Cultural Adaptation Series: Collaborating on Diabetes Peer Support in China
Patrick Tang is the newest member of the Peers for Progress Program Development Center. He will be contributing to blogs, newsletters and Peers for Progress publications. In this blog, Pat shares his first experiences in the field of peer support while working on program development for diabetes self-management in Nanjing, China.
One year ago, I traveled to Nanjing, China to work on a peer support pilot program for diabetes self-management. Under the direction of Dr. Zilin Sun and the support of the award-winning diabetes education team at Zhongda Hospital, we designed a training curriculum for peer leaders, developed Mandarin language train-the-trainer guides, and adapted process and outcome evaluation tools for the peer support program. The culmination to the summer was a weekend retreat during which we successfully trained 11 peer leaders to provide the four core functions of peer support: provide assistance in daily management, offer social and emotional support, link patients to clinical care and community resources, and provide ongoing support. Conducted over a period of two and a half days, the immersive training program combined interactive classroom sessions and lessons that were integrated into daily activities (e.g. food preparation before meals, footwear examination before exercising, blood sugar monitoring at recommended intervals).
The training curriculum focused on increasing diabetes self-management knowledge and its applications in daily management. The delivery of accurate medical information was the main priority for both clinicians and peer supporters-in-training. The diabetes education team provided hands-on training modules on nutrition, exercise, medication, foot care, and blood sugar monitoring. With this set of skills, peer leaders would be prepared to guide their peers in deciding what actions to take, describe why taking those actions are important, and most importantly, demonstrate how to integrate those practices into daily life.
Compared to peer leader training curricula developed in the West, this Chinese program placed less emphasis on teaching counseling skills, such as motivational interviewing. This can be attributed partially to cultural differences as well as the underdevelopment of counseling services in China. To address this gap, I translated and adapted materials from motivational interviewing resources to create a train-the-trainer guide for the diabetes nursing staff. The Head Nurse was especially receptive to this approach, recognizing the value it provided to peer leaders that had no prior experience interacting with patients.
I faced linguistic and cultural challenges over the course of working on the project, but the diabetes education team at Zhongda Hospital was always there to provide guidance and feedback. Their warmth and good nature made me feel instantly at ease. Furthermore, these traits enhanced their ability to connect with patients and set a model for peer leaders to emulate.
Through observations of the peer leader training, informal one-on-one conversations with peer leaders and diabetes educators, and a focus group discussion, I learned that people with diabetes in China often have the same concerns as those in the United States, but the solutions are necessarily different. For example, changes in diet and exercise represent the greatest challenge for people managing their diabetes. The typical Chinese diet includes a variety of fruits and vegetables, but certain meals (i.e. breakfast) rely heavily on simple carbohydrates. For an older adult that has grown accustomed to eating the same breakfast for decades, even changing this one component of their diet will be a challenge. Additionally, meals are shared more often than not, which means that family and friends will play a large role in adherence to nutritional guidelines. When it comes to exercise, residential apartments often have large courtyards that lend themselves to organizing group activities. However, access to parks may be limited to those within walking distance or accessible by public transit, as the majority of residents do not own automobiles.
I also learned that the process of training peer leaders is ongoing and requires regular follow-up. Initially, peer leaders may not feel fully confident in their abilities and knowledge, possibly because they compare themselves to professional diabetes educators. Throughout the trainings, the peer leaders were instructed by seasoned health professionals that spoke confidently and naturally. I often heard peer leaders speak of the instructors with glowing praise while simultaneously expressing insecurity about their ability to lead their peers (culturally, this is a sign of humility as well as a compliment to one’s teachers). In my experience, I have found that Chinese people are inclined to defer to people with higher status or authority (as determined by education, profession, age, and gender). In order to overcome these initial insecurities, peer leaders should try to begin working in the community as soon as possible, as their confidence will be bolstered once they realize how much they know compared to the average person and how much they have to contribute.
After this valuable experience, I returned to the University of North Carolina, where I graduated in May with my Masters in Public Health. I look forward to contributing to the field of peer support in my new position as a program manager in the Program Development Center with Peers for Progress.