What are the core elements of peer support programs?

In brief

Despite the growing body of evidence for the effectiveness of peer support, little is known about which elements of peer support are critical to achieve improved outcomes. To answer this question, EENet conducted a literature search to look at the core components of peer support programs across a range of health conditions. The Centre for Innovation in Peer Support at Support & Housing-Halton requested this review to help develop new training materials and inform the potential expansion of training across the healthcare system.

Read this evidence brief below or download ther PDF.

What you need to know

  • Peer support programs offer emotional, social, and informational support to people who share similar experiences.
  • These programs are available for a wide range of health conditions, including chronic disease, mental illness and addiction, cancer, and diabetes.
  • Peer support programs achieve positive outcomes, including improving a person’s ability to self-manage their disease, better self-esteem and self-efficacy to achieve specific goals, and less need for hospital care.
  • Core elements of peer support programs include:
  • Training, supervision, and monitoring;
  • Providing social connection and support;
  • Creating a safe environment;
  • Ongoing engagement of peers and participants;
  • Recruiting peer workers with specific peer characteristics.
  • Little is known about which program elements lead to positive outcomes.

What’s the problem? 

two older adults sitting at a table, talkingPeer support is a process through which a person or group with a specific experience or health condition provides emotional, social, and informational support to individuals with similar experiences or conditions.1,2,3 Peer support is founded on the principles of respect, shared responsibility, and mutual understanding.4

Peer support programs exist for a range of health conditions, including diabetes, mental illness, addiction, chronic disease, HIV/AIDS, and cancer. The way peer support is delivered can vary, from one-on-one support by a trained peer, to team-based support, or peer-run groups.4,5

Evidence on the effectiveness of peer support shows improved ability to manage chronic diseases,2 and among people with diabetes, better control of blood sugar levels.6  There is also evidence that peer support helps people stay on treatment, reduces hospital use, increases independence and a sense of hope,4,8 and may help reduce costs.2,7 In the area of mental health, peer support can build a person’s self-confidence, sense of empowerment, and ability to function.9

Results of a comprehensive literature review suggest that peer support workers are more equipped than professional staff in the following areas:10

  • Promoting empowerment;
  • Increasing self-esteem;
  • Increasing self-efficacy and self-management;
  • Improving social inclusion and engagement; and
  • Promoting the belief that recovery is possible.

Similarly, a scoping review on peer support for chronic disease management in rural areas shows positive outcomes including improved activity or weight loss and increased feelings of self-worth.3

Despite the growing body of evidence for the effectiveness of peer support, little is known about which elements of peer support are critical to achieve improved outcomes.4,6 To answer this question, we conducted a literature search to look at the core components of peer support programs across a range of health conditions. The Centre for Innovation in Peer Support at Support & Housing-Halton requested this review to help develop new training materials and inform the potential expansion of training across the healthcare system.

What did we do?

We conducted a literature search in conjunction with Centre for Addiction and Mental Health (CAMH) Library Services to determine the core elements of peer support programs. The search strategy combined terms related to peer support programs (e.g., models, interventions) and core elements (e.g., component, characteristic, best practice) across several health conditions. These included mental health and addictions, chronic disease, HIV/AIDS, diabetes, cancer, and bereavement.

Articles were included if they:

  • looked at intentional peer support, or the idea of a trained peer supporter delivering support, as opposed to social support groups or self-help models that involve patients talking to other patients;
  • discussed core elements (for more detail, see “Defining core elements”);
  • fell within the identified health areas;
  • focused on adults or youth; and
  • were published within the past five years.

Articles were excluded if they:

  • included only self-help, social support, or support group interventions;
  • had only peer support as one type of intervention within a larger review (e.g., systematic review),
  • included peer support as only one aspect of a larger intervention;
  • focused only on family members, children, or caregivers;
  • described only program aspects that study participants found beneficial (as opposed to central or key components);
  • discussed elements about willingness or interest in participating in a peer program as opposed to the program itself; or
  • discussed studies still in progress, where no results are indicated.

