How effective is a peer led education/selfmanagement programme in improving
medication adherence in individuals with a
chronic (long term) condition
Alex Johnston
1
Introduction
As the population ages and our lifestyles and habits change, an
increasing number of people are living with long term conditions. In the
UK approximately two thirds of all healthcare resources are spent
supporting the estimated 17 million adults living with chronic diseases
such as diabetes, asthma, heart failure, arthritis, dementia or depression
(Department of Health, 2004). However, since eighty to ninety per cent
of all care for people with a chronic disease is undertaken by patients
themselves and their families, it is important to recognize that patients’
with chronic disease need not be ‘mere recipients of care’. They can
become key decision-makers in the treatment process (Department of
Health, 2001)
Supporting self-management involves educating people to actively
manage their condition and adopt and maintain behaviours that can
delay disease development or progression. It has been shown to help
maintain and improve patients’ behaviour, health status, lower health
care utilisation and improve communication between patient and health
providers (Lorig et al, 1999; Fu et al 2003). However, it is not surprising
that many find it difficult to adhere to the recommended treatment plans
when faced with a complex range of lifestyle modifications sometimes,
without necessarily noticing any tangible effects (Gatchel et al 2002)
Non adherence to treatment has significant effects on treatment
outcomes often leading to increased resource utilisation, more frequent
hospital appointments and diagnostic tests, increases in doses or
changes in medications and risk to the patients if subsequent surgical
intervention is required (Gray et al, 2010). Therefore with limited
resources coupled with the escalating costs of dealing with ever more
complex conditions lay or peer led self management programmes are
becoming an increasingly important strategy in healthcare environments.
Peer led education can differ from professionally led education in that
the peer leader often has experiential knowledge based on a sharing of
similar life experiences (Dennis et al, 2003). The format may be more
informal than education from a health professional and programmes for
minority ethnic groups may offer a more culturally adapted format
reflecting specific needs (Foster et al 2008).
A number of national peer led chronic disease programmes have been
developed in response to the pioneering work of Kate Lorig and her
2
colleagues in North America. Notably, the UK’s Expert Patient’s
Programme (EPP) modeled on the Stanford Chronic Disease Self
Management Program (CDSMP) (Department of Health 2001).
Although peer led self-management programmes have the potential to
enhance participants’ abilities to cope with illness it is not clear which are
the most important features of an education programme (Bury, et al
2005). For example, outcomes may be dependent on the duration,
format, content or even context of the self management training (Foster
et al 2008).
Whilst peer support may be an element in many peer led self
management programmes this review will only be addressing
interventions that include an educational component and the self
management of disease. The less formalised peer support interventions
which involve contact with an individual or group of peers offering
information sharing and exchange, social support and sharing of
experiences will not be included.
Therefore the aim of this rapid review is to better understand the
strengths and limitations of a peer led education/self-management
programme in improving medication adherence in individuals with a
chronic (long term) condition.
Please note, given the lack of empirical studies on peer led selfmanagement programmes in improving medication adherence in
patients with glaucoma this review has expanded its search
strategy to include a range of chronic diseases and primary and
secondary outcome measures.
3
Search Strategy
A thorough search of the literature was performed in order to identify
available literature relating to the effect of a peer led education selfmanagement programme in improving medication adherence in
individuals with a chronic (long term) condition.
Inclusion Criteria
Study type
 Randomised Controlled Trials (RCT)
 Experimental design
Exclusion Criteria
 Studies that do not focus on peer or lay led education/ selfmanagement intervention
 Non English studies
Participants
 Adults
Outcomes
The primary outcome measure was improved adherence, however all
studies with various primary and secondary outcome measures were
included in order to gain a comprehensive picture of peer led
education/self-management programmes.
Language of population
English Language - 2000 to 2010
Search terms
A thorough search of electronic databases and journals was implored
using the keywords:
Condition
 Glaucoma
 Chronic open-angle glaucoma (GOAG)
 Chronic disease
 Long term condition
4
Intervention
 Peer led
 Peer leader
 Lay led
 Lay leader
 Self management
 Peer advisors
 Peer supporter
 Health educator
 Patient educator
Outcomes
 Improved adherence
 Improved compliance
 Improved concordance
 Clinical outcomes
 Improved health status
Databases/Resources Searched
A literature search of studies published between 2000 and 2012 was
performed. Databases and search engines used included: OVID,
Medline, AMED, Cochrane Library, Web of Knowledge and Google
Scholar.
