Overall, 16 peer supporters agreed to participate and completed governance procedures. Of these, 8 withdrew before, and 2 during the training. Reasons cited included concerns about references to managing mental health problems, concerns about the time that might be required and having other health problems. The remaining 6 all delivered peer support interventions and completed the study.
The process evaluation identified three key areas in which the intervention could be improved: the selection and ‘clearing’ of the peer supporters; the timing and framing of the education sessions; and the role and perception of the peer supporters delivering the intervention.
Selecting and ‘clearing’ peer supporters
The processes through which peer supporters were selected, trained and deemed appropriate for the intervention had two unforeseen consequences. Firstly, the involvement of General Practice staff in selecting the peer supporters was significant. One peer supporter, for example, was advised by the health professional that he join the study because he was her ‘star patient’. Another peer supporter was convinced to participate because he was told by the recruiting professional that she thought he ‘would be good at it’ because of his ‘life experience’. The encouragement and validation peer supporters received from recruiting health care professionals helped capture and sustain their interest in and commitment to the study. Such messages, however, also contributed to the formation of a sense of expertise amongst some of the peer supporters. For example, during one session observed by CB, a peer supporter suggested that ‘my doctor thinks I’m quite good at looking after myself, so I’m going to try and help you too’.
A second peer supporter recruitment issue was identified during the process evaluation. As described above, peer supporters were asked to complete a CRB check, occupational health check and to sign an honorary contract. Whilst much of this process was required of us by the host institution for indemnity purposes, it was found to contribute to the sense of importance and expertise mentioned above. For example, during the final peer supporter training session, at which the peer supporters completed this process by signing the honorary contract, a conversation was captured by CB in which a peer supporter declared ‘I never thought I’d be workin’ for the hospital - ‘I’ve gone up in the world!’ Such sentiments also appeared within some of the peer support sessions. In one instance, a peer supporter introduced themselves as ‘an experienced diabetes patient, who has been asked to work with the hospital to help people like you’. In moments such as these, the formal ties the intervention provided to the institution were invoked by peer supporters as a means to stabilise their social role and construct a ‘working consensus’ with participants . However, not all peer supporters displayed this tendency to cast themselves as experts or institutionally-mandated actors. Indeed, one peer supporter developed a technique for introducing the intervention and the role he was being asked to play: at the start of each session, he would say ‘I am just an ordinary person with diabetes, like you, who is here to help us all share experiences and information’. In contrast to the examples above, this peer emphasised commonality and equality in peer support sessions, and left the institutional setting ‘backstage’ .
The importance of appropriate training and education
The second set of issues identified through the process evaluation relate to the training and education provided to peer supporters and participants. The decision to train peer supporters to deliver the intervention before they received the education session with other participants proved to be unpopular. The peer supporters made it clear during training sessions, meetings with the research nurse and interviews, that they felt that the basic diabetes education should precede peer support training. One peer commented during the first day of the training session that ‘we need to know more about diabetes if we’re to support people’, ‘specially if it’s [the treatment] different to ours’. The importance of diabetes knowledge and education to those involved in the study emerged subsequently in the results to the barriers survey.
In addition to this, the peer supporters also suggested that the training relied too much on role play. For example, one peer supporter noted that during the role plays another of the peers always looked uncomfortable and awkward and felt that he did not know how to ‘play act’. Another supporter suggested that the role play seemed to make the training ‘a bit too emotional’. During a focus group with the peer supporters, facilitated by the investigators, this issue was pursued further. A further peer supporter suggested that the role play was good, as it had helped them to think about how to introduce themselves to their peers. However, the group felt that some of the role play should be substituted for ‘examples’ or ‘hypothetical problems’ that could be read out and discussed during training sessions.
The final point identified here, relates to the framing of the education sessions. The content was well received by most patients, although some felt it contained too much information to absorb in a half day session. However, observation and interview data suggest that not all participants understood how the education related to the peer support: some thought that it was the start of the peer support; others that it was a service provided by their GP practice.
The role and perception of peer supporters
The final cluster of issues pinpointed in the process evaluation related to the role and perception of the peer supporters. The expert status claimed by some of the peer supporters, combined with the difficulty some had distinguishing the education and support components, also suggested a degree of confusion surrounding the function peer supporters were fulfilling. This was further confirmed by observations from two separate peer support sessions. In one group session, the peer supporter ran the meeting as if it were a committee in session: the group sat around a conference table, an agenda was circulated along with a bundle of information taken from the internet, relating to the low GI diet, blood glucose testing and different kinds of insulin and minutes were taken by another group member. Similarly, another peer was discovered to have requested that a 1:1 participant demand a blood glucose monitor from their diabetes specialist nurse. Such interactions created temporary moments of disagreement between peer supporters and participants predicated on contrasting perceptions of the purpose of peer support. Whereas these two peer supporters understood their role to be one of information provision, quasi-expertise and practical involvement, the participants they worked with often saw such practices as ‘missing the point’, as one put it.
However, such interactions were exceptional, and not observed or reported across the intervention. By contrast, most of the peer supporters provided support sessions that followed the intervention guidelines. One supporter, for example, centred his group sessions on the sharing of stories. In one, he listened as a participant told the group that he travels regularly with a snooker club to play in international tournaments, which he felt kept him fit. Later in the meeting, another participant told the group that she found it difficult to know what to do when eating out. The peer supporter returned to the travelling snooker player and asked him how he managed his diet when he takes trips. Through such interactions, the peer supporter defined his role as one of facilitation and not leadership; acting to keep discussion moving and participants involved and not to impart instructions or knowledge. This was, as indicated above, the intent of the intervention design.
That two of the peer supporters interpreted the role in a more directive manner suggests that the intervention procedures did not always convey and instil the relational, supportive practices in the manner intended. These examples also reveal a key difference between the dynamics of group and 1:1 sessions. In the group setting, peer supporters were able to draw on the experiences and narratives shared by others, as the case of the snooker player details above. By contrast, the 1:1 interactions often mimicked the patient-health care professional interaction or, in some cases, a counselling style.