All ETDs from UAB

Advisory Committee Chair

Maria Pisu

Advisory Committee Members

Jewell Halanych

Meredith Kilgore

Monika Safford

Robert Weech-Maldonado

Document Type


Date of Award


Degree Name by School

Doctor of Philosophy (PhD) School of Health Professions


Appropriate management of diabetes has the potential to affect not only health outcomes associated with diabetes, but also its economic burden. Peer support has emerged as a promising intervention to improve diabetes self-management, with demonstrated effects on improving clinical outcomes. Whether the health improvements obtained with peer support are worth its implementation cost, has not been established. This dissertation sought to close the gap in the literature by conducting an economic evaluation of a peer support intervention for diabetes self-management. We conducted analyses of secondary data from Encourage, a randomized trial testing a peer advisor intervention conducted in rural Alabama. The first paper described the economic burden of diabetes of 424 patients and examined the effect of diabetes self-management on that burden. Patient economic burden was comprised of three domains: (1) direct costs (medical and non-medical out-of-pocket costs, and time for doctor visits and DSM), (2) indirect costs (productivity losses) and (3) intangible costs (quality of life measured by EQ-5D). The second paper builds on the first by examining the effect of peer support on patient cost, and tests if the relationship between peer support and patient cost is mediated by diabetes self-management. This analysis was restricted to the participants with complete follow-up data (n=360). The third paper used the same sample from the second study to determine the cost-effectiveness of the peer support intervention. Diabetes patients in rural Alabama bear considerable economic burden, with annual out of pocket costs totaling $1,250 and annual total cost totaling $9,000. Patients who engage in ideal self-management had higher costs compared to those with intermediate and suboptimal self-management. Peer support decreased patient direct medical costs; however, diabetes self-management did not mediate this relationship. The intervention evaluated in this trial is likely to provide a cost effective alternative to usual care in people with diabetes. These findings give a comprehensive picture of patient economic burden in a rural population. Policies to counter the cost consequences associated with higher self-management are recommended. Additionally, this analysis also provides evidence for investing in and implementing peer support programs to improve health outcomes for resource poor communities.



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