Nine-Month Longitudinal Impact of Peer Support Workers’ Recovery Attributes on Service Users’ Recovery in Hong Kong

Peer support workers (PSWs) are individuals with lived experience of mental illness who experienced significant improvement and are using their lived experience to support or serve mental health service users who are not as far along in their own journey of recovery (1, 2). PSWs are pivotal to instilling hope among service users by sharing the meaning-making process and leading a self-fulfilling life. Peer support offers the opportunity to overcome prevailing societal stigma and enhance self-esteem by utilizing experiential knowledge to actualize one’s potential and attain personal meaning (3). PSWs’ facilitative role is uniquely different from those of other health care providers and peers in mutual support groups (4).

PSWs have been increasingly recognized as important assets to the mental health services system (5). In Hong Kong, because the waiting time for professional mental health services is very long and follow-ups are infrequent, PSWs serve a particularly pivotal role in supporting people along the recovery journey. Previous evidence has shown the effectiveness of PSWs in enhancing empowerment (6), hope (1), and a range of recovery outcomes among service users (3). A randomized controlled trial has found that one-to-one peer support work enhanced self-efficacy of service users at 6-month follow-up (7). PSWs facilitate changes among service users through personal sharing and interactive exchanges with users (8). The strength of the relationship between PSWs and service users was found to be associated with empowerment, service satisfaction, and recovery at 24 months (9). As such, the recovery attributes espoused by PSWs may influence service users in developing recovery-related qualities. However, most studies have tended to investigate the impact of peer support service on the PSWs and service users independently without examining the possible effects of specific PSWs’ attributes on users’ personal recovery.

In this study, we investigated the association between PSWs’ levels of recovery, hope, self-esteem, self-stigma, and stigma resistance and service users’ recovery outcomes longitudinally. These qualities were considered because they play a crucial role in a person’s recovery. Hope is a core value in peer support service and recovery, wherein one has a sense of positive expectations toward the goals one wants to achieve. Studies have found that hope is positively related to recovery and promotion of well-being (10). Self-esteem is another important quality of recovery in mental illness (11). Studies have reported that self-esteem is positively related to an array of mental health outcomes and that it acts as a protective factor for mental well-being (12).

Internalized stigma has been investigated for its detrimental effect on recovery (13); it was found to be related to lower levels of hope, self-esteem, self-efficacy, and users’ engagement in treatment (14). One of the counterfactors of self-stigma is empowerment (15). Individuals’ empowerment is related to self-esteem, hope, and recovery, and peer support service is significantly associated with empowerment (16). Given previous evidence, in this study we hypothesized that the recovery-oriented qualities of PSWs would have positive effects on service users’ recovery. Specifically, we hypothesized that PSWs’ hope, self-esteem, self-stigma and stigma resistance, and empowerment before service commencement might be associated with subsequent changes in recovery outcomes among service users across a 9-month service period.

Methods

This study was part of a larger pilot services research study that examined the effectiveness of PSW training and peer support services in Hong Kong. It was a 3-year project funded by a charity, MINDSET, operated by a large corporation. Clinical research ethics approval was received from the Joint Chinese University of Hong Kong–New Territories East Cluster Clinical Research Ethics Committee. PSWs and service users were recruited from four local nongovernmental organizations that provided services to people in recovery; informed consent was obtained from all participants. Settings included integrated community centers for mental wellness (69%, N=18), halfway houses (19%, N=5), and sheltered workshops (12%, N=3). All workers in this study received 36 hours of elementary-level training (including introduction to different concepts, skills in self-care, rapport building, communication, and storytelling), 12 hours of advanced-level training on job-related skills (including boundary management and emergency management), and 52 hours of practicum. They regularly met with service users, provided support, and shared their own lived experience relevant to the service users’ struggles and journeys.

Data were collected from October 2012 to September 2015. Because PSWs were trained and hired in three batches, this study covered approximately up to the first 9–12 months of service for each batch. To investigate the longitudinal effects of peer support service, we used service users’ data across 9 months of the service period in the analysis. Data from one service user were excluded because they contained outliers exceeding 3 SDs from the mean. A total of 181 service users and 26 employed PSWs were included in this study. The number of users retained at times 2, 3, and 4 was 140, 98, and 64, respectively. PSWs’ recovery attributes were measured before their service commencement. Recovery-related measures of service users were assessed during their first session and every 3 months throughout their service period as part of the MINDSET Peer Support Workers Project.

