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Can peer educators influence healthy eating in people with diabetes
Project Code: N14001
University of Leeds
Cade, J ; Kirk, S; Nelson, P; Greenwood, D;
Centre for Health Economics, University of York
As the number of people suffering from diabetes rises, the need has emerged for effective methods of helping people with diabetes improve their management of the disease and thereby improve their long-term health prospects. The original aim of this research project was to develop and evaluate a peer-educator led intervention, consisting of a series of sessions based on patient activation and empowerment, designed specifically for people with diabetes. This was based on the belief that a person with diabetes who was supported and encouraged by a trained peer (from their own community), would find it easier to manage their diabetes. At the time the project was being set up, the Department of Health (DH) introduced generic self-management courses nationally, in the form of the Expert Patients Programme (EPP). This move led to a revision in the study protocol, so that instead of developing a diabetes-specific intervention, peer educators were enrolled on the generic EPP, before undertaking training to deliver the EPP to the trial participants. It was felt that this would maximise resources by utilising a peer-led programme that was to be available nationally. The EPP consists of six, weekly sessions, each lasting around two hours. An additional diabetes-specific session was added to the EPP at week seven, developed by the University of Leeds. This change in protocol therefore meant that people with diabetes were given a generic EPP followed by one diabetes specific session. However, the outcomes under study remained the same, which were to measure changes in food and nutrient intakes between the intervention group and those receiving standard care (controls) and glycosylated haemoglobin levels, as an objective measure of diabetes control.
People with type 2 diabetes were recruited from GP practices in the Burnley, Pendle and Rossendale area of Lancashire, following ethical approval from East Lancashire Local Research Ethics Committee. There were two phases to recruitment. First, participants were approached to become “peer educators”. These were people with diabetes, living in the community, who were willing to be trained in chronic disease self-management and to deliver group sessions on chronic disease self-management to other people with diabetes. The training provided was based on the (EPP), which was being launched within East Lancashire at the time of recruitment. Five people volunteered to become peer tutors. Of these four attended a residential training course for this purpose. This course was provided by the NHS EPP within East Lancashire. One participant withdrew due to delays in setting up the residential course (a factor out of the control of the research team). Subsequently, two tutors withdrew through ill health and were replaced by an additional two tutors; therefore four tutors were available to run courses for the trial. In addition, a senior trainer who had worked for the NHS EPP supported the project for a total of six months (and was paid to do so). This trainer worked alongside peer tutors to deliver the programme, thereby providing five tutors in total. Unfortunately, one tutor sadly died while in the middle of delivering a course, so that only four tutors were available throughout the study. Participants for the intervention phase were also recruited from GP practices in the Burnley, Pendle and Rossendale area.
We targeted 1726 subjects as potential participants in the study. Of these, 319 subjects consented to take part in the study. Following randomisation, some baseline measurements were available from 112 EPP and 127 control subjects (total 239 subjects). However, at six months there was a considerable drop out rate among the EPP group. Additional measures were put in place at 12 months follow up to address this, including a search of medical notes of participants. In addition, gift vouchers were provided to participants who returned the questionnaires (at a value of £5 per questionnaire returned). To this end, 12 months clinical data (glycosylated haemoglobin - HbA1c) were available on around 86 (77%) intervention participants and 118 (93%) control participants, with dietary data available on 74 (66%) of intervention participants and 101 (80%) of control participants. This means we have 12 month data on some participants for whom there are no baseline measures (e.g. 23 control and 21 intervention participants with 12 month but no baseline HbA1c). Baseline and 12 month clinical measures are available on 63 (56%) intervention and 91 (72%) control participants, with dietary data on 74 (66%) intervention and 103 (81%) control participants. However, the study failed to show any significant difference in outcome between intervention and control subjects at 12 months. The high drop out, particularly from the intervention group, will have weakened the power of this study considerably. An economic analysis was also conducted and found that the EPP was not a cost-effective use of resources in this study.
The lack of any intervention effect is disappointing, given the significant investment in the EPP by the NHS. However, the study was beset with a number of difficulties, which may go some way to explaining this lack of effect. Qualitative interviews were subsequently conducted with participants from the intervention and control groups, along with tutors and trainers involved in delivering the EPP to explore this issue. The qualitative study highlighted several important issues regarding the conduct of this trial. Intervention participants reported dissatisfaction with the lack of diabetes-specific information provided through the EPP. This was addressed to some extent by the provision of a diabetes-specific module at the end of the EPP component, but drop-out had already occurred before this session was conducted. There was also frustration that questions about diabetes could not be answered by the lay tutors. However, tutors and trainers were positive about the benefits of the EPP, at least in terms of promoting a sense of well being and quality of life.
The findings from this research highlight the difficulties involved in conducting pragmatic research within the healthcare setting, particularly involving the setting up of projects involving multiple agencies. Clearly defined protocols and effective communication between interested parties are crucial to the success of or otherwise of interventions of this nature and need to be carefully considered and documented in future research of this type.
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