Peer Coaches to Improve Diabetes Outcomes in Rural Alabama: A Cluster Randomized Trial

Abstract

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.

Contributions of Peer Support to Health, Health Care, and Prevention: Papers from Peers for Progress

“…The paper by Safford and colleagues shows significant stabilization of cardiovascular risk factors over time for participants receiving peer support compared to controls among African American residents of rural Alabama, an area of great poverty and poorly organized clinical care. 33 Tang and her colleagues have focused on peer support as a way of helping to sustain gains from diabetes self-management education. In an earlier paper concerning peer support for Latinos with diabetes, they showed that both staff community health workers and trained volunteer peer supporters were successful in this.…”

“…Safford and Richman and their colleagues in Alabama have explored the importance of seasonality and changes over time. In addition to applying these perspectives in analyzing their intervention, noted above, 33 Richman has led additional work to outline analytic approaches that accommodate the seasonal and nonlinear, dynamic characteristics of diabetes as well as research challenges common in real world settings such as variability of time between baseline and follow-up measures and secular trends. 40 Peer support and other community-focused interventions, especially those intending to reach populations that more conventional approaches fail to engage, raise a number of ethical issues, including confidentiality and informed consent.…”

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

“…22,25,29,[31][32][33][34] The pooled effect in the subgroup of 3 studies with predominantly African American participants showed a similar effect size to that seen in the Hispanic subgroup but was not statistically significant, with an SMD of 0.25 (95% CI, -0.064 to 0.571; P = .11; I 2 = 58.60%). 23,24,28 The differences in effect sizes between ethnicity subgroups were statistically significant, with a between-group P value of .03. Considering together the 7 studies with predominantly minority participants (belonging to minority culture in the country of residence), the pooled effect showed a clinically relevant improvement in HbA 1c level with peer support interventions, with an SMD of 0.266 (95% CI, 0.163-0.369; P <.001; I 2 = 9.24%), which translates to improvement in HbA 1c level of 0.53% (95% CI, 0.32%-0.73%) (Figure 4).…”

“…20 Ultimately, 14 articles with RCT designs and 3 cluster RCTs were eligible for inclusion in the meta-analysis, for a total of 4,715 participants. Of the 17 trials, 10 were done in the United States, [21][22][23][24][25][26][27][28][29][30] …”

Challenges of Prolonged Follow-up and Temporal Imbalance in Pragmatic Trials: Analysis of the ENCOURAGE Trial

“…The design of the study has been described in detail elsewhere. 1 Main study outcomes were changes in glycated hemoglobin (HbA 1c ), body mass index (BMI), cholesterol, blood pressure, diabetes distress, quality of life, and patient activation.…”