Older Adults Using Social Support to Improve Self-Care (OASIS): Adaption, Implementation, and Feasibility of Peer Support for Older Adults with T2DM in Appalachia

Approximately 34.1 million (13%) adults in the US have type 2 diabetes (T2D). The prevalence of T2D is 17% higher in rural dwellers compared to their urban counterparts, and the prevalence of T2D increases with age, with an estimated 25% of older adults (≥ 65 years) having been diagnosed. Appropriate self-care is necessary for optimal clinical outcomes in T2D, and variability in self-care accounts for 90% of the variance in glycemic control. Overall, T2D self-care is consistently poor among the general population but is even worse in rural- dwellers and older adults. Without increased attention to improving self-care, we face an epidemic of T2D and its debilitating complications in rural areas of the US. This is particularly true in rural Kentucky, where up to 23% of adults in Appalachian communities have been diagnosed with T2D and, of those, 26.8% are older adults. Social determinants of health contribute to poor T2D self-care. Social environmental factors, including social support, are integral when promoting the required T2D self-care to attain optimal clinical outcomes. Specifically, the use of peer support has shown to be efficacious in improving T2D self-care behaviors. Literature suggests that peer support is a viable means to assist those diagnosed with T2DM in that it provides emotional support, instrumental support, and education while promoting the development of new skills to help with self-care activities. Peer support has also been shown to improve health behaviors as well as clinical and psychosocial outcomes related to T2D. Due to the high levels of social support reported in Appalachian Kentucky,14 the implementation of a peer support intervention holds promise to mitigate perceived barriers to T2D self-care and improve related clinical outcomes among rural Appalachian Kentuckians. Currently available evidence-based interventions (EBIs) using peer support approaches include support groups, peer coaching/mentoring, and reciprocal peer support, but none has been utilized to target older adults living in rural communities. To address this gap in research, the goal of the proposed study is to partner with local stakeholders to adapt a peer support intervention to be contextually relevant and appropriate for rural dwelling older adults in Appalachian Kentucky. Through formative research with regional practitioners, leaders of service organizations in Appalachia, and residents, we collaboratively identified an acceptable and feasible peer support EBI—peer health coaching (PHC)—that has resulted in improved clinical and psychosocial T2D-related outcomes among participants. Through these community conversations, we have determined necessary a priori adaptations to the EBI to ensure it is culturally and contextually relevant to regional needs and values. Because PHC is a community-based and low-cost intervention, it holds promise to be a sustainable and scalable model across Appalachian Kentucky where resources are often scant but community bonds are valued. For this grant, we will extend our community conversations to finalize necessary adaptations to the EBI and implement it among older adults residing in rural Appalachian Kentucky. Specifically, we will use a randomized 2x2 factorial design to evaluate the preliminary effectiveness and feasibility of two identified adaptations to the EBI: dose and mentor selection strategy. The specific aims of this proposal are as follows: Aim 1: To determine the clinical effectiveness of the adapted EBI. We will pilot and evaluate the adapted peer support intervention in 4 Appalachian counties to determine the preliminary clinical effectiveness for each social support intervention using hemoglobin A1c as the primary outcome. Additional analysis will assess T2D- related psychosocial factors regarding observed hemoglobin A1c changes in each study arm. • Hypothesis 2a: There will be a clinically significant difference in hemoglobin A1c (≥0.5%) from baseline. • Hypothesis 2b: There will be a statistically significant difference in T2D-related psychosocial factors from baseline. Aim 2: Evaluate the pragmatic implementability of the adapted EBI. Guided by the Practical, Robust Implementation and Sustainability Model (PRISM), which incorporates RE-AIM outcomes, we will collect quantitative and qualitative data at program beginning, midpoint, and conclusion to assess PRISM domains and give context to both anticipated (i.e., pre-implementation) and unanticipated (i.e., midstream) EBI adaptations. We will use an iterative approach to RE-AIM to collaboratively monitor RE-AIM dimensions throughout implementation and guide any needed mid-course adjustments, as well as to evaluate implementation outcomes upon conclusion. Finally, feasibility, appropriateness, and acceptability of the EBI and its components will be assessed via a brief, psychometrically validated 12-item questionnaire widely used in implementation science research. Collectively, these data will provide context for this EBI, including any necessary adaptations, for future scale- up efforts to other rural communities throughout Appalachia in a 5-year R01 (or equivalent) proposal.