Peer advisers compared with specialist health professionals in delivering a training programme on self-management to people with diabetes: a randomized controlled trial

What is the volume, diversity and nature of recent, robust evidence for the use of peer support in health and social care? An evidence and gap map

Background

Peer support interventions involve people drawing on shared personal experience to help one another improve their physical or mental health, or reduce social isolation. If effective, they may also lessen the demand on health and social care services, reducing costs. However, the design and delivery of peer support varies greatly, from the targeted problem or need, the setting and mode of delivery, to the number and content of sessions. Robust evidence is essential for policymakers commissioning peer support and practitioners delivering services in health care and community settings. This map draws together evidence on different types of peer support to support the design and delivery of interventions.

Objectives

The aim of this map was to provide an overview of the volume, diversity and nature of recent, high quality evidence on the effectiveness and cost-effectiveness of the use of peer support in health and social care.

Search Methods

We searched MEDLINE, seven further bibliographic databases, and Epistemonikos for systematic reviews (in October 2020), randomised controlled trials (in March 2021) and economic evaluations (in May 2021) on the effectiveness of peer support interventions in health and social care. We also conducted searches of Google Scholar, two trial registers, PROSPERO, and completed citation chasing on included studies.

Selection Criteria

Systematic reviews, randomised controlled trials and economic evaluations were included in the map. Included studies focused on adult populations with a defined health or social care need, were conducted in high-income countries, and published since 2015. Any measure of effectiveness was included, as was any form of peer support providing the peer had shared experience with the participant and a formalised role.

Data Collection and Analysis

Data were extracted on the type of peer support intervention and outcomes assessed in included studies. Standardised tools were used to assess study quality for all studies: assessing the methodological quality of systematic reviews 2 for systematic reviews; Cochrane risk of bias tool for randomised controlled trials; and consensus health economic criteria list for economic evaluations.

Main Results

We included 91 studies: 32 systematic reviews; 52 randomised controlled trials; and 7 economic evaluations. Whilst most included systematic reviews and economic evaluations were assessed to be of low or medium quality, the majority of randomised controlled trials were of higher quality. There were concentrations of evidence relating to different types of peer support, including education, psychological support, self-care/self-management and social support. Populations with long-term health conditions were most commonly studied. The majority of studies measured health-related indicators as outcomes; few studies assessed cost-effectiveness. Studies were unevenly distributed geographically, with most being conducted in the USA. Several gaps were evident regarding the delivery of peer support, particularly the integration of peers and professionals in delivering support and interventions of longer duration.

Authors' Conclusions

Although there is evidence available to inform the commissioning and delivery of peer support in health and social care, there are also clear gaps that need to be addressed to further support provision, particularly regarding cost-effectiveness. The effectiveness of peer support in different countries, with varying health and social care systems, is a priority for future research, as is the integration of peers with professionals in delivering peer support.

'More than just chitchat': a qualitative study concerning the need and potential format of a peer mentor programme for patients with early rheumatoid arthritis

Background

Patients recently diagnosed with rheumatoid arthritis (RA) have specific educational and supportive needs. These could partly be addressed with mentoring by other patients living with RA. This qualitative study explores stakeholder perceptions towards peer mentoring in early RA care.

Methods

Two focus groups with patients with early RA (n=10), one with patient organisation representatives (n=5), one with rheumatologists (n=8) and one with rheumatology nurses (n=5) were held. Two patient research partners supported analysis and interpretation.

Results

Four overarching themes were found: added value, experience with peer mentoring, concerns and need in daily care. Patients and patient organisation representatives confirmed the potential of peer mentoring especially regarding sensitive topics not easily discussed with professionals. Patients felt it could provide additional understanding and recognition. Nurses and rheumatologists were less convinced of the added value of peer mentoring because patients never mentioned it and they were concerned about the loss of control over correct information provision. The need for peer mentoring was perceived as person and disease phase-dependent and should therefore be optional, rather than a care standard. The requirements for a peer mentorship programme remained challenging to define for stakeholders. However, all expressed the need for supervision by healthcare professionals and that peer mentors should be carefully selected, educated and matched to newly diagnosed patients.

Conclusion

Peer mentoring and its implementation remain vague concepts, especially for healthcare providers. However, patients are interested in mentoring by peers, and the current results may support in effectively implementing such programmes early in the disease.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Peer Mentoring in the Do-it-Yourself Artificial Pancreas System Community

BACKGROUND

The do-it-yourself (DIY) artificial pancreas system (APS) community is led by people with diabetes (PWD) and their families. In contrast to standard models of care, in which health care professionals are responsible for the education and training of PWD and their families, within the DIY APS, community users are reliant on their peers for education and training. The provision of this support has not previously been studied. This article focuses on the role of mentors within the DIY APS community.

METHOD

Semistructured interviews were conducted with mentors (n = 9) who were identified with assistance from the DIY APS community. Thematic analysis was undertaken. Results were presented to select participants who endorsed the results as an accurate description of mentoring in the DIY APS community.

RESULTS

Mentors' primary motivation was altruism. An empathetic, process-focused approach was modeled by prominent mentors. The use of online forums as the primary source of user support was perceived to be an effective method for sharing the workload. Key challenges for mentors included the frequency with which users asked questions that were answered in the existing documentation, dealing with conflict and managing workload. Most participants did not perceive mentoring to be risky, but did take steps to ensure that users were taking responsibility for their own systems.

