DIMPLE – Diabetes Improvement through Mentoring and Peer-led Education Project

Abstract

The nature and extent of the Type 2 Diabetes problem has become increasingly worrying for those involved in healthcare. There is an ever-rising incidence of people diagnosed with the condition in the UK and the unhealthy lifestyle factors that underlie the condition seem to characterize modern day living. Finding innovative ways to address this growing health problem has never been of more interest and exigency to public health. Proper self-care and self-management is necessary for the successful prevention and management of the condition. This report explores a peer-led approach to improving and spreading self-care and self-management in diabetes, and follows the journey of three peer-led education projects collectively called DIMPLE. DIMPLE was co-created by local residents living with diabetes and the projects have been delivered over the last 18 months in Hammersmith and Fulham and in Harrow and are already expanding into Kensington and Chelsea and Westminster. This research suggests that there are significant benefits to be found in using peer-led approaches to tackle the Type 2 diabetes problem and offers insights as to how NHS organizations can better reach those at risk and bring about appropriate behaviour change.

Introduction

Background Knowledge

Diabetes is one of the biggest health challenges facing the UK with a huge increase in the number of people diagnosed with the condition. Since 1996 the numbers of people diagnosed have increased from 1.4 million to 2.9 million1 and by 2025 it is estimated that five million people will have diabetes; roughly 90% of these cases being Type 2 diabetes. Prevalence of Type 2 diabetes is highest amongst South Asian, Arab, Chinese, African and African Caribbean communities. Obesity is the most potent risk factor and deprivation is also intimately linked with diabetes for it is associated with higher levels of risk factors such as: obesity, physical inactivity, unhealthy diet, smoking, poor blood pressure control and other life stressors. Diabetes can lead to complications such as heart disease, stroke, blindness and kidney failure if left untreated. These can be debilitating for the patient and costly for the provider. Diabetes also requires effective self-management for positive health outcomes to be achieved and can place myriad demands on the patient and their families.

A report on diabetes in the UK, by Diabetes UK, recommends that in order to ‘curb this growing health crisis and see a reduction in the number of people dying from diabetes and its complications, we need to increase awareness of the risks, bring about wholesale changes in lifestyle, improve self-management among people with diabetes and improve access to integrated diabetes care services2’

In the NHS Diabetes National Service Framework, both the prevention of diabetes in people at risk of diabetes and the identification of people with diabetes comprise two of the twelve standards3.The findings of the UK Prospective Diabetes Study found that a change in negative

1 Diabetes-in-the-uk-2012 from Diabetes UK2 Diabetes-in-the-uk-2012 from Diabetes UK 3 Department of Health 2001

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lifestyle patterns, such as consuming a low-fat, high fibre diet and exercising could reduce the risk of one developing type 2 diabetes4. The longevity of lifestyle changes in preventing onset of diabetes has also been shown in the China Da Qing Diabetes Prevention Study. Both increased exercise and/or improved diet led to a lower incidence of diabetes occurrence in the intervention groups (7%) than the control group (11%), further reiterating the importance of lifestyle intervention in the primary prevention of type 2 diabetes5 In the Finnish Diabetes Prevention Study, an intensive lifestyle modification programme yielded long-term changes in participants’ physical activity levels and diets, as well as biochemical and clinical measurements6. This reinforced the message of previous studies that highlighted that non-pharmacological methods consisting of lifestyle modification are efficacious and also far more cost-effective in reducing diabetes risk.

Of most relevance to this paper is the role of patients in delivering quality improvement in diabetes care and self-management. Such quality improvements include the provision of education to patients, with the most successful programmes being Dose Adjustment for Normal Eating (DAFNE, for type 1 diabetes) and X-PERT (for type 2 diabetes). The promotion of self-management is another example of patient targeted quality improvement. With diabetes being a lifelong condition, patients require the ability to reduce their risk of complications as much as possible. Both education and self-management are vital in order to achieve this.

Local Problem

There are over 20.000 people diagnosed as living with diabetes within the tri-borough area of Hammersmith & Fulham, Kensington & Chelsea and Westminster. There are approximately 6,000 on the GP register at high risk of developing diabetes and approximately another 8-10,000 living with the condition undiagnosed and who are thus at risk of poor health and diabetes complications. There are also large BME populations who experience higher incidence and are at higher risk of developing Type 2 diabetes 7 than the general population.

2009 QOF-recorded prevalence of diabetes in H&F was 3.2% of the GP registered population, or 6000 people. The PBS modelled prevalence was 4.1%, indicating 1,500 people undiagnosed with diabetes. 2009 QOF recorded prevalence in Harrow was 5.46% that is 11,800 people. However, the YPHO modelled prevalence was 6.30% (13,606) – a gap of 1806 undiagnosed with diabetes, similar to H&F. The difference in prevalence is due to different population groups.

Intended improvement

The National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for North-West London (NWL) worked in partnership with, Hammersmith and Fulham PCT and Harrow PCT, CITAS and Diabetes UK in order to deliver a range of diabetes management and peer-led education programmes under the acronym of DIMPLE. The project consisted of three volunteer programmes entitled Peer Educators, Diabetes Mentors and Diabetes Champions.

DIMPLE was a challenge of both engagement and behaviour change. The principal aim of DIMPLE was to improve and spread self-care management for people with, or at risk of Type 2 Diabetes. As well as supporting diabetes patients it also had a strong preventive focus. This intended improvement was seen to involve four main factors: community members’ ability to prevent/manage symptoms and risk factors, access to appropriate medical services, patient ability to self-manage the condition and compliance with self-management techniques. In those

4 Turner 19985 Li et al., 20086 Lindstrom et al., 20067 Compare 6.49% with 3.85%of general population

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reached by DIMPLE we intended for improvements to be seen in a range of patient outcomes such as: health-related quality of life, physical condition and psychological condition.

DIMPLE came about from the ideas of Diabetes Service User Groups and LINk’s members in Hammersmith and Fulham and Harrow. They wanted to address the shortage of available services providing support and education in self-management of Type 2 diabetes as well as a lack of awareness in local communities around prevention and earlier detection. They wanted to create a solution that was community driven, and in line with DoH guidance suggesting peer-to-peer support as one of the most effective ways of encouraging behaviour change. There was also evidence that peer support interventions might provide a flexible and low-cost way to supplement existing support for those with diabetes.

Peer support has been defined as support from a person who has experiential knowledge of a specific behaviour or stressor and similar characteristics as the target population.8 Within a peer support intervention people with a common illness experience share knowledge and experience that others, including many health workers, often cannot understand. Success of peer support in relation to behaviour change is hypothesised to be due in part to the non-hierarchical, reciprocal relationship that is created through the sharing of similar life experiences.

