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Table 3 Responses of the focus group discussions as themes and sub-themes with descriptions

From: Lifestyle change in Kerala, India: needs assessment and planning for a community-based diabetes prevention trial

Theme 1: What to intervene on with respect to behavioural targets and their determinants? Theme 2: How to intervene in terms of preferences with respect to programme implementation?
Sub-themes Description and quotes Sub-themes Description and quotes
1. Knowledge and beliefs of diabetes General interest to know more about diabetes and its prevention. 1. Trusted sources of health information or potential intervention agents · Health centers.
· Physicians, health care providers.
· Grass root level non-physician health workers.
· Accredited Social Health Activists (ASHAs).
· ‘Kudumbasree’ (local women’s self-help groups)
2. Risk factors · Strong family history and the modern lifestyle.   
  · Unhealthy dietary habits including regular consumption of foods rich in fats and sugar like sweets, roots like tapioca and certain fruits, particularly sweet bananas like ‘rasakathali’. High consumption of pastries and snacks as parts of urban lifestyle.   
  2. Use and acceptance of Information Communication Technology (ICT) · Telephone used by all and highly accepted for practical organization of meetings.
  · Mobile phones used and accepted for incoming calls.
  · Physical inactivity, particularly in sedentary occupations and in urban environment. “People just don’t walk now-a-days.” · SMS used but not accepted.
  · Internet not used.
  · Long-term medications: “Since I am on a lot of medication, I expect that I may get it. I have read in articles that those who take medicines for blood pressure and other things have a higher chance of getting such illnesses.”   
  · Protective factors other than healthy food habits – e.g., “using no sugar in tea for the last 15 years” – rarely mentioned.   
3. Risk perception · No awareness of pre-diabetes status. 3. Preferences for intervention delivery “If meeting points or places can be identified for each locality and the intervention is done as a group, it is better. It should be a place where people in that area can walk to or access easily.”
· Regarding low male participation to regular village meetings (Gramsabha), “active men should invite other men”.
· Venue:
a. Easy access.
b. Within walking distance.
c. Health centres, reading rooms or anganwadis.
d. Participants’ homes.
· Format:
a. Group of 10–25 participants, important for generating different ideas that would benefit the whole group.
b. Including at least two people per family and neighbours. Women might need permission from their husbands.
· Time:
a. Duration 1–1.5 h.
b. Once-a-week.
c. On holidays.
d. When children are at school (for housewives).
· Diabetes risk perceived higher for women, a group seen as less physically active, with a tendency to over eat and to ignore early symptoms.
· Perceived own risk:
i. Little to no risk: Participants, who perceived their food habits were healthy; had no family history; or had faith that regardless of habits, they were simply not at risk. “I don’t believe in any of this. I don’t feel I have any risk. I still need double sugar in my tea.”
ii. Fifty percent or more risk: Participants who already had a related illness like hypertension or myocardial infarction; or hypertensive or anti-cholesterol medication, perceived to contribute to high blood sugar; or who had significant family history. “I expect a 50% risk as I am a hypertensive for the last 18 years and have been on medication and I had a heart attack 10 years back.”iii. Don’t know: Not able or were not willing to speculate about their risk.
4. Outcome expectations · Diabetes has no cure, but can be controlled with oral medicines, injections, dietary and other lifestyle changes.
  · Low outcome expectations for lifestyle modification after the pre-clinical or very early stages of the disease: “You can only control it or decrease it. When food is controlled along with treatment, up to 80% can be controlled. Once you get the illness, you have no choice but to go for treatment.”   
5. Self-efficacy · A collective low self-efficacy regarding the ability to make and sustain changes in lifestyle. “I don’t think it is possible to make modifications in our lifestyle. No matter what you say, it will just continue like this.”
· Dietary habits not within individual control.
· Cultural norms such as “fruits other than bananas belong to children’s diet only” and collective household decision-making guide dietary practices.
· Physical activity is related to everyday chores, like walking to the market, or to job like farm work, not to leisure-time. “I am a driver working in the Gulf. When I come home for vacation, I do farming for four hours every day. I also have cows, so I get enough exercise. When I am in the Gulf, there is no time to walk or for any other exercise.” For men, availability of time is a barrier while for women both time and space restrict the possibilities to be physically active. “I used to do Yoga in the mornings. (…) When we go to the room, there should be no one else there. We need privacy. Slowly, it has become difficult to find such a time and space so, now I don’t do it anymore”. “I have heard that walking is good. But we have to start kitchen work at 6.30 in the morning, so when can we walk?” “We can’t go out of our own compound to walk. If we have space in our own backyard, it will work.”
· Quitting tobacco is hard because of social pressure. “I have quit several times, each time for varying duration (…) Inevitably, I will see some of my friends smoking or they will offer a cigarette and I will start smoking again.”
· Professional help is not sought for quitting. “If we want to stop smoking, we can decrease slowly not suddenly. If you smoke 10, you can make it 5, then 2 and then stop.”
· Women can only influence men’s use of tobacco by asking them not to smoke inside the homes.