This study aimed to explore the experiences of and perspectives from recipients and providers of support on REACHOUT, a peer-led mental health support intervention for adults with T1D living in rural and remote regions of British Columbia, Canada.

Following the completion of the pilot trial titled REACHOUT, which investigated the feasibility and acceptability of peer-led mental health support intervention delivered by a mobile app, we conducted focus groups with participants of the study. The reporting of methods and findings adheres to the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist (Checklist 1) [34].

Described in detail elsewhere, the REACHOUT pilot investigated the impact of a mobile app that delivered mental health support to adults with T1D living in Interior British Columbia over a period of 6 months. REACHOUT offered multiple support delivery modalities (one-on-one, group-based texting, and virtual face-to-face small group sessions that could be customized by recipients) [35]. Participants include individuals who receive support (recipients) and those who provide support (peer supporters). In this paper, the term “participants” will only be used when addressing both recipients and peer supporters. The eligibility criteria for recipients were as follows: (1) be diagnosed with T1D, (2) be at least 18 years or older, (3) speak English, (4) have access to the internet and/or a smartphone, (5) live in the interior region of British Columbia, and (6) have a mean subscale score of ≥2 on the type 1 Diabetes Distress Scale [36]. Peer supporters had similar requirements with the exceptions of criteria 5 and 6. They also had to be willing to complete a 6-hour training program. Training components and competency evaluation are published elsewhere [37]. It should be noted that if asked a medical question by recipients, peer supporters were instructed to refrain from answering and defer to the diabetes nurse educator.

The REACHOUT app offered multiple support delivery modalities including one-on-one support provided by a recipient-selected peer supporter, group texting support via the 24/7 chat room, and small group face-to-face support via video huddles and happy hours. Recipients were encouraged to use any or all modalities as frequently as desired. Peer supporters were invited to attend virtual wellness sessions to debrief their experiences as well as receive their own emotional support. Finally, the ongoing monitoring of group-based communication exchanges was performed by the research team, and fidelity assessments were conducted at 1, 3, and 5 months of the intervention with all participants.

This qualitative descriptive study was approved by the University of British Columbia Behavioural Research Ethics Board (H20-00276). Prior to focus groups, participants provided e-informed consent using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at the University of British Columbia [38,39]. To maintain privacy and confidentiality, recordings were anonymized to omit personal identifying information and stored securely. Only the study team could access study data. Upon completion, participants received a CAD $25 (approximately US $18) e-gift card.

Following the completion of the pilot trial REACHOUT, all those in recipient roles were contacted by a research assistant and invited to the postintervention focus groups to share their experience with the REACHOUT program and app and suggestions for improvement. Only peer supporters who had been paired with recipients were invited to join the postintervention focus groups. Those who provided consent were interviewed.

Focus groups were conducted online using Zoom; video and audio were recorded and later transcribed. Led by a female researcher (TST), focus groups were stratified into recipient versus peer supporter-only membership with approximately 6 individuals per group. The interview guide (Multimedia Appendix 1) used open-ended questions and prompts to elicit discussion around their experience in the program, peer support interactions, and app usage. Follow-up questions were posed if clarification or explanation was needed.

Recordings were transcribed verbatim and anonymized with participant roles (recipient or peer supporter) identified to capture perspectives from both groups. Transcripts were analyzed using NVivo V.14 software package [40]. Guided by an interpretivist research paradigm, which centers around subjective experiences [41], we selected an inductive thematic approach to support the possible variation of participant perceptions. Following Braun and Clarke’s 6 phases of thematic analysis, 1 coder (DL) participated in transcribing the data and another coder (PJ) who had no involvement in the interview guide development, interviews, and transcription familiarized themselves with the transcripts [42]. Both coders discussed initial ideas before independently performing open coding. The coders discussed the findings after every round of coding to enhance reflexivity and iteratively refine a unified codebook. Independently coded transcripts were combined, and codes were sorted and combined to form themes and subthemes. Themes and subthemes were reviewed and refined with clear definitions and names. Findings and any discrepancies were discussed with the principal investigator (TST) and another coauthor member (DS) who was not involved in the interview guide creation and interviews. Moreover, this was a recursive process where analysis phases moved back and forth as needed [42].

Our multidisciplinary team comprises cisgender, heterosexual women from East Asian, South Asian, and European settler backgrounds. TST has over 25 years of experience working in peer support, and her research focuses on developing models to improve mental health outcomes in high-risk and medically underserved communities. DS has over 25 years of research working in diabetes self-management at the community and provider level. FSC has over 20 years of experience working on topics related to stress, social support, and social connection and contributes a behavioral science perspective. DL and PJ are early-career researchers with master’s and medical graduate training. All authors are living in urban centers and are cognizant of their own privileges and practice reflexivity to ensure that priorities of the diabetes community are represented throughout the research process.

In total, 32 study participants (17 recipients and 15 peer supporters) who completed the REACHOUT intervention were recruited and interviewed from August to October 2022. The characteristics between focus group participants compared to nonrespondents in the pilot study population are noted in Multimedia Appendix 2. There were 9 focus groups lasting 60‐90 minutes, 4 recipient-only groups, and 5 peer supporter-only groups. As summarized in Table 1, participants were predominantly women and Caucasian, with a mean age of 48 (SD 16.3; range 23‐76) years and an average of 24 (SD 18.1; range 0‐65) years living with diabetes. Most participants received postsecondary education and had a household income greater than CAD $70,000 (approximately US $50,505).

Four overarching themes were identified and related to participants’ experiences in the peer support intervention and on their user experience with the mobile app delivery (Table 2).

