Daniel Holman

Impact of Community Based Peer Support in Type 2 Diabetes: A Cluster Randomised Controlled Trial of Individual and/or Group Approaches

Background Diabetes peer support, where one person with diabetes helps guide and support others, has been proposed as a way to improve diabetes management. We have tested whether different diabetes peer support strategies can improve metabolic and/or psychological outcomes. Methods People with type 2 diabetes (n = 1,299) were invited to participate as either ‘peer’ or ‘peer support facilitator’ (PSF) in a 2x2 factorial randomised cluster controlled trial across rural communities (130 clusters) in England. Peer support was delivered over 8–12 months by trained PSFs, supported by monthly meetings with a diabetes educator. Primary end point was HbA1c. Secondary outcomes included quality of life, diabetes distress, blood pressure, waist, total cholesterol and weight. Outcome assessors and investigators were masked to arm allocation. Main factors were 1:1 or group intervention. Analysis was by intention-to-treat adjusting for baseline. Results The 4 arms were well matched (Group n = 330, 1:1(individual) n = 325, combined n = 322, control n = 322); 1035 (79•7%) completed the mid-point postal questionnaire and 1064 (81•9%) had a final HbA1c. A limitation was that although 92.6% PSFs and peers were in telephone contact, only 61.4% of intervention participants attended a face to face session. Mean baseline HbA1c was 57 mmol/mol (7•4%), with no significant change across arms. Follow up systolic blood pressure was 2•3mm Hg (0.6 to 4.0) lower among those allocated group peer-support and 3•0mm Hg (1.1 to 5.0) lower if the group support was attended at least once. There was no impact on other outcomes by intention to treat or significant differences between arms in self-reported adherence or medication. Conclusions Group diabetes peer support over 8–12 months was associated with a small improvement in blood pressure but no other significant outcomes. Long term benefits should be investigated. Trial Registration ISRCTN.com ISRCTN6696362166963621

How do health behaviour interventions take account of social context? A literature trend and co-citation analysis

In recent years, health behaviour interventions have received a great deal of attention in both research and policy as a means of encouraging people to lead healthier lives. The emphasis of such interventions has varied over time, in terms of level of intervention (e.g. individual vs community) and drawing on different disciplinary perspectives. Recently, a number of critiques have focused on how health behaviour interventions sometimes sideline issues of social context, framing health as a matter of individual choice and, by implication, a personal responsibility. Part of this criticism is that health behaviour interventions often do not draw on alternative social science understandings of the structured and contextual aspects of behaviour and health. Yet to our knowledge, no study has attempted to empirically assess the extent to which, and in what ways, the health behaviour intervention field has paid attention to social context. In this article, we undertake this task using bibliometric techniques in order to map out the health behaviour intervention field. We find that the number of health behaviour interventions has grown rapidly in recent years, especially since around 2006, and that references to social science disciplines and concepts that foreground issues of social context are rare and, relatively speaking, constitute less of the field post 2006. More quantifiable concepts are used most, and those more close to the complexities of social context are mentioned least. The document co-citation analysis suggests that pre 2006, documents referring to social context were relatively diffuse in the network of key citations, but post 2006 this influence had largely diminished. The journal co-citation analysis shows less disciplinary overlap post 2006. At present, health behaviour interventions are continuing to focus on individualised approaches drawn from behavioural psychology and behavioural economics. Our findings lend empirical support to a number of recent papers that suggest more interdisciplinary collaboration is needed to advance the field.

Exploring the relationship between social class, mental illness stigma and mental health literacy using British national survey data

The relationship between social class and mental illness stigma has received little attention in recent years. At the same time, the concept of mental health literacy has become an increasingly popular way of framing knowledge and understanding of mental health issues. British Social Attitudes survey data present an opportunity to unpack the relationships between these concepts and social class, an important task given continuing mental health inequalities. Regression analyses were undertaken which centred on depression and schizophrenia vignettes, with an asthma vignette used for comparison. The National Statistics Socio-economic Classification, education and income were used as indicators of class. A number of interesting findings emerged. Overall, class variables showed a stronger relationship with mental health literacy than stigma. The relationship was gendered such that women with higher levels of education, especially those with a degree, had the lowest levels of stigma and highest levels of mental health literacy. Interestingly, class showed more of an association with stigma for the asthma vignette than it did for both the depression and schizophrenia vignettes, suggesting that mental illness stigma needs to be contextualised alongside physical illness stigma. Education emerged as the key indicator of class, followed by the National Statistics Socio-economic Classification, with income effects being marginal. These findings have implications for targeting health promotion campaigns and increasing service use in order to reduce mental health inequalities.

