Abstract
Increased dissemination of the CDC’s Diabetes Prevention Program (DPP) is imperative to reduce type 2 diabetes. Due to its nationwide reach and mission to improve health, Cooperative Extension (Extension) is poised to be a sustainable DPP delivery system. However, research evaluating DPP implementation in Extension remains scant. Extension professionals delivered the DPP in a single-arm hybrid type II effectiveness-implementation study. Semi-structured interviews with Extension professionals were conducted at three time points. The Consolidated Framework for Implementation Research (CFIR) guided interview coding and analysis. Constructs were rated for magnitude and valence and evaluated as facilitators or barriers of RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) outcomes. The program reached 119 participants, was adopted by 92% (n = 12/13) of trained Extension professionals and was implemented according to CDC standards: all programs exceeded the minimum 22-session requirement (26 ± 2 sessions). The program was effective in achieving weight loss (5.0 ± 5.2%) and physical activity (179 ± 122 min/week) goals. At post-intervention, eight professionals (67%) had begun or planned to maintain the intervention within the next 6 months. Several facilitators were identified, including Extension leadership structure, organizational compatibility, and technical assistance calls. Limited time to recruit participants was the primary barrier. Positive RE-AIM outcomes, facilitated by contextual factors, indicate Extension is an effective and sustainable DPP delivery system. Extension and other DPP implementers should plan strategies that promote communication, the program’s evidence-base, recruitment time, and resource access. Researchers should explore DPP implementation in real-world settings to determine overall and setting-specific best practices, promote intervention uptake, and reduce diabetes.
Similar content being viewed by others
![](https://media.springernature.com/w215h120/springer-static/image/art%3Aplaceholder%2Fimages/placeholder-figure-springernature.png)
Avoid common mistakes on your manuscript.
Introduction
With 96 million American adults living with prediabetes and 5–10% of these individuals develo** type 2 diabetes mellitus (T2DM) each year, increased dissemination of evidence-based T2DM prevention interventions is imperative (Glechner et al., 2018). The Centers for Disease Control and Prevention’s (CDC) National Diabetes Prevention Program (DPP) aims to increase screening for and detection of prediabetes and T2DM and to increase dissemination of and access to the diabetes prevention. The DPP is a 12-month lifestyle change intervention designed to reduce T2DM risk through diet, exercise, and lifestyle changes (Knowler et al., 2002, 2009). DPP clinical trials resulted in reduced rates of T2DM up to 58% in individuals with prediabetes (Allaire et al., 2020; Knowler et al., 2002, 2009). Since the initial DPP clinical trial, nearly 20 years of translational research has demonstrated similar results can be achieved using trained lay leaders in a variety of settings if critical components are upheld (i.e., use of approved curriculum, program duration, frequency of sessions) (Centers for Disease Control and Prevention, 2018; Ali et al., 2012).
Cooperative Extension (here forth, “Extension”), with its over 100-year history of providing health education interventions, presence in almost every county in every state, and trained personnel (i.e., state-level Extension leaders with health program implementation expertise: Extension Specialists), is poised as an effective platform for DPP dissemination and implementation (Franz & Townson, 2008; Molgaard, 1997). In the state of Georgia, there are 159 counties, with 57 having a county-based Extension professional that specializes in health and wellness (University of Georgia, 2023). At present, 31 Extension organizations, representing 17 U.S. states, are CDC-recognized DPP providers (CDC, 2023). While this number is growing, this is far fewer than the potential 50 states and additional U.S. territories that could be DPP providers.
While CDC is tracking overall effectiveness of the DPP among CDC-recognized providers (Ely et al., 2017), little is known about context-specific effectiveness and implementation and which organization types are uniquely positioned to succeed in effective and sustainable DPP delivery. Damschroder et al. (2017a). DPP marketing efforts to potential participants, community partners, and even potential program implementers should emphasize the DPP as a CDC, evidence-based program to improve buy-in. Extension professionals’ perceived “fit” of the DPP with Extension’s mission and programming, along with the present study’s high adoption rate, supports the value of Extension as a delivery system to increase dissemination of the DPP. When asked about increasing adoption of the DPP in other counties throughout the state, Extension professionals felt that success stories from the implementation pilot, the support provided for implementation, and the value of the DPP’s evidence base for building community rapport and Extension professionals’ impact statements would be incentives for adoption by other counties. Still, Extension professionals noted that adoption would be limited to counties with Extension professionals. With the number of county Extension professionals decreasing, considerations on how to maintain the strong adoption observed in the present study and how to promote reach throughout the state should be made in light of these realities. Delivery during the COVID-19 pandemic highlighted the value of virtual delivery for accessing residents in counties without county-based Extension professionals. Virtual delivery should be explored in the future to overcome potential adoption and reach barriers.
