DPS). (2013). Improved lifestyle and decreased diabetes risk over 13 years: Long-term follow-up of the randomised Finnish Diabetes Prevention Study (DPS). Diabetologia, 56(2), 284–293. https://doi.org/10.1007/s00125-012-2752-5 Locke, S. R., Dix, G., Te Hiwi, B., Oelke, N. D., Rush, K. L., Berg, S., Dinwoodie, M., Jung, M. E., & Martin Ginis, K. A. (2021). Improving Diabetes Care in the British Columbia Southern Interior: Developing Community‒University Initiatives to Address Service Gaps. Canadian Journal of Diabetes, 45(1), 5-14.e2. https://doi.org/10.1016/j.jcjd.2020.04.003 Mayberry, L. S., Harper, K. J., & Osborn, C. Y. (2016). Family behaviors and type 2 diabetes: What to target and how to address in interventions for adults with low socioeconomic status. Chronic Illness, 12(3), 199–215. https://doi.org/10.1177/1742395316644303 Mayberry, L. S., & Osborn, C. Y. (2014). Family involvement is helpful and harmful to patients’ self-care and glycemic control. Patient Education and Counseling, 97(3), 418–425. https://doi.org/10.1016/j.pec.2014.09.011 60 Mayberry, L. S., & Osborn, C. Y. (2012). Family Support, Medication Adherence, and Glycemic Control Among Adults With Type 2 Diabetes. Diabetes Care, 35(6), 1239–1245. http://dx.doi.org/10.2337/dc11-2103 McGowan, L. J., Powell, R., & French, D. P. (2020). How can use of the Theoretical Domains Framework be optimized in qualitative research? A rapid systematic review. British Journal of Health Psychology, 25(3), 677–694. https://doi.org/10.1111/bjhp.12437 Michie, S., West, R., Campbell, R., Brown, J., & Gainforth, H. (2014). ABC of behaviour change theories. Silverback Publishing. Ministry of Health (2023, March 9). Rural Practice subsidiary agreement. Province of British Columbia. https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/physician-compensation/rural-practice-programs/rural-practice-subsidiary-agreement Mitura, V., & Bollman, R. D. 2003. The health of rural Canadians: A rural-urban comparison of health indicators. Statistics Canada, 4(6), 1-23. Morgan, D. L. (2016). Essentials of Dyadic Interviewing. Routledge. https://doi.org/10.4324/9781315429373 Oftedal, B. (2014). Perceived support from family and friends among adults with type 2 diabetes. European Diabetes Nursing, 11(2), 43–48. https://doi.org/10.1002/edn.247 Pamungkas, R. A., Chamroonsawasdi, K., & Vatanasomboon, P. (2017). A Systematic Review: Family Support Integrated with Diabetes Self-Management among Uncontrolled Type II Diabetes Mellitus Patients. Behavioral Sciences (Basel, Switzerland), 7(3), E62. https://doi.org/10.3390/bs7030062 61 Pryce, J., Spencer, R., & Walsh, J. (n.d.). Philosophical Approaches to Qualitative Research. 19. Quashie, N. T., & Pothisiri, W. (2019). Rural-urban gaps in health care utilization among older Thais: The role of family support. Archives of Gerontology and Geriatrics, 81, 201–208. https://doi.org/10.1016/j.archger.2018.12.011 Rasmussen, B., Wynter, K., Rawson, H. A., Skouteris, H., Ivory, N., & Brumby, S. A. (2021). Self-management of diabetes and associated comorbidities in rural and remote communities: A scoping review. Australian Journal of Primary Health, 27(4), 243–254. http://dx.doi.org/10.1071/PY20110 Ritchie, J., Spencer, L., & O’Connor, W. (2003). Carrying out qualitative analysis. In J. Ritchie & J. Lewis (Eds.), Qualitative research practice: A guide for social science students and researchers. Roche, M. M., & Wang, P. P. (2014). Factors associated with a diabetes diagnosis and late diabetes diagnosis for males and females. Journal of Clinical & Translational Endocrinology, 1(3), 77–84. https://doi.org/10.1016/j.jcte.2014.07.002 Rosland, A.-M., & Piette, J. D. (2010). Emerging models for mobilizing family support for chronic disease management: A structured review. Chronic Illness, 6(1), 7–21. https://doi.org/10.1177/1742395309352254 Ross, S., Benavides-Vaello, S., Schumann, L., & Haberman, M. (2015). Issues that impact type-2 diabetes self-management in rural communities. Journal of the American Association of Nurse Practitioners, 27(11), 653–660. https://doi.org/10.1002/2327-6924.12225 Sabaté, E. (2003). Adherence to long term therapies; evidence for action. World Health Organization. 62 Schulz, R., Beach, S. R., Czaja, S. J., Martire, L. M., & Monin, J. K. (2020). Family Caregiving for Older Adults. Annual Review of Psychology, 71, 635–659. https://doi.org/10.1146/annurev-psych-010419-050754 Seixas, A., Conners, C., Chung, A., Donley, T., & Jean-Louis, G. (2020). A Pantheoretical Framework to Optimize Adherence to Healthy Lifestyle Behaviors and Medication Adherence: The Use of Personalized Approaches to Overcome Barriers and Optimize Facilitators to Achieve Adherence. JMIR MHealth and UHealth, 8(6), e16429. https://doi.org/10.2196/16429 Shaw, B. A., Gallant, M. P., Riley-Jacome, M., & Spokane, L. S. (2006). Assessing Sources Of Support For Diabetes Self-Care In Urban And Rural Underserved Communities. Journal of Community Health, 31(5), 393–412. http://dx.doi.org/10.1007/s10900-006-9018-4 Skoglund, G., Nilsson, B. B., Olsen, C. F., Bergland, A., & Hilde, G. (2022). Facilitators and barriers for lifestyle change in people with prediabetes: A meta-synthesis of qualitative studies. BMC Public Health, 22(1), 553. https://doi.org/10.1186/s12889-022-12885-8 Smith, S. A., & Ansa, B. (2016). A systematic review of lifestyle interventions for chronic diseases in rural communities. Journal of the Georgia Public Health Association, 5(4), 304–313. https://doi.org/10.21663/jgpha.5.404 Soltero, E. G., Olson, M. L., Williams, A. N., Konopken, Y. P., Castro, F. G., Arcoleo, K. J., Keller, C. S., Patrick, D. L., Ayers, S. L., Barraza, E., & Shaibi, G. Q. (2018). Effects of a Community-Based Diabetes Prevention Program for Latino Youth with Obesity: A Randomized Controlled Trial. Obesity, 26(12), 1856–1865. https://doi.org/10.1002/oby.22300 63 Tabak, A. G., Herder, C., Rathmann, W., Brunner, E. J., Kivimaki, M. (2012). Prediabetes: a high-risk state for developing diabetes. Lancet, 379(9833), 2279-2290. Tamminen, K. A., & Poucher, Z. A. (2020). Research philosophies. In The Routledge International Encyclopedia of Sport and Exercise Psychology. Routledge. The Diabetes Prevention Program Research Group. (2003). Costs Associated With the Primary Prevention of Type 2 Diabetes Mellitus in the Diabetes Prevention Program. Diabetes Care, 26(1), 36–47. https://doi.org/10.2337/diacare.26.1.36 Thirsk, L. M., & Schick-Makaroff, K. (2021). Family interventions for adults living with type 2 diabetes mellitus: A qualitative meta-synthesis. Patient Education and Counseling, 104(12), 2890–2899. https://doi.org/10.1016/j.pec.2021.04.037 Torenholt, R., Schwennesen, N., & Willaing, I. (2014). Lost in translation—the role of family in interventions among adults with diabetes: A systematic review. Diabetic Medicine, 31(1), 15–23. https://doi.org/10.1111/dme.12290 Tusubira, A. K., Nalwadda, C. K., Akiteng, A. R., Hsieh, E., Ngaruiya, C., Rabin, T. L., Katahoire, A., Hawley, N. L., Kalyesubula, R., Ssinabulya, I., Schwartz, J. I., & Armstrong-Hough, M. (2021). Social Support for Self-Care: Patient Strategies for Managing Diabetes and Hypertension in Rural Uganda. Annals of Global Health, 87(1), 86. https://doi.org/10.5334/aogh.3308 Tuomilehto, J., Lindström, J., Eriksson, J. G., Valle, T. T., Hämäläinen, H., Ilanne-Parikka, P., Keinänen-Kiukaanniemi, S., Laakso, M., Louheranta, A., Rastas, M., Salminen, V., Aunola, S., Cepaitis, Z., Moltchanov, V., Hakumäki, M., Mannelin, M., Martikkala, V., Sundvall, J., & Uusitupa, M. (2001). Prevention of Type 2 Diabetes Mellitus by Changes 64 in Lifestyle among Subjects with Impaired Glucose Tolerance. New England Journal of Medicine, 344(18), 1343–1350. https://doi.org/10.1056/NEJM200105033441801 Umberson, D., Crosnoe, R., & Reczek, C. (2010). Social Relationships and Health Behavior Across the Life Course. Annual Review of Sociology, 36, 139–157. Uusitupa, M., Khan, T. A., Viguiliouk, E., Kahleova, H., Rivellese, A. A., Hermansen, K., Pfeiffer, A., Thanopoulou, A., Salas-Salvadó, J., Schwab, U., & Sievenpiper, J. L. (2019). Prevention of Type 2 Diabetes by Lifestyle Changes: A Systematic Review and Meta-Analysis. Nutrients, 11(11), 2611. https://doi.org/10.3390/nu11112611 Wang, Z., Shi, Q., Zeng, Y., & Li, Y. (2023). Experiences and perceptions of self-management in people with prediabetes: A qualitative meta-synthesis. Journal of Clinical Nursing, n/a(n/a). https://doi.org/10.1111/jocn.16713 Warehime, S., Dinkel, D., Alonso, W., & Pozehl, B. (2020). Long-term exercise adherence in patients with heart failure: A qualitative study. Heart & Lung, 49(6), 696–701. https://doi.org/10.1016/j.hrtlng.2020.08.016 Weiss-Laxer, N. S., Crandall, A., Hughes, M. E., & Riley, A. W. (2020). Families as a Cornerstone in 21st Century Public Health: Recommendations for Research, Education, Policy, and Practice. Frontiers in Public Health, 8. https://www.frontiersin.org/articles/10.3389/fpubh.2020.00503 65 Appendices Appendix A: Semi-structured interview guides for individuals at risk of T2D and family members INTERVIEW GUIDE FOR PARTICPANT AT RISK OF T2D Section 1: General introduction, rapport building, demographic information Interview Introduction Thank you for agreeing to participate in this interview! My name is Kyra Braaten and I am a graduate student in the faculty of Health and Social Development at the University of British Columbia. I am originally from a small town in Saskatchewan and completed a degree in Kinesiology in Saskatoon. My university education combined with growing up in a small community surrounded by my family has made me passionate about chronic disease prevention, rural health and how family members are involved in the process. These interviews are part of my Masters project under the supervision of Dr. Mary Jung at the University of British Columbia on the Okanagan campus. My research is looking at how family members tend to influence health behaviours of individuals that may be at risk of developing type 2 diabetes. I hope to learn what family members do to encourage positive health behaviours such as eating a healthy diet or participating in physical activity. I also hope to understand what things family members might do that are not so helpful. The interviews will last approximately ________ minutes. For the purpose of data collection, these interviews will be recorded. Any responses to questions in these interviews will be completely anonymous and your personal information will be kept confidential. You do not have to answer any questions where you may feel uncomfortable or prefer not to disclose. If you choose to withdraw from the study at any point in time, your data will be deleted and not used for analysis. I plan to present the data from these interviews in an aggregate format at a potential conference and have the intention of possibly publishing this work as well. To protect your identity, we will be using a pseudonym/fake name for you in our transcripts and reporting of this interview. Pseudonyms can be any name you choose (other than your own). What would you like your pseudonym to be for this study? (If they don’t care, create a pseudonym and confirm that they’re okay with it). There are no right or wrong answers to these questions, we are interested in your perspective and what is important to you! Are you still willing to participate? You can leave your video on or off, I will now start the recording. 