Development and external validation of risk scores for cardiovascular hospitalisation and rehospitalisation in diabetes patients

Context Cardiovascular disease (CVD) is a common and costly reason for hospitalization and rehospitalization among patients with type 2 diabetes. Objective This study aimed to develop and externally validate two risk-prediction models for cardiovascular hospitalization and cardiovascular rehospitalization. Design Two independent prospective cohorts. Setting The derivation cohort includes 4704 patients with type 2 diabetes from 18 general practices in Cambridgeshire. The validation cohort comprises 1121 patients with type 2 diabetes from post-trial follow-up data. Main Outcome Measure Cardiovascular hospitalization over 2 years and cardiovascular rehospitalization after 90 days of the prior CVD hospitalization. Results The absolute rate of cardiovascular hospitalization and rehospitalization was 12.5% and 6.7% in the derivation cohort and 16.3% and 7.0% in the validation cohort. Discrimination of the models was similar in both cohorts, with C statistics above 0.70 and excellent calibration of observed and predicted risks. Conclusion Two prediction models that quantify risks of cardiovascular hospitalization and rehospitalization have been developed and externally validated. They are based on a small number of clinical measurements that are available for patients with type 2 diabetes in many developed countries in primary care settings and could serve as the tools to screen the population at high risk of cardiovascular hospitalization and rehospitalization.

Applying social theory to understand health-related behaviours

Health-related behaviours are a concern for contemporary health policy and practice given their association with a range of illness outcomes. Many of the policies and interventions aimed at changing health-related behaviours assume that people are more or less free to choose their behaviour and how they experience health. Within sociology and anthropology, these behaviours are viewed not as acts of choice but as actions and practices situated within a larger sociocultural context. In this paper, we outline three theoretical perspectives useful in understanding behaviours that may influence ones health in this wider context: theories of social practice, social networks and interactionism. We argue that by better understanding how health-related behaviours are performed in peoples everyday lives, more suitable interventions and clinical management can be developed.

Impact of peer support on inpatient and outpatient payments among people with Type 2 diabetes: a prospective cohort study

To investigate the impact of a low‐cost diabetes peer‐support intervention, aimed at reducing inpatient and outpatient care utilization and healthcare payments, by conducting a cohort study that followed up a randomized controlled trial.

Can peer support be cost saving? An economic evaluation of RAPSID: a randomized controlled trial of peer support in diabetes compared to usual care alone in East of England communities

Background Diabetes peer support, where one person with diabetes helps others, may improve diabetes management. The objective of this study was to perform a cost analysis of peer support strategies used in RAndomized controlled trial of Peer Support in type 2 Diabetes. Methods We performed a 2×2 factorial randomized cluster controlled trial in England. People with type 2 diabetes were invited to participate as either ‘peer’ or ‘peer support facilitator’ (PSF) through postal invitation predominantly from general practice. Clusters, based on local communities, were each randomly assigned to one arm of group, 1:1, both group and 1:1 or control interventions. The intervention was delivered over 8–12 months by trained PSFs, supported by monthly meetings with a diabetes nurse. Out-of-pocket expenses/service utilization were self-reported at baseline, midpoint and on trial completion. Intervention costs were collated. Non-hospital costs used National Health Service (NHS) reference costs. Hospital payments were obtained from one local commissioning group and mean payments calculated. The analysis employed a societal perspective. Costs were evaluated at the conclusion of the trial. Results Participants (n=1299) were recruited across 130 clusters. The four arms were well balanced and matched (60% male, mean diabetes duration 9.5 years, mean glycated haemoglobin (HbA1c) 7.4+/-1.3%, 17% insulin treated). Implementation costs at 2013 rates were £13.84/participant/annum, participant out-of-pocket expenses for any intervention were £11.41/participant/annum and the NHS-incurred costs were reduced by £138.38/participant/annum. Savings for the 1:1, group and any intervention were £233.65, £90.52 and £113.13/participant/annum, respectively. Conclusions We conclude that both 1:1 and group diabetes peer support over 8–12 months are cost saving in this setting, although much of the benefit is largely derived by differences in self-reported healthcare utilization. Long-term benefits should be investigated. Trial registration number ISRCTN66963621