Extension leadership contributed to the professionals’ knowledge of the DPP and decision to adopt the program. Compared to other settings in which the DPP might be implemented, the support infrastructure of Extension further positions it to be a strong delivery system (Franz & Fahey, 2012; Franz & Townson, 2008; Franz et al., 2010). Most Extension organizations have a nutrition and/or health Extension Specialist that provides access to expertise in DPP-related content areas (Harden et al., 2019), administrative oversight, and implementation support. Still, depending on the Extension structure, some Extension Specialists are assigned to several programs and may have limited time to support a single, complex program like the DPP. This barrier is not specific to Extension, as Damschroder et al. (2017a) cited similar challenges in the VA context. Extension professionals discussed the need for a permanent DPP coordinator to assist the Extension Specialist to overcome this challenge. CDC does suggest that programs have an assigned DPP coordinator. In small organizations, this may be particularly challenging; but in larger organizations like Extension, a staff member or graduate student can be assigned to this role, as in the case of our study.
Implementation Strategies Utilized
Implementation strategies, including technical assistance calls, created a positive learning climate that Extension professionals felt facilitated implementation. These results echo those reported by Damschroder et al., who also used bi-weekly meetings to provide pertinent updates and information and problem-solve issues (Damschroder et al., 2017a). Extension professionals also spoke to the value of the additional day of training held after the lifestyle coach training. Damschroder et al. also found leadership involvement and support to be one of the most important facilitators of DPP implementation in the VA context (Damschroder et al., 2017a). For multisite DPP delivery systems, additional training on implementation protocols specific to that delivery system may be beneficial for optimizing outcomes. Continued support from leaders in the form of consistent communication and continuing education were all cited as important components of implementation that would be important for maintenance as well as expansion of the DPP into other counties. These consistencies noted between the present and Damschroder et al., (2015, 2017a) studies indicate that the implementation strategies utilized in both (technical assistance calls, leadership involvement, training) may promote implementation outcomes across multiple contexts.
Limitations and Strengths
The present study is not without limitations. Notably, no control or comparison group was included to allow for either comparison of implementation outcomes with and without the utilization of implementation strategies, or comparison of barriers and facilitators presented by the context of Extension compared to another context, limiting conclusions that can be made from the presented results. Still, comparisons to the most comparable literature to date (Damschroder et al., 2017a) have been made throughout. Many of the implementation strategies employed in this study involved state-level leadership support and training for Extension professionals. Withholding support and training from Extension professionals is not acceptable in the setting of Extension, making comparison of outcomes with and without these implementation strategies not feasible. Future studies should consider testing different implementation strategies side by side (e.g., one-on-one technical assistance verses group-based technical assistance) and/or comparison of implementation barriers and facilitators within and outside Extension.
In addition, the research team involved in data collection and analysis was heavily involved in supporting program implementation, potentially introducing researcher bias. However, the familiarity of the researchers with the implementation process offered a more comprehensive understanding of the topics discussed in interviews. Furthermore, three of the five data analysts were not involved in supporting implementation. Additionally, no objective measure of fidelity was included in the present study. Lastly, the number of counties/Extension professionals included in the present study was limited, compared to the total possible sample size in the state of Georgia. The initial sample was limited to meet financial constraints and assess initial feasibility in the pilot implementation study. Counties and Extension professionals from every region of the state, as well as both rural and urban counties, were included in an effort to increase the generalizability of the results.
There are also several strengths. This study is unique in its contribution to the literature by using standard frameworks (CFIR and RE-AIM) to rigorously evaluate implementation of an evidence-based program in a community setting that is well positioned to be an established DPP provider: Extension. Integration of the CFIR with RE-AIM also increases the translational value of this study, as the barriers and facilitators of RE-AIM identified using the CFIR in this study provide a foundation on which implementation strategies can be built to potentially enhance RE-AIM outcomes of the DPP in Extension and potentially other community contexts.
