Peer Support for Achieving Independence in Diabetes (Peer-AID): design, methods and baseline characteristics of a randomized controlled trial of community health worker assisted diabetes self-management support

Examining Barriers to Rehabilitation and Addressing Rehabilitation Needs among Persons with Forced Migration Experiences: Interdisciplinary Perspectives

Globally, human displacement is at a record high. According to the United Nations High Commissioner for Refugees, 110 million people have been forcibly displaced worldwide due to persecution, mass conflict, or human rights violations. Conflicts continue to rage in different part of the world such as Ukraine, Palestine, Sudan, and Tigray. Large-scale political upheaval is also on the rise in many countries including Haiti, Venezuela, and Iran among others. Natural disasters fueled by climate change will further contribute to large-scale forced migration. Persons with forced migration experiences (PFME) tend to have significant rehabilitation needs due to high risk of physical injuries, mental trauma, and exacerbation of pre-existing health problems during displacement. Rehabilitation practitioners in host countries must be well equipped to address the complex needs of this population. However, there is currently limited literature to guide best practice. In this paper, a group of interdisciplinary professionals examine rehabilitation needs among PFME, provide examples of established and emerging rehabilitation interventions with PFME in the context of asylum and resettlement, identify barriers to accessing rehabilitation services in host countries, and propose avenues for professional advocacy in this area.

Effectiveness of self-management interventions for long-term conditions in people experiencing socio-economic deprivation in high-income countries: a systematic review and meta-analysis

BACKGROUND

Long-term conditions (LTCs) are prevalent in socio-economically deprived populations. Self-management interventions can improve health outcomes, but socio-economically deprived groups have lower participation in them, with potentially lower effectiveness. This review explored whether self-management interventions delivered to people experiencing socio-economic deprivation improve outcomes.

METHODS

We searched databases up to November 2022 for randomized trials. We screened, extracted data and assessed the quality of these studies using Cochrane Risk of Bias 2 (RoB2). We narratively synthesized all studies and performed a meta-analysis on eligible articles. We assessed the certainty of evidence using GRADE for articles included in the meta-analysis.

RESULTS

The 51 studies included in this review had mixed findings. For the diabetes meta-analysis, there was a statistically significant pooled reduction in haemoglobin A1c (-0.29%). We had moderate certainty in the evidence. Thirty-eight of the study interventions had specific tailoring for socio-economically deprived populations, including adaptions for low literacy and financial incentives. Each intervention had an average of four self-management components.

CONCLUSIONS

Self-management interventions for socio-economically deprived populations show promise, though more evidence is needed. Our review suggests that the number of self-management components may not be important. With the increasing emphasis on self-management, to avoid exacerbating health inequalities, interventions should include tailoring for socio-economically deprived individuals.

Improvements in physical activity and some dietary behaviors in a community health worker-led diabetes self-management intervention for adults with low incomes: results from a randomized controlled trial

People with low incomes have a disproportionate prevalence of diabetes and its complications and experience many barriers to self-management, which community health workers (CHWs) may help address. We sought to examine the effects of an in-home CHW-led intervention for adults with diabetes and incomes <250% of the federal poverty line on self-management behaviors and test mediators and moderators. From 2010 to 2013, we randomized participants from three Washington State health systems with type 2 diabetes and hemoglobin A1c (HbA1c) ≥ 8% to the CHW intervention (N = 145) or usual care control (N = 142) arms. We examined effects on 12-month self-management: physical activity, dietary behaviors, medication taking, blood glucose monitoring, foot care, and tobacco use. For behaviors with significant intervention-control group differences, we tested mediation by self-efficacy and social support. We also investigated whether intervention-associated changes in behaviors varied by race/ethnicity, gender, and baseline values of HbA1c, diabetes distress, depression, and food insecurity (moderators). Compared to controls, intervention participants engaged in more physical activity and reported better dietary behaviors for some measures (general diet, frequency of skipping meals, and frequency of eating out) at 12-months, but there was no evidence of mediation by self-efficacy or social support. Evidence of moderation was limited: improvements in the frequency of skipping meals were restricted to participants with baseline HbA1c < 10%. Study findings suggest CHWs could be integrated into diabetes care to effectively support lifestyle changes around physical activity and some eating behaviors among adults with low incomes. More research is needed to understand mechanisms of change.

