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CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0053 Page 1 of 10 O R I G I NA L R E SE A R C H Intervention Mapping as a Guide for the Development of
a Diabetes Peer Support Intervention in Rural Alabama
Andrea Cherrington, MD, MPH; Michelle Y. Martin, PhD; Michaela Hayes, MPH; Jewell H.
Halanych, MD, MPH; Mary Annette Wright, PhD; Susan J. Appel, PhD; Susan J. Andreae, MPH;
Monika Safford, MD
Suggested citation for this article: Cherrington A, Martin MY, Hayes M, Halanych JH, Wright MA, Appel SJ, et al.
Intervention mapping as a guide for the development of a diabetes peer support intervention in rural Alabama. Prev
Chronic Dis 2012;9:110053. DOI: http://dx.doi.org/10.5888/pcd9.110053 .
PEER REVIEWED Abstract
Introduction
Peer support is a promising strategy for the reduction of diabetes-related health disparities; however, few studies
describe the development of such strategies in enough detail to allow for replication. The objective of this article is to
describe the development of a 1-year peer support intervention to improve diabetes self-management among African
American adults with diabetes in Alabama’s Black Belt.
Methods
We used principles of intervention mapping, including literature review, interviews with key informants, and a
discussion group with community health workers, to guide intervention development. Qualitative data were combined
with behavioral constructs and principles of diabetes self-management to create a peer support intervention to be
delivered by trained peer advisors. Feedback from a 1-month pilot was used to modify the training and intervention.
Results
The resulting intervention includes a 2-day training for peer advisors, who were each paired with 3 to 6 clients. A oneon-one in-person needs assessment begins an intensive intervention phase conducted via telephone for 8 to 12 weeks,
followed by a maintenance phase of at least once monthly contacts for the remainder of the intervention period. A peer
support network and process measures collected monthly throughout the study supplement formal data collection
points at baseline, 6 months, and 12 months.
Discussion
Intervention mapping provided a useful framework for the development of culturally relevant diabetes peer support
intervention for African Americans living in Alabama’s Black Belt. The process described could be implemented by
others in public health to develop or adapt programs suitable for their particular community or context. Introduction
The prevalence of type 2 diabetes is increasing (1). In the United States, the disease disproportionately affects minority
populations, particularly African Americans in the rural South (2). Proper diabetes self-management can lead to
improved glycemic control, blood pressure, and lipid levels, and can mitigate the negative health effects of comorbid
conditions (3,4). However, the demands of self-management behaviors (eg, diet modification, physical activity,
medication adherence, self-monitoring of blood glucose levels) can be difficult to balance and are influenced by
socioeconomic, cultural, and psychosocial factors such as lack of social support, self-efficacy, coping skills, and
increased barriers to self-care (2,5,6). Residents of rural areas face additional barriers to diabetes self-management,
including limited access to health care services, providers, and education programs; high rates of poverty; low levels of
health literacy; and increased distances from social networks (7).
These conditions are widespread in Alabama’s Black Belt region. Named for its dark soil and agricultural history, the CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0053 Page 2 of 10 Black Belt encompasses approximately 18 counties in southern Alabama. African Americans comprise more than 30%
of the population; rates are as high as 80% in some areas. In this region, more than 30% of African Americans over the
age of 50 have diagnosed diabetes.
As diabetes self-management has received more attention, strategies (eg, increasing social support) have been
proposed to meet the needs of those living with diabetes (5,8). However, such programs may be difficult to implement
in rural settings, and limited effects of classic support (ie, family/spouse) have strengthened the case for peer-involved
programs (7,8).
Peer advisors are ideal for community-based support programs because of their ability to serve in a reciprocal,
nonhierarchical capacity. In general, peer advisors are nonprofessionals with an intimate knowledge of the difficulties
of disease management who can provide support on the basis of shared life experiences (9,10). Peer-based programs
improve health behaviors as well as health status (5). For example, a recent peer advisor program demonstrated
improved communication with health care providers, use of community resources, and diabetes management (11).
Studies in the United States indicate that peer advisors may be successful in minority populations and with people who
may distrust traditional health care systems (12,13).
In rural settings, the combination of peer advisors with telephone-based support may be particularly effective; it
eliminates barriers such as transportation, costs of group attendance, and time constraints (7,14). Studies of telephone
interventions show that they help improve glycemic control (2,15).