CONCLUSION

This study is the first to examine the role of mentors within the DIY APS community and also within the broader diabetes online community. Future research might seek to quantify the empathetic, process-focused approach to mentoring.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Effectiveness of peer led intervention in improvement of clinical outcomes among diabetes mellitus and hypertension patients-A systematic review and meta-analysis

Peer-led intervention allows the patients to develop knowledge, skills and confidence in managing their own conditions. Hence this review was done to assess the effectiveness of peer-led intervention in improving the clinical outcomes of DM and HTN patients. We conducted systematic search in Medline, CENTRAL, Sciencedirect and Google-Scholar from inception till May 2018 and retrieved 3654 citations. Meta-analysis was performed using random-effects model and pooled mean difference (MD) was reported with 95% CI. Publication bias was assessed using Egger's test. 29 trials (26 DM and 3 HTN) with 6363 participants were included. There was positive effect of peer led intervention on DM and HTN with pooled MD of -0.28% [95%CI: -0.45 to -0.11] and -7.52mmHg [95%CI: -14.39 to -0.66]. There was significant heterogeneity and publication bias in both DM and HTN trials. Sensitivity analysis showed only little improvement in the final estimate. Peer support intervention is effective and causes statistically significant reduction in HbA1C and systolic blood pressure among DM and HTN patients.

A systematic review exploring characteristics of lifestyle modification interventions in newly diagnosed type 2 diabetes for delivery in community pharmacy†

Objectives

The aim of this systematic review was to examine the characteristics of effective lifestyle modification interventions designed for patients with newly diagnosed type 2 diabetes mellitus (T2DM) in order to determine elements that have the potential to be delivered in the community pharmacy setting.

Key findings

Seven studies, comprising three each of the interventions diet and structured education and one of supported exercise, were identified. Interventions were conducted in hospital diabetes clinics and clinics situated in both urban and rural areas. Interventions were delivered face to face by highly skilled personnel including physicians, nurses and dietitians. Duration of interventions ranged from 3 months to 5 years.

Summary

Structured education and dietary interventions in newly diagnosed type 2 diabetes effectively controlled blood glucose levels without pharmacological intervention. Important characteristics included face to face, individualised and multicomponent interventions with a duration of at least 6 months. These characteristics demonstrate potential for delivery in a community pharmacy setting, given its current involvement in delivering face to face, individual services with diet and lifestyle components. Further research is required to provide evidence for ideal intervention duration and frequency as well as training requirements for pharmacists.

Recruitment, retention, and training of people with type 2 diabetes as diabetes prevention mentors (DPM) to support a healthcare professional-delivered diabetes prevention program: the Norfolk Diabetes Prevention Study (NDPS)

OBJECTIVE

Intensive lifestyle interventions reduce the risk of type 2 diabetes in populations at highest risk, but staffing levels are usually unable to meet the challenge of delivering effective prevention strategies to a very large at-risk population. Training volunteers with existing type 2 diabetes to support healthcare professionals deliver lifestyle interventions is an attractive option.

METHODS

We identified 141 973 people at highest risk of diabetes in the East of England, screened 12 778, and randomized 1764 into a suite of type 2 diabetes prevention and screen detected type 2 diabetes management trials. A key element of the program tested the value of volunteers with type 2 diabetes, trained to act as diabetes prevention mentors (DPM) when added to an intervention arm delivered by healthcare professionals trained to support participant lifestyle change.

RESULTS

We invited 9951 people with type 2 diabetes to become DPM and 427 responded (4.3%). Of these, 356 (83.3%) were interviewed by phone, and of these 131 (36.8%) were interviewed in person. We then appointed 104 of these 131 interviewed applicants (79%) to the role (mean age 62 years, 55% (n=57) male). All DPMs volunteered for a total of 2895 months, and made 6879 telephone calls to 461 randomized participants. Seventy-six (73%) DPMs volunteered for at least 6 months and 66 (73%) for at least 1 year.

DISCUSSION

Individuals with type 2 diabetes can be recruited, trained and retained as DPM in large numbers to support a group-based diabetes prevention program delivered by healthcare professionals. This volunteer model is low cost, and accesses the large type 2 diabetes population that shares a lifestyle experience with the target population. This is an attractive model for supporting diabetes prevention efforts.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

2017 National Standards for Diabetes Self-Management Education and Support

Purpose

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

Methods

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

Results

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

Conclusion

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

2017 National Standards for Diabetes Self-Management Education and Support

This article was copublished in Diabetes Care 2017;40:1409-1419 and The Diabetes Educator 2017;43:449-464 and is reprinted with permission. The previous version of this article, also copublished in Diabetes Care and The Diabetes Educator, can be found at Diabetes Care 2012;35:2393-2401 (https://doi.org/10.2337/dc12-1707).

2017 National Standards for Diabetes Self-Management Education and Support

Purpose The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends. Methods The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision. Results Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes. Conclusion Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

The Effectiveness of a Peer Coaching Education on Control and Management of Type 2 Diabetes in Women: A Protocol for a Randomized Controlled Trial

BACKGROUND

Diabetes Education by Peer Coaching is a strategy which helps the patients with diabetes in the field of behavioral and emotional problems. However, the results of studies in this field in other countries could not be generalized in our context. So, the current study aimed to examine the effectiveness of Diabetes Education by Peer Coaching on Diabetes Management.