Due to time restraints only electronic journals were appraised. Ancestral
searching of reference lists to identify all relevant empirical studies also
took place. All the included studies were published in English.
Critical Appraisal
Ten studies were identified for appraisal: Comellas et al (2010); Jerant et
al (2009); Cade et al (2009); Lorig et al (2008); Baksi et al (2008);
Kennedy et al (2006); Barlow et al (2005); Griffiths et al (2005); Fu et al
(2004); Hunkeler et al (2000) (Appendix 1).
5
Study purpose
These studies all shared a common purpose to examine if a peer led
education/self-management programme improved medication
adherence in individuals with a chronic (long term) condition. However,
the studies were delivered in different settings and used multifaceted
interventions.
 Hunkler (2000) evaluated the efficacy of two augmentations of
antidepressant drug treatment with and without peer support.
 Fu (2003) investigated the effectiveness of the Shanghai Chronic
Disease Self Management Program (CDSMP) in increasing self
managing behaviours, maintaining and improving health status and
decreasing health service utilization.
 Griffiths (2005) evaluated how a culturally adapted CDSMP may
improve self-efficacy and self care behaviour in Bangladashi patients.
 Barlow (2005) reviewed whether changes in self efficacy, cognitive
symptom management, communication with physician, fatigue,
anxiousness and depressed mood were maintained over a twelve
month period.
 Kennedy (2006) investigated if the EPP promoted changes in self
efficacy beliefs, self care behaviours, health status and decreased
health service utilization.
 Baski (2008) compared the effectiveness and acceptability of peer
advisors with specialist health professionals in delivering a self
management programme for people with diabetes.
 Lorig (2008) evaluated a Spanish diabetes self management
programme with and with out automated telephone reinforcement.
 Cade (2009) assessed if the EPP adapted to people with Type 2
diabetes promoted healthy eating to improve glycaemic control.
 Jerant (2009) compared usual care with either a telecare or one to
one home delivered variant of the CDSMP in improving self efficacy
and health status.
 Comellas (2010) evaluated a peer led self management support
programme in English and Spanish in improving medication
adherence, problem solving and goal setting, increased physical
activity and healthier eating.
6
Literature Review
All ten studies provided detailed discussions on the background to each
study/paper, succeeded in aggregating relevant information (previous
research etc.) and commented on the clinical importance of the subject.
Design
In all but one study the individual participants were randomized. (Barlow
2005 was 12 month follow-up of a sample of 171 participants who had
attended a UK CDSMP). Six of the studies compared a peer-led
intervention to usual care; Cade (2009) offered a diabetes specific EPP
or individual one off appointment with a dietitian; Baksi (2008) included a
comparison with professionally-led care; Hunkeler (2000) augmented
nurse Telehealth care with peer support. Comellas (2010) was described
as a pilot.
Chronic conditions
Those evaluating the CDSMP or EPP recruited participants with a wide
range of conditions including hypertension, heart disease, chronic lung
disease, cancer, arthritis, stroke, diabetes, chronic pain, chronic back
pain, chronic fatigue, mental health, haemophilla, endometriosis, liver
disease, asthma and neurological conditions. The remaining
interventions were all designed for specific conditions i.e. depression
and diabetes (Hunkeler 2000, Jerant 2009).
Settings
Six studies were conducted in the UK (Cade 2009, Baksi 2008, Kennedy
2006, Barlow 2005, Griffiths 2005, Hunkeler 2000). Three studies took
place in North America (Comellas 2010, Jerant 2009, Lorig 2008) and
one in China (Fu 2003).
Six of the studies took place in the community (Comellas 2010, Lorig
2008, Griffiths 2005, Barlow 2005, Kennedy 2006, Fu 2003) and four in
a primary care setting (Cade 2009, Jerant 2009, Baksi 2008 Hunkeler
2000).
Sample sizes
A total of 3951participants were recruited across all the studies, with
individual studies having between 17 and 954 participants. The sample
was predominantly female.
7
According to Aveyard (2007) researchers should demonstrate how they
determined the sample size, also known as power calculation
(Greenhalgh 1997; Polgar and Thomas 2000) and should be clearly
documented in the paper Lorig (2008), Hunkeler (2000) and Barlow
(2005) failed to do so. All studies provided information regarding
participant recruitment and inclusion and exclusion criteria and
referenced previously published study methodology.
