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Published by Oxford University Press 2009.

doi:10.1093/fampra/cmp027 Family Practice Advance Access published on 9 June 2009

Peer-based behavioural strategies to improve

chronic disease self-management and clinical

outcomes: evidence, logistics, evaluation

considerations and needs for future research

Martha Mitchell Funnell

Martha Mitchell Funnell. Peer-based behavioural strategies to improve chronic disease self-

management and clinical outcomes: evidence, logistics, evaluation considerations, and needs

for future research. Family Practice 2010; 27: i17i22.

The diagnosis of a chronic disease such as diabetes generally evokes strong emotions and often

brings with it the need to make changes in lifestyle behaviours, such as diet, exercise, medica-

tion management and monitoring clinical and metabolic parameters. The diagnosis thus affects

not only the person diagnosed but also the family members. Chronic illnesses are largely self-

managed with$

99% of the care becoming the responsibility of patients and their families orothers involved in the daily management of their illnesses. While the responsibility for out-

comes, such as metabolic control and chronic complications, are shared with the health care

team, the daily decisions and behaviours adopted by patients clearly have a strong influence

on their future health and well-being. While diabetes self-management education is essential,

it is generally not sufficient for patients to sustain behaviours and cope with a lifetime of diabe-

tes. Peers have been proposed as one method for assisting patients to deal with the behavioural

and affective components of diabetes and to provide ongoing self-management support.

This paper first describes effective behavioural strategies in diabetes, based on multiple studies

and/or meta-analyses, and then provides examples of their use by peers or in peer-based pro-grammes in diabetes. A comprehensive search using the MEDLINE and Cinahl databases

was conducted. Key search terms included peer mentors, peer leaders, peer educators, lay

health workers and community health workers. Studies that clearly identified behavioural strat-

egies used by peers were included.Keywords. behaviour change, diabetes, lay health workers, social support.

Introduction

Self-management education has long been considereda cornerstone of chronic disease care and is the initialstep in providing patients with the information theyneed to care for their health. Diabetes self-manage-ment education has been defined as the ongoing pro-cess of facilitating the knowledge, skill and ability

necessary for diabetes self-care.1 This process incorpo-rates the needs, goals and life experiences of the personwith diabetes and is guided by empirical evidence.The overall objectives of diabetes education are to sup-port informed decision making, self-care behaviours,

problem solving and active collaboration with thehealth care team and to improve clinical outcomes,health status and quality of life.1

In diabetes, self-management education provided byhealth care professionals is effective for improving clini-cal outcomes and quality of life, at least in the shortterm.28 However, while essential, education is generallynot sufficient for most patients to maintain those behav-

iours over a lifetime of diabetes. There is evidence thatwhile there is no one best educational programme, thosethat incorporate behavioural and affective strategies aremore effective912 and that ongoing support is neededto sustain the changes made during the educational

Received 14 November 2008; Revised 24 February 2009; Accepted 29 March 2009.The University of Michigan Medical School, Ann Arbor, MI, USA. Correspondence to Martha Mitchell Funnell, The Departmentof Medical Education and the Michigan Diabetes Research and Training Center, University of Michigan, 300 North Ingalls, 3D06,SPA 5489, Ann Arbor, MI 48109-5489, USA; E-mail: mfunnell@umich.edu.

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process.3,1315 Peers have been proposed as one methodfor assisting patients to deal with the behavioural and af-fective components of diabetes and to provide ongoingself-management support.

Methods

This paper first describes effective behavioural strategiesbased on multiple studies and/or meta-analyses in diabe-tes and then provides information about their use bypeers or in peer-based programmes in diabetes. A com-prehensive search using the MEDLINE and Cinahldatabases was conducted. Key search terms includedpeer mentors, peer leaders, peer educators, lay healthworkers and community health workers. Based on thiscomprehensive review, all studies clearly identifyingbehavioural strategies in peer-based programmes wereincluded.

Behavioural strategies for self-management supportWhile not all studies report a positive impact ofbehavioural approaches on outcome measures, a varietyof strategies have been shown to facilitate behaviourchange among chronically ill patients.1517 Strategies thathave demonstrated effectiveness in chronic illness andare relevant for peer programmes include self-directedbehavioural goal setting, problem solving, social support,patient-centred communication and exploration offeelings.

