Recruitment and retention in a 10-month social network-based intervention promoting diabetes self-management in socioeconomically deprived patients: a qualitative process evaluation.

OBJECTIVES: Socioeconomically deprived patients with type 2 diabetes often face challenges with self-management, resulting in more diabetes-related complications. However, these groups are often under-represented in self-management interventions. Evidence on effective recruitment and retention strategies is growing, but lacking for intensive self-management interventions. This study aims to explore recruitment, retention and effective intervention strategies in a 10-month group-based intervention among Dutch, Moroccan, Turkish and Surinamese patients from socioeconomically deprived neighbourhoods. METHODS: Participants were recruited through general practitioners (GPs) and participated in a 10-month social network-based intervention (10 groups, n=69): Powerful Together with Diabetes. This intervention also targeted the significant others of participants and aimed to increase social support for self-management and to decrease social influences hindering self-management. A qualitative process evaluation was conducted. Retention was measured using log books kept by group leaders. Further, we conducted 17 in-depth interviews with participants (multiethnic sample) and 18 with group leaders. Interviews were transcribed, coded and analysed using framework analyses. RESULTS: The GP's letter and reminder calls, an informational meeting and the intervention's informal nature facilitated recruitment. During the first months, positive group atmosphere, the intervention's perceived usefulness, opportunities to socialise and a reduction in practical barriers facilitated retention. After the first months, conflicting responsibilities and changes in the intervention's nature and planning hindered retention. Calls from group leaders and the prospect of a diploma helped participants overcome these barriers. CONCLUSION: To promote retention in lengthy self-management interventions, it seems important that patients feel they are going on an outing to a social gathering that is enjoyable, recreational, useful and easy to attend. However, rewards and intensive personal recruitment and retention strategies remained necessary throughout the entire intervention period. TRIAL REGISTRATION NUMBER: Dutch Trial Register NTR1886; Results.

Development of the Social Network-Based Intervention "Powerful Together with Diabetes" Using Intervention Mapping.

This article describes the development of the social network-based intervention Powerful Together with Diabetes which aims to improve diabetes self-management (DSM) among patients with type 2 diabetes living in socioeconomically deprived neighborhoods by stimulating social support for DSM and diminishing social influences hindering DSM (e.g., peer pressure and social norms). The intervention was specifically developed for patients with Dutch, Turkish, Moroccan, and Surinamese backgrounds. The intervention was developed according to Intervention Mapping. This article describes the first four steps of Intervention Mapping: (1) the needs assessment; (2) development of performance and change objectives; (3) selection of theory-based methods and strategies; and (4) the translation of these into an organized program. These four steps resulted in Powerful Together with Diabetes, a 10-month group-based intervention consisting of 24 meetings, 6 meetings for significant others, and 2 meetings for participants and their spouses. The IM method resulted in a tailored approach with a specific focus on the social networks of its participants. This article concludes that the IM method helped our planning team to tailor the intervention to the needs of our target population and facilitated our evaluation design. However, in hindsight, the intervention could have been improved by investing more in participatory planning and community involvement.

The DISC (Diabetes in Social Context) Study-evaluation of a culturally sensitive social network intervention for diabetic patients in lower socioeconomic groups: a study protocol.

BACKGROUND: Compared to those in higher socioeconomic groups, diabetic patients in lower socioeconomic groups have less favourable metabolic control and experience more diabetes-related complications. They encounter specific barriers that hinder optimal diabetes self-management, including a lack of social support and other psychosocial mechanisms in their immediate social environments. Powerful Together with Diabetes is a culturally sensitive social network intervention specifically targeted to ethnic Dutch, Moroccan, Turkish, and Surinamese diabetic patients in lower socioeconomic groups. For ten months, patients will participate in peer support groups in which they will share experiences, support each other in maintaining healthy lifestyles, and learn skills to resist social pressure. At the same time, their significant others will also receive an intervention, aimed at maximizing support for and minimizing the negative social influences on diabetes self-management. This study aims to test the effectiveness of Powerful Together with Diabetes. METHODS/DESIGN: We will use a quasi-experimental design with an intervention group (Group 1) and two comparison groups (Groups 2 and 3), N = 128 in each group. Group 1 will receive Powerful Together with Diabetes. Group 2 will receive Know your Sugar, a six-week group intervention that does not focus on the participants' social environments. Group 3 receives standard care only. Participants in Groups 1 and 2 will be interviewed and physically examined at baseline, 3, 10, and 16 months. We will compare their haemoglobin A1C levels with the haemoglobin A1C levels of Group 3. Main outcome measures are haemoglobin A1C, diabetes-related quality of life, diabetes self-management, health-related, and intermediate outcome measures. We will conduct a process evaluation and a qualitative study to gain more insights into the intervention fidelity, feasibility, and changes in the psychosocial mechanism in the participants' immediate social environments. DISCUSSION: With this study, we will assess the feasibility and effectiveness of a culturally sensitive social network intervention for lower socioeconomic groups. Furthermore, we will study how to enable these patients to optimally manage their diabetes.

