A systematic review of influences on implementation of peer support work for adults with mental health problems

The impact of working as a peer worker in mental health services: a longitudinal mixed methods study

BACKGROUND

Peer workers are increasingly employed in mental health services to use their own experiences of mental distress in supporting others with similar experiences. While evidence is emerging of the benefits of peer support for people using services, the impact on peer workers is less clear. There is a lack of research that takes a longitudinal approach to exploring impact on both employment outcomes for peer workers, and their experiences of working in the peer worker role.

METHODS

In a longitudinal mixed methods study, 32 peer workers providing peer support for discharge from inpatient to community mental health care - as part of a randomised controlled trial - undertook in-depth qualitative interviews conducted by service user researchers, and completed measures of wellbeing, burnout, job satisfaction and multi-disciplinary team working after completing training, and four and 12 months into the role. Questionnaire data were summarised and compared to outcomes for relevant population norms, and changes in outcomes were analysed using paired t-tests. Thematic analysis and interpretive workshops involving service user researchers were used to analysis interview transcripts. A critical interpretive synthesis approach was used to synthesise analyses of both datasets.

RESULTS

For the duration of the study, all questionnaire outcomes were comparable with population norms for health professionals or for the general population. There were small-to-medium decreases in wellbeing and aspects of job satisfaction, and increase in burnout after 4 months, but these changes were largely not maintained at 12 months. Peer workers felt valued, empowered and connected in the role, but could find it challenging to adjust to the demands of the job after initial optimism. Supervision and being part of a standalone peer worker team was supportive, although communication with clinical teams could be improved.

CONCLUSIONS

Peer workers seem no more likely to experience negative impacts of working than other healthcare professionals but should be well supported as they settle into post, provided with in-work training and support around job insecurity. Research is needed to optimise working arrangements for peer workers alongside clinical teams.

'It was the deepest level of companionship': peer-to-peer experience of supporting community-dwelling older people with depression - a qualitative study

BACKGROUND

There is an ample body of literature examining the experiences and outcomes of peer support services for mental health recovery in western countries. However, formal peer support is only recently adapted and piloted to alleviate depression among older people, and little is known about how the peer-to-peer model might be lived out in the older Chinese population. This qualitative study investigated peer supporters' (PS) perspectives of their roles and experiences of rendering formal peer support to community-dwelling older adults at risk of or living with depression in Hong Kong.

METHODS

The study adopted a qualitative design. Five semi-structured focus groups were conducted with 27 trained peer supporters between ages 54-74 (21 females and 6 males) who had provided peer-to-peer support to older adults at risk of or living with depression in the community for at least 12 months. Thematic analysis was employed to derive content and meanings from the focus group transcripts.

RESULTS

Participants' mean age was 61.9 years; two-thirds of them were retired and the rest still engaged in part-time or full-time employment. Four themes were identified in relations to the roles and experiences in rendering the peer support services: (1) peerness in health and age-related lived experiences; (2) companionship, social and emotional ties beyond formal support; (3) meaningful roles to facilitate older people's functional ability; and (4) hopes and actions against the undesirable outcomes of aging. Being a PS might provide meaningful roles for persons in transition to or living in late adulthood, and enable community-dwelling older adults with depression to maintain functional ability. On the other hand, defining the concept of 'peer' beyond the shared experience of mental distress, ensuring a healthy boundary between the peers and the service users, maintaining a careful balance between time-limited formal support and stable social ties, and providing self-management training and on-going support appear crucial.

CONCLUSIONS

This study of PS' perspectives and experiences offer insights into the age-specific dimension of the peer relationship. Despite the promising effects it might offer, careful implementation of peer support among older adults is warranted to safeguard against the ensuing loss of meaningful social ties and the potential emotional distress.

A Qualitative Study of the Experience of Peer Workers in the Czech Republic

The study deals with the employment of people diagnosed with mental illness in the position of peer worker. The aim is to demonstrate through semi-structured interviews the involvement of peer workers in the social services for people diagnosed with mental illness and to identify the influences that affect the success of peer workers involvement in services. The results of the interviews were divided into two categories (Position Specifics, Ethical Aspects) and four subcategories (Professionalism, Risk Moments, Stigmatization, Shared Values) using the Coding Method. The individual subcategories were further subdivided in detail. The results show that the most negative influence on the successful involvement of peer workers is the unclear definition of the job role and responsibilities and further, from an ethical point of view, it is the fear of subsequent labelling (stigmatization) in the search for a new job. A positive ethical influence is the sharing of social values (hope, recovery, friendship, sharing, etc.), which supports the peer worker. The study could help anchor the role in practice and could be the basis for further research in human resources management, social work and management.

Proportionate translation of study materials and measures in a multinational global health trial: methodology development and implementation

OBJECTIVES

Current translation guidelines do not include sufficiently flexible translation approaches for different study materials. We aimed to develop a proportionate methodology to inform translation of all types of study materials in global health trials.

DESIGN

The design included three stages: (1) categorisation of study materials, (2) integration of existing translation frameworks and (3) methodology implementation (Germany, India, Israel, Tanzania and Uganda) and refinement.

PARTICIPANTS

The study population comprised 27 mental health service users and 27 mental health workers who were fluent in the local language in stage 7 (pretesting), and 54 bilingual mental health service users, aged 18 years or over, and able to give consent as judged by a clinician for step 9 (psychometric evaluation).

SETTING

The study took place in preparation for the Using Peer Support in Developing Empowering Mental Health Services (UPSIDES) randomised controlled trial (ISRCTN26008944).

PRIMARY OUTCOME MEASURE

The primary outcome measure was the Social Inclusion Scale (SIS).

RESULTS

The typology identifies four categories of study materials: local text, study-generated text, secondary measures and primary measure. The UPSIDES Proportionate Translation Methodology comprises ten steps: preparation, forward translation, reconciliation, back translation, review, harmonisation, pretesting, finalisation, psychometric evaluation and dissemination. The translated primary outcome measure for the UPSIDES Trial (SIS) demonstrated adequate content validity (49.3 vs 48.5, p=0.08), convergent validity and internal consistency (0.73), with minimal floor/ceiling effects.

CONCLUSION

This methodology can be recommended for translating, cross-culturally adapting and validating all study materials, including standardised measures, in future multisite global trials. The methodology is particularly applicable to multi-national studies involving sites with differing resource levels. The robustness of the psychometric findings is limited by the sample sizes for each site. However, making this limitation explicit is preferable to the typical practice of not reporting adequate details about measure translation and validation.