66 INTERVIEW GUIDE FOR PARTICPANT AT RISK OF T2D Can you let me know what rural community you are from? Can you spell it out for me, just to make sure I get it right? Tell me a bit about yourself – how would you describe yourself? • Prompt: This could include anything you find significant in your life that you would like to share – maybe your work, or your interests and hobbies, where you live, who you live with or like to spend time with. Demographic Questions (skip any that have come up in the question before) Would it be okay if I asked you some more specific questions about yourself? These questions are to help us report who is represented in our study but not on a personal level. • Great! Please know that you do not have to answer any questions where you may feel uncomfortable or prefer not to disclose. 1. What is your age? 2. What was your biological sex at birth? 3. From a list of the following how would you identify your gender today? o Woman, Man, Intersex, Trans (male to female), Trans (female to male), Other, Prefer not to answer, Do not know 4. What is your marital status? 5. How would you describe your ethnicity? • Probe: Are there any countries you associate your cultural practices with? 6. I am going to list some options if you don’t mind telling me the highest level of education you have completed. There is quite a few options so bear with me! • Less than high-school, high-school, apprenticeship or trades certification or diploma, college, CEGEP or a different university certificate or diploma, a university certificate or diploma below the bachelor level, university certificate diploma or degree, post-graduate degree 7. The next demographic question is about income. If you don’t mind, I will do the same with this question as the one about education and list some options (again, there is quite a few!). If it is alright with you, you can just stop me when you hear a range that you feel aligns best with your household income. • $0 - $25,000, $25,000 - $50,000, $50,000 – $75,000, $75,000 – $100,000, $100,000 - $125,000, $125,000, $150,000, $150,000 - $175,000, $175,000 + • How many individuals does that household income support? 8. While chatting with you today I am hoping to learn your perspective of family support while living in a rural community. I am interested in how family support may be different for folks living in rural areas compared to those in bigger cities. Have you always lived in a rural community? How long have you lived in _______ (name of community they are living in right now)? Section 2: Knowledge, Beliefs, Emotions, Motivation Knowledge Do you have any ideas about what your family member understands about prediabetes and how to prevent type 2 diabetes? 67 INTERVIEW GUIDE FOR PARTICPANT AT RISK OF T2D • Probe: Do you think that their understanding of these topics impacts their way of supporting you in engaging in healthy behaviours to prevent type 2 diabetes, such as physical activity or eating a healthy diet? • From folks living in bigger cities we know that family’s understanding of these topics influences these types of behaviours. From a rural perspective, do you feel that your family member is informed about diabetes or has places to seek out or receive that information? Beliefs Can you describe any way that you believe your family member helps you in eating healthy diet? Can you think of anything that your family member does that you believe doesn’t help you in eating a healthy diet? • Probe related to TDF (beliefs about capabilities or consequences) • Then, probe about SFMF (culture, spiritual, or general health beliefs) Can you describe any way that you believe your family member helps you in engaging in physical activity? Can you think of anything that your family member does that you believe doesn’t help you in engaging in physical activity? • Probe related to TDF (beliefs about capabilities or consequences) • Then, probe about SFMF (culture, spiritual, or general health beliefs) Emotion Our emotions sometimes set the stage for how we behave. Can you think of any instances where you’ve felt that your family member’s emotions influenced you to eat a healthy diet or engage in physical activity? Has there ever been a time you felt that your family member’s emotions made it harder to eat a healthy diet or engage in physical activity? Motivation Can you describe a time where you felt that your family member motivated you to do something healthy? For example, maybe ate a nutritious meal or did some exercise. • Probing: what was it that motivated you? Can you think of a time where your family member made you less motivated to do something for your health? • Probing: why did that affect your motivation? Do you feel that some the things we discussed (beliefs/emotions/motivations) would be different if you lived in a larger center compared to a rural community? If so, how/why? Section 3: Health Status and Environment Health Status 68 INTERVIEW GUIDE FOR PARTICPANT AT RISK OF T2D How do you feel the health status of your family member affects the activities you do for your health? • Probe: Are they able to accompany you in healthy activities/are these activities something they are already doing or would try? Environment Think about the different environments you are exposed to – home, work, vacation, events. How do you feel that these different environments affect your family member’s support of health-related activities? • Prompt: Are there certain environments where you feel you are better supported by your family member to engage in physical activity or eat healthy foods? Why do you feel that way? • Prompt: Are there certain environments where you feel you are not supported or rather discouraged by your family member to engage in physical activity or eat healthy foods? Why do you feel that way? How might living in a rural environment affects your family’s support of health-related activities? • Prompt: Do you feel you and your family have access to facilities or spaces to engage in health behaviours? Is there anything you wish you had access to? Section 3: Behaviours, Skills and Resources What are some things your family member might be able to do to best support you in engaging in physical activity and eating a healthy diet? 2. What are some unhelpful things your family member may do that you wish they wouldn’t? When chatting about things your family member might be able to do or things you wish they wouldn’t do, is there anything that comes to mind that is specific to living in a rural community? 3. What do you think is needed for your family member to better support you in eating a healthy diet and engaging in physical activity? • Probing: Are there any resources that would help them support you? (Maybe equipment or community, financial, educational, resources, healthcare system) • Probe: From a rural perspective, what do you think is needed? 4. Have you participated in SSBC? (If not feel free to give a description of the program). Do you feel that you would benefit from family members being involved in diabetes prevention programs like Small Steps for Big Changes? • If no, why do you feel this way? 69 INTERVIEW GUIDE FOR PARTICPANT AT RISK OF T2D • If yes, in an ideal world what would this look like? (if participants has not yet alluded to anything specific to a rural community ask:) In a rural community, what would this ideally look like? • Probing idea: What parts would they be involved in and to what degree? • Probing idea: What would you want them to learn or do in this program? Is there anything else, that maybe we didn’t touch on that you would like to discuss today? Thanks again for participating in this study and taking the time today to answer our questions. To compensate you for your time we would like to provide you with $50, please provide your email address for an e-transfer or mailing address if you would prefer a cheque. We are going to try and send out compensation at the end of every month so if you don’t receive anything by ____________ reach my email! INTERVIEW GUIDE FOR FAMILY MEMBER Section 1: General introduction, rapport building, demographic information Interview Introduction Thank you for agreeing to participate in this interview! My name is Natalie Grieve I am a graduate student at UBCO and helping Kyra facilitate some of the interviews for her study. Kyra Braaten is a graduate student in the faculty of Health and Social Development at the University of British Columbia. She is originally from a small town in Saskatchewan and completed a degree in Kinesiology in Saskatoon. Her university education combined with growing up in a small community surrounded by her family has made her passionate about chronic disease prevention, rural health and how family members are involved in the process. These interviews are part of her Masters project under the supervision of Dr. Mary Jung at the University of British Columbia on the Okanagan campus. This research looks at how family members tend to influence health behaviours of individuals that may be at risk of developing type 2 diabetes. We hope to learn what family members do to encourage positive health behaviours such as eating a healthy diet or participating in physical activity. We also hope to understand what things family members might do that are not so helpful. The interviews will last approximately 60 minutes. For the purpose of data collection, these interviews will be recorded. 