Peer support has been identified as an evidence-based, effective intervention to instill greater emotional well-being and improve health outcomes for a wide range of mental and physical health issues. By increasing social connectedness and providing both emotional and tactical support for day-to-day stressors, peer support is a low-cost, effective service that can serve as a standalone offering or complementary to disease management programs. Peer support programs have the potential to reduce mortality, improve quality of life, and reduce healthcare costs with significant ROI.
- What is peer support?
- Why is digitizing peer support so important?
- Effectiveness of peer support as a behavioral health intervention
- Role of peer support as an adjunct to medical treatment
- Return on investment (ROI) of peer support programs
- Best practices for implementing a peer support program
What is peer support?
Peer support is a “system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful.”2 It is an evidence-based intervention built upon the following social and behavioral theories: social support, experiential knowledge, helper therapy principle, social learning theory, social comparison theory, and self-determination theory.4 These components lead to greater empowerment by providing hope, sense of personal responsibility, and advocacy of self and community.5 In addition, the relationship of peers is characterized by trust, acceptance, understanding, and empathy6; which are components that the healthcare industry strives for but too often misses. Participants in peer support programs have noted that the wide range of support available is different and complementary to the clinical care they receive from healthcare providers.7
Peer support provides a social forum for voluntarily expressing emotions, struggles, fears, and life challenges that is often lacking in modern life. Three in five Americans report feeling lonely8, which can be more dangerous than obesity and as damaging to health as smoking 15 cigarettes a day.9,10 Loneliness is often associated with chronic physical and mental health conditions, leading to a downward spiral with each exacerbating the other.11–13 Social isolation increases the likelihood of mortality by about 30%, but strong relationships have a protective effect and increase survival by 50%.14,15 Social connectedness is critical because not acknowledging or suppressing emotions is correlated with decreased life satisfaction, depression, anxiety, and greater psychological distress.16 Conversely, habitually accepting emotions and thoughts without judgement is linked to greater resilience, better psychological health, and reductions in depression and anxiety.17
Peer support also provides opportunities for participants to assist others who are going through difficult situations. Many studies have shown that helping others regardless of receiving any support in return has great psychological benefit, which was coined the Helper Therapy Principle by Riessman back in 1965.18 For adults, giving to others through activities such as volunteering or providing financial or emotional support improves well-being and reduces mortality.19 Even for adolescents, helping others improves mood regardless of any support received, and the benefit is greatest for those who are most depressed.20
There is evidence that listening to others who have experienced similar struggles even without actively communicating back can improve psychological well-being. Users who consume information from online support groups but do not actively participate report the same level of improvement in areas of empowerment including feeling better informed, having greater acceptance of their condition, improved self-esteem, and increased optimism and control.21 Also, the self-reflection that occurs as a response to feedback from peer supporters creates a therapeutic feedback loop.22
Why is digitizing peer support so important?
Although models of peer support have been around before the advent of the internet, the rise of internet use, social media, and online social networking have dramatically changed the way people find information and communicate. Today, 80% of internet users go online for health information23 and there are now more opportunities than ever before to connect with peers worldwide. Research has shown that online exchange of personal experiences can effectively build relationships with people that are unknown in a virtual environment.24 Motivators include reduced stigma due to anonymity and network expansion for those with limited mobility.25,26 Of note, inclusiveness was the strongest predictor of perceived helpfulness of online peer support,25 and a digital peer network can foster a sense of community just as, if not more, effectively than in-person interactions.
