The education program consists of three 30-minute interactive learning modules led by nurses or trained health educators. Content is based on information from the American Diabetes Association's 2009 Standards of Care Guidelines (30
) and from a segment we developed that focuses on "raising the BAR (Be prepared, Ask and learn, Reflect and reach out) on your doctor visit." The learning modules include 1) diabetes basics and the office visit, 2) healthy eating, and 3) exercise and stress management (Appendix B
We planned for peer advisors to provide a flexible, informal approach to assisting patients, based on role modeling and patient empowerment/activation, rather than formal delivery of a diabetes education curriculum. We identified and developed training activities consistent with 3 main roles: assist, support, and link (). Training content included discussion of peer advisor roles and expectations, principles of motivational interviewing and communication, goal-setting and problem-solving, human subjects in research protections, health care and community resources, diabetes basics, and training on the protocol and forms required for process data collection.
The intervention begins with the peer advisor conducting an in-person needs assessment to identify an area of diabetes management that the client wants to improve. The needs assessment reviews medication adherence, diet, exercise, stress, and talking to their doctor. Using motivational interviewing techniques, the peer advisor guides the participant to set 1 SMART (specific, measurable, achievable, realistic, time-oriented) goal.
After the initial meeting, the peer advisor contacts the client weekly by telephone for 8 to 12 weeks (intensive intervention phase) and at least monthly thereafter (maintenance phase). At each telephone contact, the peer advisor asks the client about new problems, reviews the client's SMART goal, and if the goal has been met, collaboratively sets a new goal. If the client does not want to discuss the goal, the peer advisor provides support and documents the discussion. If the client is having trouble attaining the goal, the peer assists the client in identifying barriers and problem-solving.
In a separate contact made a day or 2 before an office visit, the peer and client plan for the visit and develop a strategy for asking questions and understanding recommendations. Another contact is made a day or 2 after the visit to review what occurred, make plans as needed, and, if necessary, recontact the office to address unmet needs.
Pilot testing the intervention
We conducted a 4-week pilot of the training and the intervention. After completion of the pilot, study investigators conducted two 1-hour group interviews, one with peer advisors and one with the clients. Overall, the intervention was well received and the study forms were deemed reasonable. Both peers and clients felt that transitioning to monthly calls after 8 weeks may not provide enough support and recommended a flexible, client-tailored approach to lengthening the call interval. The intervention was modified accordingly.
Feedback from the pilot peer advisors also led us to create a peer support network. Peers assigned to a particular region were asked to function as a team to enhance retention and morale, minimize burnout, and permit case reassignment should a peer drop out. Monthly support meetings were planned during the intervention period, and each peer advisor was paired with another peer advisor from their area as a one-on-one supporter.
Steps 5 and 6: Planning for implementation and evaluation
To aid implementation and adoption, information from the pilot was used to modify the peer training manual so that it could serve both as a guide for the training sessions and as an ongoing resource during the intervention period and beyond. Currently, the program is being tested in a group-randomized trial. More than 60 peer advisors have completed training, 424 participants have been enrolled, and 200 have been matched to peer advisors.
Evaluation measures include biometric measures (hemoglobin A1c, blood pressure, low-density lipoprotein cholesterol, body mass index, and waist circumference) and patient-centered measures along with theory-based behavioral outcomes (see step 2). Measures have been collected at baseline and will be collected again 6 and 12 months later. To facilitate this process, the study team trained several community members to assist with data collection, including biometric assessments and face-to-face interviews.
Process measures are being collected from peer advisors. Using the pilot-tested contact forms, peers document each contact, both scheduled and spontaneous, and, through separate forms, contacts before and after the office visit. Forms are submitted to community coordinators at monthly meetings and evaluated by coordinators and the investigative team for prompt action should deficits be identified. In addition, telephone contacts between investigators, groups of 3 to 4 peer advisors, and the community coordinator take place weekly for the first 4 weeks and at 6-week intervals during the maintenance phase. These calls allow investigators and peers to review progress, troubleshoot problems, and reinforce training.