In earlier phases of the Women to Women Project women have embraced and actively participated in virtual support groups and the on-line health education activities. Based on this experience, there were several logical next steps: simplification of the research design and intervention; refinement of a model of psychosocial adaptation to chronic illness; and expansion of the recruitment range. The Phase2 research design and intervention were labor intensive, costly, and complex. Our observations and a review of the literature supported that a more streamlined intervention of shorter duration, with increased intensity could be just as effective in enhancing psychosocial adaptation. The research design would be made less complex if the number of groups was reduced from three to two, use of one chatroom in lieu of two, decreased expert participation, and revised more problem-focused health teaching units were utilized.

In addition, we refined and enriched our model of psychosocial adaptation, drawing on the work of Roy and Pollock. The Women to Women Conceptual Model for Psychosocial Adaptation to Chronic Illness now includes not only psychosocial adaptation, but also more terminal outcomes of chronic illness self-management and QOL which are considered to be prerequisite to sustained behavior change. The conceptual model for Phase3 is built on the evolving understanding of adaptation to illness introduced by Roy and colleagues and further developed by a multitude of nurse scientists including the work of the current research team. It is anticipated that the proposed research will further strengthen and refine the latest model, advance the state of the science regarding adaptation to chronic illness, and provide guidance for expanding intervention research related to chronic illness management across diagnoses, and is sensitive to the particular issues associated with living in a rural area.

More rural women are now using computers, and we have found that the women can be effectively taught the use of the intervention platform (WebCT) via the telephone and a printed tutorial, minimizing the need for home visits for computer training. We can now confidently expand our recruitment range to include not only Montana, but also all of the surrounding states with similar vulnerable rural populations. These include North and South Dakota, Nebraska, Wyoming, Idaho, eastern Washington and Oregon. Thus the unique contributions of Phase3 will be to: reduce the complexity of the research design and intervention and further develop and refine a model of psychosocial adaptation to chronic illness. The overall goal of this study is to test the impact of a computer-based intervention on psychosocial adaptation, chronic illness self-management, and QOL among rural women with chronic illness. Within this context specific aims of this research are to:

1. Test the effectiveness of a more parsimonious computer-based intervention on psychosocial adaptation.
• H.1. Compared with controls, women in the intervention group will score significantly higher on measures of psychosocial adaptation including social support, self-esteem, and acceptance.
• H.2. Compared with controls, women in the intervention group will score significantly lower on measures of psychosocial adaptation including depression, loneliness, and stress.
2. Test the effectiveness of a more parsimonious computer-based intervention on chronic illness self-management.
• H.3. Compared with controls, women in the intervention group will score significantly higher on measures of chronic illness self-management including self-efficacy, empowerment, resource utilization, and forming partnerships.
3. Test the effectiveness of a more parsimonious computer-based intervention on QOL.
• H.4. Compared with controls, women in the intervention group will score significantly higher on measures of QOL.
4. Explore associations among focal, contextual, and residual stimuli (illness characteristics, demographics, degree of rurality, hardiness, optimism, spirituality), psychosocial adaptation, chronic illness self-management, and quality of life.
5. Analyze the chatroom computer exchanges among women to explicate the complex process of managing chronic illness within the rural context.

The Women to Women Conceptual Model for Psychosocial Adaptation to Chronic Illness forms the organizing framework. Measures of environmental stimuli will focus on chronic illness, rurality/demographics, hardiness, optimism, and spirituality. Psychosocial responses will be assessed by measures of social support, self-esteem, acceptance, depression, loneliness, and stress. Illness self-management will be evaluated by measuring the women's self-efficacy and empowerment in achieving the skills of self-management, ability to utilize resources, and form partnerships with their health care providers. Quality of life will also be assessed.

A two-group study design will be used with an 11 week intervention. Measures will be taken at baseline, at the end of week 11 (at the conclusion of the intervention), and at the end of week 24. A total of eight cohorts will participate in the study (N=320) with each cohort consisting of 40 women (20 intervention and 20 control in each cohort).

Women will enter the potential participant pool based on the following criteria: (a) 35 to 65 years old; (b) diagnosis of a chronic illness; (c) visual acuity sufficient to read a computer screen; (d) upper extremity motor skills adequate to do at least one-finger keyboard strokes; (e) functional hearing and speaking ability for participation in telephone screening interviews; (f) availability of a telephone in the home; (g) ability to read and write English; (h) willingness to commit to participate for 24 weeks, and (i) residence in a non-urbanized area in Montana, North Dakota, South Dakota, Nebraska, Wyoming, Idaho, eastern Washington or Oregon. It is not required that the participant own or know how to use a computer. For the purposes of this study, rural residence will be determined using the Bureau of the Census definition (146). Urban are those areas classified as being urbanized (having a population density of at least 1,000 persons per square mile and a total population of at least 50,000) as well as cities, villages, boroughs and other designated census areas having 2,500 or more persons. All areas not classified as urban are defined as rural and generally include places of less than 2,500 persons.

Women who are randomized into the computer intervention group will have access to a virtual self-help group and will engage in the heath teaching unit activities for 11 weeks. Both the intervention and the control groups will completed the repeated measure mail questionnaires. Two NIH research topics are being addressed: (a) investigate intervention strategies that have not been adequately or previously tested; and (b) determine the influence of established approaches to self-management across chronic diseases. WTW3 is an intervention that is providing social support and enhancing self-management skills for geographically isolated women via the use of telecommunication technology. The implementation and evaluation of the first two phases of this intervention have contributed to the understanding of the role this intervention is playing in enhancing the women's self-management skills in an effort to help them successfully adapt to chronic illness. In Phase1, the technical and protocol aspects of conducting a computer-based nursing support and health education intervention were refined, and the positive impact of the intervention on the women's psychosocial well-being was demonstrated, using social support theory as a major focus. In Phase2, adaptation to chronic illness was adopted as the overarching conceptual framework for the study, and the scope of the project was expanded to include a multidisciplinary focus, a wider population, and guided learning on the WWW. In Phase3, the research trajectory will move toward reducing the complexity of the research design and intervention and further developing and refining a model of psychosocial adaptation to chronic illness.

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