Utilizing the internet or mobile technology to facilitate peer support has many advantages over in-person interactions including anonymity, access to much a larger network, and on-demand access from any location. These features of online peer support can be leveraged to increase engagement of high-risk individuals. People with stigmatized illnesses are more likely to use the internet for health information and seek care based on their findings.27 A platform that provides confidential emotional support with synchronous and asynchronous communication has even played a significant role in suicide prevention.28 Given the larger network that can be accessed digitally, online support can be more tailored to meet unique needs and circumstances that in-person options may not provide.29 Further, online peer support can overcome barriers of scheduling and arranging transportation, which are often cited as reasons for why people stop attending in-person peer support meetings.30
Many innovations in digital health still rely on getting advice from one’s doctor but the core problem is that many people do not enjoy going to the doctor.31 Patient-provider relationships are built around specific diseases. For instance, patients will see a cardiologist for congestive heart failure and a dermatologist for acne. People generally don’t want to be identified or defined by their disease(s), and this condition-centric approach impedes holistic care. Life stressors such as relationship problems, work stress, financial pressures, and caregiving are not disease-specific. Having the same condition is not a prerequisite for receiving or offering support on these topics. The sense of belonging and access to a social network for both emotional support and tactical resources can help address some of the most debilitating and costly chronic mental and physical health conditions today.
Effectiveness of peer support as a behavioral health intervention
Peer support was introduced to mental health treatment in the 1990s and has been found to increase hope and the ability to make positive changes in one’s life, improve self-care, create a sense of community and belonging, and increase life satisfaction.6 Further, peer support has been shown to reduce symptoms of mental health conditions and substance abuse over time and subsequently reduce hospitalizations and overutilization of healthcare services.38 Peer support is particularly important in mental health programs as it allows people to overcome the social isolation caused not only by their illness, which can make in-person interactions difficult, but also by the isolation caused by stigma and discrimination.38 Participants exchange advice on how to negotiate daily life struggles beyond those directly related to disease management and learn that it is possible to go from being controlled by one’s illness to taking control over the illness itself.6 Moreover, peer support directly contributes to the protective factors for mental well-being by enhancing control, increasing resilience and community assets, and facilitating participation and promoting inclusion.39
Peer support, even by itself, can be a powerful treatment for mental health. In a meta-analysis of randomized control trials (RCTs) that compared peer support to usual care for depression, peer support was significantly more effective for reducing depression scores. Further, peer support was as effective as group cognitive behavioral therapy (CBT). The authors noted that the magnitude of improvement seen from peer support in this study were similar to those of psychotherapy and antidepressant medications.40 This finding indicates that peer support could be a clinically effective standalone treatment for depression, on par or possibly more effective than the traditional standard of care.
Peer support has been shown to be clinically effective for a range of mental health conditions. For those with severe mental illness including psychosis, schizophrenia or bipolar disorders, peer support increased hope, recovery, and empowerment.41,42 Similar benefits have been found for people with post-traumatic stress disorder.43 Peer support also reduces the risk of postpartum depression and has been recommended as a key prevention strategy.44–46 The effectiveness of peer support for a variety of mental health conditions is expected due to the huge amount of symptom overlap among diagnoses. Based on the latest research on the value of the Diagnostic and Statistical Manual (DSM), experts found that focusing on a specific diagnosis minimizes the impact of life trauma and individual experiences on mental health, and may not be helpful in directing appropriate treatment.47 Peer support does not have to be disease-specific to address these underlying causes and effects of mental illness on everyday life.
As a result of these benefits, peer support has been identified as one of the 10 Fundamental Components of Recovery by the Substance Abuse and Mental Health Services Administration.48
SAMHSA states, “Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills, as well as social learning, play an invaluable role in recovery. Peers encourage and engage other peers and provide each other with a vital sense of belonging, supportive relationships, valued roles, and community. Through helping others and giving back to the community, one helps one’s self. Peer-operated supports and services provide important resources to assist people along their journeys of recovery and wellness.”