70 INTERVIEW GUIDE FOR FAMILY MEMBER Any responses to questions in these interviews will be completely anonymous and your personal information will be kept confidential. You do not have to answer any questions where you may feel uncomfortable or prefer not to disclose. If you choose to withdraw from the study at any point in time, your data will be deleted and not used for analysis. I plan to present the data from these interviews in an aggregate format at a potential conference and have the intention of possibly publishing this work as well. To protect your identity, we will be using a pseudonym/fake name for you in our transcripts and reporting of this interview. Pseudonyms can be any name you choose (other than your own). What would you like your pseudonym to be for this study? (If they don’t care, create a pseudonym and confirm that they’re okay with it). There are no right or wrong answers to these questions, we are interested in your perspective and what is important to you! Are you still willing to participate? You can leave your video on or off , I will now start the recording. Can you let me know what rural community you are from? Can you spell it out for me, just to make sure I get it right? Tell me a bit about yourself – how would you describe yourself? • Prompt: This could include anything you find significant in your life that you would like to share – maybe your work, or your interests and hobbies, where you live, who you live with or like to spend time with. Demographic Questions (skip any that have come up in the question before) Would it be okay if I asked you some more specific questions about yourself? These questions are to help us report who is represented in our study but not on a personal level. • Please know that you do not have to answer any questions where you may feel uncomfortable or prefer not to disclose. 9. What is your age? 10. What was your biological sex at birth? 11. From a list of the following how would you identify your gender today? o Woman, Man, Intersex, Trans (male to female), Trans (female to male), Other, Prefer not to answer, Do not know 12. What is your marital status? 13. How would you describe your ethnicity? • Probe: Are there any countries you associate your cultural practices with? 14. What is the highest level of education you have completed? We have a list here, and there are quite a few options so let’s see what might match. • Less than high-school, high-school, apprenticeship or trades certification or diploma, college, CEGEP or a different university certificate or diploma, a university certificate or diploma below the bachelor level, university certificate diploma or degree, post-graduate degree 71 INTERVIEW GUIDE FOR FAMILY MEMBER 15. The next demographic question is about income. If it is alright with you, you can just stop me when you hear a range that you feel aligns best with your household income. • $0 - $25,000, $25,000 - $50,000, $50,000 – $75,000, $75,000 – $100,000, $100,000 - $125,000, $125,000, $150,000, $150,000 - $175,000, $175,000 + • How many individuals does that household income support? 16. While chatting with you today we are hoping to learn your perspective of family support while living in a rural community. We are interested in how family support may be different for folks living in rural areas compared to those in bigger cities. Have you always lived in a rural community? How long have you lived in _______ (name of community they are living in right now)? Section 2: Knowledge, Beliefs, Emotions, Motivation Knowledge What do you know or understand about prediabetes and how to prevent type 2 diabetes? • Probe: Do you think that your understanding of these topics impacts your way of supporting your family member in engaging in healthy behaviours to prevent type 2 diabetes, such as physical activity or eating a healthy diet? • From folks living in bigger cities we know that family’s understanding of these topics influences these types of behaviours. From a rural perspective, do you feel that you are informed about diabetes or have places to seek out or receive that information? Beliefs Can you describe any way that you believe you help your family member in eating a healthy diet? Can you think of anything that you may do that doesn’t help? • Probe related to TDF (beliefs about capabilities or consequences) • Then, probe about SFMF (culture, spiritual, or general health beliefs) Can you describe any way that you believe you help your family member engage in physical activity? Can you think of anything that you do that you believe doesn’t help your family member in engaging in physical activity? • Probe related to TDF (beliefs about capabilities or consequences) • Then, probe about SFMF (culture, spiritual, or general health beliefs) Emotion Our emotions sometimes set the stage for how we behave. Can you think of any instances where you’ve felt that your emotions (positive or negative) influenced your family member to eat a healthy diet or engage in physical activity? Has there ever been a time you felt that your emotions made it harder for your family member to eat a healthy diet or engage in physical activity? Motivation Can you describe a time where you felt that you motivated your family member to do something healthy? For example, maybe ate a nutritious meal or did some exercise. • Probing: what do you think it was that motivated them? 72 INTERVIEW GUIDE FOR FAMILY MEMBER Can you think of a time where you made your family member less motivated to do something for their health? • Probing: why do you think that affected their motivation? Do you feel that some of the things we discussed (beliefs/emotions/motivations) would be different if you lived in a larger center compared to a rural community? If so, how/why? Section 3: Health Status and Environment Health Status How do you feel that your own health status might affect the activities your family member does for their health? • Probe: Are you able to accompany them in healthy activities/are these activities something you are already doing or would try? Environment Think about the different environments you are exposed to – home, work, vacation, events. How do you feel that these different environments affect your support of health-related activities? • Prompt: Are there certain environments where you feel you better support your family member to engage in physical activity or eat healthy foods? Why do you feel that way? • Prompt: Are there certain environments where you feel you do not support or rather discourage your family member to engage in physical activity or eat healthy foods? Why do you feel that way? How might living in a rural environment affect your support of the health-related activities for your family member? • Prompt: Do you feel you and your family have access to facilities or spaces to engage in health behaviours? Is there anything you wish you had access to? Section 3: Behaviours, Skills and Resources What are some things you might be able to do (in the future) to best support your family member in engaging in physical activity and eating a healthy diet? Are there any unhelpful things you may do (currently) that you think you shouldn’t, or things that you avoid doing? When chatting about things you might do and things you think you maybe shouldn’t do, is there anything that comes to mind that is specific to living in a rural community? What do you think is needed for you to better support your family member in eating a healthy diet and engaging in physical activity? 73 INTERVIEW GUIDE FOR FAMILY MEMBER • Probing: Are there any resources that would help you support them? (Maybe equipment or community, financial, educational, resources, healthcare system) • Probe: From a rural perspective, what do you think is needed? Are you aware if your family member has participated in the Small Steps for Big Changes diabetes prevention program? (If not you can explain a bit about the program). Do you feel that your family member would benefit from you being involved in diabetes prevention programs like Small Steps for Big Changes? • If no, why do you feel this way? • If yes, in an ideal world what would this look like? (if participants has not yet alluded to anything specific to a rural community ask:) In a small rural community, what would this ideally look like? • Probing idea: What parts would you want to be/or think you should be involved in and to what degree? • Probing idea: What would you want to learn or do in this program? Is there anything else, that maybe we didn’t touch on that you would like to discuss today? Thanks again for participating in this study and taking the time today to answer our questions. To compensate you for your time we would like to provide you with $50, please provide your email address for an e-transfer or mailing address if you would prefer a cheque. We are going to try and send out compensation at the end of every month so if you don’t receive anything by ____________ reach out to Kyra’s email! 74 Appendix B: Dyadic summaries THEME IMPACT OF PARTNERSHIP ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary 2 Eating the same meals can facilitate healthy eating States that their family member understands how diet impacts them and encourages it which they feel is supportive. “By eating what I do by understanding the impact of what I eat, how critical it is for me, and supporting me being there, only with it, you know, really, making sure I'm doing the right thing. I'm driven to do it, but fully supported not just by my partner but by my kids as well.” (24:11) States that they feel that committing to the same diet is supportive. “I'm sure. I think, you know, the way that I help now, is that I have committed to having the same diet as my partner.” (15:29) Both individuals describing that understanding and committing to the same, healthy diet facilitates healthy eating for the individual at risk of developing T2D. 4 Eating healthy together facilitates healthy eating Describes that family members eating meals with healthy choices would help them in eating a healthy diet. “And for me, the best support that I could get from family members would be to present a variety of foods that could be healthy. (48:07)” Describes that having a healthy meal together would help their sibling in eating a healthy diet. “Like if we were to, to get together and have a meal together. I know my sibling and I would try to do gear the meal as healthy as we can.” Both individuals describe that having healthy options to choose from when having a meal together would facilitate healthy eating. 1 Eating the same meals can discourage healthy eating Describes that being together can make them succumb to unhealthy diet choices. “and then doesn’t support me: when we’re together we often snack on junk food.” (10:13) Describes that eating habits that may not be particular healthy were practiced by the family and may have been passed down through generations. “we never actually found that healthy Both individuals describe situations in which the person at risk of developing T2D may not be supported. This included eating together but 75 THEME IMPACT OF PARTNERSHIP ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary eating was a thing we talked about, or particularly practiced. I do I guess I should say, equate eating with happiness… A lot of our… a lot of my good memories of growing up in that kind of thing involve family gatherings where there was always lots of food, I guess. And you remember the happy times and you remember the eating. And, I know for a fact that I have carried that through to my adult life and probably pass that on to my kids.” (15:11) eating meals that may not be healthy and therefore discourage healthy eating. 