The three DIMPLE interventions, diabetes champions, peer educators and mentors, were all iterations of this idea. Relevant theoretical research on peer-led education, self-management and primary prevention can be found in the appendix of this report.

Study question

The research focus of the project concerned whether DIMPLE could provide a viable model for service providers approaching health improvement in Type 2 Diabetes. This centred on the effectiveness of the peer-to-peer support interventions in achieving diabetes health improvement in both its preventive and supportive aspects, and looking at the cost/resource implications of the projects in the form of a social return on investment (SROI). We also investigated the role of patient and public involvement (PPI) in designing and delivering the project and issues of sustainability in the current health-care climate.

Methods

Setting

Locally we felt there was a need and an advantage to focusing on BME communities and health inequality areas. Considered high-risk and hard-to-reach, nowhere were the challenges of Type 2 diabetes for both the patient and provider more strikingly represented. When previously working with BME groups in H&F we had seen how traditional top-down approaches to health improvement and health promotion could be ineffective and inefficient; they often failed to properly engage the hard-to-reach, and could encourage a view of patients as passive recipients of care. Given the self-care and self-management requirements for living successfully with diabetes it was seen as essential that DIMPLE support those living with the condition as active-decision makers in their own health.9 We also wanted to invest in local people to deliver the DIMPLE projects and by doing so tap into the social capital inherent in our local communities. These considerations helped form the points of departure and innovation for DIMPLE, which we hoped would achieve outcomes that were locally driven, responsive and sustainable.

8 4 WHO, Peer support programmes in diabetes, 20079 It has been suggested that up to 99% of all health-related decisions are made by patients without input from formal health services.?

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Planning the intervention

Diabetes ChampionsThe main aim of the diabetes champion’s project was to train local people as volunteers to raise awareness in their communities about diabetes.10The idea being that the volunteers engage with other community members to share key health messages to bring about increased knowledge and awareness and appropriate behaviour changes. The champion’s project was a path to prevention through health promotion.

The key messages we wanted champions to convey were: the risk factors associated with diabetes, the importance of healthy lifestyles, how to reduce or delay the possibility of developing diabetes, and how to be tested for diabetes. We wanted the volunteers to:

either have diabetes or be affected by diabetes e.g. a carer or family member of someone with diabetes.

have links with people and groups in the community, be able to give a talk to local communities both in English and in their own community

language - In recruiting multi-lingual champions we hoped we would be able to better target high risk communities - and

show strong personal qualities such as trustworthiness, reliability and a caring nature.

We wanted to train volunteers in outreach skills both to enable them to better engage people and also for their own skills development. Champions would participate in a range of local community events and arrange events of their own, e.g giving a talk at a coffee morning or a running an awareness session at a local faith group.

Of the three projects the champion’s project in particular was aimed at targeting BAME communities. We planned to recruit a majority of champions from BAME communities with the hypothesis that increased awareness and behaviour change would result. The project was set-up at the beginning of 2011 and was influenced by the community champion’s project in Hammersmith & Fulham which provided a blueprint for planning and delivery. Hammersmith & Fulham and Harrow worked in close partnership designing the project which was delivered across both boroughs.

Diabetes Peer EducatorsThe peer educators’ project developed from feedback from people living with diabetes who wanted to be involved in educating and supporting other patients. We looked at how we could develop diabetes educators to work in collaboration with clinicians and services that were already delivering structured education courses such as X-Pert11 and Introduction to Diabetes Self Management (IDSM), a taster for X-Pert. Due to the collaborative nature of the project we set up an operations group to agree clinical governance, IT governance and quality procedures, and to ultimately support ongoing discussions with clinicians and managers leading the clinical service about how best to deliver the courses. We hoped that peer educators would be able to motivate and improve self-efficacy in course attendees thereby improving their ability to self-manage, with the additional benefit of potential for reducing clinician workload.

Diabetes Peer MentorsThe peer mentor project came about from evidence that diabetes patients wanted more support and needed more time than was available in primary care consultations. We developed an idea for a diabetes mentor scheme whereby referrals could be made to a mentor - someone already living with diabetes - who would offer emotional support to help others cope better through active

10 Health trainers, health champions project.

11 X-Pert is a 6 week structured education course for people with T2 diabetes, see website xperthealth.org.uk ; meets NICE guidance for diabetes education and is commissioned as our education programme in Harrow, H&F (K&C and Westminster)

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listening skills. This project was created from scratch and initially we needed to find a local education qualification in mentoring in that could be adapted for diabetes mentors and for their subsequent recruitment, training and accrediting. There were also considerations of how diabetes mentors would link in effectively and efficiently with other primary care services such as GP’s.

Ethical concerns

DIMPLE raised ethical concerns mainly regarding the volunteer workforce and the research methods used to evaluate the project. We needed to ensure that volunteers were fully CRB checked as they would be working closely with members of the public, that we provided standardised training with the scope and boundaries of the volunteer roles clearly delineated as distinct from those of professional health workers, and that they were equipped for work in the community. This last requirement necessitated delivering outreach skills training, producing a handbook and providing ongoing supervision to assess performance and training needs. Patient confidentiality and information governance issues had to be worked through particularly for the peer-educator and peer-mentor projects. With regard to the evaluation, as the DIMPLE programme was run as a service improvement initiative and not as a research project, Hammersmith and Fulham PCT determined that Ethics Approval would be waived. Issues pertaining to data protection, confidentiality and secure storage of information were given full consideration.

Planning the study of the intervention

We used process mapping to understand how the patient process of living with diabetes compared to the clinical care pathway. We used an Action Effect Diagram (AED) to develop and clarify a shared aim for the projects, along with specific primary and secondary outcome measures. This provided a visual map of the planned interventions, processes and their anticipated effect on outcomes.12 In order to obtain relevant process measures and regularly review the progression of the project CLAHRC also developed a bespoke web based platform for quality improvement.

All three interventions were expected to bring about improvements by virtue of the peer-to-peer support relationship. There was evidence to suggest that peer support provided a dynamic conducive to behaviour change. We hypothesised that this might prove particularly true with respect to a condition like diabetes which requires education and support in order to master and sustain complex self-care behaviours13. The need for a broad approach to facilitating successful behaviour change has been increasingly recognised14and key ingredients for change have been identified; self-efficacy is the best predictor of engagement in health-protective behaviour and autonomy is also seen as critical; the more we seem to tell people what to do, the more we invite resistance15

We hypothesised that the champions would be able to better reach and engage those at-risk of diabetes. As local community members they would make the key health messages and information on diabetes socially and culturally relevant. We hypothesised that peer educators would enhance the successes of clinician led self-management courses. They would serve as positive role models, successfully employing the techniques and strategies taught on the course and thereby improve confidence and self-efficacy in participants. Similarly we hypothesised that peer mentors, through active listening and support, would improve confidence and self-efficacy in patients; again improving patient ability to self-manage.