METHODS

Outcome variables for patients and peer coaches are measured at baseline and in3,6 and 12 months. The primary outcome consisted of Fasting Blood Sugar (FBS) and HbA1c. Secondary outcomes included Blood Pressure (BP), Body Mass Index (BMI,) Waist-Hip Ratio (WHR), Lipid Profile, diabetes self-care activities, diabetes-related quality of life, depression, and Social Capital levels.Initial analyses compared the frequency of baseline levels of outcome and other variables using a simple Chi-square test, t-test and the Mann-Whitney- U test. Sequential measurements in each group were evaluated by two-way analysis of variance. If significant differences in baseline characteristics were found, analyses were repeated adjusting for these differences using ANOVA and logistic regression for multivariate analyses. Additional analyses were conducted to look for the evidence of effect modification by pre-specified subgroups.

CONCLUSION

The fact is that self-control and self-efficacy in diabetes management and treatment of diabetes could be important components. It seems that this research in this special setting with cultural differences would provide more evidence about peer-coaching model. It seems that if the peer-coaching model improves learning situations between patients with diabetes by offering one-on-one Diabetes Self Management Education, it could be an interactive approach to diabetic education. Trial Registration Number: IRCT201501128175N3.

Results of a pilot study of patient-to-patient education strategy on self-management among glycemic uncontrolled patients with diabetes

OBJECTIVES

The purpose of this study was to assess the efficacy and practicability of patient-to-patient (PTP) education strategy on glycemic control among patients with type 2 diabetes mellitus.

METHODS

Eligible subjects from outpatient clinic were recruited and randomized to either intervention group or control group. Inpatients with poor outcomes and complications acted as mentors to share their experience with the intervention group in three tailored classes. Besides, the intervention group received general advice from specialists. The control group received general advice only. The glucose metabolic status and behavior modification indicators were evaluated before and after intervention. In addition, both groups finished a questionnaire survey regarding awareness to diabetic complications after intervention.

RESULTS

Eighty-four subjects were recruited (42 subjects for each group), and 51 subjects finished the study. Both the intervention group (n=29) and the control group (n=22) showed a tendency toward a decrease in glycosylated hemoglobin level (A1c, -0.8% vs -0.4%, P<0.05) and improvement in behavior modification (+5.0 vs +2.8, P<0.05) after 6 months. The intervention group (13.8%) obtained a higher percentage than the control group (9.1%) whose A1c reached ≤7%. The body mass index did not change significantly in any group. The questionnaire score about complication awareness was higher in the intervention group than in the control group.

CONCLUSION

This preliminary evidence suggests that PTP education strategy is acceptable for facilitating the outcome of glycemic control. Patient sense of complications may work on A1c reduction.

Patients' beliefs on the impediments to good diabetes control: a mixed methods study of patients in general practice

BACKGROUND

Most people with diabetes are not attaining desirable levels of HbA1c (glycated haemoglobin), or of blood pressure and cholesterol, leaving them at risk of developing complications.

AIM

To identify ways of improving diabetes control by gaining insight into patients' attitudes/beliefs.

DESIGN AND SETTING

Questionnaires were offered to patients attending for a diabetes review in the 24 GP practices of North East Hampshire and Farnham Clinical Commissioning Group.

METHOD

Infrequent attenders were contacted by post. Volunteers then participated in focus groups.

RESULTS

Self-reported medication adherence was good with 83% (98/118) of responders recording ≥9 on a 10-point scale. Patients generally accepted they 'needed' and 'could take' medication. A substantial minority reported 'not liking' taking tablets. Focus groups confirmed this and revealed a reluctance to change lifestyle, with medication reported as a way to evade it. A total of 68 out of 112 responders (60.7%) knew their HbA1c value. However, focus groups identified little understanding of HbA1c, with responders perceiving it as medical jargon. Phrases such as 'stuck-on-sugar' or 'sugarload' were suggested as being semantically easier to understand. The questionnaire revealed trust in clinicians. This was confirmed in focus groups but confounded by frequent reports of healthcare providers giving inadequate/incorrect advice.

CONCLUSION

Investment in lifestyle change is needed. Participants were reluctant to change and saw medication as a way of avoiding it. HbA1c needs to be better explained. Intuitive phrases such as 'stuck-on-sugar' or 'sugarload' could be adopted into common parlance. Inadequate/incorrect advice seems to be hampering diabetes management and there appears to be a need for more diabetes-trained clinicians.

Peer Support Interventions for Adults With Diabetes: A Meta-Analysis of Hemoglobin A1c Outcomes

PURPOSE

Peer support intervention trials have shown varying effects on glycemic control. We aimed to estimate the effect of peer support interventions delivered by people affected by diabetes (those with the disease or a caregiver) on hemoglobin A_1c (HbA_1c) levels in adults.

METHODS

We searched multiple databases from 1960 to November 2015, including Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, and Scopus. We included randomized controlled trials (RCTs) of adults with diabetes receiving peer support interventions compared with otherwise similar care. Seventeen of 205 retrieved studies were eligible for inclusion. Quality was assessed with the Cochrane risk of bias tool. We calculated the standardized mean difference (SMD) of change in HbA_1c level from baseline between groups using a random effects model. Subgroup analyses were predefined.

RESULTS

Seventeen studies (3 cluster RCTs, 14 RCTs) with 4,715 participants showed an improvement in pooled HbA_1c level with an SMD of 0.121 (95% CI, 0.026-0.217; P = .01; I² = 60.66%) in the peer support intervention group compared with the control group; this difference translated to an improvement in HbA_1c level of 0.24% (95% CI, 0.05%-0.43%). Peer support interventions showed an HbA_1c improvement of 0.48% (95% CI, 0.25%-0.70%; P <.001; I² = 17.12%) in the subset of studies with predominantly Hispanic participants and 0.53% (95% CI, 0.32%-0.73%; P <.001; I² = 9.24%) in the subset of studies with predominantly minority participants; both were clinically relevant. In sensitivity analysis excluding cluster RCTs, the overall effect size changed little.