The Value of Community Health Workers in Diabetes Management in Low-Income Populations: A Qualitative Study

To describe community health workers (CHWs) roles in a diabetes self-management intervention. Retrospective qualitative inductive analysis of open text home visit encounter form from Peer Support for Achieving Independence in Diabetes (Peer AID), a randomized controlled trial in which low-income individuals with poorly controlled diabetes received either CHW home visits or usual care. Following visits, CHWs completed encounter forms documenting the health goal of the visit, the self-management strategies discussed and participant concerns. 634 encounter reports were completed for the 145 intervention participants. CHW notes revealed three main obstacles to optimal disease control: gaps in diabetes knowledge and self-management skills; socioeconomic conditions; and the complexity of the healthcare system. CHWs helped participants overcome these obstacles through extensive, hands-on education, connecting participants to community resources, and assistance navigating the medical system. In addition, the CHWs offered uncomplicated accessibility and availability to their clients. CHWs can be a valuable asset for low-income patients with chronic health conditions who may require more support than what can provided in a typical primary care visit.

Associations between having an informal caregiver, social support, and self-care among low-income adults with poorly controlled diabetes

Objective To determine whether the presence of an informal caregiver and the patient's level of social support are associated with better diabetes self-care among adults with poorly controlled diabetes. Methods Cross-sectional study using baseline data from 253 adults of age 30-70 with poorly controlled diabetes. Participants who reported receiving assistance with their diabetes from a friend or family member in the past month were classified as having a caregiver. We used multivariate linear and logistic regression models to evaluate the associations between having a caregiver and level of social support with five self-reported diabetes self-care behaviors: diet, foot checks, blood glucose monitoring, medications, and physical activity. Results Compared to participants with no informal caregiver, those with an informal caregiver were significantly more likely to report moderate or high medication adherence (OR = 1.93, 95% CI: 1.07-3.49, p = 0.028). When we included social support in the model, having a caregiver was no longer significantly associated with medication adherence (OR = 1.50, 95% CI: 0.80-2.82), but social support score was (OR = 1.22, 95% CI: 1.03-1.45, p = 0.023). Discussion Among low-income adults with poorly controlled diabetes, having both an informal caregiver and high social support for diabetes may have a beneficial effect on medication adherence, a key self-care target to improve diabetes control.

Training peers to support older people with chronic low back pain following physiotherapy discharge: a feasibility study

OBJECTIVE

To determine the feasibility and acceptability of a training programme for peer volunteers to support older adults with chronic low back pain (CLBP) following discharge from physiotherapy.

DESIGN

Feasibility study.

SETTING

Community-based.

PARTICIPANTS

17 adults (4 male, 13 female) with CLBP or experience of supporting someone with CLBP enrolled and 12 (2 male, 10 female) completed the volunteer training.

INTERVENTION

Volunteers took part in a face-to-face or blended delivery peer support training programme based on the Mental Health Foundation's "Principles into Practice" and adapted for CLBP by the study team.

MAIN OUTCOME MEASURES

Recruitment/retention rates; demographics; time & resources used to deliver training; training evaluation (questionnaire); knowledge questionnaire, and self-efficacy questionnaire.

RESULTS

17 participants enrolled on the training programme (11 face-to-face, 6 blended delivery). 12 (71%) completed the training (73% face-to-face, 67% blended delivery). The training was positively evaluated. All but two participants passed the knowledge quiz at the end of the training, and the majority of self-efficacy scores (90%) were high.

