Recognizing peer support initiatives organized outside of the clinical setting: insights from a Belgian Delphi method with peer supporters, patients and mental health professionals

Recognizing peer support initiatives organized outside of the clinical setting: insights from a Belgian Delphi method with peer supporters, patients and mental health professionals | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Recognizing peer support initiatives organized outside of the clinical setting: insights from a Belgian Delphi method with peer supporters, patients and mental health professionals Gerard Sylvie, Tobback Els, Matthys Frieda, Van Isterdael Geert, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4648393/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Peer support in mental health involves individuals with lived experience of mental illness providing assistance and encouragement to others facing similar challenges. This care practice is endorsed in best practice guidelines and has been shown to enhance individual-centered, recovery-focused, and rights-based mental health care, according to the World Health Organization (WHO). In Belgium, there is currently no well-defined framework supporting the practical implementation of peer support in mental health practice, including role descriptions and training needs. Moreover, the added value of peer support compared to formal care is not thoroughly examined at individual and societal levels. This research aims to explore the role and organization of peer support in the mental health care system, focusing on intentional, asymmetric peer interactions organized outside the clinical setting. Methods: The Delphi method gathered insights from peer supporters, mental health professionals, and patients. Three rounds of data collection and analyses achieved consensus on key statements regarding the added value of peer support and the requirements for a framework enabling peer support as a valid care practice outside clinical settings. Results : Participants agreed that peer support can play a significant role in various stages of the recovery process, complementing clinical care. They agreed that peer support offers benefits for both patients and peer supporters. Requirements for a framework include logistical, financial, and human resources support, as well as training and status recognition. Consensus emerged on many statements, but divergent views surfaced on the peer supporter’s role limitations in the healthcare system, the balance between regulation and preserving the informal nature of peer support, and the roles of remuneration and training. Conclusions : This study achieved consensus on 38 statements, outlining requirements to optimize the organization of intentional, asymmetric peer interactions organized outside clinical settings. It underscores the added value of such peer support in Belgian mental health care. Trial registration: Ethical approval was not required as experts freely shared their experiences on peer support within a national expert group, contributing to policy recommendations and publications. mental health peer support Delphi study Figures Figure 1 BACKGROUND In recovery-oriented mental health care, peer support is becoming more prevalent. Peers are individuals who share common characteristics with a specific individual or group. Peer support has been shown to improve several indicators and symptoms related to mental and psychosocial health and promote behavioral change and self-care (Cano Prieto et al., 2022; Wang et al., 2022 ). It is, therefore, considered beneficial for many population groups, particularly those with chronic (mental) illnesses. Peer support is endorsed in various best practice guidelines. The World Health Organization (WHO, 2021) also recommends peer support as a care practice that enhances individual-centered, recovery-focused, and rights-based mental health care. Notwithstanding the scientific evidence concerning the benefits of peer support at the individual level (e.g., treatment compliance and adherence, stress, health, quality of life) and societal level (e.g., professional care utilization, frequency/length of hospital stays, socio-professional integration), peer support is not yet fully acknowledged in the current Belgian healthcare system. Peer support can manifest itself in different types and settings. Davidson et al. ( 2006 ) propose a continuum of support, ranging from unidirectional approaches (expert-to-non-expert) to reciprocal approaches (friendship, mutual support groups), where all participants are viewed as equals. According to this continuum, peer support is considered asymmetric, with the peer supporter possessing unique insights or experiences compared to the peer who receives support. Indeed, individuals earlier in their recovery process receive support from peer supporters, who are in recovery themselves and have a significant history of mental illness along with notable improvement experience. This kind of peer support is sometimes organized in close collaboration with mental health professionals or even organized in mental health care facilities. However, several organizations in the field also operate outside of this clinical setting. The organizations claim to provide a beneficial and qualitative service to patients, but find it hard to gain recognition for their work. Belgium currently lacks a recognized framework supporting the practical implementation of this kind of peer support in mental health, including job descriptions and training required to be considered a peer supporter. The quality and rigorousness of their work are, therefore, easily questioned, as the local initiatives often operate at will and do not follow clear guidelines. More often than not led by charitable organizations of former patients, this lack of recognition also leads to a lack of funding, which threatens the survival of these initiatives. The objective of this study is to explore how organizations outside of clinical institutions can best organize peer support in order to be recognized as a valuable care approach. As has been done in other countries (e.g., Campos et al., 2016 ), establishing