Behavioural goal setting. Behavioural goal setting isan interaction resulting in the development of a con-

crete, usually short-term goal. Goal setting refers to theprocess of creating an action plan whereby patients canaccomplish a specific behaviour.15 Behavioural goal set-ting is often used in programmes designed to increaseself-efficacy and empowerment.11,12,15,16,1821 The pro-cess is highly collaborative and often incorporates ele-ments of problem solving, exploration of feelings andcommunication strategies, such as reflective listeningand motivational interviewing (MI).1113,15,16,1821 Amodel for goal setting developed by Anderson and Fun-nell22 consists of five steps which are

Explore the problem Clarify feelings and meaning Develop a plan Commit to action Experiment with and evaluate the plan.

In a recent review, Shilts et al.23 concluded that goalsetting was effective for promoting dietary and physi-cal activity behaviour change among adults. Otherstudies support the use of goal setting in primary caresettings24 and chronic disease self-management educa-tion programmes.3,12,15,1721,2528

Problem solving. Problem solving generally is viewedas a process with a sequence of activities that includesproblem identification, generation of alternatives,weighing costs and benefits of those alternatives, selec-tion of strategies or solutions and evaluation of out-comes.29,30 This process is often the first step indeveloping an action plan.

Problem solving is a central component of self-management and is a key element of almost all success-ful individual and group self-management programmesreporting improved outcomes.12,15,1821,25,29,3134

A theoretical model of problem solving adapted todiabetes self-management35 identifies four key compo-nents. These are (i) problem-solving orientation,which includes attitudes and beliefs and can serve asa positive or negative motivating factor; (ii) problem-solving process which is how a person attempts to han-dle the situation; (iii) transfer of past experiences orlearning and (iv) disease-specific knowledge. In a focusgroup study designed to explore this model among ur-

ban African Americans, patients in good glycaemiccontrol reflected a positive orientation towards prob-lem solving, a rational problem-solving process anda positive transfer of past experiences. In contrast, thegroup with poor glycaemic control reported a negativeorientation, careless and avoidant problem solving anda negative transfer of past experiences.36

Social support. Social support refers to transactionsthat occur within a persons social network and in-cludes four dimensions: appraisal support, informa-tional support, instrumental support and emotionalsupport.37 The social support network for most patients

consists primarily of health care professionals and fam-ily members. Peers, however, can become part of thisnetwork and provide support in each of these dimen-sions.38 This may be particularly helpful when familymembers and friends are not available, willing or ableto provide support or are viewed as a hindrance to thepatients self-management efforts.39,40 Multilevel sup-port, particularly among ethnic minorities, appears toincrease physical activity and healthy eating behav-iours.41

Peer support connects two or more people whohave the same disease and often the same frustrations,so they can relate to each others feelings and anxi-eties.42 Peer support helps people cope with the neces-sary behaviour changes and assists them in makingpositive lifestyle changes.39,4345 Peer support can be-come part of a group programme facilitated by healthprofessionals through involving peers in the problem-solving and goal-setting processes12,30,34,46 and throughsupport groups.44,47

Creating peer partnerships is another approach to theprovision of support. Some programmes pair peers whoare similar,48 while others are designated as mentoringor coaching programmes. Mentoring programmes pair

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a person who has demonstrated successful behaviourchange with a patient who needs help.39,42,43 Coachesserve as a support for their partners efforts to achievea new goal39 and to help their partner maintain enthusi-asm and motivation.

Communication skills. Communication skills that fa-

cilitate behaviour change are generally person centredand involve active or reflective listening. A non-directive communication strategy is the AskListenEmpathize and Encourage approach,22 used effec-tively in empowerment-based programmes.22,30,34 Thisis a continuous process where open-ended questionsare used to assist the patient to reflect on areas of con-cern or behaviours and through this process to gain in-sight and identify actions to address the problem orbehaviour.

