Participant and group facilitator perspectives on a novel culturally tailored diabetes self-management program for African Americans

Background African Americans with type 2 diabetes experience disparities in their care and diabetes health-related outcomes. Diabetes self-management programs such as Healthy Living with Diabetes (HLWD) are important but do not account for the unique cultural experiences of African Americans. As well, a culturally tailored program focused on addressing sociocultural beliefs and providing race-congruent peer support, Peers LEAD (Peers Supporting Health Literacy, Self-Efficacy, Self-Advocacy, and Adherence) was implemented in two midwestern cities to improve medication adherence but does not include diabetes self-management topics included in HLWD. In attempt to fill the gaps from both HLWD and Peers LEAD, Peers EXCEL (Peers’ Experience in Communicating and Engaging in Healthy Living) was designed to integrate both programs. Methods Our study explored the perceptions of African American participants and facilitators of the separate HLWD and Peers LEAD programs, on the proposed new Peers EXCEL program using focus groups and interviews. Findings were analyzed by research assistants trained in qualitative research using deductive and inductive open coding approaches. Results Participants described the lack of cultural fit of the current HLWD program for African American communities and proposed strategies to enhance Peers EXCEL’s impact in African American communities. They shared the need to include topics such as the relationships between systemic racism and diabetes. Conclusion Participants’ feedback of Peers EXCEL reveals the importance of including various community member perspectives in the design of new diabetes self-management programs tailored for African Americans.

critical need for culturally tailored programs that address these factors associated with diabetes health disparities among African Americans.
We previously developed a peer-led intervention to speci cally address health beliefs and increase medication adherence for improving diabetes-self management among African Americans, the Peers LEAD (Peers Supporting Health Literacy, Self-E cacy, Self-Advocacy, and Adherence) program, which was found to be both feasible and acceptable by African Americans receiving peer support. In addition to providing one-on-one peer support, this intervention also includes group sessions addressing health beliefs and improving communication with healthcare providers. However, there are other important aspects of diabetes self-management, such as addressing diet and exercise, that were not included in the Peers LEAD program.
To address gaps in these other aspects of diabetes self-management, we proposed to combine Peers LEAD with a well-established, community-based diabetes self-management program, Healthy Living with Diabetes (HLWD) (6) (7). While HLWD is an evidence-based program, it has not been culturally tailored for African American populations. Notably, African Americans have been found to be less likely to participate in or complete the HLWD program (8) and addressing diabetes beliefs and knowledge using culturally tailored diabetes self-management interventions has been shown to produce positive health outcomes in African Americans (9,10). This proposed program, Peers EXCEL (Peers' Experience in Communicating and Engaging in Healthy Living), seeks to improve diabetes self-management among African Americans by combining key features of Peers LEAD and HLWD programs that complement one another. We sought to work collaboratively with African American stakeholders in developing and implementing interventions since this approach can improve their cultural relevance and subsequently, may increase their impact on reducing health disparities. In a prior work, we described perspectives of Peers EXCEL from healthcare professionals and organizational leaders serving African American communities and/or providing diabetes education. In this study, we engaged African Americans with type 2 diabetes who previously participated in either Peers LEAD or HLWD, as well as Peers LEAD peer supporters and HLWD facilitators, to obtain their perspectives on the design and implementation of Peers EXCEL to provide culturally tailored diabetes self-management.

Description of the Peers EXCEL program
Peers EXCEL is a novel diabetes self-management program that integrates the culturally tailored Peers LEAD program for African Americans with topics from HLWD, a community-based diabetes selfmanagement program (Figure 1) while also providing the one-on-one peer-support format of the Peers LEAD program. In Peers EXCEL African Americans with diabetes who self-report poor medication adherence are paired with other African Americans with diabetes who have high medication adherence.
Participants then meet during one-on-one peer support phone calls and attend group education sessions. Six weeks of group education sessions are led by a trained African American facilitator, focusing on diet and exercise, goal setting, stress management, etc. A pharmacist and a healthcare provider lead two separate group education sessions to address beliefs and misperceptions about medicines and diabetes, including enhancing provider communication. Participants are also offered the opportunity to connect with a Community Health Worker (CHW) during the program.

