Role of peertopeer interactions in diabetes management

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Role of peer-to-peer interactions in diabetes
management

• Charles M. Clark, Jr MD
• Associate Dean, CME and Professor of Medicine,
  Indiana University School of Medicine

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The Diabetes burden threatens
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• To undermine improving standards of living
• To hinder education
• To subvert economic growth

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Global projections for the diabetes epidemic
2007-2025 (millions)
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53.2 64.1 21
28.3 40.5 43
24.5 44.5 81
67.0 99.4 48
46.5 80.3 73
10.4 18.7 80
16.2 32.7 102
World 2007 246 million 2025 380
million Increase 55
Diabetes Atlas, 3rd edition, IDF 2006
IDF Atlas 2006
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Global projections for IGT 2007-2025 (millions)
0
65.3 71.2 9
19.9 28.0 40
22.4 38.6 72
111.9 14..2 28
24.2 40.3 67
19.8 27.6 39
45.2 70.5 56
World 2007 309 million 2025 419
million Increase 36
Diabetes Atlas, 3rd edition, IDF 2006
IDF Atlas 2006
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Numbers of people with Diabetes and IGT
Developed and Less developed countries
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Hundreds of millions
Diabetes
IGT
Diabetes Atlas, 3rd edition, IDF 2006
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To prevent diabetes and live long, better be
active till 80 years
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What must a person do to manage diabetes?

• Manage the disease(s)
• Maintain their life roles
• Deal with the emotional
• consequences of the disease(s)

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DIABETES DISEASE MANAGEMENT

• While the definition of diabetes disease
  management varies somewhat, its elements usually
  include system changes that result in disease
  staging, promotion of evidence-based clinical
  guidelines, patient education that promotes
  self-management, aggressive screening for
  complications and early and appropriate
  speciality referal.

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What is Comprehensive Diabetes Care?

• disease staging
• promotion of evidence-based clinical guidelines
• patient education that promotes self-management
• aggressive screening for complications and
• early and appropriate specialty referral

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Studies showing the effectiveness of Diabetes
Disease Management

• Clark CM, Snyder JW, Meek RL, Stutz LM, Parkin
  CG. A systematic approach to risk stratification
  and intervention within a managed care
  environment improves diabetes outcomes and
  patient satisfaction. Diabetes Care,
  241079-1086, June, 2001
• Sidorov J, Shull R, Tomcavage J, Girolami S,
  Lawton N, Harris R Does Diabetes Disease
  Management Save Money and Improve Outcomes?
  Diabetes Care 25684-689, 2002
• Wrobel J, Charns M, Diehr P, Robbins J, Reiber G,
  Bonacker K, Haas L, Pogach L /The Relationship
  Between Provider Coordination and
  Diabetes-Related Foot Outcomes. Diabetes Care
  263042-3047, 2003
• Polonsky W, Earles J, Smith S, Pease D, Macmillan
  M, Christensen R, Taylor T, Dickert J, Jackson R
  Integrating Medical Management with Diabetes
  Self-Management Training. Diabetes Care
  263048-3053, 2003

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Self-Management What Is It?

• Self-management is defined as the tasks that
  individuals must undertake to live with one or
  more chronic conditions.
• These tasks include having the confidence to deal
  with the medical management, role management, and
  emotional management of their conditions.

Institute of Medicine 2004
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Self-Management Support

• Self-management support is defined as the
  systematic provision of education and supportive
  interventions by health care system to increase
  patients skills and confidence in managing their
  health problems, including regular assessment of
  progress and problems, goal setting, and
  problem-solving support
• 
  Institute of Medicine 2003

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Diabetes Self-Management
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Psychological Well-being
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What do peer-to-peer support systems look like?
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Peer Led Diabetes Self-management Programs

• Kate Lorig, RN, DrPH
• Stanford Patient Education Center
• 1000 Welch Road, Suite 204
• Palo Alto CA 94304
• 650-723-7935
• self-management_at_stanford.edu
• http//patienteducation.stanford.edu/programs/

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Stanford Diabetes Self-Management Programs

• Built on structured patient and professional
  needs assessments
• Systematically use strategies to enhance
  self-efficacy
• Skills Mastery
• Modeling
• Reinterpretation of Symptoms
• Social Persuasion

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Stanford Diabetes Self-Management Programs

• Peer led (2 peer leaders)
• Standardized training for leaders
• Highly structured teaching protocol
• Standardized participant materials
• Several topics per session
• Evaluated in randomized trials

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Stanford Programs for Diabetes Self-Management

• Chronic Disease Self-Management Generic program
• Diabetes Self-Management
• Disease specific Program

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Modes of Delivery

• Six week small Group
• Six week via the Internet

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Chronic Disease Self-Management Program - What Is
It?