2 Participating in the same activities facilitates engagement in physical activity (PA) Describing that their family participating in cycling supports their engagement in physical activity. “Well, they found something I could do, which was cycling. And we all got into cycling. Prior to that, there wasn't like…I couldn't go on the walk, I couldn't do the things but being able to get involved in cycling. And me being driven to want to be on my bike. And then also find finding enjoyment. I think that made all the difference is finding something we could do together, that I was Describing that they realized that participating in cycling would encourage PA for their family member. “Discovered cycling to be really beneficial to him. I realized that I needed to get into cycling as well so that we could do it together… And so encouraged in that way by participating in something that we could both do together.” (21:44) “So definitely being excited and encouraged and, you Both individuals describe that by cycling together it encourages the individual at risk of T2D to do physical activity. 76 THEME IMPACT OF PARTNERSHIP ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary physically capable of doing. And always encouraged me to let's go do that together. My kids and my partner, and that, that, you know, that was a process that really was very helpful. And I think made all the difference was just being there, find something that you can do together.” (27:10) know, like truthfully, I love riding but it doesn't have the same impact for me as it does for my partner… like even if I wasn't always able to participate, to encourage fully and share in the excitement of something that he was interested in doing physically. Like, that was probably the biggest thing for him.” (33:47) 1 Participating in the same activities facilitates engagement in PA States that doing the same type of things, together, supports their participation in PA. “Just eating healthy and being active. And when I’m around them, they are going to be doing that. What am I going to be doing? (23:25)… So, it’s easier to do things together than it is one person to do it alone (23:41).” States that they believe that engaging in potential PA opportunities with their family member would encourage PA participation. “You know, I could benefit from doing these exercises along with my child, even if it was, even if it was online like this, we should use Zoom more, which is okay. (30:33) Both individuals explain that they believe doing PA together facilitates participation in PA for the individual at risk of T2D. 3 Engaging in similar activities at the same time facilitates PA Describes that doing similar activities at the same time can facilitate their engagement in PA. And we'd like to go out in the summer times on the lake, I have a thing called a SurfSki. They have a rowing shell. And so because they like to go out when the waters really calm, and so we'll Describes that doing similar activities might support their partner’s engagement in PA. I have a rowing shell and my partner has this kayak thing called a SurfSki. We'll go swimming. So I guess physical activities are the thing that our, I Both individuals describe their routine of doing similar activities together at the same time which is perceived to support PA participation. 77 THEME IMPACT OF PARTNERSHIP ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary get up at six in the morning. And I'll pretty much wake up then. So then I'll think, Okay, I'll go for a paddle too. So it's subtle encouragement. (14:58) guess impact us the most in terms of it being right outside of our door. (2:37) 3 Lack of participation by a family member limits activities together and can discourage PA for individual at risk Shares how they feel about instances (weather conditions) where they may not feel supported by their family member to engage in PA. At the same time, they state that when they are willing to do an activity together, it is a reinforcement to exercise. There's, there isn't really occasions where my family support member says, No, we shouldn't do physical activity. Unless of course, it's like crappy weather out. And we may not (14:58) My partner is encouraging of that unless the snow and road conditions are looking crappy then might say, maybe not. And we'd like to go out in the summer times on the lake to do activities. And so because they like to go out when the waters really calm, and so we'll get up at six in the morning. And I'll pretty much wake up then. So then I'll think, Okay, I'll go for a paddle too. So Shares that they feel their emotions may impact their willingness to do PA with their family member and when they don’t it can be viewed as unsupportive. They recognize that they are a reinforcement for their family member to engage in PA. “I don't feel like going and doing something, and it definitely, ah, makes it more difficult for my family member to go out and do something, especially if they're looking forward to doing it with someone. And because there's limited other physical people with the same kinds of interests, perhaps as us physically, that then if I'm not going to go and do something, it would definitely if I've committed, then I back out of the commitment. It definitely would impact my family member” (23:09) Both individuals explain that doing activities together is a reinforcement for PA. When the family member chooses not to participate in those activities (due to weather, emotions etc.) it can be viewed as unsupportive because the individual at risk of T2D no longer has someone to do activities with. 78 THEME IMPACT OF PARTNERSHIP ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary it's subtle encouragement (14:58) 4 Lack of participation by a family member limits activities together and can discourage PA for individual at risk Describes that living alone and not having family members to do activities with can be a barrier to PA. I can also tell you that I think living alone by myself. I don't have I'm comparing myself to my sibling, who is a grandparent and has family members and is still married. They have a lot more social activities and family activities than I do. (18:39) Recognizes that family participation is important for supporting PA engagement. Mentions that their sibling does not have regular access to family members to do things with and that can be a barrier to PA participation. I would say more active than hers, only because I have I have a spouse. So I have a partner. Yeah, they don't. I also have a child that's quite active. So I will walk with them because they have a dog. Yeah. And so you know, I think I think that's what I have. That gets me going (26:05) Both individuals describe that not having family members to participate in activities with can be seen as a barrier to PA. 2 Becoming educated together facilitates healthy eating habits Describes that watching YouTube videos with their partner helped to become educated together about health eating. “And most of that education actually came from living in a small place and, and watching YouTube videos with me… Yeah, I would watch them with my partner…And my partner was watching them with me, because I Describes that watching videos with their partner was supportive to them learning how to engage in a healthy diet. “And my partner just did research and, and then just happened to find the person, a couple of people that spoke to them. And their videos and their information. And so, it was just like, alright, Both individuals describe that watching YouTube videos together to learn about how to eat healthy encouraged the individual at risk of T2D to eat a healthy diet. 79 THEME IMPACT OF PARTNERSHIP ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary was telling her that I just wanted to cut carbs out. And that, you know, even at the time, they were saying, well, you can't do that. That's, you know, here's the Diabetes Association's information, here's this and that. I said, but I've been watching these people on YouTube, and they say, you can, you know, look at where I'm at, can we try? So we tried. And once we made the decision, or once I made the decision that that's, I wanted to try doing that. And they saw how quickly things started changing. My partner became the driver to yeah, this works. (31:02) let's give it a go. Like, let's give this a go and see where it takes us. And if it doesn't work, then, you know, we'll figure out something else.” (47:10) 4 Become educated together and having conversations about health is a facilitator to healthy eating and PA participation Explains that having conversations about health can support healthy eating and PA. Well, we like to talk about food, you know, we're, we talk about recipes. You know, we, we talk about our diet and our exercise and, and how to be healthy and positive (21:01) Explains that sharing resources to learn together can support healthy eating and PA. And then if I, hear something or I've read something, or I've been informed about something that I asked, I’ll pass it on to them. I actually went to a diabetes awareness meal plan that was held at a university here a few years ago. And so then I, I sent them all the notes that I had picked up. And, and so, you know, I tried to keep Both individuals explain that becoming educated together and having conversations about health facilitates PA participation and healthy eating. 