TRAIL REGISTRATION NUMBER

ISRCTN26008944.

A Narrative Review of Factors Influencing Peer Support Role Implementation in Mental Health Systems: Implications for Research, Policy and Practice

With increasing calls to incorporate recovery principles into conventional mental health care, the importance of peer support worker (PSW) services has gained attention. However, studies consistently show that PSWs remain underutilized. Although research addresses several factors that influence formal implementation of their role, there is lack of a comprehensive framework that synthesizes the factors and addresses their interlevel interactions. This paper provides a narrative review and synthesis of literature on multilevel factors that influence formal PSW role implementation in mental health systems. We conducted a search of literature and reviewed 38 articles that met inclusion criteria. Our thematic analysis involved identifying first and second order categories that applied across studies, and developing third order interpretations through iterations. We synthesized the findings in a multilevel framework consisting of macro, meso and micro level influences. Influencing factors at the macro level include broader socio-cultural factors (medical model, recovery values, professional power dynamics, training and certification), regulatory and political factors (policy mandates, political commitment), and economic and financial factors (funding, affordability of services). Factors at the meso level include organizational culture, organizational leadership, change management, and human resource management policies. Micro level influences pertain to relationships between PSWs and team members, and PSW wellbeing. Interlevel interactions are also outlined. Limitations and implications for research, policy and practice are addressed.

Training Peer Support Workers in Mental Health Care: A Mixed Methods Study in Central Catalonia

INTRODUCTION

A mental health peer support program was implemented at two reference institutions in Central Catalonia. The program culturally and contextually adapted successful international projects by training people with experience of mental health problems and ensuring their employment in multidisciplinary health care teams. This study explores the influence of peer interventions in mental health on the three groups of participants: peer support workers, service users, and mental health professionals.

METHODS

A mixed observational method design included pre-, inter-, and post-experimental components and a qualitative description of the impact. The triangulation of the qualitative and quantitative findings showed its coherence and facilitated the understanding of the results. Outcomes and measures were as follows: self-stigma (Self-Stigma Questionnaire); life satisfaction (Scale of Satisfaction with Life); participation in relevant activities (Engagement in Meaningful Activities Survey); personal recovery (Scale-revised Recovery Assessment); occupational performance (Canadian Occupational Performance Measure); and attitudes toward mental illness (Community Attitudes toward Mental Illness).

RESULTS

The program showed beneficial effects on peer support workers' (PSW) perceptions of occupational performance, specifically on the ability to find work (p = 0.038), work as a peer support worker (p = 0.016), give to the community (p = 0.011), and satisfaction in the ability to find work (p = 0.031). The assessment made by the three groups of participants was very positive: the PSWs showed an increase in self-esteem and a feeling of usefulness; users of the service described the experience as a source of hope and optimism in their recovery process; and professionals described the program as a positive step in their professional growth.

DISCUSSION

The peer-to-peer strategy is a source of hope in the personal recovery process, providing meaning to life for the PSWs while providing an extra source of support to service users in their process of personal recovery. The results offer us lines of improvement for future implementations. PSW's final emphasis has us reflecting on improvements to enhance their own wellness in mental health care services. The findings show the importance of working on life projects and their impact on the recovery process.

[Peer Support: Utilization and Benefit in Severe Mental Illness - Results from an Observational, Cross-Sectional Study]

OBJECTIVE

Peer support is playing an increasing role in the treatment of severely mentally ill people. International findings are available on its effectiveness. However, little is known about knowledge, use and benefit assessment in Germany. This paper addresses this question and presents results from an observational study with 10 participating clinics in southern Germany.

METHODS

As part of the observational cross-sectional study with people with severe mental illness (IMPPETUS, N=359), sociodemographic and illness- and treatment-associated data were collected by trained study staff between March 2019 and September 2019. Binary logistic regression was used to analyse a possible association with peer support use.

RESULTS

38% (N=138) of respondents reported knowledge about the possibility of peer support; 15% (N=55) affirmed its use. Use of peer support varied across sites (between 6.5 and 37.5%) and was associated with household income. Significantly less frequent use of peer support was among those with high versus low household income (OR=0.20 [95% CI: 0.06-0.68], p=0.01). Of respondents with peer support use (N=55), 78% reported perceiving peer support to be helpful or highly helpful.

DISCUSSION

Peer support not only proves to be effective under study conditions with regard to various outcomes, but is also assessed as beneficial under routine conditions in a defined care region by the majority of users. However, only a few respondents knew and used the possibility of peer support.

CONCLUSION

In order to implement peer support more strongly, information about this kind of service should be provided more effectively and a dialogue about successful implementation experiences should be initiated on a regional level.

"You have people here to help you, people like me." A Qualitative Analysis of a Blogging Intervention for Adolescents and Young Adults with Depression or Anxiety

Blogging in the lay community has been shown to be a popular means of expression for all ages exhibiting mental illness symptoms. With the recent rise of mental illness rates among adolescents, blogging in a space specifically designated to discuss mental health topics for adolescents could potentially be beneficial for this demographic. In order to reveal whether or not blogging has positive effects on adolescents and young adults, we created a moderated, anonymous eHealth intervention for those in this demographic experiencing depression and/or anxiety symptoms. This intervention, called Supporting Our Valued Adolescents (SOVA), allows a safe place for participants ages 14-26 (inclusive) to read, write, and comment on blog posts regarding various mental health topics. In this paper, we analyze 40 SOVA blog posts and their corresponding comments written by 18 participants over a six-month period to see if actively engaging on the website was beneficial for their mental health. These posts and comments were analyzed on their degree of self-disclosure, regulatory and interpersonal support, acknowledgement of others, and reader feedback. We found that the content analyzed implied that blogging had a positive effect on participants using this online intervention.

