research on peer support

• Research article
• Open access
• Published: 29 February 2024

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

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

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

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

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

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

Conclusions

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

Peer Review reports

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

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

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

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

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

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

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

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

Study design and protocol

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

Lived experience researcher involvement

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

Eligibility criteria

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

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

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

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

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

Information sources and search strategy

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

Selection process

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

Data extraction

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

Quality appraisal of included reviews

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

Synthesis methods

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

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

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

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

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

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

Study selection

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

PRISMA flow diagram [ 29 ]

Characteristics of included reviews

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

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

Results of synthesis

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

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

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

Results from meta-analyses

Clinical outcomes.

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

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

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

Recovery outcomes

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

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

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

Psychosocial outcomes

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

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

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

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

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

Summary of results from systematic reviews without meta-analysis

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

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

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

Outer setting

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

Inner setting

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

Individuals

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

Implementation process

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

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

What the PSW role can bring

Perspective of psws.

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

Perspective of service users

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

Perspective of non-peer staff

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

Perspective of peer support group members

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

Perspective of mixed samples

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

Confusion over the PSW role

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

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

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

Organisational challenges and impact

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

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

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

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

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

Summary of key findings

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

Key findings

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

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

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

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

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

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

Strengths and limitations

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

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

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

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

Implications for practice

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

Implications for policy

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

Implications for research

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

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

Lived experience commentary, written by LM and KM

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

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

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

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

Availability of data and materials

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

Abbreviations

A MeaSurement Tool to Assess systematic Reviews

Consolidated Framework for Implementation Research

Implementing Recovery through Organisational Change

Lived Experience Working Group

Population, Intervention, Comparator group, Outcome

Peer support worker

Chinman M, George P, Dougherty RH, Daniels AS, Ghose SS, Swift A, et al. Peer support services for individuals with serious mental illnesses: assessing the evidence. Psychiatr Serv. 2014;65:429–41.

Article   PubMed   Google Scholar  

NHS Health Education England: Peer support workers. https://www.hee.nhs.uk/our-work/mental-health/new-roles-mental-health/peer-support-workers . Accessed 4 Aug 2023.

Gillard S. Peer support in mental health services: where is the research taking us, and do we want to go there? J Ment Heal. 2019;28:341–4.

Article   Google Scholar  

Watson E. The mechanisms underpinning peer support: a literature review. J Ment Heal. 2019;28:677–88.

Salzer MS, Shear SL. Identifying consumer-provider benefits in evaluations of consumer-delivered services. Psychiatr Rehabil J. 2002;25:281–8.

Galloway A, Pistrang N. “We’re stronger if we work together”: experiences of naturally occurring peer support in an inpatient setting. J Ment Heal. 2019;28:419–26.

O’Connell MJ, Flanagan EH, Delphin-Rittmon ME, Davidson L. Enhancing outcomes for persons with co-occurring disorders through skills training and peer recovery support. J Ment Heal. 2020;29:6–11.

Lawn S, Smith A, Hunter K. Mental health peer support for hospital avoidance and early discharge: an Australian example of consumer driven and operated service. J Ment Heal. 2008;17:498–508.

Bellamy C, Schmutte T, Davidson L. An update on the growing evidence base for peer support. Ment Heal Soc Incl. 2017;21:161–7.

Mental Health Mates. https://www.mentalhealthmates.co.uk/our-story/ . Accessed 4 Aug 2023.

Peer Support. https://www.england.nhs.uk/personalisedcare/supported-self-management/peer-support/ . Accessed 4 Aug 2023.

National Voices. Peer support. What is it and does it work ? 2015. p. 58.

Watson E, Meddings S. Peer support in mental health. London: Bloomsbury Publishing; 2019.

Repper J, Aldridge B, Gilfoyle S, Gillard S, Perkins R, Rennison J. Briefing: Peer support workers: theory and practice. CentreformentalhealthOrgUk. 2013. p. 1–16.

Faulkner A, Basset T. A helping hand: taking peer support into the 21st century. Ment Heal Soc Incl. 2012;16:41–7.

NICE. NHS Long Term Plan » NHS Mental Health Implementation Plan 2019/20 – 2023/24. 2019.

Department of Health. The fifth national mental health and suicide prevention plan. 2017.

Farmer P, Dyer J. The five year forward view for mental health. 2016.

Integrated personal commisioning. Community capacity and peer support: summary guide. NHS Engl. 2017:66. https://pdf4pro.com/view/community-capacity-and-peer-support-nhs-england-78a0d2.html . Accesed 5 June 2023.

Mental Health Commission of Canada: Peer Support. https://mentalhealthcommission.ca/what-we-do/access/peer-support/ . Accessed 4 Aug 2023.

Chien WT, Clifton AV, Zhao S, Lui S. Peer support for people with schizophrenia or other serious mental illness. Cochrane Database Syst Rev. 2019;2019:CD010880.

PubMed Central   Google Scholar  

Lloyd-Evans B, Mayo-Wilson E, Harrison B, Istead H, Brown E, Pilling S, et al. A systematic review and meta-analysis of randomised controlled trials of peer support for people with severe mental illness. BMC Psychiatry. 2014;14:1–12.

du Plessis C, Whitaker L, Hurley J. Peer support workers in substance abuse treatment services: a systematic review of the literature. J Subst Use. 2020;25:225–30.

Ibrahim N, Thompson D, Nixdorf R, Kalha J, Mpango R, Moran G, et al. A systematic review of influences on implementation of peer support work for adults with mental health problems. Soc Psychiatry Psychiatr Epidemiol. 2020;55:285–93.

Belbasis L, Bellou V, Ioannidis JPA. Conducting umbrella reviews. BMJ Med. 2022;1:e000071.

Article   PubMed   PubMed Central   Google Scholar  

Aromataris E, Fernandez R, Godfrey CM, Holly C, Khalil H, Tungpunkom P. Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. Int J Evid Based Healthc. 2015;13:132–40.

Fusar-Poli P, Radua J. Ten simple rules for conducting umbrella reviews. Evid Based Ment Health. 2018;21:95–100.

Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ WV (editors), editor. Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane, 2022. Available from www.training.cochrane.org/handbook .

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2020;2021:372.

Google Scholar  

Cooper R, Saunders K. The effectiveness, implementation, and experiences of peer support approaches for mental health: an umbrella review of reviews. PROSPERO 2022 CRD42022362099. 2022. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022362099 .

Aromataris E, Fernandez R, Godfrey C, Holly C, Khalil H, Tungpunkom P. Chapter 10: Umbrella Reviews. In: Aromataris E, Munn Z (editors). JBI manual for evidence synthesis. JBI. 2020. https://doi.org/10.46658/JBIMES-20-11 . Available from: https://synthesismanual.jbi.global .

Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358:1–9.

Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:1–15.

Bailie HA, Tickle A. Effects of employment as a peer support worker on personal recovery: a review of qualitative evidence. Ment Heal Rev J. 2015;20:48–64.

Lyons N, Cooper C, Lloyd-Evans B. A systematic review and meta-analysis of group peer support interventions for people experiencing mental health conditions. BMC Psychiatry. 2021;21:1–17.

Fortuna KL, Naslund JA, LaCroix JM, Bianco CL, Brooks JM, Zisman-Ilani Y, et al. Digital peer support mental health interventions for people with a lived experience of a serious mental illness: systematic review. JMIR Ment Heal. 2020;7:e16460.

Fuhr DC, Salisbury TT, De Silva MJ, Atif N, van Ginneken N, Rahman A, et al. Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2014;49:1691–702.

Gaiser MG, Buche JL, Wayment CC, Schoebel V, Smith JE, Chapman SA, et al. A systematic review of the roles and contributions of peer providers in the behavioral health workforce. Am J Prev Med. 2021;61:e203–10.

Ong QS, Yang HZ, Kuek JHL, Goh YS. Implementation of peer-support services in Asia: a scoping review. J Psychiatr Ment Health Nurs. 2022;30:309–25.

Peck CKH, Thangavelu DP, Li Z, Goh YS. Effects of peer-delivered self-management, recovery education interventions for individuals with severe and enduring mental health challenges: a meta-analysis. J Psychiatr Ment Health Nurs. 2023;30:54–73.

Pitt VJ, Lowe D, Prictor M, Hetrick S, Ryan R, Berends L, et al. A systematic review of consumer-providers’ effects on client outcomes in statutory mental health services: the evidence and the path beyond. J Soc Social Work Res. 2013;4:333–56.

Pitt V, Lowe D, Hill S, Prictor M, Hetrick SE, Ryan R, et al. Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database Syst Rev. 2013;2013:CD004807.

PubMed   PubMed Central   Google Scholar  

Sun J, Yin X, Li C, Liu W, Sun H. Stigma and peer-led interventions: a systematic review and meta-analysis. Front Psychiatry. 2022;13:1–12.

Wang Y, Chen Y, Deng H. Effectiveness of family-and individual-led peer support for people with serious mental illness a meta-analysis. J Psychosoc Nurs Ment Health Serv. 2022;60:20–6.

White S, Foster R, Marks J, Morshead R, Goldsmith L, Barlow S, et al. The effectiveness of one-to-one peer support in mental health services: a systematic review and meta-analysis. BMC Psychiatry. 2020;20:1–20.

Mutschler C, Bellamy C, Davidson L, Lichtenstein S, Kidd S. Implementation of peer support in mental health services: a systematic review of the literature. Psychol Serv. 2022;19:360–74.

Fang Q, Lin L, Chen Q, Yuan Y, Wang S, Zhang Y, et al. Effect of peer support intervention on perinatal depression: a meta-analysis. Gen Hosp Psychiatry. 2022;74:78–87.

Huang R, Yan C, Tian Y, Lei B, Yang D, Liu D, et al. Effectiveness of peer support intervention on perinatal depression: a systematic review and meta-analysis. J Affect Disord. 2020;276:788–96.

Jones CCG, Jomeen J, Hayter M. The impact of peer support in the context of perinatal mental illness: a meta-ethnography. Midwifery. 2014;30:491–8.

Triece P, Massazza A, Fuhr DC. Effectiveness and implementation outcomes for peer-delivered mental health interventions in low- and middle-income countries: a mixed-methods systematic review. Soc Psychiatry Psychiatr Epidemiol. 2022;57:1731–47.

Burke E, Pyle M, Machin K, Varese F, Morrison AP. The effects of peer support on empowerment, self-efficacy, and internalized stigma: a narrative synthesis and meta-analysis. Stigma Heal. 2019;4:337–56.

Smit D, Miguel C, Vrijsen JN, Groeneweg B, Spijker J, Cuijpers P. The effectiveness of peer support for individuals with mental illness: systematic review and meta-analysis. Psychol Med. 2022;53:5332–41.

Bassuk EL, Hanson J, Greene RN, Richard M, Laudet A. Peer-delivered recovery support services for addictions in the united states: a systematic review. J Subst Abuse Treat. 2016;63:1–9.

Reif S, Braude L, Lyman DR, Dougherty RH, Daniels AS, Ghose SS, et al. Peer recovery support for individuals with substance use disorders: assessing the evidence. Psychiatr Serv. 2014;65:853–61.

Lewis HK, Foye U. From prevention to peer support: a systematic review exploring the involvement of lived-experience in eating disorder interventions. Ment Heal Rev J. 2022;27:1–17.

Pellizzer ML, Wade TD. The effectiveness of lived experience involvement in eating disorder treatment: a systematic review. Int J Eat Disord. 2022;56:331–49.

Schlichthorst M, Ozols I, Reifels L, Morgan A. Lived experience peer support programs for suicide prevention: a systematic scoping review. Int J Ment Health Syst. 2020;14:1–13.

Bowersox NW, Jagusch J, Garlick J, Chen JI, Pfeiffer PN. Peer-based interventions targeting suicide prevention: a scoping review. Am J Community Psychol. 2021;68:232–48.

Zeng G, McNamara B. Strategies used to support peer provision in mental health: a scoping review. Adm Policy Ment Heal Ment Heal Serv Res. 2021;48:1034–45.

Åkerblom KB, Ness O. Peer Workers in co-production and co-creation in mental health and substance use services: a scoping review. Adm Policy Ment Heal Ment Heal Serv Res. 2023;50:296–316.

Walker G, Bryant W. Peer support in adult mental health services: a metasynthesis of qualitative findings. Psychiatr Rehabil J. 2013;36:28–34.

Vandewalle J, Debyser B, Beeckman D, Vandecasteele T, Van Hecke A, Verhaeghe S. Peer workers’ perceptions and experiences of barriers to implementation of peer worker roles in mental health services: a literature review. Int J Nurs Stud. 2016;60:234–50.

Miyamoto Y, Sono T. Lessons from peer support among individuals with mental health difficulties: a review of the literature. Clin Pract Epidemiol Ment Heal. 2012;8:22–9.

Viking T, Wenzer J, Hylin U, Nilsson L. Peer support workers’ role and expertise and interprofessional learning in mental health care: a scoping review. J Interprof Care. 2022;36:828–38.

Article   CAS   PubMed   Google Scholar  

Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169:467–73.

Yim CST, Chieng JHL, Tang XR, Tan JX, Kwok VKF, Tan SM. Umbrella review on peer support in mental disorders. Int J Ment Health. 2023;52:379–400.

Ali K, Farrer L, Gulliver A, Griffiths KM. Online peer-to-peer support for young people with mental health problems: a systematic review. JMIR Ment Heal. 2015;2:1–9.

Repper J, Aldridge B, Gilfoyle S, Gillard S, Perkins R, Rennison J. Peer support workers: a practical guide to implementation. 2013:1–32.

Te Pou. Competencies for the mental health and addiction service user, consumer and peer workforce. 2014:1–26. https://www.hqsc.govt.nz/assets/Our-work/Mental-health-and-addiction/Resources/DG038-Te-Poucompetencies-for-mental-health.pdf . Accessed 4 Aug 2023.

Te Pou. Competencies for the mental health and addiction consumer, peer support and lived experience workforce. 2021:1–26.

Foglesong D, Knowles K, Cronise R, Wolf J, Edwards JP. National practice guidelines for peer support specialists and supervisors. Psychiatr Serv. 2022;73:215–8.

Ball M, Skinner S. Raising the glass ceiling : considering a career pathway for peer support workers - 2021. 2021.

National Health Service [NHS]. The competence framework for mental health peer support workers. 2020.

Peer C, Mentors S. Peer Support Accreditation and Certification (Canada). National Certification Handbook. 2014.

Poremski D, Kuek JHL, Yuan Q, Li Z, Yow KL, Eu PW, et al. The impact of peer support work on the mental health of peer support specialists. Int J Ment Health Syst. 2022;16:1–8.

Law D. The Goal-based Outcome (GBO) tool guidance notes. 2019.

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Acknowledgements

This work is supported by the NIHR UCLH BRC.

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

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

Authors and Affiliations

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

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

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

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

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

Phoebe Barnett

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

University of East Anglia, Norwich, UK

Sophie M. Allan

MHPRU Lived Experience Working Group, London, UK

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

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

Alan Simpson

Camden and Islington NHS Foundation Trust, London, UK

Sonia Johnson

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

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

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

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Supplementary Information

Additional file 1: appendix 1..

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

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

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

• Natasha Lyons   ORCID: orcid.org/0000-0003-1635-0681 1 ,
• Chris Cooper 2 &
• Brynmor Lloyd-Evans 1  

BMC Psychiatry volume  21 , Article number:  315 ( 2021 ) Cite this article

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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.

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.

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.

Peer Review reports

Transition to a recovery approach is a key focus of national [ 1 ] and international [ 2 ] mental health service development. Peer support has been characterized as a truly recovery-orientated intervention [ 3 ] and is now recommended in policy guidance internationally [ 4 , 5 , 6 ]. This reflects a growing recognition of the value of lived experience expertise for facilitating recovery within mainstream services [ 7 ]. Peer support enables individuals with personal experience of mental health conditions to utilise this experiential expertise to assist people accessing mental health services with the process of recovery [ 8 ]. Support may be unidirectional, such as from a paid peer support worker to a recipient, or reciprocal, as in mutual support groups [ 9 ]. Interventions involving unidirectional support have been further categorised as: peer support services, delivered alongside traditional providers; or peer-delivered services, delivered by peers as alternative providers to non-peer professionals [ 8 ]. Peer-delivered services tend to be complex interventions, and peer support services and mutual support may be delivered as one-to-one or group interventions [ 10 ].

The distinct therapeutic processes that distinguish group and individual peer support approaches are not yet clearly defined, which reflects the lack of consensus on the broader mechanisms of peer support [ 11 , 12 ]. Reviews of proposed mechanisms [ 11 , 12 ] suggest that recovery may be enhanced through personal identification and modelling of positive social behaviours [ 11 , 13 ], “upward” social comparisions [ 14 ] with recovery role models and through the exchange of experiential knowledge [ 11 , 15 ]. Experiential learning may lead to the development of an alternative knowledge base for mental health management based on individual realities of recovery [ 16 , 17 ]. Social support has been proposed to operate within peer relationships [ 18 ] through the exchange of emotional and informational resources between individuals [ 19 ]. A group setting may therefore maximise the potential for exchange of recovery resources and opportunities for experiential learning.

In spite of the potential for group peer support to improve recovery, only one review to date, has focused specifically on the effectiveness of group peer support approaches and this solely included mutual support groups [ 20 ]. This review was published over 10 years ago and synthesised studies with both randomized and non-randomized designs [ 20 ]. Studies included in this earlier review reported mixed evidence for improving clinical outcomes, such as psychiatric symptoms [ 20 ]. This contributes to the mixed evidence-base for peer support in general, though considerable risks of bias to study findings often reduce confidence in the available evidence [ 21 ]. Previous reviews of peer support have often focused on interventions for participants with particular diagnoses [ 22 , 23 ], which may mask further transdiagnostic benefits based on shared experiences of mental health conditions and of using mental health services [ 24 ].

Across reviews, current evidence suggests that peer support may have particular effectiveness for improving outcomes related to personal recovery [ 9 ] as opposed to clinical outcomes [ 21 , 25 ]. Where it has been possible to isolate the effects of group peer support within reviews, specificity for enhancing personal recovery has similarly been suggested, including improvements to hope [ 25 ] and empowerment [ 10 ] outcomes but not clinical symptoms [ 25 ]. Two descriptive reviews have also indicated positive effects on both clinical and recovery outcomes for peers-delivering educational curricula in group format [ 26 ] and mutual support groups [ 8 ].

With the continued international expansion of peer support within mental health services [ 27 ] and increasing research focus on peer support interventions [ 22 ], there is a pressing need to update to the evidence for effectiveness from previous reviews. The heterogeneity in peer support interventions has led to a call for a greater focus on specific effectiveness with respect to categorisations and contexts [ 26 ]. Determining the optimum format of intervention delivery is needed to inform the implementation of peer support within service developments and the specific effectiveness of group peer support has not been fully addressed. Recommendations guiding implementation are currently hampered by conflicting findings within the literature with respect to the relative effectiveness of group and one-to-one peer support for improving personal recovery outcomes, with one review reporting more evidence to support individual [ 25 ] and another, for group [ 10 ] approaches. Although the more recent review [ 10 ] synthesised evidence for the effectiveness of group peer support for empowerment and self-efficacy, consideration of a broader range of outcomes may contribute to a holistic appraisal of intervention effectiveness for recovery outcomes. Therefore, this review aims to narratively and quantitively synthesis evidence from randomised controlled trials (RCTs) for the effectiveness of group peer support for improving outcomes for people with mental health conditions, compared to any comparator condition; including outcomes relevant to personal and clinical recovery [ 28 ], acute service-use and social indicators of recovery, such as social support [ 29 ] and employment [ 30 ]. Our review complements a review of one-to-one peer support interventions carried out contemporaneously byWhite and colleagues at St George’s University [ 31 ]. Findings for group peer support will be discussed in the context of current evidence regarding one-to-one peer support.

The research methods of this review were conducted in accordance with the Cochrane Collaboration’s guidelines for systematic reviews of interventions [ 32 ] and reported following the Preferred Reporting Items for Systematic Reviews and Met-Analysis (PRISMA) statement [ 33 ] (the PRISMA checklist for each item is included in Additional file 2 ). The protocol for the review was prospectively registered on PROSPERO, International Prospective Register of Systematic Reviews, registration number: CRD42019145217.

Study identification

Studies were identified using both bibliographic database searching and non-bibliographic search methods [ 34 ].

Bibliographic databases

We searched the following bibliographic databases from inception: PsycINFO, MEDLINE, Embase (all via the OVID interface) and the Cochrane Central Register of Controlled Trials (CENTRAL) via the Wiley interface. Search terms were developed and piloted in PsycINFO, then adapted for use on the other databases. In order to pilot our search terms, we first identified “model” papers, which included clear examples of group peer support interventions. We identified these from an initial google and bibliographic database search for studies and reviews of peer support interventions for people who experience mental health conditions. Search terms were then revised and refined, to maximise the relevancy of the search results and to ensure all model papers were returned. The Peer Review of Electronic Search Strategies (PRESS) checklist was used to peer-review the search strategy prior to searching [ 35 ].

The search strategy adopted the structure: (search terms for peer support, such as “peer-led” or peer* adj3 support*) AND (all fields group search) AND (RCT search filter). The Cochrane Highly Sensitive Search Strategy was used in MEDLINE [ 36 ] and the Royle and Waugh filter [ 37 ], supplemented with the P3 filter to maximise sensitivity [ 38 ], for PsycINFO and Embase. No language limits were applied to the searches. The full search strategy is included in the supplementary material for this review (Additional file 1 ). The MEDLINE search is reported with a search narrative which explains the conceptual and contextual detail of the design of the search strategy [ 39 ].

Non-database search methods

The following non-database search methods were used:

Two trial registers were searched: ClinicalTrial.gov and the World Health Organization International Clinical Trials Registry platform

Citation searching on all studies meeting inclusion at full-text was undertaken. Forwards citation searching was undertaken in Web of Science and backwards citation chasing searching was undertaken manually by appraisal of the reference list of included studies

The list of included studies was manually reviewed for any systematic review identified by the searches

For any protocols returned by the searches, or any on-going trials identified by the trial registers, the corresponding authors of the study were contacted to establish if their studies had completed and if unpublished data were available.

The first 10% of all records were independently screened by two reviewers. Inter-rater agreement was 100% at this stage so the remaining abstracts were screened by one reviewer. The full text articles of potentially eligible articles were retrieved and assessed for eligibility for inclusion by one reviewer (NL). The second reviewer (CC), blind to the first reviewer’s screen, then screened all included studies and 10% of the excluded studies, to check for concordance. A third researcher (BLE) was involved to resolve any disagreements regarding inclusion. If this failed to resolve discrepancies, study authors were contacted for further clarification.

Eligibility criteria

Study design.

We included only completed RCTs with individually randomised designs. Published and unpublished, completed trials were eligible for inclusion. Cluster RCTs, incomplete RCTs and all non-randomised designs were excluded, including partially randomised and quasi-experimental designs.

Participants

Eligible participant populations were adults aged 18 and over with mental health conditions. Participants were identified as having confirmed mental health conditions if they met one or more of the following three criteria:

Use of mental health services, defined as a statutory or voluntary sector service that provides support exclusively for people with mental health conditions.

A clinical diagnosis of any condition within the International Classification of Diseases axis 1 psychiatric disorders, which includes common mental health conditions, such as depression and anxiety disorders, those defined as severe, such as bipolar and schizophrenia spectrum disorders, and other mental health conditions including personality disorders, eating disorders and dissociative disorders.

Assessed as experiencing psychiatric symptoms reaching a clinical threshold using any validated symptom rating tool.

Studies were excluded if they included only participants with organic neurological pathologies such as dementia, ordisorders typically diagnosed in childhood, such as conduct disorder, or developmental disorders such as autism, or alcohol or substance misuse related disorders.

Interventions

We included studies of intentional, group peer support interventions, delivered solely by and to people with mental health conditions. Interventions were only included if the primary focus was to promote recovery with mental health conditions. Recovery was broadly defined as “ … a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by [mental health conditions].” [ 40 ] (p257)

Both mutual support groups and peer-facilitated, peer support services delivered in group format were included. Only interventions intended for more than two participants were included.

One-to-one peer support interventions and complex interventions involving group and individual peer support were excluded. We also excluded interventions co-facilitated, facilitated or guided by health professionals. Group peer support interventions were excluded if the focus was any topic other than recovery with mental health conditions, including bereavement and physical health conditions, even if participants in these groups had mental health conditions. Interventions with a primary focus on recovery from addiction were also excluded. This is because these interventions aim to provide support to reduce or achieve abstinence from addictive behaviours as part of recovery [ 41 ], which may necessitate unique characteristics and approaches. There are a large number of active peer-led and mutual support organizations that promote recovery programs, with an independent evidence-base [ 20 ] that is outside the scope of this review.

We did not exclude any studies based on control condition and included studies that compared group peer support with treatment as usual (TAU), however defined, or a waiting list control or with any active control intervention.

We included studies that reported any of the broad groups of outcomes below, however measured:

Personal Recovery

Studies reporting any measure of recovery were included. We also included studies reporting any outcome defined as a component of recovery by the CHIME framework [ 42 ]. This acronym refers to connectedness, such as relationships, hope, identity, meaning and empowerment. Studies reporting self-esteem, personal confidence, self-efficacy and quality of life were also included.

Clinical Recovery

We included studies reporting clinical outcomes, such as any measure of psychiatric symptoms, including symptom scale ratings or clinical recovery rates, and any clinical measure of social functioning.

Acute mental health service use

Studies that reported any measure of acute mental health service use, such as number of hospital admissions, crisis care admission or inpatient bed days, were included.

Social outcomes

We included studies reporting the following outcomes: employment (voluntary or paid), independent living (defined as supported or independent accommodation type) and social support (measures of social network or other social support within the community).

Risk of bias assessment

The first reviewer (NL) conducted a risk of bias assessment for each included study using the Cochrane Collaboration’s Tool for assessing bias in randomised trials [ 43 ]. This included assessment of random sequence generation, allocation concealment, blinding of participants, researchers and of outcome assessors, completeness of outcome data and selective outcome reporting. Each domain of bias was rated as low, high or unclear risk of bias (ROB), according to the guidance specified by the tool and the Cochrane Handbook [ 44 ], indicating whether each form of bias was unlikely or highly likely to have influenced study outcomes or may have influenced study outcomes but insufficient information was reported to make a judgement, respectively. A random sample of 10% of studies were assessed by the second reviewer (CC) using the same procedure. Any disagreements were resolved through discussion with a third researcher (BLE).

Studies that were rated as low ROB in every domain of bias were categorised as low overall ROB [ 44 ]. Selection bias (random sequence generation and allocation concealment) and risks fromincomplete reporting of study data (attrition bias and reporting bias) were considered key risks of bias [ 43 ], so studies with high or unclear risks in these domains received these ratings overall. These ratings indicate the likelihood that bias influenced the overall findings of the study.

Data extraction

The Cochrane Collaboration data extraction form for RCTs was adapted and piloted with three of the included records prior to use. Data extracted from eligible studies included: study aims, study setting, study duration, participant eligibility criteria, total number of participants randomised, participant characteristics including age, gender, ethnicity and mental health diagnoses, baseline imbalances, details of attrition, intervention and control group characteristics, missing outcome data and the results of the outcomes measured at all time points recorded. Raw means and standard deviations and number of participants providing data for each outcome were extracted for the quantitative synthesis.

Statistical analysis

Meta-analyses using random effects models were conducted for outcomes where possible, using Review Manager (RevMan 5.3) software [ 45 ]. For the main analysis, meta-analyses were conducted separately for each outcome within the broad outcome groups. For example, within the recovery outcome group, studies reporting empowerment were analysed together. Studies that used TAU or active controls were analysed together for the main analysis, by combining the means and standard deviations for TAU and active comparators using the formulae recommended by the Cochrane Handbook [ 46 ].

All outcomes were categorised by timepoint as post-intervention (recorded at the end of treatment), short-term follow-up (up to 1 year after the end of treatment) and long-term follow-up (more than 1 year after the end of treatment). If outcome data at multiple time points were reported by studies, the timepoint nearest to but not exceeding one-year follow-up was used for short-term follow-up, and the longest duration of follow-up was used for long-term follow-up. Outcomes at each timepoint were analysed separately. All studies that reported an outcome and provide usable data were included in the main analyses for each outcome, regardless of study population, intervention type or ROB rating but we set three studies as a minimum number to perform any meta-analysis. The inverse variance method wasused to calculate standardised mean differences (SMD) for continuous outcomes using different outcome measures and the magnitude of this effect size (Cohen’s d ) was interpreted as small (0.2), medium (0.5) or large (0.8) [ 47 , 48 ]. For studies using the same outcome measure, mean differences were calculated. Strength of the evidence for an effect was determinedby Z statistic p -values and categorised as no evidence ( p  ≥ 0.1), weak evidence ( p  = 0.09–0.01), strong evidence ( p  < 0.01) and very strong evidence ( p  < 0.001) [ 49 ].

Heterogeneity was assessed using the non-central Chi 2 method and theI 2 statistic. We defined I 2  of greater than 50% as substantial heterogeneity [ 46 ]. Tests of funnel plot of asymmetry were planned for meta-analyses with ten or more studies only, since fewer than ten studies lack sufficient power to produce reliable estimations of publication bias [ 50 ].

For outcomes for which fewer than three studies provided usable data, study results were summarised and described narratively.

Sensitivity and subgroup analyses

Two sensitivity analyses were performed to analyse studies with low overall ROB separately from those with unclear and high ROB and to analyse studies using TAU comparators separately from those using active controls.

Two planned subgroup analyses were undertaken. First, interventions for people with mental health experiences defined as severe mental health conditions were analysed separately from those with other mental health conditions. The definition of severe mental health conditions used in this review included consideration of functional impairment [ 51 ] and included participants with bipolar disordersor psychosis spectrum disorders or participants with any diagnosis using secondary mental health services.

The second planned subgroup analysis was to analyse structured and unstructured peer support interventions separately. Structured interventions were defined as those using manuals or pre-defined programme plans, whereas unstructured interventions were defined as those where the content of group sessions was flexible and could be determined by the group.

The database search was conducted on the 13th of July 2019 and returned 7198 records. Supplementary searche sidentified a further 225 studies for screening. Following duplicate removal, the titles and abstracts of 4277 records were screened for eligibilityand 4179 records documenting clear exclusion criteria were excluded at this stage. Reasons for exclusion included clear evidence of ineligibility due to study type, intervention typeor study population in the title or abstract of the record. The full texts of 98 articles were retrieved and eight studies, reported by 11 articles, were included in the review. Of these, six studies provided usable data for meta-analyses. A total of 87 studies were excluded at full text screen (the full PRISMA Flow Diagram is presented in Additional file 3 ).

Characteristics of included studies

Study characteristics are displayed in Table  1 . All included studies were individually randomized controlled trials with parallel group designs. Seven trials took place in America and one was conducted in Switzerland. Six trials reported follow-up data [ 52 , 53 , 56 , 60 , 61 , 62 ] ranging from 3 weeks to 6 months after the end of treatment.

Participant characteristics

A total of 2131 participants were included in the review with a median study sample size of 252 and range of 82 to 555 participants. Across trials, the median of mean participant ages was 46 years, the median proportion of female participants was 66% and the proportion of participants identifying as Black, Asian and minority ethnicities ranged from 2 to 72%. The proportion of employed participants ranged from 9 to 63%. The participant eligibility criteria of all trials included a range of mental health diagnoses. One study did not report participant diagnoses but all participants were using mental health services [ 60 ]. All seven remaining trials comprised participants experiencing psychoses and affective disorders, however, in accordance with protocol specifications for categorising participant populations with mixed mental health conditions, only five of these trials met our criteria for comprising participants experiencing severe mental health conditions [ 52 , 53 , 56 , 58 , 62 ], since all participants in these studies were using secondary mental health services.

Characteristics of interventions

Details of the characteristics of study interventions are summarised in the supplementary material (Additional file 1 ). Intervention durations ranged between 3 weeks and 12 months. Only one study [ 59 ] used an unstructured intervention and was classified as mutual support. This study adopted two unmoderated, online peer support group interventions, which were combined for the analyses and compared to TAU. One intervention was a “listserv”, enabling participants to send emails to the whole intervention group and the other was an online bulletin board, where participants could post and readgroup messages.

Seven trials used structured interventions, classified as peer support groups, delivered by one to three peer facilitators. Structured interventions were further categorised as: self-management interventions, to develop coping strategies for mental health conditions [ 63 ]; or anti-stigma interventions, to improve responses to experienced stigma and reduce self-stigmatising behaviour [ 64 ]. All structured interventions included an educational component, delivered as classes with structured topics.

