A Trial of Incentives and Peer Mentors to Improve Diabetic Outcomes

In recent years, social networks have garnered attention in both academic journals and the
lay press because of strong associations demonstrated in retrospective studies between social
networks and incidence of major health problems such as obesity and smoking. Financial
incentives have also been demonstrated to improve health behaviors in obesity, smoking, and
medication adherence. We propose to conduct a randomized controlled trial among a
predominantly African American population with persistently poor diabetes mellitus (DM)
control to examine whether two novel interventions, lottery based financial incentives and
telephone based one-on-one peer mentoring (the 'buddy system'), can significantly ameliorate
disparities in poor DM control.

The intervention is based on epidemiologic evidence, randomized controlled trials, and pilot
studies demonstrating: 1) Lottery based financial incentives are a powerful motivator of
behavior change; 2) One-on-one peer mentoring is a flexible, cost-efficient means of
increasing DM specific social support and may be particularly salient in minority
communities; and 3) Matching patients with poorly controlled DM with a similar individual
from their community who has gained control of their DM draws on existing community assets in
creating an inherently culturally competent intervention. DM patients with poor DM control
will be randomized to 1 of 4 arms: usual care; telephone based one-on-one peer mentoring;
lottery based financial incentives; and peer mentoring plus financial incentives.

The Specific Aims are to test: 1) The effectiveness of telephone based one-on-one peer
mentoring in improving glycemic control relative to usual care; 2) The effectiveness of
lottery based financial incentives in improving glycemic control relative to usual care; 3)
The effectiveness of combining peer mentoring and financial incentives relative to control;
and 4) The relative cost effectiveness of all four approaches. In exploratory analyses, we
will examine whether African American patients enrolled in intervention arms have greater
improvement in glycemic control than white patients, whether intervention group patients
experience greater improvements in blood pressure (BP) and lipid control, and whether peer
mentors experience improvements in their own health. We will pair mentors with mentees based
on race, gender, age, and disease severity. The active intervention will be run for a 6-month
time period, with participants followed for an additional 6 months to determine if effects
persist post intervention.

The proposed interventions address multiple barriers to effective disease management common
among patients with DM. If effective, these interventions could provide important models for
improving glycemic control in general and, in particular, for addressing racial disparities
in DM outcomes.