PURPOSE It is unclear whether peer coaching is effective in minority populations living with diabetes in hard-to-reach, under-resourced areas such as the rural South. We examined the effect of an innovative peer-coaching intervention plus brief education vs brief education alone on diabetes outcomes. METHODSThis was a community-engaged, cluster-randomized, controlled trial with primary care practices and their surrounding communities serving as clusters. The trial enrolled 424 participants, with 360 completing baseline and follow-up data collection (84.9% retention). The primary outcomes were change in glycated hemoglobin (HbA 1c ), systolic blood pressure (BP), low density lipoprotein cholesterol (LDL-C), body mass index (BMI), and quality of life, with diabetes distress and patient activation as secondary outcomes. Peer coaches were trained for 2 days in community settings; the training emphasized motivational interviewing skills, diabetes basics, and goal setting. All participants received a 1-hour diabetes education class and a personalized diabetes report card at baseline. Intervention arm participants were also paired with peer coaches; the protocol called for telephone interactions weekly for the first 8 weeks, then monthly for a total of 10 months.RESULTS Due to real-world constraints, follow-up was protracted, and intervention effects varied over time. The analysis that included the 68% of participants followed up by 15 months showed only a significant increase in patient activation in the intervention group. The analysis that included all participants who eventually completed follow-up revealed that intervention arm participants had significant differences in changes in systolic BP (P = .047), BMI (P = .02), quality of life (P = .003), diabetes distress (P = .004), and patient activation (P = .03), but not in HbA 1c (P = .14) or LDL-C (P = .97).CONCLUSION Telephone-delivered peer coaching holds promise to improve health for individuals with diabetes living in under-resourced areas.

IntroductionUsing generic medications for chronic diseases provides efficacy similar to that of brand-name medication use, but at a lower price, potentially enhancing adherence. However, previous studies show that disadvantaged people, who may particularly benefit from cost savings, have low trust of generics and increased reluctance to switch to generics. The rural South includes areas of high poverty and minority communities whose members are at high risk for poor health outcomes; however, whether such beliefs exist in these communities has not been reported. We sought to obtain qualitative insight into beliefs about generic medication use among African Americans in the rural South.MethodsInvestigators conducted 4 focus groups with 30 community members from Alabama’s Black Belt area. Transcribed discussions were analyzed and common themes identified.ResultsParticipants were primarily unemployed middle-aged women, one-fourth of whom were uninsured and more than half of whom had a high school education or less. Barriers to generic medication use included perceptions that generics are less potent than brand-name medications, require higher doses, and, therefore, result in more side effects; generics are not “real” medicine; generics are for minor but not serious illnesses; the medical system cannot be trusted; and poor people are forced to “settle” for generics.ConclusionAlthough education about generics could rectify misinformation, overcoming views such as mistrust of the medical system and the sense of having to settle for generics because of poverty may be more challenging. Policy makers and providers should consider these perspectives when working to increase generic drug use in these populations.

No abstract

IntroductionPeer support is a promising strategy for the reduction of diabetes-related health disparities; however, few studies describe the development of such strategies in enough detail to allow for replication. The objective of this article is to describe the development of a 1-year peer support intervention to improve diabetes self-management among African American adults with diabetes in Alabama's Black Belt.MethodsWe used principles of intervention mapping, including literature review, interviews with key informants, and a discussion group with community health workers, to guide intervention development. Qualitative data were combined with behavioral constructs and principles of diabetes self-management to create a peer support intervention to be delivered by trained peer advisors. Feedback from a 1-month pilot was used to modify the training and intervention.ResultsThe resulting intervention includes a 2-day training for peer advisors, who were each paired with 3 to 6 clients. A one-on-one in-person needs assessment begins an intensive intervention phase conducted via telephone for 8 to 12 weeks, followed by a maintenance phase of at least once monthly contacts for the remainder of the intervention period. A peer support network and process measures collected monthly throughout the study supplement formal data collection points at baseline, 6 months, and 12 months.DiscussionIntervention mapping provided a useful framework for the development of culturally relevant diabetes peer support intervention for African Americans living in Alabama's Black Belt. The process described could be implemented by others in public health to develop or adapt programs suitable for their particular community or context.

PURPOSE Cognitive behavioral therapy (CBT)-based programs delivered by trained community members could improve functioning and pain in individuals who lack access to such programs. We tested the effectiveness of a peer-delivered diabetes self-management program integrating CBT principles in improving physical activity, functional status, pain, quality of life (QOL), and health outcomes in individuals with diabetes and chronic pain. METHODSIn this community-based, cluster-randomized controlled trial, intervention participants received a 3-month, peer-delivered, telephone-administered program. Attention control participants received a peer-delivered general health advice program. Outcomes were changes in functional status and pain (Western Ontario and McMaster Universities Osteoarthritis Index), QOL (Short Form 12), and physiologic measures (hemoglobin A 1c , systolic blood pressure, body mass index); physical activity was the explanatory outcome. RESULTSOf 195 participants with follow-up data, 80% were women, 96% African Americans, 74% had annual income <$20,000, and 64% had high school education or less. At follow-up, compared with controls, intervention participants had greater improvement in functional status (-10 ± 13 vs -5 ± 18, P = .002), pain (-10.5 ± 19 vs -4.8 ± 21, P = .01), and QOL (4.8 ± 8.8 vs 3.8 ± 8.8, P = .001). Physiologic measures did not change significantly in either group. At 3 months, a greater proportion of intervention than control participants reported no pain or did other forms of exercise when pain prevented them from walking for exercise. CONCLUSION This peer-delivered CBT-based intervention improved functioning, pain, QOL, and self-reported physical activity despite pain in individuals with diabetes and chronic pain. Trained community members can deliver effective CBTbased interventions in rural and under-resourced communities.