Factors related to one’s experience with REACHOUT were largely dependent on the quality of the recipient-peer supporter relationship. Many found their peer supporter extremely helpful and valued their time, but the strength of their relationship was influenced by various contributing factors.

The cornerstone of a peer-led intervention is the peer supporters who deliver mental health support. Although the goal of REACHOUT was to provide support to recipients, the sustained quality of the 6-month intervention provided opportunities for peer supporters to be nurtured as well.

Participants (recipients and peer supporters) had four ways to engage with others on the REACHOUT mobile app: (1) direct messaging, (2) 24/7 chat room, (3) virtual happy hours, and (4) virtual huddles.

This study explored recipients’ and peer supporters’ experiences with and perspectives on REACHOUT, a peer-led mental health support intervention for adults with T1D living in rural and remote regions of British Columbia. Our results identified four major themes: (1) Need for a sense of community and belonging, (2) Factors to enhance the recipient-peer supporter experience, (3) Key aspects of the peer supporter experience, and (4) Importance of personalizing the user experience while using the REACHOUT mobile app.

Consistent with our findings, the need for community and belonging, especially for geographically marginalized individuals, has also been reported in the literature. For instance, a systematic review of 12 qualitative studies on health care access for rural patients with chronic diseases found that a sense of group connection in rural areas mitigates feelings of vulnerability [43]. Similarly, Joensen et al [44] noted that while a feeling of inclusion contributes to health promotion, it is often lacking in daily life for individuals with T1D. Thus, a mobile app such as REACHOUT is especially valuable in addressing these gaps in remote and underserved communities.

With REACHOUT, recipients had the agency to choose a peer supporter based on personally relevant factors. This choice-based model deserves consideration, as it may optimize the recipient-peer supporter match [12,35]. Our data also suggest that successful pairs often referred to one another as “friends,” which supports the idea that effective emotional support is built upon friendship and trust [17,22]. To enhance participant satisfaction, future peer support studies should adopt this recipient-driven matching process as recipients are in the best position to understand their own unique support needs.

While the one-on-one and group support delivery mechanisms address different support needs, many recipients expressed greater value for the former. The advantages of personalized individual relationships address the limitations inherent in group settings. For example, in an intervention of peer support meetings for adults with T1D focusing on insulin pumps, dissatisfied participants reported a lack of relevance in the discussion topics, hindering their ability to speak about topics that mattered to them [45]. Incorporating modalities that allow recipients to seek both group-based and one-on-one peer support within the same intervention promotes greater support customization for each user. Subsequent mental health support models should prioritize flexible delivery options that balance individualized support with opportunities for group engagement.

As participation in group activities within the mobile app was optional, we observed varying levels of engagement. Passive participation, characterized by viewing (vs posting) 24/7 chat room exchanges, was the most common. Participants engaged in “lurking” behavior, which involved routinely checking the chat room, gleaning value in reading anecdotes and being exposed to new topics related to T1D. “Lurking” was also observed in an online community–based peer support forum for in-hospital patients. This study found that 7 of 30 participants opted not to post yet still experienced a positive impact on emotional well-being [46]. Additionally, Tang et al [47] found that adults with T1D who passively engaged with the digital support platform (ie, ‘lurkers’) reported greater reductions in stigma-related distress compared to active posters. These findings highlight the role of passive engagement in mental health interventions as a strategy for mitigating “social risks” [47,48]. An in-depth examination of the mental health benefits associated with passive participation on digital platforms is warranted.

While not anticipated by peer supporters, the flow of support with recipients was bidirectional. However, the content of the “give and take” exchange likely encompassed a range of topics not necessarily diabetes-specific. Nonetheless, this opportunity for mutual sharing was also cited in a systematic review of qualitative peer support studies for chronic diseases [49]. Recognizing this reciprocity as an unintentional intervention, peer support studies should routinely assess changes in outcomes for both recipients and peer supporters. Clearly, peer support fosters emotional well-being for both parties.

Ensuring ongoing support for peer supporters beyond the initial training phase is essential for peer supporter effectiveness and well-being. Our intervention addressed this need by offering peer wellness sessions, a space for peer supporters to share successes and challenges. Not surprisingly, emotional investment leading to exhaustion can harm the mental health of peer supporters [50]. Thus, having an environment to express frustrations in real time such as how to deal with nonresponsive recipients or navigate emotionally charged conversations could potentially prevent burnout or dissatisfaction. Therefore, implementing regular communication or check-ins could enhance peer supporters’ experience and overall intervention effectiveness.

First, this study only recruited matched peer supporters (vs unmatched peer supporters). Perspectives from unmatched peer supporters were not captured. Future studies should consider interviewing those peer supporters who did not participate in the one-on-one support component but had access to other support delivery features. Second, this sample was self-selected and possibly more engaged and enthusiastic than other participants. This may limit the representativeness of the original REACHOUT cohort. While we compared the characteristics of the consenting and nonconsenting sample, future studies should ensure representation across different levels of engagement. Third, the socioeconomic background for participants was relatively high. Because we did not overrecruit for individuals with lower levels of income or education, the diversity of experiences captured may be skewed. Finally, the study targeted the rural and remote communities of Interior British Columbia; therefore, the results may not be generalizable to other geographically marginalized populations in BC or Canada.

Peer support is increasingly recognized as a critical component for mental health interventions in T1D. While research has focused largely on recipients of support, our study also considered perspectives of individuals delivering support, providing a holistic view. More importantly, it is the recipient-peer supporter dynamic that most likely drives the success of the implementation of the REACHOUT program and impacts mental health outcomes. Only by understanding the experiences of both parties can we refine our interventions to provide the optimal mental health support model.