Ethical Approval
All authors, provided details on obtaining ethical approval from
committees and informed consent from participants, thus reassuring the
reader that research was conducted in accordance with accepted
community principles.
8
Follow-up and exclusions
Nine studies reported information on follow-up rates.
 6 month (Baksi 2008, Kennedy 2006, Fu 2003)
 12 month Barlow (2005)
 6 and 12 month Cade (2009)
 6 and 18 month Lorig (2008)
 6 weeks, 6 and 12 month Jerant (2009)
 6 weeks and 6 month Hunkeler (2000)
 4 month Griffiths (2005)
 Comellas (2010) did not report on a follow up
Intervention
The 10 included studies were grouped by type of intervention, as
follows:
 Diabetes Self Management Program (SDSMP) 2 studies (Lorig 2008;
Baksi 2008)
 Chronic Disease Self-Management Program (CDSMP) or its
anglicised variation The Expert Patient Programme (EPP) 6 studies
(Fu 2003; Griffiths 2005; Barlow 2005; Kennedy 2006; Jerant 2009;
Cade 2009)
 Other disease-specific peer/lay educational interventions: 2 studies
(Hunkleler 2000; Comellas 2009)
9
Brief summary of the interventions
The ASMP, CDSMP and its anglicised version, the EPP, typically consist
of a structured course of 6 (originally seven) weekly sessions each
lasting approximately 2 hours and led by one, or more usually two,
trained and accredited lay facilitators. The sessions cover goal setting
and problem solving, lifestyle changes around diet, exercise, and sleep,
identifying resources, symptom management, dealing with anger, fear
and frustration and communication with health professionals. The lay
facilitator acts as a positive role model. Participants are also given an
educational manual or booklet (Foster et al 2008)
The interventions demonstrated by the third group varied in structure:
 Hunkeler (2000), provided telehealth care, emotional support and
focused behavioural interventions in ten 6-minute calls during 4
months by primary care nurses plus peer support offering telephone
and in-person supportive contacts by trained health plan members
recovered from depression.
 Based on the American Diabetes Association programme Comellas
(2009) offered a community based, self management support
programme consisting of 5 consecutive sessions, lasting 2 hours.
(Below is a table consisting of 2 columns and eleven rows including a
header row.)
Study
Comellas 2010
Jerant 2009
Cade 2009
Baksi 2008
Lorig 2008
Kennedy 2006
Outcome measures
Improved diabetes self management behaviours
i.e. increased physical activity, healthier eating,
medication adherence, problem solving and goal
setting
Self efficacy, improved health status, medication
adherence, functional ability and depressive
symptoms
Change in glycated haemoglobin HbA1
Changes in knowledge relating to diabetes,
nutrition, exercise, monitoring and medications;
secondary outcomes changes in glycated
haemoglobin and the Diabetes Care Profile
Self efficacy, improved health status, health
behaviours, decreased health service utilization
Self efficacy, improved health status, health
behaviours, decreased health service utilisation
10
Barlow 2005
Griffiths 2005
Fu 2003
Hunkeler 2000
Physical functioning, self efficacy, behavioural
and cognitive techniques, pain and fatigue,
psychological well being
Self efficacy, self care behaviour, communication
with physician, medication adherence, health
status, depression, anxiety, pain, fatigue,
shortness of breath, healthcare use
Self efficacy, improved health status, health
behaviours, decreased health service utilisation
Greater reduction in depressive symptoms,
greater improvement in functioning and
treatment satisfaction; improved medication
adherence
11
Results
Medication adherence
The five studies that included this as an outcome measure found no
significant improvements in medication adherence (Hunkeler 2000,
Griffiths 2008, Baksi 2008, Jerant 2009 and Comellas 2010).
Self-efficacy (confidence) to manage symptoms
The following studies report considerably greater self efficacy at followup: Griffiths 2005 (P = 0.001), Jerant 2009 (P = .001), Fu 2003 (P =
0.001), Lorig 2008 (P<0.001), Barlow 2005, (P = 0.58), Kennedy 2007 (P
= 0.000).
Self management behaviour (exercise and practice of cognitive
symptom management which refers to a six-item measurement
instrument which seeks to determine the frequency of trying
various cognitive strategies such as relaxation and visualization
(Lorig 1996).
