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A peer support intervention in improving glycemic control in patients with type 2 diabetes
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Patient Education and Counseling xxx (2017) xxx–xxx
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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Research Paper
A peer support intervention in improving glycemic control in patients with type 2 diabetes Maryam Peimania , Fateme Monjazebib , Robabeh Ghodssi-Ghassemabadic , Ensieh Nasli-Esfahanic,* a
Department of Health Education & Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran c Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 24 May 2017 Received in revised form 18 September 2017 Accepted 10 October 2017
Objective: This study aims to assess the effectiveness of a peer support intervention, in which patients with T2DM were provided ongoing self-management support by trained peers with diabetes directed at improving self-care behaviors, self-efficacy and life quality. Methods: In this randomized controlled trial, 200 patients referred to a diabetes specialty clinic were allocated to peer support or control group. Participants in both groups received usual education by diabetes educators. Intervention participants worked with the trained volunteer peers who encouraged participants to engage in daily self-management and to discuss and share their experiences and challenges of diabetes management. The primary outcomes were HbA1c, BMI, self-care behaviors, self-efficacy and life quality Results: After 6 months, patients in the peer support group experienced a significant decline in mean A1c value (P = 0.045). Also, mean diabetes self-management scores, mean self-efficacy scores and mean quality of life scores significantly improved in peer support group compared to control group (P values <0.001). Conclusion: Peer support activities can be successfully applied in diabetes self-management, especially in areas with a shortage of professionals and economic resources. Practice implications: Peer support strategies should be integrated into our healthcare system to meet minimum needs of people with T2DM in Iran. © 2017 Elsevier B.V. All rights reserved.
Keywords: Peer support Diabetes type 2 Self-management Patient education
1. Introduction At a global level, type 2 diabetes mellitus (T2DM) is one of the major challenges facing health authorities and societies because of the increasing care costs and the associated impaired quality of life due to the development of chronic complications [1,2]. A recent retrospective study shows that the direct medical cost of diabetes management has progressed sharply during the past years in Iran [3]. Although strict control of blood glucose could significantly reduce the risk of chronic complications development [4,5], such control is difficult to accomplish and the care provided to patients remains far from satisfactory levels [6]. In this regard, an Iranian
* Corresponding author at: Endocrinology and Metabolism Research Institute, North Kargar Ave., 1411713137, Iran. E-mail address: [email protected] (E. Nasli-Esfahani).
survey revealed that more than 50% of elderly people with T2DM had uncontrolled status [7]. In addition, poor adherence to self-care activities is one of the main obstacles to optimal care. Research during the past several decades indicates that, up to 40% of people diagnosed with T2DM fail to adhere to treatment recommendations and lifestyle modifications due to psychological and psychosocial issues as well as the complexity of the regimens required [8]. As a result, educational programs tailored to individual patient needs, individual feedback and presence of psychological support can play a key role in improving adherence to the treatment, and predicting favorable outcomes of the disease [9,10]. However, there exist some challenges with the current practices used [11]. Physicians and staff often do not have the time or resources to provide sufficient support for patient self-management during routine visits. The time allotted for an outpatient visit is often inadequate to address all of the questions that a patient may have about self-care [12]. Moreover, effective self-management support
https://doi.org/10.1016/j.pec.2017.10.007 0738-3991/© 2017 Elsevier B.V. All rights reserved.
Please cite this article in press as: M. Peimani, et al., A peer support intervention in improving glycemic control in patients with type 2 diabetes, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.10.007
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needs to be provided on a long-term basis, which again requires personnel and resources that healthcare systems do not have. Considering such circumstances, peer support, which enables patients to connect to others who have had similar experiences, has been suggested as a reasonable approach to address this issue. Peer support programs are a promising way to boost social and emotional support, help patients in day-to-day management of living with diabetes and promote linkages to clinical care [13,14]. During the past few years, multiple review studies have been conducted about the role of peer support in diabetes selfmanagement [11,12,15,16]. These reviews identified that a growing body of literature demonstrates the value of peer models for diabetes management, but also pointed out that further research is needed. There is still much to learn about organizing effective peer support interventions, determining best types of programs for different types of patients, integrating peer interventions into other clinical services and so on [13]. Additionally, in a recent update of standards of medical care in diabetes by the American Diabetes Association has been emphasized on addressing cultural differences and socioeconomic conditions as a way to improve the effectiveness of educational strategies in diabetes care [17]. However, previous studies propose that peer support interventions have not provided robust evidence for its utility across cultures [18]. Therefore, due to differences in lifestyle behaviors and cultural aspects, we conducted the present study to assess the feasibility and effectiveness of a peer support intervention in which patients with T2DM were provided ongoing self-management support by trained peers with diabetes, with the aim of improving and sustaining self-care behaviors, self-efficacy beliefs, and life quality for a 6 months follow-up.
monitoring and the importance of patients’ active participation in their plan of care). In the second session, main focus was on increasing patients’ awareness of the importance of a healthy diet and weight reduction. The third session explained health benefits of regular physical activity and exercise. And finally, during the fourth session, they were taught how to manage the ABCs of diabetes (HbA1c, Blood pressure, Cholesterol). Illustrated educational materials and virtual clinic website address which offered additional resources to study were given to each participant. At the final session, participants were randomly allocated to either peer support group (n = 100) or control group (n = 100) using permuted block randomization technique, with block size of two. Fig. 1 is a CONSORT diagram of the study design. The sample size was calculated based on the difference of change in HbA1c from baseline to the end of the study between the two groups. Based on the results of a previous study [1], we expected an effect size of at least 0.4 in the HbA1c level, and accordingly a sample size of n = 94 in each study group was required, considering 0.05 for type two error and 80% power based on calculations performed with G-Power software. Thus, we recruited a total of 100 patients in each group. 2.2. Ethical approval As for ethical considerations, the research protocol was approved by the Medical Research Ethics Committee of the Tehran University of Medical Sciences. All participants were volunteers who provided written consent and knew that they could withdraw from the study at any time. 2.3. Recruiting peers
2. Methods 2.1. Study design and sample size This study investigated whether peer support intervention over a 6 month period improves self-care activities, reported selfefficacy, quality of life and clinical outcomes (HbA1c, BMI) in patients with T2DM. In this randomized controlled trial, 200 patients with T2DM were recruited through a diabetes specialty clinic of the Endocrinology and Metabolism Research Institute affiliated to Tehran University of Medical Sciences. All patients who come to this clinic are routinely under supervision of endocrinologists, dieticians, diabetes nurse educators and qualified psychologists if needed. In addition, all patients are registered and invited to participate in group education classes. Also patients are given access to a set of educational booklets and brochures and an educational website named diabetes virtual clinic (http://emri. tums.ac.ir/vclinic). In this study, patients referred to the clinic were screened for eligibility. The inclusion criteria were as follows: aged between 25 and 75 years, diagnosed with T2DM for more than 12 months, planned to continue receiving care at this clinic for next 6 months, and had access to a telephone. Patients were excluded if they had a current debilitating medical or related condition (e.g. severe mental illness, end-stage cancer, blindness, and inability to provide self-care). Potential participants were explained about the objectives and procedures of the study. Those who voluntarily accepted to participate in this study signed informed consent forms. At first, all participants in both groups received usual education including four weekly sessions (90 min each) by a credentialed diabetes educator as it is routine in the clinic. The first session included an overview of type 2 diabetes (symptoms of hyper and hypoglycemia, blood glucose self-
Recruiting enthusiastic and appropriate patients as peers was to some extent challenging. Overall, people are more likely to volunteer when asked by someone they know and trust. So, the physicians and diabetes educator nurses in the clinic were asked to nominate a list of 10 patients that they felt would be suitable for the role of peers according to the following criteria: Patients’ knowledge on the basis of excellent diabetes control (HbA1c < 8.5%). Patients with good interpersonal skills and qualities (e.g., patients who enjoy contact with others, personable). Patients who demonstrate flexibility, self-motivation and good problem-solving skills. Patients with good active and non-judgmental listening skills.
