Behavioral telehealth in low-resource primary care settings for anxiety and depression in youth: protocol for a randomized effectiveness-implementation study.

People living with type 1 diabetes (PwT1D) are faced with intensive self‐management and treatment routines, financial pressures, fear of hypoglycaemia, controlling chronic complications and diabetes stigma. A central psychological consequence of this lifelong burden is diabetes distress (DD), a continuous emotional response to the demands and challenges of living with diabetes [, ]. DD is associated with poorer self‐management, higher HbA1c, increased risk of diabetes‐related complications and reduced quality of life []. It is therefore a relevant and common clinical problem, with prevalence rates varying from 22% [] to 77% [] in T1D. The most commonly used and recommended person‐reported outcome measures (PROMs) to assess DD are the Problem Areas in Diabetes (PAID) [] scale and the Diabetes Distress Scale (DDS) []. Specific T1D measures include the T1‐DDS [] and Type 1‐Diabetes Distress Assessment Scale (T1‐DDAS) []. Developed in 1995, PAID is the earliest and most widely used diabetes‐specific measure of distress [], having played a foundational role in distinguishing diabetes‐specific emotional burden from general depressive symptoms. In addition to its emotional focus, PAID demonstrates psychometric validity across sex, cultures and types of diabetes, enabling direct comparisons across these populations [, ]. Although these tools are well‐validated, a key issue is determining how much change in a score reflects clinically meaningful improvement or deterioration. For this purpose, the concept of minimal clinically important difference (MCID) has been proposed []. Recent studies demonstrated the feasibility of distribution‐based approaches to estimate MCIDs for DD scales, including the DDS, T1‐DDS and T1‐DDAS [, , ]. Using PAID ≥ 40 [] alone can misrepresent meaningful change because small shifts around the cut‐off can minimise magnitudes of change (e.g., reduction in PAID score from 41 to 39 vs. 60 to 45) []. Despite PAID being the most frequently used measure of DD, it has, until recently, lacked validated sub‐dimensions and established MCID thresholds, unlike the DDS. Although sub‐dimensions for PAID have recently been proposed [], MCID estimates for PAID remain unavailable, representing a gap in both clinical interpretation and longitudinal research.