Comellas 2010 (P = .04), Fu 2003 (P = 0.005) and Baksi 2008 (P =
0.002) report that significant improvements were found in physical
activity and nutrition activities.
Health Status (e.g. energy, depression, anxiety, pain,
fatigue, shortness of breath)
Fu 2003 (P = <0.05) demonstrated significant improvements as did
Kennedy 2006 (P = 0.004) whilst Griffiths 2005 (P = 0.751) reported
marginal improvements. Hunkeler 2000 and Jerant 2009 both report no
improvement in primary outcomes.
Communication and health care use
Both Fu 2003 (P = 0.04) and Lorig 2008 (P = <0.05) reported fewer
hospital visits whilst Griffiths 2005 (P<0.05), Barlow 2005 (P = 0.732),
Kennedy 2006 (P = .956) and Jerant 2009 found there were no
significant differences between groups. Griffiths 2005 also reported no
improvements in communication whilst Lorig 2008 and Kennedy 2006
reported significant improvements in communication.
12
Health care costs
The actual or estimated costs of delivering the programme per
participant were reported in a four studies: (Lorig 2008) US$250,
(Kennedy, 2006) £250, (Griffiths 2005) £123, (Fu 2003) Yuan 82.66
Harms
None of the studies reported that they had received any complaints. No
adverse outcomes were reported in any of the included studies.
13
Discussion
This review identified eight RCTs, one follow up and one pilot study
examining the effectiveness of structured, peer-led education/selfmanagement interventions for individuals with chronic conditions in 3931
participants. Most were based on a common theoretical framework but
the studies included have variable aims and researchers have utilised a
range of different outcomes making direct comparison between studies
difficult. None of the studies used improvements in adherence as a
primary outcome. Also, the paucity of studies which examined outcomes
beyond twelve months, (Lorig, 2008 was the exception) make it difficult
to speculate whether benefits would be maintained long term, or indeed
if there are benefits which only become apparent over time.
Results from the included studies suggest that peer led education/selfmanagement programmes may lead to short-term improvements in
participants’ self-efficacy (in essence their confidence to change
behaviour) and self care behaviour both of which are associated with
better health outcomes (Newman, 2004). Griffiths (2005) tested a
culturally adapted CDSMP and reported short term improvements in self
efficacy in Bangladeshi patients, suggesting that it may be useful for
ethnic minorities. However, the changes in self efficacy are generally
modest and it is unclear how much patients value improvements in self
efficacy when compared to a reduction in symptoms or a gain in health
related quality of life.
Findings from the included studies indicate that a peer led
education/self-management programme does not improve medication
adherence in individuals with a chronic (long term) condition.
Synthesis of the three included studies which considered telehealth care
suggests that peer led education/self-management programmes did not
improve primary outcomes. Lorig’s (2008) automated telephone
intervention did not enhance outcomes nor did Jerant’s (2009) or
Hunkeler’s (2000) ‘in-person’ contact. Although very limited, there is
evidence that suggests peer led interventions are as effective as
professionally led ones (see Cochrane review Foster et al, 2008)
therefore a comparison between Hunkeler’s (2000) peer and nurse led
intervention may have been worthwhile.
From the evidence provided it is difficult to infer if disease-specific peer
led interventions are any more or less effective than generic
14
interventions. Nor it is possible to determine what components or
aspects of the interventions are the most effective.
Whilst there were small improvements in fatigue, energy, physical
activity and general well being, the improvements were not satistically
significant.
15
Conclusion
Overall there is insufficient evidence at present to justify widespread
implementation of a peer led education/self management programme, if
the sole aim is to improve medication adherence in individuals with a
chronic condition such as glaucoma. However, it is important to
recognise that there is a large amount of research on interventions for
improving adherence to glaucoma therapy. Also, due to time restrictions
and the restrictive inclusion criteria (the use of peer led selfmanagement programmes) a substantial body of relevant evidence has
not been discussed in this report.
16
References
Aveyard H (2007) Doing a Literature Review in Health and Social Care.
A Practical Guide. England: Open University Press.
Baksi AK, Al-Mrayat M, Hogan D, Whittingstall E, Wilson P, Wex J
(2008) Peer advisers compared with specialist health professionals in
delivering a training programme on self-management to people with
diabetes: a randomized controlled trial Diabetes UK. Diabetic Medicine
25. pp. 1076–1082.
