Background
Peer support services delivered to persons with severe mental illness (SMI) are based on the premise that individuals who have overcome or recovered from the effects of a mental illness can offer useful support, encouragement, and mentoring to others similarly affected [
1]. Peer services have been included as key components of supportive networks and recovery-oriented services for individuals with SMI in many Westernized countries that have well-developed ambulatory mental health systems [
2‐
4]. Peer service providers serve as positive role models by improving confidence for recovery, thus providing hope, together with reducing perceived stigma [
5].
We anticipated in our study that three groups might benefit from the development of services-peer service providers themselves, recipients of support (hereafter, “consumers”), and their family caregivers. Prior work has shown that peer service providers have felt more empowered, autonomous, and competent/confident, resulting in higher self-esteem from helping others [
6,
7]. They have become more confident in their own recovery, solidifying daily life skills and learning to focus more on their own and others’ strengths [
5]. Notably, they also have been observed to have a high rate of turnover. This may reflect a reduction in psychiatric symptoms and increase in social functioning, as many move to other higher salaried jobs [
8]. But it also may indicate dissatisfaction or a misfit between job requirements and personal needs. We studied this issue as one aspect of our study.
Consumers of peer support services have reported a greater sense of feeling understood, respected, and trusted [
9‐
11]. One study revealed statistically significant improvements for participants in self-esteem, self-efficacy, social support, and spiritual well-being [
10]. Another, however, showed no statistically significant differences on social functioning among participants suffering SMI, even as they reported improved self-efficacy [
11].
Families of people with SMI experience substantial caregiver burden [
12,
13]. They report both emotional distress [
14] and poor perceived quality of life [
15]. Of note, an Australian peer support program that interviewed family caregivers found high satisfaction with the quality of service and reported that the service gave hope to them and to their mentally ill family members. Information and support provided by peer service providers was perceived to be invaluable [
5].
Nevertheless, there are challenges evident when considering the generalizability of previous studies of peer-delivered services. The majority have come from Western countries with well-developed ambulatory services; involvement of peers in care is new to most nations that now are developing outpatient programming, and may not conform to cultural notions of family privacy or hierarchical approaches to medical and psychiatric care systems. Prior research has indicated that the operation of peer services should be consistent with local customs, values, and resource availability [
16]. Attempts to implement peer services were made in Hong Kong; these focused primarily on changing attitudes among peer support workers toward the delivery of peer services [
17]. However, there was no clarity regarding their acceptability or the overall impact of peer services delivered in Chinese communities. Inconsistent outcomes also are reported for participants of previous studies on the effectiveness of peer services [
18]: Some demonstrated improvements in social functioning and quality of life [
10], while others have not [
11]. And few studies have examined the effect of peer support service on caregivers, especially the specific impact on their emotions or perceived quality of life apart from their attitudes or satisfaction with services.
The primary objective of this project, based in Beijing, involved demonstrating the feasibility of community-based peer support services among persons with SMI. We assessed feasibility by measuring of satisfaction and perceived benefit while also assessing elements necessary to develop and sustain the project. The initial implementation of our model of peer support has been described previously [
19].
Discussion
This study examined satisfaction and perceived benefits of a community-based peer support service launched in four Beijing communities among patients with SMI. We designed it to be consistent with Chinese culture, which places care for persons with health challenges inside family and social structures. The results revealed high service satisfaction among peer service providers, consumers, and their caregivers. Almost all of them expressed willingness to continue participating in the services. In addition, the results demonstrated apparent improvements in symptoms of mental illness, social communication in the program and often at home, daily life functioning, emotional expression and self-perception, and for the majority of peer service providers, in the context of their work.
For peer service providers, distinct improvements were noted in particular items, including: working skills, social communication skills, and mood and feelings. These outcomes are consistent with most previous studies. Both pre-service training sessions and the process of providing services substantially increased providers’ job performance competency [
24], anticipatory socialization [
25], and skills in communicating positive regard, understanding, and acceptance to consumers. These, in turn, motivated consumers’ treatment engagement and adherence [
26]. In addition, service providers could increase consumers’ sense of hope, belonging and contentment in various life domains, which further improved peer service providers’ own mood [
27].
For consumers, benefits were especially demonstrated in mood and feelings about being cared by others, social communication skills, knowledge of illness and illness stability, and sense of belonging, which were consistent with evidence from prior studies [
28,
29]. For illness stability, although previous studies showed inconsistent conclusions about whether peer service could reduce rehospitalization and overall psychiatric symptoms [
11,
18,
30,
31], peer services have indeed been proven to be helpful for engaging consumers into healthcare [
27], with improved longitudinal treatment motivation and higher service attendance [
26]. The current study introduced a new illness related indicator-knowledge of mental illness. This was also tracked during peer services because of strong association between knowledge and treatment adherence [
32].
