Understanding the mechanisms generating outcomes in a Danish peer support intervention for socially vulnerable people with type 2-diabetes:a realist evaluation

BACKGROUND: Despite an increasing use and positive effects of peer support interventions, little is known about how the outcomes are produced. Thus, it is essential not only to measure outcomes, but also to identify the mechanisms by which they are generated. Using a realist evaluation approach, we aimed to identify the mechanisms generating outcomes in a Danish peer support intervention for socially vulnerable people with type 2-diabetes (peers). By investigating the participating peers’ interactions, we furthermore examined how their individual contextual factors either facilitated or hindered the mechanisms in operation. METHODS: We used a multi-method case-study design (n = 9). Data included semi-structured interviews with four key groups of informants (peer, peer supporter, project manager, and a diabetes nurse) for each case (n = 25). Furthermore, we collected survey data from peers both before and after participation (n = 9). The interview data were analysed using a systematic text condensation, and the Intervention-context-actor-mechanism-outcome framework was used to structure the analysis. RESULTS: We identified 2 groups of mechanisms that improved diabetes self-management and the use of healthcare services (outcomes): ‘perceived needs and readiness’ and ‘encouragement and energy’. However, the mechanisms only generated the intended outcomes among peers with a stable occupation and financial situation, a relatively good health condition, and sufficient energy (all defined as contextual factors). Independent of these contextual factors, ‘experience of social and emotional support’ was identified as a mechanism within all peers that increased self-care awareness (defined as output). Dependent on whether the contextual factors facilitated or hindered the mechanisms to generate outcomes, we categorised the peers into those who achieved outcomes and those who did not. CONCLUSIONS: We identified two groups of mechanisms that improved the peers’ diabetes self-management and use of healthcare services. The mechanisms only generated the intended outcomes if peers’ individual contextual factors facilitated an active interaction with the elements of the intervention. However, independent of these contextual factors, a third group of mechanisms increased self-care awareness among all peers. We highlight the importance of contextual awareness of the target groups in the design and evaluation of peer support interventions for socially vulnerable people with type 2-diabetes. TRIAL REGISTRATION: ClinicalTrials.gov, Retrospective Registration (20 Jan 2021), registration number NCT04722289

‘Doing it in the right order’ : childless men’s intentions regarding family formation

In high-income countries, parental age at first birth has increased and this postponement increases the risk of involuntary childlessness or having fewer children than desired. This interview study was conducted in Denmark and Sweden among childless men (n = 29) in their last year of an education. The aim was to explore the role of individual and societal factors on fertility decision-making and men’s reflections on barriers and enablers for earlier family formation. Data were analysed with thematic content analysis. Almost all participants wanted children in the future. Overall, there was a desire to follow the ‘right chronology’: get educated, having a stable relationship, employment and a good financial status before having children. While most men felt mature enough to have children, they were still not ready. Influences from within the inner social circle, societal expectations, the need for security and stability and being ready to give up freedom and individuality were factors that affected participants’ preferred timing of parenthood. Most men did not have suggestions for how earlier family formation could be supported. Results suggest a gap between the ideal biological and ideal social age of family formation that may lead to unfulfilled parenthood aspirations

Taking fertility for granted–a qualitative exploration of fertility awareness among young, childless men in Denmark and Sweden

Most previous studies about fertility knowledge and attitudes among men have been based on quantitative methods using questionnaires with fixed-choice response options. The aims of this qualitative study were to explore childless young men’s reflections on fertility and infertility through semi-structured interviews. Danish (n = 17) and Swedish (n = 12) young childless men aged between 20 and 30 years in their last year of education were interviewed. Data were analysed using qualitative content analysis. Few informants had considered their own fertility, and most were positive towards fertility treatment. The young men had inadequate knowledge about factors that can potentially impair male and female fertility. On average, the young men each mentioned three different factors they believed influence male and female fertility: (i) health behaviour; (ii) factors beyond personal control; and (iii) age. None mentioned sexual transmitted infections (STIs) but most appeared aware of the effect of increasing age on fertility. The results of this study highlight the need for educational strategies to improve young men’s knowledge about fertility and the factors that influence it, particularly about the potential adverse effect of STIs on fertility

Undertaking graphic facilitation to enable participation in health promotion interventions in disadvantaged neighbourhoods in Denmark

This study reports on a health promotion intervention (HPI), where graphic facilitation (GF) was used as an innovative method to enable participation in a co-design process in a multi-ethnic and disadvantaged neighbourhood in Denmark. The aim was to enable middle-aged and older residents to participate in the research process of planning and evaluating the HPI, as well as in the activities it constituted. GF was used to document statements and inputs from residents through visual meeting minutes and resident experiences with coronavirus disease 2019 (COVID-19) lockdown were drawn by a graphic facilitator. We use the ladder of participation as a framework to unfold the participation enabled by GF. During the HPI, data were produced through ethnographic field studies in and outside the neighbourhood and in design workshops with residents. The study finds that GF helped in reaching a target group difficult to engage in research and that the engagement of a graphic facilitator shifted the power-balance between the researchers and the residents, redistributing expertise. Carrying out GF in a HPI is a collaborative endeavour and in addition to research competences, it requires the artistic and relational skills of a graphic facilitator. The co-created process of the visual minutes and COVID-19 experiences created a sense of ownership and encouraged the residents to reflect on their interaction with the researchers. The redistribution of expertise was conditioned by the power dynamics present and GF helped unfold these dynamics. This is especially important in an HPI engaging socio-economically vulnerable populations