Our pilot study suggests that specialist nurse-led self-management training for peer supporters is feasible, acceptable, effective, and was highly valued by participants. The training enabled peer supporters to acquire knowledge about T2D and AH and equipped them with self-management skills to be able efficiently support other people with the same chronic disease by sharing first-hand knowledge, similar experiences and lifestyle issues. Peer supporters were successful in maintaining disease control and making positive changes in self-management behaviors, as reflected by the decrease in their BMI over the six-month period following completion of training.
The study addresses an important gap in the field of integrated healthcare services by providing new insights on the benefits of peer support models for disease self-management. The literature on this topic has primarily focused on clinical and psychosocial benefits for recipients, rather than those who provide the support (12–14). In addition, considerably less attention has been given to the various components of the intervention process, such as recruiting and training peer supporters, which can affect the quality and effectiveness of the intervention (14).
The literature has not used rigorous approaches to recruit appropriate peer supporters (12, 14). Recruitment has mainly been done through referrals from healthcare professionals based on candidate interest in volunteering and diagnosis of T2D as inclusion criteria (14, 29). In contrast to our study, some listed inclusion criteria of acceptable glycemic control (HbA1c ≤ 8.5%) (14, 16, 29, 30), which could increase the retention rate and improve the chances of success (14). We used the purposeful sampling method to ensure that recruited participants were suitable for the peer supporter role. Recruitment of peer supporters should emphasize the importance of their personal experience with the same chronic disease as people they will be supporting. This unique perspective allows them to better understand and empathize with the challenges that their support recipients are facing (10). We believe it is important to promote this uniqueness when recruiting peer supporters, as it can help to build trust and confidence in the support programme.
There is limited data available on the sociodemographic characteristics of peer supporters; most were female and had at least a high school diploma (14, 28, 30, 31), which is consistent with the findings of our study. Most of our trained peer supporters were retired, had longer duration of T2D and were older than in other studies (14, 28, 32). One study found that 90% of peer supporters were unemployed (33). The Slovenian peer supporters were mainly elderly, disease-experienced individuals who were no longer involved in the daily stress of work. They rated the training as very acceptable. Participation in the training was effortless for them, it fitted well with their life beliefs and values, and they understood the process of the entire intervention. They felt empowered and confident in their ability to transfer the knowledge and skills they acquired to other patients.
There are no clear recommendations on who should lead the training of peer supporters (nurse-educator, multidisciplinary team, research expert, etc.) and how long the training should last (from a few hours to several months) (10–13, 28, 31). The training aims to equip supporters with communication and group facilitation skills to provide ongoing emotional and social support, increase knowledge to optimize self-management behaviors and strengthen linkages to the healthcare system (10, 13, 14, 16, 28, 29). Training programs were mostly based on a structured curriculum (10, 11, 13, 14, 16, 29). Teaching methods included role-playing (10, 13, 14, 32), brainstorming, group facilitation simulations (13), PowerPoint presentations (10), training booklets (12, 14) and Conversation Maps™ (12). Our structured self-management training lasted a total of 15 hours over a 2-month period and consisted of combination of group and individual sessions that provided participants with the opportunity to gain comprehensive knowledge of T2D and AH as well as communication skills. The training was led by an educator, a specialist nurse, who provided guidance and mentored participants throughout the training and remained their mentor while providing peer support. We used four different Diabetes Conversation Maps™ as teaching tools and trained peer supporters received the same collection of four Maps™ to bring to peer support meetings after completing the training. These maps are designed to be interactive and engaging, encouraging participants to talk about the challenges of living with T2D and AH, share their stories, knowledge and experiences and emphasize the importance of medical adherence, healthy lifestyle and regular check-ups with healthcare professionals. The maps help to create a structured and supportive environment where participants can learn from one another and feel empowered to take control of their disease management (21, 34). Our detailed self-management training programme (Table 1) makes the lesson preparation transparent and allows for replication when designing future interventions.
Consistent with the findings of our pilot study, other studies have also shown that the development of self-management educational training leads to improved knowledge of T2D among peer supporters (12, 33). Our study was unique as it measured the changes in clinical measurements of peer supporters. Six months after training, peer supporters' weight and BMI decreased significantly compared with baseline measurements. There were no significant differences in the measurements of fasting BG, HbA1c, SBP and DBP after six months, nor were the changes that occurred clinically significant. We did not expect clinically significant changes in such a short period of time, as in our opinion longer study duration is needed to detect significant changes. In addition, peer supporters already had well-controlled clinical parameters at baseline. The results are still relevant as they show that patients were able to maintain their disease control and even improve some clinical parameters over the six-month period. Peer supporters who can model healthy behaviors and share their own experiences with disease management may be more effective at helping others to make positive changes in their own lives. To our knowledge, only Yin et al. have studied the effects of peer support on peer supporters’ health. However, their study was conducted in hospital-based diabetes clinics and involved a multidisciplinary team to train the peer supporters, in contrast to our primary care setting. They found improvements in peer supporters self-care behaviors and maintenance of their glycemic control over 4 years (15).
Our study has several limitations. Firstly, the lack of a control group of peer supporters who did not participate in the training makes it impossible to estimate the real effect of the intervention on the outcomes. We opted to include all 36 candidates into the training in order to get more trained peer supporters that could provide help and support to more patients. In addition, our primary goal was to implement a structured self-management training programme and to evaluate its acceptability and feasibility. Secondly, the same DKT and HKT questionnaires were used at the beginning and the end of the 2-month training and participants already knew the questions, which could influence participants' actual knowledge. However, in previous studies showing improved knowledge about T2D after training (12, 33), participants also repeated the same test, suggesting that question revealing is not predictive of the second test results. Thirdly, it is not possible to measure the long-term effects as the questionnaires were measured only after completion of the training and clinical outcomes only 6 months after the training. Also, we cannot claim that 15 hours of training is sufficient. Therefore, a follow-up evaluation is needed to examine retention and acquisition of skills and knowledge for ongoing peer support intervention.
The actual implementation of our research depends on the willingness and motivation of individuals to voluntarily provide peer support, so a gradual decline in motivation and in some cases withdrawal can be expected (9). We recognised the importance of acceptability when evaluating healthcare intervention (23). Participants assessed our training as highly acceptable and satisfactory. Consequently, we found that participation in the training was high and consistent as 86.1% of patients successfully completed the training and became trained peer supporters. All dropouts were due to external circumstances such as a change in personal or family health status. In the study by Chan et al. 74.7% completed the training and 41.8% agreed to continue providing peer support (29). In a study by Afshar et al., the retention rate among peer leaders ranged from 56–88% (14). To overcome this problem, it is important to focus on engagement and recognition strategies, such as good communication, collaboration among stakeholders and a clear presentation of the benefits of peer support (9). The future connection and collaboration between trained peer supporters, patients, family members, caregivers in the local community and health professionals could make them partners in health and care. Together they could achieve the ultimate goal of a comprehensive, patient-centred approach: empowering individuals to take an active role in managing their illness and achieving their health goals (35).