Intensified preventive care to reduce cardiovascular risk in healthcare centres located in deprived neighbourhoods: a randomized controlled trial.

BACKGROUND: We examined the effectiveness of a structured collaboration in general practice between a practice nurse, a peer health educator, the general practitioner (GP) and a GP assistant in providing intensified preventive care for patients at high risk of developing cardiovascular diseases. DESIGN: A randomized controlled trial in three healthcare centres (18 GPs) in deprived neighbourhoods of two major Dutch cities. METHODS: Two hundred seventy-five high-risk patients (30-70 years) from various ethnic groups were randomized to intervention (n=137) or usual care group (n=138). We determined group differences in outcomes [10-year absolute risk (Framingham risk equation), blood pressure, lipids and body mass index] at 12-month follow-up. RESULTS: The 10-year absolute risk was reduced by 1.76% (standard error: 0.81) in intervention and by 2.27% (standard error: 0.69) in usual care group; the difference in mean change was 0.88% [95% confidence interval: -1.16 to 2.93]. In both groups significant reductions were observed in the following individual risk factors: total cholesterol, total cholesterol/high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol, with no relevance between group differences. CONCLUSION: The cardiovascular risk profile of intervention and control patients improved after 1-year follow-up. However, no extra effect of the structured preventive care on the risk for cardiovascular diseases was achieved.

Process evaluation of an intensified preventive intervention to reduce cardiovascular risk in general practices in deprived neighbourhoods.

BACKGROUND: A RCT, conducted to examine the effectiveness of a structured collaboration in general practice to provide intensified preventive care in patients at high cardiovascular risk yielded no effect in the total group but differences across healthcare centres and ethnic groups become apparent. We conducted a process evaluation to explain these differences. METHODS: We assessed the reach of the target group and whether key intervention components (individual educational sessions, structured team meetings, and risk assessments) were performed as planned (maximum score for protocol completion is 11). RESULTS: The reach was initially 91%, but only a minority of patients completed the intervention activities as planned. The average score of the number of intervention components was low (5.66 out of 11 (sd 2.8)) and varied between centres (4.84 to 7.40) and ethnic groups (4.89 to 7.38), with team meetings as the least implemented activity conform plan. CONCLUSION: This study indicates that adding a practice nurse and a peer health educator to the general practice did not seem to result in the desired collaboration between the healthcare personnel. Further research is needed to investigate the reasons behind the low participation rate of the patients in the intervention.

Cardiovascular risk factors in Turkish immigrants with type 2 diabetes mellitus: comparison with Dutch patients.

BACKGROUND: Based on recent epidemiological studies the need for a similar approach towards management of cardiovascular risk factors in type 2 diabetics with different ethnic background can be questioned. We compared the prevalence of cardiovascular risk factors and 10-year absolute risk for a coronary heart disease between Turkish and Dutch type 2 diabetes patients. METHODS: A cross-sectional study was performed using databases from three Dutch studies on type 2 diabetes, comparing 147 Turkish to 294 Dutch diabetes patients, matched for age and gender. Main outcome measures were: total (t-) cholesterol, high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), triglyceride, blood pressure, and smoking. The 10-year absolute risk for a coronary event was calculated by means of the Framingham risk equation. RESULTS: In Turkish diabetics t-cholesterol was lower than in Dutch (5.4 vs. 5.9 mmol/l; p < 0.001), in Turkish males HDL was lower than in Dutch male patients (0.94 vs. 1.08 mmol/l; p = 0.04). The total/HDL-cholesterol ratio in Turkish and Dutch diabetics was equal (5.4 vs. 5.4). Less Turkish than Dutch females smoked (9% vs. 23%; p<0.01). The 10-year absolute risk for a coronary event in both Turkish and Dutch male patients was 24%; the risk in Turkish vs. Dutch females was 13% vs. 15% (not significant). CONCLUSION: The absolute risk for a coronary event in Turkish type 2 diabetes patients is similar to the risk in Dutch diabetes patients, although important differences in the risk profile exist, in particular, the lipid profile and smoking habits differ.