Adherence to Psychological First Aid after Exposure to a Traumatic Event at Work among EMS Workers: A Qualitative Study

Managing post-traumatic stress reactions in the first few days after exposure to a potentially traumatic event in the course of one's work remains a challenge for first responder organizations such as Emergency Medical Services (EMS). Psychological First Aid (PFA) is an evidence-informed approach to reducing initial distress and promoting short- and long-term coping strategies among staff in the aftermath of exposure. PFA provided by peer helpers is considered a promising solution for first responder organizations. Unfortunately, first responders may encounter stigma and barriers to mental health care. Therefore, a deeper investigation is needed regarding adherence over time to implemented PFA intervention. The purpose of this study is to qualitatively explore factors that influence adherence to PFA intervention of recipients and peer helpers. EMS workers (n = 11), working as PFA peer helpers for one year, participated in semi-structured interviews. Data were analyzed using thematic analysis; intercoder reliability (κ = 0.91) was also used. Researchers identified four themes and 11 subthemes influencing adherence to PFA intervention: (1) individual perceptions and attitudes of peer helpers and recipients about pfa intervention; (2) perceived impacts on peer helpers and recipients; (3) organizational support to pfa intervention; and (4) congruence with the occupational culture. Study findings herein suggest that it is conceivable to act on various factors to improve adherence to PFA intervention among peer helpers and recipients within EMS organization. This could lead to enhanced understanding of the challenges involved in sustaining a peer led PFA program for first responders.

Developing and evaluating mental health lived experience practitioner (LXP) roles in an NHS trust

BACKGROUND

The value of establishing roles for people with lived experience of mental distress within mental health services is increasingly being recognised. However, there is limited information to guide the introduction of these roles into mental health services.

AIMS

This study details the development and evaluation of a new mental health peer worker role, the Lived Experience Practitioner (LXP), within an NHS Trust.

METHODS

A three-phase exploratory mixed-methods approach was used. Qualitative data were collected and analysed in the first phase. The qualitative findings were then translated into the formal procedures for introducing LXPs into the Trust, with the approach examined quantitatively in the third phase.

RESULTS

The qualitative analysis identified five themes; role design, training, piloting, career pathways and communication. These formed the basis for working groups (workstreams) which developed policies and procedures for introducing the LXP role into the Trust. Twenty-eight applicants commenced a training programme with 10 successful completions. Seven LXPs were employed by the Trust and were still in their posts after 2 years.

CONCLUSION

In this study, three areas were viewed as important when introducing LXP roles into mental health services; organisational support, the training programme and employment procedures.

Peer support work for people experiencing mental distress attending the emergency department: Exploring the potential

OBJECTIVE

This study explored the benefits and limitations of employing peer support workers, who utilise their own lived experience of mental distress and recovery, to support people experiencing mental distress who are attending the ED.

METHODS

This co-produced qualitative study utilised four phases: (i) assemble a collaborative multi-disciplinary research team and Expert Panel, of which at least half identified as having lived experience; (ii) a site visit to an ED; (iii) focus groups with consumers, support persons and ED staff; and (iv) a learning workshop for peer workers.

RESULTS

Focus groups were run for consumers (n = 7), support persons (n = 5) and ED staff (n = 7). Eleven consumer peer workers participated in the learning workshop. Four themes were identified and triangulated: the individual in distress, peer support work, a 'Peers in EDs' service and the ED context. Overall, findings suggest that peer support workers contribute important skills including listening, de-escalation, relationship-building and empathy.

CONCLUSIONS

This study identified that peer support workers would bring important skills to an ED (e.g. empathetic support, de-escalation). However, significant workforce and organisational support would be required.

Effective Peer Employment Within Multidisciplinary Organizations: Model for Best Practice

This study sought a clearer understanding of organizational mechanisms reinforcing effective peer employment and organizational change from the perspectives of peer workers, non-peer staff and management in multidisciplinary mental health and substance use recovery services. Findings were used to develop a model for organizational best practice for peer employment and associated organizational change to promote recovery-oriented and person-directed services. Qualitative research was undertaken, involving 132 people participating in 14 focus groups and eight individual interviews. These people were employed across five U.S. multidisciplinary organizations providing mental health and substance use recovery services and deemed by a panel of experts to provide effective employment of peer workers. Study findings include the articulation of an interactive working model of best practice, comprising organizational commitment, organizational culture and effective organizational strategies necessary for a "whole-of-organization" approach to support authentic peer work and enable organizational transformation, to actualize recovery-oriented values and person-driven services. Strategies include Human Resources engagement, peers in positions of senior organizational authority, recurring whole of workforce training, along with peer training and peer-led supervision. Findings suggest whole-of-organization commitment, culture and practice are essential for the organizational transformation needed to support effective employment of peers in multidisciplinary environments.

A Longitudinal Qualitative Analysis of the Way Peer Support Specialist Roles Change Over Time in a Psychiatric Hospital Setting in Asia

The current study seeks to determine how peer support roles change as peer support specialists’ positions within organizations and departments mature. We followed ten peer support specialists over the course of a year, interviewing them at three points, starting approximately three months after they began working as peer support specialists. We used an inductive process to analyze our data and followed guidelines on the structuring of longitudinal qualitative trajectories to divide the data into watershed moments. Our participants worked in a variety of departments in the hospital, and their service use experiences generally echo those of their service users. Participants appear to pass through four phases over the course of their employment as peers: early beginnings, establishing the role, role narrowing, and role sustainability. Services wishing to integrate new peers must be aware of the time required for integration. Having general job descriptions limited to specifying that peers are expected to use their lived experience to support current service users may lead to uncertainty amongst new and existing staff. Without role clarity, peers may struggle to find their place. Pairing new staff with mentors may limit this burden. As roles consolidate, boundaries may emerge. If these boundaries narrow the role of the PSS, they may no longer find the role appealing. They may then choose other caregiver roles with wider or different spheres of influence. Organizations may benefit by clearly indicating if they expect peer support positions to be static or transitionary.

Barriers and facilitators to implementing and sustaining peer support in kidney care

Introduction

Peer support offers informational, appraisal and emotional support for people with kidney disease, is recommended in national policy, yet has low engagement levels. This paper reports results of a national survey and qualitative interviews in the UK with the aim of increasing understanding of peer support availability and its barriers and facilitators.

Literature Review

A recent narrative review highlighted the barriers and facilitators to peer support uptake among people with kidney disease however called on further studies to be conducted.

Material and Methods

The survey, adapted from a 2012 version, was sent to all 83 UK kidney units. Semistructured interviews were conducted with staff, recipients and supporters from two units.

Results

Forty‐four units completed the survey, and 10 staff, 7 patients and 2 peer supporters were interviewed. The most common facilitators were promotion with staff and having peer support champions. Barriers included lack of staff time, guidance/information, other projects taking priority and too few supporters.