80 THEME IMPACT OF PARTNERSHIP ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary them in the loop with me. 3 Having conversations about health facilitates healthy eating. Explains that having conversations about how to eat healthy supports healthy eating. I think we regularly talk about, you know, what are we going to have for dinner tonight?... And I think my partner often will point out or… we might have a conversation about different food choices and so forth, just in a general way and give viewpoints or information on what would be the optimal without also judging if I want to have an extra cookie or whatever…We do what we want kind of thing, but so I think just having an interest in trying to eat healthfully without being on a strict regime (13:20). Explains that have conversations about health and who will do what to eat healthy is supportive for maintaining a healthy diet. I guess, myself eating a healthy diet, which and encouraging my partner to eat a healthy diet and perhaps as choosing together to cook or shop or, I guess, think about our health, instead of just carrying on and not thinking about our health (13:26)… I think actually, my partner prepares more food and does more, but I would say that I'm the one that advises or recommends how we eat and what we eat and what we buy (13:42) Both individuals agree that having conversations about how to be healthy supports healthy eating for the individual at risk of T2D. 2 Having conversations about the outcomes of engaging in PA is a facilitator to engaging in PA. Explains that having conversations about how PA makes them feel encourages them to do PA. I mean, there's many instances where I've had that support, or no we've talked about that, maybe you're feeling bummed out or whatever, you know, or it's a great day. And it's like, well, you Explains that having conversations about the benefits of PA encourages their partner to engage in PA. I think my family member is really good at engaging physical activity, if anything, I think he helps me engage in it, I tend to do physical activity Both individuals state that having conversations about the positive outcomes of engaging in PA is a facilitator to engaging in PA. 81 THEME IMPACT OF PARTNERSHIP ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary know, if we go for a walk, or if you go do this, you know, remember how it makes us feel or we go for a walk or go feels so good to get out and do a little bit of exercise? And it it changes changes the mood.(17:56) for the pure enjoyment or mental health benefits from it… I've had influence in trying to do physical activity for just the enjoyment of it. And I think I have impacted them that way. And that's been a good shift (20:44). 4 Having conversations about health and goals facilitates diet and PA. Describes that they talk a lot about health and their lifestyle. I think she knows some information…I think they are conscientious and she, she and I talk about health and lifestyle a lot. (14:30) Describes that keeping in contact to talk about their progress in health behaviours is a facilitator. Luckily, we were in contact frequently. (9:39) And so we kind of challenge each other so that when talk we get there, you know, we kind of look at how did the other the graph go. (17:24) Both individuals talk about how keeping in contact and having conversations about their lifestyle and progress related to health goals is a facilitator. 2 Reciprocity in the relationship is perceived to support diet and PA Describes that support goes both ways and they are motivated to engage in healthy behaviours in order to provide for their family. “So, again, family, I, also that works both ways. It's not just what the family is doing to support you. It's how you're able to support the family, once again. And if it's not monetary, you look for other ways. And that's what I've been able to do. So, yeah, it's Describes that family members also need support. Like, there's, you know, it can be it's such a frustrating thing, but that's where, like, mental health support, probably for family members, like for the family member, but also for the other family members is is important, isn't it?... But to, to make it more apparent to Both individuals recognize that family members also need support and that relationship between the dyad must be reciprocal. 82 THEME IMPACT OF PARTNERSHIP ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary both ways. I don't want to say that, like, when you're asking, it's just how can you support family support you, you also got to put the person that has diabetes in that into that play, and understand they also have responsibility of what they can be doing for their family, and exchange. It's not just one way if family just doesn't support you, you also have to find ways either encouragement or something. And, for me, that's a driver, to dealing with my diabetes, is that I'm able to provide what I can. (1:09:31) people that you know, that you need support in order to support somebody who's going through something very difficult, right. (54:27) 3 Reciprocity in the relationship is perceived to support PA Describes that while their family member encourages them to engage in PA, they also encourage their family member. No, but I think we both actually encourage each other to do you know, things (PA) at different times. (19:15) Describes that they both encourage each other to participate in PA in different ways Um, I think my family member is really good at engaging physical activity, if anything, I think they help me engage in it … I think I have influenced on broadening or introducing different types of physical activity for them. And I've had influence in trying to do physical activity for just the enjoyment of it. (20:44) Both individuals describe that PA encouragement is not one-sided and they both work to support each other in PA participation in different ways at different times. 83 THEME MODELLING IMPACTS HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary 2 Modelling health behaviours as a facilitator Describes that their family models engaging in PA and that helps to engage in PA when they felt ready to do so. “I'm driven to do it, but fully supported not just by my partner but by my kids as well. All of them who, well, one of my daughters, maybe could get there but they're all very physical and have learned from my mistakes… Those mistakes were mine. I can't put that on them. They, they weren't doing it themselves. I was doing what they weren't. So, I can't say that I wasn't following their example. I wasn't, you know, those were my mistakes.” (25:15) Describes that they felt that encouraging by example was the best way to be supportive. “Things to help with the diet, but I also believe that nagging at some constantly reminding them that they're not eating right. If they don't want to hear it, it's not going to do any good. So, you know, it's just like, I had to, you know, also believe that you can only encourage by example” (15:29) Both individuals state that the family encouraging by example facilitated engagement in healthy behaviours. 5 Engaging in similar activities facilitates PA Describes that their partner encouraged them to get into running through teaching PA to others. Not anymore. For now, it goes I would say they did 30 years ago, when they were teaching fitness classes. That's what I became a runner, 36 years ago. Describes that their partner was running at the same time they were. at the same time while I was doing the running, my partner was also running, you know? Well, okay, we're both...try to be somewhat healthy and yeah, Exercise, right. Both individuals describe that by modelling running and PA to others, the individual at risk of T2D was encouraged to start running themselves. 5 Modelling PA routines sets a good example to engage in PA Describes that by their family member engaging in their own PA routine is a good example for them. Describes that they believe it is supportive to engage in their own PA routine and ask if their partner would Both individuals agree that when the family member engages in their own PA routine it sets a 84 THEME MODELLING IMPACTS HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary she gets out of the house pretty much every day and does her own thing, which is, you know, 2-3-4 mile walk. So she sets a good example that way. (30:06) like to come with to encourage PA. You know, go for a walk, do you want to come? Or... It's usually the other way around. But yeah, we do try to be active (10:15) good example and encourages the individual at risk of T2D to do physical activity. 4 Role model Explains that the family member that also was interviewed is someone they would like to be like because of the activities they do for their health. I have chosen a family member who I would like to be like, that I admire and I think she sets the bar. (28:44) Describes that they view themselves as a mentor for the individual at risk of T2D. Luckily, we were in contact frequently. Yeah. And because he's in a smaller demographic area that they are on their own. So we...so I guess I'm her mentor, her encouragement… (9:38) Both individuals explain that the family member acts as a role model for the person at risk of T2D to engage in positive health behaviours. 1 Lack of modelling PA can discourage PA Describes that they view their family member to be unhelpful to encouraging PA by not engaging in PA “Probably doesn't help me because we're both fairly inactive. (10:44)” Describes that PA was never promoted in their family and that could be a barrier to be supportive of PA for the individual at risk of T2D. “And I think when my kids got into school, they started learning about physical activity more. But no, nobody, nobody, including myself. We don't promote it in our family. Let's put it that way.” (18:48). Both individuals agree that by the family member not engaging in PA they are not promoting it for the individual at risk of T2D which is perceived as unhelpful. 85 THEME MODELLING IMPACTS HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary 5 Modelling good and poor health status can encourage health behaviours. Describes that observing their family member’s positive health outcomes sets a good example for them. when we go for physicals, they will come out better than I will I have high blood pressure, I have cholesterol borderline. My partner doesn't suffer from those things like, like I do. So she sets a good example. And has the results to show it (30:06) When asked: “do you think your past pre-diabetes diagnosis/status of your health influences you family member?” They describe their past diagnosis of prediabetes and how they feel their family member is motivated to engage in health behaviours to avoid the same situation. Yeah, I would say so. Yeah. And, you know, what, they don't want to be in the same situation (23:56) Both individuals describe situations in which observing the health status of a family member can influence health behaviours. 4 Modelling poor health status – comparing and using it as a motivation to be healthy Describes that by observing their family member’s poor health, it motivates them to avoid a similar situation. Because I look at their lifestyle, and I look at their health issues. And I look how they're able to handle stress. And I think Well, for me, I need to walk daily. (30:26) Explains that they as a dyad have been motivated to not have poor health outcomes like other family members. Because we have other issues in our family genetics, like we have blood pressure, high blood pressure, we have cholesterol and we have diabetes. And luckily, my sibling and I have no symptoms like we're not we're not on any of those medications. And so we've kind of made a pact that we're going to continue that way. (9:39) Both individuals describe how observing poor health status experienced by family members can be a motivator to engage in health behaviours to prevent similar consequences. 