Improving Health Outcomes in African Americans with Type 2 Diabetes: A Culturally Tailored, Resilience-Based Diabetes Self-Management Education (RB-DSME) Intervention

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Type 2 diabetes mellitus (T2DM) costs the U.S. $327 billion annually, representing a 26% increase from 2012 to 2017. African Americans (AAs) are twice as likely to have T2DM as non-Hispanic Whites, have worse health outcomes, and are less likely to engage in self-management behaviors. Interventions addressing these disparities are urgently needed. Among AAs, T2DM-associated stress is often compounded by general life stress, which further constrains diabetes self-management and is associated with poor glucose control (A1C) and complications such as depression. The impact of stress on diabetes self-management and health outcomes may be attenuated by resilience: a resolve to succeed despite adversities. Even with evidence supporting resilience resources benefiting other health outcomes, there is a dearth of evidence-based T2DM resilience interventions. Building on our promising pilot work, the proposed study uses our culturally tailored, theory-derived Resilience-Based Diabetes Self-Management Education (RB-DSME) intervention to help participants manage the psychosocial and behavioral demands of the disease. We propose a 24-month, 2-arm, cluster RCT assigning churches to the RB-DSME or standard DSME condition. Both groups will receive a 10-month intervention: 8 weekly educational sessions, followed by 8 bimonthly support group sessions, followed by 2 booster sessions. To investigate the efficacy of RB-DSME, we will compare RB-DSME to DSME on T2DM physical (A1C, FBG, lipids, BMI, waist circumference, blood pressure) and mental (depressive symptoms, diabetes distress, general stress) health outcomes. To inform more targeted future interventions, we will examine indirect effects of RB- DSME (vs DSME) on resilience resources (adaptation to stress, finding positive meaning, adaptive coping, coping with discrimination, spiritual coping, self-efficacy, social support, emotional regulation). We will also examine indirect effects of resilience resources on T2DM health outcomes through self-management behaviors (dietary intake, physical activity, glucose self-monitoring, medication adherence). Emerging evidence—including our work linking hair cortisol with A1C in AAs—suggests that improved HPA axis function, a biological marker of stress, is associated with favorable T2DM health outcomes. Thus, we will also examine indirect effects of resilience resources on T2DM health outcomes via HPA axis function (cortisol, DHEA). The Specific Aims are: 1) To compare T2DM physical (primary outcome: A1C) and mental (primary outcome: depressive symptoms) health outcomes in RB-DSME vs DSME at 3, 6, 12, and 24 months post-study entry; and 2) To test indirect effects of RB-DSME (vs DSME) on T2DM health outcomes via resilience resources, self-management behaviors, and HPA axis function. Our project will provide crucial guidance for addressing the T2DM burden among AAs by establishing the efficacy of our RB-DSME and identifying behavioral and biological mechanisms by which the program affects T2DM health outcomes. Our long-term goal is to enable AAs to effectively manage T2DM and thus avoid its serious consequences, via RB-DSME interventions in a range of community settings.