Fig. 1. Overview of recruitment, group allocation and data.
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Patients who have had type 2 diabetes. Patients who are able to read and write and attend a 3-day course. Sequential screening was implemented to minimize a potential high dropout rate in this study. So, once agreed by the physicians, potential peers were visited and interviewed by a member of research team who discussed the study goals with them and evaluated their interpersonal skills. If both thought it would be appropriate that they should enter the study, at this time, eligible participants were given time to think more about their participation in the study during the 2 weeks ahead. After this time, peers were asked to sign a consent form if they were willing to be in the study. Following recruitment, peers received a 3-day structured, buzzgroup interactive course developed and conducted by the study team. Table 1 presents a summary of the content of the course. Peers were asked to deploy the active listening and facilitating skills explored during the peers training program to engage with their group members and to support them in dealing with the daily vicissitudes of diabetes care. Moreover, peers were guided by a detailed manual that included outlines of each session with sample questions as a starting point for discussion. Peers were encouraged and asked to keep notes on challenges and questions they were facing. Throughout the study period, peers were supported through weekly phone calls from the members of research team. These
regular weekly phone supervisions, which usually lasted about 15– 20 min, included answering questions, discussing challenges, providing more support and reviewing of adherence to the program. Also research team was available for questions and supports 10 peers at all times. Venues and refreshments were provided by the study team as well. 2.4. Peer support intervention The study took place in a university specialty clinic in the city of Tehran in which people with diabetes receive state-of-the-art medical care, patient education, in addition to services for the prevention and management of complications. As mentioned before, the study included two different groups: peer support group and control group, both of which received usual clinic education. The intervention group (n = 100) was subdivided into ten groups, each comprising ten persons and randomly paired with one of the trained peers (n = 10) for the next six months. Each peer was asked to facilitate one group meeting each month during the same period. Participants were reminded by their peers to attend all of the scheduled monthly group sessions. In the first group session, the participants discussed their problems and concerns which had affected their adherence to the medications. In the second session, they discussed their views of the difficulties of complying with diabetic diet and perceptions about their obesity risk and weight control. In the third group
Table 1 Summary of peers training program. Topics
Learning Objectives
An introduction to the study
Understand the role of the peers in this study
Developing skills: Facilitation
Learn who is a facilitator and how to facilitate a meeting. Ground rules. Demonstrate facilitation skills, e.g. welcoming and making introductions (Ice Breakers), encouraging participation, sticking to the agenda, being flexible, summarizing the meeting results
Developing skills: Active listening
Learn how to become an active listener according to following steps:1. looking at the person, and stopping other things you are doing, 2. being sincerely interested in what the other person is talking about, 3. focusing on feelings and emotions, 4. asking open-ended questions (allowing the participant to tell their story), 5. making reflections (feelings and emotions), 6. being empathic and non-judgmental, 7. being aware of your own feelings and strong opinions, but avoiding conveying them. Demonstrate the skill of active listening.
Developing skills: Solving problems
Demonstrate the process of problem solving Identify strategies to stay motivated with self-management plan. Identify barriers to achieving self-management goals.
Providing emotional support
Identify diabetes specific coping skills (e.g., focusing on specific sticking points, active problem solving, persuasive communication). Identify the components of effective, compassionate communication (e.g., observations free of evaluations) Learn how to support patients using the principles of effective communication (e.g., providing support via gesture, building trust, listening, showing you care, and helping them work through their emotions and fears). Demonstrate a follow-up telephone call with a participant
Facilitating behavior changes and overcoming barriers to Demonstrate the process of self-assessment diabetes care Create a Life Plan for helping patients think about how they can take charge of their diabetes. Engage in self-reflection Describe a multi-step behavioral goal-setting strategy. Describe and demonstrate empowerment-based facilitation skills (e.g., helping participants learn from their experiences so that they can use similar strategies when making future changes). Building boundaries to diabetes management
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Learn and demonstrate, through role play, how to establish boundaries to their diabetes management with those close to them.
Dealing with difficult situations such as mild depression, Understand the different emotional experiences people with diabetes have. lack of confidence in self-care Identify effective coping strategies Practice mindful meditation Behave as a role-model Identify resources for support
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meeting, they discussed their common problems and possible solutions for being physically active and doing exercise. In the fourth session, discussion centred around the impacts of chronic illnesses like diabetes on family relationships and patients' expectations regarding compassion and support. The main focus of the fifth session was on patients' fears, worries and concerns about the future and living with diabetes and its chronic complications. And the last session was devoted to feelings of depression, hopelessness and anxiety in everyday self-care activities with the emphasis on the strategies for dealing with and overcoming these challenges. In each session, participants discussed and shared their experiences and challenges of diabetes management with each other (two by two) and with the group members and supported each other to set and achieve their goals. Peer encouraged all group members to speak and actively participate in discussions and did not allow participants go outside the mainstream of discussions. Peers were advised that group meetings should last up to 2 h. Since the presence of an observer was likely to influence both peers’ and patients’ behaviors, the research team did not attend the group meetings. In order to ensure meetings were conducted as planned, each of the six monthly meetings for each of the ten subgroups (in intervention group) was recorded and thus details of discussions and topics covered at each meeting were provided to the research team. After each group meeting, peers were requested to review the recordings of their monthly meeting based on the mentioned manual which reflected the content specified for that month so as to help them be better able to evaluate and identify their challenges and difficulties and to keep notes of them. In addition, the research team also reviewed the recordings of monthly meetings to find the strengths and weaknesses and discuss them with the peers during the phone calls. Peers had regular scheduled telephone contacts weekly with their 10 patients. The aim of these contacts, which were mostly unstructured and individualized, was to provide continuing social, emotional and behavioral support and to help the patients on how to apply their diabetes knowledge in everyday life based on the peer's personal experience and to discuss the practical issues arising from living with diabetes. Peers were allowed to make more contacts with their patients if needed. During the intervention, peers were provided with diaries in which they were requested to write the number of telephone contacts they had with each of their patients, and brief reports of the associated content and duration. It is noteworthy that the peers were given a prepaid cell phone to facilitate telephone peer communication and keep their personal contact details private.