Furthermore, peer support services are now widely reimbursable as part of recovery support services for both mental health and substance use disorders.49
Given the social isolation and, at times, low willingness to seek care with mental illness, online peer networks have been identified as a new strategy to engage this high-risk population. Surveys have demonstrated a high level of acceptance and interest in using mobile technology to enhance the delivery of peer support services.50 Digital interactions may even be preferred over in-person meetings because they offer more control in that users can choose their level of engagement and be less triggered by social anxiety.51 The anonymity can also help with social bonding for those who have trouble with face-to-face social interactions.52
In a study of online support group users for depression, 95% reported that participation improved their symptoms. Over half said that the online group prompted them to ask their provider a question, and over one-quarter of them reported a medication change as a result of advice received online. At six months, 73% were still participating and the majority of users continued with in-person depression treatment throughout the duration of the study. Frequent users with depression were five times more likely to experience resolution of their depression compared to less frequent users.53
Peer support is also a key component of recovery from substance abuse disorders. Alcoholics Anonymous (AA) is perhaps the most widely recognized peer support program for addiction. However, the religious nature of the 12-step approach can be a barrier to engagement and less structured peer support programs have been shown to be beneficial to people with substance use disorders.54 In several large reviews of the benefits of peer support and substance use disorders, peer support appears to decrease substance use, increase treatment engagement and satisfaction, decrease human immunodeficiency virus (HIV)/ Hepatitis C high risk behaviors, decrease cravings, increase self-efficacy, increase abstinence, reduce hospital readmissions, promote greater adherence to post-discharge care plans, reduce relapse, and decrease return to homelessness.54–57 Peer support has also been shown to reduce cigarette use and increased abstinence from smoking.58,59
Despite the high prevalence of mental health struggles in adolescents, their needs are often not adequately addressed.60 Youth are less likely to seek care overall but additional barriers to mental healthcare include concerns over confidentiality and lack of knowledge or access to services. When they do seek care, it is generally from the people they trust such as friends and family.61 Online peer support is a compelling strategy to overcome these barriers and reduce stigma as the majority of youth already use digital tools to connect with other people.62 Among 18-24 year olds with mental illness, 94% reported participating in online social networks. Those with mental illness were more likely than those without to seek online social networks to increase connectivity, make friends, and access resources on independent living skills and overcoming social isolation.63
Role of peer support as an adjunct to medical treatment
Today in the US, 60% of adults have at least one chronic condition and over 40% have two or more.64 Controlling these conditions is a top priority to reduce healthcare costs, morbidity, and mortality. Peer support has been identified as an important strategy to improve the quality and efficiency of healthcare and should be considered by healthcare providers, health systems, patient-centered medical homes, and commercial and government payers.65,66 Further, the internet has been recognized as a potential resource to engage high risk individuals with chronic conditions, especially those who are difficult to access with in-person intervention. People with chronic diseases are more likely to have used an online peer group compared to those who are healthy, and over half of online support group users with chronic conditions have never used in-person support. Among those with chronic conditions, online support is most commonly used by people with depression, anxiety, stroke, diabetes, cancer, and arthritis.67
In addition, peer networks can be impactful for caregiver support. Nearly 70 million people in the US are caregivers and spend on average 20 hours per week tending to the needs of their loved ones. The time and emotional toll associated with caregiving can lead to marital conflict, missed days at work or reduced productivity, exiting the workforce, and financial strain.91 Peer support can help caregivers cope with the daily stressors and leverage the lived experience of others, especially for caregivers of people with mental illness and dementia.92,93 Predictors of greater online support group use were caregivers with the most caregiving demands, neurological or psychiatric conditions in the person requiring care, and caregiver age over 50.94 These programs are generally viewed favorably and contribute to greater emotional well-being, improved quality of life, reduced distress and symptoms of trauma, and greater confidence with healthcare decision-making and care plan adherence.94
Return on investment (ROI) of peer support programs
Social isolation is not just an individual issue but a major public health concern with significant economic consequences.95 In a large systematic review, loneliness was associated with worse outcomes for numerous chronic physical conditions including chronic back pain, chronic obstructive pulmonary disease (COPD), depression, stroke, cardiovascular disease, diabetes, heart failure, cognitive decline, and obesity.11 However, irrespective of health status, social isolation is a driver of excess healthcare utilization, and it has been posited that those who are lonely seek out medical care to satisfy their need for social connection.96,97 Loneliness is associated with worse self-reported physical and mental health, increased utilization of primary care, increased utilization of emergency rooms and urgent care, and increased hospitalizations.98 In Dallas, TX a study of emergency room visits found that over 5,000 visits were attributed to only 80 patients and the top reason for overutilization was “lack of relationships and support structure.”99 Furthermore, among older adults, those who are socially isolated cost $1,608 more annually than those who are socially connected, due to expenditures for inpatient care and skilled nursing facilities.100
