a PSW: peer support worker.
The participants came from 21 countries, including higher-income (Australia: n=33; the United Kingdom: n=22; Canada: n=7; Poland: n=7; Germany: n=4; Ireland: n=4; Switzerland: n=4; Israel: n=3; Norway: n=3; Italy: n=2; the United States: n=2; New Zealand: n=1; Belgium: n=1; Singapore: n=1), middle-income (India: n=4; Tunisia: n=2; Brazil: n=1; Egypt: n=1; Argentina: n=1), and lower-income (Uganda: n=6; Tanzania: n=1) countries.
All participants completed round 1 and rated each of the 18 topics for importance. Round 1 ratings and all proposed changes are shown in Multimedia Appendix 3 . Analysis of the round 1 free-text responses (n=68) and mean rating scores resulted in multiple refinements to the round 1 topic names and definitions. Although the mean score for knowledge of mental health was ranked low compared with other topics, the free-text responses suggested that the definition should be amended to reflect PSW training needs, and this was changed markedly for round 2. Two topics— role-specific PSW skills and competencies and work skills —were identified as being relevant in some contexts but not others. These context-specific topics were presented separately in a different format for round 2, along with an explanation for the participants. Three additional topics and definitions were created— PSW supervision , developing a career as a PSW , and role-specific PSW skills and competencies —that were adapted from the subpopulation and specialized modules topic.
The revised list of 20 topics and associated definitions were used for round 2, which are shown in the fifth column of Multimedia Appendix 3 . Of 110 participants, a total of 89 (80.9%) participants completed round 2. The round 2 ratings of importance are shown in Multimedia Appendix 4 and of web-based delivery are shown in Multimedia Appendix 5 . Additional comments were received from round 2 participants about the role-specific PSW skills and competencies topic, resulting in minor refinements to the definition of knowledge of mental health topic. The final list of topics and definitions, which were used in round 3, is shown in Textbox 1 .
Topics always needing coverage
Context-specific topics
Of 110 participants, a total of 82 (74.5%) completed round 3. Of these 82 participants, 76 (93%) had completed round 2. The round 3 ratings of importance, ordered by median rating, are shown in Table 2 .
Delphi Consultation round 3 rating of importance (n=82).
Variables | Total | Participants by role | Participants by income level | |||||
| | PSW | Manager | Researcher | High | Middle | Low | |
Population, n (%) | 82 (100) | 36 (44) | 24 (29) | 22 (27) | 71 (86) | 4 (5) | 7 (9) | |
Lived experience as an asset, median (IQR) | 3 (0) | 3 (0) | 3 (0) | 3 (0) | 3 (0) | 3 (0.25) | 3 (0) | |
Ethics, median (IQR) | 3 (0) | 3 (0) | 3 (0) | 3 (0) | 3 (0) | 3 (0) | 3 (0.5) | |
PSW well-being, median (IQR) | 3 (0) | 3 (0) | 3 (0) | 3 (0) | 3 (0) | 3 (0) | 3 (0) | |
