Examining the effectiveness of a peer-led education programme for Type 2 diabetes and cardiovascular disease in a Bangladeshi population
: Dr Sinead Brophy, School of Medicine, Swansea University, Wales SA2 8PP, UK. E-mail: firstname.lastname@example.org
Aims The aim of this study was to assess an adapted version of the X-PERT® Programme for Type 2 diabetes within a Bangladeshi population.
Methods Bangladeshi adults, living in the UK, with Type 2 diabetes participated in a diabetes educational session based on an adapted version of the X-PERT® Programme. Participants attended a session, led by a trained peer educator and carried out in Sylheti. All participants who registered on the course were telephoned or visited in person the day before the course as a reminder.
Results Registration to attend the course was excellent. However, actual attendance rates were 58% (42/72) out of those registered. Once participants attended, overall they enjoyed attending the sessions and felt they benefited as they understood more about how to better self-manage their condition. Those aspects of the sessions that were most enjoyed were group discussions and interactive posters to explain diabetes. Participants requested a home-based exercise guide, which was developed by the research team. The study was underpowered to show behaviour change, but did demonstrate a trend to improvement in self-care activities. All participants reported recommending the course to others.
Conclusions There was an excellent response in terms of registration for the course. However, the time to attend the course appeared to be a barrier to participants. Nevertheless, for those attending the course, responses were very positive. The amended X-PERT® Programme could be used as a component of a package to improve outcome and self-management for people with diabetes in the Bangladeshi community.
Summary of Diabetes Self-Care Activities
Worldwide, diabetes is a leading chronic disease that is increasing in prevalence [1,2]. Type 2 diabetes is four times more common among South Asians  than in the general population [4–8]. South Asians also have a higher risk of diabetic complications, have a 40% higher mortality and develop the disease 10 years earlier than their White counterparts . In the UK there is a higher prevalence of diabetes among Bangladeshi people than in any other ethnic minority group .
The adoption of self-management skills is necessary to improve outcome for people with diabetes. The National Institute for Clinical Excellence recommends that all patients should be offered structured education , and the National Service Framework for Diabetes advocates patient empowerment through education and self-management . People from ethnic minority communities are less likely to consult about their ill health in the first place  and less likely to know about glucose monitoring and diabetic complications . Educational programmes in predominantly White groups are successful [14–19]. However, difficulties linked to language, beliefs and practices can make it difficult to deliver appropriate educational programmes for ethnic minority patients . There are very few publications related to educational intervention in South Asian Type 2 diabetes patients , and there are no specific standards for diabetes education, particularly for ethnic minority groups in developed countries despite the existence of several types of educational programmes . Adapting a successful programme to be applicable to Asian patients (in terms of dietary and exercise advice) could have major advantages in that language and cultural barriers can be overcome.
We assessed an adapted version of the X-PERT® Programme . We examined process measures such as the number of people attending and how participants learned from the course, satisfaction with the course and outcome measures such as reported change in behaviour after the course.
Patients and methods
Bangladeshi people with a diagnosis of Type 2 diabetes were recruited to the educational session regardless of time of diagnosis, age and sex. One woman and one man were recruited as peer educators. Peer educators needed to: be Bangladeshi, have Type 2 diabetes, be known in the community, have the time to run sessions, be enthusiastic and literate in English and Bangladeshi. Recruitment was through word of mouth, asking local members of the community to participate. Educators were paid for their time running the course. Peer educators were trained by a bilingual general practitioner (GP) (English and Bangladeshi) with a special interest in diabetes. Training consisted of in-depth description of the disease process, causes, symptoms, diagnosis and medication. The peer educators were given an Instructors Manual, which included the course and clearly laid out its structure. The researcher provided training on how to structure and run the sessions and how to use the visual aids. Peer educators presented the course to the researcher by role play to ensure that they understood the course and were able to use the course equipment. All translated scripts and materials were back translated to English to ensure quality.
Posters were displayed in GP surgeries, pharmacies, the Mosque and community settings (such as ethnic help centres and local ethnic shops). Peer educators and the researcher advertised the educational sessions to their contacts, who were also asked to spread the word. Announcements were made in the local Mosque, and as most people have radio transmitters linked from the Mosque to their homes, these announcements would have reached people in their houses. Participants were asked to register to come on the course. Their travel expenses were paid for and refreshments were provided during the session. All participants who registered on the course were telephoned or visited in person the day before the course as a reminder and were also telephoned on the morning of the course. The venue used was always within walking distance of the homes of registered responders (different venues were used for different courses).
The educational sessions were separated into male-only and female-only groups. The education programme was a culturally adapted version of the X-PERT® Programme . Our study only used four of the six sessions from the X-PERT® Programme, as one of the sessions was a shopping tour and the other an assessment. The purpose of the shopping tour was to give participants an overview of the different types of foods and their contents. The shopping tour was excluded as the contents of the trip were covered in the weight management section. Although the X-PERT® Programme was carried out over 6 weeks (one session per week), the educational session in this study was done over one 4-h session. This was because previous research interviews with the target group had shown that there would be a drop in numbers if sessions ran over a period of weeks. The course material used in the study was validated by Trudi Deakin, the originator of the X-PERT® Programme.
