Outcomes at 18 Months From a Community Health Worker and Peer Leader Diabetes Self-Management Program for Latino Adults

Abstract

Objective: This study evaluated the effectiveness of a community health worker (CHW) diabetes self-management education (DSME) program, followed by two different approaches to maintain improvements in HbA1c and other clinical and patient-centered outcomes over 18 months.

Research design and methods: The study randomized 222 Latino adults with type 2 diabetes and poor glycemic control from a federally qualified health center to 1) a CHW-led, 6-month DSME program or 2) enhanced usual care (EUC). After the 6-month program, participants randomized to the CHW-led DSME were further randomized to 1) 12 months of CHW-delivered monthly telephone outreach (CHW-only) or 2) 12 months of weekly group sessions delivered by peer leaders (PLs) with telephone outreach to those unable to attend (CHW+PL). The primary outcome was HbA1c. Secondary outcomes were blood pressure, lipid levels, diabetes distress, depressive symptoms, understanding of diabetes self-management, and diabetes social support. Assessments were conducted at baseline and at 6, 12, and 18 months.

Results: Participants in the CHW intervention at the 6-month follow-up had greater decreases in HbA1c (-0.45% [95% CI -0.87, -0.03]; P < 0.05) and in diabetes distress (-0.3 points [95% CI -0.6, -0.03]; P < 0.05) compared with EUC. CHW+PL participants maintained HbA1c improvements at 12 and 18 months, and CHW-only participants maintained improvements in diabetes distress at 12 and 18 months. CHW+PL participants also had significantly fewer depressive symptoms at 18 months compared with EUC (-2.2 points [95% CI -4.1, -0.3]; P < 0.05). Participants in CHW-led DSME had significant improvements in diabetes social support and in understanding of diabetes self-management at 6 months relative to EUC, but these intervention effects were not sustained at 18 months.

Conclusions: This study demonstrates the effectiveness of a 6-month CHW intervention on key diabetes outcomes and of a volunteer PL program in sustaining key achieved gains. These are scalable models for health care centers in low-resource settings for achieving and maintaining improvements in key diabetes outcomes.

Trial registration: ClinicalTrials.gov NCT00800410.

© 2018 by the American Diabetes Association.

Figures

Figure 1

Consolidated Standards of Reporting Trials flow diagram.

Figure 2

Trajectory of physical outcomes over time from LMM. Mean estimates from LMM. Covariates include time point, treatment group, interaction between time and treatment group, and high school education. B, significant intervention effect relative to EUC (control) group and CHW-combined (CHW-only and CHW+PL groups) at 6 months; B1, significant intervention effect for CHW-only group at 12 or 18 months; B2, significant intervention effect for CHW+PL group at 12 or 18 months. *P < 0.05.

Figure 3

Trajectory of psychological outcomes over time from LMM. Mean estimates from LMM. Covariates include time point, treatment group, interaction between time and treatment group, and high school education. PHQ-9, Patient Health Questionnaire-9. B, significant intervention effect relative to EUC (control) group and CHW-combined (CHW-only and CHW+PL groups) at 6 months. B1, significant intervention effect for CHW-only group at 12 or 18 months; B2, significant intervention effect for CHW+PL group at 12 or 18 months. *P < 0.05; **P < 0.01.