PSW role focus on recovery, median (IQR) | 3 (0) | 3 (0) | 3 (0) | 3 (0) | 3 (0) | 3 (0.25) | 3 (0.5) | |
Communication, median (IQR) | 3 (0) | 3 (0) | 3 (0) | 3 (0.75) | 3 (0) | 3 (0) | 3 (1) | |
Crisis management, median (IQR) | 3 (0.75) | 3 (1) | 3 (0) | 3 (1) | 3 (0.5) | 3 (0.25) | 3 (0.5) | |
Introduction to peer support and PSW, median (IQR) | 3 (1) | 3 (1) | 3 (1) | 3 (0) | 3 (1) | 2.5 (1) | 3 (1) | |
Cultural competency, median (IQR) | 3 (1) | 3 (1) | 3 (1) | 3 (1) | 3 (1) | 2.5 (1) | 2 (1) | |
PSW skills and competencies, median (IQR) | 3 (1) | 2.5 (1) | 3 (0.25) | 3 (1) | 3 (1) | 3 (0.25) | 3 (1) | |
Trauma-informed peer support practice, median (IQR) | 3 (1) | 3 (1) | 3 (0.25) | 2 (1) | 3 (1) | 2 (0.25) | 2 (0) | |
Workplace aspects of PSWs, median (IQR) | 3 (1) | 3 (1) | 3 (1) | 2.5 (1) | 3 (1) | 2.5 (1) | 2 (1.5) | |
PSW supervision, median (IQR) | 3 (1) | 3 (1) | 3 (0) | 2 (1) | 3 (1) | 2 (0.25) | 2 (1.5) | |
PSWs working with groups, median (IQR) | 2 (0) | 2 (2) | 2 (0.25) | 2 (0) | 2 (0) | 2 (0) | 2 (1) | |
Knowledge of mental health, median (IQR) | 2 (1) | 2.5 (1) | 2 (1) | 3 (1) | 2 (1) | 2.5 (1) | 2 (1) | |
Approaches, frameworks, and models used in PSW, median (IQR) | 2 (1) | 2 (1) | 2 (1) | 2 (0.75) | 2 (1) | 2.5 (1) | 2 (0) | |
Human rights and disability legislation, median (IQR) | 2 (1) | 2 (1) | 2 (1) | 2 (1) | 2 (1) | 2.5 (1) | 2 (0.5) | |
Referral and communication with other services, median (IQR) | 2 (1) | 2 (1.25) | 2 (0.25) | 2 (0.75) | 2 (1) | 2.5 (1) | 2 (1) | |
Work skills, median (IQR) | 2 (1) | 2 (1) | 2 (0.25) | 2 (1) | 2 (0) | 3 (0.25) | 2 (1) | |
Developing a career as a PSW, median (IQR) | 2 (0.75) | 2 (1) | 2 (0.25) | 2 (0) | 2 (0.5) | 2 (0.25) | 2 (0.5) | |
Role-specific PSW skills and competencies, median (IQR) | 2 (0.75) | 2 (1) | 2 (0) | 2 (0.75) | 2 (1) | 2.5 (1) | 2 (0) |
b Scale 0 (low) to 3 (high).
c Strong consensus.
d Moderate consensus.
The median rating of importance was “Quite Important” or “Very Important” for all topics. Across all participants, the first five topics in Table 2 reached a strong consensus on importance.
The round 3 ratings for web-based deliverability, ordered by median rating, are shown in Table 3 .
Delphi Consultation round 3 rating of web-based delivery (n=82).
Variables | Total | Participants by role | Participants by income level | ||||
| | PSW | Manager | Researcher | High | Middle | Low |
Population, n (%) | 82 (100) | 36 (44) | 24 (29) | 22 (27) | 71 (86) | 4 (5) | 7 (9) |
Human rights and disability legislation, median (IQR) | 2 (1) | 1.5 (1) | 2 (2) | 2 (1) | 2 (1) | 3 (0) | 2 (1.5) |
Developing a career as a PSW, median (IQR) | 2 (1) | 1.5 (1) | 2 (1) | 2 (0) | 2 (1) | 3 (0.25) | 2 (1) |
Introduction to peer support and PSW, median (IQR) | 2 (1) | 1 (1) | 2 (1) | 2 (1.5) | 2 (1) | 2.5 (1) | 1 (1) |
Knowledge of mental health, median (IQR) | 2 (1) | 1 (1) | 1.5 (1) | 2 (0.75) | 2 (1) | 3 (0.25) | 2 (1) |
