To examine whether autonomy support (defined as social support for an individual's personal a... more To examine whether autonomy support (defined as social support for an individual's personal agency) for diabetes management from informal health supporters (family/friends) reduces the detrimental effects of diabetes distress on glycemic control. Three hundred eight veterans with type 2 diabetes and one or more risk factors for diabetes complications completed a survey that included measures of diabetes distress and perceived autonomy support from their main informal health supporter. Hemoglobin A (HbA) data from 12 months before and after the survey were extracted from electronic medical records. Linear mixed modeling examined the main effects and interaction of autonomy support and diabetes distress on repeated measures of HbA over the 12 months after the survey, controlling for mean prior 12-month HbA, time, insulin use, age, and race/ethnicity. Diabetes distress ( = 0.12 [SE 0.05]; = 0.023) was associated with higher and autonomy support ( = -0.16 [SE 0.07]; = 0.032) with lo...
This study evaluated the effectiveness of a community health worker (CHW) diabetes self-managemen... more This study evaluated the effectiveness of a community health worker (CHW) diabetes self-management education (DSME) program, followed by two different approaches to maintain improvements in HbA and other clinical and patient-centered outcomes over 18 months. The study randomized 222 Latino adults with type 2 diabetes and poor glycemic control from a federally qualified health center to ) a CHW-led, 6-month DSME program or ) enhanced usual care (EUC). After the 6-month program, participants randomized to the CHW-led DSME were further randomized to ) 12 months of CHW-delivered monthly telephone outreach (CHW-only) or ) 12 months of weekly group sessions delivered by peer leaders (PLs) with telephone outreach to those unable to attend (CHW+PL). The primary outcome was HbA. Secondary outcomes were blood pressure, lipid levels, diabetes distress, depressive symptoms, understanding of diabetes self-management, and diabetes social support. Assessments were conducted at baseline and at 6, 1...
To increase the likelihood of successful implementation of interventions and promote disseminatio... more To increase the likelihood of successful implementation of interventions and promote dissemination across real-world settings, it is essential to evaluate outcomes related to dimensions other than Effectiveness alone. Glasgow and colleagues' RE-AIM framework specifies four additional types of outcomes that are important to decision-makers: Reach, Adoption, Implementation (including cost), and Maintenance. To further strengthen RE-AIM, we propose integrating qualitative assessments in an expanded framework: RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST), a mixed methods framework. RE-AIM QuEST guides formative evaluation to identify real-time implementation barriers and explain how implementation context may influence translation to additional settings. RE-AIM QuEST was used to evaluate a pharmacist-led hypertension management intervention at 3 VA facilities in 2008-2009. We systematically reviewed each of the five RE-AIM dimensions and created open-ended...
Public policies, population health initiatives, and targeted behavioral change interventions for ... more Public policies, population health initiatives, and targeted behavioral change interventions for individuals at risk for developing diabetes are all essential for diabetes prevention in Latin American countries (LACs). This scoping review examines (1) the current evidence on diabetes prevention policies and interventions in LACs to identify components of effective diabetes prevention models in those countries and (2) effective diabetes prevention interventions targeting Latino populations in the USA to explore possible lessons from these interventions for LACs. Diabetes prevention programs in LACs evaluated to date consist of short-term health professional-led face-to-face behavioral counseling sessions. Intervention components of US-based programs for Latinos that might benefit diabetes prevention programs in Latin America include (1) deployment of community health workers ("promotoras") for diabetes screening and delivery of lifestyle modification programs, (2) multiple ...
We compared a 3-month diabetes self-management education (DSME) program followed by a 12-month pe... more We compared a 3-month diabetes self-management education (DSME) program followed by a 12-month peer support intervention with a 3-month DSME program alone in terms of initial and sustained improvements in glycated hemoglobin (HbA1c). Secondary outcomes were risk factors for cardiovascular disease (CVD), diabetes distress, and social support. We randomized 106 community-dwelling African American adults with type 2 diabetes to a 3-month DSME program followed by 12 months of weekly group sessions and supplementary telephone support delivered by peer leaders or to a 3-month DSME program with no follow-up peer support. Assessments were conducted at baseline, 3, 9, and 15 months. No changes in HbA1c were observed at 3 months or at 15 months for either group. The peer support group either sustained improvement in key CVD risk factors or stayed the same while the control group worsened at 15 months. At 15 months, the peer-support group had significantly lower low-density lipoprotein cholest...