A directive communication strategy, MI, evolvedprimarily from addiction treatment programmes andwas first described by Miller.49 He defined MI as

a counselling style for eliciting behaviour change byhelping patients explore and resolve ambivalence. MImay be particularly relevant for patients who demon-strate a low readiness to change, defined in this modelas importance confidence = readiness.15 The toneof the interaction is non-judgemental, empathetic andencouraging50 and uses reflective listening and positiveaffirmations to help patients identify their own healthgoals and the discrepancies in their behaviours thatinfluence goal attainment.15,50

In a recent meta-analysis,51 MI was effective for im-proving body mass index, total blood cholesterol, sys-tolic blood pressure and blood alcohol concentration,

but the number of cigarettes per day and A1C were notsignificantly improved. In addition, MI was effective in80% of studies when implemented by psychologists andphysicians, while other health care professionals ob-tained an effect in only 46% of the studies.51 MI alsohas shown promise in promoting changes in dietary be-haviours and exercise.52,53

Exploration of feelings. The largest study of its kind,the Diabetes Attitudes, Wishes and Needs (DAWN)study, was carried out through structured interviewsconducted in 11 regions (representing 13 countries).Survey participants included 2750 randomly selectedgeneralist and specialist physicians, 1122 randomly se-lected generalist and specialist nurses and 5104 ran-domly selected patients with self-reported type 1 andtype 2 diabetes.54

The DAWN study reported that diabetes-relateddistress was common among people with both type 1and type 2 diabetes and that these issues interferedwith their self-management efforts.54,55 A large major-ity of the patient participants (85.2%) reported a highlevel of distress at the time of diagnosis, including feel-ings of shock, guilt, anger, anxiety, depression and

helplessness. Many years after diagnosis (mean dura-tion almost 15 years), problems of living with diabetesremained common, including fear of complicationsand immediate social and psychological burdens ofcaring for diabetes.54 Forty-one per cent of patients re-ported poor well-being and indicated that they wantedgreater acknowledgement and support for their dis-

tress.55

Exploring these feelings is an effective way toenhance self-efficacy and ultimately to improvepatients ability to manage their diabetes.17

Behavioural strategies in peer-based programmes

Face-to-face group peer support programmes. Groupscan be used effectively to provide self-managementsupport7 and successful programmes tend to use multi-ple behavioural strategies. In the most well-studiedpeer-led programmes, both the Asthma and ChronicDisease Self-management Programs developed byLorig et al.1821 use behavioural goal setting, problemsolving, social support and coping with negative feel-

ings. Specific clinical content is not provided, but thebenefits of healthy diets and exercise are stressed. Theultimate goal of these programmes is improving self-ef-ficacy, which is linked to successful self-management.17

Empowerment-based programmes also use a varietyof behavioural strategies12,34,45 including behaviouralgoal setting using the five-step behavioural goal-settingmodel, problem solving, reflective listening, social sup-port and exploring emotions. Clinical content is pro-vided by health professional facilitators in response toquestions and issues raised by group members. The ulti-mate goal of these programmes is to enable participantsto discover and use their own innate ability to gain mas-

tery over their diabetes.22 Similar programmes imple-mented in the UK28 and Germany56 have shownpositive results. The current activity in the evolution ofthese programmes is to train peers to serve as facilita-tors of the groups using the behavioural and other strat-egies that were found to be effective whenimplemented by health professional facilitators.

Project Dulce57,58 is a culturally specific diabetesmanagement and education programme for medicallyindigent Latino patients in California. This pro-gramme includes case management and medicationadjustment by a registered nurse and a group educa-tion programme conducted by a Spanish-speakingpeer educator. This peer-based programme consists ofan 8-week curriculum that covers all major aspects ofclinical diabetes care, with an emphasis on overcomingcultural misconceptions about diabetes and supportingpatients to take charge of managing their disease. Thisprogramme has demonstrated significant reductions inA1C values and reduced hospital expenditures.57

Clearly one of the advantages of face-to-face groupprogrammes is the ability of members to both giveand receive social support. Support groups can be fa-cilitated by either peers or health professionals and

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appear to be particularly effective for older adults andcertain ethnic groups.43,47

One-to-one peer support programmes. While one-to-one interactions with a peer may be ideal, they alsopresent a variety of logistical and access issues. In aneffort to overcome some of these issues, telephone-

based support programmes have been developed andevaluated and are continuing to be developed as tech-nological advances make these programmes more pos-sible and affordable.