The objective of this study is to describe our experience with the use of intervention mapping as a guide for the
development of a peer support diabetes intervention for a rural, medically underserved population (16). Intervention
mapping is a systematic process that combines theory, empirical evidence from the literature, and data from the
community to develop health education programs. The process involves multiple steps that begin with a community
assessment and continues by fostering collaborations with community stakeholders during intervention development
and program planning. Intervention mapping has been used successfully to develop health behavior programs, mostly
related to cancer (17,18). Methods
Intervention mapping is an iterative process encompassing 6 key stages. For several years before the grant funding for
the peer support intervention, we conducted the literature review and semi-structured interviews. This preliminary
work provided investigators with a foundation from which to respond to the Peers for Progress call for proposals; we
worked with existing community partners to develop the study design. After funding was received in 2009, 8 months
were spent developing the intervention, which included conducting unstructured interviews with community members
and a discussion group with community members of an existing community health worker (CHW) network. Step 1. Needs assessment
The needs assessment was based on 1) a literature review of existing diabetes programs involving peers or lay health
workers, 2) nationwide field experience, and 3) local needs assessment.
1. Literature review. A review of diabetes programs involving peer advisors around the United States was conducted,
the results of which have been published elsewhere (9). Briefly, we found that peer advisor roles, responsibilities, and
training varied across programs and were context-specific. After our review, the World Health Organization (WHO)
identified 3 main peer advisor roles related to diabetes self-management: to link, to assist, and to support (19). We
used information from our own review and from the WHO report to conceptualize the peer advisor role (Figure 1). CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0053 Page 3 of 10 Figure 1. Role of peer advisors in diabetes management — assist, support, and link, in the context of the chronic care
model. Abbreviations: A1c, hemoglobin A1c; BP, blood pressure; LDL, low-density lipoprotein cholesterol. [A text
description of this figure is also available.]
2. Field experience. In parallel with our literature review, semi-structured interviews were conducted with program
managers from diabetes peer advisor programs across the country, allowing for an in-depth exploration of barriers and
facilitators to implementation. This work indicated that peer advisors are prone to burnout and the positions are prone
to turnover; remuneration, both monetary and nonmonetary incentives, is another consideration. A full report of the
results has been published elsewhere (20). These lessons influenced the intervention structure and content.
Specifically, plans were made for a manageable caseload (3-6) with limited paperwork and simplified forms.
Additionally, support networks were designed to facilitate interaction between peers and extend to investigators and
community coordinators.
3. Local needs assessment. The priority population for this study was African American adults with diabetes living in
Alabama’s Black Belt. Assessments conducted by the Alabama Department of Public Health (ADPH) have documented
racial disparities related to diabetes and associated complications, particularly in many Black Belt counties. ADPH
determined that, when stratified by race and sex, diabetes prevalence among African American women was 7% higher
than among white women (21). Furthermore, diabetes prevalence was significantly higher in Alabama residents whose
annual household incomes were less than $35,000 (21). Many of these areas also lack primary health care providers,
endocrinologists, and other resources, including diabetes education. ADPH reported in 2010 that endocrinologists and
diabetes educators in Alabama are located in mostly urban counties with higher populations (21). For example, 57 of
the 67 counties have no endocrinologists, and 45 of 67 counties have no certified diabetes educators (21).
Socioeconomic constraints further exacerbate the problem; one-third of Black Belt residents have incomes below the
federal poverty level (22). Informal needs assessments conducted among members of existing cancer community
coalitions revealed that diabetes was an area of concern among community members and that a program focused on
diabetes was a natural next step. Furthermore, discussions with community members and staff at partnering practices CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0053 Page 4 of 10 revealed that a formal diabetes education program would benefit the community. Thus, in the design phases of the
study, it was decided that both trial arms would include diabetes education. Step 2: Identifying outcomes and change objectives
Results from Step 1 were used to identify outcomes and change objectives. Although the overarching objective of this
intervention is to improve glycemic control, blood pressure, and lipid levels through a peer advisor intervention
designed to improve self-care, proximal measures, including self-care behaviors, were selected as secondary outcomes
(Figure 2). Additionally, we included patient-centered outcomes such as quality of life, depressive symptoms, and
stress. Similarly, we were interested in potential antecedents to or mediators of those behaviors, such as self-efficacy
and patient empowerment. These complemented our theoretical basis and our plans for peer support. Figure 2. Development of peer support intervention: mediating variables, self-care behaviors, and primary outcomes.
Abbreviations: A1c, hemoglobin A1c; BP, blood pressure; LDL, low density lipoprotein. [A tabular version of this figure
is also available.] Step 3: Selecting theory-based methods and practical strategies
The chronic care model served as a conceptual framework for the overall intervention (23). In previous work, we have
proposed integrating peer advisors into the chronic care model at the intersection of community and health care
organizations (20). For this study, we conceptualized the peer advisors as conducting activities within the community,
helping participants access resources within the community and the health care system. The theoretical foundation of
our intervention combined several complementary theories, including the health belief model, social cognitive theory,
adult learning theory and empowerment model, and social networks and social support, each of which has been
applied to diabetes management in previous studies (Appendix A) (13,24-28). Grounding the intervention in behavior
change theory combined with measures tied to theory-based constructs allowed us to understand the pathways to any
intervention effects.
