A multi-national peer support intervention: the UPSIDES pilot phase

ABSTRACT Objective Using Peer Support in Developing Empowering Mental Health Services (UPSIDES) is evaluating implementation of a peer support worker (PSW) intervention at six recruiting sites (Germany, India, Israel, Tanzania, and Uganda) (ISRCTN26008944). The aim of this study is to evaluate the pre-trial pilot phase. Method The initial training to prepare individuals for the PSW role and the implementation of the peer support (PS) intervention was evaluated using a multi-method design comprising six focus groups (FG; n = 22) and questionnaires capturing the perspectives of service users, PSWs, peer trainers, and mental health staff members (n = 21). Results Findings were organised across eleven key implementation themes: organisational culture, PSW training, PSW role definition, staff willingness and ability to work with PSWs, resource availability, financial arrangements, support for PSW well-being, PSW access to a peer network, acceptance, preparation, and other challenges. Discussion The following recommendations are made, based on this pilot phase: the PS training should train on practical skills using role-playing exercises; PSWs should work in teams, including role reflection with colleagues (intervision) or with a highly experienced coach (supervision); necessary resources and tools for networking should be provided; and continuous awareness-raising about PS is needed.


Introduction
A priority of the current global mental health (GMH) agenda is to address long-term mental health (MH) conditions through diverse approaches (Barbui & Albanese, 2020;Bemme & Kirmayer, 2020), including person-centred, recovery-oriented services to better support people with severe mental illness (SMI) (Caldas-de-Almeida, 2020). One such approach is Peer Support (PS) interventions, which have shown promising results in encouraging hope (Bellamy, Schmutte, & Davidson, 2017) and empowerment (White et al., 2020) among people diagnosed with SMI by building trusting relationships based on shared lived experience, role-modelling, and engaging service users with services and the community (Gillard, Gibson, Holley, & Lucock, 2014).
While most research on PS is conducted in high-income countries (HICs), results from PS projects in low-and middle-income countries (LMICs) are promising (Fan, Ma, Ma, Lamberti, & Caine, 2018;Hall, Baillie, Basangwa, & Atukunda, 2017;Pathare et al., 2019). Nevertheless, although there are examples of service user and caregiver involvement in mental health system strengthening in LMICs, there is still a lack of high-quality research and a weak evidence base (Ryan, Semrau, Nkurunungi, & Mpango, 2019) and PS is still an undervalued and underutilised resource in GMH (Puschner, 2018).
UPSIDES is a six-country research consortium with partners in high-(Germany, Israel, United Kingdom), lower middle-(India) and low-income (Tanzania, Uganda) settings (Puschner et al., 2019), focused on the implementation of PS for people with SMI. The study has three phases: (1) Preparation of implementation, (2) Pilot phase, (3) Evaluation.
A key output of UPSIDES' preparation and pilot phases is a PS training and intervention to be evaluated in a multi-site randomised controlled trial (ISRCTN26008944; Moran et al., 2020). Previous research has shown that interventions adapted to country-specific contexts are more likely to be effective (Boothroyd & Fisher, 2010;Perera et al., 2020). The UPSIDES intervention and training manual was developed following a four-step framework on intervention adaption for implementation in different cultural and socioeconomic settings (Barrera & Castro, 2006;Castro, Barrera, & Holleran Steiker, 2010).
The preparatory phase of the UPSIDES project involved information gathering through a systematic review (Prospero: CRD42018107772) and focus groups (FG) exploring previous experiences with PS and expected benefits and challenges. Based on this information, the first draft of a PS training and intervention manual was developed. Peer trainers from all recruiting sites met for a training pre-test at a train-the-trainer workshop (for further information see Puschner et al., 2019).
Before systematically evaluating an intervention, best practice involves piloting to identify any difficulties related to implementation (Feeley et al., 2009). During the UPSIDES pilot phase, all study sites conducted the training, organisational readiness workshops, delivered the intervention to service users and provided supervision sessions for the PSWs. An evaluation of the pre-trial pilot phase is reported in this article. The objective of the pilot phase is to identify (1) emerging implementation challenges, (2) issues with training program content, (3) satisfaction with PS elements, and (4) suggestions for improvements of PSW training and PS intervention. ). The pilot phase was evaluated using a participatory, multi-method design, including focus group (FG) discussions and questionnaires. All sites received ethical approval from local ethic commissions (Puschner et al., 2019). The site in Tanzania was unable to conduct a FG, due to time constraints.