- 1The success of the course in terms of reaching people was assessed by process analysis. Descriptive analysis examined the number of people attending the course compared with the number registered to attend, and examined the sources of information for learning about the course.
- 2Satisfaction with the course was assessed by content analysis of tape recordings of discussions with the participants after the course and the course assessment questionnaire.
- 3The outcome of the course in terms of empowering people for self-management was assessed by analysis of the Summary of Diabetes Self-Care Activities (SDSCA) questionnaire .
Ethical approval was obtained from the Multi-Centre Research Ethics Committee for Wales.
Ten people needed to be registered before a course was run. This figure was based on the financial costs of running the course. In the original protocol we aimed to recruit mainly from Swansea, Neath, Port Talbot, Bridgend and then widen further to Cardiff with a total population size of 791 767 people . We expected a Bangladeshi population of 3796 including Cardiff, and 1250 excluding Cardiff. Of these, 156 (4.1%) were expected to have Type 2 diabetes (51 in Swansea and 105 in Cardiff). In practice, 60 participants registered to attend in Swansea alone. Therefore, six sessions were held in Swansea (three male and three female). Only one female session was put on in Cardiff due to time constraints within the grant. Therefore, 42 participants attended (although 72 had registered to attend), giving an average of six participants per session. Two-thirds (28) of participants were female, disease duration was 6.7 years (ranging from 1 month to 18 years), four participants were treated with diet only, 36 on diet and diabetes medication (oral glucose-lowering agents) and two participants on insulin. Of the participants who attended the course, none registered through reading posters, nine registered after talking to the researcher, 11 from talking to the peer educators, 10 from announcements in the Mosque, 18 from talking to other community members and one from a GP referral.
Anecdotal evidence of verbal responses from follow-up with the non-attendees and contact with those registered by telephone or in person prior to the course showed that attending the course was not important or a priority for many people. The most cited reasons were: forgot about the session, worked late and could not wake up and needed to be home with husband and children (‘We are more concerned about whether our children have eaten and house work than coming to classes like these’ (Session 4, patient 2). Many of the women attending the course also reported that they could not stay long. However, once the course started, participants often did not leave. For example, on four occasions participants borrowed the researcher's mobile phone to make arrangements, such as picking up children from school, to enable them to remain at the course.
Satisfaction with the course
All participants responded positively to the educational session. They felt that they had learned a lot about their diabetes and how to manage it better. Participants reported that the most enjoyed aspects of the session were group discussions and interactive posters. Participants liked the fact that the course was carried out in their own language and also that they were given the opportunity to discuss their problems. Recommendations for improvement were that participants requested the researcher to provide them with an exercise guide that they could do at home. We developed a home-based exercise booklet, which has now been provided to participants after the course (http://www.medicine.swan.ac.uk/documents/exercise_manual_own_pics.pdf).
From analysis of the recordings during the course, participants talked about the difficulties they faced as regards exercising, problems they had attending appointments and problems changing diet; they compared their behaviour with that in Bangladesh and talked about why they had diabetes (see Table 1). However, group discussions helped people offer each other advice and solve problems. For example, when one participant commented: ‘You know we are supposed to walk fast (for exercise), if any Bengali (Bangladeshi) men see us, then they will say look at the way so and so's wife is walking’ (Session 1, patient 3) and ‘Go out walking twice a day; Bengali men will say look at that lady—out and about so much’ (Session 6, patient 4), another participant replied ‘Forget what people say—you are doing what you think is right’ (Session 6, patient 7). Participants felt that the information they were given in the session was not only suitable for themselves, but also for their family: ‘my daughter-in-law doesn't have diabetes. Can she still come?’ (Session 1, patient 2); ‘This information can benefit my whole family, not just myself’ (Session 1, patient 1).
