The development and initial feasibility testing of D-HOMES: a behavioral activation-based intervention for diabetes medication adherence and psychological wellness among people experiencing homelessness

Abstract

IntroductionCompared to stably housed peers, people experiencing homelessness (PEH) have lower rates of ideal glycemic control, and experience premature morbidity and mortality. High rates of behavioral health comorbidities and trauma add to access barriers driving poor outcomes. Limited evidence guides behavioral approaches to support the needs of PEH with diabetes. Lay coaching models can improve care for low-resource populations with diabetes, yet we found no evidence of programs specifically tailored to the needs of PEH.MethodsWe used a multistep, iterative process following the ORBIT model to develop the Diabetes Homeless Medication Support (D-HOMES) program, a new lifestyle intervention for PEH with type 2 diabetes. We built a community-engaged research team who participated in all of the following steps of treatment development: (1) initial treatment conceptualization drawing from evidence-based programs, (2) qualitative interviews with affected people and multi-disciplinary housing and healthcare providers, and (3) an open trial of D-HOMES to evaluate acceptability (Client Satisfaction Questionnaire, exit interview) and treatment engagement (completion rate of up to 10 offered coaching sessions).ResultsIn step (1), the D-HOMES treatment manual drew from existing behavioral activation and lay health coach programs for diabetes as well as clinical resources from Health Care for the Homeless. Step (2) qualitative interviews (n = 26 patients, n = 21 providers) shaped counseling approaches, language and choices regarding interventionists, tools, and resources. PTSD symptoms were reported in 69% of patients. Step (3) trial participants (N = 10) overall found the program acceptable, however, we saw better program satisfaction and treatment engagement among more stably housed people. We developed adapted treatment materials for the target population and refined recruitment/retention strategies and trial procedures sensitive to prevalent discrimination and racism to better retain people of color and those with less stable housing.DiscussionThe research team has used these findings to inform an NIH-funded randomized control pilot trial. We found synergy between community-engaged research and the ORBIT model of behavioral treatment development to develop a new intervention designed for PEH with type 2 diabetes and address health equity gaps in people who have experienced trauma. We conclude that more work and different approaches are needed to address the needs of participants with the least stable housing.

Pilot trial results of D-HOMES: a behavioral-activation based intervention for diabetes medication adherence and psychological wellness among people who have been homeless

“…The team advised and monitored all stages of this trial. They impacted decisions including amount of compensation, presentation of informed consent using a clear infographic ( 29 ), the ethics of our comparison group, and reviewed all adverse events.…”

“…We detailed the development steps and treatment content of the Diabetes Homeless Medication Support (D-HOMES) program in a separate publication including our treatment model ( 29 ). Briefly, D-HOMES coaches used behavioral activation (BA) to work with participants to set weekly, personalized goals to improve medication adherence and psychological wellness ( 34 ).…”

“…We sought to fill that gap by using community engaged research and incremental behavioral treatment development ( 27 ) to create a behavioral intervention tailored to the unique needs of people living with type 2 diabetes who have experienced homelessness. Guided by a team of people with lived experience and a treatment model based on the Information-Motivation-Behavioral Skills model ( 28 ), we conducted preliminary qualitative work with patients and housing and health care providers which revealed high desire and initial feasibility for a lay health coaching program focused on medication adherence and psychological wellness for people who had experienced homelessness with type 2 diabetes ( 29 ). Our community engaged research team, the Quorum for Community Engaged Wellness Research (Quorum), included people who had gained knowledge through lived experience of homelessness and diabetes, a community engaged research facilitator, and housing and health care providers.…”