HEALTH EDUCATION RESEARCH

Vol.38 no.4 2023
Pages 277–285
Advance Access published 26 June 2023

Increased knowledge levels of patients with diabetes
in resource-limited communities after receiving
peer-led education

1 Arid Land Research Center, Tottori University, Tottori 680-0001, Japan, 2 School of Health Science, Faculty of
Medicine, Tottori University, Yonago 683-8503, Japan, 3 Department of Regenerative Dermatology, Graduate School of
Medicine, Osaka University, Osaka 565-0871, Japan, 4 Graduate School of Public Health, St Luke’s International University,
Tokyo 104-0045, Japan, 5 International Platform for Dryland Research and Education, Tottori University, Tottori 680-0001,
Japan, 6 Department of Rehabilitation, Daisen Rehabilitation Hospital, Hoki-cho 689-4102, Japan, 7 Department ofCommunity-based Family Medicine, Faculty of Medicine, Tottori University, Yonago 683-8503, Japan and 8 Division ofVirology, Faculty of Medicine, Tottori University, Yonago 683-8503, Japan
Correspondence to: N. Kobayashi. E-mail: kobayashi.nobuyuki@tottori-u.ac.jp
Received on 30 January 2023; editorial decision on 8 June 2023; accepted on 9 June 2023

Abstract
Diabetes self-management education throughpeer support has been beneficial, especially inregions with limited medical resources. Studying the effects of education offered by trained
peers of patients will facilitate tailoring thepeer-led education programs to the regions’specific needs. Here, we evaluated changes indiabetes-related indicators in Filipino patients
who received a peer-led education. We useddata on 23 patients (age, 67.83 ± 6.69 years;
82.6% female) who participated in all five surveys performed every 6 months from March2017 to March 2019. After the second survey
until the end of this study, the participants
were educated in diabetes self-management by
their 13 peers who previously had received thetraining in diabetes self-management. Participants’ knowledge of diabetes and the related‘cause, risk factors, nature of diabetes andcomplications’ subindicator were greater on
all surveys after starting the peer-led education compared with those on the second survey(i.e. before starting the education); these values did not differ between the first two surveys.
Because increasing patients’ knowledge canenhance their ability to self-manage their disease and thus improve their quality of life,
strategies to expand patients’ knowledge about
diabetes should be included when organizing
peer-led education in regions with limited medical resources.

Introduction
In 2021, a reported 537 million people worldwide were suffering from diabetes [1]. Maximizing
the quality of life (QOL) of patients with type 2
diabetes (T2D) rests on reducing their excessive
levels of blood glucose and glycohemoglobin [proportional to hemoglobin A1c (HbA1c)]. Diabetes
self-management education (DSME) is one means
to improve these disease indicators in patientswith T2D. For example, a review of 72 randomized control trials of DSME noted increases inpatients’ diabetes knowledge, frequency and accuracy of self-monitoring of blood glucose, selfreported dietary habits and self-initiated glycemic
control [2]. Another review of 31 randomized control trials reported that HbA1c levels
decreased by a value of 0.76% in DSME-recipientgroups [3].

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doi:https://doi.org/10.1093/her/cyad023

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Nobuyuki Kobayashi 1 , Chika Tanimura2 , Haruka Aoto2 , Abir Nagata3,4 ,Shinji Otani5 , Yasuko Tokushima2 , Mika Fukada2 , Tetsuji Morita6 ,Kazuoki Inoue7 and Seiji Kageyama8

N. Kobayashi et al.

278

addressed disease-related indicators,
which
was provided to Filipino patients by healthprofessionals; the patients’ diabetes knowledge
was significantly increased at 12 and 18 months
after they had received the training [12]. Thesepatients in our previous study comprise the peer-led
DSME providers for the current study. Assessing the effects of DSME offered by these trained
Filipino patients (i.e. peer leaders) in other Filipino patients (i.e. peer-led DSME recipients) will
help to demonstrate the benefit of peer-led DSME
programs in areas with limited medical services
and to tailor these programs to other resourcelimited areas. In this study, we evaluated thechanges in diabetes-related indicators (i.e. knowledge of diabetes, self-efficacy in management ofdiabetes, QOL with physical and mental components, HbA1c levels and emotional distress) in therecipient Filipino patients who were educated bytheir peers (peer leaders) trained in patient education as well as DSME.