Discussion

Little progress has been made since 2012; a proportion of units without peer support remains significant, with similar barriers identified in 2020. Services could be designed to limit the time needed for their creation and maintenance through having simpler referrals and designating staff liaisons.

Implications for Clinical Practice

Peer support programmes should have passionate staff and volunteers, involve recipients in the design, recruit an array of supporters and establish evaluations to determine the progress/outcomes. A resource toolkit was developed in response to this project.

Conclusion

Findings from the national survey and qualitative interviews showed that more peer support optimisation and prioritisation is needed to ensure benefits are maximised.

A systematic review and meta-analysis of group peer support interventions for people experiencing mental health conditions

BACKGROUND

Peer support is being integrated within mental health services to further the development of a recovery approach. However, the most effective models and formats of intervention delivery are unknown. We conducted this systematic review and meta-analysis to determine the effectiveness of peer support for improving outcomes for people with lived experience of mental health conditions, when delivered as group interventions.

METHODS

Studies reporting randomised controlled trials of group peer support interventions for people experiencing mental health conditions were identified by searching MEDLINE, PsycINFO, Embase and Cochrane CENTRAL, from inception until July 12th 2019 and undertaking supplementary searches. Included studies were assessed for risk of bias and meta-analyses were conducted if three or more trials provided usable data.

RESULTS

Eight trials met eligibility criteria, providing data from 2131 participants. Six trials had either high or unclear risk of bias. Interventions were categorised as mutual support groups, or peer support groups, sub-categorised as anti-stigma or self-management interventions. Meta-analyses were only possible for peer support groups and five outcomes. We found evidence that group peer support may make small improvements to overall recovery but not hope or empowerment individually, or to clinical symptoms. Evidence for effectiveness for outcomes which could not be meta-analysed was mixed.

CONCLUSIONS

Findings from the few eligible trials suggest group peer support interventions may be specifically effective for supporting personal recovery and have a limited impact on other outcomes, though there were some risks of bias to study findings. Interventions were heterogeneous and most social outcomes were absent in the literature, highlighting further limitations to the current evidence-base. There is insufficient evidence available from trials of group peer support torecommend the routine implementation of these interventions across mainstream mental health services at present. More high-quality trials of peer-developed, group peer support interventions are needed in order tomake firm conclusions about intervention effectiveness.

Barriers and facilitators of peer support work in a large psychiatric hospital: a thematic analysis

BACKGROUND

Peer support workers are an important addition to the mental healthcare profession. However, much of the literature and knowledge of the peer support role is derived from western countries. This concept is relatively new in Asian countries.

AIMS

The study sought to improve the understanding of the barriers and facilitators of peer support work in a large psychiatric hospital in Singapore.

METHODS

This study used qualitative data from a larger mixed-methods study. Thematic analysis was conducted based on the five steps recommended by Braun and Clarke (2006): (1) familiarisation of data whereby transcripts were read and reread, (2) generating initial codes, (3) searching for themes by gathering relevant codes, (4) reviewing themes and (5) defining and naming themes.

RESULTS

Four subthemes under the broader notion of facilitators (supportive figures, defined role, opportunities for personal growth and identifying personalised coping strategies) and three subthemes under the concept of barriers (unclear role, hostility from non-peer-support-specialist staff and unsupportive working environments) were identified.

CONCLUSION

Our findings echoed those of previous studies conducted in western countries providing some evidences for the cross-cultural nature of these barriers and facilitators. However, the way their impact can be mitigated or enhanced is likely to be different owing to cultural barriers, such as the general consensus and acceptance of larger personal recovery ideologies. Further research is required in community settings to better understand the boundaries and limitations of our findings. This information will allow us to continue improving peer support worker integration in diverse mental healthcare settings.

Barriers to and Facilitators of Implementing Peer Support Services for Criminal Justice-Involved Individuals

OBJECTIVE

This study sought to examine perceived barriers to and facilitators of the adoption, implementation, and sustainability of community-based mental health peer support services for criminal justice-involved individuals, also known as "forensic peer support" (FPS).

METHODS

Qualitative interviews were conducted with stakeholders (N=14) and peer specialists (N=37) to better understand delivery of peer support services for justice-involved individuals in Pennsylvania. Thematic analysis followed by directed content analysis was used to identify factors in three a priori implementation categories based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model: initial facilitators (adoption), barriers (implementation), and facilitators (maintenance) to long-term sustainability.

RESULTS

Initial service adoption was facilitated by buy-in from recovery-oriented gatekeepers in the criminal justice system. Unique implementation barriers included the chasm between the orientations of the two systems (recovery vs. punitive) and formal and informal limitations on the employment of individuals with criminal justice system exposure. For services to be sustainable and have an impact over the long term, FPS advocates and workers must develop rapport with on-the-ground employees of the criminal justice system. Funding barriers specific to the criminal justice system limited the adoption, implementation, and maintenance of FPS services.

CONCLUSIONS

Although many of the factors that affect FPS service implementation were similar to those identified in the broader peer support literature, important differences must be addressed for successful FPS service delivery. Within the criminal justice system, both policies and norms presented barriers to the expansion of peer support services for justice-involved individuals.

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

BACKGROUND

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.

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

Factors influencing the implementation of mental health recovery into services: a systematic mixed studies review

BACKGROUND

Countries around the world have committed in policy to transforming their mental health services towards a recovery orientation. How has mental health recovery been implemented into services for adults, and what factors influence the implementation of recovery-oriented services?

METHODS

This systematic mixed studies review followed a convergent qualitative synthesis design and used the best-fit framework synthesis method. Librarians ran searches in Ovid- MEDLINE, Ovid-EMBASE, Ovid-PsycInfo, EBSCO-CINAHL Plus with Full Text, ProQuest Dissertations and Theses, Cochrane Library, and Scopus. Two reviewers independently screened studies for inclusion or exclusion using DistillerSR. Qualitative, quantitative, and mixed methods peer-reviewed studies published since 1998 were included if they reported a new effort to transform adult mental health services towards a recovery orientation, and reported findings related to implementation experience, process, or factors. Data was extracted in NVivo12 to the 38 constructs of the Consolidated Framework for Implementation Research (CFIR). The synthesis included a within-case and a cross-case thematic analysis of data coded to each CFIR construct. Cases were types of recovery-oriented innovations.

