Many elements combined make the Toiora exercise class for people with diabetes an excellent example of the Whakakotahi primary care improvement challenge in action.
The core element has been the community of people who have come together to co-design the class and take part over its inaugural 12 weeks.
Making the Toiora exercise class a success: (clockwise from left) Loviana Masila, Leanne Long, Peata Schaafhausen, Pollyanne Edwards, Mere Te Paki, Kamal Chandra, Tai Pairama, Colleen Dunne (seated) and Sally Nicholl.
Named after the healthy lifestyle component of Tā Mason Durie’s model for health promotion, Toiora was co-designed by Te Kete Hauora – the patient advisory group developed by Hutt Union & Community Health Service's (HUCHS) Whakakotahi project team. It is led by Colleen Dunne, a Hutt Valley DHB physiotherapist, along with Te Kete Hauora members Patria Tamaka, Hine Chase and Mere Te Paki.
Toiora takes place at the community hall next door to the Hutt Union & Community Health Service (HUCHS) clinic in Pomare, Lower Hutt.
Dunne brings her physiotherapy expertise to Toiora, encouraging the group to push themselves without exceeding their own limits or causing injury as they do a combination of aerobic, resistance, balance and flexibility exercises. The exercise programme aligns with the American College of Sports Medicine (ACSM) guidelines for physical activity for Type 2 diabetes, Diabetes New Zealand and the Ministry of Health Quality Standards for Diabetes Care Toolkit 2014.
All participants were required to receive medical clearance before beginning the class and on commencement were provided with an information sheet on physical activity benefits and precautions, a home exercise programme, physical activity recording sheet and a Toiora t-shirt.
HUCHS manager Sally Nicholl says one of the points of difference with Toiora was that no-one went into the group cold. “Everyone knew someone else there, whether it was a member of the HUCHS team or a family member, and people would travel together to the class.
'There were pre-existing relationships to build on, whereas if we had done this ‘normally’ we would have been advertising via Facebook and promotion in the HUCHS waiting room. We might have got the numbers but I don’t think we would have had the retention that we’ve had.'
Through the co-design element feedback from the group was gathered week by week, class by class, so that the class could change as it progressed. Before classes began there was also a pre-assessment and interviews to openly address personal goals and any concerns.
Some snippets from an interim summary of feedback included:
- 'It’s good to be in a group knowing that everyone’s on the same journey – kia ora.'
- '(I) memorised parts of the class to be able to do some at home.'
- 'Music this week a bit too fast to catch up – good mixture would be good and a bit slow, to cater for older people.'
- 'Takes my breath away, ka pai.'
- 'Great camaraderie.'
- 'Getting harder but loving it.'
- 'Not so puffed today.'
And the longest comment: 'The combined approach from the multidisciplinary team/nurses/community/management has been an amazing help in managing my chronic disease. I think this has to be the approach despite the resource heaviness or demand. I don’t think it (would) be successful with a solo clinician.'
As Colleen Dunne says: 'Numbers matter when they translate into a better quality of life'. She is passionate about the approach used in Toiora.
'This has been a perfect marriage between evidence-based practice and community facilitation of self-management through a support group.
Group members measure their blood sugar before and after class.
'The main ingredients are education, recognition and reassurance on concerns and goals, demonstration and empowerment in (group members’) ability to adapt management to their individual needs.
'Chronic illness exercise classes are not a new thing but it’s the practicalities of the individuals and what they want to do that really helps them to keep going. Those practicalities are just as relevant as the statistics and theories.'
'There’s no doubt an exercise prescription for a patient population is different. You have to consider what other things people might have going on, including in terms of comorbidities.
'We already know that the trends in exercise, and diet, in chronic health demographics have been poor. Collaboration between patient, health, government and community is a must and I think it should be easy to achieve.
'We have the community leisure facilities, we have instructors, we have health care practitioners who can and do share their knowledge, we have community nurses who can monitor progress and who have patients who can take part. I believe we just need more cohesion between these public systems and people with the passion to drive it.'
Colleen says the Toiora participants started to connect the classes to results when they began to see objective changes to their blood sugar levels pre and post class, and noticing they were able to participate for longer throughout the class.
'It’s been great that lots of the group have been doing the exercises at home too and carrying this into their day-to-day lives with whānau, fono and family. It was a toss-up between varying the exercises each week to keep it interesting, versus sticking to a template. I opted to keep it quite similar so people could hopefully pick up the habit.
'Group members were integral to decisions such as the timing of a long break over the Christmas/New Year, the types of exercises completed, designing the t-shirts and choosing the music.
