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• Research article
• Open access
• Published: 11 November 2020

The effectiveness of one-to-one peer support in mental health services: a systematic review and meta-analysis

• Sarah White 1 ,
• Rhiannon Foster 1 ,
• Jacqueline Marks 1 ,
• Rosaleen Morshead 1 ,
• Lucy Goldsmith 1 ,
• Sally Barlow 2 ,
• Jacqueline Sin 1 &
• Steve Gillard   ORCID: orcid.org/0000-0002-9686-2232 1  

BMC Psychiatry volume  20 , Article number:  534 ( 2020 ) Cite this article

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Peer support is being introduced into mental health services internationally, often in response to workforce policy. Earlier systematic reviews incorporate different modalities of peer support (i.e. group and one-to-one), offer inconsistent evidence of effectiveness, and also indicate substantial heterogeneity and issues of quality in the evidence base at that time. An updated review, focussed on one-to-one peer support, is timely given current policy interest. This study aims to systematically review evidence for the effectiveness of one-to-one peer support interventions for adults using mental health services, and to explore heterogeneity in peer support interventions.

We searched MEDLINE, PsycINFO, Embase, CINAHL and Cochrane databases from inception until 13 June 2019. Included studies were assessed for risk of bias, and meta-analyses conducted where multiple trials provided usable data.

Twenty-three studies reporting nineteen trials were eligible, providing data from 3329 participants. While seven trials were of low to moderate risk of bias, incomplete reporting of data in many studies suggested bias in the evidence base. Peer support interventions included peer workers in paraclinical roles (e.g. case manager), providing structured behavioural interventions, or more flexible support for recovery.

Meta-analyses were conducted for eleven outcomes, with evidence that one-to-one peer support may have a modest positive impact on self-reported recovery and empowerment. There was no impact on clinical symptoms or service use. Analyses of heterogeneity suggest that peer support might improve social network support.

Conclusions

One-to-one peer support in mental health services might impact positively on psychosocial outcomes, but is unlikely to improve clinical outcomes. In order to better inform the introduction of peer support into mental health services, improvement of the evidence base requires complete reporting of outcome data, selection of outcomes that relate to intervention mechanisms, exploration of heterogeneity in the implementation of peer support and focused reviews of specific types of one-to-one peer support.

Trial registration

Prospero identifier: CRD42015025621 .

Peer Review reports

Mental health and workforce policies in a number of countries advocate the introduction of large numbers of peer workers into mental health services [ 1 , 2 ]. In this context, peer workers are people with personal experience of using mental health services and/ or of mental distress, employed to make use of that experience in providing support to others currently using mental health services. Peer support more generally refers to a mutual exchange of emotional and practical support between people who identify as peers on the basis of shared or similar experiences of mental distress, with the recent origins of organised forms of peer support often ascribed to the mutual aid movement [ 3 , 4 ]. The emergence of trained peer workers, providing peer support to people using mental health services, is a comparatively newer phenomenon, stimulated perhaps in part by assumptions about economic prudence [ 5 ], and in part by suggestions that peer support aids individual recovery [ 6 ]. Peer workers have been employed in a range of roles, providing one-to-one support to individuals using mental health services, as we explore below, supporting and facilitating mutual support groups, or running services provided as an alternative to mainstream provision.

The peer support literature has been reviewed before, with Pitt and colleagues [ 7 ] finding a small reduction in emergency service use where peer workers were compared with other mental health professionals working in similar roles (primarily case management), while Lloyd Evans and team [ 8 ] found a modest positive effect of peer-provided interventions on self-reported recovery and hope. However, both reviews combined studies of individual and group-based peer support – noting substantial heterogeneity in both intervention and trial population – and in both reviews authors cautioned that the majority of trials were of low to moderate quality and that reporting bias in particular might explain these results. More focused reviews have considered peer support for people experiencing depression [ 9 ], and for those experiencing psychosis [ 10 ]. The former considered only group interventions, while the latter combined group, one-to-one and service-level modalities of peer support, and found no evidence of effectiveness of one-to-one peer support. However, a recent, informal review has indicated that a number of new trials of one-to-one peer support in mental health services have been reported [ 11 ], offering a timely opportunity for a systematic review focusing on one-to-one peer support in order to provide an evidence base for the ongoing introduction of peer workers into mental health services internationally.

Exploring heterogeneity of peer support interventions

We note that Pitt and colleagues [ 7 ] identified small differences in effect when considering ‘consumer provider [peer] vs professional staff’ in comparison to ‘consumer provider as an adjunct vs usual care alone’, warranting exploration of this aspect of intervention heterogeneity in the context of one-to-one peer support in this review. Both Pitt [ 7 ] and Lloyd Evans [ 8 ] also note that peer support is often under specified in trial papers, and that it is not always clear how peer support is different from mental health support provided by other types of mental health worker. A wider literature has identified a values-base that specifies how peer support is distinctive from other mental health support, suggesting that peer support is characterised by: a relationship grounded in a sense of connection based on shared experiences [ 12 ]; the use of experiential, rather than formal (taught) knowledge in the peer worker role [ 13 ]; the reciprocal nature of the relationship, with both parties learning from each other in contrast to the uni-directional clinician-patient relationship [ 14 ]. However, it is also noted how the formal, health services environment is not always conducive to the delivery of peer support [ 15 , 16 ].

Studies have identified a number of organisational factors that facilitate the implementation of distinctive peer support into practice, including: a clear, shared understanding of the values informing peer support in the peer worker role [ 17 ]; the importance of dedicated peer support training programmes for peer workers [ 18 ]; the need for support and supervision for peer workers [ 19 ]. Some actors in the peer support community have called for standards in the delivery of peer support in mental health services to ensure that a distinctive, values-based peer support is delivered [ 20 ]. Currently there is a lack of evidence of any association between outcomes and organisational variables supporting the delivery of peer support. There is therefore a case for exploring whether it is possible to operationalise, as a subgroup analysis, the quality of organisational support for one-to-one peer support interventions as an additional approach to exploring the heterogeneity of peer support in mental health services.

This study aims to:

systematically review all the available peer-reviewed evidence for one-to-one peer support interventions for adults using mental health services

evaluate the effects of one-to-one peer support in mental health services on a range of pre-specified outcomes

investigate, using subgroup analyses, how heterogeneity in intervention (i.e. type of peer support, quality of organisational support for peer support) is related to outcome.

This systematic review and meta-analysis adheres to PRISMA guidelines and is funded by the UK National Institute for Health Research as part of larger programme of research investigating peer support in mental health services. The review protocol is registered with the International Prospective Register Of Systematic Reviews, identifier: CRD42015025621.

Definitions

For the purpose of this review we consider one-to-one peer support in mental health services to be support delivered by an individual with personal experiences of using mental health services and/or of mental distress. We refer to the person delivering peer support here as a peer worker , noting that other terms, including peer support worker , peer specialist and consumer employee , have been used elsewhere. Peer workers are employed – whether paid or unpaid – and trained to make use of their experiential knowledge in providing support to someone who shares similar experiences, as part of or alongside the care and treatment they are receiving from mental health services.

Eligibility criteria

Studies were included where peer support was:

provided one-to-one;

intentionally provided by a peer worker;

for adults using mental health services.

Studies were excluded if peer support was:

not the primary means of delivering the intervention;

not one-to-one or intentionally provided by a peer worker;

where mental health was not the primary focus of the intervention.

Other exclusions were applied if the study was not in the English language, non-retrievable, or did not contain empirical data.

Study design

All types of randomised controlled trial (RCT) were included. Other study types were excluded.

Intervention and comparison conditions

We noted above that one-to-one peer support in mental health services has been characterised as either: an adjunctive intervention, delivered by peer workers in addition to care as usual or as an additional component to a treatment or therapy; or as peer workers delivering similar interventions to those delivered by other mental health workers (e.g. where peer workers are employed in a substitute capacity) [ 7 ]. We include both ‘adjunctive’ and ‘substitute’ peer support interventions in this review, and consider all comparator conditions in our primary analysis. Where trials had two or more intervention arms (e.g. with and without peer support) and a control arm, in all cases the comparison chosen was peer support (as intervention condition) and the other enhanced or active condition (as control condition), rather than care as usual or an attention control arm.

As noted above, a variety of outcomes have been assessed in peer support trials. Given that a number of additional trials have emerged since the publication of existing systematic reviews, it is of interest to consider whether the range of outcomes of interest remains broad or has begun to coalesce. We extract data using the set of outcomes explored in the review conducted by Lloyd-Evans and colleagues [ 8 ]. In addition, we consider use of emergency services in order to explore further findings in the Pitt review [ 7 ] and, following other published research into the mechanisms of peer support we include a small number of more socially-focused outcomes that may be impacted by peer support [ 21 ]. The full set of outcomes of interest for this review is as follows:

Hospitalisation

Emergency service use

Overall psychiatric symptoms

Symptoms of psychosis

Depression and anxiety

Quality of Life

Recovery (self-rated)

Empowerment

Satisfaction with services.

Social functioning

Social network support

Working alliance (clinician rated/ patient rated)

Self-stigma

Experienced stigma

Engagement with services

Search methods for identification of studies

The following online bibliographic databases were identified in 2015 based on then existing reviews [ 6 , 7 ] – Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsychINFO and CINAHL Plus – and searched initially from inception until the end of April 2015.

Existing reviews were used to provide a basis for search terms, with authors using their knowledge of the area, including service user researchers JM and RF, to add to search terms. The diagnostic manual DSM 5 [ 22 ] was consulted to provide a systematic structure to ensure mental health terms were inclusive. The search strategy was tested and refined as necessary. All databases were searched using a similar set of terms, strategies and Boolean operators, amended solely for the purposes of the research database management interface and not for content. An example of the search strategy, for MEDLINE, EMBASE and PsychINFO using the OVID interface, is given in Supplementary materials 1 .

Searches were updated on 13 June 2019, with no changes to search terms or search strategy. All papers returned by the search were imported into an Endnote library and any duplicates removed first using the software and then by manual review.

Study selection

Titles and abstracts of all studies returned in the search were independently screened for inclusion in the review by two researchers (two of JM, RF and RM). Disagreements were resolved by discussion using the full text of the paper, with remaining differences resolved by discussion with SG. Reference list and forward citation searching of included studies were used to identify additional papers for inclusion in the review.

Data extraction

Data were extracted for study characteristics from each included study by one of JM, RF or RM using a structured data extraction data sheet (see Table  1 below), with a second researcher (SG) checking for accuracy of extraction for 25% of studies.

For the purposes of exploring heterogeneity of intervention as subgroup analyses in the meta-analysis we also recorded where peer support was provided as an adjunctive intervention and where peer workers were working in a substitute role, as defined above, and in addition rated the quality of organisational support provided for peer support. To do this, studies were independently coded by two members of the team (JM and RM) where they reported any of the following indicators:

Dedicated peer support training;

Clear description of theory, processes or understanding of peer support;

Support structures for peer workers (e.g. supervision).

Discrepancies between researchers were discussed until agreement was reached. Studies were then categorised as having a ‘higher level’ of organisational support for peer support if they fulfilled at least two of the three indicators, or ‘lower level’ if they met one or less indicators.

Extraction of data for meta-analysis

One researcher (RM) extracted data for outcomes onto a bespoke extraction sheet. Data were included if they were assessed using a standardised measure or, in the case of service use data, captured in clinical records. For continuous outcomes, sample sizes, mean and standard deviations by arm were extracted, and for dichotomous outcomes, the number of events and sample size per arm were extracted. All outcome data extraction was checked by statistician SW for accuracy and completeness. If data for a particular outcome were only reported by a single paper that outcome was not included in the meta-analysis. We wrote to authors of included studies for additional information and trial data where it was not included in the published article.

Where outcome data were reported for more than one follow-up point, the longest timepoint was used. Where more than one measure was used to report the same outcome in a study, we included the measure more commonly reported by other studies in the analysis.

Assessment of risk of bias

Each included study was assessed for risk of bias by two researchers (RM, JM), with any differences in assessment resolved by a third researcher (SW), in accordance with Cochrane Collaboration Risk of Bias Tool [ 80 ]:

adequate sequence generation (selection bias)

allocation concealment (selection bias)

blinding of outcome assessment (detection bias)

incomplete outcome data (attrition bias)

selective outcome reporting (reporting bias)

It is important to note that although blinding of participants to allocation is usually assessed, in this particular instance the nature of a peer intervention means that all trial participants are unblinded. As such this particular source of bias is not assessed in this review, in line with existing reviews of peer support.

Statistical analysis

Effect sizes for continuous data were calculated as standardised mean difference (SMD), Hedges’ g, with studies weighted using the inverse variance method [ 81 ]. Risk ratios were calculated for dichotomous outcomes, and studies combined again using the inverse variance method. All pooled effect sizes are reported with 95% confidence intervals calculated using random-effects models. We used intention to treat data in all analyses.

Statistical heterogeneity was assessed through the I 2 statistic which describes the percentage of the variability in effect estimates that is due to heterogeneity rather than chance and the p -value of the χ 2 test (Q) for heterogeneity. A p-value < 0.10 and an I 2  > 50% suggests substantial heterogeneity. Where substantial heterogeneity of effect sizes across trials is observed, subgroup analyses were conducted, comparing studies where:

peer support was provided as an adjunctive intervention, against those studies where peer workers were working in a substitute role;

a higher level of organisational support for peer support were reported, against those studies where a lower level was reported.

Differences between subgroups of studies were tested using the Qint test for heterogeneity, testing if effect sizes differ across subgroups. Review Manager (RevMan 5.2 for Windows) software [ 82 ] was used to conduct the meta-analyses.

A total of 6502 records were identified in the updated search. Of these, 311 studies were potentially eligible and, after further review (as described above) 23 eligible papers were identified, reporting on 19 trials. One trial was reported across four papers [ 23 , 83 , 84 , 85 ] and another trial reported across two papers [ 45 , 86 ]. See Fig.  1 below.

Flowchart of inclusion of studies

Study characteristics

Twelve studies were conducted in the USA [ 23 , 28 , 30 , 31 , 39 , 42 , 44 , 45 , 54 , 63 , 66 , 68 ], three were conducted in the UK [ 35 , 59 , 76 ], one in Canada [ 62 ], one in Australia [ 50 ], one in Germany [ 71 ], and one in Japan [ 74 ]. Eighteen trials were individually randomised and one was a cluster randomised trial [ 54 ]. Six studies described themselves as pilot trials [ 28 , 35 , 45 , 59 , 62 , 68 ], four studies were three-arm trials [ 30 , 31 , 42 , 50 ], and one study used a waitlist control [ 68 ].

Fifteen studies fell into the ‘adjunctive’ peer support group, with eleven of those comparing peer support as an adjunctive intervention to care as usual [ 28 , 31 , 35 , 42 , 45 , 54 , 59 , 66 , 71 , 74 , 76 ]. Two of the eleven [ 31 , 42 ] were three arm trials comparing care as usual, an adjunctive intervention, and the intervention plus an additional peer support component. Another three-arm trial [ 50 ] compared an attention control, intervention, and the intervention plus an additional peer support component. Two papers reported two arm trials of an intervention, with and without adjunctive peer support [ 44 , 63 ], and one study compared the peer support intervention with a waitlist condition (i.e. no-comparator intervention) [ 68 ]. Four studies compared peer workers working in a substitute capacity compared with other mental health workers performing a similar role [ 23 , 30 , 39 , 62 ]. One of these studies was also a three-arm trial [ 30 ], with care as usual as the third arm. Further details about study characteristics can be seen in Table 1 below, with indication given of which comparators were used in the subsequent meta-analysis.

Participants in all studies were adults, although in one study participants were aged 55 or older [ 68 ]. In the majority of studies – twelve – participants were using community mental health services [ 23 , 28 , 30 , 35 , 39 , 44 , 50 , 54 , 62 , 63 , 66 , 76 ]. In three studies participants were recruited as inpatients [ 42 , 45 , 59 ], and in two studies participants were recruited as either inpatients or outpatients [ 71 , 74 ]. In two studies participants were recruited directly from depression clinics [ 31 , 68 ]. Most studies indicated diagnostic inclusion criteria, with seven studies specifying that participants would have diagnoses of either psychotic, or major depressive or mood disorders [ 23 , 30 , 39 , 42 , 45 , 54 , 66 ]. Two studies specified a diagnosis of bipolar disorder [ 44 , 50 ], one of major depressive disorder [ 31 ], one of mild to moderate depression and anxiety [ 68 ], one of either psychotic or personality disorders [ 71 ], and one of dual mental health, and drug or alcohol disorder [ 28 ]. Two studies defined eligibility by duration of mental illness with one specifying at least two years [ 71 ], and the other indicating that mental illness should be persistent [ 62 ]. A number of studies defined the population by service use history. In three studies eligibility criteria were defined by a minimum number of previous, recent psychiatric hospital admissions [ 42 , 45 , 54 ]. One study recruited participants as they approached hospital discharge [ 59 ], one study recruited participants who had been referred to specialist crisis and home treatment teams [ 76 ], and another study recruited participants who were under a court order mandating community mental health treatment [ 63 ].

Sample sizes

Samples sizes in the studies ranged from 21 [ 62 ] to 468 [ 54 ], with a total of 3329 participants in the 19 trials.

Interventions

While descriptions of peer support interventions remains thin in some studies published since the last review [ 8 ], a number of more recent studies do provide detailed descriptions of peer worker roles and what constitutes peer support. Peer workers were reported as delivering a range of different interventions. Five studies reported peer workers working in case management roles [ 23 , 30 , 39 , 42 , 54 ]. Typically, peer workers were expected to fulfil a similar, brokerage-type case management function to other mental health workers, and in addition, to role model their own strengths and experiences of recovery [ 39 ], or to provide social support by arranging social activities [ 42 ]. Three studies reported peer workers working in mentoring or coaching roles [ 44 , 45 , 50 ]. Mentoring and coaching roles varied considerably from offering a very loosely described partnership relationship that aimed to be different to a clinician-patient relationship [ 45 ], to structured online coaching to support participants in producing a detailed, behaviourally-informed recovery plan [ 44 ]. Three studies described peer workers providing support for self-management [ 31 , 62 , 76 ]; for example, in one study peer workers provided one-to-one assistance with rehabilitation goals set by occupational therapists [ 62 ], while in another peer workers supported participants to complete a structured recovery workbook [ 76 ]. Another three studies describing peer workers offering support for recovery [ 59 , 63 , 71 ]. What support for recovery entailed was generally poorly defined, with the exception of Mahlke and colleagues [ 71 ], describing in some detail how peer workers were trained and supported to reflect on and make use of their own experiences as a resource in supporting others with their recovery, but also reported that the intervention was not further manualised, and that peer workers had flexibility in the role, with an emphasis on enhancing the sense of control over their lives that people experienced. Two studies reported peer workers providing support for living independently in the community [ 28 , 66 ]. Peer support in both studies had a strong social focus and in the case of the latter [ 66 ], support was highly individualised and self-directed, involving the peer worker helping the individual to access social support that they identified themselves. Other studies described peer workers providing support for shared decision making in clinical consultations, again with a strong focus on a structured self-management approach [ 74 ], delivering a cognitive behavioural intervention using a structured workbook [ 68 ], and working in a healthcare assistant role [ 35 ].

Most peer support was provided face-to-face but in one study peer support was provided either face to face or by telephone [ 31 ], and in two studies peer support was provided online [ 44 , 50 ]. We note that in three studies peer workers were employed by peer-led organisations or agencies [ 23 , 63 , 66 ]. As noted above, four studies evaluated peer workers as a substitute for other mental health workers working in a similar role, three of those in a case management capacity [ 23 , 30 , 39 ], and in the fourth, providing support for self-management [ 62 ]. In all other studies peer support was adjunctive to care as usual or evaluated as an enhancement to another intervention.

Level of support for peer support interventions

The majority of studies – fourteen and thirteen respectively – described the support and/ or supervision provided to peer workers to deliver the peer support intervention [ 23 , 28 , 35 , 42 , 44 , 45 , 54 , 59 , 62 , 63 , 66 , 68 , 71 , 76 ], and the peer support-specific training provided to peer workers [ 31 , 35 , 39 , 44 , 45 , 54 , 59 , 62 , 63 , 66 , 71 , 76 , 85 ]. In contrast, only five studies explicitly described the theory, processes or understandings of peer support that underpinned the intervention evaluated [ 23 , 28 , 35 , 54 , 71 ].

There was variation in the degree of reporting of support given to peer workers. Reporting of training provided varied from noting that peer workers had received accredited peer specialist training prior to delivering the intervention [ 44 ], to a more detailed description of an extended, structured training program describing module content and mode of delivery [ 71 ]. Description of the support and supervision provided for peer workers also varied, from studies that simply reported that peer workers were provided with support and supervision for the duration of the study [ 59 ], to one which described in some detail the areas covered during weekly, 90 min group supervision sessions for peer workers [ 45 ]. One study said that supervision was provided by a peer support coordinator, with preference being given to employing someone with lived experience of mental illness in that role [ 62 ], while another stated that the director of the consumer case manager team was a consumer [ 23 ]. However no studies clearly stated that supervision for peer workers was provided by someone who was themselves employed to use their personal experiences of mental distress or of having used mental health services in the role. Theory, processes and understanding of peer support also varied in description, with one study [ 71 ] describing a specific peer support change model that underpinned the intervention, while others gave a more general description of the processes that characterise peer support as distinctive from other forms of mental health support [ 35 ].

Three studies did not report any of these organisational support components (dedicated peer support training; underlying theory; support for peer support) [ 30 , 50 , 74 ], and four reported just one component [ 31 , 39 , 42 , 68 ]. In contrast, four studies reported all three components [ 23 , 35 , 54 , 71 ], and eight reported two out of three [ 28 , 44 , 45 , 59 , 62 , 63 , 66 , 76 ].

Studies reported measuring thirteen of the eighteen outcomes of interest, with no studies of one-to-one peer support providing usable data assessing employment, symptoms of psychosis, self-stigma or experienced stigma, or emergency service use. Studies most often measured were hospitalisation [ 23 , 28 , 30 , 35 , 42 , 45 , 59 , 71 , 76 ] and quality of life [ 23 , 28 , 42 , 54 , 59 , 62 , 63 , 66 , 71 ], both measured in nine studies. We note that hospitalisation was variously measured as days in hospital, number of admissions or re-admissions, and community tenure (days spent living in the community, post-intervention, before hospital admission). Overall psychiatric symptoms were measured eight times [ 23 , 42 , 45 , 54 , 63 , 71 , 74 , 76 ], and both of social functioning [ 28 , 31 , 35 , 45 , 50 , 71 , 74 ] and social network support [ 23 , 28 , 35 , 42 , 45 , 63 , 76 ], seven times. Given that many studies used a more general measure of functioning - i.e. the Global Assessment of Function scale [ 29 ] – we subsequently report this outcome as General and Social Functioning. Satisfaction with services [ 31 , 35 , 42 , 45 , 76 ], empowerment [ 50 , 54 , 66 , 71 , 74 ] and working alliance [ 23 , 39 , 66 , 68 , 74 ] were all measured five times. We note that some studies reported both a participant rating of working alliance with staff and a staff rating of working alliance with the participant [ 23 , 74 ], while others only reported a participant rating of staff [ 39 ]. Self-rated recovery was measured in four studies [ 54 , 63 , 66 , 76 ], with wellbeing [ 28 , 42 , 45 ] and engagement with services [ 35 , 39 , 66 ] both measured in three studies. We grouped measures of physical health (e.g. two studies separately reported scores on the physical health subscale of the Lehman Quality of Life Scale) [ 26 ] with a more general measures of wellbeing (Life Skills Profile) [ 36 ], and so we report wellbeing as Physical Health and Wellbeing going forward. Depression and anxiety were also measured in three studies, with only Seeley and colleagues [ 68 ] using a separate measure for each, Proudfoot and colleagues [ 50 ] using a generalised measure for both, and Hunkeler and colleagues [ 31 ] measuring depression only. As a result we retain Depression and Anxiety as a single outcome for the purposes of this review. Finally, hope was measured in two studies [ 44 , 45 ]. Details of the specific tools used to measure these outcomes in each study can be found in Table 1 and are discussed further in the context of the meta-analysis reported below.

Risk of bias

The Risk of Bias ratings are displayed in Fig.  2 . Sequence generation was not sufficiently described in 7 of the 19 trials and was at high risk of bias in one trial. Concealment of the allocation sequence was not sufficiently described in 11 trials, and again at high risk of bias in one trial. Lack of blinding of assessors created a high risk of bias in 3 studies, and in 8 further trials it was unclear if assessors were blind. At the trial level, 3 were at high risk of bias for missing data (i.e. attrition bias) and 6 were unclear. Included studies may have measured but not reported outcomes that are included in this review; 10 with unclear description and 4 with high risk of reporting bias. Seven of the 19 studies [ 44 , 50 , 59 , 63 , 68 , 71 , 76 ] were at low risk of bias on at least three of the five bias categories and not high risk of bias for any category (i.e. might be described as being of low to moderate risk of bias overall), with the majority of those studies having been published since previous reviews. However on balance, overall quality of trials, when compared to previous reviews, remains low to moderate.

Summary of risk of bias of included studies

Quantitative synthesis

Data were available for the meta-analysis from fourteen of the nineteen trials included in the review (sixteen papers), with two or more trials contributing to meta-analyses of nine of our original outcomes. Because of the way data were reported in the studies, we analyse these as eleven outcomes, analysing days in hospital and hospitalised as two discrete outcomes in place of hospitalisation, and separating working alliance into staff-rated and client-rated outcomes. This analysis includes data obtained from one study after contacting study authors [ 74 ]. The number of studies contributing data to each outcome included in the analyses can be seen in Table  2 below. Median length of follow-up was 12 months post randomisation, ranging from 2.5 to 24 months. In the following analyses a positive standardised mean difference (SMD) for the following outcomes - quality of life, social network support, empowerment, recovery, service satisfaction, working alliance (client and staff rated) - indicates the peer support intervention being more effective than the control condition, the opposite being the case for the following; general psychiatric symptoms, depression and anxiety, days in hospital and hospitalised.

Five trials reported the dichotomous outcome of whether hospitalised during follow-up period or not. Follow-up ranged from 3 to 24 months with data on a total of 497 participants. The risk of being hospitalised was reduced by 14% for those receiving peer support (RR = 0.86: 95% CI 0.66, 1.13). Moderate heterogeneity (I 2  = 38%) was found across trials for this outcome. A similar result of a non-significant effect of peer support (SMD = -0.10: 95% CI -0.34, 0.14) and moderate heterogeneity (I 2  = 39%) was found for the days in hospital outcome. The five trials in this meta-analysis had follow-up ranging from 9 to 24 months and a total sample size of 453.

Six trials reported overall psychiatric symptoms with follow-up ranging from 6 to 24 months. Total sample size was 857. There was no evidence of the effect of peer support on symptoms; pooled standardised mean difference was − 0.01 (95% CI -0.21, 0.20). There was a high level of heterogeneity across trials, I 2  = 53%, χ 2 test of heterogeneity. Q = 10.7, p  = 0.057.

Quality of life

A total of 688 participants had quality of life data reported from five trials with follow-up ranging from 12 to 24 months. No effect of peer support was found on quality of life, SMD = 0.08 (95% CI -0.11, 0.26) with moderate heterogeneity across trials, I 2  = 32%.

Three trials reported appropriate recovery data with follow-up ranging from 12 to 18 months and a total sample size of 593. Peer support is shown to have a small but statistically significant benefit on recovery (SMD = 0.22: 95% CI 0.01, 0.42: p  = 0.042) (Fig.  3 ). Only moderate heterogeneity is indicated, I 2  = 38%.

Forest plot for recovery outcome

Four trials with a total sample size of 519 participants and follow-up ranging from 6 to 12 months reported empowerment related outcomes. Empowerment was significantly higher in those receiving peer support, a small effect size, SMD = 0.23 (95% CI 0.04, 0.42: p  = 0.020) (Fig.  4 ). Heterogeneity was low, I 2  = 14%.

Forest plot for empowerment outcome

Satisfaction with services outcome data was available from two trials and a total of 286 participants. Follow-up in the two trials ranged from 12 to 18 months. No effect of peer support was found (SMD = 0.19: 95% CI − 0.05, 0.42) with no heterogeneity, I 2  = 0%.

General and social functioning

Three trials provided data for the general and social functioning outcome on a total sample size of 181. Follow-up in the two trials ranged from 6 to 12 months. No effect of peer support was found (SMD = 0.01: 95% CI -0.32, 0.35) with little heterogeneity, I 2  = 21%.

Four trials reported social network support outcome data with follow-up ranging from 12 to 24 months and a total sample size of 512 participants. While the pooled SMD = 0.09 (95% CI -0.25, 0.42) indicated no effect of peer support on social network support, there is significant heterogeneity across the trials, I 2  = 67%, χ 2 test of heterogeneity. Q = 9.2, p  = 0.027.

Working alliance

Client rated working alliance about staff was reported in three trials and by a total of 213 participants. Follow-up ranged from 6 to 24 months. No heterogeneity was found across trials, I 2  = 0%, but the SMD = 0.24 (95% CI -0,03, 0.51: p  = 0.080) indicates a potentially positive outcome for peer support. The SMD = 0.15 (95% CI -0.18, 0.48) was lower for staff ratings of the working alliance, again with no heterogeneity, I 2  = 0%. This outcome was only rated in 2 trials, a total of 139 participants.

Subgroup analyses

Only two outcomes – overall psychiatric symptoms and social network support – satisfied our condition of sufficient heterogeneity in the data to warrant undertaking subgroups analyses (see Table  3 below). We conducted subgroups analyses of those outcomes as defined earlier: adjunctive peer support interventions compared to those where peer workers were working in a similar or substitute role to other mental health workers; studies reporting a higher level of organisational support for peer support compared to those studies reporting a lower level of organisational support for peer support. These analyses did not explain heterogeneity with respect to overall psychiatric symptoms. A single study [ 42 ], reporting a lower level of organisation support for peer support, found a moderate, significant increase in social network support for people in the peer support arm of the trial (SMD = 0.50: 95% CI 0.14, 0.87), compared to three other studies with a higher level of organisational support for peer support where no significant difference in social network support was found (SMD = -0.04: 95% CI -0.37, 0.28) (Fig.  5 ). It can also be seen in Table 3 that there is evidence that whether peer support is being provided as adjunctive to usual care or as a substitute role impacts the effectiveness of peer support in increasing social network support, Qint = 4.27, p  = 0.039. The effect of peer support is significantly greater when it is delivered as an adjunctive, SMD = 0.23, as opposed to substitute intervention, SMD = -0.30, a difference of 0.53 (Fig.  6 ).

Sub group analysis; social network support by level of organisational support

Subgroup analysis; social network support by type of peer support

Our review has indicated that a number of additional studies of one-to-one peer support have been published in the years following previous systematic reviews, suggesting that it has become viable to consider different modalities of peer support – e.g. group, one-to-one, peer-led services – in separate reviews. Studies remain predominantly conducted in the US, but with a gradual increase in studies being conducted in Europe and beyond. With health systems operating differently in different countries, caution does need to be taken when considering any results in the round.

While this review is focused on one-to-one peer support, we still see the heterogeneity of intervention observed by Pitt [ 7 ] and Lloyd Evans [ 8 ] across modalities of peer support. However it is interesting to note that most studies of peer workers in paraclinical roles, including case-management [ 23 , 30 , 39 , 42 ] and healthcare assistant roles [ 35 ], are now well over 10 years old, as are the majority of studies that compare peer workers to other mental health workers performing a similar role (‘substitute’ peer support) [ 23 , 30 , 39 ]. It is also worth noting that none of those studies of peer workers in paraclinical roles, or of peer workers in substitute roles, contributed data to analyses of those outcomes where a significant positive effect of peer support was found (recovery and empowerment).

Peer support interventions evaluated in more recent studies, in contrast, are almost exclusively evaluating adjunctive peer support, and tend to have either a structured, behavioural focus [ 44 , 62 , 68 , 74 , 76 ], or a more social focus, with peer workers providing a less structured, more peer-led support for recovery [ 45 , 59 , 63 , 66 , 71 ]. We suggest that there is potential, as more trials are published, of conducting focused reviews of specific groups or families of similar one-to-one peer support interventions.

We observe that a wide range of outcomes continue to be used. Of the original list of outcomes considered by Lloyd Evans and colleagues [ 8 ], we found that neither employment nor symptoms of psychosis were measured in the nineteen trials of one-to-one peer support that we reviewed. While Pitt and colleagues [ 7 ] found a small reduction in emergency service use for people receiving peer support we did not include data on emergency service use in our review as we excluded self-reported service use data from our analysis; Pitt and colleagues [ 7 ] themselves had suggested that recall bias and selective reporting of this outcome undermined the reliability of this particular finding.

While measures of general psychiatric symptoms were used in nearly half of all trials, measures of specific symptoms – of depression – were only used in those studies which exclusively recruited from a population diagnosed with depression [ 31 , 50 , 68 ]. Of our additional set of, largely, more socially-focused outcomes, neither internalised nor experienced stigma have been measured to date, although social functioning, social network support and working alliance were all measured in multiple studies, including in older trials [ 23 , 35 ]. If we consider just those outcomes used in multiple studies (outcomes included in our meta-analysis), we see a more focused outcomes-set emerging, balancing clinically-orientated outcomes of general severity of symptoms, functioning and hospitalisation with a set of self-reported, psychosocial outcomes including empowerment, recovery, working alliance and social network support.

As with previous reviews, once data from multiple studies were pooled, we found no difference between peer support and control across the majority of outcomes we considered. This included hope, where Lloyd Evans and colleagues [ 8 ] found a moderate positive impact of peer support, but we note again that their review included peer support provided to groups while we found insufficient studies of one-to-one peer support reporting measurement of hope as an outcome. However, our review does suggest that trial participants offered one-to-one peer support in mental health services experience modest but significant improvement in empowerment and self-reported recovery compared to control group participants, the latter reflecting similar findings by Lloyd Evans and colleagues [ 8 ].