1 Cultural tradition passed Describes that they cook similarly to meals made Explains that unhealthy meals made Both individuals describe that 86 THEME MODELLING IMPACTS HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary on through generations impacts diet choices. at home while growing up. Like they always made homemade meals at home… And mealtime was kind of a big thing where it was a homemade meal and whole family sitting around the table… Yeah, for the most part, somewhat rich in carbohydrates often because Ukrainians like their carbs, let's face it. But a lot healthier than, than say takeout or, or something frozen from the grocery store. (13:51) as a family may have been a practiced passed on to their kids. Everything Ukrainian is covered in a cream sauce. No, I'm exaggerating just a little bit. But yeah, cream and butter are very important components of a lot of a cooking rich, rich foods, I would say. So yeah, totally. I would say that the the background of my culture centers a lot on food. My parent is 93 And you still can't go to their house without them saying, Oh, you need something to eat. (12:55) cultural meals made as a family are a practice passed on through generations that can impact diet choices. 3 Culture affecting food choices Describes that when they don’t cook with their family member they will often resort to unhealthier comfort foods. Sometimes I don't feel like cooking and they don't and we're like, yeah, we'll say okay, so We're each doing our own dinner thing. And so at times, then I can go to some of my comfort foods (33:12) Explains that when they don’t cook together their partner will resort to unhealthier foods as a result of cultural influence of family. On the day that we don't want to make something. Yeah. And I'll be the one that will say, well, let's just cut up a bunch of veggies on rice and throw some glory bowl on or something like that, where as I think my family members, and this speaks back to Both individuals describe that cultural meals made as a family are a practice passed on through generations that can impact diet choices. 87 THEME MODELLING IMPACTS HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary that first question about cultural influence, goes for the comfort food more, that would be a probably a pasta with some kind of like, because we are vegetarian, that'll be the day maybe that he'll go for a vegetarian, more processed product, like a veggie dog or something like that. So to those days, where you don't feel like doing thing, he'll want to more often go for the pasta, and the veggie dog or something like that. THEME IMPACT OF ATTITUDES ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary 1 Autonomy in diet choices When asked if there was anything they wished their family wouldn’t do, they described that they felt it was an individual responsibility. “Like I like to think we are all adults, we can make our own decisions… regarding what we put in our bodies” States that now eating healthy is their own responsibility. “But now, I personally think it’s up to them. That’s my attitude. What I often say is, I am not the food police.” (10:14) Both individuals state that diet choices are up to the individual to make. 2 Autonomy in diet choices Explains that family members supported health behaviour change but only once they decided they were ready Explains that encouragement is important, but it is ultimately up to the Both individuals explain that while family support is helpful in health behaviour 88 THEME IMPACT OF ATTITUDES ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary to engage in such behaviours. I didn't think, never thought, even 20 years ago, I'd be able to do what I do now. So those, those were, those were my mistakes, but the support and changing my mistakes when I was ready to make those changes at all the difference (26:01) Your family's got to support you. If they see you're unhealthy. They got to find ways even if you're a stubborn person to have to look for ways and minded (45:05) individual to change their behaviour. So, I've learned that, like, you know, that the encouragement part is so strong, and just to stay as positive as you can. But I learned you can do all that and unless they want to do it, like, too bad, right? (54:27) change, it is up to the individual at risk of T2D to decide they are ready to engage in healthy behaviours. 3 Promoting autonomy for t he individual at risk of T2D and respecting balance can facilitate healthy behaviours. Explains that it is important to discuss healthy decisions with their family member but there must be a balance, and family members should refrain from judgement when the individual at risk of T2D engages in an unhealthy behaviour. And I think my partner often will point out or will... we might have a conversation about different food choices and so forth, just in a general way and give viewpoints or information on what would be the optimal without also judging if I want to have an extra Recognizes that they must be helpful but also refrain from judgement and respect balance when it comes to engaging in healthy behaviours. I think being respectful and, and helpful to somebody that's trying to improve is important. Like, I do think it's important, like if I was not eating well, for somebody to check in with me, but I guess it's that respecting that balance and, and making sure that you're trying to model and understand what somebody's going Both individuals perceive that while having conversations about health is important, it is also importance to respect balance and refrain from being judgmental about every choice being made. 89 THEME IMPACT OF ATTITUDES ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary cookie or whatever that get not that we have limitations, right. We do what we want kind of thing, but so I think just having an interest in trying to eat healthfully without being on a strict regime. (13:20) through and be helpful without being judgmental. (17:41) 4 Respecting balance and refraining from judgement can facilitate healthy behaviours. Describes that respecting a balance can support diet. and we try to put less emphasis on, on the things that you do when you're dieting. We're far more accepting of our body type. And our limitations. (21:01) Explains a strategy that they felt supports healthy behaviours. We both decided in the new year we threw out the scale (35:03) Both individuals explain that less emphasis on restrictive behaviours can support healthy behaviours. 1 Different views on the type of environments that encourage healthy behaviours Describes camping with their family discourages healthy behaviours. “Yeah, I would say it like camping for sure. You just want to sit around and do nothing and eat potato chips.” (19:50) Describes that they perceive camping encourages healthy behaviours. A lot of them are very good environments for supporting physical activity, like, like the camping, for instance, you know, right. There's a fair bit of like, you know, physical activity, getting things set up, but, but as far as being out in nature and that kind of thing, you certainly there's lots of opportunity, then to go for a hike in the woods to walk around the lake or, you know, multiple things, whether they involve some, you know, The individuals seem to have differing views on camping and whether it is a helpful or discouraging activity for improving healthy behaviours. 90 THEME IMPACT OF ATTITUDES ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary really active things, you know, where you're, you're climbing or that sort of thing (23:33) 4 Different views on the type of environments that encourage healthy behaviours Describes that she feels that the area in which she lives motivates her to stay healthy. And whereas I think I'm so fortunate here because I can just walk out my front door. And I'm in a wooded area and there's lots of birds and you know, it's just...I really liked the quality that a rural area has given me. And so I'm trying to find ways, how I can maintain my personal lifestyle for as long as I can. And part of that I realize is, you know, I'm going to have to be able to take care of myself, you know, I'm gonna have to be able to, to drive into pack my own groceries and, you know, shovel snow when I need to. I have to if I want to live here, I have to be in the best shape that I can be. (40:54) Believes that moving to a larger city would be more encouraging of healthy behaviours. I try to encourage them to come here. There would be more family support. I feel well, I feel that our area has the opportunity to have more access than she does. But they say that, you know, she has a good doctor, and she is quite comfortable there. (9:39) Individuals seem to have differing views on what living location would be the most helpful for encouraging healthy behaviours. 1 Different views on the degree of family involvement needed to encourage healthy behaviours Describes that eating healthy and being active together is helpful. “Just eating healthy and being active. And when I’m around her, she’s going to be doing that. Explains that they don’t feel the need to encourage physical activity for their family member. “They are unable to do probably a lot of Both individuals seem to have differing views on the degree of involvement that is considered helpful for encouraging 91 THEME IMPACT OF ATTITUDES ON HEALTH BEHAVIOURS DYAD SUBTHEMES Individual at risk of T2D Family member Dyadic code/summary What am I going to be doing? (23:25)… So, it’s easier to do things together than it is one person to do it alone (23:41).” physical activity. She's really she's come a long way in her illness. But yeah. So no, need to encourage any form of physical activity. They are lucky to do what they can. (14:21) healthy behaviours. 5 Different views on the type of environments that encourage healthy behaviours Describes that they feel they engage in unhealthy diets while travelling. you know, we travel a fair amount. And I, we got, and we both liked that. And I think you've probably don't eat as well as you should we probably drink too much… We're not foodies, but we don't go hungry when we're traveling either. (27:32) Describes that their diet changes when travelling but is not necessarily unhealthy. Only because you know, a lot of times when you are away, you know you don't have your kitchen in front of you where we do fine. When we are on vacation…we probably do tend to eat um different, of course, when you're not at home, yeah. But then when you know those cases, and we try to eat maybe breakfast and have our early dinner and a bigger lunch. We probably wouldn't eat as much or you know as many times. Right, but we probably are eating, you know, depending on where you're vacationing or what kind of food they have in their country (18:36) Individuals seem to have differing perspectives on how travelling impacts their diet. 92 Appendix C: Agreements between KB and NG during the deductive coding process Number Agreement 1 Any time that a participant describes a behaviour by a family member that is both supportive and unsupportive it should be coded as both a barrier and a facilitator. 