RESULTS

Seventy studies met our inclusion criteria. These were grouped into seven types of recovery-oriented innovations (cases) for within-case and cross-case synthesis. Themes illustrating common implementation factors across innovations are presented by CFIR domain: Intervention Characteristics (flexibility, relationship building, lived experience); Inner Setting (traditional biomedical vs. recovery-oriented approach, the importance of organizational and policy commitment to recovery-transformation, staff turnover, lack of resources to support personal recovery goals, information gaps about new roles and procedures, interpersonal relationships), Characteristics of Individuals (variability in knowledge about recovery, characteristics of recovery-oriented service providers); Process (the importance of planning, early and continuous engagement with stakeholders). Very little data from included studies was extracted to the outer setting domain, and therefore, we present only some initial observations and note that further research on outer setting implementation factors is needed.

CONCLUSION

The CFIR required some adaptation for use as an implementation framework in this review. The common implementation factors presented are an important starting point for stakeholders to consider when implementing recovery-oriented services.

Management of a High-Performing Mental Health Recovery Research Group

A personal perspective is given on the processes involved in managing and sustaining a high-performing mental health recovery research group. The broader context of scholarship in the United Kingdom is outlined, in which academic productivity is commodified specifically in relation to peer-reviewed journal papers. Four leadership choices in developing a high-performing research group are discussed: optimal group size; sharing the workload; maintaining a programmatic focus; and performance expectations. Approaches to maximising innovation are identified, including emotional and intellectual engagement of team members, working with diverse stakeholders and convening communities of practice. We use a highly managed approach to publications from inception to acceptance, which is described in detail. The use of these approaches is illustrated in relation to the Recovery Research Team which was formed in 2009. Specific recovery-related issues covered include demonstrating the ability to develop a significant recovery research portfolio (our four current large [>UK£2 m] studies relate to recovery narratives, global mental health peer support work, digital interventions and Recovery Colleges); the positive implications of actively recruiting researchers with mental health lived experience; how performance issues are managed; our approach to involving lived experience co-authors in papers; and our decision to conduct mixed-methods rather than solely qualitative studies.

Peer support worker training: Results of the evaluation of the Experienced Involvement training programme in Switzerland and Germany

The 'Experienced Involvement' (EX-IN) training programme prepares and certifies individuals who have experienced mental health problems to work as peer support workers and to support others challenged by similar conditions. We aimed to assess the impact of the EX-IN training on hope, self-efficacy, introspection, stigma resistance, personal recovery, health-related quality of life and employment in participants. Data was collected using standardized assessment instruments before the training started (t1) and upon course completion (t2). Data from 103 participants who participated in both measurement times were included into data analysis. Participants significantly improved their recovery, stigma resistance and introspection during the EX-IN training. In addition, a significant higher proportion of participants were employed at t2. Participants whose last inpatient stay was 0-1 year before the start of the EX-IN training showed significantly lower levels of stigma resistance, and self-efficacy at t1 than participants with two or more years since the last inpatient stay. There were no significant changes in mean values over time, or in the mean values at t2 between the two groups. EX-IN training has a positive influence on the handling of stigma, on one's recovery path and introspection. This indicates that EX-IN training has a therapeutic effect on the participants. EX-IN training seems to meet the challenges of peer support work. Therefore, the training can be recommended as preparation for working as a peer support worker as well as an intervention to improve one´s recovery process.

Evolvement of Peer Support Workers' Roles in Psychiatric Hospitals: A Longitudinal Qualitative Observation Study

Peer support workers (PSWs) use their experiential knowledge and specific skills to support patients in their recovery process. The aim of our study was to examine the integration and role-finding process of PSWs in adult psychiatric hospitals in Germany. We conducted open nonparticipant observations of 25 multiprofessional team meetings and 5 transregional peer support worker meetings over a period of six months. The data were analyzed using qualitative content analysis. Regarding the integration of PSWs into multiprofessional teams, we identified three subcategories: "Features of success," "challenges" and "positioning between team and patients." Concerning the PSWs' roles, we developed two subcategories: "Offers" and "self-perception." The PSWs' specific roles within a multiprofessional mental healthcare team evolve in a process over a longer period of time. This role-finding process should be supported by a framework role description which leaves sufficient freedom for individual development. Regular opportunities for mutual exchange among PSWs can help to address specific support needs at different points in time.

Strategies Used to Support Peer Provision in Mental Health: A Scoping Review

The employment of peer providers (people who draw on their lived experience of mental health challenges) has grown in conjunction with the increased acceptance of recovery as a key principle in mental health policy and practice. Barriers to the integration of peer providers in mental health services have been well documented. This review addresses an under-explored area by consolidating strategies undertaken by mental health organizations for the successful implementation of peer provision. A scoping review was chosen to facilitate the rapid summary and dissemination of research findings that are relevant to policymakers and practitioners. Peer-reviewed articles and grey literature were sourced from three databases, key peer support websites and a hand search of the included studies. Following screening, data were extracted from 28 studies: 25 qualitative and three mixed methods studies. The data were analyzed using thematic analysis and organized into themes. Four themes emerged from the data. Championing of peer provision initiatives by organizational leadership is central to the success and sustainability of peer provision. Leadership undergirds three strategies that were discussed: organizational preparation, recruitment, training and induction, and support and development. When peer provision is championed by organizational leadership, measures can be undertaken to prepare the organization for peer provision; recruit, train and induce peer providers successfully into the organization; and support peer providers on the job.

Training mental health peer support training facilitators: a qualitative, participatory evaluation

The facilitator's training for peer support workers in mental health course was a recovery-based initiative addressed to professionalize peer support in Catalonia, Spain. Our aim was to elicit participants' motivations, significant learnings, and opinions regarding the training programme. A qualitative approach was used through content and thematic analyses of the course contents and participation narratives. The motivations to attend the course were helping others, learning, and supporting the implementation of the peer support profession. Participants learnt concepts on pedagogy, peer support, and recovery. The key resulting themes were organization and moderation; peer support's role, skills, functions, and values; language; health system knowledge; and types of support. The course programme seems appropriate in preparing people who have lived experience of mental health problems as facilitators of future peer support training courses. The present analysis identifies the participants' vision regarding their learning needs. It aims to serve as a guide for similar train-the-trainers courses.

