InGEAR Network Funding

Leveraging Community-Clinical Linkages to Address Unmet Social Needs in a Rural Setting.

The goal of this study is to develop and test a co-created, community-driven approach to building a strong social needs screening, referral, and resolution network based on community-clinical linkages. This approach aims to address the unmet social needs of people living with diabetes in rural settings. This project will implement and evaluate the community-driven approach using a hybrid effectiveness-implementation design. The study will yield a strategy to implement community-clinical linkages that can be expanded to rural communities across the country. It may be used to develop community-tailored social needs screening, referral, and resolution models, with the goal of improving quality of life for people with diabetes.

This project is a collaboration between DDT and the University of Kentucky.

Identifying and Testing Community-Based Practices for Community-Clinical Linkages to Manage and Prevent Diabetes in African American, Indigenous, and Rural Populations in Minnesota

The purpose of this project is to conduct a 1-year pilot study in three communities in Minnesota that implement innovative community-clinical linkage strategies. Mathematica is supporting implementation in these pilot communities and evaluating the strategies using an equitable evaluation design. This project will convene a diverse group of clinical and community partners, with the goal of promoting and expanding community-clinical linkages to improve access to prevention and care for people with or at risk for diabetes across Minnesota. This project will provide CDC, the Minnesota Department of Health, and other states with population-specific information about factors that hinder or promote access to diabetes resources. The project will also share patient perspectives on prediabetes and diabetes that could improve community-clinical linkage efforts. This study is designed to further CDC's mission to strengthen the evidence base of effective strategies to reduce diabetes inequities and enhance collaboration between public health, health care, and community health organizations.

This project is a collaboration between DDT and Mathematica.

Utilization of New Beginnings as a Social Support Intervention and On-Ramp to DSMES Through African American Church Health Ministries

The objective of this project is to evaluate the effectiveness of New Beginnings: A Discussion Guide for Living Well with Diabetes, implemented in African American faith-based communities. The project will be implemented in both a church and clinical setting and will evaluate participants' engagement with and attitudes toward diabetes self-management education and support (DSMES) services. The key research outcomes will include:

• Key barriers to DSMES engagement (e.g., cost, transportation, trust in health care, cultural beliefs).
• Preferred program features (interactive lessons, support networks, cooking demos, faith-based integration).
• Recommendations to tailor New Beginnings for faith-based settings.

This project is a collaboration between DDT and ICF NEXT.

New Beginnings as a Diabetes Management Social Support Intervention Complementary to Diabetes Support Program in Cooperative Extension

This study will conduct an evaluation of New Beginnings: A Discussion Guide for Living with Diabetes among participants in the Cooperative Extension's Balanced Living with Diabetes (BLD) intervention. BLD is a community-based diabetes management program, and New Beginnings will be tested as supplemental intervention. New Beginnings focuses on the emotional aspects of living with diabetes and building positive, supportive relationships to develop goal-setting, positive coping, and problem-solving skills. This aligns with the social cognitive theory constructs addressed in the BLD intervention. This study will evaluate how the interventions may complement each other in adults with diabetes living in rural Virginia. Existing validated scales will be used to assess diabetes-related social support and empowerment.

This project is a collaborative effort between DDT, the National Association of Chronic Disease Directors (NACDD) and Virginia Tech University.

The Systematic Engagement of Nurse Practitioners to Increase Enrollment in Diabetes Self-Management Education and Support (DSMES) Services

This project identifies and explores systematic strategies for increasing nurse practitioner referral to diabetes self-management education and support (DSMES) services. DSMES services are an evidence-based, cost-effective tool to improve health behaviors and health outcomes among people with diabetes. However, provider referrals are low, and these services continue to be greatly underutilized.

Referral from a health care provider is required for a person recently diagnosed or living with diabetes to enroll in DSMES services. Nurse practitioners (NPs) practice in every health care setting and have the same authority to refer patients to DSMES services as doctors, except for patients on Medicare. For patients with diabetes younger than 65, NPs may be an overlooked referral source for DSMES services.

Through this study, CDC aims to identify approaches for increasing NP referrals to DSMES services. One outcome of this project is the development of a continuing education webinar for NPs introducing them to resources and strategies for streamlining patient referrals to DSMES. Learn more here: Strengthening Patient Connections to Diabetes Self-Management Education and Support (DSMES) Services: A Training for Nurse Practitioners (Web on Demand).

This project is a collaboration between FHI 360 and DDT.

Identifying Effective Media and Messaging to Enroll Rural Populations in the Online National DPP Lifestyle Change Program

The project team generated evidence-based recommendations on the lowest effective media dose, optimal marketing mix, and most effective messaging to successfully enroll rural populations in the online lifestyle change program. The project revealed that a 6-month, small quantity, paid media campaign is not effective on its own for increasing enrollment. However, the team identified several effective tactics for rural settings. The team also provided guidance on creating an effective ad, optimizing paid media efforts (both digital and traditional) to enroll rural populations, and designing messaging and frequency that showed promise.