Barlow JH, Wright CC, Turner AP, Bancroft GV (2005) A 12-month
follow-up study of self-management training for people with chronic
disease: Are changes maintained over time? British Journal of Health
Psychology. Vol. 10. pp. 589-599.
Bury M, Newbould J, Taylor D (2005) A rapid review of the current state
of knowledge regarding lay-led self-management of chronic illness.
Evidence review. National Institute for Health and Clinical Excellence.
Available from: www.publichealth.nice.org.uk
Cade JE, Kirk SFL, Nelson P, Hollins L, Deakin T, Greenwood DC,
Harvey EL (2009). Diabetes UK. Diabetic Medicine. Vol.26, pp.1048–
1054.
Comellas M, Walker EA, Movsas S, Merkin S, Zonszein J, Strelnick H
(2010) Training Community Health Promoters to Implement Diabetes
Self-Management Support Programs for Urban Minority Adults. Diabetes
Education. Volume 36(1). pp. 141–151.
Dennis (2003) Peer support within a health care context: a concept
analysis. International Journal of Nursing Studies Volume 40 pp. 321-32.
Department of Health (2004) Improving chronic disease management.
London.
Department of Health (2001) The Expert Patient: A New Approach to
Chronic Disease Management for the 21st Century.
Foster G, Taylor SJC, Eldridge SE, Ramsay J, Griffiths CJ (2008) Selfmanagement education programmes by lay leaders for
people with chronic conditions (Review). The Cochrane Collaboration.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/17943839
17
Fu D, Fu H, McGowan P, Shen Y, Zhu L, Yang H (2003) Implementation
and quantitative evaluation of chronic disease self management
programme in Shanghai, China: randomized controlled trial. Bulletin of
the World Health Organisation. Volume 81(3). pp.174–82.
Gatchel RJ, Oordt MS (2002) Clinical Health Psychology and Primary
Care. Washington DC: American Association.
Gray TA, Henson LC, Harper R, Waterman H (2010) Interventions for
improving adherence to ocular hypotensive therapy (Review). The
Cochrane Collaboration.
Greenhalgh T (1997) Assessing the methodological quality of published
papers. British Medical Journal. 315 pp.305-309.
Griffiths C, Motlib J, Azad A, Ramsay J, Eldridge S, Feder G, Khanam R,
Munni R, Garrett M, Turner A, Barlow J (2005) Randomised controlled
trial of a lay-led self-management programme for Bangladeshi patients
with chronic disease. British Journal of General Practice.
Hunkeler EM, Meresman JF, Hargreaves WA, Fireman B, Berman WH,
Kirsch AJ, Groebe J, Hurt SW, Braden P, Getzell M, Feigenbaum PA,
Peng T, Salzer M (2000) Efficacy of Nurse Telehealth Care and Peer
Support in Augmenting Treatment of Depression in Primary Care.
Archive Family Medicine. Vol. 9.
Jerant A, Moore-Hill M, Franks P (2009) Home-Based, Peer-Led Chronic
Illness Self-Management Training: Findings From a 1-Year Randomized
Controlled Trial. Annals of Family Medicine. Volume 7. No. 4.
Kennedy A, Reeves D, Bower P, Lee V, Middleton E, Richardson G,
Gardner C, Gately C, Rogers A (2006) The effectiveness and cost
effectiveness of a national lay-led self care support programme for
patients with long-term conditions: a pragmatic randomised controlled
trial. Epidemiol Community Health. Vol. 61. pp. 254–261.
Lorig K, Ritter PL, Villa F, Piette JJK (2008) Spanish Diabetes SelfManagement With and Without Automated Telephone Reinforcement
Diabetes Care. Volume 31 Number 3.
Lorig K Sobel D Stewart A. (1999) Evidence suggesting that a chronic
disease self-management program can improve health status while
18
reducing hospitalization: a randomized trial. Medical Care 1999;37: pp.
5–14.
Newman S, Steed L,Mulligan K. Self-management interventions for
chronic illness. Lancet 2004. 364(9444). Pp.1523–1537.
Polgar S and Thomas SA (2000) Introduction to Research in the Health
Sciences (4th Edition). Edinburgh: Churchill Livingstone.
19