Peel Family Diabetes Prevention Program

Definition: The perception among our intervention participants (SA and BAC) and coaches that the delivery of the intervention curriculum is agreeable, palatable, or satisfactory.

Level and unit of analysis: At the provider (coaches) and study participant level.

Measure: Level of rating and perceived intervention's approval, appeal, likeness, and welcoming.

Data will be collected from intervention participants and study coaches using semi-structured interviews and surveys. Interviews will use open-ended questions to explore perceived acceptability, including appropriateness, appeal, likeability, and a sense of welcome. Acceptability will also be measured using the 4-item Acceptability of Intervention Measure (AIM), rated on a 5-point Likert scale ranging from 1 (completely disagree) to 5 (completely agree), with higher scores indicating greater acceptability.

Definition: The perceived fit, relevance, or compatibility among our intervention participants and coaches (frontline intervention providers) of the intervention content and format in addressing their needs for T2D prevention associated with T2D risk factors.

Level and unit of analysis: At the provider (coaches) and study participants' level.

Measure: Level of rating and perceived fit, relevance, compatibility, suitability, and usefulness.

Data collection and instruments: Data collected through individual semi-structured interviews and surveys. Interviews will explore perceived fit, relevance, compatibility, suitability, usefulness and practicality of the intervention content and format. The survey includes a 4-item Acceptability scale with a 1-5 score (1 = Completely disagree, 2 = Disagree, 3 = Neither agree nor disagree, 4 = Agree, 5 = Completely agree), as well as qualitative questions.

Definition: The proportion of and representation of the targeted SA and BAC family dyads that participated in the intervention.

Level and unit of analysis: At the study participant level. Measure: Reach rates and related factors. Data collection and instruments: Measured as the reach rate of the targeted population (percentage of eligible families with children aged 14-18 in Peel of BAC and SA communities that were enrolled in the study), and the percentage of representativeness of the enrolled participants in relation to the SA and BAC population as related to socio-demographic and T2D risk.

Qualitative questions exploring drivers of participation will be assessed at screening and enrolment using the expression of interest form, eligibility assessment form, and/or consent form. For example, participants will be asked: "What motivated you to participate in this study?"

Definition: The decision or effort to begin using/implementing the plans/advice from the coaches.

Level and unit of analysis: At the study participant level. Measure: Level of rating and perceived intervention's approval, appeal, likeness, and welcoming.

Data collection and instruments: Quantitative measures will include enrolment rates; initial uptake (defined as the proportion of intervention participants and family dyads attending at least two sessions within the first month of enrolment); uptake at the end of the active intervention stage; and uptake at the end of the sustainability stage. Qualitative data will be collected through interviews using open-ended questions to explore reasons for enrolment, initiation of the health and wellness T2D coaching intervention, and factors influencing participation, adherence, and completion.

Definition: The extent to which the intervention is supplied and accessible at any given time.

Level and unit of analysis: At the provider (coaches) and study participant level.

Measure: Level of availability and perceived accessibility. Data collection and instruments: Data will be obtained from quantitative measures derived from study and intervention delivery logs at the coach and site levels, as well as from individual semi-structured interviews (accessibility perceptions and driving factors) with the study's intervention coaches and participants in the intervention group.

Examples of specific measures: 1) Percentage of participants able to access a session within the first month of enrolment (randomization); 2) Attendance rates at scheduled sessions; 3) Percentage of participants reporting satisfaction with program availability; and 4) Number of last-minute cancellations by participants (participant-related diverse reasons).

Definition: The degree to which the intervention was consistently implemented as planned.

Level and unit of analysis: At the provider (coaches) and study participant level.