Materials and methods
A 2-year longitudinal study was designed. Theinterventions and data collection were performed
in a diabetes clinic in a municipality of Metro
Manila, Philippines. This municipality is one of
the smallest in Metro Manila in terms of area andtotal population (approximately 67 000 people).
The municipality suffers from low levels of funding
for medical services and a shortage of health-care
professionals.

Intervention
The patients with diabetes who had attended thediabetes clinic in the municipality were screened
for inclusion in the study. Criteria for the participants were as follows: age ≥20 years; T2D, no
pregnancy, no dementia and no cognitive impairment nor mental illness making it difficult toanswer the questionnaires or undergo a physical examination, or both; no substantial musculoskeletal nor incurable disease making it difficult to undergo physical examination or exercise;

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DSME is particularly effective when it is offeredby the peers of patients with diabetes. For example, monthly educational programs on diabetes
knowledge and skills that were provided by trained
peer leaders (in the form of sharing their knowledge and skills) decreased diabetes-distress scoresamong Chinese adults with T2D, compared withno significant improvement in scores among those
who did not receive peer support [4]. Similarly, 6 months of peer-led education significantly
improved metabolic indices and the psychological status of Chinese patients with T2D and emotional disorders [5]. In addition, peer-led DSME
programs have long-lasting effects. In one study,
patients with diabetes still maintained benefits inglycemic control and systolic blood pressure at
18 months after they began a peer-led DSME program; the same program did not achieve this effectwhen offered by community health workers [6].
Therefore, peer-led DSME programs may be more
effective than education provided by health-care
professionals.
Peer-led DSME programs for patients with diabetes are particularly beneficial where medical
resources are limited because they are relatively
inexpensive compared with education provided byhealth-care professionals [7]. In that regard, theUniversal Health Coverage Index of the Philippines in 2019 (55) was below both the average
global value (67) and that of the Western PacificRegion (which includes the Philippines) (80) [8].
In 2020, diabetes was the fourth most frequentcause of death among Filipinos [9], and in 2021,
the morbidity rate due to diabetes in the Western Pacific Region (11.9%) exceeded the global
average (10.5%) [1]. Furthermore, the numberof Filipinos with diabetes has increased markedly
recently due to increases in obesity accompanied by rapid urbanization and dietary changes,
and available health services are insufficient toaccommodate these patients [10, 11]. Given the
expected increase in disease prevalence [1], thechallenges to diabetes control in the Philippines arelikely to increase as well.
We previously conducted a 2-year evaluationof training in diabetes self-management that

Change in diabetes indicators after peer education
the training for peer leaders (i.e. hands-on learning,demonstrations, quizzes, role-playing and groupsharing of experiences) were applied; the Diabetes
Textbook and the self-guided materials on physicalexercise and balanced meals were used. Activities
given by the peer leaders to the participants weremonitored through regular visits of the authorsof this study and by the physician (diabetologist)
assigned by the municipality to the diabetes clinic.
These visits revealed that after peer-led educationof patients had begun, the peer leaders preparedposters about diabetic complications on their own
initiative, and they frequently used these posters toraise the participants’ awareness regarding ways toprevent disease exacerbation.
Because of ethical considerations, we did notinclude in the current study a no-treatment control group that did not receive peer-led education.
It was also because the patients all resided in thesame community, it would be difficult to ensure thatpatients in the treatment group did not share theirincreased knowledge with their neighbors, who
might be in the control group.