SUBSTANTIAL: evidence documents the benefits of peer support provided by community health workers... more SUBSTANTIAL: evidence documents the benefits of peer support provided by community health workers, lay health advisors, promotores de salud, and others. The papers in this supplement, all supported by the Peers for Progress program of the American Academy of Family Physicians Foundation, contribute to the growing body of literature addressing the efficacy, effectiveness, feasibility, reach, sustainability, and adoption of peer support for diabetes self-management. They and additional papers supported by Peers for Progress contribute to understanding how peer support can be implemented in real world settings. Topics include examination of the peers who provide peer support, reaching the hardly reached, success factors in peer support interventions, proactive approaches, attention to emotions, peer support in behavioral health, dissemination models and their application in China, peer support in the patient-centered medical home, research challenges, and policy implications.
Purpose The goal of this study is to describe the process of developing a program that trains pee... more Purpose The goal of this study is to describe the process of developing a program that trains peers to facilitate an empowerment-based diabetes self-management support intervention. Methods To guide and advise the development process, the authors formed a peer leader training action committee. The committee was an interdisciplinary group (principal investigator, nurse—certified diabetes educators, dietitian— certified diabetes educators, nutritionist, physician, and 3 community members) that met every 3 months over a 1-year period for continuous quality improvement meetings. During meetings, the committee reviewed and supervised the curriculum development, provided feedback, and informed modifications and improvements. Results The resulting peer leader training program is a 46-hour program with 2 training sessions conducted per week over a 12-week period. The competency-based training program is based on the theory of experiential learning, and it consists of 3 major components—name...
American Muslims represent a growing and diverse community. Efforts at promoting cultural compete... more American Muslims represent a growing and diverse community. Efforts at promoting cultural competence, enhancing cross-cultural communication skills, and improving community health must account for the religio-cultural frame through which American Muslims view healing. Using a community-based participatory research model, we conducted 13 focus groups at area mosques in southeast Michigan to explore American Muslim views on healing and to identify the primary agents, and their roles, within the healing process. Participants shared a God-centric view of healing. Healing was accessed through direct means such as supplication and recitation of the Qur’an, or indirectly through human agents including imams, health care practitioners, family, friends, and community. Human agents served integral roles, influencing spiritual, psychological, and physical health. Additional research into how religiosity, health care systems, and community factors influence health-care-seeking behaviors is warr...
OBJECTIVE To compare a peer leader (PL) versus a community health worker (CHW) telephone outreach... more OBJECTIVE To compare a peer leader (PL) versus a community health worker (CHW) telephone outreach intervention in sustaining improvements in HbA1c over 12 months after a 6-month diabetes self-management education (DSME) program. RESEARCH DESIGN AND METHODS One hundred and sixteen Latino adults with type 2 diabetes were recruited from a federally qualified health center and randomized to 1) a 6-month DSME program followed by 12 months of weekly group sessions delivered by PLs with telephone outreach to those unable to attend or 2) a 6-month DSME program followed by 12 months of monthly telephone outreach delivered by CHWs. The primary outcome was HbA1c. Secondary outcomes were cardiovascular disease risk factors, diabetes distress, and diabetes social support. Assessments were conducted at baseline, 6, 12, and 18 months. RESULTS After DSME, the PL group achieved a reduction in mean HbA1c (8.2–7.5% or 66–58 mmol/mol, P < 0.0001) that was maintained at 18 months (−0.6% or −6.6 mmol/...
About half of people with glaucoma do not adhere to their recommended medications. Interventions ... more About half of people with glaucoma do not adhere to their recommended medications. Interventions for other chronic conditions have successfully utilized reminder systems and motivational interviewing (MI)-based counseling. This study was designed to pilot a personalized intervention that leverages these strategies to assess their impact on medication adherence in glaucoma patients. Glaucoma patients taking ≥ 1 medication will be pre-screened by telephone survey for adherence to their medication(s). Those who self-report poor adherence will be enrolled in a 3-month monitoring period to measure medication adherence using electronic medication monitors. Participants who are non-adherent (take </=80% of their medication doses) over the 3-month run in phase will be eligible for the study. We plan to enroll 57 participants who are non-adherent to their medications. Participants' adherence will then be continuously measured with electronic medication monitors, by self-report, and vi...