12 Consensus was achieved on these with support from public health consultants and from the literature review.13 Peer to peer support DoH14 Bothelo, 2004; Rollnick, Mason & Butler, 199915 Australian Psychological Society

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As the most established intervention, evaluation has predominantly focused on the DIMPLE Champions project. Evaluation has also been undertaken for the peer educators project and to a lesser extent the peer mentors project. The projects were all collaborative and community delivered so it was essential to develop a culture of ongoing evaluation through stakeholder engagement. We employed a dedicated volunteer coordinator to oversee the DIMPLE projects and we formed a cohesive operations group including service users, third sector organisations, Public health and CLAHRC which steered the projects.

Methods of evaluation

The impact evaluation on the champion’s project was carried out as a masters in Public Health, entitled “Diabetes Prevention, Peer-Led Education and Self-Management Programmes (DIMPLE): an Impact Evaluation of the Champions Project.” It was primarily qualitative in nature with the main methods of data collection being the self-reporting of project participants and event attendees via questionnaires and focus groups. This involved an assessment of the impact of the project on both the Diabetes Champions themselves and the public with whom they interacted, in terms of a range of outcome variables: changes in diabetes knowledge (its symptoms, signs and risk factors, sources of help and support etc) health behaviours (eating habits, exercise frequency) and psychological factors (self-confidence and psychological wellbeing.) For the Diabetes Champions, changes in confidence managing diabetes (if diabetic), professional skillset and social skills were also assessed.

Two questionnaires were designed; one for the Diabetes Champions and another for the public event attendees. Attention was given to simplicity of language and avoiding leading questions.16

We decided not to field baseline data as we thought this might encourage a smaller sample size. Evidence existed in the literature review that the effects of peer led-interventions on behaviour change had been validated through use of standardised questionnaires. ‘Survey Monkey’ was used to produce an online version of the questionnaires and Public Event Attendees also had the choice of completing the questionnaire via telephone interview with the researcher.

Two focus groups were held, with each focus group containing a total of 8 people; the recommended number in order to gain a diverse range of views, to encourage participation between attendees and to avoid precluding quieter individuals17. For the Diabetes Champions focus group, purposive sampling was used to recruit 24 Champions who had held most events and were considered more willing and able to contribute to a group discussion.18 A range of genders, ethnicities and age groups were sought but due to a sampling limit of 8, a wide representation could not be achieved. Convenience sampling was used to recruit participants for the Public Event Attendee focus group; inviting members of a local coffee morning, held at Askew Road, Hammersmith, back to a subsequent future focus group in July 2012. As with the interviews, each focus group was recorded on a Dictaphone for future analysis.

A form of cost/benefit analysis called a social return on investment (SROI) was conducted over a 15 month period between April 2011 and July 2012. A SROI is a ‘sum of benefits’ calculation; the sum total benefits of the project are divided by the total cost of the project, this produces an SROI value. It permits measurement of the social impact that health interventions have on their target population19. It assigns a return to the initial investment in monetary terms and enables the full value of an intervention to be captured. It was considered important to carry out an SROI for the DIMPLE Champions project as primary prevention and health promotion programmes deliver benefits beyond simple economics. With respect to the DIMPLE champions project notably:

16 ensuring that the range of potential answers were all inclusive and not limiting (Payne, 195117 Lacey and Luff, 200718 Purposive sampling is also known as theoretical sampling and is often used as a method of avoiding selection bias in qualitative research (Mays and Pope, 1995). This was expected to have the advantage of gathering a heterogeneous focus group which ideally expresses a diverse range of opinions.19 as well as the wider population in general

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benefits of developing a local volunteer workforce, reduction in clinician workload and corollary public health benefits deriving from improved lifestyle choices as a result of DIMPLE interventions.

The DIMPLE peer educator’s project has been initially evaluated by way of a range of specifically designed questionnaires for course participants and educators themselves. End of course questionnaires were devised to evaluate patients’ satisfaction with having a peer educator as part of the teaching team. Participants had to indicate the extent of their agreement with a range of statements such as: ‘I felt the Peer Educator had a good understanding of how it felt to be someone with Diabetes,’ ‘I had confidence in the Peer Educator delivering the sessions,’  ‘I was happy to be taught by a Peer Educator,’ with a score given between 1 – 5. We also scored empowerment questionnaires which were given on the first day of the course (Pre) and last day (Post). The questionnaires assessed changes in levels of empowerment and the role of peer educators as experienced by course participants. Telephone interviews with both educators and clinicians who delivered the self-management courses were also conducted. The peer mentor project is in the early stages of analysis, with low referrals precluding significant analysis at this point.

We also worked closely with CLARHC to design evaluative methods and tools to be used throughout the delivery of DIMPLE. These included plan-do-study-act cycles (PDSA’s) and web-reporting tools. PDSA’s enabled us to test and trial aspects of the interventions in an iterative way. Through the web tool we were able to record qualitative data in the form of feedback from volunteers and key stakeholders, and quantitative data against variables such as numbers of champion events held and number of people and patients reached by DIMPLE. As stated, discussion feedback and interviews with key stakeholders were integral to evaluation.

Analysis

For the Diabetes champions impact evaluation and peer educators evaluation, multiple sources of data were collected combining quantitative with qualitative techniques. The combination of data collection methods is termed methodological triangulation20 and is widely accepted to increase the internal validity of a study21. Within healthcare and public health research qualitative methods have achieved renewed prominence since the definition of quality within the NHS and public health systems was modified to include the opinion of the lay-person22. Descriptive statistics were used to arrange and display the data in the form of simple counts, percentages, ratios and cross tabulations of both demographic and main variables. Thematic analysis was used to identify repeated patterns of meaning when listening to focus group recordings. This involved developing thematic codes based both on postulated outcomes and readings of the data and then connecting and grouping the codes into themes. The top four occurring themes from each focus group were reported in a narrative format and via the use of direct quotes.

The Social Return on Investment (SROI) analysis in this report comprised a total of 6 stages: establishing scope and identifying key stakeholders, mapping outcomes – involving a theory of change impact map, evidencing outcomes and giving them a monetary value23, establishing impact24, calculating the social return on investment, and finally reporting using and embedding. This last stage involved recommending how NHS NWL can share the results of the report, disseminate the results to stakeholders and inform commissioners of the value and future potential of the Diabetes Champions project.20 (Cohen and Manion, 2000)21 Jick, 197922 NHS, 2000).23 using various websites, peer-reviewed journals, NHS costing databases and other associated sources (see section 4.0. and appendix ? for more information on this process and the methodology behind it).24 This stage involved adjusting for confounding factors that could have impacted upon the outcomes of the DIMPLE Champions project.

