Public Expectations and Needs Related to Type 2 Diabetes Prevention: A Population-Based Cross-Sectional Study in Poland

Objective: This study aimed to understand the public’s expectations regarding type 2 diabetes prevention and to identify factors associated with willingness to participate in preventive activities among adults in Poland. Methods: A cross-sectional survey was carried out using a computer-assisted web interview (CAWI) on a representative sample of 1,046 adults in Poland. A non-probability quota sampling method was used. A study tool was a self-prepared questionnaire. Results: Most respondents (77.3%) declared willingness to participate in preventive activities. Consultation with a diabetologist (75.1%) or family doctor consultation (74.9%) were the most often selected. Lifestyle interventions in the form of dietary and culinary workshops (58.1%) were the least chosen. Having higher education (OR = 3.83, 1.64–8.94, p = 0.002), chronic diseases (OR = 1.36, 1.01–1.85, p = 0.04), and a history of diabetes in the family (OR = 1.67, 1.21–2.30, p = 0.002) were significantly associated with a higher interest in type 2 diabetes prevention. Conclusion: The adults in Poland are keen on participating in diabetes prevention programs, mostly those based on medical counselling rather than lifestyle-oriented interventions. Educational level was the most important factor associated with willingness to participate in type 2 diabetes prevention.


INTRODUCTION
Type 2 diabetes, a prevalent chronic disease, imposes a substantial burden on individuals and societies worldwide, resulting in multifaceted health, social, and economic costs.The prevalence of type 2 diabetes has reached pandemic proportions, with an estimated global prevalence of 9.3% in 2019, affecting over 463 million people, and is projected to rise to 10.9% by 2045 [1].The health-related consequences of type 2 diabetes encompass a range of complications, including cardiovascular disease, neuropathy, nephropathy, and retinopathy, all of which contribute to reduced quality of life and increased mortality rates [1].
Beyond the direct health impact, type 2 diabetes exerts substantial social and economic costs [2,3].It necessitates ongoing medical care, including medication and monitoring, straining healthcare systems and increasing healthcare expenditures [2].Furthermore, individuals with type 2 diabetes often experience reduced productivity and missed workdays due to illness and medical appointments, affecting their economic wellbeing and placing a financial burden on society [3].
The preventable nature of type 2 diabetes underscores the pivotal role of patient involvement in effective diabetes prevention strategies [1,4].Recent research has demonstrated that lifestyle modifications, including dietary improvements, increased physical activity, and weight management, can significantly reduce the risk of developing type 2 diabetes among high-risk individuals [4,5].These interventions necessitate active patient engagement, demanding sustained behavioral changes and adherence to health-promoting practices.Patient involvement extends beyond mere compliance with medical recommendations; it encompasses education, empowerment, and self-management skills, all of which are integral to the success of diabetes prevention efforts [6].Encouraging individuals to take an active role in their health and providing them with the necessary tools and support to make informed decisions and sustain healthy lifestyles are paramount in the fight against type 2 diabetes.
There is an increasing recognition of the need to take measures to reduce the risk, detect early, and limit the consequences of type 2 diabetes.Diabetes prevention has become a priority at the global [7], regional [8], and national levels.
In Poland, central and local authorities are taking action to prevent diabetes under The National Health Programme 2021-2025 [9].Nonetheless, type 2 diabetes prevalence in Poland is on the rise [10].It is estimated that the number of patients diagnosed with diabetes exceeds 2.5 million [11], and up to a million are unaware of the diagnosis [12].
Preventing type 2 diabetes involves two main strategies: primary and secondary prevention.Primary prevention aims to reduce the occurrence and progression of the condition in individuals without diabetes who are at risk due to factors such as obesity, physical inactivity, and poor dietary habits [13].Lifestyle modification programs are crucial in primary prevention, focusing on behavioural changes like healthy eating, regular exercise, and weight management to lower the risk of developing type 2 diabetes [14].Secondary prevention involves early detection of the disease in seemingly healthy individuals who have subclinical forms of diabetes.Secondary prevention strategies often involve targeted [15] or opportunistic [16] screening (mainly blood sugar testing) and advice or counselling provided by medical professionals (i.e., brief intervention) [17].
Barriers to effective preventive actions include organizational issues such as administrative or financial limitations [18,19], as well as participants' dependent factors that limit attendance in offered activities [20,21].The importance of determining the scope/method of intervention following participant expectations and capabilities [22] and selecting the appropriate outreach [23] strategies to reach the proper target population was underlined.
Therefore, the objective of this study was to characterize public expectations and needs relating to type 2 diabetes prevention and identify factors associated with willingness to participate in activities aimed at type 2 diabetes prevention among adults in Poland as determinants of the effectiveness of preventive measures.

