Evidence demonstrates the benefits of diabetes self-management education (DSME) on diabetes knowledge and self-care behavior, clinical outcomes, quality of life, use of primary and preventive services, and lower costs. While the initial benefits of DSME are well documented, the effects decline approximately six months following DSME. Additionally, the majority of studies in this area are singularly focused and comparisons between multiple approaches are limited. The 2012 National Standards for DSME and Support emphasize the importance of providing both initial DSME and on-going diabetes self-management support (DSMS) to assist people with diabetes in maintaining effective self-management throughout a lifetime. While a great deal is understood about how to provide effective DSME, less is known about how to provide effective DSMS. Additionally, DSME is a covered benefit in the healthcare system, while DSMS is not. This ultimately limits access and availability of DSMS programs; therefore posing a critical need to develop, evaluate, and understand effective DSMS models that are ongoing, patient-driven, responsive to change, and embedded in existing community infrastructures. African-American churches are a potentially effective venue for delivering such interventions. The goal of this proposal is to examine the effectiveness of three DSMS approaches compared to enhanced usual care within the context of churches. A cluster randomized, practical behavioral trial with three parallel intervention groups will be implemented. Twenty-one churches in metro-Detroit will be randomized to either 1) Parish Nurse+Peer Leader DSMS 2) Parish Nurse DSMS, or 3) Peer Leader DSMS. All participants will begin with enhanced usual care and transition into the respective DSMS groups based on church membership. Each church will enroll 20-23 individuals with type 2 diabetes, who will be offered six weeks of DSME, followed by 12 months of support group sessions led by either the parish nurse, peer leader, or a combination of both. Following DSMS, all participants and churches will transition into a one-year period of on-going support to evaluate if participants parish nurses, and peer leaders sustain self-management efforts by capitalizing on the infrastructure of the church. We hypothesize that 1) participants in both Parish Nurse DSMS and Peer Leader DSMS will have improved outcomes over enhanced usual care, and that 2) participants in Parish Nurse + Peer Leader DSMS will sustain improvements in outcomes achieved following DSME at significantly higher levels than participants in Parish Nurse DSMS and Peer Leader DSMS. We anticipate that providing formal infrastructure and supervision for peer leaders is critical in the uptake of DSMS. All interventions will be superior to enhanced usual care. A similar pattern of findings is anticipated for blood pressure, weight, and quality of life. The cost effectiveness and long term impact of each approach will be determined. This information will have significant public health impact and will be pivotal in determining effective sustainable strategies and approaches to address DSMS in underserved communities.
Without continued follow-up and support, professionally-led diabetes self-management education programs only improve diabetes-related health outcomes in the short-term. Sustainable models of ongoing diabetes self- management support (DSMS) are needed and should be ongoing, patient-driven, responsive to change, and embedded in existing community infrastructures, such as the church. Training parish nurses and peer leaders to facilitate theory-driven, empowerment-based DSMS interventions in church-based settings may be a viable and promising approach to curtail type 2 diabetes related disparities in ethnic/racial communities.