2 Any time that a participant describes a behaviour by a family member that does not provide enough context to be considered as supportive or unsupportive code as neither a barrier or a facilitator. 3 Quotes that contain statements about eating out, drinking wine, and travelling will not be coded as a financial resource. There must be enough context in order to code it as a resource such as “we can afford to eat out x times per week”. 4 If there isn’t context included in the certain quote being coded, but from the interview we know exactly what the individual is referring to, we can still code based on their story. For example, one participant talking about their issues being able to walk (we know that is because of gout because they had expressed it earlier in the transcript) 5 In order to code reinforcement, there must be an explicit arrangement of a relationship described that is influencing the behaviour. 6 Reflections containing any word or adjective that indicates a feeling or emotion will be coded as emotion for the TDF. 7 Any quotes mentioning behaviours of engaging in a certain sport should be coded as a skills. 8 Before coding intentions, start the quote being coded with “I intend to”. If it still makes sense in that context, it can be coded as an intention. Appendix D: Examples of reflections categorized within Barrier and Facilitators and to the TDF and SFMF Code Barriers and Facilitators 1 Barrier “Well, I think growing up, you know, being in a very ethnic background, my parents had certain ways of preparing food, and superstitions about food, that, you know, when we, when I look at it now, as an adult, I think a lot of it, we had to do that. You know, I don't think my parents ate as well.” (Sharon) “I have to say that when I'm when it's stress, anxiety...and I get into a slump... then I, I'm not emotionally supportive for them.” (Amanda) 2 Facilitator “Well, they found something I could do, which was cycling. And we all got into cycling...I think that made all the difference is finding something we could do together, that I was physically capable of doing. And always encouraged me to let's go do that together. My kids and my partner, and that was a process that really was very helpful.” (Pat) 93 Code Barriers and Facilitators “Well, I guess, by, I guess, myself eating a healthy diet, which and encouraging my partner to eat a healthy diet and perhaps as choosing together to cook or shop or, I guess, think about our health, instead of just carrying on and not thinking about our health.” (Sally) 3 Both a barrier and a facilitator “We made our own bread… a great bread. Even 2 years after me making the changes, we're still making break for other people. Because we love making bread, but cutting out that stuff. (Pat) “You know if you're in a good mood, you, you probably tend to eat better too, I think. And you might tend to, you know, celebrate with extra dessert or something when you feel good” (Taylor) 4 Neither a barrier or a facilitator And personally, I think it’s up to them. That’s my attitude. What I often say is, I am not the food police. And yeah, I actually don't do anything. (Bushy) I think is attitudes, I think, that's a difficult question. Because if a family member would tell me don't go walking, it wouldn't stop me, I would still go walk. (Sharon) Code TDF/SFMF 1 Knowledge (an awareness of the existence of something) I would say she did 30 years ago, when they were teaching fitness classes. That's what I became a runner (Cooky) And then if I, if I hear something or I've read something and or my, I've been informed about something that I asked pass it on to them. I actually went to a diabetes awareness meal plan that was held at the university here a few years ago. And so then I, I sent all the notes that I had picked up. And, and so, you know, I tried to keep them in the loop with me. (Patricia) 2 Skills (an ability or proficiency acquired through practice) So we like to go cross country skiing a lot (Dan) My partner just did research and, and then just happened to find the person, a couple of people that spoke to them and their, with their videos and their information and whatever. And so it was just like, alright, let's give it a go. (Sally) 3 Social/professional role and identity (A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting) My family, my kids and wife are very slim and healthy and no medical problems whatsoever. No medications, no, nothing, none of them. So for me getting to be more like them just meant being able to spend more time as a family doing what we could do as a family. (Pat) I don't think I help really at all in helping with a healthy diet. In if we're talking as a child we, I would say we never, we never actually found that healthy eating was a thing we talked about, or particularly practiced. I was, I was admittedly a busy mom, because I worked full time and had, you know, three children. So yeah, we didn't talk about it at home. (Bushy) 4 Beliefs about capabilities (Acceptance of the truth, reality, or validity about an ability, talent or facility that a person can put to constructive use) 94 Code TDF/SFMF I think in some ways they were right that when, when you have a long term illness, you have to pick and choose where you're going to expend your energy. And then in other ways, well, if you're eating well, you'll have more energy to do other things too. (CL) Their physical limitations, limit our activities together (Bushy) 5 Optimism (The confidence that things will happen for the best or that desired goals will be attained) They have a Kinesiology background. You know, has nutrition information so that's definitely helpful. And a positive outlook. And so I'm pretty fortunate, actually (Dan) And so we we've kind of made a pact that we're going to continue that way (Patricia) 6 Beliefs about consequences (Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation) I mean, there's many instances where I've had that support, or no we've talked about that, maybe you're feeling bummed out or whatever, you know, or it's a great day. And it's like, well, you know, if we go for a walk, or if you go do this, you know, remember how it makes us feel or we go for a walk or go feels so good to get out and do a little bit of exercise? And it changes the mood? (Dan) When we are on vacation we usually are healthier, because we try and walk everywhere (Taylor) 7 Reinforcement (Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and given stimulus) And we'd like to go out in the summer times on the lake, I have a thing called a SurfSki. My partner has a rowing shell. And so because they like to go out when the waters really calm, and so we'll get up at six in the morning. And I'll pretty much wake up then. So then I'll think, Okay, I'll go for a paddle too. (Dan) Yeah, they kind of I guess, to each other a little. You know? Id say I’m going for a walk. They want to come with me kind of (Taylor) 8 Intentions (A conscious decision to perform a behaviour or a resolve to act a certain way) I think if it had a purpose, if you say okay, when you come out this weekend, we're going to go for a bike ride, or we're going to go make it affordable, make it something that is in your comfort level (Sharon) I realized that I needed to get into cycling as well so that we could do it together (Sally) 9 Goals (Mental representations of outcomes or end states that an individual wants to achieve) She, she eats what I eat. That's it. So she we just make sure we have it. But traveling being in a wrong place. You have to be able to plan ahead. And these were things that were trial and error (Pat) But we had a goal of doing this huge ride called the Great Divide. Through the, you know, the rocky range, right, like, there's a trail that many people do so. And then so it's just like, so definitely being excited and encouraged and, and I'm, you know, like truthfully, like, I love riding but I'm not it doesn't have the same impact for me as it does for them (Sally) 95 Code TDF/SFMF 10 Memory, attention, and decision processes (The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives) I think they do a pretty good job. I mean, she I've been in agonizing over whether they will spend $50 to do this run on the Saturday and she's encouraged me all the way to just do it. I think they do a good job (Cooky) When I'm doing it, you know, I feel like there's a lot going on in life, then for sure. It might be harder for me to get up and go do that thing I committed to doing too. And I can go through these little battles in my head and try to make myself do it anyways, because I committed to that family member... Because in a rural place right now, we're partner in activity, because we are the only ones that you can count on to go off and do the types of activities that we like. So yeah, if I wasn't able or interested or keen to do something then it would definitely impact my partner to a certain degree, though, only to a certain degree, because at the same time, we also know that its really important for us (Amanda) 11 Environmental context and resources (Any circumstance of a person’s situation that discourages or encourages the development of skills and abilities, independence, social competence and adaptive behaviour) A gym would be fantastic, though. We're kind of creating our own downstairs. But it's also nice to go out to your house and go to somewhere right?...we've got some weights and we said, okay, we're gonna get more, you know, weights to be able to do stuff at home, so we don't have to go into town. (Dan) We, we both decided in the new year, we threw out the scale. We just decided that, you know, we have certain things that we were and just have to just, you know, yeah. She sends me a little icon. If she's gone for a walk, just send me that. (Taylor) 12 Social influences (Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours) They like to eat out more than I probably think is healthy. And typically when we're… they don't suggest it very often, but every time I suggest that she jumps right on it, so that probably something like drinking too much, we shouldn’t eat out as much (Cooky) Okay, you go online, and you look for a zoom class that's geared to