Peer Support groups:

Self-management interventions

Four trialswere peer-led, self-management interventions [ 52 , 53 , 56 , 58 ]. Two of the included trials were of Wellness Recovery Action Planning (WRAP) [ 52 , 53 ]. One study used WRAP as the control group to assess the comparative effectiveness of FOCUS, a self-management mobile phone application [ 52 ]. Two studies compared interventions to a Waiting List Control (WLC) [ 53 , 56 ] and one study used both TAU and a clinician-led group of the intervention as control groups [ 58 ].

The number of classes ranged from eight to 12 across interventions. All interventions adopted different approaches to developing and implementing recovery-focused coping strategies. These included increasing knowledge through an educational course for Building Recovery of Individual Dreams and Goals (BRIDGES) [ 56 ], use of recovery workbooks for vet-to-vet, an intervention for veterans experiencing mental health conditions [ 58 ] and development of a personalised daily and crisis management plan for WRAP [ 52 , 53 ].

Anti-stigma interventions

Three trials were manualised anti-stigma interventions [ 60 , 61 , 62 ]. Two trials were studies of the three session Coming Out Proud (COP), compared to a WLC [ 60 ] or TAU [ 61 ]. The remaining trial was a study of ten sessions of photovoice compared to a WLC [ 62 ]. Group discussions for COP included support and strategies for disclosure of mental health conditions, and for Photovoice, education about mental health stereotypes and use of a camera to develop narratives about mental health and stigma.

The ROB assessment for individual studies is displayed in Fig.  1 . One study [ 56 ] had unclear risk of attrition bias since the rate of overall attrition from the study exceeded 20% [ 65 ] the participant characteristics of those who dropped out and those who remained in the study were not described and no reasons for attrition were documented. A further study [ 60 ] had high risk of attrition bias as overall attrition exceeded 20%, there was an imbalance in the numbers remaining in intervention and control groups and participant characteristics of those who dropped out and reasons for attrition were not documented. One study [ 61 ] had high risk of reporting bias as not all outcomes included in the protocol were reported and three studies received unclear ratings as the protocol was not available [ 59 , 60 , 62 ]. Three studies did not report details of allocation concealment [ 59 , 60 , 62 ] and two studies did not report details of random sequence generation [ 58 , 60 ], so were rated as unclear in these domains.

Three studies blinded outcome assessors [ 52 , 53 , 56 ] and for one study [ 59 ], participants returned outcomes online so these had low risk for detection bias. Four studies did not report details of blinding procedures for outcome assessments so were rated as unclear. No studies reported blinding of participants, however participant blinding would not have been feasible due to the need for participants to know details of study conditions to give informed consent and breaches of ethical conduct may also influence participant outcomes. Therefore, risk of performance bias decisions were based on the potential for knowledge of participants’ study conditions to influence the behaviour of personnel. Of the three studies that documented any blinding procedures, two clearly specified that “single blind” procedures referred to assessor blinding [ 53 , 56 ]. Personnel were not blinded but since peer facilitators delivered the active intervention and were not involved in delivering TAU, these two studies were judged to have low risk of performance bias. Similarly, the third study reporting blind procedures [ 52 ] stated an “assessor-blind” design was used and no blinding of personnel was documented. However, the two active conditions were delivered by separate personnel, peer facilitators and mhealth specialists [ 52 ], so the risk of performance bias was judged to be low. The remaining five studies did not provide any information on blinding procedures so were rated as unclear risk for performance bias [ 58 , 59 , 60 , 61 , 62 ].

Only two studies [ 52 , 53 ] had low overall risk of bias, due to having low risk for all individual domains of bias. Since one study [ 60 ] had high risk of attrition bias and one study had high risk of reporting bias [ 61 ], these both had high overall risk of bias. The remaining four studies had unclear overall risk of bias, due to having unclear risk of selection bias [ 58 , 59 , 62 ], attrition bias [ 56 ] or reporting bias [ 59 , 62 ].

Study outcomes and quantitative synthesis

No studies reported outcomes at follow-up exceeding 12 months so outcomes are described at two time-points; post-intervention (end of “treatment”) and follow-up (less than 12 months post-intervention). Six trials [ 52 , 53 , 56 , 58 , 61 , 62 ] provided usable data for meta-analyses, providing data for 1626 participants (76% of all participants). Results of the main analyses are displayed in Table  2 . Forest plots for the main analysis, subgroup analysis and sensitivity analysis are displayed in the supplementary material (Additional file 1 ). No studies reported outcomes related to the meaning or connectedness components of the CHIME framework [ 42 ], acute service use, independent living or employment outcomes. Findings from studies which did not provide usable data for meta-analysis and for outcomes where there were insufficient studies to conduct meta-analysis are both reported for each outcome below, in addition to the results from the quantitative synthesis summarised in Table 2 .

The maximum number of trials included in any meta-analyses was five, so no statistical tests of funnel plot asymmetry were carried out. Planned subgroup analyses of structured and unstructured interventions were not possible as all studies providing usable data for meta-analyses were structured interventions. Subgroup analysis that included only studies solely involving participants with mental health conditions defined as severe was conducted for empowerment at post-intervention by removing the only study providing usable data for meta-analyses without a participant population with severe mental health conditions [ 61 ]. For the main analysis of all other outcomes, only studies including participants experiencing severe mental health conditions provided usable data. Planned sensitivity analyses of studies with low overall ROB werenot possible, since only two studies [ 52 , 53 ] met the criteria for low overall ROB. TAU only sensitivity analyses wereconducted for recovery, hope, empowerment and depression outcomes by removing the study with an active comparator [ 52 ] and using only TAU data for the three-armed trial [ 58 ].

Personal recovery outcomes

Five trials providing post-intervention data which were useable in meta-analyses found strong evidence for a small effect of group peer support on recovery. One study did not provide usable data for meta-analyses and found no evidence for an effect of the intervention on recovery [ 59 ]. Sensitivity analyses including only studies with TAU control groups and excluding a study which used an outcome measure that was not fully validated [ 62 ] did not differ substantially from the results of the main analysis.

Four trials provided usable follow-up data for meta-analysis, which found strong evidence for a small effect of group peer support on recovery at three- and six-months follow-up. Results of sensitivity analysis including only studies using TAU control groups did not differ substantially from the main analysis.

Of the two studies reporting recovery with low overall ROB, one study reported evidence for an increase in recovery for participants receiving WRAP relative to TAU [ 55 ] at both post-intervention and six-month follow-up, and one study reported no evidence for a statistically significant difference in recovery between the two conditions found at either time point [ 52 ].

Three trials provided usable post-intervention data for meta-analysis, which found no evidence for an effect of group peer support on hope. Sensitivity analysis using only studies with TAU control groups did not alter this result. Only two studies reported follow-up data for hope, so meta-analyses were not possible. One study reported evidence for an effect [ 53 ] and the other reported no effect [ 56 ] of group peer support on hopeacross post-intervention and 6 months follow-up.

Empowerment

Self-advocacy was reported by two studies [ 54 , 57 ], which we categorised as an empowerment outcome because it shared concepts with empowerment such as assertiveness and self-direction [ 66 ]. One study found evidence for increased self-advocacy following the intervention [ 54 ] and the other no effect [ 57 ], relative to TAU. Since the same authors used measures of both self-advocacy and empowerment, measures of self-advocacy were excluded from meta-analyses. One study reporting no usable data for meta-analyses found no evidence for an effect of the intervention on empowerment [ 59 ]. Four trials provided usable post-intervention data for meta-analysis, which found no evidence for an intervention effect on empowerment. Sensitivity analysis only including studies with TAU control groups and subgroup analysis only including studies with participants experiencing mental health conditions defined as severe did not alter these results.

Three trials reported usable follow-up data formeta-analysis, which found no evidence for an effect of group peer supporton empowerment at 3 weeks, 3 months and 6 months follow-up. No sensitivity or subgroup analyses were conducted as all studies included used a TAU control and only two studies had participant populations with mental health conditions defined as severe.

All three anti-stigma intervention trials reported self-stigma [ 60 , 61 , 62 ], which we categorised within the domain of recovery. Trials reported data at post-intervention and at follow-up of 3 weeks [ 61 ], one month [ 60 ] or 3 months [ 62 ]. Interventions effects on identity were mixed, with one study reporting evidence for a reduction in self-stigma relative to TAU [ 62 ] and one study reporting no difference between groups [ 61 ] across the full study periods. One study reported improvements relative to TAU for two subscales and no effect for two subscales of a self-stigma measure at both time points [ 60 ]. This study did not provide useable data, so identity could not be quantitively synthesised.

Quality of life

Three studies reported quality of life at post-intervention [ 52 , 53 , 59 ] and two studies reported follow-up at three months [ 52 ] or 6 months [ 53 ]. Evidence for intervention effectiveness was mixed with one study reporting evidence for improvements in quality of life relative to TAU across the full study period [ 53 ] and two studies reported no difference [ 52 , 59 ], with one of these two studies [ 59 ] providing no usable data, so this outcome could not be quantitively synthesised.

Self-efficacy

Two studies reported self-efficacy at post-intervention and at follow-up of 3 weeks and 3 months respectively and found no evidence for an effect of the intervention [ 61 , 62 ].

Clinical recovery

Psychiatric symptoms.

One study reported anxiety [ 55 ], with evidence for improvements following the intervention relative to TAU across post-intervention and six-month follow-up. Another study reported psychosis [ 52 ] and found no difference between groups at either post-intervention or three-month follow-up. Since some studies included both global symptom severity and depression outcomes, these were analysed separately.

Global symptoms

One study reporting global symptoms found no evidence for an effect of the intervention relative to TAU but provided no usable data for meta-analyses [ 59 ]. In post-hoc analysis, this study reported weak evidence that participants with high use of the online intervention experienced more symptoms than those with low or no use at post-intervention, and an increase in symptoms between four and 12 months [ 59 ]. However, the direction of the relationship for causal inference could not be established [ 59 ]. Threetrials provided usable post-intervention data for meta-analysis, whichfound weak evidence for an intervention effect in the direction of symptom reduction, though the magnitude of this effect was found to be negligible. Planned sensitivity analyses were not possible due to an insufficient number of studies.

Since only two trials reported follow-up data [ 52 , 53 ] meta-analyses were not possible. One study reported evidence for reductions in symptoms following the intervention relative to TAU across time [ 53 ] and the other reported no between-group differences at 3 months follow-up [ 52 ].

One study [ 60 ] providing no usable data for meta-analyses reported evidence for a reduction in depressive symptoms following group peer support relative to TAU for women but not for men at post-intervention. Four trials provided usable post-intervention data for meta-analyses, which found no evidence for an effect of group peer support on depression. Sensitivity analyses including only studies with TAU control groups did not alter this result. Three trials provided usable follow-up data for meta-analysis, which found no evidence for an effect of group peer support on depression at three- and six-monthsfollow-up. Sensitivity analyses were not possible due to an insufficient number of studies.

Social support

One study [ 59 ] reported social support at post-intervention and found no evidence for an effect of the intervention. No further studies reported social support or any other social outcome.

Summary of findings

This review represents a synthesis of findings from trials of group peer support. All studies included in the meta-analyses were structured peer support groups. We found evidence that group peer support may make small improvements to overall personal recovery for people with mental health conditions that are maintained at follow-up of up to 6 months. This effect was unaltered by sensitivity analyses. However, we found no evidence for an effect on empowerment, hope or depressive symptoms either after the intervention or at follow-up. There was weak evidence that group peer support may influence psychiatric symptoms following the intervention but the size of effect for improvement was negligible. These findings cannot offer conclusive evidence for the effectiveness of group peer support for clinical and recovery outcomes, as it was not possible to solely analyse studies with a low overall risk of bias, due to an insufficient number of studies meeting these criteria for planned sensitivity analyses. Quantitative syntheses of most outcomes included in our review protocol were not possible due to none or only one to two of the included studies reporting them. Only one included study was a mutual support intervention, which did not report evidence for an effect on any outcome and had an unclear overall risk of bias on the findings. The study also found evidence of an association between greater use of the online intervention and more difficult experiences of psychiatric symptoms, although the direction of effect was unclear. This study included a measure of social support and was the only study reporting any outcome from the social outcomes group. There was mixed descriptive evidence on the impact of anti-stigma interventions on identity and for self-management interventions on quality of life. Anti-stigma intervention studies reported no descriptive evidence for an effect on self-efficacy, though these similarly had some considerable risks of bias on findings.

Strengths and limitations

To our knowledge, this is the first review to focus solely on evidence for the effectiveness of group peer support interventions, delivered only by people with lived experience of mental health conditions. This reduced heterogeneity in methods of intervention delivery and statistical heterogeneity was low for the meta-analyses, suggesting relative consistency in intervention effects across studies [ 67 ]. There was a distinction in focus between interventions that aimed to reduce self-stigma [ 10 ] and those that aimed to improve self-management. Effectiveness for improving recovery may differ between intervention subtypes, however only one included anti-stigma intervention reported recovery [ 62 ], so it was not possible to analyse these separately. Variation in participant characteristics was a source of clinical heterogeneitybetween studies [ 68 ]. Main analyses of all outcomes except empowerment, however included only participants experiencing mental health conditions that were defined as severe, providing a specific evaluation of intervention effectiveness for these outcomes for people with these experiences. Full appraisal of the effectiveness of group peer support for people with other mental health conditions was not possible due to current limitations of the evidence-base.

Since the focus of this review was intervention effectiveness, we included only RCTs to enhance the potential for causal inference and reduce the influence of bias on the findings [ 69 ]. Conversely, this may have limited the studies returned by the search and therefore, the scope of the meta-analyses. We also excluded cluster RCTs since we characterized group peer support as a discrete intervention, which can be randomised at the individual level. However, many mutual support and peer support programs have arisen out of user-led organizations [ 70 ], which might more parsimoniously function as the unit of randomisation. Of our 12 methodological exclusions, only one of these was due to the study being a cluster RCT [ 71 ]. However, the study did not meet other inclusion criteria, for example, the intervention included both group and one-to-one components [ 72 ]. Therefore, although it is unlikely that our exclusion of cluster RCTs has altered the findings of this review, future reviews of group peer support may wish to include this study design within inclusion criteria in order to minimise the risk of missing relevant evidence.

We adopted strict and limited eligibility criteria for this review in order to present a comparable group of interventions for which group peer support was the active ingredient, and to enable valid comparisons of intervention effects. However, this approach may have led to relevant evidence being missed, which could provide interesting and important contributions to our current knowledge of group peer support interventions. For example, we excluded all interventions with any one-to-one support elements. This may have led to the exclusion of potentially helpful programs, which blended group and one-to-one approaches. Combined one-to-one and group peer support programs may be particularly beneficial for flexibly accommodating the diverse needs of people using peer support interventions and require evaluation and synthesis in future reviews.

Our adoption of strict eligibility criteria for the review attempted to address the heterogeneity peer support interventions, through focusing on the effectiveness of one narrowly defined sub-type. However, this may limit the generalisability of these findings to other peer support interventions. Only one included study met our definition of mutual support, which was delivered online, so findings may not be generalisable to face-to-face groups due to distinctive barriers to peer support utilisation delivered via technology [ 73 ]. Therefore, the review findings are specifically generalisable to structured peer support groups. Studies were predominantly conducted in America, which may further limit the generalisability of the findings identified here. We also adopted a strict definition of peer support to exclude all health professional involvement. However, some group peer support interventions are often co-delivered with health professionals and maintain a non-diagnostic, recovery-orientated ethos, such as peer support groups provided internationally by the Hearing Voices Network [ 74 ]. These groups may have many benefits for recovery and require independent evaluation. Similarly, we excluded all groups with any focus other than promoting recovery with mental health conditions. This was to enable us to report any impact on recovery outcomes as direct effect of the interventions, rather than as possible secondary benefits experienced through addressing other issues, such as bereavement or physical health conditions. Peer-led and delivered group interventions targeting experiences commonly experienced by people who experience mental health conditions may also have benefits for recovery. These require independent syntheses and may further contribute to the evidence-base for the effectiveness of group peer support interventions.

Of the 4277 papers returned by our search, only 11 met our eligibility criteria for inclusion, reporting findings of eight trials. However, we used intentionally broad search terms in order to collect a large number of papers and to ensure that no potentially eligible studies were missed (see Supplementary Material, Additional file 1 for full search strategy). A large number of papers were also excluded at the full text screening stage. We were conservative about retrieving full text studies and retained all papers with any evidence of relevancy for detailed consideration. There were some studies that proved problematic for eligibility decisions, included in the supplementary material (Additional file 1 ). If there was any doubt that a study met eligibility criteria it was excluded, in accordance with recommended procedures for systematic reviews [ 32 ].

A methodological limitation of this review was the omission of terms related to “consumer” within the intervention terms of our search strategy, included in Appendix 1 of the Supplementary Material (Additional file 1 ). In North America, Australia and other countries outside of the UK, this term is often used to describe people who use mental health services. Our initial drafts of our search strategy did include a larger number of terms for peers, including the term “consumer”. However, when piloting our search terms we found that a simplified search, excluding some intervention terms, continued to pick up all our model papers and streamlined the results more closely to our inclusion criteria. In spite of these considerations, we cannot rule out the possibility that our reduced search strategy may have missed some relevant studies. This shortcoming highlights the difficulties of conducting reviews in fields where the language used is not well-defined and varies across study locations.

At the stage of peer review, it was highlighted that the inclusion of social support as an outcome for appraising the effectiveness of group peer support may be problematic, since initiating an intervention involving contact with others may physically increase social support. Only one study included in the present review included social support as an outcome and found no evidence for an effect of the intervention. This issue of circularity is particularly pertinent with respect to studies that do not include follow-up measurements beyond the end of the duration of the intervention. Only one included study reported social support as an outcome, which was assessed during and at the end of the intervention but not at longer-term follow-up. However, the study reported no effect of the intervention on social support. In order to appraise the impact of group peer support interventions on social support, it may be necessary for future studies to consider follow-up points beyond the end of the intervention. If any change in the outcome is maintained, this would be a more reliable indicator of any effect of the intervention.

Interpretation and contribution to the evidence-base

The findings of this review contribute to the mixed evidence-base for the effectiveness of peer support interventions based on findings from RCTs. Similarly, to the earlier review by Lloyd-Evans and colleagues [ 21 ], interventions categorised as peer support services were found to improve recovery but not empowerment. Previous reviews have found that group peer support may increase empowerment [ 10 ] and hope [ 25 ], however, not all studies included in these reviews met our eligibility criteria, often due to the involvement of non-peer professionals in the delivery or moderation of the intervention. Compared to the more recent review [ 10 ], this may have reduced the power of the meta-analyses to detect a small effect across studies. Since empowerment is a component of recovery [ 42 ] and the effect of group peer support on recovery is small, intervention effects on recovery components are less likely to be detected by smaller studies and meta-analyses.

The meaning of recovery may differ between different individuals as it is a personally defined process [ 75 ] and since peer support is a complex intervention, it may also work in different ways for different individuals. Therefore, individual domains of recovery may change at different rates within the recovery process, though broader measures of recovery are more able to capture overall improvement within the short timeframe of most included RCTs. Although further high-quality studies are needed to fully rule out potential influences of bias on study findings [ 21 ], the findings of this review are indicative of a positive effect of group peer support on recovery. Four of the five studies included in the quantitative synthesis were self-management interventions, which suggests this intervention-type may be effective for recovery. It is worth noting that sensitivity analyses using just TAU comparison groups did not alter findings for recovery, though only two studies [ 52 , 58 ] employed active comparator conditions involving non-peer clinicians, which tentatively suggests that structured peer-delivered self-management interventions may be comparably effective for enhancing recovery to those delivered by other providers. This supports the findings of a previous review [ 76 ], which found no difference in the effectiveness of interventions delivered by peer and non-peer providers for improving recovery outcomes. All self-management interventions involved contributions of examples from the lived experience of group facilitators, and recovery-orientated education, suggesting that recovery may be exemplified through practical strategies suggested by facilitators and group members, which could contribute to experiential knowledge and intervention effectiveness [ 77 ]. However, it is possible that within peer support interventions delivering a structured curriculum, the potential for the exchange of experiential knowledge developed through individual experience may be limited. Mutual support groups might offer the potential to increase recovery through the sharing of personalised experiential knowledge [ 15 ] and coping strategies [ 78 ] though the relative absence of these trials in the literature prohibited comparisons of these intervention types on recovery outcomes.

Previous reviews have found no evidence for an effect of group peer support on global symptoms [ 25 ] and no difference in symptoms compared to TAU [ 25 ], or to non-peer providers [ 76 ], across peer support interventions. Interpretation of our findings for global symptoms as fully consistent with those of previous reviews is complicated by the small number of trials contributing to the meta-analysis and heterogeneity in trial design, since one study [ 52 ] compared two self-management interventions. This may have reduced the relative effectiveness of group peer support for symptoms since self-management interventions, delivered by either peers or non-peers, were found to improve psychiatric symptoms by a recent review and meta-analysis [ 79 ] and the study included in the present review found evidence for improvements within both groups [ 52 ]. Previous reviews have also found more consistent evidence for peer-delivered self-management interventions than other forms of peer support [ 9 ], though the present review found no evidence for an effect of group peer support on depressive symptoms. It has been suggested that recovery outcomes may be more appropriate than clinical outcomes for assessing the effectiveness of peer support [ 26 ], since the aim of interventions are to improve recovery rather than to eliminate symptoms [ 75 ], which may still be present throughout the process of reclaiming personal well-being and satisfaction in life [ 40 ]. However, it was not possible to assess the impact of group peer support on other outcomes that may be important for recovery, such as quality of life or social outcomes [ 30 ], as either no or few studies reported these. These outcomes may also have greater value to many individuals with lived experience of mental health conditions than traditional clinical outcomes [ 80 ].

Our findings for group peer support broadly parallel those of the concurrent review by White and colleagues [ 31 ] for the effectiveness of one-to-one peer support for improving outcomes for people using mental health services. The available evidence base for one-to-one peer support similarly suggests that interventions may be more likely to improve personal recovery than outcomes related to clinical recovery. Both reviews indicate a small positive effect for recovery, from a similar number of trials, indicating that this may be a consistent effect for peer support, irrespective of whether the intervention is delivered individually or in groups. Although our review does offer a tentative suggestion for a potential intervention effect on global symptoms, which could later be confirmed through expansions to the evidence-base, our more positive finding may be explained by the high representation of self-management interventions in the synthesis [ 9 ] rather than by the format of delivery. In the case of both reviews, the use of lived experience within included interventions in relation to its hypothesised contribution to the mechanisms of effect is rarely described, which could be further specified in order to fully appraise the mechanisms of peer support. Comparably to the findings of the present review, White and colleagues also note the limited number of studies reporting each outcome and the continued presence of some risks of bias to included study findings, limiting interpretation of the available evidence base for both approaches and its utility for informing policy and service developments.

Research implications

The findings of this review highlight the current paucity of evidence from high quality trials of group support interventions needed to draw firm conclusions about effectiveness for a broad range of outcomes. As a result, many reviews of peer support have combined heterogeneous groups of interventions to attempt to appraise effectiveness [ 26 , 78 ]. The present findings suggest one distinction in terms of anti-stigma and self-management as subcategorizations within existing typologies, based on a limited number of included studies. The question of the most effective forms of peer support within different settings remains [ 26 ] and cannot fully be addressed by meta-analytic approaches at present, due to an insufficient number of trials to group interventions appropriately [ 78 ]. Future trials could clearly define the model of group peer support used and ensure people with mental health conditions adopt leadership roles in the design of the intervention, to ensure lived experience expertise is optimised [ 81 ].

A more holistic appraisal of effectiveness for recovery would also be facilitated by the inclusion of a broader range of outcomes and service settings in order to expand the current evidence-base. In particular, there is a current lack of high-quality trials of mutual support group interventions, in spite of the high prevalence and uptake of this form of mental health support across the UK and the United States [ 82 ] and the large body of qualitative literature detailing personal benefits derived through this form of intervention [ 20 ]. Trials of group peer support interventions to improve outcomes for people diagnosed with common mental health conditions are virtually absent in the literature and these are also strongly encouraged. Expansions to the current evidence-base could establish more conclusive evidence for a positive effect of group peer support on recovery outcomes. Future reviews could then determine the specific effectiveness of structured and unstructured interventions, self-management and anti-stigma interventions, and for different clinical groups, to guide implementation within primary and secondary care settings. The present review found no evidence that small improvements in recovery were due to changes in hope or empowerment. Although these findings were based on a limited number of studies, this raises questions regarding causal mechanisms of existing group interventions. It is possible that increases in recovery could be caused by changes in component processes such as meaning or connectedness [ 42 ], which were not reported by included studies and future studies could include measurements of these. Qualitative accounts of individuals participating in group peer support interventions, both as process evaluations embedded within trials and as independent studies could indicate the elements of the intervention that are helpful and mechanisms of effect [ 83 ]. This may be particularly informative for determining whether self-management is an essential intervention component for improving recovery. Previous reviews [ 11 , 12 , 84 ] have provided useful summaries of proposed mechanisms of effect for peer support interventions, which have also been identified in qualitative analysis [ 18 ]. Future group peer support interventions need a clear theory of change and proposed mechanism of hypothesised effect as it is uncertain how any of the positive results presented were achieved from the included studies.

Policy and practice implications

The findings of this review and of other reviews that have included group peer support approaches [ 8 , 10 , 25 , 26 ] are promising with respect to the potential for group peer interventions to enhance recovery for people using mental health services. The current evidence base, however comprises a small number of trials of heterogeneous group interventions, often with considerable risks of bias to study findings. There is also limited available evidence to make conclusions about effectiveness for a broad range of outcomes that may be important for recovery, particularly social outcomes. This prohibits recommendations for the routine implementation of specific forms of group peer support across mainstream services at present. Some negative psychological outcomes have been reported previously by a trial of an online mutual support intervention for women with breast cancer [ 85 ] and by a study included in this review [ 59 ], in spite of high user satisfaction in both instances. If online mutual support group interventions are adopted by services, these may benefit from moderation, either by peer or non-peer professionals [ 59 ], to guard against any potentially negative effects.

The findings of the present and previous reviews [ 10 , 25 ] suggest that where structured peer support groups are implemented locally, these may make small improvements to personal recovery for individuals accessing these services. International goals to implement recovery-orientated services within mental health systems [ 86 ] may also be assisted by increasing implementation of interventionsdelivered by people with lived mental health conditions, ensuring individuals who use mental health services have had a lead role in the development of these [ 81 ] in order to truly facilitate the integration of recovery principles and values [ 87 ] and cultural change in working practices.

We found that participation in structured peer support groups may make small contributions to supporting personal recovery for people with lived experience of mental health conditions. Evidence from the few trials available indicated a limited impact on other outcomes. However, we adopted a more limited conceptualisation of group peer support interventions than some previous reviews, which may restrict the generalisability of our findings. All findings should be treated with caution, due to the quality and quantity of available evidence, which is insufficient to make firm policy and practice recommendations at present. Appraisals of intervention effectiveness for many outcomes that may promote personal recovery were not possible due to a near absence from the literature. Group peer support represents a heterogeneous group of interventions: we propose a distinction between anti-stigma and self-management programmes. This review stresses the need for more high-quality trials of group peer support, which consider a broader range of recovery-orientated outcomes, target particular service settings and optimise the use of experiential expertise within both intervention development and delivery.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its additional files.

Abbreviations

Randomised Controlled Trial

Preferred Reporting Items for Systematic Reviews and Met-Analysis

Cochrane Central Register of Controlled Trials

Peer Review of Electronic Search Strategies

Treatment As Usual

Connectedness Hope Identity Meaning Empowerment

Risk of Bias

Review Manager

Standardised Mean Difference

Wellness Recovery Action Planning

Waiting List Control

Building Recovery of Individual Dreams and Goals

Coming Out Proud

NHS England (GB). Implementing the five year forward view for mental health. London (GB): NHS England; 2016. Available from: https://www.england.nhs.uk/publication/implementing-the-fyfv-for-mental-health/

Google Scholar  

World Health Organization (CH). Mental Health Action Plan 2013–2020. Geneva (CH): World Health Organization; 2013. Available from: https://www.who.int/mental_health/publications/action_plan/en/

Slade M, Amering M, Farkas M, Hamilton B, O’Hagan M, Panther G, et al. Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems. World Psychiatry. 2014;13(1):12–20. https://doi.org/10.1002/wps.20084 .

Article   PubMed   PubMed Central   Google Scholar  

Department of Health (AU). The Fifth National Mental Health and Suicide Prevention Plan. Canberra (AU): Department of Health, Commonwealth of Australia; 2017. Available from: https://www.mentalhealthcommission.gov.au/monitoring-and-reporting/fifth-plan

Farmer P, Dyer J. The five year forward view for mental health. London (GB): The Mental Health Taskforce; 2016. Available from: https://www.england.nhs.uk/mental-health/taskforce/

Myrick K, Del Vecchio P. Peer support services in the behavioral healthcare workforce: state of the field. Psychiatr Rehabil J. 2016;39(3):197–203. https://doi.org/10.1037/prj0000188 .

Article   PubMed   Google Scholar  

Turner-Crowson J, Wallcraft J. The recovery vision for mental health services and research: a British perspective. Psychiatr Rehabil J. 2002;25(3):245–54. https://doi.org/10.1037/h0095018 .

Davidson L, Chinman M, Kloos B, Weingarten R, Stayner D, Tebes J. Peer support among persons with severe mental illnesses: a review of evidence. Clin Psychol Sci Pract. 1999;6(2):165–87.

Article   Google Scholar  

Bellamy C, Schmutte T, Davidson L. An update on the growing evidence base for peer support. Ment Heal Soc Incl. 2017;21(3):161–7. https://doi.org/10.1108/MHSI-03-2017-0014 .

Burke E, Pyle M, Machin K, Varese F, Morrison AP. The effects of peer support on empowerment, self-efficacy, and internalized stigma: a narrative synthesis and meta-analysis. Stigma Heal. 2018;4(3):337–56.

Solomon P. Peer support/peer provided services. Psychiatr Rehabil J. 2004;27(4):392–401. https://doi.org/10.2975/27.2004.392.401 .

Watson E. The mechanisms underpinning peer support: a literature review. J Ment Heal. 2017;0(0):1–12. Available from:. https://doi.org/10.1080/09638237.2017.1417559 .

Bandura A. Self-efficacy: toward a unifying theory of behavioural change. Psychol Rev. 1977;84(2):191–215. https://doi.org/10.1037/0033-295X.84.2.191 .

Article   CAS   PubMed   Google Scholar  

Festinger L. A theory of social comparison processes. Hum Relat. 1954;A:117–40.

Borkman T. Self-help groups at the turning point: emerging egalitarian alliances with the formal health care system? Am J Community Psychol. 1990;18(2):321–32. https://doi.org/10.1007/BF00931307 .

Borkman T. Experiential knowledge: a new concept for the analysis of self-help groups. Soc Serv Rev. 1965;50(3):445–57.

Faulkner A. Survivor research and mad studies: the role and value of experiential knowledge in mental health research. Disabil Soc. 2017;32(4):500–20. Available from:. https://doi.org/10.1080/09687599.2017.1302320 .

Proudfoot JG, Jayawant A, Whitton AE, Parker G, Manicavasagar V, Smith M, et al. Mechanisms underpinning effective peer support: a qualitative analysis of interactions between expert peers and patients newly-diagnosed with bipolar disorder. BMC Psychiatry. 2012;12:1–11.

Shumaker SA, Brownell A. Toward a theory of social support: closing conceptual gaps. J Soc Issues. 1984;40(4):11–36. https://doi.org/10.1111/j.1540-4560.1984.tb01105.x .

Pistrang N, Barker C, Humphreys K. Mutual help groups for mental health problems: a review of effectiveness studies. Am J Community Psychol. 2008;42(1–2):110–21. https://doi.org/10.1007/s10464-008-9181-0 .

Lloyd-Evans B, Mayo-Wilson E, Harrison B, Istead H, Brown E, Pilling S, et al. A systematic review and meta-analysis of randomised controlled trials of peer support for people with severe mental illness. BMC Psychiatry. 2014;14(1):39. Available from. https://doi.org/10.1186/1471-244X-14-39 .

Chien WT, Clifton AV, Zhao S, Lui S. Peer support for people with schizophrenia or other serious mental illness. Cochrane Database Syst Rev. 2019;2019(4):CD010880.

Pfeiffer PN, Heisler M, Piette JD, Rogers MAM, Valenstein M. Efficacy of peer support interventions for depression: a meta-analysis. Gen Hosp Psychiatry. 2011;33(1):29–36. Available from:. https://doi.org/10.1016/j.genhosppsych.2010.10.002 .

Mead S, Hilton D, Curtis L. Peer support: a theoretical perspective. Psychiatr Rehabil J. 2001;25(2):134–41. https://doi.org/10.1037/h0095032 .