Study Design and Sample
This cross-sectional study was conducted between 15 and 18 September 2023 on a representative sample of 1,046 adults in Poland.
Data were collected using a computer-assisted web interview (CAWI) technique by the professional public opinion research company (Nationwide Research Panel Ariadna, Warsaw, Poland), which acted on behalf of the research team [24].The participants in the survey were chosen from a pool of over 100,000 registered and verified individuals who actively participate in web-based surveys conducted by the public opinion research company [24].A non-probability quota sampling method was used, with a stratification model that accounted for variables such as gender, age, size, and location of the place of residence.This stratification was based on sociodemographic datasets collected and published by the Central Statistical Office of the Republic of Poland in Warsaw.Similar methods were used in previous population-based crosssectional studies in Poland [25,26].
This study was approved by the Ethical Review Board at the Centre of Postgraduate Medical Education, decision number 404/ 2023 as of 23 August 2023.

Participants and Public Involvement
Participants in this study were not involved in developing the design or recruitment.Results will be disseminated via publication in an open-access journal.

Measures
The questionnaire was self-prepared and based on a literature review [15][16][17][18][19][20].The study questionnaire included ten questions on public health interventions related to type 2 diabetes prevention.Additionally, questions on sociodemographic characteristics were addressed.A pilot survey was carried out.A group of 11 adults (aged from 19 to 73 years) filled out the questionnaire twice, 7 days apart.Responses from the pilot survey were analyzed and two questions (including answer options) were modified to clarify the text.
Willingness to participate in activities aimed at type 2 diabetes prevention: Respondents were asked about their willingness to participate in activities aimed at type 2 diabetes prevention, using the question: "Would you like to take advantage of activities aimed at preventing type 2 diabetes?"with a 5-point Likert scale.
Public interest in various activities aimed at type 2 diabetes prevention: Respondents were asked about their interest in various activities aimed at type 2 diabetes prevention, using the question: "Which activities aimed at type 2 diabetes prevention would you like to take advantage of?" with ten mutually nonexclusive answers.Respondents were asked to select "yes" or "no" for each answer choice.
Health status: Respondents were asked about their health status, using the following questions: "Has ever doctor said that you had diabetes?"(If yes, which type of diabetes you had diagnosed: type 1, type 2, gestational diabetes, other types of diabetes, I do not remember), and "Do you have chronic diseases or health problems lasting at least 6 months (yes/no).Moreover, respondents were asked about the history of diabetes in the family, using the question: "Does anyone in your immediate family have diabetes (e.g., children, parents, siblings, grandparents)?" (yes/no).Sociodemographic characteristics included gender, age, educational level, marital status, having children, place of residence, number of household members, occupational status (active-currently employed or self-employed or passive-unemployed, retired, student), and self-declared financial status.

Data Analysis
Data were analyzed using SPSS package version 28 (IBM, Armonk, NY, USA).The distribution of categorical variables was presented with frequencies and proportions.Crosstabulations and chi-square tests were used to compare categorical variables.The statistical significance level was set at p < 0.05.

Characteristics of the Study Population
This study is based on responses from 1,046 adults in Poland (53.4% were females).Among the respondents, 43.6% had chronic diseases, and 14.1% were diagnosed with diabetes (Table 1).Over one-third of respondents (36.7%) declared a history of diabetes in the immediate family (Table 1).

Public Expectations and Needs Related to Type 2 Diabetes Prevention
Most of the respondents (77.3%) declared willingness (definitely yes or rather yes) to take advantage of activities aimed at preventing type 2 diabetes (Table 2).Out of 10 different diabetes prevention measures analyzed in this study, having a blood glucose level measurement performed at a pharmacy (75.4%), medical consultation with a diabetologist (75.1%), family doctor consultation (74.9%), dietary consultation (71.8%), and BMI calculation (70.6%) were the most common type 2 diabetes prevention measures expected by public in Poland (Table 2).