Using the search strategy above, a CAMH librarian searched PsycINFO, Medline, and CINAHL databases. The initial search resulted in 63 articles. We then scanned titles and abstracts using the inclusion/exclusion criteria above and selected 24 articles for full text review. While reading the full-text articles, we used a snowball method to identify additional relevant papers that discussed core elements. After a full review, we found 12 relevant articles for this evidence brief. Using a data extraction table we then conducted a thematic review of the core element themes.

Defining core elements

counsellor with female clientThe articles defined the core elements of peer support programs based on the opinions of subject matter experts, authors’ conclusions based on reviews of interventions, and study participants’ descriptions.

Most of the articles comment on the core elements of “successful” peer support programs, but not all. In some cases, authors drew conclusions about core elements by looking at interventions that didn’t discuss outcomes, so it’s unclear whether authors and participants are commenting on core elements of successful programs. Still, we felt it was important to include the core elements since the literature on this topic is so limited.

As a result of these limitations, the focus of this evidence brief is on core elements of peer support programs rather than core elements of successful programs. However, in instances where the literature does mention components of “successful” programs, we indicate that in the findings.

What did we find?

Our search of the peer-reviewed literature identified the following core elements of peer support programs:

Training, supervision, and monitoring

Effective training, and ongoing monitoring and supervision are core components of peer support programs.4,5,7,8,12 Peer workers value training and credentialing as the key to greater acceptance of this work by the wider health system8. Certification that is recognized by other agencies and stakeholders is also important for future employment opportunities.5

Evidence-based training for peer workers is critical to delivering a structured peer support program.12 Though comprehensive training takes time, it’s important that peer workers have a good grasp of the organizational culture they are working with and the ability to assess risk and maintain boundaries4. Peer workers should also understand the values, philosophy, and standards of peer support services and have the competencies required to be an effective peer worker, including active listening.4,5 Peer workers value training materials that are specific to their work, such as manuals, handouts, structured guidelines, and checklists, and documents that list frequently asked questions.1,12,13

Ongoing supervision and monitoring is an important success factor for peer support programs.7 Peer workers should also have a monitoring system in place that provides support if they need it4. For example, a program support team could oversee peers and help identify training and capacity-building opportunities5. Peer programs should also have close partnerships with health professionals who can step in when a client needs their help.12

Providing social connection and support

Social support between peers and people engaging in services is an essential component of peer support programs.2,3,7,11 It is important that programs promote social connectedness, where peers are able to reflect the values of clients and translate information in ways that are meaningful to them.2,7 This is especially important when engaging with marginalized populations or with populations that share a specific culture.2 The sense of feeling connected to others also helps motivate people to participate in program activities.2

Drawing on lived experience and being a role model is an important aspect of authentic peer support,8 and it’s central to a peer worker’s ability to relate to the client and demonstrate that recovery is possible3,8. However, peer workers must establish clear personal boundaries to make sure that the work does not derail their own recovery.8

The way social support is delivered, and who delivers it, is also important. Non-directive support, or support that is person-centred and promotes empowerment, has demonstrated benefits in helping reduce depressive symptoms in people with diabetes11. Along with promoting empowerment and self-efficacy, peers should also reflect client’s values and problems when providing suppor.7 This type of support can lead to benefits for the peers as well, who often receive as much support as they give.2,3

Creating a safe environment

Within successful peer programs, it’s important to provide an environment where people feel welcome, safe, and respected.4 Peers should be able to “just listen” and attend to the client’s emotions.7 Strategies to mitigate stigma, such as ensuring confidentiality, and choosing program locations that are publicly accessible can help improve program participation.2 Confidentiality was also highlighted as a key component of  successful programs for bereaved survivors, as people want to make sure their personal information is kept private.4 

