Telephone based self-management support by ‘lay health workers’ and ‘peer support workers’ to prevent and manage vascular diseases: a systematic review and meta-analysis

Background Improved prevention and management of vascular disease is a global priority. Non-health care professionals (such as, ‘lay health workers’ and ‘peer support workers’) are increasingly being used to offer telephone support alongside that offered by conventional services, to reach disadvantaged populations and to provide more efficient delivery of care. However, questions remain over the impact of such interventions, particularly on a wider range of vascular related conditions (such as, chronic kidney disease), and it is unclear how different types of telephone support impact on outcome. This study assessed the evidence on the effectiveness and cost-effectiveness of telephone self-management interventions led by ‘lay health workers’ and ‘peer support workers’ for patients with vascular disease and long-term conditions associated with vascular disease. Methods Systematic review of randomised controlled trials. Three electronic databases were searched. Two authors independently extracted data according to the Cochrane risk of bias tool. Random effects meta-analysis was used to pool outcome measures. Results Ten studies were included, primarily based in community settings in the United States; with participants who had diabetes; and used ‘peer support workers’ that shared characteristics with patients. The included studies were generally rated at risk of bias, as many methodological criteria were rated as ‘unclear’ because of a lack of information. Overall, peer telephone support was associated with small but significant improvements in self-management behaviour (SMD = 0.19, 95% CI 0.05 to 0.33, I2 = 20.4%) and significant reductions in HbA1c level (SMD = -0.26, 95% CI −0.41 to −0.11, I2 = 47.6%). There was no significant effect on mental health quality of life (SMD = 0.03, 95% CI −0.12 to 0.18, I2 = 0%). Data on health care utilisation were very limited and no studies reported cost effectiveness analyses. Conclusions Positive effects were found for telephone self-management interventions via ‘lay workers’ and ‘peer support workers’ for patients on diabetes control and self-management outcomes, but the overall evidence base was limited in scope and quality. Well designed trials assessing non-healthcare professional delivered telephone support for the prevention and management of vascular disease are needed to identify the content of effective components on health outcomes, and to assess cost effectiveness, to determine if such interventions are potentially useful alternatives to professionally delivered care.


Methods
Setting: 43 General practices Warwickshire, Coventry, UK. Recruitment: Potential patient participants recruited from 3 general practice clinics; Diabetes Specialist Nurses (DSNs) recruited through DSN directory; Peers recruited through Warwick Diabetes Care User Group, plus email support group. Asked to give their experience on offering telephone advice, counselling and reasons for participating in the study. Engaged and interested participants were allocated roles and paid a small amount (not reported). Randomisation: RCT 3 arm Definition of non-health care professionals: 'Based on the concept of sharing mutual experience and experiential knowledge' benefiting the peer and the participant by increasing feelings of self worth and changes in self-management behaviour'. Peer training: Peers attended a two day training programme developed for the study which focused on empowerment, motivational interviewing, active listening skills, and telephone role playing. Participants 231 Patients with diabetes; 9 Peers (males n = 4; females n = 5; age range 35 -75 years; type 2 diabetes n = 6; 5 -28 years duration of diabetes);12 DSNs (all female; 35 -63 years age range; 6 -22 years diabetes nursing experience; type 2 diabetes n = 1).

Interventions
Calls for up to 6 months. The first call was made 3-5 days later and at the following days: 7-10, 14-18, 28-35, 56-70, 120-150. More intense reinforcement of behaviour change occurred during the early weeks following initiation. The frequency of calls was intended to be tailored to patients' individual needs and callers were taught to negotiate the time of subsequent contact as part of the closure of each call. Caller: Made telephone calls from a confidential space in the workplace or home. Invited to share challenging cases at 6 month review meetings. Control group: Patients were informed that they were allocated to the routine care group; Received a single call from a researcher at day 3 -5; Encouraged to follow the advice of GP or practice nurse.

Outcomes
Mental health: Diabetes distress. Training: CDAs were selected based on recommendations of the church and trained over a 1-month period -4 weekly, 4 hour sessions -in the areas of motivational interviewing techniques, listening skills, diabetes self-management, and telephone counselling. Participants 20 years or older; diagnosis of type 2 diabetes, clinical care provided by a primary care practitioner; plans to reside within 50 miles of church for 1 year; and telephone access.

Interventions
Special Intervention (SI) involved 1 individual 60 minute counselling visit to a dietician to facilitate subsequent counselling by the CDAs and 12 bi-weekly group education sessions at each church (led by the dietician and assistance of a CDA), each lasting 90 -120 minutes, encouraging behaviour change and education. CDA delivered monthly telephone calls for 1 year to offer support for behaviour change to improve diabetes self-management. Caller: Calls made by CDAs. Control group: Minimal Intervention (MI) was a direct mailing of 2 pamphlets ("Healthy Eating" and "Staying Active") and 3 bimonthly newsletters, published by the American Diabetes Association, providing general health information and study updates.

Outcomes
Mental health: General health. Self management/ PROMS: Amount of physical activity; Diabetes related knowledge; Diabetes-related health status; dietary intake. Clinical outcomes: Change in HbA1c level (determined by a finger sample collected at participant's church).
Health utilisation: None recorded.
Costs: None recorded.