Stress-Adapted Dining with Diabetes Program for Rural Communities: Implementation and Effectiveness

About This Grant

PROJECT SUMMARY/ ABSTRACT Rural individuals with type-2 diabetes mellitus (T2D) face higher rates of complications including amputation, renal failure, and blindness compared to their urban counterparts, which is particularly concerning in Missouri where 99 of 101 rural counties are health professional shortage areas. Our pilot study in the Missouri Bootheel, which has the state’s highest diabetes prevalence rate, revealed that participants experiencing higher stress levels had suboptimal health self-management practices, underscoring the need to integrate stress management into diabetes self-management education programs (DSMEP). This project aims to address this gap by systematically adapting the Stress Process Model (SPM) into the evidence-based Dining with Diabetes (DWD) program for rural Missourians living with T2D. Therefore, in response to PAS-25-102 (Small R01 for Clinical Trials Targeting Disease within the Mission of NIDDK), this research project addresses these intersecting challenges through three specific aims: 1) to systematically adapt SPM into the DWD program for rural populations; to assess the feasibility and preliminary efficacy of the adapted DWD+SPM intervention in rural Missouri by implementing a pilot cluster randomized trial and 3) to evaluate implementation outcomes of the DWD+SPM adapted intervention to inform future scale-up efforts. Using the ADAPT-ITT framework, we will engage Extension Specialists and community partners from six Bootheel Missouri counties to incorporate SPM into the DWD program (DWD+SPM). We will identify rural-specific challenges to diabetes self-management, document necessary adaptations to program content and delivery methods, and develop stress resilience components based on the Stress Process Model. We will assess the acceptability, feasibility, and preliminary efficacy of the adapted DWD+SPM intervention through a pilot hybrid type 1 effectiveness-implementation trial comparing the adapted and traditional DWD programs. Finally, using mixed methods, we will evaluate implementation outcomes to inform future scale-up efforts, measuring implementation outcomes, documenting adaptations, identifying challenges and enablers, and examining how community-specific resources influence program implementation across rural contexts. The expected outcomes will significantly contribute to improving T2D management among rural individuals in Missouri, with underserved rural residents receiving additional stress management services through county extension. Findings will inform the development of a larger-scale R01 randomized controlled trial testing the efficacy and cost-effectiveness of the DWD+SPM intervention across various rural DSMEP delivering settings. This project directly addresses rural health disparities by incorporating stress management into an evidence-based education program to improve T2D outcomes in rural Missouri and responds to the need for interventions specifically effective for rural populations.