Diabetes Peer Support Research Articles

Diabetes distress mediates the relationship between depressive symptoms and glycaemic control among adults with type 2 diabetes: Findings from a multi-site diabetes peer support intervention.

Diabetes distress is positively associated with HbA1c and may mediate the relationship between depressive symptoms and HbA1c . This study examined these relationships in a geographically, socioeconomically, and ethnically diverse sample of adults with type 2 diabetes. Using data from five US sites evaluating peer support for diabetes management (n= 917), Structural Equation Modeling (SEM) examined whether diabetes distress (four items from Diabetes Distress Scale) mediated the relationship between depressive symptoms (PHQ-8) and HbA1c . Sites compared interventions of varying content and duration with control conditions. Time from Baseline Assessment to Final Assessment varied from six to 18 months. Site characteristics were controlled by entering site as a covariate along with age, sex, education, diabetes duration, insulin use, and intervention/control assignment. Depressive symptoms, diabetes distress, and HbA1c were all intercorrelated cross-sectionally and from Baseline to Final Assessment (rs from 0.10 to 0.57; ps <0.05). In SEM analyses, diabetes distress at Final Assessment mediated the relationship between Baseline depressive symptoms and HbA1c at Final Assessment (indirect effect: b= 0.031, p< 0.001), controlling for Baseline HbA1c and covariates. Parallel analysis of whether depressive symptoms mediated the relationship between Baseline diabetes distress and HbA1c at Final Assessment was not significant. In this diverse sample, diabetes distress mediated the influence of depressive symptoms on HbA1c but the reverse, depressive symptoms mediating the effect of distress, was not found. These findings add to the evidence that diabetes distress is a worthy intervention target to improve clinical status and quality of life among individuals with type 2 diabetes.

Influence to Inspire (I2I) – A Novel Diabetes Peer Support Program

Influence to Inspire (I2I) – A Novel Diabetes Peer Support Program

Type 1 Diabetes Peer Support Groups

Type 1 diabetes (T1D) is emerging as a major healthcare challenge impacting a significant percentage of the population. Management of T1D remains a concern in India with the diversity in socio-economic backgrounds, poor literacy levels, and inadequate resources and facilities which impact timely diagnosis, treatment, and management of this condition. All over the world in general, and in India, many peer support groups have come into existence and are even blossoming. A peer support system instils a sense of security, allows for better care practices, and builds quality relationships and a sense of belonging which can help improve their glycemic control and self-confidence and help them live a good quality of life. There are more than 40 T1D peer support groups in India offering emotional and financial support, knowledge, clinic services, matrimonial support as well as guidance in specialized areas of need such as celiac disease, sports, etc. While there is a need to understand and evaluate the most effective way to deliver these programs to effectually meet the various needs of people with T1D, there is also a need to integrate the various T1D peer support programs in India as there are many good practices that one group can learn and emulate from the other. The aim of this review article is to share the experience of the authors and to review available literature on T1D peer support groups to understand the role and impact of peer support groups in improving health outcomes and quality of life in people with T1D.

Evaluation of diabetic peer support in Malawi.

Type 2 diabetes is a major health concern worldwide and requires urgent attention from health care providers and policy makers. Due to shortage of health care workers in low-income countries, peer support programs have been viewed as a viable option in management of diabetes and have shown to be effective in sub-Saharan Africa. The aim of this study is to assess and evaluate the Kamuzu Central Hospital (KCH) diabetic peer support program's (DPSP) impact 4 years after its establishment by assessing knowledge, self-efficacy and behaviours of DPSP members compared to non-members. This is a cross-sectional study done among diabetic patients attending clinics between 12th August and 25th September 2018 at KCH. Self and interviewer-administered questionnaires (designed based on validated survey instruments) were used. The participants (n=176) were recruited consecutively after consenting. Results showed DPSP members were more knowledgeable regarding the effects of skipping meals and sweet juice on blood glucose and conditions not associated with diabetes. In terms of self-efficacy and behaviour changes, DPSP members believe that they are more able to correct hypoglycaemia, to communicate their concerns to health workers and to perform daily foot exam compared to non-members. The KCH (Lilongwe) Diabetes Peer Support program has positively impacted its members and should be scaled up to engage all diabetic patients in Malawi. Ongoing training for peer supporters is necessary to update and reinforce management, knowledge and skills, and to ensure fidelity in program implementation.

A diabetes peer support intervention: Patient experiences using the Mmogo-method®.