Ongoing engagement with peers and participants

Peer programs should design strategies to recruit peer workers that offer a high level of engagement before the program begins.1 Peer workers need to be able to stay connected, share concerns, and learn from each other, while staying up to date on upcoming events or activities5. Regular and ongoing communication with peers, including weekly teleconferences and e-newsletters, are ways to keep peer workers engaged.1,5

Successful peer support programs also engage participants proactively through strategies such as face-to-face contact and active initiation of peer support.2,7 Peer support programs should also consider engaging with groups who are not well-connected to health services, such as ethnic minorities or people with socioeconomic challenges, as peer support may be even more successful with these groups.7

Recruiting peer workers with specific peer characteristics

There are several characteristics of peer workers that are important to consider when developing a peer support program, both when recruiting peer workers and when matching them with participants.3,4,5,6 Peer workers should be good communicators, authentic, motivated, calm, and agreeable, and they should exercise good judgement.4 Other positive characteristics are compassion, optimism, competence, and acceptance.14 Peer workers who don’t have these characteristics should be well trained in these areas.14

A good match between the peer worker and client’s experiences is also important to help create more trust and openness between them.3,4 For example, for bereaved survivors, matching the peer and client’s loss experience (e.g. suicide) or occupation (e.g. military) is key to the program’s success.4  Ensuring peers reflect the cultural diversity of the community is also important.5

male trainer with two female peer support workersIn one study of peer support for individuals with diabetes, participants who were matched with peer workers who were older and had higher diabetes-related distress at baseline had better control of their blood sugar levels six months later6. The authors suggest this association may be due to people seeing a peer struggling with their diabetes, which in turn could have helped increase motivation for managing their own disease6. This preference for having an older peer is also echoed in another study of peer preferences among cancer survivors.13 Participants in this study also noted a preference for having someone who was the same gender as them.14

In a mental health context, it’s important for peer workers to be well and in recovery,3 while bereavement peer workers should have already worked through their own loss experience and should not be dealing with unresolved guilt while engaging with clients.4

What are the limitations of this review?

male peer support worker with male clientOne limitation of this review is the variability and subjectivity of terms related to core components and peer support. For example, when reading through full text articles we came across the term “peer coaching,” which was used synonymously with “peer support.” It’s possible that other terms are being used in the peer support literature and are not captured by this review. Terms related to core components may also not capture all the literature on this topic. Though we tried to be as comprehensive as possible in identifying related terms, it’s possible that we did not cover all of them.

In our efforts to keep this review current, we used a five-year cut off. This may have inadvertently excluded important research that fell outside of this date range. To mitigate this limitation, we used a snowball method, which yielded two relevant previously-unidentified articles.

It’s important to reiterate that we only draw conclusions about the core components of peer support programs as identified by authors, subject matter experts, and study participants. We were unable to comment definitively on the core components of successful programs because not all the studies indicated whether they achieved positive outcomes.

What are the conclusions?

Peer support programs have positive outcomes for people with a range of health conditions, including diabetes, chronic disease, mental illness and cancer. They help people manage their illness by providing emotional and social support, and by employing peer workers who have gone through similar experiences as participants. While research on the effectiveness of peer support programs is building, little is known about which elements contribute to program success. The core elements of peer support programs across a range of disciplines include:

  • Training, supervision and monitoring;
  • Providing social connection and support;
  • Creating a safe environment;
  • Ongoing engagement of peers and participants;
  • Recruiting peer workers with specific peer characteristics.

Existing peer support programs, or agencies that are developing — or plan to implement — peer support programs may want to consider the evidence outlined in this review to help them understand which program elements are most important. More research is needed on the core elements of successful programs to fully understand what makes them effective. Until then, the available literature provides some indication about how to best design and deliver peer support programs.

Acknowledgements

The author of this rapid review is Rebecca Phillips Konigs, Knowledge Broker. The author would like to acknowledge Fiona Inglis a CAMH Librarian, for assistance with the database search and, for editorial support, Rossana Coriandoli, Communications Coordinator.

