Peers for Progress Blog
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Huyen Vu, MSPH
Involving peer support workers in mental health services is an effective means to improve the recovery outcomes for people living with mental illness. Evidence from the U.K., Australia, New Zealand and the U.S. suggests that by sharing their own experience of mental illness and supporting other patients in their own recovery journeys, peer workers can significantly improve treatment and recovery outcomes of people with psychiatric disability, and contributes to a substantial reduction in re-admission rates and bed days of mentally ill patients.
In the U.S., peer worker programs should grow in importance as the Affordable Care Act comes into effect. With an additional 8 million people eligible for Medicaid, and with the requirement to include mental health service coverage in all health plans, peer worker programs may be an effective strategy to alleviate the shortage of mental health professionals.
However, inclusion of the peer worker interventions as part of a national strategy for mental health care has been hampered by a lack of systematic evidence and robust evaluation on the value of peer workers as measured by gold-standard trials. A group of Australian researchers conducted a systematic review of 11 randomized control trials and found inconclusive evidence of the benefit of peer workers as providers of mental health services, and concluded that the lack of a clear change model was the potential limitation for those trials. (A change model is “an understanding of how what peer workers do is associated with outcomes.”)
To this end, Steve Gillard and colleagues recently developed a model articulating the change mechanisms that highlight the impact of peer workers on mentally-ill patients (Figure 1). Theoretical and practical components included in the model were derived from a comparative, qualitative case study. Seventy-one peer workers from 10 mental health services in England were interviewed about their role as peer workers and the implementation issues they experienced, such as human resource issues, working on teams, and training and support.
Analysis of the qualitative data helped the researchers to construct a change model for peer worker interventions. It indicates that building trust relationships based on shared experience is the primary mechanism behind the success of peer worker interventions, and establishing a personal connection is the necessary first stage of relationship building. Specifically, peer workers might share their lived experience of mental illness, or of utilizing services, which patients may recognize as a similar or shared experience. The next stage in building a trust relationship is through talking and listening. In this stage, it is important that peer worker shows understanding of the patient’s experiences based on their own lived experience, and give the patient a sense of validation. Once the relationship is formed, the peer worker should allow the patient to initiate discussion and disclosure instead of requiring it from them. Patients may thus be more willing to share their experience with peer workers and listen to their advice.
As the relationship is established, two parallel mechanisms arise from the trust relationship:
- Role model for recovery and learning to live with mental health problems: Peer workers act as role models to the patients they support by showing their own recovery progress and ability to function well socially. Patients then observe that the peer worker has moved on from where they currently see themselves, and they start to develop a sense of hope for the future. Seeing peer workers in the care role also has a significant impact on the patient, as it demonstrates their usefulness and value, and acts as a powerful symbol of recovery. As role models, peer workers challenge the self-stigmatizing effects of mental illness by the fact of their working role, increased resilience, empowerment and self-efficacy, and this prompts patients to engage in better self-care and to improve their social functioning.
- Bridging the engagement with mental health services and the community: As the relationship between the patient and peer worker grows stronger, it helps ease the patient’s engagement and connection with mental health professionals, care services, and the wider community. Through this bridging function, the patient’s trust in peer workers can also be extended to other non-peer members of the team which may enable the patient to overcome their fear of being stigmatized and their reticence to disclose difficult personal issues with the mental health team. In this role, peer workers may facilitate patients’ engagement with the community by encouraging them to attend outside activities, helping them break their isolation and increase the range and quality of their social networks.
Gillard’s change model aligns closely with the four key functions of peer support, as articulated by Peers for Progress. Our experience with peer support programs have taught us that building rapport between the peer supporter and the patient is the first step in engaging that patient. We share the belief that fostering positive interpersonal relationships is the driving force in peer support interventions.
In summary, the change model can provide a theoretically grounded framework to develop, evaluate, and plan peer support interventions. The model can identify associations between process outcomes and clinical outcomes, thus providing a strategy for formal evaluation of peer support interventions. This approach would facilitate the inclusion of the peer worker role and intervention as a recognized element of a national strategy for mental health care.
Yudy Galvan and Lizette Martinez
Alivio Medical Center
Evoking the energy and warmth of the sun, the Fiesta del Sol festival in Chicago has grown from a block party into the largest Latino festival in the Midwest. Fiesta del Sol began in 1972 as a celebration to commemorate Pilsen Neighbors Community Council’s (PNCC) PNCC’s role in securing the city’s commitment to building Benito Juarez Leadership Academy. Today, Fiesta del Sol continues to reflect the organization’s desire for social transformation.
Recognizing the burden of chronic health diseases in Latino communities, Alivio Medical Center’s Mi Salud es Primero Diabetes Program organizes the Keeping Healthy Campaign with Fiesta del Sol every year. The Keeping Healthy Campaign encourages healthy lifestyles, good eating and exercise habits, stress reduction, healthy cooking, weight control, and high blood pressure and diabetes prevention and control. CHWs from Alivio Medical Center led the community outreach efforts over the three-day festival. The CHWs are the ideal ambassad ors for health, drawing in thousands of visitors with their enthusiasm and helpful nature.
This year, more than 2,689 people (2141 adults and 548 children) visited the Health Booth, receiving information on healthy eating and healthy weight, and prevention of overweight, obesity, sedentary lifestyle, hypertension, and diabetes. Visitors also received information about the programs and services that were available at neighborhood health clinics.