Intervention
The UPSIDES pilot phase intervention involved between two and eight contacts over six weeks, in one-to-one or mixed one-to-one and group formats, delivered by peer support workers (PSWs), people with lived experience of MH conditions and recovery. The intervention focused on social inclusion (Boothroyd & Fisher, 2010) and aimed to help people living with SMI to advance in their recovery. The specific tasks of PSWs include practical support with daily life, helping to endure and understand crises, supporting recovery, providing information, mediating in conflicts, and promoting recovery in MH teams. PS was implemented in three inpatient (India, Tanzania) and three outpatient (Israel, Germany [Hamburg and Ulm]) settings, and at one site (Uganda) was implemented in inpatient and outpatient settings.

Participants
Overall, n = 22 participants were selected through purposive sampling, with the goal of including a variety of different local stakeholders. These included: trainers who facilitated the UPSIDES training, training participants (with lived experience of SMI), MH staff members from the host organisation, and other important local stakeholders e.g. policy makers. All participants were fluent in the local languages used during data collection. Reasons for exclusion included the inability to provide informed consent and being a minor (age <18).

Focus groups
Each FG was led by either one or two researchers at each site following a semi-structured discussion guide and the focus groups ranged in duration from 45 to 90 min (M = 70.2, SD = 19.9). All participants gave written informed consent. FG facilitators presented the training concept and the resulting PS intervention. Afterwards, participants' questions regarding the presented materials were clarified and the materials were discussed.

Questionnaires
To complement the FG discussions, the FG participants and additional local stakeholders were asked to fill in study-specific questionnaires to rate the delivery of the different elements of the pilot phase. All stakeholders filled in questionnaires adapted to their personal role in the project.

Analysis
The FGs were recorded, transcribed, and translated into English (except for the transcript from Pune, due to resource constraints). The transcripts were analysed using a deductive coding approach (Hsieh & Shannon, 2005). The coding frame covered eight implementation influences on PS identified in a previous systematic review (Ibrahim et al., 2020): Organisational culture, PSW training, PSW role definition, Staff willingness and ability to work with PSWs, Resource availability, Financial arrangements, Support for PSW wellbeing, and PSW access to a peer network. Following data immersion, LN and RN double-coded all transcripts, except for one FG (Pune, India), which was coded by PK in the local language. All coding discrepancies were discussed until a consensus was reached, with advice from CM as needed. Where excerpts of text could not be captured by the pre-defined coding frame, inductive coding was used to add additional codes (which numbered three in total). All codes were captured in a code book and excerpts were then recoded using the revised coding frame.

Participant characteristics
Five FG discussions were held (N = 22). Table 1 presents the socio-demographic characteristics of the participants. Additionally, the delivery of the different elements of the pilot phase were rated through questionnaires by 21 local stakeholders: N = 7 trainers (from Beer Sheva, Hamburg, Kampala, and Pune), n = 3 service users (from Hamburg, Pune, and Ulm), n = 3 PSWs (from Hamburg, Pune, and Ulm), and n = 8 MH staff members (from Beer Sheva, Hamburg, Pune, and Ulm).

Codebook
The codebook containing all themes used to analyse the FG transcripts is presented in Table 2.

