Peer-support interventions to improve diabetes management: The impact on utilisation of health services

Background: As in other countries, Type 2 diabetes (T2DM) is a major public health problem in Australia. The disease can have a significant negative impact on health and quality of life; it increases the risk of disability and early death and consequently, it contributes to very significant individual as well as societal economic losses. Many different approaches and strategies have been proposed to improve management of diabetes and support of those people with T2DM. However, improvements in health literacy, appropriate access to and utilisation of health services and maintenance of healthy behaviours, which are all essential for diabetes self-management, still remain a big challenge in all countries. In recent years, peer support interventions have been proposed as one way of improving support for people with diabetes, and thereby leading to improved self-management, and perhaps also, improved diabetes and other health outcomes. However, the evidence base for this approach is still uncertain. Methods: The findings presented in this thesis are derived from a cluster randomised community-based trial to evaluate a peer support intervention involving people with T2DM in the state of Victoria, Australia. The intervention focused on key functions of diabetes self-management that included daily self-management, social and emotional supports, linkages to clinical care and continuity of care. The data collected are used to determine the extent to which people with T2DM are able to achieve targets according to the Royal Australian Collage of General Practitioners (RACGP) Guidelines for T2DM management. The thesis also examines the impact of a peer support intervention on diabetes knowledge, utilisation of health services, diabetes self-care behaviour, self-efficacy in diabetes self-management and satisfaction with general practice (GP) care. Further, it reviews currently available evidence concerning prevention and management of T2DM in low-income and middle-income countries (LMICs) as a step towards evaluating the importance of undertaking more research related to diabetes self-management in resource constrained settings. Results: At baseline, the majority of people with T2DM had visited a GP (92%) and had their HbA1c measured (92%) in the last 6 months; but, less than one-third (29%) had visited a practice nurse during the same period. Fifty percent had achieved an HbA1c target of ≤7.0%, 40% a total cholesterol ≤4.00mmol/L, 39% BP Systolic ≤130 mmHg, 51% BP Diastolic ≤80 mmHg, 15% body mass index ≤25kg/m2 and 34% had a moderately intense level of physical activity ≥30minutes, five days a week. At 6-month follow-up of a peer support intervention, peer support participants showed a trend towards improvement in some aspects of diabetes knowledge compared with controls, particularly “knowledge of HbA1c test as a measure of average blood glucose level” (intervention participants improved by 7%, whereas controls declined by 8%, odds ratio (OR) = 2.4, 95% CI 1.4 to 4.2, p=0.002). The mean diabetes self-care behaviour scores increased in peer support participants whereas controls exhibited little change; difference between the groups’ mean change scores = 0.3 (95% CI 0.1 to 0.5, p=0.01). The peer support participants were observed to have improved satisfaction on all aspects of GP care compared with controls; however, only the difference in satisfaction with care from a Practice Nurse was statistically significant (mean difference 0.4, 95% CI: 0.1 to 0.7, p=0.03). In addition, while the peer support participants indicated a trend towards improvement in all aspects of self-efficacy in diabetes self-management, none of these improvements were statistically significant, when compared with changes observed for control participants. The improving trend was also observed in the achievement of some measures of clinical outcomes at 6-month than at baseline in the intervention arm compared with controls, however, most of the measures remained unchanged. For example, the proportion of participants who achieved HbA1c ≤7% increased by 6% in the peer support arm compared with a 3% decline in controls, however, this difference was not significant (OR 1.3, 95% CI 0.6 to 2.8, p=0.6). The results based on a published review paper presented in Chapter 7 are indicative of lifestyle and non-pharmacological interventions improving diet and physical activity levels in a number of LMICs. The interventions were found to be effective in reducing the risk of developing T2DM in people with impaired glucose tolerance, and improving glycaemic control in people with T2DM. Conclusions: These results provide a possibility that the Australians with T2DM may benefit from involvement in a community-based peer supporter-led intervention. However, more research is needed to demonstrate the clear benefits of such interventions. While there is a high burden of T2DM in LMICs, these countries lack effective programs to manage diabetes effectively. The findings presented in Chapter 7 and the initial discussion made in Chapter 8 on potential uptake of peer support program in LMICs suggest the need for development and evaluation of cost-effective and culturally appropriate intervention approaches that build on available resources in LMICs.