Fuhr DC, Salisbury TT, De Silva MJ, Atif N, van Ginneken N, Rahman A, et al. Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2014;49(11):1691–702. https://doi.org/10.1007/s00127-014-0857-5 .

Chinman M, George P, Dougherty RH, Daniels AS, Ghose SS, Swift A, et al. Peer support services for individuals with serious mental illnesses: assessing the evidence. Psychiatr Serv. 2014;65(4):429–41. https://doi.org/10.1176/appi.ps.201300244 .

Ibrahim N, Thompson D, Nixdorf R, Kalha J, Mpango R, Moran G, et al. A systematic review of influences on implementation of peer support work for adults with mental health problems. Soc Psychiatry Psychiatr Epidemiol. 2020;55(3):285–93. https://doi.org/10.1007/s00127-019-01739-1 .

Slade M, Amering M, Oades L. Recovery : an international perspective; 2019. p. 128–37.

Corrigan PW, Phelan SM. Social support and recovery in people with serious mental illnesses. Community Ment Health J. 2004;40(6):513–23. https://doi.org/10.1007/s10597-004-6125-5 .

Lloyd C, King R, Moore L. Subjective and objective indicators of recovery in severe mental illness: a cross-sectional study. Int J Soc Psychiatry. 2010;56(3):220–9. https://doi.org/10.1177/0020764009105703 .

White S, Foster R, Marks J, Morshead R, Goldsmith L, Barlow S, et al. The effectiveness of one-to-one peer support in mental health services: a systematic review and meta-analysis. BMC Psychiatry. 2020;20(1):1–20.

Higgins JPT, Green S. Editors. Cochrane handbook for systematic reviews of interventions. Version 5. London: Cochrane Collaboration; 2011. Available from: www.handbook.cochrane.org

Liberati A, Altman D, Tetzlaff J, Mulrow C, Gøtzsche P, Loannidis J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100. https://doi.org/10.1371/journal.pmed.1000100 .

Cooper C, Booth A, Varley-Campbell J, Britten N, Garside R. Defining the process to literature searching in systematic reviews: a literature review of guidance and supporting studies. BMC Med Res Methodol. 2018;18(1):1–14.

McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS peer review of electronic search strategies: 2015 guideline statement. J Clin Epidemiol. 2016;75:40–6. Available from:. https://doi.org/10.1016/j.jclinepi.2016.01.021 .

Lefebvre C, Manheimer E, Glanville J. Chapter 6: searching for studies. In: Higgins JP, Green S, editors. Cochrane handbook for systematic reviews of interventions version 510 [updated March 2011]. London (GB): Cochrane Collaboration; 2011. Available from: http://handbook.cochrane.org/ .

Royle PL, Waugh NR. Making literature searches easier: a rapid and sensitive search filter for retrieving randomized controlled trials from PubMed. Diabet Med. 2007;24(3):308–11. https://doi.org/10.1111/j.1464-5491.2007.02046.x .

Cooper C, Varley-Campbell J, Carter P. Established search filters may miss studies when identifying randomized controlled trials. J Clin Epidemiol. 2019;112:12–9. Available from:. https://doi.org/10.1016/j.jclinepi.2019.04.002 .

Cooper C, Dawson S, Peters J, Varley-Campbell J, Cockcroft E, Hendon J, et al. Revisiting the need for a literature search narrative: a brief methodological note. Res Synth Methods. 2018;9(3):361–5. https://doi.org/10.1002/jrsm.1315 .

Anthony WA. Recovery from mental illness: the guiding vision of the mental health service system in the 1990s. Psychosoc Rehabil J. 1993;16(4):11–23 Available from: http://doi.apa.org/getdoi.cfm?doi=10.1037/h0095655 .

Reif S, Braude L, Lyman DR, Dougherty RH, Daniels AS, Ghose SS, et al. Peer recovery support for individuals with substance use disorders: assessing the evidence. Psychiatr Serv. 2014;65(7):853–61. https://doi.org/10.1176/appi.ps.201400047 .

Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. Br J Psychiatry. 2011;199(6):445–52. https://doi.org/10.1192/bjp.bp.110.083733 .

Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343(7829):1–9.

Higgins J, Altman D, Sterne J. Chapter 8: Assessing risk of bias in included studies. In: Higgins J, Green S, editors. Cochrane handbook for systematic reviews of interventions version 510 [updated March 2011]; 2011. Available from: http://handbook.cochrane.org .

Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: Nordic Cochrane Centre, Cochrane Collaboration; 2014.

Deeks J, Higgins J, Altman D. Chapter 9: Analysing data and under-taking meta-analyses. In: Higgins J, Green S, editors. Cochrane handbook for systematic reviews of interventions version 510 [updated March 2011]. London: Cochrane Collaboration; 2011.

Sedgwick P. Effect sizes. BMJ. 2012;345(7882):1–2.

Sedgwick P, Marston L. Meta-analyses: standardised mean differences. BMJ. 2013;347(December):1–2. Available from:. https://doi.org/10.1136/bmj.f7257 .

Goodman SN. Toward evidence-based medical statistics. 1: the P value fallacy. Ann Int Med. 1999;130(12):995–1004. https://doi.org/10.7326/0003-4819-130-12-199906150-00008 .

Sterne J, Egger M, Moher D. Chapter 10: addressing reporting biases. In: Higgin J, Green S, editors. Cochrane handbook for systematic reviews of interventions version 510 [updated March 2011]. London: Cochrane Collaboration; 2011. Available from: www.handbook.cochrane.org .

Schinnar AP, Rothbard AB, Kanter R, Jung Y. An empirical literature review of definitions of severe and persistent mental illness. Am J Psychiatry. 1990;147(12):1602–8. https://doi.org/10.1176/ajp.147.12.1602 .

Ben-Zeev D, Brian RM, Jonathan G, Razzano L, Pashka N, Carpenter-Song E, et al. Mobile health (mHealth) versus clinic-based group intervention for people with serious mental illness: a randomized controlled trial. Psychiatr Serv. 2018;69(9):978–85. https://doi.org/10.1176/appi.ps.201800063 .

Cook JA, Copeland ME, Jonikas JA, Hamilton MM, Razzano LA, Grey DD, et al. Results of a randomized controlled trial of mental illness self-management using wellness recovery action planning. Schizophr Bull. 2012;38(4):881–91. https://doi.org/10.1093/schbul/sbr012 .

Jonikas JA, Grey DD, Copeland ME, Razzano LA, Hamilton MM, Floyd CB, et al. Improving propensity for patient self-advocacy through wellness recovery action planning: results of a randomized controlled trial. Community Ment Health J. 2013;49(3):260–9. https://doi.org/10.1007/s10597-011-9475-9 .

Cook JA, Copeland ME, Floyd CB, Jonikas JA, Hamilton MM, Razzano L, et al. A randomized controlled trial of effects of wellness recovery action planning on depression, anxiety, and recovery. Psychiatr Serv. 2012;63(6):541–7. https://doi.org/10.1176/appi.ps.201100125 .

Cook JA, Steigman P, Pickett S, Diehl S, Fox A, Shipley P, et al. Randomized controlled trial of peer-led recovery education using building recovery of individual dreams and goals through education and support (BRIDGES). Schizophr Res. 2012;136(1–3):36–42. Available from:. https://doi.org/10.1016/j.schres.2011.10.016 .

Pickett SA, Diehl SM, Steigman PJ, Prater JD, Fox A, Shipley P, et al. Consumer empowerment and self-advocacy outcomes in a randomized study of peer-led education. Community Ment Health J. 2012;48(4):420–30. https://doi.org/10.1007/s10597-012-9507-0 .

Eisen SV, Schultz MR, Mueller LN, Degenhart C, Clark JA, Resnick SG, et al. Outcome of a randomized study of amental health peer education and support group in the VA. Psychiatr Serv. 2012;63(12):1243–6. https://doi.org/10.1176/appi.ps.201100348 .

Kaplan K, Salzer MS, Solomon P, Brusilovskiy E, Cousounis P. Internet peer support for individuals with psychiatric disabilities: a randomized controlled trial. Soc Sci Med. 2011;72(1):54–62. Available from:. https://doi.org/10.1016/j.socscimed.2010.09.037 .

Corrigan PW, Larson JE, Michaels PJ, Buchholz BA, Del Rossi R, Fontecchio MJ, et al. Diminishing the self-stigma of mental illness by coming out proud. Psychiatry Res. 2015;229(1–2):148–54. https://doi.org/10.1016/j.psychres.2015.07.053 .

Rüsch N, Abbruzzese E, Hagedorn E, Hartenhauer D, Kaufmann I, Curschellas J, et al. Efficacy of coming out proud to reduce stigma’s impact among people with mental illness: pilot randomised controlled trial. Br J Psychiatry. 2014;204(5):391–7. https://doi.org/10.1192/bjp.bp.113.135772 .

Russinova Z, Rogers ES, Gagne C, Bloch P, Drake KM, Mueser KT. A randomized controlled trial of a peer-run antistigma photovoice intervention. Psychiatr Serv. 2014;65(2):242–6. https://doi.org/10.1176/appi.ps.201200572 .

Petros R, Solomon P. Reviewing illness self-management programs: a selection guide for consumers, practitioners, and administrators. Psychiatr Serv. 2015;66(11):1180–93. https://doi.org/10.1176/appi.ps.201400355 .

Gronholm PC, Henderson C, Deb T, Thornicroft G. Interventions to reduce discrimination and stigma: the state of the art. Soc Psychiatry Psychiatr Epidemiol. 2017;52(3):249–58. https://doi.org/10.1007/s00127-017-1341-9 .

Dumville JC, Torgerson DJ, Hewitt CE. Reporting attrition in randomised controlled trials. Br Med J. 2006;332(7547):969–71. https://doi.org/10.1136/bmj.332.7547.969 .

Brashers DE, Haas SM, Neidig JL. The patient self-advocacy scale: measuring patient involvement in health care decision-making interactions. Health Commun. 1999;11(2):97–121. https://doi.org/10.1207/s15327027hc1102_1 .

Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses need for consistency. Bmj. 2003;327(7414):557–60. https://doi.org/10.1136/bmj.327.7414.557 .

Gagnier JJ, Moher D, Boon H, Beyene J, Bombardier C. Investigating clinical heterogeneity in systematic reviews: a methodologic review of guidance in the literature. BMC Med Res Methodol. 2012;12(1):1 Available from: BMC Medical Research Methodology.

Reeves B, Deeks J, Higgins J, Wells G. Including non-randomized studies. In: Higgins J, Green S, editors. Cochrane handbook for systematic reviews of interventions version 510 [updated March 2011]. London: Cochrane Collaboration; 2011. Available from: www.handbook.cochrane.org .

Faulkner A, Basset T. A helping hand: taking peer support into the 21st century. Ment Heal Soc Incl. 2012;16(1):41–7. https://doi.org/10.1108/20428301211205892 .

Atif N, Nisar A, Bibi A, Khan S, Zulfiqar S, Ahmad I, et al. Scaling-up psychological interventions in resource-poor settings: training and supervising peer volunteers to deliver the ‘Thinking Healthy Programme’ for perinatal depression in rural Pakistan. Glob Ment Heal. 2019;6:4.

Sikander S, Ahmad I, Atif N, Zaidi A, Vanobberghen F, Weiss HA, et al. Delivering the Thinking Healthy Programme for perinatal depression through volunteer peers: a cluster randomised controlled trial in Pakistan. The Lancet Psychiatry. 2019;6(2):128–39. Available from:. https://doi.org/10.1016/S2215-0366(18)30467-X .

McColl LD, Rideout PE, Parmar TN, Abba-Aji A. Peer support intervention through mobile application: an integrative literature review and future directions. Can Psychol. 2014;55(4):250–7. https://doi.org/10.1037/a0038095 .

Dillon J, Hornstein GA. Hearing voices peer support groups: a powerful alternative for people in distress. Psychosis. 2013;5(3):286–95. https://doi.org/10.1080/17522439.2013.843020 .

Slade M, Longden E. Empirical evidence about recovery and mental health. BMC Psychiatry. 2015;15(1):1–14. Available from:. https://doi.org/10.1186/s12888-015-0678-4 .

Pitt V, Lowe D, Hill S, Prictor M, Hetrick SE, Ryan R, et al. Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database Syst Rev. 2013;2013(3):CD004807.

Gillard S, Holley J. Peer workers in mental health services: literature overview. Adv Psychiatr Treat. 2014;20(4):286–92. https://doi.org/10.1192/apt.bp.113.011940 .

Mahlke CI, Krämer UM, Becker T, Bock T. Peer support in mental health services. Curr Opin Psychiatry. 2014;27(4):276–81. https://doi.org/10.1097/YCO.0000000000000074 .

Lean M, Fornells-Ambrojo M, Milton A, Lloyd-Evans B, Harrison-Stewart B, Yesufu-Udechuku A, et al. Self-management interventions for people with severe mental illness: systematic review and meta-analysis. Br J Psychiatry. 2019;214(5):260–8. https://doi.org/10.1192/bjp.2019.54 .

Faulkner A, Thomas P. User-led research and evidence-based medicine. Br J Psychiatry. 2002;180(1):1–3. https://doi.org/10.1192/bjp.180.1.1 .

Gillard S. Peer support in mental health services: where is the research taking us, and do we want to go there? J Ment Heal. 2019;28(4):341–4. Available from:. https://doi.org/10.1080/09638237.2019.1608935 .

Markowitz FE. Involvement in mental health self-help groups and recovery. Heal Sociol Rev. 2015;24(2):199–212. https://doi.org/10.1080/14461242.2015.1015149 .

Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350(mar19 6). https://doi.org/10.1136/bmj.h1258 .

Davidson L, Bellamy C, Guy K, Miller R. Peer support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry. 2012;11(2):123–8. https://doi.org/10.1016/j.wpsyc.2012.05.009 .

Salzer MS, Palmer SC, Kaplan K, Brusilovskiy E, Ten Have T, Hampshire M, et al. A randomized, controlled study of internet peer-to-peer interactions among women newly diagnosed with breast cancer. Psychooncology. 2010;19(4):441–6. https://doi.org/10.1002/pon.1586 .

Le Boutillier C, Chevalier A, Lawrence V, Leamy M, Bird VJ, Macpherson R, et al. Staff understanding of recovery-orientated mental health practice: a systematic review and narrative synthesis. Implement Sci. 2015;10(1):Article: 87.

Newman-Taylor K, Stone N, Valentine P, Sault K, Hooks Z. The recovery college: a unique service approach and qualitative evaluation. Psychiatr Rehabil J. 2016;39(2):187–90. https://doi.org/10.1037/prj0000179 .

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NL wrote the manuscript, contributed to the design of the review and the search strategy, carried out the searches and was first reviewer, screening all texts and carrying out all risks of bias assessments and conducted the narrative and statistical analysis. CC contributed to the design of the search strategy and study methods, wrote the search narrative, supervised the project and was second reviewer, for both screening and risk of bias assessments. BLE designed the research question, contributed to the design of the review and analysis, supervised the project and was third reviewer, resolving any discrepancies arising between first two reviewers during screening and risk of bias assessments. All authors read and approved the final manuscript.

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Lyons, N., Cooper, C. & Lloyd-Evans, B. A systematic review and meta-analysis of group peer support interventions for people experiencing mental health conditions. BMC Psychiatry 21 , 315 (2021). https://doi.org/10.1186/s12888-021-03321-z

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Peer Support Services Reaching People with Schizophrenia pp 31–42 Cite as

Theoretical Foundations of Peer Support

• Megan Evans 2  
• First Online: 12 April 2023

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The theoretical underpinnings of peer support are broad and come from a diversity of disciplines including public health, psychology, and sociology. The main theoretical driver of peer support work is that of the health-promoting effects of social support. Social support is the functional content of social relationships and comprises the categories of emotional, instrumental, informational, and appraisal support. Peer support workers can provide each of these types of support in a variety of ways. A second fundamental perspective of peer support work is the value of lived experience and experiential knowledge. Knowing about illness as a subject is a perspective that is often undervalued in traditional approaches to care, whereas it is the central basis of peer support. Additionally, social cognitive theory and social comparison theory lend important theoretical rationales for peer support. Stigma is another construct that is important to consider when thinking about peer support work, especially in relation to a highly stigmatized condition such as schizophrenia. Finally, socioecological models inform our understanding of peer support. As such, this chapter presents a conceptual model outlining inputs and outcomes of peer support programs for people with schizophrenia at each level of the socioecological framework.

• Peer support
• Social support
• Social cognitive theory
• Social comparison theory
• Socioecological model

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Cohen S. Social relationships and health. Am Psychol. 2004;59(8):676.

Article   PubMed   Google Scholar  

Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psychol Bull. 1985;98(2):310.

Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Med. 2010;7(7):e1000316.

Article   PubMed   PubMed Central   Google Scholar  

House JS, Landis KR, Umberson D. Social relationships and health. Science. 1988;241(4865):540–5.

Strine TW, Chapman DP, Balluz L, Mokdad AH. Health-related quality of life and health behaviors by social and emotional support. Soc Psychiatry Psychiatr Epidemiol. 2008;43(2):151–9.

Uchino BN. Social support and physical health: understanding the health consequences of relationships. Yale University Press; 2004.

Book   Google Scholar  

Leigh-Hunt N, Bagguley D, Bash K, Turner V, Turnbull S, Valtorta N, et al. An overview of systematic reviews on the public health consequences of social isolation and loneliness. Public Health. 2017;152:157–71.

Holt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci. 2015;10(2):227–37.

Gonzalez JS, Penedo FJ, Antoni MH, Durán RE, McPherson-Baker S, Ironson G, et al. Social support, positive states of mind, and HIV treatment adherence in men and women living with HIV/AIDS. Health Psychol. 2004;23(4):413.

Catz SL, Kelly JA, Bogart LM, Benotsch EG, McAuliffe TL. Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychol. 2000;19(2):124.

Stentzel U, van den Berg N, Schulze LN, Schwaneberg T, Radicke F, Langosch JM, et al. Predictors of medication adherence among patients with severe psychiatric disorders: findings from the baseline assessment of a randomized controlled trial (Tecla). BMC Psychiatry. 2018;18(1):1–8.

Article   Google Scholar  

Fiore M. Treating tobacco use and dependence: 2008 update: clinical practice guideline. Diane Publishing; 2008.

Google Scholar  

van den Brand FA, Nagtzaam P, Nagelhout GE, Winkens B, van Schayck CP. The association of peer smoking behavior and social support with quit success in employees who participated in a smoking cessation intervention at the workplace. Int J Environ Res Public Health. 2019;16(16):2831.

Wing RR, Jeffery RW. Benefits of recruiting participants with friends and increasing social support for weight loss and maintenance. J Consult Clin Psychol. 1999;67(1):132.

Gorin A, Phelan S, Tate D, Sherwood N, Jeffery R, Wing R. Involving support partners in obesity treatment. J Consult Clin Psychol. 2005;73(2):341.

Holt-Lunstad J. Why social relationships are important for physical health: a systems approach to understanding and modifying risk and protection. Annu Rev Psychol. 2018;69:437–58.

Heaney CA, Israel BA. Social networks and social support. In: Health behavior and health education: theory, research, and practice, vol. 4; 2008. p. 189–210.

Berkman LF, Glass T. Social integration, social networks, social support, and health. Soci Epidemiol. 2000;1:137–73.

House JS. Work stress and social support. 1981.

Kowitt SD, Urlaub D, Guzman-Corrales L, Mayer M, Ballesteros J, Graffy J, et al. Emotional support for diabetes management: an international cross-cultural study. Diabetes Educ. 2015;41(3):291–300.

Repper J, Aldridge B, Gilfoyle S, Gillard S, Perkins R, Rennison J. Peer support workers: theory and practice. Citeseer; 2013.

Kowitt S, Yu S, Owens AK, Carey LA, Fisher EB. Social support needs among patients with advanced breast cancer: sensitivity trumps substance. J Commu Support Oncol. 2016;14(12):509–14.

Fisher E, Bickle C, Harber K, Hughes C, Jeffe D, Kahl L, et al. Benefits of directive and nondirective support are moderated by severity of circumstances. San Francisco: Annual Meeting of Society of Behavioral Medicine; 1997.

Gabriele JM, Carpenter BD, Tate DF, Fisher EB. Directive and nondirective e-coach support for weight loss in overweight adults. Ann Behav Med. 2010;41(2):252–63.

Evans M, Fisher EB. Social isolation and mental health: the role of nondirective and directive social support. Community Ment Health J. 2021;58:20. https://doi.org/10.1007/s10597-021-00787-9 .

Fisher EB, Bhushan NL, Coufal MM, Kowitt SD, Parada H, Sokol RL, et al. Peer support in prevention, chronic disease management, and Well-being. In: Principles and concepts of behavioral medicine. Springer; 2018. p. 643–77.

Chapter   Google Scholar  

Oborn E, Barrett M, Gibson S, Gillard S. Knowledge and expertise in care practices: the role of the peer worker in mental health teams. Sociol Health Illn. 2019;41:1305.

Bandura A. Social learning theory. Englewood Cliffs: Prentice Hall; 1977.

McAlister AL, Perry CL, Parcel GS, Glanz K, Rimer BK, Viswanath K. Health behavior and health education: theory, research, and practice. In: How individuals, environments, and health behaviors interact: social cognitive theory; 2008.

Schunck D. Peer models and children’s behavior change. Rev Educ Res. 1987;57:149–74.

Festinger L. A theory of social comparison processes. Hum Relat. 1954;7(2):117–40.

Kotera Y, Llewellyn-Beardsley J, Charles A, Slade M. Common humanity as an under-acknowledged mechanism for mental health peer support. Int J Ment Heal Addict. 2022:1–7. https://doi.org/10.1007/s11469-022-00916-9 .

Goffman E. Asylums: essays on the social situation of mental patrients and other innates. Dubledzay; 1961.

Rosenhan DL. On being sane in insane places. Science. 1973;179(4070):250–8.

Smith TE, Easter A, Pollock M, Pope LG, Wisdom JP. Disengagement from care: perspectives of individuals with serious mental illness and of service providers. Psychiatr Serv. 2013;64(8):770–5.

Link BG, Phelan JC. Labeling and stigma. In: Handbook of the sociology of mental health. Springer; 2013. p. 525–41.

Corrigan PW, Druss BG, Perlick DA. The impact of mental illness stigma on seeking and participating in mental health care. Psychol Sci Public Interest. 2014;15(2):37–70.

Schulze B. Stigma and mental health professionals: a review of the evidence on an intricate relationship. Int Rev Psychiatry. 2007;19(2):137–55.

Fisher EB, Earp JA, Maman S, Zolotor A. Cross-cultural and international adaptation of peer support for diabetes management. Fam Pract. 2009;27(suppl_1):i6–i16.

PubMed   Google Scholar  

Fisher EB, Boothroyd RI, Coufal MM, Baumann LC, Mbanya JC, Rotheram-Borus MJ, et al. Peer support for self-management of diabetes improved outcomes in international settings. Health Aff. 2012;31(1):130–9.

Evans M, Daaleman TP, Fisher EB. Peer support for chronic medical conditions. In: Avery J, editor. Peer support in medicine: a quick guide. New York: Springer; 2021. p. 49–70.

Fisher EB, Ballesteros J, Bhushan N, Coufal MM, Kowitt SD, McDonough AM, et al. Key features of peer support in chronic disease prevention and management. Health Aff. 2015;34(9):1523–30.

Fisher EB, Tang PY, Evans M, Bhushan N, Graham MA, Valovcin DD, et al. The fundamental value of presence in peer and mutual support: observations from telephone support for high risk groups. Global J Commu Psychol Pract. 2020;11(3):1–20.

Plett H. The art of holding space: a practice of love, liberation, and leadership. Page Two Books, Incorporated; 2020.

Kahlon MK, Aksan N, Aubrey R, Clark N, Cowley-Morillo M, Jacobs EA, et al. Effect of layperson-delivered, empathy-focused program of telephone calls on loneliness, depression, and anxiety among adults during the COVID-19 pandemic: a randomized clinical trial. JAMA Psychiatry. 2021;78(6):616–22.

Thorpe CT, Fahey LE, Johnson H, Deshpande M, Thorpe JM, Fisher EB. Facilitating healthy coping in patients with diabetes: a systematic review. Diabetes Educ. 2013;39(1):33–52.

Peers for Progress. Global evidence for peer support: humanizing health care. Report from an International Conference hosted by Peers for Progress and the National Council of La Raza. American Academy of Family Physicians Foundation. Leawood, 2014.

Pickett SA, Diehl SM, Steigman PJ, Prater JD, Fox A, Shipley P, et al. Consumer empowerment and self-advocacy outcomes in a randomized study of peer-led education. Community Ment Health J. 2012;48(4):420–30.

del Vecchio P. Peer service providers as colleagues. In: Handbook of community psychiatry. Springer; 2012. p. 117–23.

Lorig K, Ritter PL, Plant K. A disease-specific self-help program compared with a generalized chronic disease self-help program for arthritis patients. Arthritis Rheum. 2005;53(6):950–7.

Earp JA, Eng E, O'Malley MS, Altpeter M, Rauscher G, Mayne L, et al. Increasing use of mammography among older, rural African American women: results from a community trial. Am J Public Health. 2002;92(4):646–54.

Sallis JF, Owen N, Fisher E. Ecological models of health behavior. Health Behav Theory Res Pract. 2015;5:43–64.

Bellamy C, Schmutte T, Davidson L. An update on the growing evidence base for peer support. Ment Health Soc Incl. 2017;21(3):161–7.

Pitt V, Lowe D, Hill S, Prictor M, Hetrick SE, Ryan R, et al. Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database Syst Rev. 2013;2013:CD004807.

PubMed   PubMed Central   Google Scholar  

Download references

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Evans, M. (2023). Theoretical Foundations of Peer Support. In: Peer Support Services Reaching People with Schizophrenia. Springer, Cham. https://doi.org/10.1007/978-3-031-29042-8_3

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• Published: 31 March 2022

Peer support for people with chronic conditions: a systematic review of reviews

• Dean M. Thompson 1 ,
• Lesley Booth 2 ,
• David Moore 1 &
• Jonathan Mathers 1  

BMC Health Services Research volume  22 , Article number:  427 ( 2022 ) Cite this article

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People with chronic conditions experience functional impairment, lower quality of life, and greater economic hardship and poverty. Social isolation and loneliness are common for people with chronic conditions, with multiple co-occurring chronic conditions predicting an increased risk of loneliness. Peer support is a socially driven intervention involving people with lived experience of a condition helping others to manage the same condition, potentially offering a sense of connectedness and purpose, and experiential knowledge to manage disease. However, it is unclear what outcomes are important to patients across the spectrum of chronic conditions, what works and for whom. The aims of this review were to (1) collate peer support intervention components, (2) collate the outcome domains used to evaluate peer support, (3) synthesise evidence of effectiveness, and (4) identify the mechanisms of effect, for people with chronic conditions.

A systematic review of reviews was conducted. Reviews were included if they reported on formal peer support between adults or children with one or more chronic condition. Data were analysed using narrative synthesis.

The search identified 6222 unique publications. Thirty-one publications were eligible for inclusion. Components of peer support were organised into nine categories: social support, psychological support, practical support, empowerment, condition monitoring and treatment adherence, informational support, behavioural change, encouragement and motivation, and physical training. Fifty-five outcome domains were identified. Quality of life, and self-efficacy were the most measured outcome domains identified. Most reviews reported positive but non-significant effects.

Conclusions

The effectiveness of peer support is unclear and there are inconsistencies in how peers are defined, a lack of clarity in research design and intervention reporting, and widely variable outcome measurement. This review presents a range of components of peer support interventions that may be of interest to clinicians developing new support programmes. However, it is unclear precisely what components to use and with whom. Therefore, implementation of support in different clinical settings may benefit from participatory action research so that services may reflect local need.

Peer Review reports

Introduction

Noncommunicable diseases or chronic conditions are illnesses, which typically persist for 12 months or more, resulting in functional impairments involving some limitation in social, occupational, or other sphere of life due to illness, requiring health or social care intervention [ 1 , 2 ]. These include, though are not limited to cardiovascular disease, respiratory disease, cancer and diabetes. Global premature avertable mortality across 43 chronic conditions is estimated at 9008 years of life lost per 100,000 population [ 3 ], and the prevalence of chronic conditions and multimorbidity is increasing in the twenty-first century [ 4 ].

Chronic conditions, for example diabetes, affects labour market participation with greater absence, unemployment, early retirement and disability pension [ 5 ], with total health care expenditure estimated at $727 billion globally [ 6 ]. Approximately 12-18% of NHS expenditure is directed towards chronic conditions associated with poor mental health [ 7 ]. People with chronic conditions experience lower quality of life [ 8 ], and greater economic hardship and poverty [ 9 ]. A sense of isolation, alienation and loneliness are common to people with chronic conditions [ 10 ], with multiple co-occurring chronic conditions predicting an increased risk of loneliness [ 11 ]. Loneliness is associated with a poorer course of disease progression and predicts treatment outcomes [ 12 , 13 ].

Progress in addressing chronic conditions has been inconsistent, with government policy insufficient to scale back the epidemic of disease [ 14 ]. In the US, people with chronic conditions without health insurance are less likely than those with health insurance to visit a healthcare professional [ 15 ], and the burden of disease is greatest in low- and middle-income countries where health and social care provision is scarce [ 16 ]. The World Health Organization (WHO) global action plan on noncommunicable disease relies on the overarching principle of empowerment of people and communities through participation in grass-roots organisations and the provision of tools to enable self-management [ 17 ]. People with chronic conditions spend as much as 2 h per day on self-management of their health [ 18 ]. Much of this effort is informally supported by family who may lack experiential knowledge to offer holistic support while also being at heightened risk of experiencing emotional, social, physical and financial burden themselves [ 19 , 20 , 21 ]. Formal peer support interventions represent one potential solution to empower people to manage their own health, while reducing burden on informal carers and healthcare systems. Peer support involves people with lived experience of a condition helping others to manage the same condition, potentially offering a sense of connectedness and purpose, and experiential knowledge to manage disease. The introduction of formal peer support interventions such as the Stanford Chronic Disease Self-Management Program (CDSMP) and the Expert Patient Programme (EPP) offers potential for economies of scale and cost savings for healthcare services [ 22 , 23 , 24 ]. Major chronic conditions share common modifiable risk factors including unhealthy diet, physical inactivity, tobacco use, and harmful alcohol use, which feed into intermediate risk factors including raised blood pressure and blood glucose, abnormal blood lipids and obesity. Yet most reviews of peer support focus on one chronic condition in isolation, and there are few reviews on peer support that cut across chronic conditions. Those that do are limited to online peer support [ 25 , 26 ], peer support specifically delivered in rural areas and other hard to reach populations [ 27 , 28 ], peer support for adolescent populations [ 29 ], peer support focused on chronic pain only [ 30 ], and meta-ethnography of qualitative research focused on self-reported experience of peer support [ 10 ].

It is unclear what outcomes are important across the spectrum of chronic conditions, what works and for whom. These uncertainties impede healthcare services and charitable organisations from developing, implementing and evaluating peer support interventions. As the WHO 2013-2020 global action plan draws to an end with limited progress in preventing and controlling noncommunicable disease, a systematic review of reviews on peer support summarising and comparing conclusions across chronic conditions is timely.

The aims of this review of peer support in chronic conditions were to (1) describe peer support intervention components, (2) identify the outcome domains that have been used to evaluate peer support, (3) summarise evidence of effectiveness, and (4) identify mechanisms of effect that have been proposed for peer support interventions.

This review was written in accordance with PRISMA guidance (see Supplementary Material 1 for the PRISMA checklist).

Protocol registration

A systematic review of reviews protocol was written with reference to PRISMA guidelines [ 31 ], and registered on PROSPERO (International Prospective Register of Systematic Reviews) on 25 September 2019: CRD42019127906.

Eligibility criteria

Study eligibility criteria were developed using the PICOS (Population, Intervention, Comparison, Outcome, and Study design) framework. We included adults and children with one or more chronic condition, defined as a disease or illness, which typically persists for 12 months or more, resulting in functional impairments requiring health or social care intervention [ 1 , 2 ]. We included any peer support intervention, defined here as any formal support provided and received by people with a shared experience of having a chronic condition. ‘Formal’ peer support refers to interventions arranged by organisations rather than spontaneous peer support between individuals or groups in their day-to-day environment. No reviews were excluded on the basis of outcomes, comparators or control conditions. Any type of review listed in Grant and Booth’s (2009) typology of reviews were included [ 32 ]. We included each of these review types to be inclusive and comprehensive in identifying intervention components. We excluded reviews where peer support interventions were not the primary focus of the review or where the intervention, outcome domain, effectiveness and mechanism data for peer support interventions could not be delineated from other types of interventions. Reviews that combined eligible and ineligible types of ‘peers’ were included if the intervention, outcome domain, effectiveness or mechanism data could be delineated by definition of ‘peer’.