Social Quality and Health: Examining Individual and Neighbourhood Contextual Effects Using a Multilevel Modelling Approach

Social quality focusses on the nature of ‘the social’, arguing that people are realised as social beings through interacting with a range of collectives, both from the formal world of systems and the informal lifeworld. Four conditional factors are necessary for this to occur, which at the same time are assumed to influence health and well-being: socio-economic security, social cohesion, social inclusion and social empowerment. In this paper we test the utility of social quality in explaining self-rated health as a response to arguments that the social determinants of health (SDH) framework often lacks a theoretical basis. We use multilevel models to analyse national English and Welsh data (the Citizenship Survey) to test for both individual- and neighbour-level affects. Our key findings are that (1) neighbourhood contextual (cross-level) effects are present with respect to collective action, personal trust, cross-cutting ties, income sufficiency, and income security; (2) measures of national, community and personal identity as indicators of social cohesion show clear associations with health alongside more common measures such as trust; (3) the security aspects of socioeconomic determinants are especially important (housing security, income sufficiency, and income security); (4) social rights, including institutional rights but especially civil rights have effects of particularly large magnitude. Social quality offers a theoretically-driven perspective on the SDH which has important policy implications and suggests a number of promising avenues for future research.

Shirt sponsorship by gambling companies in the English and Scottish Premier Leagues: global reach and public health concerns

Abstract While the nature of gambling practices is contested, a strong evidence base demonstrates that gambling can become a serious disorder and have a range of detrimental effects for individuals, communities and societies. Over the last decade, football in the UK has become visibly entwined with gambling marketing. To explore this apparent trend, we tracked shirt sponsors in both the English and Scottish Premier Leagues since 1992 and found a pronounced increase in the presence of sponsorship by gambling companies. This increase occurred at the same time the Gambling Act 2005, which liberalized rules, was introduced. We argue that current levels of gambling sponsorship in UK football, and the global visibility it provides to gambling brands, is a public health concern that needs to be debated and addressed. We recommend that legislators revisit the relationship between football in the UK and the sponsorship it receives from the gambling industry.

Derivation and external validation of risk algorithms for cerebrovascular (re)hospitalisation in patients with type 2 diabetes: Two cohorts study

AIMS Cerebrovascular disease is one of more typical reasons for hospitalisation and re-hospitalisation in people with type 2 diabetes. We aimed to derive and externally validate two risk prediction algorithms for cerebrovascular hospitalisation and re-hospitalisation. METHODS Two independent cohorts were used to derive and externally validate the two risk scores. The development cohort comprises 4704 patients with type 2 diabetes registered in 18 general practices across Cambridgeshire. The validation cohort includes 1121 type 2 patients from a post-trial cohort data. Outcomes were cerebrovascular hospitalisation within two years and cerebrovascular re-hospitalisation within ninety days of the previous cerebrovascular hospitalisation. Logistic regression was applied to derive the two risk scores for cerebrovascular hospitalisation and re-hospitalisation from development cohort, which were externally validated in the validation cohort. RESULTS The incidence of cerebrovascular hospitalisation and re-hospitalisation was 3.76% and 1.46% in the development cohort, and 4.99% and 1.87% in the external validation cohort. Age, gender, body mass index, blood pressures, and lipid profiles were included in the final model. Model discrimination was similar in both cohorts, with all C-statistics > 0.70, and very good calibration of observed and predicted individual risks. CONCLUSION Two new risk scores that quantify individual risks of cerebrovascular hospitalisation and re-hospitalisation have been well derived and externally validated. Both scores are on the basis of a few of clinical measurements that are commonly available for patients with type 2 diabetes in primary care settings and could work as tools to identify individuals at high risk of cerebrovascular hospitalisation and re-hospitalisation.