Nurse manager Kelly Johnston of the Ann Arbor VA Medical Center checks the blood pressure of Allen Shuh, who took part in a study of peer support for Veterans with diabetes.
In the Milwaukee area, members of Veterans of Foreign Wars posts volunteered as peer health leaders and helped other VFW members stay on track with managing their high blood pressure.
In Philadelphia, African American Veterans with diabetes served as peer mentors to others in their community to help them keep their blood sugar in check.
In Ann Arbor, Veterans with diabetes who took part in a mutual peer support program did as well as — or even better than — Veterans who were assigned nurse care managers.
These examples, all from recent VA research, show the benefits of an approach that is gaining increasing traction nationwide among doctors and health policy experts. Peer support, for one thing, is a smart way to leverage resources in strained health care systems. The arrangement also taps into a powerful social force — the ability of peers to motivate one another — that no medical system can replicate on its own.
“Patients know a lot about living with their condition and the strategies they have developed,” says Michele Heisler, MD, MPA. “They have a lot to share with others who are also struggling.”
Heisler is a physician-investigator with the Center for Clinical Management Research at the VA Ann Arbor Healthcare System. She’s also an associate professor at the University of Michigan’s Medical School and School of Public Health.
She observed firsthand the positive effects of peer support in a recent trial that involved 244 Veterans with diabetes. Some of the patients took part in mutual peer support, while others worked with a nurse care manager instead.
In the peer group, Veterans were trained in communication skills and asked to talk with their partners by telephone at least once a week. They were encouraged to both give and receive support, focusing on self-care areas they and their partners were working on to boost their diabetes control. They also took part in nurse-run group sessions to exchange experiences with other patients.
After six months, those on the peer program had achieved, on average, a small reduction in their blood sugar levels, compared with a slight increase in blood sugar among the nurse management group. Those in the peer group were also more likely to have started on an insulin regimen. That’s not necessarily a worse outcome, though. The researchers say peer support — especially from partners who were themselves already on insulin — may have helped Veterans overcome their resistance to an intensive therapy that was tough to adapt to but medically necessary. Those working with nurse managers may have been less able to adjust to the idea.
Veterans in the peer group, not surprisingly, also reported more diabetes-specific social support. Importantly, each peer who received support also gave it, and this aspect of the interaction yielded its own benefits.
“The Veterans in our study were very motivated when they felt they were helping someone else,” says Heisler. “Our model was testing the hypothesis that a good way to activate patients was to give them some skills and encouragement to both help and be helped. Just as in education, they say that the best way to learn something is to try to teach it.”
Training is essential
Martha Mitchell Funnell, MS, RN, CDE, a colleague of Heisler’s at the University of Michigan, says peer support is an effective way to deliver tried-and-true behavioral strategies such as problem-solving and goal-setting.
One challenge, though, is ensuring that peers receive proper training. Researchers still need to better understand this area, says Funnell.
“Very little is known about the training required for peers to successfully implement behavioral strategies and even less is known about the supervision needed or the qualities or qualifications that enable a person to become an effective peer partner,” she wrote in a recent review article in the journal Family Practice.
She, Heisler and other researchers in Ann Arbor are working toward creating and disseminating best practices to address this point. Earlier this year in the journal Diabetes Educator, they shared an approach they believe can be effective, even if it entails a serious commitment on the part of prospective peers. Their training program, developed over a year by a multidisciplinary team, involves 46 hours of training over 12 weeks.
It covers both diabetes knowledge and communication and behavior-change skills. The training sessions are designed to be lively and interactive, featuring role plays, brainstorming and practice support groups. The materials are now available for use in similar programs at other VA medical centers.
Other work at the Ann Arbor VA is exploring the role of peer support in depression. According to Marcia Valenstein, MD, a mental health researcher at the site, “Peer support interventions have been recommended by prestigious national task forces and incorporated into the VA Comprehensive Mental Health Strategic Plan.”
Mentors Lead the Way
Unlike Heisler’s diabetes study, some peer research involves mentor, not reciprocal, relationships. This form of peer support appears equally effective.
A team led by Judith Long, MD, of the Center for Health Equity Research and Promotion at the Philadelphia VA Medical Center, tested peer mentoring along with another strategy — financial incentives — to help minority Veterans manage their diabetes.
The pilot study included 118 Veterans, all of whom were struggling to control their diabetes. One group received usual care, a second received counseling from trained peer mentors, and a third became eligible for payments of up to $200 if they succeeded in significantly lowering their hemoglobin A1C levels — a measure of blood sugar — over six months.
The peer mentors were Veterans who had overcome their own challenges in managing diabetes. After a brief training session, they earned a modest reward — $20 per month — if they contacted the person they were counseling at least four times a month during the study.
The results, presented in February at a national VA meeting, were very favorable for peer mentoring. Financial incentives failed to show the same benefit. Long is now doing further research on the peer model used in the study.
Glenn Cuff, who took part in the Philadelphia research as a peer mentor, says he found the study worthwhile on several counts. “Although it’s not for everyone, peer support is an extremely beneficial supplement to the clinical experience. Additionally, the experience gave me the chance to establish friendships with other Veterans that I am still in contact with today.”
VA Research Week