Diabetes shared medical appointments (SMAs) and reciprocal peer support programs have been found ... more Diabetes shared medical appointments (SMAs) and reciprocal peer support programs have been found in efficacy trials to help adults with diabetes improve their self-management and achieve short-term gains in clinical and patient-centered outcomes. In order to translate this evidence to system-level interventions, there is a need for large-scale, pragmatic trials that examine the effectiveness, implementation, and costs of SMAs and reciprocal peer support across diverse settings. The Shared Health Appointments and Reciprocal Enhanced Support (SHARES) study is a multisite, cluster randomized trial that is evaluating the effectiveness and implementation of SMAs with and without an additional reciprocal Peer-to-Peer (P2P) support program, when compared to usual care. The P2P program comprises periodic peer support group sessions and telephone contact between SMA participant pairs to promote more effective diabetes self-management. We will examine outcomes across three different treatment...
Objective In a randomized trial, a guided diabetes peer support intervention improved glycemic co... more Objective In a randomized trial, a guided diabetes peer support intervention improved glycemic control (A1c), with a difference in A1c change between groups of 0.58% ( p = 0.004). The current study examined whether improvements in insulin uptake and perceived diabetes social support mediated the intervention’s impact on A1c. We also examined potential moderation by patients’ health literacy, diabetes social support, or diabetes distress. Methods We conducted secondary analyses for 212 type 2 diabetes patients participating in the trial using accepted methods for testing mediation and moderation effects. Results: Roughly half (49%, 95% CI: 3–80%) of the A1c effect was mediated by increased insulin use, while changes in diabetes social support had a negligible impact. A1c impacts varied across subgroups defined by baseline diabetes social support and functional health literacy (both p < 0.01). The intervention was particularly beneficial among patients with low baseline diabetes su...
Families, systems & health : the journal of collaborative family healthcare, Dec 1, 2017
Family and friends often help chronically ill adults manage their conditions. Information about s... more Family and friends often help chronically ill adults manage their conditions. Information about specific ways supporters help with disease management, and their experiences with and concerns about helping are lacking. This study describes key roles and concerns of family members who support the health management of adults with chronic illness, and compares experiences of health supporters living in and outside of support recipients' homes. Data were obtained from a national internet survey of 1,722 adults selected to represent the U.S. Detailed survey questions were completed by 703 respondents who reported providing regular disease-management help to at least one functionally-independent family member or friend with at least one of five chronic conditions (diabetes, heart failure, chronic lung disease, arthritis, depression). Current supporters assisted 834 chronically ill adults: 257 receiving in-home support and 577 receiving out-of-home support. Current supporters spent 2.1 ...
To examine whether autonomy support (defined as social support for an individual's personal a... more To examine whether autonomy support (defined as social support for an individual's personal agency) for diabetes management from informal health supporters (family/friends) reduces the detrimental effects of diabetes distress on glycemic control. Three hundred eight veterans with type 2 diabetes and one or more risk factors for diabetes complications completed a survey that included measures of diabetes distress and perceived autonomy support from their main informal health supporter. Hemoglobin A (HbA) data from 12 months before and after the survey were extracted from electronic medical records. Linear mixed modeling examined the main effects and interaction of autonomy support and diabetes distress on repeated measures of HbA over the 12 months after the survey, controlling for mean prior 12-month HbA, time, insulin use, age, and race/ethnicity. Diabetes distress ( = 0.12 [SE 0.05]; = 0.023) was associated with higher and autonomy support ( = -0.16 [SE 0.07]; = 0.032) with lo...
This study evaluated the effectiveness of a community health worker (CHW) diabetes self-managemen... more This study evaluated the effectiveness of a community health worker (CHW) diabetes self-management education (DSME) program, followed by two different approaches to maintain improvements in HbA and other clinical and patient-centered outcomes over 18 months. The study randomized 222 Latino adults with type 2 diabetes and poor glycemic control from a federally qualified health center to ) a CHW-led, 6-month DSME program or ) enhanced usual care (EUC). After the 6-month program, participants randomized to the CHW-led DSME were further randomized to ) 12 months of CHW-delivered monthly telephone outreach (CHW-only) or ) 12 months of weekly group sessions delivered by peer leaders (PLs) with telephone outreach to those unable to attend (CHW+PL). The primary outcome was HbA. Secondary outcomes were blood pressure, lipid levels, diabetes distress, depressive symptoms, understanding of diabetes self-management, and diabetes social support. Assessments were conducted at baseline and at 6, 1...
To increase the likelihood of successful implementation of interventions and promote disseminatio... more To increase the likelihood of successful implementation of interventions and promote dissemination across real-world settings, it is essential to evaluate outcomes related to dimensions other than Effectiveness alone. Glasgow and colleagues' RE-AIM framework specifies four additional types of outcomes that are important to decision-makers: Reach, Adoption, Implementation (including cost), and Maintenance. To further strengthen RE-AIM, we propose integrating qualitative assessments in an expanded framework: RE-AIM Qualitative Evaluation for Systematic Translation (RE-AIM QuEST), a mixed methods framework. RE-AIM QuEST guides formative evaluation to identify real-time implementation barriers and explain how implementation context may influence translation to additional settings. RE-AIM QuEST was used to evaluate a pharmacist-led hypertension management intervention at 3 VA facilities in 2008-2009. We systematically reviewed each of the five RE-AIM dimensions and created open-ended...