• Small groups 10-16 people
• People with many different diseases and comorbid
  conditions in same group
• 2 ½ hours per week for 6 weeks
• Peer taught

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What is Taught?

• Managing symptoms-(pain, fatigue,
  depression, shortness of breath)
• Exercise
• Relaxation Techniques
• Healthy Eating
• Communication Skills
• Medication management
• Problem Solving
• Action Planning

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Diabetes Self-ManagementWhat is Taught?

• Healthy Eating 6 weeks
• Sharing/Problem Solving 6 weeks
• Action Planning 5 weeks
• Exercise 2 weeks
• Preventing Hypoglycemia 1 week
• Monitoring glucose 1 week
• Stress/Depression 3 weeks
• Medications 1 week
• Preventing Complications 1 week
• Communication skills 2 weeks
• Sick Days 1 week

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What benefits are achieved with peer support?
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Small Group Chronic Disease Self-Management
Program - Randomized Trial

• Demographic Data
• Age 62 years
• Male 27
• Education 14 years
• No. Diseases 2.2

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Percent with Common Diseases

• Lung disease 21
• Heart disease 24
• Diabetes 26
• Arthritis 42

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Chronic Disease Self-Management

• 6-Month Improvements
• in Health Outcomes
• Self-Rated Health
• Disability
• Social and Role Activities Limitations
• Energy/Fatigue
• Distress with Health State
• All plt.05
• 
  

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Chronic Disease Self-Management

• Improvements in
• Utilization and Costs
• Average .8 fewer days in hospital in the past six
  months (p.02)
• Trend toward fewer outpatient and ER visits
  (p.14)
• Estimated cost of intervention 200

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Diabetes Self-Managementsmall group randomized
trial (n417)

• Demographic Data
• Spanish Speakers
• Age 52.8 years
• Male 38
• Education 7.5 years
• Born in Mexico 72
• All type 2 diabetics

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Diabetes Self-Management6 and 18 month outcome

• HBA1c(-.36)------Baseline (7.3)
• Less Health Distress
• Fewer Symptoms of Hyperglycemia
• Fewer Symptoms of Hypoglycemia
• At 18 months all improvements remained as well as
  -.5 MD visits and-.2 ED visits in six months
• all
  plt.05

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Characteristics of Successful Programs

• Based on patient needs assessment
• Emphasis on
• Problem-solving
• Goal-setting/action planning
• Improving self-efficacy
• Patients helping patients
• Self-tailoring
• modeling

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EXPERIENCES IN PEER TO PEER TRAINING

• CHALLENGES AND SOLUTIONS
• ARUN BAKSI
• ISLE OF WIGHT, UK

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Assessments

• Demographic data
• Knowledge
• Michigan Care Profile
• WHO Well being index
• HbA1c
• Assessments
• Before 3months after 1 year after

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Michigan Care Profile
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Coventry Asian Diabetes Support Group

• Established Coventry Diabetes Study
• House to house screening survey of 10,300 adults
  in electoral ward 1985-1988
• Electoral ward 50 South Asian-hi poverty
• South Asians with new/known diabetes referred to
  new Support Group set up by research team and
  local community
• Linking research with intervention

Simmons D. Diabetes self help facilitated by
local diabetes research the Coventry Asian
Diabetes Support Group. Diab Med 19929866-869
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Coventry Asian Diabetes Support Group

• 1st meeting 30/4/87- evaluated 1991- still
  running
• Mainly Punjabi-Gujeratis rarely attended
• Aims
• To educate utilizing invited speakers and videos
• To provide mutual support
• To share information relating to diabetes
• To form the basis of a social group
• Attendance 15-50
• Led by patient/community leader HP present at
  the back
• Monthly speakers/discussions

Simmons D. Diabetes self help facilitated by
local diabetes research the Coventry Asian
Diabetes Support Group. Diab Med 19929866-869
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CADSG Evaluation among those with HbA1 9.5

• Attendance
• N
• Age
• Insulin/tabs
• Duration
• ?HbA1
• ?Knowledge S
• ? over 2 yrs

• 1 time
• 18
• 5510
• 5.6/77.8
• 8.5(4-17)
• 0.4
• 3.1

• 2 times
• 21
• 5312
• 19.0/61.9
• 10(6-16)
• -1.4
• 12.5

Simmons D. Diab Med 19929866-869 plt0.01
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The Caribbean Experience in Peer Support
Interventions The Jamaica Lay Diabetes
Facilitators Education Program World Health
OrganizationGeneva, SwitzerlandNov. 5-7,
2007Presenter Lurline Less Diabetes
Association of Jamaica Kingston, Jamaica
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Objectives for the Lay Diabetes Facilitators
Education

• A To empower persons with diabetes and support
  groups on diabetes management and care.
• B To increase the level of knowledge and
  awareness on diabetes.
• C To improve self-management for better
  glycaemic control and quality of life.
• D To reduce the overall burden of diabetes to
  families, communities, and the country.

