| Background:International Diabetes Federation(Abbreviation: IDF) have estimated that there are 415 million patients with dabetes in 2015 and have projected that more than 642 million people will have diabetes by 2040. China is one of the developing countries where the prevalence of diabetes has increased rapidly over the last 30 years. Data from five national surveys indicated that the prevalence of diabetes grew from 0.7% in 1980 to 11.6% in 2010. Overall, more than 113 million Chinese adults are affected by diabetes at present, making China the leading nation globally in terms of the number of diabetes patients. Furthermore,the prevalence of prediabetes was 50.1% among adults aged ≥ 18 years old. Observational evidence showed theat 5~10% of people per year with prediabetes will progress to diabetes. Therefore, diabetes(predominantly type 2 diabetes(Abbreviation: T2DM) is one of the largest global health emergencies of the 21 st century.World Health Organization(Abbreviation: WHO) and goverments pay high attention to improve the prevention and control of diabetes. In addition to medication, a large number of studies have indicated that non-pharmacological intervention on T2 DM can play an effective role in prevention and control diabetes. At present, therapeutic lifestyle changes along with pharmacological approach are recommended by Chinese Diabetes Society. According to the China Type 2 Diabetes Standard Management Practice, health education activities, including regular health lectures and individual consultations are recommended at primary health centers. How to improve compliance is the key and difficult problem in future studies. In recent years, health interventions delivered by technology platform and the integration of social resources, such as peer support and information technology, have shown several promising prospect in increasing compliance and saving resource.Objective:1) To assess the feasibility and effectiveness of community-based comprehensive intervention on T2 DM on a large population.2) To assess the effects of peer support at improving glycemic control in patients with T2 DM.3) To construct a new intervention model for prediabetes based on peer support and information technology platform.Methods:1) An intervention study was conducted on 7200 patients with type 2 diabetes according to the China Type 2 Diabetes Guidelines(2010) and the National Essential Public Health Services Standard(2010) within one year. A “knowledge, attitude and practice”(Abbreviation: KAP) survey and fasting plasma glucose(Abbreviation: FPG) measurement were conducted at baseline and after the intervention, respectively.2) A meta-analysis of Randomized Controlled Trials(Abbreviation: RCTs) that evaluated the effect of peer support on type 2 diabetes was conducted. Relevant electronic databases,including CNKI, CBM, MEDLINE, EMBASE, Cochrane Collaborative database were sought for RCTs. The risks of bias were assessed tby using The Cochrane Collaboration’s tool. Statistical analyses were conducted by Review Manager 5.2 and Stata version 12.1 software. Outcome was the pooled mean difference(Abbreviation: MD) in Glycated hemoglobin A1C(Abbreviation: Hb A1c) levels between the intervention and control groups, along with the 95% Confidence interval. To assess the potential confounding effect of Heterogeneity, subgroup analyses were performed, according to the characteristics of studies, the Hb A1 c levels of participants at baseline, the mode of peer support, the frequency of contact, and the length of intervention.3) A new intervention model based on behavioral intervention theory was constructed for prediabetes. The intervention content was determined through qualitative research. Representative intervention and control cohorts were established in communities and the comparability of the two groups was analyzed. The communication network based on peer support and information technology was established for each participant in intervention group and their preliminary behavior compliance was evaluated through regular behavior surveillance.Results:1) A total of 6586 T2 DM patients completed the intervention. After one year intervention, the average FPG has decreased from 8.52 mmol/L(Standard Deviation(Abbreviation: SD): 2.84) to 7.44 mmol/L( SD: 2.06) and participants’ glycemic control rate has increased from 27.18% to 52.82%(p < 0.001). Patients’ KAP level had improved from 39.95% ~ 74.83% to 72.50 ~ 85.44%(p < 0.001). Percentage of participants’ adherence to medication compliance, lifestyle modification and