This article previously appeared on the Ontario HIV Treatment Network (OHTN) website here.
What interventions, programs, or community initiatives have been used to support and facilitate peer engagement in service provision roles?
Key Take-Home Messages
- Peer support workers offer unique and valuable support to their peers by sharing similar lived experiences, particularly in mental health services and chronic disease management (1).
- Peer support workers are motivated by intrinsic desires to improve their own well-being and the well-being of their peers (1-3).
- To engage and retain peers, organizations should reinforce intrinsic rewards for peers (1-3), take steps to protect and nurture their health and well-being (5;6), and invest in ongoing and frequent training that is focused on both skills and content (4-6).
- Lack of role clarity is challenging for peers. To integrate peer support workers into the workplace (4;7), organizations should clarify peer roles and create a culture that highlights the integral services peers provide (4).
- The role of monetary incentives in engaging and retaining peers has not been explored in the literature and requires more thought and study (8;9).
The Issue and Why It’s Important
Peer support worker interventions are becoming increasingly popular as a strategy for reaching marginalized groups around the world (1), particularly in the fields of mental health and chronic disease management. Although models vary, all peer support worker programs seek to build on peers’ strengths, knowledge and experience (10).
Peer support workers offer unique and valuable support to others through sharing similar lived experiences. Peer support workers are generally well-respected members of the target population who assume a leadership role (5). A recent mixed-method Canadian study by Jacobson et al found that the main types of activities peer workers engage in include: advocacy work, connecting peer clients to resources, sharing experiences, connecting peer clients to programs, building trust and rapport, and group facilitation. Peer support workers are also involved in administrative duties, training, education and awareness, and research (11).
In terms of their impact, peer support worker programs have proven successful in reducing harmful health behaviours, improving disease management (i.e., diabetes), and improving depression outcomes (10). The success of such interventions appears to be related to the mutual and non-hierarchical relationship developed between peer support workers and clients (10). A recent systematic review on behavioural interventions to prevent HIV or assist HIVpositive individuals by Simoni et al (12) found that peer interventions contributed to outcomes such as sexual risk reduction and improved attitudes and knowledge about HIV; however, they did not result in changes that could be measured in terms of biomarkers (e.g., HIV and STI tests, CD4 counts and viral load). Not surprisingly, peer interventions that do not formally employ peers but use non-paid peers have been found to be more cost-effective than employing salaried health professions (13).
Given the increasing interest in peer support worker programs, it is important to understand the interventions and programs that are effective in engaging and supporting peer support workers within the health field. Consistent with the literature, this summary defines peer support workers as individuals who are responsible for a variety of duties, as outlined above, whether engaging directly or indirectly with their peer clients.
What We Found
In our search, we did not find any studies specifically examining interventions or programs to engage peer support workers. However, we did find a number of studies exploring the experiences, satisfaction and dissatisfaction of peer support workers in their duties, and studies describing training procedures for peer support workers. Studies of peer workers came from populations with chronic conditions such as diabetes, renal failure, cancer, HIV and, more commonly, mental illness. We did not find any literature on lesbian, gay, bisexual and transgendered peer support engagement programs.
Reinforce intrinsic motivators/rewards of peer work
Peer support workers are motivated by intrinsic desires to improve their own wellbeing or help others cope:
A Canadian qualitative study with 30 burn victims by Badger et al (2) found that two-thirds of study participants had provided support to other burn victims by visiting them in hospital, assisting in burn camps or participating in support groups. This act of reaching out to peers seemed a source of pride or accomplishment in the participants’ own recovery path (2).
In another Canadian study of 12 people living with HIV, Harris et al (3) found that those who acted as peer workers felt good knowing they were helping others through a difficult situation. Some suggested that their involvement in peer work also increased their self-worth and gave them purpose in their lives (3).
A US study by Hilfinger Messias et al (1) had similar findings: women living with HIV reported they worked as peer support workers to make connections with others, gain knowledge and skills, and increase their self-esteem and confidence. Peer support workers also valued their duties and took pride in their ability to empathize, understand and share common experiences with their clients (14).
Programs to engage and support peer support workers should work to reinforce these intrinsic motivators.
Peer support workers living with a chronic disease (e.g., HIV, diabetes, cancer, mental health issues) may be vulnerable to physical and mental health issues. A number of studies have explored peer support workers’ relapse of mental health conditions and unanimously agree that peer support workers should have easy access to resources that support their personal care and well-being. For example:
In a qualitative study among health care providers, peers and patients, Hallum-Montes et al (15) identified concerns about emotional burnout of peer workers.
An article by Kemp et al (6) suggests that agencies employing peer support workers should have a written agreement outlining the agency’s role in providing support in the case of relapse.
Other experts recommend regular supervision of peer support workers, and access to expert advice from clinicians or mental health practitioners (5).
On the other hand, some studies found that participation in peer support worker programs had no harmful effects on peer workers. For example:
An Australian study (17) with 10 previous users of mental health services who participated in 16-weeks of peer support training found no evidence to suggest the psychological well-being of trainees suffered as a result of peer interactions.
A Canadian study on psychological well-being of renal peer support volunteers (18) found that, over time, the level of psychological distress and well-being in peer volunteers remained stable.