References

  1. Aziz, Z., Riddell, M., Absetz, P., Brand, M., & Oldenburg, B. (2018). Peer support to improve diabetes care: an implementation evaluation of the Australasian Peers for Progress Diabetes Program. BMC Public Health, 18(1), 262. https://doi.org/10.1186/s12889-018-5148-8
  2. Lauckner, H. M., & Hutchinson, S. L. (2016). Peer support for people with chronic conditions in rural areas: a scoping review. Rural and Remote Health, 16(1), 3601.
  3. Solomon, P. (2004). Peer support/peer provided services underlying processes, benefits and critical ingredients. Psychiatric Rehabilitation Journal, 27(4), 392−401
  4. Bartone, P. T., Bartone, J., Gileno,Z. & Violanti, J. (2018). Exploration into best practices in peer support for bereaved survivors. Death Studies, 42(9), 555−568. DOI: 10.1080/07481187.2017.1414087
  5. Daniels, A., Bergeson,S., Fricks, L., Ashenden, P. & Powell, I. (2012). Pillars of peer support: advancing the role of peer support specialists in promoting recovery. The Journal of Mental Health Training, Education and Practice, 7(2), 60−69, https://doi.org/10.1108/17556221211236457
  6. Kaselitz, E., Shah, M., Choi, H., & Heisler, M. (2018). Peer characteristics associated with improved glycemic control in a randomized controlled trial of a reciprocal peer support program for diabetes. Chronic Illness, 0(0), 1−8. DOI: 10.1177/1742395317753884
  7. Fisher, E. B., et al. (2015). Key features of peer support in chronic disease prevention and management. Health Affairs, 34(9), 1523−1530. DOI: 10.1377/hlthaff.2015.0365
  8. Rebeiro Gruhl, K. L., LaCarte, S., & Calixte, S. (2016). Authentic peer support work: challenges and opportunities for an evolving occupation. Journal of Mental Health, 25(1), 78−86. DOI: 10.3109/09638237.2015.1057322
  9. Resnick, S.G., & Rosenheck, R.A. (2008). Integrating peer-provided services: a quasi-experimental study of recovery orientation, confidence, and empowerment. Psychiatric Services, 59, 1307−14. In Daniels, A., Bergeson,S., Fricks, L., Ashenden, P. & Powell, I. (2012). Pillars of peer support: advancing the role of peer support specialists in promoting recovery. The Journal of Mental Health Training, Education and Practice, 7(2), 60−69, https://doi.org/10.1108/17556221211236457
  10. Repper, J., & Carter, T. (2011). A review of literature on peer support in health services. Journal of Mental Health, 20(4), 392−411. In Daniels, A., Bergeson,S., Fricks, L., Ashenden, P. & Powell, I. (2012). Pillars of peer support: advancing the role of peer support specialists in promoting recovery. The Journal of Mental Health Training, Education and Practice, 7(2), 60−69, https://doi.org/10.1108/17556221211236457
  11. Kowitt, S. D., Ayala, G., Cherrington, A., Horton, L., Safford, M., Soto, S.,. . . Fisher, E.B. (2017). Examining the support peer supporters provide using structural equation modeling: Nondirective and directive support in diabetes management. Annals of Behavioral Medicine, 51(6), 810−821. DOI: 10.1007/s12160-017-9904-2
  12. Huntingdon, B., et al. (2016). Toward structured peer support interventions in oncology: a qualitative insight into the experiences of gynaecological cancer survivors providing peer support. Supportive Care in Cancer, 24(2): 849−856.
  13. Paul, G., Keogh, K., D’Eath, M., & Smith, S. (2013). Implementing a peer-support intervention for people with type 2 diabetes: a qualitative study. Family Practice, 30(5), 593−603. DOI: 10.1093/fampra/cmt027
  14. Haynes-Maslow, L., Allicock, M., & Johnson, L.S. (2017). Peer support preferences among African-American breast cancer survivors and caregivers. Supportive Care in Cancer, 25(5), 1511−1517. DOI: 10.1007/s00520-016-3550-2
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