Program Design Discussion 6

After reading

this article

, create an initial discussion post regarding your assessment of the cultural competence of the program identified in the article. Do you think that the healthcare program adequately addressed cultural competence or not? Explain your reasoning. Incorporate the principles used in the article in your program critique.

*Article Attached*

RESEARCH ARTICLE Open Access

A critique of the design, implementation, and
delivery of a culturally-tailored self-management
education intervention: a qualitative evaluation
Manbinder S Sidhu1*, Nicola K Gale2, Paramjit Gill1, Tom Marshall1 and Kate Jolly3

Abstract

Background: Self-management education is at the forefront of addressing the increasing prevalence of chronic
diseases. For those at greatest risk, such as minority-ethnic and/or socio-economically deprived groups, self-management
education can be culturally-tailored to encourage behavioural change. Yet, the application of culturally appropriate
material and expertise within health promotion services continues to be debated. We critique the design,
implementation, and delivery of a culturally-tailored self-management intervention, with particular focus on
the experiences of lay educators.

Methods: A mixed methods qualitative evaluation was undertaken to understand self-management service
provision to culturally diverse communities (i.e. how components such as lay workers, group-based design,
and culturally-appropriate educational material are intended to encourage behavioural change). We interviewed lay
educators delivering the Chronic Disease Educator programme along with attendees, whilst observing workshops. Data
were thematically analysed using a content-based constant comparison approach through a number of interpretative
analytical stages.

Results: Lay educators felt part of the local community, relating to attendees from different races and ethnicities.
However, lay educators faced challenges when addressing health beliefs and changing lifestyle practices.
Culturally-tailored components aided communication, with educator’s cultural awareness leading to close relationships
with attendees, while the group-based design facilitated discussions of the emotional impact of illness.

Conclusions: Lay educators bring with them a number of nuanced skills and knowledge when delivering
self-management education. The development and training required for this role is inhibited by financial
constraints at policy-level. The interpretation of being from the ‘community’ links with the identity and status of
the lay role, overlapping notions of race, ethnicity, and language.

Keywords: Self-management, Education, Ethnicity, Lay, Culture

Background
Migrant populations are at greater risk of developing
and living with long term conditions than the general
population [1]. Further, migrant groups practice fewer
self-management behaviours and demonstrate higher
utilisation of emergency healthcare services in compari-
son to the general population [2]. One method to ad-
dress the growing demand for health care services is by

improving patients’ ability to self-manage by attending
chronic disease self-management programmes (CDSMPs).
Following a model developed by Lorig et al. [3] for pa-
tients living with arthritis, CDSMPs are weekly, group-
based workshops delivered in primary care or community
settings. Theoretically, CDSMPs intend to improve inter-
action with health care providers, making self-care deci-
sions, managing the physical and emotional aspects of
living with a chronic illness, and re-interpreting rela-
tionships with close others [4].
CDSMPs employ lay people (non-health professionals)

from the ‘community’. In this context, lay people may be

* Correspondence: m.s.sidhu@bham.ac.uk
1Primary Care Clinical Sciences, University of Birmingham, Edgbaston,
Birmingham B15 2TT, UK
Full list of author information is available at the end of the article

© 2015 Sidhu et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.

Sidhu et al. BMC Health Services Research (2015) 15:54
DOI 10.1186/s12913-015-0712-8

mailto:m.s.sidhu@bham.ac.uk

http://creativecommons.org/licenses/by/4.0

http://creativecommons.org/publicdomain/zero/1.0/

living with chronic diseases, have received self-management
training, have knowledge of cultural beliefs and practices
as well as societal issues facing the community. Within
the UK Kennedy et al. [5], with their evaluation of the
Expert Patients Programme (EPP), reported white, middle
class, women are, particularly, attracted to volunteer lay
positions as a method of accessing employment in the
health care sector. Health policy has encouraged lay per-
son recruitment according to ethnic concordance [6] and/
or addressing language concerns. What remains inconclu-
sive is how ‘being from the community’ enhances the
experiences of those attending CDSMPs, and ultimately,
encourage behaviour change in comparison to lay educa-
tors recruited elsewhere.
Cultural adaptation refers to the extent to which ethnic/

cultural characteristics, experiences, values, behavioural
patterns and beliefs of a target population as well as rele-
vant historical, environmental and social factors are incor-
porated in the design, delivery, and evaluation of targeted
health promotion materials and programs [7]. There re-
mains a lack of evidence to guide practitioners on how
best to culturally adapt interventions. Zeh et al. [8] have
identified a number of cultural barriers for minority
groups living with diabetes, where services need to address
linguistic differences, different beliefs about health and ill-
ness, as well as addressing low concordance patients may
have with western professional advice. Notably, Greenhalgh
et al. [9] identified that among Sikh, Hindu and Muslim
groups self-management was secondary to adhering to re-
ligious beliefs. However, some cultural barriers are more
specific to certain ethnic groups and grouping all ethnic
groups together, in terms of their health service needs,
may be contentious [10].
Services are culturally tailored using five main strat-