Public policies, population health initiatives, and targeted behavioral change interventions for ... more Public policies, population health initiatives, and targeted behavioral change interventions for individuals at risk for developing diabetes are all essential for diabetes prevention in Latin American countries (LACs). This scoping review examines (1) the current evidence on diabetes prevention policies and interventions in LACs to identify components of effective diabetes prevention models in those countries and (2) effective diabetes prevention interventions targeting Latino populations in the USA to explore possible lessons from these interventions for LACs. Diabetes prevention programs in LACs evaluated to date consist of short-term health professional-led face-to-face behavioral counseling sessions. Intervention components of US-based programs for Latinos that might benefit diabetes prevention programs in Latin America include (1) deployment of community health workers ("promotoras") for diabetes screening and delivery of lifestyle modification programs, (2) multiple ...
We compared a 3-month diabetes self-management education (DSME) program followed by a 12-month pe... more We compared a 3-month diabetes self-management education (DSME) program followed by a 12-month peer support intervention with a 3-month DSME program alone in terms of initial and sustained improvements in glycated hemoglobin (HbA1c). Secondary outcomes were risk factors for cardiovascular disease (CVD), diabetes distress, and social support. We randomized 106 community-dwelling African American adults with type 2 diabetes to a 3-month DSME program followed by 12 months of weekly group sessions and supplementary telephone support delivered by peer leaders or to a 3-month DSME program with no follow-up peer support. Assessments were conducted at baseline, 3, 9, and 15 months. No changes in HbA1c were observed at 3 months or at 15 months for either group. The peer support group either sustained improvement in key CVD risk factors or stayed the same while the control group worsened at 15 months. At 15 months, the peer-support group had significantly lower low-density lipoprotein cholest...
SUBSTANTIAL: evidence documents the benefits of peer support provided by community health workers... more SUBSTANTIAL: evidence documents the benefits of peer support provided by community health workers, lay health advisors, promotores de salud, and others. The papers in this supplement, all supported by the Peers for Progress program of the American Academy of Family Physicians Foundation, contribute to the growing body of literature addressing the efficacy, effectiveness, feasibility, reach, sustainability, and adoption of peer support for diabetes self-management. They and additional papers supported by Peers for Progress contribute to understanding how peer support can be implemented in real world settings. Topics include examination of the peers who provide peer support, reaching the hardly reached, success factors in peer support interventions, proactive approaches, attention to emotions, peer support in behavioral health, dissemination models and their application in China, peer support in the patient-centered medical home, research challenges, and policy implications.
Purpose The goal of this study is to describe the process of developing a program that trains pee... more Purpose The goal of this study is to describe the process of developing a program that trains peers to facilitate an empowerment-based diabetes self-management support intervention. Methods To guide and advise the development process, the authors formed a peer leader training action committee. The committee was an interdisciplinary group (principal investigator, nurse—certified diabetes educators, dietitian— certified diabetes educators, nutritionist, physician, and 3 community members) that met every 3 months over a 1-year period for continuous quality improvement meetings. During meetings, the committee reviewed and supervised the curriculum development, provided feedback, and informed modifications and improvements. Results The resulting peer leader training program is a 46-hour program with 2 training sessions conducted per week over a 12-week period. The competency-based training program is based on the theory of experiential learning, and it consists of 3 major components—name...
American Muslims represent a growing and diverse community. Efforts at promoting cultural compete... more American Muslims represent a growing and diverse community. Efforts at promoting cultural competence, enhancing cross-cultural communication skills, and improving community health must account for the religio-cultural frame through which American Muslims view healing. Using a community-based participatory research model, we conducted 13 focus groups at area mosques in southeast Michigan to explore American Muslim views on healing and to identify the primary agents, and their roles, within the healing process. Participants shared a God-centric view of healing. Healing was accessed through direct means such as supplication and recitation of the Qur’an, or indirectly through human agents including imams, health care practitioners, family, friends, and community. Human agents served integral roles, influencing spiritual, psychological, and physical health. Additional research into how religiosity, health care systems, and community factors influence health-care-seeking behaviors is warr...