Sociodemographic Differences in Public Expectations Towards Type 2 Diabetes Prevention
There were sociodemographic differences in public expectations towards participation in activities aimed at preventing type 2 diabetes (Table 3).Respondents with higher education (84.0%) more often declared interest in type 2 diabetes prevention measures compared to other educational groups (p < 0.001).The lowest percentage of respondents who declared willingness to participate in activities aimed at preventing type 2 diabetes was observed among respondents who declared being single (68.2%; <0.001).Respondents with a history of diabetes in the family more often declared willingness to participate in activities aimed at preventing type 2 diabetes compared to those without a history of diabetes in the family (82.8% vs. 74.2%;p = 0.001).Moreover, respondents with chronic diseases more often declared interest in type 2 diabetes prevention measures (80.9% vs. 74.6%;p = 0.02) compared to healthy individuals (Table 3).There were sociodemographic differences in public expectations towards activities aimed at type 2 diabetes prevention (Table 4).Having a family member diagnosed with diabetes had a significant influence on the likelihood of choosing all but one (consultation with a family doctor, p = 0.1) preventive services.Marital status was also linked to significant differences in preferences.Single respondents were less likely to opt for all but two (advice on physical activity, p = 0.3 and sports activities, p = 0.08) preventive actions.People diagnosed with diabetes more often than healthy respondents declared a willingness to participate in 6 out of 10 preventive activities.The selfdeclared financial status of respondents had no significant influence on their preferences, and the place of residence was linked only with a higher interest in outdoor events or stands during special events (61.1% vs. 48.9% in the biggest cities, p = 0.03).

DISCUSSION
To the authors' best knowledge, this is the first study on the expectations and needs relating to type 2 diabetes prevention and on factors associated with willingness to participate in activities aimed at type 2 diabetes prevention among adults in Poland.Most of the respondents declared interest in diabetes-preventing activities was high.Out of Educational level, history of diabetes in the family and presence of chronic diseases were significantly associated with expectations towards participation in activities aimed at preventing type 2 diabetes among those without diabetes, both among all participants as well as those without diabetes.
Those results correspond to the previously published data [27] on the awareness of diabetes in Polish adults.As it was recently confirmed by Sękowski et al. [11], knowledge of diabetes in Poland is strongly related to the patient's level of education.Rising awareness of diabetes among Polish adults, its risk factors and symptoms results in higher readiness to participate in diabetes prevention actions.However, an educational gradient of this attitude may result in greater health inequalities [28], as only a part of the population is ready to take advantage of such preventive measures.This is especially of consideration in the case of Poland, where a substantial part of the population had never undergone a blood glucose test [29], and the number of undiagnosed patients with type 2 diabetes is estimated to be up to 1 million [30].
Most of the respondents declared willingness to participate in diabetes prevention activities based on healthcare services such as blood sugar tests, consultations with specialists (diabetologists) and family doctors.Lifestyle-related interventions were the least chosen.Those preferences towards medical services and, in consequence, secondary prevention may be due to two reasons.The Polish health system is considered to have problems in meeting the health needs of the society [31,32].Therefore, patients may prefer actions that provide them with the opportunities to meet the demand for health services.This seems especially true for the oldest patients (60+ age group), who most often choose the medical interventions through consultations with a family doctor or a diabetologist (89.5% and 80%, respectively).The inadequate availability of medical services is also perceived as a problem by doctors who provide such services to senior patients [33].
On the other hand, the knowledge of lifestyle-related risk factors for diabetes remains inadequate in Poland [12].This may result in higher demand for services that meet the social notion of effective diabetes prevention.
Numerous studies have determined the influence of physical activity and exercise on health outcomes.The research indicates that physical activity increases the quality of life and lowers death rates with little to no safety issues [34].A recent study by Biernat et al. [35] revealed low declared physical activity levels among Poland's adults.It showed that the likelihood of participation in physical activities depends among other things, on age and education level.Those findings correspond with the results of this study in which sports activities, as a form of diabetes prevention, were chosen mostly by younger participants (70% in the 30-39 age group) with higher education (68.4%) and active occupational status (68.8%).The latter correlates with the findings of Meyer et al. [36], who showed that higher socioeconomic status was associated with involvement in all intensity levels of physical activity.
The diet is a second lifestyle factor considered key in diabetes prevention and mitigation of its complications [37].Some studies show that due to dietary intake, never-married men in Poland manifest, on average, higher systolic and diastolic blood pressure [38] as risk factors for diabetes [39] and common comorbidities [40].Despite those circumstances, single respondents were less willing to participate in all diet-related activities (culinary workshops, dietary consultations).Moreover, being single was also negatively correlated with lower preferences towards all consultations with healthcare professionals (family doctors, diabetologists, nurses and educators).Contrasted with, on average, lower quality of life and perceived health condition observed among non-married adults in Poland [41], the attitude of single adults towards preventive health services identified in this study poses a serious challenge.
The results of this study also demonstrated that having a family member with diabetes increases the willingness to participate in all but one (consultation with family doctor) activities.We can hypnotically assume that this is because diabetes has a particular characteristic in that it is a chronic disease that typically manifests in older age, and the patient frequently needs family support and involvement in disease management.Therefore, the patient's family may have a higherthan-average understanding of this disease (its risk factors and its prevention), as reported by Sękowski et al. [12].These may complement proper diabetic education that should be offered as part of a public health intervention on diabetes but should not be used in its place.This study has practical implications for the implementation of a community pharmacist-physician collaborative working model in Poland.This study revealed that there is a need to strengthen the role of pharmacists in interprofessional care.Pharmacists should be encouraged to perform drug reviews and report drug interactions and polypharmacy.Pharmacist-physician collaborative working should be included in postgraduate training programs.Both groups should improve communication skills and learn how to build proper relationships based on respect and trust.There is also a need to promote the role of the pharmacist in the healthcare system -no longer as a distributor of drugs, but as an advisor and consultant in matters related to pharmacotherapy [18].Public authorities should remove barriers to pharmacist-physician collaborative working.Pharmacists should gain access to basic electronic health records that are necessary for pharmaceutical care [16,42].Moreover, the development of clear guidelines on what information should be recorded in the patients' records from the point of view of optimizing pharmacotherapy will also contribute to better cooperation between pharmacists and physicians.