Role-specific PSW skills and competencies, median (IQR) | 1 (0) | 1 (0.25) | 1 (0.25) | 1 (0.75) | 1 (0) | 1.5 (1) | 1 (0) |
Referral and communication with other services, median (IQR) | 1 (1) | 1 (1) | 2 (1) | 2 (1) | 1 (1) | 2 (0.25) | 1 (1) |
Work skills, median (IQR) | 1 (1) | 1 (1) | 1 (1) | 2 (0.75) | 1 (1) | 2 (0.5) | 1 (1) |
Approaches, frameworks, and models used in PSW, median (IQR) | 1 (1) | 1 (1) | 1 (1) | 2 (1) | 1 (1) | 2 (0.25) | 1 (0) |
Workplace aspects of PSWs, median (IQR) | 1 (1) | 1 (1) | 1 (1) | 2 (1) | 1 (1) | 2 (0.25) | 1 (1) |
PSW supervision, median (IQR) | 1 (1) | 1 (1) | 1 (1) | 2 (0.75) | 1 (1) | 2 (0.25) | 2 (1) |
PSW well-being, median (IQR) | 1 (1) | 1 (1) | 1 (0.25) | 1 (1) | 1 (1) | 2 (0.5) | 1 (1) |
PSW role focus on recovery, median (IQR) | 1 (1) | 1 (0) | 1 (1) | 1 (1) | 1 (1) | 2 (0.25) | 1 (0.5) |
Cultural competency, median (IQR) | 1 (1) | 1 (1) | 1 (1) | 1 (1) | 1 (1) | 2 (0) | 1 (1.5) |
Ethics, median (IQR) | 1 (1) | 1 (0.5) | 1 (0.25) | 1 (1) | 1 (0) | 2.5 (1) | 1 (0.5) |
PSW skills and competencies, median (IQR) | 1 (1) | 1 (0) | 1 (1) | 1 (1) | 1 (1) | 1 (0.5) | 1 (1) |
Trauma-informed peer support practice, median (IQR) | 1 (1) | 1 (1) | 1 (1.25) | 1 (1) | 1 (1) | 2.5 (1.25) | 1 (0.5) |
PSW working with groups, median (IQR) | 1 (1) | 1 (1) | 1 (2) | 1 (0) | 1 (1) | 2.5 (1.25) | 1 (0.5) |
Crisis management, median (IQR) | 1 (1) | 1 (1) | 0.5 (1) | 1 (0.75) | 1 (1) | 2 (0.5) | 1 (0) |
Lived experience as an asset, median (IQR) | 1 (1) | 1 (1) | 0 (1) | 1 (1) | 1 (1) | 1 (0.5) | 1 (1) |
Communication, median (IQR) | 1 (1) | 1 (1) | 0 (1) | 1 (1) | 1 (1) | 1.5 (1.5) | 1 (0) |
b Scale 0 (face-to-face) to 3 (fully via the internet).
d Moderate consensus .
The round 3 median ratings for web-based delivery indicated that all topics can be delivered partly or fully on the web with moderation but none without moderation. No topics reached a strong consensus for the mode of training delivery. The range of median responses relating to web-based delivery was smaller for PSWs (1-1.5) than for managers (0-2) and researchers (1-2), indicating that PSWs were more consistent in placing importance on some face-to-face training contact.
In this 21-country study, 20 topics were identified that can be recommended for inclusion in the curriculum of a PSW initial training program. There was a strong consensus about the high importance of five topics: lived experience as an asset , ethics , PSW well-being , PSW role focus on recovery , and communication . There were no substantial differences between role perspectives (PSW, managers, and researchers) and countries with different resource levels relating to importance. All training topics were identified as being partly or fully deliverable on the web, but none could be provided on the web without moderation. There was no consensus about the right balance between face-to-face and web-based training with moderation, even though PSWs were more consistent in identifying the need for a face-to-face training component.
