Effectiveness of Technologically Enhanced Peer Support in Improving Glycemic Management Among Predominantly African American, Low-Income Adults With Diabetes.

PURPOSE: The purpose of the study was to examine whether a peer coaching intervention is more effective in improving clinical outcomes in diabetes when enhanced with e-health educational tools than peer coaching alone. METHODS: The effectiveness of peer coaches who used an individually tailored, interactive, web-based tool (iDecide) was compared with peer coaches with no access to the tool. Two hundred and ninety Veterans Affairs patients with A1C ≥8.0% received a 6-month intervention with an initial session with a fellow patient trained to be a peer coach, followed by weekly phone calls to discuss behavioral goals. Participants were randomized to coaches who used iDecide or coaches who used nontailored educational materials at the initial session. Outcomes were A1C (primary), blood pressure, and diabetes social support (secondary) at 6 and 12 months. RESULTS: Two hundred and fifty-five participants (88%) completed 6-month and 237 (82%) 12-month follow-up. Ninety-eight percent were men, and 63% were African American. Participants in both groups improved A1C values (>-0.6%, P < .001) at 6 months and maintained these gains at 12-month follow-up ( >-0.5%, P < .005). Diabetes social support was improved at both 6 and 12 months ( P < .01). There were no changes in blood pressure. CONCLUSIONS: Clinical gains achieved through a volunteer peer coach program were not increased by the addition of a tailored e-health educational tool.

Study protocol: The Technology-Enhanced Coaching (TEC) program to improve diabetes outcomes - A randomized controlled trial.

Background: Racial and ethnic minority adults with diabetes living in under-resourced communities face multiple barriers to sustaining self-management behaviors necessary to improve diabetes outcomes. Peer support and decision support tools each have been associated with improved diabetes outcomes. Methods: 290 primarily African American adults with poor glycemic control were recruited from the Detroit Veteran's Administration Hospital and randomized to Technology-Enhanced Coaching (TEC) or Peer Coaching alone. Participants in both arms were assigned a peer coach trained in autonomy-supportive approaches. Coaches are diabetes patients with prior poor glycemic control who now have good control. Participants met face-to-face initially with their coach to review diabetes education materials and develop an action plan. Educational materials in the TEC arm are delivered via a web-based, educational tool tailored with each participant's personalized health data (iDecide). Over six months, coaches call their assigned participants once a week to provide support for weekly action steps. Data are also collected on an Observational Control group with no contact with study staff. Changes in A1c, blood pressure, other patient-centered outcomes and mediators and moderators of intervention effects will be assessed. Results: 290 participants were enrolled. Discussion: Tailored e-Health tools with educational content may enhance the effectiveness of peer coaching programs to better prepare patients to set self-management goals, identify action plans, and discuss treatment options with their health care providers. The study will provide insights for scalable self-management support programs for diabetes and chronic illnesses that require high levels of sustained patient self-management.

Mediators and Moderators of Improvements in Medication Adherence.

OBJECTIVE: In a randomized controlled trial we compared two models of community health worker-led diabetes medication decision support for low-income Latino and African American adults with diabetes. Most outcomes were improved when community health workers used either an interactive e-Health tool or print materials. This article investigates mediators and moderators of improved medication adherence in these two models. METHOD: Because both programs significantly improved satisfaction with medication information, medication knowledge, and decisional conflict, we examined whether improvements in each of these outcomes in turn were associated with improvements in self-reported medication adherence, and if so, whether these improvements were mediated by improvements in diabetes self-efficacy or diabetes distress. Potential moderators of improvement included gender, race/ethnicity, age, education, insulin use, health literacy, and baseline self-efficacy, diabetes distress, and A1c. RESULTS: A total of 176 participants (94%) completed all assessments. After adjusting for potential confounders, only increased satisfaction with medication information was correlated with improved medication adherence ( p = .024). Improved self-efficacy, but not diabetes distress, was associated with improvements in both satisfaction with medication information and medication adherence. However, the Sobel-Goodman Mediation test did not support improvements in self-efficacy as a mechanism by which improved satisfaction led to better adherence. None of the examined variables achieved statistical significance as moderators. CONCLUSIONS: Improvements in satisfaction with medication information but not in medication knowledge or decision conflict were associated with improvements in medication adherence. Interventions that target low-income ethnic and racial minorities may need to focus on increasing participants' satisfaction with information provided on diabetes medications and not just improving their knowledge about medications. Future research should explore in more depth other possible mediators and moderators of improvements in medication adherence in low-income minority populations.

Who Signs Up for and Engages in a Peer Support Heart Failure Self-management Intervention.

BACKGROUND: Many programs for patients with heart failure (HF) fail to improve clinical outcomes in part because of low rates of patient enrollment and engagement. A better understanding of patient characteristics associated with willingness to enroll and then engage in HF self-management programs will improve the design and targeting of programs. METHODS AND RESULTS: Analyses of screening, baseline, and engagement data from a randomized controlled effectiveness trial of an HF peer self-management support program were conducted. The median age of the 266 recently hospitalized HF patients who enrolled in the study was 69 years, 51% were female, and 26% were minorities (primarily African American). Of 135 randomized to the peer support intervention, only 39% engaged in either the group sessions or telephone peer support calls. Older white women who reported higher baseline health status, functioning, social support, and confidence in their ability to manage and less difficulty with the physical and emotional aspects of living with HF were the most likely to engage in program activities. Minority status and reporting a need for social support were both correlated with higher enrollment but lower engagement in the intervention. CONCLUSIONS: Although minority patients with poorer reported health status and social support were most likely to consent to participate in the study, participants who engaged in program activities were more likely to have higher baseline health status, functioning, and social support. Developing HF interventions that successfully engage participants most in need of HF self-management support remains a difficult challenge.