egies described by Kreuter and Wray [11]. These are:
peripheral strategies (designing materials to appeal to a
given group e.g. visual information); evidential strategies
(presenting epidemiological evidence to raise awareness
of health concerns), linguistic strategies (delivering in
the dominant or native language of the target group),
constituent-involving strategies (drawing on the experi-
ence of the group which includes hiring members of the
indigenous population); and sociocultural strategies (dis-
cussing health-related issues in the context of broader
social and/or cultural values).
These five main strategies for cultural tailoring fit

within two broad categories with regard to adaptations
that can be potentially used for interventions designed
for minority-ethnic communities. First, cultural adapta-
tion (adapting delivery or tailoring health information to
reflect community values, beliefs, and practices); second,
structural (modifying the intervention to encourage at-
tendance and completion). The differentiation allows
for the possibility to target specific components, where

cultural adaptations relate to the nature of the content
provided, and structural adaptations focus on issues of
implementation. In addition, data collection with multi-
ethnic populations can be problematic, as traditional
‘written’ methods are suited to the White population,
whereas some South Asian sub-groups requiring assist-
ance or audio delivery [12].
We evaluated a local service serving an ethnically di-

verse socio-economically disadvantaged inner city com-
munity. Our objectives were to i) describe the experiences
of lay educators educating members of their own com-
munity with regard to self-management and ii) evaluate
whether a culturally tailored self-management interven-
tion is delivered as intended to an ethnically diverse
population through observation and interpreting the
views of completers.

Methods
Study design
To describe the experiences of lay educators and critique
components of design, implementation, and delivery we
undertook a theoretically-guided service evaluation. The
objective was to evaluate whether components led to
intended outcomes. For example, the group-based design
is intended to enhance peer-to-peer exchanges amongst
attendees, the application of visual aids and interactive
tasks is expected to familiarise participants with low liter-
acy, while lay educators are assumed to have greater
knowledge of health beliefs and practices that can act as
potential barriers to healthy living.
A qualitative approach was well suited to our evalu-

ation, because qualitative methods can document and
interpret the experiences of delivering and attending a
self-management service. We collected both observa-
tional and interview data to gain multiple perspectives
on the service. Semi structured interviews were conducted
to understand lay educator’s experiences of delivering the
intervention to an ethnically diverse population. We ob-
served workshops delivered by each lay educator. Work-
shops varied considerably by: content, language in which
content was delivered, and the characteristics of partici-
pants in a single group (ethnicity, gender, literacy needs).
Therefore, it was imperative that as many different
sessions were observed to interpret the various styles
of delivery. Semi structured interviews were conducted
with participants who had completed the intervention
(attended at least 3 out of 4 workshops). Interviews were
aimed at collecting data regarding participant experience
and their views of lay educators.

Setting
The intervention was delivered in Birmingham, UK. Ac-
cording to Quality and Outcomes Framework (QOF)
data for April 2010- March 2011, for the local vicinity in

Sidhu et al. BMC Health Services Research (2015) 15:54 Page 2 of 11

which the intervention was delivered (74 practices, with
321 456 patients registered) the prevalence of CHD,
diabetes mellitus, CKD were similar or greater than na-
tional levels.

Intervention
The characteristics of lay educators/attendees inter-
viewed and a description of the intervention are pre-
sented in Tables 1 and 2. We have used the Abraham
and Michie [13] taxonomy to describe behaviour change
techniques used within the intervention. The Chronic
Disease Educator (CDE) programme was first delivered
in March 2008 within general practitioner (GP) practices
and community settings in Birmingham, UK. The inter-
vention was delivered by a community interest company
(CIC), providing lay health services to the local popula-
tion. Patients suffering from diabetes mellitus (DM), cor-
onary heart disease (CHD) and/or chronic kidney disease
(CKD) were invited to attend.
The intervention was culturally-tailored and differed

from the CDSMP model developed by Lorig et al. [14].

The service was delivered over four weeks, once a week
for 90 minutes each time, by a single lay educator. Partici-
pants were allocated to groups (3–15 people) according
to language requirements, with non-English-speaking
participants (exclusively South Asian individuals) allo-
cated to groups with a bi-lingual lay educator (Punjabi,
Urdu, Hindi or Sylheti) or if a bi-lingual educator was
unavailable, an interpreter with necessary language
skills was used. Participants were referred to the
programme by GPs, practice nurses, practice staff or lay
educators.
Content included information on weight management,

choosing healthier foods, meal planning, physical activ-
ity, checking and improving metabolic control and pre-
venting complications associated with chronic diseases.
The programme content was underpinned by social
learning theory [15] and included skills mastery, action
planning, social support (via the group), goal setting,
and problem solving. To accommodate participants from
socio-economically disadvantaged backgrounds with low
literacy levels the programme used visual aids and dem-
onstrations, understandable terminology, and was deliv-
ered in community locations.