2.5. Outcome measures Prior to the intervention, the participants’ demographic and clinical data was extracted and recorded as baseline levels. The data pertaining to self-care activities and self-efficacy was collected utilizing the following well-validated and reliable established questionnaires: Diabetes Self-Management Questionnaire (DSMQ) [19] and the Diabetes Management Self-Efficacy Scale (DMSES) [20]. Dimensions of health-related quality of life was measured through a questionnaire which was based on the Swedish Health-Related Quality of Life Survey (SWED-QUAL) [21]. This scale was translated into Farsi by Peimani et al. [22] and the content validity was determined by giving the questionnaire to 20 medical and nursing professionals for review. After gathering their opinions, the questionnaire was revised. The internal consistency was confirmed with a Cronbach alpha of 0.77 and Pearson correlation coefficient of 0.72. Outcome measurements were clinical measures (HbA1c levels and BMI), diabetes self-care activities, patients’ self-efficacy and quality of life. The HbA1c levels and BMI were measured and all the questionnaires were filled once again 6 months later. The Diabetes Self-Management Questionnaire consisted of 16 items with the main objective of investigating how patients had followed their diabetes treatment plan in the previous 8 weeks. Responses were rated on a four-point scale from “Never = 0” to “Very much = 3”. Subsequently, results were summed to produce a single score for self-care activities where higher scores indicated superior self-care. The Self-Efficacy Scale was comprised of 20 items that assessed the extent to which respondents were confident in certain competencies. Responses were ranked on a six-point scale of agreement, with“1 indicating strongly agree” to “6 demonstrating strongly disagree”. Responses were summed to create a score for self-efficacy, with lower scores indicating superior self-efficacy. The Health Related Quality Of Life questionnaire consisted of 53 items, which assessed various dimensions of quality of life including physical functioning and satisfaction with one's physical abilities (12 items), mental and emotional health (16 items), sleep problems (4 items) general health perception (10 items), satisfaction with family and social functioning (11 items). Responses were rated on a five-point scale from “Not at all = 1” to “Very much = 5”. The items scores were added and higher scores indicated superior quality of life. Total scores of each questionnaire (DSMQ, DMSES, HRQOL) were rescaled to a value of 0 to 100 for all participants. The original versions of DSMQ and DMSES questionnaires were first translated into Farsi and then back translated to English by
Table 2 Demographic characteristics of the study groups. Variables
Peer-Support group (n = 100)
Control group (n = 100)
P-value
Gender (Male/Female) Age (years) Diabetes Duration (years)
53/47 59.0 11.3 6. 7 6.63
51/49 58.8 11.7 6.5 7.41
0.85 0.91 0.27
Education Level Primary school education High school education Diploma and upper
33 (33%) 38 (38%) 29 (29%)
35 (35%) 35 (35%) 30 (30%)
0.52
Occupation Employee House Worker Retired Unemployed
24 25 29 22
22 27 27 24
0.28
(24%) (25%) (29%) (22%)
(22%) (27%) (27%) (24%)
Data are mean SD or number (%). No statistically significant differences were seen between two groups in terms of sex, age, duration of diabetes, occupation, and level of education.
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two independent bilingual translators. Then, an English literature PhD compared the back translated versions and the original versions of the questionnaires and recommended changes if needed. In order to conduct face validity, five experts were requested to comment on ambiguity of each questionnaires’ items and five well-educated patients were asked on how they understood the questions. Final Persian version of questionnaires were used after the implementation of these comments. The intraclass correlation was 0.92 and 0.89, and also the internal consistency with the Cronbach's alpha was 0.88 and 0.82 for DSMQ and DMSES scales, respectively. 2.6. Statistical analysis Descriptive statistics was used to summarize the sample characteristics; frequencies and percentages for categorical data, means and standard deviations for continuous data. The Chisquared test used for comparing categorical data between the two groups at baseline. In order to compare baseline characteristics of the two groups, independent sample t-test was used and differences between pre and post intervention measurements were tested by paired t-test. P-values of less than 0.05 were considered as significant. The data was analyzed by means of SPSS version 21. 3. Results 200 patients with T2DM were recruited for the study (100 patients in the intervention group and 100 patients in the control group), with a mean (SD) age of 60.2 12.1. Also 52% of the participants were male and 48% were female. Patients' characteristics are summarized in Table 2. 3.1. Differences in clinical outcomes(HbA1c, BMI) Table 3 shows the initial values at baseline and the changes in outcomes after six months. As shown, there were no significant
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differences in mean BMI (P = 0.859) and mean HbA1c levels (P = 0.670) between the two groups at baseline. Although peer support group experienced a decline in mean BMI during the study (28.11 vs 27.52), it was not statistically significant (P = 0.162). The mean BMI of the control group (28.35 vs 28.50 with P = 0.85) did not also differ significantly from the baseline value. No statistical significant difference was observed in the mean of BMI change between the two groups (P = 0.197). Although baseline mean HbA1c values were close to 7% in both groups, a marginally significant decrease was observed in the mean HbA1c value in the intervention group at the end of the study (7.29 vs 6.98 with P = 0.045). Also HbA1c changes were significantly different between two groups (P = 0.027). 3.2. Differences in diabetes self-management, self-efficacy and life quality The mean diabetes self-management, diabetes management self-efficacy and diabetes quality of life scores were calculated and compared with the pre-intervention scores. No differences were observed in self-management activities, self-efficacy and life quality mean scores between the two groups at the beginning of the study (Table 3). After the intervention, mean self-management activities score significantly increased in peer-support group (P < 0.001) while it significantly decreased in the control group (P < 0.001). A significant reduction was observed in mean diabetes management self-efficacy score (P < 0.001) in peer support group, whereas it significantly increased in the control group in comparison with the beginning of the study (P < 0.001). Also there was a significant increase in the mean score of quality of life in peer support group (P < 0.001) after the intervention. However, a significant decrease was observed in the mean score of patients’ quality of life in the control group (P < 0.001). Finally, at the end of the study period, diabetes self-management, self-efficacy and quality of life change scores differed significantly (all P values <0.001) between the two groups (Table 3).
Table 3 Effect of intervention on BMI, HbA1c, Diabetes self-management activities, Diabetes self-efficacy and Quality of life. Baseline (mean SD)
After 6 months (mean SD)
*
Diff (post-pre) (mean SD)
**
28.11 5.29 28.35 4.80 0.859
27.52 5.52 28.50 5.20
0.162 0.85
0.59 4.19 0.15 3.89
0.197
Glycosylated hemoglobin (%) Peer-Support group 7.29 1.33 Control group 7.47 1.49 P valuez 0.670
6.98 1.31 7.50 1.44
0.045 0.84
0.31 1.02 0.03 1.14
0.027
Diabetes Self-management Peer-Support group Control group P valuez
37.35 10.54 22.68 11.25
<0.001 <0.001
9.24 8.06 4.59 8.13
<0.001
Diabetes management self-efficacy Peer-Support group 60.40 12.90 Control group 61.95 11.86 P valuez 0.091
40.77 11.50 69.95 11.38
<0.001 <0.001
19.63 9.54 8 9.01
<0.001
Diabetes quality of life Peer-Support group Control group P valuez
198.75 26.5 132.50 18.50
<0.001 <0.001
48.41 19.02 15.9 14.35
<0.001
Variables
P-value
P value
2
Body mass index (kg/m ) Peer-Support group Control group P valuez
* ** z
28.11 10.26 27.27 9.13 0.890
150.34 20.49 148.40 18.55 0.749
P-value of paired t-test for comparison of pre and post measurements within each group. P-value of Independent sample t-test for comparison of change of responses between two groups. P-value of Independent sample t-test for comparison of baseline measures between two groups.
