Informing a Randomized Control Trial in Rural Populations: Adaptation of a Diabetes Self-Management Education and Support Intervention.

BACKGROUND: Over 34 million people in the United States have diabetes, with 1.5 million diagnosed every year. Diabetes self-management education and support (DSMES) is a crucial component of treatment to delay or prevent complications. Rural communities face many unique challenges in accessing DSMES, including geographic barriers and availability of DSMES programs that are culturally adapted to rural context. OBJECTIVE: Boot Camp Translation (BCT) is an established approach to community-based participatory research used to translate complex clinical and scientific information into concepts, messages, and materials that are understandable, meaningful, and relevant to community members and patients. This study aimed to utilize BCT to adapt an existing DSMES program for delivery in rural primary care for English- and Spanish-speaking people with diabetes. METHODS: The High Plains Research Network (HPRN) Community Advisory Council (C.A.C.) partnered with researchers at the University of Colorado and University of Utah to use BCT to aid in translating medical jargon and materials from an existing DSMES program, called "Diabetes One Day (D1D)." BCT consisted of 10 virtual meetings over a 6-month period among the C.A.C., which included 15 diverse community stakeholders. Both English-speaking and bilingual Spanish-English-speaking C.A.C. members were recruited to reflect the diversity of the rural communities in which the adapted program would be delivered. RESULTS: The BCT process guided adaptations to D1D for use in rural settings (R-D1D). R-D1D adaptations reflect both content and delivery to assure that the intervention is appropriate and likely to be accepted by rural English- and Spanish-speaking people with diabetes. Additionally, BCT informed the design of recruitment and program materials and identification of recruitment venues. During the BCT process, the importance of tailoring materials to reflect culture differences in English- and Spanish-speaking patients was identified. CONCLUSIONS: BCT was an effective strategy for academic researchers to partner with rural community members to adapt an existing DSMES intervention for delivery in rural areas to both English- and Spanish-speaking patients with diabetes. Through BCT, adaptations to recruitment materials and methods, program content and delivery, and supplemental materials were developed. The need to culturally adapt Spanish materials with input from stakeholders rather than simply translate materials into Spanish was highlighted. The importance of increasing awareness of the connection between diabetes and depression or diabetes distress, adaptations to include local foods, and the importance of the relationship between people with diabetes and their primary care practices were identified.

A Telehealth Diabetes Intervention for Rural Populations: Protocol for a Randomized Controlled Trial.

BACKGROUND: Diabetes self-management education and support (DSMES) is a crucial component of diabetes care associated with improved clinical, psychosocial, and behavioral outcomes. The American Association of Diabetes Care and Education Specialists, the American Diabetes Association, and the American Academy of Family Physicians all recommend DSMES yet accessing linguistically and culturally appropriate DSMES is challenging in rural areas. The Diabetes One-Day (D1D) program is an established DSMES group intervention that has not been adapted or evaluated in rural communities. OBJECTIVE: The specific aims of this paper are (1) to adapt the existing D1D program for use in rural communities, called rural D1D (R-D1D); and (2) to conduct a patient-level randomized controlled trial to examine the effects of R-D1D and standard patient education, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. METHODS: This is a protocol for a pilot type II hybrid implementation-effectiveness trial of a culturally adapted virtual DSMES program for rural populations, R-D1D. We will use Boot Camp Translation, a process grounded in the principles of community-based participatory research, to adapt an existing DSMES program for rural populations, in both English and Spanish. Participants at 2 rural primary care clinics (4 cohorts of N=16 plus care partners, 2 in English and 2 in Spanish) will be randomized to the intervention or standard education control. The evaluation is guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Patient-level effectiveness outcomes (hemoglobin A1c, diabetes distress, and diabetes self-care behaviors) will be assessed using patient-reported outcomes measures and a home A1c test kit. Practice-level and patient-level acceptability and feasibility will be assessed using surveys and interviews. RESULTS: This study is supported by the National Institute of Nursing. The study procedures were approved, and the adaptation processes have been completed. Recruitment and enrollment started in July 2021. CONCLUSIONS: To our knowledge, this will be the first study to evaluate both effectiveness and implementation outcomes for virtually delivered DSMES, culturally adapted for rural populations. This research has implications for delivery to other rural locations where access to specialty diabetes care is limited. TRIAL REGISTRATION: ClinicalTrials.gov NCT04600622; https://clinicaltrials.gov/ct2/show/NCT04600622. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/34255.

The Balance Between Serving the Community and the Reality of Treating Opioid Use Disorder in Rural Primary Care Practices.

Medication assisted treatment (MAT) is an evidence-based solution to combatting opioid use disorder (OUD); however, MAT is largely unavailable in rural areas. This study investigated clinician and staff perceptions related to OUD and MAT, in particular, buprenorphine treatment, in rural primary care practices. In this qualitative study, we interviewed staff members from 42 practices and analyzed the data using a grounded hermeneutic editing approach. Four key themes emerged: 1) policies and procedures to reduce opioid prescribing were already in place, 2) there was an emotional toll to treating "those types" of patients, 3) there is a lack of local resources for help with chronic pain and buprenorphine treatment, and 4) there is a strong desire to help local patients and community members but hesitancy to engage in buprenorphine treatment. Although there was almost no provision of MAT, many practices were interested in learning more to help their communities.