OBJECTIVE To compare a peer leader (PL) versus a community health worker (CHW) telephone outreach... more OBJECTIVE To compare a peer leader (PL) versus a community health worker (CHW) telephone outreach intervention in sustaining improvements in HbA1c over 12 months after a 6-month diabetes self-management education (DSME) program. RESEARCH DESIGN AND METHODS One hundred and sixteen Latino adults with type 2 diabetes were recruited from a federally qualified health center and randomized to 1) a 6-month DSME program followed by 12 months of weekly group sessions delivered by PLs with telephone outreach to those unable to attend or 2) a 6-month DSME program followed by 12 months of monthly telephone outreach delivered by CHWs. The primary outcome was HbA1c. Secondary outcomes were cardiovascular disease risk factors, diabetes distress, and diabetes social support. Assessments were conducted at baseline, 6, 12, and 18 months. RESULTS After DSME, the PL group achieved a reduction in mean HbA1c (8.2–7.5% or 66–58 mmol/mol, P < 0.0001) that was maintained at 18 months (−0.6% or −6.6 mmol/...
About half of people with glaucoma do not adhere to their recommended medications. Interventions ... more About half of people with glaucoma do not adhere to their recommended medications. Interventions for other chronic conditions have successfully utilized reminder systems and motivational interviewing (MI)-based counseling. This study was designed to pilot a personalized intervention that leverages these strategies to assess their impact on medication adherence in glaucoma patients. Glaucoma patients taking ≥ 1 medication will be pre-screened by telephone survey for adherence to their medication(s). Those who self-report poor adherence will be enrolled in a 3-month monitoring period to measure medication adherence using electronic medication monitors. Participants who are non-adherent (take </=80% of their medication doses) over the 3-month run in phase will be eligible for the study. We plan to enroll 57 participants who are non-adherent to their medications. Participants' adherence will then be continuously measured with electronic medication monitors, by self-report, and vi...
Diabetes shared medical appointments (SMAs) and reciprocal peer support programs have been found ... more Diabetes shared medical appointments (SMAs) and reciprocal peer support programs have been found in efficacy trials to help adults with diabetes improve their self-management and achieve short-term gains in clinical and patient-centered outcomes. In order to translate this evidence to system-level interventions, there is a need for large-scale, pragmatic trials that examine the effectiveness, implementation, and costs of SMAs and reciprocal peer support across diverse settings. The Shared Health Appointments and Reciprocal Enhanced Support (SHARES) study is a multisite, cluster randomized trial that is evaluating the effectiveness and implementation of SMAs with and without an additional reciprocal Peer-to-Peer (P2P) support program, when compared to usual care. The P2P program comprises periodic peer support group sessions and telephone contact between SMA participant pairs to promote more effective diabetes self-management. We will examine outcomes across three different treatment...
Objective In a randomized trial, a guided diabetes peer support intervention improved glycemic co... more Objective In a randomized trial, a guided diabetes peer support intervention improved glycemic control (A1c), with a difference in A1c change between groups of 0.58% ( p = 0.004). The current study examined whether improvements in insulin uptake and perceived diabetes social support mediated the intervention’s impact on A1c. We also examined potential moderation by patients’ health literacy, diabetes social support, or diabetes distress. Methods We conducted secondary analyses for 212 type 2 diabetes patients participating in the trial using accepted methods for testing mediation and moderation effects. Results: Roughly half (49%, 95% CI: 3–80%) of the A1c effect was mediated by increased insulin use, while changes in diabetes social support had a negligible impact. A1c impacts varied across subgroups defined by baseline diabetes social support and functional health literacy (both p < 0.01). The intervention was particularly beneficial among patients with low baseline diabetes su...
Families, systems & health : the journal of collaborative family healthcare, Dec 1, 2017
Family and friends often help chronically ill adults manage their conditions. Information about s... more Family and friends often help chronically ill adults manage their conditions. Information about specific ways supporters help with disease management, and their experiences with and concerns about helping are lacking. This study describes key roles and concerns of family members who support the health management of adults with chronic illness, and compares experiences of health supporters living in and outside of support recipients' homes. Data were obtained from a national internet survey of 1,722 adults selected to represent the U.S. Detailed survey questions were completed by 703 respondents who reported providing regular disease-management help to at least one functionally-independent family member or friend with at least one of five chronic conditions (diabetes, heart failure, chronic lung disease, arthritis, depression). Current supporters assisted 834 chronically ill adults: 257 receiving in-home support and 577 receiving out-of-home support. Current supporters spent 2.1 ...
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Papers by Michele Heisler