[Roles and Work Content of Peer Workers and Experts by Experience in Mental Health Practice, Education, Research and Development - Results of a Survey in Switzerland]

AIM OF THE STUDY

To identify work contents, roles and tasks of peer workers in mental health services in the German-speaking part of Switzerland.

METHODS

A survey was conducted among peers in the German-speaking part of Switzerland.

RESULTS

Most respondents stated that they work mainly in specialized services in the treatment of people with psychoses and affective disorders and in direct contact with service users. "Building bridges" between service users and professionals, conveying hope and confidence, empowerment as well as support in symptom management was most frequently indicated as a work activity. The majority of respondents have job descriptions that correspond to their activities.

CONCLUSIONS

For mental health services, the challenge is to integrate the new professional group of peers workers as well as possible without undermining their proximity to the service users or their possibly critical perspective with regard to the existing practice.

Nurses' psychological changes and coping strategies during home isolation for the 2019 novel coronavirus in China: A qualitative study

AIMS

To explore the psychological changes of nurses during home isolation, the factors that related with these changes, and coping strategies in home isolation during the epidemic of COVID-19 in China.

DESIGN

A qualitative study based on grounded theory.

METHODS

Individual semi-structured telephone interviews were conducted from January 2020-February 2020 with 10 nurses who were isolated at home sharing the experiences of the epidemic of COVID-19. All interviews were audio recorded, transcribed, and analysed using constant comparative data analysis.

RESULTS

Analyses of the collected data reveal that the psychological changes of nurses during home isolation reflect a complex, dynamic, and gradually adaptive process that was affected by many factors. Nurses had many negative emotional reactions in the early stages of isolation and positive emotions gradually increased during home isolation. After release from home isolation, they become more confident and calm after. Six categories of coping strategies were identified, including reasoned cognition; autosuggestion; develop healthy protective behaviours; shifting attention; social support; and the power of a role model.

CONCLUSIONS

The study provides a better understanding of the psychological changes and the coping strategies used among nurses isolated at home. It is necessary to pay more attention to negative emotions in the early stages of home isolation to help nurses adjust quickly. The coping strategies used by nurses are likely to help those in home isolation reduce negative psychological changes and experience more optimal self-adjustment.

IMPACT

This study explored the psychological changes and coping strategies of home isolation among nurses, providing useful advice for psychologists to develop psychological crisis interventions to help individuals reduce negative psychological and have more actively coping strategies when faced sudden stressful infectious diseases.

Challenges to peer support in low- and middle-income countries during COVID-19

BACKGROUND

A recent editorial urged those working in global mental health to "change the conversation" on coronavirus disease (Covid-19) by putting more focus on the needs of people with severe mental health conditions. UPSIDES (Using Peer Support In Developing Empowering mental health Services) is a six-country consortium carrying out implementation research on peer support for people with severe mental health conditions in high- (Germany, Israel), lower middle- (India) and low-income (Tanzania, Uganda) settings. This commentary briefly outlines some of the key challenges faced by UPSIDES sites in low- and middle-income countries as a result of Covid-19, sharing early lessons that may also apply to other services seeking to address the needs of people with severe mental health conditions in similar contexts.

CHALLENGES AND LESSONS LEARNED

The key take-away from experiences in India, Tanzania and Uganda is that inequalities in terms of access to mobile technologies, as well as to secure employment and benefits, put peer support workers in particularly vulnerable situations precisely when they and their peers are also at their most isolated. Establishing more resilient peer support services requires attention to the already precarious situation of people with severe mental health conditions in low-resource settings, even before a crisis like Covid-19 occurs. While it is essential to maintain contact with peer support workers and peers to whatever extent is possible remotely, alternatives to face-to-face delivery of psychosocial interventions are not always straightforward to implement and can make it more difficult to observe individuals' reactions, talk about emotional issues and offer appropriate support.

CONCLUSIONS

In environments where mental health care was already heavily medicalized and mostly limited to medications issued by psychiatric institutions, Covid-19 threatens burgeoning efforts to pursue a more holistic and person-centered model of care for people with severe mental health conditions. As countries emerge from lockdown, those working in global mental health will need to redouble their efforts not only to make up for lost time and help individuals cope with the added stressors of Covid-19 in their communities, but also to regain lost ground in mental health care reform and in broader conversations about mental health in low-resource settings.

Primary Care Peer-Supported Internet-Mediated Psychological Treatment for Adults With Anxiety Disorders: Mixed Methods Study

Background

The effect of internet-delivered cognitive behavioral therapy (iCBT) on anxiety in adults is well-known. However, patient dropouts and poor adherence to treatment are common. Feelings of belonging and empowerment from the treatment might be key to the completion of iCBT. Peer support workers are people with a personal experience of mental health problems, trained to provide professional support to people who require mental health care.

Objective

This study aims to assess patient experiences; the feasibility, safety, and acceptability; and preliminary effectiveness on anxiety and depression, empowerment, and adherence to treatment in an 8-week peer-supported iCBT program for patients with anxiety disorders treated in primary care.

Methods

This was a single-arm mixed methods feasibility study. Participants were patients referred to a central unit for iCBT in primary care. Quantitative data were collected pre-, post-, and 3 months postintervention. Qualitative data were collected through semistructured interviews.

Results

A total of 9 participants completed the quantitative outcome assessment. Statistically significant improvements were observed in perceived empowerment at a 3-month follow-up, and significant decreases in anxiety, depression, and psychological distress at the end of the treatment were maintained at a 3-month follow-up. In total, 8 of the 9 patients showed improvement in the severity of their symptoms of anxiety. Adherence to treatment was good among the participants. No serious adverse events were reported. Eight participants were enrolled in the qualitative analysis. The qualitative results showed 3 main themes: (1) real contact in an online world, (2) empowering experiences, and (3) being behind the wheel. Qualitative results largely emphasized the personal relationship and supported the acceptability of adding peer support to iCBT.

Conclusions

Peer support in digital treatment seems to be a safe and acceptable intervention. The preliminary results suggest the effectiveness of peer support on patient empowerment, anxiety, depression, psychological distress, and adherence to treatment. The results indicate the need for future studies to evaluate the effect of adding peer support to iCBT in larger randomized controlled trials.

Pathways to psychiatric care and factors associated with delayed help-seeking among patients with mental illness in Northern Ethiopia: a cross-sectional study

OBJECTIVE

This study aimed to assess pathways to psychiatric care and factors associated with delayed help-seeking among patients with mental illness in Northern Ethiopia using the WHO Pathway Study Encounter Form.