CONCLUSIONS

It is feasible to develop, implement and evaluate a peer support training programme for the facilitation of CLBP self-management in older adults following discharge from physiotherapy. Blended delivery of training may facilitate the recruitment of greater numbers of peer support volunteers in future studies. Supported self-management of CLBP pain is widely recommended but can be difficult to achieve. Peer support might be a promising method of facilitating CLBP self-management without additional burden to health services, and should be further evaluated in a larger study.

Randomized Controlled Trial of a Community Health Worker Self-Management Support Intervention Among Low-Income Adults With Diabetes, Seattle, Washington, 2010-2014

Introduction

Community health workers (CHWs) can improve diabetes outcomes; however, questions remain about translating research findings into practical low-intensity models for safety-net providers. We tested the effectiveness of a home-based low-intensity CHW intervention for improving health outcomes among low-income adults with diabetes.

Methods

Low-income patients with glycated hemoglobin A_1c (HbA_1c) of 8.0% or higher in the 12 months before enrollment from 3 safety-net providers were randomized to a 12-month CHW-delivered diabetes self-management intervention or usual care. CHWs were based at a local health department. The primary outcome was change in HbA_1c from baseline enrollment to 12 months; secondary outcomes included blood pressure and lipid levels, quality of life, and health care use.

Results

The change in HbA_1c in the intervention group (n = 145) (unadjusted mean of 9.09% to 8.58%, change of −0.51) compared with the control group (n = 142) (9.04% to 8.71%, change of −0.33) was not significant (P = .54). In an analysis of participants with poor glycemic control (HbA_1c >10%), the intervention group had a 1.23-point greater decrease in HbA_1c compared with controls (P = .046). For the entire study population, we found a decrease in reported physician visits (P < .001) and no improvement in health-related quality of life (P = .07) in the intervention group compared with the control group.

Conclusion

A low-intensity CHW-delivered intervention to support diabetes self-management did not significantly improve HbA_1c relative to usual care. Among the subgroup of participants with poor glycemic control (HbA_1c >10% at baseline), the intervention was effective.

Self management interventions for type 2 diabetes in adult people with severe mental illness

BACKGROUND

People with severe mental illness are twice as likely to develop type 2 diabetes as those without severe mental illness. Treatment guidelines for type 2 diabetes recommend that structured education should be integrated into routine care and should be offered to all. However, for people with severe mental illness, physical health may be a low priority, and motivation to change may be limited. These additional challenges mean that the findings reported in previous systematic reviews of diabetes self management interventions may not be generalised to those with severe mental illness, and that tailored approaches to effective diabetes education may be required for this population.

OBJECTIVES

To assess the effects of diabetes self management interventions specifically tailored for people with type 2 diabetes and severe mental illness.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, EMBASE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the International Clinical Trials Registry Platform (ICTRP) Search Portal, ClinicalTrials.gov and grey literature. The date of the last search of all databases was 07 March 2016.

SELECTION CRITERIA

Randomised controlled trials of diabetes self management interventions for people with type 2 diabetes and severe mental illness.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts and full-text articles, extracted data and conducted the risk of bias assessment. We used a taxonomy of behaviour change techniques and the framework for behaviour change theory to describe the theoretical basis of the interventions and active ingredients. We used the GRADE method (Grades of Recommendation, Assessment, Development and Evaluation Working Group) to assess trials for overall quality of evidence.

