Finding Patients Where They Are: Diabetes, Garages, and Praise

Two diabetes self-management education programs find success by looking for effective ways to connect

with Jeannie Concha PhD, MPH and Gretchen Piatt PhD, MPH

Two men looking into the engine of a car

For patients with diabetes, Diabetes Self-Management Education (DSME) is recommended when they are first diagnosed with an annual session after that. If there are changes in diabetic status or transition of care, DSME is again recommended (1). The effectiveness of these education programs is supported with mixed results, especially in communities with fewer resources. For example, a 2018 meta-analysis of programs focused on African Americans with diabetes found no significant improvement in A1c levels, although patients tended to have an improved perception of their quality of life (2). In contrast, a 2015 meta-analysis found that DSME programs were beneficial in Hispanic/Latino populations at lowering the groups’ A1c. The authors of this study recommended that better delivery methods are needed to optimize DSME effectiveness. Five years later, another team came to the same conclusion (4), suggesting that not much has changed. 

So how do you create DSME programs that can assist people with diabetes that traditionally suffer from a lack of equity and are often hard to convince of the benefit of such programs? New research presented at the 81st Scientific Session of the Ameican Diabetes Association (ADA2021) outlined the success of two programs directed at these two populations.

Churches can raise the roof on diabetes support

Data from the Praise Diabetes Project, presented by Gretchen Piatt PhD, MPH, assistant professor at the University of Michigan, sought to improve DSME outcomes by engaging African Americans through their local churches (5). Churches (N=21) in Michigan and Ohio were randomized to one of three diabetes self-management support (DSMS) systems:         

  • parish nurse and a peer leader (PNPL)
  • peer leader only (PL)
  • parish nurse only (PN)

Parish nurses and peer leaders were trained to lead diabetes education sessions at one of the churches enrolled. The participants (N= 123 in PNPL, 127 in PL, 109 in PN) were evaluated at baseline, then again at 6, 9, 21 and 33 months. 

All groups experienced a mild, but not significant improvement in A1c, with a drop of 0.2 percentage points in the PNPL and PN groups and a 0.3 decrease in the PL group. More than 80% of all participants who achieved A1c below 7% at month 9 sustained it through 33 months. The groups with a parish nurse had the most patients with sustained glycemic control – 86.9% in PN, compared to 81.6% in PNPL. Only 76.7% maintained control with the peer leader alone.

All the groups saw a significant improvement in diabetes distress scores over the 33 months, including a 50% reduction in those with moderate diabetes distress in the peer leader group and in severe diabetes distress in the parish nurse group.

Bringing the care to people

“The idea of reaching out to specific groups in specific ways has been around for a while,” says study author Dr. Gretchen Piatt. “We used to focus on bringing people into the health center, but over time, we have realized that we will never make an impact and the results we find will not be generalizable if we don’t go where the people are.”

The program was based in churches that had at least 100 parishioners. Most DSMS groups had about 10 people, although size wasn’t limited, and most churches had a couple of these groups running. Dr. Piatt was surprised at how well the group with only the peer leaders (PL) did. “Our hypothesis going in was that the group that had both leaders [peer and nurse] would do best as it has the most resources. But I also think it’s a personality thing. For whatever reason, maybe the group that had just the peer leaders felt a special kinship.”

The church, as a research site, was chosen in part because it is a social gathering place and a place of social support where people feel comfortable.  “We went in with the thought that the churches could sustain it [their diabetes support groups] in the future in any way that is meaningful,” Dr. Piatt says. “If they decided that they wanted to do the group as a walking group, they could keep it up after the formal program ends. In about half the churches, they continued doing something after we were done. The other half, when we asked what they needed to continue, they said they needed us.”

While the formal program was open only to those with diabetes, Dr. Piatt says that post study, churches may open it up to those with prediabetes or those who are obese. The program was not limited to members of the churches involved, but the participants had to be willing to go to the church for the DSMS program, which may have limited the interest for some people. “We probably weren’t getting a lot of people who were off the charts in terms of diabetes management, and that might be a weakness.”

Dr. Piatt and her colleagues have done other work on diabetes programs in churches and says people who come to the education sessions are happy to talk about their diabetes there, but they say that diabetes isn’t something they talk of when they encounter each other at other times. “It is a separate thing that isn’t covered in everyday chit chat,” she says. Dr. Piatt thinks it’s because at church, people put on the best versions of themselves, and many still view being diabetic as a flaw. “But when they come to a diabetes group, it’s okay to let their guard down.”

Piatt will publish further on this study as data analysis continues.