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Results

Outcomes

1. DIMPLE ChampionsBy the end of August 2012 over 5000 people had been reached through over 200 champion events, with over 70% from BME communities. A total of 51 champions have been trained in total.

The champions project proved the most straightforward to deliver. Hammersmith & Fulham and Harrow PCTs worked in close partnership delivering champion training and events in both boroughs. A diverse range of community events have been delivered, including coffee mornings stalls at community events, talks at local community groups and associations. Delivery levels one year into the project were above the 4 per month target. Between the first and second year of the project, thanks to ongoing review and PDSAs, we improved our recruitment methods and training for the champions. At the outset we used the established Diabetes UK Champions Training and subsequently developed a two-day in-house training programme in year 2 of the project using some of our lead champions as trainers. In order to assess the impact of the project we decided to carry out a full impact evaluation. To assess the quality of the champion’s events we reviewed events with champions to ascertain if there were training and/or support needs.

ChampionsA total of 12 Diabetes Champions took part in the impact evaluation. All but one rated the importance of being a diabetes champion with a score of 8 or more out of 10, and overall the champions reported improvements in their own health and well-being, expressing fulfilment in their roles. High percentages of champions stated improvements against measures of behaviour change, knowledge and awareness. 85% claimed their role has positively affected their own health. Reported changes included increased exercise uptake, paying more attention to nutritional information when food shopping, eating healthier foods, avoiding saturated fats and a greater sense of responsibility in managing diabetes. 82% were more aware of the signs and symptoms of diabetes and 92% were more aware of the range of diagnostic and support services available.

With regard to other benefits, all reported improved social skills as a result of their work and that they felt they were giving something back to their community. 75% felt that their professional skills had improved, i.e. C.V. and employability. All those diagnosed with diabetes felt more confident in managing their own condition and 58% were confident in managing the diabetes of others. Increased self-worth was an additional benefit mentioned by 42% of champions.

The overarching motive for becoming a Diabetes Champion was altruism. Reasons included “wanting to help the community”, “wanting to help other people” and “to be one of a group who help others”. Several identified their desire to reduce the burden of diabetes in their community and to also aid in identifying undiagnosed cases. Other factors for involvement included “to give something back to the NHS, after years of treatment and support as a patient” and family history of diabetes.

The findings from the thematic analysis centered around four main areas:

(1)Diabetes knowledge and management All champions with diabetes mentioned that their confidence in managing their own diabetes and that of others has improved since becoming Diabetes Champions. “I definitely feel more confident and in control of my own diabetes; I am feeling the best I have done for years. In my last check-up, my HbA1c has gone down to its lowest value in many years.’

(2)Community spirit

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Many expressed pride at being part of the DIMPLE Diabetes Champions initiative; “a chance to help their own people” was particularly valued as was their position as peers, “I can speak to people in my area in their own language, which I think really makes a difference. Some South Asian communities in London don’t like talking about their personal problems with healthcare professionals, or even white people, due to language barriers”

(3)Social networks and supportThe opportunity of forging new friendships and interacting with a range of individuals was highly valued, with reported reasons being improved confidence and gains in self-esteem, “ I definitely have a get up and go approach to life now, whereas before I was in the doldrums, so to speak. I was not sure what direction my life was heading but I am much more optimistic now”

(4)Professional skills Gains in professional skills were evident. One young individual plans on entering medical school and is using her role as a Champion to gain first-hand experience of patients. Another had a diploma in social care, and the role of a Champion inspired her to reach new heights and achieve further goals: “I am going to start my nurse training this September. If it was not for the Champions role, with the confidence and ambition it has given me, I really doubt I would have been motivated to go for it” (P8, female).

When asked about any costs of becoming a Diabetes Champion, 58% mentioned travel time and distance as a drawback, financial costs (42%) and time spent away from family (33%). 58% asserted that the programme had scope for improvement, namely: a better integration of other local health improvement initiatives, a scaled remuneration system in accordance with Champions performance, a longer training period, a continuous programme of training (with regular updates) and a better structure and organization of event delivery.

Public event attendeesA total of 41 public event attendee’s respondents attempted the questionnaire. 77% of respondents considered the event as of high importance to them. High percentages reported changes against behaviour change and awareness measures. 95% claimed to know more about the causes of diabetes after attending the event with most able to explain risk factors such as lack of exercise, unhealthy diet and too much sugar. 90% were more aware of the signs and symptoms of diabetes. 68% were more aware of the range of diabetes services available to them within London. 74% claimed to have shared the information received at the event with others; including family members, friends, workmates and neighbours. 74% claimed to have changed their diet since attending the event while 82% claim to have become more physically active. In terms of increased access to services, 8 out of the 31 underwent subsequent testing for diabetes; of the 23 who had not yet been for a diabetes test, 74% planned to in the near future.

The findings from the thematic analysis centered around four main areas: (1)Lay understanding of diabetes Most agreed that they knew more about the cause of diabetes: “I feel I am more aware of the role fatty foods and foods with lots of sugar have in making people have diabetes” and most stated that eating unhealthy foods will increase the risk of diabetes. A minority thought that it was primarily a genetic condition, and that if a member of family has the condition, relatives will also definitely suffer with diabetes, irrespective of diet.

(2)Living a “healthy life” All focus group participants actively voiced their appreciation of the benefits that a healthy lifestyle brings with some claiming to have become healthy living advocates, seeking to make positive lifestyle decisions wherever possible, “The guy who gave the presentation told me about the red lights on the food and to avoid stuff with that on as it is bad for you. I don’t buy nothing like that anymore” An increased awareness of the importance of physical activity was also reported.

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(3)Affability of the Diabetes Awareness Event The presence of a two-way dialogue between “health advisor”25and those attending the event was appreciated by all. Additionally, the fact that the events are delivered by peers tended to remove the barrier that sometimes exists when patients have a consultation with a healthcare professional, such as a doctor: “Sometimes I don’t want to go to the doctor and be a burden to them” (P1, female). “I really enjoyed the fun way the guy presented the event and it made me comfortable and I could ask questions without thinking I would look stupid in front of others” (P7, female). “Well I went just because it was already arranged by our coffee morning leader… I found it very interesting and informative. I definitely would not have volunteered to attend something like this...” (4)Dissemination of information All focus group participants gave poignant examples of situations in which information gained from the Diabetes Awareness Event had been shared with others, “In general conversations, I must have told tons of people, including those closest to me such as my daughter and neighbours, as well as others I chat to randomly, like people in supermarkets and when out and about” Further, the conservative nature of human beings with regard to disclosing health information was evident

Social Return on Investment The SROI figure produced can be summarized in the following equation: Value of Outputs [£884,405.24] / Value of Inputs [£134,281.00. For every £1 spent on the DIMPLE Diabetes Champions project, a total of £6.59 is generated in social value.

