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Peer support for patients with type 2 diabetes: cluster randomised controlled trial

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d715 (Published 15 February 2011) Cite this as: BMJ 2011;342:d715

Caution in generalizing from null effects of a diabetes peer support intervention

A recent paper posted by the BMJ online, "Peer support for patients
with type 2 diabetes: cluster randomized controlled trial"1 reports
disappointing results of peer-led discussion groups. The prominence of the
report and its conclusion that "the results do not support the widespread
adoption of peer support" raise concerns for the field. However, details
of the intervention point up important differences from widely endorsed
features of peer support and call into question the generality of these
null findings.

A vast amount of evidence links social support to health and well
being. Primates derive great advantage from the support of parents, kin
and familiars.2 Social support is strongly related to numerous health
indicators3 and its absence, social isolation, has been estimated to be as
lethal as smoking a pack of cigarettes per day.4-5 Reviews indicate
widespread benefits6 and promising results of peer support interventions
within important areas like diabetes management.7 Individual controlled
studies indicate substantial benefits of specific peer support
interventions, such as with "Lady Health Workers" reducing by half
prevalence of post-partum depression in Pakistan8 or "Asthma Coaches"
reducing rehospitalization for asthma by half among children with very low
income, single mothers in the U.S.9 Peer support programs are numerous
around the world, but are often poorly evaluated, reported, and
disseminated. Thus, how to organize and deploy peer support remains
elusive.

The paper by Smith and colleagues1 shows null results in a cluster
randomized evaluation of periodic diabetes information groups led by peers
plus enhancements of clinical care, compared to enhanced clinical care
alone. A number of features of the study may have accounted for the
disappointing results. At entry, the clinical status of participants was
not remarkable (e.g., mean HbA1c = 7.2%), making demonstration of
improvement difficult. Additionally, the enhancement of clinical care
common to both conditions appears to have been appreciable, e.g.,
reduction of systolic blood pressure from 144 to 137 mm Hg in controls.

Most important, however, is the particular approach taken to
operationalizing peer support in this study. The intervention itself
focused on nine peer support group meetings spaced over two years. Based
on the description of "Specific topics discussed in the peer support
meetings" posted at BMJ.com, meetings addressed varied topics of interest
to those with diabetes (e.g., heart and vascular disease, blood sugar
levels, healthy eating, exercise, medications, foot care). "In general,
the groups followed and discussed the planned topics".p. 5,1 However,
meetings appeared not to include a focus on individualized plans for
behavior change and follow up of these plans, a feature commonly observed
to be important in achieving improvements in self management of diabetes
and other chronic diseases.10-12 The description of the "Peer supporter
training," also posted at BMJ.com, indicates there were two, 90-minute
training sessions for the peer supporters. Communication skills and role
play of them were covered only in the second session, which also addressed
lifestyle and medication issues, confidentiality, and support for the peer
supporters. From the report, there appears to have been no contact with
participants outside the group meetings. Those who failed to attend the
meetings were contacted by study nurses and the study manager but
apparently not by the peer supporters themselves.p. 5,1

Was peer support achieved? Average attendance was only five of the
nine meetings schedule over two years. Eighteen percent attended none. If
an intervention was intended to provide peer support but was only modestly
attended, one might question whether peer support has been provided
sufficiently to be tested.

From this important and well designed study, one can conclude that
spending time in an intervention led by a peer is not magic. Offering
adults with diabetes the opportunity to meet in occasional groups led by a
peer to discuss issues of common interest appears insufficient to effect
improvements in clinical status or well being. However, features of peer
support recognized in the field as important may not be well appraised by
this study. In particular, focus on adjusting management plans to the
specifics of individuals' lives, social and emotional support, linkage to
clinical care, individualized contact, ongoing support, and other features
common to successful peer support interventions13-16 do not appear to have
been emphasized in the intervention reported by Smith and colleagues.
Perhaps most important, the apparent limitation of contacts with the peer
supporters to the nine structured meetings appears to have eliminated the
easy availability of peer support often emphasized as a strength of social
support interventions.17

It is surely correct that the results of the study of Smith and
colleagues "do not [in and of themselves] support the widespread adoption
of peer support".(abstract) However, it would be a tortured interpretation
of null findings to extend this observation to all of peer support. As
indicated above, there are many reasons to believe that peer support is
indeed highly effective. Rather than overwhelming that evidence, the
present results point to the challenges in developing ways to deliver peer
support that is responsive to the complex and dynamic set of emotional,
practical, and social needs of people with diabetes. Peers for Progress
(peersforprogress.org), a program of the American Academy of Family
Physicians Foundation, is dedicated to promoting global exchange to
identify effective and feasible peer support interventions. Surely the
field needs the "future research" for which Smith and colleagues call, but
the failure of this particular study should neither discourage that
research nor efforts to find effective and efficient ways to bring peer
support to the many who may benefit from it.