Studies reporting empowerment were for the most part were published since the 2013 [ 7 ] and 2014 [ 8 ] reviews, reflecting the suggestion made by Bellamy and colleagues [ 87 ] that more recent studies indicate that new peer support initiatives might usefully be directed to interventions that, broadly speaking, support individual empowerment. We grouped assessments of empowerment and related constructs together for the purposes of this review, and the studies in the analysis variously used the Patient Activation Measure [ 57 ], the General Self-Efficacy Scale [ 73 ], and the Empowerment Scale [ 67 ]. As a construct, patient activation has a clear focus on the extent to which the individual is able to access the healthcare they need, and is a good fit for interventions that specifically address the way in which the individual engages with their mental health care [ 54 , 74 ]. Self-efficacy taps into the individual’s ability to make use of a wider range of support and care, while the Empowerment Scale has been shown to weight heavily on hope as a factor [ 67 ]. Again, these measures would seem appropriate for interventions focused on supporting recovery [ 63 ] and independence [ 66 ] respectively.

Studies reporting recovery as an outcome again used a range of measures. Salzer and colleagues [ 66 ] use the Recovery Assessment Scale [ 65 ], which measures recovery across five domains of personal confidence, hope, willingness to ask for assistance, goal and success orientation, and coping, and as such would seem particularly attuned to an intervention designed to support independent living. Johnson and colleagues [ 76 ] use the Questionnaire about the Process of Recovery [ 78 ], which comprises an ‘intrapersonal’ subscale that relates to “intrapersonal tasks that an individual is responsible for carrying out and that they complete in order to rebuild their life”, and an ‘interpersonal’ subscale relating to “individuals’ ability to reflect on their value in the external world and on how recovery is facilitated by external processes and interpersonal relationships with others”. Seventeen of the 22 items that comprise the measure load onto the ‘intrapersonal’ subscale, as would seem apposite for the evaluation of a self-management intervention. Chinman and colleagues [ 54 ] use the Mental Health Recovery Measure [ 55 ], measuring recovery in the seven domains of Overcoming Stuckness, Self-Empowerment, Learning and Self-Re-definition, Basic Functioning, Overall Well-Being, New Potentials, and Advocacy/Enrichment. This balance between functioning and wellbeing, and then moving on and realising potential seems well-suited to the case management function of the intervention.

These findings indicate what would seem to be an important relationship between positive impact on outcome, the assessment tool used and the intervention. As such we would suggest that trials exploring these, or indeed other outcomes, in the future should be cognisant of the constructs informing specific assessment tools (e.g. domains, subscales), and ensure that these relate closely to the mechanisms underpinning particular peer worker interventions. We reiterate calls in previous reviews [ 7 ] for a clearer understanding of the mechanisms of peer support, and the theory driven selection of outcomes that relate specifically to what peer workers do.

We note that one further outcome, client-rated working alliance, while not quite significant, demonstrated a similar effect size to the other positive outcomes. In two studies [ 23 , 39 ] participants rated working alliance with peer workers in the intervention arm of the trial, compared to working alliance with mental health professional in the control arm, while in the third study [ 74 ] working alliance with a mental health professional was rated in both arms of the trial, with and without additional peer support. Once data were pooled there was a relatively small sample size for this outcome; more data would produce a more precise estimate of the effect size. This finding suggests that there is merit in exploring working alliance in future studies of one-to-one peer support, especially given other research indicating a potential mechanism for peer support in bridging and enabling connection between service users and mental health professionals [ 21 ].

We note that while both measures of hospitalisation analysed were in a positive direction (i.e. a reduction in days in hospital and risk of hospitalisation), neither were significant. The lack of positive association between the offer of peer support and reduction in psychiatric symptoms also suggests that, while studies are using a balance of clinical and more psycho-socially focused outcomes, one-to-one peer support in mental health services is unlikely to impact on clinical outcomes.

There was significant heterogeneity of data for two outcomes (overall psychiatric symptoms and social network support). While our subgroup analyses did not explain heterogeneity with respect to overall psychiatric symptoms, analyses did offer insight into the relationship between peer support and social network support. Finding that a single study [ 42 ], reporting a lower level of organisation support for peer support, indicated a moderate, significant increase in social contacts, while studies reporting a higher level of support for peer support did not, appears counter-intuitive. Looking closely, authors note that the increase in positive outcome was accounted for by additional contacts with peer workers and professional staff, rather than any increase in contacts with family or friends [ 42 ].

Furthermore, peer support that was provided in addition to care as usual was significantly more likely to increase social network support than peer support provided by peer workers employed in a substitute role. At the least, these findings suggest that it is worth considering measuring social network support in future studies, while giving consideration to how the peer support intervention might be functioning to increase social contacts. In addition, we would suggest that we have demonstrated that our approach to operationalising an analysis of organisational support for peer support is feasible and might be pursued in future reviews, subject to the availability of suitable data. Continued improvement in reporting peer support interventions might usefully include good description of the organisational support provided for peer workers [ 88 ].

While cost was not one of our outcomes of interest we note that claims have been made about the potential contribution to reducing the cost of mental healthcare that peer support might make [ 5 ]. Only one of the nineteen trials included in our review considered cost, but was not sufficiently powered to draw any conclusions [ 59 ]. As such, analysis of the cost-effectiveness of one-to-one peer support in mental health services is largely absent from the evidence base to date.

Limitations

Overall quality of trials, when compared to previous reviews, remains low to moderate, although we note that, in our set of trials of one-to-one peer support, more recent trials appear less likely to have serious risk of bias and more likely to have low risk of bias on a majority of assessments, and so we tentatively suggest that the quality of studies is improving. Reporting bias, due to incomplete reporting of outcomes data, remains an issue and, as such, this downgrading of the quality of the overall evidence base does limit the strength of findings of this review. We note that for our two main positive outcomes, self-reported recovery and empowerment, all but one of the studies that reported measuring these outcomes included usable data in trial papers. However completeness of reporting of outcomes is essential to inform good quality evidence with respect to peer support in mental health services going forward.

In focusing on one-to-one peer support we have produced a more focused review than previous studies. However we acknowledge that studies remain heterogenous, especially with respect to clinical population (for example, only one study [ 71 ] specified chronicity of diagnosis). In addition, we note the range of terms used to describe peer support roles and acknowledge that our search might not have been wholly inclusive. Like all reviews, the validity of our study is defined by the strategy we describe above.

One-to-one peer support in adult mental health services has a modest, positive effect on empowerment and self-reported recovery, and might potentially also impact on measures of working alliance between service users and mental health workers, and social network support. It seems unlikely that one-to-one peer support has a positive impact on clinical outcomes such as symptoms or hospitalisation, given data available for this review, suggesting that the benefits of peer support are largely psychosocial, operating at both individual (interpersonal) and relational (intrapersonal) levels. The quality of reporting, both of trial methods and design of peer support interventions, has improved somewhat but needs to continue to do so - especially with respect to complete reporting of outcome measurements - in order to maximise the usefulness of the evidence base for service providers and policymakers. Future trials should also consider appropriate assessment of cost-effectiveness of peer support in mental health services.

While some older trials of one-to-one peer support evaluated peer workers working in paraclinical roles, and/ or in substitute roles, newer studies focus on peer workers providing adjunctive interventions; either structured, behavioural interventions, or more socially focused, self-directed, flexible support for recovery. This review suggests that future trials of one-to-one peer support in mental health services should focus on peer workers providing interventions that are additional to usual care; outcomes for peer support are no better than control where peer workers are compared to other mental health workers doing similar work, and might be worse for outcomes such as social network support, possibly because such roles do not enable peer workers to enact a more distinctive way of working.

We suggest that studies should carefully consider the specific mechanisms of action of peer support, with trials designed so that choice of assessment tools (the constructs that are measured) reflect the specific function of the peer support intervention and the distinctive way in which peers work compared to other mental health workers. If and where peer support is having a beneficial effect, there will be a greater likelihood of observing this in a more carefully designed trial. Furthermore, as the evidence base for peer support grows it would be methodologically desirable to conduct more focused reviews of groups of similar interventions (rather than continuing to review a heterogenous group of interventions as a whole). Finally, this review demonstrated the potential to explore heterogeneity in peer support, in relation to outcome, in terms of the quality of organisational support provided to peer workers.

It is of interest to compare our findings with the concurrent review of group peer support conducted by Lyons and colleagues. We similarly identified that heterogeneity of intervention remains a feature of the evidence base while noting that a small number of types or functions of peer support are emerging (with a number of trials of peer-supported self-management identified by both reviews). Both reviews are also indicative of a modest, positive effect of peer support on self-reported recovery and an absence of effect, in the evidence to date, on clinical outcomes. Again, both reviews indicate that reporting bias – incomplete reporting of outcomes – continues to undermine the quality of the evidence base as whole.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

Confidence Interval

Diagnostic and Statistical Manual

Standard Mean Difference

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This work was supported by the UK National Institute for Health Research, Programme Grants for Applied Research funding programme (grant number RP-PG-1212-20019). This paper presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. The funder played no roll in the design of the study, the collection, analysis, and interpretation of data, or in writing the manuscript.

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SW and SG contributed to formulating the research question, designing the study, carrying it out, analysing the data and writing the article; RF, JM and RM contributed to designing the study, carrying it out, analysing the data and writing the article; LG, SB and JS contributed to designing the study and writing the article. The author(s) read and approved the final manuscript.

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White, S., Foster, R., Marks, J. et al. The effectiveness of one-to-one peer support in mental health services: a systematic review and meta-analysis. BMC Psychiatry 20 , 534 (2020). https://doi.org/10.1186/s12888-020-02923-3

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Supporting Peer Support Workers and Their Supervisors: Cluster-Randomized Trial Evaluating a Systems-Level Intervention

• Louis D. Brown , Ph.D. ,
• Denise Vasquez , M.P.H. ,
• Jessica Wolf , Ph.D. ,
• Jason Robison , B.A. ,
• Libby Hartigan , B.A. ,
• Ruth Hollman , B.A.

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Peer support workers are a substantial and growing part of the mental health workforce. Because little research has investigated how to effectively support and supervise peer support workers, the authors evaluated the efficacy of a training program to strengthen the peer support workforce and the supervision of its workers.

Mental health services sites with peer support workers and supervisors in Los Angeles County were recruited for this cluster-randomized trial and 10-month follow-up. Of 348 peer support workers and 143 supervisors at 85 sites, 251 (72%) peer support workers and 115 (80%) supervisors completed baseline surveys. SHARE! the Self-Help And Recovery Exchange, a peer-run organization, delivered four training sessions on strategies to reduce stigma and to build an effective peer workforce, cultural competence, and a trauma-informed developmental model of supervision. Primary outcomes were peer-supportive organizational climate, mental health stigma, and peer support worker recovery.

Intention-to-treat analyses indicated that sites receiving the training had significantly higher scores on peer-supportive organizational climate (Cohen’s d=0.35, 95% CI=0.02–0.68, p=0.04) relative to sites not receiving the training. No significant differences were found between the two conditions for mental health stigma (Cohen’s d=0.04) or peer support worker recovery (Cohen’s d=0.14).

Conclusions:

The training had no impact on mental health stigma or peer support worker recovery. However, the findings suggest that the training increased the value organizations gave to peer support work, which may help improve peer support worker retention and outcomes among those served. Efforts to incorporate principles of the training into practice may strengthen outcomes.

SHARE! the Self-Help And Recovery Exchange is a peer-run organization that created a series of training sessions designed to strengthen the mental health peer workforce and peer support workers’ supervision.

This cluster-randomized trial evaluated the training’s efficacy among peer support workers and their supervisors at 85 mental health services sites in California.

The findings suggest that the training increased the extent to which the sites provided an environment supportive of peer support workers, which may help with worker retention.

Peer support services are increasingly available in mental health systems across the United States, yet research on how to support the peer workforce has been minimal ( 1 ). Working in both mental health and substance use treatment settings, peer support specialists draw from their own experience of recovery and from skills obtained through formal training for peer services providers ( 2 ). Peer occupations are diverse, including consumer peer support workers who serve other consumers and parents of children with mental health issues who serve other parents of children having the same issues ( 3 , 4 ). Nevertheless, the principles of peer support and supervision apply across contexts ( 5 ). Rather than treatment and control of symptoms, peer support services focus on a recovery-oriented, person-driven mutual support model ( 6 ). Findings from randomized trials ( 7 , 8 ) have suggested the potential of peer support workers in improving mental health outcomes, reducing hospitalizations, and enhancing quality of life.

Despite the popularity of peer support services, creating work environments that aid the success of peer support workers remains challenging ( 9 ). Supervision of peer support workers is critical and requires a nuanced understanding of their role ( 10 , 11 ). Problematic issues include having supervisors who are inexperienced in the delivery of peer support services and a lack of clarity about the peer role ( 12 ). Stigma (both implicit and explicit) toward workers with lived experience of mental illness further impedes successful working relationships, as do trauma histories among mental health providers that are not accommodated by the workplace ( 13 ). Addressing these challenges requires organizational or systems-level interventions aimed at supporting the peer support workforce and its supervision.

To address problems with ambiguity and misunderstandings about peer support roles, peer support workers and their supervisors need common ground on best practices for peer support. Although more research is needed, five evidence-informed peer service interventions are peer listening and disclosing, peer bridging, use of the helper therapy principle, engagement in self-help support groups, and recovery planning ( 14 ). Peer listening and disclosing are core skills, which peer support workers cultivate through active listening and then sharing related experiences without advice or judgment ( 15 ). These skills are critical in peer bridging, in which peers use experiential knowledge to support others in making life transitions similar to those they have navigated, such as from inpatient to outpatient or from homeless to housed ( 16 , 17 ). In using the helper therapy principle, peer workers support others’ engagement in helper roles ( 18 , 19 ). To this end, one avenue is that peer support workers can encourage their clients to join self-help support groups ( 20 ). Another peer support strategy is recovery planning, in which personalized guides are developed to achieve recovery-related goals, such as in the evidence-based Wellness Recovery Action Plan ( 7 ).

Despite evidence supporting the utility of the peer workforce, stigma remains a central challenge facing peer support workers ( 2 ). Along with internalized stigma, peer support workers face stigmatizing attitudes held by their nonpeer coworkers, whose attitudes may be comparable to those of the general population ( 21 ). Peer support workers also contend with being perceived as inferior service providers, with lower salaries, less formal training, and limited leadership in provider organizations ( 22 ). Antistigma training delivered by mental health consumers can help address these challenges ( 23 ).

Peer support workers and their supervisors often have histories of trauma, which affect work performance ( 24 ). If not recognized and accommodated, these trauma histories can lead to misunderstandings, conflict, further traumatization, and burnout ( 25 ). Self-care is critical to avoiding these issues ( 26 ). A trauma-informed approach to supervision can help build workplaces that accommodate trauma histories and reduce chronic work stress ( 27 ).

Despite these challenges, the supervisory relationship is critical for building peer workforce capacity ( 13 ). A developmental model of supervision, in which experts in the delivery of peer support cultivate the skills and performance of peer support workers over time, can help maximize workers’ efficacy ( 28 ). By collaborating with peer support workers as allies to ensure a supportive work environment, supervisors are central to peer workforce success ( 9 ).

Given the importance of peer workforce supervision and the absence of evidence-based training models, the peer-run organization SHARE! the Self-Help And Recovery Exchange developed and delivered a series of training sessions, called Supervising the Peer Workforce ( 14 ). The training was designed to develop the skills of supervisors, but also to develop peer support workers’ abilities to use peer support in their own recovery and in helping others. Given the centrality of the worksite in shaping peer support worker experiences, we conducted a cluster-randomized trial, with baseline and 10-month follow-up data, to evaluate the efficacy of the training program. For our primary outcomes, we hypothesized that recipients of the training would report an improved peer-supportive organizational climate, reduced mental health stigma, and increased peer support worker recovery. For secondary outcomes, we examined the recovery orientation of services (i.e., valuing service users with honest and respectful communication), perceived utility of peer support, job satisfaction, supervision quality, quality of the supervisor–peer support worker relationship, discrimination experience, use of peer support (i.e., proportion of time spent delivering peer support services), mental health symptoms, work-related burnout, sick leave taken, and social support.

Trial Design

With funding from the State of California, SHARE! initiated and helped direct this evaluation of the Supervising the Peer Workforce training. This cluster-randomized trial used parallel assignment, with mental health provider sites serving as clusters assigned to one of two arms via a balanced 1:1 allocation ratio. Sites in the intervention arm received the training, whereas sites in the control arm did not have access to the training until after the data collection was complete. Peer support workers and supervisors at all sites completed baseline and 10-month follow-up surveys. All study procedures were approved by the institutional review board at the University of Texas Health Science Center at Houston. No adverse events were reported.

Mental Health Provider Site Recruitment

To be eligible, mental health services sites had to have peer support workers and supervisors who could attend the training in Los Angeles County. All directly operated and contracted service-providing sites for the Los Angeles County Department of Mental Health (LACDMH) were invited to participate in the study. Sites unaffiliated with LACDMH were not actively recruited but were allowed to participate if staff members were willing to travel to the in-person training.

Site recruitment began in June 2018, with an e-mail from the LACDMH director to all provider sites explaining the study and encouraging participation. Project team members followed up with the sites via telephone and e-mail to further explain the study and to obtain contact information of peer support workers and supervisors. Site recruitment concluded in October 2018. The study sample size depended on the number of LACDMH-serving worksites employing peer support workers willing to enroll, because grant funding was for those providers only.

Allocation of Sites to a Study Arm

After site recruitment, we matched pairs of sites according to the following four rank-ordered criteria: whether the site was directly operated by the LACDMH, annual budget, number of peer support workers and supervisors, and whether the site focused on youths and families, with parent partners hired as peer support workers. Because of the rank ordering of the matching criteria, we could exactly match sites solely on whether a site was directly operated by LACDMH. We matched sites to their nearest neighbor on lower-ranking criteria, without compromising nearest-neighbor matches from higher-ranking criteria ( 29 ). After the matching was complete, a person unaffiliated with the study used the random.org website to generate a random number seed for use with the SAS PROC SURVEYSELECT procedure in order to assign one site from each matched pair to the intervention condition and the other to the standard practice condition. The intervention and comparison groups showed no significant differences in any matching criteria. Data collection staff were blind to intervention status.

Participants

Participants were peer support workers and their supervisors at the enrolled sites. Peer support workers were defined as people with lived experience in the mental health system (as consumers or as parents, other family members, or caregivers of consumers) employed to provide peer support services in the system. Job titles of these workers included family advocates, family navigators, parent partners, peer specialists, and peer navigators. To ensure sufficient work investment, unpaid peers volunteering <15 hours per week were excluded. Supervisors tended to be clinicians or administrators and had little or no training in peer services. Supervision practices varied greatly, possibly because of a lack of standards for supervision of peer support workers.

Data Collection

In October 2018, we e-mailed the initial online survey invitation to peer support workers and supervisors listed by the participating sites. An accompanying letter explained the study. Nonresponders received weekly e-mail reminders and telephone calls to encourage completion. Peer support workers and supervisors were allowed to complete the baseline survey up until their first training session.

As detailed in the flow diagram in the online supplement to this article, 348 peer support workers and 143 supervisors from 85 sites were eligible for study participation, after four sites dropped out during baseline data collection. Of the 85 sites, 32 were directly operated by LACDMH, 51 had contracts with LACDMH, and two were unaffiliated sites north of the county. In total, 251 peer support workers and 115 supervisors completed the baseline survey, yielding a response rate of 72% among peer support workers and 80% among supervisors. Between the baseline and 10-month follow-up data collection events, 39 peer support workers and 15 supervisors left their jobs. Those who left and those remaining did not significantly differ in demographic characteristics or outcome measures at baseline. The follow-up survey was administered only to the 212 peer support workers and 100 supervisors who completed the baseline survey and remained employed at their site. Of these participants, 169 peer support workers and 86 supervisors completed the survey, yielding a response rate of 80% for peer support workers and 86% for supervisors. Data collection ended in January 2020. Details of the outcome measurement are reported in the online supplement ( 30 – 43 ).

The Peer Workforce Intervention

SHARE! provided the following four training sessions from December 2018 through May 2019: Strategies for an Effective Peer Workforce, Cultural Competence: Becoming an Ally, Trauma-Informed Developmental Model of Supervision, and Stigma . . . in Our Work and in Our Lives. To accommodate participants’ schedules, these workday training sessions were held in several Los Angeles County locations and at various times. Box 1 outlines the session topics. The curriculum was delivered as intended by the developers of the training, with peer support workers and supervisors attending on average 2.0 and 1.5 sessions, respectively. Among the 91 peer support workers in the intervention condition with baseline and follow-up data, 57 (63%) attended the first session, 40 (44%) attended the second, 47 (52%) attended the third, and 40 (44%) attended the fourth. Among the 44 peer supervisors in the intervention condition with baseline and follow-up data, 22 (50%) attended the first session, 15 (34%) attended the second, 16 (36%) attended the third, and 12 (27%) attended the fourth.

BOX 1. Overview of the mental health workforce training for peer support workers and their supervisors

Session 1: strategies for an effective peer workforce (7 hours).

Discuss best practices in peer services:

◦ Peer listening and disclosing

◦ Recovery planning

◦ Use of self-help support groups

◦ Peer bridging

◦ Use of the helper therapy principle

Explain differences between peer worker and clinician responsibilities.

Introduce strategies for peer providers and supervisors to reduce stress and improve self-care.

Session 2: Cultural Competence: Becoming an Ally (7 hours)

Address discrimination within agencies and the community.

Convey that allies allow people to move away from stigma and “othering.”

Convey that allies support people by speaking up when they witness stigma and discrimination.

Cultivate a dialogue with balanced inquiry and advocacy.

Session 3: Trauma-Informed Developmental Model of Supervision (7 hours)

Teach trauma-informed practical tips and strategies for self-care and supervision.

Emphasize that supervisory relationships are between allies working together for better results.

Help peers and supervisors understand how their trauma experience is connected to mental health.

Build self-awareness, motivation, and autonomy.

Help peers and supervisors to develop a joint trauma-informed developmental model of supervision for their specific work.

Session 4: Stigma . . . in Our Work and in Our Lives (3 hours)

Present evidence-based training, delivered by On Our Own of Maryland, a peer-run organization ( 23 ).

Help participants recognize how they are impeded by stigma against people with mental illness.

Teach participants to recognize stigma within and around them and gain awareness of stigmatizing comments and behaviors.

Explore changing behavior to reduce stigma in the workplace.

Two aspects of the planned intervention proved difficult to implement. The first was a learning collaborative, imagined as monthly conference calls with intervention participants. The second was the creation of implementation teams at the participating sites to facilitate implementation of the training principles into practice. Interest among participating sites for these two components of the intervention was limited, and both aspects were abandoned before reaching 10% of the participating sites.

Statistical Analysis

A statistical power analysis, conducted with Optimal Design software ( 44 ), indicated that a sample size of 68 sites, with two participants per site (intraclass correlation coefficient=0.05), would provide a power of 0.80 to detect an effect size of Cohen’s d=0.50 at p=0.05. We completed intention-to-treat analyses in 2022 to test our hypotheses that recipients of the training would report improvements in all the previously listed primary and secondary outcomes, relative to participants in the practice-as-usual comparison condition. With each outcome serving as a dependent variable in a separate regression model, intervention status was the primary independent variable. All regression models included baseline levels of the dependent variable, gender, age, educational attainment, and mental health consumer status (yes or no) as covariates. Mixed-effects regression models accounted for the nesting of participants within sites, with multiple imputation used to estimate missing data. Dependent variables were standardized (mean=0 and SD=1), so regression estimates for the intervention effect reflected Cohen’s d measures of effect size. All analyses were done with SAS, version 9.4.

Table 1 shows the gender, race, age, educational attainment, and consumer identity of the peer support worker and supervisor samples, by study condition. Among the 169 peer support workers included in the analysis, 74% (N=125) were women; most workers were ages 36–50 years and had a high school diploma, GED, or less. The sample of peer support workers was racially diverse (29% White, 18% Black, and 30% “other” race). Most of the peer support workers self-identified as mental health consumers (N=96, 57%). Peer support workers also self-identified as family members (N=56, 33%), parents (N=54, 32%), and caregivers (N=28, 17%) of a consumer.

a “Other” gender included a response to the question, “With which gender do you most identify?”

b Participants could check all that apply.

c “Family” is a broader term than “parent” and may not involve caregiving.

TABLE 1. Characteristics of the peer support workers and their supervisors, by study condition

The 86 supervisors were similar to peer support workers in terms of gender and age. However, supervisors had substantially more education than peer support workers, with 74% possessing a graduate degree. Supervisors’ professional discipline was typically administrator (N=46, 54%) or clinician (N=27, 31%), rather than peer support worker (N=5, 6%). Overall, 29% (N=25) of the supervisors self-identified as mental health consumers, 40% (N=34) as a family member of a consumer, 13% (N=11) as a parent of a consumer, and 14% (N=12) as a caregiver of a consumer. Supervisors spent a mean±SD of 3.3±3.4 hours per week supervising peer support workers, with 28 (33%) having received peer support worker supervision training at baseline.

Table 2 shows the findings from the intention-to-treat analysis for all primary and secondary outcomes. Analyses identified significant improvements in the site outcomes—peer-supportive organizational climate and recovery orientation of services. After the training, peer support workers in the intervention condition rated their organization as having peer-supportive organizational climate scores that were significantly higher than those reported by peer support workers in the comparison condition (Cohen’s d=0.35, p=0.04). Similarly, being in the intervention condition predicted a significant increase in ratings of the recovery orientation of services, relative to the comparison condition (Cohen’s d=0.44, p=0.01). Recovery orientation of services was based on peer support workers’ ratings of how providers interacted with service users.

a Assessed at the 10-month follow-up. Only primary outcomes are specified in parentheses; all others were secondary outcomes. See the online supplement for further definitions of outcomes.

b Peer rated.

c Supervisor rated.

TABLE 2. Difference between intervention and comparison conditions in primary and secondary outcomes, by outcome level a

No significant differences between the intervention and comparison conditions were detected in supervisor outcomes after the training. Supervisors’ mental health stigma, perceived utility of peer support, job satisfaction, and ratings of supervisor–peer support worker relationships were similar across the two study conditions. The training did not produce significant differences between the intervention and comparison conditions in the peer support worker outcomes of discrimination experience or workers’ time spent on actual peer support services (e.g., peer mentoring and referral to self-help groups, rather than other tasks, such as case management and clerical work). Finally, the distal peer support worker outcomes were all nonsignificant for recovery, work contributions, job satisfaction, work-related burnout, sick leave and disability days used, brief symptom inventory score, stress, and social support.

To our knowledge, this study is the first randomized trial of an intervention designed to strengthen supervision of the peer workforce. The training did not improve individual-level supervisor or peer support worker outcomes. However, the intervention improved peer support workers’ perceptions of the supportiveness of their organization. Significant improvement in site outcomes was observed for peer-supportive organizational climate and recovery orientation of services, yielding small to medium effect sizes ( 45 ). The improved ratings of peer-supportive organizational climate suggest that the training led the provider organizations to place greater value on their peer support workers. Although recovery orientation of services is a complex construct, it was defined in this study as the presence of respectful, honest, and equitable relations between service providers and recipients ( 31 ). These changes in the culture of the sites are important outcomes, linked to job satisfaction and service quality ( 30 ). The changes may also be related to client treatment outcomes, which could be examined in future research.

The intention-to-treat analyses indicated null findings for all supervisor and peer outcomes. Limited attendance at the training sessions among participants in the intervention condition (ranging from 27% to 63% participation per session) may have affected the detection of statistically significant findings. Supervisors and peer support workers were not paid to attend the sessions and had to manage ongoing work responsibilities while pursuing the training voluntarily. Financial support to undergo training may have enhanced training engagement and trial outcomes.

A more robust intervention, as initially planned, may also be needed to bring the training principles into practice and to have an impact on supervisor and peer support worker outcomes. Previous research ( 46 ) has suggested that ongoing support is necessary for training to successfully lead to a change in behavior. We were unable to implement the full intervention as planned. Specifically, the monthly learning collaborative and the formation of implementation teams at worksites reached <10% of the study participants. Formal action planning among all supervisors and peer support workers at a given site is likely necessary to fully integrate training content into practice ( 47 ).

This study’s strengths included the high internal validity of the randomized trial and the use of established measures with good internal consistency. The intervention was carried out under the substantial constraints of a real-world practice setting, which improved the study’s external validity. Positive response bias was a threat to validity because participants knew their intervention condition. However, why this bias would drive site outcomes, but not individual outcomes, remains unclear.

The minimal funding available for this trial presented challenges, particularly the absence of participant incentives for survey completion. The large number of outcomes examined increased the risk for type I error. Additional research is needed to ensure that the findings are replicable. Another challenge was the project’s short timeline. Training sessions had to be developed quickly, without the benefit of pilot testing. Finally, mental health stigma may have impeded the project’s success: supervisors with stigmatizing attitudes may have been reluctant to learn supervision techniques from a peer-run organization.

Conclusions

Our findings suggest that the Supervising the Peer Workforce training program of SHARE! did not improve supervisor or peer support worker outcomes. However, the results suggest that the training helped change organizational culture to be more supportive of peer support workers and to create more equitable relationships between service providers and recipients. The training helped supervisors and peer support providers recognize and address barriers to successful inclusion of peer support workers. Further integration of the training’s principles into practice may strengthen peer support workers’ capacity to improve the quality of life and recovery of the individuals they serve.

This work was supported by a grant from the California Department of Health Care Access and Information, formerly known as California’s Office of Statewide Health Planning and Development.

The authors report no financial relationships with commercial interests.

Clinicaltrials.gov ID: NCT03709537.

These views represent the opinions of the authors and not necessarily those of the California Department of Health Care Access and Information.

The authors thank the mental health workforce members who participated in this research, especially those affiliated with the Los Angeles County Department of Mental Health.

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• Attitudes toward mental illness
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Peer-reviewed

Research Article

Peer Support Workers in Health: A Qualitative Metasynthesis of Their Experiences

* E-mail: [email protected]

Affiliation University College London, Research Department of Infection and Population Health, 4th floor Mortimer Market, off Capper Street, London, United Kingdom

• Jennifer MacLellan, 
• Julian Surey, 
• Ibrahim Abubakar, 
• Helen R. Stagg

• Published: October 30, 2015
• https://doi.org/10.1371/journal.pone.0141122
• Reader Comments

Peer support models, where an individual has a specific illness or lifestyle experience and supports others experiencing similar challenges, have frequently been used in different fields of healthcare to successfully engage hard-to-reach groups. Despite recognition of their value, the impact of these roles on the peer has not been systematically assessed. By synthesising the qualitative literature we sought to review such an impact, providing a foundation for designing future clinical peer models.

Systematic review and qualitative metasynthesis of studies found in Medline, CINAHL or Scopus documenting peer worker experiences.

1,528 papers were found, with 34 meeting the criteria of this study. Findings were synthesised to reveal core constructs of reframing identity through reciprocal relations and the therapeutic use of self, enhancing responsibility.

Conclusions

The ability of the Peer Support Worker to actively engage with other marginalised or excluded individuals based on their unique insight into their own experience supports a therapeutic model of care based on appropriately sharing their story. Our findings have key implications for maximising the effectiveness of Peer Support Workers and in contributing their perspective to the development of a therapeutic model of care.

Citation: MacLellan J, Surey J, Abubakar I, Stagg HR (2015) Peer Support Workers in Health: A Qualitative Metasynthesis of Their Experiences. PLoS ONE 10(10): e0141122. https://doi.org/10.1371/journal.pone.0141122

Editor: Ali Montazeri, Iranian Institute for Health Sciences Research, ACECR, ISLAMIC REPUBLIC OF IRAN

Received: June 26, 2015; Accepted: September 5, 2015; Published: October 30, 2015

Copyright: © 2015 MacLellan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Data Availability: All relevant data are within the paper.

Funding: Funding was provided by Department of Health Policy Research Programme, grant number 015/0306, JM, JS, IA, HRS. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The use of peer support models in healthcare is well established in mental health services where peer support workers (PSWs) serve to improve engagement with healthcare and positive health outcomes among their clients [ 1 – 15 ]. PSWs are usually recruited from the same client pool as the individuals that they are looking after, thus sharing similar experiences or characteristics with the target intervention group. They are given a basic level of training or orientation to the role and join a team of PSWs to offer support and encouragement to others on their illness journey [ 16 ]. This can range from informal visits and sharing of experiences to formal appointments focused on practical information giving and support in relation to the intervention.

The ability of the PSW to engage with clients on the same level through an understanding of the challenges of their situation is a core feature of their effectiveness. Of further significance is the fluidity of the peer worker role, enabling them to move successfully between client and service provider roles to facilitate client wellbeing and positive care outcomes. Such outcomes could include attendance at hospital appointments, HIV medication adherence, self monitoring of blood sugar, commitment to a healthy diet and exercise regime, or continuation of breastfeeding. The value of peer support models for improving client access, uptake and engagement with health services and for adding value to the client experience is widely recognised. Their success has been replicated in engagement with hard to reach groups from middle aged men with chronic disease [ 17 – 21 ], to those with stigmatised disease [ 16 , 22 – 25 ] and people who misuse substances [ 26 , 27 ].

In spite of the number of studies qualitatively analysing the impact of the role on the PSWs in healthcare, their focus is often narrow and related to issues of personal recovery. The over-arching experiences of PSWs, as described in their own words, have not been systematically synthesised. Collating this evidence is a vital task to bring together what is known with the aim of maximising the effectiveness of PSWs. Furthermore, such synthesis plays a valuable role in contributing PSW perspectives into the design of standardised guidance for the planning and training of future PSW intervention programmes in healthcare. This review aimed to fill this evidence gap by systematically reviewing PSW perceptions of their experiences of the role from qualitative studies and synthesising findings to identify common constructs in these experiences in order to provide new understandings from the data. We also assessed how this evidence could impact PSW effectiveness and promote the standardisation and thus potential accreditation of peer support work.

The meta-synthesis process aims to draw together qualitative studies from a related area and search for relationships across records to expose new perspectives and understandings of a phenomena. Systematic and reproducible search techniques are thus used to identify relevant records to the topic under study, quality assessment of records are made, findings are then presented and related to each other to gain new insight [ 28 ].

Systematic Literature Search

This review investigated qualitative studies documenting PSW perceptions of their experiences of the role. The search terms utilised were (“peer supporter” or “peer mentor” or “peer educator” or “peer advocate” or “peer listener”) AND “health”, thus capturing the broad use of terminology for the PSW experience. These were informed by a wide selection of preparatory reading as no MeSH terms covered the topic. Experts in the area were consulted (HRS, IA) to ensure the use of appropriate and wide search terms. For consistency in this synthesis, the term PSW is used throughout.