Table 1. Themes arising in discussions during the course
|Exercise||You know we are supposed to walk fast (for exercise), if any men see us, then they will say look at the way so and so's wife is walking (Session 1, patient 3)|
|Go out walking twice a day; Bengali men will say ‘look at that lady—out and about so much’ (Session 6, patient 4)|
|My husband tells me to go out walking. (Session 6, patient 5)|
|Do you know, I exercise three times a week and am constantly on the move but I still don't loose weight—why? (Session 6, patient 10)|
|Where can we go swimming? (Session 1, patient 3)|
|As part of exercising, is there a particular way to walk? With speed? (Session 2, patient 6)|
|Attending appointments||If we go to see a doctor, they are English, you need someone with you. If there was a Bengali doctor there, I could tell them about my problems myself (Session 4, patient 5)|
|‘My doctor doesn't even listen to what I have to say—he just starts writing a prescription for me’ (Session 6, patient 2)|
|If you can talk about your illness to your GP, then half of your illness is cured (Session 4, patient 6).|
|Even if you take someone—your child—to translate, the doctors don't seem to pay much attention (Session 6, patient 9)|
|Diet||How can I get everyone in my family to eat more fruit and vegetables? They don't like to eat any (Session 6, patient 2)|
|When cooking meat, any excess fat/oil in the pan, we put down the sink (Session 1, patient 1)|
|In our house, we boil the meat first to get rid of the fat (Session 1, patient 2)|
|We use a little bit of oil (Session 1, patient 3)|
|Why is it that once I have eaten I feel so tired? (Session 6, patient 2)|
|Behaviour in the UK compared with Bangladesh||In Bangladesh I used to eat so much more, whereas here I am more aware that if I eat too much, I am not working as much as I used to in Bangladesh in the fields, so I will get bigger than what I am and have more problems moving about (Session 4, patient 2)|
|Development of diabetes||What can we do—Allah made us big/fat (Session 1, patient 3)|
|Oh Allah, have mercy. You have given us different illnesses in this world because of all of our sins (Session 6, patient 5)|
Outcome following course
Participants were asked to fill in a translated SDSCA questionnaire during and 1 month after attending the session. A sample size of 40 would have only 50% power to detect a 1-day improvement (sd 2.0) in self-care activities. Therefore, this finding looked at evidence of a trend only. Participants were not able to complete the questionnaires independently. Therefore, questionnaires in the female sessions were completed by volunteers sitting with the participant and discussing the questions and answers. Questionnaires were completed in a ‘class’ setting in the male sessions, with the peer educator reading out each question and discussing the range of answers. Three people left before the end of the session and did not complete the SDSCA questionnaire, and two forms were left incomplete. Therefore, at the end of the study there were 37 fully filled in questionnaires. Follow-up questionnaires were completed by visiting the participants in their home or telephoning participants and talking through the questions and interviewer recording the answers. The final follow-up rate was 95% (35/37, one participant had moved to Bangladesh and one could not be reached). Analysis of the SDSCA questionnaire is shown in Table 2.
Table 2. SDSCA questionnaire
|General diet||4.4 days||4.7 days||0.3 days||–0.06, 0.7|
|Specific diet||3.8 days||4.1 days||0.3 days||–0.2, 0.8|
|Exercise||2.5 days||2.6 days||0.1 days||–0.7, 0.8|
|Foot care||5.3 days||5.4 days||0.1 days||–0.9, 0.6|
Peer educator experience
Peer educators also felt that the study was good and said they supported the concept fully. Peer educators enjoyed running the sessions. They highly valued what they were doing and found that participants attending the course were keen to learn, which in turn encouraged them. In the initial session, peer educators identified that filling in the SDSCA questionnaires was difficult for participants. They therefore recommended that it would be better to have a shorter version, which was implemented. ‘What I understand is that the questions (in the questionnaire) are very lengthy, the questions that are very long, they ... um ... everybody is not educated so it is hard for them to understand. If they were shorter then it would be better’ (peer educator 1).
The response in terms of registration was good, showing methods of disseminating information about the study were successful. However, attendance was only 53% of those registered, despite phoning or visiting people before the course. Prior to the course even attendees did not see the benefits of attending (‘Why would people want to come to this class when they can just go to their doctors and get medication?’ (Session 3, patient 1). However, after the course the feedback was highly positive, and all participants contacted at 1 month's follow-up reported talking to others about the course and recommending others to attend. The most valued aspects of the course were: information in a language that the participants understood and the opportunity to discuss problems and solutions with others. The attendance was lower among men than among women. Women reported relevance to the whole family and enjoyed the group discussion. However, men were more concerned with work, and finding a suitable time of day was more problematic, as many worked shifts and worked late in the evening/night and slept in the morning. The course for men was centred more around information giving, whereas for women it developed into group discussions and problem solving.
Peer educators are the most important part of the course, as they have to be very well know in the community, yet have the time and inclination to devote to it, have diabetes, and be literate in Bangladeshi and to an extent in English, and have the ability to learn and teach the course. This makes them difficult to find, yet a vital component in the success of the course.
Finally, running the course for 4 h for people not generally used to intensive education was a risk. However, previous interviews with members of the community had suggested that there would be a drop in numbers if the sessions were run over a period of weeks (as the X-PERT programme was designed). We feel our findings suggest that the intensive 4-h session was a success. However, we cannot comment on how successful a session of weeks might be, as after one session the majority of participants were very enthusiastic and so we feel this give some limited evidence that this approach could also be a success.
In summary, the adapted X-PERT patient course was highly successful and well received and could form part of a strategy to improve outcome for people with diabetes from the Bangladeshi community. This pilot study has demonstrated that it is feasible to run an adapted X-PERT programme in the Bangladeshi community. Further study with larger sample sizes is needed to examine the best way of ‘rolling out’ the programme to reach more people.
Nothing to declare.
This study was funded by the BUPA Foundation.