Information sources

Six data sources were used: (1) electronic bibliographic databases ( n  = 9) were searched on 30th September 2019 and updated on 30th July 2020, including MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus, Web of Science, Cochrane Database of Systematic Reviews, Google Scholar, and ProQuest Dissertations & Theses Global; (2) PROSPERO was searched for ongoing systematic reviews and corresponding authors contacted for unpublished manuscripts; (3) one website was hand-searched ( http://peersforprogress.org/ ); (4) forward citation tracking of included publications via Scopus, (5) backward citation tracking of included publications by hand-searching reference lists was performed; and (6) a preliminary list of included publications was sent to experts ( n  = 53; authors of included reviews) requesting additional eligible publications.

The search strategy combined terms for peer support with terms for chronic conditions. Peer support search terms were adapted from a published systematic review concerning peer support [ 33 ] and peer reviewed by an expert in literature search design. Terms for chronic conditions encompassed those conditions representing greater than 1% of global Disability Adjusted Life Years (DALYs) according to the World Health Organisation estimates (2018) [ 34 ], were specified in the search. The search strategy was tailored to each electronic bibliographic database and where available and possible used index terms in addition to free text terms (see Supplementary Material 2 for the search strategy used for MEDLINE).

Study selection

Citations were exported into Clarivate Analytics’ EndNote X9 software [ 35 ], and duplicates were removed by using the ‘find duplicate’ function and manually hand-searching the list of publications. DT screened the title and abstract of each identified publication against the inclusion criteria. A randomly selected sample of 10% of title and abstracts were independently assessed by two reviewers (concordance = 91%). The full text of each publication was screened by DT. A randomly selected sample of 10% of full texts were independently assessed by two reviewers (concordance = 91%).

For each publication, we extracted data on: (1) review information including the type of review, review aims, definition of peer support used in the reviews, review eligibility criteria, primary research design, primary research comparators, date of searches and review risk of bias appraisal tool and appraisal findings; (2) setting of primary research; (3) participants of primary research, including demographic and clinical characteristics; (4) the peer support programmes used in primary research (adapted from [ 36 , 37 ]; (5) outcome measurement domains used in primary research; (6) a narrative summary of reviews’ findings on effectiveness (effect sizes and confidence intervals are reported where these have been systematically reported; and (7) theories and mechanisms of effect reported in the findings of included publications.

DT and JM independently piloted the data extraction table with a sample of 5 publications. DT and JM or MG discussed their data extraction (concordance = 85%). Discrepancies were identified and resolved through discussion and the data extraction table instructions were refined until agreement in the pilot sample was greater than 90% (with no data extraction omissions by the lead reviewer, DT) before DT completed data extraction.

Risk of bias in individual reviews

Included reviews underwent critical appraisal using AMSTAR 2 [ 37 ]. AMSTAR 2 is a 16-item measurement tool to assess systematic reviews, though was applied to other types of reviews to enable a best evidence synthesis. DT assessed each included review against each of the 16 items. A randomly selected sample of 10% of included reviews were independently assessed along with all other data items as described in the process above (concordance = 85%). Each review was organised into AMSTAR 2 categories including critically low, low, moderate, and high overall confidence in the results of the review [ 38 ].

Synthesis of results

A 3-stage narrative synthesis was conducted based on Popay and colleagues’ (2006) guidance [ 39 ]. Stage 1 involved developing a preliminary synthesis. Intervention components, outcome domains, and mechanisms of effect in peer support interventions were tabulated and an initial framework was developed using simple content analysis to group related data [ 40 ]. Vote counting was performed to determine the number of reviews identifying each intervention component, outcome domain, and mechanism. The identified components, outcomes, and mechanisms were iteratively grouped from the bottom-up using the extracted data. The effectiveness of the peer support interventions was tabulated for the outcome domains most frequently reported by the included reviews. Pooled effect sizes from the included reviews were reported here where available. Stage 2 involved exploring relationships between studies. Effectiveness data and mechanisms of effect are presented according to chronic condition. Stage 3 involved assessing the robustness of the synthesis. A best evidence synthesis of intervention components, outcome domains, effectiveness, and mechanisms of effect in high quality reviews (based on AMSTAR2) was planned.

The search identified 6222 unique publications (Fig. 1 ). Of the 215 screened full-texts, 184 were excluded (see Supplementary Material 3 for list of and reasons for excluding each publication from electronic bibliographic databases). Thirty-one publications were eligible for inclusion [ 10 , 25 , 27 , 36 , 37 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ].

Flow diagram of study selection

Developing a preliminary synthesis and exploring relationships between studies

Study characteristics.

Reported review types include systematic reviews ( n  = 14), literature reviews ( n  = 6), reviews including meta-analysis ( n =  6), scoping reviews ( n  = 3), and qualitative evidence syntheses ( n  = 2). The primary research designs reported in the reviews were organised into 4 tiers (Fig. 2 ), including Randomised control designs (number of reviews including this desig n  = 26), Non-randomised comparative designs ( n  = 13), Single group observational studies ( n  = 12), and Qualitative studies ( n  = 5). Randomised controlled designs included RCTs ( n =  26), and Cluster Randomised Trials (CRTs) ( n  = 4; see Supplementary Material 4 for study datasets). Non-randomised comparative designs included non-randomised comparative studies ( n  = 6), quasi-experimental design ( n  = 3), cross-sectional studies ( n =  3), a survey with comparison group ( n  = 1), and a case comparison study ( n =  1). Single group observational studies included pre-post studies ( n  = 7), descriptive studies ( n  = 6), and surveys without comparison group ( n  = 2). Qualitative studies included unspecified qualitative research ( n  = 3), interviews ( n =  2), focus groups ( n  = 1), and participant observation ( n  = 1). Some reviews reported primary research designs which could not be categorised or did not appear to be evaluative including feasibility or pilot studies ( n  = 2), an experimental study ( n  = 1), a case study ( n =  1), and a needs assessment ( n  = 1).

Peer support primary research study designs

The conditions reviewed included cancer ( n  = 9), diabetes ( n  = 7), cardiovascular disease ( n  = 4), acquired brain injury, cerebral palsy, and spina bifida ( n  = 1), asthma ( n =  1), kidney disease ( n =  1), HIV ( n =  1), and somatic illness ( n =  1). Six reviews included any chronic condition. The reviews included primary research across 26 countries or semi-autonomous regions (Fig. 3 ). Reviews reported on primary research based in USA ( n =  24), Australia ( n =  14), Canada ( n =  12), the UK ( n  = 11), Republic of Ireland ( n  = 6), Netherlands ( n  = 4), Argentina ( n  = 3), China, Germany, Mozambique, South Korea, Sweden, Uganda, and Vietnam ( n  = 2); Austria, Botswana, Denmark, Hong Kong, Iran, Israel, Jordan, Mali, Philippines, South Africa, Spain, and Taiwan ( n  = 1). Reviews reported on primary research based in community settings ( n  = 8), general hospitals ( n  = 5), outpatient clinics ( n  = 4), HIV/AIDS clinics ( n  = 3), school or other educational settings ( n =  3), US Veterans Affairs centres ( n =  3), camps ( n  = 2), primary care settings ( n =  2), church ( n  = 1), haemodialysis centre ( n  = 1), HIV/AIDS clinical trials unit ( n  = 1), infectious disease hospital unit ( n  = 1), physiotherapy department ( n =  1), public health clinic ( n =  1), seniors’ centre ( n =  1), stroke rehabilitation centre ( n =  1), University clinic ( n =  1), workplace ( n =  1).

Peer support primary research settings

Peer support intervention description

Reviews reported on peer support delivered in groups ( n  = 21) and one-to-one ( n  = 17), by telephone ( n =  21), face-to-face ( n  = 16), and online ( n  = 13). Descriptions of peer support intervention components most frequently comprised education ( n =  13), self-management techniques ( n  = 9), discussion ( n  = 7), reciprocal support ( n =  7), sharing personal experiences ( n  = 6), and unspecified social support ( n =  6). Other specific forms of social support were numerous, wide ranging, and are listed in full in Table  1 . Peers were consistently defined by their role in providing or exchanging support between people with similar experiences or circumstances, though only seven specified that this similarity extends to first-hand experience of living with a shared chronic condition, and three reviews did not give a definition of what constitutes peer support. The duration of peer support interventions ranged from a single session to 2 years. Most reviews reported on interventions with one contact per week, with a range of daily (for up to 1 week) to 3- and 12-monthly follow-ups.

Peer training content and methods were organised into 11 categories including delivery methods, counselling skills, communication skills, condition and treatment information and adherence, meta-competency and safety, social skills and story sharing, intervention and pedagogical theory, culture and religion, physical training techniques, intervention facilitation skills, and availability of community resources. Training most frequently involved teaching communication skills ( n  = 7), condition and treatment information ( n  = 5; see Supplementary Material 5 for training description table). Five reviews reported whether primary research peer support included the use of an intervention manual.

Eleven reviews reported on the supervision of peer support. Three reviews simply indicated whether supervision was a component of the primary research intervention, and 2 reviews indicated whether supervision was professionally delivered. Six reviews described supervision in more detail including supervision of the first session only ( n  = 1), weekly supervision from a psychologist, nurse, and community outreach coordinator ( n  = 1), a study coordinator called participants to identify problems, including problems with the peer support relationship at week 3 of the intervention ( n  = 1), an endocrinologist, an exercise physiologist and an exercise health psychologist were available to answer questions throughout the study period ( n  = 1), psychologist supervision ( n =  1), nurse supervision ( n =  1), facilitators were present to ensure fidelity to the research protocol ( n =  1), children and young people overseen by adults ( n  = 1).

Four reviews reported on screening practices to recruit peer support workers based on success (e.g. reduction in severity of condition or improved self-management) from past treatment ( n  = 1), previous experience facilitating a group, ability to motivate, good listening and problem-solving skills ( n  = 1), knowledge of diabetes and an interest in helping people and effective communication patterns ( n  = 1), a competency test involving role play ( n  = 1), severity of chronic condition ( n =  1); from the same community ( n  = 1), demonstration of leadership qualities ( n =  1), ability to engage in conversation ( n =  1), give information clearly ( n =  1), share experiences and display appropriate listening skills ( n =  1). Twelve reviews reported on peer matching including matching by age ( n  = 5), ethnicity ( n  = 2), cultural similarities ( n =  2), type of cancer ( n =  2), life factors ( n  = 1), gender ( n =  1), primary language ( n =  1), men who have sex with men ( n =  1), chronic pain ( n =  1), injection drug use ( n =  1), ex-smoker status ( n =  1).

Outcome domains

Fifty-five outcome domains were identified and organised across 15 categories (Table  2 ). Mental health and psychosocial processes and adjustment were the most frequently reported outcome categories. Quality of life ( n  = 14), self-efficacy ( n =  14), clinical surrogates ( n  = 12), depression ( n  = 11), distress (n = 11), and health knowledge ( n  = 9) were the most frequently analysed outcome domains in reviews. Psychosocial process and adjustment was the most variably measured category, spanning 21 outcome domains.

Effectiveness

For the most frequently identified outcome domains ( n  = 6), the majority reviews that were designed to evaluate effectiveness and reported pooled effect sizes and confidence intervals reported mostly statistically non-significant effects of peer support (Table  3 ). Though most reviews reported findings favouring peer support, Table  3 shows that these were significant only in reviews of cardiovascular disease and diabetes measuring HBA1c and blood pressure. Specifically, three meta-analyses pooled data on clinical surrogates, indicating small to medium statistically significant differences in favour of peer support effect sizes for HBA1c [ 55 , 64 , 65 ]. Effect sizes were small though not statistically significant for quality of life and depression [ 53 , 59 ], and negligible and not statistically significant for distress [ 54 ].

Twenty-three mechanisms or theories were identified across 9 reviews (Table  4 ). Most mechanisms or theories were identified in two reviews that focused on theory and treatment experience [ 10 , 42 ]. Most reviews did not aim to address intervention theory. Appraisal, emotional and informational social support ( n  = 5), social cognitive theory ( n  = 3), and social comparison theory ( n =  3) were the most frequently cited mechanisms or theories of effect in peer support interventions.

Assessing the robustness of the synthesis

Overall confidence in reviews were rated high in two Cochrane reviews [ 46 , 53 ], low ( n  = 5) and critically low ( n  = 24). Most reviews were rated ‘critically low’ due to 2 recurring critical weaknesses: absence of explicit reference to a protocol established prior to the conduct of the review ( n  = 16), and the absence of reference to a list of excluded studies and justification for exclusions ( n  = 18; Table  5 ). However, each of these reviews did not necessarily set out to be read as a comprehensive systematic review. Of the reviews that assessed risk of bias, most used the Cochrane risk of bias tool ( n  = 13), and a further three referred to the EPOC-specific Cochrane risk of bias tool [ 67 ]. Reviews’ risk of bias findings were rated favourably with low risk of bias and high confidence in the findings (regarding cancer, cardiovascular disease, and somatic illness; n  = 5); equivocal or unclear ( n  = 6); and rated unfavourably with high risk of bias and low confidence in the findings ( n  = 8).

Best evidence synthesis

Due to a lack of ‘high quality’ comprehensive systematic reviews, this best evidence synthesis presents a descriptive summary of Dale and colleagues (2008) and Kew and colleagues (2017) only [ 46 , 53 ]. Dale and colleagues reviewed across chronic conditions, though included some primary research involving peers without direct experience of a shared chronic condition (i.e., people with shared spiritual beliefs). We abstracted only data concerning people with direct experience of a shared chronic condition (post myocardial infarction or with angina). Peer support included educational telephone-based interventions based in Australia and USA. Dale and colleagues measured health status, mental health, quality of life, self-efficacy, and behaviour change (i.e., diet). No differences were found between any physical health outcomes, mental health, quality of life or self-efficacy. Peer support telephone calls were associated with dietary change in one primary research study only.

Kew and colleagues (2017) reviewed peer support for asthma [ 53 ]. Peer support comprised education, strategic thinking, discussion, and encouragement in the context of the Triple A programme that teaches older participants to educate and empower their peers based in Australia, Jordan, and USA. Kew and colleagues measured quality of life, severity of asthma (via exacerbations requiring a course of oral steroids, and asthma control), health care use, health behaviours (i.e., smoking), and adverse events. The asthma-related quality of life random-effects model was imprecise and showed no differences (MD 0.40, 95% confidence interval − 0.02 to 0.81). Most other outcomes did not show an effect favouring peer support. One study found a reduction in adherence in peer support and comparator. Asthma control and nicotine dependence favoured peer support, though this finding was not statistically significant.

Meta-analysis was prevented by heterogeneity between studies, weaknesses in blinding and incomplete reporting. Both reviews shared the conclusion that their findings should be interpreted with caution due to weaknesses in the underlying primary research literature, and that more high-quality clinical trials are indicated.

This systematic review of reviews indicates that peer support may be effective for people with chronic conditions. However, there are methodological weaknesses across the underlying research literature and there is a lack of consistent statistically significant effects of peer support across the included reviews. Therefore, at present it is not possible to draw definitive conclusions about effectiveness, although the potential for peer support interventions is apparent. An obvious difficulty in drawing conclusions is the wide range of intervention components, modalities, and definitions of what constitutes a ‘peer’ identified in this review. Peer support is a complex intervention. Several theories and mechanisms of effect were described in a minority of the reviews included in this study. Peer support was broadly conceptualised as a social intervention. According to Social identity theory , group membership confers a sense of belonging that acts as a behavioural guide via a set of ingroup social norms [ 68 ]. Therefore, it is plausible that the success of peer support may partly depend on how group membership is defined by the recipient of peer support – people with shared clinical characteristics, or people from the same neighbourhood with similar demographics characteristics. Similarly, social comparison theory posits that people use peer support to evaluate themselves in relation to others to validate their thoughts, emotions, and experiences, and make positive upward social comparisons to create a sense of hope in a process of recovery or self-management [ 69 ]. Understanding how such comparisons might diverge between peers matched on the basis of experiential knowledge of a condition and those with shared demographic factors or other circumstances could help to plan peer support programmes that mitigate the negative impact of less positive social comparisons. Embuldeniya and colleagues (2013) [ 10 ] review of mechanisms of peer support reinforces the importance of a shared condition contributing to the bonds formed between people in peer support, and helping others enabled peers to find meaning in their own chronic condition, suggesting that peer support may result in different outcomes depending on how ‘peerness’ is defined. However, relatively few reviews and underpinning primary research explore how peer support works, nor answer specific questions about variation in effectiveness of different types of peers. As a consequence, the extent to which peer support can be optimized by targeting mechanisms of effect remains unclear. Mediation analysis of peer-matching in peer support would be one approach to investigate the importance of this variable, which would inform process measurement in clinical trials.

No single outcome domain was measured across all primary research, suggesting a lack of consensus on what is essential to measure in peer support interventions. This study highlighted that it is common practice to measure clinical recovery in outcome measurement (symptom remission to ‘get back to normal’) alongside psychosocial processes of personal recovery such as a sense of connectedness. However, some reviews solely focused on physical symptoms of chronic conditions [ 55 , 63 ]. Most reviews of peer support synthesised clinical surrogates and mental health outcomes, acknowledging the co-occurrence of chronic physical conditions and mental health problems [ 70 ]. However, mental health problems are not simply a symptom of an underlying chronic health condition that can uniformly be addressed by taking away the chronic condition. If peer support does indeed work through creating a sense of connectedness and hope derived from upward social comparisons, it is important to evaluate these processes of personal recovery more consistently in future research [ 71 ]. As few as four studies measured a sense of hope and three measured connectedness. The inconsistency in outcome measurement highlighted by this study points toward a lack of consensus regarding what and how to measure when evaluating peer support interventions to enable comparisons in future evidence syntheses which may in turn inform commissioning of new peer support services. A core outcome set is a standardised minimum set of outcomes that should be measured in all clinical trials in an area of health or social care. Research to develop a core outcome set through Delphi consensus methodology would help the research community to bridge this gap.

Confidence in the quality of the included reviews was mostly low or critically low when measured against AMSTAR 2. Most included reviews omitted explicit reference to a protocol established prior to the conduct of the review and a reference to a list of excluded studies with justification for exclusions. Furthermore, many of the included reviews did not assess risk of bias nor robustly conduct study selection and data abstraction in duplicate. Though the authors of the included reviews may not have set out to produce methodologically robust systematic reviews, some of the published reports made conclusive remarks about the effectiveness of peer support without critical appraisal of the primary research informing this view. Therefore, renewed efforts to review the peer support literature ought to be preceded by accessible protocols detailing a robust systematic approach to the literature to facilitate the commissioners’ decision-making process in funding peer support services.

This study presents peer support intervention components summarised in other reviews rather than lengthier descriptions of interventions in primary research. As a result, these data do not represent a complete and detailed catalogue of all published forms of peer support. Furthermore, the use of vote counting in this review of reviews does not provide a robust assessment of the magnitude of effect conferred by intervention components, nor does it account for the relative sizes of the studies included. Due to the variation in outcomes measured, and inconsistent findings between them, it is not possible to conclude what works, for whom, and in what circumstances with these data. The value of understanding the mechanisms of effect in peer support has also been acknowledged in Gopalan and colleagues’ (2017) scoping review of youth peer support for mental health problems [ 72 ]. Realist research would be well-suited to exploring these uncertainties to produce a programme theory that explores the mechanisms of effect and highlights the active ingredients to facilitate change in a way that accommodates rather than controls for the heterogeneity across peer support interventions and populations they service.

The evidence base for peer support comprises a wide range of definitions, theories, and methods of peer support. Peers were variably defined as people sharing the same chronic condition, family and friends, community health workers and others in the community, some combination of the above, or not defined at all. This leads to two challenges. Firstly, by attempting to synthesise primary research that adopts different definitions of ‘peerness’ and different theories and components of peer support interventions, evidence syntheses often struggle to compare apples and oranges. Secondly, attempts to pool data from heterogeneous interventions risks overlooking opportunities for learning between different paradigms of peer support across settings and conditions.

This systematic review of reviews focused on peer support between people with a shared chronic condition. In doing so, this review compares a set of interventions that cohere around concepts of shared identity informed by direct lived experience of a chronic condition. However, this prevented any exploration of similarities and differences between different conceptualisations of ‘peerness’. As other gaps in the literature recommended in this discussion are addressed, an update to this review using a meta-narrative design would help to unpick such a heterogeneous topic by comparing and contrasting the different ways in which clinical services and academics have developed and evaluated peer support for people across a broad spectrum of chronic conditions.

This review presents a range of components of peer support interventions that may be of interest to clinicians when developing new peer support programmes. However, there is a lack of high-quality primary research (outside of studies on cancer, cardiovascular disease, and somatic illness) underpinning few robust systematic reviews, which limits understanding of what components of peer support to use and with whom. Until this changes, the implementation of peer support in different clinical settings may benefit from participatory action research so that services may reflect patient preference at a local level. Furthermore, for those clinical services intending to implement novel peer support interventions, this review provides a matrix of mechanisms of effect that may guide theory-driven intervention development.

Though four major chronic conditions (cancer, diabetes, cardiovascular, and chronic respiratory disease) are well-represented in reviews focusing exclusively on peer support between people with a chronic condition, there was a marked absence of reviews on many other prevalent chronic conditions with different pathologies and lived experience. This review highlights a window of opportunity to scope the literature to determine whether there is a need for further primary research or systematic reviews of peer support for chronic conditions absent from this review.

Availability of data and materials

Included study data are included in this report’s supplementary information files.

Abbreviations

A Measurement Tool to Assess Systematic Reviews

Chronic Disease Self-Management Program

Expert Patient Programme

Mean difference

Population, Intervention, Comparison, Outcome, and Study design

International Prospective Register of Systematic Reviews

World Health Organization

Goodman RA, Posner SF, Huang ES, Parekh AK, Koh HK. Defining and measuring chronic conditions: imperatives for research, policy, program, and practice. Prev Chronic Dis. 2013;10:e66. https://doi.org/10.5888/pcd10.120239 .

Article   PubMed   PubMed Central   Google Scholar  

Hwang W, Weller W, Ireys H, Anderson G. Out-of-pocket medical spending for care of chronic conditions. Health Aff. 2001;20:267–78. https://doi.org/10.1377/hlthaff.20.6.267 .

Article   CAS   Google Scholar  

Martinez R, Lloyd-Sherlock P, Soliz P, et al. Trends in premature avertable mortality from non-communicable diseases for 195 countries and territories, 1990–2017: a population-based study. Lancet Glob Health. 2020;8:e511–23.

Article   Google Scholar  

Van Oostrom SH, Gijsen R, Stirbu I, Korevaar JC, Schellevis FG, Picavet HSJ, et al. Time trends in prevalence of chronic diseases and multimorbidity not only due to aging: data from general practices and health surveys. PLoS One. 2016;11:e0160264. https://doi.org/10.1371/journal.pone.0160264 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Pedron S, Emmert-Fees K, Laxy M, Schwettmann L. The impact of diabetes on labour market participation: a systematic review of results and methods. BMC Public Health. 2019;19:25. https://doi.org/10.1186/s12889-018-6324-6 .

International Diabetes Federation. IDF Diabetes Atlas. 2017. Retrieved from Brussels, Belgium: http://www.diabetesatlas.org

Naylor C, Parsonage M, McDaid D, Knapp M, Fossey M, Galea A. Long-term conditions and mental health: the cost of co-morbidities. The King's fund, London, UK.

Megari K. Quality of life in chronic disease patients. Health Psychol Res. 2013;2012(1):27. https://doi.org/10.4081/hpr.2013.e27 .

Jeon Y-H, Essue B, Jan S, Wells R, Whitworth JA. Economic hardship associated with managing chronic illness: a qualitative inquiry. BMC Health Serv Res. 2009;9:182. https://doi.org/10.1186/1472-6963-9-182 .

Embuldeniya GV, Bell P, Bell E, Mary; Nyhof-Young, J., Sale, J.E.M. & Britten, N. The experience and impact of chronic disease peer support interventions: a qualitative synthesis. Patient Educ Couns. 2013;92:3–12. https://doi.org/10.1016/j.pec.2013.02.002 .

Article   PubMed   Google Scholar  

Stickley A, Koyanagi A. Physical multimorbidity and loneliness: a population-based study. PLoS One. 2018;13(1):e0191651. https://doi.org/10.1371/journal.pone.0191651 .

Hawkley LC, Cacioppo JT. Loneliness matters: a theoretical and empirical review of consequences and mechanisms. Ann Behav Med. 2010;40:218–27. https://doi.org/10.1007/s12160-010-9210-8 .

Reijnders T, Schuler M, Jelusic D, Troosters T, Janssens W, Schultz K, et al. The impact of loneliness on outcomes of pulmonary rehabilitation in patients with COPD. Chronic Obstr Pulm Dis. 2018;15:446–53. https://doi.org/10.1080/15412555.2018.1471128 .

NCD Countdown 2030 collaborators. NCD Countdown 2030: pathways to achieving Sustainable Development Goal target 3.4. Lancet. 2020;396:918–34. https://doi.org/10.1016/S0140-6736(20)31761-X .

Wilper AP, Woolcer S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. A national study of chronic disease prevalence and access to care in uninsured U.S. adults. Ann Intern Med. 2008;149:170–6. https://doi.org/10.7326/0003-4819-149-3-200808050-00006 .

Stuckler D, Basu S, McKee M. Drivers of inequality in millennium development goal progress: a statistical analysis. PLoS Med. 2010;7:e1000241. https://doi.org/10.1371/journal.pmed.1000241 .

World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013-2020. 2013. Retrieved from http://www.who.int/iris/handle/10665/94384

Google Scholar  

Jowsey T, Yen L, W, P. M. Time spent on health related activities associated with chronic illness: a scoping literature review. BMC Public Health. 2012;12:1044. https://doi.org/10.1186/1471-2458-12-1044 .

Adelman RD, Tmanova LL, Delgado D, Dion S, Lachs MS. Caregiver burden: a clinical review. JAMA. 2014;311:1052–60. https://doi.org/10.1001/jama.2014.304 .

Article   CAS   PubMed   Google Scholar  

Courtin E, Jemiai N, Mossialos E. Mapping support policies for informal carers across the European Union. Health Policy. 2014;118:84–94. https://doi.org/10.1016/j.healthpol.2014.07.013 .

Fujisawa R, Colombo F. The long-term care workforce: overview and strategies to adapt supply to a growing demand. OECD health working papers. 2009;44. OECD publishing. Paris. https://doi.org/10.1787/225350638472 .

Lorig KR, Ritter P, Stewart AL, Sobel DS, Brown BW Jr, Bandura A, et al. Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care. 2001;39:1217–23.

Wilson PM, Kendall S, Brooks F. The expert patients Programme: a paradox of patient empowerment and medical dominance. Health Soc Care Community. 2007;15:426–38. https://doi.org/10.1111/j.1365-2524.2007.00701.x .

Wingate L, Graffy J, Holman D, Simmons D. Can peer support be cost saving? An economic evaluation of RAPSID: a randomized controlled trial of peer support in diabetes compared to usual care alone in east of England communities. BMJ Open Diabetes Res Care. 2017;5:e000328. https://doi.org/10.1136/bmjdrc-2016-000328 .

Kingod N, Cleal B, Wahlberg A, Husted GR. Online peer-to-peer communities in the daily lives of people with chronic illness: a qualitative systematic review. Qual Health Res. 2017;2017(27):89–99. https://doi.org/10.1177/1049732316680203 .

Munce S, Shepherd J, Perrier L, Allin S, Sweet SN, Tomasone JR, et al. Online peer support interventions for chronic conditions: a scoping review protocol. BMJ Open. 2017;7:e017999. https://doi.org/10.1136/bmjopen-2017-017999 .

Lauckner HMH, Susan L. Peer support for people with chronic conditions in rural areas: a scoping review. Rural Remote Health. 2016;16:3601.

PubMed   Google Scholar  

Sokol R, Fisher E. Peer support for the hardly reached: a systematic review. Am J Public Health. 2016;106:1308. https://doi.org/10.2105/AJPH.2016.303180a .

Article   PubMed Central   Google Scholar  

Kohut SA, Stinson J, van Wyk M, Giosa L, Luca S. Systematic review of peer support interventions for adolescents with chronic illness. Int J Child Adolesc Health. 2014;7:183–97.

Cooper K, Kirkpatrick P, Wilcock S. The effectiveness of peer support interventions for community-dwelling adults with chronic non-cancer pain: a systematic review. JBI Database Syst Rev Implement. 2014;12:319–48. https://doi.org/10.11124/jbisrir-2014-1590 .

Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart L. A. Preferred reporting items for systematic review and Meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015;4:1. https://doi.org/10.1186/2046-4053-4-1 .

Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Inf Libr J. 2009;26:91–108. https://doi.org/10.1111/j.1471-1842.2009.00848.x .

Pitt V, Lowe D, Hill S, Prictor M, Hetrick SE, Ryan R, et al. Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database Syst Rev. 2013;3:CD004807. https://doi.org/10.1002/14651858.CD004807.pub2 .

World Health Organization. WHO methods and data sources for global burden of disease 2000-2016. Global Health Estimates Technical Paper. 2018;WHO/HIS/HSI/GHE/2016.4. Geneva: World Health Organization. Retrieved from ( http://www.who.int/healthinfo/statistics/GlobalDALYmethods_2000_2016.pdf ).

EndNote reference management software. Clarivate Analytics 2019;Version X9.

Hoey LMI, Sandra C, White VM, Jefford M. Systematic review of peer-support programs for people with cancer. Patient Educ Couns. 2008;70:315–37. https://doi.org/10.1016/j.pec.2007.11.016 .

Meyer A, Coroiu A, Korner A. One-to-one peer support in cancer care: a review of scholarship published between 2007 and 2014. Eur J Cancer Care. 2015;24:299–312. https://doi.org/10.1111/ecc.12273 .

Shea, B. J., Reeves, B. C., Wells, G., Thuku, M., Hamel, C., Moran, J., et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017;j4008. https://doi.org/10.1136/bmj.j4008 .

Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the conduct of narrative synthesis in systematic reviews: a product of the ESRC methods programme. 2006;(version I). Lancaster, UK: University of Lancaster.

Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277–88.

Bennett PN, Russell SC, J., Atwal, J., Brown, L., & Schiller, B. Patient-to-patient peer mentor support in dialysis: improving the patient experience. Semin Dial. 2018;31:455–61. https://doi.org/10.1111/sdi.12703 .

Boucher LM, Liddy C, Mihan A, Kendall C. Peer-led self-management interventions and adherence to antiretroviral therapy among people living with HIV: a systematic review. AIDS Behav. 2020;24:998–1022. https://doi.org/10.1007/s10461-019-02690-7 .

Campbell HS, Phaneuf MR, Deane K. Cancer peer support programs-do they work? Patient Educ Couns. 2004;55:3–15.

Cici D. How is the effect of peer support on type 2 diabetes mellitus patients? A systematic Review. 2018; eprints.ners.unair.ac.id .

Clayton C, Catrin M, Sakakibara B. Enhancing social support among people with cardiovascular disease: a systematic scoping review. Curr Cardiol Rep. 2019;21:123. https://doi.org/10.1007/s11886-019-1216-7 .

Dale J, Caramlau IO, Lindenmeyer A, Williams SM. Peer support telephone calls for improving health. Cochrane Database Syst Rev. 2008;4:CD006903. https://doi.org/10.1002/14651858.CD006903.pub2 .

Dale JR, Williams SM, Bowyer V. What is the effect of peer support on diabetes outcomes in adults? A systematic review Diabet Med. 2012;29:1361–77. https://doi.org/10.1111/j.1464-5491.2012.03749.x .

Dunn J, Steginga SK, Rosoman N, Millichap DA. Review of peer support in the context of Cancer. J Psychosoc Oncol. 2003;21:55–67. https://doi.org/10.1300/J077v21n02_04 .

Enriquez MC, Vicki S. Peers as facilitators of medication adherence interventions. J Prim Care Community Health. 2016;7:44–55. https://doi.org/10.1177/2150131915601794 .

Fisher EB, Boothroyd RI, Elstad EA, Hays L, Henes A, Maslow GR, et al. Peer support of complex health behaviors in prevention and disease management with special reference to diabetes: systematic reviews. Clin Diabetes Endocrinol. 2017;3:4. https://doi.org/10.1186/s40842-017-0042-3 .

Gatlin TK, Serafica R, Johnson M. Systematic review of peer education intervention programmes among individuals with type 2 diabetes. J Clin Nurs. 2017;26:4212–22. https://doi.org/10.1111/jocn.13991 .

