Date of Graduation


Document Type


Degree Type



School of Public Health


Social and Behavioral Sciences

Committee Chair

Ranjita Misra

Committee Member

Ruchi Bhandari

Committee Member

Danielle Davidov

Committee Member

Sijin Wen


Background: Type 2 diabetes mellitus (T2DM) is a highly prevalent chronic disease and one of the leading causes of morbidity and mortality in the United States (US) and in West Virginia (WV), a mostly rural Appalachian state. West Virginia has the highest prevalence of diabetes (16.0%) in the nation. Furthermore, the prevalence of two common comorbidities of T2DM, i.e., obesity (38.1%) and hypertension (43.5%), is the highest and second highest in WV. Chronic diseases are frequently associated with psychological stress. Diabetes distress is psychological stress prevalent in T2DM individuals, which encompasses emotional stress and worries related to diabetes self-care regimen and complications on a day-to-day basis. T2DM individuals who experience diabetes distress have poor glycemic status due to nonadherence to diet, physical activity, medication regimen. Diabetes self-management education (DSME) programs are proven to help T2DM individuals improve diabetes outcomes. However, very few studies have assessed the impact of DSME programs on reducing diabetes distress. The Diabetes and Hypertension Self-Management Program (DHSMP), which combined three evidence-based, widely accepted, and scientifically acclaimed disease management programs was one of the first evidence-based 12 weeks randomized controlled trials (RCT) on diabetes self-management in WV. The DHSMP was a 12-week randomized control trial (RCT) non-pharmacological lifestyle intervention delivered by trained health coaches and experts. Eighty nine adults with comorbid T2DM and hypertension were randomized into the intervention (n=44) and 6-month, wait-listed control group (n=45). Eighty five and 81 participants completed the 12- and 24-week assessments with a completion rate of 91%. The program was implemented in two churches in Morgantown and Charleston, WV, in 2018-2019.

Specific Aims: This doctoral research utilized data from the DHSMP to determine the effectiveness of DHSMP to reduce diabetes distress in T2DM individuals. Three aims were explored for this dissertation research. Aim 1 evaluated the impact of DHSMP on changes in diabetes distress among the participants at post-intervention (24 weeks) from the baseline; Aim 2 evaluated the predictors (demographic, clinical, and behavioral factors) and changes in diabetes distress at 12- and 24 weeks. Aim 3 had two sub-aims. Aim 3a explored DHSMP participants’ everyday lived experiences and challenges to managing diabetes and its related distress & Aim 3b explored the efficacy of DHSMP participation on the participants’ perceptions of program components that were deemed helpful for adherence to diabetes self-management behaviors and reducing diabetes-related distress.

Methods: All participants completed baseline, 12- and 24-week assessments, which included anthropometrics, behavioral and clinical factors for the larger study. The participants completed three self-reported surveys that were used for this study: the Diabetes Distress Scale (DDS), and Morisky Medication Adherence Survey (MMAS), and Lifestyle Profile II Survey. Demographic information included age, gender, body mass index, race, level of education, number of household members, duration of diabetes and hypertension, family history, and access to health insurance. Clinical data included serum cortisol, serum cholesterol, glycosylated hemoglobin or HbA1c. The dependent variables included diabetes distress (total diabetes distress, and 4 domains) and serum cortisol. Bivariate relationships were analyzed between the dependent variables and demographic, behavioral, and clinical variables. A linear mixed model with main effects assessed the effect of program attendance on diabetes distress (Aim 1), and behavioral and clinical predictors of diabetes distress and changes after the DHSMP intervention (Aim 2). For Aim 3, qualitative data were collected using semi-structured phone interviews (33 participants) and 4 focus groups (23 participants). Quantitative data entry and analysis were conducted using Research Electronic Data Capture (REDCap) and IBM Statistical Package for Social Sciences (SPSS) for Windows (version 27), respectively. Qualitative data entry and coding were completed by two coders, and thematic analysis was conducted using NVivo.

Results: The mean age was 60.82 ± 12.16 years of age. The majority (64%) were females and Non-Hispanic Whites (90.2%). Overall, the study participants had mild total diabetes distress, emotional distress, physician-related distress, and interpersonal distress. However, participants had moderate regimen-related distress. Participation in DHSMP reduced diabetes distress by 0.16 point between baseline and 24 weeks. Greater adherence to medication regimen, dietary guidelines, glycemic and lipid control among program participants reduced diabetes distress, and its domains. A dose-response relationship was noted with greater attendance for the 12-week DHSMP sessions resulted in significant reduction in diabetes distress and regimen-related distress for participants. The participant narratives (qualitative analysis) revealed an understanding of the interconnectedness of the four domains of the diabetes distress experienced by participants, as well as improvement in their coping strategies with knowledge/skills from participation in the program. Participants described physical and emotional challenges in the day-to-day management of their disease and maintaining relationships and communication with family, friends, and health care providers regarding their distress.

Conclusion: Findings demonstrated that diabetes distress was prevalent in rural adults with T2DM, and participation in DSME or evidence-based self-management programs such as the DHSMP reduce diabetes distress. Results have several implications for DSME programs, health care providers in rural Appalachia, and public health research. Findings from this dissertation research indicate that DSME programs such as DHSMP can help T2DM individuals self-manage their diabetes distress which they experience in their everyday life. Health care providers, especially in rural Appalachia, should inform their T2DM patients on diabetes distress and educate them on managing it using diabetes self-management strategies.