BackgroundSelf-management is the backbone of diabetes care. For the patient with type 2 diabetes, this implies making decisions about a healthy diet, regular exercise and taking treatment appropriately. Some patients may experience barriers to the self-management of diabetes, such as lack of support. In this respect, peer support has been identified as a promising strategy in the self-management of diabetes.AimThe study aimed to explore the experiences of adults with type 2 diabetes who took part in a diabetes peer support intervention in the Free State, South Africa. Such information may lead to the development of practical methods for diabetes self-management and control.MethodsTwelve purposively sampled Sesotho-speaking women (aged 51–84 years) participated in the Mmogo-method®, a visual-based narrative enquiry. Textual data from audio recordings of discussions, visual data from photographs of constructions and field notes were triangulated and analysed thematically.ResultsParticipants described the peer support intervention as very valuable. They regarded community health workers as an important source of support. Three themes emerged from the intervention: positive lifestyle changes, continuous support, and improved confidence and sense of connectedness. This was a significant finding reported in patients with diabetes, as it will contribute to successfully sustaining effective self-management behaviour.ConclusionsPeer support for patients with type 2 diabetes appeared to be a valued intervention, as participants related well to community health workers, who are ideally positioned in the healthcare system to provide the service.

Association Between Systolic Blood Pressure and Cardiovascular Inpatient Cost Moderated by Peer-Support Intervention Among Adult Patients With Type 2 Diabetes: A 2-Cohort Study

ObjectivesPeople with type 2 diabetes and increased systolic blood pressure (SBP) are at high risk of cardiovascular disease (CVD). In this study, we aimed to investigate the association between CVD-related hospital payments and SBP and tested whether this association is influenced by diabetes peer support. MethodsTwo cohorts comprising people with type 2 diabetes were included in the study. The first cohort comprised 4,704 patients with type 2 diabetes assessed between 2008 and 2009 from 18 general practices in Cambridgeshire and followed up to 2009–2011. The second cohort comprised 1,121 patients with type 2 diabetes from post-trial follow-up data, recruited between 2011 and 2012 and followed up to 2015. SBP was measured at baseline. Inpatient payments for CVD hospitalization within 2 years since baseline was the main outcome. The impact of 1:1, group or combined diabetes peer support and usual care were investigated in the second cohort. Adjusted mean CVD inpatient payments per person were estimated using a 2-part model after adjusting for baseline characteristics. ResultsA “hockey-stick” relationship between baseline SBP and estimated CVD inpatient payment was identified in both cohorts, with a threshold at 133 to 141 mmHg, suggesting increased payments for patients with SBP below and above the threshold. The combined peer-support intervention altered the aforementioned association, with no increased payment with SBP above the threshold, and payment slightly decreased with SBP beyond the threshold. ConclusionsSBP maintained between 133 and 141 mmHg is associated with the lowest CVD disease management costs for patients with type 2 diabetes. Combined peer-support intervention could significantly decrease CVD-related hospital payments.

337-OR: Continuous Glucose Monitoring Shared Medical Appointments Improve A1C and Diabetes Self-Efficacy

Background: Personal continuous glucose monitoring (CGM) is patient owned and often inaccessible due to cost and insurance requirements. Professional CGM is clinic owned, worn for 3-14 days and is an affordable, underutilized option. The present study combined diabetes education and professional CGM into a shared medical appointment (SMA). The SMA allows providers to deliver diabetes education in the setting of medical management and peer support. It was hypothesized that the SMA method of delivering professional CGM would positively impact clinical outcomes (improvements in self-efficacy, A1c and medication doses). Methods: Adults with type 1 and type 2 diabetes who attended the two-part CGM SMA at a large academic medical center were included in this retrospective, single-center study. The CGM SMA included 4-6 patients, diabetes educator and pharmacist. Participants wore professional CGM for 7 days. The primary outcome was change in diabetes self-efficacy through a validated 8-item Likert scale. Secondary objectives were changes in A1c, and changes in diabetes medications (dosage adjustments, time of administration). Paired t-tests were used to analyze change in A1c and diabetes self-efficacy scores. Results: Diabetes self-efficacy scores increased by a mean of 1.63 ± 2.09 points (p&amp;lt;.001) out of 10 points. The A1c decreased by a mean of 0.80 ± 1.52% (p&amp;lt;.001) with a mean follow-up A1C of 7.80 ± 1.60%. Those with baseline A1c ≤8.0% (n=70) experienced a decrease in A1c of 0.24% compared to 1.20% in those with A1c &amp;gt; 8.0% (n=101). Participants utilizing the real time device (n=133) experienced a decrease in A1c by 0.75% compared to 1.0% in those with the blinded device (n=38). Most medication changes made in the CGM SMA were dosage adjustments and changes in administration time. Discussion: The CGM SMA is a novel practice model incorporating diabetes education, peer support, professional CGM, and inter-professional care that demonstrated improvements in diabetes self-efficacy and A1c. Disclosure D. Isaacs: Consultant; Self; Companion Medical, LifeScan, Inc. Speaker’s Bureau; Self; Dexcom, Inc., Novo Nordisk Inc., Xeris Pharmaceuticals, Inc. A. Simonyan: None. J.E. Blanchette: Other Relationship; Self; Tandem Diabetes Care. S. Lekic: None. D. Noe: Consultant; Self; Pyure Organic Stevia. N.R. Galloway: None.

