Improving Health in Low Income Communities: Virtual Delivery of a Diabetes Prevention Program Facilitated by Community Care Coordination

Our 5-year core research project (2019-2024) will assess the feasibility and pathways for implementing a virtually-delivered Diabetes Prevention Program (v-DPP) to adults with limited economic resources who are at risk for type 2 diabetes, and who are residents of New Haven or the Lower Naugatuck Valley in CT.

The virtual program delivery will be facilitated locally by community health workers (CHWs) and hospital-based community nurses (HCNs), who will provide care coordination to help identify and address barriers to successful program participation.

We have selected a v-DPP platform developed by incentaHEALTH as the program for use in our study. It will be offered to study participants using the customized title of “Healthy Me: A Lifestyle Program from the Yale-Griffin Prevention Research Center.”

We expect to demonstrate that this year-long program will lead to improved behavioral and cardio-metabolic outcomes among the adults who enroll in this study and participate in the program. 

As part of our process evaluation, we will apply Program Impact Pathways (PIP) and Reach Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to assess the implementation processes, including program delivery bottlenecks, and outcomes.

Our organizational partners on this project include the Community Alliance for Research and Engagement (CARE), Elm City Communities, Griffin Community Outreach Programs and Valley Parish Nurse Program, and incentaHEALTH.

HealthyMe program logo

Project Purpose and Goal

The risk of diabetes is significantly higher among people with limited economic resources. Lifestyle interventions that focus on healthful eating and physical activity can often prevent prediabetes from progressing to type 2 diabetes and its complications.

The Diabetes Prevention Program (DPP) is a year-long lifestyle intervention with proven success. It is typically offered onsite in small-group settings. However, people with limited economic resources often face barriers to onsite engagement in the DPP. Examples of barriers include irregular work schedules, or limited access to transportation, childcare, quality healthcare, affordable healthful foods, or safe places to be physically active.

Offering a virtual version of the DPP (v-DPP) to people who face barriers to the onsite DPP could improve program participation, engagement, and outcomes. Combining the v-DPP with personally tailored guidance and care coordination from community health workers (CHWs) or hospital-based community nurses (HCNs) could help address many barriers to successful participation in the DPP.

The goal of this project is to assess the feasibility of and pathways for implementation of a virtually-delivered DPP (v-DPP) supported by community-based care coordination involving CHWs and HCNs. Ultimately, we hope to demonstrate improvements in diet quality, physical activity levels, blood sugar, body weight status, and blood pressure among our population of focus, thereby reducing their risk for type 2 diabetes.

Project Timeline

Year 1


  • Select a v-DPP platform for program delivery
  • Review literature on relevant topics
  • Interview key informants and residents
  • Finalize study assessment instruments
Year 2


  • Develop PIP and RE-AIM frameworks
  • Recruit and enroll pilot study participants
  • Pilot-test the v-DPP program
  • Start intervention & assessments
  • Revise PIP framework
Years 3 and 4


  • Continue intervention and assessments
  • Conduct preliminary data analyses
  • Further revise the PIP framework
Year 5


  • Conduct final data analyses
  • Develop dissemination toolkit
  • Share results and toolkit with audiences

Year 1 Activities (2019-2020)

Selection of a virtual Diabetes Prevention Program (v-DPP) platform

  • After exploratory meetings with companies that use virtual platforms to deliver the DPP, we selected incentaHEALTH as our v-DPP provider and research partner.

Review of published literature on relevant research topics

  • We conducted a realist review to determine how, why, and in what circumstances v-DPPs can improve diabetes risk factors among adults with limited economic resources.

Interviews with key informants and residents in New Haven, Ansonia, and Derby

  • We interviewed people who work with adults with limited resources to gain their insights on offering the v-DPP facilitated by care coordination from community health workers or community health nurses.
  • We interviewed residents who represent our population of focus to elicit their opinions and perceived barriers regarding healthful eating, physical activity, and the use of digital technology.

Final selection of study assessment instruments

  • We selected assessment tools to measure pre-post changes in behavioral and cardio-metabolic outcomes among the adults who enroll and participate in the program.

Year 2 plans and timeline

  • We used our reflections from Year 1 findings to guide plans for a pilot study of the v-DPP in Year 2, which will be followed by a more comprehensive intervention and evaluation in Years 3 and 4.

Primary Contacts

Rafael Pérez-Escamilla, PhD
PRC Principal Investigator

Kathleen O’Connor Duffany, PhD
PRC Co-Director

Beth Patton Comerford, MS
PRC Co-Director

Alycia Santilli, MSW
Director, Community Alliance for Research and Engagement (CARE)