2. Peer EducatorsIn total 21 peer educators were trained. They have co-facilitated 15 courses in an 18 month period. Peer educators co-delivered all of the X-Pert courses held in H&F in 2011. . We were able to double the number of courses run as only one HCP was required per session instead of two previously. 50% of X-Pert course participants came from BME communities, with an even distribution of male and female participants, and a significant minority with unemployed status.

In the initial stages of delivering this project there were meetings held with clinical commissioning groups (CCG’s) with the X-Pert contract itself being reviewed and an improvement plan established. The volunteers were trained to teach parts of the X-Pert course and also to make phone calls to encourage uptake of courses after referral. Peer educators have since been recruited in Harrow with training held in London in May. Arrangements have also been made with the diabetes specialist nurses to work together with the educators on future courses. Initially the peer educators were expected to teach two sections of the course, before moving on to deliver more. By the end of the project a number were ready to move on and teach more parts of the course.

There were several challenges in the delivery of this programme. Firstly the partnership working with clinical X-Pert providers has been challenging on both sides. The clinical team put in a lot of time to contribute to the development of the program: the training of volunteers, assessing their readiness to teach and providing feedback on their performance whilst services and structures changed around them and without having extra time for their regular work. Secondly data collection has been problematic and unsystematic and there have been organisational difficulties with agreeing information governance around the use of the X-Pert database. Thirdly there was a 50% conversion rate from peer educators we trained to those who were able to deliver. The first round of recruitment was not critical enough in assessing people’s skills to facilitate groups, their availability and the demands training would place on them. Because each volunteer only teaches 2 courses per year it takes a long time to build up confidence and experience in teaching. The project also suffered from low patient attendance, a long-standing issue, limiting the evaluation of the project against DIMPLE outcomes.

25 a Public Event Attendees term for the Diabetes Champion

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Regarding the evaluation, 32 questionnaires were completed out of a possible 54 course participants. The mean of total scores was 18/20, with 20 being the maximum possible score, indicating participants liked and had confidence in the peer educators. On the empowerment scale the mean score of the participants increased from 3.5 to 4.2 showing an increase of 20% in empowerment over 6 weeks. This is consistent with data from the national audit for XPert which identifies a 23% improvement nationally highlighting that the presence of peer educators does not diminish feelings of empowerment.

Qualitative data from interviews with peer educators suggests a high degree of personal satisfaction experienced in the role with high levels of confidence and competence reported with respect to delivering their parts of the course. A majority reported improvement in management of their own health, that their role as peer educator makes a difference in participant’s experiences on the course and their understanding of diabetes, and a high level of support from clinicians. Many mentioned shared learning taking place between peers and patients due to the opportunity for exchange and discussion. However others recommended that the structure of the course needs to be adapted to include more time for free exchange and discussion. They cited the importance of the opportunities therein for participants to discuss individual issues and challenges, believing more exchange and discussion would make better use of the peer-support dynamic by capitalizing on the skills and experiences which educators bring to the learning environment. Other challenges expressed included low numbers attending courses and difficulties in making commitments to the role due to its voluntary nature.

Qualitative data from clinicians also shows a high degree of corroboration with respect to effectiveness of the project in terms of delivery, “The collaboration between health professionals and the volunteers has been excellent”. Universally the project was reported as a success, with some mentioning they would recommend it to other departments and PCTs. The effects of the peer-support relationship on self-efficacy were also reported, with clinicians suggesting that support from peer educators is well received by patients ‘For patients, to have a ‘non-medical’ person to re-emphasise self management during sessions is very important. Patients identify well with volunteers as they share common challenges. The re-assurance from volunteers that Diabetes is manageable also removes the issues of self-doubt.’ Some challenges experienced were: time management factors and extra workload and a need for a more thorough recruitment process to ensure professionalism of volunteers.

Peer MentorsTo date 30 mentors have been trained. 4 GP practices in Hammersmith and Fulham are actively involved. 9 mentees have taken up the service to date, all interested in receiving more support for developing healthy eating habits.

This programme was created from scratch and posed several challenges. Initially there was a need to create infrastructure for the intervention. This required a training and accreditation programme for diabetes mentors, arranging for mentor placements with GP surgeries, developing a handbook and code of practice, establishing secure referral systems and agreeing information governance. The web reporting tool was also set up to assess how the service was used and the impact on the health of the volunteers and a handbook created explaining how volunteers could input their own data. As the use of the mentoring programme is defined by the individual patient accessing it, it was the least defined and structured of the three programmes. Due to low uptake we developed personal mentor profiles for publishing in GP surgeries to encourage self-referral. Low referrals throughout prevented the programme from better establishing itself and our ability to properly evaluate it. In order to investigate why referrals have been low when the ideas for this came from service users, a social marketing project has been commissioned which will report in October 2012. .Mentors Case Study

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A middle aged man referred himself to the mentor project as he felt he needed support to manage his diet and mood around diabetes. He met with his mentor 7 times in coffee shops. In each meeting they agreed an action plan, focusing on starting with keeping a food diary, finding out his latest blood glucose test results and walking for 30 minutes every day. They worked together to achieve a more balanced diet by increasing fruit and vegetables and protein and reducing carbohydrates. In his fourth session he agreed to an additional action of stopping smoking. In his final session he agreed to attend an X-Pert diabetes self management course, and to find out about basic cooking courses in his area.

After the sessions, the mentee agreed that he felt better able to turn his diabetes goals into workable plans; to overcome the barriers to achieving his goals; and felt better about having diabetes. In addition he strongly agreed that he had confidence in the mentor and found he had a good understanding of diabetes; would recommend mentoring to someone else with diabetes; and would not have preferred to cover the topics discussed with a healthcare professional. The mentor, who was just beginning his role as a mentor, felt unsure at the start whether the meetings were of any use at all to the mentee. By the end he could see the progress made in the mentee’s confidence and resolve to achieve his goals. He now could see how he could make a difference.

Discussion

SummaryDIMPLE has been considered a success by all stakeholders involved. It has been shown to have provided a rich and rewarding experience for the volunteer workforce and the people reached through the project. The champions project in particular has been shown to deliver against hypothesised outcomes and has generated real, measurable impact. The educator’s project likewise has shown positive findings with regard to the effect of peer-support in self-management of diabetes. The mentors project is not yet at the stage for full evaluation but again shows encouraging results with respect to the benefits of peer-support relationships in self-management.

The delivery and evaluation of DIMPLE has provided lessons for us as to how we continue to approach the problems associated with Type 2 diabetes locally. As a community centred and peer-led approach DIMPLE has demonstrated clear merits, namely: wider engagement capabilities particularly evidenced in hard-to-reach and high-risk communities, positive impact derived from peer-led support dynamics with regard to prevention and behaviour change and positive cost/resource implications including wider social impact and sustainability benefits. DIMPLE has also provided many challenges such as: how to develop appropriate project infrastructures, the effective management of a volunteer workforce and collaborative challenges of integrating peer-led interventions into existing diabetes care pathways.

