Telephone peer-delivered intervention for diabetes motivation and support: The telecare exploratory RCT

Abstract

Objective

To test trial design issues related to measuring the effectiveness of a peer telephone intervention to enhance self-efficacy in type 2 diabetes; evaluate the impact on self-efficacy and clinical outcome; and describe patient and peer experience.

Methods

Eligible patients had raised HbA1c (initial threshold >8%, reduced to >7.4% mid-way through trial). Patients were recruited from 40 general practices and randomised (40:40:20 ratio) to receive routine care alone or, in addition, motivational telephone support from a peer supporter or a diabetes specialist nurse (9 peers and 12 DSNs) for a period of up to 6 months. The primary outcome measure was self-efficacy score, and secondary outcome measures included HbA1c. Patient and telecare supporter satisfaction and experience were evaluated.

Results

In all, 231 patients participated. At 6 months there were no statistically significant differences in self-efficacy scores (p = 0.68), HbA1c (p = 0.87) or other secondary outcome measures. There was evidence of a high level of acceptability, but peer telecare support was less highly valued than that from a DSN. Some patients stated that they would have valued more information and advice.

Conclusions

Further consideration needs to be given to the targeting of the telecare peer support, its intensity, the training and ongoing supervision of peer supporters, and the extent to which information and advice should be incorporated.

Practice implications

While some patients with poorly controlled type 2 diabetes value peer telephone support, this approach appears not to suit all patients. Further intervention development and evaluation is required before widespread adoption can be recommended.

Introduction

Around 200 million people worldwide have diabetes, and in line with the obesity epidemic this figure is set to increase substantially [1]. Effective self-management may improve diabetes health and prevent or delay the onset of complications [2], [3], [4], but is difficult and complex to achieve [5], [6]. It can be encouraged by enabling patients to understand their condition, combined with resolution of obstacles to adherence [7].

A number of diabetes self-management training interventions exist [7], [9], [10], and an effective time to intervene may be when a therapeutic change is occurring [8]. Peer support and mentorship may also be important, and in the UK the value of patient experience and knowledge in the provision of effective education and support is being promoted by health policy [11]. There is increasing interest in peer-led and ‘expert patient’ type interventions [12], [13], [14]. These have been applied to disease-related, illness-prevention and health promotion topics [15], [16], [17], [18] utilising a range of approaches (e.g. individual one-to-one sessions, self-help/support groups, online computer-mediated groups, telephone) based on the concept of sharing mutual experience [17] and ‘experiential knowledge’ [19]. Offering support may benefit the peer, as well as the person being helped, resulting in improved physical health [20], [21]; increased feelings of self-worth [4], [22], [23], [24]; reduced depressive symptoms [22], [25]; improved communication skills [23]; and changes in self-management behaviours [12].

A potential method of promoting effective self-management is through telephone contact. A recent Cochrane review reported the acceptability of telecommunication for patient care [26]. Such contact is already common in diabetes specialist nurse practice in the UK, and may positively affect adherence to self-management activities [27], enhance autonomy and confidence in managing diabetes [28], and enable adjustment of diabetes management goals [29], [30]. In a recent study conducted in Greater Manchester, individuals living with inadequately controlled type 2 diabetes (HbA1c >7%) were provided with telephone support delivered by trained lay telephonists supported by a diabetes specialist nurse for a period of up to 1 year. Compared with usual care, they had a significant improvement in glycaemic control [31]. The intervention was highly acceptable [32]. However, the study involved only one specialist nurse, so limiting its generalisability.

The telephone intervention tested in the study reported here was designed to allow comparison of peer and nurse support for patients with inadequately controlled type 2 diabetes. Following the recommendations of the UK Medical Research Council (MRC) framework for the development and evaluation of complex interventions to improve health [33], a theoretical basis for the intervention was established drawing on Bandura's self-efficacy theory and the principles of motivational interviewing [34], [35]; feasibility work was conducted to develop an understanding of the intervention and its potential outcomes; and finally a pilot study was undertaken [36]. The intervention was intended to increase self-efficacy in relationship to lifestyle behaviours and medication adherence, leading to improvements in clinical outcomes [35].

The current study was an exploratory randomised controlled trial (RCT) undertaken to test methodologies and generate hypotheses rather than produce evidence of a confirmatory nature. Its aims were to test trial design issues related to measuring the effectiveness of a peer telecare support to enhance self-efficacy in type 2 diabetes; to evaluate its impact on self-efficacy and clinical outcome against nurse telecare provision or routine care alone; and to describe patient and peer experience.