MAIN RESULTS

We included one randomised controlled trial involving 64 participants with schizophrenia or schizoaffective disorder. The average age of participants was 54 years; participants had been living with type 2 diabetes for on average nine years, and with their psychiatric diagnosis since they were on average 28 years of age. Investigators evaluated the 24-week Diabetes Awareness and Rehabilitation Training (DART) programme in comparison with usual care plus information (UCI). Follow-up after trial completion was six months. Risk of bias was mostly unclear but was high for selective reporting. Trial authors did not report on diabetes-related complications, all-cause mortality, adverse events, health-related quality of life nor socioeconomic effects. Twelve months of data on self care behaviours as measured by total energy expenditure showed a mean of 2148 kcal for DART and 1496 kcal for UCI (52 participants; very low-quality evidence), indicating no substantial improvement. The intervention did not have a substantial effect on glycosylated haemoglobin A1c (HbA1c) at 6 or 12 months of follow-up (12-month HbA1c data 7.9% for DART vs 6.9% for UCI; 52 participants; very low-quality evidence). Researchers noted small improvements in body mass index immediately after the intervention was provided and at six months, along with improved weight post intervention. Diabetes knowledge and self efficacy improved immediately following receipt of the intervention, and knowledge also at six months. The intervention did not improve blood pressure.

AUTHORS' CONCLUSIONS

Evidence is insufficient to show whether type 2 diabetes self management interventions for people with severe mental illness are effective in improving outcomes. Researchers must conduct additional trials to establish efficacy, and to identify the active ingredients in these interventions and the people most likely to benefit from them.

Promotora assisted depression care among predominately Hispanic patients with concurrent chronic illness: Public care system clinical trial design

Depression frequently negatively affects patient overall self-care and social stress management within United States safety net care systems. Rates of major depression are significantly high among low-income predominantly Hispanic/Latino with chronic illness, such as diabetes and heart disease. The study design of the A Helping Hand to Activate Patient-Centered Depression Care among Low-income Patients (AHH) randomized clinical trial aims to enhance patient depression care receipt and overall bio-psychosocial self-care management. The AHH trial is conducted in collaboration with three Los Angeles County Department of Health Services (DHS) safety net clinics that provide Patient-Centered Medical Home (PCMH) care. The study compares AHH intervention (AHH) in which community-based bilingual promotoras provide in-person or telephone patient engagement and intervention aimed to reduce the burden and strain on patients, families, and care providers by assessing, enhancing, and facilitating patient depression and co-morbid illness self-care management skill, and activating patient communication with clinic medical providers versus DHS PCMH team usual care (PCMHUC). AHH independent bilingual recruiters screened 1957 and enrolled 348 predominantly Hispanic/Latino patients, of whom 296 (85%) had diabetes, 14 (4%) with heart disease, and 38 (11%) with both diseases. Recruiters identified depressed patients by baseline Patient Health Questionnaire-9 scores of 10 or more, completed baseline assessments, and randomized patients to either AHH or PCMHUC study group. The comprehensive assessments will be repeated at 6 and 12months by an independent bilingual follow-up interviewer. Baseline and outcome data include mental health assessment and treatment receipt, co-morbid illness self-care, social relationships, and environmental stressor assessments.

The Relationship Between Food Insecurity and Depression, Diabetes Distress and Medication Adherence Among Low-Income Patients with Poorly-Controlled Diabetes

BACKGROUND

Food insecurity- lack of dependable access to adequate food-may play a role in poor diabetes control.

OBJECTIVE

We aimed to determine the relationship between food security status and depression, diabetes distress, medication adherence and glycemic control.

DESIGN

Secondary analysis of baseline data from Peer Support for Achieving Independence in Diabetes, a randomized controlled trial that enrolled patients from November 2011 to October 2013.

PARTICIPANTS

Participants had poorly controlled type 2 diabetes (A1c ≥ 8.0 % on eligibility screen), household income < 250 % of the federal poverty level, were 30-70 years old, and were recruited from a large public hospital, a VA medical center and a community-health center in King County, Washington.

MAIN MEASURES

We measured food insecurity determined by the Department of Agriculture's 6-Item Food Security Module. Depression, diabetes distress and medication adherence measured by PHQ-8, Diabetes Distress Scale and Morisky Medication Adherence Scale, respectively. Diet was assessed through Summary of Diabetes Self-Care Activities and Starting the Conversation tool. Incidence of hypoglycemic episodes was by patient report. Glycemic control was assessed with glycosylated hemoglobin (A1c) values from fingerstick blood sample.