Measure: Level of fidelity and driving factors. Data collection and instruments: Quantitative/qualitative measures using intervention delivery logging, fidelity checklist, audio-recorded coaches' sessions, and semi-structured interviews. Measures include 1) A self-fidelity score ( based on a self-reported fidelity checklist collected after each coaching session). 2) External-fidelity monitoring. A trained independent assessor will also evaluate intervention delivery logs and a sample (10-20%) audio-recorded coaching sessions to determine a fidelity score on a 0-100 scale for the following dimensions: a) Adherence /Content delivered, b) Dose/Dose delivered and received; and c) Coaching Delivery Quality (competence delivery).

Measure: 1)Capillary Blood Hemoglobin A1C (%), measured using Point-of-care (POC) A1C testing.

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: 1) As a quantitative (continuous) outcome measure (%); and 2) as a clinically significant range (Non-prediabetic (non-prediabetic diabetic): A1C <6.0%. Prediabetes: A1C between 6.0% and <6.5%. Diabetes: A1C > 6.5%).

Measure: 1) Overall quality of life (QoL) will be assessed using the EQ-5D-5L tool. The EQ-5D-5L measures five dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), each rated on a 5-level scale (1 = no problems to 5 = extreme problems).

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: 1) The EQ-5D-5L overall health index score. 2) The EQ-5D-5L dimension-specific scores.

Measure: It will be measured using the EQ VAS, whose values range from 0 to 100, reflecting overall health (0 = worst imaginable health; 100 = best imaginable health).

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Overall health rated score of the EQ VAS.

Measure: The perceived level of health-related quality of life (QoL) will be assessed using qualitative questions, such as:

• When you think about health, what does it personally mean to you, and how does that meaning relate to the number you selected on the health scale (EQ-VAS)?
• Can you explain why you chose that number on the health scale (EQ-VAS) today?
• What aspects of your health, daily life, or overall well-being influenced your rating? Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Salient findings will be derived from qualitative data.

Measure: 1) Well-being will be assessed using the VAS-Happiness Scale, with a value range of 0 to 100 (0 = completely unhappy, 100 = completely happy). 2) A qualitative happiness assessment using open-ended questions will complement the VAS-Happiness Scale, exploring participants' perceptions of the meaning and interpretation of VAS-Happiness Scale score selection.

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: 1) Overall VAS-Happiness score; and 2) Salient qualitative happiness themes (definition and driving scoring factors).

Measure: It will be assessed using qualitative questions to help participants contextualize their happiness rating level and express their unique perceptions. Qualitative questions that will be used are as follows: 1) When you think about happiness, what does it personally mean to you, and how does that meaning relate to the number you selected on the scale? 2) Can you describe what influenced your rating on the happiness scale today? Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Salient happiness definition and driving scoring factors.

Measure: 1) Diabetes Prevention Knowledge level for the "Causes" and "Duration" of diabetes using the Diabetes Knowledge Questionnaire (DKQ). The DKQ dimension questions are rated using a three-response format: true (T), false (F), and don't know (DK). A score with a range of 0-100 will be calculated using the following formula: Number of correct responses /maximum possible score in that dimension, multiplied by 100.

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: At the dimension-specific score.

Measure: It will be measured using qualitative open-ended questions such as follows:

• Since participating in this program, what new information have you learned about T2D that you didn't know before?
• Has your awareness of how to manage or prevent diabetes improved? If yes, in what ways?

• Which aspects of diabetes prevention (e.g., diet, exercise, stress management, seek help) do you feel more confident about now compared to before the intervention? 3) Have your attitudes or intentions toward diabetes prevention changed due to your participation in this program?

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Salient drivers of diabetes prevention knowledge will be identified from the qualitative data.

Measure: The lipid panel will include total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), and non-high-density lipoprotein-cholesterol (non-HDL-C). It will be obtained using the participant's capillary blood (finger-prick) sample with a validated Point-of-Care (POC) device.

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: 1) Quantitative (continuous) outcome measure (mm/L) for each of the lipid panel components (TC, HDL, LDL, TG, non-HDL). 2) As a clinically significant range (category) according to the 2021 Canadian Cardiovascular Society Guidelines using the Framingham Risk Score (FRS) stratification and paediatrics guidelines.