DESIGN

A cross-sectional study design was used.

SETTING

Data were collected using face-to-face interview from patients with various diagnoses of mental illness attending outpatient treatment at Ayder Comprehensive Specialized Hospital in Mekelle City, Tigray, Northern Ethiopia.

PARTICIPANTS

Participants who came to attend outpatient treatment during the study period were included in the study using consecutive sampling technique.

OUTCOME MEASURES

Pathways to psychiatric care, delayed psychiatric treatment and factors affecting delayed psychiatric treatment.

RESULTS

The median duration from problem onset to contact with first care provider was 4 weeks, whereas contact with modern psychiatric services was 52.0 weeks. Study participants who were single (adjusted OR (AOR)=2.91, 95% CI 1.19 to 7.11), divorced (AOR=3.73, 95% CI 1.33 to 10.49) and who perceived mental illness as shameful (AOR=3.29, 95% CI 1.15 to 9.41) had delayed treatment-seeking behaviour, whereas participants with no history of substance use (AOR=0.43, 95% CI 0.20 to 0.92) were less likely to have delayed treatment-seeking behaviour.

CONCLUSIONS

There is significant delay in seeking modern psychiatric treatment. Religious healers were the first source of help for mental illness. Majority of the respondents described that mental illness was due to supernatural causes. Stigma and lack of awareness about where treatment is available were barriers to seeking appropriate care.

[Self-Perception and External Perception of Peer Support Workers in Clinical Psychiatric Practice]

OBJECTIVE

Since 2016, peer support workers (PSW) have been working in a clinical group with nine psychiatric clinics. The aim of this study was to collect expectations and experiences with peer support work.

METHOD

Twelve PSW and 32 clinicians (key informants, KI) from all clinics participated in an anonymous, written survey.

RESULTS

Both PSW and KI evaluated the overall importance of peer support, the cooperation between PSW and the clinical staff and the support from supervisors positively. KI rated the importance of peer support higher than the PSW themselves. PSW expressed the wish to act more independently. Compared to the self-perception of PSW, KI experienced them more insecure and burdened.

CONCLUSION

Our findings speak in favor of a high level of satisfaction with peer support work, but they also point to critical differences between external and self-perceptions of PSW. Qualitative and more extensive quantitative surveys are required.

Psychosocial therapies in severe mental illness: update on evidence and recommendations

PURPOSE OF REVIEW

To provide an overview of the update of the evidence-based and consensus-based German S3 guideline on psychosocial therapies for severe mental illnesses (SMI), with particular attention to current developments and future research tasks.

RECENT FINDINGS

There has been a significant increase in studies on the effectiveness of psychosocial interventions in treatment of people with SMI. In the guideline a distinction is made between system-level interventions (e.g. multidisciplinary team-based psychiatric community care) and single-handed (nonteam-based) interventions (e.g. psychoeducation). Furthermore, principles of treatment (e.g. recovery-orientation) and self-help interventions (e.g. peer support) are addressed. The update of the guideline includes 33 recommendations and 12 statements. Compared with the first edition, there were upgrades in the recommendation of Supported Employment (A) and Supported Housing (A). Interventions such as peer support (B) and lifestyle interventions (A) were included for the first time. Developments are discussed in the context of most recent literature. Areas for further research are highlighted and fields for next updates such as antistigma interventions and supported parenting were identified.

SUMMARY

The present guideline offers an important opportunity to further improve health services for people with SMI. However, guideline implementation is challenging.

Peer support for people with severe mental illness versus usual care in high-, middle- and low-income countries: study protocol for a pragmatic, multicentre, randomised controlled trial (UPSIDES-RCT)

BACKGROUND

Peer support is an established intervention involving a person recovering from mental illness supporting others with mental illness. Peer support is an under-used resource in global mental health. Building upon comprehensive formative research, this study will rigorously evaluate the impact of peer support at multiple levels, including service user outcomes (psychosocial and clinical), peer support worker outcomes (work role and empowerment), service outcomes (cost-effectiveness and return on investment), and implementation outcomes (adoption, sustainability and organisational change).

METHODS

UPSIDES-RCT is a pragmatic, parallel-group, multicentre, randomised controlled trial assessing the effectiveness of using peer support in developing empowering mental health services (UPSIDES) at four measurement points over 1 year (baseline, 4-, 8- and 12-month follow-up), with embedded process evaluation and cost-effectiveness analysis. Research will take place in a range of high-, middle- and low-income countries (Germany, UK, Israel, India, Uganda and Tanzania). The primary outcome is social inclusion of service users with severe mental illness (N = 558; N = 93 per site) at 8-month follow-up, measured with the Social Inclusion Scale. Secondary outcomes include empowerment (using the Empowerment Scale), hope (using the HOPE scale), recovery (using Stages of Recovery) and health and social functioning (using the Health of the Nations Outcome Scales). Mixed-methods process evaluation will investigate mediators and moderators of effect and the implementation experiences of four UPSIDES stakeholder groups (service users, peer support workers, mental health workers and policy makers). A cost-effectiveness analysis examining cost-utility and health budget impact will estimate the value for money of UPSIDES peer support.

DISCUSSION

The UPSIDES-RCT will explore the essential components necessary to create a peer support model in mental health care, while providing the evidence required to sustain and eventually scale-up the intervention in different cultural, organisational and resource settings. By actively involving and empowering service users, UPSIDES will move mental health systems toward a recovery orientation, emphasising user-centredness, community participation and the realisation of mental health as a human right.

TRIAL REGISTRATION

ISRCTN, ISRCTN26008944. Registered on 30 October 2019.

An ethnographic study of the implementation of a transitional discharge model: peer supporters' perspectives

Background

Over the last three decades, there has been worldwide recognition of peer support contributions to improve mental healthcare provision. However, in the current literature, little attention has been paid to exploring perspectives of peer supporters on their involvement in mental health services provision. The purpose of the present study was to examine peer supporters’ perspectives on the implementation of a transitional discharge model (TDM), an intervention for the community integration of people with mental illness.