CONCLUSIONS

Peer support interventions for diabetes overall achieved a statistically significant but minor improvement in HbA_1c levels. These interventions may, however, be particularly effective in improving glycemic control for people from minority groups, especially those of Hispanic ethnicity.

Effectiveness of a Peer Support Programme versus Usual Care in Disease Management of Diabetes Mellitus Type 2 regarding Improvement of Metabolic Control: A Cluster-Randomised Controlled Trial

AIM

Testing the effectiveness of peer support additionally to a disease management programme (DMP) for type 2 diabetes patients.

METHODS

Unblinded cluster-randomised controlled trial (RCT) involving 49 general practices, province of Salzburg, Austria. All patients enrolled in the DMP were eligible, n = 337 participated (intervention: 148 in 19 clusters; control: 189 in 20 clusters). The peer support intervention ran over 24 months and consisted of peer supporter recruitment and training, and group meetings weekly for physical exercise and monthly for discussion of diabetes related topics.

RESULTS

At two-year follow-up, adjusted analysis revealed a nonsignificant difference in HbA1c change of 0.14% (21.97 mmol/mol) in favour of the intervention (95% CI -0.08 to 0.36%, p = 0.22). Baseline values were 7.02 ± 1.25% in the intervention and 7.08 ± 1.25 in the control group. None of the secondary outcome measures showed significant differences except for improved quality of life (EQ-5D-VAS) in controls (4.3 points on a scale of 100; 95% CI 0.08 to 8.53, p = 0.046) compared to the intervention group.

CONCLUSION

Our peer support intervention as an additional DMP component showed no significant effect on HbA1c and secondary outcome measures. Further RTCs with a longer follow-up are needed to reveal whether peer support will have clinically relevant effects.

TRIAL REGISTRATION

This trial has been registered with Current Controlled Trials Ltd. (ISRCTN10291077).

Behavioral Programs for Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis

BACKGROUND

Behavioral programs may improve outcomes for individuals with type 2 diabetes mellitus, but there is a large diversity of behavioral interventions and uncertainty about how to optimize the effectiveness of these programs.

PURPOSE

To identify factors moderating the effectiveness of behavioral programs for adults with type 2 diabetes.

DATA SOURCES

6 databases (1993 to January 2015), conference proceedings (2011 to 2014), and reference lists.

STUDY SELECTION

Duplicate screening and selection of 132 randomized, controlled trials evaluating behavioral programs compared with usual care, active controls, or other behavioral programs.

DATA EXTRACTION

One reviewer extracted and another verified data. Two reviewers independently assessed risk of bias.

DATA SYNTHESIS

Behavioral programs were grouped on the basis of program content and delivery methods. A Bayesian network meta-analysis showed that most lifestyle and diabetes self-management education and support programs (usually offering ≥ 11 contact hours) led to clinically important improvements in glycemic control (≥ 0.4% reduction in hemoglobin A1c [HbA1c]), whereas most diabetes self-management education programs without added support-especially those offering 10 or fewer contact hours-provided little benefit. Programs with higher effect sizes were more often delivered in person than via technology. Lifestyle programs led to the greatest reductions in body mass index. Reductions in HbA1c seemed to be greater for participants with a baseline HbA1c level of 7.0% or greater, adults younger than 65 years, and minority persons (subgroups with ≥ 75% nonwhite participants).

LIMITATIONS

All trials had medium or high risk of bias. Subgroup analyses were indirect, and therefore exploratory. Most outcomes were reported immediately after the interventions.

CONCLUSION

Diabetes self-management education offering 10 or fewer hours of contact with delivery personnel provided little benefit. Behavioral programs seem to benefit persons with suboptimal or poor glycemic control more than those with good control.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO registration number: CRD42014010515).

Rethinking peer support for diabetes in Vancouver's South-Asian community: a feasibility study

AIM

To examine the feasibility and potential health impact of a diabetes self-management education and support intervention involving peer support on glycaemic control and diabetes distress.

METHODS

A total of 41 South-Asian adults with Type 2 diabetes were recruited for a 24-week diabetes self-management education and support pilot intervention involving peer support. The intervention consisted of six weekly education sessions co-facilitated by a certified diabetes educator and two peer leaders, followed by 18 weekly support sessions facilitated by two peer leaders. Education sessions were guided entirely by participants' self-management questions and also emphasized goal setting and action planning. Support sessions were based on empowerment principles and participants discussed self-management challenges, shared emotions, asked self-management questions, problem-solved in a group, set goals, and developed and evaluated action plans. Feasibility outcomes included recruitment and retention. Primary health-related outcomes included HbA1c levels and diabetes distress (measured at baseline, 6 and 24 weeks). Programme satisfaction was also assessed.

RESULTS

Pre-established criteria for recruitment and retention were met. Paired t-tests showed no changes in HbA1c and diabetes distress at 6 weeks. At 24 weeks, HbA1c levels deteriorated [54 mmol/mol (7.1%) vs 61 mmol/mol (7.7%)] while diabetes distress scores improved (2.0 vs 1.7).

CONCLUSIONS

Although feasible, findings suggest this peer-support model may have a positive impact on diabetes distress, but not on HbA1c levels. Culturally responsive modifications (e.g. intervention location) to the pilot model are needed and could lead to more favourable health outcomes for this community. Such a re-designed peer-support model will require further investigation.

Adult community health-promoting interventions in primary health care: A systematic review

OBJECTIVE

To examine evidence on the effectiveness of health-promoting community interventions carried out in primary health care.