a framework can provide the foundations for the design and implementation of recognized peer support programs outside of the clinical practice. Doing this also provides insights for other countries to develop their own approaches and recommendations for peer support adapted to their specific healthcare settings. Accordingly, this research addresses the following main questions: How should peer support outside of the clinical setting best be organized in order to be recognized as a valid qualitative offer besides traditional care? And can the added value of such peer contact be recognized as a tool in the mental health care system towards patient recovery? METHODS The study was conducted in collaboration with the Belgian Superior Health Council and carried out under its supervision. The Belgian Superior Health Council produces scientific advisory reports aimed at guiding policymakers and healthcare professionals (FPS Public Health, 2024). A working group was established within the Superior Health Council, comprising peer supporters and specialized experts from various fields, including psychiatry, psychology, sociology, medicine, and nursing. The group was in charge of the design, conduct, analysis, and reporting of the present study. Members of this group provided a general and ad hoc declaration of interests, which was evaluated by the Ethics Committee of the Superior Health Council (an external and independent body tasked with assessing potential conflicts of interest). A Delphi method of consensus was conducted to gather insights from peer supporters, mental health professionals, and patients. This systematic and interactive research procedure, first developed by the Rand Corporation in the 1950s, aims to achieve consensus through experts' subjective opinions (McPherson et al., 2018 ; Linstone & Turoff, 2002 ). Recognized for its effectiveness in structuring group communication, the Delphi technique addresses questions beyond experimental or epidemiological means (Jorm, 2015 ) and has been widely utilized in psychosocial research (De Meyrick, 2003 ). The process involves asking qualitative questions individually, collecting written responses, summarizing them into statements, and seeking agreement from participants through quantitative evaluation. Statements for which consensus is achieved are reviewed for meaning and importance; statements that are near consensus are reviewed to clarify areas of possible ambiguity and linguistically revised before inclusion in the next Delphi round; and, lastly, statements that do not reach consensus are discarded unless modification and inclusion in the next Delphi round are warranted based on for example qualitative input of the respondents. The iterative nature of the Delphi method structurally translates individual responses into quality-driven conclusions backed by a larger group. Participants There is a lack of definitive guidelines regarding the optimal number of respondents needed for Delphi studies (Wilhelm, 2001 ; Chalmers and Armour, 2019 ), with participant numbers ranging widely from 4 to 3000 individuals in different research works (Thangaratinam & Redman, 2005 ). Typically, Delphi studies involve panels consisting of 10 to 100 respondents, whereby smaller groups tend to reach consensus faster than larger ones. While some argue that Delphi studies with over 25–30 panel members do not yield new insights, the ultimate panel size is eventually influenced by various practical considerations such as research question complexity, resource availability, and study logistics. The quality of respondents engaged in a Delphi study is crucial to the reliability of the research outcomes, whereby this quality surpasses the importance of the quantity of respondents involved. While professional participants are typically utilized in most Delphi studies, there is a growing recognition of the value of diverse expertise, leading to the inclusion of consumer advocates and informal caregivers in Delphi panels (Jorm, 2015 ). This trend is evident in the present study, where three distinct groups of participants were identified and utilized: mental health professionals, patient representatives, and peer supporters. The Belgian Superior Health Council maintains an extensive and active database of Belgian health experts, particularly in the field of psychosocial health, including healthcare professionals, patient associations, and peer supporters. These experts can be consulted whenever specific questions arise. Utilizing this network, an initial invitation for the Delphi was sent to all contacts of the Superior Health Council in the field of mental health (N = 2216), inviting them to participate in the study if they were either a) a (mental) healthcare professional collaborating with peer supporters or treating patients assisted by peer supporters for mental health issues; b) a user of mental healthcare services; or c) a former user of mental healthcare services actively involved as an expert through peer support. The invitation specified that the Superior Health Council was seeking participants regarding a study on peer support defined as : a) support in the field of mental health, b) provided by individuals who are or have been affected by mental illness, c) offered by individuals recognized as experts (whether remunerated or not), d) intentionally provided support, and e) organized outside the institutional, clinical framework. The email also requested recipients to disseminate the survey further amongst their contacts. It was also sent to mental health associations, professional associations of psychologists, psychiatrists, and physicians; as well as patient, family, and peer support associations, with a request to share it with their members. The working group members also disseminated the Delphi invitation to their contacts. By using this snowball method, it is believed that the relevant expert base in Belgium was reached. Study Design The Delphi process in this research comprised three rounds (Fig. 1 ). This chart presents the three rounds of the Delphi study and the number of eligible participants involved at each stage. Du, Dutch speaking participants; Fr, French