Effectiveness of a peer-led self-management program for older people with type 2 diabetes in China by Huixia Shen MHSc (Nursing), RN A thesis submitted in partial fulfilment of the requirements for the degree of the Doctor of philosophy School of Nursing, Faculty of Health Queensland University of Technology 2008 Abstract Type 2 diabetes is a common chronic disease, which has a negative health impact and results in enormous economic burden. The prevalence of type 2 diabetes is increasing dramatically and it affects older people disproportionately. The healthcare system in China is faced with an overwhelming burden due to a large ageing population, high prevalence of diabetes and limited healthcare resources. Self-management has been widely accepted as the cornerstone of the clinical management of type 2 diabetes. Since self-management usually involves complex behaviour change and can be emotionally challenging, effective education is essential to facilitate this transition. However, there has been no existing program of type 2 diabetes self-management for older patients in China until now. Furthermore, the generalisation of any health education programs is often hampered due to limited healthcare resources in China. The primary purpose of this study was to develop a socially and culturally suitable self-management program, which addressed self-efficacy and social support to facilitate behaviour change and subsequent health improvement, for older people with type 2 diabetes living in the community in China. The secondary purpose was to test a feasible delivery model of the program through involvement of peer leaders and existing community networks. i This study was conducted in three phases. Phase one gathered information about barriers related to self-management behaviours and help needed to address them, from the perspective of older people with type 2 diabetes and community health professionals, through focus group discussion. Data from Phase One, together with guidelines of the selected theoretical frame work, results from an extensive literature review, and experiences of previous relevant studies provided the basis for development of a peer-led type 2 diabetes self-management program (Phase Two). Phase Three involved a pre-test, post-test non-equivalent control group design to test the effectiveness of the self-management program on older people with type 2 diabetes in the community. The impact of the program on peer leaders was examined using a one group pre-test, post-test design. In addition, evaluation of the program from peer leaders’ and older people’s perceptions was conducted through a post-test questionnaire. Older people with type 2 diabetes and health professionals expressed broadly the same concerns, which were: social support; confidence to practice self-management behaviours; self-management behaviours; barriers to self-management behaviours; and advice for ongoing health education. However, their points of view were not always identical and different emphases were identified. The peer-led program produced significant improvement in social support, ii self-efficacy, self-management behaviours and depressive status in the experimental group, as compared to the non-equivalent control group. However, there was no significant effect on quality of life nor health care utilisation. Therefore, the effectiveness of the program among older people with type 2 diabetes was partially confirmed. In addition, the participants were supportive, giving positive feedback about the program. Suggestions for future improvement were provided as well. After receiving specific peer leader training and assisting in most of the delivery process of the program, the peer leaders improved, significantly, in overall self-management behaviours and in specific areas of social support and self-efficacy, though they did not improve in depressive status, quality of life and health care utlisation. In addition, these peer leaders enjoyed being peer leaders, and gave very positive feedback about the whole program. In conclusion, this study has implications for understanding and facilitating self-management behaviours for older people with type 2 diabetes in China. The peer-led self-management program was effective in improving levels of self-efficacy, social support, self-management behaviours and depressive status among older people with type 2 diabetes living in the community in China. The delivery process involving peer leaders was deemed feasible to implement within the health care system in China. The program is suitable to be used by community health iii professionals in their practice in China. The study also has potential wider benefit to nursing practice and global health practice. iv Key Words Type 2 diabetes Older people Self-management Self-efficacy Social support Peer education Intervention v vi Table of Contents Contents Abstract………………….