Practical strategies for intervention delivery were based on evaluation of literature and existing peer-based programs
(described earlier), including an assessment of specific needs of volunteers (29). Strategies were further informed by a
discussion group with 7 peer advisors from previous cancer awareness projects in the Black Belt. The purpose of the
discussion group was to solicit feedback on the structure of the peer advisor program, recruitment and retention
strategies, methods for intervention delivery, and perceived needs. Additional input was solicited for developing
training manuals, educational materials, and participant incentives. Step 4: Developing the program
Because many communities in rural Alabama lack access to diabetes education, we chose to develop a diabetes
education program for both intervention and control participants. For the peer support intervention, we hypothesized
that people with diabetes coached by trained peer advisors will experience more observational learning opportunities,
reinforcement, and social support, leading to improved health behaviors, metabolic measurements, and, ultimately,
quality of life. On the basis of a literature review, the team felt that people who either lived with diabetes themselves or
helped a close friend or family member with their daily diabetes self-care would be the best peer advisors (29).
We then conducted a 4-week pilot of the training and the intervention. We trained 2 peer advisors and recruited 7
participants from a community health center, from an existing community diabetes support group, and by word of
mouth. Peer advisors met their clients on enrollment day to conduct the needs assessment and then called their clients
weekly. Peer advisors also had weekly calls with investigators to report on progress and troubleshoot problems. The
calls provided an opportunity to observe intervention fidelity, reinforce skills taught during training, and offer support. CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0053 Page 5 of 10 Results
The education program consists of three 30-minute interactive learning modules led by nurses or trained health
educators. Content is based on information from the American Diabetes Association’s 2009 Standards of Care
Guidelines (30) and from a segment we developed that focuses on “raising the BAR (Be prepared, Ask and learn,
Reflect and reach out) on your doctor visit.” The learning modules include 1) diabetes basics and the office visit, 2)
healthy eating, and 3) exercise and stress management (Appendix B).
We planned for peer advisors to provide a flexible, informal approach to assisting patients, based on role modeling and
patient empowerment/activation, rather than formal delivery of a diabetes education curriculum. We identified and
developed training activities consistent with 3 main roles: assist, support, and link (Figure 1). Training content
included discussion of peer advisor roles and expectations, principles of motivational interviewing and
communication, goal-setting and problem-solving, human subjects in research protections, health care and community
resources, diabetes basics, and training on the protocol and forms required for process data collection.
The intervention begins with the peer advisor conducting an in-person needs assessment to identify an area of diabetes
management that the client wants to improve. The needs assessment reviews medication adherence, diet, exercise,
stress, and talking to their doctor. Using motivational interviewing techniques, the peer advisor guides the participant
to set 1 SMART (specific, measurable, achievable, realistic, time-oriented) goal.
After the initial meeting, the peer advisor contacts the client weekly by telephone for 8 to 12 weeks (intensive
intervention phase) and at least monthly thereafter (maintenance phase). At each telephone contact, the peer advisor
asks the client about new problems, reviews the client’s SMART goal, and if the goal has been met, collaboratively sets
a new goal. If the client does not want to discuss the goal, the peer advisor provides support and documents the
discussion. If the client is having trouble attaining the goal, the peer assists the client in identifying barriers and
problem-solving.
In a separate contact made a day or 2 before an office visit, the peer and client plan for the visit and develop a strategy
for asking questions and understanding recommendations. Another contact is made a day or 2 after the visit to review
what occurred, make plans as needed, and, if necessary, recontact the office to address unmet needs. Pilot testing the intervention
We conducted a 4-week pilot of the training and the intervention. After completion of the pilot, study investigators
conducted two 1-hour group interviews, one with peer advisors and one with the clients. Overall, the intervention was
well received and the study forms were deemed reasonable. Both peers and clients felt that transitioning to monthly
calls after 8 weeks may not provide enough support and recommended a flexible, client-tailored approach to
lengthening the call interval. The intervention was modified accordingly.
Feedback from the pilot peer advisors also led us to create a peer support network. Peers assigned to a particular
region were asked to function as a team to enhance retention and morale, minimize burnout, and permit case
reassignment should a peer drop out. Monthly support meetings were planned during the intervention period, and
each peer advisor was paired with another peer advisor from their area as a one-on-one supporter. Steps 5 and 6: Planning for implementation and evaluation
To aid implementation and adoption, information from the pilot was used to modify the peer training manual so that it
could serve both as a guide for the training sessions and as an ongoing resource during the intervention period and
beyond. Currently, the program is being tested in a group-randomized trial. More than 60 peer advisors have
completed training, 424 participants have been enrolled, and 200 have been matched to peer advisors.
