1. P EER S UPPORT AS A S TRATEGY FOR R EDUCING D ISPARITIES : T HE C ASE OF D IABETES Edwin B. Fisher, Ph.D. Global Director, Peers for Progress, American Academy of Family Physicians Foundation - o - Professor Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina - Chapel Hill Rebeccah L. Woodke Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina - Chapel Hill BMS Foundation/Together on Diabetes Partnership for Diabetes Health Equity, Morehouse School of Medicine Webinar – August 27, 2014

2. Human beings are more effective and happier when they have someone they can talk to about personal matters who cares about them who can help them when they need help The risk of death associated with social isolation is greater than the risk associated with cigarette smoking House, Landis & Umberson. Science, 1988 241: 540-544. Holt-Lunstad, Smith, & Layton PLOSMedicine, 2010, 7: July e1000316 www.plosmedicine.org Harlow, H.F., & Harlow, M. (1966) Learning to love. American Scientist 54: 244-272. Fundamental Role of Social Connections and Support

3. peersforprogress.org

4. WHO Consultation, November, 2007 Australia Bangladesh Bermuda Brazil Cameroon Canada China Egypt Gambia India Indonesia Jamaica Mexico Netherlands Pakistan Philippines Saudi Arabia Singapore Switzerland (WHO) Turkey Ukraine United Kingdom United Republic of Tanzania United States 1.Key functions are global 2.How they are addressed needs to be worked out within each setting

5. Key Functions of Peer Support 1.Assistance, consultation in applying management plans in daily life 2.Social and Emotional Support 3.Linkage to clinical care 4.Ongoing support, extended over time Fisher et al. Fam Pract 2010 27 Suppl 1: i6-16.

6. KEY FUNCTIONS Assist in managing diabetes in daily life Social and emotional support Link to clinical care Ongoing support Diverse Implementation of Key Functions Local, Regional, Cultural Influences “Standardization by function, not content” Hawe et al. British Medical Journal 328:1561-1563, 2004. Aro et al. Eur J Public Health 18:548-549, 2008

7. Ways in Which Disadvantaged are Hardly Reached Lack of network ties to sources of health information Distrust of “mainstream” sources – Tuskegee is still very present Economic barriers to care, self management Disparities in neighborhood resources – e.g., healthy food or safe, attractive places for physical activity Discrimination among providers – conscious and unconscious

8. Interventions for hardly reached populations should be focused on: –Trust and Respect –Flexibility –Partnership Working –User Involvement Peer Support How does it address disparities? Flanagan and Hancock, BMC Hlth Svcs Res 2010 10: 92 doi:10.1186/1472-6963-10-92

9. Trust and Respect –Peer support comes from “people like me” –Likeness in disease experience and/or culture fosters trust and mutual respect within the peer/participant relationship –Continued follow-up and support enables the participant to trust her or his peer Peer Support How does it address disparities?

10. Flexibility –Peer support models are flexible to regional, local, and individual variation Ex: In a South African peer support program, because women often attributed their disease to sin or witchcraft, sessions began and ended with song and prayer –Peer support is also flexible to individual schedules, enabling peers and participants to meet when it works best Peer Support How does it address disparities?

11. Partnership Working –A key function of peer support is linking participants to clinical care and community resources –Peers encourage participants to obtain clinical care and connect them to health care professionals and appropriate community organizations Peer Support How does it address disparities?

12. User Involvement –Goal setting is collaborative –Peer/participant co-involvement in setting goals enhances the participant’s commitment to improved behavior change

13. Asthma Coach for Low- Income, Single Mothers of Medicaid-Covered Children Hospitalized for Asthma

14. STUDY DESIGN Randomized Controlled Trial Children, aged 2 - 8 Hospitalized for Asthma Very Low Income; almost all in homes without fathers Enrollment only contingent on willingness to complete reimbursed assessments Thus, assess reach of intervention to generalizable sample Total enrolment = 189 96 Asthma Coach, 93 Usual Care

15. Standardized Approach 7 Key Asthma Management Behaviors Asthma Action Plan Use of Controller Medications Use of Responder Medications Regular Physician Visits Partnership with Physician Avoidance of Second-hand Smoke Avoidance of Cockroach Allergen Defined Schedule of Planned Contacts

16. Low Demand, Persistent, Nondirective, Flexible Approach Flexible application of schedule  If not interested, “check in” next month  Thus, No Such Thing as A Drop-Out Staged Approach – Key behaviors addressed according to mother’s readiness to do them Accept feelings, reluctance to pursue recommendations Flexible contact by phone, home visit, accompany to physician visit, neighborhood locations

17. Coaches Reach “Hardly Reached” Substantive Contact (Face-to-face or by phone in which at least one key management behavior discussed) 35% within 7 days of assignment of Coach 63% with 1 month 89% within 3 months Sustained Engagement: ≥ 1 contact per quarter throughout last year of 2-year intervention

18. Hospitalizations Admissions in Year Prior to Randomization (Year Pre) and 1st and 2nd Years of Coach Program Interaction of Group X Time significant, p <.02. Year 1 is adjusted by subtraction of index hospitalization. Thus Year 1 mean reflects hospitalizations other than index. Fisher et al. Arch Ped & Adol Med 2009 163 (3), 225-232.

