type 2 diabetes is a public health concern across the united states , with certain ethnic groups bearing a disproportionate burden [ 1 , 2 ] .
native hawaiians and other pacific islanders ( nh / pi ; e.g. , samoan , chuukese ) have higher type 2 diabetes incidence and prevalence compared to other ethnic groups [ 3 , 4 ] .
they are two times more likely to die from diabetes than the general population and suffer from high rates of diabetes - related medical complications and preventable hospitalization [ 5 , 6 ] . addressing
the burden of type 2 diabetes is a priority in eliminating health disparities among nh / pi . culturally relevant ,
diabetes self - management interventions are important in treating type 2 diabetes among nh / pi [ 4 , 8 , 9 ] .
found that a culturally adapted diabetes self - management intervention , called partners in care ( pic ) , significantly improved glycemic control and diabetes self - care behaviors in nh / pi compared to a wait - list control . despite the effectiveness of diabetes self - management education intervention , the maintenance of improved glycemic control continues to be a challenge across ethnic groups .
the long - term , postintervention maintenance of optimal glycemic control is important in judging an intervention 's effectiveness .
diabetes - related social support groups for those with type 2 diabetes have shown promise as a maintenance component for diabetes self - management interventions to improve long - term glycemic control and diabetes - related psychosocial functioning , self - care activities , and quality of life [ 13 , 14 ] .
diabetes - related social support can include four types : appraisal support ( e.g. , alternative perspectives of stressors ) , informational support ( e.g. , knowledge ) , emotional support ( e.g. , expression of care ) , and tangible support ( e.g. , providing material help ) .
the incorporation of a diabetes - related social support group for nh / pi as a maintenance component to a diabetes self - management intervention is also consistent with their shared ethnocultural values and preferences for group - based interactions .
they often rely on their immediate and extended family network ( e.g. , friends and neighbors ) for emotional , physical , and spiritual support and daily decision - making .
group participation with other nh / pi offers a safe and supportive environment that can increase the cultural relevance of activities and participation and enhances diabetes self - care . to examine the effects of a diabetes - specific social support maintenance component , the community - academic partnership , the pili
's study conducted another study of pic with an added social support component that emphasized the four types of support .
the pop partnership designed a 3-month , 6-session , semistructured support group ( ssg ) to reinforce positive changes made during the 3-month pic intervention .
specifically , the maintenance effects of a novel ssg on hba1c control and diabetes self - care behaviors were examined against a control group in a sample of nh / pi with type 2 diabetes who were randomized into these conditions following their completion of pic .
the institutional review boards of the native hawaiian health care systems and university of hawaii at mnoa approved this study .
community researchers recruited nh / pi from their respective communities and the larger nh / pi population on the island of oahu .
eligibility criteria were hba1c > 7% , nh / pi ethnicity , age 18 years , and physician - diagnosed type 2 diabetes .
eligible participants provided consent and baseline assessments ( t1 ) were done just prior to starting pic .
pic involves 12 , 1-hour weekly group meetings , providing information on diabetes self - management and encouraging participants to work with their diabetes team that includes the individual , their family , physician , and other diabetes experts ( e.g. , certified diabetes educator ) .
the intervention is based on the american diabetes association and the national diabetes education program guidelines .
pic was culturally adapted for nh / pi based on information from focus groups with nh / pi living with diabetes and nh / pi community leaders as described in sinclair et al . .
the community partners included kula no na poe hawaii ( a nonprofit serving urban hawaiian homesteads ) , hawaii maoli ( a nonprofit serving the hawaiian civic clubs ) , ke ola mamo ( the native hawaiian health care system for oahu ) , and kkua kalihi valley ( a health clinic serving low - income pi ) .
the community partners recruited participants , delivered the intervention , and conducted the baseline and outcomes assessments at their respective organizations .
all participants completed a baseline assessment ( t1 ) , received pic , and underwent a second assessment at 3 months ( t2 ) .
the protocol used at each assessment and measures were the same as used by sinclair et al . .
following assessment at t2 , participants were randomized , based on a 1  :  1 randomization by site , to either the 3-month ssg or standard follow - up control group .
participants randomized to the ssg attended six bimonthly , semistructured group meetings , lasting for about 1 hour , to reinforce skills taught in pic .
trained community facilitators ( cf ) led two of the sessions and health professionals ( i.e. , pharmacist , nutritionist , physician , and psychologist ) led the remaining four sessions .
community facilitators were instructed to provide appraisal and emotional support ( e.g. , talking through difficulties and encouraging connection between group members ) on how to garner additional support from family / friends for diabetes self - management activities ( i.e. , healthy eating , physical activity , and medication adherence ) .
the health professionals concentrated on providing informational and appraisal support around managing diet , medications , diabetes - related complications , and maintaining self - care activities .
the control group received only six bimonthly postcards reminding them of performing diabetes self - management activities .
all participants underwent a final assessment at t3 after the 3-month maintenance component ( i.e. , six months after t1 ) .