Codes and examples
Implementation theme 1: organisational culture There was a learning curve in implementing organisations, even when PS was already a well-known intervention. For successful implementation, willingness to learn from each other and a focus on staff preparation are needed: Because the fact that these professionals would sit and give their time and listen to me as I shared my lived experiences kind of gave me a feeling of being accepted as part of the team.
It helped me understand that as a PSW I have a role to play and that whatever service I have to offer is accepted within the organization. (PSW, Kampala) Participants indicated that MH staff might feel challenged by the new service and that disclosure of experiences is sometimes discouraged: As an agenda in most companies, they don't encourage self-disclosure. (PSW, Beer Sheva) We must be a bit more proactive here in the region, which is not the case in other regions. Because people are simply a bit more closed off here and many simply feel as if we are taking their jobs away. (PSW, Ulm) Implementation theme 2: PSW training Overall, the participants provided positive feedback about the benefits of the training: It was very vital, guided me, helped me explore my wellness, and how to help others. (PSW, Kampala) In addition, participants named aspects that were missing from the training or could be improved: What was just unfortunate was that there was so much theory at the beginning. I have to say that. It was a bit overwhelming. But because of the short time, it was unfortunately not possible otherwise. You have to take a little more time, so that people can absorb it. And of course, more practical examples. (PSW, Ulm) In the questionnaires, core training content was rated as important to very important, on average, by trainers and training participants. The proposed content for additional training was also rated as important, on average work preparation and group facilitating were identified as core topics. Nonetheless, participants reported difficulties in distinguishing the specific role of the PSW from other staff members: Even during the organizational readiness workshop, it was discussed that the role of PSWs is not clear to the staff members even if they meet the PSW every day. (Peer trainer, Pune) Implementation theme 4: staff willingness and ability to work with PSW At some sites, it was emphasised that the PSWs were well integrated into the teams and their unique contribution was appreciated: I did get the chance a few times passing my experiences to professionals that did want to hear my opinion in a direct way. (PSW, Beer Sheva) To integrate there as well, because [the PSW] could of course also give input, what he experiences with the clients or visitors and he of course also experiences something completely different probably, and for him that he can also get feedback if he has any difficulties. (MH staff member, Hamburg) Also, different ways of guiding within teams were described: Someone who does supervision can sit in on some conversation with the client, who then just sits in the background. In other words, the PSW and the [service user] talk together, and somewhere in the corner sits someone who just watches. Who can then directly reflect on the conversation afterwards with the PSW. (Peer trainer, Ulm) We will train the staff on the role and work of [PSW]. And this will further aid us to find master trainers in each ward who can be the assigned PSW's first point of contact if they need help. These master trainers can then supervise the PSW who is assigned to their ward. (Peer trainer, Pune) Implementation theme 5: resource availability For the PSWs it was difficult to get the necessary working equipment. At several sites, for example, a lack of work cell phones was mentioned. I was told not to give out my number. But I'm getting a cell phone. I'm still waiting for it today. (PSW, Ulm) Particularly in low-income settings, it became clear that PSW faced gaps in care within the system: I think it would be a little more helpful to have a contact person on the ward because you find the nurses busy; one time they directed me to look for a [service user] but I searched in vain. (PSW, Kampala) Implementation theme 6: financial arrangements The participants from sites in low-income countries mentioned that the financial situation of their service users was particularly problematic, as well as the difficulty of covering any travel costs themselves: My peer was at first staying in [one place], then shifted to [another]. I used a lot of money to go there, it rained on me, then she was complaining about poverty, poverty, poverty … but I didn't have anything to give her. (PSW, Kampala) Implementation theme 7: support for PSW well-being Over six weeks the PSWs received on average 3.7 (SD = 2.9) supervision sessions. The supervision was provided by trainers, researchers, or external supervisors in one-toone or group settings. The following topics were discussed in supervision: challenges with the organisation, challenges with service users, and challenges working as a PSW. About two-thirds (67%) of the PSWs stated that supervision supported them in their work.