Data collection
We collected data through five surveys performed
every 6 months from March 2017 to March 2019[i.e. March 2017 (6 months before the start ofthe peer leaders’ education of patients); August
2017 (immediately before the start); March 2018
(6 months after the start); August 2018 (12 months
after the start); and March 2019 (18 months after
the start, at the end of the peer-led education)].
Each of the surveys was performed when a free
medical checkup was offered to the patients withdiabetes in the municipality.
Population for analysis in this study was the
800 members of a nongovernmental organization(Diabetes Association) established in the municipality. This organization has been established in
the municipality and composed of most of thepatients with diabetes in the municipality. The collected data from the patients who completed all
five surveys were used for analysis. We estimatedthe minimum sample size (n = 17) by using G
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no cardiovascular disorders requiring hospitalization (e.g. myocardial infarction or stroke); and nor
the need for hospitalization due to complications
associated with diabetes (e.g. renal impairment,
retinopathy or gangrene).
The intervention of this study (peer leaders’ education of patients) started in August 2017 immediately after the peer leaders received the training.
The participants in the intervention were provided with education on diabetes self-managementby their peers (peer leaders) when they attended
weekly checkups at the diabetes clinic. The education was offered by the 13 peer leaders for
18 months [from immediately after the second
survey (August 2017) until the end of this current study (March 2019)] after they had received
training on diabetes self-management and on theenhancement of self-efficacy to motivate patientswith diabetes for their diabetes self-management.
This training for peer leaders was organizedon the basis of previously reported DSME [13],the theory of self-efficacy [14, 15] and the attention, relevance, confidence and satisfaction model[16]. The training comprised 12 modules spanning 10 h with each module lasting between 45
and 60 min [12]. It was performed over 2 days inAugust 2017 by the authors of this study with thesupport of health-care professionals in the municipality [12]. Owing to the limited time available forsupport from municipal health-care professionals,
the training modules in the reported DSME [17]were modified. Specifically, we omitted ‘stress,
coping and depression’ and ‘diabetes medication’in the reported modules [17] and added sessions
to enhance the peer leaders’ capacity to properly communicate with patients [12], stressing theessence of the DSME (i.e. as a continuous process to facilitate patients’ knowledge, skills andabilities in diabetes self-care) [13]. The authors of
this study specifically prepared a Diabetes Textbook(in the Tagalog language) and self-guided materials on physical exercise and balanced meals (in the
Tagalog language) for the training.
Then, each of the 13 peer leaders was responsible
for educating 5–10 participants. For the educationof participants, instructional styles introduced inN. Kobayashi et al.

Indicators used for data analysis
Knowledge of diabetes was measured by using
the scores of test with the 30 questions preparedon the basis of the Diabetes Knowledge Test [18]and the Diabetes Knowledge Questionnaire [19].
Before the start of this study, the face validity
and content validity of these questions were confirmed through discussions with diabetologists inthe municipality. Then, the questions were administered to patients with diabetes residing in themunicipality who were not enrolled in the study(n = 32). The value of Cronbach’s coefficient of thequestions (𝛼 = 0.772) demonstrated the reliability(i.e. internal consistency) of the original questions.
We finalized this set of 30 questions for use ineach of the five data collection surveys. These 30
questions on knowledge of diabetes were categorized into the following subindicators for analysis:(i) cause, risk factors, nature of diabetes and complications; (ii) importance of self-management of
their own disease; (iii) diet and nutrition and (iv)280

exercise. The questions categorized in the subindicator (i) were designed to determine the participants’ understanding of diabetes in terms of cause,
exacerbating factors and complications. The questions in the subindicator (ii) accounted for the participants’ attitudes toward their diabetes and toward
the importance of disease self-management, as wellas their establishment of partnerships with healthprofessionals.
Self-efficacy in the management of diabetes wasmeasured by using the Diabetes Self-efficacy Scale[20]. This scale consists of eight Likert-type items,
each scored from 1 (not at all confident) to 10(totally confident). The mean score for the eightitems is the overall score, with a higher scoreindicating greater confidence.
The QOL of participants was measured by using
the Eight-Item Short Form QOL Survey (SF-8)[21]. The SF-8 is composed of eight multiplechoice questions. Each of the eight questions isscored according to reported values allocated to thechosen answers. The eight scores are summed after
applying the weights allocated to all eight questions, and then two summary scores [i.e. the physical component summary (PCS) and mental component summary (MCS)] are calculated. High PCS
and MCS scores indicate better QOL [21]. Because
neither values applied to the chosen answers nor
weights for the eight questions used in the calculation have been reported in the Philippines, we usedthe values and weights for PCS and MCS appliedin the United States [22]. The SF-8 was used withthe permission of iHope International Co., Ltd(Kyoto, Japan), in accordance with their royalty
rules.
Plasma HbA1c levels were measured with a
Clover A1c Self Analyzer (Infopia Co., Ltd,
Gyeonggi-do, South Korea). Emotional distress
was assessed by using the Problem Areas in
Diabetes (PAID) instrument, which is a selfadministered 20-item questionnaire [23]. Each item
is scored from 1 (not a problem) to 5 (a serious
problem). The sum of all item scores gives the total
PAID score (range: 20–100), with higher scoresreflecting greater emotional distress [23].