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4. Discussion and conclusion 4.1. Discussion More recently, peer support has been found to be a potential resource for diabetes self-management [15]. The most influential theoretical perspective on peer-based social support hypothesizes that support reduces the effects of stressful life events on the health outcomes of people with T2DM through supportive actions of others. Supportive actions are thought to enhance perception, coping performance and subsequent self-care behavior [23]. So this study was designed to assess whether a peer support intervention, based on social support theory, may result in improved diabetes care outcomes and subsequently improved quality of life in patients with T2DM. It is noteworthy that unlike the peer led educational interventions such as the Chronic Disease Self-Management Program (CDSMP) pioneered by Lorig et al. [24], the intervention in this study focused more on peer-based social support than education and was, in fact, in line with Peers for Progress, a global initiative developed by the American Academy of Family Physicians Foundation (AAFPF) [25]. So the usual comprehensive education by qualified diabetes educators was offered to all participants before the intervention. Our results demonstrated that HbA1c level reduced after the intervention and this reduction was significant (P = 0.045). Consistent with this study’s finding, Thom et al. in their study showed that after 6 months, HbA1c levels decreased by 1.07% in the coached group (P = 0.001) [26]. But what we are facing in comparison to their study is that baseline HbA1c values of our participants were close to 7%, whereas the baseline HbA1c values of their participants were close to 10% (poorly controlled diabetes). So this may reflect a more significant effect of the intervention in their study than ours. Besides, as mentioned earlier, relatively high-quality care is provided to all patients in this clinic and both intervention and control participants received comprehensive diabetes education, so there may have been little they needed that peer support could provide. In Heisler et al. study, the findings showed reciprocal peer support participants had a mean baseline HbA1c of 8.02%, which improved to 7.73% after six months (0.29%) compared to an average increase in HbA1c among nurse-care management participants (7.93 to 8.22 [SD 0.29]). The difference between the groups was 0.58% (P = 0.004) [27]. Another similar study reported that HbA1c values at six months were significantly lower in the peer group (P < 0.01) [1]. However, a study performed by Khodneva et al. demonstrated that there was no statistically significant effect of the peer support intervention on change in HbA1c [28] a finding different from the present study results. In this regards, some of the above-mentioned studies in their limitations noted that since they had chosen a group of underserved patients who had poorly controlled diabetes, they did not know to what extent their results would generalize to other populations such as middle class patients or patients with better diabetes control [26,27]. Therefore, due to baseline HbA1c levels of our participants, it can be concluded that the peer support intervention is associated with a significant improvement in glycemic control even in patients with a relatively good baseline control of their diabetes. In this study, patients’ mean scores in performing selfmanagement activities significantly increased in peer-support group (P < 0.001). Moreover, our results demonstrated that peer support intervention is significantly effective in promoting the sense of self-efficacy (P < 0.001) and subsequently the quality of life (P < 0.001). Comparable results were reported by Fisher et al. the global director of Peers for Progress, a global initiative by AAFPF as noted
earlier [29]. Peers for Progress selected four peer-support projects for diabetes management from Cameroon, South Africa, Thailand, and Uganda, in which project teams developed and then evaluated different peer support models for adults with diabetes during 6 months. Assistance in applying a diabetes management plan in daily life, social and emotional support to encourage the management of behavior and help patients deal with stress, linkage to clinical care and community resources, and ongoing support were key functions as a template for peer support models. The four projects’ self-evaluations documented both the feasibility and early impacts of peer support in addition to how each project modified the template of key functions to its own unique population and cultural concerns, and health care system. In Thailand and all three African countries, peer support interventions demonstrated to be feasible in varied settings, successful in involving their intended audiences and effective health behavior change, improving metabolic control and patients’ quality of life as well [25,29]. However, it should be noted that in most studies, nutrition behaviors and physical activity were the most frequently measured self-care behaviors, instead of evaluating self-care behaviors as a whole [30], as we did. Similar data regarding the effectiveness of peer support in improved diabetes knowledge, self-management behaviors, diabetes distress and quality of life were reported by Liu et al., who implemented an approach relatively similar to our own [31]. Also several previous studies showed that psychosocial outcomes leading to greater self-efficacy and higher quality of life were the most favorable findings of peer support interventions [27,32]. Although it can be concluded that based on the results of the prior studies and the findings of the current study, peer support interventions appear to have a positive impact on diabetes management outcomes, conclusions must be drawn with caution. There is still much to know about designing, implementing and evaluating different models of peer support to meet the needs of different populations in diverse settings [13]. In this sense, we combined monthly face-to-face group meetings, and telephonebased peer support so as to give participants opportunities to discuss their concerns and challenges with self-care activities with a peer. In doing so, weekly phone calls were a complement to peer-led group meetings to provide a source of ongoing support between scheduled monthly group meetings. Because in our country many people with T2DM need more support for self care than what now is provided by our health-care system, relatively novel models such as this can not only take the pressure off the health care staff to provide self-management support, but also improve patients’ glycemic control [33]. Since our study ended after 6 months, and that behavioral intervention effects frequently diminish with time [34], It seems that a future direction is determining sustainability of peer support interventions in future studies. To achieve this matter, one strategy would be to transfer those who achieved glycemic control among the participants to peer supporter roles. This way, they become highly motivated to continue and maintain their control to be a good role model [13]. On the other hand, due to health workforce shortages in our settings, this makes patients as potential resources available to strengthen our primary care capacity. Our results showed that psychological factors like self-efficacy can be greatly influenced by peer support intervention. Therefore, since several studies in the Iranian population have reported that the psychological factors (e.g. fear of injection, skepticism about insulin's effectiveness) are the major cause of the patient reluctance to initiate insulin treatment [35,36], future studies should utilize different models of peer support interventions so as to reduce patients' experiential concerns about insulin. Moreover, it seems that this type of intervention can target the diabetic foot
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patients who experience substantial psychological distress [37] and need more social and emotional support. 4.2. Conclusion The results of this study strongly suggest that peer support intervention focusing on provision of social, emotional and behavioral support is able to significantly improve diabetes selfmanagement, quality of life and HbA1c after 6 months. These results can be of value especially in developing countries with a shortage of professionals and economic resources and many health inequalities. However, further larger research is needed to provide insight into how best to design and manage a peer support program and to maintain its gains in the future. 4.3. Practice implications The randomized controlled trial of a peer support intervention proposes that incorporating peer-led components into the diabetes care programs has a great potential for improving behavioral and psychological health outcomes in people with T2DM even in those patients who received comprehensive, personalized care and education and had a relatively good baseline level of glycemic control. Furthermore, our findings showed that this approach is acceptable to our patients and can be integrated into our existing healthcare system to meet minimum needs of our patients and optimize health care delivery in our country and may potentially reduce costs in the future. Conflict of interest The authors disclose that there is no conflict of interest including any financial, personal, or other relationships with other people or organizations within 3 years of beginning the submitted work that could inappropriately influence, or be perceived to influence, this work. Acknowledgements This study was supported by funding from Endocrinology and Metabolism Research Institute from Tehran University of Medical Sciences. The authors also would like to express thanks to the researchers and staff at diabetes specialty clinic affiliated to Tehran University of Medical Sciences. References [1] J.J. Gagliardino, V. Arrechea, D. Assad, G.G. Gagliardino, L. González, S. Lucero, et al., Type 2 diabetes patients educated by other patients perform at least as well as patients trained by professionals, Diabetes Metab. Res. Rev. 29 (2013) 152–160. [2] A. Morsanutto, P. Berto, S. Lopatriello, R. Gelisio, D. Voinovich, P.P. Cippo, et al., Major complications have an impact on total annual medical cost of diabetes: results of a database analysis, J. Diabetes Complications 20 (2006) 163–169. [3] M. Davari, Z. Boroumand, M. Amini, A. Aslani, M. Hosseini, The direct medical costs of outpatient cares of type 2 diabetes in Iran: a retrospective study, Int. J. Prev. Med. 7 (2016) 72. [4] E. Nasli-Esfahani, M. Peimani, C. Rambod, M. Omidvar, B. Larijani, Developing a clinical diabetes guideline in diabetes research network in Iran, Iran. J. Public Health 43 (2014) 713–721. [5] R.R. Holman, S.K. Paul, M.A. Bethel, D.R. Matthews, H.A. Neil, 10-year follow-up of intensive glucose control in type 2 diabetes, N. Engl. J. Med. 359 (2008) 1577–1589. [6] A.M. Mosadeghrad, Factors influencing healthcare service quality, Int. J. Health Policy Manage. 3 (2014) 77–89. [7] O. Tabatabaei-Malazy, M. Peimani, R. Heshmat, M. Pajouhi, Status of diabetes care in elderly diabetic patients of a developing country, J. Diabetes Metab. Disord. 10 (2011) 1–8.