Relation to other evidence

The results of DIMPLE can be seen in the context of other evidence sourced as part of the literature review.

Coe and Boardman (2008) found lifestyle changes to have occurred at both the individual and household level in the Apnee Sehat initiative; the delivery of culturally sensitive information by peers, to their respective community, boosted engagement of attendees.

The Altogether Better (2012) study26 is a collection of 16 projects falling into three broad themes of physical activity, healthy eating and mental health and wellbeing. It reported positive findings similar to DIMPLE in analysis of the impact on the Community Health Champions and the respective community, namely: increased confidence, self-esteem and wellbeing and a spread of health knowledge to individuals throughout a community. The health and social capital of communities targeted were also reported to have benefited from the initiative (Woodall, White and

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South, 2012). Furthermore, a positive social return on investment of between £0.79 and £112.42 per £1 spent was calculated for each of the 16 projects (Altogether Better, 2012).

Diabetes UK currently hold a Healthy Lifestyles Roadshow, reaching many parts of the U.K., offering free at point of care risk assessments for Type 2 Diabetes Mellitus (T2DM). In 2011, 15,000 people were reached in such a manner (Diabetes UK, 2012).

There are many other locally funded initiatives of primary prevention throughout the UK that have increased detection of diabetes and helped deliver lifestyle advice; including “The Big Bolton Health Check”, where over 73,000 individuals were engaged and over 900 cases of diabetes were detected (Department of Health, 2012).

Increased risk assessments and earlier identification of diabetes are of continued importance. NHS Health Checks, in which individuals between 40 and 74 years old are invited to risk assessment of diabetes, cardiac disease, stroke and kidney disease, offers promise (Department of Health, 2009). Moreover, Type 2 diabetes is increasingly manifesting at an earlier age, especially in BME community groups (Haines et al., 2007). Consequently, a level of unmet need would still exist even if universal implementation of the Health Check programme occurred, highlighting the continual need for initiatives such as that of the DIMPLE Diabetes Champions.

Evidence with regard to supporting patients in self-management suggests a broad skills training appears essential and programme effectiveness also seems related to the amount of contact time between the educator and patient, as well as the availability of ongoing follow-up and support27

Limitations

With respect to the DIMPLE champions project we cannot, without continued monitoring and study, assess the long-term significance of the behaviour changes seen. Generally, however, the evidence suggests positive long-term outcomes with surveys of DIMPLE participants suggesting that lasting behaviour changes have occurred in those who were first reached by the project 6 months prior to their evaluation.

Although controlled for as much as possible, interviewer bias along with sampling issues may have affected the study outcomes: of a total of 3000+ champion participants only 40 completed the champion’s questionnaire, due to the relatively small cohort of Diabetes Champions it was not feasible to conduct more than one focus group, only one researcher was involved in generating the thematic analysis, recordings from the telephone interviews were not transcribed and the study also only utilized self-reported methods to measure impact and assess change. There are also limitations to what can be concluded from both the peer mentors and peer educators projects at present given problems with data collection and smaller population size.

Interpretation

Peer-led approachEvidence suggests that peer-led support interventions successfully encourage behaviour change with respect to diabetes. It seems that peers play different roles in education than those of healthcare professionals. Triangulated data from all sources used in the impact evaluation on Diabetes Champions showed consistency with regard to positive knowledge, awareness and behavioural change outcomes. This suggests that a peer-to-peer support mechanism is an effective way of administering health promotion and prevention. Champion event attendees also stated that they shared newly acquired knowledge of diabetes and its signs and symptoms with others, including neighbours, friends and family members. This has the potential for knock-on effects, particularly in younger generations, and is important considering the alarming recent rise

27 Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes; a systematic review of randomised controlled trials.

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in T2DM prevalence in children and young adults28. The views of those reached by DIMPLE projects shows overwhelmingly positive feedback with respect to the peer-led nature of the interventions e.g. 98% of participants on self-management courses welcomed the role peer educator’s play alongside that of healthcare professionals, with clinicians also citing benefits.. Recruiting volunteers with a personal experience of diabetes seems to make for a high level of commitment and personal significance to being involved in the project and has been seen to positively affect the peer-to-peer support relationship. People reached by DIMPLE welcome the addition of peers to the range of support they are offered and are able to receive messages from peers which. Further evaluation is however needed to explore what it is about peers that patients respond to – i.e. who they are; how they are perceived by those they reach i.e. being seen as ‘the same’ as them, the content/messages they deliver; and with respect to peer educators, people who manage the condition easily or people who struggle with it daily.

The champions project requires development to assist champions effectively deliver in their role as peers. They need visual aids to assist the training they do and a brand which people can respond to e.g. an image, t-shirts, business cards. They also require culturally specific DVDs about food/diet to help them make healthy living messages culturally relevant.

Volunteer workforceIt is clear that there are a large number of people willing to be engaged as volunteers who find the engagement stimulating and of benefit to their health, who are also motivated by giving back to the community. People with diabetes have wanted to be involved in supporting others and have contributed considerable energy and skill to the work. In total 51 champions, 30 mentors and 21 peer educators were recruited and trained.

The process of building a volunteer workforce has been successful and there is evidence that an enthusiastic and engaged volunteer workforce improves care delivery and would improve clinical outcomes in the long term. This seems partly due to the flexibility and adaptability of using a community centered approach. DIMPLE has grown responsively and sensitively to the demands of our local communities, providing the opposite of a one-size fits all service. The type of engagement and outreach has been shaped by our workforce and what they have brought in terms of their own experiences, interests and skills. This is in line with evidence29 that the roles of peers are defined by their community and varies depending on their communities’ needs and resources. We have been fortunate in recruiting people with a lot of passion skill and commitment and their efforts have had a considerable impact on what was achievable.

Volunteer programmes require adequate support in terms of recruitment, training, management and coaching to be successful. Processes such as information governance, clinical governance, CRB checks, and honorary contracts need to be streamlined across all projects. Going forward we feel volunteer educators and mentors need practice to develop and hone their skills. There is also the question of how to strengthen the collaborative elements of the projects. Overall it is clear HCPs are keen to work with volunteers - particularly to improve service delivery to hard to reach groups and to support self management - however a volunteer workforce places additional demands on HCPs which need to be taken in to account. HCPs also need support to work effectively with volunteers particularly in order to be comfortable giving negative feedback. The mentor project also requires development in terms of how GP’s and other clinicians make referrals to the programme.