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Power 3.1.9.7 (Heinrich Heine University, Dusseldorf, Germany), with a statistical significance of
0.05, a power of 0.8 and an effect size (Cohen’s F)of 0.3. Although the number of sessions or hours
offered to each of the participants was not counted,
records of weekly medical checkups in the diabetes
clinic confirmed that all the participants received
the peer-led education at least once a month, when
they attended the medical checkups. Therefore, it
was estimated that all the participants were offered
the peer-led education at least 18 times during thisstudy period.
This study was conducted according to theguidelines of the Declaration of Helsinki andapproved by the ethics committee of the Facultyof Medicine, Tottori University, Tottori, Japan(No. 1608B013 on 23 May 2017) after being
registered in the national clinical trials registry (UMIN000027073). The objectives, potential
impact, methods, risks and benefits of the study
were explained in a document provided to all potential participants. All participants provided signed
informed consent.

Change in diabetes indicators after peer education

Data analysis

Results
The number of patients who completed each survey ranged from 95 to 145, out of which 23 patientscompleted all five surveys; this number of patientswas more than our estimated minimum sample size
for analysis (n = 17). Data of these patients (participants) were used for further analysis. The average age of the participants was 67.8 ± 6.7 (range,
57–84) years. Of the 23 patients, 82.6% werefemale, 91.4% were not working and 47.8% were
married (Table I).
None of the indicators or subindicators ofthe 23 participants showed significant differences
between the first two time points (i.e. before thestart of the peer-led education) (Tables II and III,Supplementary Appendix A and B). The two significant increases were found in levels of the participants’ knowledge of diabetes at 12 and 18 months
after the start (both P < 0.05), compared withthose immediately before the start (August 2017)(Table II). Furthermore, a significant increase(P < 0.05) was observed in the category of ‘cause,risk factors, nature of diabetes and complications’

Variable

Number (%)

Age (years)
Sex
Male
4 (17.4)
Female19 (82.6)
Occupation
Employed
2 (8.7)
Not working
21 (91.3)
Highest level of
education
Primary
3 (13.0)
Secondary
14 (60.9)
College
4 (17.4)
No answer
2 (8.7)
Marital status
Married11 (47.8)
Single12 (52.2)
Complications(self-declared)
Renal disorder
3 (13.0)
Neuropathy
4 (17.4)
Eye disorder
11 (47.8)
Peripheral
0 (0.0)circulatory
disturbanceClassification by neuropathy
symptom (self-declared)
Normal3 (13.0)Mild
7 (30.4)
Moderate
13 (56.5)
Severe0 (0.0)Mean ± 1 SD (range)
67.8 ± 6.7 (57–84)

under the subindicator of ‘knowledge of diabetes’at 6 months after the start (Table III).

Discussion
The participants’ levels of knowledge were significantly higher at 12 and 18 months after the
initiation of peer-led education than immediately
before it began (Table II), with the lack of a significant difference between the two time points
before the peer-led education began. The scores inthe subindicator ‘cause, risk factors, nature of diabetes and complications’ were significantly higher

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To minimize bias that might result from the lackof a control group for analysis, we confirmedwith paired t-tests that—as expected—values fordiabetes-related indicators did not differ significantly between the first two time points (i.e. March2017 and August 2017), which occurred before thepeer-led education began. Then, we assessed differences between the indicator values immediately
before the start of peer-led education (August 2017)
and those at the three later time points (March
2018, August 2018 and March 2019), by using
repeated-measure analysis of variance and Bonferroni’s multiple comparisons. P-values less than
0.05 through multiple comparisons were considered statistically significant. SPSS Statistics version 22 (IBM, Armonk, NY, USA) was used for allof the statistical analyses.