Hu J, Wang X, Guo S, Chen F, Wu YY, Ji FJ, et al. Peer support interventions for breast cancer patients: a systematic review. Breast Cancer Res Treat. 2019;174:325–41. https://doi.org/10.1007/s10549-018-5033-2 .

Kew KM, Carr R, Crossingham I. Lay-led and peer support interventions for adolescents with asthma. Cochrane Database Syst Rev. 2017;4:CD012331. https://doi.org/10.1002/14651858.CD012331.pub2 .

Kong LN, Hu P, Zhao QH, Yao HY, Chen SZ. Effect of peer support intervention on diabetes distress in people with type 2 diabetes: a systematic review and meta-analysis. Int J Nurs. 2020;26:e12830. https://doi.org/10.1111/ijn.12830 .

Krishnamoorthy Y, Sakthivel M, Sarveswaran G, Eliyas SK. Effectiveness of peer led intervention in improvement of clinical outcomes among diabetes mellitus and hypertension patients-a systematic review and meta-analysis. Prim Care Diabetes. 2019;13:158–69. https://doi.org/10.1016/j.pcd.2018.11.007 .

Lee MK, Suh SR. Effects of peer-led interventions for patients with cancer: a meta-analysis. Oncol Nurs Forum. 2018;45:217–36. https://doi.org/10.1188/18.ONF.217-236 .

Levy BB, Luong D, Perrier L, Bayley MT, Munce S. Peer support interventions for individuals with acquired brain injury, cerebral palsy, and spina bifida: a systematic review. BMC Health Serv Res. 2019;19:288. https://doi.org/10.1186/s12913-019-4110-5 .

Macvean ML, White VM, Sanson-Fisher R. One-to-one volunteer support programs for people with cancer: a review of the literature. Patient Educ Couns. 2008;70:10–24.

McCaughan E, Parahoo K, Hueter I, Northouse L, Bradbury I. Online support groups for women with breast cancer. Cochrane Database Syst Rev. 2017;3:CD011652. https://doi.org/10.1002/14651858.CD011652.pub2 .

Jackson AM, Gregory S, McKinstry B. Self-help groups for patients with coronary heart disease as a resource for rehabilitation and secondary prevention-what is the evidence? Heart Lung. 2009;38:192–200. https://doi.org/10.1016/j.hrtlng.2009.01.009 .

Merianos AL, King KA, Vidourek RA, Nabors LA. Mentoring and peer-led interventions to improve quality of life outcomes among adolescents with chronic illnesses. Appl Res Qual Life. 2016;11:1009–23. https://doi.org/10.1007/s11482-015-9415-x .

Parry M, Watt-Watson J. Peer support intervention trials for individuals with heart disease: a systematic review. Eur J Cardiovasc Nurs. 2010;9:57–67. https://doi.org/10.1016/j.ejcnurse.2009.10.002 .

Qi L, Liu Q, Qi X, Wu N, Tang W, Xiong H. Effectiveness of peer support for improving glycaemic control in patients with type 2 diabetes: a meta-analysis of randomized controlled trials. BMC Public Health. 2015;15:471. https://doi.org/10.1186/s12889-015-1798-y .

Small N, Blickem C, Blakeman T, Panagioti M, Chew-Graham CA, Bower P. Telephone based self-management support by 'lay health workers' and 'peer support workers' to prevent and manage vascular diseases: a systematic review and meta-analysis. BMC Health Serv Res. 2013;13:533. https://doi.org/10.1186/1472-6963-13-533 .

Tang TS, Ayala GX, Cherrington A, Rana G. A review of volunteer-based peer support interventions in diabetes. Diabetes Spectr. 2011;24:85–98. https://doi.org/10.2337/diaspect.24.2.85 .

Walshe C, Roberts D. Peer support for people with advanced cancer: a systematically constructed scoping review of quantitative and qualitative evidence. Curr Opin Support Palliat Care. 2018;12:308–22. https://doi.org/10.1097/SPC.0000000000000370 .

Higgins, J. P. T., Green, S. (editors). Cochrane Handbook for Systematic Reviews of Interventions. 2011;Version 5.1.0 [updated March 2011]. The Cochrane Collaboration. www.cochrane-handbook.org .

Festinger L. A theory of social comparison processes. Hum Relat. 1954;7:117–40.

Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet. 2007;370:859–77. https://doi.org/10.1016/S0140-6736(07)61238-0 .

Leamy M, Bird V, Le Boutillier C, Williams J, Slade M. Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis. The Br J Psychiatry. 2011;199(6):445–52. https://doi.org/10.1192/bjp.bp.110.083733 .

Gopalan G, Lee SJ, Harris R, Acri MC, Munson MR. Utilization of peers in services for youth with emotional and behavioral challenges: a scoping review. J Adolesc. 2017;55:88–115. https://doi.org/10.1016/j.adolescence.2016.12.011 .

Tajfel H. The achievement of inter-group differentiation. In H. Tajfel (Ed.), differentiation between social groups 1978;77–100. London: Academic Press.

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We would like to thank Dr. Michael Gardner (Research Fellow, Institute of Applied Health Research) who kindly supported data extraction.

This work was part supported by a grant from Bowel Research UK.

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Thompson, D.M., Booth, L., Moore, D. et al. Peer support for people with chronic conditions: a systematic review of reviews. BMC Health Serv Res 22 , 427 (2022). https://doi.org/10.1186/s12913-022-07816-7

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What does science say about the value of peer support.

Much evidence supports that peer support is a critical and effective strategy for ongoing health care and sustained behavior change for people with chronic diseases and other conditions, and its benefits can be extended to community, organizational and societal levels.

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Peer Support for Diabetes

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Lived experience peer support programs for suicide prevention: a systematic scoping review

• Marisa Schlichthorst   ORCID: orcid.org/0000-0003-2627-7238 1 ,
• Ingrid Ozols 2 ,
• Lennart Reifels 1 &
• Amy Morgan 1  

International Journal of Mental Health Systems volume  14 , Article number:  65 ( 2020 ) Cite this article

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Peer-led support models have gained increasing popularity in suicide prevention. While previous reviews show positive effects of peer-led support for people with mental health problems and those bereaved by suicide, little is known about the types of lived experience peer support programs in suicide prevention and whether these are effective in improving the health and wellbeing of people at risk of suicide. The aim of this paper is to provide an overview of peer support programs that aim to reduce suicidality and are led by people with lived experience of suicide.

We conducted a systematic scoping review, involving a search of three academic (Medline, PsycINFO, Embase) and selected grey literature databases (Google Scholar, WHO Clinical Trials Registry) for publications between 2000 and 2019. We also contacted suicide prevention experts and relevant internet sites to identify peer support programs that exist but have not been evaluated. The screening of records followed a systematic two-stage process in alignment with PRISMA guidelines.

We identified 8 records accounting for 7 programs focussed on peer-led support programs in suicide prevention. These programs employed a range of different designs and included a variety of settings (schools, communities, rural and online). Only 3 of the 7 programs contained data on effectiveness. With the small number of eligible programs the findings from this review are limited and must be interpreted with caution.

Conclusions

Despite the increased focus of policymakers on the importance of peer support programs in suicide prevention, our scoping review confirms an evidence gap in research knowledge regarding program design, implementation, and effectiveness. More rigour is required in reporting peer-led support initiatives to clarify the underlying definition of peer support and lived experience and to enhance our understanding of the types of current peer support programs available to those experiencing suicidality. Further, we need formal and high-quality evaluations of peer support suicide prevention programs led by people with lived experience to better understand their effectiveness on participant health across different settings and delivery modalities and to allow for comprehensive systematic reviews and meta-analysis in future.

Peer support is a subjective and context specific relationship which is based on lived experience, sharing common life experiences, circumstances, situations and values [ 1 ]. It is generally viewed as a “system of giving and receiving help, founded on key principles of respect, shared responsibility and mutual agreement of what is helpful” [ 2 ]. This mutual experience creates a deep, holistic understanding where people are able to ‘be’ with each other, without the constraints of a hierarchical (expert/patient) relationship [ 2 ] and can focus on the understanding of another’s situation empathically through the shared experience of emotional and psychological pain which can aid recovery [ 3 ]. Peer support programs have been shown to offer alternative support options in crisis and care, and an effective strategy to engage with people that traditional health services fail to reach [ 4 ].

Aiming to address restrictive psychiatric and mental health care models in the late 18th century, the ex-patient/psychiatric survivor movement advocated for mutual support, user-led activities, reduction of marginalisation and stigma and civil rights for mental health patients [ 5 , 6 ]. As such the interest in peer support by health care services and research was first focussed on mental health conditions and in line with a greater focus on recovery-based and consumer-focussed care in mental health [ 3 ]. Since the early 1990s support has come from government and policy agencies and advocacy groups for building a peer support workforce in health care across a broad range of health conditions [ 7 , 8 , 9 ]. More recently Government agencies call to incorporate peer support models within conventional health services for recovery and expand the peer support workforce [ 10 , 11 ], therefore encouraging new services to be offered to people at risk of suicide.

As such, peer-led mental health support programs both in community and services settings have steadily grown and some evidence for their effectiveness has emerged [ 12 ]. For example, studies found that peer support can improve empowerment and hope for recovery for people with severe mental health conditions [ 13 , 14 ], and reduce mental health symptoms for those individuals with severe mental health conditions (e.g. schizophrenia and clinical depression) [ 15 ].

Similarly to the recovery pathway from mental health issues, using peer specialists in suicide prevention may be crucial for constructive coping, support, empowerment, hope and rediscovering meaning in life through the experience of someone who survived suicide [ 16 ]. Some evidence on effectiveness is also available for postvention programs for people bereaved by suicide. Summarised in recent literature reviews, peer support programs were effective in reducing grief symptoms, improving psychosocial and suicide related outcomes, and increasing personal growth and well-being in bereaved suicide survivors [ 17 , 18 , 19 ]. A few qualitative studies also provide insight into how peer support can positively impact on recovery from suicidality through experiencing mutual understanding, non-judgemental environments and acceptance [ 16 , 20 , 21 ]. However, little is known about what types of peer support models exist for people who experience suicidality and whether these are effective in reducing suicidality [ 22 ]. This knowledge gap is at contrast with the growing recognition and presence of peer support programs in health service delivery today.

Addressing this knowledge gap, we undertook a systematic scoping review of literature on peer-led suicide prevention programs with a focus on reducing suicidality in individuals and supporting recovery from suicidality. Our aim was to identify what types of peer-led suicide prevention support programs exist and investigate whether these have been evaluated on their effectiveness to reduce suicide risk. For this review peer support was defined as a suicide prevention program or initiative that was delivered by peers with a lived experience of suicide to people experiencing suicidality or having personal history of suicidality in a formal or informal manner. Hereby formal delivery refers to a specifically designed service or program while informal delivery means an organically grown support initiative mostly found in peer support groups [ 10 ]. Lived experience is highlighted as essential in suicide prevention as it follows the rationale of added benefit of personal experience in recovery [ 8 ].

This scoping review was designed following a methodological framework for scoping studies developed by Arksey and O’Malley’s in 2005 and further revised by Levac et al. in 2010 [ 23 , 24 ]. The review process followed the recommended five stages: identifying the research question; identifying relevant studies; selecting studies; charting the data; and collating and summarising findings. We included key stakeholder consultations as part of our grey literature search strategy, which is described in detail below.

This review was conducted in accordance with the PRISMA recommendations for systematic reviews [ 25 ] and the review protocol was registered with PROSPERO (CRD42018109620).

Identifying the research question

A research team was convened consisting of three researchers in field of suicide prevention (MS, AM, LR) and one researcher with lived experience and consultancy roles in mental health and suicide related peer-support (IO). Using a co-design methodology, the team met to discuss the purpose of the review and was guided by IO’s experience in the peer support sector of suicide prevention in developing the review protocol and research questions [ 26 , 27 ].

Two exploratory research questions were developed: What types of suicide prevention peer-support programs delivered by people with lived experience currently exist? What do we know about their effectiveness? These broad questions allow us to generate an overview of research undertaken on this topic and to identify where the research gaps in peer-led support programs in suicide prevention lie.

Identifying relevant studies

We undertook a systematic search for peer reviewed articles, a search of grey literature databases, and a website search and expert consultations to identify eligible programs. A systematic search of the literature was conducted for articles published between 2000 and 2019 using Medline (PubMed), PsycINFO (OVID interface), and EMBASE (OVID interface). Bibliographies of previous systematic reviews and included papers were also searched. Grey literature was searched to include research that had not been peer-reviewed, including Google Scholar and the World Health Organization (WHO) Clinical Trials Registry (limited to a 5-year period from 2013 to 2018). To identify existing suicide prevention peer-led support programs, we also approached clinical and academic content experts and searched relevant internet sites including organisations known to be active in suicide prevention. See Additional file 1 : Table S1 for a list of identified and screened websites and programs.

Search terms were developed relating to the three key concepts underpinning the literature review: suicide, peer support and lived experience. These were in alignment with our definition of lived experience peer-led support programs in suicide prevention. Alternative terms for peer support were developed and refined during iterative test searches. The final search strategy was developed using medical subject headings and free text words related to peer support and suicide prevention. Search terms were adjusted to fit the requirements of different databases. A complete list of search terms by database is available in Additional file 2 : Table S2.

Study selection

All records were imported into Endnote (version X8.2) and screened for inclusion in two stages. In the first stage, one researcher (AM) screened titles and abstracts for potential inclusion. In stage 2, the full texts of retrieved articles were screened independently by two researchers (AM and MS). Discrepancies were resolved in a meeting between the two researchers. Google Scholar records were screened first by title and abstract and then by full text by MS. WHO Clinical Trials Registry entries were screened by LR. Grey literature was retrieved by IO via internet search and consultations with experts in the area and then screened for inclusion in a team meeting by IO, LR, MS and AM.

Records were eligible if they included a peer-led support program with a focus on suicide prevention for people who experience suicidality. Peer supporters had to have lived experience of suicide; they could be community volunteers, people with similar experiences, or health professionals/health care staff if they had a lived experience of suicide and this informed their support role as peer supporter. Our review was not restricted to programs with matched lived experiences. There were no restrictions on the delivery mode of the programs; for example, programs could be delivered one-on-one, in group settings, as telephone support, online, at home, or in respite care.

We excluded records if programs were not delivered by people with a lived experience of suicide or where this could not be determined from the program description; were suicide bereavement programs; were capacity building or workforce training programs such as gatekeeper training, suicide awareness raising or suicide literacy programs; were focussed on improving mental health more broadly; or were a component of a multi-component intervention and not described separately within the larger program.

Articles in academic databases and Google Scholar had to be published between January 2000 and August 2019 and trials had to be registered on the WHO Clinical Trials Registry between 2013 and 2018. Academic databases were first searched on 14 June 2018. A second search of the academic databases was run on 29 August 2019 after the authors became aware of new evidence published since the original search. Google Scholar was searched on 21 June 2018 and the Trial Registry was searched on 7 September 2018. There was no time restriction on programs and records identified through expert consultation and web searches. We included any evaluation reports of eligible programs, irrespective of study design, setting, participant age, and publication language, so long as they could be translated into English. The Flow Diagram in Fig.  1 includes the number of records at each screening stage for all data searches and data sources combined.

Flow diagram illustrating the literature search process

Following these criteria, we identified 4077 records through electronic searches and 408 through searching other sources including grey literature, websites and expert consultations. Following removal of duplicates, 3058 records were screened by title and abstract information. This led to the exclusion of 2925 records. The remaining 133 records were read in full text by AM and MS who reached consensus on the final inclusion of 8 records according to the selection criteria. Of these 8 records, two referred to the same program, and were therefore summarised as one program in the results section.

Charting the data

Records identified for final inclusion were extracted into a charting table which documented the following information: Reference, title and country of the program; program description including setting modality and lived experience mode; study aim and methodology; sample characteristics and key findings (if the program had been evaluated). Table  1 lists details on all identified programs.

Collating and summarising findings

The information in the charting table was then synthesised in accordance with the two research questions of this paper. Due to the variation in study design and the absence of evaluation data for many identified programs we focussed on a narrative summary of studies. First, we provide an overview of the types of peer support suicide prevention programs (research question 1) by briefly summarising programs by their setting, modality and the role of lived experience. Secondly, for those programs that had been evaluated we characterise the study aim and methodology and discuss key findings regarding their effectiveness for suicide prevention (research question 2) (Table  1 ).

Types of suicide prevention peer support programs

Our search identified eight records that fulfilled the inclusion criteria. These described seven programs that were from four different countries: USA [ 3 ], Germany [ 2 ], China [ 1 ], and Australia [ 1 ], and which varied in setting and design (see Table  1 ). Of the seven programs, four included an evaluation component [ 28 , 29 , 30 , 31 , 32 ] and three provided descriptive accounts of a program [ 33 , 34 , 35 ]. Four peer support programs provided group support [ 28 , 29 , 30 , 31 , 34 ], two were designed to deliver one-on-one support [ 32 , 33 ] and one program included mixed modes of support [ 35 ]. Regarding the program settings, two programs were delivered in clinical settings [ 32 , 35 ], two in the community [ 28 , 33 ], two online [ 29 , 30 , 31 ] and one in schools [ 34 ].

Salvatore [ 35 ] presented a mixed mode peer support program within a psychiatric hospital. It was offered to patients of the hospital and their families. The hospital employed two peer support staff to deliver one-on-one peer support as well as group support. While this program has been implemented as part of the Montgomery County Emergency Service, evaluation data on its effectiveness has yet to be published. The second program designed for patients in clinical settings was the Peers for Valued Life (PREVAIL) program [ 32 ]. This program is a one-on-one support service for people who had attempted suicide and were patients of a psychiatric ward. Patients were teamed up with a peer specialist with lived experience of suicide and weekly meetings were held for up to 12 weeks after discharge from the ward. Peer specialists received training on risk assessment, using suicide prevention tools, communication and relationship building and motivational interviewing. In situations of acute risk clinicians were contacted. The aim of this program was to reduce suicide risk post-discharge from a psychiatric ward.

The two community-based suicide prevention programs were designed to provide support to those in crisis or experiencing suicidal ideation. Firstly, the Alternatives to Suicide program (USA) runs peer support groups for people experiencing suicidality [ 28 ]. Open group discussions are facilitated by trained peer supporters to enable conversations around the reasons and factors that may have contributed to someone wanting to die. Reflective of the key principles of Validation, Curiosity, Vulnerability and Community the conversations are non-judgemental and free of boundaries. Groups provide a safe and comfortable space to talk and focus on offering a non-clinical environment to build trust. Secondly, the Peer CARE Companion Program (Australia) offered through the Way Back Support Service is a new program which is currently being trialled [ 33 , 36 , 37 ]. It is directed at supporting people with a lived experience of suicide (experiencing a suicidal crisis or after a suicide attempt) in one-on-one peer support settings. The program was developed through a collaboration between three mental health organisations in Australia (Beyond Blue, New Horizons and Roses in the Ocean). Two trials and a consultation process including people with lived experience in 2017 and 2018 led to a revision of the program and the results of a second trial are yet to be released.

Two programs were set online using data from online messaging boards [ 29 , 30 , 31 ]. Both aimed at better understanding the benefits and risks of participation to people experiencing suicidality by looking at the effect that using online messaging boards has on participants. These online messaging boards are best described as informal group support interventions. While meaning to support people who experience suicidality, due to their open entry format they allow both people with lived experience and non-suicidal people to participate. The content is participant/online user driven with limited control for quality and safety for people at risk.

Finally, a school-based program aimed at early detection of at-risk youth in Chinese schools, offered peer group support sessions led by students and supported by teachers and the school community [ 34 ]. Students at risk were identified by peers or teachers and invited to participate in student-led support groups that met regularly. Teachers visited the groups monthly to help address any issues if needed. Group membership was voluntary and group leadership rotated. Group members were taught how to recognise unhappy and depressive behaviour in peers. Group leaders reported to the teacher and were able to refer students further if concerned.

With the exception of the school-based peer support program, which broadened its scope to include mood, depression and self-esteem as early warning indicators of suicidality, all programs were specifically aimed at supporting people with a lived experience of suicide. It was however decided to include the school based intervention as its overall goal was described as reducing suicide risk in youth.

Effectiveness of suicide prevention peer support programs

Three of the seven identified programs contained evaluation data; two were quantitative studies [ 28 , 29 , 30 ], one was qualitative [ 31 ] (see Table  1 ).

The Alternatives to Suicide program reported early findings from internal feedback surveys with attendees of the support groups [ 28 ]. Findings indicate that attending the groups was perceived as helpful as participants felt that they could talk freely about their experiences. Attending the groups had improved at least one area in attendees’ lives. Areas of greatest improvement were increased sense of community and a better understanding of why suicidal thoughts may come up.

Kral and Eichenberg found that participation in online peer support forums decreased the intensity of suicidal thoughts [ 29 , 30 ]. The authors collected data from participants of the online forums via an online survey. Thirty-one percent of participants self-reported a decrease in intensity of suicidal thoughts as a result of their participation in the messaging boards. While 22% of respondents said they were more motivated to seek professional help, using suicide messaging boards did not increase help-seeking outside the forums. The main motivation for using online forums was for emotional support, to feel understood and receive comforting reactions.

In a qualitative analysis of threads from a suicide online forum Niederkrotenthaler and colleagues [ 31 ] found that participation in this forum can help to improve a person’s suicidality. The authors downloaded threads from seven pre-identified suicide message boards and thematically analysed a random selection of these threads. Several communicative strategies were associated with psychological improvements in online forum participants; these were receiving constructive advice, being actively listened to, receiving sympathy for one’s struggle, and provision of alternatives to suicide by other members of the forum.

While the Pilot Randomised Controlled Trial of the PREVAIL program did assess the programs feasibility and acceptability by collecting quantitative and qualitative data on peer specialist performance, this trial was unable to assess the programs efficacy in reducing suicidality in participants due lack of power [ 32 ].

Peer-led support programs are increasing in mental health and suicide prevention and are seen as worthy additions to conventional clinical care and alternative support options for community care [ 38 ]. While there is evidence for the effectiveness of peer support programs for people with severe mental illness and also for people bereaved by suicide [ 14 , 18 ], only little and mostly anecdotal data has been published on peer-led support programs with a focus on reducing suicidality. While Government organisations and peak agencies are calling for an inclusion of peer-led support into standard mental health care models, the evidence on what these support services look like, how they can be integrated into conventional care and how effective they are as a stand-alone service is lacking. This led to believe that research in this space is still in its infancy and therefore warrants further attention.

This study is the first scoping review of published literature on peer support programs for people experiencing suicidality. We systematically searched academic databases, grey literature databases, searched the web and consulted experts in the field, strictly focussing on peer-led support programs that set out to reduce suicidality in participants. We strictly excluded programs with a broader focus on mental health and also excluded bereavement programs. Our search identified 8 records accounting for 7 programs that focussed on peer-led support programs in suicide prevention. The 7 eligible programs employed a range of different designs and included a variety of settings (schools, communities, rural and online). Only three programs provided evaluation data, and this data was descriptive on all accounts. This small number of eligible programs highlights a general scarcity of publications on peer-led suicide prevention programs and their evaluation. While the little data available indicates some positive and promising results for peer-led support in suicide prevention, it remains anecdotal at this stage. Despite the increased recognition of peer-led support programs this review highlights that the evidence gap on effective designs and efficacy of programs persists.

Our findings hint at the potential for online forums as a support hub for people with lived experience of suicide and the potential for increased research for peer-led support in this setting, keeping in mind the risk that these unmoderated environments can carry. During the screening of records we identified a large number of community driven initiatives, yet none of them had been evaluated and many focussed on awareness raising and training of support workers and were therefore not included here. In essence there is an evidence gap for peer-led community-based suicide prevention programs regarding their effectiveness to reduce suicidality in the community.

On an exciting note, our consultations with experts suggests there are signs for new peer-led community-based peer support programs to be developed and future evaluations of some of these programs are planned. The pilot trial of the PREVAIL peer support program shows that it is possible and feasible to integrate peer support into the care program for people who experience suicidality, yet formal evaluation of these kinds of programs is needed to determine their effectiveness to reduce suicidality [ 32 ]. Since the potential for peer-led support in suicide prevention has increasingly been acknowledged by policy makers [ 39 ] we anticipate that this in turn will positively influence program development and evaluation in the future and that we will continue to expand our knowledge and understanding of peer-led suicide prevention.

Challenges and limitations

In screening the literature, we identified that 84 records had to be excluded in the full-text review stage due to either not providing enough information on the nature of the lived experience of peer supporter workers or because lived experience was defined more broadly and not specific to suicidality. For example, it was frequently unclear if a peer support program was in fact peer-led or led by a clinician, and when the program was peer-led it did not specify if the peer supporter had lived experience of suicide or whether this was defined more broadly in the context of mental health. It is possible that the lack of clarity in the definition of peer support may have led to the exclusion of otherwise eligible programs during the screening process of this review.

Further, we found that in some programs the definition of peers was not aligned with our selection criteria. Some programs described their intervention as peer group support, yet the group was led by a health professional [ 40 ]. Others had a peer supporter as co-facilitator alongside a leading health professional, therefore not qualifying as a peer-led program [ 41 ]. In particular, school-based programs working with students tended to select peers on the basis of age or belonging to the same social group but did not make suicidal experiences part of the condition for becoming a peer supporter [ 42 , 43 ].

Despite the effort that has gone into defining peer support and lived experience in the context of suicide prevention in recent years [ 2 , 10 ], this seemingly has not yet translated into research designs and publications. The findings from this review highlight that authors follow varying definitions for peer-led support and often fail to provide adequate detail in the description of their program about what constitutes peer-led support in their respective program. This limits our understanding of the nature of peer support within existing programs and ultimately affects what implications we can draw from existing literature on the effectiveness of peer-led support suicide prevention programs.

Implications for future research, policy and practice

To advance knowledge on peer-led support programs in suicide prevention we suggest a few areas for future investment. Firstly, the development of a framework for standard reporting on peer support initiatives would greatly improve our understanding of the breadth and depth of current peer support programs [ 44 ]. In addition, improved quality of reporting on peer support roles in suicide prevention programs would help to clarify the underlying definition of peer support. Secondly, we need high-quality evaluations of peer support suicide prevention programs and of peer-led components within larger programs to better understand their effectiveness on participant health across different settings and delivery modes and to allow for comprehensive systematic reviews and meta-analysis in the future. This evidence can help enhance our efforts to better integrate peer-led support with conventional crisis support and find mutual benefit in both. Thirdly, while peer support is generally accepted as a positive addition to care by legislative bodies, we currently lack models for the efficient and effective integration of these programs alongside conventional care [ 38 , 45 ]. Addressing this issue would facilitate peer support to become a care component in its own merit.

It should also be noted what is already known about the positive effects of peer-led support in other related areas. While the knowledge is scarce on peer-led suicide prevention programs, it could be beneficial to revisit evidence from mental health peer support and investigate whether similar approaches could be adapted to suicide prevention. This practical approach could then be subject to further testing and refining to cater to specific needs in suicide prevention.

While peer support programs are seeing greater support in the community, in health care and by policy makers, very little is known about their effectiveness in the context of suicide prevention. This scoping review set out to review the evidence available to date. Yet, we identified very few peer-led support suicide prevention programs and even fewer evaluations. To improve our understanding in this field we encourage greater clarity in the reporting of key program characteristics and components and highlight the need for formal program evaluation. This will greatly assist in creating a vital evidence base to inform future program development and implementation which is much needed in this space.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files. The literature compiled through this search is available through publications and the internet.

Barnet I. Peer support in practice—a research report with recommendations for practice. Online; 2018.

Mead S, Hilton D, Curtis L. Peer support: a theoretical perspective. Psychiatr Rehabil J. 2001;25(2):134.

Article   CAS   PubMed   Google Scholar  

Davidson L, Bellamy C, Guy K, Miller R. Peer support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry. 2012;11(2):123–8.

Article   PubMed   PubMed Central   Google Scholar  

Sokol R, Fisher E. Peer support for the hardly reached: a systematic review. Am J Public Health. 2016;106(7):e1–8.

Chamberlin J. On our own: Patient-controlled alternatives to the mental health system. New York: McGraw-Hill; 1978.

Google Scholar  

Stratford AC, Halpin M, Phillips K, Skerritt F, Beales A, Cheng V, et al. The growth of peer support: an international charter. J Mental Health. 2017;28:1–6.

Department of Health, Commonwealth of Australia. The Fifth National Mental Health and Suicide Prevention Plan. 2017. Report No.: 11g26.

Repper J, Carter T. Using personal experience to support others with similar difficulties. Together/University of Nottingham/NSUN www together-uk org/wpcontent/uploads/downloads/2011/11/usingpersexperience pdf. 2010.

United Nations. Convention on the Rights of Persons with Disabilities (CRPD) New York, USA: United Nations; 2006. https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html .

Daniels AS, Bergeson S, Fricks L, Ashenden P, Powell I. Pillars of peer support: advancing the role of peer support specialists in promoting recovery. J Mental Health Train Educat Pract. 2012;7(2):60–9.

Article   Google Scholar  

Australian Government Department of Health. Peer workforce role in mental health and suicide prevention online: Australian Government Department of Health; 2019. https://www1.health.gov.au/internet/main/publishing.nsf/content/2126B045A8DA90FDCA257F6500018260/$File/PHN%20Guidance%20-%20Peer%20Workforce%20role%20in%20Mental%20Health%20and%20Suicide%20Prevention.pdf .

Bellamy C, Schmutte T, Davidson L. An update on the growing evidence base for peer support. Mental Health Soc Incl. 2017;21(3):161–7.

Fuhr DC, Salisbury TT, De Silva MJ, Atif N, van Ginneken N, Rahman A, et al. Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2014;49(11):1691–702.

Lloyd-Evans B, Mayo-Wilson E, Harrison B, Istead H, Brown E, Pilling S, et al. A systematic review and meta-analysis of randomised controlled trials of peer support for people with severe mental illness. BMC psychiatry. 2014;14(1):39.

Repper J, Carter T. A review of the literature on peer support in mental health services. J Mental Health. 2011;20(4):392–411.

Chi MT, Long A, Jeang SR, Ku YC, Lu T, Sun FK. Healing and recovering after a suicide attempt: a grounded theory study. J Clin Nurs. 2014;23(11–12):1751–9.

Article   PubMed   Google Scholar  

Andriessen K, Krysinska K, Hill NT, Reifels L, Robinson J, Reavley N, et al. Effectiveness of interventions for people bereaved through suicide: a systematic review of controlled studies of grief, psychosocial and suicide-related outcomes. BMC Psychiatry. 2019;19(1):49.

Bartone PT, Bartone JV, Violanti JM, Gileno ZM. Peer support services for bereaved survivors: a systematic review. OMEGA-J Death Dying. 2017;80:0030222817728204.

Linde K, Treml J, Steinig J, Nagl M, Kersting A. Grief interventions for people bereaved by suicide: a systematic review. PLoS ONE. 2017;12(6):e0179496.

Bergmans Y, Langley J, Links P, Lavery JV. The perspectives of young adults on recovery from repeated suicide-related behavior. Crisis. 2009;30(3):120–7.

Sun FK, Long A. A suicidal recovery theory to guide individuals on their healing and recovering process following a suicide attempt. J Adv Nurs. 2013;69(9):2030–40.

Huisman A, van Bergen DD. Peer specialists in suicide prevention: Possibilities and pitfalls. Psychol Serv. 2018;16:372.

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.

Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5(1):69.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9.

Roper C, Grey F, Cadogan E. Co-production–putting principles into practice in mental health contexts. Melbourne: University of Melbourne; 2018.

Pinfold V, Szymczynska P, Hamilton S, Peacocke R, Dean S, Clewett N, et al. Co-production in mental health research: reflections from the people study. Mental Health Rev J. 2015;20(4):220–31.

Davidow S, Mazel-Carlton C. Alternatives to Suicide. Unpublished manuscript, retrieved from the authors. 2018.

Eichenberg C, Otte TA, Fischer G. Suizidselbsthilfe-Foren im internet: eine befragungsstudie. Zeitschrift für klinische Psychologie und Psychotherapie. 2006;35(1):30–8.

Kral G. Online communities for mutual help: fears, fiction, and facts. In: Murero M, Rice RE, editors. The Internet and health care: theory, research, and practice. 1st ed. New Jersey: Lawrence Erlbaum Associates; 2006. p. 215–32.

Niederkrotenthaler T, Gould M, Sonneck G, Stack S, Till B. Predictors of psychological improvement on non-professional suicide message boards: content analysis. Psychol Med. 2016;46(16):3429–42.

Pfeiffer PN, King C, Ilgen M, Ganoczy D, Clive R, Garlick J, et al. Development and pilot study of a suicide prevention intervention delivered by peer support specialists. Psychol Serv. 2019;16:360–71.