Inclusion and Exclusion Criteria

Our inclusion criteria were for articles to report PSW experiences of face to face peer support models as some component of the primary qualitative data. All health domains relating to adults were included, from all geographical locations. Records were excluded if they did not contain information on the experience of peer support work from the perspective of the peer in a health context. Online and telephone peer support models were excluded due to the lack of face-to-face interaction and the complicating dimension of online communication styles and rules of interaction. Records reporting client outcomes without inclusion of the PSW experience were also excluded. Peer work with adolescents in schools was excluded as a unique domain of practice with the peer usually recruited from the target rather than the affected population. Only publications available in English were reviewed.

Search Results

Records were de-duplicated, then screened for inclusion by the two reviewers JM and JS, with a third reviewer available to resolve any discrepancies (HRS). Inter-rater agreement for screening of full text records was 95%.

Literature Synthesis

JM and JS independently read the records and summarised the key constructs as interpreted by the research authors into an Excel grid to facilitate the cross-comparison process of the synthesis. The initial agreement level in coding was 87% between JM and JS. Meta-synthesis is influenced by the perspective of the researchers as they aim to inductively generate higher order constructs from the author themes of the records. This prompted extensive discussion and refinement of coding decisions before 100% consensus was reached.

Since there is no universally recognised method of synthesis, each record was listed alphabetically and constructs from each paper were compared with the next in the alphabetical list [ 29 ]. As the records were synthesised, categories were merged and collapsed while the researchers remained open to emergent themes. Synthesis of commonalities and contradictions across records built an explanatory model or ‘line of argument’ of the phenomenon, bringing fresh interpretation to the topic. This approach to meta-synthesis has its origins in grounded theory and aims to develop a model inductively from the data [ 30 ].

Critical Appraisal

Study quality was graded using the Critical Appraisal Skills Programme tool for qualitative studies (CASP) [ 31 ]. The two reviewers (JM and JS) graded the records independently, conferred on a random selection and discussed discrepancies to achieve consensus, with the third reviewer available to resolve any discrepancies (HRS). Records were not excluded as a result of a low score, recommended by Atkins et al . [ 29 ], although they were integrated to this synthesis with these concerns in mind. Such records tended to be descriptive rather than interpretive, and contributed fewer insights to this synthesis.

Medline, CINAHL and Scopus databases were searched during June 2014. In order to identify potentially eligible studies not available through these databases, manual searching of article reference lists and grey literature supplemented the findings.

The three databases yielded 1,520 publications post deduplication, plus 8 records from manual searching of article reference lists and grey literature. Search Results are recorded in the PRISMA diagram ( Fig 1 ). Eligibility criteria for this review was fulfilled by 39 articles. On full text analysis, a further 5 articles were discarded as not providing a peer perspective, leaving 34 records to complete the objectives of this paper.

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https://doi.org/10.1371/journal.pone.0141122.g001

Table 1 presents the 34 included records. Study participants ranged from 1 (study presenting a narrative) to 154 (completing an online questionnaire). All were self-selecting, although some efforts were made by the researchers to purposively sample to reflect participant diversity across project sites and in demographic characteristics. The principle method of data collection was in-depth interview (18) followed by focus group discussion (3), or a mix of both these approaches (5). One study presented a peer narrative without researcher interpretation while the remaining 7 included studies employing a combination of methods, such as questionnaire and observation.

https://doi.org/10.1371/journal.pone.0141122.t001

The field of mental health gave the greatest yield of records to meet the criteria of this review (14), followed by peer work in non-communicable diseases (9) ranging from diabetes and heart disease to weight management and renal failure. Infectious disease followed (6), focusing on HIV peer support workers, with hepatitis C and tuberculosis having a presence. Breastfeeding and new mother support added the final 5 articles.

The synthesis revealed two core constructs that provide insight and possible explanation of effectiveness in the PSW role. These were:

Reframing of identity through reciprocal relations

• Therapeutic use of self, enhancing responsibility

These core constructs form the PSW conceptual framework emerging from this synthesis, and expose the complex and inter linked sociological phenomena of PSW experience. As can been seen in Fig 2 , with an increased incidence of the therapeutic use of self care model by the PSW, there is a corresponding increase in both the sense of responsibility to others and the self, and in the extent and quality of the reciprocal relationship with the client and colleagues. This relationship is mirrored on the identity axis, as the PSW experiences an evolution and reframing in their identity. The quality and extent of reciprocal relations formed through their role are increased with a corresponding rise in the sense of responsibility to themselves and others. Naturally this theoretical framework is not necessarily linear in reality as individuals oscillate along the axes of their experience. However, we feel the linear representation aids conceptual understanding of the synthesised constructs. Each core construct is discussed in detail under strengths of PSW experiences and challenges in their experiences, with discordant findings across records and constructs reported in the challenges section.

As the therapeutic use of self increases in the PSW-client relationship, reciprocity increases. As the reframing of identity process progresses in the PSW, the sense of responsibility to the client, colleagues and self also increases.

https://doi.org/10.1371/journal.pone.0141122.g002

Strengths of PSW experiences.

A consistent author construct across records was the benefit of the PSW engaging in a reciprocal relationship through their work. Analysis of this construct revealed interlinking aspects with reciprocal relations and the evolving identity of the PSW. Through interaction with other PSWs and clients, the benefits of belonging and reframing of the past to give meaning to their suffering and experiences, enhances an awareness of their ability to participate and give something back. The evolution of their identity into this giving role is stimulated by the relationships, and also develops and further benefits those relationships.

Reciprocity reflects a bi-directional relationship, stimulating a greater degree of personal insight and awareness of the impact of PSWs behaviour on others [ 1 , 8 , 14 ]. Such insight into the self led to greater self acceptance and understanding of their own position on the recovery journey [ 4 , 8 , 12 , 13 , 25 , 27 ]. Greater insight into others’ experiences put individual egos aside and led to an appreciation of what others had been through [ 3 , 8 , 13 , 19 , 25 ]. Close PSW teams were facilitated by their shared illness experience, shared programme goals and support of each other’s different positions in the recovery journey [ 3 , 4 , 12 , 15 , 22 ]. Connection with other PSWs was highly valued and allowed individuals to feel safe as themselves, integrating their psychiatric or physical condition into their life [ 1 , 3 , 4 , 8 , 22 , 32 ]. Furthermore, insight of the PSWs into their own personal illness led to regaining control over their life by actively participating in their illness management and recovery. The reciprocal nature of the PSW and client network, embodying social participation, was specifically linked to the peer’s recovery in the study by Moran [ 7 ], but was also seen in a mental health, infectious disease and non-communicable disease context [ 8 , 12 , 13 , 16 , 20 , 24 , 27 ]. While this insight helped to define the PSW identity, it increased their awareness of the presence of their overlapping identities [ 3 , 4 ].

Participation in social networks with clients and other PSWs acted as both a motivation and a support in reducing feelings of isolation in 14 of the articles in this synthesis [ 1 , 3 , 11 , 13 , 15 , 17 , 18 , 22 , 27 , 32 – 35 ]. Social participation has been shown to remove anxiety and unhappiness while the existence of social relations increases the motivation for helping [ 36 ]. Helping others in the role of PSW was felt to be a worthwhile and positive job [ 3 , 13 , 27 ]. Pillemer et al . reported 88% of their 45 respondents cited ‘helping others’ as their principle motivation for joining the PSW programme [ 32 ]. Altruism is described by Mollica as one of the most powerful social tools to stimulate an individual’s self-healing [ 37 ]. This motivation supports development of the PSW identity, by repaying the gift of having their story heard by colleagues and clients through telling the client’s story and making them visible. This motivation was reported across the papers of this review [ 1 , 2 , 14 , 22 – 24 , 27 , 32 , 33 ].

While combating personal isolation, in some cases participation also eased the pressure in the relationship with their partner [ 34 ], taught the PSW to ‘stay clean’ [ 27 ], and to receive acceptance and validation of their new recovery identity [ 3 , 4 , 6 , 12 , 27 , 38 ]. The easy acceptance of each other in the PSW teams produced a safe and positive work environment in the study by Mowbray et al [ 13 ]. In such an environment, the intangible ‘smoky’ stigma and fear surrounding their psychiatric illness was described as becoming positive, creating an air of recovery, and even assuring recovery for participating individuals [ 8 ]. Joining the PSW network was also described as facilitating reintegration into the community [ 11 , 19 ]. This was a result of doing something perceived as positive for the community, not just receiving but participating [ 27 , 33 , 35 ].

The belongingness theory of Baumeister and Leary describes this need to belong as a fundamental human motivation [ 36 ]. Part of a person’s identity and self-understanding is their place in relation to family, friends and their community. If these relations are severed or compromised, as in the case of many of the subjects presented in the studies of this review, it fundamentally impacts the person’s own self understanding [ 39 ]. This is based on the belief that individuals are socially embedded, where social relations constitute an individual’s identity and this is reaffirmed or discredited through interaction with others. Since the PSWs’ emerging identity is dependent on this interaction, it was seen to engender a sense of purpose and increased self esteem [ 9 , 11 , 12 , 19 , 21 , 22 , 25 , 33 – 35 , 40 ].

The reciprocal relations with others encouraged goal setting by the PSWs relating to what type of person they wish to be in the studies by Freeman et al and Moran et al [ 8 , 39 ]. Their life and illness experiences gained new meaning and involved not denying the past but validating and reframing it to accept who they are [ 1 – 3 , 8 , 12 , 14 , 22 , 23 , 32 , 33 ]. It gave meaning to suffering and made it all worthwhile [ 3 , 8 , 33 ]. Thus the PSW learns to reinterpret their own life story as a positive experience, worthwhile because of what they can now give to others. This reinterpretation or reframing of identity is an essential experience as it is not possible for individuals to be extracted from the context and histories within which they understand themselves. Acceptance of their illness or history in their current relational context reflects evolution of the self seen through personal validation and a positive outlook [ 39 ]. This was seen to translate into feeling more hopeful about the future, affirming their new PSW role identity and a general improvement in quality of life [ 1 – 3 , 9 , 12 , 14 , 15 , 18 , 19 , 22 , 23 , 25 , 27 , 32 , 33 ].

Challenges in PSW experiences.

We examined author constructs in the records to expose discordant findings in our synthesised themes. Across the 34 records there was a significant variety of experience with contrasting findings supporting our constructs. For example, an emotional disconnect from the PSW was reported if they felt they were not needed. They described a lost opportunity if they were unable to connect with a client [ 14 , 17 , 21 , 35 ]. Those PSWs who did not experience positive engagement with clients often reacted with a lack of motivation to continue in the role and emphasised the time commitment required by the programme [ 41 ]. However, it was also acknowledged that the PSW intervention was perhaps not appropriately timed for some clients [ 22 , 23 ]. In Murphy et al . when clients were unaware of the role of the PSW there was frustration and difficulty in making a connection [ 41 ].

PSW work was described as relational and not captured in service documentation [ 10 , 23 , 42 ]. Most information was described by PSWs as being carried in their head, which increases trust from the client, but clashed with the note writing culture and accountability of the mental health system [ 10 ]. PSWs described how patient behaviour can be disciplined by the information kept about them in the medical notes. They reported writing collaborative notes in an empowering way, or struggling to manage time for the administrative commitment [ 5 , 10 , 42 ].

This first synthesised construct is intimately linked with the second: Therapeutic use of self enhancing responsibility. This is because the developing reciprocal relationship enhances the peer identity and sharing of one’s story is a unique component of this identity. Sharing one’s story and realising its impact through the relationship (therapeutic use of self) stimulates a sense of responsibility to the client, the programme, colleagues and to the self.

Therapeutic use of self enhancing responsibility

Strengths of psw experience..

Analysis of the common author constructs of sharing one’s story and responsibility revealed a unique body of practice in the therapeutic use of self by the PSW as the core component of their effectiveness. The type and level of disclosure was related to a sense of responsibility to the client but also to the PSW themselves.

Some PSWs in this synthesis described their position as unique, drawing dignity and pride from a belief in their unique skills [ 43 ]. The sense of responsibility and commitment PSWs brought to their work can be seen as a way to import meaning into their role. This is an important source of dignity for workers whose role is perhaps undervalued or invisible in the health economy [ 43 ]. Focusing on their current recovery position and reframing the past through the lens of the present, to offer a model of recovery, was seen as a foundation of the PSW role [ 2 ]. In many of the records reviewed for this synthesis, the sharing of personal experiences was described as a unique characteristic of the PSW and a mechanism for gaining trust with clients [ 3 , 16 , 23 , 25 , 41 ].

Sharing could be supportive through the giving of advice and assistance with problem solving [ 1 , 3 , 14 , 22 , 23 , 26 , 33 , 41 ]. Clients could openly discuss with the PSW their drug use and their feelings of having let the medical staff down by having a relapse [ 26 ]. Judgement of client behaviour, whether perceived or real, was described as a huge barrier to engagement and the PSW felt they could alleviate this [ 16 , 26 ]. Their equality of relationship put the PSW in a unique position to help as they could move between the role of service user and service provider depending on the requirements of the situation [ 21 , 23 , 26 , 32 , 44 ]. In both HIV and hepatitis C treatment contexts, PSWs described their role as integral because the treatment process is so complex and challenging due to multidisciplinary involvement and issues of stigma among the client group [ 16 , 26 ].

Sharing personal experiences is an important component of the recovery journey as individuals search for coherence in their challenging experience of illness or marginalisation [ 45 ]. Most people who have faced adversity are interested in how their story can help others. While teaching others about survival, they are also transferring some of their suffering to the listener and extending their own healing process [ 46 ]. The self-disclosure of the PSW also acts as validation of who the PSW is and what they have survived to tell [ 47 ]. Having a listener for your story is part of the therapeutic process of the reciprocal relationship, both recognising and supporting the storytellers’ healing process [ 48 ]. The PSW shares their story and in exchange the client discloses their experience. Self-disclosure from the PSW as ‘service provider’ is known to promote client engagement, rapport and trust in a therapist-client context [ 49 ]. This style of engagement models the therapeutic use of self, a powerful but unmeasurable technique used in the establishment of a positive therapeutic alliance in psychosocial care contexts and vital to the achievement of positive outcomes [ 50 ].

Part of this therapeutic contract is the normalising of the client experience and creation of an egalitarian relationship [ 49 ]. The PSWs of this synthesis felt they could achieve this through their ability to enjoy group membership in both service user and service provider roles. Being able to understand the clients’ frame of reference, or practising empathy, has been shown to link to positive outcomes and form the foundation of a positive therapeutic alliance [ 51 , 52 ]. Being caring, asking the client questions, discussing options and providing explanations are all positively associated with the therapeutic alliance, satisfying the basic needs in the client of autonomy and belonging. Giving directions and advice were negatively associated with a positive relationship [ 52 ].

Working as a PSW gave a sense of responsibility to the peers to the extent that one PSW described joining the programme as a ‘moral obligation’ [ 8 , 14 , 17 , 25 , 27 , 32 ]. Some PSWs approached the position with a dedicated work ethic and desire to be successful [ 14 , 18 ]. In some cases this led to increased motivation for self care behaviour and illness management to live up to the perceived expectations of service users and act as a role model [ 1 , 8 , 17 , 21 ]. In one study this led to a reduction in the use of acute services by the PSWs [ 9 ]. Even if the PSW described having a ‘relapse’, they felt encouraged to return to the PSW programme through this sense of responsibility to the clients and fellow PSW colleagues [ 12 , 13 ].

Some participants saw the PSW role as a stepping stone back into employment with the benefits of gaining skills, having money, and practicing scheduling [ 6 , 11 , 13 , 15 , 25 ]. The structure and responsibility involved with going to a job every day and focusing energy on something deemed as constructive work was described as strong treatment [ 8 ]. Learning communication skills that encouraged assertiveness rather than aggression and being able to talk to medical staff and clients without offending them were seen as valuable lessons [ 13 , 22 , 34 ]. This helped PSWs feel more professional in their conduct [ 2 ]. It also gave an opportunity for the development of transferable, under-developed skills and increased personal flexibility [ 3 , 33 , 34 , 44 ].

The work environment played a significant role in the experience of the PSW. In a positive environment, staff were described as treating PSWs as equals. Peer experiences were respected, they felt treated as a whole person rather than as their diagnosis, and strengths were emphasised [ 6 , 8 , 15 , 25 ]. Role playing different ways in which to respond to situations where boundaries are challenged was felt to be particularly valuable in the mental health PSW study reported by Gillard et al . [ 2 ].

Challenges in PSW experience.

The discordant findings linked to this core construct supported the synthesis findings, for example if the PSWs were unable to share their story and work according to a therapeutic model of practice, support and assistance in the drawing of boundaries was requested. Generally, transition from the role of service user to PSW was described as challenging, particularly as to where to draw the line between service provider and friend [ 2 , 5 , 6 , 11 , 13 , 19 , 23 , 26 ]. It was described as a hard place, occupying the middle ground between provider and service user [ 2 ]. However, more engagement from clients was reported when the PSWs socialised with them and the relationship became more reciprocal [ 13 , 14 ]. Managing the power imbalance between client and health provider through transition to the role of PSW revealed some hostility against the system, and a ‘chip on the shoulder’ from the PSW side that had to be addressed [ 6 ]. Communicating with staff in a more professional manner was felt necessary to aid this role transition [ 6 ]. However, this required assertiveness and could be a struggle for some [ 2 ]. One PSW described the transition as getting to know the teachers and hoping you won’t get caught misbehaving [ 12 ]. The ‘best behaviour’ metaphor was also used by the PSWs in Gillard et al when referring to the pressure to gain acceptance from the team and the worry that if they get upset, people will think ‘she is having a service user moment’ [ 2 ]. This statement reflects the multiple, shifting identities of the PSW and their vulnerability.

The ‘lay expert’ position sometimes caused role confusion, with a golden rule stated by Watson that the PSW is never the expert [ 12 ]. Some PSWs reported feeling unsure of how to do the job or what was expected of them [ 6 , 12 , 13 , 15 , 26 ]. This lack of clarity was felt by some PSWs to be empowering [ 6 , 17 ], while others felt daunted [ 12 ]. Consequently, clarification in the extent and nature of PSW involvement at recruitment was deemed important [ 2 , 4 , 5 ]. This included knowing when to disclose their own story and how much to disclose. It was described as a fine balance, between sharing experiences and self preservation [ 3 , 5 , 6 , 12 ]. It also made the PSW vulnerable as their recovery journey is exposed to criticism by others [ 2 , 12 ]. Furthermore, care was necessary not to devote too much time to the PSW disclosure as this could detract clients from a willingness to engage [ 49 ]. Consequently, this drawing of boundaries was described as necessary to enact personal responsibility to the self [ 2 , 12 ]. The PSWs in Kemp et al . [ 5 ] recommended the provision of training in boundaries and ethics to overcome this danger, allowing them to manage the client relationship while keeping themselves ‘safe’. Interestingly, in Gillard et al .’s mental health study, PSWs reported non-peer staff to not value the ‘giving of personal experience’ as it crossed boundaries that were in place to protect the PSWs and service users. This tension was felt to constrain the emergence of a distinctive practice of PSW that the whole team could agree upon.

When feeling unsupported, some PSWs felt their role carried too much responsibility [ 13 ] or too much pressure to be a role model [ 6 ]. They felt inhibited about the extent to which they could share their experiences [ 2 ], and described feeling ‘out of their depth’ [ 6 , 26 ]. As a result, accessibility of a support person from this environment, either professional [ 5 , 13 ], in other PSWs [ 19 , 35 ] or from an outside network when there was no supportive PSW team [ 6 , 26 ], was mentioned as essential for managing some situations that arose [ 14 , 18 , 21 , 41 ]. However, professional supervision was not always felt to be constructive [ 2 ].

Finally, working with colleagues of different abilities caused frustration in the study reported by Yuen & Fossey as some could not do much without having a symptom relapse while others were ready to move on and be more active [ 15 ]. Thus clearly defined tasks would have been appreciated to fit the different abilities and motivation of the PSWs. Equally, being dependant on colleagues to facilitate a group that is then cancelled because they are on leave results in no payment and a feeling of powerlessness [ 2 ]. Regular updates of developments in treatments and advances relevant to the role were requested by some PSWs so they could give the most up to date advice [ 21 ]. Others requested more detailed medical information about the client to better target their advice [ 18 ].

Some discrimination and prejudice was experienced in the work environment with condescending humour from staff about clients in the mental health service [ 5 , 11 ]. In a hepatitis C context mistrust from clinicians was expressed through complaints about PSW behaviour [ 26 ]. This was also experienced among breastfeeding PSWs when the midwives would not refer clients to them for support [ 42 ]. Fitting in or being accepted in the workplace was a challenge for some [ 2 , 6 ]. A lack of identity and understanding of the PSW role by professionals was cited as a barrier and led to feelings of being an outsider [ 2 , 42 , 53 ]. With time, the breastfeeding PSWs interviewed by Ingram were ‘trusted’ with a wider range of mothers, but midwives found the role conflict and different advice given by the PSWs as a challenge they had to address [ 53 ]. This gatekeeping of access to clients and control over PSW activities was felt to constrain the effectiveness of the PSW role [ 2 , 34 ]. This was perceived by the PSW as the health professional being territorial, feeling threatened and being unwilling to relinquish ‘power’ [ 34 ]. This could relate to the practices of the PSW not corresponding neatly to existing clinical practice boundaries [ 2 ]. For example, by contributing practical suggestions in the team meeting but feeling a more psychodynamic approach is expected [ 2 ].

Balancing the volunteer PSW role and expectations of clients and health professionals with their own commitments was also described as challenging [ 5 , 26 , 41 ]. Others felt a sense of loss at the end of the PSW programme, or for clients who had died [ 22 , 23 ].

Systematically reviewing the literature on the experience of working as a PSW across 34 identified studies from a range of health disciplines has revealed diverse peer practice models applied across health contexts. However, regardless of whether the PSW is working in renal care, substance misuse, or with carers of relatives with Alzheimer’s disease, new insights relating to the reframing of identity through reciprocal relations and the therapeutic use of self, enhancing responsibility have emerged and appear shared across these contexts. These insights form the core constructs of the PSW conceptual framework emerging from this synthesis, exposing the complex and inter linked sociological phenomena involved in the PSW experience.

Traditional boundaries of provider-client separation originate in the medical model of clinical care and aim to guard against professional misconduct while preventing unhealthy dependence and emotional attachment [ 54 ]. However, contemporary post-structural therapeutic approaches in social work care advocate transparency and a deconstruction of power relations between professional and client. The model proposed by O’Leary et al [ 54 ] moves away from separation to a promotion of connection and the use of self. Boundaries or limits of the relationship are agreed between the client and social worker. Flexible arrangements could include contact outside of working hours, disclosure of personal details of the worker where it is relevant to the aim of the relationship, and the sharing of food or drinks [ 54 ]. These activities directly reflect the core components of the PSW role, and could provide theoretical direction to an accredited PSW model of practice.

Limitations

The principle limitation of this synthesis is the reliance on other authors’ interpretations of their findings and selection of evidence in opposition to direct reporting from PSWs of their experiences. Challenges were carefully reported in the literature to perhaps avoid any blaming. This leaves the recommendations for components of a standardised peer model arising from this review more focused on positive aspects than situations to be avoided. Consequently, any peer support model influenced by this work would require ongoing assessment and potential revision.

Due to time constraints, coding and categorising of all the studies of this synthesis was completed by JM. A random selection of these studies was then read, discussed and coding revised accordingly with JS. The agreement level in coding was 87% between JM and JS, which prompted a review of an additional 6 randomly, selected included papers to clarify the coding decisions, at which 100% consensus was reached. Although the fact that a selection, rather than all, studies were coded independently by both researchers could compromise the validity of the findings, this is unlikely because of the level of agreement reached in coding discussions and achievement of saturation with the additional 6 studies reviewed together.

The records reviewed for this synthesis reported different models of peer support with varying degrees of PSW preparation, PSW–client contact, formal and informal contact structures, different contact environments and frequency of contacts. Often the details of the model design were described very briefly. All of these factors impact on the outcome and experiences of the PSWs and would inform recommendations to increase effectiveness of the PSW role. Since this information was not routinely available in an appropriate level of detail, structural programme recommendations are not available from this synthesis. It is recommended that a ‘realist review’ is conducted of published model designs to achieve this aim.

PSWs were represented from a variety of health domains though there was no specific analysis of the experiences of older people or ethnic minority groups. Thus it is not reliable to relate the findings of this synthesis specifically to different social populations, however there were older people included in the Alzheimer’s PSW study of Pillemer et al [ 32 ] and black American participants in the HIV PSW study by Hilfinger et al [ 23 ].

Furthermore, the restricted geographical distribution of included research reflects the focus of inquiry on the peer experience. This is in contrast to the outcome evaluations and reports of beneficiary experiences of peer support that proliferate across multinational contexts.

Implications

The greater understanding of benefits and challenges of PSW experiences and their effectiveness from this synthesis calls for the greater availability of current peer support model details in the public domain. These practice models can then be joined with research findings to inform development of an accredited training course as recommended by Kemp et al [ 5 ]. Formalisation of the PSW role will clearly benefit PSWs, clients and health providers by informing expectations, facilitating positive working relationships and standardising remuneration for PSW time and expertise [ 24 ].

Acknowledgment of the emerging identity of the PSW using the theory of belongingness and its link to relationship formation and participation exposes positive psychological and lifestyle outcomes in the PSW. Furthermore, the ability of the PSW to actively engage with other marginalised individuals based on their own experiences emphasises the value of a therapeutic model of care based on the therapeutic use of self and the benefits of increasing responsibility to the self and others. This equalising of the client-provider power differential offers an exciting direction for practise and lies at the core of PSW effectiveness from this synthesis. Further exploration of PSW’s therapeutic use of self could inform formal design of an accredited model of peer practise, removing ambiguity from the role, standardising training, supervision and expectations. The benefits of the role to the PSW are a significant element of PSW interventions but decisions on their use should always be balanced with evidence relating to client benefit from the intervention.

This synthesis of the literature exploring the PSW experience of their work has revealed useful insights into their effectiveness through analysis of benefits and challenges of their role. This exposes the PSW perspective for use in the future design of PSW models of effective practice. The synthesised constructs from this analysis identified the therapeutic use of self and reframing of peer identity as core to PSW effectiveness. These are influenced by the reciprocity of formed relations and the sense of responsibility of the PSW to clients, colleagues and themselves. The movement to a position of belonging and giving through the PSW programme supports the transition from social marginalisation to active participation in the role of PSW. The ability of the PSW to actively engage with other marginalised or excluded individuals based on their unique insight into their own experience supports a therapeutic model of care based on appropriately sharing their story. This offers an exciting direction for practise that equalises the power differential and separation ethos of traditional professional boundaries within the health service. Further exploration of this therapeutic use of self could inform formal design of an accredited model of peer practise, removing ambiguity from the role, standardising training, supervision and expectations.

Supporting Information

S1 prisma checklist..

https://doi.org/10.1371/journal.pone.0141122.s001

Acknowledgments

This report is independent research commissioned and funded by the Department of Health Policy Research Programme (Effectiveness of testing for, and treatment of, hard-to-reach groups for latent tuberculosis, hepatitis B virus and hepatitis C virus in England: The HALT study, 015/0306). The views expressed in this publication are those of the author(s) and not necessarily those of the Department of Health.

Author Contributions

Conceived and designed the experiments: JM IA HRS. Performed the experiments: JM JS. Analyzed the data: JM JS HRS. Wrote the paper: JM JS IA HRS.

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The working conditions for personal support workers in the Greater Toronto Area during the COVID-19 pandemic: a mixed-methods study

• Special Section on Equity and the COVID-19 Response in Canada: Mixed Research
• Published: 26 May 2022
• Volume 113 , pages 817–833, ( 2022 )

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• Ayu Pinky Hapsari 1 ,
• Julia W. Ho 1 ,
• Christopher Meaney 2 ,
• Lisa Avery 3 , 4 ,
• Nadha Hassen 5 ,
• Arif Jetha 3 , 6 ,
• A. Morgan Lay 7 ,
• Michael Rotondi 8 ,
• Daniyal Zuberi 9 , 10 &
• Andrew Pinto   ORCID: orcid.org/0000-0003-1841-9347 1 , 2 , 3 , 11  

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During the height of the COVID-19 pandemic, personal support workers (PSWs) were heralded as healthcare ‘heroes’ as many of them cared for high-risk, vulnerable older populations, and worked in long-term care, which experienced a high number of COVID-19 outbreaks and deaths. While essential to the healthcare workforce, there is little understanding of PSW working conditions during the pandemic. The aim of our study was to examine the working conditions (including job security, work policies, and personal experiences) for PSWs in the Greater Toronto Area during the COVID-19 pandemic from the perspectives of PSWs.

This study used a mixed-methods design. From June to December 2020, we conducted a survey of 634 PSWs to understand their working conditions during the COVID-19 pandemic. Semi-structured interviews with 31 survey respondents were conducted from February to May 2021 to understand in greater depth how working conditions were impacting the well-being of PSWs.

We found PSWs faced a range of challenges related to COVID-19, including anxiety about contracting COVID-19, reduced work hours, taking leaves of absences, concerns about job security, and losing childcare. While the COVID-19 pandemic highlighted the PSW workforce and their importance to the healthcare system (especially in the long-term care system), pre-existing poor work conditions of insecure jobs with no paid sick days and benefits exacerbated COVID-19–related challenges. Despite these hardships, PSWs were able to rely on their mental resilience and passion for their profession to cope with challenges.

Significant changes need to be made to improve PSW working conditions. Better compensation, increased job security, decreased workload burden, and mental health supports are needed.

Au plus fort de la pandémie de COVID-19, les préposés aux bénéficiaires (PAB) étaient salués comme les « héros » des soins de santé, car beaucoup s’occupaient de populations vulnérables et âgées à risque élevé et travaillaient dans le milieu des soins de longue durée, qui était aux prises avec un grand nombre d’éclosions de COVID-19 et de décès. Malgré l’importance névralgique des PAB dans la main-d’œuvre des soins de santé, leurs conditions de travail durant la pandémie sont peu connues. Nous avons cherché à examiner les conditions de travail (sécurité d’emploi, régimes de travail et expériences personnelles) des PAB dans la région du Grand Toronto durant la pandémie de COVID-19 selon la perspective de ces PAB.

Nous avons utilisé un plan d’étude à méthodes mixtes. De juin à décembre 2020, nous avons sondé 634 PAB pour connaître leurs conditions de travail durant la pandémie de COVID-19. Des entretiens semi-directifs ont été menés auprès de 31 répondants et répondantes entre les mois de février et de mai 2021 pour approfondir notre compréhension de l’impact des conditions de travail des PAB sur leur bien-être.

Nous avons constaté que les PAB ont connu de nombreuses difficultés en lien avec la COVID-19, dont l’anxiété à l’idée de transmettre la COVID-19, les heures de travail réduites, la prise de congés, les craintes pour leur sécurité d’emploi et la perte de services de garde. Bien que la pandémie de COVID-19 ait braqué les projecteurs sur les PAB et leur importance pour le système de soins de santé (surtout dans le système de soins de longue durée), leurs mauvaises conditions de travail préexistantes – des emplois précaires sans congés de maladie payés ni avantages sociaux – ont exacerbé les problèmes posés par la COVID-19. Malgré ces épreuves, les PAB ont pu compter sur leur résilience mentale et leur passion pour la profession pour faire face aux difficultés.

D’importants changements doivent être apportés pour améliorer les conditions de travail des PAB. De meilleurs salaires, une plus grande sécurité d’emploi, une charge de travail allégée et des mesures d’appui à la santé mentale sont nécessaires.

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A nationwide cross-sectional study of workers’ mental health during the COVID-19 pandemic: Impact of changes in working conditions, financial hardships, psychological detachment from work and work-family interface

Mario Alberto Trógolo, Luciana Sofía Moretti & Leonardo Adrián Medrano

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Introduction

The COVID-19 pandemic is taking an enormous toll on healthcare workers (HCWs), from facing greater risk of contracting the virus (Nguyen et al., 2020 ) to experiencing mental burnout (Havaei et al., 2021 ). Despite these stressors, HCWs have continued to care for patients to the best of their capacity. A contingent of HCWs who have garnered much attention for their work throughout the pandemic are personal support workers (PSWs). They generally support people with their daily needs, such as hygiene and mobility, in long-term care homes (also known as nursing homes), hospitals, and community settings (Kelly & Bourgeault, 2015 ). Most residents of long-term care homes are seniors, have serious chronic health conditions like dementia, and require continuous monitoring (Canadian Institute for Health Information, 2021a ). In contrast, PSWs working in community settings support people of all ages with complex health needs, including children and adults with developmental disorders and people needing end-of-life care (Canadian Healthcare Association, 2009 ). Some PSWs also work at adult day programs that offer leisure activities for elderly or those with chronic conditions and cognitive disability.

In Canada, the National Occupational Classification allows other titles to describe PSWs, including home support worker, healthcare aide, patient aide, and personal care attendant, among others (Government of Canada, 2021a , 2021b ). PSWs are currently not self-regulated in many provinces, although some employers require PSWs to have vocational training certificates (Zagrodney & Saks, 2017 ). Some provinces have also begun the effort to regulate the PSW profession. For example, Alberta has developed a Health Care Aide Registry and a provincial curriculum for healthcare aides in Alberta (Government of Alberta, 2018 ).

Evidence suggests that PSWs in Canada tend to be the lowest paid and considered the least skilled group in the healthcare workforce (Zagrodney & Saks, 2017 ). The PSW workforce is characterized by high turnover rates and high numbers of short-term, casual, and part-time workers (Zeytinoglu et al., 2009 ). PSWs also experience a high degree of job stress due to repetitive and physically strenuous tasks, exposure to abuse and violence, and inadequate psychosocial support (Hignett et al., 2016 ; Van Den Tooren & De Jonge, 2008 ). Furthermore, many PSWs work in the long-term care sector, which has historically been underfunded and continues to be overlooked by policy makers despite the critical shortage of PSWs as the population ages (Armstrong & Day, 2017 ; Canadian Institute for Health Information, 2021b ). In Ontario, where females make up 90% of the PSW workforce and 41% of PSWs identify as members of a visible minority (Ministry of Long-Term Care, 2020 ), it has been argued that the poor treatment of PSWs is emblematic of the general pattern of sexism and discrimination faced by women and ethnic minorities (Block & Galabuzi, 2011 ).