Measure: Three blood pressure (SBP) and diastolic blood pressure (DBP) measurements will be taken using a digital blood pressure device.

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: As continuous measures, the average systolic blood pressure (SBP, mmHg) and diastolic blood pressure (DBP, mmHg) were calculated from three readings. Then, the optimal blood pressure level will be analyzed by categorizing SBP and DBP values into clinically significant ranges according to the Hypertension Canada Guidelines (2025): Optimal blood pressure is defined as the mean of three readings: <130 (SBP)mmHg/80 (DBP) mmHg.

Measure: Body weight (kg) will be measured by the research team rather than self-reported, using a validated weighing scale.

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: As a continuous outcome (kg).

Measure: It will be measured with a waist circumference tape (cm) by a trained team member following WHO STEPS procedures.

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: The obtained WC values will be analyzed as a continuous variable for all participants and as a categorical variable for participants aged 18 or older (Low-risk WC and High-risk WC).

Measure: It will be derived from body weight (kg) and height (m) measurements to obtain Body Mass Index (BMI) in kg/m². Height will be measured using a mobile height-measurement stadiometer by our trained research team, following WHO STEPS procedures. The weight measure has been explained in the weight-level outcome.

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: BMI will anayzed as continuous vairbale , as well as categoric weight variable as follows: Normal (BMI ≥18.5- 24.9 kg/m²), Overweight (BMI ≥ 25- 29.9 kg/m²), Obese (BMI ≥ 30 kg/m²)for participants aged 18 or older. For participants under 18 years, BMI will be categorized into weight status groups (possibly underweight, healthy weight, possibly overweight, possibly obese) based on children's age and sex WHO growth charts (ages 2 to 19) for Canada.

Measure: A five-point Likert scale, ranging from always=5 to never =1, of their healthy cooking practice behaviours in the last week, using the following questionnaire:

• Does not add salt to food at the table
• Replaces salt with herbs and spices
• Replaces shortening/lard with vegetable oil
• Modifies recipes to lower sugar or fat
• Modifies recipes to increase fibre
• Uses healthy cooking methods (e.g., baking, grilling, steaming, or air frying) instead of deep frying
• Adds extra vegetables to casseroles and soups
• Plans meals using MyPlate method (or other meal planning methods) to include balanced and nutritious
• Checks nutrition facts label on food packages
• Prepares meals and snacks at home Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Item-level scores range from 1-5. Responses of "sometimes" to "always" will be recoded as 1(yes) and "rarely" or "never" as 0(no), then summed in a total score (0-10).

Measure: It will be assessed using the following qualitative questions:

• What kinds of challenges or barriers, if any, have you [your family caregiver for youth, if they do not cook] experienced when trying to cook healthy meals at home? 2) Has the program helped you [ your family caregiver for youth, if they do not cook], find ways to overcome some of these barriers? 3) How have your family's preferences or cultural traditions influenced the way you [your family caregiver for youth is they do not cook] cook or the changes you've made since the program? 4) Have you found ways to make traditional dishes healthier? Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Salient food preparation driven factors.

Measure: It will be measured using the following question: How confident do you feel in your ability [or your family caregiver's ability for youth if they do not cook] to prepare healthy meals regularly? The response options will be rated on a 5-point Likert scale: Not at all confident (1); Slightly confident (2); Moderately confident (3); Very confident (4); Extremely confident (5).

Assessment participant unit: Adult family caregiver participants and youth participants. As self-efficacy cooking score, range 1 to 5.

Measure: It will be measured using the following qualitative questions: 1) Can you describe what makes you feel confident [or your family caregiver's ability for youth if they do not cook] or not confident in preparing healthy meals regularly? 2) How does your confidence [or your family caregiver's ability for youth, if they do not cook] in meal preparation affect your family's eating habits or routines? 3) Have you noticed any changes over time in your confidence [or your family caregiver's ability for youth, if they do not cook] and what contributed to those changes? 4) How have your family members responded to these changes? Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Salient driving factors for self-efficacy in cooking.