This project was a collaboration between FHI 360 and DDT.

National DPP Employer Adoption Study

The project team conducted research to understand barriers and facilitators to employer adoption and coverage of the National Diabetes Prevention Program lifestyle change program (LCP). Team members used literature reviews as well as interviews with insurance brokers, wellness consultants, and employers. They also assessed current employer-focused materials to identify potential gaps. Through the formative research, team members determined that the main barrier was lack of knowledge about the program. The team developed, implemented, and evaluated an intervention to encourage program adoption. Tailored materials were developed to:

• Educate insurance brokers about the National DPP LCP.
• Encourage health benefits consultants to offer coverage.
• Support employer adoption of the program as a covered benefit.
• Support employer implementation of the program.
• Information on program cost effectiveness was also made available for employers and insurers.

This project was a collaboration between Abt Associates and DDT.

To learn more about these projects, listen to Supporting Enrollment Through Health Communication and Behavioral Science.

Using Social Media Research and Analysis to Increase Engagement

Researchers used social media research and listening, internet search analytics, and website usage data to gain insight into how National DPP LCP audiences engage with key terminology related to prediabetes. Researchers also looked at how this engagement has-or has not-evolved over time. The project used advanced analytics tools and artificial intelligence technologies, such as machine learning and natural language processing, to develop insights into how the National OPP can use social media to increase recruitment, enrollment, and retention for the LCP.

A few recommendations from this project include:

• Use paid media to attract more participants instead of free media.
• Look for collaboration opportunities with companies.
• Use keywords for effective marketing, such as diabetes prevention, diabetes, prediabetes, diabetes education, prediabetic diet recommendations, and type 2 diabetes.

This project was a collaboration between Guidehouse and DDT.

Examining Lifestyle Coach and Master Trainer Characteristics Associated with Participant Engagement and Retention

The project team examined training factors associated with successful implementation and sustainability of the National DPP LCP among organizations that employ Master Trainers. Using quantitative and qualitative methods, researchers analyzed organizational, Lifestyle Coach, and Master Trainer characteristics, as well as data outcomes. The data were collected from existing records, surveys with study participants, and interviews with organization stakeholders, Master Trainer Select participants, and Lifestyle Coaches. The first manuscript was published in Implementation Science Communications. Articles about the project were published in Implementation Science Communications and Healthcare.

This project was a collaboration between Emory University's Diabetes Training and Technical Assistance Center and DDT.

To learn more about these projects, listen to Understanding Behaviors and systems to Support Growth and Change.

Testing the Effectiveness of a Text-Based Strategy to Streamline Enrollment in the National DPP

The goal of Text TODAY was to package and streamline the pathway of enrollment in the National DPP LCP by putting actionable information into the hands of the program participant. Text TODAY was promoted through geographically targeted social media, traditional media, and strategic state and local partners in selected media markets. The project prompted people to use a mobile device to text TODAY (or HOY if using Spanish), take the Prediabetes Risk Test, and take appropriate action based on their test result. People receiving a high-risk score were referred to the National DPP LCP, and program staff reached out to initiate enrollment. Of the estimated 400,000 people reached by the media campaign, 180 people texted the keyword and 111 people completed the Prediabetes Risk Test. Of those 111, 33 people received a status of high risk for prediabetes and five people enrolled and attended at least one session of a National DPP LCP.

Researchers noted that the multi-step process may have led to lower-than-expected enrollment. Ideas to improve future enrollment include segmenting the potential audience, tailoring materials to each audience, and marketing the media campaign through community-based organizations in the same communities.

This project was a collaboration between the National Association of Chronic Disease Directors (NACDD) and DDT.

The Effect of Mobile 360° Videos and MAPS on Enrollment in the National DPP

The project team tested the real-world efficacy of mobile 360° videos and a motivational coaching approach known as Motivation and Problem Solving (MAPS) to increase enrollment in the National DPP LCP. The study's key outcomes were data on LCP enrollment and 4-week engagement. In addition, the team collected data on the cost effectiveness and scalability of the interventions. Researchers conducted a three-armed, randomized clinical trial comparing enrollment and 1-month engagement in the LCP among adults with prediabetes from two health care settings. People who received standard prediabetes risk notification and education were compared to participants invited to view two mobile 360° videos and participants who received up to five short MAPS coaching sessions via telephone. Results revealed no effects of risk notification, mobile 360° videos, or MAPS coaching sessions on enrollment rates in the National DPP LCP.

This project was a collaboration between the University of Utah and DDT.

