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Summary: Background: Diabetes self-management education and support (DSMES) improves glycemia via improved care coordination and self-management behaviors driven by educational programs tailored to individual needs, but scalable models for its delivery in low- and middle-income countries are lacking. We evaluated the effectiveness of two scalable models of DSMES delivery: two sessions with a nurse (nurse-led) or one each with a nurse and a lay volunteer (peer-assisted). Methods: A three-arm cluster randomized trial was conducted comparing two DSMES interventions (nurse-led or peer-assisted) to routine care. The interventions consist of two DSMES sessions (once at baseline and a refresher at 6 months). The nurse-led group was delivered only by nurses, while the peer-assisted group was delivered by nurses with peer assistance. Seven primary care units were allocated to each arm. Newly diagnosed (at enrollment) or high risk glycemia (baseline HbA1c >10%) people with type 2 diabetes were eligible. Primary outcomes were differences in HbA1c and Thai-CV risk score (estimates ten-year risk of cardiovascular events in Thai population based on various clinical parameters) at 12 months relative to routine care. Secondary outcomes were individual cardiovascular risk factors. Findings: 693 individuals were enrolled (mean age 59 years, 269 (39%) male, and 424 (61%) female) and 664 completed the study (4% total drop-outs). For the control, nurse-led, and peer-assisted arms respectively, the means (SD) for primary outcomes are as follows. For HbA1c: at baseline; 8.5% (1.4), 8.5% (1.9), and 8.8% (2.0), at 12-month; 7.8% (1.6), 7.7% (1.3), and 8.1% (1.6). For Thai-CV risk scores: at baseline; 22 (15), 23 (15), and 23 (14) at 12-month; 21 (14), 23 (15), and 22 (13). Mean differences at 12-month from control (95% confidence intervals) for nurse-led and peer-assisted arms respectively were: HbA1c; −0.1% (−0.4 to 0.1) and 0.1% (−0.2 to 0.5), Thai-CV risk scores; 0% (−2 to 2) and −0% (−2 to 2). Interpretation: While there were no improvements in HbA1c or CV risk scores, low drop-out rates observed demonstrate the feasibility of the models. Future explorations of the appropriate balance between the intensity and feasibility of program delivery are needed. Funding: UK Medical Research Council (MR/R020876/1). Thailand Research Fund (DBG6180007).
Aramrat et al. (Tue,) studied this question.