Preclinical phase
Theoretical and empirical evidence for peer support was identified in the literature search.
Peer support within the healthcare context is defined as "the provision of emotional, appraisal, and informational assistance by a created social network member who possesses experiential knowledge of a specific behaviour or stressor and similar characteristics as the target population, to address a health-related issue of a potentially or actually stressed focal person" [
16]. This definition of peer support falls within the social support model, that is defined as the process through which social relationships might promote health and well-being [
17]. Within the social support model, the direct effect model would postulate that peer support could reduce feelings of isolation and loneliness, provide information about access to health services or the benefits of behaviours that positively improve health and well-being and encourage more positive health practices [
16].
The logic behind peer support programmes is that peers have a greater understanding of the target population's situation than other naturally embedded social networks [
16]. During times of need or in stressful situations individuals often turn to social contacts and relationships for support to supplement the care given by the health services [
16].
Members of their own social network may not be able to offer appropriate support for various reasons. For example they may lack experience and knowledge of the stressful life event; they may feel uncomfortable about the issue or are too upset to provide support [
18].
Peer support groups provide individuals with a unique support system where they can gain understanding and feel a sense of belonging. As the group evolves attachments are formed and expressions of caring and genuine concern from the group provides emotional support [
18].
Peer support was found to be successful in some health care settings. It has improved outcomes in diverse health settings such as maternal child health development[
19], neonatal mortality [
20,
21] and cardiac surgery [
22].
Peer support workers also known as lay health workers are defined in a Cochrane review as "any health worker carrying out functions related to health care delivery; trained in some way in the context of the intervention; having no formal professional or paraprofessional certificated or degree tertiary education" (page 1) [
23]. Training for peer support workers should incorporate exploration of the skills required to use experiential knowledge and peer's appreciation and understanding of the target group [
16]. However Giblin warns against too much specific training, as this may destruct the concept of "peerness" [
24]. In addition to peer support benefiting recipients, peer supporters have reported benefits from their role [
25‐
27].
Qualitative research conducted for the Diabetes National Service Framework revealed that people with diabetes felt it would be helpful to meet others in similar circumstances. Peers were viewed as an under-utilised, helpful, source of information and support [
28]. However there are no reported randomised controlled trials of peer support in type 2 diabetes. The literature review highlighted the need for a careful consideration of an underlying theoretical framework and the importance of exploratory qualitative work with individuals with type 2 diabetes in the context within which the study was planned.
Phase 1
In Phase 1, issues raised in the interviews with experts included the identification of social support as a theoretical framework for the study. In addition, experts working in the volunteering sector highlighted the importance of continuing support for the peer supporters to sustain the programme over time.
The patients involved in the exploratory qualitative work expressed enthusiasm for the idea of peer support.
FG1.5 "I thought it would be a good idea for me because from the point of view of the diet it could help me keep me on track. Hearing others ideas and sharing them and so on"
They reported a tendency to turn to peers for advice but felt that a structured support network would be more helpful.
FG2.3 "Very helpful because you are going into a hospital, seeing a doctor, but you are not seeing other people who have it like ourselves"
They had a preference for group rather than individual meetings. Both patients and practice staff felt that peer supporters required specific training that should include the basics of treatment for diabetes and managing a group. However there was a consensus that medical questions from group members should be referred to the GP or practice nurse.
FG7.2 "It is very important for the peer supporters to know their boundaries. They are not doctors"
The work in the Preclinical Phase and in phase 1 led to the identification of four preliminary intervention components:
3.
Retention and support for peer supporters
Phase 2
Phase 2, the exploratory trial/pilot study, involved testing the following preliminary intervention in two general practices:
1. Peer supporters
The GPs and practice nurses in each practice were asked to select two patients with type 2 diabetes who would be suitable for the role of peer supporter. All four peer supporters recruited by the GPs and practice nurses had type 2 diabetes for over a year and were compliant to their treatment regime. Further peer supporter characteristics are presented in Table
2. Findings from the semi structured interviews indicated that the GP's and practice nurses felt they should identify the peer supporters within their own practices.