Edwards B. The way back support service—peer care companion program. Personal communication. 2018.

John W, Bagley C, Hoi-Wah M. Preventing suicidal behaviour in Chinese youth: the role of peer counselling. Suicidal behaviour, bereavement and death education in Chinese adolescents: Hong Kong Studies: Routledge; 2018. p. 25-37.

Salvatore T. Peer specialists can prevent suicides: properly trained peers play a vital role in regional suicide prevention effort. Behav Healthcare. 2010;30(9):31–3.

Beyond Blue. Support after suicide attempt https://www.beyondblue.org.au/the-facts/suicide-prevention/after-a-suicide-attempt/support-after-a-suicide-attempt .

Roses in the ocean. peer care companions. https://rosesintheocean.com.au/peer-care-companions/ .

Klee A, Chinman M, Kearney L. Peer specialist services: new frontiers and new roles. Psychol Serv. 2019;16(3):353.

U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention. 2012 National Strategy for Suicide Prevention: goals and objectives for action. Washington DC: US Department of Health & Human Services; 2012

Smith D. CADS: carer and depression support group. Australian J Primary Health. 2006;12(3):9–11.

Hom MA, Davis L, Joiner TE. Survivors of suicide attempts (SOSA) support group: preliminary findings from an open-label trial. Psychol Serv. 2018;15(3):289.

Wright-Berryman J, Hudnall G, Hopkins R, Bledsoe C. Hope squads: peer-to-peer suicide prevention in schools. Children Schools. 2018;40(2):125–6.

Pickering TA, Wyman PA, Schmeelk-Cone K, Hartley C, Valente TW, Pisani AR, et al. Diffusion of a peer-led suicide preventive intervention through school-based student peer and adult networks. Front Psychiatry. 2018;9:598.

Dennis C-L. Peer support within a health care context: a concept analysis. Int J Nurs Stud. 2003;40(3):321–32.

Beales A, Wilson J. Peer support–the what, why, who, how and now. J Mental Health Train Educat Pract. 2015;10(5):314–24.

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Acknowledgements

We would like to acknowledge the support of the National Leadership in Suicide Prevention Research Project, led by Prof. Jane Pirkis at the Centre for Mental Health, the University of Melbourne, and its Steering Group members who provided valuable feedback on this review.

This study was supported through funding from the Australian Government Department of Health.

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AM designed the study in consultation with LR, MS and IO. AM and MS finalised the search terms, conducted the search and screened entries from academic literature databases. MS carried out the search and screening of Google Scholar entries. LR carried out the search and screening of entries from the WHO Clinical Trials Registry. IO searched websites and consulted with content experts in the field, whilst discussing findings with MS, AM and LR. MS compiled the charting table, summarised the findings, and drafted the manuscript. All authors read and approved the final manuscript.

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Additional file 1: table s1..

Search strategies by data bases.

Additional file 2: Table S2:

Programs identified through web search and expert consultations and screened for inclusion.

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Schlichthorst, M., Ozols, I., Reifels, L. et al. Lived experience peer support programs for suicide prevention: a systematic scoping review. Int J Ment Health Syst 14 , 65 (2020). https://doi.org/10.1186/s13033-020-00396-1

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More than 35% of Aboriginal and Torres Strait Islander adults live with cardiovascular disease, diabetes, or chronic kidney disease. There is a pressing need for chronic disease prevention and management among Aboriginal and Torres Strait Islander people in Australia. Therefore, this review aimed to synthesise a decade of contemporary evidence to understand the barriers and enablers of chronic disease prevention and management for Aboriginal and Torres Strait Islander People with a view to developing policy and practice recommendations.

We systematically searched for peer-reviewed published articles between January 2014 to March 2023 where the search was performed using subject headings and keywords related to “Aboriginal and Torres Strait Islander peoples,” “Chronic Disease,” and “Primary Health Care”. Quality assessment for all included studies was conducted using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. The data were extracted and summarised using a conventional content analysis approach and applying strength-based approaches.

Database searches identified 1653 articles where 26 met inclusion criteria. Studies varied in quality, primarily reporting on 14 criteria of the Aboriginal and Torres Strait Islander Quality Appraisal Tool. We identified six key domains of enablers and barriers of chronic disease prevention and management programs and implied a range of policy and practice options for improvement. These include culturally acceptable and safe services, patient-provider partnerships, chronic disease workforce, primary health care service attributes, clinical care pathways, and accessibility to primary health care services. This review also identified the need to address social and cultural determinants of health, develop the Aboriginal and Torres Strait Islander and non-Indigenous chronic disease workforce, support multidisciplinary teams through strengthening clinical care pathways, and engage Aboriginal and Torres Strait Islander communities in chronic disease prevention and management program design and delivery.

Enabling place-based partnerships to develop contextual evidence-guided strategies that align with community priorities and aspirations, with the provision of funding mechanisms and models of care through policy and practice reforms will strengthen the chronic disease prevention and management program for Aboriginal and Torres Strait Islander people.

Peer Review reports

Introduction

Aboriginal and Torres Strait Islander people have continuously demonstrated strength, tenacity, and resilience in the face of a high burden of chronic disease associated with profound health, social, economic and cultural and wellbeing impacts. The disproportionate burden of chronic disease—particularly cardiovascular disease (CVD), type II diabetes and chronic kidney disease (CKD)—is driven by the effects of colonisation. These effects include intergenerational trauma, racism and commercial determinants such as the introduction of ultra-processed foods, tobacco, sugar-sweetened beverages, and alcohol [ 1 , 2 ].

More than 35% of Aboriginal and Torres Strait Islander adults report having CVD, diabetes or CKD, 38% have two of these conditions and 11% have all three [ 3 ]. Nearly 70% of Australia’s burden of disease from CVD is attributable to modifiable risk factors including high blood pressure, dietary risks, high body weight, high cholesterol and smoking [ 4 ]. These risk factors, and subsequent disease, can be prevented. This prevention can be primordial (by addressing the structural drivers at a population level, such as food supply and recreation facilities) or primary (through identifying people at risk and taking individual steps to reduce that risk).

Primary prevention and management of chronic disease among Aboriginal and Torres Strait Islander people in Australia predominantly occurs in primary care settings. Universal primary care in Australia is largely funded through a fee-for-service model via the Medicare Benefits Scheme (MBS), with some augmentation for Aboriginal and Torres Strait Islander people through the Indigenous Australian’ Health Programme [ 5 ]. Primary care is delivered by a range of providers, including Aboriginal Community Controlled Health Organisations (ACCHOs) which are governed by a local board, Aboriginal Medical Services run by State and Territory governments, and private primary care services (sometimes referred to as ‘mainstream’ providers). Chronic disease services in primary care include risk assessment, support for healthy behaviours, referrals to allied health and pharmacology for risk reduction. High quality, culturally safe primary care can prevent the development of disease, and manage complications, for individuals and communities [ 6 , 7 , 8 ]. Strengthening primary care is a key strategic priority of the Australian government, [ 9 , 10 ] peak bodies and other stakeholders working to improve the health and well-being of Aboriginal and Torres Strait Islander communities [ 11 , 12 ].

Understanding how primary care services, prevention and management programs can best meet the needs of Aboriginal and Torres Strait Islander people, who are living with or at risk of chronic disease, is critical to addressing disparity in outcomes. A review conducted by Gibson et al. in 2015 explored chronic disease care for Indigenous communities globally, but there has been no comprehensive contextual evidence available focusing on Aboriginal and Torres Strait Islander people [ 13 ]. Therefore, there is a need for local evidence disease on chronic prevention and management for Aboriginal and Torres Strait Islander people in Australia. The Aboriginal and Torres Strait Islander People’s Health Assessment (MBS item number 715) is an annual health check funded for Aboriginal and Torres Strait Islander people and a cornerstone of early detection for chronic disease [ 14 ]. The number of Health Assessments fell for the first time in 2020 and 2021 after years of sustained growth [ 15 ]. The reduction in Health Assessments is likely to reflect disruption to routine primary care services during the COVID-19 pandemic [ 16 ].

Our team were contracted by the Australian Commonwealth Department of Health and Aged Care to understand best practice delivery of chronic disease care for Aboriginal and Torres Strait Islander people in 2020. The effects of the COVID-19 pandemic accelerated the need for this research and necessitated a pivot to rapid review strategy. The Oxford Centre for Evidence-Based Medicine highlights [ 17 ] that rapid review methodology can be used to meet the needs of commissioning bodies in policy-relevant timeframes. Therefore, this rapid review aims to synthesise contemporary and contextually relevant barriers and enablers for chronic disease care in primary care settings for Aboriginal and Torres Strait Islander people with a view to developing near term policy and practice recommendations.

This review applied the SelecTing Approaches for Rapid Reviews (STARR) decision tool that includes interaction with commissioners, scoping the literature, selecting approaches to literature search, methods for data extraction and evidence synthesis [ 18 ]. It was conducted based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline [ 19 ]. We searched two databases (Medline and Web of Science) to identify relevant studies from January 2014 to March 2023. These two databases were chosen because of following reasons: (i) Medline database provides access to articles from 5,200 journals in about 40 languages covering the biomedical and life sciences including Aboriginal and Torres Strait Islander peoples as a MeSH Headings and (ii) Web of Science is the world’s oldest interdisciplinary and widely used database of research publications that covers over 34,000 journals today.

This timeframe follows on from a systematic review conducted by Gibson et al. [ 13 ] which included data up to December 2013. This rapid review mirrors the Gibson methodology with two main changes: i) narrowing focus from Indigenous communities globally to Aboriginal and Torres Strait Islander contexts in Australia, ii) narrowing focus from all chronic diseases to focus on the three major contributors to chronic disease burden (cardiovascular disease, diabetes and chronic kidney disease). The review was performed between January to August 2023.

In this review, Aboriginal and Torres Strait Islander researchers and Thiitu Tharrmay Aboriginal and Torres Strait Islander Reference Group members rather than Thiitu Tharrmay Aboriginal Reference Group members were actively engaged and consulted in all steps, from the inception of the research questions to the completion of this review. Throughout the process, the research team met monthly with the Australian Commonwealth Department of Health and Aged Care during the period of this review to inform the scope of evidence synthesis.

Positionality: The senior author of this review Pearson (nee Gibson, first author of the 2015 review), is Kuku Yalnji/Torres Strait Islander health systems researcher. KB-B ( Torres Strait Islander ) and JC ( Gumbaynggir ) are experienced researchers with particular expertise in quality assessment of Aboriginal and Torres Strait Islander research studies. UNY ( Madhesi, Nepal ) is an implementation scientist, JD is a non-Indigenous medical student and RW is a non-Indigenous practising general practitioner and researcher.

Operational definition of key terminology used in this review:

Holistic care or support: The care process that involved strategies to support mental, physical, cultural and spiritual health which is beyond the individual level that values family and community capacity and governance [ 20 ].

Systems thinking: Systems thinking is c onceptual  orientation concerned with inter-relationships between different levels, institutions, systems, and people nested within social, cultural, economic, political contexts to deliver a holistic care [ 21 ].

Place-based partnerships: Place-based partnerships involve collaborative arrangements the unique needs and circumstances of both the community and service provider. In this context, place-based partnerships involve a formal partnership among government, service providers and First Nations representatives. These partnerships are specific to geographical locations and population groups and are aimed at designing or delivering services that directly respond to community needs, aspirations and local priorities, while valuing local cultural values [ 22 , 23 ].

Scoping the literature:

The search was performed using a combination of subject headings and keywords related to “Aboriginal and Torres Islander peoples,” “Chronic Disease,” and “Primary Health Care” using “OR” and “AND” iterated from the search strategy described in a study by Gibson et al. [ 13 ] The search strategy has been provided in Box 1. The search results obtained from two databases were imported to Endnote and uploaded on the Covidence platform for title and abstract and full-text screening [ 24 ]. Three reviewers (UNY, JMD and RW) independently screened the titles and abstracts of potential studies for eligibility based on inclusion and exclusion criteria (Table  1 ). Full-text articles were assessed by two reviewers and any disagreement that appeared during the screening process was resolved through discussion with the third reviewer (RW). The details of the screening process are documented as a PRISMA flow diagram (Fig.  1 ).

PRISMA 2020 flow diagram that included searches of databases and included studies

Box 1: Search strategy

Data extraction.

An iterative process was used to define data extraction domains. A total of fourteen potential domains were identified from the systematic review conducted by Gibson et al., alongside the He Pikinga Waiora Implementation Framework [ 25 ] and an access framework for Aboriginal and Torres Strait Islander people [ 26 ]. Further, three discussions were held within the team and with other Aboriginal and Torres Strait Islander researchers that identified eight domains of interest for both barriers and enablers (design attributes, chronic disease workforce, patient/provider partnership, clinical care pathways, access-accessibility, access-acceptability, system thinking and knowledge translation). A data extraction tool was prepared to extract information about the study characteristics (title, author, publication year, study setting, study objective, study design, types of services) and eight domains decided from the discussions mentioned above. A data extraction tool was shared with the  Thiitu Tharrmay Aboriginal and Torres Strait Islander Reference Group members rather than Thiitu Tharrmay Aboriginal Reference Group members  at the National Centre for Aboriginal and Torres Strait Islander Wellbeing Research at the Australian National University for their input. Based on inputs from Thiitu Tharrmay Aboriginal and Torres Strait Islander Reference Group members rather than Thiitu Tharrmay Aboriginal Reference Group members  and team discussion, some domains were consolidated and made an agreement of extracting data focusing six domains (culturally acceptable and safe services, patient provider partnerships, chronic disease workforce, primary health care service attributes, clinical care pathways and accessibility to primary health care services) the final data extraction tool included study characteristics and six domains (Fig.  2 )focusing both barriers and enablers. The data extraction tool was piloted on five included studies that facilitated shared understanding of approach to data extraction between team members. The data were extracted by UNY and JMD between May to June 2023.

Barriers and enablers to chronic disease prevention and management for Aboriginal and Torres Strait Islander people

Evidence synthesis and quality appraisal

Quality assessment for all included studies was conducted using the Aboriginal and Torres Strait Islander Quality Appraisal Tool that privileges Aboriginal and Torres Strait Islander people’s (knowing) epistemology, (being) ontology, (doing) axiology and ethical research governance [ 27 ]. The extracted data were analysed and summarised using a conventional content analysis approach [ 28 ] that allows the categories and the name of the categories to flow from the data and applying strength-based approaches [ 29 ].

Study selection and its characteristics

For the period 2013- 2023, a total of 1653 articles were retrieved from Medline ( n  = 927) and Web of Science ( n  = 726) databases. Of the total, 313 were duplicates which left 1340 articles for screening. Following the screening, 115 studies were selected for the full-text review. Upon full-text review, 89 articles were excluded, leaving 26 articles to be included for extraction and evidence synthesis. Service delivery models of the included studies were ACCHOs, government-run Aboriginal Medical Services and private general practice. The majority of the studies applied qualitative or mixed-method evaluation approaches (see Additional file 1 ).

Quality appraisal results

All studies met two criteria from the Aboriginal and Torres Strait Islander Quality Appraisal Tool: priority determined by community (criterion 1) and use of an Indigenous research paradigm (criterion 9). Over 92% studies met criteria for community protocols (criterion 5), 80% of studies met criteria addressing community consultation and engagement (criterion 2), Aboriginal and Torres Strait Islander leadership (criterion 3) and 76% studies had demonstrated Aboriginal and Torres Strait Islander governance in research (criterion 4). While 30% or less of the studies addressed existing intellectual and cultural property (criterion 6 and 7), 70% studies met the following criteria: Aboriginal and Torres Strait Islander people control over collection and management of research materials (criteria 8), use of strength based approach and acknowledging practices that have harmed Aboriginal and Torres Strait Islander communities (criterion 10) translation of findings into sustainable changes (criterion 11), benefit the participants and Aboriginal and Torres Strait Islander communities (criterion 12), demonstrate capacity strengthening for Aboriginal and Torres Strait Islander people (criterion 13), and researchers have opportunities to learn from each other (criterion 14). Details are provided in Table  2 .

Enablers and barriers to the implementation of chronic disease initiatives

Enablers and barriers (see Additional file 2 ) are presented under six thematic domains and relevant sub-themes presented below:

Primary health care service attributes

Aboriginal and Torres Strait Islander engagement and Aboriginal leadership in system design: Aboriginal and Torres Strait Islander project leadership and community engagement were overwhelmingly identified as key determinants for system design [ 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ]. Engagement through outreach cultural community events and stakeholder partnerships appear to amplify these effects [ 48 ]. Six studies investigated how information was exchanged between knowledge-users and researchers throughout the studies [ 30 , 38 , 44 , 45 , 46 , 47 ]. Knowledge users included Aboriginal and Torres Strait Islander communities, primary health care providers (ACCHOs and mainstream providers), Aboriginal and/ or Torres Strait Islander health workers and practitioners, other service providers, and policymakers. Alongside this, one study acknowledged the utilisation of cultural and scientific evidence to provide best-practice healthcare [ 37 ]. Aboriginal and Torres Strait Islander project leadership consistently facilitated trust and satisfaction. Use of evidence-based clinical care guideline in project implementation within community and services were other key benefits of knowledge translation.

Primary health car responsive to local community needs: Prospective analysis of potential barriers for program development were essential to program success, in order to actively address these in the program design and implementation. Many studies clearly demonstrated how barriers were overcome through tailored solutions including: outreach services to save patient time and cost [ 30 , 31 , 45 , 49 ]; free of charge services [ 31 , 49 , 50 , 51 ]; 24-h culturally safe service [ 32 , 37 , 50 ]; and telehealth specialist services [ 51 , 52 ]. Outreach services (delivered outside of the clinic facility) included home medication delivery, general visits by health workers to build trust and screening for conditions at community-based events. Services which were free at point of care included medications, nicotine patches, hospital specialist clinics, supplementary services (e.g. cooking class, aged care services), and preventive initiatives (e.g. blood pressure measurement, glucose monitor and health promotion activities). Innovative primary care models for Aboriginal and Torres Strait Islander patients included flexible appointment systems [ 32 , 37 , 50 ], multidisciplinary teams for providing holistic care [ 37 , 38 , 51 ], and clinical audits for quality improvement were also effective [ 31 , 34 , 39 , 45 , 46 ]. Incorporating chronic disease prevention into primary care occurred through health promotion initiatives [ 30 , 35 , 37 , 50 , 51 ], and patient-led prevention initiatives and management plans [ 30 , 46 , 50 ] were also found to be invaluable in addressing community needs. Six studies explicitly emphasised the importance of adequate resources and flexible funding for primary care services to meet local Aboriginal and Torres Strait Islander community priorities and needs [ 30 , 32 , 36 , 37 , 38 , 39 ].

A holistic approach to care: Aligned with Aboriginal and Torres Strait Islander peoples’ perception of health , holistic support [ 30 , 38 , 44 ] and care coordination was critical, necessitating flexible funding, and systems thinking and innovative, locally-adapted reforms [ 30 , 31 , 46 ]. Social referral approaches that connected people to non-clinical services were an important component in Aboriginal community controlled primary care settings, for example: connecting patients to exercise groups, providing access to housing, opportunities for hobbies, or home care services such as ‘Meals on Wheels’ [ 38 , 40 , 41 , 53 ].

Primary care access: Several barriers were identified, including: a lack of support specific to Aboriginal and Torres Strait Islander leadership [ 34 , 39 , 51 , 53 , 54 ]; competing priorities of healthcare service delivery [ 30 , 34 , 39 ]; and a lack of funding specifically address social determinants of health [ 31 , 55 ]. These were more pronounced in Aboriginal PHC. There were also insufficient resources to engage stakeholders in the co-development of primary care programs. This contributed to poor connections and relationships between multidisciplinary teams in health centres and other actors, including clinical information management systems [ 34 , 48 , 51 , 54 ], and high turnover of trained staff [ 34 , 50 , 54 ]. Some studies highlighted challenges in creating culturally appropriate services, due to the heterogeneity of Aboriginal and Torres Strait Islander populations [ 32 , 39 , 55 ]. Moreover, accessing primary care services was particularly challenging for people with the greatest health needs [ 31 ], including those with limited health literacy which made it difficult for people to engage with chronic disease care [ 48 , 49 ].

Chronic disease workforce

Creating supportive environment and building capacity of primary healthcare workforce: Enabling safe and good work environments for Aboriginal and Torres Strait Islander Health Workers and Practitioners [ 30 , 35 , 54 ], and a shared sense of purpose amongst staff to address the complex needs of patients [ 30 , 47 ] were consistently identified as enablers. Eight studies highlighted the importance of dedicated staff for chronic disease management, with clear delegation of responsibilities and a positive team culture created through an engaging and collaborative work environment [ 30 , 36 , 37 , 39 , 43 , 46 , 51 , 54 ]. Establishing the health care workforce with chronic disease ‘portfolios’ were considered more able to provide recurrent, culturally safe, preventative, and responsive healthcare for Aboriginal and Torres Strait Islander people because they had a greater chance of forming trusting relationships [ 32 , 41 , 48 , 50 ]. Included studies highlighted the need for training and development of the primary healthcare workforce [ 30 , 31 , 33 , 55 ]. Four studies had a particular focus on local Aboriginal and Torres Strait Islander Health Workers and Practitioners including the importance of recruitment and retention strategies [ 31 , 34 , 39 , 46 ], alongside a need to clarify their roles, provide Aboriginal and Torres Strait Islander role models [ 40 , 41 , 50 , 52 ], and ensure they are involved in clinical decision making [ 30 , 33 , 35 , 37 , 39 , 43 , 44 , 52 , 54 ]. The importance of intensive cultural safety training for staff to deliver safe care was emphasised in five studies [ 37 , 47 , 49 , 54 , 55 ].

Barriers to sustainable chronic disease workforce at primary health care services: Nine studies noted staff shortages and high staff turnover as adversely impacting continuity of care [ 32 , 33 , 34 , 39 , 43 , 46 , 50 , 51 , 53 ], and three studies noted inadequate clinical training for non-Indigenous staff [ 32 , 46 , 53 ]. Workforce limitations contributed to lack of time and resources to reach the patients that needed healthcare the most [ 31 , 45 , 46 ]. Nine studies specifically emphasised the substantial shortages, high turnover, and high rates of burnout of Aboriginal and Torres Strait Islander staff [ 33 , 34 , 39 , 43 , 46 , 51 , 53 , 54 , 55 ]. Work overload, inadequate support and a sense of being undervalued contributed to these issues [ 32 , 33 , 43 ]. Four studies noted shortages of specialists as a key barrier to integrated chronic disease management pathway [ 34 , 43 , 46 , 47 ].

Patient-provider partnerships

Optimal care achieved by effective trustful patient-provider partnerships: Eight studies found that enablers of trusting patient-provider relationships included strengthening patient knowledge through interactive learning, culturally appropriate conversation, and strengths-focused clinical engagement [ 30 , 32 , 33 , 35 , 38 , 50 , 53 , 55 ]. Numerous studies highlighted that holistic care required mechanisms for communities, families/carers and community leaders to be engaged with service providers [ 30 , 45 , 52 , 53 , 54 ]. ACCHOs were generally identified as meeting these needs by offering culturally safe care, longer consultation times to facilitate patient/provider partnerships [ 32 , 37 ], and communicating with the community when there were changes in services, or the implementation of new programs [ 31 ].

Contextual barriers to patient-provider partnership: Barriers to partnership included competing priorities for patients [ 53 ], patient experiences of racism and discrimination [ 32 ], patient discomfort with non-Indigenous services [ 32 ], and patients sensing that their holistic needs were unmet [ 42 ]. Two studies reported that limited health literacy with little shared provider-consumer understanding of chronic conditions were barriers to forming positive relationships [ 31 , 46 ]. Three studies noted a general lack of connection between the clinician and patient but did not interrogate the contributors to this [ 32 , 49 , 55 ].

Clinical care pathways

Enablers to effective clinical information systems: Nine studies found in-house information technology support within primary healthcare services was crucial for effective patient referral, coordination, and follow-up care [ 30 , 31 , 32 , 34 , 38 , 39 , 43 , 46 , 55 ]. Of these, two highlighted the importance of partnership-enabled integration across health service organisations using a shared electronic health record system, disease registration multidisciplinary care plans, and a patient recall system [ 30 , 36 ]. While translation of evidence-based care guidelines were not mentioned, five studies explained the importance of capacity building of staff and investment in systems development for the effective use of clinical information systems [ 30 , 34 , 39 , 43 , 51 ].

Barriers to efficient clinical information systems: Information technology barriers were profound, including poor integration information technology systems, mixed paper and electronic records [ 43 , 46 , 51 , 53 ], and poor infrastructure – most notably internet access [ 34 , 52 , 54 ]. Four studies noted shortages of trained and regular staff to implement new pathways, as a key barrier to integrated chronic disease management pathways [ 34 , 43 , 46 , 47 ]. Inconsistent models of care [ 44 ], and poor communication between different hospital and primary care systems [ 50 ] were also barriers.

Access to primary health care services

Many of the recognised domains of healthcare access (accessibility, accommodation, availability, accessibility and affordability) were identified [ 56 ].

People and family-centred reforms improve access to adequate primary care: Enablers of access to primary health care services were identified in ten studies [ 30 , 31 , 32 , 38 , 39 , 40 , 41 , 43 , 45 , 49 , 53 ]. Transportation support was a determining and/or motivating factor for clients to access health services [ 31 , 38 , 39 ] Other studies [ 45 , 49 ] [ 43 ] identified accommodation factors, particularly flexible appointment systems, reduced waiting times and co-location with allied health services as key enablers. In this review, a number of motivational factors were identified for people to attend services, including support or referral from family members, higher motivation to look after oneself following the death of a family member, and motivation texts or invitational messages for health check from service providers [ 32 , 41 , 53 ]. In addition, one study identified providing financial incentives as an enabler for health checks [ 32 ].

Unaddressed social determinants prevent access to primary care services: Barriers to accessing primary health care services related to socio-economic factors, health system factors and lack of health promotion factors. Socio-economic factors included accessibility and affordability considerations; lack of transport [ 30 , 31 , 32 , 44 , 46 , 49 , 50 , 53 , 54 , 55 ], inability to afford health and social services, and medication costs [ 31 , 32 , 44 , 47 , 49 ]. Some studies alluded to socioeconomic factors being prioritised over primary care attendance, including household crowding and food insecurity. Ensuring that services account for competing priorities, including family and cultural responsibilities, was an important enabler [ 45 , 55 ].

System related access barriers: Health system factors included high staff turnover, lack of availability of appointments, long waiting periods, physically inaccessible clinics [ 43 , 44 , 46 ], poor leadership of primary care services [ 32 , 45 , 47 , 48 , 49 ], and limited internet and computer access [ 47 ]. Inadequate awareness of available services was also problematic [ 31 , 33 , 49 ]; initiatives run by primary care services had limited uptake when the community was not made aware of these programs [ 46 ]. Health systems need to be able to deliver services and information multimodally. For example, not all patients have phones or phone credit all the time, so several forms of communication may be required.

Culturally acceptable and safe services

Enablers to deliver culturally safe and acceptable services: Cultural safety is essential to the development of a mutually respectful relationship between providers and Aboriginal and Torres Strait Islander people. A systems level approach is needed to address racism experienced by Aboriginal and Torres Strait Islander people in primary care settings [ 30 , 44 ]. Strategies for addressing or achieving cultural safety varied by context, but the role of Aboriginal and Torres Strait Islander healthcare workers including cultural brokerage was emphasised in two studies [ 31 , 52 ]. The need for gender-specific services and gender sensitivity was emphasised by five papers as an important part of providing culturally safe care. This included delivery of programs such as gender-based exercise groups, private consultation areas for males and females, gender specific health assessment days, and employing male and female Aboriginal and Torres Strait Islander healthcare workers [ 31 , 41 , 45 , 46 , 52 ]. The provision of culturally safe services also included a need for culturally appropriate education materials, artwork, and Aboriginal and Torres Strait Islander people’s voices and images as signifiers of belonging [ 30 , 44 , 45 , 46 , 53 ]. Three studies recognised the importance of enabling Aboriginal and Torres Strait Islander patients and staff access to flexibly attend to family, community, cultural and spiritual responsibilities, and obligations to provide a culturally safe service [ 37 , 42 , 44 ]. One study identified the need for robust anonymous feedback systems for staff and patients to improve culturally safe care delivery [ 47 ].

Barriers to deliver culturally safe and acceptable services: Barriers to delivering culturally safe and acceptable services related to systems, structures and lived experiences. Systems issues to providing culturally safe services included language barriers [ 32 ], poor health literacy among patients [ 54 ], long wait times due to staff shortages [ 32 , 50 , 54 ], a sense that services were superficial/rushed [ 31 , 42 ], and lack of physical space to provide holistic care or gender-based services [ 43 , 44 , 46 ]. Lived experiences of treatment of Aboriginal and Torres Strait Islander people within Western systems, including health and social services, elicits feelings of harm rather than help: a fear of discrimination and racism was a key barrier to Aboriginal and Torres Strait Islander patients accessing healthcare services in five studies [ 31 , 32 , 44 , 49 , 53 ] alongside fear of diagnosis due to historical trauma [ 53 ]. These barriers were amplified where there was limited access to Indigenous-specific services [ 32 , 44 , 46 ]. One study mentioned a tokenistic approach where very limited community input to governance, planning, and program design was sought to develop culturally safe initiatives [ 46 ].

This is the first review since 2014 [ 13 ] to present the barriers and enablers of implementing chronic disease prevention and management programs for Aboriginal and Torres Strait Islander people. The enablers and barriers found in this study have several policy and practice implications that should be considered in design, implementation, and funding targets for future chronic disease prevention and management programs.

The most striking addition to our findings, relative to the 2014 [ 13 ] review, is the acknowledgment of Aboriginal and Torres Strait Islander culture (including staff, protocols, leadership, practices and ways of doing business) as a key enabler to engagement and care delivery. Partly, this is attributable to this review’s narrower focus on the Australian context. It also likely reflects increasingly detailed academic descriptions of the ways in which leadership and governance tangibly affect care delivery as part of contemporary Closing the Gap reform. All studies included in this review made some acknowledgement of culture, albeit with variations in how deeply culture was considered as an enabler of care. Our review team grappled with how best to reflect this focus on culture, given that it is both a distinct concept and intimately embedded in all thematic domains. Ultimately, we have chosen to keep Aboriginal and Torres Strait Islander culture as a separate domain to ensure that culture is given independent consideration, in addition to attention within other thematic domains. It is evident that access to culturally appropriate, affordable and comprehensive services are vital for preventing and managing chronic conditions [ 37 ]. There is no one-size-fits-all approach for models of care for Aboriginal and Torres Strait Islander communities, and programs must be tailored to local context. Recent studies have identified numerous opportunities for improving access to primary care services: creating welcoming spaces, improving the cultural safety of healthcare services, building strong trustworthy relationships between patients and providers, and building primary healthcare workforce capacity [ 37 , 57 , 58 ]. The span of this theme is necessarily broad, encompassing Aboriginal and Torres Strait Islander leadership, physically welcoming spaces, training for non-Indigenous staff, time to build trusting relationships. Ensuring that culture is prospectively and proactively considered in funding and delivery of primary care of chronic disease should be a priority for practitioners and policy makers.

There is clear evidence that addressing holistic needs of Aboriginal and Torres Strait Islander people enables greater engagement, rather than a narrow clinical focus on physical aspects of health. This requires primary care services to acknowledge and address the broader social and cultural determinants of health for Aboriginal and Torres Strait Islander people. Many of these have a direct impact on both chronic disease risk factors and capacity to access care (chronic disease management), including poor access to healthy and nutritious food, inadequate housing, rurality, lack of transportation, and financial barriers [ 59 , 60 ].Some of these disparities more pronounced in remote and rural Australia, where Aboriginal and Torres Strait Islander communities are further marginalised by distance and poverty [ 61 , 62 ]. Enablers of chronic disease care, such as outreach services, transportation, and referrals networks to other allied health and community groups are more likely to be effective where holistic approaches are adopted. This is consistent with data from the Australian Institute of Health and Welfare highlighting the experiences of social inequity in Aboriginal and Torres Strait Islander communities and the positive impact on health outcomes when inequities are reduced [ 63 ]. Previous studies [ 13 , 64 ] have identified various obstacles to accessing primary health care services which include inadequate infrastructure, inflexible and inadequate funding to care for people holistically. Evidence also suggests that for Aboriginal and Torres Strait Islander people, travel to access health care means being separated from their country, family and social network that directly impacts their health and wellbeing as described by Milroy’s Dance of Life [ 65 ]. While government subsidies are in place, travel and accommodation costs incurred by Aboriginal and Torres Strait Islander people to access healthcare, may require upfront payment or indirect costs, perpetuating financial barriers for Aboriginal and Torres Strait Islander people living in rural and remote areas [ 66 ]. Therefore, it is crucial that primary health care initiatives take a holistic and system thinking approach to program design, considering the impact of social and cultural determinants on the health of individual, family members and their communities, with every attempt to reduce systemic barriers to access to healthcare where possible.This is only possible when funding mechanisms and models of care are flexible enough to account for local and individual contexts.