clinical measures included hba1c , measured with the bayer dca 2000 via a fingerstick sample of whole blood .
the same blood sample was used to measure total cholesterol , high - density lipoprotein ( hdl ) , and low - density lipoprotein ( ldl ) and triglycerides with the cholestech ldx lipid profile system .
blood pressure , weight ( kg ) , and height ( cm ) were measured twice at each assessment with the average of the two values used in the analysis .
the understanding subscale of the diabetes care profile ( dcp ) measured understanding of diabetes self - care activities .
it consists of 12 items with a 1 ( poor understanding ) to 5 ( excellent understanding ) likert - type response scale .
the scores for the 12 items were averaged to yield a total score between 1 and 5 .
seven of the 11 items from the summary of diabetes self - care activities ( sdsca ) were used to measure the frequency with which participants conducted self - care activities ( e.g. , checked their feet ) during the previous week .
the scoring for each item was as follows : 1 ( not at all during the past 7 days ) , 2 ( 2 - 3 days ) , 3 ( 46 days ) , and 4 ( 7 days ) .
higher scores indicate greater frequency of self - care activities . the 20-item problem areas in diabetes ( paid ) assessed quality of life such as physical / social functioning and mental / emotional well - being specific to living with diabetes .
the possible responses to each item ranged from 0 ( not a problem ) to 4 ( serious problem ) .
the total score was the sum of all items multiplied by 1.25 so that scores ranged from 0 to 100 .
demographic and clinical measures were summarized by frequencies and percentages for categorical variables and means ( m ) and standard deviations ( sd ) for continuous variables .
support and control groups were compared using chi - square or fisher 's exact test when appropriate for continuous and categorical variables .
analysis of covariance ( ancova ) was used to test between group differences at t2 and t3 , adjusting for between - group differences at t1 and t2 , respectively .
the baseline characteristics for the 47 nh / pi receiving the pic intervention are summarized in table 1 .
it indicates that , among the participants , slightly over half were female , married , and native hawaiian and had a high school diploma or its equivalent .
participants on average had bmi in the severely obese category ( m = 36.01  6.77 ) , blood pressure in the prehypertensive range ( sbp m = 129.59  mmhg  15.77 ; dbp m = 76.46  mmhg  11.00 ) , and mean hba1c of 9.98  2.23 .
although mean total cholesterol ( m = 183.45  mg / dl  43.77 ) and ldl cholesterol ( m = 93.36  mg / dl  38.49 ) were within the recommended range , participants had low hdl cholesterol ( m = 40.72  mg / dl  13.40 ) and high triglyceride levels ( m = 240.59  171.07 ) . 

table 1 also summarizes participant characteristics by group at 3-month assessment ( t2 ) . at t2 ,
both the ssg and control group had mean bmis that remained in the severely obese category ( m = 37.27  7.66 and m = 35.42  4.63 , resp . ) .
the ssg had slightly higher mean systolic ( m = 137.48  24.81 ) and diastolic blood pressure ( m = 81.72  14.22 ) but lower hba1c ( m = 8.96  1.82 ) compared to the control group ( m = 132.03  21.43 , m = 76.50  12.96 , m = 9.47  2.69 , resp . ) . however , none of these differences between groups at t1 or t2 were statistically significant .
data in table 2 shows the mean changes in behavioral and biological measures across three assessment periods and for the combined sample for both the complete case and the intent - to - treat analysis . in the complete case analysis
, there were significant improvements in the following variables from t1 to t2 : hba1c ( m = 0.76  1.86 , p < 0.01 ) , dcp ( m = 0.73  0.97 , p < 0.001 ) , paid ( m = 11.1  21.87 , p < 0.001 ) , and sdsca ( m = 2  5.12 , p < 0.01 ) . except for hba1c , significant improvements in these variables were also found from t1 to t3 .
examining change between t2 and t3 shows a significant increase in ldl ( m = 13.55  mg / dl  26.42 , p < 0.05 ) , decrease in sbp ( m = 7.62  mmhg  16.6 , p < 0.05 ) , and increase in sdsca ( m = 1.7  4.67 , p < 0.05 ) . the intent - to - treat analysis
provided similar results , with the exception of change in hba1c from t1 to t3 , which showed a significant decrease ( m = 0.53  1.80 , p < 0.05 ) .
a comparison of the mean changes in variables between t2 and t3 by group is presented in table 3 . at t2
, 25 participants were randomized to the ssg and 22 to the control group , with 22 and 12 participants being retained at t3 , respectively .
there were no significant differences in the changes in variables between the ssg and control group from t2 to t3 , controlling for t2 values .
there was a statistically significant reduction in sbp in the ssg ( m = 8.36  mmhg  16.22 , p = 0.025 ) but not in the control group ( m = 6.25  mmhg  17.93 , p = 0.253 ) .