The supervision always run as a preparation and follow-up for the next meetings. With the question, 'What else do you need?' or, 'Can you implement the tools that were taught in theory?' And I sometimes had the feeling that the link was still somewhat difficult. So what theoretical content can I implement now? (MH staff member, Ulm) It was also observed that the new PSWs themselves need to assess when they feel ready to lead their own activities, such as a recovery group. One PSW in Hamburg for example did not yet feel ready to offer their own group or something similar. Implementation theme 8: PSW access to a peer network Participants indicated hiring two peers would be helpful so they can work together, shape the PS within the organisation and support each other: I also thought, perhaps rather two, that they could exchange with each other and also develop something. (MH staff member, Hamburg) Participants recommended attending other recovery and PS events in addition to the training, for example programs in which service users, relatives and mental health workers reflect together (trialogue): There are the trialogical events [part of the services on offer at Ulm]. It would be helpful, so to speak, if the people who do the training to become PSW attended such events. (Peer trainer, Ulm) Implementation theme 9: acceptance Participants reported several indications that PSW were accepted within organisations and by service users: I have the feeling that [the PSW] is already well accepted by the [service users]. He is always in contact with other [service users] and that he also enjoys it, that's what I experience. (MH staff member, Hamburg) And the first two or three appointments were very difficult in that area. But then we got used to each other. Then [the service user] always came to the appointment with a smile. (PSW, Ulm) Implementation theme 10: preparation All PSWs reported feeling prepared to work in a peer role after training completion. Challenges included a new working environment, starting conversations and covering different topics with service users. Workshops were held at all pilot phase organisations to introduce the MH staff to PS, recovery and the UPSIDES project, to discuss expected benefits and hopes regarding the implementation of PS, and to talk about questions, worries and expected challenges. On average the organisations were rated as being ready to work with PSWs (M = 2.6; SD = 1.3) on a scale from 1 (strongly disagree) to 5 (strongly agree). Participants stated that the workshop had prepared them well for PS (M = 2.2; SD = 0.4) and that the staff in the organisation understand the specific role of a PSW (M = 2.4; SD = 0.9).
At the second workshop, a lot of things became clear to me because I was able to clarify a lot of questions. (MH staff member, Hamburg) From my point of view, I found this workshop very interesting, that both parties, the organization and the future PSW really came together. (Peer trainer, Ulm) Participants recommended to advertise the UPSIDES intervention more strongly in the media to improve preparation: The public relations work, I missed that a bit. (MH staff member, Ulm) Implementation theme 11: other challenges Participants identified barriers to introducing a new service and that it may not initially be accepted by clients or services: I ran into difficulties disclosing at work. (PSW, Beer Sheva) The difficulty for us was to find people who would like to make use of the PS. (MH staff member, Ulm) At the same time, all participants from the low-income countries reported facing stigma when working in the community as well as the difficulty of continuing to work with service users in the community: There is a lot of stigma in the community. When you introduce yourself, their attitude changes and they start making funny signals … it happened to me twice. (PSW, Kampala) The first peer gave me a wrong number because when I called, the person said he didn't know her. He was very harsh and told me never to disturb him again. (PSW, Kampala) Lack of language skills was mentioned as a challenge for cooperation and joint preparation of the project: Many different countries, everything in English, only the English with native language, so communication was sometimes very difficult. (Peer trainer, Ulm) Overall, in the questionnaire the intervention duration was rated by PSWs and service users as rather short on average (M = 2.2; SD = 1.3) on a scale from 1 (too short) to 5 (too long). The participants preferred weekly or bi-weekly meetings over a period of 1 -3 months and up to 1 year.