self-monitoring of blood glucose more than 1 time per week significantly increased(from 19.48% to 75.19%; 19.02% to 68.10%; 18.78% to 41.62%, respectively; p < 0.001). After one year intervention, FPG of participants in rural areas and low education level were 7.77mmol/L(SD: 2.27) and 7.60mmol/L(SD: 2.21), significantly higher than those in urban regions and with high education level. Patients’ glycemic control rate in rural areas and low education level were 44.80% and 49.70%, significantly lower than those in urban regions and with high education level.2) A total of 3223 citations were identified initially and thirteen RCTs met the inclusion criteria, involving 2352 participants. There was significant heterogeneity among the trials regarding changes in Hb A1c( I2 = 80.0%), thus, a random effects model was used for meta-analysis. Peer support resulted in a significant reduction in Hb A1c( MD-0.57 [95% CI:-0.78 to-0.36]). The reduction in Hb A1 c were greater among patients with a baseline Hb A1 c ≥ 8.5%(MD-0.78 [95% CI:-1.06 to-0.51]) and between 7.5 ~ 8.5%( MD-0.76 [95% CI:-1.05 to-0.47]), than patients with Hb A1 c < 7.5%( MD-0.08 [ 95% CI:-0.32 to 0.16]). Programs with moderate or high frequency of contact showed a significant reduction in Hb A1 c levels( MD-0.52 [95% CI:-0.60 to-0.44] and-0.75 [95% CI:-1.21 to-0.29], respectively), whereas programs with low frequency of contact showed no significant reduction( MD-0.32 [95% CI:-0.74 to 0.09]). Patients in four studies were provided with individual intervention and responded by a greater reduction in Hb A1 c level(MD-0.91) in comparison with patients provided with group session education(MD-0.42) or a combination of group and individual education(MD-0.52). Three of the four peer-led individual intervention RCTs were conducted by telephone. No major differences in Hb A1 c levels relative to publication year, the mode of peer support, study location or the duration of intervention.6 3) A series of standardized intervention contents was designed by experts, including diet, physical activity and traditional Chinese medicine, which were divided into ten tasks. A total of 522 prediabetes were recruited and assigned into intervention group(285 prediabetes) or control group(237 prediabetes). Peer support network including community health workers, family menbers, other prediabetes, and mobile software was established for each participant in intervention group. The basic emographic characteristic, glucose level and lipidemia level of participants in intervention and control group were equally comparable. The compliance of some health behavior of prediabetes in intervention group was improved after 8 weeks intervention.Conclusions:1) The result indicated that the community-based comprehensive intervention strategy was effective on decreasing T2 DM patient’s FPG and increasing glucose control rate, however, the glycemic control rate was still very poor. Improving and repeating the comprehensive strategy is greatly recommended in order to sustain the impact.2) The effect of the community-based comprehensive intervention strategy was influenced by several factors. Patients in rural areas and with lower education level showed higher FPG, poorer awareness of type 2 diabetes-related health-knowledge and poorer attitudes and practices towards diabetes self-care. Therefore, different strategies should be implemented for different population.3) Peer support has shown promising prospects in the worldwide. The results indicated that peer support had a significant impact on Hb A1 c levels among patients with T2 DM. Priority should be given to programs with moderate or high frequency of contact(more than one contact in a month per patient) for target patients with poor glycemic control rather than programs with low frequency of contact that target the overall population of patients. Therefore, if carefully designed and implemented, telephone-based peer support might be a satisfactory choice for diabetes management and should be introduced on a large scale.4) The new intervention model based on peer suppot and information technology might be cost-effective. Further evaluation will provide the basis for decision-making for diabetes control and prevention in future in Chongqing.5)Poor awareness of diabetes prevention and poor compliance were very common among prediabetes. It should be useful to improve compliance by implementing more detailed intervention strategies. Futhermore, family-based intervention might be beneficial to improve effectiveness. |
PDF Full Text Request