Participant Recruitment
We recruited English-speaking adults 30-65 years of age with type 2 diabetes who self-identify as Black/African American and previously participated in either the Peers LEAD or HLWD programs. We used records of participants from these programs and personal contact by community partners to facilitate recruitment including word of mouth, phone calls, and emails. All participants provided verbal informed consent. All research activities were reviewed by the (University name) Institutional Review Boards (IRB) staff, which deemed the study exempt due to being interview and focus group research. The study was conducted in accordance with the Declaration of Helsinki.

Individual Interviews with Peers LEAD and HLWD Participants
Interviews were conducted by the research team members, who were trained in conducting qualitative interviews by the Principal Investigator (P.I.) (initials). The researchers conducted 30-45-minute semistructured, individual interviews with Peers LEAD and HLWD participants. The interviews occurred via a secure web-based meeting platform (WebEx, Cisco Systems, San Jose, CA, USA) from September 2020 to December 2020. An interview guide was developed based on three domains of the Consolidated Framework for Implementation Research (CFIR): (1) intervention characteristics (e.g., relative advantage, complexity), (2) outer setting (e.g., individual needs, barriers), and (3) inner settings (e.g., compatibility).
Interviewers provided participants with gures describing the topics and focus of the separate Peers LEAD and HLWD programs, and the integrated program, Peers EXCEL ( Figure 1).
Individual interviews were used because they are ideal for gathering in-depth views about a particular topic in a safe environment and allow researchers to delve deeply into delicate issues that participants may otherwise be uncomfortable sharing in a large group (11). The interview guide included open-ended questions that allowed participants to share their in-depth perspectives of Peers EXCEL. Interviews were audio-recorded and transcribed verbatim by a professional transcriptionist with any identifying information redacted. Interview participants received a $50 stipend.

Focus Group Meetings with Peers LEAD peer supporters and HLWD facilitators
We conducted two separate focus group meetings with past Peers LEAD peer supporters, who lead the one-on-one peer support phone calls, and HLWD facilitators, who led group sessions for HLWD participants. Each 90-minute meeting was hosted via a secure web-based meeting platform (WebEx, Cisco Systems, Inc., San Jose, CA) and the meetings were conducted from October 2020 to December 2020. The P.I. (initials), an experienced focus group facilitator, an academic pharmacist, and a qualitative researcher, moderated the sessions. The focus group moderator was supported by research team members, who assisted with taking notes and managing the virtual platform. Focus group participants were provided with gures describing the topics and focus of the Peers LEAD, HLWD, and Peers EXCEL programs ( Figure 1). Focus groups are complementary to individual interviews by expanding discussion upon group responses (12). The focus group guide contained open-ended questions that allowed participants to share their in-depth perspectives on combining the Peers LEAD and HLWD programs. Focus group discussions were audio-recorded and transcribed verbatim by a professional transcriptionist with all identifying information redacted. Focus group participants received a $50 stipend.

Data Analysis
Research assistants trained in qualitative research (health services research graduate students: (initials) and pharmacy professional students: (initials)) used deductive and inductive open coding approaches to conduct a directed content analysis (13) of the interviews and focus groups transcripts. To establish rigor of the data, research assistants focused on two criteria: (1) credibility and (2) con rmability. These criteria were achieved by having multiple research assistants code the transcripts independently and then met together with the entire research group to discuss similarities and differences to reach a consensus in interpreting the results.
Two research teams were formed to analyze the focus groups (initials) and interview (initials) transcripts independently. The rst cycle of analysis consisted of creating a coding framework. The frameworks were nalized through an iterative review process with feedback from the P.I. and (initials). In the second analysis cycle, the analysis teams met independently to code and discussed their observations and ndings. Differences in their ndings were discussed among the analysis teams and shared with the entire research group until a consensus on data interpretation was reached. During the nal analysis cycle, the analysis team met with O.S and M.M. to present ndings and to t codes from interviews and focus groups into higher-order categories. The interview and focus group data and coding methods were also reviewed by members of the (University Name) Institute for Clinical and Translational Research-Community Academic Partnership (ICTR-CAP) Qualitative Research Group. Data management was facilitated using NVivo software, Version 11.4.1 (QSR International, Melbourne, Australia).