Fidelity of the intervention
Lay educators were provided with a ‘manual’ detailing
the aims, content, and goals that should be completed in
each workshop of the intervention. For example, lay
educators were expected to inform attendees of the aim
at the beginning of each workshop. Lay educators were
assessed on: whether there was group interaction be-
tween participants and educators, use of appropriate cul-
tural adaptations for the demographic characteristics of
the participants, appropriate translation, supporting self-
efficacy, setting goals and reviewing progress against
targets.

Recruiting lay people from the community
Lay educators were recruited from the local community.
These were people from different ethnic communities,
who lived in Birmingham and had knowledge of local
social issues. At the beginning of data collection six lay
educators were delivering the programme. Training was
provided in partnership with a local college, with lay ed-
ucators completing a national vocational qualification in
health and social care.

Sample
All six lay educators agreed to be interviewed. A purpos-
ive sampling method was used with regards to observing
the CDE programme and generating a sample of partici-
pants that completed the intervention [16]. All sessions
(workshops 1–4) were observed for a single bi-lingual
and mono-lingual educator, while the first and last

Table 1 Characteristics of participants interviewed/observed

Characteristic Lay educators (N) Attendees (N)

Gender

Male 2 11

Female 4 9

Ethnicity

White British 1 7

White Other – 1

Asian- Indian – 5

Asian- Pakistani 2 1

Asian- Bangladeshi 1 2

Black Caribbean 1 4

Mixed Race- White British
and Black Caribbean

1 –

Age

Up to 29 years 4 –

30-39 years 2 –

40-49 years – 4

50-59 years – 3

60-69 years – 10

70 or older – 3

Language

Bi-lingual 3 17

Non-Bi-lingual 3 3

Years since diagnosis

Less than 5 years – 7

5-10 years – 4

10 years or more – 9

Sidhu et al. BMC Health Services Research (2015) 15:54 Page 3 of 11

workshops were observed for the remaining educators.
We observed workshops delivered in various community
languages, to men and women, and to different ethnic
groups to understand the acceptability of the intervention
for different sub-groups. Completers of the programme
invited for interviews were purposively sampled by ethni-
city. In order to ascertain whether the intervention was
delivered as intended we wished to gather the views of
participants completing the intervention, to identify
what they felt was positive or could be improved about
the intervention, with regard to content and delivery,
for future service users. Lay educators asked participants
attending workshops whether they would like to be inter-
viewed and share their views about the intervention.

Data collection
MS completed semi-structured interviews with lay educa-
tors (N = 6) and a sample of participants who completed

the CDE programme (N = 20). MS is a sociologist by back-
ground (BA Hons at the time of data collection). Inter-
views with lay educators were conducted at their place of
work, while interviews with participants took place in
their homes or a meeting room at the Central Library,
Birmingham. All interviews were completed by MS. An
interview guide was used (different for lay educators and
participants, Additional files 1 and 2), based on a review
of the literature and discussions within the research team
(MS, NG and KJ). With reference to the work of Brown
et al. [17] and Tozer et al. [18], the interview guide was
structured about the lay educator role, its responsibilities,
training and the experience of being and working within
the local community. The interview guide for participants
was thematically designed incorporating questions about
style of facilitation, meeting cultural/language needs, ap-
plication of behavioural change techniques, and delivery
of content. A key focus was placed on understanding the

Table 2 Description of the chronic disease educator intervention

Reporting criteria CDE Programme

Where was the intervention delivered and why? Primary care settings (GP surgeries) and community settings with a single lay
educator (or with the use of interpreters when necessary

What behavioural change theory has intervention been based
on (if any)?

Social learning theory

What behaviour change techniques were used by people
delivering the intervention (if any)*?

1, 2, 4, 6, 8, 10, 19, 22, 24

A description of the activities and material provided in each
workshop and their intended outcomes?

Material: information on weight management, choosing healthier foods, meal
planning, physical exercise, checking and improving metabolic control and
preventing complications.

Activities: participants taking each other’s blood pressure, BMI calculations,
understanding sugar and salt content in foods, Eat-well plate, food maps, guided
imagery, ‘freethink’.

Intended outcomes: desirable body weight, learn to shop for food, increase physical
activity, take medication properly and regularly, recognise early symptoms of
condition, regularly attend clinics, improved symptom control, reduced BMI,
improved quality of life and knowledge of condition, reduced level of prescribing,
slower disease progression, management of condition, carry out normal roles and
activities, and manage emotional impact of illness.

What support (if any) was provided to individuals outside of
workshops?

No contact outside of workshops.

Was a manual or protocol used to deliver the intervention
and are there details on how it can be accessed?

Manual is available to lay educators, however, not used during intervention. Can be
accessed via permission from Health Exchange.

How were individuals referred to the programme? Patients suffering from diabetes mellitus, coronary heart disease and/or chronic
kidney disease were invited to attend the programme. Patients referred to the
programme by general practitioners, practice nurses or practice staff. Practices citing
a lack of time asked CDEs to contact patients on chronic disease registers directly by
phone or postal mail.