By increasing social connectivity, peer support could be an integral low cost intervention101 to help contain healthcare spend. Peer support programs have the potential to reduce length of hospital stay of chronic physical conditions such as diabetes.102 Similarly, Optum’s peer support services have demonstrated a 32% reduction in hospitalizations over 5 years and a 32% reduction in 30-day admissions. They have also used peer support to help with transitions from hospital discharge back to the community and subsequently observed over 60% reduction in inpatient days.103
The potential cost savings are particularly compelling for behavioral health issues. In an RCT of patients with severe mental illness who had been hospitalized at least three times in the past 18 months, patients were randomized to usual care or usual care plus a peer mentor. The group with the peer mentor had fewer hospitalizations and hospital days were nearly half of the control group (10 vs. 19 days).104 This finding is consistent with other research that has shown reductions in readmissions and increases in likelihood of crisis stabilization with peer support.105,106 In addition to savings in acute care for mental illness, peer support could also save over $5,000 per person annually in day treatment costs107 and reduce overall behavioral health costs by nearly 50% (from $9,999 to $5,292 per person).103
Much of the cost associated with mental illness and other chronic conditions come from lost productivity, including absenteeism and presenteeism.108–110 Cigna reports that loneliness decreases productivity through lower quality work, decreased employee engagement, and lower retention. Their research also found that lonely employees are twice as likely to miss work due to illness and five times more likely to miss work due to stress.8,111 Aside from the direct economic benefits of reducing high-cost healthcare utilization, peer support programs may reduce indirect costs and improve productivity. Peer support has been shown to reduce absenteeism related to alcohol dependence,112 improve management of chronic health conditions73 so that fewer days of work are missed, and can support caregivers so they can maintain productivity.91,92,94
Peer support has the potential to generate cost-savings by reducing overutilization, decreasing hospital readmissions, reducing inpatient days, improving self-management of chronic physical and behavioral health conditions, and increasing productivity. Longer term studies are necessary to fully understand these economic benefits. Moreover, the return on investment (ROI) of specifically digital peer networks needs to be researched. Given the widespread use of online and mobile technology, low implementation costs, and low requirement for personnel resources; digital peer support may become the dominant and most cost-effective modality of this intervention.
Best practices for implementing a peer support program
Given the broad range of how peer support programs can be administered, it can be daunting to plan how to implement a program. Further, internally developing a peer support solution can be challenging with barriers to trust and limited personnel resources including those for training and supervision.113 Outsourcing peer support services is time and cost-efficient and can drive greater engagement. By examining what has worked and what hasn’t from the available research, we can determine a set of best practices to consider while implementing a peer support program.
When designing a peer support program, one of the first steps is to determine how the program will be delivered. The choice between a digital or in-person program is directed mostly by the culture and logistical requirements of an organization. In populations where people are most comfortable with face-to-face interactions or are uncomfortable with mobile technology, in-person may be the first option, but transportation and time conflicts are commonly cited reasons for discontinuing participation in peer support programs.30 Digital resources have been especially effective in rural communities and those with limited mobility.25,114 Further, in-person interactions do not provide anonymity and might not be available during times of greatest need. Anonymity can be especially important if users are discussing mental health or stigmatized issues.27 For populations that are dispersed geographically or have a high level of comfort with digital communication and telemedicine, the convenience of an on-demand peer network might be more appealing and drive greater engagement. In-person and digital peer support options are not mutually exclusive and can be complementary when offered together.115
The growth of internet use and digital social networks has allowed people to find more information and connect more easily worldwide. Approximately 7% of Google’s searches are related to health, equating to more than 1 billion searches daily.116 However, online health resources are generally not regulated for safety or accuracy.117 Social media use for healthcare information can lead to shorter and suboptimal relationships between patients and providers.118 While free of cost, advising a population to seek support online without direction can lead to worse outcomes. Online communication with people who are personally unfamiliar carries risk of disrespectful or hostile behavior, inaccurate information, and distribution of medical advice from people who are not qualified.4,119 This can lead to worse emotional health, self-doubt, and potentially dangerous health outcomes. Thought leaders have recognized that online communication tools can be highly valuable for facilitating peer support but raise concerns that users might share and adopt negative behaviors in addition to positive ones.51,65 Incorporating moderators into a peer support program ensures positive interactions and maximizes the benefits of participation.