Results
Fourteen African Americans participated in the individual interviews and 19 African Americans participated in three separate focus groups to provide their perspectives on the combined Peers EXCEL program. The main themes were: (1) the lack of cultural t of the HLWD program for African American communities, (2) proposed strategies to enhance Peers EXCEL's impact in African American communities, and (3) important topics to cover in the Peers EXCEL program.
Lack of cultural t of the HLWD program for African American communities How to deliver Peers EXCEL in African American communities Participants perceived a lack of cultural t between the delivery of HLWD content by facilitators who are not African American/Black (Table 1). Their concerns included the lack of African American facilitators, and that HLWD facilitators lacked experience in working with African Americans to deliver the program in a culturally sensitive manner.
"I co-led [HLWD] with someone of another race [who is not Black]. And [HLWD participants] speci cally requested for someone else that looked like me, basically, and looked like us, because majority of [HLWD participants] were Black…And [the non-Black HLWD co-facilitator], like they pulled me to the side after the meeting several times … would say things offensively, not necessarily intentional, but she just wasn't, she didn't have cultural humility." -HLWD Facilitator #3 The contents and methods used to deliver HLWD were also areas of signi cant concern for HLWD participants. Participants perceived that the language used in the written script could have been better suited for an African American audience. HLWD facilitators also perceived that they had to read the HLWD script and could not adapt their delivery style to engage their audience more effectively. Advantages of Peers EXCEL relative to either the HLWD and Peers LEAD programs Participants described how the Peers EXCEL format of group-based discussions and one-on-one peer mentorship pairings empower African Americans to ask questions, receive advice from peers, and encourage building connections between community members.
"And then when I joined this group, and I saw the erceness of it and just listening to people talk about it, just really opened my eyes...I'm not afraid to ask questions now… So it opened me up to be a little more free to ask some questions from somebody else who gone through [living with diabetes] and to listen and get the advice from them." -Peers LEAD Participant #6 A prominent feature of Peers EXCEL for participants is how it recognizes the disproportionate prevalence of diabetes in African American communities.
"I think the program is much needed, is important. Usually, illness that strike the community, it strikes the African community the worst. We need to begin to focus on our community because there's a need.
Period." -Peers LEAD Participant #4 Perceptions of key topics, content, and format of Peers EXCEL Participants noted having opportunities to interact with a healthcare provider in Peers EXCEL could improve communication between African Americans and their healthcare providers.
"I just think that just having real conversations with African Americans about how important it is to have a primary care doctor, just something that simple. I know my family, a lot of them didn't even have a primary care doctor." -Peers LEAD Participant #3 Participants emphasized the importance of trust in African American communities and how having a physician and pharmacist that African Americans can trust is an important part of the program.
"It seems like a couple things I think makes [Peers EXCEL] important, especially for the African American community…is trust. A lot of times, you're not going to talk to your doctor or talk to individuals about things that are really causing you some issues, for whatever reason. And if you have an intimate connection with a doctor or a pharmacist or someone that you can trust to ask some of these questions, I think that would help as well with the community." -Peers LEAD Participant #7 Peers LEAD participants perceived that having group meetings and receiving one-on-one phone calls from their peers made the program personal, which was viewed as a strength.
"The … program was very personal, one-on-one… But there's something personal about working … one-onone and knowing you're going to get that [mentoring] phone call [from the Peers LEAD Ambassador] and then working with the entire group." -Peers LEAD Participant #9 Participants shared how the Peers LEAD one-to-one peers support format was unique and that they appreciated being partnered. According to participants, an added bene t of the Peers LEAD one-on-one peer support is that having a partner makes them accountable for achieving their goals as they manage their diabetes.
"Peers LEAD was one-on-one. You actually had a one-on-one mentor. Very few are able to supply that. That one-on-one connection is nice." -Peers LEAD Participant #8 "I think that [one-on-one peer support] would help because it would encourage the person to continue on with the ght. So with someone checking in constantly, I think it would push and motivate you to do your goals or succeed with your goals." HLWD Participant #2 Participants described how HLWD content that focuses on goal setting would result in greater accountability regarding diabetes self-management when African Americans are provided with one-onone peers support.  (Table 2). These included broadening the program's reach by including a wide range of individuals with different roles who could be involved in the recruitment. Additionally, participants perceived an opportunity for diabetes education to be tailored toward the diabetes selfmanagement needs of young African Americans. How to encourage participation in Peers EXCEL Some participants recommended that the research team use monetary incentives for recruitment into the Peers EXCEL program such as using vouchers that could be used towards purchasing healthy food or by providing gym memberships to promote positive lifestyle changes.
"Money is an incentive to get you there, which means once you get into that program, you might get motivated enough that you actually come out of there with something because it's very informational if you've got diabetes. No telling, this program might just have turned somebody around…it might help save so many more." -Peers LEAD Participant #6 "I think an incentive would be great, especially if the incentive also goes to purchasing food. Like for them to be a part of this, you're talking about healthy eating, then they actually have vouchers to get these foods...if you're talking about exercise…Maybe incentive to get back to the gym safely, that they have like a membership for six months or three months, or something like that, to actually get into gym or something like that…Because we're talking about a lifestyle change." -Peers LEAD Participant #1 Participants perceived that the recruitment process should be thorough in identifying individuals who are genuinely interested in improving their diabetes management and not only focused on the potential monetary incentives.
"I think the key is recruitment, recruiting people and getting people…You can kind of start to weed out the people who just want the cash and not really concerned." -Peers LEAD Participant #5 Participants also shared how including interactive activities in Peers EXCEL could enhance trust and camaraderie within the Peers EXCEL program beyond discussing only diabetes-related topics.
"… a social outing and gathering and still having fun, doing something other than doing the diabetes thing, some fun activities, as well…they went out to eat together and did things together and took trips together… They can trust one another with what they had to say about the struggle of diabetes. And it's just that camaraderie that helps outside of the thought of we're just here for diabetes." -Peers LEAD Participant #3