Conclusions
Although freely available, the Diabetes Prevention Program is a complex intervention with many considerations for enhancing dissemination and implementation to reduce the public health burden of T2DM. Using the CFIR and RE-AIM frameworks, this study demonstrated similar reach, effectiveness, adoption and maintenance in Extension to DPP implementation in clinical contexts, and revealed Extension-system specific facilitators of RE-AIM outcomes. The supportive leadership structure, with state-level Extension Specialists and local community health educators (Extension professionals), compatible mission, access to content and implementation expertise, and established communication channels were discussed as benefits of this organizational structure. The strong Implementation, Adoption, and Maintenance observed in this study support the value of Extension as an effective and sustainable delivery system for the DPP. Future research should use similar methods to explore implementation in Extension and other contexts across the U.S. to further test the promising implementation strategies utilized in this study that promote communication and access to information, resources, and support to promote uptake and implementation of the DPP in Extension and beyond.
Data Availability
The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.
Change history
15 March 2024
A Correction to this paper has been published: https://doi.org/10.1007/s11121-024-01665-y
Abbreviations
- CDC:
-
Centers for Disease Control and Prevention
- CFIR:
-
Consolidated Framework for Implementation Research
- DPP:
-
Diabetes Prevention Program
- PA:
-
Physical activity
- RE-AIM:
-
Reach, Effectiveness, Adoption, Implementation, Maintenance
- StaRI:
-
Standards for Reporting Implementation Studies
- T2DM:
-
Type 2 diabetes mellitus
- VA:
-
Veterans Health Administration
References
Ali, M. K., Echouffo-Tcheugui, J., & Williamson, D. F. (2012). How effective were lifestyle interventions in real-world settings that were modeled on the Diabetes Prevention Program? Health Affairs (millwood), 31(1), 67–75. https://doi.org/10.1377/hlthaff.2011.1009
Allaire, B. T., Tjaden, A. H., Venditti, E. M., Apolzan, J. W., Dabelea, D., Delahanty, L. M., Edelstein, S. L., Hoskin, M. A., Temple, K. A., Wylie-Rosett, J., Jaacks, L. M., & Group, D. P. P. R. (2020). Diet quality, weight loss, and diabetes incidence in the Diabetes Prevention Program (DPP). BMC Nutrition, 6(1), 74. https://doi.org/10.1186/s40795-020-00400-4
Association of Diabetes Care and Education Specialists (ADCES). (2021). Data Analysis of Participants System (DAPS). Retrieved March 3, 2021, from https://daps.adces.org/
ATLAS.ti. (2019). ATLAS.ti 8 Windows. Retrieved March 3, 2021, from https://atlasti.com/product/v8-windows/
Centers for Disease Control and Prevention (CDC). (2018). Centers for Disease Control and Prevention Diabetes Prevention Recognition Program: Standards and Operating Procedures. Retrieved March 1, 2018, from www.cdc.gov/diabetes/prevention/recognition
Centers for Disease Control and Prevention (CDC). (2021). Keys to success: how to adjust program delivery of your lifestyle change program during the COVID-19 Public Health Emergency. Retrieved September 29, 2021, from https://nationaldppcsc.cdc.gov/s/article/Keys-to-Success-Adjusting-Program-Delivery-to-COVID-19
Centers for Disease Control and Prevention (CDC). (2023). Registry of All Recognized Organizations. Retrieved January 27, 2023, from https://dprp.cdc.gov/Registry
CFIR Research Team-Center for Clinical Management Research. (2019). Constructs. Retrieved September 1, 2019, from https://cfirguide.org/constructs/
Curran, G. M., Landes, S. J., McBain, S. A., Pyne, J. M., Smith, J. D., Fernandez, M. E., Chambers, D. A., & Mittman, B. S. (2022). Reflections on 10 years of effectiveness-implementation hybrid studies. Frontiers in Health Services—Implementation Science, 2, 1053496. https://doi.org/10.3389/frhs.2022.1053496
Damschroder, L. J., & Lowery, J. C. (2013). Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implementation Science, 8, 51. https://doi.org/10.1186/1748-5908-8-51
Damschroder, L. J., Moin, T., Datta, S. K., Reardon, C. M., Steinle, N., Weinreb, J., Billington, C. J., Maciejewski, M. L., Yancy, W. S., Jr., Hughes, M., Makki, F., & Richardson, C. R. (2015). Implementation and evaluation of the VA DPP clinical demonstration: Protocol for a multi-site non-randomized hybrid effectiveness-implementation type III trial. Implementation Science, 10, 68. https://doi.org/10.1186/s13012-015-0250-0