Comparison of community health worker-led diabetes medication decision-making support for low-income Latino and African American adults with diabetes using e-health tools versus print materials: a randomized, controlled trial.

BACKGROUND: Health care centers serving low-income communities have scarce resources to support medication decision making among patients with poorly controlled diabetes. OBJECTIVE: To compare outcomes between community health worker use of a tailored, interactive, Web-based, tablet computer-delivered tool (iDecide) and use of print educational materials. DESIGN: Randomized, 2-group trial conducted from 2011 to 2013 (ClinicalTrials.gov: NCT01427660). SETTING: Community health center in Detroit, Michigan, serving a Latino and African American low-income population. PARTICIPANTS: 188 adults with a hemoglobin A1c value greater than 7.5% (55%) or those who reported questions, concerns, or difficulty taking diabetes medications. INTERVENTION: Participants were randomly assigned to receive a 1- to 2-hour session with a community health worker who used iDecide or printed educational materials and 2 follow-up calls. MEASUREMENTS: Primary outcomes were changes in knowledge about antihyperglycemic medications, patient-reported medication decisional conflict, and satisfaction with antihyperglycemic medication information. Also examined were changes in diabetes distress, self-efficacy, medication adherence, and hemoglobin A1c values. RESULTS: Ninety-four percent of participants completed 3-month follow-up. Both groups improved across most measures. iDecide participants reported greater improvements in satisfaction with medication information (helpfulness, P = 0.007; clarity, P = 0.03) and in diabetes distress compared with the print materials group (P < 0.001). The other outcomes did not differ between the groups. LIMITATIONS: The study was conducted at 1 health center during a short period. The community health workers were experienced in behavioral counseling, thereby possibly mitigating the need for additional support tools. CONCLUSION: Most outcomes were similarly improved among participants receiving both types of decision-making support for diabetes medication. Longer-term evaluations are necessary to determine whether the greater improvements in satisfaction with medication information and diabetes distress achieved in the iDecide group at 3 months translate into better longer-term diabetes outcomes. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality and National Institute of Diabetes and Digestive and Kidney Diseases.

Heart failure patients' experiences of a self-management peer support program: a qualitative study.

OBJECTIVES: Explore the experiences of patients with heart failure in a self-management support program to inform the development of future interventions that support and motivate patients to engage in self-management. BACKGROUND: Peer-support programs have led to improved outcomes among patients with other chronic conditions and may result in similar improvements for heart failure patients. Yet, among patients recently hospitalized for heart failure, over half had no or minimal engagement with a reciprocal peer support program. METHODS: Qualitative semi-structured interviews with a purposive sample of 28 patients (mean age 72; 71% Female; 21% African-American; 75% Caucasian) with different levels and types of engagement in a heart failure self-management support program. RESULTS: Key themes that emerged included the importance of heart failure specific-social support, sharing information, comparing self to others, depression, and functional status. CONCLUSIONS: Useful services for heart failure patients provide comfort, restore confidence, and offer practical solutions.

Community-based participatory research and user-centered design in a diabetes medication information and decision tool.

BACKGROUND: Together, community-based participatory research (CBPR), user-centered design (UCD), and health information technology (HIT) offer promising approaches to improve health disparities in low-resource settings. OBJECTIVES: This article describes the application of CBPR and UCD principles to the development of iDecide/Decido, an interactive, tailored, web-based diabetes medication education and decision support tool delivered by community health workers (CHWs) to African American and Latino participants with diabetes in Southwest and Eastside Detroit. The decision aid is offered in English or Spanish and is delivered on an iPad in participants' homes. METHODS: The overlapping principles of CBPR and UCD used to develop iDecide/Decido include a user-focused or community approach, equitable academic and community partnership in all study phases, an iterative development process that relies on input from all stakeholders, and a program experience that is specified, adapted, and implemented with the target community. RESULTS: Collaboration between community members, researchers, and developers is especially evident in the program's design concept, animations, pictographs, issue cards, goal setting, tailoring, and additional CHW tools. CONCLUSIONS: The principles of CBPR and UCD can be successfully applied in developing health information tools that are easy to use and understand, interactive, and target health disparities.

Randomized controlled effectiveness trial of reciprocal peer support in heart failure.

BACKGROUND: Although disease management programs for patients hospitalized with heart failure (HF) are effective, they are, however, often resource intensive, limiting their uptake. Peer support programs have led to improved outcomes among patients with other chronic conditions and may result in similar improvements for patients with HF. METHODS AND RESULTS: In this randomized controlled trial, reciprocal peer support (RPS) arm patients participated in a HF nurse practitioner-led goal setting group session, received brief training in peer communication skills, and were paired with another participant in their cohort with whom they were encouraged to talk weekly using a telephone platform. Participants were also encouraged to attend 3 nurse practitioner-facilitated peer support group sessions. Patients in the nurse care management arm attended a nurse practitioner-led session to address their HF care questions and receive HF educational materials and information on how to access care management services. The median age of the patients was 69 years; 51% were female and 26% were racial/ethnic minorities. Only 55% of RPS patients participated in peer calls or group sessions. In intention-to-treat analyses, the RPS and nurse care management groups did not differ in time-to-first all-cause rehospitalization or death or in mean numbers of rehospitalizations or deaths. There were no differences in improvements in 6-month measures of HF-specific quality of life or social support. Conclusions- Among patients recently hospitalized for HF, more than half of RPS participants had no or minimal engagement with the RPS program, and the program did not improve outcomes compared with usual HF nurse care management. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. UNIQUE IDENTIFIER: NCT00508508.