While being a peer worker may or may not put stress on a peer’s health, a successful peer support worker program does depend on the positive well-being of peer support workers and should take steps to nurture their health and well-being (1).
Support ongoing training
Ongoing training is an important component of engaging and retaining peer support workers because it enhances their capacity to complete their duties, contributes to their skill development and can be used as an incentive for them to become and stay engaged in the program. Experts agree that peer workers should meet specific standards prior to beginning their duties, and should participate in ongoing weekly training sessions to maintain their skills (4;5). According to the literature, training programs for peers often provide educational and skills-based content; however the success of these training programs in engaging peers was difficult to assess. In general, the most important components of training appear to support worker practitioners from 17 countries participated in a three-round Delphi process rating the importance of statements generated from existing literature. There was strong consensus that peer supporter workers should receive training in listening, psychological first aid and referrals. Experts also agreed that peer support workers should not receive training for higher-level interventions (5).
Another study (4) suggested that training topics for peer support workers should include communication and writing, and effective client management and referrals. Because of the challenges peers may face disclosing their condition or defining their role on the team, Kemp et al (6) recommend that peer support workers also receive training on maintaining boundaries, how to disclose, and how much to disclose to their health care provider colleagues.
In an Australian study (17) of mental health peer workers, peers found training in communication and counseling skills particularly useful; however, they found it more difficult to assimilate large amounts of complex material in the initial four weeks of training. These findings suggest that it may be important to spread training out over a longer period of time.
In a US-based study by Tang et al (19), nine diabetic African-American adults participated in two-hour, face-to-face peer leadership group training sessions held two times a week for 12 weeks. The training sessions included diabetes educational content, communication, facilitation, and behaviour change (19). Participants, who were tested at the end of the training for their competency in diabetes knowledge, empowerment-based facilitation, active listening and self-efficacy, were satisfied with the length of the training and the balance between content and skill (19).
Clarify roles and integrate peers into the organization
A major challenge that peer support workers face is the lack of clarity within the organization about their roles. Clients and accredited health staff may not understand the peers’ role – particularly when the peer has been a client of the organization. The lack of clarity can make it difficult for peers to integrate into the work environment (16). A qualitative multi-site case study (7) conducted in Canada found that peer workers had difficulties dealing with the challenges associated with their unique roles as both a service provider and a service user. Peer workers also find it difficult to approach staff with their personal issues, for fear it will blur the boundaries between their previous and current roles (7;20).
Peer support workers also reported feeling distinct from other staff members (4;16). When peer roles are not clearly defined, the peers may be treated as junior staff by other staff members, particularly accredited health workers (4). Kemp et al (6) reported that some peer support workers also experience conflicting expectations related to time commitment and workload.
To engage peers and integrate them, organizations should aim to create a culture that highlights the integral services peer support workers provide (4;5). Organizations can use a number of strategies to integrate peers, including: having a manager support or mediate their interactions with staff (6), creating an accredited peer support worker course for other employees in the workplace, encouraging peer support workers to participate in activities with other professionals (4;15), and having staff act as mentors for peer support workers (7; 20).
To support peer workers, a Canadian report by the Mental Health Commission of Canada (Making the Case for Peer Support) strongly recommended national guidelines to define roles of peer support workers, the funding of peer support workers, and the development of support for peer support work (21).
Address the issue of monetary incentives
Grassroots self-help groups around the world have historically been run entirely by volunteers; however, recent interest in integrating peer support workers into organizations has led to greater consideration of whether and how peers should be remunerated (21).
Few studies reviewed used monetary incentives to engage peer support workers. A US study by Barber et al (8) found that although peer support workers’ satisfaction was not associated with payment, payment was associated with being engaged in meaningful activities, spirituality and positive recovery attitudes or workers. Another US-based study by Broadhead et al (9) that aimed to improve antiretroviral adherence among HIV-positive people who use drugs offered monetary incentives to peer health advocates when their clients kept clinical appointments, attended referral appointments and picked up prescriptions. During the study period, 14 peer clients kept 84% of their scheduled appointments with health care providers, the overall adherence score for peer clients was 90%, and 75% of peer clients enrolled in drug treatment programs (9). Study authors proposed that this model could be a feasible alternative to increasing drug users’ access to medical care (9).
Factors That May Impact Local Applicability
All studies included in this summary were conducted in high income countries that have similar HIV epidemics as Canada. However, none of the literature focused specifically on interventions to engage peer workers; instead the studies discussed the experience of peer workers or described training procedures for peer workers, and we have extrapolated from that data.
What We Did
We searched Medline for articles using a combination of text terms [(support*) or (engage*) or (marginali*) or (retain*)] in the titles AND [text term (peer) in the titles or MeSH term (Peer Group)]. We also searched the Cochrane Library for relevant systematic reviews using the text term (peer). All searches were limited to articles published since 1996 onwards, in English. In addition, references provided by the requestor were reviewed and related article searches on PubMed of selected articles were conducted. Grey literature sources including Google, Google Scholar, Open Grey, and the New York Academy of Medicine Grey Literature Report were also used.
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