Table 2
Personal characteristic of the patients and peer supporters that participated in the study
Male | 13 (59%) | 4 (100%) |
Mean age (yrs) | 66 | 65 |
Mean yrs since diagnosis of type 2 diabetes | 4 | 7 |
Entitled to medical card | 14 (64%) | 2 (50%) |
Smoker | 3 (14%) | 0 (0%) |
2. Peer supporter training
Two evening training sessions were organised for the peer supporters. The content of these sessions included the role of the peer supporter, basics of diabetes, lifestyle and medication issues, communication skills, managing groups, confidentiality, role play and support for the peer supporters. The sessions were interactive and informal. They were given a handbook that covered issues raised in the training session. The focus group with the peer supporters revealed that the peer supporters found the training informative and pitched at the correct level. They valued the handbook and referred to it on several occasions during the course of the exploratory trial.
3. Retention and support for peer supporters
A support system for the peer supporters was implemented. This consisted of the project manager contacting each peer supporter after each group session. This was to allow the peer supporter to debrief and discuss any problems that arose during the course of the meeting. The peer supporters reported that they appreciated this contact.
FG5.6 "Someone out there behind you...Someone behind you saying well how did it go, so you are not left"
4. Peer support meetings
Patients were allocated, by GPs and PNs, to each peer supporter within each practice. Three meetings per group were organised and two groups met in the evening and the other two met during the day. Eighty per cent of patients went to two or three group meetings. Feedback in the focus groups with the peer supporters and patients was positive. Both patients and peer supporters reflected that they enjoyed meeting other people with type 2 diabetes. Exchanging practical information, comparing each others situations, conversing in lay terms and general support amongst the group were identified as particularly positive elements of the group meetings.
FG5.4 "I think there is a common thing here in that the people are not looking for a theoretical understanding of it, you know they don't want to know the Latin. What everybody I think is striving for is kinda practical things"
FG5.4 "the mood was terrific there were delighted to be together they took a lot out of it, there were happy"
Patients and peer supporters agreed that more structure in the group meetings would enhance the peer support experience, for example having a set theme for each meeting. Peer supporters suggested a system of 'frequently asked questions' in order to answer any queries that the group members had identified during a meeting.
FG7.4"after the meeting, somebody should put in their questions into the centre and somebody should answer them and bring it back to the group"
Some peer supporters were anxious to have more professional involvement while others pointed out that this would just reproduce some of the services they currently accessed.
The definitive intervention
Following the exploratory phase we finalised the study protocol. The definitive intervention is as follows:
1. Peer supporters
Potential peer supporters are identified by GPs and practice nurses in the intervention practices. Peer supporters are recruited and trained at a ratio of approximately one peer supporter to seven/eight patients with type 2 diabetes. They are eligible to be trained if they meet the inclusion criteria outlined in Table
3.
Table 3
Summary of the development of the intervention
Peer supporters
| No formal professional training | To be selected by GPs and PNs | 4 peer supporters identified by GPs and PNs | Inclusion criteria: • Identified by GPs and PNs • Have type 2 diabetes for 1 year min • Adherent to diabetes regieme • Understand concept of confidentiality • Liaise with PN/GP if unanticipated problems |
| | Inclusion/exclusion criteria considered | | |
Peer support training
| Non specific training | 2 training sessions | 2 training sessions- interactive | • 2 training sessions conducted by PN and GP • Conducted locally • Training sessions focused on materials to be used at group meetings • Resource pack/handbook |
| | Content: basics of diabetes, lifestyle and medication issues, communication skills | Peer supporters handbook | |
Retention and support for peer supporters
| | Support for peer supporters vital | Project manager contacted peer supporters following each meeting | Structures in place to ensure retention of peer supporters: • Feasible time commitment to the project • Outline of responsibilities/peer support policy • Adequate training • Resource pack • Contact details and explicit support from the project team and GP/practice nurse • Telephone call from project manager following each session • Annual social event/education session • Travel and related expenses |
| | Volunteer (no formal payment) | Support from each other at training sessions and focus group following intervention | |
Peer meetings
| | 7 patients per group | Duration 1–1.5 hours | • 9 peer support meetings per group in 2 years of intervention, held in general practice • 7 patients per group • 10 minute structured component for beginning of each meeting • Any unanswered questions (FAQ) feedback to research team at the end of each session and answers discussed at next session |
| | 3 meetings | Meeting held in general practice | |
| | | Frequently asked questions (FAQ) | |
2. Peer supporter training
The peer supporters attend two evening training sessions, which are conducted by a GP and nurse on the research team. Topics covered in Session 1 included: introduction to the project; role of the peer supporter; basics of type 2 diabetes and complications of type 2 diabetes. Session 2 covered the following topics: lifestyle and medication issues; communication skills and working with groups; dealing with difficult group members; role play and confidentiality.