In-Person and Technology-Mediated Peer Support in Diabetes Care: A Systematic Review of Reviews and Gap Analysis.

The purpose of this study is to report a systematic review of reviews of evidence and gaps focused on in-person and technology-mediated diabetes peer support and its impact on clinical, behavioral, and psychosocial outcomes. We conducted a systematic review of reviews in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Reviews published in English from December 1978 through December 2018 examining clinical, behavioral, and psychosocial outcomes were included. The search yielded 167 reviews that were examined for inclusion/exclusion criteria. Nine systematic reviews and meta-analyses meeting criteria were included. Findings suggest peer support interventions can have a positive impact on clinical (A1C, blood pressure, cholesterol, weight), behavioral (diabetes knowledge, being active, healthy eating, medication management, self-management, self-efficacy, empowerment), and psychosocial (social support, health and diabetes distress, depression, quality of life) outcomes. Research gaps exist related to understanding the effects of emerging technology-mediated peer support modalities and the effects of peer support on gestational diabetes. Many clinical, behavioral, and psychosocial benefits related to in-person and technology-mediated peer support exist. Diabetes care and education specialists should incorporate and recommend peer support resources for people with diabetes.

Peer support interventions in type 2 diabetes: Review of components and process outcomes.

This review seeks to identify (a) the various components and process outcomes of type 2 diabetes peer support (PS) interventions and (b) the measures implemented to monitor intervention fidelity and evaluate outcomes in these studies. The MEDLINE, PubMed, EMBASE (Excerpta Medica Database), CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO databases were searched from inception to May 2019. Two reviewers independently screened and extracted data from eligible articles via the Template for Intervention Description and Replication (TIDieR) checklist (why, what, who provided, how, where, when and how much, tailoring, modifications, and how well). Twenty-three trials were included. The total number of participants was 7178. Most interventions were in primary care. Although face-to-face was the most common modality of contact, rates of contact were highest for telephone. Potential peer leaders (PLs) were identified primarily through recommendations from health professionals, based on their communication skills, glycosylated hemoglobin (HbA1c), and coaching interest. PLs were mostly female, university educated, and had a long history of diabetes (≥ 10 years). PL training varied significantly in length and content; the two most frequent topics were communication skills and diabetes knowledge. Although several studies implemented methods to evaluate "intervention fidelity," only few rigorously assessed the two key components of fidelity, "adherence" and "competence," through audio- and video-taping or direct observations. The impact of PS on participants' health outcomes is well investigated; however, the implementation and evaluation strategies vary significantly across these studies. In the present review, we define the various components of PS interventions and propose suggestions for enhancing the implementation and evaluation of future PS models.

Learning from the experience of peer support facilitators and study nurses in diabetes peer support: A qualitative study.

We report on the experiences of peer support facilitators and study nurses who participated in a large trial of peer support for type 2 diabetes. The support was led by volunteer peer support facilitators, who were trained in overcoming barriers to diabetes care, motivational interviewing, listening skills and setting up and running group support sessions. There is currently a distinct lack of qualitative evidence on what works in peer support. The peer support facilitators and study nurses completed open-answer questionnaire items on what worked well and less well, problems encountered and how they were resolved, group dynamics and suggestions for improvement. We also collected data from end-of-study meetings. Inductive thematic analysis was used to allow the emergent themes to be strongly based in the data.Findings: We find that process factors, peer support facilitator and peer characteristics, their relationships with each other and group dynamics are all fundamental for effective peer support. Sustaining and ending support also emerged as a key theme. Given the increasing interest in peer support, these findings will be useful to those interested in running groups in the future. Training programmes should help peer support facilitators develop confidence whilst emphasising that peer support ideally entails an equal, democratic dynamic. More attention is needed on to how to end groups appropriately.