Across Canada, deadly COVID-19 outbreaks in long-term care homes spurred healthcare policy debates centering on PSWs and their essential role within the health system. In Ontario, the government launched the Long-Term Care COVID-19 Commission to investigate the spread of COVID-19 in long-term care homes and to identify promising measures to improve long-term care in the province. The commission found a correlation between the lack of PSWs and the severity of COVID-19 impacts during the first wave of the pandemic, which led to the recommendation of increasing the supply of PSWs (Marrocco et al., 2021 ). Subsequently, the Ontario government introduced measures to recruit and train more PSWs, and offered temporary wage increases (Marrocco et al., 2021 ). Similar initiatives were introduced in other provinces, including British Columbia and Quebec (CBC Radio, 2020 ).

Given the increased policy attention on PSWs in Canada during the COVID-19 pandemic, and to further highlight areas of improvement within the PSW sector that need to be addressed in anticipation of future public health crises, it is important to closely examine PSWs’ working conditions during the pandemic from the perspectives of PSWs. This paper therefore aims to explore the impact of the COVID-19 pandemic on PSWs, a marginalized workforce whose working conditions were difficult even prior to the pandemic. We specifically address the following research questions: (1) How did the early stages of the COVID-19 pandemic impact the work and well-being of PSWs in Ontario? (2) How did PSWs overcome any work-related challenges during the COVID-19 pandemic?

Setting and context

We conducted this study in the Greater Toronto Area (GTA) of Ontario, Canada, which is the country’s largest metropolitan area with a population of approximately 5.9 million (Statistics Canada, 2016 ). There are an estimated 90,000–100,000 PSWs in the province of Ontario (population of 14.5 million) (Kelly & Bourgeault, 2015 ). To our knowledge, there are no estimates for the number of PSWs working in the GTA or the municipalities of which it is composed. While not formally regulated by a professional college, there are accredited PSW training programs at colleges and vocational schools in Ontario. The average wage of PSWs across different work settings ranges from $17.30/h (home care) to $25.01/h (municipally operated long-term care homes) (Ministry of Long-Term Care, 2020 ). During the COVID-19 pandemic, the provincial government mandated that long-term care home workers only work in one facility to reduce the spread of the virus ( O. Reg. 146/20: Limiting Work to a Single Long-Term Care Home , 2020 ). It also introduced a temporary wage increase of up to $3/h from October 1, 2020 until August 23, 2021, which was subsequently extended until March 31, 2022 (Government of Ontario, 2021a ).

Study design

We used a community-based participatory action research approach (Israel et al., 1998 ) where an Advisory Committee of eight PSWs was engaged in all aspects of the study, including overall design, development of the survey and interview guide, and interpretation of data and results. Members of the Advisory Committee received training in research methods and community advocacy. To recognize their contributions and compensate them for their time, the PSW committee members received a $30 honorarium for each hour they contributed. To obtain a comprehensive picture of PSWs’ experiences related to their employment during the COVID-19 pandemic, we chose a mixed-methods design comprised of quantitative survey and qualitative interviews (Shorten & Smith, 2017 ). We used an exploratory sequential approach (Ivankova et al., 2006 ) where a quantitative survey was first administered to generate a summary of challenges faced by PSWs during the pandemic, followed by qualitative interviews to contextualize and complement the quantitative results.

Quantitative arm

We conducted a cross-sectional survey from June to December 2020 and recruited PSW participants using a respondent-driven sampling (RDS) approach. RDS is a chain-referral sampling method suitable for hard-to reach populations (Heckathorn, 2002 ), such as PSWs in Ontario who often work in multiple settings, are not registered, and have limited availability due to irregular work schedules. This approach improves upon regular snowball sampling methods by accounting for participants’ social network size and recruitment structure to calculate asymptotically unbiased population estimates (Heckathorn, 2011 ). The RDS-II estimator was chosen to create sampling weights based on the network size (Volz & Heckathorn, 2008 ), which was estimated by asking each participant “How many friends do you know who work as PSW in the Greater Toronto Area, whom you have communicated with regularly in the past year (in-person/online/by texts)?”.

A convenience sample of 24 ‘seeds’ were initially recruited through recommendations from the PSW Advisory Committee and online advertisements. These seeds then propagated into waves of referrals, whereby each participant received a $20 honorarium for completing the survey and an additional honorarium for referring up to 3 eligible peers ($10 per peer referral). Participants had to be at least 18 years old and had to have worked as a PSW in the GTA within the past year. Participants completed the survey online on Qualtrics (Qualtrics, 2020 ), with the exception of a small number of participants who preferred to complete the survey over the phone. A sample size of 600 was projected to allow for a proportion estimate of PSWs reporting poor quality of life within 5% accuracy and 95% confidence. Detailed descriptions of the survey recruitment and the applied RDS method have also been described elsewhere (Pinto et al.,  2022 ).

Participants were asked sociodemographic questions that included age, gender, racial background, place of birth, current student status, educational attainment, and low-income status as measured by the 2018 Canadian low-income cut-off (LICO) (Statistics Canada, n.d. ). The survey included COVID-19 pandemic-related questions on their work location, access to and training around protective personal equipment (PPE), COVID-19 testing and status, concerns around contracting and passing COVID-19 to family members, and the impact of the pandemic on their work conditions (e.g., got laid off or fired, reduced work hours). The survey also asked about job security concerns and childcare during the pandemic (see Supplement 1 ). RDS-II adjusted proportion estimates were generated for each variable.

Qualitative arm

Three members of the research team (APH, JWH, ESA) conducted 31 one-to-one interviews between March and June 2021, using a semi-structured interview guide that included open-ended prompting questions to further explore the subjects covered in the survey (see Supplement 2 ). In particular, the interviews aimed at understanding the impacts of the COVID-19 pandemic on PSWs’ work conditions, personal life, and health. They also focused on any challenges experienced by PSWs during the pandemic, including their experience with PPE, and on how PSWs navigated these issues.

To ensure breadth and depth of perspectives, participants were selected from the survey sample population who had agreed to be contacted for future research using a stratified random sampling based on their race and work location. Each interview participant received an additional honorarium of $30. All interviews were conducted in English and took place online via the Zoom platform video-conferencing and audio-conferencing. The duration of the interviews ranged from approximately 45 min to 1 h. All interviews were audio recorded and transcribed verbatim by a professional transcriptionist.

We employed a thematic analysis approach (Braun & Clarke, 2006 ) to analyze the interview transcripts. Data analysis was managed using NVivo 12 (QSR International Pty Ltd, 2020 ). Two members of the research team (APH, JWH) independently reviewed four transcripts and met to develop an initial codebook based on a consensus of common themes. The remaining 26 transcripts were divided randomly into half and analyzed by the same two researchers, who met on several occasions during the analysis process to revise and refine the codebook. The final codebook was developed by consensus between the principal investigator (AP) and the two coders. The final themes were presented to the PSW Advisory Committee as a means of respondent validation (Green & Thorogood, 2018 ). This study was approved by the St. Michael’s Hospital Research Ethics Board (#18-103), Toronto, Canada.

Sociodemographic results

A total of 658 PSWs participated in the survey; 634 participants were included in the analysis after excluding the 24 seeds. Table 1 presents participants’ background, and Supplement 3 provides details on the recruitment structure. Participants were predominantly female (90.1%) and foreign-born (97.4%). In terms of racial background, most participants self-identified as non-white, with Black PSWs (76.5%) making up the largest proportion of the participants. Most participants were between 30 and 49 years of age (70.4%) and on average, participants had been working as a PSW for 4.4 years (standard deviation (SD): 4.9 years). One fifth (21.1%) were enrolled in school at the time of the survey. Over half of the participants were considered low income (55.1%) despite the majority of them having at least some college or university education (88.6%). The comprehensive sociodemographic characteristics of the survey participants are also presented elsewhere (Pinto et al.,  2022 ).

During the pandemic, most survey participants worked in home care in the community (49.3%), followed by in long-term care (34.3%) (Table 1 ). Other work locations included hospitals, institutions for people with disabilities, shelters, and rehabilitation and reactivation centres. Among those working in long-term care, over a third (37.8%) reported working for private for-profit organizations, and a further 35.2% did not know their employer type.

The characteristics of the interview participants were comparable to those of the survey participants (Table 1 ). About half of them worked in home care (51.6%) and a third (32.3%) in long-term care. Slightly less than 30% worked for private for-profit organizations and a considerable proportion (29.0%) did not know their employer type. Approximately one third (32.3%) belonged to a union. Similar to the survey respondents, most interviewees were female (90.3%) and Black (61.3%), with an average age of 42.9 years old (SD: 7.3). They had worked as a PSW for an average of 5 years (SD: 4.5) and two thirds had a college or university degree (67.7%). Most participants (67.7%) were not Canadian citizens.

Overview of themes

Four major themes emerged from our analysis of the interview data and are supported by the survey results. Addressing the first research question, “How did the early stages of the COVID-19 pandemic impact the work and well-being of PSWs in Ontario?”, we found that: (1) the pandemic took a significant toll on the health and well-being of PSWs and required great sacrifices; (2) the pandemic significantly impacted the job security of PSWs; and (3) despite some improvements brought about by the pandemic policies, PSWs still experienced largely poor working conditions. Addressing the research question “How did PSWs overcome any work-related challenges during the COVID-19 pandemic?”, we found that: (4) PSWs demonstrated resilience by employing several coping mechanisms during difficult circumstances.

Theme 1: The pandemic took a significant toll on the health and well-being of PSWs and required great sacrifices

Comments on the impacts of COVID-19 on workers coalesced around several sub-themes: (1) mental health impacts, (2) anxiety about contracting COVID-19, and (3) contracting COVID-19.

PSWs in the interview noted that COVID-19-driven public health protocols influenced their mental health. For example, they had to limit their interactions with colleagues (e.g., during breaks and meals), which left them feeling isolated at work. In some circumstances, PSWs had to isolate themselves from their families, especially during the height of the pandemic. As an example, one PSW described living in a hotel for 7 weeks, which left them feeling lonely and depressed (Table 2 , Quote 1).

Interview participants also reported experiencing anxiety about contracting COVID-19 at work and during their commute to work using public transportation. As an example, when asked about how COVID-19 has affected their work, one participant working in a long-term care facility noted the risk they were taking by going to work (Table 2 , Quote 2).

Aligned with the interview results, most survey respondents (66.6%) were worried about contracting COVID-19 at work, and 75% were worried about transmitting it to people at home. Finally, from 70.4% of survey participants who were tested for COVID-19, 4.7% received a positive result (Table 3 ). Some interview participants pointed to fatigue due to increased workload and understaffing as risk factors for COVID-19 exposure (Table 2 , Quote 3).

Theme 2: The pandemic significantly impacted the job security of PSWs

Reduced hours and lost employment were noted as major contributors to job insecurity during the pandemic. First, PSWs who worked mainly in home care experienced a reduction in their work hours due to a reduced number of clients as some became sick and others were afraid of being exposed to COVID-19. For example, some home care clients refused PSW service in their private homes (Table 2 , Quote 4) . Second, PSWs who mainly worked in long-term care facilities reported losing employment due to COVID-19 and consequently lost important sources of income. The Ontario government’s mandate that PSWs working in long-term care facilities only work in one home resulted in reduced income: PSWs who either worked as part-time staff at multiple facilities or worked for multiple staffing agencies were no longer able to do so following the mandate (Table 2 , Quote 5).

In keeping with the interview results, over 60% of the survey participants also reported some form of work-related impacts (Table 3 ). More than 20% had their work hours significantly reduced, while over a quarter (25.7%) reported uncertain work hours. Some survey participants had to take a leave of absence (14.9%) for a number of reasons, such as difficulty arranging childcare, being worried about contracting COVID-19 and/or transmitting it to their family, having an underlying condition, and being required to self-isolate due to potential or confirmed diagnosis of COVID-19. In addition, a small proportion of the survey participants was laid off (6.1%), fired (0.9%), or had their wages delayed (2.1%). Over half (54.6%) of the survey participants also expressed having much more concern about their job security than they did prior to the pandemic (Table 3 ), which may be explained by the loss of income sources described in the interview.

Theme 3: Despite some improvements brought about by the pandemic policies, PSWs still experienced largely poor working conditions

The interviews also illuminated how the pandemic exacerbated pre-existing workplace challenges, such as inadequate paid sick days, staff shortages, and inadequate hours, in addition to new challenges, such as increased tasks and issues related to PPE. In summary, PSWs’ comments focused on six areas: (1) PPE impacts, (2) lack of paid sick days offered by employers, (3) delayed or inadequate temporary wage increase, (4) lost childcare, (5) increased workload and extra tasks, and (6) challenges with management.

Some interview participants reported scarce supplies of PPE at the beginning of the pandemic, including masks, gloves, gowns, and face shields (Table 2 , Quote 6). However, the supply of PPE increased over time and there was generally a sufficient supply of PPE later on in the pandemic (Table 2 , Quote 7). The improved supply of PPE was reflected in the survey, where only less than 5% of participants reported rarely or never having gloves, masks, hand sanitizers, and access to hand-washing station to use between clients (Table 4 ). Approximately one in ten survey participants reported rarely or never having gowns and face shields to use between clients. Most participants (81.4–87.4%, depending on the type of PPE) also reported receiving training to safely put on and take off different PPE (gloves, masks, gowns, face shield) (Table 4 ). Among those who received training, about 90% found it helpful.

Wearing PPE for extended periods of time was challenging for many PSWs who were interviewed. For example, a PSW described their difficulty with breathing (Table 2 , Quote 8). PSWs also experienced headaches due to wearing face shields. Additionally, it was challenging for PSWs to take breaks because doing so required doffing and donning PPE.

Some PSWs noted the persistent absence of paid sick days from their employers as an important issue. Many agencies did not offer paid sick days or they were only available to permanent, full-time employees in some workplaces (Table 2 , Quote 9). Thus, PSWs who contracted COVID-19 and were unable to work were not paid by their employers for the time off to recover and isolate. PSWs described the only benefit they could access was through Ontario’s Workplace Safety and Insurance Board (WSIB). Some PSWs described how they had to go through the WSIB claims process themselves and they were unable to recoup their full pay (Table 2 , Quotes 10 and 11).

In October 2020, the Ontario government instated a temporary wage increase for PSWs of up to $3/h. Four PSWs stated that they did not receive the wage increase, and five others reported a delay in receiving their pay increase. One PSW did not receive their wage increase until February 2021, 5 months after the start of the mandated increase. Many PSWs also described the amount of pay increase as insufficient or indicated that more compensation should be given for their work, particularly when they were not given full-time hours (Table 2 , Quote 12).

Some of the PSWs with children described losing childcare during the pandemic and, as a result, they were forced to reduce their work hours or not work at all. For example, one PSW with school-aged children had to reduce her work hours so she could care for her children and help them with virtual learning during closure of in-person learning (Table 2 , Quote 13). Similarly, among survey participants with child dependents, about 40% found it much more difficult to arrange for childcare during the pandemic (Table 3 ).

Some interviewees also described an increase in their workload due to colleagues contracting COVID-19. For example, when long-term care facilities experienced staff shortages, PSWs were forced to pick up extra shifts (Table 2 , Quote 14) . In response to the staff shortage, some long-term care facilities used staffing agencies, and some PSWs noted the stark differences in compensation and quality of work between the facility staff and the agency staff (Table 2 , Quote 15). The staff shortage also resulted in a larger and unmanageable ratio of clients to PSW (Table 2 , Quote 16), which could go as high as 16 clients per PSW compared to the average of 8–10 clients prior to the pandemic.

The challenge posed by the staffing shortage was exacerbated by the increased burden and extra tasks at work due to the pandemic. For example, PSWs in long-term care had to apply strict infection control protocols, including confining long-term care residents to their rooms. In some cases, patients became aggressive because they could not leave the facility (Table 2 , Quote 17).

In addition to staffing policy issues, PSWs in long-term care experienced other challenges related to management policies. For example, some PSWs perceived management as not prioritizing their well-being (Table 2 , Quote 18). When PSWs made complaints to management, their complaints were either not addressed at all or were not resolved in a timely manner. At times, the importance of their complaints was minimized. Some PSWs also reported having difficulties contacting managers to discuss problems (Table 2 , Quote 19).

Despite the challenges, however, the participants were able to draw on some benefits of the policies that were implemented in response to the pandemic. Benefits and pay raises given during the pandemic were a welcome change for PSWs who had struggled with inadequate wages (Table 2 , Quote 20). Some PSWs also reported that wearing PPE gave them a sense of better infection control than during pre-pandemic times. As face masks had to be worn by everyone during the pandemic, PSWs could wear them without offending their clients (Table 2 , Quote 21). The policy of working in one long-term care facility also promoted a sense of security from COVID-19 exposure. For PSWs working in long-term care facilities, they were assigned to work with the same residents for infection control purposes. One positive aspect of this change was that they got to know the same group of residents better, whereas in pre-pandemic times, they shifted frequently between different clients (Table 2 , Quote 22).

Theme 4: PSWs demonstrated resilience by employing several coping mechanisms during difficult circumstances

We found that PSWs applied several strategies to cope with the pandemic and the challenges it posed for their work and personal life, which include (1) relying on their family and friends for both emotional and logistical supports, (2) drawing strength from their faith and spirituality, and (3) reflecting on their passion for the profession.

Many interviewees credited their spouses, children, and friends for supporting them both emotionally and physically during the pandemic. Some PSWs who lost childcare described that their neighbours or their older children helped look after younger children during school closures (Table 2 , Quote 23). In other instances, participants received encouragement from their spouses or children when they were overwhelmed by their work and relied on their spirituality and faith during uncertain times (Table 2 , Quote 24).

Moreover, PSWs drew on their passion for the profession to cope during challenging times. Generally, PSWs find their work personally rewarding because they are able to make a positive impact on their clients’ lives. Some PSWs said they consider their clients like family members while others described the feeling of personal fulfillment from their work with clients (Table 2 , Quote 25).

We found that the COVID-19 pandemic significantly impacted the work conditions, job security, and well-being of PSWs. Pre-existing poor work conditions, such as insecure jobs with no benefits, absence of paid sick days from employers for non-permanent and agency staff, and lack of full-time hours, contributed to COVID-19–related challenges. Part-time PSWs in long-term care facilities could not work in other locations, and PSWs working in home care experienced a reduction in their work hours that resulted in reduced income and concerns around job security.

These poor working conditions were compounded by issues related to PPE scarcity at the beginning of the pandemic, staff shortages and increased work burden in long-term care settings, difficult relationships with management, and loss of childcare for PSWs with young children. Furthermore, job insecurity and social isolation stemming from pandemic policies significantly impacted the mental health of PSWs. A sizable proportion of PSWs also expressed anxiety about contracting COVID-19 and transmitting it to their family, while some were infected with COVID-19. Despite these hardships, PSWs were able to rely on their mental resilience and passion for their profession to cope with challenges.

Our findings are consistent with previous work on PSWs in Ontario, which demonstrated the precarious work conditions and significant stress that they experience (Zagrodney & Saks, 2017 ; Zeytinoglu et al., 2017 ). In addition, our study was able to highlight any changes in PSW work conditions during the early stage of the pandemic, based on the perspective of PSWs. One notable finding is the benefits of the pandemic policies, which may be considered in future policy reforms. For example, the temporary wage increase provided by the Ontario government was a welcome change that could be made permanent as an incentive to retain PSWs. As PSW staffing shortage had been associated with severe COVID-19 outbreaks across Canada (Marrocco et al., 2021 ), effective retention strategies will be needed to avoid similar issues in future pandemics.

Along with job insecurity, negative work relationships have also been linked to adverse health outcomes, such as chronic health conditions and mental health problems among workers (de Castro et al., 2008 ; Kim et al., 2013 ). Unmanageable workload and job stress have also been associated with suboptimal care by healthcare workers (Ruotsalainen et al., 2020 ). With many PSWs struggling to manage the increasing workload during the pandemic while also experiencing anxiety about contracting and transmitting COVID-19, it is pertinent for employers to be transparent about their decision-making process and provide adequate support to PSWs to prevent rapid turnover due to burnout and health issues. Efforts to provide a better sense of security, such as providing adequate COVID-19 testing and supply of PPE, can help alleviate anxiety among PSWs. Indeed, the PSWs in our study described better infection control as a positive implication of the pandemic policy.

Paid sick days have been consistently shown to offer benefits to employers and improve public health, such as improving workers’ productivity and reducing the spread of virus, respectively (Scheil-Adlung & Sandner, 2010 ; Zhai et al., 2018 ). Nevertheless, our findings suggest that many PSWs with non-permanent contracts in both long-term care and home care rarely received paid sick days from their employers. Combined with insufficient wages, lack of paid sick days placed PSWs in the difficult position of having to choose between financial obligations and their health. This could potentially lead to adverse public health outcomes, especially since PSWs work with individuals who are susceptible to worse outcomes from infectious diseases such as COVID-19. To help limit COVID-19 and in anticipation of future public health emergencies, the federal government and the province of British Columbia have legislated permanent paid sick days for employees (Government of British Columbia, 2021 ; Government of Canada, 2021c ). However, other provinces such as Ontario only offered temporary paid sick days for reasons related to COVID-19 (Government of Ontario, 2021b ).

The mandate limiting long-term care workers to one facility also revealed the negative implications of casualization of PSWs, who struggled with unpredictable work hours and loss of income sources during the pandemic. The trend towards casualization has also been seen in other Canadian provinces and in the United States, and has been described as negatively impacting caregiver–client relationships and contributing to high turn-over rates and lower quality of care (Ranucci & Berry, 2021 ; Sharman et al., 2008 ). Similarly, our interview participants described continuous relationships with long-term care residents as a positive outcome of the new workplace policy that assigned the PSWs to work with the same residents during the pandemic. Therefore, future policy may consider incentivizing employers to offer more permanent, full-time positions for PSWs in all settings to improve the job security of PSWs, strengthen the relationship between clients and PSWs, and help improve the quality of care. Future models could consider the strategy adopted by the British Columbia government, which took over as the employer for all long-term care workers in the province and hired the workers full-time at a stage of the pandemic when workers were barred from working in multiple settings (Moist, 2020 ).

The COVID-19 pandemic has exacerbated and brought to the forefront workplace challenges faced by PSWs. The aging Canadian population, coupled with the growing preference towards home care over hospital care, will continue to raise the demand for PSWs (Canadian Healthcare Association, 2009 ; Saari et al., 2018 ). While initiatives such as providing training funding and incentives for recent PSW graduates can help attract new workers into the PSW profession (Government of Ontario, 2020 ), a more sustainable solution is to improve the work conditions for workers already in the field.

Limitations

Our survey sampling method (RDS) should produce more reliable estimates than convenience sampling; however, it might not be able to capture the full diversity of the PSW population in our geographical area of interest. The large proportion of Black participants in the survey may be attributed to the disproportionate number of Black participants in the ‘seeds’. The collective experiences of PSWs of different ethnic backgrounds may differ from those who identified as Black. Our study is also limited to the experience of PSWs in the Greater Toronto Area, which may not be generalizable to other jurisdictions with different population densities, socioeconomic characteristics, ethnic diversities, and health-related policies.

While this study was focused on understanding PSW working conditions during COVID-19 from the perspectives of PSWs, there are other perspectives that could be examined for a more fulsome picture of PSW working conditions. We did not survey or interview other key stakeholders, such as employer organizations, policy makers, and clients and family members to garner their perspectives. Further research could focus on these important stakeholders.

Finally, despite emerging themes specific to a certain work setting, such as staffing shortages in long-term care facilities, or refusal of service by clients in private homes, our study did not have adequate sample to conduct in-depth comparative analysis across the different work settings. Future research can therefore focus on the commonalities and differences in PSW work conditions across different settings to inform strategies for human resource planning that consider the specific needs and challenges of each setting.

As we recover from the COVID-19 pandemic and reflect on strategies to improve our public health response to future threats, it is imperative that we consider decent work for personal support workers who provide care for our most vulnerable. Our findings highlight potential areas for labour policy reforms related to the PSW workforce. First, PSWs need to be better compensated for their work. While the Ontario government’s temporary wage increase prompted by the pandemic was a welcomed improvement, PSWs need this wage increase to be made permanent. Second, PSWs need full-time, permanent jobs with benefits. Our study indicated that the COVID-19 pandemic significantly impacted PSWs who worked part-time, casual, and short-term contract jobs. Their precarious work arrangements create the conditions whereby PSWs needed to cobble together multiple jobs and work long hours to make a living and support their families. Income loss due to limiting PSWs to work in one healthcare setting had significant impacts on their livelihood. In the absence of permanent position, many of them also did not have paid sick days or health benefits. Third, PSWs were subjected to difficult working conditions, such as large client loads and challenging clients, which were worsened by staffing shortages. We recommend that PSW workload be evaluated to allow for high-quality care provision to clients in more ideal conditions (e.g., a smaller client to PSW ratio). In conclusion, policy changes that improve the working conditions for PSWs are urgently needed to retain these professionals as Canada’s population ages and healthcare needs continue to grow.

Contributions to knowledge

What does this study add to existing knowledge?

Pre-existing poor work conditions of insecure jobs with no paid sick days and benefits exacerbated COVID-19–related challenges for PSWs.

During the height of the COVID-19 pandemic, PSWs were subjected to significant stress; however, they exhibited great mental resilience and dedication to their work.

PSWs want to be better compensated for their work and COVID-19’s restrictions on multiple work settings significantly impacted PSW incomes.

There are positive implications of pandemic policies, including a temporary wage increase, better infection controls, and consistent assignments of staff to clients, which may be considered for future workplace standards.

What are the key implications for public health interventions, practice or policy?

Temporary wage increases need to be made permanent to sustain the PSW workforce and ensure workers receive fair compensation.

There needs to be a shift in improving working conditions by ensuring more full-time, permanent jobs with benefits.

Stressful working conditions, such as large client loads in long-term care due to staffing shortages, need to be addressed to provide high-quality care as well as to improve working conditions for PSWs.

Data availability

Not applicable

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Acknowledgements

The authors are grateful for time and guidance provided by the personal support workers in the advisory committee during all phases of the study. We also thank Ellah San Antonio for her support with conducting the interviews.

Code availability

This research was made possible through funding from the Metcalf Foundation. The funder did not have any involvement in the collection, analysis, and interpretation of data, nor did they have any involvement in the writing of the report and in the decision to submit. Dr. Andrew Pinto is supported as a Clinician-Scientist by the Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, the Department of Family and Community Medicine, St. Michael’s Hospital, and the Li Ka Shing Knowledge Institute, St. Michael’s Hospital. Dr. Pinto is also supported by a fellowship from the Physicians’ Services Incorporated Foundation and as the Associate Director for Clinical Research at the University of Toronto Practice-Based Research Network (UTOPIAN).

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Ayu Pinky Hapsari, Julia W. Ho & Andrew Pinto

Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada

Christopher Meaney & Andrew Pinto

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Lisa Avery, Arif Jetha & Andrew Pinto

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Faculty of Environmental and Urban Change, York University, Toronto, ON, Canada

Nadha Hassen

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Institute of Population and Public Health, Canadian Institutes of Health Research, Toronto, ON, Canada

A. Morgan Lay

School of Kinesiology and Health Science, York University, Toronto, ON, Canada

Michael Rotondi

Munk School of Global Affairs & Public Policy, University of Toronto, Toronto, ON, Canada

Daniyal Zuberi

Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada

Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON, Canada

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All the authors contributed to the study conception and design. Data collection and analysis were performed by APH, CM, JWH, and AP. The first draft of the manuscript was written by APH and JWH. All the authors commented on previous versions of the manuscript. All the authors read and approved the final manuscript.

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Hapsari, A.P., Ho, J.W., Meaney, C. et al. The working conditions for personal support workers in the Greater Toronto Area during the COVID-19 pandemic: a mixed-methods study. Can J Public Health 113 , 817–833 (2022). https://doi.org/10.17269/s41997-022-00643-7

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The effectiveness, implementation, and experiences of peer support approaches for mental health: a systematic umbrella review

• Ruth E. Cooper 1   na1 ,
• Katherine R. K. Saunders 1   na1 ,
• Anna Greenburgh 2 ,
• Prisha Shah 6 ,
• Rebecca Appleton 2 ,
• Karen Machin 6 ,
• Tamar Jeynes 6 ,
• Phoebe Barnett 2 , 3 , 4 ,
• Sophie M. Allan 2 , 5 ,
• Jessica Griffiths 1 ,
• Ruth Stuart 1 ,
• Lizzie Mitchell 6 ,
• Beverley Chipp 6 ,
• Stephen Jeffreys 6 ,
• Brynmor Lloyd-Evans 2 ,
• Alan Simpson 1 , 7 &
• Sonia Johnson 2 , 8  

BMC Medicine volume  22 , Article number:  72 ( 2024 ) Cite this article

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Peer support for mental health is recommended across international policy guidance and provision. Our systematic umbrella review summarises evidence on the effectiveness, implementation, and experiences of paid peer support approaches for mental health.

We searched MEDLINE, EMBASE, PsycINFO, The Campbell Collaboration, and The Cochrane Database of Systematic Reviews (2012–2022) for reviews of paid peer support interventions for mental health. The AMSTAR2 assessed quality. Results were synthesised narratively, with implementation reported using the CFIR (Consolidated Framework for Implementation Research). The protocol was registered with PROSPERO (registration number: CRD42022362099).

We included 35 reviews (426 primary studies, n  = 95–40,927 participants): systematic reviews with ( n  = 13) or without ( n  = 13) meta-analysis, or with qualitative synthesis ( n  = 3), scoping reviews ( n  = 6). Most reviews were low or critically low (97%) quality, one review was high quality. Effectiveness was investigated in 23 reviews. Results were mixed; there was some evidence from meta-analyses that peer support may improve depression symptoms (particularly perinatal depression), self-efficacy, and recovery. Factors promoting successful implementation, investigated in 9 reviews, included adequate training and supervision, a recovery-oriented workplace, strong leadership, and a supportive and trusting workplace culture with effective collaboration. Barriers included lack of time, resources and funding, and lack of recognised peer support worker (PSW) certification. Experiences of peer support were explored in 11 reviews, with 3 overarching themes: (i) what the PSW role can bring, including recovery and improved wellbeing for service users and PSWs; (ii) confusion over the PSW role, including role ambiguity and unclear boundaries; and (iii) organisational challenges and impact, including low pay, negative non-peer staff attitudes, and lack of support and training.

Conclusions

Peer support may be effective at improving some clinical outcomes, self-efficacy, and recovery. Certain populations, e.g. perinatal populations, may especially benefit from peer support. Potential strategies to successfully implement PSWs include co-production, clearly defined PSW roles, a receptive hierarchical structure and staff, appropriate PSW and staff training with clinical and/or peer supervision alongside safeguarding. Services could benefit from clear, coproduced, setting specific implementation guidelines for PSW. PSW roles tend to be poorly defined and associations between PSW intervention content and impacts need further investigation. Future research should reflect the priorities of providers/service users involved in peer support.

Peer Review reports

Peer support in mental health care is a recovery-orientated approach delivered by individuals who have lived experience of mental health difficulties (as service users, carers, parents or supporters). Peer support workers (PSWs) are employed to draw on these experiences to support mental health service users or carers of people with mental health conditions [ 1 , 2 ]. As such, PSWs are uniquely positioned to facilitate recovery through empathic engagement with service users and their support networks. The success of peer support is thought to be based in the sharing of lived experiences and mental health knowledge and through interpersonal connection [ 3 , 4 ]. Across diagnoses, peer support may promote recovery through the modelling of coping strategies, and by providing hope and an example of recovery to those dealing with mental health difficulties [ 5 ].

Peer support has been utilised across various populations and types of service, for example in services for early intervention in psychosis [ 6 ], for people with co-occurring substance abuse and mental health difficulties [ 7 ], and in community interventions to reduce mental health inpatient admissions [ 8 ]. The format of peer support varies across services, for example it may involve one-to-one or group sessions, online or face-to-face delivery, unstructured open-ended conversations or more structured manualised support, or activities such as walking groups [ 9 , 10 ]. Peer support may be delivered by trained peer support staff or on a more ad hoc basis among peers [ 11 ]. Peer support for mental health takes place within mental health services in both statutory and voluntary sector settings [ 11 ]. Although PSWs may be paid or unpaid [ 6 , 12 ], paid roles have become increasingly available in mental health care settings [ 13 ]. Professionalising PSW roles as paid demonstrates the value of the role and appropriately rewards work done, should ensure formal training, supervision and management, and may help to clarify the boundaries of the role [ 14 ].

Service user networks and researchers in relevant fields have strongly advocated for provision of peer support [ 14 , 15 ], and peer support is now recognised and recommended across international mental health policy guidance, reflecting an increased understanding of the value of embedding lived experience support in formal mental health services [ 16 , 17 , 18 , 19 , 20 ]. In the UK, peer support is currently being expanded in the NHS [ 16 ].

There have been many reviews of the peer support literature separately evaluating the efficacy, implementation, and experiences of peer support from a variety of different perspectives (e.g. [ 21 , 22 , 23 , 24 ]). Given the numerous and sometimes inconclusive results from existing reviews on this topic, our research group, the NIHR Mental Health Policy Research Unit, agreed with policy makers in England to conduct an umbrella review of peer support to provide clinicians, policy makers and researchers with an overall assessment on the evidence available, comparing results between reviews, while taking the quality of these reviews into account [ 25 , 26 ]. The aim of this systematic umbrella review is to collate, synthesise and summarise the available evidence from published reviews to address the following research questions:

What is the effectiveness (e.g. clinical, social, functional) and cost-effectiveness of paid peer support approaches for mental health?

What influences the implementation of peer support approaches for mental health?

What are the experiences of peer support approaches for mental health (e.g. of acceptability) from the perspective of PSWs, healthcare practitioners, service users, carers?

This umbrella review was conducted by the NIHR Mental Health Policy Research Unit (MHPRU), based at King’s College London and University College London, which delivers evidence to inform government and NHS policy in England, agreeing a programme of rapid research with policymakers.

Study design and protocol

We conducted a systematic umbrella review following guidance from Fusar-Poli et al. [ 27 ] and Cochrane [ 28 ]. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (see Additional file 1 : Appendix 1 for the PRISMA checklist) [ 29 ]. The protocol was registered with PROSPERO (registration number: CRD42022362099) [ 30 ]. One amendment was made to the protocol after registration. We amended the ‘intervention’ section to state that reviews were excluded if the majority of interventions did not meet eligibility criteria, e.g. because we found that reviews often included paid and unpaid peer support interventions and did not report results separately.