A strength of this study is the number of participants (N=110) from different countries (n=21) and the low attrition (round 1-2: 19%; round 1-3: 25%) compared with other Delphi studies [ 46 ]. Another strength is that the Delphi was reported in line with the Checklist for Reporting Results of Internet e-Surveys checklist [ 47 ]. This study has several limitations. First, there is a need for more representation from middle- and lower-income countries, which might have allowed between-setting differences to emerge, which was not achieved despite purposive sampling efforts. Second, participation in a web-based consultation may be more difficult for people in environments with poorer internet access and intermittent electricity, which may disproportionately affect PSWs. Third, participants were asked if they had completed web-based training earlier but not specifically web-based PSW training, which could then have been further explored in the analysis. In addition, web-based deliverability was not defined and was based on participant judgment rather than evidence from experience. Fourth, the use of two web-based platforms that may have confused participants and were not specifically designed for Delphi consultations. Alternative Delphi-specific platforms exist, including ExpertLens [ 48 ], Mesydel [ 49 ], and Delphi2 [ 50 ]. Fifth, PSW training manuals available in languages other than English or Arabic might have identified a wider range of training topics.
Finally, a full systematic review was not conducted, and the limitations associated with implementing a systematic review include the following: (1) lack of patient, population, intervention, comparison, and outcomes criteria; (2) included and excluded manuals were not listed; (3) methodological quality assessment and reliability of manuals were not explored; and (4) discrepancies between reviewers were not reported.
Achieving an international consensus on topics that are of high importance in PSW training is important for three reasons. First, it offers prospective PSWs a description of the tasks and skills involved in the PSW role, which may inform their decision making about whether to train as a PSW. Second, it provides training providers and organizations with a list of core topics that should be covered in the content of initial PSW training programs in all settings and two additional context-specific topics that may be relevant. Third, it provides an evidence base for developing training curricula and a framework for PSW accreditation. The standardization of PSW training across settings and countries is contentious. On the one hand, an international consortium of peer leaders from 6 continents developed an international charter, which defined peer support and identified key principles and guiding values [ 51 ]. In conjunction with this Delphi consultation, a framework is emerging that could underpin the international PSW accreditation process. On the contrary, unintended consequences of institutionalizing the PSW role are emerging, with one qualitative study in the United States concluding that it “has the potential to reduce the very centrality of experiential expertise, reproduce social inequalities, and paradoxically impact stigma” [ 52 ].
The identification of training topics relevant to specific contexts reflects cultural and organizational influences on implementation [ 53 ]. Identified barriers that may lead to context-specific modifications include the lack of credibility of peer worker roles, professionals’ negative attitudes, tensions with service users, struggles with identity construction, cultural impediments, poor organizational arrangements, and inadequate overarching social and mental health policies [ 54 ]. These influences can lead to preplanned modifications implemented during initial PSW training, as well as unplanned extensions to the PSW role [ 55 ]. Several studies have found that this role extension can reduce role clarity and integrity, such as by incorporating medical ways of working [ 56 ] and creating identity conflict [ 57 ]. For example, a 10-site comparative case study across England found that different understandings of professionalism and practice boundaries can erode the distinctiveness of the PSW role [ 58 ].
PSW training has evolved in response to organizational needs and more recently the COVID-19 global pandemic. In a recent commentary, barriers to implementing web-based peer support in low- and middle-income countries in the context of COVID-19 were identified [ 59 ]. The low-to-moderate consensus about web-based delivery of training found in our study indicates that further work is needed to explore the relative costs and benefits of web-based versus face-to-face training.
All topics were rated as candidates for at least partial web-based delivery, which raises two questions. First, what is the role of web-based moderation? In addition to knowledge and skills development, an important component of PSW training is ensuring that participants have the ability to maintain role integrity in a context where many will have to deal with microaggressions [ 60 ]. Similarly, a recent editorial identified specific contested areas relating to the role of PSW in restraint, administration of medication, and lone working in the community [ 61 ]. These may all be sensitive issues for PSWs to explore in training, for example, due to personal experiences, which may be more difficult to explore in moderated web-based discussions. Furthermore, individuals considering PSW training may struggle with motivation [ 62 ] and the pressure to succeed [ 63 ], and role challenges can include overwork and symptom recurrence [ 64 ]. There is some evidence that a therapeutic alliance in digital interventions is possible [ 65 ], but the extent to which the requisite resilience and motivation for the PSW role can be fostered through web-based training delivery is an important future focus.