To learn more about these projects, listen to Growing Enrollment, Retention and Behavior Change Using Technology.

Innovations in the Use of the Self-Directed On Your Way to Preventing Type 2 Diabetes Tool with Rural Low Socioeconomic Status Audiences

This project used an evidence-informed approach to adapt CDC's On Your Way to Preventing Type 2 Diabetes resource for people who live in rural areas, have low literacy, and experience food insecurity. The demonstration study aimed to understand and describe the barriers prevention activities for this population, as well as potential drivers of engagement, particularly around public health partnerships with food banks and pantries. The project also identified strategies for engaging people with prediabetes who may not be ready to join the CDC National Diabetes Prevention Program Lifestyle Change Program but may benefit from self-guided behavior change resources.

This project was a collaboration between ICF NEXT and DDT.

Development and Evaluation of a Family Approach to the National DPP LCP

Through the Family Approach pilot study, researchers assessed whether the enrollment of mutually supportive dyads (pairs) in the National DPP LCP positively affected enrollment rates, retention rates, program satisfaction, and overall program completion. For this project, a dyad could be spouses/partners, parents and adult children, or any combination of friends/family members with close contact or some influence on food and physical activity choices. At least one member of the dyad had to meet the criteria for participating in the LCP because of risk for type 2 diabetes.

Across the six sites, retention of participants at risk of type 2 diabetes was 89.2% at 6 months and 79% at 11–12 months/end of program. Twenty of 34 dyads (59%) completed the program. Of the at-risk participants who completed the program, at least 40% achieved the program goal of losing 5% of their body weight at fix of six sites.

Baur C, Ledsky R, Elkins A, et al. An Exploratory Partner Approach to Participation in the National Diabetes Prevention Program Lifestyle Change Program in Maryland. The Science of Diabetes Self-Management and Care. 2025;0(0). doi:10.1177/26350106251350628

This project was a collaboration between FHI 360 and DDT.

Using Community Pharmacies to Expand Access to the National DPP

The project team increased the number of CDC-recognized National DPP LCP providers in rural and medically underserved communities. The team worked with independent pharmacies to train pharmacists and pharmacy technicians to identify, recruit, engage, and retain participants in the program. The goal was to address social determinants of health in rural areas (shortage of health care providers, limited access to health information, etc.) and increase access to patient education that would help pharmacy consumers reduce their risk of developing type 2 diabetes. Findings included facilitators and barriers to program implementation, such as increasing enrollment in the LCP, addressing staffing shortages, addressing cost, using the data collection system, and retaining participants during the COVID-19 public health emergency.

Best practices included using existing community partnerships (churches, health-focused organizations, and large employers such as school districts) to increase recruitment and enrollment, developing comprehensive retention plans, and using pharmacy technicians as Lifestyle Coaches.

This project was a collaboration among the National Community Pharmacists Association, OmniSys, the Association of Diabetes Care & Education Specialists, and DDT.

Engaging the Mobile Workforce in the National DPP Through Audio Content

This project aimed to help long-haul truckers overcome work-specific barriers to and reap the benefits of participating in the National DPP LCP through a podcast series. The intent was to deliver key messages of CDC's PreventT2 curriculum as a complement to the online LCP. The team used interviews, focus groups, and observations of truckers in their working environment to understand the intended audience and inform the development of the podcast series. Researchers created 22 podcast episodes to supplement the PreventT2 curriculum and tested portions of the content to ensure it resonated with the intended audience before developing the full series. Researchers used quantitative and qualitative methods to assess the comparative effectiveness of the podcasts through a demonstration project. Findings from the demonstration study suggest that the intervention was successful.

This project was a collaboration between ICF Next and DDT.

Identification and Evaluation of Innovative Retention Strategies for the National DPP LCP and Diabetes Self-Management Education and Support

The goal of the project was to evaluate retention strategies used by the National DPP lifestyle change program (LCP) and diabetes self-management education and support (DSMES) services. The focus was on approaches that reduce or eliminate barriers to participation associated with social determinants of health. Successful retention strategies used across Eskenazi Health and the MetroHealth STRIDES program included:

• Using participant-centered approaches.
• Addressing both medical and social needs.
• Leveraging community partnerships.
• Being flexible and adaptable.

Key strategies for DSMES were:

• Addressing social and economic risk factors.
• Using multifaceted strategies and partnerships.
• Assessing and adapting strategies throughout the program.

Key strategies for the LCP were:

• Using rolling enrollment and flexible class options to improve attendance.
• Using community connections and technology to foster engagement.
• Continually improving the program.

This project was a collaboration between Deloitte and DDT.

To learn more about these projects, listen to Innovative Approaches to Engage, Retain, and Improve Outcomes for Priority Populations.