………………………………………………………………. i Key words……..……………………………………………………………………….... v Table of contents……..…………………………………………………………………. vii List of figures…………………………………………………………………………….. xi List of tables.…………………………………………………………………………….. xiii List of appendixes……..…………………………………………………….………….. xv Authorship……..……..………………………………………………………………….. xvii Acknowledgements …..………………………………………………………………….. xix Chapter 1 Introduction 1 1.1 Background ……………………………………………………………………...…… 1 1.2 Theoretical framework ……………………………………………………….………. 9 1.2.1 General introduction: triadic causation reciprocal model………………….……….. 9 1.2.2 Self-efficacy & behaviour…………………………………………………………... 13 1.2.3 Sources of self-efficacy……………………………………………………………... 15 1.2.4 Social support & behaviour………………………………………………………… 16 1.2.5 Social support & self-efficacy………………………………………………………. 18 1.2.6 Self-management behaviour and health outcome…………………………………... 19 1.2.7 Summary…………………………………………………………............................. 20 1.3 Definition of terms……………………………………………………………………. 21 1.4 Purpose……………………………………………………………….……………….. 23 1.5 Objectives, questions and hypotheses…………………………………………............ 24 1.5.1 Objectives………………………………………………………………………....... 24 1.5.2 Questions……………………………………………………………………………. 25 1.5.3 Hypotheses………………………………………………………………………….. 27 1.6 Overview of methodology………………………………………………………......... 29 1.7 Structure of the document…………………………….................................................. 30 Chapter 2 Literature Review Type 2 Diabetes and Self-Management 33 2.1 Overview of type 2 diabetes………………………………………………………….. 33 2.1.1 Definition…………………………………………………………………………… 33 2.1.2 Prevalence………………………………………………………………………….. 34 2.1.3 Health influence……………………………………………………………………. 37 2.1.4 Cost……………………………………………………………………………….... 38 2.2 Management of type 2 diabetes………………………………………………………. 40 2.2.1 Treatment of type 2 diabetes: glycemia control…………………………………….. 40 2.2.2 Significance of type 2 diabetes self-management…………………………………... 42 2.2.3 Current status of type 2 diabetes self-management in China………………………. 44 2.3 Summary……………………………………………………………………………... 46 vii Chapter 3 Literature Review Type 2 Diabetes Self-Management Education 47 3.1 Type 2 diabetes self-management education………………………….…………….... 47 3.1.1 Importance of diabetes education in type 2 diabetes management……………….… 47 3.1.2 Trends in diabetes education…………………………………………………...…… 49 3.1.3 Brief introduction of contemporary diabetes education…………………………….. 50 3.2. Social cognitive theory and type 2 diabetes self-management education……………. 54 3.2.1 Social cognitive theory and its application in health studies……………………..… 54 3.2.2 Self-efficacy and type 2 diabetes self-management………………………...………. 55 3.2.3 Social support in type 2 diabetes self-management………………………...………. 91 3.2.4 The relationship between self-efficacy and social support……………………...….. 123 3.3 Current studies on type 2 diabetes self-management education in China……………. 125 3.4 Summary………………………………………………………………………...……. 135 Chapter 4 Literature Review Peer Education Program 137 4.1 Overview of peer education program………………………………………………… 137 4.1.1Definition of peer education program………………………………………….…… 137 4.1.2 Utilisation of peer education in health programs…………………………………… 139 4.1.3 Organisation of peer education program …………………………………………… 140 4.1.4 Advantages of peer education program………………………………....................... 148 4.2 Integration of self-efficacy & social support in peer education program…………….. 151 4.2.1 Enhancing self-efficacy through peer education program ……………………...….. 152 4.2.2 Strengthening social support through peer education program ……………………. 153 4.3 Feasibility and significance of peer education in China………………………….…... 155 4.4 Summary…………………………………………………………………………………... 157 Chapter 5 Methodology 159 5.1 Overview of the research design ……………………………………..…………… 159 5.2 Research settings..………………………………………………………………….… 161 5.3 Ethical consideration…………………………………………………………………. 162 5.4 Phase One…………………………………………………………………………….. 166 5.4.1 Research design…………………………………………………………………….. 166 5.4.2 Sampling framework………………………………………………………………... 167 5.4.3 Data collection procedures……………………………………………………….… 170 5.4.4 Data analysis…………………………………………………………………..…… 173 5.5 Phase Two…………………………………………………………………………….. 175 5.6 Phase Three…………………………………………………………………………… 177 5.6.1 Effectiveness test among general participants…………………………………….... 177 5.6.2 Effectiveness test among peer leaders………………………….……………….….. 199 5.6.3 Evaluation of the program…………………… ……………………………………. 202 5.7 Summary ………………………………………………………………...…… 204 viii Chapter 6 Findings and Discussions of Focus Groups 205 6.1 Findings of