Strategy for dissemination of diabetes peer support through community health centers of Shanghai

为了解社区糖尿病患者自我管理影响因素及同伴支持模式推广的可行性，本研究通过个人深入访谈，由培训后的调查员对社区糖尿病管理医护人员及糖尿病患者进行访谈，并采用主题框架分析法进行资料分析。 结果：显示，社区糖尿病患者的疾病管理及用药知识有待加强；患友间的经验分享和行为影响是鼓励患者自我管理信念和行为改变的关键；营养、运动相关的适宜工具有待强化；"协作式"同伴支持技能培训和社会资源的支持有待完善。.

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. A total of 1121 adults with Type 2 diabetes were recruited through general practices in Cambridgeshire and Hertfordshire, UK, and were followed up for 3.25 financial years after 8-12 months of one-to-one, group or combined diabetes peer support and usual care. Use of, and payments for inpatient and outpatient services were fully recorded in the follow-up. Adjusted mean inpatient and outpatient payments per person were estimated using a two-part model after adjusting for baseline characteristics. The mean age of the recruited adults was 65.6±11.4 years, 60.4% were male, and 16.8% were insulin-treated. Compared with the control group, less healthcare utilization (especially non-elective inpatient care and outpatient consultations) was observed in each of the intervention groups, particularly the combined intervention group. Over the course of 3.25 financial years, significant reductions of 41% (£909.20 per head) were observed for overall inpatient payments (P<0.0001), 51% (£514.67 per head) for non-elective inpatient payments (P=0.005) in the combined intervention group, and 34% (£413.30 per head) and 32% (£388.99 per head) for elective inpatient payments in the one-to-one (P=0.029) and combined intervention (P=0.048) groups, respectively. Type 2 diabetes peer support, whether delivered using a one-to-one, group or combined approach was associated with reduced inpatient care utilization (particularly non-elective admissions) and payments over 3.25 years.

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

BackgroundDiabetes 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...

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

BackgroundDiabetes 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.MethodsPeople 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.ResultsThe 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.ConclusionsGroup 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 RegistrationISRCTN.com ISRCTN6696362166963621

Peer support: time to tap the (largely) untapped

AbstractThere is growing evidence that the physical and mental health of people with, or at risk of, diabetes can benefit from support from a person with diabetes: known as diabetes peer support. Peer support involves the social and emotional help that supplements the assistance provided by health professionals and others in the life of the person with diabetes. By sharing, discussing, finding and facilitating the ways that can improve diabetes and overcome barriers to care and self-care, metabolic control and wellbeing can improve. Linking peer support to clinical care is thought to strengthen its effectiveness. Peer support complements diabetes education and facilitates implementation of the knowledge gained.There are a range of different ways in which peer support can be provided. Peer support might arise from a casual discussion with another person with diabetes or within a more structured programme. The degree of training can vary from life with diabetes in the casual encounter, to group leadership, ...

Peer support: time to tap the (largely) untapped

AbstractThere is growing evidence that the physical and mental health of people with, or at risk of, diabetes can benefit from support from a person with diabetes: known as diabetes peer support. Peer support involves the social and emotional help that supplements the assistance provided by health professionals and others in the life of the person with diabetes. By sharing, discussing, finding and facilitating the ways that can improve diabetes and overcome barriers to care and self‐care, metabolic control and wellbeing can improve. Linking peer support to clinical care is thought to strengthen its effectiveness. Peer support complements diabetes education and facilitates implementation of the knowledge gained.There are a range of different ways in which peer support can be provided. Peer support might arise from a casual discussion with another person with diabetes or within a more structured programme. The degree of training can vary from life with diabetes in the casual encounter, to group leadership, to paraprofessional training including motivational interviewing and a range of educational and management skills. The media for delivery vary from face‐to‐face, telephone and online approaches.At a time of a growing diabetes epidemic, peer support could well be a key strategy in supporting those with and at risk of diabetes, reducing downstream demands on health services while improving quality of life. If this turns out to be the case, every neighbourhood, village and clinic should have one or more peer coaches to support diabetes prevention and diabetes management. Copyright © 2013 John Wiley &amp; Sons.This paper was presented as the 2013 Janet Kinson Lecture at the 2013 Diabetes UK Annual Professional Conference held in Manchester