Damschroder, L. J., Reardon, C. M., AuYoung, M., Moin, T., Datta, S. K., Sparks, J. B., Maciejewski, M. L., Steinle, N. I., Weinreb, J. E., Hughes, M., Pinault, L. F., **ang, X. M., Billington, C., & Richardson, C. R. (2017a). Implementation findings from a hybrid III implementation-effectiveness trial of the Diabetes Prevention Program (DPP) in the Veterans Health Administration (VHA). Implementation Science, 12(1), 94. https://doi.org/10.1186/s13012-017-0619-3
Damschroder, L. J., Reardon, C. M., Sperber, N., Robinson, C. H., Fickel, J. J., & Oddone, E. Z. (2017b). Implementation evaluation of the Telephone Lifestyle Coaching (TLC) program: Organizational factors associated with successful implementation. Translational Behavioral Medicine, 7(2), 233–241. https://doi.org/10.1007/s13142-016-0424-6
Ely, E. K., Gruss, S. M., Luman, E. T., Gregg, E. W., Ali, M. K., Nhim, K., Rolka, D. B., & Albright, A. L. (2017). A national effort to prevent type 2 diabetes: Participant-level evaluation of CDC’s National Diabetes Prevention Program. Diabetes Care, 40(10), 1331–1341. https://doi.org/10.2337/dc16-2099
Emory University. (2021). Diabetes Training and Technical Assistance Center (DTTAC). Retrieved March 3, 2021, from https://emorycenters4phtraining.emory.edu/dttac/
Franz, N., Stovall, C., & Owen, M. (2010). The perceived value of an extension leadership network: Enhancing personal and organizational effectiveness. Journal of Agricultural Education and Extension, 16(4), 433–443.
Franz, N. K., & Fahey, C. (2012). Tea time: Raising awareness and support for extension. Journal of Extension, 50(3).
Franz, N. K., & Townson, L. (2008). The nature of complex organizations: The case of Cooperative Extension. Journal of Extension, 120, 5–14. https://doi.org/10.1002/ev.272
FreeConferenceCall.com. (2021). FreeConferenceCall.com. Retrieved March 3, 2021, from https://www.freeconferencecall.com/
Glasgow, R. E., Harden, S. M., Gaglio, B., Rabin, B., Smith, M. L., Porter, G. C., Ory, M. G., & Estabrooks, P. A. (2019). RE-AIM planning and evaluation framework: Adapting to new science and practice with a 20-year review [Mini Review]. Frontiers in Public Health, 7(64). https://doi.org/10.3389/fpubh.2019.00064
Glechner, A., Keuchel, L., Affengruber, L., Titscher, V., Sommer, I., Matyas, N., Wagner, G., Kien, C., Klerings, I., & Gartlehner, G. (2018). Effects of lifestyle changes on adults with prediabetes: A systematic review and meta-analysis. Primary Care Diabetes, 12(5), 393–408. https://doi.org/10.1016/j.pcd.2018.07.003
Gorczyca, A. M., Washburn, R. A., Smith, P., Montgomery, R. N., Koon, L. M., Hastert, M., Suire, K. B., & Donnelly, J. E. (2022). Feasibility and comparative effectiveness for the delivery of the National Diabetes Prevention Program through Cooperative Extension in Rural Communities. International Journal of Environmental Research and Public Health, 19(16). https://doi.org/10.3390/ijerph19169902
Harden, S. M., Ramalingam, N. S., Breig, S. A., & Estabrooks, P. A. (2019). Walk this way: Our perspective on challenges and opportunities for extension statewide walking promotion programs. Journal of Nutrition Education and Behavior, 51(5), 636–643. https://doi.org/10.1016/j.jneb.2018.12.010
IBM. (2020). SPSS Statistics 27. Retrieved December 4, 2020, from https://www.ibm.com/support/pages/downloading-ibm-spss-statistics-27
King, E. S., Moore, C. J., Wilson, H. K., Harden, S. M., Davis, M., & Berg, A. C. (2019). Mixed methods evaluation of implementation and outcomes in a community-based cancer prevention intervention. BMC Public Health, 19(1), 1051. https://doi.org/10.1186/s12889-019-7315-y
Kirk, M. A., Kelley, C., Yankey, N., Birken, S. A., Abadie, B., & Damschroder, L. (2016). A systematic review of the use of the Consolidated Framework for Implementation Research. Implementation Science, 11, 72. https://doi.org/10.1186/s13012-016-0437-z
Knowler, W. C., Barrett-Connor, E., Fowler, S. E., Hamman, R. F., Lachin, J. M., Walker, E. A., & Nathan, D. M. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346(6), 393–403. https://doi.org/10.1056/NEJMoa012512
Knowler, W. C., Fowler, S. E., Hamman, R. F., Christophi, C. A., Hoffman, H. J., Brenneman, A. T., Brown-Friday, J. O., Goldberg, R., Venditti, E., & Nathan, D. M. (2009). 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet, 374(9702), 1677–1686. https://doi.org/10.1016/s0140-6736(09)61457-4
Molgaard, V. K. (1997). The extension service as key mechanism for research and services delivery for prevention of mental health disorders in rural areas. American Journal of Community Psychology, 25(4), 515–544.