Recovery

The Chinese version of the Recovery Assessment Scale (17) is a 24-item self-assessment that measures recovery in terms of personal confidence and hope, willingness to ask for help, goal and success orientation, reliance on others, and no domination by symptoms. Items were scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The Cronbach’s α was 0.89 for PSWs and 0.94–0.97 for service users across the different time points.

Hope

We measured hope using the Chinese version of the 6-item State Hope Scale (18). The items were scored on an 8-point Likert scale ranging from 1 (definitely false) to 8 (definitely true). The Cronbach’s α was 0.70 for PSWs and 0.88–0.92 for service users.

Self-Esteem

The Chinese version of the Rosenberg Self-Esteem Scale (19) is a 10-item, self-report assessment that measures workers’ self-worth. The items were scored on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). The Cronbach’s α was 0.80 for PSWs.

Self-Stigma and Stigma Resistance

The 9-item Self-Stigma Scale-Short Form, developed and validated among Chinese participants in Hong Kong, was used to measure internalized stigma among PSWs and service users (20). The items were rated on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). The Cronbach’s α was 0.92 for PSWs and 0.92–0.93 for service users. The stigma resistance subscale of the Internalized Stigma of Mental Illness scale is a 5-item, self-report scale rated on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree); it has been translated and used among Chinese participants (21). The Cronbach’s α was 0.82 for PSWs and 0.78–0.83 for service users.

Empowerment

The self subscale of the Chinese version of the Empowerment Scale-Mental Health (15) was used to measure the service users’ sense of empowerment and control over their recovery and the mental health services that they were receiving. The items were scored on a 5-point Likert scale ranging from 1 (never) to 5 (always). The Cronbach’s α was 0.88–0.92 for service users.

We used multilevel mixed-effects linear regression analyses with restricted maximum likelihood to analyze possible associations of PSWs’ qualities with service users’ recovery outcomes. The model assumed that data from different time points was nested within service user data and that service user data was nested within PSWs’ data, because each participant was served by the same PSWs throughout the service period.

The time and PSWs’ attribute interaction term described whether the level of certain PSW recovery attributes at service commencement was associated with time-dependent changes in service users’ outcomes. Because no evidence was found that gender and age significantly affected the association between PSWs’ attributes and service users’ changes in recovery, and because the inclusion of covariates did not produce results that were significantly different, no covariates were included in the final analyses. We performed these analyses with R, version 4.0.2, and its integrated interface RStudio, version 1.1.423. The Holm-Bonferroni method was used to adjust p values to account for multiple comparisons (22).

Results

Of the 181 service users whose data were included in this study, 128 (71%) were women. All were ethnically Chinese with a mean±SD age of 45.3±11.8 years, 152 (84%) of whom had at least a secondary school education. The primary psychiatric diagnoses of the service users included schizophrenia (60%, N=109), major depressive disorder (27%, N=49), bipolar disorder (7%, N=12), and other disorders (6%, N=10). Data from 26 employed PSWs (N=18, 69% female) were included, and the PSWs’ mean age was 38.7±11.3 years. The demographic characteristics of the PSWs and service users are shown in Table 1.

As shown in Table 2, after accounting for Holm-Bonferroni adjustment, results showed that PSWs’ levels of hope and self-esteem at the commencement of service were related to the change of specific recovery qualities of service users across the 9-month service period. In particular, improvements in service users’ hope were reflected by significant interaction effects of time with PSWs’ hope (β=0.23, p=0.002) and self-esteem (β=0.43, p=0.011). In other words, service users showed an improvement in hope across time that was significantly higher than their peers’ hope improvement rate if the PSWs had higher levels of hope and self-esteem. Similarly, for service users’ empowerment, we noted a significant interaction effect of time by PSWs’ self-esteem (β=0.32, p<0.001). Service users’ increase in empowerment across time was significantly higher than peers’ empowerment improvement rate if their PSWs had higher levels of self-esteem.

No significant interaction effect was found between time and self-stigma on service users’ hope across time; in addition, no significant interaction was found between time and personal recovery on service users’ empowerment across time. Finally, no significant interaction effect was found between time and PSWs’ qualities on service users’ personal recovery, self-stigma, and stigma resistance across time.