The authors are, respectively, Global Director, and Director of the
Program Development Center of Peers for Progress, a program of the
American Academy of Family Physicians Foundation dedicated to evaluating
and promoting peer support in health, health care and prevention around
the world.

References

1. Smith SM, Paul G, Kelly A, Whitford DL, O'Shea E, O'Dowd T. Peer
support for patients with type 2 diabetes: cluster randomised controlled
trial. BMJ 2011;342:d715.

2. Harlow HF. The nature of love. American Psychologist 1958;13:673-
85.

3. Uchino BN. Social support and health: a review of physiological
processes potentially underlying links to disease outcomes. J Behav Med
2006;29(4):377-87.

4. House JS, Landis KR, Umberson D. Social relationships and health.
Science 1988;241:540-44.

5. Holt-Lunstad J, Smith TB, Layton JB. Social relationships and
mortality risk: a meta-analytic review. PLoS Med 2010;7(7):e1000316.

6. Swider SM. Outcome effectiveness of community health workers: an
integrative literature review. Public Health Nursing 2002;19:11-20.

7. Norris SL, Chowdhury FM, Van Let K, Horsley T, Brownstein JN,
Zhang X, et al. Effectiveness of community health workers in the care of
persons with diabetes. Diabetic Medicine 2006;23:544-56.

8. Rahman A, Malik A, Sikander S, Roberts C, Creed F. Cognitive
behaviour therapy-based intervention by community health workers for
mothers with depression and their infants in rural Pakistan: a cluster-
randomised controlled trial. Lancet 2008;372(9642):902-9.

9. Fisher EB, Strunk RC, Highstein GR, Kelley-Sykes R, Tarr KL,
Trinkaus K, et al. A randomized controlled evaluation of the effect of
community health workers on hospitalization for asthma: the asthma coach.
Arch Pediatr Adolesc Med 2009;163(3):225-32.

10. Bodenheimer T, Davis C, Holman H. Helping Patients Adopt
Healthier Behaviors. Clinical Diabetes 2007;25:66-70.

11. Bodenheimer T, Handley MA. Goal-setting for behavior change in
primary care: an exploration and status report. Patient Educ Couns
2009;76(2):174-80.

12. Funnell MM, Brown TL, Childs BP, Haas LB, Hosey GM, Jensen B, et
al. National Standards for diabetes self-management education. Diabetes
Care 2011;34 Suppl 1:S89-96.

13. World Health Organization. Peer Support Programmes in Diabetes:
Report of a WHO Consultation 5-7 November 2007. Geneva, 2008.

14. Boothroyd RI, Fisher EB. Peers for progress: promoting peer
support for health around the world. Fam Pract 2010;27 Suppl 1:i62-8.

15. Funnell MM. Peer-based behavioural strategies to improve chronic
disease self-management and clinical outcomes: evidence, logistics,
evaluation considerations and needs for future research. Fam Pract 2010;27
Suppl 1:i17-22.

16. Heisler M. Different models to mobilize peer support to improve
diabetes self-management and clinical outcomes: evidence, logistics,
evaluation considerations and needs for future research. Fam Pract 2010;27
Suppl 1:i23-32.

17. Fisher EB, Jr. Two approaches to social support in smoking
cessation: Commodity Model and Nondirective Support. Addictive Behaviors
1997;22:819-33.

Competing interests: The authors are, respectively, Global Director, and Director of the Program Development Center of Peers for Progress, a program of the American Academy of Family Physicians Foundation dedicated to evaluating and promoting peer support in health, health care and prevention around the world.

04 March 2011
Edwin B. Fisher
Professor
Renee I Boothroyd
University of North Carolina - Chapel Hill