Were any cultural or structural adaptations used? Delivery in various languages, cultural adaptation of educational material, application
of visual aids and demonstrations, understandable terminology, emotional well-
being, culturally sensitive approach to delivery, recruitment of lay personnel, delivery
in community locations, and religious/cultural acknowledgement.

*Abraham and Michie [13] Taxonomy of behaviour change techniques:
1. Provide general information on behaviour-health link; 2. Provide information on consequences; 3. Provide information about others’ approval; 4.Prompt intention
formation; 5. Prompt barrier identification; 6. Provide general encouragement; 7. Set graded tasks; 8. Provide instruction; 9.Model/Demonstrate the behaviour; 10. Prompt
specific goal setting; 11. Prompt review of behavioural goals; 12. Prompt self-monitoring of behaviour; 13. Provide feedback on performance; 14. Provide
contingent rewards; 15. Teach to use prompts/cues; 16. Agree behavioural contract; 17. Prompt practice; 18. Use of follow-up prompts; 19. Provide opportunities
for social comparison; 20. Plan social support/social change; 21.Prompt identification as role model/position advocate; 22. Prompt self-talk; 23. Relapse prevention;
24. Stress management; 25. Motivational interviewing; 26. Time management.

Sidhu et al. BMC Health Services Research (2015) 15:54 Page 4 of 11

interactions amongst participants during group based
education and whether this method was acceptable for at-
tendees. Data collection ceased when no new descriptive
themes were emerging from interviews. All interviews
were audio-taped and transcribed verbatim. Three inter-
views with participants were in Punjabi or Urdu and one
conducted with an interpreter and transcribed in English
(Bengali speaker). Translation was independently checked
for conceptual equivalence by another researcher with ap-
propriate language skills.
To develop an understanding of the CDE programme

we observed educational workshops (N = 14 [workshops]).
MS observed all sessions. There were three areas evalu-
ated for fidelity: observing the nature of interactions be-
tween participants with each other and educators, the
approach and language (literally and conceptually) used
by educators, and whether cultural and social norms (in
relation to healthy living) were addressed. The role of
observer as participant (the researcher has minimal
interaction in the research setting) was chosen [19].
Observational data were recorded using a thematically-
designed research instrument categorised into programme
delivery and participant interaction. The instrument
(Additional file 3), designed by the research team, was
developed to collect data with regard to group dynam-
ics, behavioural change techniques, variation in lan-
guage used, delivery styles and cultural competency of
lay educators.

Data analysis
Data analysis occurred in tandem with data collection.
MS conducted and transcribed all interviews (English
and non-English) and recorded data from observations.
Transcriptions of non-English interviews were verified
for conceptual equivalence with another researcher within
the university with experience of conducting interviews in
South Asian languages. With regard to reliability, a pur-
posive sample of transcripts was independently coded by
NG (medical sociologist). The intention was to independ-
ently identify areas of interest within data that could lead
to the generation of themes. Monthly (NG and KJ) and bi-
annual meetings (PG and TM) to discuss the generation
of themes were held to increase methodological rigour
[20]. Using a constant comparison approach, we used
applied thematic analysis via an inductive process. We
used content analysis and themes emerged from the
data inductively. In an attempt to be systematic
throughout, our coding was completed in a number of
cycles, iteratively moving back and forth between data
collection and analysis.
First cycle coding involved reading transcripts [and ob-

servational data], identifying data of interest and encoding
prior to interpretation [21]; hence, codes were created that
“summarize, synthesise, and sort many observations made

of the data” ([22]: 112). Once complete, the second cycle
involved the application of axial coding; placing relating
codes together that are based on a single phenomenon
and making connections. Throughout axial coding, we
adopted a technique of writing brief analytical memos to
detail the development of categories, make relationships
between codes, facilitating theoretical interpretation, and
linking findings with the literature. Finally, themes were
generated by writing initial descriptive themes, then clus-
tering themes together to generate an inductive deduced
integrative theme. NVivo software was used to assist data
analysis.

Consent and ethical issues
Ethical approval was obtained from South Birmingham
Research Ethics Committee. Participants were given
written information about the evaluation and gave writ-
ten informed consent. Quotes have been given identifiers
to ensure anonymity.

Results
Findings: Lay educators
A table of themes and supporting quotes are attached at
the end of the manuscript (Additional file 4).

Cultural receptivity
Lay educators interpreted themselves as knowledgeable
experts, where knowledge and information they dissemi-
nated was perceived to be of greater value compared to
health beliefs held by participants on the programme. Par-
ticipants were allowed to discuss their health beliefs; how-
ever, discussions were concluded by distinguishing whether
a belief was ‘fact’ (conformed to scientific-based evidence)
or ‘myth’ (related to folk beliefs). This was complemented
by participants placing greater value on information given
by lay educators, particularly about healthy foods, in com-
parison to other members of the group:

They just ask me, “is this true, is this true”, I go this is
what’s true and some are myths, so try not to follow
the myths just the facts (CDE, interview).