Comparisons between service effects on peer service providers and consumers revealed that the current program was beneficial, but targeted at different areas of knowledge and functioning within each group. Generally speaking, compared with the consumers, peer service providers were more likely to benefit in areas other than disease stability, which probably was due to a ceiling effect that resulted from the peer service providers’ better initial illness stability. Furthermore, working skill was the only area that showed significant differences between peer service providers and consumers, and it was consistent with providers’ work experience through the process of delivering services to others. The results also suggested that the challenge of organizing peer support services could help prepare the peer service providers for future employment, both technically (e.g., organization ability and work habit) and mentally (e.g., dealing with stress).
The reported areas of improvement of peer service participants from their caregivers’ perspectives included: social communication skills, confidence in recovery, and illness stability-i.e., results consistent with the self-reported assessments of peer service providers and consumers. In addition, as the participants became more and more independent, the findings also indicated that peer service further benefited caregivers themselves with improved mood, reduced caring burden, and more confident in their family member’s recovery progress.
Participants from the later communities rated relatively higher satisfaction and perceived more benefits than those from the initial ones. This may reflect our being able to draw upon experiences gained from the initial communities. When developed peer support services for the initial communities, we also encountered the most common challenges faced in Western culture, including a lack of clear role definitions for peer service providers as well as for professionals such as community doctors [
33]. We sought to allow peer service providers substantial latitude in their roles, as they reported feeling significant pressure when serving as a peer service provider for the first time. Thus, we did not limit the service schedule or the targeted content at first. We observed, however, that this apparent lack of structure did not decrease stress among peer service providers; indeed, it was our impression that it compounded whatever stress they experienced when fulfilling the supportive tasks associated with their consumers. The later assessed results of service satisfaction underscored our observation. Both peer service providers and consumers from the initial communities rated a relatively low score on richness of activity topics. As a result, when implementing peer support services in the later communities, we provided a schedule with a fixed service timetable, and offered peer service providers eight choices of service content. It is our sense that, in the later communities, the significantly higher satisfaction on service punctuality as well as richness of activity topic, and generally better feedback on all aspects of perceived service benefits, related directly to programming improvements derived from our initial experiences.
As for implications, this study revealed the outcomes of peer-delivered service under Chinese culture, which enriched its implementation and effectiveness under diverse contexts and customs. Furthermore, when evaluating service benefits, it targeted at a variety of key stakeholders including peer service providers, consumers, and their caregivers, which provided a more reliable and comprehensive understanding. Because the assessments were conducted at approximately 1 year after the service implementation, these results could support the sustainability and feasibility of peer service.
Some limitations in this study need to be addressed. First, our participation numbers in this study were small. While there were no apparent differences among those who dropped out and those who continued, it is uncertain how their views would have affected our apparent results. Second, although the measures used in this study were developed deliberately, most of them have not been validated. In addition, we used interval scales to query our participants; we realize that these do not offer definitive metrics to assure the equivalence of one interval, or one scale, with another. Nonetheless, the scales provided a structure to assist interviewing our participants and to compare the initial and later communities qualitatively. Third, due to difficulties with providing services to enough consumers, the study was conducted in two waves. Two initial communities were involved, and then another two were added. Although we compared the consistency and disparity between the two waves. Future studies should make more effort to reduce or control the potential biases introduced by unsimultaneous recruitment. Fourth, despite the study conducted follow-up assessment at 1 year after service implementation, effectiveness of service was only evaluated by retrospective interviews. Future studies should develop comparable measures and combine baseline and follow-up assessments to reveal the longitudinal effect. Fifth, even as we see positive outcomes in this small-scale demonstration, there will be a need for more research. Beijing, especially its resource-filled Chaoyang District, cannot be viewed as representative of all communities across China, especially those in rural regions. Future work must grapple with the extraordinary diversity of community resources, geography, transportation, and education-all key ingredients when offering care to persons with SMI. While a program such as ours may work well in an urban environment, it may be much more challenging in areas with a lower population density and convenient access to a central meeting site may be more difficult due to transportation or competing work needs. Finally, it will be essential to study in greater depth the roles of community doctors, who have relatively little training in mental health concerns. These clinicians are central to service delivery in China, and their observations were indispensable to charting the responses of peer service providers, consumers, and family members who often interact with them. Future research should must involve community doctors-both as sources of information and as potential participants themselves.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.