Methods

This paper represents ethnographic qualitative data collected as part of a study that used mixed methods to evaluate the implementation of TDM across nine hospitals from the Province of Ontario, in Canada. The study involved a sample of 66 peer supporters, who were recruited from participating Consumer/Survivor Initiative Organizations and Peer Support Programs. The study collected data using two sets of focus groups, which were held at 6 months and 1-year post implementation. Data analysis used an ethnography model of qualitative analysis.

Results

Peer supporters expressed that their involvement in mental healthcare enhanced clients’ autonomy and hope about their recovery, as well as established a safety net and reduced hospital readmissions. Peer supporters articulated that they assumed several roles to facilitate clients’ transition from hospital to the community. These roles included: assisting clients in building their capacity and developing healthy routines; attending regular on-ward and community meetings; accompanying clients to their appointments; and working with clients to set goals for their recovery. The study showed hindrances to effective implementation of peer support programs, such as a lack of understanding and appreciation of peer supporter roles, lack of careful allocation of peer supporters to clients, and an absence of appropriate protocols for ensuring the safety and supervision of the peer supporters.

Conclusions

Results of the TDM implementation demonstrated that involving peer supporters in mental healthcare delivery may benefit clients by enhancing autonomy and hope about their recovery, as well as establishing a safety net and reducing hospital readmissions. Results from the study have the potential to inform healthcare professionals and managers of strategies for developing effective peer support programs.

Experts by Experience: Qualitative Evaluation of Adolescent Participation in the Development of a Technological Intervention to Prevent Youth Suicide in Chile

Adolescent suicide is a pressing problem in Chile that has not yet been sufficiently addressed, as suicide rates have stagnated in recent years. One possible explanation could be linked to the adult-centered paradigm that continues to prevail in relation to adolescent health initiatives. In light of this, programs that seek to promote youth mental health should consider incorporating adolescents in the design process using participatory methodologies, to ensure that these initiatives are well-suited for the population. In line with this recommendation, a group of seven adolescents, 13 to 20 years of age, were incorporated into a research team to actively guide the design, development, and validation of a technology-based intervention, known as Project Clan, which was piloted to reduce adolescent suicide in schools in Chile. This group was known as the "Group of Experts," in acknowledgment of their role as experts by experience on adolescence. A qualitative case study was conducted to explore their lived experiences, through semistructured individual in-depth interviews with six members of the group. Results showed that the adolescents had a high level of interest in mental health and had experienced problems of their own or accompanied friends who were struggling, which motivated their participation in the study. They had a critical view of the previous interventions they had received through educational institutions and valued their role in the promotion of their peers' mental health through the Group of Experts. They also highlighted the importance of creating tools that complement their daily lives and provide an alternative to existing social networks, by respecting their anonymity, providing a secure place for divulgation and self-expression, and facilitating access to professional support. We conclude that programs that address issues that affect adolescents should incorporate adolescents in the decision-making and design processes to ensure the acceptability and effectivity of their interventions.

INCRESE: Development of an Inventory to Characterize Recorded Mental Health Recovery Narratives

OBJECTIVE

Mental health recovery narratives are increasingly used in clinical practice, public health campaigns, and as directly-accessed online resources. No instrument exists to describe characteristics of individual recovery narratives. The aims were to develop and evaluate an inventory to characterize recorded recovery narratives.

RESEARCH DESIGN AND METHODS

A preliminary version of the Inventory of Characteristics of Recovery Stories (INCRESE) was generated from an existing theory-base. Feasibility and acceptability were evaluated by two coders each rating 30 purposively-selected narratives. A refined version was produced and a formal evaluation conducted. Reliability was assessed by four coders each rating 95 purposively-selected narratives. Inter-coder reliability was assessed using Fleiss's kappa coefficients; test-retest reliability was assessed using intra-class correlation coefficients (ICCs).

RESULTS

Multiple refinements to description, coding categories, and language were made. Data completeness was high, and no floor or ceiling effects were found. Intercoder reliability ranged from moderate (k=0.58) to perfect (k=1.00) agreement. Test-retest reliability ranged from moderate (ICC=0.57) to complete (ICC=1.00) agreement. The final INCRESE comprises 77 items spanning five sections: Narrative Eligibility; Narrative Mode; Narrator Characteristics; Narrative Characteristics; Narrative Content.

CONCLUSION

INCRESE is the first evaluated tool to characterize mental health recovery narratives. It addresses current concerns around normative recovery narratives being used to promote compulsory wellness, e.g. by identifying narratives that reject diagnosis as an explanatory model and those with non-upward trajectories. INCRESE can be used to establish the diversity of a narrative collection and will be used in the NEON trials (ISRCTN11152837, ISRCTN63197153, ISRCTN76355273) to allow a recommender system to match narratives to participants.

Peer support for frequent users of inpatient mental health care in Uganda: protocol of a quasi-experimental study

BACKGROUND

Reducing readmissions among frequent users of psychiatric inpatient care could result in substantial cost savings to under-resourced mental health systems. Studies from high-income countries indicate that formal peer support can be an effective intervention for the reduction of readmissions among frequent users. Although in recent years formal peer support programmes have been established in mental health services in a few low- and middle-income countries (LMICs), they have not been rigorously evaluated.

METHODS

This protocol describes a quasi-experimental difference-in-differences study conducted as part of a broader evaluation of the Brain Gain II peer support programme based at Butabika National Referral Hospital in Kampala, Uganda. The primary objective is to investigate whether frequent users of psychiatric inpatient care who have access to a peer support worker (PSW+) experience a greater reduction in rehospitalisation rates and number of days spent in hospital compared to those who do not have access to a peer support worker (PSW-). Frequent users, defined as adults diagnosed with either a mental disorder or epilepsy who have had three or more inpatient stays at Butabika over the previous 24 months, are referred to Brain Gain II by hospital staff on five inpatient wards. Frequent users who normally reside in a district where peer support workers currently operate (Kampala, Jinja, Wakiso and Mukono) are eligible for formal peer support and enter the PSW+ group. Participants in the PSW+ group are expected to receive at least one inpatient visit by a trained peer support worker before hospital discharge and three to six additional visits after discharge. Frequent users from other districts enter the PSW- group and receive standard care. Participants' admissions data are extracted from hospital records at point of referral and six months following referral.

DISCUSSION

To the best of our knowledge, this will be the first quasi-experimental study of formal peer support in a LMIC and the first to assess change in readmissions, an outcome of particular relevance to policy-makers seeking cost-effective alternatives to institutionalised mental health care.