Table 2 Interview code and content

Implementation Process

Evaluation and reflection of the trial implementation by community health care providers and the completion of each step.

Community healthcare practitioners

Attitude toward trials and the ability to perform rigorously

Medical Staff Interviews (4/4), Couple Interviews (11/12), Attendance

1. Practitioners generally reported that older adult was difficult to educate and manage.

2. It is not feasible to change the deep-rooted habits and behaviors of the older patient in the short term.

3. Some of the Practitioners did not strictly control the quality, especially they did not emphasize the concept of “couple synergy”, which weakened the difference between the intervention group and the control group, and the specificity was not outstanding compared with other health education course.

“Because the age of our participants in the course, the average would be 65 years old, I think. They are already elderly, and some of their perceptions of diseases are more fixed… The health education points that we say, they accept, may not change so easily, their glucose will not be controlled easily, and this is a longer process.” (Community health worker 2)

" At that time it was the concept of couple synergy was not deliberately emphasized in their courses.” (Community health worker 3)

Implementation Steps

Medical Staff Interviews (4/4), Couple Interviews (11/12)

Difficulties faced by community healthcare practitioners

Difficulties that are still unsolvable through efforts

Medical Staff Interviews (4/4)

Trial differentiation

Whether to highlight the role and importance of “couples”

Medical Staff Interviews (2/4), Couple Interviews(3/12)

Couple’s roles

The relationship basis of the patient with the spouse and other family members, the distribution of health management responsibilities between the couple.

Role assignment

Who is the dominant party in life

Medical Staff Interviews (1/4), Couple Interviews (10/12)

1. Almost all patients and spouses agree on the independence centrality of health management and ignore the effect of spousal help.

2. Spousal disharmony significantly affects the willingness and ability of spouses to participate in patient health management.

Wife: “Look at him, I have to manage him? He can do everything by himself”.

Husband: “Manage by myself, measure glucose and diet are managed by myself”. (Couple 07, husband, patient; wife, spouse)

“I feel very impatient, to serve a patient at such an old age… I’m barely able to take care of her, so I don’t have any energy to worry about you.” (Couple 06, husband, spouse; patient with hemiplegia)

Couple relationship

Medical Staff Interviews (1/4), Couple Interviews (7/12)

Patient independence centrality

The belief that a spouse’s help isn’t needed

Couple Interviews (11/12)

Spousal willingness to help

Couple Interviews (12/12)

Influence of other family members

Perceptions of how to treat patient health management

Couple Interviews (11/12)

Belief and perception

Focus on patient and spouse perceptions of the disease and trial.

Perceptions of the disease

Correctness and importance of knowledge about diabetes

Couple Interviews (11/12)

1. Diabetes is considered a “natural disease that comes with age” and is not given enough attention.

2. The vast majority of couples mention some wrong ideas and stick to them.

3. Adherence to the established exercise and diet practices, believing that the new methods are not as effective as the established self-management.

“I don’t know much about it yet, anyway, I can eat or sleep, I don’t feel anything.” (Couple 08, wife, patient)

“The doctor told me to take metformin three times a day, I just take it once, I don’t take so much, (I’m) worried about the liver (that there will be side effects).” (Couple 05, husband, patient)

“Then I’d rather go to Baiyun Mountain exercise, that doctor, she told me many time but I didn’t come, I just think don’t bother me.” (Couple 02, wife, spouse)

Perceptions of the trial

Perceptions of health education and couple-based intervention

Couple Interviews (12/12)

Own opinion

Misconceptions that are difficult to change even after intervention

Medical Staff Interviews (2/4), Couple Interviews (5/12)

Long-term adherence

Long-held mindsets and lifestyle habits before intervention

Couple Interviews (8/12)

Objective obstacle

Barriers to participation in the intervention or the occurrence of behavior change

Economic burden

Medical Staff Interviews (1/4), Couple Interviews (6/12)

1. The physical discomfort of older adult such as being easily hungry and tired, disability, etc. can significantly hinder them from making changes in diet and exercise.

2. The content of the courses is too elaborate and strict, which makes it difficult to follow, and can cause fear and reluctance to implement or adhere to them.

“She just has hemiplegia and can’t do much exercise right now, and it affects her glucose which is poorly controlled for a long time.” (Couple 07, husband, spouse)

“Eating only a finger-sized amount of meat, it’ s funny. I didn’t refute it at the time, how could it be less like that.” (Couple 04, husband, patient)

Difficult to implement

Interventions that are too severe or too burdensome to implement

Couple Interviews (6/12)

Lack of culture

Unable to understand the content of the intervention

Couple Interviews (2/12)

Physiological hindrance

Couple Interviews (7/12)

Time and distance conflicts

There is an incompatibility of time or distance between affairs and intervention

Couple Interviews (6/12)

Subjective initiative

Factors that promote or encourage behavior change

Experience’

Spouses and others’ experiences

Couple Interviews (5/12)

1. Half of the patients treated their spouse’s reminders with rejection and exclusion. The vast majority of patients believe that diabetes management is their own problem and not their spouse’s, which also reduces their spouse’s desire to participate in health management.

Wife: “(Diet) less oil and salt is healthier”.

Husband: “Is it healthy? If it’s healthy, you’re still like this (physical condition)”? (Couple 04, both husband and wife are patients)

Spousal Persuasion

Couple Interviews (8/12)

Physiological feedback

Couple Interviews (10/12)

New knowledge

Affirming the correctness of knowledge of health education

Couple Interviews (10/12)

Trust in physicians

Couple Interviews (2/12)

Behavior change

Behavioral changes occurring after the intervention

Sole change

Couple Interviews (11/12)

1. Female patients are more likely to be the bearers of family life, and male spouses may give less support in life.

Wife: “Every time I (help him) injection (insulin), he does not know, and he does not learn, director He said (patients) to learn how to inject, it should be their own task. I do not follow him 24 hours a day”.

Husband: " So why you need a spouse? " (Couple 04, both husband and wife are patients)

Change with spousal assistance

Behavior change that requires spousal companionship, services, and substitution.

Couple Interviews (11/12)

Lack of behavior change

Couple Interviews (10/12)