The profound impact of workforce was clear throughout this review. Recruiting, and retaining staff and effective training, were found to be key barriers to implementing and maintaining holistic patient-centred chronic disease prevention and management programs [ 13 , 67 ]. Evidence has shown that Aboriginal and Torres Strait Islander people prefer support delivered by Aboriginal and/or Torres Strait Islander staff and clinicians who have a better understanding of Indigenous wellbeing [ 64 , 68 ]. Despite the growth of the Aboriginal and/or Torres Strait Islander health workforce over time, this expansion has not matched the Aboriginal and Torres Strait Islander population growth [ 69 ] and increasing incidence of chronic disease. Unsurprisingly, being members of the community, they serve, Aboriginal and/or Torres Strait Islander Health Workers play an essential and unique role in delivering culturally safe and holistic care. However, a demanding work environment, low salary, inadequate support, [ 70 ] and demanding cultural brokerage with non-Indigenous colleagues [ 70 , 71 ] contribute to burnout that contributes to poor retention rates of Aboriginal and Torres Strait Islander primary care staff. This requires urgent attention, by individual primary care providers and through the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021 – 2031 [ 72 ]. Given the ongoing need for the non-Indigenous workforce in fulfilling workforce gaps required to deliver services for Aboriginal and Torres Strait Islander people, building cultural competence, continuing appropriate training and education pathways and strategies, providing job security and adequate remuneration are also crucial to address primary care workforce issues including the overburdening of the Aboriginal and Torres Strait Islander workforce [ 58 , 71 , 73 ]. Our findings highlight the need to develop the overall chronic disease workforce, with a specific focus for recruitment and retention of Aboriginal and Torres Strait Islander Health Workers and Practitioners and providing cultural safety training for all non-Indigenous staff. Alongside this, mechanisms for recognising the value and load of cultural mentorship/education should be developed. This reflects a recent research findings that showed 39% of Aboriginal and/or Torres Strait Islander workers ( n  = 1033) across Australia experienced high cultural load in terms of extra work demands and their engagement in educating others [ 74 ].

Chronic disease management requires multidisciplinary team input for effective care delivery [ 75 ]. When optimally resourced, primary care can serve a coordinating role in patient care, and effectively ensure patients have access to all allied health and specialist care they need [ 76 ]. Therefore, in order to engage Aboriginal and Torres Strait Islander people with chronic disease care and maintain continuity of care, there needs to be established, streamlined, and practitioner and patient friendly systems in place [ 76 , 77 ]. Existing evidence also documented inadequate number of general practitioners and lack of specialists in rural and remote settings of Australia compared to urban or city areas which hinders individuals, particularly Aboriginal and Torres Strait Islander people, to receive timely treatment for their co-occurring conditions in an integrated care approach [ 78 , 79 ]. A lack of integrated IT systems, poor infrastructure, and poor communication between primary care team members were found in this review to impede provision of such care. It is evident that strategies like GP care plans and tertiary care follow up are important sources of information for primary care providers, hospitals and patients which are supported by IT infrastructure [ 80 ]. Previous research highlighted the feasibility of system integration through utilising continuous quality improvement processes and community co-design [ 81 ]. Infrastructure investment such as internet access, in-house IT support and automated systems for follow-up care, is urgently required to ensure that patients who do present or engage with primary care in regional or remote settings, are retained in the system to enable coordinated access to the multidisciplinary care required for chronic disease management. Moreover, rapidly evolving technology such as tele-health, videoconferencing and Point-of-Care Testing may can facilitate access to the Aboriginal and Torres Strait Islander people in remote and rural areas. However, implementing these tools should be part of broader strategy rather than a substitute for solving problems faced by PHC such as workforce retention, undersupply or maldistribution issues [ 82 ]. Therefore, when implementing an integrated team care program [ 83 ] or any other integrated model of care, both barriers and facilitators identified herein should be applied to improve the continuity of care with considering the context.

Effective engagement of Aboriginal and Torres Strait Islander communities and their leadership in program design, delivery and evaluation of chronic disease programs is integral to improving Aboriginal and Torres Strait Islander health and increasing access to primary care services [ 84 , 85 ]. Previous studies have identified the following factors that enable engagement with Aboriginal and Torres Strait Islander communities: employment of local Aboriginal health workforce; trust and relationships; Aboriginal and Torres Strait Islander leadership; availability of flexible services to address holistic needs of local communities; benefits of engagement in service design and delivery; cost of participation and recognition of local Aboriginal knowledge and cultural traditions on study design implementation and dissemination [ 84 , 86 , 87 , 88 ]. These enablers align with those reported in health service research that engaged with Indigenous and marginalised communities in an international context [ 89 ]. Similarly, this review identified a range of impeding factors to engagement of Aboriginal and Torres Strait Islander people with primary health care. Key factors included: a fear or lack of trust on mainstream health facilities, lack of respect from health care providers, experiences of interpersonal and structural racism, lack of understanding of cultural differences to initiate an open discussion and a narrow concept of health that fails to consider the Aboriginal definition of health which is more comprehensive than the Western biomedical perspective of health that focuses on treating health conditions [ 90 , 91 , 92 ]. Evidence also shows that Aboriginal and Torres Strait Islander people in rural and remote communities do not have equitable access to PHC services, including lack of local available services to meet their holistic needs, inadequate infrastructure, high costs, long travel distance and insufficient workforce [ 59 , 93 ]. Therefore, trustful, and culturally safe engagement of Aboriginal and Torres Strait Islander communities through all aspects of the program design, implementation and evaluation is essential to program success, and where possible, the Aboriginal Health Workforce and ACCHOs should be utilised.

Policy and practice recommendations: This study identified several policy and practice recommendations (Table  3 ) that need to be considered for the implementation of chronic disease prevention and management programs for Aboriginal and Torres Strait Islander people in primary care. Our recommendations align with Australia’s Primary Health Care 10 Year Plan 2022–2032 ($632.8 million new investment) that has identified three streams of work: future focused health care; person-centred primary health care supported by funding reform; and integrated care, locally delivered [ 94 ].

Strengths and limitations

Strengths of the present study include (i) the generation of an evidence summary required to guide policy and practice is a short time frame, (ii) the application of iterative process from the design to completion of review with engagement of Aboriginal and Torres Strait Islander researchers and Thiitu Tharrmay Aboriginal and Torres Strait Islander Reference Group members rather than Thiitu Tharrmay Aboriginal Reference Group members , (iii) a quality appraisal of the included studies using Aboriginal and Torres Strait Islander Quality Appraisal Tool that privileges Aboriginal and Torres Strait Islander people’s ways of knowing, being, doing and (iv) interpretation of findings validated by Aboriginal and Torres Strait Islander knowledge champions.

One limitation of this review was that search was restricted to only two databases as the decision makers seek the evidence is a short period of time and were based on peer reviewed articles published in English language. We also acknowledge that the findings might not be comprehensive as the review was conducted in short timeframe, limitations in key words used and subjected to publication bias, as we omitted published program reports, grey literature, and policy guidelines from our inclusion criteria. Moreover, our search was limited to specific databases and terms, which could result in overlooking articles present in other databases or identified through alternate search terms. Despite these limitations, this review is Aboriginal and Torres Strait Islander researchers led that allowed Indigenous perspectives and knowledge to be integrated in the evidence synthesis; ensuring findings are meaningful for the broader sector.

This rapid review synthesises the barriers and enablers to designing and implementing chronic disease prevention and management programs for Aboriginal and Torres Strait Islander communities. While there is no one-size-fits-all approach to the heterogeneous Aboriginal and Torres Strait Islander communities, several policy and practice recommendations are broadly applicable to service providers. These include addressing social and cultural determinants of health, developing the Aboriginal and Torres Strait Islander and non-Indigenous chronic disease workforce, supporting multidisciplinary teams through strengthening clinical care pathways, and engaging Aboriginal and Torres Strait Islander communities in design and delivery of chronic disease prevention and management programs. This requires funding mechanisms and models of care that are flexible enough to account for local and individual context through policy and practice reforms. Moreover, enabling place-based partnerships to develop local and population-based strategies that align with community priories and aspiration is crucial for tackling increasing burden of chronic disease.

Availability of data and materials

All available materials are available as Additional material.

Abbreviations

Aboriginal Community Controlled Health Organisations

Medicare Benefits Schedule

Cardiovascular Disease

Chronic Kidney Disease

Preferred Reporting Items for Systematic Review and Meta-analysis Protocols

SelecTing Approaches for Rapid Reviews

Kairuz CA, Casanelia LM, Bennett-Brook K, Coombes J, Yadav UN. Impact of racism and discrimination on physical and mental health among Aboriginal and Torres Strait islander peoples living in Australia: a systematic scoping review. BMC Public Health. 2021;21(1):1302.

Article   PubMed   PubMed Central   Google Scholar  

Penm, E., Cardiovascular disease and its associated risk factors in Aboriginal and Torres Strait Islander peoples 2004–05, 2008, Australian Institute of Health and Welfare: Canberra.

Cardiovascular disease, diabetes and chronic kidney disease-Australian facts: Aboriginal and Torres Strait Islander people 2015 [ https://www.aihw.gov.au/reports/heart-stroke-vascular-disease/cardiovascular-diabetes-chronic-kidney-indigenous/summary ]

Australian Burden of Disease Study 2018-Key findings [ https://www.aihw.gov.au/reports/burden-of-disease/burden-of-disease-study-2018-key-findings ]

Swerissen H, Duckett S, Moran G. Mapping primary care in Australia. 2018. Grattan Institute. Available from: https://grattan.edu.au/wp-content/uploads/2018/07/906-Mapping-primary-care.pdf .

Shi L, Macinko J, Starfield B, Politzer R, Xu J. Primary care, race, and mortality in US states. Soc Sci Med. 2005;61(1):65–75.

Article   PubMed   Google Scholar  

Lavoie JG, Forget EL, Prakash T, Dahl M, Martens P, O’Neil JD. Have investments in on-reserve health services and initiatives promoting community control improved First Nations’ health in Manitoba? Soc Sci Med. 2010;71(4):717–24.

Thomas SL, Zhao Y, Guthridge SL, Wakerman J. The cost-effectiveness of primary care for Indigenous Australians with diabetes living in remote Northern Territory communities. Med J Aust. 2014;200(11):658–62.

Commonwealth of Australia, Department of the Prime Minister and Cabinet. Closing the Gap Prime Minister’s report 2017. Canberra: Department of the Prime Minister and Cabinet, 2017. Available at www.niaa.gov.au/sites/default/files/publications/ctg-report-2017.pdf .

Australian Institute of Health and Welfare 2023. Aboriginal and Torres Strait Islander Health Performance Framework: summary report July 2023. Canberra: AIHW. Viewed:17/07/2023.

The Royal Australian College of General Practitioners. Vision for general practice and a sustainable healthcare system. East Melbourne, Vic: RACGP, 2019. Available at www.racgp.org.au/advocacy/advocacy-resources/the-vision-for-general-practice/the-vision .

TOWARDS A NATIONAL PRIMARY HEALTH CARE STRATEGY: FULFILLING ABORIGINAL PEOPLES ASPIRATIONS TO CLOSE THE GAP.National Aboriginal Community Controlled Health Organisation, February 2009. https://www.naccho.org.au/publications-resources/ .

Gibson O, Lisy K, Davy C, Aromataris E, Kite E, Lockwood C, Riitano D, McBride K, Brown A. Enablers and barriers to the implementation of primary health care interventions for Indigenous people with chronic diseases: a systematic review. Implement Sci. 2015;10:71.

Yadav UN, Smith M, Agostino J, Sinka V, Williamson L, Wyber R, Butler DC, Belfrage M, Freeman K, Passey M, et al. Understanding the implementation of health checks in the prevention and early detection of chronic diseases among Aboriginal and Torres Strait Islander people in Australia: a realist review protocol. BMJ Open. 2023;13(6): e071234.

Australian Institute of Health and Welfare. Indigenous-‍specific health checks during the COVID-19 pandemic. https://www.aihw.gov.au/reports/indigenous-australians/indigenous-health-checks-during-the-covid-pandemic/contents/about

Follent D, Paulson C, Orcher P, O’Neill B, Lee D, Briscoe K, Dimopoulos-Bick TL. The indirect impacts of COVID-19 on Aboriginal communities across New South Wales. Med J Aust. 2021;214(5):199-200.e191.

Plüddemann A, Aronson JK, Onakpoya I, Heneghan C, Mahtani KR. Redefining rapid reviews: a flexible framework for restricted systematic reviews. BMJ Evid Based Med. 2018;23(6):201–3.

Pandor A, Kaltenthaler E, Martyn-St James M, Wong R, Cooper K, Dimairo M, O’Cathain A, Campbell F, Booth A. Delphi consensus reached to produce a decision tool for SelecTing approaches for rapid reviews (STARR). J Clin Epidemiol. 2019;114:22–9.

Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, Moher D, Peters MDJ, Horsley T, Weeks L, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73.

Lutschini M. Engaging with holism in Australian Aboriginal health policy–a review. Aust New Zealand Health Policy. 2005;2:15.

Oetzel J, Scott N, Hudson M, Masters-Awatere B, Rarere M, Foote J, Beaton A, Ehau T. Implementation framework for chronic disease intervention effectiveness in Māori and other indigenous communities. Glob Health. 2017;13(1):69.

Article   Google Scholar  

National Indigenous Australians agency. Priority Reform One: Formal partnerships and shared decision-making. 2023 Commonwealth Closing the Gap Implementation Plan. [ https://www.niaa.gov.au/2023-commonwealth-closing-gap-implementation-plan ].

Naylor C, Charles A. Place-based partnerships explained. The King's Fund. 2022 [ https://www.kingsfund.org.uk/publications/place-based-partnerships-explained ].

Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. www.covidence.org .

Oetzel J, Scott N, Hudson M, Masters-Awatere B, Rarere M, Foote J, Beaton A, Ehau T. Implementation framework for chronic disease intervention effectiveness in Māori and other indigenous communities. Global Health. 2017;13(1):69.

Davy C, Harfield S, McArthur A, Munn Z, Brown A. Access to primary health care services for Indigenous peoples: a framework synthesis. Int J Equity Health. 2016;15(1):163.

Harfield S, Pearson O, Morey K, Kite E, Canuto K, Glover K, Gomersall JS, Carter D, Davy C, Aromataris E, et al. Assessing the quality of health research from an Indigenous perspective: the Aboriginal and Torres Strait Islander quality appraisal tool. BMC Med Res Methodol. 2020;20(1):79.

Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–88.

Martin K, Mirraboopa B. Ways of knowing, being and doing: A theoretical framework and methods for indigenous and indigenist re‐search. J Aus Stud. 2003;27(76):203–214.

Askew DA, Togni SJ, Schluter PJ, Rogers L, Egert S, Potter N, Hayman NE, Cass A, Brown ADH. Investigating the feasibility, acceptability and appropriateness of outreach case management in an urban Aboriginal and Torres strait Islander primary health care service: a mixed methods exploratory study. BMC Health Serv Res. 2016;16:178.

Bailie J, Schierhout G, Laycock A, Kelaher M, Percival N, O’Donoghue L, McNeair T, Bailie R. Determinants of access to chronic illness care: a mixed-methods evaluation of a national multifaceted chronic disease package for Indigenous Australians. BMJ Open. 2015;5(11): e008103.

Canuto K, Wittert G, Harfield S, Brown A. “I feel more comfortable speaking to a male”: Aboriginal and Torres Strait Islander men’s discourse on utilizing primary health care services. Int J Equity Health. 2018;17(1):185.

Deshmukh T, Abbott P, Reath J. 'It’s got to be another approach’: an Aboriginal health worker perspective on cardiovascular risk screening and education. Aust Fam Physician. 2014;43(7):475–8.

PubMed   Google Scholar  

Bailie J, Laycock A, Matthews V, Bailie R. System-level action required for wide-scale improvement in quality of primary health care: synthesis of feedback from an interactive process to promote dissemination and use of aggregated quality of care data. Front Public Health. 2016;4:86.

Barrett E, Salem L, Wilson S, O’Neill C, Davis K, Bagnulo S. Chronic kidney disease in an Aboriginal population: a nurse practitioner-led approach to management. Aust J Rural Health. 2015;23(6):318–21.

Reeve C, Humphreys J, Wakerman J, Carroll V, Carter M, O’Brien T, Erlank C, Mansour R, Smith B. Community participation in health service reform: the development of an innovative remote Aboriginal primary health-care service. Aust J Prim Health. 2015;21(4):409–16.

Davy C, Kite E, Sivak L, Brown A, Ahmat T, Brahim G, Dowling A, Jacobson S, Kelly T, Kemp K, et al. Towards the development of a wellbeing model for aboriginal and Torres Strait islander peoples living with chronic disease. BMC Health Serv Res. 2017;17(1):659.

Blignault I, Norsa L, Blackburn R, Bloomfield G, Beetson K, Jalaludin B, Jones N. “You Can’t Work with My People If You Don’t Know How to”: Enhancing Transfer of Care from Hospital to Primary Care for Aboriginal Australians with Chronic Disease. Int J Environ Res Public Health. 2021;18(14):7233.

Bailie J, Matthews V, Laycock A, Schultz R, Burgess CP, Peiris D, Larkins S, Bailie R. Improving preventive health care in Aboriginal and Torres Strait Islander primary care settings. Global Health. 2017;13(1):48.

Seear KH, Atkinson DN, Henderson-Yates LM, Lelievre MP, Marley JV. Maboo wirriya, be healthy: community-directed development of an evidence-based diabetes prevention program for young Aboriginal people in a remote Australian town. Eval Program Plann. 2020;81: 101818.

Seear KH, Atkinson DN, Lelievre MP, Henderson-Yates LM, Marley JV. Piloting a culturally appropriate, localised diabetes prevention program for young Aboriginal people in a remote town. Aust J Prim Health. 2019;25(5):495–500.

Spurling GK, Bond CJ, Schluter PJ, Kirk CI, Askew DA. 'I’m not sure it paints an honest picture of where my health’s at’—identifying community health and research priorities based on health assessments within an Aboriginal and Torres Strait Islander community: a qualitative study. Aust J Prim Health. 2017;23(6):549–53.

Stoneman A, Atkinson D, Davey M, Marley JV. Quality improvement in practice: improving diabetes care and patient outcomes in Aboriginal community controlled health services. BMC Health Serv Res. 2014;14:481.

Webster E, Johnson C, Kemp B, Smith V, Johnson M, Townsend B. Theory that explains an Aboriginal perspective of learning to understand and manage diabetes. Aust N Z J Public Health. 2017;41(1):27–31.

Wood AJ, Graham S, Boyle JA, Marcusson-Rababi B, Anderson S, Connors C, McIntyre HD, Maple-Brown L, Kirkham R. Incorporating Aboriginal women’s voices in improving care and reducing risk for women with diabetes in pregnancy—a phenomenological study. BMC Pregnancy Childbirth. 2021;21(1):624.

Woods C, Carlisle K, Larkins S, Thompson SC, Tsey K, Matthews V, Bailie R. Exploring systems that support good clinical care in indigenous primary health-care services: a retrospective analysis of longitudinal systems assessment tool data from high-improving services. Front Public Health. 2017;5:45.

Sebastian S, Thomas DP, Brimblecombe J, Arley B, Cunningham FC. Perceived impact of the characteristics of the Indigenous Queensland B.strong brief intervention training program on uptake and implementation. Health Promot J Austr. 2022;33(1):245–56.

Kirkham R, Trap-Jensen N, Boyle JA, Barzi F, Barr ELM, Whitbread C, Van Dokkum P, Kirkwood M, Connors C, Moore E, et al. Diabetes care in remote Australia: the antenatal, postpartum and inter-pregnancy period. BMC Pregnancy Childbirth. 2019;19(1):389.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Cuesta-Briand B, Saggers S, McManus A. “It still leaves me sixty dollars out of pocket”: experiences of diabetes medical care among low-income earners in Perth. Aust J Prim Health. 2014;20(2):143–50.

Govil D, Lin I, Dodd T, Cox R, Moss P, Thompson S, Maiorana A. Identifying culturally appropriate strategies for coronary heart disease secondary prevention in a regional Aboriginal Medical Service. Aust J Prim Health. 2014;20(3):266–72.

Kirkham R, Boyle JA, Whitbread C, Dowden M, Connors C, Corpus S, McCarthy L, Oats J, McIntyre HD, Moore E, et al. Health service changes to address diabetes in pregnancy in a complex setting: perspectives of health professionals. BMC Health Serv Res. 2017;17(1):524.

Macniven R, Gwynn J, Fujimoto H, Hamilton S, Thompson SC, Taylor K, Lawrence M, Finlayson H, Bolton G, Dulvari N, et al. Feasibility and acceptability of opportunistic screening to detect atrial fibrillation in Aboriginal adults. Aust N Z J Public Health. 2019;43(4):313–8.

Conway J, Tsourtos G, Lawn S. The barriers and facilitators that indigenous health workers experience in their workplace and communities in providing self-management support: a multiple case study. BMC Health Serv Res. 2017;17(1):319.

Schmidt B, Campbell S, McDermott R. Community health workers as chronic care coordinators: evaluation of an Australian Indigenous primary health care program. Aust N Z J Public Health. 2016;40(Suppl 1):S107-114.

Campbell S, Roux N, Preece C, Rafter E, Davis B, Mein J, Boyle J, Fredericks B, Chamberlain C. Paths to improving care of Australian Aboriginal and Torres Strait Islander women following gestational diabetes. Prim Health Care Res Dev. 2017;18(6):549–62.

Saurman E. Improving access: modifying Penchansky and Thomas’s theory of access. J Health Serv Res Policy. 2016;21(1):36–9.

Davy C, Cass A, Brady J, DeVries J, Fewquandie B, Ingram S, Mentha R, Simon P, Rickards B, Togni S, et al. Facilitating engagement through strong relationships between primary healthcare and Aboriginal and Torres Strait Islander peoples. Aust N Z J Public Health. 2016;40(6):535–41.

Jongen C, McCalman J, Campbell S, Fagan R. Working well: strategies to strengthen the workforce of the Indigenous primary healthcare sector. BMC Health Serv Res. 2019;19(1):910.

Nolan-Isles D, Macniven R, Hunter K, Gwynn J, Lincoln M, Moir R, Dimitropoulos Y, Taylor D, Agius T, Finlayson H, et al. Enablers and Barriers to Accessing Healthcare Services for Aboriginal People in New South Wales, Australia. Int J Environ Res Public Health. 2021;18(6):3014.

Christidis R, Lock M, Walker T, Egan M, Browne J. Concerns and priorities of Aboriginal and Torres Strait Islander peoples regarding food and nutrition: a systematic review of qualitative evidence. Int J Equity Health. 2021;20(1):220.

Andermann A. Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ. 2016;188(17–18):E474-e483.

Markwick A, Ansari Z, Sullivan M, Parsons L, McNeil J. Inequalities in the social determinants of health of Aboriginal and Torres Strait Islander People: a cross-sectional population-based study in the Australian state of Victoria. Int J Equity Health. 2014;13(1):91.

Australian Institute of Health and Welfare (2022). Australia’s health 2022: in brief, catalogue number AUS 241. Australia’s health series number 18, AIHW, Australian Government. https://www.aihw.gov.au/reports/australias-health/australias-health-2022-in-brief/summary .

Hayman N. Strategies to improve indigenous access for urban and regional populations to health services. Heart Lung Circ. 2010;19(5–6):367–71.

Purdie P., Dudgeon P., Walker R. Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice. 2nd ed. Australian Government Department of the Prime Minister and Cabinet. ACT; Canberra, Australia: 2014.

Kelly J, Dwyer J, Willis E, Pekarsky B. Travelling to the city for hospital care: access factors in country Aboriginal patient journeys. Aust J Rural Health. 2014;22(3):109–13.

Moore L, Britten N, Lydahl D, Naldemirci Ö, Elam M, Wolf A. Barriers and facilitators to the implementation of person-centred care in different healthcare contexts. Scand J Caring Sci. 2017;31(4):662–73.

McGrath PD, Patton MA, Ogilvie KF, Rayner RD, McGrath ZM, Holewa HA. The case for Aboriginal health workers in palliative care. Aust Health Rev. 2007;31(3):430–9.

Lahn J., Puszka S., Lawton P., Dinku Y., Nichols N. and Markham F. (2020) Beyond Parity in Aboriginal and Torres Strait Islander Health Workforce Planning: Achieving Equity through Needs-Based and Strengths-Based Approaches, Commissioned Report No. 6, Centre for Aboriginal Economic Policy Research, Australian National University. https://doi.org/10.25911/5f88175975c5b

Lai GC, Taylor EV, Haigh MM, Thompson SC. Factors Affecting the retention of indigenous Australians in the health workforce: a systematic review. Int J Environ Res Public Health. 2018;15(5):914.

Gwynne K, Lincoln M. Developing the rural health workforce to improve Australian Aboriginal and Torres Strait Islander health outcomes: a systematic review. Aust Health Rev. 2017;41(2):234–8.

Australian Government Department of Health . National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021–2031. Available from: https://www.health.gov.au/sites/default/files/documents/2022/03/national-aboriginal-and-torres-strait-islander-health-workforce-strategic-framework-and-implementation-plan-2021-2031.pdf . In .

McCalman J, Campbell S, Jongen C, Langham E, Pearson K, Fagan R, Martin-Sardesai A, Bainbridge R. Working well: a systematic scoping review of the Indigenous primary healthcare workforce development literature. BMC Health Serv Res. 2019;19(1):767.

Diversity Council Australia/Jumbunna Institute (Brown, C., D’Almada-Remedios, R., Gilbert, J. O’Leary, J. and Young, N.) Gari Yala (Speak the Truth): Centreing the Work Experiences of Aboriginal and/or Torres Strait Islander Australians, Sydney, Diversity Council Australia/Jumbunna Institute, 2020.

Harris MF, Jayasinghe UW, Taggart JR, Christl B, Proudfoot JG, Crookes PA, Beilby JJ, Davies GP. Multidisciplinary team care arrangements in the management of patients with chronic disease in Australian general practice. Med J Aust. 2011;194(5):236–9.

Digital technologies and chronic disease management. Australian Journal for General Practitioners 2014, 43:842-846.

Michielsen L, Bischoff EWMA, Schermer T, Laurant M. Primary healthcare competencies needed in the management of person-centred integrated care for chronic illness and multimorbidity: results of a scoping review. BMC Primary Care. 2023;24(1):98.

Street TD, Somoray K, Richards GC, Lacey SJ. Continuity of care for patients with chronic conditions from rural or remote Australia: a systematic review. Aust J Rural Health. 2019;27(3):196–202.

Comorbidity Guidelines. Rural and remote populations [ https://comorbidityguidelines.org.au/part-c-specific-population-groups/rural-and-remote-populations#:~:text=The%20lack%20of%20specialists%20in%20rural%20and%20remote,of%20employed%20medical%20practitioners%20decreasing%20according%20to%20remoteness .]

Trankle SA, Usherwood T, Abbott P, Roberts M, Crampton M, Girgis CM, Riskallah J, Chang Y, Saini J, Reath J. Integrating health care in Australia: a qualitative evaluation. BMC Health Serv Res. 2019;19(1):954.

McCalman J, Bainbridge R, James YC, Bailie R, Tsey K, Matthews V, Ungar M, Askew D, Fagan R, Visser H, et al. Systems integration to promote the mental health of Aboriginal and Torres Strait Islander children: protocol for a community-driven continuous quality improvement approach. BMC Public Health. 2020;20(1):1810.

Thomas SL, Wakerman J, Humphreys JS. Ensuring equity of access to primary health care in rural and remote Australia—what core services should be locally available? Int J Equity Health. 2015;14(1):111.

Australian Government Department of Health and Aged Care. Integrated Team Care Program.

Durey A, McEvoy S, Swift-Otero V, Taylor K, Katzenellenbogen J, Bessarab D. Improving healthcare for Aboriginal Australians through effective engagement between community and health services. BMC Health Serv Res. 2016;16(1):224.

Banks E, Haynes A, Lovett R, Yadav UN, Agostino J. Output-orientated policy engagement: a model for advancing the use of epidemiological evidence in health policy. Health Res Policy Syst. 2023;21(1):6.

O’Brien P, Prehn R, Rind N, Lin I, Choong PFM, Bessarab D, Coffin J, Mason T, Dowsey MM, Bunzli S. Laying the foundations of community engagement in Aboriginal health research: establishing a community reference group and terms of reference in a novel research field. Res Involve Engage. 2022;8(1):40.

Barnett L, Kendall E. Culturally appropriate methods for enhancing the participation of Aboriginal Australians in health-promoting programs. Health Promot J Austr. 2011;22(1):27–32.

Bessarab D, Durey A, Christou A, Katzenellenbogen JM, Taylor K, Brankovich J. Evaluation of the South Metropolitan Health Service Community Engagement Process Perth: Curtin University. 2014.

Yadav UN, Lloyd J, Baral KP, Bhatta N, Mehata S, Harris M. Evaluating the feasibility and acceptability of a co-design approach to developing an integrated model of care for people with multi-morbid COPD in rural Nepal: a qualitative study. BMJ Open. 2021;11(1): e045175.

Kaihlanen A-M, Hietapakka L, Heponiemi T. Increasing cultural awareness: qualitative study of nurses’ perceptions about cultural competence training. BMC Nurs. 2019;18(1):38.

Askew DA, Foley W, Kirk C, Williamson D. “I’m outta here!”: a qualitative investigation into why Aboriginal and non-Aboriginal people self-discharge from hospital. BMC Health Serv Res. 2021;21(1):907.

Gee G, Dudgeon P, Schultz C, Hart A, Kelly K. Aboriginal and Torres Strait Islander Social and Emotional Wellbeing. In: Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. 2014.

Bywood P, Katterl R, Lunnay B. Disparities in primary health care utilisation: Who are the disadvantaged groups? How are they disadvantaged? What interventions work? Adelaide: Primary Health Care Research and Information Service (PHCRIS), Policy Issue Review; 2011.

Australian Government Department of Health. Future focused primary health care: Australia’s Primary Health Care 10 Year Plan 2022–2032. 2022.Canberra ACT 2601.

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Acknowledgements

We are grateful for the support of Chelsea Liu assisted with the use of the Quality Appraisal Tool and the support of Dr. Deborah Wong (Research Coordinator- Chronic Disease | Cervical Cancer) in designing Fig. 2 . We would also like to acknowledge Thiitu Tharrmay Aboriginal and Torres Strait Islander Reference Group members rather than Thiitu Tharrmay Aboriginal Reference Group members  at the National Centre for Aboriginal and Torres Strait Islander Wellbeing Research at the Australian National University for their continuous feedback without which this research piece wouldn’t have been completed.

The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of their affiliated institutions.

This work was supported by funding from the Australian Government Department of Health-—First Nations Health Division. The funding body had no role in the writing of this article.

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Uday Narayan Yadav and Rosemary Wyber have contributed equally to this work.

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National Centre for Aboriginal and Torres Strait Islander Wellbeing Research, Australian National University, Canberra, ACT, Australia

Uday Narayan Yadav & Rosemary Wyber

Centre for Primary Health Care and Equity, University of New South Wales, Sydney, Australia

Uday Narayan Yadav

Melbourne Medical School, The University of Melbourne, Melbourne, Australia

Jasmine Meredith Davis

The George Institute for Global Health, Sydney, Australia

Keziah Bennett-Brook & Julieann Coombes

Telethon Kids Institute, Perth, WA, Australia

Rosemary Wyber

South Australian Health and Medical Research Institute, Adelaide, SA, Australia

Odette Pearson

Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia

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Conceptualization & original draft: Uday Narayan Yadav and Rosemary Wyber. Data curation: Uday Narayan Yadav, Jasmine Meredith Davis and Rosemary Wyber. Review, edits and revision: Uday Narayan Yadav, Jasmine Meredith Davis, Keziah Bennett-Brook, Julieann Coombes, Rosemary Wyber and Odette Pearson.

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Additional file 1..

Study characteristics.

Additional file 2.

Meta aggregated study findings.