Nicole, B., Heather, N. B., Katherine, C., & Lovoria, B. W. (2021). Process evaluation of the early implementation stages of the National Diabetes Prevention Program through Kentucky Cooperative Extension: Perceptions of Adopters and Potential Adopters Journal of Human Sciences and Extension, 9(3). https://www.jhseonline.com/article/view/1116
Pinnock, H., Barwick, M., Carpenter, C. R., Eldridge, S., Grandes, G., Griffiths, C. J., Meissner, P., Murray, E., & Sheikh, A. (2017). Standards for reporting implementation studies (StaRI) statement. British Medical Journal, 356, i6795. https://doi.org/10.1136/bmj.i6795
Rev.com. (2021). Rev. Retrieved March 12, 2021, from https://www.rev.com/
Swindle, T., Curran, G. M., & Johnson, S. L. (2019). Implementation science and nutrition education and behavior: Opportunities for integration. Journal of Nutrition Education and Behavior, 51(6), 763-774.e761. https://doi.org/10.1016/j.jneb.2019.03.001
Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349–357. https://doi.org/10.1093/intqhc/mzm042
University of Georgia. (2023). FACS Extension Agents. Retrieved January 27, 2023, from https://www.fcs.uga.edu/extension/facs-extension-agents
U.S. Economic Research Service. (2020). Rural-Urban Continuum Codes. Retrieved December 10, 2020, from https://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx
Varsi, C., Ekstedt, M., Gammon, D., & Ruland, C. M. (2015). Using the consolidated framework for implementation research to identify barriers and facilitators for the implementation of an internet-based patient-provider communication service in five settings: A qualitative study. Journal of Medical Internet Research, 17(11), e262. https://doi.org/10.2196/jmir.5091
Whittemore, R. (2011). A systematic review of the translational research on the Diabetes Prevention Program. Translational Behavioral Medicine, 1(3), 480–491. https://doi.org/10.1007/s13142-011-0062-y
Wilson, H. K., Averill, B., Cook, G., & Campbell, C. L. (2022). Implementation of the National Diabetes Prevention Program in FCS Extension During the COVID-19 Pandemic: Participant Experiences, Lessons Learned. Journal of Family & Consumer Sciences, 114(3), 11–19. https://doi.org/10.14307/JFCS114.3.11
Zoom Video Communications, Inc. (2021). Zoom. Retrieved March 12, 2021, from https://zoom.us/
Acknowledgements
We would like to acknowledge the DPP participants and the Extension professionals who were the subject of this research. Without the incredible dedication of these thirteen outstanding professionals and their commitment to the health and wellbeing of their DPP participants and to the mission of Extension, this research would not be possible.
Funding
This work was supported by the University of Georgia Interdisciplinary Seed Grant Program and the National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1TR002378. Funds were used to support faculty and graduate student effort on the project, support training and related costs, and to purchase DPP supplies and materials, subscription to the Data Analysis of Participants System to track session data, and ATLAS.ti software for qualitative data analysis.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Ethics Approval
All methods and procedures were approved by the University of Georgia’s Institutional Review Board of Human Subjects.
Consent to Participate and Publish
All participants provided informed consent to participate and for publication of this trial.
Competing Interests
The authors declare no competing interests.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
The original online version of this article was revised due to a retrospective Open Access order.
Supplementary Information
Below is the link to the electronic supplementary material.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Wilson, H., Wieler, C., Bell, D. et al. Implementation of the Diabetes Prevention Program in Georgia Cooperative Extension According to RE-AIM and the Consolidated Framework for Implementation Research. Prev Sci 25 (Suppl 1), 34–45 (2024). https://doi.org/10.1007/s11121-023-01518-0
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11121-023-01518-0