Increasing Capacity for Treatment of Opioid Use Disorder in Rural Primary Care Practices.

PURPOSE: Evidence supports treatment for opioid use disorder (OUD) with buprenorphine in primary care practices (PCPs). Barriers that slow implementation of this treatment include inadequately trained staff. This study aimed to increase the number of rural PCPs providing OUD treatment with buprenorphine. This evaluation describes the impact of a practice team training on the implementation and delivery of OUD treatment with buprenorphine in PCPs of rural Colorado. METHODS: Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado (IT MATTTRs) was a multilevel implementation study that included a practice-focused intervention to improve awareness, adoption, and use of buprenorphine treatment for OUD. Participating PCP teams received the IT MATTTRs Practice Team Training and support. Practices' implementation of treatment components was assessed before and after training. Practice-reported and population-level data from the Prescription Drug Monitoring Program were obtained to describe changes in delivery of treatment after training. RESULTS: Forty-two practices received team training. Practices reported an average of 4.7 treatment-related components in place at baseline compared with 13.0 at 12-month follow-up (F[2,56] = 31.17, P <.001). The proportion of participating practices providing or referring patients for treatment increased from 18.8% to 74.4%. The increase in number of people with a prescription for buprenorphine was significantly greater in the study region over a 4-year period compared with the rest of the state (Wald χ2 = 15.73, P <.001). CONCLUSIONS: The IT MATTTRs training for PCP teams in OUD treatment with buprenorphine addressed elements beyond clinician waiver training to make implementation feasible and effectively increased implementation and delivery of this treatment in rural Colorado.

Does a Rural Community-Based Intervention Improve Knowledge and Attitudes of Opioid Use Disorder and Medication-Assisted Treatment? A Report From the IT MATTTRs Study.

PURPOSE: Understanding knowledge of and attitudes toward medication-assisted treatment (MAT) for opioid use disorder (OUD) is important to changing the conversation about this devastating public health problem. While several studies report clinician knowledge and attitudes and training, less is known about community member perspectives. As part of the Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado study (IT MATTTRs), this study describes the implementation of community-based interventions developed by rural community members and researchers to increase awareness and promote positive attitudes toward MAT for OUD and explores changes in community members' OUD and MAT knowledge and beliefs. METHODS: Using the Boot Camp Translation process, the High Plains Research Network and Colorado Research Network MAT Advisory Councils developed multicomponent interventions on MAT for OUD. Baseline and postintervention surveys were administered using venue-based sampling of community members in rural communities. FINDINGS: Surveys were completed by 789 community members at baseline and 798 at postintervention. Nearly half (49%) reported exposure to at least 1 intervention product. Greater exposure to intervention materials was associated with beliefs that using opioids to get high in rural communities is a problem (P < .0001), that opioid addiction is a chronic disease (P = .0032), and that OUD can be treated locally (P = .0003). CONCLUSIONS: Partnering with local community members resulted in the successful development and implementation of community-based interventions, exposure to which was associated with OUD knowledge and beliefs. Locally created interventions should be included in comprehensive approaches to stem the OUD epidemic.

Building Capacity for Medication Assisted Treatment in Rural Primary Care Practices: The IT MATTTRs Practice Team Training.

OBJECTIVES: In response to rural communities and practice concerns related to opioid use disorder (OUD), the Implementing Technology and Medication Assisted Treatment Team Training in Rural Colorado study (IT MATTTRs) developed a training intervention for full primary care practice (PCP) teams in MAT for OUD. This evaluation reports on training implementation, participant satisfaction, and impact on perceived ability to deliver MAT. METHODS: PCPs in the High Plains Research Network and Colorado Research Network were randomized to receive team training either in-person or through virtual tele-mentoring. Training attendance logs recorded the number of participants and their roles. Participants completed a survey within one month of the last training session to evaluate satisfaction and ability to deliver components of MATs. RESULTS: 441 team members at 42 PCPs were trained, including 22% clinicians, 47% clinical support staff, 24% administrative support staff. Survey respondents reported high levels of satisfaction, including 82% reporting improved understanding of the topic, and 68% identifying actions to apply information. Self-rated ability was significantly higher after training for all items (P < .0001), including ability to identify patients for MAT and to manage patients receiving MAT. Mean change scores, adjusted for role, were significantly greater for all measures (P < .001) in SOuND practices compared to ECHO practices. CONCLUSIONS: The IT MATTTRs Practice Team Training successfully engaged PCP team members in diverse roles in MAT for OUD training and increased self-efficacy to deliver MAT. Results support the training as a resource for a team-based approach to build rural practices' capacity to deliver MAT.