Lived experience researcher involvement

Members of the MHPRU Lived Experience Working Group (LEWG), who collectively have substantial experience of delivering or receiving peer support, contributed extensively to this review, including protocol development, study selection, data extraction, quality appraisal, data synthesis, drafting the manuscript and lived experience commentary, and attending working group meetings.

Eligibility criteria

The eligibility criteria are detailed in full in the protocol [ 30 ]. In summary, we included:

Study designs : Published, peer-reviewed systematic, scoping or realist reviews which synthesised quantitative or qualitative data (narratively or formally using, e.g. a meta-analysis or meta-synthesis) that examined outcomes or experiences relevant to our research questions.

Intervention : We defined peer support as ‘involving a person who has lived experience of mental health condition(s), or caring for those with mental health conditions, being employed to use and draw on their experiences and empathy to support service users who have mental health conditions or carers or parents of people with mental health conditions.’ Eligible peer support approaches were paid, meaning that the PSW was paid for their work, and delivered face-to-face or remotely, for people with mental health conditions or for carers of people with mental health conditions, across any mental healthcare settings. Peer support approaches were ineligible if the PSWs were not in a dedicated peer support role, if they were primarily for physical health, or automated (i.e. peer support ‘bots’ or avatars). We excluded reviews where over 50% of primary studies in the review did not meet eligibility criteria, e.g. if the majority of people delivering the interventions were unpaid.

Population : Children, young people and adults with a mental health condition (including substance use disorders), carers, paid PSWs and mental healthcare practitioners working alongside PSWs. We excluded service users with a primary diagnosis of an organic mental disorder (e.g. dementia), neurodevelopmental disorders, acquired cognitive impairment and adjustment disorders.

Outcome measures : Included reviews reported outcomes or data on at least one of the following peer support related outcomes that addressed our research questions: (i) clinical outcomes, (ii) economic or cost-effectiveness, (iii) recovery outcomes, e.g. hope, empowerment, goal-attainment, quality of life, (iv) social outcomes, (v) implementation outcomes and barriers and facilitators to implementation, (vi) experiences of delivering, receiving or working alongside peer support and (vii) theories of what works for whom in peer support.

Information sources and search strategy

We combined terms for peer support, reviews and mental health conditions using Boolean operators (AND, OR). We searched the following databases: MEDLINE, EMBASE, PsycINFO, The Campbell Collaboration and The Cochrane Database of Systematic Reviews (see Additional file 1 : Appendix 2 for full search strategy). Searches were run from January 2012 to November 2022 as these reviews will include primary research published before 2012 [ 31 ]. There was no time limit for the primary papers in the included reviews. We had no language restrictions.

Selection process

Reviewers (KS, RC, JG, RS, RA, KM, PS, SA) screened titles and abstracts, and subsequently full texts. To ensure consistent application of eligibility criteria all reviewers initially independently screened the same ten titles and abstracts and discussed inclusion/exclusion. The remaining titles and abstracts were then screened. Records were double screened blind by two reviewers at both the title and abstract (94% agreement) and full text (86% agreement) stages. All disagreements were resolved through discussion with the study team.

Data extraction

Data extraction was completed in Microsoft Excel by the review team (RC, KS, KM, PS, JG, RS, PB, RA). The data used in the paper were checked by another member of the review team. The extracted data included basic information about reviews (e.g. number of included studies, number of participants, review type, aim/objectives), basic information about primary studies (e.g. references, designs), search strategy (e.g. databases searched, eligibility criteria), population (e.g. gender, age), peer support approach (e.g. peer support type and description), type of comparator, additional information (e.g. quality appraisal methods, review author conclusions), primary and secondary outcomes of systematic review or qualitative results.

Quality appraisal of included reviews

The quality of included reviews was independently assessed by reviewers (RC, KS, KM, PS, JG, RS, PB, RA) using the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews), a 16-point tool for assessment of the methodological quality of systematic reviews [ 32 ]. We adapted the AMSTAR 2 to apply for scoping reviews and systematic reviews of qualitative data (described in full in Additional file 1 : Appendix 3). The following questions were adapted: (1) PICO criteria, (2) Protocol requirements, (8) Detail of included studies, (9) Risk of Bias requirement. Two reviewers (KS, AG) 100% double-scored reviews blind with any outstanding disagreements resolved through discussion between AG, KS, and RC. Overall ratings for each study were calculated according to guidance [ 32 ], based on 7 critical domains and 6 non-critical domains within the AMSTAR 2 tool. Studies with no or one non-critical weakness and no critical flaws were rated as high quality. Studies with more than one non-critical weakness and no critical weaknesses were rated as moderate quality. Studies with one critical flaw irrespective of non-critical weaknesses were rated as low quality, and those with more than one critical flaw irrespective of non-critical weaknesses were rated as critically low quality. The AMSTAR 2 guidance [ 32 ] states that reviews of critically low quality should not be relied on for comprehensive and accurate summaries of the literature.

Synthesis methods

Rq 1: what is the effectiveness (e.g. clinical, social, functional) and cost-effectiveness of paid peer support approaches for mental health.

Data were tabulated and summarised narratively by two researchers (KS, AG); effectiveness meta-analysis data calculated from two or more studies were tabulated separately from non-meta-analysis effectiveness outcomes. Review outcomes were similar, but not similar enough to combine meaningfully in a meta-analysis. Effect sizes (with 95% CIs and p -values) were reported along with I 2 statistic (with 95% CIs, p -values, χ 2 , and degrees of freedom) where available. We did not tabulate data for subgroup analyses.

RQ 2: What influences the implementation of peer support approaches for mental health?

Outcomes were tabulated according to the main domains in the Consolidated Framework for Implementation Research (CFIR) [ 33 ]. The CFIR provides a comprehensive framework, composed of 5 domains, associated with the effective implementation of interventions [ 33 ]. The 5 domains are as follows: Innovation (the ‘thing’ being implemented); Outer setting (the setting in which the inner setting exists, e.g. hospital system); Inner setting (the setting in which the innovation is implemented, e.g. hospital); Individuals (the roles and characteristics of individuals); Implementation process (the activities and strategies used to implement the innovation) [ 33 ]. Synthesis was conducted using a collaborative process involving one member of the study team (RA) and one lived experience researcher (PS).

RQ 3: What are the experiences of peer support approaches for mental health (e.g. of acceptability) from the perspective of PSWs, healthcare practitioners, service users and carers?

Experiences were synthesised narratively, by three researchers, including two lived experience researchers (TJ, KM, RC) [ 34 ]. Themes from reviews which were identified as addressing research question 3 were extracted and similar themes across the reviews were grouped together. Each group was accounted for using an existing theme from one or more of the reviews or if this was not possible a new theme was developed. Three overarching themes were identified through iterative scrutiny of the data and discussion between TJ, KM, and RC. A summary of the common themes across the reviews, grouped under the three overarching themes, was then developed, including highlighting contrasting findings.

Study selection

The search strategy identified 777 references to be screened (a further 2 papers were identified through other methods); 93 full text articles were assessed for eligibility with 57 excluded (see Additional file 1 : Appendix 4 for reasons for exclusion). Thirty-five reviews (reported in 36 papers) were included (see Fig.  1 ).

PRISMA flow diagram [ 29 ]

Characteristics of included reviews

Review characteristics are detailed in Table  1 . Of the 35 included reviews, 13 were systematic reviews with meta-analyses, 13 were systematic reviews without meta-analyses, 3 were systematic reviews with a qualitative synthesis and 6 were scoping reviews. The individual reviews included between 95 and 40,927 participants; 6 reviews did not report the number of participants. For reviews where the population were service users, almost all were categorised as adults with mental health problems. Thirteen reviews specified that participants had severe mental illness (SMI) diagnoses [ 1 , 21 , 22 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ], six reviews explicitly included studies with participants accessing mental health services [ 22 , 37 , 38 , 43 , 45 ] [ 46 ], three reviews were conducted in perinatal populations [ 47 , 48 , 49 ], three reviews included participants with any/common mental health conditions [ 50 , 51 , 52 ], four reviews included participants with substance use disorders [ 1 , 38 , 53 , 54 ], two reviews included participants with eating disorders [ 55 , 56 ], one included people experiencing suicidality [ 57 ] and one included articles on peer support for crisis management [ 58 ]. The samples in the remaining reviews were PSWs and various stakeholders (e.g. non-peer staff, service users) [ 23 , 24 , 34 , 59 , 60 , 61 , 62 , 63 , 64 ]. Most reviews included interventions involving any form of peer support, individual, group or combined, although three reviews looked at group peer support alone [ 35 , 43 , 49 ], and three reviews looked at individual peer support alone [ 1 , 40 , 45 ]. Reviews looked at peer support delivered in-person, online or over the phone, and surveyed a range of approaches including both structured and unstructured peer support (see Table  1 ). The reviews included 426 primary studies. We assessed study overlap; most primary studies ( n  = 300) were only included in one review; however, many primary studies were included twice ( n  = 72), three times ( n  = 18) to a maximum of nine times ( n  = 1) (see Additional file 1 : Appendix 5 for overlapping studies). Only 1 review reported that people with lived experience were involved in the review [ 57 ]. Only 2 reviews assessed certainty of evidence (using GRADE) [ 21 , 22 ].

Most reviews were appraised as low or critically low (97%) quality and one review was appraised as high quality. The most common weaknesses were in critical domains concerning registering protocols before commencement of the review (21 studies), justification of excluding individual studies (28 studies) and considering risk of bias when interpreting results (13 studies). Reviews without meta-analyses were not scored in the critical domains assessing meta-analytical method or publication bias. There were 13 studies with meta-analyses assessed in these two domains: two of these exhibited one critical weakness and two exhibited two critical weaknesses. As scoping reviews are intended to provide overviews of existing literature regardless of risk of bias [ 65 ], scoping reviews were not scored in the critical domain concerning risk of bias assessment techniques (see Additional file 1 : Appendix 3 for adjustments to quality appraisal for scoping and qualitative reviews). Of the 29 reviews that were eligible to be scored in this domain, 10 exhibited a critical weakness. The review eliciting high confidence was a Cochrane review [ 21 ]. No reviews were rated as moderate. AMSTAR 2 ratings are detailed in Table  1 and in full in Additional file 1 : Appendix 3.

Results of synthesis

Rq1: what is the effectiveness (e.g. clinical, social, functional) and cost-effectiveness of paid peer support approaches for mental health.

Effectiveness outcomes were reported in 23 reviews (66% of total). A wide variety of clinical, recovery and psychosocial effectiveness outcomes were reported across both meta-analysis [ 21 , 22 , 37 , 40 , 41 , 42 , 43 , 44 , 45 , 47 , 48 , 51 , 52 ] and narrative results [ 1 , 21 , 22 , 35 , 36 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 48 , 50 , 51 , 53 , 54 , 56 , 57 , 58 , 60 ]. Comparator groups also varied across the primary studies included in the reviews, including Treatment as Usual (TaU), active controls (e.g. a comparable standard treatment) and waitlist control groups.

All outcomes except for one (family or carer use of formal community support services; [ 44 ]) were service user outcomes, rather than carer, staff or PSW outcomes. Outcomes from systematic reviews with meta-analysis are reported in Tables  2 , 3 and 4 . Effectiveness results from reviews not including meta-analysis are summarised at the end of this section and reported in full in Additional file 1 : Appendix 6. Evidence was heterogenous across all outcomes and reviews, with many analyses reporting no effect. In the meta-analysis results, there was often notable heterogeneity. There was limited data on cost and cost-effectiveness, but the evidence available from three systematic reviews without meta-analyses (See Additional file 1 : Appendix 6) suggested that peer support interventions were low cost and cost-saving [ 38 , 48 , 50 ].

Results from meta-analyses

Clinical outcomes.

For depression outcomes, evidence from two reviews with meta-analyses suggested that peer support is effective in improving perinatal depression [ 47 , 48 ]. Three reviews of peer support for adults and adolescents with mental health problems including those with SMI diagnoses reported no effect on depression post-intervention [ 22 , 35 , 43 ], where two of these reviews looked at group-based peer support alone [ 35 , 43 ]. Two of these reviews reported follow-up results; one review of group peer support for adults with any mental health condition continued to find no effect at 3–6 months follow-up [ 35 ], while the other involving adults with SMI reported improvements in depression and anxiety at 6 months follow-up, despite reporting no effect at post-intervention [ 22 ]. One review [ 52 ] measured clinical recovery in adults with any mental health diagnosis, reporting improvements post-intervention and at 6–9-month follow-up, but no improvement at 12–18-month follow-up.

Most evidence regarding mental health symptom severity among adults and adolescents with mental health diagnoses or who were using mental health services suggested no effect [ 22 , 35 , 41 , 42 , 43 , 44 ], other than for perinatal depression as previously summarised. One review [ 40 ] of individual peer support for adults with primarily SMI diagnoses reported improvements in symptom severity, while another involving adults with SMI [ 44 ] reported symptom improvements following family-led peer support, but no improvement following individual-led peer support. Results for service use varied depending on the measure, for example, peer support was associated with reduced risk of hospitalisation [ 44 ], including after a follow-up period [ 45 ], but no effect was found regarding length of stay [ 41 , 42 ].

All reviews providing meta-analytic evidence relevant to this question were rated low or critically low quality, except from one high-quality review [ 21 ] which found no effect of peer support on patient activation between 1 and 6 months follow-up (a person’s perceived ability to manage their illness and their approach to healthcare) in adults with schizophrenia diagnoses or similar SMI.

Recovery outcomes

Of the seven reviews with meta-analyses reporting data on overall self-reported recovery, five reported improvements in recovery in adults with mental health diagnoses including SMI [ 22 , 35 , 40 , 44 , 45 ]. Two studies found effects for individual peer support interventions alone [ 40 , 45 ], and one reported an effect for group-based peer support alone [ 35 ]. Only two reviews reported no effect [ 21 , 43 ], where one included studies of adults with SMI in both individual and group-based peer support [ 21 ], and the other involved studies with adults and adolescents with any mental health problem in group-based peer support alone [ 43 ].

Three reviews reported follow-up data showing continued improvements for adults with mental health diagnoses including SMI at follow-ups of 6 months [ 22 ], 3–6 months [ 35 ] and 12–18 months [ 45 ], the former and the latter reviewing individual and group peer support, and the second focussing on group peer support alone. One further review reported no improvements at medium-term follow-up (1–6 months) [ 21 ]. One review of adults with any mental health diagnosis identified improvements in personal recovery post-intervention, but not at 6–9 or 12–18 months follow-up, and found no improvements in functional recovery post-intervention or at 12–18 months follow-up, but did report improvements at 6–9 months follow-up [ 52 ].

All reviews providing meta-analytic evidence for these outcomes were rated as critically low or low quality, except for one [ 21 ] which was rated high quality. Based on evidence from three studies, this latter review [ 21 ] found no effect of peer support on recovery in the medium term for adults with schizophrenia diagnoses or similar SMI.

Psychosocial outcomes

Evidence regarding hope or hopefulness was mixed. Four reviews with meta-analyses suggested that peer support resulted in improvements in adults with SMI [ 22 , 37 , 40 , 44 ], where one of these studies looked at individual peer support alone [ 40 ] and the rest included both individual and group peer support. However, three reviews of studies including SMI and mixed mental health diagnoses samples reported no effect [ 21 , 35 , 43 ], where two of these reviews focussed on group-based peer support alone [ 35 , 43 ]. One study [ 22 ] followed up adults with SMI and those using secondary MH services at 3–6 months and found continued improvements in hope. However, another review investigating longer-term outcomes (over 6 months) in adults with SMI found no effect [ 21 ].

Improvements in empowerment were evidenced by two reviews with meta-analyses [ 40 , 51 ] of studies involving adults with any mental health diagnosis including SMI. No effects were reported in four reviews [ 22 , 35 , 43 , 44 ]. One of the meta-analyses finding positive effects of peer support on empowerment looked at individual peer support alone [ 40 ], whereas two of the meta-analyses with no effect solely involved group-based peer support [ 35 , 43 ]. Three studies reported follow-up data. Two showed improvements at 6 months in adults with SMI [ 22 ] and at 6–12 months follow-up among adults using mental health services with any diagnoses [ 45 ]. The other showed no improvements from group-based peer support only in adults with mental health diagnoses including SMI between 3 weeks and 6 months follow-up [ 35 ].

Quality of life reportedly improved in two reviews with meta-analyses [ 37 , 44 ] of studies involving adults with SMI, while there was no evidence of improvement in one other with an SMI sample [ 22 ]. The two studies which reported follow-up data continued to find no effect [ 22 , 45 ].

There were improvements in self-efficacy in adults with any mental health problem in all three reviews with meta-analyses reporting this outcome [ 43 , 44 , 51 ]. Decreases in self-stigma and stigma-related stress in adults and adolescents with any mental health problem were found by one review with meta-analysis of group-based peer support [ 43 ]. There was no evidence for peer support improving satisfaction with care [ 22 , 41 , 42 , 44 , 45 ] or relational outcomes (including social support and network) and building relationships (both personally and with staff) [ 41 , 42 , 44 , 45 ].

All reviews providing meta-analytic evidence for these outcomes were rated as critically low or low quality, except one high-quality review [ 21 ] which found no effect of peer support on hope in adults with schizophrenia diagnoses or similar SMI in the medium or long term.

Summary of results from systematic reviews without meta-analysis

Effectiveness results from systematic reviews without meta-analyses are tabulated in full in Additional file 1 : Appendix 6. These reviews presented mixed results pertaining to clinical outcomes including depression, anxiety, eating disorder pathology, and psychosis. However, two scoping reviews reported evidence of peer support in improving suicidal ideation [ 57 , 58 ]. Evidence was deemed inconclusive regarding the impact of peer support on indicators of service use, where three reviews failed to find evidence for peer support [ 21 , 22 , 41 , 42 ], three reported mixed results [ 1 , 38 , 54 ], and one found evidence for improvements associated with peer support [ 36 ]. More consistent evidence was found indicating peer support improves recovery outcomes [ 1 , 36 , 38 , 40 , 44 , 53 ]. For most psychosocial outcomes, systematic reviews presented mixed evidence, for example different effects were found by one high-quality review for empowerment, hope and self-efficacy, depending on what measures were used [ 21 ]. Despite mixed effects being reported overall for the impact of peer support on satisfaction with care, one review cited some possible associated moderating factors such as the number of conversations had between peer supporter and recipient [ 48 ]. Evidence was marginally less mixed for relational outcomes, such as strength of interpersonal relationships and sense of community, as the majority (three) of relevant reviews found evidence in support of peer support [ 21 , 38 , 58 ], although one review found this did not persist long term [ 21 ].

Implementation was investigated in nine reviews [ 23 , 24 , 36 , 39 , 46 , 50 , 55 , 59 , 62 ]. Table 5 shows an overview of implementation outcomes by CFIR domain [ 33 ]. All reviews relevant to this research question were rated as critically low quality based on the adapted AMSTAR 2 rating scale (see Additional file 1 : Appendix 3).

Studies reported generally high acceptability and feasibility of PSW-led interventions [ 36 , 39 , 46 , 50 ]. When planning a peer-led service, co-producing the design of peer support provision with the community and stakeholders was found to be key [ 59 ].

Outer setting

The existence of national policy and funding provisions for employing and retaining PSWs facilitated PSW-led care [ 39 , 46 , 59 ], as did integration of interventions within existing healthcare systems [ 50 ]. However, barriers included power hierarchies [ 39 ], difficulties incorporating PSWs in medical mental health care models [ 24 , 39 , 46 ], interference of work with welfare benefits [ 62 ] and a lack of recognised PSW certification [ 62 ].

Inner setting

A workplace culture emphasising recovery-orientated practice [ 24 , 59 ], and organisational openness and readiness to employ PSWs [ 39 ], was important. Facilitators included strong leadership and support at the highest level [ 46 ], and flexible and understanding employers, especially in times of crisis [ 59 ]. A key facilitator was a supportive, accepting and trusting workplace culture where PSWs occupy a central position and fit in well with other staff members [ 24 ]. A trusting culture allowed the management of risk in a psychologically safe space [ 59 ]; effective communication and collaboration between PSWs and other workers facilitated this [ 24 ], while stigmatising staff attitudes were a barrier [ 62 ]. It was easier to implement PSWs in a more collaborative and less hierarchical service [ 59 ]. There were practical facilitators and barriers for PSWs also, such as access to desk space or administrative data [ 24 , 46 ], time restraints, high caseloads [ 23 , 24 ] and insufficient funding for PSW role [ 24 , 50 ].

Individuals

The professionalisation and legitimisation of the PSW role was seen as important, with associated performance standards and/or a code of ethics [ 24 ] which was linked to rigorous recruitment practices, ensuring parity in the recruitment of PSWs and other staff [ 46 ]. A further facilitator was high levels of competency among peer-counsellors when delivering interventions and having relevant skills and knowledge, e.g. mental health conditions [ 50 ]. PSWs were often required to have recovered from their mental health difficulties [ 55 ] and be able to use their coping skills and resilience to avoid potential negative impacts on their wellbeing [ 24 ]. PSWs reported a conflicted sense of identity between being a ‘peer’ with experience of mental health problems and a ‘professional’ as a barrier to their work [ 62 ]. The use of champions and implementation leaders to drive the set up and maintenance of PSW interventions was reported as a facilitator [ 46 ], as was staff willingness and ability to work with PSWs and accept them as part of the service [ 24 ].

Implementation process

Studies emphasised the importance of comprehensive training for PSWs delivered both prior to starting work and on an ongoing basis, alongside regular clinical supervision [ 24 , 46 , 50 , 55 ] supporting the management of any problems encountered [ 59 ]. PSW roles should be clearly defined [ 24 , 62 ] and training should also be delivered to other members of staff to help them work effectively with PSWs [ 46 ]. Establishing sustainable models of cost and supervision from the outset was key for the longevity of PSW [ 50 ].

Experiences of both the benefits and challenges of peer support were reported in 11 reviews [ 23 , 34 , 39 , 42 , 46 , 49 , 55 , 60 , 61 , 63 , 64 ] from a range of perspectives: PSWs [ 23 , 34 , 39 , 55 , 61 ], service users [ 39 , 55 , 61 ], non-peer staff [ 61 ], peer support group members [ 49 ], and mixed samples which consisted of combinations of PSWs, service users, non-peer staff, carers, mental health organisations, policy makers and peer programme developers [ 23 , 39 , 42 , 46 , 55 , 60 , 61 , 63 , 64 ]. In one review, it was unclear whose perspective was being presented [ 46 ], although this review only contributed to one theme. All reviews providing evidence for this research question were rated as critically low quality based on the adapted AMSTAR 2 rating scale (see Additional file 1 : Appendix 3). We identified 3 overarching themes: (i) what the PSW role can bring, (ii) confusion over the PSW role and (iii) organisational challenges and impact. Table 6 gives an overview of the overarching themes and subthemes (with more detail in Additional file 1 : Appendix 7). The following provides an overview of each overarching theme from the perspective of the different samples (i.e. PSWs, service users, mixed samples).

What the PSW role can bring

Perspective of psws.

PSWs experienced improved wellness and recovery from working in the role, reporting increased self-esteem, personal growth, and social networks [ 23 , 34 , 55 , 61 ]. They benefited in a variety of ways, e.g. the role provided a route back into employment, improving functioning and social inclusion, and allowed them to learn more about their own mental health [ 23 , 34 ]. PSWs also reported increased self-acceptance as they no longer had to hide their mental health issues [ 34 ]. The role was therefore often reported to be mutually beneficial for PSWs and service users [ 34 , 55 ]. PSWs felt it was important that they were role models for service users, being ‘the evidence of recovery’ [ 34 ]. However, working as a PSW could also have a negative impact on the PSWs’ wellbeing and recovery [ 23 , 34 ]. Reasons for this included the role reminding them of their mental health condition and the ‘sick’ label staying with them [ 23 ].

Perspective of service users

For service users, PSWs could be role models, giving them hope of recovery [ 39 , 55 , 61 ]. PSW support normalised and de-medicalised service user experiences [ 55 ]. Lack of judgement from PSWs reduced feelings of self-stigma for service users [ 55 ]. Service users felt empowered by and valued gaining experiential knowledge from PSWs, perceiving them to be more insightful than non-peer staff, and trusting their services [ 39 ]. Service users also built rapport more easily with PSWs than non-peer staff, feeling they were more approachable and had greater empathy than non-peer staff [ 39 , 61 ]. However, some service users reported that PSWs are not role models and found it challenging to view them as professionals or fully trust their knowledge, due to their lack of training and concerns about their mental health history [ 39 , 61 ].

Perspective of non-peer staff

From working with PSWs, non-peer staff developed increased empathy towards service users and a belief in recovery [ 61 ].

Perspective of peer support group members

Forming relationships in peer support groups and having their experiences validated by others was valuable for recovery [ 49 ]. However, group members could feel isolated when other members’ experiences contrasted with their own [ 49 ].

Perspective of mixed samples

PSWs were perceived to be role models, providing valuable support to service users and giving them hope of recovery [ 60 , 64 ]. Working as a PSW could enable service users to find a role in the community, beyond the identity of being a ‘patient’ [ 61 ]. PSWs could build trust-based pathways to function as a bridge between service users and non-peer staff [ 64 ]. Within teams, working with PSWs could improve recovery-oriented care and PSWs carried out various roles, such as providing psychosocial support, advocating for service users, providing insights based on their lived experiences [ 64 ]. For mental health organisations, PSW roles decreased stigma towards mental health problems and set a positive example [ 61 ]. However, there were fears that the PSWs’ mental health condition could impact the provided support, such as increased PSW absenteeism which could increase non-peer staff caseloads and concerns that service users’ and PSWs’ could experience distress due to exposure to difficult (‘triggering’) content [ 42 , 55 , 60 ]. PSWs experienced pressure due to the perception that they were pioneers, leading to expectations, e.g. failure could reduce future PSW opportunities [ 64 ]. There was also concern that PSWs lacked mental health knowledge, beyond their own experience [ 64 ].

Confusion over the PSW role

A lack of clarity about the PSW job description led PSWs to feel the role was undervalued and tokenistic and meant they felt confused in their role. This impacted their perception of competence which affected their recovery and led to uncertainty in their responsibilities with service users [ 23 , 34 ]. PSWs also found the transition from service user to PSW and knowing where to draw the line between friend and service provider to be challenging [ 23 , 61 ]. Linked to this, their dual identity as a service user and provider could be a source of stress. For example, it meant they could closely connect with service users who had similar difficulties to their own, but this could also be triggering and lead to a recurrence of the PSWs’ own mental health issues [ 34 ]. PSWs expressed varying views on disclosing their recovery story [ 34 , 39 ]. For some, sharing elements of their story was linked to their own personal recovery [ 34 ]. However, other PSWs felt fearful of disclosure, e.g. they were concerned about being labelled ‘mentally ill’ and service users not trusting them [ 39 ].

A lack of clarity on the PSW role could lead service users to view the role as informal, leading to negative perceptions of the PSW services. Perceptions of tokenism of peer support could lead to the content of the PSW intervention ‘feeling irrelevant’ [ 39 ].

PSWs and non-peer staff found the PSW role to be ambiguous, e.g. the role was not clearly defined [ 63 ] and job descriptions were ‘vague’ [ 64 ]. Although this gave flexibility to define the role [ 64 ], it also led to challenges. Some PSWs felt they were expected to develop the role over time and received insufficient training, which hampered service delivery and could result in perceptions that PSWs were tokenistic [ 42 , 63 , 64 ]. Uncertainty about the role also led to a lack of support from non-peer staff [ 63 ]. Relatedly, there was confusion for PSWs over when/with whom to disclose their lived experience [ 63 , 64 ]. Some PSWs felt vulnerable and were reluctant to disclose, but disclosure could build trust with service users, enabled PSWs to be recovery role models, and could educate non-peer staff on alternative views [ 63 , 64 ]. Disclosure was also felt to require discretion when fitting with professional relationships. However, ‘professionalisation’ of PSWs may not challenge the existing boundaries (e.g. traditional hospital-based boundaries which could make it difficult for the sharing of lived experience to be valuable), when challenging these boundaries could change culture [ 63 , 64 ]. The transition for PSWs from patient to staff was challenging, e.g. non-peer staff were concerned about the PSW becoming unwell, making PSWs feel like they are being treated like patients [ 63 , 64 ]. There were issues around boundaries, including whether PSWs should relate to service users as friends or service users [ 63 ].

Organisational challenges and impact

PSWs experienced a lack of support and training for their role, potentially related to unclear job descriptions, and insufficient supervision [ 23 , 34 ]. This meant that PSWs struggled to develop the skills for their roles, including to work with service users with more complex needs than their own experiences [ 23 ]. Although there were some contrasting views, PSWs were concerned that they received low pay which made them feel that they were not valued, and they perceived themselves to be ‘cheap labour’ [ 23 , 34 , 61 ]. Some PSWs felt accepted in their teams however others experienced negative and rejecting non-peer staff attitudes [ 23 , 34 , 61 ]. For example, PSWs reported not being invited to social events and being treated like patients [ 61 ]. Consequently, some PSWs felt excluded, that their roles were tokenistic and experienced self-stigma [ 23 , 34 ]. PSWs as part of the newer recovery model reported challenges around integrating into traditional treatment models, e.g. where doctors spent the least time with service users but held the majority of power and decision making for service users. PSWs were expected to contest the traditional treatment model in support of a recovery focus, e.g. by their presence or in some cases being openly challenging, and this clash between old and new treatment models could lead to friction [ 23 ].

There was a fear that ‘cheap labour’ provided by PSWs may lead to fewer non-peer staff positions [ 61 ].

PSWs often received low pay, which led to role dissatisfaction for PSWs, suggesting the job was tokenistic or the role was unclear [ 63 , 64 ]. One reason for low pay was due to PSWs not requiring certification (i.e. specific qualifications, which e.g. a social worker would require) [ 63 ]. Some PSWs were positive about certification but others felt it could conflict with the grassroots ethos of peer support. However, there was the view that lived experience was not solely sufficient to work in interprofessional teams [ 64 ]. Despite this, supervision and support were often not offered to PSWs leading to risks [ 60 , 64 ].

There were challenges in PSW relationships with non-peer staff which could lead to a lack of support and hostility from non-peer staff. Non-peer staff felt threatened that they may be replaced by PSWs [ 64 ], were uneasy about working with people they previously treated [ 46 ], were concerned about the effectiveness of peer support [ 39 ], and felt expectations to support PSWs, increasing their workload [ 42 ]. This undermined the role of PSWs, e.g. they were subsequently given fewer responsibilities [ 39 ]. For PSWs, they wanted to challenge stigma by taking on more responsibility but high, varying workloads could jeopardise relationships with non-peer staff and team hierarchies hindered their ability to challenge clinically dominant ways of thinking [ 64 ].

A final theme was the perception that service users should be able to choose among PSWs as service providers [ 60 ].

Summary of key findings

An overview and summary of the key findings for each research question is presented in Table  7 .

Key findings

Our umbrella review of 35 reviews explored the effectiveness, implementation and experiences of peer support for mental health.

Effectiveness was reported in 23 reviews. Many reviews reporting effectiveness data reported no effect of peer support on a range of outcomes, mirroring the findings from other reviews [ 9 , 66 ] including those focusing on other types of peer support (e.g. online peer support for young people) [ 67 ]. However, there was consistent evidence from meta-analyses that peer support may improve the clinical outcomes of perinatal depression and risk of hospitalisation of adults with severe mental illness, as well as recovery outcomes, and self-efficacy and stigma-related outcomes. Mixed meta-analytic results were found for the clinical outcomes of overall psychiatric symptoms in adults with SMI, psychosis symptoms, length of hospital stay and patient activation, and for psychosocial outcomes such as hope, empowerment, and quality of life. There was no meta-analytic evidence for improvements in relational support. Evidence from systematic reviews without meta-analysis similarly gave a mixed picture regarding psychosocial and clinical outcomes, but indicated more consistent evidence that peer support has a positive impact on recovery, suicidal ideation, and, to some degree, satisfaction with care.

Many possible sources of heterogeneity across the included reviews could contribute to the mixed findings in this study, such as low-quality methodologies, differences in the populations included, and poor specification of peer support roles or the content of interventions delivered. One important potential contributor to our mixed results is that the primary studies contributing to the included reviews often varied in the type of control groups they considered, for example studies with treatment as usual, active controls and waitlist controls were often reviewed within the same paper. As such, it was not possible to determine whether peer support is effective in comparison to certain types of care provision but not others. In a similar vein, we could not perform subgroup analysis to determine whether specific forms of peer support are more effective on certain populations as most reviews with meta-analyses involved a combination of different formats and a range of participant groups. Nevertheless, there was some indication that differences in the format of peer support may impact its effectiveness on empowerment, as the two meta-analyses involving individual peer support alone found a positive effect on empowerment, but the two looking at group-based peer support alone did not. However, further research is needed to adequately address such questions.

Although this overview of quantitative evidence does not give unequivocal support for peer support on a variety of outcomes, the mixed results must be understood not only in the context of heterogeneity of the quantitative research conducted thus far, but with regard to the qualitative evidence documenting strong support for this intervention (as discussed in more detail below). Given that the implementation of peer support in mental health services is still relatively rare and highly variable, many of the trials conducted thus far may have tested peer support in environments where it is not fully embedded in the organisation and culture. Indeed, peer support may have positive impacts on the operation of mental health services that have not been measured as quantitative outcomes in existing trials—such as a stronger culture of person-centred care. More consistent quantitative results demonstrating the benefit of peer support may increasingly emerge as it becomes better integrated in the mental health care system.

We identified several factors reported to be important for the successful implementation of peer support, which were summarised and structured using the CFIR. These factors included adequate training and supervision for PSWs, a recovery-oriented workplace structure, strong leadership and a supportive and trusting workplace culture with effective collaboration between PSWs and non-peer staff. Barriers to peer support being implemented effectively included a lack of time, resources, and appropriate funding, and a lack of recognised PSW certification. Policy, research and campaign groups have advocated implementation approaches in line with these findings, for example, ImROC (implementing Recovery through Organisational Change) [ 14 , 68 ], who support peer support implementation globally and international competence frameworks from New Zealand [ 69 , 70 ], outline recovery focus as a core principle of peer support and emphasise the importance of training and ongoing professional development; peer support practice guidelines in the USA outline the importance of and give guidelines for supervision [ 71 ]. Formalised career pathways for PSWs [ 72 ] may help to address some of the identified barriers to effective implementation of peer support work, although these are still early in their development [ 68 ].