speaking participants. During the initial phase, participants were presented with a series of open-ended questions (Table 1 ), to which each had to respond individually using SurveyMonkey (an online survey site). Table 1 List of open-ended questions round 1 1) For professionals: - At what point or for what reasons do you refer a patient to peer support? - In your opinion, what is the added value of peer support in the recovery process of psychologically vulnerable people? - What is the added value of peer support in the mental health care system? - What do you think is needed to organize peer support professionally? - What are the logistical requirements for organizing peer support? - What training do you think peer experts need? - In your opinion, is there a need for a legal and/or ethical framework for peer support? - What should be included in this framework, and what would the practical implications be? - Do you have any examples of good (or bad) practice in organizing peer support outside the institutional framework? What have you learned from these practices? - What are the limits of peer support? - Is there anything else you would like to add? 2) Peer supporters: The same questionnaire as for professionals was distributed, with additional specific questions: - On what basis do you identify yourself as a 'peer expert'? What defines you as a peer expert? - As a peer supporter, what difficulties do you encounter? - As a peer supporter, what resources help you in your practice? - What do you gain from being a peer supporter? What motivates you to be a peer supporter? 3) Patients - When and/or for what reasons have you needed or do you think you need peer support? - In your opinion, what is the added value of peer support in the recovery process of psychologically vulnerable people? - What are the limits of peer support? - Do you have any examples of good (or bad) practice in organizing peer support outside the institutional framework? What have you learned from these practices? - As patients, what difficulties do you encounter in organizing peer support? - Is there anything else you would like to add? Subsequently, the eligibility of peer supporters was evaluated by examining their responses to the first question posed (see Table 1 : On what basis do you identify yourself as a 'peer expert'? What defines you as a peer expert?) compared to the definition of Davidson et al. ( 2006 ). Following this first round, the responses of eligible participants were independently and ethnographically analyzed (Altheide & Schneider, 2013 ) by three researchers. A French-speaking researcher analyzed the responses in French, and two Dutch-speaking researchers divided the responses in Dutch between themselves. The analyses of each researcher were then consolidated and structured into statements summarizing the answers. The three researchers presented and discussed their findings together during a group session to reach a consensus on a set of collectively approved statements and to enhance the structure and readability of the remaining statements. To ensure methodological consistency and validity of the defined research statements, the entire process was presented to the full working group members, who did not participate in the analysis process itself. Members of this group ensured that the methodology was followed properly, that the statements corresponded to the analysis results and that they were formulated unambiguously. A structured online questionnaire containing these statements was then sent to the eligible participants who supplied their contact email addresses, for the subsequent second and third rounds. For each statement, participants were asked to indicate their level of agreement using a 7-point Likert scale, ranging from "strongly disagree" to "strongly agree." They could also provide comments and explanations for their responses, allowing them to offer feedback on any aspect of the statements. Statements were considered as a consensus if over 70% of participants agreed (i.e., rating 5 or above) and the median was 5 or above, with an interquartile range (IQR) not surpassing 1 (Diamond et al., 2014 ; Von der Gracht, 2012 ). Statements with over 70% rating 1 or 2, or a median below 2 and IQR less than or equal to 1, were rejected. The IQR is a measure of dispersion around the median, which reflects the agreement level. An IQR of zero indicates full consensus, while higher values indicate greater data dispersion, thus revealing the experts' disagreement. Finally, a synthesis report, including the detailed analysis and the statements for which a consensus was reached, was sent to participants in the second and third phases, allowing them to confirm if they agreed with the conclusions or had anything to add. The data collection period and approval of the synthesis extended from June 12, 2023, to November 30, 2023. RESULTS A flow chart of the three rounds of the Delphi study is presented in Fig. 1 , detailing the eligible participants by group and language. Initially, 441 participants responded to the first round. After evaluating eligibility, 65 peer supporters were excluded because they did not meet the inclusion criteria (i.e. the definition of peer supporter elaborated for this research), resulting in 376 eligible participants. Of these 376, 99 did not provide email addresses, leaving 277 participants who were invited to the second round. In the second round, 169 participated and were invited to the third round, in which 115 participated. Based on the first round of open-ended questions, 52 initial statements were produced, addressing both the need for and different elements of a framework helping the organization of peer contact support outside of the clinical setting and the added value of such peer support. When sent to participants for the second round, they reached sufficient agreement for 28 out of 52 statements (53.8%). No statements were rejected (0%) and 24 statements were reformulated (46.2%) based on the feedback received. During that process, one statement was split into two distinct ones, leading to a total of 53 statements, including the 25 reformulated. No major differences were