Effect of Peer Mentors in Diabetes Self-management vs Usual Care on Outcomes in US Veterans With Type 2 Diabetes: A Randomized Clinical Trial

“Diabetes self-care activities take place primarily outside of clinical encounters. Intensive clinic-based programs have been reported to be effective in improving self-care behaviors; however, they are often resource intensive, and participant engagement wanes over time. Peer support models that include peers with the same chronic illness and experiential knowledge may help augment patients’ existing social support structures and improve self-care. Models using peers, such as shared medical appointments and community health worker programs, have been shown to improve diabetes clinical outcomes.

A more informal, flexible, and potentially inexpensive means of providing peer support is through volunteer peer coaches or mentors. Peer mentor programs have been shown to improve glycemic control and adherence to medications, diet, exercise, and blood glucose monitoring.

[..] this study builds on prior literature of telephone-based peer support to explore a potentially sustainable model in which former mentees serve as mentors. Our main hypotheses were (1) patients with diabetes and poor glycemic control would benefit from peer mentoring from peers with previously poor glycemic control but who had achieved good control, (2) patients with poor glycemic control would benefit from peer mentoring from former mentees who became mentors, and (3) becoming a mentor would provide additional benefit to those who had previously been mentees.

[..] In phase 1, patients with diabetes and poor glycemic control were randomized to receive mentoring from peers with well-controlled diabetes whose diabetes was once in poor control or to usual care (phase 1 mentees vs usual care). In phase 2, different patients with poor glycemic control were randomized to receive mentoring from former mentees in phase 1 or to usual care (phase 2 mentoring from former mentee vs usual care). To assess whether becoming a mentor in phase 2 was associated with any benefit for phase 1 mentees, those patients were randomized to either become a mentor or not in phase 2 (phase 2 mentors vs nonmentors).

[..] Patients with a diagnosis of diabetes were eligible to be a phase 1 or 2 mentee if they received their primary care from a Philadelphia or Camden VA facility and had a hemoglobin A1c (HbA1c) level greater than 8% on at least 2 occasions in the 24 months prior to enrollment, 1 of which was within the 3 months prior to enrollment. [..] Phase 1 mentors had to have at least 1 HbA1c less than or equal to 7.5% in the 3 months prior to enrollment but have at least 1 HbA1c greater than 8% in the 3 years prior to enrollment. Former mentees who became mentors in phase 2 were not required to have achieved HbA1c levels less than or equal to 7.5% to become mentors. Additional inclusion criteria included age 30-75 years, type 2 diabetes, access to a telephone for contact with mentor or mentee, and ability to understand English. Veterans (mentees and mentors) who agreed to participate completed a written consent form during their first in-person visit. All participants received $50 for each visit requiring a blood draw and survey (baseline, 6 months, and 12 months).

[..] Peer mentors participated in a 1-hour, 1-on-1 training session consisting of (1) instruction designed to help learn the mentee’s story, understand their motivations, help set a realistic plan for goal achievement, assess and support progress, and deal with failure in an accepting manner; (2) role-playing exercises; and (3) review of sample questions for potential mentee encounters. Each peer mentor was then matched with a mentee based on age (plus or minus 10 years), self-reported race/ethnicity, sex, and insulin use (with or without experience with insulin) and introduced to their mentees by research staff via telephone. If an appropriate mentor was not found within 2 weeks, matching criteria were loosened except for experience with insulin. Mentors were given $20 for each month they contacted or attempted to contact their mentee via telephone at least weekly.

[..] We assessed 4501 patients for eligibility; 2524 were unable to be contacted or had other reasons to decline, 1131 patients contacted were eligible, 644 declined to participate, and 487 eligible participants were enrolled: 365 patients into phase 1 and 122 patients into phase 2. [..] For the primary outcomes evaluating change in HbA1c level at 6 months, we had follow-up HbA1c data on more than 87% of participants. We imputed the following data: phase 1, 30 of 202 in the mentee arm and 16 of 154 in the usual care arm; phase 2, 10 of 68 mentoring from a former mentee arm and 3 of 47 in the usual care arm.

[For phase 1 versus usual care] At 6 months, the mean change in HbA1c was −0.20% (95% CI, −0.46% to 0.06%) in the usual care arm and −0.52% (95% CI, −0.76% to −0.29%) for the intervention arm (P = .06). There was no difference in HbA1c between arms at 12 months. The intervention did not affect BP, LDL, diabetes distress, or depressive symptoms.

[For phase 2 from a former mentee versus usual care] At 6 months, compared with usual care participants, mentees who received mentoring from a former mentee showed statistically significant improvement in the Diabetes Distress Scale score of 0.10 points; 95% CI, −0.20 to 0.41 for the usual care arm vs −0.41 points; 95% CI, −0.68 to −0.14 for the intervention arm; P = .02). Similar to phase 1, effects did not persist. No other outcomes showed statistically significant differences.

[..] Becoming a mentor in phase 2 did not prove beneficial to former mentees.

[..] The marginal effects seen at 6 months did not persist at 1 year regardless of starting HbA1c. This outcome is comparable with other programs that address behavior change, such as diabetes self-management education, which show a diminishing effect after the intervention ends. One possible explanation for the lack of sustained effects on glycemic control is the loss of support for peer pairs to stay in touch. Our peer mentor model, like others, supported mentors with financial incentives and monthly phone calls from research staff. The financial incentive of $20 a month to call the mentee weekly plus the monthly training enforcement and contact from the study staff did not continue after 6 months. Future peer mentor interventions may benefit from supporting longer-term interactions.

[..] Our qualitative analysis of mentor-mentee pairs indicated that multiple comorbidities, especially poor mental health, hindered the mentor-mentee relationship. A peer mentor model may not be appropriate for patients also dealing with severe mental health issues.”

Full article, Long JA, Ganetsky VS, Canamucio A. JAMA Network Open 2020.9.11