Experiences of peer support were from a range of perspectives (e.g. PSWs, service users, non-peer staff) and were organised under three main themes. The benefits of peer support for PSWs, service users and non-peer staff were expressed in many reviews; however, there were also conflicting and challenging experiences of the role. The mental health experience of PSWs was viewed as valuable, but also subject to some stigmatising views. For PSWs, the role could improve their personal wellness and recovery, providing a route back into employment and improving functioning, and provide service users with role models of recovery. The reciprocal benefits of peer support have also been highlighted as an advantage of peer support in resources developed by NHS England [ 19 ]. However, PSWs reported the ‘sick’ label stayed with them in the role, with non-peer staff at times concerned that PSWs mental health would impact their work, and some service users reported that they found it challenging to trust PSWs knowledge due to their lack of training and mental health history. A key experience, which became the core of our second theme, was the ambiguity of the PSW job description, including lack of clarity over boundaries with service users and when to disclose PSWs’ personal experiences. This ambiguity meant that the role was flexible, but also led to the perception that it was tokenistic and left PSWs feeling confused which impacted their own recovery. IMROC recommend the prioritisation of clear roles when implementing peer support [ 68 ]. Professional accreditation can counter the view of peer support as tokenistic, e.g. the UK Peer Support Competence Framework outlined by the Royal College of Psychiatrists [ 73 ] and the Canadian Peer support Accreditation and Certification, a national standard endorsing peer support work as a valuable career, developed in 2017 by PSWs themselves [ 74 ]. The final theme ‘organisational challenges and impact’ included experiences such as PSWs receiving inadequate support, training and supervision, and receiving low pay, leaving them feeling undervalued. Some non-peer staff attitudes were also a reported issue; while some PSWs felt accepted within teams, others experienced negative and rejecting non-peer staff attitudes, such as being treated as patients and not being invited to staff social events. Organisations should prepare, structurally and culturally, for the introduction of PSWs in order to ensure PSW wellbeing and reduce the risk of absences due to sickness [ 68 , 75 ].

Strengths and limitations

We conducted a comprehensive search of several relevant databases and identified a large number of reviews for inclusion, providing the first detailed summary of review findings relating to effectiveness, implementation and experiences of peer support. We also had consistent involvement of researchers with lived experience of mental health and peer support delivery and receipt throughout the design, data screening and extraction, analysis and synthesis, and manuscript drafting for this paper, which allowed lived experience priorities and experiences to guide our approaches to data and our decision making throughout.

We aimed to focus our review on paid peer support; however, this information was underreported in the reviews, and even when reported, interventions were often grouped with peer support interventions that did not fully meet our eligibility criteria (e.g. were unpaid). We also synthesised data from studies where payment status of PSWs was ambiguous, i.e. not reported. This limits our ability to draw firm conclusions around paid peer support specifically, as a significant portion of the data synthesised was from studies investigating unpaid or voluntary peer support. Another limitation was the lack of involvement of people with lived experience in the included reviews, with involvement reported in only one review [ 57 ]. Given the service user-led origins of peer support, future reviews should ensure involvement of people with lived experience. This is addressed in more detail later in this paper. Most included reviews were appraised by the AMSTAR 2 as low or critically low (97%) quality with only one review appraised as high quality. Although the low quality of reviews is a limitation, we aimed to report an overview of all current evidence for peer support to inform policy makers and healthcare practitioners, therefore to maximise the evidence base, we synthesised the reviews scored as ‘critically low quality’. Our ratings are also in line with a prior umbrella review of peer support which rated 87% of reviews as critically low quality and the remainder as low quality, but reported outcomes from all reviews [ 66 ].

Beyond the aforementioned limitations regarding variation in studies within each review, there is also a loss of granular detail through the umbrella review process of summarising data across reviews, which themselves contain many studies which have been summarised. The person-centred nature of peer support may mean that there are meaningful outcomes for the service user which are not easily captured in standard outcome measurement tools or recognised as clinically significant. Variation in peer support roles across studies may have contributed to the contradictions in our findings for RQ3, e.g. the challenges around PSW roles being ambiguous, but also the reported benefits of a flexible role.

A strength of our review was our broad inclusion criteria, for example, for qualitative data on experiences of peer support we reported data from the perspectives of service users, non-peer staff and PSWs. Though some data was reported separately by role, there were studies where experiences were reported together, and these perspectives were difficult to disentangle. Finally, we did not conduct a formal meta-synthesis of the qualitative experiences data; therefore, some detail may have been missed.

Implications for practice

Peer support may be effective at improving some clinical outcomes, self-efficacy and recovery outcomes for some people and could augment the standard service range. Certain groups may benefit from peer support more than others; evidence was strongest for depression outcomes within perinatal populations, but extremely variable for other populations. Peer support may differ in effectiveness depending on population needs and characteristics. PSWs need adequate pay, clear role descriptions and guidelines (e.g. about boundaries and disclosure), ongoing training and supervision, and opportunities for progression. Attitudes about peer support held by non-peer staff may significantly support or impede the implementation and experience of PSWs, and non-peer staff may require training about PSW roles and how to work collaboratively with PSWs. Culture, hierarchical structure and staff acceptability of peer support impact implementation and experience of peer support—structural and cultural change may be required for peer support to succeed, e.g. ensuring a recovery-oriented care model is operating in the service.

Implications for policy

Successful implementation of PSWs in healthcare settings is likely to require a coproduction approach with clearly defined PSW roles, a receptive hierarchical structure and staff, strong leadership and appropriate training (for PSWs and staff) with clinical and/or peer supervision alongside safeguarding. Issues relating to cost, lack of time and lack of resources are key considerations for service providers aiming to implement PSW that is sustained and effective within services. Additionally, Services could benefit from clear, coproduced guidelines, outlining the steps that are most likely to lead to successful PSW implementation.

Implications for research

Future primary and secondary research could usefully explore the differences in efficacy, implementation and experiences in paid PSW over time as it becomes more established; an important distinction as there are likely to be differences in these outcomes as the role of PSW develops. Such studies could consider using more personalised outcome measures such as goal-based outcome measurement [ 76 ]. Current PSW roles are still poorly defined and PSW content, including PSW variations (such as whether PSWs should deliver structured or more loosely structured, informal interventions, or whether interventions should vary according to need and context), need further exploration. Realist investigations around what works for whom, how and in which contexts would uncover more fine-grained detail on the specific contexts and mechanisms that explain these differences. Very few reviews included in this umbrella review reported lived experience researcher leadership or involvement in the undertaking of the study. It is imperative for future research in this area to appropriately reflect the priorities of those who are directly involved in PSW, either as providers or as service users. As the number of PSWs increases and more formalised roles are created, positive impact may not be restricted to outcomes of those supported by PSWs, but also to the functioning of services at an organisational level [ 68 ]. Further research is needed to evaluate how teams function with and without PSWs in order to understand how they may impact experiences through changes at a system level [ 68 ].

Our umbrella review has summarised data from 35 reviews on the effectiveness, implementation, and experiences of peer support for mental health. Although we attempted to focus solely on paid peer support, this detail was often not reported in the reviews. While data on effectiveness was mixed, there was some evidence of improvements on outcomes including depression, particularly perinatal depression, self-efficacy, and recovery, illustrating the potential benefits of wider PSW implementation across mental health services. Good implementation of peer support depends on co-design with people with lived experience, clear job descriptions, a recovery-oriented workplace culture, strong leadership, appropriate training for PSWs and staff , and supervision for PSWs. However due to limited information on cost or cost-effectiveness, we are unable to draw conclusions around resources required to implement PSWs. Experiences of peer support were from a range of perspectives. Peer support was mutually beneficial for PSWs’ and service users’ wellbeing and recovery and PSWs became role models. However, at times PSW roles were ambiguous, this meant that the role was flexible but could also lead to confusion which could impact PSWs own recovery. Potential strategies to successfully implement peer support include that the PSW roles should be clear, PSWs should be appropriately trained and paid, as well as supported and supervised within a trusting and accepting workplace structure and culture that advocates for a recovery-oriented model of care.

Lived experience commentary, written by LM and KM

This study provides a useful summary of the available research on peer support. By providing an overarching review of 35 reviews including 426 available studies, the paper brings together the knowledge on a topic of growing importance and understanding of the experiences, effectiveness, and implementation of peer support. However, this evidence is limited to ‘paid peer support workers’ included in data from academic literature of systematic reviews.

The nature of an umbrella review means that the systematic reviews themselves are synthesised, limiting our ability to look at specific details in the primary studies, for example to look for evidence of lived experience involvement or co-authorship or demographics of participants. The papers within the review are likely to have originated from traditionally funded research enquiries, and an umbrella review potentially magnifies academic or clinical perspectives over user voices and interests. While this is a frustration in any mental-health-related topic, this is particularly concerning in relation to peer support, with its origins in our user-led history.

The roots in user-led peer support are also overlooked when limiting the studies to paid peer support work. Although they might use the same language of mutuality and reciprocity, the two feel different. We are hesitant to suggest that we would prefer the skills and expertise of our supporters to be voluntary and unpaid; we strongly believe their expertise should be valued and funded. But there is something magical about informal peer support which can be lost when it is over-policed in bureaucratic cultures. Additionally, with studies included in the review dating back to 1979, we question how relevant these studies are in informing England’s evolving peer support landscape.

A crucial area of future research is exploring what type of peer support works best for whom and in what circumstances, and how we can deliver this. Furthermore, we need to better understand how NHS cultures can be supported to value the expertise that originates in our lived experience, including the marginalised experiences which have been disproportionately represented in mental health services.

Availability of data and materials

The data used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

A MeaSurement Tool to Assess systematic Reviews

Consolidated Framework for Implementation Research

Implementing Recovery through Organisational Change

Lived Experience Working Group

Population, Intervention, Comparator group, Outcome

Peer support worker

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Acknowledgements

This work is supported by the NIHR UCLH BRC.

This study is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Author information

Ruth E. Cooper and Katherine R. K. Saunders are joint first-authors.

Authors and Affiliations

NIHR Mental Health Policy Research Unit, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK

Ruth E. Cooper, Katherine R. K. Saunders, Jessica Griffiths, Ruth Stuart & Alan Simpson

NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK

Anna Greenburgh, Rebecca Appleton, Phoebe Barnett, Sophie M. Allan, Brynmor Lloyd-Evans & Sonia Johnson

Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK

Phoebe Barnett

National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK

University of East Anglia, Norwich, UK

Sophie M. Allan

MHPRU Lived Experience Working Group, London, UK

Prisha Shah, Karen Machin, Tamar Jeynes, Lizzie Mitchell, Beverley Chipp & Stephen Jeffreys

Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, London, UK

Alan Simpson

Camden and Islington NHS Foundation Trust, London, UK

Sonia Johnson

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Contributions

All authors (RC, KS, AG, PS, RA, KM, TJ, PB, SA, JG, RS, LM, BC, SJ, BLE, AS, SJ) substantially contributed to the conception or design of this study. Data acquisition was undertaken by: KS, RC, JG, RS, RA, KM, PS, SA, PB. The data were synthesised and interpreted by: KS, AG, RA, PS, KM, TJ, and RC. KS and RC led on drafting the manuscript with input and/or editing by all other authors (AG, PS, RA, KM, TJ, PB, SA, JG, RS, LM, BC, SJ, BLE, AS, SJ). All authors (RC, KS, AG, PS, RA, KM, TJ, PB, SA, JG, RS, LM, BC, SJ, BLE, AS, SJ) read and approved the final manuscript.

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Twitter handles: @soniajohnson (Sonia Johnson); @cityalan (Alan Simpson); @MentalHealthPRU (Mental Health Policy Research Unit).

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Correspondence to Ruth E. Cooper or Katherine R. K. Saunders .

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Competing interests.

KM is a Director of With-you Consultancy Ltd who provide peer support training and consultancy. All other authors declare no competing interests.

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Supplementary Information

Additional file 1: appendix 1..

Prisma checklist [ 29 ]. Appendix 2. Full search strategy. Appendix 3. AMSTAR2 ratings. Appendix 4. Excluded studies following full text screening, with reasons. Appendix 5. Study overlap. Appendix 6. Effectiveness of peer support outcomes: results for non-meta-analysis results. Appendix 7. Experiences of peer support (detailed themes).

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Cooper, R.E., Saunders, K.R.K., Greenburgh, A. et al. The effectiveness, implementation, and experiences of peer support approaches for mental health: a systematic umbrella review. BMC Med 22 , 72 (2024). https://doi.org/10.1186/s12916-024-03260-y

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• Peer support
• Mental health
• Systematic review
• Umbrella review

BMC Medicine

ISSN: 1741-7015

• Submission enquiries: [email protected]
• General enquiries: [email protected]

What do peer support workers do? A job description

Affiliation.

• 1 Centre for Research on Employment and Workplace Health, Centre for Addiction and Mental Health, 455 Spadina Avenue, Suite 300, Toronto M5S 2G8, Canada. [email protected]
• PMID: 22812608
• PMCID: PMC3483205
• DOI: 10.1186/1472-6963-12-205

Background: The extant literature suggests that poorly defined job roles make it difficult for peer support workers to be successful, and hinder their integration into multi-disciplinary workplace teams. This article uses data gathered as part of a participatory evaluation of a peer support program at a psychiatric tertiary care facility to specify the work that peers do.

Methods: Data were gathered through interviews, focus groups, and activity logs and were analyzed using a modified grounded theory approach.

Results: Peers engage in direct work with clients and in indirect work that supports their work with clients. The main types of direct work are advocacy, connecting to resources, experiential sharing, building community, relationship building, group facilitation, skill building/mentoring/goal setting, and socialization/self-esteem building. The main types of indirect work are group planning and development, administration, team communication, supervision/training, receiving support, education/awareness building, and information gathering and verification. In addition, peers also do work aimed at building relationships with staff and work aimed at legitimizing the peer role. Experience, approach, presence, role modeling, collaboration, challenge, and compromise can be seen as the tangible enactments of peers' philosophy of work.

Conclusions: Candidates for positions as peer support workers require more than experience with mental health and/or addiction problems. The job description provided in this article may not be appropriate for all settings, but it will contribute to a better understanding of the peer support worker position, the skills required, and the types of expectations that could define successful fulfillment of the role.

Publication types

• Research Support, Non-U.S. Gov't
• Attitude of Health Personnel
• Hospitals, Psychiatric*
• Job Description*
• Patient Care Team*
• Peer Group*
• Professional-Patient Relations
• Program Evaluation
• Qualitative Research
• Social Support*

Grants and funding

• Canadian Institutes of Health Research/Canada

• Open access
• Published: 03 April 2024

Health workforce incentives and dis-incentives during the COVID-19 pandemic: experiences from Democratic Republic of Congo, Nigeria, Senegal, and Uganda

• Suzanne N. Kiwanuka 1 ,
• Ziyada Babirye 1 ,
• Steven N. Kabwama 1 ,
• Andrew K. Tusubira 1 ,
• Susan Kizito 1 ,
• Rawlance Ndejjo 1 ,
• Marc Bosonkie 2 ,
• Landry Egbende 2 ,
• Berthold Bondo 3 ,
• Mala Ali Mapatano 2 ,
• Ibrahima Seck 4 ,
• Oumar Bassoum 4 ,
• Mamadou MM Leye 4 ,
• Issakha Diallo 4 ,
• Olufunmilayo I. Fawole 5 ,
• Segun Bello 5 ,
• Mobolaji M Salawu 5 ,
• Eniola A Bamgboye 5 ,
• Magbagbeola David Dairo 5 ,
• Ayo Steven Adebowale 5 ,
• Rotimi . F Afolabi 5 &
• Rhoda K. Wanyenze 1  

BMC Health Services Research volume  24 , Article number:  422 ( 2024 ) Cite this article

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The COVID-19 pandemic presented a myriad of challenges for the health workforce around the world due to its escalating demand on service delivery. A motivated health workforce is critical to effectual emergency response and in some settings, incentivizing health workers motivates them and ensures continuity in the provision of health services. We describe health workforce experiences with incentives and dis-incentives during the COVID-19 response in the Democratic Republic of Congo (DRC), Senegal, Nigeria, and Uganda.

This is a multi-country qualitative research study involving four African countries namely: DRC, Nigeria, Senegal, and Uganda which assessed the workplace incentives instituted in response to the COVID-19 pandemic. Key informant interviews ( n  = 60) were conducted with staff at ministries of health, policy makers and health workers. Interviews were virtual using the telephone or Zoom. They were audio recorded, transcribed verbatim, and analyzed thematically. Themes were identified and quotes were used to support findings.

Health worker incentives included (i) financial rewards in the form of allowances and salary increments. These motivated health workers, sustaining the health system and the health workers’ efforts during the COVID-19 response across the four countries. (ii) Non-financial incentives related to COVID-19 management such as provision of medicines/supplies, on the job trainings, medical care for health workers, social welfare including meals, transportation and housing, recognition, health insurance, psychosocial support, and supervision. Improvised determination and distribution of both financial and non-financial incentives were common across the countries. Dis-incentives included the lack of personal protective equipment, lack of transportation to health facilities during lockdown, long working hours, harassment by security forces and perceived unfairness in access to and inadequacy of financial incentives.

Although important for worker motivation, financial and non-financial incentives generated some dis-incentives because of the perceived unfairness in their provision. Financial and non-financial incentives deployed during health emergencies should preferably be pre-determined, equitably and transparently provided because when arbitrarily applied, these same financial and non-financial incentives can potentially become dis-incentives. Moreover, financial incentives are useful only as far as they are administered together with non-financial incentives such as supportive and well-resourced work environments. The potential negative impacts of interventions such as service delivery re-organization and lockdown within already weakened systems need to be anticipated and due precautions exercised to reduce dis-incentives during emergencies.

Peer Review reports

The health workforce constitutes an indispensable and costly input to any health system [ 1 ]. Indeed, the health workforce is fundamental to achieving health outcomes in the immediate term and ultimately universal health coverage and global health security [ 2 ]. The COVID-19 pandemic highlighted the critical importance of the health workforce in handling emergencies across the globe. By the end of 2022, over 6.4 million deaths were due to COVID-19 globally, with 222,276 deaths in Africa [ 3 ]. The unprecedented nature of the COVID-19 pandemic has posed manifold challenges for healthcare workers around the world [ 4 ]. These have manifested in terms of work overload [ 5 ], mental stress [ 6 , 7 , 8 ], infections [ 9 , 10 ] and death [ 11 ]. The World Health Organization (WHO) estimates that between January 2020 to May 2021, approximately 80,000 to 180,000 health and care workers respectively may have died from COVID-19 globally (WHO 2021). These challenges and consequences have also resulted in health workers either absconding from duty [ 12 ] or in extreme circumstances resigning from the health profession [ 13 ] and opting for alternative professions [ 14 ]. During the 2014 Ebola epidemic, health workers in Liberia and Sierra Leone resorted to industrial actions due to poor pay, unsafe work conditions and death of their colleagues [ 15 , 16 ] further compromising efforts to respond to the epidemic [ 17 ]. The training and skilling of health workers is an enormous investment of resources (both financial and time) for many countries. Hence, countries particularly those in resource-constrained settings cannot afford to lose their health workforce [ 18 ].

Health worker incentives refer to financial or non-financial mechanisms geared towards achieving a specific preferably positive behavioral change among health workers [ 19 ]. Non-financial incentives are those which do not involve financial worth or equivalent, to an individual [ 19 ]. These may include but are not limited to, promotion, continuing education, hospital infrastructure (working environment), availability of equipment and supplies, management and supervision, recognition or appreciation, job security and safety [ 20 , 21 ]. Financial incentives on the other hand, may include allowances for overtime, risk allowances, insurance, and salary increments among others [ 20 ]. Available evidence revealed the need for a diversity of incentives to health workers [ 22 ]. Incentives for health workers have potential for motivating health workers [ 23 ], however, the nature of incentives during emergencies could differ from those offered routinely. During the Ebola outbreak response in Sierra Leone, Guinea, Liberia, and DRC, a broad package of incentives was instituted [ 24 ]. For example, in Sierra Leone, the incentives included provision of equipment, capacity building of health workers, social media support system, including trainings on how to deal with the stigma associated with being a health worker and a risk allowance [ 25 ]. In Serbia, Culafic (2020) highlighted the significance of health worker incentives during the COVID-19 response [ 26 ]. During COVID-19, several strategies were employed to motivate health workers. For instance, in Europe, compensation to families was offered following death of health workers e [ 27 ]. In sub Saharan Africa, where most countries have historically reported health workforce shortages [ 28 ], maldistribution [ 29 , 30 ] and absenteeism [ 31 ], it is not known what strategies countries used to motivate and retain their health workforce during the COVID-19 pandemic. Moreover, most countries grappled with overwhelmed health systems characterized by overstretched facilities, insufficient drugs and stock-outs of personal protective equipment (PPE), which further exacerbated working conditions.

Poor implementation of incentives can result in dis-incentives for health workers. For instance, the perceived inadequacy, inconsistency, or unfair distribution of financial incentives can be a financial dis-incentive while inadequate staff, lack of supplies, unsafe environment and longer working hours may be a non-financial disincentive [ 32 ]. The inadequacy and perceived unfair distribution of incentives can generate dissatisfaction and overall loss of morale among health workers [ 33 ]. All these issues and their consequences are amplified during health emergencies and need to be interrogated further. In extreme circumstances, lack of incentives can result in health workforce migration [ 34 ]. Different approaches have been implemented to incentivize the health workforce across African countries during the COVID-19 pandemic. However, the scope of incentive strategies, their distribution, and the dis-incentives across the health workforce during the COVID-19 pandemic have not been well documented. Evidence on these incentive strategies and mitigating dis-incentives is critical for informing future outbreak response appropriate for already weakened health systems contexts. This study explored the scope of incentive strategies, experiences in their distribution and accompanying dis-incentives across the health workforce in DRC, Senegal, Nigeria, and Uganda during the COVID-19 response.

This study is part of a broader multi-country project that was conducted across two anglophone (Uganda and Nigeria) and two francophone (DRC, and Senegal) African countries, to assess and curate country experiences and their health system response to COVID-19.

Democratic Republic of Congo (DRC)

The DRC is in Central Africa and occupies an area of 2,267,050 Km2 (875,313 sq. miles). It is the largest country in Sub-Saharan Africa [ 35 ]. The population of DR Congo is 95,675,956 as of October 02, 2022 [ 36 ]. DRC has 1.05 doctors, nurses and midwives per 1000 population. This is below the sub-Saharan African average of 1.2 per 1000 population, and far below the Sustainable Development Goals threshold of 4.45 doctors, nurses and midwives per 1000 population [ 37 ]. By December 31 2021, the DRC had reported 79,632 confirmed COVID-19 cases and 1,225 deaths, 35 of whom were health workers (Table  1 ). Only 0.25% of the population had been vaccinated [ 38 ].

Nigeria, in West Africa, has a total area of 910,770 Km2 (351,650 sq. miles) and its current population as of 2022 was 217,611,667 [ 39 ]. The Nigerian Health System is decentralized into three tier structures with responsibilities at federal, state and local government levels [ 40 ]. The country has 2.0 nurses, midwives, and doctors for every 1,000 people, less than the minimum recommended by the World Health Organization to provide adequate access to care [ 41 ]. By December 2021, Nigeria had reported 243,450 COVID-19 cases and 3031 deaths, 7 of whom were health workers from Rivers state, one of the 36 states in Nigeria [ 42 ] (Table  1 ).

Senegal is located on the bulge of West Africa [ 43 ]. It covers an area of 192,530 Km2 (74,336 sq. miles), with a population of 17,734,708 (2022) [ 44 ]. Senegal’s health care system operates with a three-tiered structure [ 45 ]. The number of doctors and nurses is 0.38 per 1,000 population in Senegal which is way below the 2.3 doctors and nurses per 1000 population that is recommended by the World Health Organization guidelines [ 46 ]. The cumulative confirmed cases by 31 December 2021 were 75,055 [ 47 ], and 1890 deaths, 5 of whom were health workers (Table  1 ).

Uganda is in Africa’s eastern region. It has 93,065 square miles, 76,100 of which are made up of land and 16,964 square miles as water sources [ 48 ]. As of October 2022 the population of Uganda was 48,985,049 [ 49 ]. The health system in Uganda comprises the national, regional, and local levels [ 50 ]. The number of doctors, nurses and midwives in Uganda was 2.58 per 1,000 population in the financial 2021/2022 [ 51 ]. By December 2021, Uganda had reported 146,030 COVID-19 cases and 3306 deaths, 37 of whom were health workers (Table  1 ).

Study design

This was a qualitative descriptive cross sectional study which supported obtaining information about health worker incentive strategies and dis-incentives during the COVID-19 response across the four countries.

Data collection

An unstructured key informant questionnaire guide (additional file 1) was developed with questions and probes interrogating health worker incentives and these were peer-reviewed across the research team and later translated into French for the franco-phone countries. The tool was pre-tested in Uganda and revised accordingly. Virtual interviews through the phone and Zoom were conducted with purposively selected key informants from November 2020 to March 2021 across the countries. Data were collected by 21 trained research assistants using the standardized pretested tools across the countries. Key informant interviews ( n  = 60) were conducted with managers in ministries of health ( n  = 17), policy makers ( n  = 18) and health workers ( n  = 25) to describe the health worker incentive strategies and dis-incentives during the COVID-19 response. Twelve (12) key informants were interviewed in DRC, 7 in Nigeria, 20 in Senegal, and 21 in Uganda. On average, interviews lasted about 30–45 min.

Data management and analysis

All interviews were conducted via telephone and online platforms and were all digital voice recorded. The records were later transcribed verbatim. All data was de-identified and stored separately. Deductive content analysis was done manually, by teams across the 4 countries through interactive weekly virtual meetings during the process of data analysis. Initially the Ugandan team comprising of four members identified emerging major themes and codes for the transcripts. Codes corresponding to financial and non-financial incentives and dis-incentives were identified which were shared for guiding other country teams. This allowed for deductive and iterative exploration and assignment of the codes. Categories and themes were generated according to the study objectives. Appropriate quotes were used to support the findings and to capture variation across the countries. Two to four researchers coded interviews across the countries based on the number of interviews conducted.

Description of the key informants

Across the four countries, 60 key informants were interviewed 18 of whom were policy makers and 25 health providers (Table  2 ).

Health workforce incentives

The analysis categorized health worker incentives into two thematic areas: (i) financial and (ii) non-financial incentives, with the accompanying dis-incentives. The financial incentives included allowances, temporary tax exemptions, and salary increments, while non-financial incentives included services re-organization, supplies augmentation and increased staffing among others. The modalities through which some of these incentives were implemented also led to dis-incentives as described below.

Theme 1: Financial incentives and dis-incentives for health workers

Financial incentives in the form of allowances and salary increments were provided for health workers to mitigate the effects of increased workload, working hours, and other psychological impacts during the COVID-19 response across the four countries in 2020/2021. The financial incentives were delivered under varying modalities and the way they were implemented generated dis-incentives in some settings (Table  3 ).

Allowances, salary increments and short-term tax exemptions

Health managers and workers in DRC, Nigeria, Senegal, and Uganda reported that health workers received monetary benefits in the form of salaries and allowances as a means of motivation for their effort towards the continuity of health services during the COVID-19 response. In Senegal, it was mostly financial motivation. They reported that from March 20 to December 20, there was a financial incentive of one hundred and fifty thousand FCFA (150,000 FCFA or 240 USD). In the DRC, the salaries of health workers involved in testing for COVID-19 was similar to all other staff involved in the response in any committee (epidemiological surveillance, case management, communication, etc.) but a temporary suspension of taxes was used as an incentive for health workers during the pandemic.

“… the government decided to temporarily remove the tax-fee deducted from the remuneration of health workers of the public health system for two months to compensate for the lack of payment for overtime due to the increased workload resulting from the COVID-19 pandemic.” (KII, DRC). “To my knowledge like I said earlier, health workers were paid some COVID-19 allowance for three months, which was a proportion of their salaries depending on where they work,, your grade, or level of employment.” (KII, Nigeria). “There is the financial motivation that we gave but also the equipment…., the endowment of materials. It even goes beyond individual motivation” (KII, Senegal). “We heard allowances were paid according to the number of days someone worked…allowances for those ones working in the Corona treatment unit…and then, we also had allowances of course for anybody exposed” ( KII, Uganda).

However, since financial incentives were mostly administered in an unstructured/ad-hoc manner, some health workers felt they were unfairly distributed and complained about the lack of transparency in the allocation of these incentives. In Nigeria, it was reported that payments did not meet the health worker expectations, while in Uganda it was reported that allowances were given selectively to some health workers such as those involved in contact tracing, COVID 19 testing, and COVID 19 isolation units but not to others. In the DRC, there were concerns about delayed payments and the fact that the payment of health workers involved in testing for COVID-19 did not differ from other staff involved in the response in other committees such as epidemiological surveillance, case management, or communication. The key informants revealed that although allowances were availed, there was a sense of dissatisfaction due to delays and some health workers not getting paid as quoted below.

“The government has been giving allowances to staff who are working in isolation units. Although I do not know about other hospitals because I’ve heard people complain that some of them have not been getting allowances.” (KII, Uganda). “But regarding the incentives, this is where the problem lies, because last week we were paid for the month of May and June of last year. The Government recognizes this and only keeps promising.” (KII, DRC). “There were some issues around special allowances for frontline workers in COVID-19 response. The allowance wasn’t provided as the workers expected but to some extent, it was provided so that’s just it.” (KII, Nigeria).

Non-financial incentives and dis-incentives

The non-financial incentives reported across the countries included those that were related to COVID-19 management such as capacity building, safety and risk protection, welfare including recognition and service re-organization (Table  4 ). Services re-organization included re-organizing of service delivery points, and re-scheduling of services and was done to protect health workers from work overload and reduce contact with potentially infected clients. There was also the recruitment of additional staff on contractual short-term basis. These were perceived to positively affect motivation and performance of health workers. However, these strategies also generated counter effects on workforce motivation including discontent as described below.

Capacity building

Training for health workers.

Across the four countries, efforts were made to strengthen and optimize the skills and performance of health workers particularly regarding COVID-19 management and infection control practices such as environmental cleanliness and disinfection and PPE protocols. Trainings in infection control were perceived to make the workplace safer and a motivation to the continuity of health care services provision as mentioned by some respondents:

“…like I said every health worker has been trained on protection, prevention, control and how to protect themselves. They have been provided with the necessary equipment to protect themselves” (KII 26, Nigeria). “…From the first day, we did an accelerated training on how to wear PPE and gowns, and how to wash our hands and the circuit that we must do. It was first a training problem that we first faced.” (KII, Senegal).

In DR Congo, several trainings were offered to health workers cutting across hygiene and sanitation to clinical training for health professionals. DRC also used a variety of training approaches including virtual training to cover aspects of hygiene and sanitation but also to ensure continuity of services using approaches conducive to the demands of the pandemic.

“The following trainings and capacity building workshops were organized on the disposal of waste and used family planning supplies;…. integrating new approaches into community-based services; on COVID-19 transmission prevention in maternity wards; on initiation of breastfeeding and exclusive breastfeeding in the context of COVID-19; and on the COVID 19 nutrition management protocol.” (KII, DRC).

Supervision and mentorship

During the pandemic, the ability to have online supervision and to work from home was an incentive because it ensured that only the most critical staff needed to report on duty to minimize infection risks. In Uganda for instance direct supervision from those in higher levels of management was perceived to be beneficial.

“…we have ward managers that actually supervise these workers. So, we had direct supervision right from the top management that is the director” (KII,Uganda). “During COVID-19, with online work, we are the department head, we ensure the minimum service. Our subordinates worked online, and they reported to us on their personal work daily. (KII, DRC). “Yes, those people would be trained in IPC and patient management and I would personally mentor them as a unit in-charge.,….I would ensure a balance of seniority for example I pair those who have been there for a month or two with a new person.” (KII, Uganda).

Safety and risk protection

Provision of covid-19 management medicines and supplies.

Respondents across the countries revealed that efforts to provide sufficient quantities of medical supplies and sundries were crucial for COVID-19 management as one of the most compelling incentives as noted below:

“…Usually when people mention motivation, they think of financial rewards but what I have seen is that if I have the right equipment, I have the right sundries [and] resources I can do my work without having to plead for gloves or masks, and that alone gives me reason to go and work. Even without thinking of government is going to pay or not pay. I have had staff here manage COVID-19 and we have not paid them a coin.” (KII, Uganda). “There is the financial motivation that we gave but also the equipment, the endowment of materials. It even goes beyond individual motivation.” (KII, Senegal). “The equipment are full, I think you have just seen a container that has just arrived, I think the container has been deposited there, this container is to support the prevention of infection.” (KII, DRC).

Prioritizing health worker medical care

Deliberate efforts were made to monitor the well-being of healthcare workers who were involved in the COVID-19 response. In Uganda, Nigeria and Senegal, this included continuous screening of health personnel to identify those infected, those who fell sick and those who died in order to prioritize them for vaccination and treatment so as to reduce their vulnerabilities. Prioritizing COVID-19 testing, and treatment were some of the incentives provided to motivate health workers in DRC and Uganda as part of the countries’ response to COVID-19. Health workers were tested for COVID-19 regularly, and priority treatment and isolation were given to those who tested positive for COVID-19. Senegal had policies and guidelines that provided a framework for providing priority health services to health care workers who become ill because of engagement in a public health emergency response and shown in some of the quotes:

“Health workers were prioritized for free testing…Yes, we have been tested free of charge of course… When the vaccines came, the very first group were the health workers. This was a national pronouncement and a guideline which health workers had to abide with and comply.” (KII, Uganda). “…They were also tested regularly in case of suspicion and were taken care of in case of confirmation. In case of death, funeral expenses were also covered” (KII, DRC).

COVID-19 vaccination for health workers

Across the four nations and at the beginning of vaccination campaigns, the limited quantities of vaccines meant that the vaccination of health workers was prioritized because of their higher risk of exposure at the frontline of the response.

“The country first sensitized health care workers to get vaccinated. This is why the majority of health workers are vaccinated. In turn, we have also strengthened the capacities of the community health workers; we have sensitized them to be vaccinated” (KII, DRC). “….But also when it comes to vaccines, we started by vaccinating health personnel” (KII, Senegal).