A diabetes peer support intervention that improved glycemic control: mediators and moderators of intervention effectiveness

OBJECTIVE In a randomized trial, a guided diabetes peer support intervention improved glycemic control (A1c), with a difference in A1c change between groups of 0.58% (p = 0.004). The current study examined whether improvements in insulin uptake and perceived diabetes social support mediated the intervention's impact on A1c. We also examined potential moderation by patients' health literacy, diabetes social support, or diabetes distress. METHODS We conducted secondary analyses for 212 type 2 diabetes patients participating in the trial using accepted methods for testing mediation and moderation effects. Roughly half (49%, 95% CI: 3-80%) of the A1c effect was mediated by increased insulin use, while changes in diabetes social support had a negligible impact. A1c impacts varied across subgroups defined by baseline diabetes social support and functional health literacy (both p < 0.01). The intervention was particularly beneficial among patients with low baseline diabetes support or literacy levels. The intervention had a greater impact on A1c among patients with more frequent engagement in peer support calls (p < 0.01). DISCUSSION Patients receiving increased peer support had improved glycemic control largely due to their greater likelihood of initiating insulin. Greater intervention engagement was associated with stronger effects. The intervention had its greatest benefits among patients with low support or poorer health literacy.

Diabetes education: "Personal" family member or "impersonal" diabetes educator?

Sir, The role of patient and peer involvement in the management of metabolic and chronic disease burden like diabetes, as suggested by Indian Journal of Endocrinology and Metabolism, offers a novel and practical idea.[1] Diabetes self-management education has long been considered to be an important part of the clinical management of diabetes in the West.[2] There is a growing need to develop an effective educational program to enable patients of chronic, especially people with diabetes (PwD) deal adequately with the complexities of living with their chronic condition.[3] Generally, physicians/diabetologists have limited time; thus, training of medical, paramedical, and nonmedical personnel, especially empowered PwD and their close family members as diabetes educators would be of immense help. They use interpersonal and communication skills to develop a tailor made patient-centered diabetes management plan.[4] On the lines of Certification of Diabetes Educator in the West, a National Diabetes Educator Program (NDEP), under the auspices of the Indian Association of Diabetes Educators and Dr Mohan's Diabetes Education Academy, was completed from June 2011 to March 2012 to create a cadre of certified diabetes educators in India. The 10 enrolled participants, in a center at Karnal, Haryana were followed-up after a year of NDEP training for six cardinal management targets (fasting and prandial blood glucose levels, HBA1c, blood pressure, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and triglycerides)[5] for diabetes. Simultaneously, the PwD relatives were also educated about the same targets on first visit and followed-up similarly. Interestingly, the PwD relatives had a better recall of these cardinal targets and their respective family members had a much better disease control (HbA1C). This difference could be because of direct contact of the family members with the patient and the doctor. Moreover, the relatives are more responsible, responsive, and empathetic to the problems of the patients, thus can manage them better.[6] Thus, an ideal diabetes educator should have a triad of NDEP training, sociosensitive skills, and act as a family member to the patient. Last, the editor has appropriately expressed the need for Diabetes Peer Support Program involving the PwD and their families. Further, this peer support system can be strengthened by development of recall improving audiovisual mechanisms and even smartphone applications in coming years.

Intervention Mapping as a Guide for the Development of a Diabetes Peer Support Intervention in Rural Alabama

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. 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. The resulting intervention includes a 2-day training for peer advisors, who were each paired with 3 to 6 clients. A one-on-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. 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.

A Culturally Sensitive Diabetes Peer Support for Older Mexican‐Americans

The purpose of this study was to determine if a peer-led diabetes support group intervention could improve adherence to recommendations for self-management in 42 Mexican-American elders with type 2 diabetes. This mixed-method pilot study occurred at a community-based diabetes education centre in Texas. The 10-week intervention programme was compared to usual care on five self-reported questionnaires and blood tests during four collection periods. Participants displayed statistically significant improvements in blood sugar, self-efficacy, transformational change and personal resources. Qualitative themes were derived from 30 focus group meetings, which were as follows: do not trust the system, choice + control = power and the social cost of diabetes. The results suggested a consultation role for occupational therapists in training peer leaders to learn to lead and manage community-based diabetes self-management programmes. Limitations were the sample size of the convenience sample, and the lack of qualitative analysis of the control group discussions. Future research should involve a study of expanded community-based social networks using experimental design.