Peer-delivered Cognitive Behavioral Therapy-based Intervention Reduced Depression and Stress in Community Dwelling Adults With Diabetes and Chronic Pain: A Cluster Randomized Trial.

BACKGROUND: Finding effective, accessible treatment options such as professional-delivered cognitive behavioral therapy (CBT) for medically complex individuals is challenging in rural communities. PURPOSE: We examined whether a CBT-based program intended to increase physical activity despite chronic pain in patients with diabetes delivered by community members trained as peer coaches also improved depressive symptoms and perceived stress. METHODS: Participants in a cluster-randomized controlled trial received a 3-month telephonic lifestyle modification program with integrated CBT elements. Peer coaches assisted participants in developing skills related to adaptive coping, diabetes self-management goal-setting, stress reduction, and cognitive restructuring. Attention controls received general health advice with an equal number of contacts but no CBT elements. Depressive symptoms and stress were assessed using the Centers for Epidemiologic Studies Depression and Perceived Stress scales. Assessments occurred at baseline, 3 months, and 1 year. RESULTS: Of 177 participants with follow-up data, 96% were African Americans, 79% women, and 74% reported annual income <$20,000. There was a significant reduction in perceived stress in intervention compared to control participants at 3-months (ß = -2.79, p = .002 [95% CI -4.52, -1.07]) and 1 year (ß = -2.59, p < .0001 [95% CI -3.30, -1.87]). Similarly, intervention participants reported significant decreases in depressive symptoms at 3-months (ß = -2.48, p < .0001 [95% CI -2.48, -2.02]) and at 1 year (ß = -1.62, p < .0001 [95% CI -2.37, -0.86]). CONCLUSIONS: This peer-delivered CBT-based program improved depressive symptoms and stress in individuals with diabetes and chronic pain. Training community members may be a feasible strategy for offering CBT-based interventions in rural and under-resourced communities. CLINICAL TRIAL REGISTRATION: NCT02538055.

Peer-Delivered Cognitive Behavioral Training to Improve Functioning in Patients With Diabetes: A Cluster-Randomized Trial.

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. METHODS: In 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 A1c, systolic blood pressure, body mass index); physical activity was the explanatory outcome. RESULTS: Of 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 CBT-based interventions in rural and under-resourced communities.

Development of a Community Health Worker-Delivered Cognitive Behavioral Training Intervention for Individuals With Diabetes and Chronic Pain.

Cognitive behavioral therapy (CBT) programs have the potential to improve quality of life in individuals with chronic pain and diabetes. Rural communities often lack the infrastructure necessary to implement such programs. CBT traditionally requires trained therapists, who are rarely available in these areas. An alternative may be programs delivered by community health workers (CHWs). We present an iterative developmental approach that combined program adaptation, pretesting, and CHW training processes for a CBT-based diabetes self-care program for individuals living with diabetes and chronic pain. Collaborative intervention refinement, combined with CHW training, is a promising methodology for community-engaged research in remote, underresourced communities.

Identifying Patient Profiles for Developing Tailored Diabetes Self-Management Interventions: A Latent Class Cluster Analysis.

Purpose: Interventions that are tailored to the specific psychosocial needs of people with diabetes may be more effective than a "one size fits all" approach. The purpose of this study is to identify patient profiles with distinct characteristics to inform the development of tailored interventions. Methods: A latent class cluster analysis was conducted with data from the ENCOURAGE trial based on participant responses to 6 baseline psychosocial measures, including trust in physicians, perceived discrimination, perceived efficacy in patient-physician interactions, social support, patient activation, and diabetes distress. The trial's primary outcomes were hemoglobin A1c, body mass index, systolic blood pressure, low-density lipoprotein cholesterol, and quality of life; secondary outcomes were diabetes distress and patient engagement. Results: Three classes of participants were identified: Class 1 (n = 72) had high trust, activation, perceived efficacy and social support; low diabetes distress; and good glycemic control (7.1 ± 1.3%). Class 2 (n = 178) had moderate values in all measures with higher baseline A1c (8.1 ± 2.1%). Class 3 (n = 155) had high diabetes distress; low trust, patient engagement, and perceived efficacy; with similar baseline A1c (8.2 ± 2.1%) as Class 2. Intervention effects differed for these 3 classes. Conclusion: Three distinct subpopulations, which exhibited different responses to the ENCOURAGE intervention, were identified based on baseline characteristics. These groups could be used as intervention targets. Future studies can determine whether these approaches can be used to target scarce resources efficiently and effectively in real-world settings to maximize the impact of interventions on population health, especially in impoverished communities.