We have also seen that there can be a lack of control and prescription in the coordination and delivery of a volunteer led project, however this has been offset by the project developing in directions we hadn’t anticipated. Also the more structured the programme is, the more barriers there are likely to be from NHS organisations to get it up and running.

28 Balasanthiran et al., 2012 and Haines et al., 200729 WHO

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At-risk communitiesDIMPLE has shown that recruiting volunteers from at risk communities and holding events in community settings is an effective way of reaching and increasing access into those communities: 75% of people reached through Champions events were from BME communities. As hypothesised, it was seen that levels of community knowledge about diabetes and knowledge about what can be done to reduce the risk of developing Type 2 diabetes are low. This reminds us of the pressing need for interventions such as DIMPLE. Imkampe and Gulliford30highlight an increase in the socio-economic inequalities for T2DM in the UK. The Diabetes Champions initiative has the benefit of reaching those most likely to be afflicted with diabetes, through its work with BME groups. With the use of Public Health data it has been possible to target key communities with high prevalence or need. Champions recruited from BME communities know what the issues are there and know how to talk about them.

Patient and Public Involvement and SustainabilityPatient and public involvement was central to the design and delivery of DIMPLE, influencing decision making throughout. Service users and LINks members have been active and engaged members of the team co-designing and co-delivering the project and playing a key role in accountability. This inverse hierarchy was a definitive feature of DIMPLE. They challenged NHS-isms and were critical friends, expecting us to deliver better and more locally rooted and responsive services. Without them we would have been satisfied with less and would have chosen ways of working which fit easily into our systems and organisation.

Models which involve patients in the design and delivery of peer education services seem to generate a self-sustaining momentum. Volunteers improved their own health and well-being and ability to manage the condition. They all contributed and led to service improvements. With respect to project delivery, initiating 3 new volunteer programmes at the same time was ambitious, but it also provided a development pathway for volunteers one which has supported the sustainability of the projects. DIMPLE provided a way for volunteers to develop their community outreach skills, helping the volunteers develop professionally and these skills in turn fed back into DIMPLE i.e. the champions who performed well went on to train as mentors or as peer educators and to take on part-time paid roles as lead champions, supporting other champions to set up and run their own events. The volunteers themselves added considerable value to the project linking it in with other services and groups: i.e. men’s health, prostate cancer, children’s activities and many faith groups.

For our project, sustainability lies in using local resources to make the projects work e.g. working with local community organisations like CITAS. We also need to be able influence key commissioners in different organisations. Therefore the continued evidencing of DIMPLE projects is essential. Upon reflection we found that the sustainability tool created by CLARHC didn’t directly relate to the DIMPLE’s key considerations as it didn’t cover relationships with budget holders and decision makers.

Current climateThe Health and Social Care Act 2012 will be implemented in April 2013, abolishing the 152 PCTs throughout England and the 10 Strategic Health Authorities. In their place, more than 300 Clinical Commissioning Groups (CCGs) will have the responsibility of ensuring effective purchasing, integration and delivery of diabetes services in local communities. The Health and Wellbeing boards have an important task of ensuring that CCGs work with local authorities so that commissioning accurately reflects the local public health priorities.31 A reduction in premature mortality in diabetics can be achieved via more integrated levels of care, as highlighted in the

30 201131 (Department of Health, 2012).

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North West London Integrated Care Pilot32. In the ‘Health Improvement’ domain of the recently published Public Health Outcomes Framework for 2013-201633, indicators such as diet, excess weight in adults, self-reported wellbeing, proportion of physically active adults and recorded diabetes prevalence can all be positively affected by local initiatives. Evidence that the DIMPLE Diabetes Champions initiative has affected these outcomes is provided in this study.

Evaluation and analysisSystematic data collection and evaluation has been critical to understanding the impact of DIMPLE. The impact evaluation showed various strengths including strong internal validity of results due to triangulation. Continued analysis of long-term impact would clearly be beneficial. It would be advantageous to see, for example, if a statistically significant difference in outcome measures occurs before and after a Diabetes Champions intervention. With respect to ongoing evaluation the web-reporting tool worked well for reporting on champions events, and reviewing and revising of programmes with service users we feel has lead to improved outcomes. The SROI analysis proved an appropriate and useful tool for evaluating DIMPLE and can now be used by NHS NWL, the local authority and other PCTs and local authorities nationwide to compare the DIMPLE Champions project with other health promotion initiatives and interventions to gain a sense of value that differing interventions bring. A social return on investment of £6.59 per £1 spent represents a “good investment”.

Financial considerationsIt is essential that commissioners ‘invest to save’ to reduce the long-term burden of diabetes via effective population based primary preventive initiatives34. DIMPLE champions project shows the potential to influence positively two of the five domains that encompass the NHS Outcome Framework for 2012/201335, with a peer-led intervention targeting local populations.

DIMPLE initiatives have the potential to offer cost savings in the following areas: i) Prevention – a proportion of those at high risk of developing diabetes will reduce their

risk levels through lifestyle changes and not go on to develop the condition ii) Diagnosis – some of those at-risk yet undiagnosed will be diagnosed at an earlier

stage leading to earlier treatment and the decreased likelihood of complications developing

iii) Self-management – people with diabetes will have a range of options to choose from for support at different points in their life, reducing the burden on healthcare professionals. and

iv) Public Health – many people from hard-to-reach groups will make improved lifestyle choices which will reduce the risks of obesity, cancers and heart disease as well as diabetes.

.Conclusions

This report concludes that interventions based on peer-to-peer support relationships offer a promising approach to diabetes improvement. It is suggested that initiatives such as the DIMPLE Diabetes Champions and Educators projects have an important role to play in reducing the overall burden of diabetes throughout the country. It is essential that commissioners can appreciate the importance and value of primary prevention initiatives in the forthcoming years. This is especially true considering the budget reductions currently being applied in healthcare. The Kings Fund predicts that the future financial sustainability of the NHS will depend upon the implementation of systematic primary prevention initiatives in order to reduce the future incidence

32 which shares both patient records and clinical care pathways between multi-disciplinary teams (Majeed et al., 201233 Department of Health, 201234 NHS Primary Care Commissioning, 200935 Department of Health, 2012

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of disease and associated complications in the years ahead. DIMPLE has the additional benefit of reaching those most likely to be afflicted with diabetes. It could be argued that initiatives such as the DIMPLE Diabetes Champions project have the potential to positively influence two of the five domains that encompass the NHS Outcome Framework for 2012/201336. Likewise the indicators in the Public Health Outcomes Framework for 2013-2016 all have the potential to be positively affected by local initiatives such as the DIMPLE champions project. Individual level and community level empowerment and the respective effects on health improvement have been evident throughout and across all projects.

