Self management
Training peers to provide ongoing diabetes self-management support (DSMS): Results from a pilot study

https://doi.org/10.1016/j.pec.2010.12.013Get rights and content

Abstract

Objective

This study determined the feasibility of training adults with diabetes to lead diabetes self-management support (DSMS) interventions, examined whether participants can achieve the criteria required for successful graduation, and assessed perceived efficacy of and satisfaction with the peer leader training (PLT) program.

Methods

We recruited nine African-American adults with diabetes for a 46-h PLT pilot program conducted over 12 weeks. The program utilized multiple instructional methods, reviewed key diabetes education content areas, and provided communication, facilitation, and behavior change skills training. Participants were given three attempts to achieve the pre-established competency criteria for diabetes knowledge, empowerment-based facilitation, active listening, and self-efficacy.

Results

On the first attempt 75%, 75%, 63%, and 75% passed diabetes knowledge, empowerment-based facilitation, active listening, and self-efficacy, respectively. Those participants who did not pass on first attempt passed on the second attempt. Participants were highly satisfied with the program length, balance between content and skills development, and preparation for leading support activities.

Conclusion

Findings suggest that it is feasible to train and graduate peer leaders with the necessary knowledge and skills to facilitate DSMS interventions.

Practical implications

With proper training, peer support may be a viable model for translating and sustaining DSMS interventions into community-based settings.

Introduction

Diabetes is a chronic illness that not only requires patients to initiate a complex regimen of self-care behaviors, but, more importantly, to sustain these efforts over one's lifetime. While diabetes self-management education (DSME) programs improve diabetes-related health outcomes in the short-term, without continued follow-up and support, these gains cannot be maintained [1], [2], [3], [4], [5]. Although current national standards for DSME call for ongoing diabetes self-management support (DSMS) [6], our health care system is not currently designed to financially support long-term DSMS [7], [8], [9], [10]. As a result, there is increasing interest in developing “peer support” programs as a promising model for long-term chronic illness management [11], [12].

In the context of peer support interventions, peers may play different roles, have different responsibilities, and assume different levels of involvement. For instance, depending on the nature and purpose of the intervention, peer supporters can function as educators, advocates, cultural translators, mentors, case managers, or group facilitators [13], [14], [15], [16]. Similarly, peer supporters can be charged with multiple responsibilities including teaching patients how to seek emotional support, communicate effectively with providers, establish linkages to clinical care, make informed self-management decisions, identify and obtain health care resources, set goals, make action plans, and solve problems [13], [14], [15], [16]. Finally, peer supporters can be involved in interventions at varying degrees from playing an adjunct role in a larger, multi-component intervention [14], [17], [18], [19], [20] to playing a primary role in the intervention delivery [21], [22], [23].

Depending on the specific role, responsibilities, and involvement peers have in a given intervention, the “training process” peers undergo can vary considerably. For instance, Dale et al. [24], [25] trained peer supporters to deliver a 6-session, telephone-based, self-management support intervention designed to enhance routine clinic visits. The goal of the intervention was to motivate patients to implement treatment recommendations made by health care providers during clinic visits. To deliver this intervention competently, peer supporters participated in a 2-day training workshop that emphasized active listening skills, behavior change strategies and techniques to assess and enhance readiness to change. Peer supporters had the opportunity to practice and refine newly learned skills through role-play and telephone simulation exercises. Given that peers were serving in an adjunct role providing supplementary telephone-based support, such a brief and focused training process was appropriate.

Alternatively, in Lorig et al.’s study [21], peer educators were expected to facilitate a 6-week, comprehensive diabetes self-management program (DSMP) using a highly structured and scripted protocol. To successfully deliver the DSMP, peer educators completed a 4-day intensive training program (32 h in total) that involved several activities. First, trainers played the role of “peer educators” and participants played the role of “patients” in a series of DSMP session simulations. Immediately following each session simulation, trainers discussed the rationale behind the information taught as well as the instruction methods used to deliver the information. Peer educators also learned additional skills including how to manage group dynamics and how to use various teaching approaches. Because peer educators in Lorig et al.’s [21] peer support intervention assumed a significantly larger and primary role, the peer training process required to prepare peer educators was more intensive and time consuming. Indeed, the type and extent of training peers receive likely reflects the nature and complexity of the intervention they are expected to deliver.

To date, most training programs have exclusively focused on preparing peer leaders to deliver DSME interventions that are time-limited and based on tightly scripted standardized, structured curricula [21]. Few published studies describe programs training peer leaders to facilitate DSMS interventions that are designed to be ongoing and driven by patients’ self-management priorities, concerns, and questions.

The present authors developed a program training peer leaders to assist community-based African-American patients in sustaining and/or improving the diabetes-related health gains achieved through a completed short-term formal DSME program. Specifically, we sought to train peer leaders to facilitate the Peer-Led, Empowerment-based Approach to Self-management Efforts in Diabetes (PLEASED) intervention, an ongoing DSMS intervention with patients who recently completed 3 months of DSME delivered by certified diabetes educators (CDEs). The purpose of this study is:

  • 1.

    To determine the feasibility of implementing a program training peers to lead DSMS interventions. Feasibility of conducting the PLT pilot program was defined as: the ability to (1) enroll 10 peer leader candidates, (2) maintain 80% attendance rate during the training program, (3) retain 4 peer leaders at the end of the program, and (4) maintain participants’ commitment to facilitate the PLEASED program at the end of the program's completion.

  • 2.

    To examine the extent to which participants achieve competency criteria (diabetes-related knowledge, empowerment-based facilitation skills, active listening skills, self-efficacy) required for successful graduation.

  • 3.

    To assess participants’ satisfaction with and perceived efficacy of the PLT program.

While there are multiple terms used for describing individuals who provide peer support throughout this paper, we will use the term, “peer leader.”

Section snippets

Participant recruitment and selection

This study was approved by the University of Michigan Institutional Review Board. We recruited participants via contacting graduates from our previous professional-led DSMS programs, and obtaining recommendations from diabetes-specific providers and community leaders. We employed two levels of eligibility screening. Individuals interested in participating were instructed to call a toll-free number to undergo the first level of eligibility screening. During this telephone call, we described the

Characteristics of the sample

Participants were between the ages of 48 and 72 years with a mean of 63 years (SD = 7.2). Of the participants, 75% (n = 6) were women and 25% (n = 2) were men. Mean years since diagnosis was 14.3 (SD = 5.0). Seventy-five percent had a college degree or higher.

Feasibility of conducting the PLT pilot program was defined as the ability to (1) enroll 10 peer leader candidates, (2) maintain a mean attendance rate of 80%, (3) retain 4 peer leaders at the end of the program, and (4) have all graduating

Discussion

Peer support has been proposed as a potentially effective model for diabetes management. While preliminary evidence demonstrates that peer support models for DSME are promising [14], [33], [34], there has been less research examining its application for ongoing DSMS.

Results from this study confirm the feasibility of implementing the PLT program. We recruited 9 participants who all passed the first and second level of eligibility screening. Early on in training, one participant dropped out due

Acknowledgements

This study was supported by a BRIDGES Grant from the International Diabetes Federation (IDF). BRIDGES, an IDF project, is supported by an educational grant from Eli Lilly and Company. The study is also supported by a Peers for Progress Grant from the American Association of Family Physicians Foundation, and a K23 patient-oriented career development award from National Institutes of Health, 1 K23 DK068375-01A1, National Institute of Diabetes and Digestive and Kidney Diseases.

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