Mediating engagement in a social network intervention for people living with a long‐term condition: A qualitative study of the role of facilitation

Abstract Background Successful facilitation of patient‐centred interventions for self‐management support has traditionally focussed on individual behaviour change. A social network approach to self‐management support implicates the need for facilitation that includes an orientation to connecting to and mobilizing support and resources from other people and the local environment. Objective To identify the facilitation processes through which engagement with a social network approach to self‐management is achieved. Method Thematic analysis was used to analyse data from a longitudinal study design using quasi‐ethnographic methods comprising non‐participant observation, video and qualitative interviews involving 30 participants living with a long‐term condition recruited from a marginalized community. Results Findings centred on three themes about the social network approach facilitation processes: reversing the focus on the self by bringing others into view; visualization and reflection as a mediator of positive disruption and linking to new connections; personalized matching of valued activities as a means of realizing preference elicitation. Discussion and conclusions Engagement processes with a social network approach illuminated the relevance of cognizance of an individual's immediate social context and forefronting social participation with others as the bases of self‐management support of a long‐term condition. This differs from traditional guided facilitation of health behaviour interventions that frame health as a matter of personal choice and individual responsibility.


| BACKG ROU N D
The onset and trajectory of a long-term condition (LTC) often results in a retreat from activities and interactions taking place in the public sphere. 1 People with LTCs identify loss of social contact, the ability to reciprocate and contribute to society and receipt of resources from the community and locality. 2 The latter has contributed to the burden of illness and preventing living life as fully as possible. 3,4 A social network approach (SNA) to self-management provides a means of mobilizing, mediating and accessing support. 5 It enables people to access and incorporate the resources and connections that provide support for living everyday life and requires attention to be placed on the local environments as a means of engaging individuals in self-management support (SMS) activities. 5 Whilst guided facilitation is recognized as a necessary component of implementing patient-centred interventions and means of engaging with patients in introducing strategies and practices of SMS, [6][7][8] little attention has been given to how to effectively bring into view and facilitate elements of social context relevant to a social networked and broader orientation to SMS.
In theory, the delivery of self-management interventions and shared decision making acknowledges the role of social context. [9][10][11] In practice, the social and emotional aspects tend to be side-lined, whilst SMS trainers' primary orientation is towards prioritizing pre-determined health behaviour change and individuals' capacity and responsibility to initiate and sustain strategies for self-management. [12][13][14][15] Research suggests a risk of creating a sense of disempowerment from a traditional, guided facilitation approach (eg behavioural activation) stemming from the need for individuals to acknowledge that they are unable to cope alone without professionals' support. This in turn risks compounding feelings of worthlessness, low mood and loss of a valued identity. 16 By contrast, the design of facilitation in a SNA needs to reflect as a central tenet the social context and possibilities for social participation relevant to people's lives, particularly of those living in disadvantaged circumstances. 17,18 Thus, the elements and process of the successful facilitation of socially orientated and networked interventions are likely to differ in terms of processes as well as content. Building rapport and good communication skills are important pre-requisites for facilitating any SMS intervention. However, a SNA differs in its facilitation processes in orientation towards the idea of connections and linkages based on what is familiar to people in their everyday, domestic lives. There is a need to explore and better understand the nuances of these processes and the potential for achieving engagement by focusing on what is external to the person rather than the focus being internal as part of a personalized, therapeutic process.

| A social network intervention (SNI) and facilitation of SMS
Facilitation of a SNI centres on connecting people to and engaging them in relationships, valued activities and resources through participating in local activities. 19 This is informed by a capabilities approach, which suggests that opportunities individuals have to undertake valued activities are shaped by interactions between individuals, their environment and in particular their social relationships and expressions of values and preferences. 20,21

| The social network intervention
An online tool (GENIE-Generating Engagement in Network Involvement) maps social networks, helping people to select their preferences and engage with local support resources. The components of GENIE are described in Table 1.
The role of facilitation. This requires the facilitator to place the emphasis on the participant at the centre of the circle and encourage them to think about why and how some people and resources might be more or less important to them. 25 2. Preference elicitation and linking to resources: Reflecting on availability and connection to localized support and resources based on personal preferences and acceptability that provide opportunities and encouragement to engage with sustainable health choices.
Previous research suggested that GENIE worked best as a facilitated process (Kennedy, 2016), rather than being completed by an individual alone, but questions remain about the content and mechanisms of facilitation when using a SNA in a community setting. We were interested in exploring the facilitator role when taken up by lay health workers living and working in the same community setting as participants, as they were likely to be familiar with the culture and values of that locality.

| RE S E ARCH AIMS
To explore the role of facilitation of a SNI delivered by lay health workers in a community setting.
To identify the facilitation processes through which engagement with a SNA to SMS is achieved.

