Study participants
As illustrated in Table 1, the 9 peers included 7 males and 2 females. They were primarily male, middle-aged, of Danish origin, outside of the labour market, and with short and intermediate education backgrounds as well as multiple diagnoses and diabetes complications.
Table 1
Peers’ sociodemographic characteristics
|
Peers
|
N
|
9
|
Sex
Male
Female
|
7
2
|
Age
Below 50
50–65
Above 65
|
1
6
2
|
Country of Birth:
Denmark
Other Western countries
Non-Western countries
|
7
1
1
|
Source of income
Social security
State pension
Disability pension
|
4
2
3
|
Education
Primary
Secondary
Higher
|
4
4
1
|
Living situation
Alone
With children
With others
|
7
1
1
|
Other diagnoses (N)
Mental health disorders
Arthritis
Oral health problems
KOL
Other chronic diagnoses
|
6
4
3
2
3
|
Diabetes complications (N)
Cardiovascular diseases
Hypertension
Neuropati
Nefropati
|
7
5
4
4
|
(Baseline survey data) |
The ten peer supporters included 6 males and 4 females. They had different educational backgrounds, employment status and experience of working as a support volunteer. The diabetes nurse had 20 years of experience as a nurse and had previously worked as a home nurse. The project manager had 10 years of experience working with socially vulnerable groups and in peer support programmes.
Differences in peers’ outcomes
Survey and interview data revealed large differences in peers’ outcomes from the intervention. The intended outcomes (improved DSM and use of healthcare services) were only identified among four peers (See Figs. 2 and 3). A common pattern for those who achieved outcomes, compared to those who did not achieve any, was the implementation of a minimum of two of the three intervention activities in the peer support, meetings. In the four cases, the peer supporters had been providing social and emotional support assisted with daily tasks (grocery shopping, cleaning, cooking healthy meals and exercising) and/or acted as a link to healthcare services (that is, being an observer at GP appointments and assisting in communication with other relevant healthcare services). In contrast, in the five cases in which none of intended outcomes where achieved, the peer support meetings had mainly consisted of social and emotional support.
Contextual factors influencing variation in mechanisms and outcomes
Four main contextual factors in peers’ everyday lives were found to explain why some peers achieved the intended outcomes and others did not: ‘occupation and financial situation’, ‘health condition’, ‘energy’ and ‘other life events’) (See Figs. 2 and 3). The peers who achieved the intended outcomes were characterised by a stable occupation and financial situation, receiving a state or disability pension, combined with being in a better state of health. Moreover, some peers’ participation in other social activities during the intervention might have facilitated the outcomes. Conversely, for the peers, who did not achieve any of the intended outcomes, these contextual factors functioned as barriers to how the peers interacted in the intervention. This group was characterised by an unstable occupation and financial situation, receiving social security benefits, combined with being in a worse state of health with severe pain due to multiple diabetes complications and both psychical and chronic mental diagnoses. In addition, some experienced negative life events during the intervention, such as accidental falls and the death or illness of close relatives, which interrupted their participation. Due to these barriers, which were on the individual contextual level, many peers described how they lacked energy to interact in the intervention.
Mechanisms generating outputs and outcomes
Interview data revealed two groups of mechanisms within the peers that generated the intended outcomes: ‘perceived needs and readiness’ and ‘encouragement and energy’ (See Figs. 2 and 3). However, data showed a large variation in how these mechanisms operated depending on whether the contextual factors functioned as facilitators or barriers to the peers’ interactions in the intervention. Independent of the influence from the contextual factors, a third mechanism, ‘experience of social and emotional support’, was identified within all peers that increased self-care awareness (output).
Perceived needs and readiness
Peers’ perceived needs and readiness to interact in the intervention were found as interrelated mechanisms that generated both the intended cognitive (outputs) and behavioural changes (outcomes) in DSM and the use of healthcare services. However, as mentioned, these mechanisms operated differently between the peers depending on their context. For the peers where contextual factors in their everyday lives functioned as facilitators, a common pattern was that they had a perceived need for support in accessing and navigating the healthcare system and/or to improve central tasks in their DSM, for example, to get started with daily walks or cooking daily meals. In addition, they demonstrated a sufficient amount of readiness to interact in the intervention to meet these needs. This is illustrated in the following quote from one peer:
"I needed a little help to get started cooking for myself because it had come to a complete standstill (…) To get started with grocery shopping so I could start making some proper food." (Peer, outcomes achieved)
In contrast, the peers’ perceived needs and readiness came into play more differently among those who were challenged by an unstable occupation and financial situation, a poor health condition, lack of energy and other negative life events. In general, they were less reflective about what they wanted to achieve with their participation. In the interviews, the majority expressed not having specific needs other than a need for social contact in their lives. Some mentioned not wanting to make health behaviour changes to improve their DSM or receive support in navigating the healthcare services. This is illustrated in the following case, where a peer explained how he did not want to stop drinking alcohol as he felt it did not matter anyway:
“I don’t want to do that [stop drinking alcohol red.] (…) because I feel better when I drink. I am happy (…) Diabetes you have for life, no matter what you do, you know? So, so what? I am dying anyway.” (Peer, no outcomes achieved)
According to the informants in this case, the peer’s poor life circumstances were causes of this lack of need and readiness to stop drinking alcohol. When entering the intervention, he had severe mental and physical challenges due to several chronic diagnoses and diabetes complications. Moreover, he had recently lost his job and had to focus his sparse energy on attending meetings at the jobcentre. In the interview, he mentioned that he was worried about being evicted from his home if he could not pay the next month’s rent. He had previously lived on the streets but was no longer capable of this due to his poor health condition. Thus, he was satisfied as long as he had a roof over his head.