Discussion and Conclusions

PSWs offer a unique advantage over nonpeer mental health service providers by instilling hope and facilitating self-understanding and empowerment through self-disclosure and sharing of lived experience (3). In the process of personal sharing, PSWs’ understanding of their own recovery and recovery attributes were manifested in their interaction with service users, affecting service users’ outcomes. Although evidence of peer support service’s effectiveness has been emerging, previous research often has evaluated PSWs’ effects and service users’ recovery outcomes separately, without revealing possible attributes of workers that might contribute to service users’ outcomes. This study is one of a few quantitative and longitudinal studies (7, 9) measuring the associations between PSWs’ recovery-related attributes and service users’ recovery outcomes every 3 months during 9 months of service.

The findings of this study reveal that levels of hope and self-esteem of the PSWs were associated with improvements in hope and empowerment among service users over time. Whereas previous qualitative studies documented the importance of PSWs’ personal qualities and sharing in the facilitation of service users’ recovery (5), this study provided quantitative support that PSWs’ levels of hope and self-esteem were related to service users’ hope and empowerment over time. This finding points to the importance of hope and self-esteem among people with lived experience, which not only can benefit them in their own recovery but can also spur improvement among others along the recovery journey. Training and support of PSWs can prepare them for adopting a role in the organization; in addition, their personal improvement can benefit service users (8).

Because PSWs are further along in the recovery journey and are expected to provide guidance and support to service users, measures of personal improvement may be useful in providing a reference point in assessing whether a PSW candidate might be suitable for such a position and effective in supporting service users in their personal recovery. Our findings shed light on the need for adaptive support and training of PSWs to maximize a person’s ability to fill the PSW role. Nonetheless, our results also show that other PSWs’ attributes at work commencement, including self-stigma, stigma resistance, and recovery, were not significantly associated with service users’ outcomes. Because the recovery process is highly personal, these stigma and recovery experiences may be less instrumental to service users’ outcomes than PSWs’ hope and self-esteem, indicating that their sharing of their lived experience mainly inspires service users’ hope and empowerment.

Limitations

Despite the encouraging results of this longitudinal examination of peer support service on service users’ recovery outcomes, some limitations warrant attention. First, because this study was part of a larger pilot services investigation in Hong Kong, participants were existing service users who might have been receiving other services. We were unable to include objective data, such as hospitalization duration and number of psychiatric consultations received by the users, to corroborate their self-report data because such data were unavailable in the public mental health services system. Moreover, the frequency of psychiatric consultations was low (e.g., once every 6 months), which may have precluded observation of any meaningful effects over the course of 9 months. Thus, generalization of our findings to other service settings may need to be investigated by future studies.

We also recognize that the sample size for this study was small for an investigation of cross-level interaction, posing a limitation to the interpretation of the results. One of the reasons for the small sample size was that the PSW role is new in Hong Kong; moreover, this investigation was the first quantitative study evaluating peer support services in local mental health services over time. The limited resources for training and positions created for PSWs increased the value of this study by showing the importance and association of PSWs’ training and recovery attributes with service users’ recovery outcomes. Although we could measure PSWs’ recovery, we could not match PSWs’ and service users’ assessment time points during the service period, which was a limitation of our study design.

Future Directions

The results of this study suggest associations of PSWs’ recovery-related attributes at service commencement with service users’ recovery across 9 months of service. Our results show that PSWs’ specific elements of recovery, notably hope and self-esteem, were associated with service users’ hope and empowerment. Because PSWs and service users may affect each other throughout the intervention process, future studies may investigate the bidirectional effects and mechanisms involved. In this way, timely intervention and adjustment in the service process may maximize personal growth and recovery of both PSWs and service users and promote recovery trajectories.

Because the PSW role is relatively new in the mental health workforce in Hong Kong, the scope and responsibilities of this role may be unclear for the PSWs themselves and also for colleagues and service users. In future studies, researchers should investigate the fidelity of the peer support services provided and other service utilization by service users to more precisely tap into the contribution of peer support services to service users’ recovery. The effects of the work environment, including organizational support and supervision, clarity of job duties, and prospect of peer support service, on the quality of peer support services should be investigated; in addition, how these factors affect outcomes for service users should also be considered. The success of peer support services depends not only on the attributes of individual PSWs but also on how the services are organized and made available for service users.