| ME THODS
A longitudinal study design using quasi-ethnographic methods comprising non-participant observation, video and qualitative interviews.
Participants (n = 30) living with a LTC were recruited from a marginalized community. Data collected (T1) comprised visually recordings of intervention delivery, observational notes and audio recordings of post-intervention interviews. The use of videos allowed members of the research team to observe each intervention taking place, rather than a single researcher, and enabled a more accurate, nuanced and collective analysis of the facilitation process.
Follow-up data were collected at 3 months (T2, face-to-face semi-structured interviews) and 6 months (T3, telephone interviews) to capture change over time. The circle diagram captured changes over time in the position of network members on the map (Vassilev, 2018).
The mapping exercise was also a heuristic device which could indicate relational shifts in people's lives over time and enabled the facilitator to elicit people's underlying rationales for these. Data collected at different time points reflected how things changed subtly, including small changes in relationships and changes in meanings of relationships.
Audio recordings were transcribed verbatim. Thematic analysis informed by framework analysis included a priori codes/categories relating to the role of facilitation and facilitation processes, alongside an inductive approach whereby coding and theme generation were directed by the content of the data. Initial coding and collating were undertaken by researcher (EJ) to identify broad patterns of meaning prior to the viability of potential themes being discussed and agreed within the team. In addition, parts of the data set were coded independently (AR/AK/IV/JE) to ensure inter-rater reliability and coding consistency. Themes were refined and defined, including a detailed analysis of each theme to draw out key findings.
Most salient to this study was engagement in the network mapping, as an initial exercise. However, we were also interested in how

| Sample and recruitment
The sample was drawn from a marginalized community, the Isle of Wight. Separated from the mainland, social, economic and political barriers contribute to the marginalization of the Island, as does an ageing, vulnerable population (27% aged 65+ years, 1 in 6 of whom live alone). The full sample took part in observations and interviews (3 participants withdrew). Table 2 shows participants' age, gender, LTC and where the intervention took place.
Participants were recruited via two routes. Firstly, lay health workers identified clients who matched the inclusion criteria, introduced them to the study and invited them to participate. Secondly, the researcher and PPI representative visited support groups (eg Diabetes Support Group, Heart Care Club) for recruitment purposes. The facilitator met with the participant on one occasion to deliver GENIE. The researcher was responsible for all the follow-up data collection. Services employing lay health workers were approached to discuss involvement in the research, including training, identifying participants and intervention delivery. Facilitators comprised Health Trainers (n = 4), Care Navigators (n = 3), Community Navigators (n = 1) and Local Area Co-ordinators (n = 1). A PPI representative and researchers (n = 3) were also trained.

| RE SULTS
Observational data provided a visual record of facilitation style, how participants related to facilitators and how comfortable they appeared physically. Notes taken on body language and gestures (eg leaning towards laptop screen, pointing to network map, positive response to visual cues) indicated that most participants felt

Stage Activity Purpose
Step at ease with the facilitator and engaged in the network mapping.
Observations revealed that a natural balance of eye contact between participant, laptop and paperwork on the part of the facilitator helped to maintain engagement and co-production (Box 1).
Facilitation is viewed as something that is initially co-produced but orientated towards individual ownership of the network map and links to favoured activities. Three themes illuminated the social network mapping and preference linking processes:

| Reversing the focus on the self and bringing others into view
An exclusive focus on individuals' capacity and responsibility to initiate and sustain strategies for self-management can leave those living        that mutual empathy can lead to rapport and co-appreciation of the preferences and choices being elicited and the links forged to others in a personal network. The latter is perhaps a salient quality to add to the facilitator-patient relationship and addition to the lexicon of person-centred interventions taking place in primary care and community settings.

| Limitations
Data for this study comprised observations of the intervention delivery and qualitative, post-intervention interviews with participants.
Data collected directly from facilitators were limited to group feedback from lay health workers who took on the GENIE facilitator role for research purposes. Future research would benefit from conducting qualitative interviews with facilitators.

| CON CLUS IONS
Our findings indicate that facilitating a SNI that includes a network mapping exercise as the key object of engagement requires an orientation towards the idea of connections and linkages and skills of enabling the exploration of relationships and interactions within people's everyday social world and requires an appreciation of the social environment and sense of place in order that the two people involved can work together authentically.

ACK N OWLED G EM ENTS
The authors wish to thank the participants who kindly gave their time and contributed to intervention delivery and interviews; recruiters and facilitators from the lay health workforce on the IoW; and Sandy Ciccognani, the PPI champion.

CO N FLI C T O F I NTE R E S T
The authors have no conflict of interest to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Access to anonymized data may be granted following review.