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[8] S. Sapkota, J.A. Brien, J. Greenfield, P. Aslani, A systematic review of interventions addressing adherence to anti-diabetic medications in patients with type 2 diabetes-impact on adherence, PLoS One 10 (2015) 1–17. [9] M. Peimani, C. Rambod, M. Omidvar, B. Larijani, R. Ghodssi-Ghassemabadi, A. Tootee, et al., Effectiveness of short message service-based intervention (SMS) on self-care in type 2 diabetes: a feasibility study, Primary Care Diabetes 10 (2016) 251–258. [10] C.A. Chrvala, D. Sherr, R.D. Lipman, Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control, Patient Educ. Couns. 99 (2016) 926–943. [11] A. Kadirvelu, S. Sadasivan, S.H. Ng, Social support in type II diabetes care: a case of too little, too late, Diabetes Metab. Syndr. Obes. 5 (2012) 407–417. [12] C.A. Brownson, M. Heisler, The role of peer support in diabetes care and selfmanagement, Patient 2 (2009) 5–17. [13] X. Zhang, S. Yang, K. 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Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Research Paper
A peer support intervention in improving glycemic control in patients with type 2 diabetes Maryam Peimania , Fateme Monjazebib , Robabeh Ghodssi-Ghassemabadic , Ensieh Nasli-Esfahanic,* a
Department of Health Education & Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran c Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 24 May 2017 Received in revised form 18 September 2017 Accepted 10 October 2017
Objective: This study aims to assess the effectiveness of a peer support intervention, in which patients with T2DM were provided ongoing self-management support by trained peers with diabetes directed at improving self-care behaviors, self-efficacy and life quality. Methods: In this randomized controlled trial, 200 patients referred to a diabetes specialty clinic were allocated to peer support or control group. Participants in both groups received usual education by diabetes educators. Intervention participants worked with the trained volunteer peers who encouraged participants to engage in daily self-management and to discuss and share their experiences and challenges of diabetes management. The primary outcomes were HbA1c, BMI, self-care behaviors, self-efficacy and life quality Results: After 6 months, patients in the peer support group experienced a significant decline in mean A1c value (P = 0.045). Also, mean diabetes self-management scores, mean self-efficacy scores and mean quality of life scores significantly improved in peer support group compared to control group (P values <0.001). Conclusion: Peer support activities can be successfully applied in diabetes self-management, especially in areas with a shortage of professionals and economic resources. Practice implications: Peer support strategies should be integrated into our healthcare system to meet minimum needs of people with T2DM in Iran. © 2017 Elsevier B.V. All rights reserved.
Keywords: Peer support Diabetes type 2 Self-management Patient education
1. Introduction At a global level, type 2 diabetes mellitus (T2DM) is one of the major challenges facing health authorities and societies because of the increasing care costs and the associated impaired quality of life due to the development of chronic complications [1,2]. A recent retrospective study shows that the direct medical cost of diabetes management has progressed sharply during the past years in Iran [3]. Although strict control of blood glucose could significantly reduce the risk of chronic complications development [4,5], such control is difficult to accomplish and the care provided to patients remains far from satisfactory levels [6]. In this regard, an Iranian
* Corresponding author at: Endocrinology and Metabolism Research Institute, North Kargar Ave., 1411713137, Iran. E-mail address: [email protected] (E. Nasli-Esfahani).
survey revealed that more than 50% of elderly people with T2DM had uncontrolled status [7]. In addition, poor adherence to self-care activities is one of the main obstacles to optimal care. Research during the past several decades indicates that, up to 40% of people diagnosed with T2DM fail to adhere to treatment recommendations and lifestyle modifications due to psychological and psychosocial issues as well as the complexity of the regimens required [8]. As a result, educational programs tailored to individual patient needs, individual feedback and presence of psychological support can play a key role in improving adherence to the treatment, and predicting favorable outcomes of the disease [9,10]. However, there exist some challenges with the current practices used [11]. Physicians and staff often do not have the time or resources to provide sufficient support for patient self-management during routine visits. The time allotted for an outpatient visit is often inadequate to address all of the questions that a patient may have about self-care [12]. Moreover, effective self-management support
https://doi.org/10.1016/j.pec.2017.10.007 0738-3991/© 2017 Elsevier B.V. All rights reserved.
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needs to be provided on a long-term basis, which again requires personnel and resources that healthcare systems do not have. Considering such circumstances, peer support, which enables patients to connect to others who have had similar experiences, has been suggested as a reasonable approach to address this issue. Peer support programs are a promising way to boost social and emotional support, help patients in day-to-day management of living with diabetes and promote linkages to clinical care [13,14]. During the past few years, multiple review studies have been conducted about the role of peer support in diabetes selfmanagement [11,12,15,16]. These reviews identified that a growing body of literature demonstrates the value of peer models for diabetes management, but also pointed out that further research is needed. There is still much to learn about organizing effective peer support interventions, determining best types of programs for different types of patients, integrating peer interventions into other clinical services and so on [13]. Additionally, in a recent update of standards of medical care in diabetes by the American Diabetes Association has been emphasized on addressing cultural differences and socioeconomic conditions as a way to improve the effectiveness of educational strategies in diabetes care [17]. However, previous studies propose that peer support interventions have not provided robust evidence for its utility across cultures [18]. Therefore, due to differences in lifestyle behaviors and cultural aspects, we conducted the present study to assess the feasibility and effectiveness of a peer support intervention in which patients with T2DM were provided ongoing self-management support by trained peers with diabetes, with the aim of improving and sustaining self-care behaviors, self-efficacy beliefs, and life quality for a 6 months follow-up.
monitoring and the importance of patients’ active participation in their plan of care). In the second session, main focus was on increasing patients’ awareness of the importance of a healthy diet and weight reduction. The third session explained health benefits of regular physical activity and exercise. And finally, during the fourth session, they were taught how to manage the ABCs of diabetes (HbA1c, Blood pressure, Cholesterol). Illustrated educational materials and virtual clinic website address which offered additional resources to study were given to each participant. At the final session, participants were randomly allocated to either peer support group (n = 100) or control group (n = 100) using permuted block randomization technique, with block size of two. Fig. 1 is a CONSORT diagram of the study design. The sample size was calculated based on the difference of change in HbA1c from baseline to the end of the study between the two groups. Based on the results of a previous study [1], we expected an effect size of at least 0.4 in the HbA1c level, and accordingly a sample size of n = 94 in each study group was required, considering 0.05 for type two error and 80% power based on calculations performed with G-Power software. Thus, we recruited a total of 100 patients in each group. 2.2. Ethical approval As for ethical considerations, the research protocol was approved by the Medical Research Ethics Committee of the Tehran University of Medical Sciences. All participants were volunteers who provided written consent and knew that they could withdraw from the study at any time. 2.3. Recruiting peers
2. Methods 2.1. Study design and sample size This study investigated whether peer support intervention over a 6 month period improves self-care activities, reported selfefficacy, quality of life and clinical outcomes (HbA1c, BMI) in patients with T2DM. In this randomized controlled trial, 200 patients with T2DM were recruited through a diabetes specialty clinic of the Endocrinology and Metabolism Research Institute affiliated to Tehran University of Medical Sciences. All patients who come to this clinic are routinely under supervision of endocrinologists, dieticians, diabetes nurse educators and qualified psychologists if needed. In addition, all patients are registered and invited to participate in group education classes. Also patients are given access to a set of educational booklets and brochures and an educational website named diabetes virtual clinic (http://emri. tums.ac.ir/vclinic). In this study, patients referred to the clinic were screened for eligibility. The inclusion criteria were as follows: aged between 25 and 75 years, diagnosed with T2DM for more than 12 months, planned to continue receiving care at this clinic for next 6 months, and had access to a telephone. Patients were excluded if they had a current debilitating medical or related condition (e.g. severe mental illness, end-stage cancer, blindness, and inability to provide self-care). Potential participants were explained about the objectives and procedures of the study. Those who voluntarily accepted to participate in this study signed informed consent forms. At first, all participants in both groups received usual education including four weekly sessions (90 min each) by a credentialed diabetes educator as it is routine in the clinic. The first session included an overview of type 2 diabetes (symptoms of hyper and hypoglycemia, blood glucose self-
Recruiting enthusiastic and appropriate patients as peers was to some extent challenging. Overall, people are more likely to volunteer when asked by someone they know and trust. So, the physicians and diabetes educator nurses in the clinic were asked to nominate a list of 10 patients that they felt would be suitable for the role of peers according to the following criteria: Patients’ knowledge on the basis of excellent diabetes control (HbA1c < 8.5%). Patients with good interpersonal skills and qualities (e.g., patients who enjoy contact with others, personable). Patients who demonstrate flexibility, self-motivation and good problem-solving skills. Patients with good active and non-judgmental listening skills.