Peer coach delivered storytelling program improved diabetes medication adherence: A cluster randomized trial.

BACKGROUND: Because medication adherence is linked to better diabetes outcomes, numerous interventions have aimed to improve adherence. However, suboptimal adherence persists and necessitate continued research into intervention strategies. This study evaluated the effectiveness of an intervention that combined storytelling and peer support to improve medication adherence and health outcomes in adults with diabetes. METHODS: Living Well with Diabetes was a cluster randomized controlled trial. Intervention participants received a six-month, 11-session peer-delivered behavioral diabetes self-care program over the phone. Control participants received a self-paced general health program. Outcomes were changes in medication adherence and physiologic measures (hemoglobin A1c, systolic blood pressure, low-density lipoprotein cholesterol, body mass index). RESULTS: Of the 403 participants with follow-up data, mean age was 57 (±SD 11), 78% were female, 91% were African American, 56.4% had high school education or less, and 70% had an annual income of < $20,000. At follow-up, compared to controls, intervention participants had greater improvement in medication adherence (ß = -0.25 [95% CI -0.35, -0.15]). Physiologic measures did not change significantly in either group. Intervention participants had significant improvements in beliefs about the necessity of medications (ß = 0.87 [95% CI 0.27, 1.47]) concerns about the negative effects of medication (ß = -0.91 [95% CI -1.35, -0.47]), and beliefs that medications are harmful (ß = -0.50 [95% CI -0.89, -0.10]). In addition, medication use self-efficacy significantly improved in intervention participants (ß = 1.0 [95% CI 0.23, 1.76]). 473 individuals were enrolled in the study and randomized. DISCUSSION: Living Well intervention resulted in improved medication adherence, medication beliefs, and medication use self-efficacy but not improved risk factor levels.

Peer coach delivered storytelling program for diabetes medication adherence: Intervention development and process outcomes.

INTRODUCTION: Diabetes medications can substantially lower blood sugar, thereby improving health outcomes. Despite substantial efforts targeting this issue, diabetes medication adherence remains suboptimal. We present the development and implementation of an intervention emphasizing peer modeling and support as strategies to improve medication adherence. METHODS: Program adaptation, pretesting, and peer coach training were combined in an iterative process with community stakeholders. Peer coaches were community residents who had diabetes or took care of family members with diabetes. Study participants were community-dwelling adults taking diabetes oral medications who reported medication non-adherence or wanted help taking their medications. RESULTS: The resulting intervention consisted of a six-month, 11-session telephone-delivered program. Nineteen peer coaches were trained and certified to deliver the intervention. The 473 study participants were mostly African-Americans (91%), women (79%), and low-income (70% reporting annual income <$20,000). Of the 203 intervention participants, 85% completed the program, with 82% completing all program sessions. Ninety-five percent reported high program satisfaction, and 91% found the program materials helpful, 96% found the videos helpful, 93% felt their peer was easy to talk with, and 95% reported that support from their peer was great or good. Moreover, 93% reported peers knew the program well, and 93% would recommend a peer to a relative with a similar health condition. DISCUSSION: This intervention was developed and implemented in underserved communities with high retention and fidelity. Participants expressed high satisfaction with the program. Our approach may be helpful for others seeking to develop a medication adherence program in their communities.

Social support among African Americans with heart failure: is there a role for community health advisors?

OBJECTIVE: The study had 2 objectives: (1) to gather the observations of community health advisors (CHAs) on the role of social support in the lives of African Americans; and (2) to develop a lay support intervention framework, on the basis of the existing literature and observations of CHAs, depicting how social support may address the needs of African American patients with heart failure. METHODS: Qualitative data were collected in semistructured interviews among 15 CHAs working in African American communities in Birmingham, Alabama. RESULTS: Prominent themes included the challenge of meeting clients' overlapping health care and general life needs, the variation in social support received from family and friends, and the opportunities for CHAs to provide multiple types of social support to clients. CHAs also believed that their support activities could be implemented among populations with heart failure. CONCLUSION: The experience of CHAs with social support can inform a potential framework of a lay support intervention among African Americans with heart failure.