Moderators must be rigorously selected, trained, and supervised. To ensure continued high quality of care and development of their skills, they should have regular opportunities for feedback and continuing education. Protocols for remediation and disciplinary action for poor performance need to be in place to protect the safety of participants.
Maintaining high engagement is another key factor in program success. In a study on in-person support group participation, the authors found improvement in self-esteem and quality of life but minimal improvement in mental health symptoms. However, over the course of 18 months, the frequency of communicating with group members declined from 1-2 times per month to 1-2 times per year.30 This low level of engagement likely contributed to the modest outcomes. Several studies have shown that peer support is more effective for users who are highly engaged. Greater participation in peer support was associated with greater recovery and quality of life.122 Higher levels of engagement in online support groups such as posting or responding to messages is related to better outcomes22 and more frequent users of online peer support groups tend to have greater reduction in depressive symptoms.123
Thoughtful user experience and product design can help drive engagement with a diverse population, especially for those who tend to engage less with health systems such as older men.124 Also, providing 24/7 on-demand availability can help attract participants who need a solution outside of normal business hours or prefer the convenience of accessing the peer group whenever there is a desire to connect with others. In addition, finding a solution with adequate scalability is important for providing a diversity of health and life experiences that peers can draw upon to help one another. Furthermore, a secure and independent third-party that does not share individual data with the health plan or employer can drive engagement by reducing privacy concerns. For employers, this separation of personal health information also ensures legal compliance.
Peer support is not one-size fits all, and an individual’s needs can vary day to day. Therefore, having access to a range of resources including education and self-help resources, opportunities to actively communicate in the peer support network, and care escalation during times of crisis ensure that a platform can be relevant to a large portion of the population at any given time. The technology of a digital peer support platform creates an opportunity for seamless care escalation if a user shows signs of acute distress and needs immediate attention. This could be done through integration with a 24/7 nurse hotline, telemedicine services, or the user’s healthcare provider. Moderators can be trained to facilitate these hand-offs or suggest other services offered by the participant’s health plan or employer.
Digital communication also allows for the application of natural language processing (NLP) and artificial intelligence (AI) to automatically infer mental or physical health needs.22 This technology would be instrumental for early identification and intervention of health conditions before they worsen, management of crisis situations, or even close gaps in care. Moreover, once a participant is comfortable expressing emotions and struggles on a given platform, the same platform could be used to engage him or her in higher levels of care or additional health resources when necessary. By already establishing trust and empathy, the barriers to entry to other forms of healthcare are likely lowered.
Below is a summary of the best practices to consider when implementing a peer support program:
- Determine whether an in-person and/or digital peer support solution is the best fit for your population based on their needs, preferences, and culture. Facilitate peer support with vetted and trained moderators who are closely supervised for adherence to ethical standards.
- Maximize engagement with thoughtful user experience design, 24/7 accessibility, and scalability.
- Adhere to strict privacy and security standards.
- Include resources for education, self-help, peer interaction, and care escalation.
The ways in which social networks are created and leveraged for health are shifting dramatically with digital technology. Peer support, especially through digital peer networks, can be powerful for reducing social isolation, increasing emotional and physical well-being, and improving outcomes for a variety of health conditions in diverse populations. Understanding the implications of these new tools and disseminating clinically effective solutions for increasing social connectivity can greatly benefit public health. When properly implemented, peer support programs offer a clinically effective and low-cost strategy to engage difficult-to-reach and high-risk populations. Online and mobile platforms can provide high-quality peer support that integrates seamlessly with healthcare ecosystems, allowing for holistic care that addresses all the determinants of health at scale.