The CHWs conducted 812 screenings for weight, blood pressure, and diabetes for 356 participants. These screenings helped identify 28 people that were pre-diabetic and 19 people that did not have their diabetes under control. People that were identified to be at risk of overweight, obesity, hypertension and diabetes were offered the option to help get a medical appointment for a more thorough assessment and receive appropriate treatment if needed.
Alivio Medical Center’s outreach and education programming at Fiesta del Sol always offers a great opportunity to meet people in the community and engage them in open discussions about the health of themselves and their families. We look forward to seeing everyone at next year’s festival!
Sarah Kowitt, MPH
This past week, I was in Orlando, FL for the American Association of Diabetes Educators (AADE) Conference. While the conference was geared towards diabetes education, I was glad to see several sessions that recognized the importance of support for diabetes self-management.
For instance, Marti Funnell, who gave a keynote lecture on one of the most important diabetes studies in the last decade—the DAWN study—stressed that while we may be doing a good job tackling clinical issues in diabetes care, psychosocial issues, such as emotional well-being and support are under-addressed. For example, while 73% of people with diabetes received regular clinical assessments like HbA1c measurements, only 32% reported that they were asked by members of their healthcare team in the past 12 months about being anxious or depressed.1 Most healthcare professionals (63%) even agreed that there is a major need for better availability of resources for the provision of psychosocial support.2
Peers for Progress sponsored a group of diabetes peer supporters to attend the AADE Conference, from two projects that we funded in Alabama and California. As I got to know them over of the course of the conference, I learned more about their perspectives within the context of diabetes education and support.
Peer Supporters As Extensions of Diabetes Educators
The peer supporters felt that they were able to reach patients in a way that was not possible for other medical providers in large part because they came from the same background as their clients. For instance, one peer supporter from California said, “In our area, it’s easier for us to come in and gain people’s trust because we are peers and we are equal to them. We don’t know more than them. Because we are just like them, they let us in.”
By reaching patients, peer supporters said that they made the work of diabetes educators easier because patients were more receptive and willing to participate in diabetes education classes. In fact, all of the peer supporters emphasized that their roles complemented that of diabetes educators, a sentiment that was echoed by diabetes educators themselves. As one diabetes educator put it, “Peer supporters are extensions of educators. A lot of us [diabetes educators] are being cut and when we have peer supporters reach out to patients, then that is an asset. It is so useful”.
Thinking about diabetes education and diabetes support as a continuum of care, it becomes easier to see how their work is connected and mutually beneficial. In the end, diabetes educators and peer supporters are two sides of the same coin, united in the service of persons living with diabetes.
Helping Peers Overcome Barriers at Work
Peer supporters were proud of their achievements in reaching and engaging patients, helping them lose weight, improving clinical outcomes such as HbA1c, and empowering patients to improve their lifestyles. However, they struggle with barriers in many areas of their work.
For instance, some peer supporters mentioned that they had trouble reaching their patients either because they lived in a rural area where transportation was difficult and expensive or because they didn’t want to use up patients’ telephone minutes. Peer supporters also mentioned that many of the patients they worked with were in denial, experienced stigma as a result of their diabetes, or believed myths about the condition. This made patients less likely to communicate with medical providers about their diabetes and reinforced why peer supporters were helpful. Simply put, “It’s hard work,” as one peer supporter stated. The only way we can make this work easier is to remove some of these barriers and focus on support for peer supporters.
Support Peers with More Resources
When asked how researchers and policy-makers can better support peer supporters, the resounding answer was: resources. Peer supporters mentioned that they needed 1) updated information and 2) funding. A lot of the materials used by the peer supporters were from previous projects and were outdated or unlikely to be used by patients, and they emphasized that better materials were needed. Interestingly, while diabetes educators talked about the need for support in caring for diabetes patients, peer supporters also need access to the latest educational materials. Creating more opportunities for dialogue between the diabetes education and peer support communities can ensure that the needs of both groups are being met. Finally, peer supporters stressed the value of funding, not necessarily for themselves, but rather for reaching and better supporting their patients.
Refresh, Recharge, Renew
The theme of this year’s AADE conference was “Refresh, Recharge, Renew”, tapping into the need to take a step back every once in a while and remind ourselves about the important things in life so our fuel tanks aren’t running on empty.
The future of diabetes care will need the best efforts of those working in diabetes education and diabetes support. We hope that bringing more peer supporters into diabetes care will refresh the way that we approach diabetes education and renew our passion for this important work.
- Nicolucci, A., Kovacs Burns, K., Holt, R. I. G., Comaschi, M., Hermanns, N., Ishii, H., … & Peyrot, M. (2013). Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross‐national benchmarking of diabetes‐related psychosocial outcomes for people with diabetes. Diabetic Medicine, 30(7), 767-777.
- Holt, R. I. G., Nicolucci, A., Kovacs Burns, K., Escalante, M., Forbes, A., Hermanns, N., … & Peyrot, M. (2013). Diabetes Attitudes, Wishes and Needs second study (DAWN2™): Cross‐national comparisons on barriers and resources for optimal care—healthcare professional perspective. Diabetic Medicine, 30(7), 789-798.