METHODS

Systematic review of originals and systematic reviews of health-promoting community interventions with the participation of primary health care. A working definition of community activities was used in the inclusion criteria. Databases searched up to 2013: PUBMED, EMBASE, CINHAL, Web of SCIENCE, IBECS, IME, and PSICODOC. No restrictions on year of publication or design. Articles were reviewed by separate researchers to identify risks of bias.

RESULTS

Fifty-one articles published between 1966 and 2013 were included: 11 systematic reviews and 40 originals that described 39 community interventions. There is evidence on the effectiveness of community interventions in reducing cardiovascular risk factors, encouraging physical exercise, preventing falls and improving self-care among chronic patients compared with usual individual care. The effectiveness of some interventions increases when the community is involved in their development. Most assessments show positive results despite design limitations.

CONCLUSIONS

The community approach may be more effective than the individual in usual preventive interventions in primary care. There is a lack of evidence on many community interventions in primary care and further research is needed.

Effect of peer education on self-management and psychological status in type 2 diabetes patients with emotional disorders

Aims/Introduction

The purpose of the present study was to assess the effect of peer education in type 2 diabetes patients with emotional disorders on the metabolic index and psychological status.

Materials and Methods

Educators use psychological scales to screen type 2 diabetes patients with emotional disorders. Participants were divided into usual and peer education groups. Both groups received usual diabetes education. Peer leaders were recruited to provide support with the peer education group for 6 months. The metabolic index, diabetes knowledge, self-management, diabetes-related distress, emotional status and quality of life were compared at the end of the study.

Results

A total of 127 patients participated in the study. There were 20 peer leaders engaged in the study as volunteers for peer education. All participants completed the study and fulfilled the scales. Improvements in the peer education group were significant compared with the usual education group with respect to anxiety (49.0 ± 9.65 vs 54.0 ± 8.48), depression (51.3 ± 7.97 vs 55.8 ± 7.52), diabetes knowledge (18.8 ± 2.46 vs 16.3 ± 2.08), distress (2.67 ± 0.55 vs 3.02 ± 0.56), self-management (66.5 ± 4.26 vs 62.4 ± 5.88) and quality of life (−1.98 ± 0.82 vs −2.50 ± 0.71), whereas no significant difference existed with respect to the metabolic index.

Conclusions

Peer education, providing more attention to diabetes patients with emotional disorders, is a preferred model for delivering care.

Increasing capacity to deliver diabetes self-management education: results of the DESMOND lay educator non-randomized controlled equivalence trial

AIM

To develop and test a format of delivery of diabetes self-management education by paired professional and lay educators.

METHODS

We conducted an equivalence trial with non-randomized participant allocation to a Diabetes Education and Self Management for Ongoing and Newly Diagnosed Type 2 diabetes (DESMOND) course, delivered in the standard format by two trained healthcare professional educators (to the control group) or by one trained lay educator and one professional educator (to the intervention group). A total of 260 people with Type 2 diabetes diagnosed within the previous 12 months were referred for self-management education as part of routine care and attended either a control or intervention format DESMOND course. The primary outcome measure was change in illness coherence score (derived from the Diabetes Illness Perception Questionnaire-Revised) between baseline and 4 months after attending education sessions. Secondary outcome measures included change in HbA1c level. The trial was conducted in four primary care organizations across England and Scotland.

RESULTS

The 95% CI for the between-group difference in positive change in coherence scores was within the pre-set limits of equivalence (difference = 0.22, 95% CI 1.07 to 1.52). Equivalent changes related to secondary outcome measures were also observed, including equivalent reductions in HbA1c levels.

CONCLUSION

Diabetes education delivered jointly by a trained lay person and a healthcare professional educator with the same educator role can provide equivalent patient benefits. This could provide a method that increases capacity, maintains quality and is cost-effective, while increasing access to self-management education.

"Someone like us": delivering maternal mental health through peers in two South Asian contexts

BACKGROUND

Peer-led psychosocial interventions are one solution to address the great paucity of skilled mental health human resources in South Asia. The aim of this study was to explore peer-delivered care for maternal depression in two diverse contexts in South Asia.

METHODS

The study was carried out in the urban setting of Goa, India and rural setting in Rawalpindi, Pakistan. In total, 61 in-depth interviews (IDIs) and 3 focus group discussions (FGDs), and 38 IDIs and 10 FGDs, were conducted with multiple stakeholders in urban Goa and rural Rawalpindi respectively. We used the framework approach to analyze data.

RESULTS

Peers from the same community were the most preferred delivery agents of a community-based psychosocial intervention in both sites. There were contextual similarities and differences between the two sites. Preferred characteristics among peers included local, middle-aged, educated mothers with similar experiences to participants, good communication skills and a good character. Key differences between the two contexts included a greater emphasis on the peer׳s family social standing in rural Rawalpindi and financial incentives as motivators for individual peers in urban Goa.

LIMITATIONS

Generalizability of our findings is limited to two specific contexts in a vast and diverse region.

DISCUSSION

Our study demonstrates that peers have the potential to deliver maternal psychosocial interventions in low-income settings. There are contextual differences in the preferred characteristics and motivators between the sites, and these should be carefully considered in program implementation.

Type 2 diabetes patients educated by other patients perform at least as well as patients trained by professionals

BACKGROUND

Diabetes education can improve the quality of care of people with diabetes, but many organizations are not equipped to manage its implementation. Involving people with diabetes in the education process can overcome the problem. Thus, we compared clinical, metabolic and psychological outcomes in people with type 2 diabetes 1 year after attending a structured diabetes education programme implemented by professional educators versus the same programme implemented by trained peers with diabetes that also provided ongoing peer support.