observed between responses from French-speaking and Dutch-speaking participants, nor between patients, professionals, and peer supporters. For the third round, the 25 reformulated statements were resubmitted to the participants following the same principle. Sufficient consensus was found for 10 statements (40.0%), with no statements being rejected (0%), and 15 statements still requiring further reformulation (60.0%). Table 2 lists the accepted statements, the Delphi round in which consensus was reached, and the scores obtained. Table 2 Accepted statements, with scores obtained and the Delphi cycle during which a consensus was reached and the Median %>5 Approval round 1. ADDED VALUE OF PEER CONTACT Peer support can be useful at various stages of the recovery process (at the beginning, continuously, at the end, at the return to work, etc.), in complementarity with clinical care. 7 93.5 2 Peer support can meet different patient needs: · need for hope and perspective; 7 94.6 2 · need for additional support or contacts; 7 95,24 2 · in case of difficulties in coping with the diagnosis, anxiety and (self-)stigma 7 87.5 2 Peer support provides a complementary form of support that · Can approach the patient with a different perspective compared to conventional healthcare providers 7 94.8 3 · has particular legitimacy and credibility thanks to a good understanding of the disease and the difficulties encountered; 7 91.7 2 · offers a vision of the care pathway that is not purely medical; 7 94.6 2 · Can be perceived as more horizontal 7 91.4 3 Peer support has added value for the patient, as it · empowers them through the exchange of tools, best practices, knowledge about the disease, and advice for recovery with appropriate language; 7 94.1 2 · Facilitates psychoeducation, when the peer support worker is trained in this subject 6 90.5 3 · brings hope and perspectives, because it allows them to identify with a patient who has recovered: an example of success, proof that it is possible, that gives confidence, hope; 7 93.5 2 · Can help break isolation or loneliness; 7 93.1 3 · Can offer support in the care process, especially when things are not going well, in difficult times (taking into account their own fragilities) 7 92.2 3 · allows them to speak freely because they feel listened to without judgment, with kindness and empathy (bond of trust). 7 91.1 2 Peer support also has added value for the peer supporter himself, because it · also promotes their own recovery, in particular by strengthening their self-esteem, providing them with recognition, satisfaction in helping, being useful, giving meaning to their own difficulties; 7 91. 7 2 · helps them reintegrate, by giving them a place in society (sense of belonging), by giving purpose and meaning to their days, by integrating them into a learning and training path. 7 91.7 2 II. NEEDS FOR PROFESSIONAL SUPPORT The peer supporter must benefit from logistical support according to his needs: having offices if necessary, meeting rooms set up in a friendly way, in a safe and accessible place, furniture, equipment for activities, IT tools, etc. 7 88.8 3 The peer support worker must have financial support: · transport and operating costs, 7 91.7 2 · In some cases (depending on the role), salary 7 87.9 3 The peer supporter must benefit from support in terms of human resources (socio-professional integration into the teams/organizations in which they are employed) 7 88.7 2 The peer supporter must be integrated into a network of peer supporters and associations that support peer support (professional associations and support/expertise centers), ensuring availability everywhere and for all mental health disorders. 7 85.7 2 This network should support the peer support in terms of communication: · Raising awareness among the general public (breaking taboos) 7 89.9 2 · with (mental) health professionals to recognize peer support workers as partners in patient care 7 90.5 2 · Peer support details should only be shared in accordance with the law on the protection of privacy, i.e. no personal data, only professional data, if available 7 93.1 3 In order to be professionally organized, the peer supporter must have a status (based on a job description) 7 87.5 2 This job description should define o the rights and duties (e.g. professional secrecy) of the peer supporter, 7 93.5 2 o The limits of the function 7 88.7 2 Training should include, but is not limited to, the following: - practical elements of communication and group dynamics: oral expression, public speaking, motivational interviewing, active listening; 7 91.1 2 - elements of ethics (professional secrecy, GDPR) 7 91.1 2 - elements relating to the network in which it operates: available functions, place and limits of the function in relation to others, exchanges with other professionals, functioning of a team, etc. 7 85.7 2 - elements relating to the well-being of the peer supporter: knowing how to set the limits of his commitment (in particular the limits between a friendly and professional relationship), having sufficient distance from his own experience, keeping a healthy lifestyle (time for himself, listening to his own needs, etc.) 7 90.5 2 These trainings can be organized by patient organizations in cooperation with professional organizations (mental health professionals) or training institutes in order to ensure quality. 7 87.9 3 To maintain their status, it is recommended that peer experts, like other health care providers, also participate in intervisions, supervision, and continuing education. 7 91.4 3 This status would make it possible to: - to improve the legitimacy, credibility and recognition of the peer supporter among other health professionals (a function integrated into the panel of possible functions) and to better identify his or her place among them; 7 88.7 2 - protect both the patient and the peer supporter, 7 89.9 2 - reassure patients, employers and other professionals, and reduce the stigma that may still be experienced by peer supporters; 7 85.1 2 - to give a fair remuneration to the peer supporter (definition of scales). 