Body Mechanics: Changing how men think about their diabetes

Another study by Jeannie Concha PhD, MPH (Department of Public Health Sciences, University of Texas in El Paso) used automotive garage analogies to get men — particularly Mexican American men — into a DSME program. The Diabetes Garage Study (6) used teams of certified diabetes educators and automotive technicians to engage local Mexican American men with diabetes into better self-care. 74 participants were recruited to attend 4 workshops over the course of 4 weeks. Each workshop was 2 hours long.  

Workshops included topics as “checking your gauges” to encourage participants to be vigilant about diabetic signs and symptoms; “high performance fuels” which covered nutrition; and “tune ups and inspections” to encourage regular checkups with their health care practitioners. 

Data was collected before and after completion of the program, and included changes in behaviors, such as food portions and physical activity, and physical data such as A1c, blood pressure, weight, and waist circumference.

Knowledge is power

Behavioral measures benefitted the most from the garage analogy approach.  At the beginning of the study, 29.5% of the men reported not knowing how to measure food portions and 32% did not know how to count their carbs. After the program, 61% were measuring food portions at least once a week and 20% of them were doing it at least 4 days a week. Carb counting went from only 13% of men doing it at least 4 days a week to 22%.  

After the workshops, 93% of men felt more confident in their diabetes management.  The program also increased their confidence in their access to diabetes resources and support access.  

The physical outcomes were statistically insignificant, but they tended to trend in the right direction, says Dr. Concha.  There was a small increase in weekly physical activity and no increase in weight or waist circumference. HbA1C remained stable (7.36 pre and 7.34 post) as well as blood pressures (systolic: 132.7 pre and 129.3 post; diastolic: 80.3 pre and 78.7 post)

 Regular tune-up: Going beyond the Garage Study

Many of the men who came in the early years of the garage workshops have returned for “tune ups,” says Dr. Concha. There are refresher workshops, but men can come to any of the specific sessions that they feel applies to them. “You don’t get your car serviced just once.”

There is also an “open garage” every three months, to which anyone who has finished the four seminars is invited. “It’s a 2-hour online session where you can talk to diabetes educators,” says Dr. Concha. “There is no structure, just checking in. Men come for all two hours or drop in for two minutes. At the last one, 14 men logged in.” The next one, in August, will be a hybrid, with both in person and online participation.

Some of the participants struggled during COVID. The Hispanic community in Texas was hard hit by the pandemic, and those with diabetes were at higher risk. “The men shared resources with each other,” Dr. Concha says, adding that “if you provide them with space, they are willing to open up and be vulnerable. We cover stress in the workshops, so they may feel more comfortable opening up about it in the open garage.”

The improvements they found in the study didn’t surprise Dr. Concha. “I see people LOOK different between week one and week two. We talk about medication and the importance of taking medications correctly in week 1. We talk about the importance of drinking more water, and when to take the medications.” 

Currently, Concha is working on a grant to look at longitudinal data for the program – at 6 and 12 months, and she hopes in the future to have the program approved as a certified diabetes education curriculum so it can be copied and implemented in other locations. In the meantime, she has fielded calls from people interested in this concept.

Diabetes Garage is exclusively for those already diagnosed with diabetes. “I think we see men coming to this program because something serious has happened that has encouraged them to engage with their health. I wish more men came in preventive stages, but they just don’t see it as serious.”

She says she tried to open it up to those who were not yet diabetic, but it didn’t work out. “We had one man come whose A1c was 5.4, and he said he wasn’t going to continue. He didn’t think this applied to him.”

As for women, the last session is opened up to family members and other people who support the patient. However, this particular program is, in general, just for men. It could be replicated to be multi-gendered, but she does think that women and men respond a lot more openly in single-sex groups. “There is a disparity in that men don’t often attend diabetes education. When you see a disparity, you target the group not getting the intervention. This would work for women, too, but I think the analogy of cars and bodies both needing maintenance really speaks to a lot of men.”

When you talk in analogies, she continues, she can often see a light bulb of understanding go on in a man. “They respond when we talk about cars, especially in this part of the country. But rather than just do off-the-cuff analogies, we made it a whole program.”

The one thing she would like to improve is the referral network. “I thought it would be easier. We sent out 200 letters to providers, and we are working on reminders, but a lot are just not aware of DSME programs and how impactful they can be.”

Both of the programs highlighted at the ADA conference have the same thing in common, says Piatt: “They are reaching people where they are in terms they understand and can relate to. Meet them where they are and allow them to drive how much program they want, and you will make an impact.”

Continue Reading:
Online Self-Management Tools Found to be Useful for Patients with Poorly Controlled Type 2 Diabetes
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