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LAY DIABETES FACILITATORS TRAINING PROGRAMME

• Aim
• To Train Resource Persons In Communities
• Selection Criteria For Participants
• - Have gt Seven Years Of Schooling
• - Be A Member Of The Community
• - 50 from the Government Community Health
  Workers
• - 50 from target groups
• eg. teachers, pastors, farmers, police, youth
  group and service club leaders

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LAY DIABETES EDUCATION CONTD

• Training Sites
• Health Centers/Church Halls
• Community Centers
• Delivery of Information
• Lecturers (1 hour each)
• -Physician
• -Chiropodist
• -Nutritionist
• -Diabetes Educator (Lay Person)

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LAY DIABETES EDUCATION CONTD

• Training of Facilitators
• Pre-test
• Education Demonstration Using A Visual Aid - Body
  Map - 1hour
• Post Test Course Evaluation
• Certification of those achieving scores of gt
  90

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Methodology - Patients

• Sample of 264
• 132 cases and 132 controls
• expected difference in A1c, of 0.5 and 2 change
  in attitude between the cases and controls
• Patients were sorted by age and gender
• All males included
• Females selected by systematic random sampling

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Education Counselling
80 of cases received education counselling

Groups
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Knowledge status of patients
96 of patients who received counselling were
more knowledgeable

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Medical Checks done in past year
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Complications
Most common problems were with eyes and poor
glucose control
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Mean A1c diff. between groups
Difference of A1c within cases of 0.6
P 0.00
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Conclusions
            Who should be a Peer? 1. Peers
should either have diabetes or be affected by
diabetes an example of the latter would be a
parent of a child with diabetes. 2. Peers should
be formally recognized, but not compensated. That
is, the importance of their role and
contributions to diabetes care should
be acknowledged by their communities but they
should be volunteers, not employees.
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What should be the role of Peers? 3. Peers
should be advocates for people with diabetes in
their community. 4. The role of peers is
distinct and should not replace roles of current
disciplines involved in diabetes care. 5. The
programmatic development and roles of peers
should be defined by their community and will
vary depending upon their communitys needs and
resources. Peers should specifically consider the
needs of indigenous populations.  6. It is
likely and desirable that there be more than one
approach to the development and implementation of
peer to peer programs. In general, they will be
expected either to develop within the existing
health care systems or as a naturalistic
extension of ongoing NGO programs such as
diabetes organizations that are members of the
International Diabetes Federation. 7. Themes
that should be constantly present in all programs
are a patient-centered approach, self-efficacy,
problem solving and goal setting. 8.Diabetes
peer to peer programs already exist and we should
learn from these programs
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How should Peers be trained? 9. Sustainability
is a key aspect of the value of peer to peer
programs.  Such sustainability will depend upon
the development of standardized curricula and
evaluation programs. Peer to peer programs will
need to develop organized and standardized
curricula and training programs. 10. The
development of standardized curricula and
training programs and evaluation of the
effectiveness of peer to peer programs will be
critical for their sustainability. 11.Because
peer to peer programs will be locally based and
vary from community to community, the
development of effective communication among
programs will be critical to assist programs to
develop and improve.  Modern communication
methods such as the internet will be ideal in
this process.
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How should Peers be evaluated? 13. The roles and
effectiveness of peer to peer programs will need
to be objectively evaluated and such evaluation
should be used to improve their
effectiveness. 14. Evaluation will also be
needed to justify the expense of peer to peer
programs whether they are supported by
governmental agencies or by NGOs. It is
recognized that low-resource communities may have
difficulties carrying out evaluation.
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Future Research

• Confirm efficacy of different behavioral
  approaches in peer support interventions
• Are mechanisms of benefits from peer support
  different from those from formal health care?
  How?
• Need qualitative AND quantitative assessments
• Most successful peer-led model of all is AA, lots
  to learn from that learn from the 12-step model
• Learn more about conversational maps