The two sessions focus on the materials to be used during the group meetings (described below) and peer supporters receive a resource pack with a manual and resource material to support these training sessions.
3. Retention and support of peer supporters
Retention of peer supporters is crucial to the study. Structures are in place to ensure peer support workers are supported in the role (See Table
3)
4. Peer support meetings
Peer support meetings are held in the general practice premises at a convenient time for practice staff, peer supporters and participants. The intervention consists of nine peer support meetings held over two years; at month 1, month 2 and every 3 months thereafter. There is a defined ten to fifteen minute structured component for each meeting available to the peer supporters (see Table
4 for a summary of the meeting content). At the end of each meeting there is general discussion and the group identifies and records any questions regarding the meeting focus. These are fed back to the research team who compile written answers based on the feedback from all groups, which are presented and discussed at the start of the next meeting.
Table 4
Summary of content of meetings
• Introduction to each other • What is peer support? • Ground rules • Discussion on course content (9 sessions) • Video/DVD 15 mins • Entitlements in diabetes • Identifying a substitute peer supporter • Contact details for the group | • Why is it so important? • How you can reduce your risk of heart disease and other vascular complication ◦ Hypothetical individual and what they would advise them to do Questions relating to heart disease including blood pressure and cholesterol medication and taking tablets |
SESSION 3- BLOOD SUGAR LEVELS
|
SESSION 4- HEALTHY EATING
|
• Information on hypo/hyperglycaemia • Blood sugar testing Questions on blood sugar levels What to do when you are sick | Discussion of healthy 'eating plate' • Laminated picture of the 'healthy plate' Healthy eating quiz and discussion of answers Questions on healthy eating in diabetes |
SESSION 5- MEDICATION
|
SESSION 6- EXERCISE
|
• Control of type 2 diabetes ◦Diet ◦Tablets ◦Insulin Questions regarding medication including side effects | • Importance of exercise • Use of a pedometer ◦each person will be given a pedometer Questions about exercise Maybe arrange a walk in locality |
SESSION 7- FOOT CARE
|
SESSION 8-EYE AND KIDNEY COMPLICATIONS
|
• Why foot care matters in diabetes • Discussion on how to check feet ◦Laminated sheet to cover all aspects of foot care Questions relating to the feet Information on local chiropody services | • What happens to the eyes and kidneys in diabetes • Importance of good blood pressure and blood sugar control in order to prevent complications Questions relating to eye and kidney disease |
SESSION 9- LIVING WITH DIABETES
| |
This is intended to be a relatively open session in which the group can discuss any remaining concerns and consider whether they would like to continue to meet Importance of follow up data collection | |
It became evident to the research team during the Preclinical Phase and Phase 2 that monitoring the delivery of the intervention was crucial. We therefore decided to include a process evaluation and an assessment of treatment fidelity of the definitive intervention. The process evaluation will map the actual implementation of the intervention. Data from peer supporter log diaries of each meeting and the project manager's record of contact with the peer supporters will be recorded and analysed.
The assessment of treatment fidelity will monitor the reliability and validity of the intervention. The Bellg framework will be used. It consists of five treatment fidelity strategies: Treatment design, Training procedures, Delivery of treatment, Receipt of treatment and Enactment of treatment skills [
29].