Fig. 1. Overview of recruitment, group allocation and data.
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Patients who have had type 2 diabetes. Patients who are able to read and write and attend a 3-day course. Sequential screening was implemented to minimize a potential high dropout rate in this study. So, once agreed by the physicians, potential peers were visited and interviewed by a member of research team who discussed the study goals with them and evaluated their interpersonal skills. If both thought it would be appropriate that they should enter the study, at this time, eligible participants were given time to think more about their participation in the study during the 2 weeks ahead. After this time, peers were asked to sign a consent form if they were willing to be in the study. Following recruitment, peers received a 3-day structured, buzzgroup interactive course developed and conducted by the study team. Table 1 presents a summary of the content of the course. Peers were asked to deploy the active listening and facilitating skills explored during the peers training program to engage with their group members and to support them in dealing with the daily vicissitudes of diabetes care. Moreover, peers were guided by a detailed manual that included outlines of each session with sample questions as a starting point for discussion. Peers were encouraged and asked to keep notes on challenges and questions they were facing. Throughout the study period, peers were supported through weekly phone calls from the members of research team. These
regular weekly phone supervisions, which usually lasted about 15– 20 min, included answering questions, discussing challenges, providing more support and reviewing of adherence to the program. Also research team was available for questions and supports 10 peers at all times. Venues and refreshments were provided by the study team as well. 2.4. Peer support intervention The study took place in a university specialty clinic in the city of Tehran in which people with diabetes receive state-of-the-art medical care, patient education, in addition to services for the prevention and management of complications. As mentioned before, the study included two different groups: peer support group and control group, both of which received usual clinic education. The intervention group (n = 100) was subdivided into ten groups, each comprising ten persons and randomly paired with one of the trained peers (n = 10) for the next six months. Each peer was asked to facilitate one group meeting each month during the same period. Participants were reminded by their peers to attend all of the scheduled monthly group sessions. In the first group session, the participants discussed their problems and concerns which had affected their adherence to the medications. In the second session, they discussed their views of the difficulties of complying with diabetic diet and perceptions about their obesity risk and weight control. In the third group
Table 1 Summary of peers training program. Topics
Learning Objectives
An introduction to the study
Understand the role of the peers in this study
Developing skills: Facilitation
Learn who is a facilitator and how to facilitate a meeting. Ground rules. Demonstrate facilitation skills, e.g. welcoming and making introductions (Ice Breakers), encouraging participation, sticking to the agenda, being flexible, summarizing the meeting results
Developing skills: Active listening
Learn how to become an active listener according to following steps:1. looking at the person, and stopping other things you are doing, 2. being sincerely interested in what the other person is talking about, 3. focusing on feelings and emotions, 4. asking open-ended questions (allowing the participant to tell their story), 5. making reflections (feelings and emotions), 6. being empathic and non-judgmental, 7. being aware of your own feelings and strong opinions, but avoiding conveying them. Demonstrate the skill of active listening.
Developing skills: Solving problems
Demonstrate the process of problem solving Identify strategies to stay motivated with self-management plan. Identify barriers to achieving self-management goals.
Providing emotional support
Identify diabetes specific coping skills (e.g., focusing on specific sticking points, active problem solving, persuasive communication). Identify the components of effective, compassionate communication (e.g., observations free of evaluations) Learn how to support patients using the principles of effective communication (e.g., providing support via gesture, building trust, listening, showing you care, and helping them work through their emotions and fears). Demonstrate a follow-up telephone call with a participant
Facilitating behavior changes and overcoming barriers to Demonstrate the process of self-assessment diabetes care Create a Life Plan for helping patients think about how they can take charge of their diabetes. Engage in self-reflection Describe a multi-step behavioral goal-setting strategy. Describe and demonstrate empowerment-based facilitation skills (e.g., helping participants learn from their experiences so that they can use similar strategies when making future changes). Building boundaries to diabetes management
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Learn and demonstrate, through role play, how to establish boundaries to their diabetes management with those close to them.
Dealing with difficult situations such as mild depression, Understand the different emotional experiences people with diabetes have. lack of confidence in self-care Identify effective coping strategies Practice mindful meditation Behave as a role-model Identify resources for support
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meeting, they discussed their common problems and possible solutions for being physically active and doing exercise. In the fourth session, discussion centred around the impacts of chronic illnesses like diabetes on family relationships and patients' expectations regarding compassion and support. The main focus of the fifth session was on patients' fears, worries and concerns about the future and living with diabetes and its chronic complications. And the last session was devoted to feelings of depression, hopelessness and anxiety in everyday self-care activities with the emphasis on the strategies for dealing with and overcoming these challenges. In each session, participants discussed and shared their experiences and challenges of diabetes management with each other (two by two) and with the group members and supported each other to set and achieve their goals. Peer encouraged all group members to speak and actively participate in discussions and did not allow participants go outside the mainstream of discussions. Peers were advised that group meetings should last up to 2 h. Since the presence of an observer was likely to influence both peers’ and patients’ behaviors, the research team did not attend the group meetings. In order to ensure meetings were conducted as planned, each of the six monthly meetings for each of the ten subgroups (in intervention group) was recorded and thus details of discussions and topics covered at each meeting were provided to the research team. After each group meeting, peers were requested to review the recordings of their monthly meeting based on the mentioned manual which reflected the content specified for that month so as to help them be better able to evaluate and identify their challenges and difficulties and to keep notes of them. In addition, the research team also reviewed the recordings of monthly meetings to find the strengths and weaknesses and discuss them with the peers during the phone calls. Peers had regular scheduled telephone contacts weekly with their 10 patients. The aim of these contacts, which were mostly unstructured and individualized, was to provide continuing social, emotional and behavioral support and to help the patients on how to apply their diabetes knowledge in everyday life based on the peer's personal experience and to discuss the practical issues arising from living with diabetes. Peers were allowed to make more contacts with their patients if needed. During the intervention, peers were provided with diaries in which they were requested to write the number of telephone contacts they had with each of their patients, and brief reports of the associated content and duration. It is noteworthy that the peers were given a prepaid cell phone to facilitate telephone peer communication and keep their personal contact details private.