Table I. The characteristics of survey participants at 6 months
before the start of peer education (n = 23)

63.6 (12.9)
62.0 (14.4)
46.5 (7.0)
47.9 (5.2)
7.43 (2.03)
39.6 (15.0)

Knowledge (score: 0–100)
Self-efficacy (score: 8–80)
QOL (PCS)QOL (MCS)
HbA1c (%)
PAID (score: 20–100)

6 monthsafter
69.6 (8.5)
60.5 (11.1)
47.7 (5.9)
44.3 (8.4)
7.70 (1.74)
46.1 (15.8)

Immediately
before65.5 (8.0)†
55.2 (16.6)
46.3 (7.5)
47.3 (6.4)
7.40 (1.72)
48.7 (14.2)

73.8 (12.4)‡
60.4 (12.1)
46.6 (6.7)
48.5 (7.4)
7.58 (1.98)
46.2 (13.2)

12 months
after
75.3 (13.2)§
62.0 (10.7)
48.6 (7.5)
49.8 (6.7)
7.29 (1.89)
47.1 (15.9)

18 months
after
6.474
1.901
0.829
2.845
1.369
0.167

F
0.001
0.166
0.477
0.051
0.264
0.879

P

† < ‡ (P < 0.05), † < § (P < 0.05)

Bonferroni’s multiple
comparison test

63.4 (18.7)
71.0 (25.2)

62.1 (15.9)
75.4 (18.0)

59.6 (13.4)
73.9 (17.3)

50.9 (13.5)§
75.4 (23.0)

57.6 (17.6)

63.0 (16.6)

76.9 (15.7)

64.1 (25.9)

76.9 (11.6)‡

67.6 (11.6)†

69.2 (11.6)

12 months after

67.4 (15.9)

6 months after

Immediately
before6 months
before63.8 (13.9)¶
73.9 (17.3)

68.1 (21.3)

75.3 (16.7)

18 months after

3.798
0.232

1.728

3.834

F

0.025
0.852

0.176

0.016

P

§ < ¶ (P < 0.01)† < ‡ (P < 0.05)

Bonferroni’s multiple
comparison test

(i.e. excluding ‘6 months before’)—F- and P-values therefore refer to those four time points.

† Values are the percentages of questions in the category under ‘knowledge of diabetes’ that the participants answered correctly (Table II).
‡ Normally distributed continuous variables are expressed as mean (1 SD).
§ Paired t-tests confirmed the lack of significant difference (P > 0.05) between indicators at 6 months prior to and immediately before the start of peer education.
¶ Repeated-measures analysis of variance and Bonferroni’s multiple comparison tests were used to assess changes in indicators values among the four later time points

Cause, risk factors,
nature of diabetes, andcomplications
Importance of selfmanagement of theirown disease
Diet and nutrition
Exercise

Subindicator

Table III. Values of subindicators categorized under ‘knowledge of diabetes’ before and after the start of peer education of participants with T2D(i.e. excluding ‘6 months before’)—F- and P-values therefore refer to those four time points.

† Normally distributed continuous variables are expressed as mean (1 SD).
‡ Paired t-tests confirmed the lack of significant difference (P > 0.05) between indicators at 6 months prior to and immediately before the start of peer education.
§ Repeated-measures analysis of variance and Bonferroni’s multiple comparison tests were used to assess changes in indicators values among the four later time points

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282

Indicator

Table II. Values of indicators before and after the start of peer education of participants with T2D