METHODS

People with type 2 diabetes (25-75 years) were randomly assigned to attend a 4-week structured diabetes education course delivered by professional educators (control) or previously trained peers (peer). Peers also received continuing psychological support, including examples on how to apply diabetes knowledge in daily life via weekly peer cellular phone calls and bimonthly face-to-face interviews in small groups (ten patients), using a structured questionnaire related to the patient's clinical, metabolic and psychological progress. Identical outcome data from both groups were used for follow-up.

RESULTS

Both groups had a comparable positive effect on clinical, metabolic and psychological indicators immediately following the programme. Over the following year, peer-educated subjects had lower A(1C) and systolic blood pressure and showed higher adherence to physical activity and better control of hypoglycaemic episodes.

CONCLUSION

The non-inferiority of the peer outcomes and the mentioned improvements in this group suggest that volunteer trained peer educators and ongoing support can be successful. This approach provides an effective alternative method of education, especially in areas with limited availability of professionals and economic resources.

Testing a peer support intervention for people with type 2 diabetes: a pilot for a randomised controlled trial

BACKGROUND

People with Type 2 diabetes face various psycho-social, self-management and clinical care issues and evidence is mixed whether support from others with diabetes, 'peer support', can help. We now describe a 2 month pilot study of different peer support interventions.

METHODS

The intervention was informed by formative evaluation using semi-structured interviews with health professionals, community support groups and observation of diabetes education and support groups. Invitations to participate were mailed from 4 general practices and included a survey of barriers to care. Participants were randomized by practice to receive individual, group, combined (both individual and group) or no peer support. Evaluation included ethnographic observation, semi-structured interviews and questionnaires at baseline and post-intervention.

RESULTS

Of 1,101 invited, 15% expressed an interest in participating in the pilot. Sufficient numbers volunteered to become peer supporters, although 50% of these (8/16) withdrew. Those in the pilot were similar to other patients, but were less likely to feel they knew enough about diabetes (60.8% vs 44.6% p = 0.035) and less likely to be happy with the diabetes education/care to date (75.4% vs 55.4% p = 0.013). Key issues identified were the need to recruit peer supporters directly rather than through clinicians, to address participant diabetes educational needs early and the potential for group sessions to have lower participation rates than 1:1 sessions.

CONCLUSIONS

Recruitment to a full trial of peer support within the existing study design is feasible with some amendments. Attendance emerged as a key issue needing close monitoring and additional intervention during the trial.

A process evaluation using a Self Determination Theory measure of the co-delivery of self management training by clinicians and by lay tutors

OBJECTIVE

To evaluate the co-delivery style of lay and clinician co-tutors of courses for patients, and courses for clinicians to support their patients' self-management skills.

METHODS

Motivational style of course delivery was assessed in 37 patient course sessions and 14 clinician workshops by independent observers using four Self Determination Theory rating scales and ethnographic notes. Forty-five tutors and 35 attendees were interviewed about their experience of co-delivered courses.

RESULTS

Lay and clinician tutors had similar motivational styles, with significant differences between the four motivational style scales; patient courses (F(3, 216)=3.437, p=.018); and clinician courses (F(3, 78)=3.37, p=.025). The courses were experienced as co productive in style as suggested during interviews, but adherence to manuals limited the tutors' contributions. Lay and clinician tutors scored higher on providing structure and engaging participants than they scored on supporting autonomous decision making and involvement.

CONCLUSION

Co-delivery was a successful model, affording opportunities to demonstrate co-production skills.

PRACTICE IMPLICATIONS

There is more scope to enable lay and clinician tutors to use their respective expertise in supporting self-management, and for tutor training to encourage a less didactic delivery style.

What is the effect of peer support on diabetes outcomes in adults? A systematic review

AIM

There is increasing interest in the role that peers may play to support positive health behaviours in diabetes, but there is limited evidence to inform policy and practice. The aim of this study was to systematically review evidence of the impact and effectiveness of peer support in adults living with diabetes.

METHODS

We searched the Cochrane Library, MEDLINE, PubMed, EMBASE and CINHAL for the period 1966-2011, together with reference lists of articles for eligible studies. Data were synthesized in a narrative review.

RESULTS

Twenty-five studies, including fourteen randomized, controlled or comparative trials, met the inclusion criteria. There was considerable heterogeneity in the design, setting, outcomes and measurement tools. Peer support was associated with statistically significant improvements in glycaemic control (three out of 14 trials), blood pressure (one out of four trials), cholesterol (one out of six trials), BMI/weight (two out of seven trials), physical activity (two out of five trials), self-efficacy (two out of three trials), depression (four out of six trials) and perceived social support (two out of two trials). No consistent pattern of effect related to any model of peer support emerged.

CONCLUSIONS

Peer support appears to benefit some adults living with diabetes, but the evidence is too limited and inconsistent to support firm recommendations. There remains a need for further well-designed evaluations of its effectiveness and impact. Key questions remain over its suitability to the needs of particular individuals, populations and settings, how best to implement its specific components and the sustainability of its effects.

Participants' experiences of care during a randomized controlled trial comparing a lay-facilitated angina management programme with usual care: a qualitative study using focus groups

AIM

This paper is a report of a qualitative study conducted as part of a randomized controlled trial comparing a lay-facilitated angina management programme with usual care. Its aim was to explore participants' beliefs, experiences, and attitudes to the care they had received during the trial, particularly those who had received the angina management intervention.