Measure: Healthy food intake patterns. It will be assessed using the MyPlate method over a week (more than 3 days), in which participants self-report typical eating patterns following MyPlate recommendations (half the plate filled with non-starchy vegetables, a quarter of the plate filled with carbohydrate foods, and a quarter of the plate filled with protein foods), other foods, and beverage intake.

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: As categorial intake patterns and count-based intake frequency (0,1,2,3…) of non-starchy vegetables, carbohydrate foods, protein foods, beverages, and other foods. Beverage intake type and frequency (number of glasses).

Measure: It will be measured using the following questions:

• What are the main reasons you were not able [or able] to follow the MyPlate food intake recommendations (for example, filling half your plate with vegetables, one-quarter with carbohydrates, and one-quarter with protein)? Lack of time to prepare balanced meals.

• Limited access or affordability of healthy foods.
• Cultural or taste preferences.
• Lack of knowledge or cooking skills.
• Family or household food preferences. __Other (please specify)________________ Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Salient driving factors of healthy food intake.

Measure: Physical activity engagement level will be evaluated using the Physical Activity Vital Sign (PAVS) 2-item tool.

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Weekly physical activity engagement level as a continuous measure: Total minutes of physical activity /week (minutes/week). Additionally, physical activity engagement will be categorized as a clinically significant variable based on the World Health Organization (2020) guidelines on physical activity and sedentary behaviour for adults (≥18 years) as low (< 150 of average minutes/week) or high (≥150 of average minutes /week), and for children (<18 years) as low (< 60 of average minutes minutes/day, or <420 minutes/week) or high (≥60 of average minutes minutes/day, or ≥420 minutes/ week).

Measures: It will be assessed using the following qualitative open-ended questions:

• What makes it difficult [easy] for you to engage in regular physical activity?
• Can you describe any personal, economic, social, or environmental factors that limit [ encourage] your activity? 3) Are there specific programs, spaces, or tools that make it easier for you to exercise? 4) In what ways has engagement in the prevention program impacted your engagement in physical activity on a regular basis? Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level:

Measure: Sleep duration will be measured using the adapted 24-hour sleep duration question used in the National Longitudinal Study of Adolescent to Adult Health Parent Study. How many hours of sleep do you typically get each day? [HH:MM]. The question has been adapted to assess sleep duration patterns between the typical work or school day and the non-work or non-school day.

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Total minutes of sleep duration (minutes/week), as well as sleep duraction on workday/school days (minutes/week) and on weekend days (minutes/week).

Measures: It will be assessed using qualitative questions as follows. Workdays/schooldays Sleeping: 1)How would you describe the overall quality of your sleep on workdays or school days? 2) How satisfied are you with the amount and quality of sleep you typically get during workdays or school days? 3) Are there any environmental factors (e.g., noise, light, temperature, or household distractions) that affect your ability to get sufficient sleep during workdays or school days? Non-workday or Non-school Days: 1) How would you describe the overall quality of your sleep on weekend days? 2) How satisfied are you with the amount and quality of sleep you typically get during the weekend days? 3) Are there any environmental factors (such as noise, light, temperature, or household distractions) that affect your ability to get su get sufficient sleep during the weekend? Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Salient factors.

Measure: It will be measured using the 14-item Warwick-Edinburgh Mental Well-being Scale (WEMWBS), in which each item is rated on a 5-point Likert scale (1 = One of the time, 2 = Rarely, 3 = Some of the time, 4 = Often, 5 = All of the time).

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: As the total WEMWBS score, and as a categorical: Meaningful improvement (defined as an increase of ≥3 points from baseline) and Non-meaningful improvement (an increase of less than <3 points from baseline).