2.5. Outcome measures Prior to the intervention, the participants’ demographic and clinical data was extracted and recorded as baseline levels. The data pertaining to self-care activities and self-efficacy was collected utilizing the following well-validated and reliable established questionnaires: Diabetes Self-Management Questionnaire (DSMQ) [19] and the Diabetes Management Self-Efficacy Scale (DMSES) [20]. Dimensions of health-related quality of life was measured through a questionnaire which was based on the Swedish Health-Related Quality of Life Survey (SWED-QUAL) [21]. This scale was translated into Farsi by Peimani et al. [22] and the content validity was determined by giving the questionnaire to 20 medical and nursing professionals for review. After gathering their opinions, the questionnaire was revised. The internal consistency was confirmed with a Cronbach alpha of 0.77 and Pearson correlation coefficient of 0.72. Outcome measurements were clinical measures (HbA1c levels and BMI), diabetes self-care activities, patients’ self-efficacy and quality of life. The HbA1c levels and BMI were measured and all the questionnaires were filled once again 6 months later. The Diabetes Self-Management Questionnaire consisted of 16 items with the main objective of investigating how patients had followed their diabetes treatment plan in the previous 8 weeks. Responses were rated on a four-point scale from “Never = 0” to “Very much = 3”. Subsequently, results were summed to produce a single score for self-care activities where higher scores indicated superior self-care. The Self-Efficacy Scale was comprised of 20 items that assessed the extent to which respondents were confident in certain competencies. Responses were ranked on a six-point scale of agreement, with“1 indicating strongly agree” to “6 demonstrating strongly disagree”. Responses were summed to create a score for self-efficacy, with lower scores indicating superior self-efficacy. The Health Related Quality Of Life questionnaire consisted of 53 items, which assessed various dimensions of quality of life including physical functioning and satisfaction with one's physical abilities (12 items), mental and emotional health (16 items), sleep problems (4 items) general health perception (10 items), satisfaction with family and social functioning (11 items). Responses were rated on a five-point scale from “Not at all = 1” to “Very much = 5”. The items scores were added and higher scores indicated superior quality of life. Total scores of each questionnaire (DSMQ, DMSES, HRQOL) were rescaled to a value of 0 to 100 for all participants. The original versions of DSMQ and DMSES questionnaires were first translated into Farsi and then back translated to English by
Table 2 Demographic characteristics of the study groups. Variables
Peer-Support group (n = 100)
Control group (n = 100)
P-value
Gender (Male/Female) Age (years) Diabetes Duration (years)
53/47 59.0 11.3 6. 7 6.63
51/49 58.8 11.7 6.5 7.41
0.85 0.91 0.27
Education Level Primary school education High school education Diploma and upper
33 (33%) 38 (38%) 29 (29%)
35 (35%) 35 (35%) 30 (30%)
0.52
Occupation Employee House Worker Retired Unemployed
24 25 29 22
22 27 27 24
0.28
(24%) (25%) (29%) (22%)
(22%) (27%) (27%) (24%)
Data are mean SD or number (%). No statistically significant differences were seen between two groups in terms of sex, age, duration of diabetes, occupation, and level of education.
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two independent bilingual translators. Then, an English literature PhD compared the back translated versions and the original versions of the questionnaires and recommended changes if needed. In order to conduct face validity, five experts were requested to comment on ambiguity of each questionnaires’ items and five well-educated patients were asked on how they understood the questions. Final Persian version of questionnaires were used after the implementation of these comments. The intraclass correlation was 0.92 and 0.89, and also the internal consistency with the Cronbach's alpha was 0.88 and 0.82 for DSMQ and DMSES scales, respectively. 2.6. Statistical analysis Descriptive statistics was used to summarize the sample characteristics; frequencies and percentages for categorical data, means and standard deviations for continuous data. The Chisquared test used for comparing categorical data between the two groups at baseline. In order to compare baseline characteristics of the two groups, independent sample t-test was used and differences between pre and post intervention measurements were tested by paired t-test. P-values of less than 0.05 were considered as significant. The data was analyzed by means of SPSS version 21. 3. Results 200 patients with T2DM were recruited for the study (100 patients in the intervention group and 100 patients in the control group), with a mean (SD) age of 60.2 12.1. Also 52% of the participants were male and 48% were female. Patients' characteristics are summarized in Table 2. 3.1. Differences in clinical outcomes(HbA1c, BMI) Table 3 shows the initial values at baseline and the changes in outcomes after six months. As shown, there were no significant
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differences in mean BMI (P = 0.859) and mean HbA1c levels (P = 0.670) between the two groups at baseline. Although peer support group experienced a decline in mean BMI during the study (28.11 vs 27.52), it was not statistically significant (P = 0.162). The mean BMI of the control group (28.35 vs 28.50 with P = 0.85) did not also differ significantly from the baseline value. No statistical significant difference was observed in the mean of BMI change between the two groups (P = 0.197). Although baseline mean HbA1c values were close to 7% in both groups, a marginally significant decrease was observed in the mean HbA1c value in the intervention group at the end of the study (7.29 vs 6.98 with P = 0.045). Also HbA1c changes were significantly different between two groups (P = 0.027). 3.2. Differences in diabetes self-management, self-efficacy and life quality The mean diabetes self-management, diabetes management self-efficacy and diabetes quality of life scores were calculated and compared with the pre-intervention scores. No differences were observed in self-management activities, self-efficacy and life quality mean scores between the two groups at the beginning of the study (Table 3). After the intervention, mean self-management activities score significantly increased in peer-support group (P < 0.001) while it significantly decreased in the control group (P < 0.001). A significant reduction was observed in mean diabetes management self-efficacy score (P < 0.001) in peer support group, whereas it significantly increased in the control group in comparison with the beginning of the study (P < 0.001). Also there was a significant increase in the mean score of quality of life in peer support group (P < 0.001) after the intervention. However, a significant decrease was observed in the mean score of patients’ quality of life in the control group (P < 0.001). Finally, at the end of the study period, diabetes self-management, self-efficacy and quality of life change scores differed significantly (all P values <0.001) between the two groups (Table 3).
Table 3 Effect of intervention on BMI, HbA1c, Diabetes self-management activities, Diabetes self-efficacy and Quality of life. Baseline (mean SD)
After 6 months (mean SD)
*
Diff (post-pre) (mean SD)
**
28.11 5.29 28.35 4.80 0.859
27.52 5.52 28.50 5.20
0.162 0.85
0.59 4.19 0.15 3.89
0.197
Glycosylated hemoglobin (%) Peer-Support group 7.29 1.33 Control group 7.47 1.49 P valuez 0.670
6.98 1.31 7.50 1.44
0.045 0.84
0.31 1.02 0.03 1.14
0.027
Diabetes Self-management Peer-Support group Control group P valuez
37.35 10.54 22.68 11.25
<0.001 <0.001
9.24 8.06 4.59 8.13
<0.001
Diabetes management self-efficacy Peer-Support group 60.40 12.90 Control group 61.95 11.86 P valuez 0.091
40.77 11.50 69.95 11.38
<0.001 <0.001
19.63 9.54 8 9.01
<0.001
Diabetes quality of life Peer-Support group Control group P valuez
198.75 26.5 132.50 18.50
<0.001 <0.001
48.41 19.02 15.9 14.35
<0.001
Variables
P-value
P value
2
Body mass index (kg/m ) Peer-Support group Control group P valuez
* ** z
28.11 10.26 27.27 9.13 0.890
150.34 20.49 148.40 18.55 0.749
P-value of paired t-test for comparison of pre and post measurements within each group. P-value of Independent sample t-test for comparison of change of responses between two groups. P-value of Independent sample t-test for comparison of baseline measures between two groups.
