This program will utilize a peer intervention model, called a buddy system, to support Native American people who are living with diabetes and experiencing poor glucose management to improve their health through exercise. Using this system, contact hours for each person could be increased by 3-5 times the current amount per week or month. Plus, the contact will come from people like the patients themselves, who have to face many of the same challenges as they do in maintaining glucose management and exercise behaviours. By increasing the frequency and quality of social support using the buddy system, we hope to produce the kinds of positive social influence and beliefs in self-efficacy that will increase exercise in our sample and therefore increase behaviours relevant to glucose management.
We will train bicycle riders from previous events to serve as buddies, peer educators who will be able to help and support other individuals to obtain better glucose and weight management through exercise as they ride, in a highly visible fashion, through Tucson metropolitan area and the reservation on training rides, preparing for El Tour. Each rider will work with between 1 and 5 participants, helping them to try new exercise activities and motivating them to stay with their exercise program. We will evaluate the feasibility of conducting this type of program within an existing tribal network and clinical setting, and will evaluate the short-term effects of this program.
All buddies must meet the following eligibility criteria: 1) They must be registered in the El Tour de Tucson (a cost which we hope to cover). 2) They must have their own transportation. 3) They must be enrolled in a tribe. 4) They must be currently adhering to clinical goals for healthy diabetes management. All levels of riders are welcome to join the program as support buddies or participants. All potential riders will complete a short screening interview to identify eligibility and then selected individuals will be scheduled to attend a buddy training.
All support buddies will undergo a day long training workshop. The training will prepare riders for interacting and motivating patients to try a new exercise program as a method of improving diabetes control. The workshop will include a session on state of the science in diabetes control and current strategies taught by clinicians at the tribal clinic. It will also include training in motivational interviewing, support techniques, probing for barriers to activity and healthy eating, exercise options, and record keeping and other means of monitoring progress. Upon completing the training program, the support buddy will receive an assignment of participants.
Each trained buddy will be assigned between 1 and 5 participants, depending on interest and load. This will happen in one of two ways. The buddy may have a relative or friend who wants or needs a buddy and is interested in getting a buddy from the program. In addition, the clinic will keep a list of identified patients who agree to be part of a buddy system. The eligibility criteria to be a participant includes 1) registered patient with diabetes at the tribal clinic, 2) HbA1c of 9% or higher at last clinic visit, 3) aged 18-80 years, and 4) approved for exercise by their primary care provider. After the participant consents to be in the program, their contact information will be provided to the buddy and an initial contact will be made by telephone.
The first meeting between a buddy and a participant will follow a common format, although there will be room for discussion of topics that either the patient or the rider identify. First, they will introduce each other and will share a bit about what brought them to the meeting. Second, they will talk about options for exercise and specifically what the patient would like to try. Third, they will set a plan for the first exercise activity, which they will perform together. This could be a bicycle ride but we will work with people who want to swim or walk at first. We realize that not all patients will become world class bicycle riders, but we will offer training toward El Tour in order to help them set and achieve a goal.
Subsequent meetings will involve some movement or exercise activity and discussion of the barriers facing the participant. The buddy will keep a log of activities and topics discussed and will try to help the patient overcome barriers to exercise that they are experiencing. The pair will discuss ongoing activity, possible bicycle rides, and other kinds of activity if desired. We will start slowly and keep within the patient’s abilities, while encouraging them to try new behaviours and to do them together, with the buddy. After the first few sessions the participant can stay in touch by telephone or in person, as they choose. The dyad will meet at least weekly to check in and to provide support to continue exercising.
We expect that buddies will provide their participants with multiple kinds of social support, including emotional support (concern, acceptance, understanding, encouragement, and reassurance); instrumental assistance or aid (the provision of material goods such as money and services such as transportation or childcare); and informational support (knowledge, advice, guidance, and feedback. Emotional support might come from hearing from a peer with understanding of the situations that participants often experience. Instrumental support might come from having an experienced bicycle rider with diabetes help develop one’s capacity to ride and manage glucose levels. Informational support could be delivered by a knowledgeable buddy who has had several experiences previously. The training and preparation will include all three and will help buddies determine what types of support are best delivered to which patients.
Buddies will meet monthly as a group with program and clinic staff to discuss progress, review each of their participants, and exchange ideas for motivating and supporting their participants in improving glucose management. Program staff and medical staff will also be on call for questions or issues that come up outside of monthly meetings. This ongoing support will help the buddies learn from experienced clinicians about how best to help with weight loss and glucose management and will help to integrate the buddy system into ongoing clinical care. We feel that it is important for the buddies to see themselves as part of a continuum of care, going beyond what clinical staff might do to reach the patient in their daily activities. During this period the staff will evaluate each buddy-rider’s interactions with their buddies and provide clinical feedback to the buddy-riders on the process of providing support for diabetes control and exercise.
The primary outcomes of interest include bodyweight, waist circumference and HbA1c. These health outcomes have been proven to be strongly correlated with a reduction of complications for people living with Type 2 diabetes. At the end of two years, we hypothesize that we will have increased the number of diagnosed tribal members with a baseline HbA1C level of 11 to an average level of 9 as well as helping with significant weight loss. We will also use surveys to measure the amount of exercise undertaken, medical knowledge gained and association of individuals with the community.