In Senegal, the government prioritized vaccinating health personnel and the elderly and people with comorbidities, i.e. 3% of the population [ 52 ].

Welfare-related non-financial incentives

Welfare support for health workers.

Efforts made to improve the welfare of health workers during the COVID-19 response included the provision of meals, housing, and transport in countries like Senegal and Uganda.

“…the transport of medical students who came in addition to the doctors out of service, now we have made efforts; plus housed and transported them” (KII, Senegal). “…They were feeding all health workers and they would bring lunch; posho (corn meal), rice and beans which they would serve to the doctors at the hospital, they did that for close to three months. And another thing is these guys gave transport to our staff because remember during the COVID-19 response, there was a total lockdown….and you know government hospitals cannot house 50% of the staff…actually I think they offered two buses to be transporting staff from their homes to the hospitals every single morning and evening (KII, Uganda). “…We had to identify a house to provide extra accommodation for our staff who were working so much and we did not want them to travel to their homes to transmit the disease to their family members.” (KII, Uganda).

Provision of psychosocial support

Across the four countries, frontline healthcare workers caring for patients in intensive care units (ICUs) faced extreme pressure, from extra workload and this was exacerbated whenever their own colleagues succumbed to COVID-19 infection. Stress was reported from multiple sources including the loss of patients and other challenges for which they received psychosocial support as a coping strategy. This was delivered through counseling, meetings, and health education.

“… Like in my facility, there is no way you could be absent because the work was too much and the staffing was low so your absence would be noticed.” (KII, Uganda). “Yes, there is psychosocial support for health workers at the Nigeria Center for Disease Control (NCDC)… I think they had a place where you can talk to somebody if you are feeling the weight of the response.” (KII, Nigeria). “ The first wave of COVID-19 was very stressful. I frequently tested for COVID-19. Before the results were announced, I was receiving psychosocial care.” (KII, DRC). “The facility managers or in-charges also had sessions where presentations were made to them…we also had social workers among the psychosocial staff….time to time in our hospital every Wednesday we have a meeting for the senior….in such meetings we have the psychosocial officer….and then we are counseled. Then we also have staff who tend to panic a lot we also call the psychosocial officer to talk to them…there were both individual (one on one) and group counseling sessions done…whenever need arose.” (KII, Uganda). “…some of (the health workers) got scared; we had many staffs who were sick, about fourteen were sick of COVID-19 discouraging most of the others but we had to morale boost them, support them by counselling by continuity of communication.” (KII, Uganda).

In DRC, a standard operating procedure was developed and provided for the cascade training of psychosocial agents, the organization of psycho-educational sessions for patients and contacts, and the organization of psychosocial support for personnel involved in the response. In Senegal, at the start of the pandemic, simulation exercises were used to get teams prepared psychologically. Discussion groups were organized in the treatment centers and these structures benefited from the support of the psychosocial unit of the Ministry of Health, which provided support supervision for the health workers. During the second wave, this psychological support was not provided.

“…we must already continue to make staff aware of the presence of the pandemic, which is still there. Second thing, you have to do simulation exercises. At our level, we do a guard maneuver every day, a person who takes guard. Every morning after guard duty, this team does a guard maneuver and sometimes we take the COVID-19 theme with the example of a person with COVID-19 or a person who died of COVID-19 and see how the body should be handled. We do exercises and it is to push the staff to become better acquainted with these different forms of intervention because we are not used to doing it. So it’s the sensitization so that the guys are psychologically ready, then it’s the simulation exercises and after the simulation exercises we come to the material preparation with the verification.” (KII, Senegal).

Provision of health insurance

Differences in the provision of health insurance to health workers were noted across the countries. Life insurance was provided in Nigeria as part of the compensation package during the COVID-19 response. However, in Uganda with no insurance measures in place to protect public health workers in pandemic response situations, only contracted health workers had access to health insurance.

“The health workers that were insured were those not on the government payroll.…The government payroll system is a bit different, for those who were not there, they were insured, then of course those who were enrolled during the response were not insured and that is the truth” (KII,Uganda).

In Senegal, according to the workforce management plan, additional incentive measures such as health insurance covering the treatment of COVID-19, sickness allowances for workers who either contracted the virus or self-isolated due to close contact with infected workers, and payment in the event of death were put in place [ 53 ].

In the DRC, health care workers generally did not have full coverage of health insurance. The government provided a bonus to health workers that unfortunately did not cover all their social needs.

“… No, the government has only paid the premium for management of the sick. The COVID-19 management of the inputs had to be bought by the health worker.” (KII, DRC). “I believe that the problem of financing in the health sector remains. Generally, the government supported our structures in terms of bonuses granted to us and certain benefits that we derive as agents of the state, but the effective implementation of activities requires support from partners.” (KII, DRC).

Recognition

Our analysis revealed that some health workers received recognition for the effort they invested into the COVID-19 response in countries like Uganda and DRC. Appraisals were common and recognition of outstanding performers during functions or in the event of officials coming around the health facilities:

“…we recognize best performers…we tried to recognize them, especially whenever we had officials coming in, we kept appraising those who have really performed well in front of them the officials” ( KII, Uganda).

In the DRC, the president of the republic recognized the work done by health workers during the 35th Council of ministers and decided to reward their efforts and bravery with an additional bonus on the occasion of the 60th anniversary of the country’s independence.

“ These kinds of bonuses must continue. Not just for a month, but continuously …” (KII, DRC).

However, there was a sense of dissatisfaction because these recognitions were perceived to be unfair.

“Yeah people were recognized although not uniformly” (KI, Uganda).

Service delivery re-organization

Across the four countries, multiple strategies were taken to de-congest facilities and reduce infection spread. These included the re-scheduling of selected services to specific clinic days, task shifting to community health workers, recruitment of additional staff and the designation of facilities to cater for COVID-19 cases (Table  4 ).

In Senegal, particularly in Thies, there was a re-organization of services:

“…in fact, it was the internal medicine department that was amputated, we had two units in the internal medicine department; the unit of men and that of women; so, when COVID-19 emerged,…. it was the women’s unit which was more accessible and more isolated, and we transformed it into a treatment center. (KII, Senegal). “…before (during the early COVID 19 period), the COVID-19 centers were established in the mental health clinics, hospital administrators were asked to work with the lower level health units to establish alternative mental health isolation units” (KII, Uganda).

In the DRC, some health programs were affected by COVID-19 because of the minimum service requirements established to deal with the pandemic. Some organizations utilized additional human resources, but others were not able to obtain additional workers.

“…There has been an impact because in the health zones, the same community relays who sensitize parents to come and vaccinate their children in the health care facilities have been reassigned to go and do sensitization against on COVID-19, which has resulted in a decrease in facility personnel for the vaccination activity. ”… (KII,, DRC).

However, because of shifting services to other facilities, health workers had to be re-deployed from COVID-19-designated facilities to other peripheral facilities resulting in longer travel routes which was a disincentive to them.

Recruiting additional staff

All countries made efforts to co-opt additional staff during the pandemic. Uganda and Senegal recruited health professionals while DRC recruited volunteers. The Ugandan government in partnership with development partners, made available a budget to recruit additional health workers to serve especially in hard-pressed settings. Advertisements sent out on April 27th 2020 and July 27th 2021 for health workers resulted in 31 and 70 contracted workers respectively with payments for a period of 6 months in the different years mentioned [ 54 , 55 ]. Overall, around 700 health workers were hired in Uganda during the COVID-19 emergency response. These included anesthesiologists, laboratory professionals and nurses among others. In Senegal, the government initially requested for health personnel, and recruitment of health personnel on contractual basis for varying periods of time and these were paid by the government to bolster the numbers available to provide services:

“To overcome this difficulty of lack of staff, the hospital at the beginning had requisitioned doctors, nurses to come and help us. But afterwards, we were forced to recruit outright especially the Ministry which had to recruit staff at the level of the Emergency Treatment Centre and make fixed-term contracts of three months, six months, and 1 year for some so that we could have more staff.” (KII, Senegal).

In DRC, the recruitment of additional health workers for the COVID-19 response was focused on volunteers until a specific number was reached per commission and level. But the leadership of the commissions was under officers experienced in the response.

“ I presented myself as a volunteer at the start of the COVID-19 pandemic (March 2022), I was recruited very easily…” (KII, DRC). “Recruiting is too hard, but we resorted to the example of medical schools and universities all over our provinces that train doctors, so since everything was already paralyzed, we had to resort to these people so that they could quickly help to minimize the situation.” (KII, DRC).

Unfortunately for Uganda, the contracts for staff recruited during the COVID 19 pandemic were terminated approximately one year later in 2022 due to depletion of personnel budgets [ 56 ]. This created a sudden gap in numbers and skills of health workforce as well as despondency among contracted staff as noted by a key informant in quote;

“… Right now, the staff don’t even know if they’re going to be absorbed within a government system or if they should start looking for other jobs because the contract is expiring in July. There was a validation exercise where they came to check whether these staff are actually working. They interviewed one by one, but that was in December and till now in February we have not got any kind of communication.” (KII,Uganda).

Health systems in Africa have long been plagued by weak institutional and human resource capacities, health worker migration, inadequate incentives, and un-coordinated development support, among others. Experiences gleaned from the COVID 19 amidst chronically weakened health systems emphasize the need to anticipate, enhance incentives, and exercise due precautions in order to reduce dis-incentives during emergencies.

In our study health worker incentives during the COVID-19 response were mostly unplanned, predominantly non-financial, and invariably implemented. Across these countries there were neither guiding frameworks nor standard pre-determined packages of financial and non-financial incentives for health workers during emergencies. Consequently, each country implemented varying incentive strategies during the COVID-19 pandemic. The financial incentives provided for health workers in the form of allowances and enhanced salaries to mitigate the effects of increased workload and risks were appreciated. However, these tended to generate discontent due to their perceived inadequacy, unfairness in their implementation, and delayed remittance among others. The real or perceived inconsistencies and the lack of transparency in the way incentives were provided resulted in a degree of dis-incentivization for the health workers who opined that things should be planned better. Moreover, the non-pharmaceutical interventions implemented to reduce the spread of COVID-19 such as lockdown, quarantine and isolation, further exacerbated the health worker stress by compromising their mobility. This study reveals that within these already weakened health systems, poorly implemented incentives may easily erode motivation of health workers more so during emergencies.

Health workers allude to the necessity to access the basic environmental amenities as a baseline to committed and satisfactory work. During emergencies, the absence of basic supplies in the workplace creates a scenario where health workers experience heightened stress and feel oppressed because their ability to work safely and productively is already constrained.

The broad scope of non-financial incentives included the provision of medical supplies for management of COVID-19 in the form of PPEs, sanitizers, equipment, training of health workers, medical care, free testing, vaccination, welfare in the form of free meals, transport, housing, psychosocial support, recognition, and supervision although these were not equitably spread across the four countries. The provision of medical supplies for management of COVID-19 in the form of PPEs, sanitizers, equipment and others was perceived as a motivator for the continuity of health services across the four countries. This gave health workers a sense of protection and confidence to manage COVID-19 cases and other patients with minimal fear of infection. Similar findings have been reported in Zimbabwe, Kenya, Egypt, Uganda and South Africa [ 57 , 58 ]. It is pertinent to note, however, that the primary goal of providing PPEs is not to motivate health workers but rather to prevent cross-infection [ 59 ]. In any infectious disease epidemic, PPEs should be availed as a matter of urgency. However, this was not always the case especially in resource limited settings where rationing is prevalent and stock outs are frequent, and PPEs may be deemed to be a privilege rather than an entitlement [ 60 ]. Moreover, in some settings PPEs were predominantly provided to those facilities managing COVID-19 cases yet health workers all over the country perceived themselves to be at a heightened risk of infection because they engage with all sorts of patients before they are diagnosed. This too was a major dis-incentive to the health workers in the non-COVID treatment facilities because they felt that governments were placing them at undue risk. In this kind of environment, even the provision of financial incentives may not yield the anticipated benefits. Other non-financial incentives implemented such as, welfare (transportation), recognition and systems re-organization such as the re-organizing of service delivery points and re-scheduling of services among others decongested health facilities and supported health workers. They, however, also created dissatisfaction because they were perceived to be haphazardly implemented. Moreover, these incentives were variably implemented across the countries highlighting the need for further study around their potential value and detriment to the system during emergencies and perhaps to inform future planning.

Governments bracing for future infectious outbreaks should consider enhancing capabilities for the local production of PPEs and other related supplies which are critically needed as demonstrated countries during the COVID-19 pandemic [ 61 ]. Across countries, governments partnered with other stakeholders including the WHO and implementing partners, like Baylor, Infectious Diseases Institute, UNICEF, and other private organizations to provide incentives. However, these partnerships and roles were largely uncoordinated. A similar situation was reported during the Ebola outbreak where the WHO, Africa Centers for Disease Control and Prevention, UNICEF, the Red Cross movement and other international and local partners, donors, researchers and communities worked hard to end the Ebola outbreak in West Africa [ 62 ]. The critical need for strategic partnerships to enhance health workforce before and during emergencies cannot be overemphasized. So is the need for strong and coordinated alliances between governments, pharmaceutical companies, and manufacturing companies to anticipate and meet demands to mitigate some of the restrictions relating to supply chain, costs, and procurement procedures.

The COVID-19 pandemic was characterized by unpredictable surges in cases which enormously constrained health systems globally [ 28 ], particularly in Africa with already weakened health care systems and a shortage of critical care specialists and equipment [ 63 ]. Health workers as first responders were more at risk of contracting the disease [ 64 ]. In fact a number of health workers died in the event of saving others [ 11 ]. The loss of colleagues within the workforce has previously resulted in fear and stress [ 65 ] and in worst cases abscondment from duty [ 66 ]. It is encouraging that across the study countries, governments and other stakeholders prioritized regular and cost-free testing for health workers to prevent infection and mitigate the potential loss of health workers which could have had deleterious effects on other workmates. Across the four countries, life insurance was only provided in Nigeria and this motivated health workers during the COVID-19 response. The lack of medical and even life insurance for the health workforce is a huge oversight because health workers experience increased morbidity and mortality during disease outbreaks. This is because more often than not, these uninsured health workers also happen to be at the frontline of the response [ 67 ]. Available evidence has shown that health workers have lost their lives during epidemics without being compensated by their governments [ 68 ]. Brocardo (2017) affirmed health insurance as an enhancer to health worker performance in Ethiopia [ 69 ]. Most countries like Uganda and DRC have no policy on providing health insurance for health workers during emergencies. Consequently, health workers that were insured during the response were those who worked with other organizations, and private practitioners but not public sector workers and those that were non-gratuitable. There is a need to develop policies that cover both health and life insurance for health workers in low-income countries especially during epidemics. For Africa, which has had a 63% increase in diseases spread from animals to humans seen in last decade [ 70 ], these policies are long overdue [ 71 ]. In addition to instituting policies on health and life insurance, countries should consider providing more benefits to health workers such as covering out of pocket costs during emergencies in addition to prioritizing health workers for treatment and psychosocial support.

In Uganda, Senegal and Nigeria, welfare support was offered as an incentive in the form of free food, transport, and housing. Similar findings have been reported in the United states where food, transport, housing were offered as incentives during the COVID-19 pandemic response to health workers [ 72 ]. Health worker incentives like housing in Lesotho, Mozambique, Malawi and Tanzania; staff transport in Lesotho, Malawi and Zambia and free food in Mozambique and Mauritius had been reported to address social needs of health workers [ 73 ]. In Tanzania for instance, the provision of housing allowance to health personnel was noted to improve the quality of care through compliance to Integrated Management of Childhood Illness (IMCI) guidelines in Tanzania [ 74 ].

By virtue of the heightened anxiety during disease outbreaks, the need to provide psycho-social support for health workers cannot be overstated. Across the countries, psychosocial support was offered to frontline health workers especially the COVID-19 Treatment Unit (CTU) staff. This was in the form of counseling, meetings, and health education. Through these avenues, health workers would share concerns and obtain emotional support that enabled them to continue in the line of duty amidst the prevailing challenges. The value of social and psychological support through interpersonal interactions during the COVID-19 response in Africa has been echoed by [ 75 , 76 ]. Additionally, psychosocial support allowed for continuity of service by health workers during the Ebola epidemic in Sierra Leon [ 77 ]. More emphasis is needed to practically boost the psychosocial support component highlighted in the COVID-19 response guidelines for better pandemic response in the future. In settings where health workers are already overworked, underpaid and de-motivated, improvements in their welfare and psychosocial during outbreaks and other emergencies should be a matter of priority.

The recognition of health worker performance was reported to motivate key front line health workers in Uganda although the pandemic restrictions hampered adequate recognition in some public hospitals. In other countries, public recognition was not reported as a key motivator during the pandemic response due to COVID 19 public gathering restrictions. Relatedly, other studies have reported recognition to influence of health workers motivation [ 69 ]. It is therefore important to institute regular schedules to recognize outstanding health workers and more so for notable efforts during epidemic because this enhances health worker motivation.

Training in IPC and COVID-19 management, although a necessary component of epidemic management, was seen to inspire health workers who were involved in the response across the countries. The provision of training has also been reported to be a great spur to health worker efforts during the COVID-19 pandemic in Serbia [ 26 ]. Furthermore, the COVID-19 pandemic highlighted the value and necessity of evolving alternative approaches to training including virtual/online training or tele-applications to build the capacity of health personnel and to supervise them. The utility of these beyond the COVID-19 pandemic need to be evaluated and sustained [ 78 ]. However even more critical is the need to anticipate, provide training, and certify health workers prior to outbreaks. Certification of training has also been revealed to be a great motivator for health workers [ 79 ].

In Uganda, response team leads and hospital managers monitored the performance of staff in CTUs on IPC measures and their presence at work. Health worker supervision also aided the management of bonus payments because health workers in CTUs in Uganda were paid according to the extra days worked. A systematic review in low- and middle-income countries highlights the importance of supervision to boost the performance of health workers [ 80 ]. Supervision during epidemics enhances health worker motivation because it makes work enjoyable, pleasant, and calm [ 81 ].

The implementation of financial incentives tended to vary across the four countries. Incentives provided ranged from nothing at all beyond the usual stipulated salary, to intermittent allowances, to carefully calculated allowances based on extra days of work. Several countries reported that some cadre got allowances for instance workers at testing stations and ICUs in Uganda, while others at treatment facilities received no additional payments. It appeared that none of the countries had in place any guidelines on how to provide incentives for health workers during epidemics. The reports of perceived unfair provision of allowances were rife across all countries exposing a gap in the countries to foster the predetermined fair and accountable provision of incentives. The challenges posed by the lack of guidelines on incentives during emergencies have not only been noted in Africa. In Europe there were calls to harmonize guidelines around incentives for health workers when it was realized that health workers were often under immense pressure to care for severely ill patients with a new disease, under strict hygiene conditions and with lockdown measures creating practical barriers to working [ 27 ].

The value of providing financial incentives during disease outbreaks cannot be overemphasized because during epidemics, health workers encounter work pressures beyond routine service delivery. In the European Union, most countries instituted financial incentives. These were intended to support health workers and enable them to do their job. These included additional financial support and compensation above normal salaries to health care workers involved in the COVID-19 response, a lumpsum payment to families in the event of death of a health worker following COVID-19 infection, allowances to cover childcare costs during the crisis in the case where a health worker’s partner could not take paid leave, and temporary salary increment [ 27 ]. It is reported that in Sierra Leon during the Ebola epidemic, risk allowance motivated health workers [ 25 ]. Most financing for emergencies focusses on administrative and service delivery enhancement with little or no attention given to incentives to boost health worker motivation. Digital payments have been proposed as an avenue to streamline payments of health workers and could be an option to consider during emergencies.

Although a diverse package of incentives was implemented across the four countries, inconsistencies, lack of transparency, perceived inadequacy and inequity of incentives were reported in the study countries as has been elsewhere in Africa [ 22 ]. In Nigeria and Uganda, the phenomenon of some health personnel missing out on financial incentives following irregularities in payment of allowances has been reported in other studies [ 22 , 33 ]. There is therefore a need to develop guiding frameworks within which governments and partners can deliver incentives and reduce dis-incentives for the health workforce during emergencies.

The study was qualitative implying the extent of the health worker incentive strategies and experiences around the incentives cannot be quantified. Future studies could reflect on measuring these aspects. We obtained information from various stakeholders including health managers, policy makers and health workers which allowed for triangulation of the findings.

Health related emergencies call for incentive packages to stretch beyond those normally provided because of the additional risks and stress encountered by the workforce operating amidst already weakened health systems. The elevated risks and heightened workload necessitate the mandatory provision of safety gear and adequate supplies. Although important, financial and non-financial incentives may end up being dis-incentives if perceived to be unfair in their implementation. Financial and non-financial incentives should preferably be pre-determined, equitably and transparently provided during health emergencies because arbitrarily applied financial and non-financial incentives become dis-incentives. Moreover, financial incentives are useful only as far as they are administered together with non-financial incentives such as supportive and well-resourced work environments. The potential negative impacts of interventions such as service delivery re-organization and lockdown on health worker motivation need to be further interrogated and due precautions exercised to reduce unintended consequences on the workforce during emergencies. Governments need to develop guidelines on incentives during emergencies with careful consideration of mitigating potential dis-incentives. The harmonization of roles across state and non-state sector players in incentivizing the health personnel during health emergencies is paramount.

Data availability

The notes from the key informants are available on request from the corresponding Author.

Abbreviations

Corona Virus Disease of 2019

COVID-19 Treatment Unit

Democratic Republic of Congo

United Nations Children’s Emergency Fund

Community HIV/AIDs Initiative

Intensive Care Unit

Key Informant Interview

Personal Protective Equipment

The Cheikh-Anta-Diop University

World Health Organization

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Acknowledgements

We extend our sincere appreciation to all the people who took part in this study including research assistants across the countries for the tremendous work they did to make this study a success.

This work was supported in whole or in part by the Bill and Melinda Gates Foundation. [Opportunity ID: INV-019313]. The views, opinions, and content of this publication are those of authors and do not necessarily reflect the views, opinions, or policies of the Bill and Melinda Gates Foundation. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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SNK, SNKa, RN and RKW technically conceptualized the study. MB, LE, BB, and MAM steered the data collection, analysis, interpretation and evaluated results from DRC. OIF, BS, SMM, EAB, MDD, ASA, RFA steered the data collection, analysis, interpretation and evaluated results from Nigeria. IS, OB, MMML, and ID steered the data collection, analysis, interpretation and evaluated findings from Senegal. SNK, SNKa, RN, SKi, AKT and ZB conducted data collection, analysis, and interpretation and evaluated findings from Uganda. SNK, ZB, RN, AKT, SKi, SNKa, and RKW conducted the cross-country synthesis of findings. SNK and ZB wrote the first draft of the manuscript. All authors reviewed and approved the final version of the manuscript.

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The study executed in accordance with relevant guidelines and regulations. The study protocol was approved by the national ethics committees in each of the four countries before commencement of data collection.In DRC, approval was granted by the Kinshasa School of Public Health Ethics Committee (ESP/CE/198/2020 of December 2, 2020). In Nigeria approval was granted by the National Health Research Ethics Committee while in Senegal, the National Committee of Ethics and Research provided ethics permission. In Uganda, the study was approved by the Makerere University School of Public Health Higher Degrees, Research and Ethics Committee (HDREC #903) and registered by the Uganda National Council for Science and Technology (UNCST #HS1121ES).Across the countries, informed consent was obtained from all the study participants. The research protocols and data collection tools were written in English and translated into French for use in the Francophone countries (DRC and Senegal). Confidentiality was observed in handling and communication of results.

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What is already known about this topic

Financial and non-financial incentives are important for health worker motivation during health emergency responses.

What this study adds

The study provides information on financial and non-financial incentives deployed during health emergencies across the four countries and why they should be predetermined, administered simultaneously, equitably and transparently to avoid the same becoming dis-incentives. This information on financial and non-financial incentives can guide development of new public health policies and establishing of budgetary priorities during health emergency responses.

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Kiwanuka, S.N., Babirye, Z., Kabwama, S.N. et al. Health workforce incentives and dis-incentives during the COVID-19 pandemic: experiences from Democratic Republic of Congo, Nigeria, Senegal, and Uganda. BMC Health Serv Res 24 , 422 (2024). https://doi.org/10.1186/s12913-024-10822-6

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DOI : https://doi.org/10.1186/s12913-024-10822-6

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The interactive, conversational, analytical, and generative features of GenAI offer support for creativity, problem-solving, and processing and digestion of large bodies of information. Therefore, these features can act as cognitive resources for knowledge workers. Moreover, the capabilities of GenAI can mitigate various hindrances to effective performance that knowledge workers may encounter in their jobs, including time pressure, gaps in knowledge and skills, and negative feelings (such as boredom stemming from repetitive tasks or frustration arising from interactions with dissatisfied customers). Empirical research and field observations have already begun to reveal the value of GenAI capabilities and their potential for job crafting.

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• Maryam Alavi is the Elizabeth D. & Thomas M. Holder Chair & Professor of IT Management, Scheller College of Business, Georgia Institute of Technology .

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Happier workers and customers

The year-long experiment also revealed that AI assistance improved customer satisfaction, reduced requests for managerial intervention and improved employee retention.

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• Employees with higher satisfaction demonstrate a 17% increase in productivity, a 25% decrease in turnover, and a 41% decrease in absenteeism.
• Moreover, rewarding jobs and career advancement opportunities offer upward economic mobility to frontline workers and their families.
• Support is achieved by understanding frontline workers’ unique needs and motivations, custom-fitting services and supports, creating the right culture, and facilitating upward mobility.

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Diversity, Equity, and Inclusion

/ article, supporting frontline workers is a boon to the bottom line.

By  Lina Bankert ,  Julia Dhar ,  Sara Wasserteil ,  Molly Verghese ,  Claire Roehri ,  Cassandra Di Prizio , and  Adriann Negreros

Key Takeaways

This article was developed in collaboration with Cara Plus.

The 100 million frontline workers in the US play a critical role, forming the backbone of many of the largest US companies. But more than half of the people in this important demographic say they feel burned out, according to BCG research, and more than a quarter are either actively or passively looking for a new job—citing low pay, low morale, lack of flexibility, underappreciation, and limited advancement opportunities.

It doesn’t have to be this way. And it shouldn’t be.

With proper attention and investment, frontline workers constitute a motivated workforce that can unleash an organization’s highest potential, providing significant business value, reducing turnover costs, and serving as a pipeline for higher-level roles. (See the sidebar, “The Impact of Frontline Workers.”) The benefits for employers are significant: employees with higher satisfaction demonstrate a 17% increase in productivity, a 25% decrease in turnover, and a 41% decrease in absenteeism.

Moreover, rewarding jobs and career advancement opportunities offer upward economic mobility to frontline workers and their families—64% of whom are women, 40% of whom identify as nonwhite, and 23% of whom are members of low-income families, according to the US Equal Employment Opportunity Commission. This means employers can directly impact diversity, equity, and inclusion and generate ripple effects on state and local economies.

The Impact of Frontline Workers

What makes frontline workers so valuable? They… …are employed across industries including customer service, financial and professional services, health care, hospitality, manufacturing, retail, shipping, logistics, and transportation. …number approximately 100 million in the US, making up more than 70% of the workforce. …are motivated employees. Frontline workers want to stay in their jobs and progress along a career trajectory. In fact, lack of career advancement opportunities is the second-leading motivator of attrition (41%) after lack of flexibility and work-life balance (50%), followed by insufficient pay (30%), lack of enjoyment of current role (15%), and lack of recognition for contributions (14%). …become thoughtful managers. Frontline workers most value managers who offer clear and transparent communications, recognize good work, and provide support when help is needed—and they bring the same qualities as they grow into leaders.

To provide the optimal environment for frontline workers—and to capture benefits themselves—companies can rethink how they support and engage those workers.

In partnership with Cara Plus (a division of the workforce development organization Cara Collective), BCG spoke to employers across a variety of industries to understand how they designed and executed initiatives targeting their frontline workforce. Our analysis found that companies tackled the work on four fronts (see the exhibit).

Understanding Unique Needs and Motivations

Employers that take the time to understand what frontline workers care about, what an organization successfully delivers to such employees, and where it falls short are best able to meet the needs of their frontline workforce. In our research, we saw that when issues arose that affected frontline workers’ performance, a “curious, not furious” employer mindset helped uncover the root causes.

For example, Advocate Health Care, which operates in the Midwest, found that it was losing 75% of its frontline staff across some departments. Leaders were puzzled: Advocate offered a breadth of services and DEI programs to train leaders and make employees feel welcome and supported.

To uncover how employees were really feeling, Advocate launched a series of surveys within targeted departments, surfacing some less-visible barriers to retention, such as a lack of access to transportation and childcare . Before they received their first paychecks, new employees were often short on funds to cover these basic needs during their first few weeks on the job, so they were leaving because they had no easy way to get to work. Advocate realized it needed to take action and began to explore solutions.

Likewise, Kroger, a leading grocery retail chain, acknowledged that its limited awareness of its frontline employees’ needs and preferences impacted both hiring and retention. How, the company wondered, could it identify and address specific pain points ?

Observations from managers were informative for leadership, but the most powerful findings came directly from associate resource groups (ARGs), which were created as affinity groups for frontline associates. Consistently, ARGs requested more support for “well-being”—financial, physical, and emotional—even as different ARGs championed specific priorities (the Parents’ ARG, for example, pushed to expand family-support benefits). Equipped with this new understanding, Kroger was able to design more purpose-fit services for its associates.

Custom-Fitting Services and Supports

Find creative solutions to flexibility challenges. While employees in many roles across the US welcomed the flexibility of remote work during and after the pandemic, this was not an option for most frontline workers. Their largely onsite job requirements created a conundrum for employers, which needed to adjust their employee value propositions in response. Our conversations with company leaders revealed that flexibility—and the ability to have predictability and control over their schedules—was not only a high priority for frontline workers but also a factor that enabled them to stay on the job.

For instance, a large retailer headquartered in the western US had struggled to staff its warehouses, given the tight labor market and high turnover. Rather than staying on the hiring and replacement treadmill, the retailer sought to improve retention, with an explicit focus on addressing its associates’ request for flexible work schedules. Instead of assigning shifts, warehouse managers invited frontline workers to choose four-hour shifts compatible with their personal schedules. The shorter scheduling blocks were easier to swap or cancel and reduced no-shows. Giving frontline employees more agency over their schedules led to increases in hiring and retention—especially among women and parents.

Reassess pay and benefits. Because many frontline roles are low wage, it’s not uncommon for frontline workers to live paycheck to paycheck. Receiving competitive wages—or needed support when higher pay isn’t possible—helps decrease turnover.

After receiving feedback from its frontline associates, Kroger decided to focus its well-being strategy on financial support. To achieve this, the company invested in competitive hourly starting wages for its frontline talent, with the HR and finance departments working together to benchmark pay and benefits, including 401K contributions, leave-of-absence policies, and transportation support.

Kroger also brought on Goldman Sachs Ayco, a provider of financial planning benefits, to extend a financial coaching program to frontline workers and began communicating the offerings during training and onboarding sessions, to good early uptake.

Like Kroger, Advocate Health Care channeled its energy toward expanding benefits that resonated with its frontline workforce. As a pilot program, the company brought in coaches to liaise directly with workers in select departments and cocreate solutions to the basic-needs challenges identified in employee surveys. For example, to address transportation accessibility, Advocate began to offer gas cards and bus and rail passes; for employees with food insecurity, it supplied cafeteria and grocery vouchers. Today, 86% of frontline workers in Advocate’s Teammate Success Coaching Program have used a support service, and six-month retention among those who completed the program increased to 95%—a dramatic improvement.

Creating an Inclusive, Communicative Culture

Tap the power of direct managers. Despite companies’ redoubled efforts to improve workplace culture since the pandemic, frontline workers have continued to report low feelings of belonging. Nonetheless, we found glimmers of hope in a key but often overlooked stakeholder: the frontline supervisor. Feelings of belonging improved when frontline managers played a hands-on role in creating a positive workplace culture, offering what employees valued most: clear and transparent communication, recognition of good work, and generous support when help was needed. The reverse was also true: managers who did not thoughtfully communicate or support staff actively eroded culture. (See the sidebar “Managers Matter.”)  

Managers Matter

• 23% more likely than peers to have had frequent manager-led career discussions
• 15% more likely to have received positive feedback from their managers
• 50% more likely than peers to feel burned out
• Three times more likely not to recommend their employer as a place to work
• Twice as likely to leave

Walmart’s longstanding culture of promoting from within and focusing on frontline advancement ensures that managers understand the needs of frontline workers because many are former frontline workers themselves. Leadership invested heavily in developing its frontline associates to prepare them to be future supervisors—an effort that has paid off. Seventy-five percent of Walmart’s salaried managers began as entry-level frontline workers for the retailer, and 88% of roles above entry level were filled internally in fiscal year 2023, creating advancement opportunities for junior staff and a talent pipeline for managers. As one director at Walmart reported, the emphasis on frontline experience among the leadership team “helped prioritize the needs of associates” and bring their perspectives to the forefront.

Advocate Health Care also saw the importance of involving managers in establishing an inclusive culture. When frontline managers were informed of the program’s aim from the beginning and positioned to codevelop the details, the initiative excelled: managers could address questions about whether it was better to have frontline employees train in the morning or the afternoon, for example, or how to release new employees from duties for a meeting with their coach. As a result, the proposed actions were much more quickly adopted.

BCG research has shown that changes tend to “stick” when those who are directly impacted are closely involved in planning and implementation. Thus, treating frontline workers and managers as thought partners and change enablers can boost their buy-in and improve the chances that the initiative will succeed.

Communicate, communicate, communicate. While reaching desk-based workers is relatively easy—because they are often logged in to their computers and checking email or online messaging systems—engaging frontline workers can be more difficult, especially if their roles don’t require them to be online all day.

To address communications gaps, Kroger devised a multimodal strategy, providing managers with talking points to deliver face-to-face while simultaneously circulating the messages through in-store tablets that frontline workers used regularly. Kroger also normalized usage of a customized mobile phone app, originally used for learning and development, as a primary means of communication, pushing out important organization-wide notifications and celebrating milestones like work anniversaries. The app also provided another feature that was critical for its frontline workforce: translation services, which gave non-native-English speakers the ability to access key communications.