A feasibility study of an Interactive Voice Responsetelephone system was recently conducted at a VeteransAdministration Medical Center.47 Patients werematched with a peer partner based on insulin use andself-identified diabetes self-management goals, whenpossible. At the conclusion of the study, participants re-ported that their partners listened to them talk abouttheir concerns and feelings, assisted them in solvingproblems and helped them to adopt healthy behav-

iours. Interestingly, in this pilot study, the least success-ful matches were made between those who weresuccessfully managing their diabetes and those whowere not. Participants recommended that training inlistening skills and how to be a more effective peer beprovided in future studies of this type.

Two small studies of mentoring based on the trans-theoretical model have been conducted. Josephet al.39 trained peer coaches for 2 hours in active lis-tening techniques. The coaches then met with their as-signed partner for 1 hour face-to-face and spoke bytelephone weekly for 1015 minutes over the next 8weeks. Although no metabolic data were collected,

participants reported in focus groups that coachingwas personal, useful in disease management and help-ful for making progress towards changing their behav-iour related to diet, exercise and blood glucosemonitoring. MacPherson42 implemented a similarmodel and found similar results.

Two similar studies using peer telephone support havebeen conducted among African Americans. The NewLeaf program, designed to increase physical activityamong women with type 2 diabetes, incorporatedmonthly calls by a Community Diabetes Advisor intoa community-based programme.38 The group who re-ceived the dietitian-led intervention enhanced bymonthly advisor calls to provide social support and rein-force behaviour change demonstrated superior physicalactivity outcomes. The majority (86%) of the partici-pants identified the calls as important to their success.

The New Diabetes Awareness and Wellness Net-work is a church-based programme for African Ameri-cans that included health professional-led group andindividual sessions and monthly telephone follow-upby a Church Diabetes Advisor (CDA).59 The CDAsall had type 2 diabetes and were trained in MI techni-ques, listening skills and diabetes content, with a focus

on diet and exercise. The CDAs provided support forbehaviour change, follow-up on diet and activity goals,problem solving, information and connections withcommunity resources. The results of this study havenot yet been published.

Web and email peer support programmes. The

Chronic Disease Self-Management program60

wasadapted to an Internet-based programme and foundto be at least as effective as the small group-based pro-grammes. The same behavioural strategies were usedto promote self-efficacy. This approach to peer coach-ing has the potential to increase access to peersupport.

The D-Net program61 was designed to provide infor-mation, personal diet coaching by a health professionaland the opportunity to participate in a peer directedbut professionally monitored chat room. The purposeof the chat room was to provide a forum for partici-pants to interact with their peers to express their feel-

ings and obtain support for behaviour change. Whileall groups improved in behavioural, psychosocial andbiological outcomes, the addition of the peer coachesdid not significantly improve results.61,62

Summary and conclusions

While behavioural and affective strategies and ongo-ing support can be effectively provided by health careprofessionals through educational and case manage-ment programmes,8,1315 many health care professio-nals and systems are not equipped to provide the type

of education and/or the behavioural and psychosocialsupport needed for long-term self-management.

With training, peers can fill this need both effec-tively and economically using established and effectivecommunication and behavioural and strategies (e.g.goal setting, problem solving and providing social sup-port) in community settings and through the use oftechnology.

However, there are still things that we need to learnin order to maximize the effectiveness of these pro-grammes. These include the following:

While affective and behavioural strategies gener-ally increase the effectiveness of self-managementprogrammes, not all interventions result in im-proved outcomes. Thus, we do not fully under-stand which strategies are most effective forimproving metabolic and other outcomes and ifthere are strategies that are more effectively im-plemented by professionals or peers.

Many peer-based programmes described in the lit-erature do not clearly identify or describe thebehavioural strategies used by peers to provideself-management support.

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Very little is known about the training requiredfor peers to successfully implement behaviouralstrategies and even less is known about the super-vision needed or the qualities or qualificationsthat enable a person to become an effective peerpartner.

While peers and lay health workers are utilized to

provide education and support in many countries,very little is known about the relative effective-ness of behavioural strategies in particular coun-tries or among patients from particular culturesand/or religious beliefs.

Declaration

Funding: National Institute of Diabetes and Digestiveand Kidney Diseases of the National Institutes of

Health (NIH5P60 DK20572, 1 R18 0K062323-01).Ethical approval: none.Conflict of interest: none.

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