Accelerating Best Practices in Peer Support Around the World

How Limited Workforce Capacity Hinders Providers’ Buy-In In China

Reflections on Program Development in China

Maggy Coufal, MA, MPH

As part of our mission to accelerate best practices in peer support and provide technical assistance to healthcare organizations around the world, Peers for Progress has been collaborating closely with the Chinese Diabetes Society’s Education and Management Group (CDS-EMG) and Dr. Zilin Sun at Zhongda Hospital in Nanjing. Our focus is on training and ongoing consultation for peer support program development and implementation. To date, we have trained healthcare providers from about 30 hospitals and community health centers in China.

In spite of these accomplishments, many organizational and system challenges continue to hinder the integration of peer support into the Chinese healthcare system. In this blog, I will share my personal observations and reflections on how limited workforce capacity can impede buy-in from healthcare providers such as diabetes specialists, primary care physicians, and nurses. I will draw on my interactions with providers during trainings and ongoing consultation, as well as post-training surveys.


Encouragement from Organizational Leadership is NOT Enough

Approximately 80% of these 30 healthcare organizations have attempted to or are currently taking steps toward program development. However, despite the encouragement of from healthcare leaders to adopt innovative strategies such as peer support, progress has been relatively slow. One major challenge is getting broad buy-in from the wide range of providers. Three emerging issues are highlighted below:

Low quality of life and lack of peer support among providers

“I don’t have time and am struggling to maintain a balance between work and life” is a common theme found in the feedback we’ve received from providers. Initiating and organizing peer support among patients requires an upfront investment of staff time and resources that may be considered a sunk cost. With an endless stream of patients, competing priorities, and a lack of peer support between themselves, providers are frequently overwhelmed by their daily workload, which leads to rapid physical, emotional, and mental burnout. Through our continuous follow-ups, we are strengthening the networks between providers so that they can share tips, lessons, and frustrations.

Need for better understanding of peer support and patients’ psychosocial needs

In order for providers to be able to effectively advocate for peer support among colleagues, patients, and patients’ families, they must first have a solid understanding of behavior change principles and basic human social and emotional needs. However, without medical education in these areas, providers felt unable to troubleshoot problems and advocate for the importance of peer support. Many providers have expressed the need for a training curriculum targeted at physicians because they have the greatest impact on patient attitudes. Reaching physicians is vital to the spread of peer support because they are the ones that can convince patients to accept and participate in peer support programs.

Lack of capacity to provide high quality diabetes education

The capacity to provide high quality diabetes education is critical to starting a peer support program. However, it varies significantly among the organizations we’ve engaged.  The difference between the ones that can deliver high quality diabetes education and those who don’t is linked to the availability and accessibility of technical support; for example, support from a well-resourced specialty care team in a tertiary/specialty hospital. I often find that those who show low confidence in their ability to provide “up-to standard” diabetes education also illustrate low self-efficacy in providing ongoing supervision and support for peer supporters, a critical element to effective peer support.

Emphasizing “workforce capacity building” may be an over-simplified answer to the challenges, but seeking small wins, along with creative problem-solving, can create opportunities for breakthrough.

Recently, there is an increasing emphasis on building providers’ capacity in China, a positive trend in diabetes care. However, capacity building centered on knowledge and technical skills will not suffice. Instead, this is going to require individual and organizational transformation which can include leadership commitment (not just encouragement) to staff time, financial resources and re-prioritization, providers’ personal experience of the benefits of peer support, internal advocacy among providers and patients, workflow and tracking mechanism redesign to allow better integration and team communication.

In reality, having all these changes in place will take years of hard work. Through my ongoing learning with these Chinese collaborators, addressing workforce capacity issues internally in order to increase providers’ buy-in seems to work best through a small-wins approach. This can be as simple as first starting a peer support group for providers within their hospitals/community health centers to help with stress copying and bonding. I also would recommend simplifying roles and responsibilities for peer supporters and first targeting patients who are ready to change instead of those hard to reach. In this way, they can build on successes and learn along with their patients with a lower demand on their resources and time. Provider champions can also emerge organically in this approach.

I admire the work done by Dr. Zilin Sun at Zhongda Hospital in Nanjing and the Beijing Diabetes Prevention and Treatment Association (BDPTA). In Nanjing, Dr. Sun is leveraging medical student volunteers to assist with program development and implementation. In Beijing, BDPTA provides centralized diabetes education resources for network of hospitals to reduce the burden on individual hospitals and to build a group of physician leaders to advocate for broader buy-in.


There are three critical elements to promote and advance peer support in China: advocacy targeting organizational leaders and policy makers, networking for quality improvement, and training with ongoing consultation for providers.  I hope that the upcoming Continuing Medical Education Courses on diabetes peer support held by Peers for Progress, CDS-EMG, and Zhongda Hospital this August in Suzhou, in conjunction with the 2nd Asia-Pacific Conference on Diabetes Education (APCDE) and 2013 International Symposium on Diabetes Education and Management (ISDEM), will be a good platform to launch this three-arm approach.

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