Topics to include in Peers EXCEL
Recommendations for additional topics to be addressed in Peers EXCEL include addressing the mental health issues experienced by those living with diabetes, and the historical context and impact of systemic racism on African Americans' experiences of living with diabetes (Table 3). Explore holistic approaches to diabetes management, including alternative medicine and exercise "The topics are wonderful. But I think there needs to include like instead of medication, a holistic approach to it…So if, different teas, different herbs, things such as that, if that could be shared, and if it's really true that it work, that would be good to educate African Americans on without having to take a lot of medication." -Peers LEAD Participant #1 "One of the things that was initially touched on in Peers LEAD about tness and working out and weightlifting and, you know, just being a little bit more active. I wish that would've been … focused on a little bit more." -Peers LEAD Participant #3 Some participants shared personal experiences growing up in segregated environments and how that impacted their ability to lead healthy lives while living with diabetes.
"I know when we talked about the histories of some of our participants, we heard where they came from. Many of them came from segregated environments growing up… when they were younger, [they] would have been going the direction of leading a healthy life, but they had, of course, life issues that got in the way of eating…what's considered to be a proper healthy diet." -HLWD Facilitator #4 Participants discussed how the topics of HLWD such as diet and exercise will help them in achieving personal goals related to their diabetes self-management such as losing weight.
"I think the more active components of Healthy Living with Diabetes would kind of help me with the active parts. Also, the dietary parts of it could help me to lose the weight I've been trying to lose for a while… [These] would be useful tools." HLWD Participant #3 Participants perceived the importance of the topics addressed in Peers EXCEL, especially stress management, which has a substantial impact on their ability to manage their diabetes.