Their [White British and Black/Black Caribbean]
mentality is slightly different to the Asian culture so
you know they don’t eat many spices anyway, their
lifestyles, their little habits. I find that’s its easier for
them to make the changes than it is of Asian people
because they just have their set plans you know, you
make one dish and you have it twice a day, and
everybody has the same and you have your chapattis
(CDE, interview).

Cultural adaptations were made, in their majority, to
meet the needs of South Asian participants attending

Sidhu et al. BMC Health Services Research (2015) 15:54 Page 5 of 11

the programme. Activities were adapted by incorporating
established Asian brands when discussing cooking prac-
tices and nutritional value. Female only groups were de-
livered for Muslim participants on request:

We show them the traffic light system, like types of
food, so instead of using English brands I use Asian
brands, like East End (CDE, interview).

if it was Muslim women, sometimes they prefer a
women only group so you have to be sensitive to that
(CDE, interview).

The activities on the CDE programme were culturally
adapted to include visual aids for illiterate and/or poorly
educated participants to get across the message of
healthy eating. Visual aids were not always applicable to
certain ethnic groups, where they would be more useful
if they were culturally orientated to meet particular
needs for individual communities:

the visual aids aren’t culturally relevant, like with the
food plate the oils and fats that we’ve got, even the
bits of salt aren’t culturally relevant… the oils we
purchased from an outside agency, the salt’s again
have been purchased by an outside agency as well, so
it’s what they provide (CDE, interview).

Working with and without interpreters
The need to establish a productive working relationship
between lay educator and interpreter was imperative,
particularly to ascertain that their roles did not overlap.
Mono-lingual educators recognised the importance inter-
preters played when there was no ethnic concordance
with participants. As interpreters were ethnically matched
with participants, they acted as a link and helped to break
any perceived barriers of us and them:

The interpreter that I work [with], they (South Asian
community) really value her, they do, I suppose
they’re also seen as part of her community as well. Us
working alongside together has been, very positive. I
suppose it has broken down perhaps a barrier that
may have been between me and the group in a way, if
that was ever felt (CDE, interview).

For South Asian bi-lingual educators (N = 3), speaking
a second language provided the opportunity to apply
contextual knowledge about beliefs, practices and experi-
ences of living with chronic diseases. However, being eth-
nically, rather than linguistically matched, with members
of the South Asian community resulted in a number of
difficulties. There were issues with multiple community
languages being spoken in a single workshop:

I have to be very strict and say I’m going to do a
language only course, cause it’s very hard to chop and
change, we tried it and it doesn’t work…cause it
would be a lot easier delivering it in a community
language than it is delivering half in a community
language then in English and back into a community
language, cause people just get frustrated, they get
tired (CDE, interview).

Lay educators were faced with the experience of deal-
ing with practices that were culturally ingrained while
simultaneously delivering health information that was
medically validated. Therefore, there were difficulties
trying to translate health education messages designed
for western lifestyles for South Asian communities:

It’s quite tiring because working with Asian people is
a challenge, because I find it very challenging, because
it’s a very tough community to work with and
especially trying to send out the message that we
want, because they’re so set in their ways (CDE,
interview).

Being ‘from the community’ addresses surface level
cultural needs such as establishing clear lines of commu-
nication through a single language. Conversely, validated
health education messages based on western diets and
lifestyles were difficult to translate and considered cul-
turally irrelevant which led educators to adapt content
to fit participant lifestyles:

they’ve all got their individual problems, for example
Jamaican’s they tend to use a lot of salt on their salt
fish and everything, you’ve got Asian’s with the fat
and the ghee [clarified butter] (CDE, interview).

Findings: observations for fidelity
Use of appropriate cultural adaptations
Visual aids were perceived to be valuable when educat-
ing South Asian members of the group. The CDEs felt
that, in general, South Asian people in their groups had
lower baseline knowledge of the content provided on the
programme compared to people from White British and
Black Caribbean communities. For example, CDEs would
first explain what the different food groups are before ac-
tivities using a food mat or food traffic light system were
carried out with South Asian participants. The use of vis-
ual aids was able to make the ‘take home message’ of the
activities much clearer and easy to understand for mem-
bers of this group:

The use of the visual aids (images of food portions
and the sugar bags- identifying how much sugar is in
different types of food) makes a considerable impact

Sidhu et al. BMC Health Services Research (2015) 15:54 Page 6 of 11

on providing a complete picture and makes the
content very relevant. PT (1) responds in English,
“My God”- PT (5) responds in Punjabi and English
combined when she sees a picture of some ice cream,
“bhoort tasty” [very tasty]- CDE picks up image and
replies that it is very sugary and unhealthy- PT (1)
takes sugar bag- PT (3) in Urdu, “herani”
[shocked/amazed] (CDE, observational notes).