N. Kobayashi et al.

Change in diabetes indicators after peer education
thus caused the lack of increase in the participants’
self-efficacy levels.
The values of QOL were slightly (albeit notsignificantly) higher 18 months after the start ofthe peer-led education (PCS, 48.6; MCS, 49.8)
than immediately before the education (PCS, 46.3;
MCS, 47.3), although no significant differenceswere observed in the participants’ QOL (both PCS
and MCS) among all the surveys. They were higher
than those reported using the SF-8 in the UnitedStates (PCS, 47.2; MCS, 48.2) [21]. Positive influences of Filipino patients’ levels of diabetes knowledge on their self-efficacy regarding the management of diabetes and on their QOL (both PCS andMCS) have previously been reported in patientswith T2D at this same study site [11]. In addition,
another study at the same site reported a positive correlation between diabetes knowledge levels
with self-efficacy for the management of diabetes
among the peer leaders who educated the participants in the current study [12]. Improving patients’knowledge of diabetes may promote increases intheir self-efficacy and QOL; additional long-term
studies to explore the effects of enhancing patients’diabetes knowledge on these two indicators are
warranted.
No significant improvements were observed inplasma HbA1c levels. In a previous report, there
was an improvement in HbA1c levels in the patientswith T2D and HbA1c >8.0% who received individual education on metabolic control, diabetes
knowledge and psychosocial outcomes, whereas
there was no significant change in HbA1c levelsin those with HbA1c <8.0%; this suggested that
benefits from the program would appear in patientswith high HbA1c levels [25]. Likewise, the lackof a significant improvement in the participants’
HbA1c levels through the peer-led education in
our current study may have been attributable totheir fairly well-controlled HbA1c levels before theintervention (7.43% and 7.40% at 6 months andimmediately before the start of peer-led education).
The PAID scores did not differ significantly
among all the surveys. A lack of significant changeover 3 years in the PAID values of patients who

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at 6 months after the peer-led education began
than immediately after the education (P = 0.04);
later scores remained similar to the 6-monthvalue (Table III). These findings suggest that thepeer-led education of participants increased theirknowledge levels. A previous study reported asignificant increase in patients’ levels of knowledge of diabetes at 12 and 18 months after they
had received training on diabetes self-management,
compared with their level 6 months before the training [12]; it was expected that this increased knowledge obtained by the patients could be extended
to other patients with diabetes. Indeed, in thisstudy, absorbed knowledge of the patients (i.e. peer
leaders) was extended to the other patients (i.e.
participants). The use of the posters prepared by
the peer leaders after starting the education ofparticipants might have contributed to increasing
the participants’ levels of knowledge on diabetes
and on its ‘cause, risk factors, nature of diabetes
and complications’. The lack of significant differences between the scores of subindicator ‘cause,risk factors, nature of diabetes and complications’immediately before the start of education and thoseat 12 and 18 months after the education started(P = 0.09 and 0.23, respectively) was attributable
to increases in the standard deviations of the scoresat both of these two time points. By contrast, thelack of improvement in the scores of subindicator‘importance of self-management of their own disease’ (P = 0.176) emphasized the need to enhanceknowledge around this subindicator when facilitating peer-led education of patients.
The self-efficacy levels did not differ significantly among all the surveys (Table II). A previous
report suggested the Dunning–Kruger effect as acause of the lack of increase in self-efficacy levels of the peers who educated the participants inthis current study [12]. In other words, among individuals who incorrectly appraise their competence
as being higher than it really is, their confidence
in their behavior decreases as they gain experience [24]. This effect could have counteracted the
expected increase in our participants’ self-efficacy
levels in response to the peer-led education andN. Kobayashi et al.

Conclusion
The knowledge levels of Filipino patients with diabetes regarding the disease and its related subindicator ‘cause, risk factors, nature of diabetes andcomplications’ increased after they started receiving peer-led education. These findings—together
with a previously reported positive correlation ofpatients’ knowledge levels with their self-efficacy
and QOL—support the incorporation of strategies
to enhance patients’ knowledge about diabetes into
peer-led education programs targeted to communities and regions with limited medical resources.
Increasing patients’ knowledge could improve theirself-management of their disease and enhance their
QOL. Additional long-term studies are needed toverify the effects of enhancing patients’ knowledge
on the indicators of self-efficacy and QOL.

Supplementary data
Supplementary data are available at HEAL online.

Funding
International Platform for Dryland Research and
Education, Tottori University, Japan, and the
Health Promotion and QOL Improvement Projectfor Diabetics in Metro Manila of Japan International Cooperation Agency.
284

Conflict of interest statement
None declared.

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had attended a single 6-h group education program (baseline PAID values were not mentioned)
has been reported before [26, 27]. Another study
performed at this same site demonstrated no significant differences in the patients’ PAID values
over a 2-year period (P = 0.24) [12], which is thesame duration of follow-up as in our current study.
The lack of a significant change in the participants’
PAID values in our current study suggests either
that the effect of the intervention in mitigating thepatients’ emotional distress appears after more than
2 years or that there is no effect.

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