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Yadav, U.N., Davis, J.M., Bennett-Brook, K. et al. A rapid review to inform the policy and practice for the implementation of chronic disease prevention and management programs for Aboriginal and Torres Strait Islander people in primary care. Health Res Policy Sys 22 , 34 (2024). https://doi.org/10.1186/s12961-024-01121-x

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Scientific Consensus

It’s important to remember that scientists always focus on the evidence, not on opinions. Scientific evidence continues to show that human activities ( primarily the human burning of fossil fuels ) have warmed Earth’s surface and its ocean basins, which in turn have continued to impact Earth’s climate . This is based on over a century of scientific evidence forming the structural backbone of today's civilization.

NASA Global Climate Change presents the state of scientific knowledge about climate change while highlighting the role NASA plays in better understanding our home planet. This effort includes citing multiple peer-reviewed studies from research groups across the world, 1 illustrating the accuracy and consensus of research results (in this case, the scientific consensus on climate change) consistent with NASA’s scientific research portfolio.

With that said, multiple studies published in peer-reviewed scientific journals 1 show that climate-warming trends over the past century are extremely likely due to human activities. In addition, most of the leading scientific organizations worldwide have issued public statements endorsing this position. The following is a partial list of these organizations, along with links to their published statements and a selection of related resources.

American Scientific Societies

Statement on climate change from 18 scientific associations.

"Observations throughout the world make it clear that climate change is occurring, and rigorous scientific research demonstrates that the greenhouse gases emitted by human activities are the primary driver." (2009) 2

American Association for the Advancement of Science

"Based on well-established evidence, about 97% of climate scientists have concluded that human-caused climate change is happening." (2014) 3

American Chemical Society

"The Earth’s climate is changing in response to increasing concentrations of greenhouse gases (GHGs) and particulate matter in the atmosphere, largely as the result of human activities." (2016-2019) 4

American Geophysical Union

"Based on extensive scientific evidence, it is extremely likely that human activities, especially emissions of greenhouse gases, are the dominant cause of the observed warming since the mid-20th century. There is no alterative explanation supported by convincing evidence." (2019) 5

American Medical Association

"Our AMA ... supports the findings of the Intergovernmental Panel on Climate Change’s fourth assessment report and concurs with the scientific consensus that the Earth is undergoing adverse global climate change and that anthropogenic contributions are significant." (2019) 6

American Meteorological Society

"Research has found a human influence on the climate of the past several decades ... The IPCC (2013), USGCRP (2017), and USGCRP (2018) indicate that it is extremely likely that human influence has been the dominant cause of the observed warming since the mid-twentieth century." (2019) 7

American Physical Society

"Earth's changing climate is a critical issue and poses the risk of significant environmental, social and economic disruptions around the globe. While natural sources of climate variability are significant, multiple lines of evidence indicate that human influences have had an increasingly dominant effect on global climate warming observed since the mid-twentieth century." (2015) 8

The Geological Society of America

"The Geological Society of America (GSA) concurs with assessments by the National Academies of Science (2005), the National Research Council (2011), the Intergovernmental Panel on Climate Change (IPCC, 2013) and the U.S. Global Change Research Program (Melillo et al., 2014) that global climate has warmed in response to increasing concentrations of carbon dioxide (CO2) and other greenhouse gases ... Human activities (mainly greenhouse-gas emissions) are the dominant cause of the rapid warming since the middle 1900s (IPCC, 2013)." (2015) 9

Science Academies

International academies: joint statement.

"Climate change is real. There will always be uncertainty in understanding a system as complex as the world’s climate. However there is now strong evidence that significant global warming is occurring. The evidence comes from direct measurements of rising surface air temperatures and subsurface ocean temperatures and from phenomena such as increases in average global sea levels, retreating glaciers, and changes to many physical and biological systems. It is likely that most of the warming in recent decades can be attributed to human activities (IPCC 2001)." (2005, 11 international science academies) 1 0

U.S. National Academy of Sciences

"Scientists have known for some time, from multiple lines of evidence, that humans are changing Earth’s climate, primarily through greenhouse gas emissions." 1 1

U.S. Government Agencies

U.s. global change research program.

"Earth’s climate is now changing faster than at any point in the history of modern civilization, primarily as a result of human activities." (2018, 13 U.S. government departments and agencies) 12

Intergovernmental Bodies

Intergovernmental panel on climate change.

“It is unequivocal that the increase of CO 2 , methane, and nitrous oxide in the atmosphere over the industrial era is the result of human activities and that human influence is the principal driver of many changes observed across the atmosphere, ocean, cryosphere, and biosphere. “Since systematic scientific assessments began in the 1970s, the influence of human activity on the warming of the climate system has evolved from theory to established fact.” 1 3-17

Other Resources

List of worldwide scientific organizations.

The following page lists the nearly 200 worldwide scientific organizations that hold the position that climate change has been caused by human action. http://www.opr.ca.gov/facts/list-of-scientific-organizations.html

U.S. Agencies

The following page contains information on what federal agencies are doing to adapt to climate change. https://www.c2es.org/site/assets/uploads/2012/02/climate-change-adaptation-what-federal-agencies-are-doing.pdf

Technically, a “consensus” is a general agreement of opinion, but the scientific method steers us away from this to an objective framework. In science, facts or observations are explained by a hypothesis (a statement of a possible explanation for some natural phenomenon), which can then be tested and retested until it is refuted (or disproved).

As scientists gather more observations, they will build off one explanation and add details to complete the picture. Eventually, a group of hypotheses might be integrated and generalized into a scientific theory, a scientifically acceptable general principle or body of principles offered to explain phenomena.

1. K. Myers, et al, "Consensus revisited: quantifying scientific agreement on climate change and climate expertise among Earth scientists 10 years later", Environmental Research Letters Vol.16 No. 10, 104030 (20 October 2021); DOI:10.1088/1748-9326/ac2774 M. Lynas, et al, "Greater than 99% consensus on human caused climate change in the peer-reviewed scientific literature", Environmental Research Letters Vol.16 No. 11, 114005 (19 October 2021); DOI:10.1088/1748-9326/ac2966 J. Cook et al., "Consensus on consensus: a synthesis of consensus estimates on human-caused global warming", Environmental Research Letters Vol. 11 No. 4, (13 April 2016); DOI:10.1088/1748-9326/11/4/048002 J. Cook et al., "Quantifying the consensus on anthropogenic global warming in the scientific literature", Environmental Research Letters Vol. 8 No. 2, (15 May 2013); DOI:10.1088/1748-9326/8/2/024024 W. R. L. Anderegg, “Expert Credibility in Climate Change”, Proceedings of the National Academy of Sciences Vol. 107 No. 27, 12107-12109 (21 June 2010); DOI: 10.1073/pnas.1003187107 P. T. Doran & M. K. Zimmerman, "Examining the Scientific Consensus on Climate Change", Eos Transactions American Geophysical Union Vol. 90 Issue 3 (2009), 22; DOI: 10.1029/2009EO030002 N. Oreskes, “Beyond the Ivory Tower: The Scientific Consensus on Climate Change”, Science Vol. 306 no. 5702, p. 1686 (3 December 2004); DOI: 10.1126/science.1103618

2. Statement on climate change from 18 scientific associations (2009)

3. AAAS Board Statement on Climate Change (2014)

4. ACS Public Policy Statement: Climate Change (2016-2019)

5. Society Must Address the Growing Climate Crisis Now (2019)

6. Global Climate Change and Human Health (2019)

7. Climate Change: An Information Statement of the American Meteorological Society (2019)

8. American Physical Society (2021)

9. GSA Position Statement on Climate Change (2015)

10. Joint science academies' statement: Global response to climate change (2005)

11. Climate at the National Academies

12. Fourth National Climate Assessment: Volume II (2018)

13. IPCC Fifth Assessment Report, Summary for Policymakers, SPM 1.1 (2014)

14. IPCC Fifth Assessment Report, Summary for Policymakers, SPM 1 (2014)

15. IPCC Sixth Assessment Report, Working Group 1 (2021)

16. IPCC Sixth Assessment Report, Working Group 2 (2022)

17. IPCC Sixth Assessment Report, Working Group 3 (2022)

Discover More Topics From NASA

Explore Earth Science

Earth Science in Action

Earth Science Data

Facts About Earth

Peer Support Specialist

Job posting for peer support specialist at freedom house recovery center inc.

Provide interventions that promote the consumer?s personal safety, self-worth, confidence, and growth, connection to the community, boundary setting and planning, self-advocacy, personal fulfillment and development of social supports, and effective communication skills. Specifically:

• Assist and support consumers with transition from crisis, inpatient or medical setting to appropriate outpatient treatment settings.
• Work with clinician, QP or discharge planners to develop and implement treatment plan.
• Provide intervention strategies to consumers and their supports in accordance with the treatment plan.
• Engage consumers in activities aimed to assist in a wide range of skill development, symptom management, wellness education and work readiness when appropriate.
• Initiate and maintain contact with consumers to facilitate transition between services.
• Provide or assist with transportation to initial appointments.
• Maintain and submit accurate and timely documentation requirements and assist with service authorizations as needed.
• Maintain confidentiality and comply with service definition.
• Other duties and responsibilities as assigned by immediate supervisor.

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Peer Support Activities for Veterans, Serving Members, and Their Families: Results of a Scoping Review

Jean-michel mercier.

1 Atlas Institute for Veterans and Families, Ottawa, ON K1Z 7K4, Canada

Fardous Hosseiny

Sara rodrigues, anthony friio.

2 National Police Federation, Ottawa, ON K2P 1P1, Canada

Suzette Brémault-Phillips

3 Heroes in Mind Advocacy and Research Consortium, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada

Duncan M. Shields

4 Faculty of Medicine, University of British Columbia, Vancouver, BC V6T 1Z4, Canada

Gabrielle Dupuis

Associated data.

For data supporting the reported results, please contact the authors of this review.

For many, including military veterans and their families, support between individuals with shared lived experiences, or peer support, has long been utilized as a way to support each other through many different challenges. Building on other reviews and guided by the seven domains of well-being in the Canadian veteran well-being framework, the objective of this paper is to describe and catalogue the nature of peer support activities and related outcomes in the veteran, serving member, and family member populations. A scoping review following the five stages outlined by Arksey and O’Malley was conducted; it was guided by the question: What is currently known about peer support activities for veterans, serving members, and their families that has been evaluated in the literature? In total, 101 publications from 6 different countries were included in this review and catalogued based on publication characteristics, participant information, peer support activity information, and peer information. Peer support activities have the potential to positively influence the well-being of veterans, serving members, and their families on a holistic level across multiple domains. This scoping review highlights the existing gaps in the literature and provides an important foundation for future research on peer support for these populations, specifically in the Canadian context.

1. Introduction

For many, including military veterans and their families, peer support has long been utilized as a way to support each other through many different challenges, health-related or otherwise [ 1 , 2 ]. While many definitions exist to describe peer support activities, the concept of shared life experiences between individuals remains constant [ 3 , 4 , 5 ]. Specific to the military and veteran field, though many peer support activities are community-based, peers are also being utilized more formally in the provision of programs and activities by government departments such as the Department of National Defence in Canada and the Veterans Health Administration in the United States [ 1 , 2 , 3 , 6 , 7 , 8 ]. Considering the increased interest in peer-supported activities in the literature, the question of the effectiveness of these activities on improving well-being is one that is becoming increasingly important to answer [ 2 , 9 ].

A clear definition of well-being and its components, however, currently seems to lack consensus [ 10 , 11 , 12 , 13 , 14 ]. Looking to address this need and to facilitate future research for Veterans Affairs Canada’s (VAC) programs and policies, efforts were undertaken by VAC to create a well-being framework specific to the Canadian veteran population and their families [ 10 ]. With the social determinants of health as a foundation, the final framework proposed that holistic well-being is made up of seven domains: employment and meaningful activity or purpose, finances, health, life skills and preparedness, social integration, housing and physical environment, and cultural and social environment [ 10 , 15 , 16 ]. A detailed description of this veteran well-being framework is outside the scope of this paper but can be found in Thompson et al.’s publication [ 10 ]. Measuring the indicators for each of these domains can serve as a way to tailor programs and services for families and veterans across their life course “from cradle to the grave” [ 10 ] (p. 4). The framework also highlights the importance of the military-civilian transition (MCT) period on well-being, which begins before the serving member’s release [ 10 ]. For this framework to be best utilized to improve well-being, the related activities and policies must align with the same components [ 10 ]. These activities include those utilizing peers, which are recognized in the aforementioned framework as a type of service that can contribute to overall well-being [ 10 ].

Currently, the peer support literature is quite heterogeneous, which may be contributing to the lack of empirical support on effectiveness [ 2 , 17 ]. Although previous reviews have explored the peer support literature, a gap still exists relating to the landscape of such activities on multiple, holistic dimensions of well-being for veterans, serving members, and their families. Specific to these populations, existing reviews such as those by Williams et al. [ 18 ] and Bird [ 19 ] focused on a specific activity category (one-to-one support), or a specific type of program (peer outdoor support therapy programs), respectively. Other reviews on peer support activities not specific to military populations include those related to particular conditions, such as mental illness or depression [ 4 , 17 , 20 ], substance use or addiction [ 21 , 22 ], and cancer [ 23 , 24 ]. Additionally, other publications focus on specific population groups, such as children with neurodevelopmental and intellectual disabilities [ 25 ], individuals with neurological conditions [ 26 ], and prisoners [ 27 ], among others.

Recognizing the increase in peer support activities for veterans, serving members and their families and the lack of empirical support for these activities, Ramchand et al. [ 2 ] attempted to bring clarity to the field by categorizing various peer-supported interventions’ components, peer roles, outcomes, and effectiveness [ 2 ]. Completed for the eventual benefit of veterans, serving members, and their families, Ramchand et al.’s [ 2 ] review considered randomized controlled trials for all populations. Building off this work and using it as a foundation, the current scoping review includes many types of study designs and publications. The current review aims to describe the nature of all evaluated peer support activities specific to veterans, serving members, and their families. Additionally, the current review aims to align presented outcomes within the aforementioned Canadian veterans’ well-being framework created by VAC. Peer support activities were catalogued according to their characteristics, population and peer characteristics, and by associated domains of well-being. Drawing on these results, this paper intends to fill a knowledge gap by presenting and clarifying the current state of the international peer support literature for veterans, serving members, and their families, and laying the foundation for future research, especially on the effectiveness of peer support on multiple dimensions of well-being in the Canadian veteran and military context.

2. Materials and Methods

The authors conducted a scoping review following the five stages outlined by Arksey and O’Malley, and expanded on by Levac, Colqunhoun, and O’Brien [ 28 , 29 ]. This type of review was deemed appropriate as the research on peer support is ever emerging and the authors were looking to “examine the extent, range and nature” of peer support activities [ 28 ] (p. 21).

2.1. Identification of Research Question

Keeping a broad approach to the search, the scoping review was guided by the question: what is currently known about peer support activities for veterans, serving members, and their families that has been evaluated in the literature? Considering the wide scope of the research question, the following sub-questions were developed to further refine the review:

• What are the characteristics of the veterans, serving members, and their families participating in these peer support activities?
• What are the types and characteristics of the peer support activities evaluated in the literature for veterans, serving members, and their families?
• Which domains of well-being are these activities aiming to improve?
• What are the gaps and limitations in the literature on peer support activities for veterans, serving members, and their families?

2.2. Identification of Relevant Publications

The search strategy was created in consultation with a research librarian and advisory group consisting of individuals with lived and living expertise, as well as professional and academic expertise. Six electronic databases were searched in July 2020: Medline, Embase, PsychInfo, Cochrane, CINAHL, and Web of Science. A search of other credible electronic sources outside of peer-reviewed journals was also completed in January 2021 in order to capture the full spectrum of publications. These included Google, Veterans Affairs Canada’s website, National Institute for Health and Clinical Excellence, Centre for Disease Control and Prevention, Department of National Defence Canada’s website, and RAND Corporation’s website. The searches were conducted with a combination of terms related to peer and social support in military, veteran, first responders or other public safety personnel (PSP), and family member populations. The search terms chosen were used to capture the broad extent of peer support activities, and serving members were added as a population of interest, considering the MCT period begins while individuals were still serving. The search was limited to English or French publications from January 2000 or later. Limitations due to language were added due to translation capacity, with the timeframe chosen to be large enough to capture the breadth of the relevant literature. No limitations were added in relation to the outcomes. The search was re-run across all sources and databases in December 2021 using the same strategy to update the results. The full search strategy is available in the Supplementary File S1 , with an example from one database available in Table 1 .

Embase search strategy.

* denotes wildcard.

2.3. Article Selection

A team approach was utilized for the publication selection process [ 28 ]. Prior to initiating the screening, a sample of abstracts was reviewed by each reviewer to assess understanding of the inclusion and exclusion criteria. Two independent reviewers reviewed the abstracts, appraising each against the inclusion and exclusion criteria. Conflicts between reviewers were addressed through consensus, with third-party consultation by a third reviewer when required. Each reviewer then reviewed the full text publications, utilizing the same inclusion and exclusion criteria. To effectively answer the research questions while taking into account the available resources and the identified publications, post hoc inclusion and exclusion criteria were added [ 28 , 29 ]. The added criteria further limited the scope to include only primary studies describing a specific peer support activity with an evaluation component included. While initially part of the search, the publications relating solely to PSP were excluded to narrow the scope of the review, as were dissertations, studies relating solely to training programs for peer supporters, and editorials/commentaries. The article selection process was completed in Covidence, an online review workflow platform. To capture the breadth of the literature and clarify the publications to include, a clear definition of peer support activities had to be identified. As no current consensus exists, the definition of a peer support activity was determined by the authors with the support of the study’s advisory group as being any activity providing any kind of support from one or many individuals to another with a shared lived or living experience.

2.4. Data Collection

Using a data extraction form initially created in consultation with the study’s advisory group and guided by Cochrane’s data collection forms for qualitative and quantitative studies, two reviewers were responsible for the independent data extraction from the included articles. A third reviewer provided consensus on any data extraction conflicts. After an initial extraction of a sample of studies, the data extraction form was revised. The final data extraction was then completed using the revised form.

2.5. Collating and Summarizing Results

The final data, presented in the results section, was collated based on four categories:

• Publication characteristics: including year of publication, country, journal, and design of the publication;
• Participant information: including group (veteran, serving member, families), health condition, phase of the life course, and sex and gender;
• Activity information: including name, format, modality, timing, duration and intensity, supervision, cost, reported adverse effects, and measured outcomes;
• Peer information: including main role of peer, integration in a clinical team, training, and category related to remuneration. A ‘yes’ or ‘no’ approach to the training component was used, due to the varied nature of training described in the literature.

For the activity information category, all evaluated outcomes from publications were identified and categorized under the related domain of well-being. To identify if peer support activities were associated with an improvement in well-being, outcomes were also categorized as positively associated with the peer support activity, or not. The identification of positive association varied by study design. For controlled studies, only statistically significant ( p < 0.05) between-group differences were included. For uncontrolled studies, only outcomes with a statistically significant ( p < 0.05) improvement were included. Lastly, for qualitative studies, an outcome was included if the authors identified it as a theme commonly mentioned by participants. In the timing category, activities for which peer support was provided in real time were categorized as synchronous, and those for which it was not, such as recorded videos, were categorized as asynchronous.

Related to the peer information category, the definitions and roles described by Ramchand et al. [ 2 ], which built upon those proposed by Webel et al. [ 30 ], were used to categorize the role of the peers and were adapted when necessary. The initial roles vary from peer support, described as unstructured “buddy” support, up to the peer case manager, used to describe a peer with a service coordination and management role. Other roles included peer counsellor, for peers providing knowledge and guidance; peer educator, for peers providing education on a topic based on a curriculum; and peer facilitator, for peers “responsible for facilitating group interactions” [ 2 ] (p. 159). For this review, the roles remain as named by Ramchand et al. [ 2 ], with the exception of “peer support”, which was renamed to “informal peer support” by the authors, considering the definition of peer support activity used in this review as being all-encompassing of these types of roles. The term “peer supporter” is used in this review to describe every type of role.

After the removal of duplicates, 4378 title/abstracts were screened. Of these, 3252 publications were excluded, leaving a total of 1126 to be reviewed. After full text review and application of the post hoc criteria, the team excluded another 1025 publications, providing a total of 101 publications meeting the inclusion criteria ( Figure 1 ). Considering the purpose of the current scoping review, no critical appraisal of the evidence was conducted.

PRISMA diagram.

A total of 101 publications from 6 different countries were included in this review, with the majority coming from researchers in the United States (3 of these publications included a co-author from Spain; the participants from these studies were located in the United States) (n = 85; 84%). The publications also came from the United Kingdom (n = 6; 6%), Australia (n = 3; 3%), Iran (n = 3; 3%), Canada (n = 2; 2%), and Israel (n = 2; 2%). The details on the years of publication are available in Figure 2 , with many of the included documents published either in 2020 (n = 19; 19%) or 2021 (n = 17; 17%).

Count of studies by year of publication.

Combinations of many different study designs were utilized in the included publications. The most common designs were experimental (n = 32; 32%), mixed-method (n = 22; 22%), quasi-experimental (n = 22; 22%), and qualitative (n = 16; 16%) ( Table 2 ). Of all publications, 27 (27%) were identified as pilot studies, with most being uncontrolled (n = 20).

Information of included publications.

3.1. Participant Characteristics

Although the inclusion criteria for the search included peer support activities for veterans, serving members, and their families, most of the included publications reported on activities for veteran participants only (n = 77; 76%) ( Table 3 ). Looking at sex and gender, the publications were categorized as having “almost all/all” participants of one sex or gender if over 80% were identified as that sex/gender, “majority” if between 60–80% of participants were of the same sex/gender, and “both” if the other categories did not apply. Only 11% of all reviewed publications (n = 11) included a majority or almost all/all female participants. All but one of these eleven were publications conducted with families, with three also including serving members, and one with only serving members. None of the publications with veteran populations were conducted with samples involving solely or predominantly female participants. Of note, none of the identified publications focused on peer support activities for veterans, families, or serving members who were part of the 2SLGBTQ+ community, individuals who have experienced military sexual trauma (MST), or those who identified as Indigenous. Only two publications focused specifically on people of color.

Information of participants in included publications.

The majority of the publications reported on activities for participants with particular health conditions (n = 72; 71%). Specifically, 50% of all publications included participants with mental health conditions (n = 51) ( Table 3 ).

3.2. Activity Characteristics

To be included in the analysis, the publications had to relate to specific peer support activities. Some of the included publications reported on the same activity, and the counts presented reflect those of individual publications, not of unique activities. Of the 101 publications, 59 unique activities were identified and 24 activities were not named ( Table A1 ).

The publications were categorized based on the format of the evaluated activity, modality, timing, activity supervision, and measured outcomes. The publications evaluated activities that were mostly delivered in-person (n = 58; 57%), with the format for all activities almost evenly divided between one-to-one support (n = 45; 45%), and group-based support (n = 46; 46%).

The activities were also categorized based on the timing of the delivery. In total, 93 publications (92%) related to a peer support activity being delivered synchronously. All six publications evaluating asynchronous peer support were in relation to online or remotely delivered activities; however, not all publications reporting on activities delivered online/remotely were asynchronous (n = 4 synchronous).

Although separate, peer support activities can occur in conjunction with other care. Some publications used a peer support activity not as the main intervention but adjunctively to enhance the main intervention (n = 12). This included using peers to help reduce attrition with therapist-delivered prolonged exposure therapy and to support engagement with online programs and mobile applications. The complete results of all characteristics are available in Table 4 below.

Information of peer support activities and peer characteristics in included publications.

1 Publications could be associated with multiple domains.

3.3. Peer Characteristics

In terms of peer roles, relating to the aforementioned categories highlighted by Ramchand et al. [ 2 ], peer supporters most frequently acted as informal peer supporters (n = 34) and counsellors (n = 30). This was followed by facilitators (n = 20), educators (n = 14), and case managers (n = 3). In some instances, peer supporters were also included as part of the broader clinical team (n = 35). The peer supporters included in the clinical teams most frequently fulfilled the role of counsellors (n = 15); however, every other role was utilized as part of the clinical team at least once.

3.4. Veterans’ Well-Being Framework

The publications on peer support activities were further categorized based on the measured outcomes related to the domains of well-being and the phases of the life course. All measured outcomes from publications were categorized into the corresponding domain of well-being, with publications evaluating most frequently the association between the peer support activity and the outcomes related to the health domain (n = 56; 55%). Other outcomes evaluated included those related to life skills (n = 44; 44%), social integration (n = 39; 39%), purpose (n = 13; 13%), housing and physical environment (n = 4; 4%), and culture and social environment (n = 2; 2%). Twenty publications explored outcomes which could not be categorized under any of the domains of well-being, most of which were related to the program evaluation.

Once all measured outcomes were categorized within the related domain of well-being, those reported by the publications’ authors as being positively associated with the peer support activity were identified. The outcomes positively associated with a peer support activity were most frequently related to the health domain (n = 34) ( Table 4 ). This translates to 61% of the 56 publications evaluating outcomes related to the health domain, showing a positive association between the activity and the outcomes. Among others, the outcomes associated with the health domain included mental health condition-related descriptors (e.g., PTSD or depression symptoms), glucose control, and weight loss. The publications also identified a positive association between peer support activities and outcomes related to the life skills (n = 30) and social integration (n = 26) domains. A positive association was reported in 68% of all publications related to the life skills domain, and 67% of publications related to the social integration domain reported a positive association. The outcomes associated with the life skills domain included measures of healthy daily habits, self-efficacy/confidence, coping skills, and others, while the indicators in the social integration domain included perceived social support and connectedness. Less frequently, some publications reported that the peer support activity was positively associated with the employment or other meaningful activity/purpose domain (n = 6), the housing and physical environment domain (n = 2), and the culture and social environment domain (n = 1). A positive association between the activity and the outcomes was reported in 46% of all publications evaluating employment or other meaningful activity/purpose-related outcomes, 50% of those evaluating housing and physical environment-related outcomes, and 50% of those evaluating culture and social environment-related outcomes.

An attempt was made to categorize the publications according to the phase of the life course of the participants; however, the ability to do so was limited because the time since discharge was only rarely presented. Lastly, an analysis was conducted to identify the trends in the role of the peer supporter by associated well-being domains for positively associated outcomes. Considering each associated domain by publication, peer supporters were more frequently involved as informal support for both the health domain (35%) and the social integration domain (62%) when a positive association was identified ( Figure 3 ). The details of the peer role and domains of well-being per publication are available in Table A2 in the Appendix A .

Main peer role by positively associated domain.

4. Discussion

This scoping review identified 101 relevant publications about peer support activities for veterans, serving members, and their families, demonstrating the breadth of peer support activities evaluated in these populations. With the vast majority of publications coming from the United States, it was not possible to compare activities between countries, therefore, all publications were grouped and analyzed together. Some authors have indicated a gradual increase in peer support publications from Europe and other countries, however, the findings from this review were unable to verify this trend in relation to veterans, serving members, and their families [ 31 ].

This review found that peer support activities in the literature are evaluated using various designs, many based on pilot studies. The presence of many pilot studies should be considered when interpreting the results of this review, as findings from these types of publications could differ with larger sample sizes. The increase in the number of publications from the last two years, as well as the presence of many pilot studies, emphasizes the emergent nature of the literature in this area and the increased attention that peer support activities are receiving in the veteran, serving member, and family member populations.

4.1. Participant and Activity Characteristics

The wide scope of this review allowed the authors to identify the myriad of components currently being utilized and evaluated in the delivery of support from peers to veterans, serving members, and their families. While the majority of identified publications evaluated synchronously delivered programs for male veterans with a mental health condition, a vast heterogeneity was present in relation to the other catalogued characteristics of activities and participants. Additionally, the successful categorization of peer roles using types of peers described by Ramchand et al. [ 2 ] supports this role characterization method for future studies aiming to evaluate peer support activities in the veteran, serving member, and families populations. Although outside of the scope of this current review, future publications should attempt to identify the existence of associations between activity characteristics, peer supporter roles, and associated outcomes and domains. Identifying these associations could help tailor peer support activities according to individual situations and needs.

4.2. Domains of Well-Being

Recognizing the limitations in the current method of identifying positive associations between measured activity and well-being, a strength of this review is the categorization of outcomes by well-being domain. Although some publications did not report an improvement, this study found that positive associations between peer support activities and six of the seven domains, excluding finances, were identified by at least one publication. Considering this, it can be concluded that peer support may have the potential to positively influence the well-being of veterans, serving members, and their families holistically.

Categorizing the evaluated outcomes by domain of well-being also revealed that the main interest of evaluated peer support activities lies in three of the seven domains. In the identified publications, the outcomes related to health, life skills, and social integration were more frequently mentioned or evaluated. On the other hand, the outcomes related to purpose, housing and physical environment, and culture and social environment were only rarely included, with no identified studies including measures categorized to the finance domain. Although more research evaluating peer support activities and their association to improving all domains of well-being is needed, it would be important for future research to consider including measurements for the latter four domains, as well-being is considered by VAC as being made up of all seven domains [ 10 ]. A true picture of the potential for peer support activities for veterans, serving members, and their families may only be achieved if future research takes into account all the domains when evaluating these activities.

Although evaluation of the alignment between the well-being framework and published peer support activities was not an objective of the current review, it was found that 80% of publications (n = 81) evaluated at least one outcome that aligned with a domain presented in the framework. This categorization was meant to test this method for future peer support studies in this population, while aligning with the recommendations of select authors suggesting the need to look beyond measures of clinical recovery to better assess the effectiveness of peer support activities [ 32 ].

4.3. Gaps and Limitations in the Literature

The findings from this review allowed the authors to identify gaps in the current literature. First, only two Canadian publications were identified, limiting the generalizability of the results within the Canadian context. Furthermore, only a few, or no, publications were found to be specifically evaluating peer support activities for serving members or family members, for individuals who have experienced military sexual trauma (MST), in 2S/LGBTQ+ populations, in Indigenous populations, or in women veterans. Considering the heterogeneous nature of Canadian serving members and veterans, unique sex- and gender based-differences, and recent developments with regards to individuals who have experienced MST and the LGBT Purge in the Canadian Armed Forces, future research should be conducted to evaluate the use of peer support activities for a more representative spectrum of veterans, serving members, and their families [ 33 , 34 , 35 , 36 , 37 ].

Finally, the included publications rarely considered the time since discharge when evaluating the peer support activities for veterans. Considering the differing nature of needs and well-being during different phases of the life course, identifying and reporting time since discharge could prove useful in expanding knowledge on peer support activities and their outcomes, and should be considered in future research [ 10 ].

4.4. Study Limitations

Though this scoping review can be used as a foundation for future research in the area of peer support for Canadian veterans, serving members, and their families, some limitations should be considered when interpreting the results beyond the ones already mentioned. The first relates to the descriptive nature of the analysis. Based on the purpose and nature of this review, no critical appraisal of individual sources was conducted and many study designs were considered. This limits the authors’ ability to confirm the benefits of the peer support activities on each domain of well-being and future research should aim to reach more definitive conclusions by establishing the strength of the available evidence, considering research designs and effect sizes. Another limitation is related to the categorizations of outcomes to their respective well-being domain. The well-being framework used is composed of seven domains, however, not all of them are mutually exclusive and some overlap may exist between domains. For this study, the authors categorized outcomes based on subjective best fit, which may have led to misclassification. A final limitation is related to the search criteria used. Although the search for publications was kept as wide as possible, some relevant articles may have been missed due to search terms used.

5. Conclusions

The purpose of this review was to describe the nature of peer support activities specific to veterans, serving members, and their families and to align their outcomes within VAC’s Canadian veterans’ well-being framework. Already utilized by some government departments, peer support activities in these populations are receiving increased attention in the literature and have the potential to improve well-being across all domains. This scoping review provides an important foundation for future research related to peer support in Canadian veterans, serving members, and their families. Utilizing a consultative approach with an advisory group of varied expertise, this review builds on existing research and is another step towards standardizing the peer support vocabulary, as well as the way these activities are designed, evaluated, and presented in the Canadian context.

Acknowledgments

The authors would like to thank and acknowledge Alexandra Heber, Debbie Lowther, and James Thompson for their invaluable insight and guidance. They would also like to thank Molly Nannarone for her support and Michal Juhas for his insights and support.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/ijerph20043628/s1 , File S1: Full search strategy.

Counts of unique peer support activities.

Detailed evidence table of all publications.

Funding Statement

The Atlas Institute for Veterans and Families is funded by Veterans Affairs Canada. Views and opinions expressed are solely those of the Atlas Institute and may not reflect the views and opinions of the Government of Canada.

Author Contributions

Conceptualization and methodology, J.-M.M., G.D., F.H., D.M.S. and S.B.-P.; writing—original draft preparation, J.-M.M.; writing—review and editing, G.D., F.H., S.R., A.F., D.M.S. and S.B.-P. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Data availability statement, conflicts of interest.

The authors declare no conflict of interest.

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