This report would recommend adding to diabetes service pathways in order for people with diabetes to become involved in delivering education, and designing how that education is delivered. To the degree it has been evaluated DIMPLE has shown itself as a viable approach for HCPs to consider when tackling health improvement in diabetes. There is however much to learn about how best to organise and deliver effective interventions and how to integrate them with other support services.

Other informationFunding

References

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AppendicesPeer-led Education, Self-Management and Primary Prevention Kate Lorig developed the Chronic Disease Self-Management Programme (CDSMP) at Stanford University and is one of the foremost researchers in the area of chronic disease self-management worldwide. In the CDSMP, individuals with a specific chronic disease (i.e. arthritis or diabetes) are trained as peer-advisors and are responsible for the delivery of a myriad of information to fellow sufferers, appertaining to symptom management, exercise, nutrition and communication with healthcare professionals. Improvements in a plethora of outcome variables at 6 month follow-up were observed in comparison to the control group (Lorig et al., 1999).

In 2001, the NHS published ‘The Expert Patient’, emphasising an appreciation of the role of the patient in chronic disease management as knowledgeable and useful adjuncts to traditional medical care (Department of Health, 2001). This led to the formulation of the UK’s equivalent of the CDSMP, which was named the Expert Patient Programme.

The Kings Fund recently acknowledged the need for the NHS to re-orient its health service priorities away from acute and episodic treatment of illness to the prevention of chronic disease. Active support for self-management of chronic diseases and improved primary prevention of chronic conditions such as diabetes were two of the top ten priorities highlighted by the researchers for commissioners to invest in throughout the forthcoming years (Kings Fund, 2012).

The University of East Anglia has developed an Impaired Fasting Glycaemia Programme. This involves lay members of the public who are already afflicted with diabetes being trained to provide motivational phone calls to members of the public who were considered high risk for future development of diabetes. It was shown that such a peer-led diabetes prevention programme was viable and more cost-effective than using healthcare workers in a motivational health promoting capacity (Murray et al., 2012). One report has suggested that there are four key domains in which diabetes education and self-management programmes should be evaluated with regard to effectiveness. These are knowledge and understanding, self-management, self-determination and psychological adjustment (Egenmann and Colagiuri, 2007).

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In a meta-analysis of quality of life (QOL) outcomes after self-management training, Cochran and Conn (2008) found statistical significance between control and intervention groups; those that underwent self-management courses experienced an increase in QOL whereas the control group had no change. The National Institute for Health and Clinical Excellence (2012) asserted that the successful implementation of patient education programmes in the management of type II diabetes is subject to adequate training programmes and staff numbers being available. Such training and an increase in staff numbers would bear a significant additional cost to NHS resources. This is where peer-led volunteer programmes can be most beneficial. ****

The NHS Expert Patient Programme was initiated in 2002 as a pilot programme, successfully providing peer-led self-management courses for a range of chronic disease sufferers, including those of diabetes. They enable individuals to improve both mental and physical health via skill acquisition and structured education.

Tricco et al. (2012) found that if baseline glycated haemoglobin is greater than 8.0%, the patient education strategy has the greatest effect, with more modest improvements being observed in patients with glycated haemoglobin values below 8.0%. Thus, targeted education referral for patients with HbA1C value > 8.0% could be most efficacious, in order to save costs for the NHS.

Deakin et al. (2006) initiated the ‘X-PERT’ programme, which aims to educate people with type II diabetes via a six week training course. This covers tips on eating, physical activity, what diabetes is and how it can be management better. A recent review has found it to lead to increases in confidence, healthy eating, physical activity, blood glucose control and requirement for diabetes medication.*** Further, in a systematic review of lifestyle modification interventions in diabetic patients, the X-PERT programme was considered most likely to be cost-effective (Jacobs-Van Der Bruggen et al., 2009).

A study by Kennedy et al. (2008) also found that a peer-led self-care support programme improved health related quality of life, with increases in self-efficacy and self-reported energy also being observed.

Conversely, a RCT of peer support in patients with T2DM in GP surgeries in Ireland found no difference in both biophysical and psychosocial outcomes between the intervention and control groups. This led to the assertion that universal adoption of peer-support and the scope for it having beneficial effects upon patient management is limited (Smith et al., 2011). More research is required in order to elucidate whether a targeted approach, involving patients with poorly controlled diabetes at high risk of complications or assessing alternative mediums of support.

Dose Adjustment for Normal Eating (DAFNE) is an educational programme for the management of type I diabetes. A recent systematic review into the effectiveness of the DAFNE programme found that both glycated haemoglobin and quality of life were significantly improved in all of the intervention settings using DAFNE. However, paucity exists as to the long-term effectiveness of the programme, and thus more research is needed (Owen and Woodward, 2012).

Khunti et al. (2012) reviewed the effectiveness of DESMOND and found that changes in both lifestyle and biomedical outcomes at one year post-intervention were not sustained at year three of follow-up. However, four out of the five illness beliefs of participants (seriousness, personal responsibility, timeline and coherence) were sustained. This finding does question the long-term use of diabetes education models.

CLAHRC NWL is one of nine NIHR funded centres around the UK. Some other centres have also developed type II diabetes primary prevention programmes which are currently under implementation and evaluation. CLAHRC Leicestershire, Northampton and Rutland are currently in the process of conducing a cluster randomized controlled trial to investigate the effect of structured education on walking in individuals at high risk of developing type II diabetes (CLAHRC

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Leicestershire, Northamptonshire and Rutland, 2012). CLAHRC Greater Manchester (2011) has also implemented evidence-based preventive lifestyle changes for primary care patients that are of a greater risk of developing type II diabetes in the future. This consisted of health trainers delivering face to face or telephone lifestyle support for a period of six months to high-risk patients. Improved clinical outcome data was evident, with reduction in mean waist circumference and weight being evident. At the CLAHRC for Birmingham and Black Country, an evaluation is currently being conducted on the ‘ChronicDisease Educator’ self-management programme for individuals with diabetes and other common chronic conditions.

The World Health Organization have defined peer-led education as the process by which individuals who either have diabetes or have been affected by the condition (i.e. via family or friends) engage with fellow diabetes patients or members of the public and deliver health information and support.

A randomised controlled trial aimed to assess the effectiveness of using peer advisors compared with specialist health professionals in the delivery of diabetes self-management training. It was found that both specialist health professionals and peer advisors were equally as efficacious at educating peers, with knowledge diabetes and the importance of a healthy lifestyle encompassing good nutrition, regular exercise and medication compliance being improved post-intervention (Baksi et al., 2008).

In an era of increasing economic uncertainly and financial austerity, the mantra of value is continually being asserted in the NHS. In particular, new medicines and interventions have to be cost-effective. The National Institute for Health and Clinical Excellence (NICE) have recommended patient education models in both the prevention and treatment of T2DM (NICE, 2012).

 

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