Discussion
Study participants perceived that the Peers EXCEL program combined the bene ts of Peers LEAD and HLWD into a culturally adapted program that could effectively help African Americans with diabetes achieve their diabetes self-management goals. These participants shared the need for culturally adapting the HLWD program, strategies to enhance the impact of the Peers EXCEL program in African American communities, and important topics to cover in the Peers EXCEL program. Our participants also highlighted the importance of providing social support and building a trusting environment when engaging with African Americans by designing culturally appropriate programs.
A distinguishing feature of Peers EXCEL is the use of African American peer supporters and African American healthcare professionals to deliver the program. Culturally appropriate peer support programs engage members of the target community who understand the culture of the people, have an equal standing, have the same illness condition, and can connect with the group in a way acceptable to them (14). In addition, the shared experience of being African American has a powerful in uence on how African American facilitators effectively approach their teaching by creating a supportive classroom environment where participants felt comfortable being honest in sharing their experiences, questions, and frustrations without the fear of judgment, condemnation, or ridicule (15). HLWD was a poor t for African American communities because the facilitators were neither people of color nor had a history of working with African American communities. The HLWD program was perceived as scripted in its delivery which needed to allow for facilitators to tailor their delivery to t its predominantly African American audience. An integral part of culturally appropriate programs is leveraging the cultural identities of the facilitators to adapt their assigned curricula so that the program will be more relevant to their African American participants (16).
We also found that our participants valued having trusted healthcare providers share their expertise within the Peers EXCEL program and that relationships between systemic racism and diabetes should be discussed. Mistrust of the healthcare system stemming from historical and current racism faced by African Americans signi cantly contributes to diabetes-related healthcare disparities (17). Mistrust was also identi ed as the most signi cant contributor to low rates of African American participation in diabetes self-management programs such as the HLWD (8). As such, it is important to note the signi cance of our participants' outlook of Peers EXCEL as a program that could enhance trust between African American communities and pharmacists/healthcare providers. Furthermore, our participants recommended a discussion of the relationships between systemic racism and diabetes in Peers EXCEL, which is consistent with the nding that racism impacts diabetes beliefs among patients (18). Some African Americans perceive slavery as a factor that contributed to their development of diabetes (17,19).
Diabetes scholars support using Critical Race Theory (CRT) -inclusion of historicized and contextualized questions of race and racism -in health inequities research and diabetes self-management programs (20). Peers EXCEL has the potential to explicitly address the topic of systemic racism's intersections with diabetes in the African American community.
In addition to the need to cover critical topic areas, our study participants recognized that a novel intervention such as Peers EXCEL would need rigorous recruitment strategies. Participants recommended the use of incentives related to program goals. For example, vouchers to purchase foods that promote healthy eating and gym membership to promote exercise. Studies have shown that individuals with diabetes are willing to consider nancial incentives to improve diabetes self-management (21). Studies examining recruitment strategies of African Americans in a diabetes program showed that incentives are highly valued by participants (22,23). However, our study participants also perceived that providing incentives for participating in the program should be complemented by using recruitment strategies that attract motivated participants to minimize the risk of high attrition rates during the program, given how challenging it can be to achieve goals set for diet and exercise.

Limitations
In addition to its strengths, our study also had some limitations. While the CFIR framework was used to develop the focus group and interview guides, we found that participants' responses did not adequately t within the CFIR domains. Thus, we used an inductive approach to analyze the data. In addition, individuals who agreed to participate in interviews and focus groups may not represent all who participated in the Peers LEAD or HLWD programs.

Conclusion
We conducted individual interviews and focus groups with African American stakeholders with prior experience in Peers LEAD and HLWD to further develop and re ne the combined Peers EXCEL intervention. Interventions designed with the engagement of community members in a cultural context can improve health outcomes and potentially meet the unique needs of African Americans for diabetes self-management.

Consent for publication: not applicable
Availability of data and materials: the data used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Competing interests: the authors declare that they have no competing interests.
Funding: This research was funded by the Clinical and Translational Science Award (CTSA) program, through the National Institutes of Health (NIH) National Center for Advancing Translational Sciences, grant UL1TR002373-02. The content is solely the responsibility of the authors and does not necessarily represent the o cial views of the NIH. Also, funding support for this research was provided by the Baldwin Wisconsin initiative.
Authors' contributions: OS-designed and conceptualized the study, supervised data analysis, lead the program, and revised the manuscript. AT-contributed to the study design, data analysis and drafted the original manuscript. ES-analyzed the data, contributed to drafting the manuscript and revised the manuscript. PX-analyzed the data, contributed to drafting the manuscript and revised the manuscript.
CB-analyzed the data, contributed to drafting the manuscript and revised the manuscript. MMcontributed to the study design, data collection and revised the manuscript. YL-contributed to the study design, data collection and revised the manuscript. All authors read and approved the nal manuscript. Description of diabetes self-management programs shared with study participants