19. Alivio Medical Center, Chicago Reaching Entire Population of Adults with Diabetes

20. Approximately 3800 with diabetes High Priority – HbA1c > 8%, Psychosocial Distress, Physician’s Referral 472 of the 3,800 Individual contact biweekly, then monthly Focus on regular care, diet, exercise, emotional support, assistance with other problems Normal Priority – Education classes, Support groups, activities, contacts at clinic visits Progress to Date –– August, 2012 – June, 2014: 89% of 472 High Priority have been reached 78% of 3328 Normal Priority have been reached

21.  Low Demand -- initial call to describe and offer services, not push to accept  Persistent -- Repeat calls in 2-4 weeks and/or according to judgment of Compañero  “Check in With” not “Check up On” patient  Two-year availability to patient  After patient is engaged, begin working on individually chosen goal from set of key (AADE 7) behaviors, health eating, etc.

22. Peer Support in San Francisco Thomas Bodenheimer, University of California, San Francisco Clinical Setting Six Depart- ment of Public Health safety- net primary care clinics serving patients covered by Medicare/Medical or San Francisco’s coverage for uninsured residents Patient Contact Patients had average of 7.02 interactions with their coach, including 5.37 telephoned calls Outcomes Reduction in HbA1c by > 1 point: 49.6% vs 31.5% HbA1c < 7.5%: 22% vs 14.9% Thom et al., Annals of Family Medicine 2013 11: 137-144. Moskowitz et al. J Gen Intern Med. 2013 28: 938-942.

23. CHW Interventions for Hispanic Adults with Type 2 Diabetes in 3 Inner-City Health Centers CHWs were recruited from the community 6-month intervention: Individual educational sessions with participants and their families (mean number of sessions = 11.3) Outcomes: Participants in the CHW group decreased BMI Achieved greater improvements than controls in: Health status Emergency department utilization Dietary and physical activity, Medication adherence Babamoto et al. Health Educ Behav, 2009 36(1), 113-126.

24. Low Literacy among Older Adults Meals on Wheels Volunteers as Health Literacy Coaches Community members served as Meals on Wheels volunteers Trained to provide health-literacy education to homebound elderly adults “Improving health literacy, especially with “hardly reached” populations, demands a multilateral approach that at once enhances provider communication, simplifies health information, renders health care systems easier to navigate, and also fosters information- seeking and -processing skills for patients and consumers” This is Peer Support! Rubin et al. Health Promot Pract 2014 15: 448-454.

25. Reaching the “Hardly Reached” PS more effective among those low in self-reported medication adherence and/or self management (Moskowitz et al. J Gen Intern Med. 2013 28: 938-942.) PS more effective among those with low baseline diabetes support or literacy levels (Piette et al. Chron Illn 2013 Dec;9(4):258-67) PS more effective in reducing post-partum depression among women with household debt and/or lower levels of economic empowerment (Rahman et al. Br J Psychiatry 2012 Dec;201(6):451-457.) PS more cost-effective among those with depressed mood or poorer baseline clinical status (C. Campbell, PhD Dissertation, University of Alabama- Birmingham, 2014) PS effective in reaching and significantly reducing HbA1c among low-income Latino patients of FQHC, 43% of whom had 6 th -grade education or less.

26. Not Just Peer Support – Community and Social Network Approaches COMMIT results among light-moderate smokers without post-secondary education (The COMMIT Research Group, Am J. Public Hlth, 1995 85: 183-192, 193-200). Impacts of program for Vermont women greatest among those with incomes  $25,000 (Secker-Walker et al. Am J Public Hlth 2000 90: 940-946) Impacts of Neighbors for a Smoke Free North Side greatest among those with incomes  $20,000 (Fisher et al. Am J Public Hlth 1998 88: 1658-1663)

27. National Peer Support Collaborative Learning Network Beyond efficacy to person centered, population focused, community oriented, comprehensive & programmatic Advisory Committees: Quality Assurance (incl. definition, certification, supervision/monitoring) Financial Models Special Audiences and Populations Advocacy Communications & Networking Organizational Factors and Integration Contact: sbarger@live.unc.edu