ONLINE PEER SUPPORT FOR ABORIGINAL AND TORRES STRAIT ISLANDER QUEENSLANDERS WITH TYPE 2 DIABETES

Background
Aboriginal and Torres Strait Islander Australians are at higher risk of diabetes than non-Indigenous Australians.
•	The prevalence of type 2 diabetes is three times greater.
•	Hospitalisation rates for type 2 diabetes are four times greater.
•	The death rate from diabetes is almost six times greater. 
Innovative solutions to improve access to services to this priority group are vital in order to ensure optimal management and prevent complications. 

Peer support programs are acknowledged as an effective supplement to more traditional diabetes management services and programs and may have particular relevance to Aboriginal and Torres Strait Islander people. 

Health Systems in Australia are struggling with the growing demands of increasing numbers of people diagnosed with diabetes.  Often management plans and clinical outcomes such as blood glucose levels and diabetes complications are discussed with healthcare professionals, while the need for support in mastering and sustaining complex self-management behaviours to improve long-term outcomes has been largely overlooked [1]. 
Effective self-management behaviours include maintaining a healthy diet, being more active and taking prescribed medications, self-monitoring, and coping emotionally with the rigours of living with diabetes.  However many patients face barriers including lack of sufficient knowledge of diabetes or its management, lack of self-confidence or skills, lack of financial resources for medications and supplies, lack of effective support from family and friends and physical limitations [2]. There is a need for sustained, effective and less resource intensive support for patient with diabetes.  
In diabetes self-management education, peer support has been shown to reduce depression and in several randomised controlled trials, has contributed to improved diabetes management including improving behaviours related to medication adherence, diet, physical activity and blood glucose level monitoring [3].  Peer support is a cost effective intervention which complements professional diabetes information and education services from a health team.

Social networking is an innovative way to improve access to services. The growing popularity of online sites such as Facebook provides an avenue for Aboriginal and Torres Strait Islander people to link with others in similar situations to provide support, encouragement, information and advice.   

The online peer support program is an online platform that enables Aboriginal and Torres Strait Islander Queenslanders living with type 2 diabetes to connect with their peers for support, advice and information around more effective self-management. The platform is a Closed Facebook Group. Its closed nature means that it offers some privacy and confidentiality, and links Aboriginal and Torres Strait Islander people across the state.

It is recognised that program participants will be at different stages of readiness to make changes as per the Stages of Change Model: Pre-Contemplation; Contemplation; Preparation; Action; and Maintenance. The program keeps diabetes themed information as part of a participant’s regular experience to increase the likelihood that pertinent information will be presented at the exact moment it is relevant for the participant’s individual stage of change.

The information presented regularly does not come from health professionals, it comes from trained Aboriginal and Torres Strait Islander peer volunteers who do the regular posting and share aspects of their lives and diabetes management through short video clips. Volunteers interact with participants to encourage self-management, set goals, provide information, refer to professional and allied health services and/or provide social and emotional support.

Peer Volunteers complement formal primary care services. Their role is distinct and does not replace the role of professional health care providers. Volunteers receive training in Motivational Interviewing though when questions arise which may be clinical in nature, volunteers connect with health professionals in Diabetes Queensland for appropriate advice that can then be passed on to the participant.

The on line peer support program is a culturally appropriate way of assisting in the management of their condition. Talking about diabetes to other people is mentally tough and challenging as they come to terms with their own condition.  The peer support program encourages participants to openly talk and to listen to peers who are going through the same challenges in a culturally safe environment.


Aims
The program aims assess whether a culturally tailored peered support program, offered through an online medium, is an effective approach to connect Aboriginal and Torres Strait Islander people with their peers to enhance effective diabetes self-management.
The aim is focussed primarily on participants’ increased confidence with self-management and the addition of at least one self-management behaviour. Expectations are to see improved confidence and health literacy evidenced by participants having made, or in the process of making positive changes in their diabetes management around the following seven health care behaviours [1]:

1.	Eating
2.	Being Active
3.	Monitoring
4.	Medications
5.	Problem Solving
6.	Coping
7.	Reducing Risks

Methodology
The program is hosted in a closed Facebook group and is led by trained Aboriginal and Torres Strait Islander peer volunteers. Volunteers share aspects of their diabetes management through short video clips focusing on the AADE7 self-management behaviours. The clips are then utilised to prompt and facilitate group discussion on Facebook with their peers, encouraging goal setting, direction to appropriate resources or health services and/or provide social and emotional support.

Peer Volunteers complement formal primary care services. Their role is distinct and does not replace the role of professional health care providers. When questions arise which may be clinical in nature, volunteers connect with health professionals in Diabetes Queensland for appropriate advice that can then be passed on to the participant.

Results
Given the mode of program delivery and the nature of interactions that occur on Facebook, rigorous evaluation is challenging. To date, the Facebook group has 233 members with 28% engagement, as measured by viewing rates.

Based on limited participant feedback and monitoring of Facebook comments, the program is effective in supporting participants to adopt self-management behaviours including weight loss, healthy eating, increasing physical activity and positive behaviour regarding coping and medication adherence.

Discussion
Social networking is an innovative way to improve access to services particularly for hard to reach communities. The growing popularity of sites such as Facebook provides an avenue for Aboriginal and Torres Strait Islander people to link with others in similar situations to provide support, encouragement, information and advice. 

The early success of the program warrants further investigation of the use of the approach for other Indigenous communities as well as other priority groups such as culturally and linguistically diverse and rural and remote communities.

To improve understanding of the effectiveness of the program, and undertake quality improvement an evaluation tool that is culturally appropriate, and specific to this type of peer support is currently being developed. With improved methods of data collection and evaluation we hope to build evidence to support this program and its effectiveness seen at this early stage.

References
1.	Fisher et al, (2012). Effectiveness of a diabetes education and self-management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. British Medical Journal. Apr 26; 344: doi: 10.1136/bmj.e2333).
2.	Heisler, M. (2007). Overview of Peer Support Models to Improve Diabetes Self-Management and Clinical Outcomes. Diabetes Spectrum Volume 20, Number 4,.
3.	Heisler, M. et al. (2010). Diabetes control with reciprocal peer support versus nurse care management: a randomized trial. Annual of Internal Medicine. Oct 19;153(8):507-15. doi: 10.7326/0003-4819-153-8-201010190-00007
4.	https://www.diabeteseducator.org/patients/aade7-self-care-behaviors

Online peer support for Aboriginal and Torres Strait Islander Queenslanders with type 2 diabetes