whatever the specific needs, you know, force exercise for people with? Yeah, certain, certain limitations. And, you know, we both could benefit from that. Mm hmm. You know, I could benefit from doing these exercises along with my child (Bushy) 13 Emotions (A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event) Okay, I think when my partner passed away, my grief. My family members encouraged me to to get plugged back into life, you know, to take care of myself emotionally, physically and spiritually and to make social connections. So I think it's their support during my grief that has helped (Sharon) A lot of my good memories of growing up in that kind of thing involve family gatherings where there was always lots of food, I guess. And you remember the happy times and you remember the eating? And, and I know, I know for a fact that I have carried that through to my adult life and probably pass that on to my kids. And getting together. It seems like eating, 96 Code TDF/SFMF having a meal having something together. A time together involves some form of eating (Bushy) 14 Behavioural regulation (Anything aimed at managing or changing objectively observed or measured actions) Well, I guess because we talk about it so often. You know I may... the next day, think, okay, yeah, I'm gonna go do this, because we talked about yesterday that, you know, we feel better when we go for a bike ride or something along that line (Dan) Whenever we're together, we encourage each other Yeah. to, I mean, we will slip in here and share something or we'll do something but I know my sibling has a tendency to slip and gain weight. And I know how much that frustrates them. So I try to, to not put us in a situation like I would never travel to go see them and bring a whole bunch of things. I know that they have less of willpower (Taylor) 15 Motivation (Motivation to self-manage) I think she motivates me. We are very similar as far as our activities that we like to do (Cooky) Things to help with the diet, but I also believe that nagging at some constantly reminding them that they're not eating right. If they don't want to hear it, it's not going to do any good. So, you know, it's just like, I had to, you know, also believe that you can only encourage by example (Sally) 16 Life patterns (Life transitions that may influence self-management behaviours and skills) I would say they did 30 years ago, when they were teaching fitness classes. That's when I became a runner (Cooky) But I'd also would say fortunately, both of us have grown and, and developed and had a lot of diverse experiences to know that there's always room for improvement and growth in our diet and lifestyle (Amanda) 17 Health Status (comorbidity, condition severity, symptoms) And when I was, you know, when I was really losing my sight, and it was really serious, like, it became pretty darn serious. And my partner was watching videos with me, because I was telling her that I just wanted to cut carbs out (Pat) So no, need to encourage any form of physical activity. They are lucky they can do what they can (Bushy) 18 Healthcare system (access, navigation, continuity of care, provider relationships) I think that we would probably, so our family doctor, or I think we would go to VHA. Which is the Vancouver Island Health unit. To see what information they have? You know, I would seek out the establish mainstream avenues (Sharon) Because they still ask me, why am I eating a certain way and why, why? Why am I engaging myself into physical activities? And I will, I would tell them what I'm doing for myself, you know, what has been proven to help. And I took it on, I encouraged them by the fact that, you know, I have blood tested every six months for my thyroid, nothing has changed since back into my late 30s (Patricia) 97 Code TDF/SFMF 19 Focus on illness needs (taking ownership, learning, health promotion) Allowing me time to, to do the research to supporting what my decisions were. You can't see, I'll walk with you. You're having trouble, let's do an even easier trail. Encourage me to walk. Oh, you're looking like you're, you're moving today, let's go for a walk...You know, my daughter coming over and saying, Hey, let's just go for a walk around the block. Oh, my legs ready? Oh, well, let's try. You know, so be in there. And when you say enough is enough, then that's when we go home (Pat) I guess, by, I guess, myself eating a healthy diet, which and encouraging my partner to eat a healthy diet and perhaps as choosing together to cook or shop or, I guess, think about our health, instead of just carrying on and not thinking about our health (Amanda) 20 Living with the condition (processing emotions, adjusting, integration the condition into life, making meaning of the situation) You know just because I'm not eating this, you have to eat. You know, like, if you don't have the same body functions or body makeup I do (Pat) Like to get a little bit more maybe support in learning more about diabetes and stuff like that, like, you know, I'm, like, I'm decent at research and stuff like that I don't get into it quite the same way my partner does about everything they want to learn about, they go, like, over the top...And so it's just like, so I've learned that, like, you know, that the encouragement part is so strong, and just to stay as positive as you can (Sally) 21 Health beliefs (cultural, spiritual, general health beliefs) Well, I think growing up, you know, being in a very ethnic background, my parents had certain ways of preparing food and superstition about food, that, you know, when we, when I locate now, as an adult, I think a lot of it, we have to do that. You know, I don't think my parents ate as well (Sharon) Totally, totally. I did mention my Ukrainian background. They grew up on a farm. They always had milk cream. Ah, yeah. Everything Ukrainian is covered in a cream sauce. No, I'm exaggerating just a little bit. But yeah, cream and butter are very important components of a lot of a cooking rich, rich foods, I would say. So yeah, totally. I would say that the background of my culture centers a lot on food. My mom's 93 And you still can't go to her house without her saying, Oh, you need something to eat (Bushy) 98 Appendix E: Rural and Remote Communities Themes THEME: FAMILY SUPPORT THAT IS UNIQUE TO RURAL AND REMOTE COMMUNITIES I live with my family member… And like, for example, people would often make comments that I should be caring for them and provide them with the food that they need to be healthy and what not…So I would say that's different in rural communities, because people who know me are telling me well, you should tell your family member to do that. – CL I think there is a difference because you end up relying on each other… I could go up for a ski and meet up with a group of people from within our club, a lot easier (in the city), versus here if I want to go for a ski, it's my partner and me, or just me. -Dan THEME: ACCESSIBILITY AS A BARRIER TO PA AND HEALTHY EATING there's a private gym in Grand Forks. But again, you have to drive them to it. And there's a pool, and we just learned that they have a small gym there as well. So you really have to drive to get anywhere and, and it in some ways, seems more than when, yeah, if I lived in the city, we still might drive 20 minutes to go to a gym. But maybe, because you're always in this city, it doesn't feel like you're having to get out and go onto the highway, you know, and drive into town… But I think if you want like fitness classes and those kinds of things, then you have to commute to that. And then it's like, weather sucks. I don't want to drive into that. - Dan Very rurally, which, what made it a lot harder to have access to, to food easily. I mean, it was 75 kilometers to get into town – Sally THEME: FEW SOCIAL OPPORTUNITIES AS A BARRIER TO PA I think in larger centers, you can become connected to different activities and different groups. That exists, there's a few of them, you know, in small places, but you know, going for a walk at Stanley Park, for example, or, or groups that, you know, do rollerblading or roller derby, or, you know, different things like that, that you can try. Because I mean, here, it's like you're either cross country skier or mountain biker, if you don't fit into any of those, then you're like, Well, that's it kind of thing. -CL So from a demographic perspective, think that sometimes that can be whether it's a barrier, or discouraging to go and do things, or makes it a little more difficult to go out. It's not quite as easy to join into a group because there's not as many groups, or sometimes and this kind of ties in with earlier, you know, we're talking about living in a big place versus a small place. In a big place, there's like, quite a diversity of groups that you can join. So you can usually find one that kind of fits maybe how you view the world, not that everybody needs to be the same and your, your physical abilities and all those things. Whereas I find here and I think that that kind of.... you have to be more intrinsically motivated to do things by yourself versus being able to join into a group… But connecting with people that will want to do sort of a similar thing can be harder here. – Dan THEME: RELY ON INTERNET FOR HEALTH INFORMATION AND APPTS I would say so for sure. Yeah, okay. Very, because, especially since COVID, we're realizing more and more that, that we need the internet. And, you know, now health appointments are online, things like that. Right. And my parent was part of a diabetes group that was online, things like that we kind of need it to function. – CL And most of that education actually came from living in a small place and, watching YouTube videos with me. – Pat 99 THEME: ACCESSIBILITY AS A FACILITATOR TO PA AND HEALTHY EATING And we go hunting on those islands. You know, so we mostly an indigenous diet we and the rest we buy from a local farmer – Pat It's a beautiful area, lots of opportunities for outdoor recreation…So I guess physical activities are the thing that our, I guess impact us the most in terms of it being right outside of our door. - Sharon THEME: ADAPTATIONS FOR RURAL ENVIRONMENT CAN FACILITATE PA AND HEALTHY EATING I have my bike on a bike trainer, and we've got some weights and we came home from Mexico and said, okay, we're gonna get more, you know, weights to be able to do stuff at home, so we don't have to go into town. – Dan Because I find most of the recommendations are made to people living in urban areas are how most people live – Pat
Thesis/Dissertation
eng
Health and Exercise Sciences
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Jung, Mary E.
The role of family support in preventing type 2 diabetes in rural and remote British Columbia
Text