“Nothing is clear, you know? (…) They can send me a letter tomorrow stating that I will no longer receive cash benefits.” (Peer, no outcomes achieved)
Because of the peers’ lack of need and readiness to achieve the intended outcomes, the peer support meetings mainly consisted of social and emotional support. This was a source of great frustration for many of the peer supporters, who felt unsuccessful in their roles while not being able to implement all three activities in the peer support meetings. One peer supporter put it this way:
"I was prepared for meeting someone who had a goal, who had signed up because he/she wanted to make improvements, and X (the peer, red.), has never wanted that." (Peer supporter)
Encouragement and energy
Another group of interrelated mechanisms that generated both the intended cognitive and behavioural changes in DSM and use of healthcare services was the encouragement received from the peer supporter and the peer’s level of energy to interact in the intervention. Encouragement from peer supporters to regularly attend diabetes-related appointments with the GP or get started with healthier eating or exercise patterns positively affected the peers’ levels of energy to interact in the intervention and set meaningful, achievable goals. However, this was only seen in cases where peers’ individual contextual factors facilitated this engagement. In the following interview excerpt, the diabetes nurse described a case where encouragement from the peer supporter to improve eating habits and attend diabetes-related appointments with the GP was the push needed for the peer to make these behavioural changes:
"Now, all of a sudden, there are some people around him who support him in the importance of visiting the GP (…). He knows what he has to do, but his challenge is in getting it done. (…) ‘Together on Diabetes’ has helped him get things done and that is what makes the big difference regarding his health, and health condition as I see it. It's simply a matter of getting that little push.” (Diabetes nurse)
In contrast, encouragement from the peer supporters did not generate outcomes among peers for whom contextual factors functioned as barriers. In the interviews, many described how their unstable financial situation, poor state of health condition, lack of energy and other life events resulted in them not being able to respond to their peer supporters’ encouragement. As one peer described:
“I appreciate when somebody tries to help me, you know? Try to lift me (…) what you tell me now, I won’t do tomorrow but it is on my mind, and I try (…)” (Peer, no outcomes achieved)
As this quote illustrates, the peer supporter’s encouragement activates a reflection within the peer. However, the peer’s challenging life circumstances and lack of energy constitute a barrier to respond and make the behavioural changes needed.
Experience of social and emotional support
The experience of receiving social and emotional support was found as a mechanism that generated increased self-care awareness (output). Unlike the other mechanisms, it was found within all peers regardless of their occupation and financial situation, health condition, amount of energy, and other life events. In the interviews, the peers emphasised how they valued the regular meetings with their peer supporter. In the majority of cases, these meetings were the only social contact they had. Many mentioned the importance of the peer supporter as a voluntary like-minded person that they could talk to about issues related to everyday life with T2D. One peer elaborated:
“When I talk with a person, who is like me, who has diabetes, it is easier to explain because he understands (…) because he has the same problems as me.” (Peer, no outcomes achieved)
Several described being in the same situation as their peer supporter – in contrast to the feeling they experience with some healthcare professionals, where they sometimes feel judged:
"When she has diabetes, and I have diabetes, we are kind of conspirators (…) Then the relationship becomes a little closer compared to if it was, for example, a doctor who probably always is set on keeping a distance (…) And I like that. That you are not judged all the time.” (Peer, outcomes achieved)
ICAMO-models
Based on our empirical findings, we revised our initial ICAMO model. We developed two ICAMO models (Figs. 2 and 3), to illustrate how the identified contextual factors in peers’ everyday lives either facilitated or hindered their interactions in the intervention, thus affecting how the mechanisms within the peers were at stake. Figure 2 illustrates the ICAMO for the peers who achieved the intended outcomes and Fig. 3 illustrates the ICAMO for the peers who did not achieve these outcomes.