Measure: It will be assessed using qualitative open-ended questions, as follows:

• What kinds of experiences, relationships, social/cultural influence or daily activities have the greatest positive impact on your mental well-being?
• Can you describe any challenges or situations that make it harder for you to feel mentally/emotionally well or maintain a positive outlook?
• What supports, resources, or community connections help you the most in maintaining or improving your mental well-being?
• Have there been any changes in your mental well-being recently? Do you think participating in this community and research-informed study has contributed positively [or negatively] to your mental well-being changes? Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Salient driving factors of mental well-being.

Measure: It will be measured using the Perceived Stress Scale (PSS-10), a 10-item questionnaire assessing feelings and thoughts over the past month on a 5-point Likert scale (0 = never to 4 = very often).

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: The total score of the PSS-10, and as perceived stress categories (constructs) scores: a) Perceived helplessness total score, and b) Perceived self-efficacy total score.

Measure: It will be assessed using qualitative, open-ended questions, such as follows:

• Can you describe the main things in your life that currently cause you stress or make you feel overwhelmed?
• Who or what supports you the most when you are feeling stressed (e.g., people, activities, places, beliefs)?
• How do your surroundings, such as school, work, family, or community, affect your stress levels?
• Have you noticed any changes in what causes you stress or how you handle it over time?
• Do you think the intervention you are participating in contributed to these changes? Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Salient driving factors of perceived stress.

Measure: Measured using 1) the Connor-Davidson Resilience Scale (CD-RISC-2), 2-item version, rated on a 5-point Likert scale (0 = Not true at all, 1 = Rarely true, 2 = Sometimes true, 3 = Often true, 4 = True nearly all the time).

Assessment participant unit: Adult family caregiver participant and Youth participant.

Analytical level: Total score of the CD-RISC-2.

Measure: Driving factors of resilience related to self-perception of resilience, learning from challenges, and resilience support/connections will be assessed using the following qualitative open-ended questions:

• How would you describe your ability to bounce back from setbacks, and what do you think makes you resilient?
• Can you share an experience where facing a difficulty helped you grow or see things differently?
• Who or what do you turn to for support during tough times, and how does that help you? Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Salient driving factors of resilience.

Measure: It will be assessed using the Brief Assessment of Family Functioning Scale (BAFFS), which comprises three items rated on a 4-point Likert scale (1 = Strongly Agree, 2 = Agree, 3 = Disagree, and 4 = Strongly Disagree).

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: The total score of the BAFFS. As family functioning's categories (construct) based on total BAFFS score: a) Satisfaction with family functioning: BAFFS ≤ 6. b) Family distress: BAFFS > 6.

Measure: Driving factors of family functioning related to support and cohesion, roles and problem-solving, and the program contributing to family functioning will be assessed with qualitative questions:

• What kinds of support do family members provide to each other?
• How are responsibilities and problem-solving roles shared within your family?
• How does it contribute to family functioning?
• How has your family's functioning changed, if at all, because of participating in this program?
• In what ways do you think your family relationships, communication, or other factors [such as social support, stress, or cultural values] have influenced these changes or your experience with the program? Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: Salient driving factors of family functioning.

Measure: It will be assessed with a yes/no closed-ended question to determine whether a positive effect is present at the broader family level. If yes: a) Impact will be assessed using multiple-choice options and a self-reported rating on a 7-point Likert scale (1 = very low positive impact; 7 = maximum positive impact); b) Impact areas will be measured using a closed-ended question covering nine domains (e.g., healthier eating habits, increased physical activity, improved knowledge of diabetes prevention, reduced stress or improved emotional well-being, better communication about health and lifestyle, increased family support for healthy behaviours); and c) Respondents will indicate which family members were impacted. If no family members were impacted, an open-ended question will explore the reasons why.

Assessment participant unit: Adult family caregiver participants and youth participants.

Analytical level: As the categorical and ordinal impact levels, and as salient insights.