KEY RESULTS

The prevalence of food insecurity was 47.4 %. Chi-square tests revealed participants with food insecurity were more likely to be depressed (40.7 % vs. 15.4 %, p < 0.001), report diabetes distress (55.2 % vs. 33.8 %, p < 0.001) and have low medication adherence (52.9 % vs. 37.2 %, p = 0.02). Based on linear regression modeling, those with food insecurity had significantly higher mean A1c levels (β = 0.51; p = 0.02) after adjusting for sex, age, race/ethnicity, language, education, marital status, BMI, insulin use, depression, diabetes distress and low medication adherence.

CONCLUSIONS

Almost half of participants had food insecurity. Food insecurity was associated with depression, diabetes distress, low medication adherence and worse glycemic control. Even with adjustment, people with food insecurity had higher mean A1c levels than their food-secure counterparts, suggesting there may be other mediating factors, such as diet, that explain the relationship between food security status and diabetes control.

Puentes hacia una mejor vida (Bridges to a Better Life): Outcome of a Diabetes Control Peer Support Intervention

PURPOSE

Peer support can promote diabetes control, yet research on feasible and effective peer support models is lacking. This randomized controlled trial tested a volunteer-based model of peer support for diabetes control.

METHODS

Thirty-four volunteer peer leaders were recruited and trained to provide support to 5 to 8 patients each through telephone contact, in-person, individual, and group support. Planned dose was 8 contacts, preferably in the first 6 months. Patients with uncontrolled diabetes were randomly sampled from the medical records of 3 community clinics. After a baseline interview and medical records review to obtain baseline values for the primary outcome, HbA1c, 336 patient participants were randomly assigned to a 12-month peer support intervention or usual care. The assessment protocol was repeated at 6 and 12 months after baseline.

RESULTS

Thirty peer leaders delivered an average of 4 contacts each per assigned participant (range 1-24). Despite the lack of intervention fidelity, the intervention was effective at reducing glycated hemoglobin (HbA1c) among intervention as compared with usual care participants (P=0.05). Similar trends were observed in frequency of meeting fruit and vegetable guidelines (P =0.09), a secondary outcome. Counterintuitively, usual care participants reported checking their feet more days out of 7 than intervention participants (P =0.03).

CONCLUSIONS

Given the modest changes we observed, combined with other evidence for peer support to promote diabetes control, additional research is needed on how to modify the system of care to increase the level of peer support delivered by volunteers.

Community Health Worker Interventions to Improve Glycemic Control in People with Diabetes: A Systematic Review and Meta-Analysis

OBJECTIVES

We set out to review the efficacy of Community Health Worker (CHW) interventions to improve glycemia in people with diabetes.

METHODS

Data sources included the Cochrane Central Register of Controlled Trials, Medline, clinicaltrials.gov, Google Scholar, and reference lists of previous publications. We reviewed randomized controlled trials (RCTs) that assessed the efficacy of CHW interventions, as compared to usual care, to lower hemoglobin A1c (A1c). Two investigators independently reviewed the RCTs and assessed their quality. Only RCTs with a follow-up of at least 12 months were meta-analyzed. A random effects model was used to estimate, from unadjusted within-group mean reductions, the standardized mean difference (SMD) in A1c achieved by the CHW intervention, beyond usual care.

RESULTS

Thirteen RCTs were included in the narrative review, and nine of them, which had at least 12 months of follow-up, were included in the meta-analysis. Publication bias could not be ruled-out due to the small number of trials. Outcome heterogeneity was moderate (I(2)= 37%). The SMD in A1c (95% confidence interval) was 0.21 (0.11-0.32). Meta-regression showed an association between higher baseline A1c and a larger effect size.

CONCLUSIONS

CHW interventions showed a modest reduction in A1c compared to usual care. A1c reduction was larger in studies with higher mean baseline A1c. Caution is warranted, given the small number of studies.