Setting goals and reviewing progress against targets
Goal setting was primarily performed at the end of the
intervention (week 4) rather than setting goals in each
session based on the content covered. Furthermore, goal
setting was vague and non-personalised; for example,
encouraging participants to lose weight but not distin-
guishing how much weight to lose and over what length
of time. Food diaries were inappropriately used on the
programme. Rather than identifying potential areas for
change in a participant’s diet they were seen as a tool that
could be used by individuals in isolation. Therefore, food
diaries highlight a potential area where personalised be-
havioural changes can be made with the help of the CDE:

No recap of the previous week- all participants
present in this session were present in the previous
session- PT 3,6,8,9,13 bring their food dairies to the
session- CDE does have a look at these diaries, however,
gives the diaries back to them, “it’s for you guys to use
really”. Some appear to think that it was bit of a useless
task, maybe wished to gain more feedback from the
CDE; advice on where changes could be made, more
knowledge and guidance (CDE, observational notes).

CDE goes round the table- not asking everyone- on
what changes they have made since they began the
course- PT 3- “look at labels, more oats, trying to cut
down the salt” PT 2-“I’ve learnt a lot, cut down on the
chocolate, started telling everyone else” (CDE, obser-
vational notes).

Group interaction between participants and educators
Throughout workshops there was a shift between the
roles of an ‘educator’ (providing health-related informa-
tion through a didactic approach) or a ‘facilitator’ (encour-
aging participants to direct sessions in areas they felt were
relevant and narrating personal experiences). Educators
were comfortable in an ‘expert-led’ position which allowed
them to maintain greater control in sessions. This position
allowed parameters to be set around group discussions i.e.
ensuring participants discussed the content covered which
could be personalised:

Discussion about tension [stress], thoughts and
sadness. CDE informing PT 1 to take care of his

blood pressure- caring daughter approach (CDE,
observational notes).

Participants were able to interact with each other at
ease, once lay educators had set the topic of discussion.
Small groups formed, primarily by gender, where both
men and woman felt more comfortable discussing life-
style behaviours that they felt were gender specific, for
example weight maintenance. Yet, interactions were di-
rected towards being more informed so instigating life-
style changes:

PTs are very interactive with those who are closest to
them (PT 13, 7, 6) (PT 8 and 9) and (PT 2 and 3):
small groups have formed. PT 6,7 very interactive- PT
5 not present- PT 13 joins this group- females of her
age- feels she can relate to them better. PT 13 asks
PT 7 if she would like to go to the gym with her- has
no one to go with- PT 7 declines- problem with self-
image- in front of others (CDE, observational notes).

PT 2 and 3 (both male)- in conversation for a long
time- conversations lead to questions directed to the
CDE- all related to the discussion- salt causing high
BP- giving each other more information (CDE,
observational notes).

Supporting self-efficacy
Discussions with participants were occasions when be-
havioural change techniques, underpinned by social
learning theory, were applied. The most common tech-
nique was encouraging self-efficacy i.e. improving an in-
dividual’s perception that they can successfully perform
a behaviour that will have successful outcomes:

CDE stated that going out, socialising, and going to
church encourages positive well-being. Participants
already confident of undertaking tasks that will improve
their emotional well-being (CDE, observational notes).

The use of persuasion. Outlining the benefits of
undertaking certain tasks such as exercise which can
improve stress management and (CDE) stating to the
participant more exercise will result in a positive
outlook; participant nods in agreement (CDE,
observational notes).

Appropriate translation
Workshops delivered in Urdu and Punjabi, either
through an interpreter or a bi-lingual educator had a
‘stop-start’ feature. Workshops with an interpreter often
involved the educator speaking in English and then the
interpreter translating information into Punjabi and, at
times, adding more information than what was actually

Sidhu et al. BMC Health Services Research (2015) 15:54 Page 7 of 11

said. The interpreter would often answer patient queries
directly as a result of previously working on the
programme. CDEs would struggle to control interactions
as participants directed their questions to the interpreter
rather than the CDE. This often resulted in CDEs expli-
citly asking what was being said in discussions:

Sorry, so what’s being said? (CDE, observational
notes).

The use of interpreters and participants with various
language requirements created a ‘chain of translation’,
where the information is first delivered by the educator
in English, translated into Punjabi by the interpreter
and then further translated into another community
language e.g. Bengali, by participants to other members
of the group, with information being lost along the
chain:

PT 5 states she did not understand the translation
delivered to her by the interpreter- firstly in
Punjabi, and then does it in Urdu- slightly better.
PT 5 speaks Bengali- not spoken by the interpreter
which did make her slightly isolated
(CDE, observational notes).

Workshops delivered in a single language tended to
have less of a ‘stop-start’ feature. This allowed discus-
sions to develop from activities which led to greater par-
ticipation from the majority of people in a group.

Findings: the participant experience
The promotion and development of chronic disease self-
management programmes has led to an array of terms
being used to describe lay people, such as peer mentors,
peer leaders, peer educators, lay health workers, com-
munity health workers, community health educators and
many more. Unsurprisingly, participants were unfamiliar
with the term ‘Chronic Disease Educator’ or the role:

The impression I got with him … I was a bit
apprehensive about him, but when he started talking
… I think if you need to ask him, he was there to ask
(CDE-ATT-17, Male, White British, T2D and heart
conditions).