Advocate Health Care’s coaches proved to be another avenue for transparent communication. The company told us that it was surprised by how quickly frontline workers opened up to their coaches—trust was almost immediate. The issues that were shared were not new, but having a safe space to talk about them was. Not surprisingly, employees were not comfortable sharing certain issues (if a worker had been struggling to find stable housing, for example) with their boss but felt they could be more honest and transparent with someone in an ombudsman role, especially one using open and judgment-free prompts like “What brings you here?”

Facilitating Upward Mobility

Create learning and development opportunities. In a 2022 BCG survey of frontline workers, 41% of respondents cited lack of career advancement opportunities as the reason for wanting to leave their jobs. That made it the second biggest complaint, behind lack of flexibility.

Kroger, like many other employers, acknowledged that frontline workers were motivated to progress in their careers—but the company also acknowledged that its decentralized approach to training left it without a simple and consistent way to upskill associates. In response, Kroger partnered with Axonify, a specialist in AI-powered learning for frontline workers, to launch Fresh Start, a tailored learning and development program, which provided purposeful, bite-size lessons related to an associate’s role and next steps for their career path, personalized to each associate’s pace and level. It also had a library of resources that allowed for individualized learning and progression—all through just three to five minutes of learning per day.

The University of Chicago took a different approach, building a new set of pathways for frontline workers through apprenticeships and internships that laddered up to full-time employment. Modeled on best practices, the program allowed frontline apprentices to “learn and earn”—to gain credentials while working. Academic partnerships with City Colleges of Chicago were intentionally crafted to accommodate workers’ job and classroom schedules. And cohort-based training helped apprentices feel less on their own in navigating logistics, institutional culture, and job progression.

Prove program value—and continue innovating. BCG research has highlighted the importance of measuring the effectiveness of learning and development programs , including programs that establish frontline skills. And the companies we studied agreed: tracking the impact of new efforts helped take what worked to a wider audience—or it revealed that a program didn’t work out as planned.

When the University of Chicago launched its youth internship program, it assigned participants to administrative roles or placed them on random tracks, assuming that the opportunity to experience what it’s like to work in an office would be sufficient. But surveys and feedback that participants shared with their mentors revealed that youths in the program had developed clear interests and wanted to pursue particular fields. They felt that a program to match the opportunities at the university with their interests would make the program more valuable—and the university successfully adapted it.

At Kroger, Fresh Start began as a pilot at a large store with supportive management. To test if it had wider potential, the company’s vice president of total rewards and HR systems monitored the program and worked collaboratively with senior finance and talent leaders to examine the impact on key performance indicators, such as the customer return rate, sales, and staff friendliness. Deemed a success on those measures, Fresh Start was scaled companywide. It was also a success in terms of adoption: 80% to 85% of Kroger associates engage with Fresh Start regularly and turnover has decreased.

Said Kroger’s senior director of HR, “We understood that Fresh Start would be a big undertaking, but we were able to show senior executives that it would be a good investment too. Now, the program has proven its positive impact on our workers and our business.”

Companies can successfully address the needs and potential of frontline workers in myriad ways. These efforts deliver dividends as well: they often end up benefiting employees beyond the frontline worker population, and they create a more motivated, productive workforce that is less likely to leave and more likely to advance to management or leadership roles.

That’s an encouraging return on investment. And it shows that the frontline and the bottom line are inextricably linked.

The authors thank the following BCG and Cara Collective colleagues for their contributions to this article: Aine Keel, Alex Damiano, Ben Ruxin, Chenault Taylor, Hannah Paul, Hope Allen, Kate Myhre, Mariya Bokvun, Mark Toriski, Nico Lake, and Rohan Angadi. In addition, Cara Plus wishes to thank the Stand Together Foundation and Walmart for the funding support that made Cara’s contributions possible.

About Cara Plus

As an entity of Cara Collective, Cara Plus engages companies and nonprofits across the nation to build, launch, and grow workforce solutions so that people experiencing poverty can find and keep quality employment. Since its launch, Cara Plus has worked with more than 40 companies and 80 nonprofits in 29 states to adopt and adapt our methodology and create more inclusive employment pathways around the country. Learn more at www.caraplus.org .

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Managing Director, Cara Plus

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• JMIR Ment Health
• v.8(5); 2021 May

Initial Training for Mental Health Peer Support Workers: Systematized Review and International Delphi Consultation

Ashleigh charles.

1 School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom

Rebecca Nixdorf

2 Department of Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Nashwa Ibrahim

3 Psychiatric and Mental Health Nursing Department, Faculty of Nursing, Mansoura University, Masoura, Egypt

Lion Gai Meir

4 Department of Social Work, Ben Gurion University of the Negev, Beer Sheva, Israel

Richard S Mpango

5 Butabika National Referral Hospital, Butabika, Uganda

6 School of Health Sciences, Soroti University, Soroti, Uganda

7 MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda

Fileuka Ngakongwa

8 Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania

9 Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania

Hannah Nudds

Soumitra pathare.

10 Centre for Mental Health Law and Policy, Indian Law Society, Pune, India

11 Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom

Julie Repper

12 ImROC, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, United Kingdom

Heather Wharrad

13 Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, United Kingdom

Philip Wolf

14 Department of Psychiatry II, Ulm University II, Ulm, Germany

Candelaria Mahlke

Associated data.

Search strategy for the systematized review.

Coding framework developed from the thematic synthesis of peer support worker initial training manuals (n=32).

Changes suggested in round 1 of the Delphi consultation (N=110).

Round 2 Delphi consultation rating of importance (n=89).

Round 2 Delphi consultation rating of web-based delivery (n=89).

Initial training is essential for the mental health peer support worker (PSW) role. Training needs to incorporate recent advances in digital peer support and the increase of peer support work roles internationally. There is a lack of evidence on training topics that are important for initial peer support work training and on which training topics can be provided on the internet.

The objective of this study is to establish consensus levels about the content of initial training for mental health PSWs and the extent to which each identified topic can be delivered over the internet.

A systematized review was conducted to identify a preliminary list of training topics from existing training manuals. Three rounds of Delphi consultation were then conducted to establish the importance and web-based deliverability of each topic. In round 1, participants were asked to rate the training topics for importance, and the topic list was refined. In rounds 2 and 3, participants were asked to rate each topic for importance and the extent to which they could be delivered over the internet.

The systematized review identified 32 training manuals from 14 countries: Argentina, Australia, Brazil, Canada, Chile, Germany, Ireland, the Netherlands, Norway, Scotland, Sweden, Uganda, the United Kingdom, and the United States. These were synthesized to develop a preliminary list of 18 topics. The Delphi consultation involved 110 participants (49 PSWs, 36 managers, and 25 researchers) from 21 countries (14 high-income, 5 middle-income, and 2 low-income countries). After the Delphi consultation (round 1: n=110; round 2: n=89; and round 3: n=82), 20 training topics (18 universal and 2 context-specific) were identified. There was a strong consensus about the importance of five topics: lived experience as an asset , ethics , PSW well-being , and PSW role focus on recovery and communication , with a moderate consensus for all other topics apart from the knowledge of mental health . There was no clear pattern of differences among PSW, manager, and researcher ratings of importance or between responses from participants in countries with different resource levels. All training topics were identified with a strong consensus as being deliverable through blended web-based and face-to-face training (rating 1) or fully deliverable on the internet with moderation (rating 2), with none identified as only deliverable through face-to-face teaching (rating 0) or deliverable fully on the web as a stand-alone course without moderation (rating 3).

Conclusions

The 20 training topics identified can be recommended for inclusion in the curriculum of initial training programs for PSWs. Further research on web-based delivery of initial training is needed to understand the role of web-based moderation and whether web-based training better prepares recipients to deliver web-based peer support.

Introduction

Peer support is rapidly developing into a central approach to support mental health recovery [ 1 ]. It has been defined as “a system of giving and receiving help founded on the key principles of respect, shared responsibility, and a mutual agreement of what is helpful” [ 2 ]. Formal peer support involves individuals with lived experience of mental health conditions and/or mental health services—variously called peer providers, peer specialists, peer support volunteers, or as peer support workers (PSWs)—who are engaged in a peer support capacity to support others’ recovery from mental health conditions [ 3 ].

There is strong empirical evidence for the positive benefits of implementing PSW roles. PSWs contribute to an increase in service user engagement, a sense of empowerment [ 4 ], improved social relationships [ 5 ], self-efficacy [ 6 ], hope [ 7 ], self-management [ 8 ], and positive clinical outcomes [ 9 , 10 ]. PSW roles are being implemented internationally, increasingly in lower middle-income countries such as India [ 11 ] and Uganda [ 12 ], where PSWs are engaged to address the mental health care gap [ 13 ].

Numerous PSW training programs exist [ 14 , 15 ]. These programs are designed to prepare individuals for the PSW role and sometimes also to meet the required competencies for accreditation. However, PSW roles and activities vary depending on their particular setting and context. For example, PSWs may work one-on-one or in a group setting with people who use mental health services, they may support individuals through service transitions, from hospital to the community, into employment, and/or to access local opportunities or resources. Training programs vary depending on the setting, local context, and resources.

Peer support has traditionally been provided as a face-to-face intervention. However, with the growth of digital mental health interventions changing the ways in which mental health care is delivered, peer support is increasingly being offered via digital technologies known as digital peer support. Digital peer support is defined as automated or live peer support services that can be delivered through multiple modalities [ 16 ], such as web-based peer support [ 17 ], smartphone-supported interventions [ 18 , 19 ], and web-based peer-to-peer networks [ 20 ]. A recent systematic review concluded that digital peer support appears to be both acceptable and feasible, with a strong potential for clinical effectiveness [ 16 ]. The use of web-based PSW approaches such as digital peer support is likely to increase in response to the COVID-19 global pandemic [ 21 ]. This new development means that PSW training may also be offered on the web, and some initial training topics may need to be updated or reviewed.

Initial training is essential for a formal PSW role. Several studies have reported the need to identify core peer support competencies in mental health [ 22 , 23 ]. However, there is no consensus on the core training topics required for PSW roles and accreditation [ 24 ]. Given the advances in digital peer support and lack of evidence about what topics are important in initial PSW training, there is a need to establish the level of consensus about the content of initial PSW training. A specific knowledge gap relates to the extent to which initial PSW training topics can be delivered on the web. Web-based training may offer benefits, including opportunities to access more prospective PSWs on a larger scale and the reduction of costs as compared with face-to-face training but may not be feasible for training in the relational aspects of the PSW role.

Aims and Objectives

The aim of this study is to conduct a Delphi consultation technique to establish the level of consensus regarding initial PSW training topics. The objectives were (1) to identify training topics; (2) to identify the extent to which each identified training topic can be delivered on the web; and (3) to assess the degree of consensus that exists with respect to findings from objectives (1) and (2) overall, between PSWs and PSW managers versus PSW researchers and between countries with different resource levels.

This study was conducted as a part of UPSIDES (Using Peer Support in Developing Empowering Mental Health Services), a 5-year (2018-2022) European Union–funded multinational study that aims to replicate and scale up peer support interventions for people with severe mental illness. Ethics approval was obtained from the University of Nottingham, Faculty of Medicine and Health Sciences Research Ethics Committee (FMHS 377-1908). All participants provided web-based informed consent after reading the participant information sheet available on the web.

A systematized review was conducted to develop a preliminary list of training topics, followed by a three-round Delphi consultation. Round 1 refined the preliminary list, and rounds 2 and 3 established a consensus.

Participants

Inclusion criteria were age 18 years or above, able to provide informed consent electronically, and one of the following: publication record relating to peer support work (researcher group) or experience of working as a PSW group or clinical or practical experience in training and/or supervision of peer support (manager group). Participants were not screened for inclusion but self-identified as belonging to one or more of the above groups.

Systematized Review

First, we conducted a systematized review of initial PSW training manuals to identify a preliminary list of topics for use in initial PSW training. A systematized review includes elements of a systematic review process while stopping short of being a full systematic review [ 25 ]. The inclusion criteria were as follows:

• Training manuals designed specifically for mental health PSWs, that is, designed for people with lived experience of mental health conditions, to prepare them to work in a PSW role with other people with mental health conditions.
• Involved face-to-face training, web-based training, or a combination of both.
• Training with and without accreditation or certification was included, as countries vary in their progress toward an accreditation process.
• Training for both a generic PSW role or for work with a specific mental health subpopulation, for example, dual diagnosis with substance misuse, dementia, and young people.
• Published in the English or Arabic language.

Exclusion criteria were as follows:

• Training manuals not specifically for mental health PSWs.
• Does not include initial PSW training, for example, focus is on stigma related to mental health, human rights, peer leadership, consumer-run organizations, gender identity, and childhood trauma.
• Train the trainer manuals.

Training programs were identified from seven sources:

• The MEDLINE database was searched using the search strategy shown in Multimedia Appendix 1 .
• Gray literature databases (OpenGrey, New York Academy of Medicine’s Grey Literature Report, TRIP, and Health Quality Ontario) were searched using the phrases: “mental health peer support work training manuals,” “mental health consumer provider training manuals,” “certification training for mental health peer support workers,” and “mental health peer support workers’ core competencies.”
• Google and Google Scholar were searched using the same phrases mentioned above. The first 100 hits were then screened.
• Massive open online course platforms (Coursera, edX, FutureLearn, Canvas Network, and Independent) were searched using the massive open online course list website [ 26 ], using the same phrases mentioned above.
• The preliminary findings from a related ongoing systematic review [ 27 ].
• The websites of mental health organizations include the Substance Abuse and Mental Health Services Administration [ 28 ], National Mental Health Commission [ 29 ], Scottish Recovery Network [ 30 ], Mental Health America [ 31 ], Mental Health Innovation Network [ 32 ], Depression and Bipolar Support Alliance [ 33 ], and REdeAmericas [ 34 ].
• The websites of PSW certification, accreditation, and professional bodies include the Missouri Peer Specialist [ 35 ], Nevada Certification Board [ 36 ], National Association of Peer Supporters [ 37 ], and Global Mental Health Peer Network [ 38 ].

Searches were conducted in April 2019, and no date restrictions were applied. Endnote software was used to collate the identified manuals. Screening and data extraction were equally divided between AC and NI. Both researchers independently analyzed their allocated manuals and discussed any discrepancies with MS (eg, inclusion and exclusion of manuals). The data abstraction table was populated by extracting data relating to country (specific country and country income level), service setting (eg, community or inpatient), target population (eg, general mental health or dementia), training modality (face-to-face, internet-based, or both), training topics (using terms from source documents), definitions or training goals or learning objectives (where specified), and examples of the training exercises.

Both AC and NI independently conducted thematic analysis [ 39 ]. Vote counting for each theme was conducted, and the 2 analysts discussed the discrepancies. AC, NI, and MS then conducted a process of data reduction, which involved comparing the training topics within and across themes and merging and integrating subthemes to generate one coherent coding framework or codebook comprising the training topic name and definition.

Delphi Consultation

A three-round Delphi consultation was then conducted. Delphi consultation is a systematic method of determining how much agreement exists on a particular topic based on experts’ opinions [ 40 ]. The method involves an iterative and multistage process, comprising multiple rounds of questions designed to combine opinions and assess group consensus.

Compared with the traditional Delphi method, which is delivered via questionnaires through face-to-face meetings, a web-based Delphi offers participants the time to deliberate their responses, thus increasing the validity of results, and requires less resources, for example, time and costs [ 41 ]. In addition, given the growth of PSW roles internationally and the wide range of peer support programs that exist, the web-based Delphi was chosen as an appropriate method to answer the research question, as it has the potential to access a diverse and large group of experts engaged in peer support from around the world [ 42 ]. Compared with other research designs, the Delphi method can produce rigorous and rich data because of multiple rounds and refinement based on response feedback [ 43 ]. Limitations include a low level of reliability of judgment among experts, lack of clear methodological guidelines, and difficulty in assessing the degree of expertise included [ 44 ].

Participants for the Delphi consultation were recruited through advertising (1) across networks including the Recovery Research Network [ 45 ], UPSIDES consortium, Recovery College Network, and Being Network (Australia); (2) by partner organizations including Nottinghamshire Healthcare National Health Service Foundation Trust, Institute of Mental Health; (3) social media, including Twitter; and (4) snowball sampling. Purposive sampling was used to obtain a balance in role (researcher, PSW, and manager) and income level (high, middle, and low).

In each round, prospective participants were invited via email to complete an anonymous web-based survey using the Jisc survey platform (round 1 and 2) or Google Forms (round 3). Participants were sent 2 reminder emails to complete each round of the survey. All correspondence with the participants occurred via email. An initial pilot test of each round was conducted with 5 nonparticipants, which resulted in minor amendments. Round 1 was distributed over eight screen pages, and rounds 2 and 3 were distributed over four pages. The personal information collected was stored separately from the results’ data on a secure webserver, and participants were allocated identification numbers, for example, P001, which were used to track responses and duplicates. Only the research team had access to personal and research data. No incentive was offered for participation. Participants were able to change their responses using a back button but could not complete the survey without answering all questions. Round 1 began in November 2019, and round 3 was completed in July 2020.

In round 1, after reading the participant information sheet outlining the length of time of the survey, how data are stored, where, and for how long, and the purpose of the study, participants gave informed consent and provided sociodemographic details including if they had any experience of web-based training (about anything). Participants then rated each training topic and associated definition for importance using a 4-point Likert scale (“0=Not important at all,” “1=A bit important,” “2=Quite important,” and “3=Very important”). A free-text response was available to participants, providing the opportunity to suggest additional training topics or changes to the topic name or definition. Qualitative data were analyzed thematically. Two analysts (AC and NI) independently reviewed and synthesized responses using the following framework: proposed topic name, change to language or definition, and additional topics to be covered. Agreement on the topics and definitions arising from the first round was determined by further discussion, refinement, and synthesis with a third analyst (MS). The finalized list of training topics was created based on these responses, including the deletion of topics quantitatively rated as not important, refinement of name or definition, and addition of new topics where relevant.

In round 2, participants rated each topic and associated definition for importance using the same rating scale as in round 1, and also rated the extent to which the topic could be delivered on the web using a 4-point Likert scale (“0=No, it can only be delivered through face-to-face training,” “1=Partially, eg, as blended learning with some aspects delivered online and some face-to-face,” “2=Fully online as a moderated online course, ie, with a peer support worker trainer providing online support and moderation,” and “3=It can be fully delivered online as a standalone course without moderation”).

In round 3, participants were shown their own round 2 ratings and the mean round 2 ratings from other participants in (1) their group (researcher, PSW, and manager or supervisor), (2) the income level of their country setting (high, middle, and low), and (3) overall. Participants were asked to rerate each component for importance and web-based delivery using the same rating scales as in round 2.

For the Delphi consultation, strong consensus was defined as at least 80% of participants in the group with the same rating, and moderate consensus was defined as at least 50% of participants in the group with the same rating. An arbitrary threshold for a high- and moderate-level consensus was implemented.

The systematized review identified 32 training manuals in English, comprising face-to-face and web-based PSW training from 14 different countries (Argentina, Australia, Brazil, Canada, Chile, Germany, Ireland, the Netherlands, Norway, Scotland, Sweden, Uganda, the United Kingdom, and the United States). Training varied in length from 54 hours to 1 year, and the manuals covered a range of PSW training from working with adults, older adults, adolescents, and young people. A total of 502 topics and 348 learning objectives or definitions were extracted. The coding framework synthesized from the training manuals comprised 18 themes and is shown in Multimedia Appendix 2 . The coding framework was used as the basis for developing 18 topics and associated definitions, as shown in the first column of Multimedia Appendix 3 .

The characteristics of the Delphi consultation participants, including the number of responses for each round, are shown in Table 1 .

Characteristics of the Delphi consultation participants (N=110).

a PSW: peer support worker.

Participant Characteristics

The participants came from 21 countries, including higher-income (Australia: n=33; the United Kingdom: n=22; Canada: n=7; Poland: n=7; Germany: n=4; Ireland: n=4; Switzerland: n=4; Israel: n=3; Norway: n=3; Italy: n=2; the United States: n=2; New Zealand: n=1; Belgium: n=1; Singapore: n=1), middle-income (India: n=4; Tunisia: n=2; Brazil: n=1; Egypt: n=1; Argentina: n=1), and lower-income (Uganda: n=6; Tanzania: n=1) countries.

All participants completed round 1 and rated each of the 18 topics for importance. Round 1 ratings and all proposed changes are shown in Multimedia Appendix 3 . Analysis of the round 1 free-text responses (n=68) and mean rating scores resulted in multiple refinements to the round 1 topic names and definitions. Although the mean score for knowledge of mental health was ranked low compared with other topics, the free-text responses suggested that the definition should be amended to reflect PSW training needs, and this was changed markedly for round 2. Two topics— role-specific PSW skills and competencies and work skills —were identified as being relevant in some contexts but not others. These context-specific topics were presented separately in a different format for round 2, along with an explanation for the participants. Three additional topics and definitions were created— PSW supervision , developing a career as a PSW , and role-specific PSW skills and competencies —that were adapted from the subpopulation and specialized modules topic.

The revised list of 20 topics and associated definitions were used for round 2, which are shown in the fifth column of Multimedia Appendix 3 . Of 110 participants, a total of 89 (80.9%) participants completed round 2. The round 2 ratings of importance are shown in Multimedia Appendix 4 and of web-based delivery are shown in Multimedia Appendix 5 . Additional comments were received from round 2 participants about the role-specific PSW skills and competencies topic, resulting in minor refinements to the definition of knowledge of mental health topic. The final list of topics and definitions, which were used in round 3, is shown in Textbox 1 .

Final list of topics and definitions for initial peer support worker training.

Topics always needing coverage

• Presenting the local and international history of peer support, survivor or activist grassroots knowledge, and key information on the context of peer support, PSW, principles, and concept of expertise by experience is essential to formal PSWs
• Teaching about the meaning, stages, and culture of recovery, allowing integration into the PSW’s own experiences and practice. Additionally, teaching leadership, supporting informed choice, and working with service users in difficult times
• Familiarizing prospective PSWs with approaches and frameworks underlying which peer support could be practiced. For example, the tree of life, coaching frameworks, strengths-based approach, Intentional Peer Support, and Wellness Recovery Action Planning
• Introducing prospective PSWs to different frames of understanding of mental health, including nonmedical models of understanding mental distress (eg, Hearing Voices, Alternatives to Suicide, or Mad Studies) and medical models (eg, diagnosis or interventions), the different types of service setting (eg, inpatient units), and the mental health needs of different populations (eg, age groups, dual diagnosis, or marginalized and minority groups)
• Providing training about the meaning and implications of human rights legislation, including regional or national mental health laws and international legislation such as Convention on the Rights of Persons with Disabilities, to inform values-based PSW practice and skills in working within systems to uphold and protect the rights and social justice for people they work with, for example, through advocacy
• Teaching about PSW values, beliefs, and actions, supporting self-reflection and an understanding about mental health practice and accountability including the importance of boundaries, levels of disclosure, and confidentiality
• Practicing PSWs in a way compatible with the cultural needs, values, background, and context of people using services
• Providing prospective PSWs with essential competencies needed for formal PSWs through an overview of different PSWs’ job descriptions; teaching the importance of maintaining role integrity and reflecting on the essential qualities and values of PSWs
• Highlighting how the experience of mental health problems, alongside other peer experiences such as service use, is a central resource for the PSW role; exploring methods and strategies for using lived experience with service users, including the safe, purposeful, and appropriate use of one’s story to benefit others
• Supporting self-reflection and offering strategies for PSWs to promote wellness, recovery, and resilience (eg, teaching PSWs about their workplace rights, self-advocacy, stress management techniques, vicarious trauma, self-care, and how to use reflective practice)
• Ensuring prospective PSWs have the fundamental connecting skills (eg, listening skills, use of language, and awareness of verbal and nonverbal cues), which facilitate effective communication with service users in different settings and situations, and helping them develop these skills if necessary
• Offering peer support to understand and respond to the trauma of people using services to help them regain or achieve wellness and healing
• Helping PSWs to understand how to respond collaboratively, supportively, respectfully, and empathically to someone in a crisis
• Training prospective PSWs on the skills needed to start, facilitate, or cofacilitate a peer support group, in addition to understanding the group processes, dynamics, and coproduction practices and addressing any arising issues
• Ensuring PSWs have the skills needed to deal with workplace challenges, including knowledge of support options and training in dealing with work-related pressures, such as working with other professionals with conflicting values, workplace culture, organizational structures, exposure to violence, discrimination, bullying, and managing power dynamics and conflict
• Ensuring prospective PSWs know about local services and community resources and about formal communication or referral processes to other services; ensuring PSWs are sensitive to the balance between helpful referrals and supporting self-management or being heard
• Introducing PSWs to the purpose, types of, and importance of supervision
• Involves teaching prospective peers about the professionalization of the PSW role, including motivational drivers, career development, training opportunities, and financial management

Context-specific topics

• Equipping PSWs with role-specific skills (eg, motivational interviewing, solution-focused thinking, family therapy approach, intentional sharing, and understanding cognitive behavioral therapy and mindfulness), understanding of service settings (eg, inpatient units and community teams) and the mental health needs of different populations (eg, age groups, dual diagnosis, homelessness, and marginalized and minority groups)
• Teaching the administrative skills of recording and documenting direct mental health care and incidents and other work-related skills, such as time management

Of 110 participants, a total of 82 (74.5%) completed round 3. Of these 82 participants, 76 (93%) had completed round 2. The round 3 ratings of importance, ordered by median rating, are shown in Table 2 .

Delphi Consultation round 3 rating of importance (n=82).

b Scale 0 (low) to 3 (high).

c Strong consensus.

d Moderate consensus.

The median rating of importance was “Quite Important” or “Very Important” for all topics. Across all participants, the first five topics in Table 2 reached a strong consensus on importance.

The round 3 ratings for web-based deliverability, ordered by median rating, are shown in Table 3 .

Delphi Consultation round 3 rating of web-based delivery (n=82).

b Scale 0 (face-to-face) to 3 (fully via the internet).

d Moderate consensus .

The round 3 median ratings for web-based delivery indicated that all topics can be delivered partly or fully on the web with moderation but none without moderation. No topics reached a strong consensus for the mode of training delivery. The range of median responses relating to web-based delivery was smaller for PSWs (1-1.5) than for managers (0-2) and researchers (1-2), indicating that PSWs were more consistent in placing importance on some face-to-face training contact.

Principal Findings

In this 21-country study, 20 topics were identified that can be recommended for inclusion in the curriculum of a PSW initial training program. There was a strong consensus about the high importance of five topics: lived experience as an asset , ethics , PSW well-being , PSW role focus on recovery , and communication . There were no substantial differences between role perspectives (PSW, managers, and researchers) and countries with different resource levels relating to importance. All training topics were identified as being partly or fully deliverable on the web, but none could be provided on the web without moderation. There was no consensus about the right balance between face-to-face and web-based training with moderation, even though PSWs were more consistent in identifying the need for a face-to-face training component.

Strengths and Limitations

A strength of this study is the number of participants (N=110) from different countries (n=21) and the low attrition (round 1-2: 19%; round 1-3: 25%) compared with other Delphi studies [ 46 ]. Another strength is that the Delphi was reported in line with the Checklist for Reporting Results of Internet e-Surveys checklist [ 47 ]. This study has several limitations. First, there is a need for more representation from middle- and lower-income countries, which might have allowed between-setting differences to emerge, which was not achieved despite purposive sampling efforts. Second, participation in a web-based consultation may be more difficult for people in environments with poorer internet access and intermittent electricity, which may disproportionately affect PSWs. Third, participants were asked if they had completed web-based training earlier but not specifically web-based PSW training, which could then have been further explored in the analysis. In addition, web-based deliverability was not defined and was based on participant judgment rather than evidence from experience. Fourth, the use of two web-based platforms that may have confused participants and were not specifically designed for Delphi consultations. Alternative Delphi-specific platforms exist, including ExpertLens [ 48 ], Mesydel [ 49 ], and Delphi2 [ 50 ]. Fifth, PSW training manuals available in languages other than English or Arabic might have identified a wider range of training topics.

Finally, a full systematic review was not conducted, and the limitations associated with implementing a systematic review include the following: (1) lack of patient, population, intervention, comparison, and outcomes criteria; (2) included and excluded manuals were not listed; (3) methodological quality assessment and reliability of manuals were not explored; and (4) discrepancies between reviewers were not reported.

Comparison With Other Work

Achieving an international consensus on topics that are of high importance in PSW training is important for three reasons. First, it offers prospective PSWs a description of the tasks and skills involved in the PSW role, which may inform their decision making about whether to train as a PSW. Second, it provides training providers and organizations with a list of core topics that should be covered in the content of initial PSW training programs in all settings and two additional context-specific topics that may be relevant. Third, it provides an evidence base for developing training curricula and a framework for PSW accreditation. The standardization of PSW training across settings and countries is contentious. On the one hand, an international consortium of peer leaders from 6 continents developed an international charter, which defined peer support and identified key principles and guiding values [ 51 ]. In conjunction with this Delphi consultation, a framework is emerging that could underpin the international PSW accreditation process. On the contrary, unintended consequences of institutionalizing the PSW role are emerging, with one qualitative study in the United States concluding that it “has the potential to reduce the very centrality of experiential expertise, reproduce social inequalities, and paradoxically impact stigma” [ 52 ].

The identification of training topics relevant to specific contexts reflects cultural and organizational influences on implementation [ 53 ]. Identified barriers that may lead to context-specific modifications include the lack of credibility of peer worker roles, professionals’ negative attitudes, tensions with service users, struggles with identity construction, cultural impediments, poor organizational arrangements, and inadequate overarching social and mental health policies [ 54 ]. These influences can lead to preplanned modifications implemented during initial PSW training, as well as unplanned extensions to the PSW role [ 55 ]. Several studies have found that this role extension can reduce role clarity and integrity, such as by incorporating medical ways of working [ 56 ] and creating identity conflict [ 57 ]. For example, a 10-site comparative case study across England found that different understandings of professionalism and practice boundaries can erode the distinctiveness of the PSW role [ 58 ].

PSW training has evolved in response to organizational needs and more recently the COVID-19 global pandemic. In a recent commentary, barriers to implementing web-based peer support in low- and middle-income countries in the context of COVID-19 were identified [ 59 ]. The low-to-moderate consensus about web-based delivery of training found in our study indicates that further work is needed to explore the relative costs and benefits of web-based versus face-to-face training.

All topics were rated as candidates for at least partial web-based delivery, which raises two questions. First, what is the role of web-based moderation? In addition to knowledge and skills development, an important component of PSW training is ensuring that participants have the ability to maintain role integrity in a context where many will have to deal with microaggressions [ 60 ]. Similarly, a recent editorial identified specific contested areas relating to the role of PSW in restraint, administration of medication, and lone working in the community [ 61 ]. These may all be sensitive issues for PSWs to explore in training, for example, due to personal experiences, which may be more difficult to explore in moderated web-based discussions. Furthermore, individuals considering PSW training may struggle with motivation [ 62 ] and the pressure to succeed [ 63 ], and role challenges can include overwork and symptom recurrence [ 64 ]. There is some evidence that a therapeutic alliance in digital interventions is possible [ 65 ], but the extent to which the requisite resilience and motivation for the PSW role can be fostered through web-based training delivery is an important future focus.

Second, does web-based training prepare recipients better to deliver web-based peer support? Relationships are central to PSWs [ 66 ], and one impact of COVID-19 is to increase the use of web-based approaches by trained PSWs as an alternative relationship medium. Combining web-based and offline peer support has been shown to be a promising concept, with one qualitative Norwegian study of peer support recipients finding it enabled connectedness and allowed individuals to balance anonymity and openness [ 67 ]. Web-based training may help future PSWs to have both technological skills and the confidence to engage with PSW recipients on the web. In middle- and low-income countries, this blend of training delivery could also provide an accessible, wide-reaching, and cost-effective approach to increase the availability of PSW training places. A systematic review identified that the role content of PSWs is often underreported [ 68 ]. The topics identified in our study can inform the reporting of both the training program and PSW role components in future PSW evaluations.

This study developed a list of training topics for the initial PSW training. One use is to inform PSW training manuals, such as the UPSIDES PSW training program [ 69 ], which is being evaluated in Germany, India, Israel, Tanzania, and Uganda [ 70 ]. The use of an evidence-based training curriculum will increase the effectiveness of programs to prepare individuals for working as PSWs.

Acknowledgments

The study UPSIDES is a multicenter collaboration between the Department for Psychiatry and Psychotherapy II at Ulm University, Germany (Bernd Puschner, coordinator); the Institute of Mental Health at University of Nottingham, United Kingdom (MS); the Department of Psychiatry at University Hospital Hamburg-Eppendorf, Germany (CM); Butabika National Referral Hospital, Uganda (Juliet Nakku); the Centre for Global Mental Health at London School of Hygiene and Tropical Medicine, United Kingdom (GR); Ifakara Health Institute, Dar es Salaam, Tanzania (Donat Shamba); the Department of Social Work at Ben Gurion University of the Negev, Be’er Sheva, Israel (Galia Moran); and the Centre for Mental Health Law and Policy, Pune, India (Jasmine Kalha). UPSIDES received funding from the European Union’s Horizon 2020 Research and Innovation Programme under grant 779263. MS acknowledges the support of the Center for Mental Health and Substance Abuse, University of South-Eastern Norway, the National Institute for Health Research Nottingham Biomedical Research Centre, and research group work support from the Economic and Social Research Council (grant ES/J500100/1 and ES/P000711/1). This publication only reflects the authors’ views. The Commission is not responsible for any use that may be made of the information it contains. The funding bodies had no role in the design of the study, writing of the manuscript, or decision to submit the paper for publication.

Abbreviations

Multimedia appendix 1, multimedia appendix 2, multimedia appendix 3, multimedia appendix 4, multimedia appendix 5.

Authors' Contributions: AC, MS, NI, RN, and CM conceptualized the study. AC, MS, and NI conducted a systematized review, analyzed, and interpreted the data. AC had full access to all the data in the study and had final responsibility for the decision to submit for publication. RN and CM contributed to the design of the Delphi consultation, analysis, and interpretation of data for the work. HN contributed to the design of the Delphi consultation, quality review, and data acquisition. LGM contributed to ethical processes. AC, NI, and MS drafted the manuscript. All authors contributed to the interpretation of the data, critically revised the manuscript, and approved the final submitted draft.

Conflicts of Interest: None declared.