Evaluation measures include biometric measures (hemoglobin A1c, blood pressure, low-density lipoprotein
cholesterol, body mass index, and waist circumference) and patient-centered measures along with theory-based
behavioral outcomes (see step 2). Measures have been collected at baseline and will be collected again 6 and 12 months
later. To facilitate this process, the study team trained several community members to assist with data collection,
including biometric assessments and face-to-face interviews.
Process measures are being collected from peer advisors. Using the pilot-tested contact forms, peers document each
contact, both scheduled and spontaneous, and, through separate forms, contacts before and after the office visit. Forms
are submitted to community coordinators at monthly meetings and evaluated by coordinators and the investigative
team for prompt action should deficits be identified. In addition, telephone contacts between investigators, groups of 3
to 4 peer advisors, and the community coordinator take place weekly for the first 4 weeks and at 6-week intervals
during the maintenance phase. These calls allow investigators and peers to review progress, troubleshoot problems,
and reinforce training. CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0053 Page 6 of 10 Discussion
The systematic and collaborative approach to program development described in this article is guided by principles of
intervention mapping in the context of community-based participatory research. The 6-step intervention mapping
framework resulted in a peer-delivered diabetes self-management program that was informed by health behavior
theory and local context to be responsive to community needs. The resultant intervention is patient-centered, peerdelivered via telephone, and focuses on building goal-setting and problem-solving skills. Community involvement in
the early planning stages led to adjustments in program design and implementation that, although specific to this
study, may have implications for programs targeting rural areas more broadly.
For most communities, willingness to partner with research institutions is balanced with the desire to advocate for
needed resources. Randomized controlled trials are often viewed with skepticism as individuals or entire communities
risk being relegated to the control arm, often without tangible benefits (31-33). The need to respond to communityidentified needs and create sustainable partnerships becomes more apparent as research efforts increasingly focus on
translating interventions into real-world settings. This is evident in the increasing number of investigators employing
community-based participatory research methods.
Although implementing alternative designs to randomized controlled trials can overcome the resistance by many
communities to the control arm, our development process, particularly feedback obtained from partnering practices
and community leaders, provided us with a potential solution. We elected to develop education services for both trial
arms. In the Black Belt, community health centers and organizations attempt to provide quality health care with very
limited resources, and formal diabetes education is unavailable. In this study, early discussions with providers and key
community leaders even before applying for funding confirmed the importance of providing education to all
participants, and our community partners cited the offer of such a program as a key component of successful
recruitment efforts and community engagement.
Early formative work with community partners also proved essential for developing support strategies for peer
counselors. Previous studies have found that peer advisors are prone to burnout, leading to high turnover rates (20).
Contributing factors include perceived isolation and lack of ongoing support, coupled with a high caseload and heavy
paperwork (20,34-36). These lessons were confirmed by discussions with existing peer advisors in the Black Belt.
Therefore, plans were made during the pilot phase for weekly calls between investigators and peers to debrief and
provide support. A “buddy system” and a regional support group added another dimension of peer support. The
challenge of this extensive approach is the need for significant investigator and study staff time and resources.
However, investigators profited considerably from these labor-intensive contacts, obtaining reassurance on
intervention fidelity, having opportunities to reinforce training, and deepening bonds with the peer advisors. Future
studies are needed to better understand peer advisor support needs and to develop sustainable strategies to deliver
such support beyond the life of study.
Intervention mapping was a comprehensive approach to community-based intervention development that was both
highly regarded by our community partners and scientifically rigorous. Key features included engaging community
members from the beginning, even before applying for grant funding, and staying engaged throughout program
development and implementation. Although details and specific procedures were designed for and with African
Americans living in Alabama’s Black Belt and may not be generalizable to other settings, our experience and strategies
may be helpful for others developing interventions in underserved communities. Acknowledgments
Support for this study was provided by a grant from Peers for Progress, a program of the American Academy of Family
Physicians Foundation supported by the Eli Lilly and Company Foundation, Inc, and the University of Alabama at
Birmingham Diabetes Research and Training Center (no. P60 DK079626). Author Information
Corresponding Author: Andrea Cherrington, MD, MPH, Division of Preventive Medicine, 624 Medical Towers,
University of Alabama at Birmingham, 1530 3rd Ave S, Birmingham, AL 35205-4410. Telephone: 205-996-2885. Email: acherrington@mail.dopm.uab.edu.
Author Affiliations: Michelle Y. Martin, Michaela Hayes, Jewell H. Halanych, Susan J. Andreae, Monika Safford,
School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Mary Annette Wright, Susan J.
Appel, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama. References CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0053 Page 7 of 10 1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and
projections for 2030.
Diabetes Ca...
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