Problem Addressed
Compared to whites, African Americans disproportionately suffer from type 2 diabetes, struggle more with glucose control, and experience higher rates of diabetes-related complications. Peer support can be effective in helping patients keep diabetes under control, but the resource-intensive nature of such programs often limits their use.
- Higher incidence among African Americans: About a quarter of African Americans between the ages of 65 and 74 suffer from diabetes, and overall, African Americans are 1.8 times more likely than non-Hispanic whites to have the disease.1 At the Philadelphia Veterans Affairs (VA) Medical Center, 45 percent of patients with diabetes are African American.
- Poorer control, more complications: Compared with whites, African Americans with diabetes tend to have worse glucose control, which leads to more disease-related complications, including eye disease, amputations, and kidney disease. For example, African Americans with diabetes are roughly 1.5 times more likely to develop retinopathy and 2.7 times more likely to have a lower limb amputated than are whites with the disease.1
- Unrealized potential of peer mentoring: Studies suggest that peers who are successfully managing diabetes can be effective in helping those with poor control improve self-management of the disease. However, these programs are not common due to their resource intensity, since mentors may require significant upfront training, substantial ongoing incentives, and/or periodic assistance from professional support staff, particularly when programs involve inperson group meetings. For example, most programs require mentors to attend multiple training sessions and in some cases college courses to prepare them for patient interactions.2
Description of the Innovative Activity
At the Philadelphia VA Medical Center, African-American veterans with diabetes who had their blood glucose under control served as mentors to diabetes patients with a similar background who did not. After completing a brief training session, mentors telephoned (and in some cases met with) their assigned patient regularly over a 6-month period to help them address diabetes-related challenges, such as diet, exercise, and insulin use. A detailed description follows:
- Marketing and enrollment: The program served African Americans with diabetes between the ages of 50 and 70 who used the medical center's primary care clinic and whose last two hemoglobin tests were above 8 percent, indicating a persistent problem in controlling glucose levels and a high risk of diabetes-related complications. Eligible patients received a letter and followup phone call. Those interested could sign up at the hospital.
- Initial measurement and goal-setting: Those who signed up had their glucose level tested. Program staff called them a day later to provide the results and to suggest a 6-month goal for bringing glucose levels under control. (In the trial of this program, a control group also received this service as part of "usual care.")
- Match to demographically similar peer: Typically within 2 weeks of enrolling, participants were assigned a mentor with the same general demographic background—including being within 10 years of the participant's age along with being the same race and gender. Each mentor had already been successful in getting their glucose levels under control (defined as falling from above 8 percent sometime in the past 3 years to below 7.5 percent in the past 3 months). Like the participants, mentors signed up for the program after learning about it in a letter and/or through a followup phone call. While the program was open to both males and females, all the mentors and their assigned patients were men. Matching peers by sex, race, and gender made the program innately culturally competent in that mentors and patients came from the same cultural background. This made it likely that the patients would quickly build rapport with their mentors and have someone to talk with about commonly experienced problems.
- Brief mentor training: A research assistant provided an hour of one-on-one training to each mentor, focusing on use of motivational interviewing techniques. Techniques included asking about the participant's background and then using this information to understand his motivations; helping him identify the differences between behaviors and goals; and guiding him toward a realistic plan for achieving these goals. The trainer also provided tips on making followup calls and assessing whether the patient was heeding the advice. The trainer provided sample questions that could be asked of patients, but encouraged mentors to draw on their own experiences as well. Mentors received $25 for completing the training session.
- Nominal incentives for weekly contact: Mentors were encouraged to call their patients at least once a week, and/or to meet face-to-face if desired, and they could have more frequent contacts if both parties wanted to. To encourage regular contact, at the end of each month mentors whose patients confirmed that they had spoken at least weekly during that month received $20. On average, mentors and participants talked the most during the first month (an average of four calls) and then tended to communicate somewhat less often over time, with an average of two calls by the sixth month. Some pairs met regularly in person at the VA Medical Center (supplemented by phone calls), while most used only phone conversations.
- Practical advice during sessions: While conversations varied, mentors often helped participants overcome challenges related to insulin injections and gave them specific suggestions on how to maintain a healthy diet and/or find time to exercise. Pairs who had frequent contact tended to develop a strong rapport, in some cases leading to participants revealing things to their mentors that they did not feel comfortable sharing with their doctor. Participants' shared cultural background often proved to be helpful. For example, one participant told his mentor that he had a hard time resisting home-made foods at family gatherings, such as biscuits and gravy and sweet potato pie. Having been through the same experience, the mentor offered practical, real-world strategies for resisting tempting foods.
References/Related Articles
English T. Veterans with diabetes "battle" to stay healthy in Philadelphia. Newsworks.org website. April 16, 2012. Available at: http://www.newsworks.org/index.php/nwtonight/item/37012-veterans-with-diabetes-qbattleq-to-stay-healthy.
Long JA, Jahnle EC, Richardson DM, et al. Peer mentoring and financial incentives to improve glucose control in African American veterans: a randomized trial. Ann Intern Med. 2012;156:416-24. [PubMed]
Long, JA. "Buddy system" of peer mentors may help control diabetes. Leonard Davis Institute of Health Economics: Issue Brief. 2012 Mar;17(6):1-4. Available at: http://ldi.upenn.edu/uploads/media_items/buddy-system-of-peer-mentors-may-help-control-diabetes.original.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
Shacter HE, Shea JA, Akhabue E, et al. A qualitative evaluation of racial disparities in glucose control. Ethn Dis. 2009;19:121-7. [PubMed]
Contact the Innovator
Judith Long, MD
Penn Medicine
Division of General Internal Medicine
1201 Blockley Hall
423 Guardian Drive
Philadelphia, PA 19104-6021
(215) 898-4311
E-mail: jalong@mail.med.upenn.edu
Innovator Disclosures
Dr. Long reported having no financial interests or business/professional affiliations relevant to the work described in this profile. |
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