there were marginally significant improvements in dcp ( m = 0.24  0.55 , p = 0.054 ) and sdsca ( m = 1.41  3.49 , p = 0.072 ) scores in the ssg but not in the control group ( m = 0.12  0.80 , p = 0.621 , and m = 2.27  6.62 , p = 0.281 , resp . ) .
type 2 diabetes is a serious threat to the health and well - being of nh / pi as culturally tailored , diabetes self - management interventions , such as pic , can help attenuate .
the 12-week pic intervention led to significant improvements in hba1c , diabetes self - care knowledge and activities , and emotional well - being .
however , we did not find significant differences in the maintenance of these improvements between participants randomized to either the ssg or control group following completion of pic .
participants ' glycemic control at 6 months was not significantly different from their control immediately after pic .
this suggests that participants were able to maintain initial improvements from pic with or without the ssg . while not significantly different between groups , the ssg group had a significant within - group decrease in systolic blood pressure from t2 to t3 while the control group did not .
the ssg also had improvements in understanding of diabetes and frequency of self - care activities that were marginally significant .
although this study did not support the hypothesis that ssg can improve the maintenance of glycemic control after intervention , we did find some improvements in other outcomes ( e.g. , systolic blood pressure ) . to date
our results are consistent with other studies that found modest improvements in diabetes understanding and self - care activities but no change in hba1c [ 14 , 22 ] .
our results indicate that the social support provided to the ssg may have helped to improve their systolic blood pressure .
a similar study in african americans found that despite no improvements in hba1c after a 3-month diabetes self - management intervention , participants randomized to a 12-month social support group had significant improvements in systolic blood pressure while the control group did not .
this finding is important given that over time cardiovascular disease risk factors , such as systolic blood pressure , tend to worsen .
additionally , the ukpds study found that maintaining blood pressure in the normal range resulted in an 11% decrease in diabetes complications over 10 years .
other studies have found that intensive blood pressure control can save approximately $ 2,000 per quality - adjusted life - year in patients with type 2 diabetes . despite mixed findings in the research on the impact of social support on hba1c in patients with diabetes ,
based on communication with community researchers , there is a belief that social support groups can help to build relationships among community members and encourage interaction outside of the intervention
. this could provide participants with a sense of accountability and opportunities to learn from each other , which may increase motivation to maintain positive behavior changes and improve psychosocial functioning [ 14 , 28 ] .
also , participants in the control group received bimonthly postcards reminding them of the skills they learned in the pic intervention .
these postcards may have been effective at helping participants maintain the self - care activities they initiated during the intervention , lessening any between group differences at t3 . as a rct
, participants were randomized after the 12-week pic intervention . due to the fact that several of these groups were small ( e.g. , 8 people ) , the number of people randomized to ssgs was very small , which may have limited the amount of support each group was able to provide . additionally , some participants formed relationships in pic but were separated by randomization into different groups , which possibly decreased the motivation of these participants .
the structure of the ssg was set a priori ; however some participants expressed an interest in diabetes - related topics not included and/or in an order different from what was scheduled , which may have caused participants to lose interest .
, in which they state that future research on the use of social support groups in improving hba1c and blood pressure is necessary , a belief with which the community agrees . the use of rcts in which participants are randomized at the individual level after intervention may not be an appropriate design in testing support group components .
future designs could randomize by community site , allowing relationships built during the intervention to continue during support groups .
other recommendations include the use of support groups that occur on an ongoing basis facilitated by health professionals with diabetes expertise .
consequently , participants could attend as they feel necessary and exercise control in determining topics discussed . in conclusion ,
the pic diabetes self - management intervention is effective at decreasing participants ' hba1c and improving their self - management skills .
 native hawaiians and other pacific islanders ( nh / pi ; e.g. , samoan and chuukese ) have higher type 2 diabetes prevalence compared to other groups in hawaii . partners in care ( pic ) , a culturally tailored , community - based , diabetes self - management education intervention ( dsme ) , is effective at improving participants ' glycemic control and self - care behaviors . 
 maintenance of improvements is challenging . 
 diabetes - related social support groups ( ssg ) are a promising maintenance component for dsme . 
 this study examined the effects of a diabetes - specific ssg component relative to a control group , after the receipt of the 3-month pic intervention , which was delivered to 47 adult nh / pi with type 2 diabetes . 
 participants were then randomized to either a 3-month , 6-session ssg or a control group . hemoglobin a1c 
 ( hba1c ) , blood pressure , triglycerides , cholesterol , and diabetes self - management knowledge and behaviors were assessed at baseline , 3 months , and 6 months . 
 results indicated significant improvements in hba1c , diabetes - related self - management knowledge , and behaviors from baseline to 3-month assessment . 
 however , no differences between the ssg and control group from 3-month to 6-month assessment suggest that all participants were able to maintain initial improvements . 
 the ssg group had a significant decrease in systolic blood pressure from 3-month to 6-month assessment while the control group did not . 
 study limitations and future directions are discussed . 
1. Introduction
2. Methods
3. Results
4. Discussion