Second, does web-based training prepare recipients better to deliver web-based peer support? Relationships are central to PSWs [ 66 ], and one impact of COVID-19 is to increase the use of web-based approaches by trained PSWs as an alternative relationship medium. Combining web-based and offline peer support has been shown to be a promising concept, with one qualitative Norwegian study of peer support recipients finding it enabled connectedness and allowed individuals to balance anonymity and openness [ 67 ]. Web-based training may help future PSWs to have both technological skills and the confidence to engage with PSW recipients on the web. In middle- and low-income countries, this blend of training delivery could also provide an accessible, wide-reaching, and cost-effective approach to increase the availability of PSW training places. A systematic review identified that the role content of PSWs is often underreported [ 68 ]. The topics identified in our study can inform the reporting of both the training program and PSW role components in future PSW evaluations.
This study developed a list of training topics for the initial PSW training. One use is to inform PSW training manuals, such as the UPSIDES PSW training program [ 69 ], which is being evaluated in Germany, India, Israel, Tanzania, and Uganda [ 70 ]. The use of an evidence-based training curriculum will increase the effectiveness of programs to prepare individuals for working as PSWs.
The study UPSIDES is a multicenter collaboration between the Department for Psychiatry and Psychotherapy II at Ulm University, Germany (Bernd Puschner, coordinator); the Institute of Mental Health at University of Nottingham, United Kingdom (MS); the Department of Psychiatry at University Hospital Hamburg-Eppendorf, Germany (CM); Butabika National Referral Hospital, Uganda (Juliet Nakku); the Centre for Global Mental Health at London School of Hygiene and Tropical Medicine, United Kingdom (GR); Ifakara Health Institute, Dar es Salaam, Tanzania (Donat Shamba); the Department of Social Work at Ben Gurion University of the Negev, Be’er Sheva, Israel (Galia Moran); and the Centre for Mental Health Law and Policy, Pune, India (Jasmine Kalha). UPSIDES received funding from the European Union’s Horizon 2020 Research and Innovation Programme under grant 779263. MS acknowledges the support of the Center for Mental Health and Substance Abuse, University of South-Eastern Norway, the National Institute for Health Research Nottingham Biomedical Research Centre, and research group work support from the Economic and Social Research Council (grant ES/J500100/1 and ES/P000711/1). This publication only reflects the authors’ views. The Commission is not responsible for any use that may be made of the information it contains. The funding bodies had no role in the design of the study, writing of the manuscript, or decision to submit the paper for publication.
PSW | peer support worker |
UPSIDES | Using Peer Support in Developing Empowering Mental Health Services |
Multimedia appendix 2, multimedia appendix 3, multimedia appendix 4, multimedia appendix 5.
Authors' Contributions: AC, MS, NI, RN, and CM conceptualized the study. AC, MS, and NI conducted a systematized review, analyzed, and interpreted the data. AC had full access to all the data in the study and had final responsibility for the decision to submit for publication. RN and CM contributed to the design of the Delphi consultation, analysis, and interpretation of data for the work. HN contributed to the design of the Delphi consultation, quality review, and data acquisition. LGM contributed to ethical processes. AC, NI, and MS drafted the manuscript. All authors contributed to the interpretation of the data, critically revised the manuscript, and approved the final submitted draft.
Conflicts of Interest: None declared.
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Consumer Operated Services Program (COSP) Multisite Research Initiative Overview and Preliminary Findings, Missouri Institute of Mental Health (2004) Perceptions of Supervisors of Peer Support Workers (PSW) in Behavioral Health: Results from a National Survey, National Center for Biotechnology Information, U.S. National Library of Medicine (2021)
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MS acknowledges the support of the Center for Mental Health and Substance Abuse, University of South-Eastern Norway, the National Institute for Health Research Nottingham Biomedical Research Centre, and research group work support from the Economic and Social Research Council (grant ES/J500100/1 and ES/P000711/1).