Practical Implications
Numerous practical ramifications for public health actions in Poland can be drawn from this study.It shows a high level of interest in participating in diabetes prevention activities among adults in Poland.This interest is, however, directed towards medical services, while willingness to participate in lifestyle interventions is lower.
This finding emphasizes a need for improved education on diabetes, with special consideration for its risk factors and prevention methods.It is important to pay close attention to communication addressed to individuals with lower education, as that group was identified as less likely to participate in any diabetes prevention activities.Single males, especially those not active in the labour market, should be approached with targeted actions focusing on lifestyle risk factors and prevention methods of diabetes.
Moreover, this study provides evidence of inadequate education of patients diagnosed with diabetes in Poland and their low motivation to participate in activities that could prevent or delay complications of their disease.The results of this study also highlight the beneficial effect that having a family member with diabetes has on the degree of diabetes awareness among other family members.
The findings of this study can have implications for other countries, particularly those that are facing similar epidemics and economic challenges, like the former Eastern block countries.Nonetheless, it's important to consider that social and cultural differences may also play a role.

Limitations
This research has several limitations.The CAWI research approach was used to conduct the study, which forgoes direct interaction between the interviewer and the respondent (for example, the ability to judge the respondents' abilities and capacity to comprehend the questions posed).The study's questionnaire was restricted to the most common activities offered in the Polish health system.Due to the study's design, medical records were not validated, and participants self-reported health information and information on their family health history.Nevertheless, this is the most thorough and recent survey on the general public's attitude towards diabetes prevention activities conducted among adults in Poland.

Conclusion
The findings of the study were unequivocal and demonstrated a remarkable level of interest among Polish adults in activities aimed at preventing diabetes.Notably, the education level of respondents emerged as a crucial and statistically significant factor linked to their willingness to participate in such activities.Additionally, the study revealed a preference for medical interventions over lifestyle-oriented interventions, with only younger, better-educated, and working respondents showing a greater inclination towards the latter.
These results underscore the importance of comprehensive diabetes education, particularly in relation to lifestyle-related risk factors and prevention methods.
Int J Public Health | Owned by SSPH+ | Published by Frontiers January 2024 | Volume 69 | Article 1606790 4

TABLE 3 |
Sociodemographic differences in public expectations towards participation in activities aimed at preventing type 2 diabetes (N = 1,046) (Warsaw, Poland, 2023).Grudziąż-Sękowska et al.Public Expectations in Diabetes Prevention Bold font was used to mark the results that met the statistical significance criteria (p < 0.05).IntJ Public Health | Owned by SSPH+ | Published by Frontiers January 2024 | Volume 69 | Article 1606790 5
Int J Public Health | Owned by SSPH+ | Published by Frontiers January 2024 | Volume 69 | Article 1606790 6
Bold font was used to mark the results that met the statistical significance criteria (p < 0.05).IntJ Public Health | Owned by SSPH+ | Published by Frontiers January 2024 | Volume 69 | Article 1606790 7

TABLE 5 |
Factors associated with public expectations towards participation in activities aimed at preventing type 2 diabetes (N = 1,046) (Warsaw, Poland, 2023).

TABLE 6 |
Factors associated with public expectations towards participation in activities aimed at preventing type 2 diabetes among those without diabetes (N = 898) (Warsaw, Poland, 2023).