Discussion
This multi-method study evaluates the implementation of a pilot PS intervention at six sites across five countries with varying income levels. Key findings regarding successful implementation in the pilot phase included: engaging training to practice the PSW role, shared role understanding and clear job description, preparation of the team to discuss recovery-orientation and the integration of the new PSWs, necessary equipment, opportunities to share experiences, and advertisement to promote the new intervention.
Although the literature on successful implementation and guidelines for PSW training are scarce, the identified influencing factors are in line with the available literature (Ibrahim et al., 2020;Mutschler, Bellamy, Davidson, Lichtenstein, & Kidd, 2021). Particularly in organisations where no PS for people living with SMI was previously available, preparation through workshops was especially helpful in initiating the process of shared learning and providing a framework for discussing the new role of the PSW (Moran, Russinova, Yim, & Sprague, 2014). The teams developed different ideas for interaction, for example intercollegiate exchange, jointly leading groups, or feedback after conversations with service users.
Furthermore, it was reported that the training must emphasise skills, be continuous, allow for the possibility of job shadowing for PSWs and include role play, which has been previously identified as particularly important for training Pathare et al., 2019). This is in line with previous recommendations for PSW trainings (Rebeiro Gruhl, LaCarte, & Calixte, 2016) to include peer-specific skills, such as communication of lived experience, setting boundaries, and self-care. Other studies have also highlighted manualized, accredited training programs as key to an evidence-based professionalisation of PS (Davidson, Chinman, Sells, & Rowe, 2006;Repper & Carter, 2011), as training and supervision of PS workers increase fidelity of PS (King & Simmons, 2018).
This study also identified clear PSW roles (Chinman et al., 2016;Moran et al., 2020;Pathare et al., 2019), respect for the PSWs within the organisation (Davis, 2013;Moran et al., 2014;Mutschler et al., 2021) and a positive relationship between PSWs and other staff as important to the integration of PSWs (Ibrahim et al., 2020). Although some evidence suggested that PSWs were accepted within organisations and by service users, potential competition with established services in the implementation area was reported as a challenge. Further, the success of PS relies upon adequate resources being available, and appropriate renumeration of PSWs (Ibrahim et al., 2020).
Similarly, it is important that a peer network is available to PSWs (Ibrahim et al., 2020;Moran et al., 2020). The UPSIDES peer network should be further expanded to allow for more cross-site learning. A lack of resources and/or time constrains the work of the PSWs (Ibrahim et al., 2020). It was recommended to schedule more time for the training and the implementation of the PS. The sites differed by income level, highlighting the need for local adaptation (Smith, Rodríguez, & Bernal, 2011). In LMICs in particular, financial arrangements and access to resources were challenges. This is in line with Mpango et al. (2020) who discussed the challenges for PS in the context of COVID-19, and found that PSWs in LMICs are in especially vulnerable situations due to lack of access to resources such as mobile phones and secure income. In our study, PSWs in LMICs also faced stigma in the community, while topics like organisational culture, access to PSW networks and support for PSW well-being emerged as bigger issues in high-income settings. Further research into the similarities and differences between LMIC and high-income country sites and how these affect implementation is needed to ensure appropriate adaptation for different settings.

Strengths and limitations
This study piloted the implementation of a shared PS intervention across a variety of HIC and LMIC settings. The perspectives of different stakeholders were included. The multimethod approach (questionnaires, FG discussions) allowed for a deeper understanding of the factors affecting implementation, while the deductive coding approach made it possible to draw and build upon existing research (Hsieh & Shannon, 2005). Nevertheless, the sample size was small, and unfortunately the site in Tanzania was unable to conduct an FG, due to time constraints. While data came from a mix of HIC and LMIC settings, all the coders and analysts (RN, LN, PK) were early career researchers from high-and middle-income countries.

Conclusion
The aim of this study was to inform the implementation of a new PS intervention for people living with SMI in the context of a larger randomised trial. Several findings are particularly relevant for this trial. First, the training should be expanded to include practical skills, modules on leading groups and work preparation, and more role-playing exercises. Second, several PSWs should be placed together, with exchange encouraged through intervision and supervision. Third, PSWs should be provided with necessary resources. Fourth, there is still a lack of public knowledge on PS, and therefore it is recommended to continuously advertise it. Fifth, PS should be available for at least up to six months. And finally, tools for further networking between PSWs should be introduced (e.g. online groups, joint training platform).