Lay educators and participants developed relation-
ships that were trusting, consisted of rapport and em-
pathy. In part, the relationships established were,
paradoxically, given value and meaning through com-
parison with the relationship participants had with
their GP. Participants were asked whether lay educa-
tors recruited from the community influenced the nature
of the relationship which ensued. Ethnic concordance, for

some was valued less than other characteristics such as
being understanding:
[Interviewer] So, was it of any benefit that [CDE] was

from a similar background?

[Respondent] No, whoever’s a good person, like we
speak to white people, we speak to Black people, so
what’s wrong if everybody is friendly with each other
(CDE-ATT-13, Female, Asian Indian, heart
conditions).

South Asian respondents, overall, valued lay educators
from their community because they were able to deliver
the course in community languages. Instances where
there were ethnic differences (Indian Sikh participant/
Pakistani Muslim educator) made little or no difference,
with the exception of one person who felt a ‘bit more
comfortable that she [CDE] was Pakistani’ (CDE-ATT-12,
Female, Asian Pakistani, T2D):

She was telling everyone in Punjabi, do this, do that,
she spoke good Punjabi, sometimes she spoke in
English, everything was fine with her (CDE-ATT-11,
Female, Asian Indian, T2D and Hypertension).

For the majority of participants, their relationship with
lay educators was determined by their prior knowledge
of self-management. Primarily, there were two types of
relationships; first, informal and ‘friendly’, and second, a
didactic teacher-pupil relationship with a clear intention
of learning:

He was mostly happy with the fact that on how
she [CDE] advised on how to lose the weight, how
to minimise your food [consumption] and stuff
because he wasn’t very aware of it (CDE-ATT-07,
Male, Asian Bangladeshi, T2D, via interpreter).

No, no it didn’t feel like a classroom at all, no, it was
just like you were going in to have a talk with a normal
friend in a friendly atmosphere (CDE-ATT-03, Female,
White British, T2D).

Members from various ethnic groups described experi-
encing different types of relationships. White British and
Black/Black Caribbean interviewees described the rela-
tionship as informal, based on personal conversations,
friendliness, and listening. In contrast, South Asian in-
terviewees described a formal relationship based on
learning and developing skills that would potentially im-
prove the management of their conditions. South Asian
participants appeared content with a ‘teacher-pupil’ rela-
tionship acknowledging that the lay educator was better
informed and should lead workshops.

Sidhu et al. BMC Health Services Research (2015) 15:54 Page 8 of 11

Peer-to-peer exchanges were limited to sharing per-
sonal narratives, discussing past experiences of living
with and managing conditions, and relieving emotional
distress. Participants listened with scepticism to the narra-
tives of other group members. For some, self-management
of chronic diseases, particularly diabetes, was interpreted
as a personalised experience, for example, participants liv-
ing with diabetes spoke of dealing with hypoglycaemic
episodes:

if you ask another person with diabetes, he will tell
you his experience, you could ask a hundred people, if
you talk to a hundred people they all give you their
advice, of their experience, but sometimes it doesn’t
work with you, you know (CDE-ATT-15, Male, Asian
Indian, T2D).

Because we’re all individuals, what suits me, they
could not copy me because it may not suit them
(CDE-ATT-04, Female, Black Caribbean, T2D).

The whole condition was brought out in the group
because people were at different stages with their
diabetes and on different medication and they were
experiencing different things because a lot of them, or
some of them, had different health issues, medical
issues, as well as their diabetes (CDE-ATT-10, Female,
Black Carribbean, T2D).

Notably, when participants shared a personal narrative
there was a lack of facilitation from lay educators. None
of the lay educators had the experience of living with
chronic diseases. Greater facilitation by concentrating on
positive experiences e.g. appropriately dealing with
hypoglycaemic events, rather than negative experiences
could potentially result in greater peer-to-peer learning.

Discussion
Design
The group-based format of the programme allowed partici-
pants to share personal experiences of living with chronic
diseases but were unstructured and without a specific goal
in mind. In comparison, Greenhalgh et al. [23] ‘sharing stor-
ies’ intervention had a clear focus on a topic of discussion
(medication), participants sharing problems (specific issues
with taking a combination of drugs), identification of com-
mon problem (group members not taking medication), and
an outcome (telling GPs about non-concordance and GP
informing participants how to deal with side effects from
drugs). The group-based approach lacked an exchange of
skills and/or learning from each other’s experiences.
Analysis of participant accounts has shown that people

from certain ethnic communities have different learning
requirements and skills they wish to develop. A review

by White et al. [24] investigating the effectiveness of in-
terventions to promote healthy eating in people from
minority-ethnic groups found behavioural modification
was more effective in European origin (White) groups
compared to minority-ethnic groups. Interventions ac-
commodating South Asian groups should concentrate on
addressing cultural barriers to effective self-management,
specifically addressing commitment to religious beliefs,
linguistic differences between patients and health workers,
and low literacy levels [8].