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4. Discussion and conclusion 4.1. Discussion More recently, peer support has been found to be a potential resource for diabetes self-management [15]. The most influential theoretical perspective on peer-based social support hypothesizes that support reduces the effects of stressful life events on the health outcomes of people with T2DM through supportive actions of others. Supportive actions are thought to enhance perception, coping performance and subsequent self-care behavior [23]. So this study was designed to assess whether a peer support intervention, based on social support theory, may result in improved diabetes care outcomes and subsequently improved quality of life in patients with T2DM. It is noteworthy that unlike the peer led educational interventions such as the Chronic Disease Self-Management Program (CDSMP) pioneered by Lorig et al. [24], the intervention in this study focused more on peer-based social support than education and was, in fact, in line with Peers for Progress, a global initiative developed by the American Academy of Family Physicians Foundation (AAFPF) [25]. So the usual comprehensive education by qualified diabetes educators was offered to all participants before the intervention. Our results demonstrated that HbA1c level reduced after the intervention and this reduction was significant (P = 0.045). Consistent with this study’s finding, Thom et al. in their study showed that after 6 months, HbA1c levels decreased by 1.07% in the coached group (P = 0.001) [26]. But what we are facing in comparison to their study is that baseline HbA1c values of our participants were close to 7%, whereas the baseline HbA1c values of their participants were close to 10% (poorly controlled diabetes). So this may reflect a more significant effect of the intervention in their study than ours. Besides, as mentioned earlier, relatively high-quality care is provided to all patients in this clinic and both intervention and control participants received comprehensive diabetes education, so there may have been little they needed that peer support could provide. In Heisler et al. study, the findings showed reciprocal peer support participants had a mean baseline HbA1c of 8.02%, which improved to 7.73% after six months (0.29%) compared to an average increase in HbA1c among nurse-care management participants (7.93 to 8.22 [SD 0.29]). The difference between the groups was 0.58% (P = 0.004) [27]. Another similar study reported that HbA1c values at six months were significantly lower in the peer group (P < 0.01) [1]. However, a study performed by Khodneva et al. demonstrated that there was no statistically significant effect of the peer support intervention on change in HbA1c [28] a finding different from the present study results. In this regards, some of the above-mentioned studies in their limitations noted that since they had chosen a group of underserved patients who had poorly controlled diabetes, they did not know to what extent their results would generalize to other populations such as middle class patients or patients with better diabetes control [26,27]. Therefore, due to baseline HbA1c levels of our participants, it can be concluded that the peer support intervention is associated with a significant improvement in glycemic control even in patients with a relatively good baseline control of their diabetes. In this study, patients’ mean scores in performing selfmanagement activities significantly increased in peer-support group (P < 0.001). Moreover, our results demonstrated that peer support intervention is significantly effective in promoting the sense of self-efficacy (P < 0.001) and subsequently the quality of life (P < 0.001). Comparable results were reported by Fisher et al. the global director of Peers for Progress, a global initiative by AAFPF as noted
earlier [29]. Peers for Progress selected four peer-support projects for diabetes management from Cameroon, South Africa, Thailand, and Uganda, in which project teams developed and then evaluated different peer support models for adults with diabetes during 6 months. Assistance in applying a diabetes management plan in daily life, social and emotional support to encourage the management of behavior and help patients deal with stress, linkage to clinical care and community resources, and ongoing support were key functions as a template for peer support models. The four projects’ self-evaluations documented both the feasibility and early impacts of peer support in addition to how each project modified the template of key functions to its own unique population and cultural concerns, and health care system. In Thailand and all three African countries, peer support interventions demonstrated to be feasible in varied settings, successful in involving their intended audiences and effective health behavior change, improving metabolic control and patients’ quality of life as well [25,29]. However, it should be noted that in most studies, nutrition behaviors and physical activity were the most frequently measured self-care behaviors, instead of evaluating self-care behaviors as a whole [30], as we did. Similar data regarding the effectiveness of peer support in improved diabetes knowledge, self-management behaviors, diabetes distress and quality of life were reported by Liu et al., who implemented an approach relatively similar to our own [31]. Also several previous studies showed that psychosocial outcomes leading to greater self-efficacy and higher quality of life were the most favorable findings of peer support interventions [27,32]. Although it can be concluded that based on the results of the prior studies and the findings of the current study, peer support interventions appear to have a positive impact on diabetes management outcomes, conclusions must be drawn with caution. There is still much to know about designing, implementing and evaluating different models of peer support to meet the needs of different populations in diverse settings [13]. In this sense, we combined monthly face-to-face group meetings, and telephonebased peer support so as to give participants opportunities to discuss their concerns and challenges with self-care activities with a peer. In doing so, weekly phone calls were a complement to peer-led group meetings to provide a source of ongoing support between scheduled monthly group meetings. Because in our country many people with T2DM need more support for self care than what now is provided by our health-care system, relatively novel models such as this can not only take the pressure off the health care staff to provide self-management support, but also improve patients’ glycemic control [33]. Since our study ended after 6 months, and that behavioral intervention effects frequently diminish with time [34], It seems that a future direction is determining sustainability of peer support interventions in future studies. To achieve this matter, one strategy would be to transfer those who achieved glycemic control among the participants to peer supporter roles. This way, they become highly motivated to continue and maintain their control to be a good role model [13]. On the other hand, due to health workforce shortages in our settings, this makes patients as potential resources available to strengthen our primary care capacity. Our results showed that psychological factors like self-efficacy can be greatly influenced by peer support intervention. Therefore, since several studies in the Iranian population have reported that the psychological factors (e.g. fear of injection, skepticism about insulin's effectiveness) are the major cause of the patient reluctance to initiate insulin treatment [35,36], future studies should utilize different models of peer support interventions so as to reduce patients' experiential concerns about insulin. Moreover, it seems that this type of intervention can target the diabetic foot
Please cite this article in press as: M. Peimani, et al., A peer support intervention in improving glycemic control in patients with type 2 diabetes, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.10.007
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patients who experience substantial psychological distress [37] and need more social and emotional support. 4.2. Conclusion The results of this study strongly suggest that peer support intervention focusing on provision of social, emotional and behavioral support is able to significantly improve diabetes selfmanagement, quality of life and HbA1c after 6 months. These results can be of value especially in developing countries with a shortage of professionals and economic resources and many health inequalities. However, further larger research is needed to provide insight into how best to design and manage a peer support program and to maintain its gains in the future. 4.3. Practice implications The randomized controlled trial of a peer support intervention proposes that incorporating peer-led components into the diabetes care programs has a great potential for improving behavioral and psychological health outcomes in people with T2DM even in those patients who received comprehensive, personalized care and education and had a relatively good baseline level of glycemic control. Furthermore, our findings showed that this approach is acceptable to our patients and can be integrated into our existing healthcare system to meet minimum needs of our patients and optimize health care delivery in our country and may potentially reduce costs in the future. Conflict of interest The authors disclose that there is no conflict of interest including any financial, personal, or other relationships with other people or organizations within 3 years of beginning the submitted work that could inappropriately influence, or be perceived to influence, this work. Acknowledgements This study was supported by funding from Endocrinology and Metabolism Research Institute from Tehran University of Medical Sciences. The authors also would like to express thanks to the researchers and staff at diabetes specialty clinic affiliated to Tehran University of Medical Sciences. References [1] J.J. Gagliardino, V. Arrechea, D. Assad, G.G. Gagliardino, L. González, S. Lucero, et al., Type 2 diabetes patients educated by other patients perform at least as well as patients trained by professionals, Diabetes Metab. Res. Rev. 29 (2013) 152–160. [2] A. Morsanutto, P. Berto, S. Lopatriello, R. Gelisio, D. Voinovich, P.P. Cippo, et al., Major complications have an impact on total annual medical cost of diabetes: results of a database analysis, J. Diabetes Complications 20 (2006) 163–169. [3] M. Davari, Z. Boroumand, M. Amini, A. Aslani, M. Hosseini, The direct medical costs of outpatient cares of type 2 diabetes in Iran: a retrospective study, Int. J. Prev. Med. 7 (2016) 72. [4] E. Nasli-Esfahani, M. Peimani, C. Rambod, M. Omidvar, B. Larijani, Developing a clinical diabetes guideline in diabetes research network in Iran, Iran. J. Public Health 43 (2014) 713–721. [5] R.R. Holman, S.K. Paul, M.A. Bethel, D.R. Matthews, H.A. Neil, 10-year follow-up of intensive glucose control in type 2 diabetes, N. Engl. J. Med. 359 (2008) 1577–1589. [6] A.M. Mosadeghrad, Factors influencing healthcare service quality, Int. J. Health Policy Manage. 3 (2014) 77–89. [7] O. Tabatabaei-Malazy, M. Peimani, R. Heshmat, M. Pajouhi, Status of diabetes care in elderly diabetic patients of a developing country, J. Diabetes Metab. Disord. 10 (2011) 1–8.
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Please cite this article in press as: M. Peimani, et al., A peer support intervention in improving glycemic control in patients with type 2 diabetes, Patient Educ Couns (2017), https://doi.org/10.1016/j.pec.2017.10.007