'They really were the masters of their own destiny when it came to our weekly sessions. The regular recording and acknowledgement of feedback and responses to this on a weekly basis gave participants added confidence and trust (in the process) and ensured the class was something they enjoyed.
'In terms of my own practice I’m now convinced that providing written feedback will be something I continue with all my patients to provide back to me. It did seem like a hassle at first when there are other clinical duties, but the all-round benefits and input into shaping future ideas are absolutely worth it.'
Colleen moved from Ireland to New Zealand five years ago, and having a father with diabetes has given her additional insights.
'My dad knows all about Toiora and he messages me from Ireland to ask how it’s going.
'My wish would be for all diabetics to be given a wristband activity tracker in addition to the blood sugar monitors they currently receive. Exercise tracking would provide objective and relevant prognostic information and makes it easier for patients to monitor and comply with an exercise programme. We need to throw everything at this.'
At the end of the Toiora session attended by Commission staff on 22 February, the group met with Hutt Valley District Health Board dietician Rhiannon Jones for guidance and discussion on healthy eating.
This prompted a conversation about breakfast choices, accommodating preferences (a marmite versus vegemite debate ensued!), the importance of regular eating through the day and not skipping meals, and drinks and snacks. One of the shared messages was to avoid the mindset of being "on a diet", which can create feelings of restriction and deprivation.
What next for this Whakakotahi initiative?
With the completion of the cycle of 12 sessions, the next steps for Toiora include a collective debrief and the opportunity for group members to continue co-designing and planning a future path. There will also be an evaluation undertaken by an external team.
Ideas under consideration include continuing with the group for a longer period and starting a new class with new participants at HUCHS’ other clinic in Petone.
HUCHS manager Sally Nicholls highlighted another possible direction.
'An inspiring idea raised within the group has been the idea of mentoring, and that’s new. They were saying ‘we could bring along new people and be their support people’. Imagine if that happened and everyone involved brought along two new people.'
Mere Te Paki, HUCHS community health worker, is clear on the kaupapa of any further Toiora work.
'It needs to be owned by the community. It’s about strengthening relationships.'
These ideas showcase the beauty of co-designed quality improvement initiatives that are community-based, consumer-centred and that exercise the power of word-of-mouth promotion. Consumer engagement that works.
A story in pictures
Loviana Masila pictured preparing for the last of the 12 sessions of Toiora. 'I’ve been to other exercise classes but this one is important to my heart and to my life. We work together and we know each other and help to exercise together. I’m happy – I can’t explain, from my heart, how I feel for this class.'
Mere Te Paki, a HUCHS community health worker for 24 years. 'The quality improvement science to this has worked very well with our set-up. It’s just terminology to me but it mirrors our kaupapa and it’s a reminder that we forget that not everyone works the way we do. From the very beginning you have community members involved and you’re doing things with a good process to bring it all together. Things then become embedded.'
Peata Schaafhausen: 'I was rung by my nurse. First thing, she said ‘Oh don’t be shy! I’ll be there, and other people you know. Just come along. So I said ‘OK, I’ll give it a go’. It’s been fun and something to look forward to.'
Tai Pairama: 'A few years ago I weighed in at 175kg. We’re not spring chickens but we do alright. It doesn’t really matter what the music is, the only thing we listen for is the ‘Beep’ and the words ‘You can rest now’!'
Polly Edwards: 'For me, I didn’t have the confidence. I wouldn’t be here if it weren’t for my daughter Hine because she’s involved in Te Kete Hauora. I was scared that someone would say ‘Ooh, she can’t keep up’, or ‘she can’t keep in time’. I think that’s what I feared. Leanne would say ‘C’mon Polly, get up’ and I’d go ‘Uhhh, I don’t know if I can do this..’., but as the weeks progressed it got easier.'
Kamal Chandra: 'I’m a work in progress. Taking advantage of this class got me moving and has kept me encouraged and supported. Now I’m starting to get in touch with a lot of my friends who have diabetes to introduce Toiora – they’re quite keen to get involved. We’re the first class but no matter what after we finish we know we can always come along and join in (at HUCHS).'
Leanne Long, HUCHS nurse and participant: 'We wanted to start with a small group and that’s what we did. Thinking back to the first week, everyone was scared to do anything in front of the group in case it looked bad – now we’ve got our t-shirts and we’re visible to the community. Having diabetes myself, it’s a different relationship with my patients and the whole group has become tremendously close. Part of this is about knowing you’re not alone. I’m so proud of everyone.'