Implementation
Understanding the role of lay educators was important
for participants, as it influenced the type of role they
adopted within workshops and their interpretation of
the CDE programme. The relationship between partici-
pants and CDEs was contextualised and understood in
relation to perceptions towards the quality of care they
expected to receive from health professionals. As a re-
sult, the relationship was performing a core aspect of
their perceived ‘doctor-patient’ relationship; an on-going
personalised therapeutic relationship based on listening
and allowing the patient to have a greater say in their
treatment [25]. Lay educators (and organisations deliver-
ing CDSMPs) need to demonstrate how this programme
fits within wider health services. Lay educators may
benefit from formally being introduced in a team model
with health professionals (GPs, practice nurses); with lay
people, from the local community, playing a valuable
role by providing contextual information about a pa-
tient’s attitudes, behaviour, and environment [26].

Delivery
The training needs of lay people delivering group-based
health education to minority-ethnic disadvantaged popu-
lations need to be examined. There were a number of
areas where training could be provided: how to commu-
nicate with health professionals, facilitating discussions
with adult learners, and how to work with interpreters.
In contrast to findings presented by Brown et al. [17],
lay educators did not express any need to develop their
knowledge on healthy living or chronic diseases as they
were comfortable dealing with health beliefs held by
members from various ethnic communities. Hipwell
et al. [27] noted the need for cultural competence train-
ing i.e. enhancing tutor confidence when dealing with
multi-ethnic groups. Through observation of the CDE
programme it was clear lay people delivering self-
management interventions need to be adequately
trained (or undertake further training) in techniques
which encourage a person to change their behaviour.
The techniques that need to be developed are:

1) recognising which behaviours to change,

Sidhu et al. BMC Health Services Research (2015) 15:54 Page 9 of 11

2) making explicit the health benefits of making
changes,

3) setting realistic targets (use of SMART goals or
action planning),

4) reviewing targets, and
5) informing individuals how to deal with potential

setbacks.

The definition and application of these techniques
have been explained in Improving Health: Changing Be-
haviour, NHS Health Trainer Handbook [28]. Recruiting
lay educators from the community benefited members
from the South Asian population most compared to other
ethnic groups. South Asian participants who attended the
CDE programme benefited from improved communica-
tion while Black Caribbean and White participants bene-
fited from establishing close understanding relationships.
Ethnic concordance is thought to reduce the potential
for power disparities between patient and health care
provider, consequently patients becoming more in-
volved in the decision making process. Yet, in this
programme ethnic concordance had little or no differ-
ence with regard to participant involvement, particu-
larly with South Asian participants.

Strengths and limitations
Strengths of our study are the use of mixed methods,
the application of research instruments that were the-
matically designed with reference to self-management
literature and data were collected from a diverse sample
of different ethnic and religious groups, male and female
and living with a range of chronic diseases. Participants
with language requirements were included within the
sample (Punjabi, Bengali and Urdu speakers). There
were a number of limitations. Participants, in their major-
ity, came from courses delivered by three lay educators.
For some interviewees there was also a considerable
amount of time between completing the course and
conducting the interview which inevitably affected
what participants could remember about attending the
programme.

Conclusion
Understanding the role of educators delivering self-
management interventions within the UK is under-
developed, particularly with minority-ethnic populations.
Analysis of our findings show greater considerations need
to be made in relation to designing content, methods of
implementation, and on-going training for lay educators
when facilitating behavioural change. Lay educators re-
cruited from the community bring a number of skills,
particularly knowledge of health beliefs and practices,
yet, for participants attending self-management inter-
ventions, skills such as empathy, understanding, and

providing health information bypassed issues of ethnic
concordance.

Additional files

Additional file 1: Research Instrument for Chronic Disease Educator
Semi-Structured interviews.

Additional file 2: Research Instrument for Chronic Disease Educator
programme: Participant interviews.

Additional file 3: Research instrument for observation.

Additional file 4: Themes and supporting quotes.

Competing interests
The authors declare that they have no competing interests.

Authors’ contributions
MS collected data, conducted analysis and co-wrote this paper. NG and KJ
contributed to the interpretation of analysis and co-wrote this paper. PG and
TM reviewed the final draft of this paper. All authors read and approved the
final manuscript.

Acknowledgements
This work was funded by the National Institute for Health Research (NIHR)
through the Collaborations for Leadership in Applied Health Research and
Care for Birmingham and Black Country (CLAHRC-BBC) programme. Primary
Care Clinical Sciences is a member of the NIHR National School of Primary
Care Research. The views expressed in this publication are not necessarily
those of the NIHR, the Department of Health, NHS Partner Trusts, University
of Birmingham or the CLAHRC-BBC Theme 6 Steering Group. KJ and TM are
part-funded by the NIHR CLARHC-WM.

Author details
1Primary Care Clinical Sciences, University of Birmingham, Edgbaston,
Birmingham B15 2TT, UK. 2Health Services Management Centre, School of
Social Policy, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK.
3Department of Public Health, Epidemiology and Biostatistics, University of
Birmingham, Edgbaston, Birmingham B15 2TT, UK.

Received: 8 October 2014 Accepted: 19 January 2015

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