BACKGROUND

Angina affects over 50 million people worldwide. Over half of these people have symptoms that restrict their daily life and would benefit from knowing how to manage their condition.

DESIGN

A nested qualitative study within a randomized controlled trial of lay-facilitated angina management.

METHOD

We conducted four participant focus groups during 2008; three were with people randomized to the intervention and one with those randomized to control. We recruited a total of 14 participants to the focus groups, 10 intervention, and 4 control.

FINDINGS

Although recruitment to the focus groups was relatively low by comparison to conventional standards, each generated lively discussions and a rich data set. Data analysis demonstrated both similarities and differences between control and intervention groups. Similarities included low levels of prior knowledge about angina, whereas differences included a perception among intervention participants that lifestyle changes were more easily facilitated with the help and support of a lay-worker.

CONCLUSION

Lay facilitation with the Angina Plan is perceived by the participants to be beneficial in supporting self-management. However, clinical expertise is still required to meet the more complex information and care needs of people with stable angina.

A motivational peer support program for type 2 diabetes prevention delivered by people with type 2 diabetes: the UEA-IFG feasibility study

PURPOSE

The purpose of this study was to develop a peer support program for individuals at high risk of type 2 diabetes as part of a novel Diabetes Prevention Programme (The UEA-IFG Study). Lay members of the public with existing type 2 diabetes volunteered as peer supporters (termed type 2 trainers) for participants at high risk of developing type 2 diabetes. The feasibility of type 2 trainer recruitment, training, and retention was tested.

METHODS

Between January and September 2009, 1500 potential type 2 trainers with existing type 2 diabetes were contacted and 168 (11%) expressed an interest. From this group, 26 type 2 trainers were appointed to begin training. All completed 7 training seminars, covering diabetes prevention, nutrition, physical activity, listening skills, motivation, and goal planning. Motivational calls were made every 12 weeks to each study participant by each type 2 trainer in addition to health care professional-delivered education sessions.

RESULTS

Twenty-six type 2 trainers were recruited to enter the program. One type 2 trainer withdrew before beginning their role. The retention rate was high, with 22 (89%) of the type 2 trainers continuing until study end (July 2010; 20 months), with a total of 240 phone calls made.

CONCLUSION

The recruiting and training of lay volunteers with existing type 2 diabetes as type 2 trainers to support study participants at risk of developing the same condition was a cost-effective strategy in comparison to employing salaried health care professionals and warrants further investigation on health outcomes.

International Forum for the Advancement of Diabetes Research and Care, April 29-30, 2011, Athens, Greece

The International Forum for the Advancement of Diabetes Research and Care brought together distinguished international experts in diabetes to discuss diverse trends and emerging issues in diabetes therapy and management. The plenary sessions on the first day focused on trends in insulin therapy, the role of glucagon-like peptide-1 receptor agonists in diabetes treatment, the relationship between diabetes and cardiovascular risk, and the challenges associated with the development of clinically relevant treatment guidelines. Interactive breakout sessions addressed the following topics: microvascular complications of diabetes; the need for a team approach to patient education; optimal management of Asian people with diabetes; the role of continuous glucose monitoring in assessing glucose variability; and lessons learned from biosimilar drugs. The plenary sessions on the second day covered self-monitoring of blood glucose, treatment and prevention of type 1 diabetes, and future directions for diabetes therapy. The meeting represented an excellent forum for the presentation of new research and the exchange of ideas aimed at improving outcomes for people with diabetes.

Impact of education and training on type of care provided by community-based breastfeeding counselors: a cross-sectional study

BACKGROUND

Studies using community-based breastfeeding counselors (CBBCs) have repeatedly shown positive impact on breastfeeding initiation, exclusivity and duration, particularly among low-income mothers. To date, there has not been a comprehensive study to determine the impact of CBBC attributes such as educational background and training, on the type of care that CBBCs provide.

METHODS

This was a cross-sectional study of a convenience sample of CBBCs to ascertain the influence of counselor education and type of training on type of support and proficiency of CBBCs in communities across the United States. Invitations to participate in this online survey of CBBCs were e-mailed to program coordinators of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), La Leche League, and other community-based health organizations, who in turn invited and encouraged their CBBCs to participate. Descriptive analysis was used to describe participants (N = 847), while bivariate analysis using χ2 test was used to examine the differences between CBBC education, training received and breastfeeding support skills used. Multivariate logistic regression was used to assess the independent determinants of specific breastfeeding support skills.

RESULTS

The major findings from the research indicate that overall, educational attainment of CBBCs is not a significant predictor for the curriculum used in their training and type of support skills used during counseling sessions, but initial training duration was positively associated with the use of many breastfeeding support skills. Another major influence of counselor support to clients is the type of continuing education they receive after their initial training, with higher likelihood of use of desirable support skills associated with counselors continuing their breastfeeding education at conferences or trainings away from their job sites.

CONCLUSIONS

Our results show that different programs use different training curricula to train their CBBCs varying in duration and content. Counselor education is not a significant predictor of the type of training they receive. Continuing breastfeeding education is a significant determinant of type of counseling techniques used with clients. Further research is therefore needed to critically examine the content of the various training curricula of CBBC programs. This may show a need for a standardized training curriculum for all CBBC programs worldwide to make CBBCs more proficient and efficient, ensuring successful and optimum breastfeeding experiences for mothers and their newborns.

Peer interventions to promote health: conceptual considerations

Peers have intervened to promote health since ancient times, yet few attempts have been made to describe theoretically their role and their interventions. After a brief overview of the history and variety of peer-based health interventions, a 4-part definition of peer interveners is presented here with a consideration of the dimensions of their involvement in health promotion. Then, a 2-step process is proposed as a means of conceptualizing peer interventions to promote health. Step 1 involves establishing a theoretical framework for the intervention's main focus (i.e., education, social support, social norms, self-efficacy, and patient advocacy), and Step 2 involves identifying a theory that justifies the use of peers and might explain their impact. As examples, the following might be referred to: theoretical perspectives from the mutual support group and self-help literature, social cognitive and social learning theories, the social support literature, social comparison theory, social network approaches, and empowerment models.

Peer interventions to promote health: conceptual considerations

Peers have intervened to promote health since ancient times, yet few attempts have been made to describe theoretically their role and their interventions. After a brief overview of the history and variety of peer-based health interventions, a 4-part definition of peer interveners is presented here with a consideration of the dimensions of their involvement in health promotion. Then, a 2-step process is proposed as a means of conceptualizing peer interventions to promote health. Step 1 involves establishing a theoretical framework for the intervention's main focus (i.e., education, social support, social norms, self-efficacy, and patient advocacy), and Step 2 involves identifying a theory that justifies the use of peers and might explain their impact. As examples, the following might be referred to: theoretical perspectives from the mutual support group and self-help literature, social cognitive and social learning theories, the social support literature, social comparison theory, social network approaches, and empowerment models.

Peer support for patients with type 2 diabetes: cluster randomised controlled trial

OBJECTIVE

To test the effectiveness of peer support for patients with type 2 diabetes.

DESIGN

Cluster randomised controlled.

SETTING

20 general practices in the east of the Republic of Ireland.

PARTICIPANTS

395 patients (192 in intervention group, 203 in control group) and 29 peer supporters with type 2 diabetes.

INTERVENTION

All practices introduced a standardised diabetes care system. The peer support intervention ran over a two year period and contained four elements: the recruitment and training of peer supporters, nine group meetings led by peer supporters in participant's own general practice, and a retention plan for the peer supporters.

MAIN OUTCOME MEASURES

HbA(1c); cholesterol concentration; systolic blood pressure; and wellbeing score.

RESULTS

There was no difference between intervention and control patients at baseline. All practices and 85% (337) of patients were followed up. At two year follow-up, there were no significant differences in HbA(1c) (mean difference -0.08%, 95% confidence interval -0.35% to 0.18%), systolic blood pressure (-3.9 mm Hg, -8.9 to 1.1 mm Hg), total cholesterol concentration (-0.03 mmol/L, -0.28 to 0.22 mmol/L), or wellbeing scores (-0.7, -2.3 to 0.8). While there was a trend towards decreases in the proportion of patients with poorly controlled risk factors at follow-up, particularly for systolic blood pressure (52% (87/166) >130 mm Hg in intervention v 61% (103/169) >130 mm Hg in control), these changes were not significant. The process evaluation indicated that the intervention was generally delivered as intended, though 18% (35) of patients in the intervention group never attended any group meetings.

CONCLUSIONS

A group based peer support intervention is feasible in general practice settings, but the intervention was not effective when targeted at all patients with type 2 diabetes. While there was a trend towards improvements of clinical outcomes, the results do not support the widespread adoption of peer support. Trial registration Current Controlled Trials ISRCTN42541690.

Experiences in peer-to-peer training in diabetes mellitus: challenges and implications

This paper briefly describes the functions of peer advisers in diabetes (PADs) and their training. The formal process used in the assessment of the peer advisers at the completion of the training courses is also stated. The findings of a recent randomized controlled trial to study the effectiveness of peer advisers in delivering a programme of education on self-management are also described. The experience gained after the completion of four courses for the training of peer advisers, in addition to a review of the literature, forms the basis for discussion of the subject of peer-to-peer support activities in diabetes. PADs are effective in the provision of one-to-one psychosocial support and advice on self-management. They are also effective as committee members and advocates for diabetes. More recently, they have been shown to be effective as teachers on self-management to their peers with diabetes. With the imminent explosion in the number of people with diabetes, there will be increased need for psychosocial support and in the requirement for the provision of education on self-management. It is unlikely that health services would be given sufficient resources to cope with this. Society should identify alternative resources. People with diabetes and their close carers are the obvious choice, and we need to commence their training now. The implications for primary care are discussed.

Can peer educators influence healthy eating in people with diabetes? Results of a randomized controlled trial

AIMS

To assess whether the Expert Patient Programme (EPP), adapted for people with Type 2 diabetes, can be used to promote healthy eating to improve glycaemic control.

METHODS

Adults with Type 2 diabetes (n = 317) were randomized to receive either a diabetes-specific EPP (n = 162) or individual one-off appointments with a dietitian (control group) (n = 155). The diabetes-specific EPP followed the standard National Health Service programme although all participants in the group had diabetes only, rather than a mix of chronic conditions. Participants attended a group session for 2 h once per week for 6 weeks. In addition, a final seventh-week 2-h session was included that was specific to issues concerning diabetes. Outcomes were assessed at baseline, 6 and 12 months.

RESULTS

There were no statistically significant differences between the control and the intervention group in any of the clinical outcomes measured. There was no significant difference between the groups in any dietary outcome. There was a higher starch intake in the EPP group, although this did not reach statistical significance (effect size for starch adjusted for baseline values 8.8 g; 95% CI -1.3 to 18.9). There was some loss of participants between baseline measurement and randomization, although this did not appear to have had an important impact on baseline balance.

CONCLUSIONS

In this study of people with Type 2 diabetes, the EPP approach was not effective in changing measures of diabetes control or diet.