7 87.5 2 Note: Possible range for agreement score 1–7. For some statements requiring reformulation in this third round, the results indicated differences in acceptance between French-speaking and Dutch-speaking participants and/or between expert groups. For certain statements, the issue lay in the IQR, meaning that they were generally accepted but with a significant diversity in responses. For others, there was a clear rejection of the proposals, particularly concerning the added value of peer support in the healthcare system, which focused on the role of the peer supporter as a facilitator of the connection between the patient and the professional, or as additional support in case of reluctance to enter the care pathway or in case of a waiting list. Additionally, for some statements, agreement was better in the previous stage, with the reformulation being less well-received (these statements had been reformulated negatively: "it is not the role of the peer supporter to..."). Given that remarks on these statements expressed highly divergent views that were challenging to reconcile into a single statement, researchers decided not to reformulate them for another round. The various perspectives on these more complex concepts are discussed below. DISCUSSION The present Delphi study aimed at providing a framework for the effective implementation of peer support in mental health outside of the clinical setting and to establish whether this kind of peer support is capable of adding value to the recovery process. Consensus was reached for 38 statements in three rounds. The consensus on these statements is noteworthy: with one exception, all statements have a median score of 7 and over 85% of participants gave a score of 6 or 7 to each statement. According to these statements, participants acknowledged that intentional, asymmetric peer interactions organized outside the clinical setting can be beneficial at various stages of the recovery process (at the beginning, continuously, towards the end, when returning to work), complementing clinical care. It can address different patient needs and offers added value for both the patients (empowerment and psychoeducation, hope and perspectives, support in case of difficulty, breaking isolation, empathetic listening) and the peer supporters themselves (self-esteem, reintegration). However, for this kind of peer support to be recognized as a valid resource, participants agreed that a certain framework is needed, including logistical support (facilities), financial support (transportation or operational expenses, salary), and human resources support (integration into teams). Peer supporters should also be integrated into a network that can support them, especially in communication (raising awareness among the general public and healthcare professionals, communicating with patients with respect for privacy). Participants found that intentional, asymmetric peer interactions organized outside the clinical setting should also be regulated, based on a job description defining the rights and duties (e.g., confidentiality) of the peer supporter and the boundaries of their role. This would improve the legitimacy, credibility, and recognition of the peer supporter among healthcare professionals (function integrated into the range of possible functions) and better identify their place when working with them. According to the participants, a clearer demarcation would protect both the patient and the peer supporter, reassure patients, employers, and other professionals, and reduce any stigma that peer supporters may still face. Additionally, it would facilitate a discussion on fair remuneration for peer supporters (establishment of pay scales). An important requirement to be able to be recognized as a peer supporter, is the idea that peer supporters should undergo training including practical elements of communication and group dynamics, ethics, networking skills, and elements related to the well-being of the peer supporter (including knowing how to set boundaries and maintain a professional distance from personal experiences). To maintain their recognition, peer supporters should also participate in peer supervision, and ongoing training. Statements on which there was insufficient agreement highlighted some specifications. For example, it is essential to clearly define the role of the peer supporter, particularly regarding their role in the healthcare system. While participants agreed that peer support can be a complementary resource in the healthcare system, especially in addressing gaps or issues in conventional care (e.g., waiting lists, patient distrust, breakdown of communication), they emphasized that this should not be the primary role of peer supporters. According to the participants, it is the responsibility of the conventional healthcare system to address potential gaps and resolve these issues instead of relaying these problems to peer supporters. The specific added value of peer supporters lies in being a peer and this specificity should be protected. While some sort of regulation of the term peer supporter is deemed necessary by the respondents, overly stringent requirements for becoming a peer supporter also form a potential risk. Some participants voiced the concern that stringent requirements may also lead to the exclusion of people with valuable experience. They, therefore, emphasized the importance of striking a balance between the need for regulation (especially to protect patients and peer supporters) and the preservation of the informal and accessible nature of peer support. A solution that was brought up, is to explicitly distinguish peer supporters who play an explicit role in the healthcare system from other forms of support that operate independently outside of that framework (e.g., self-help groups). All kind of support (individual or group) naturally exist and do not all need to be regulated. It is, particularly, asymmetric peer interactions organized outside the clinical setting that would benefit from regulation. There were also divergent views regarding remuneration and training conditions. While study participants agreed that remuneration adds value and can motivate peer supporters contributing to their sense of recognition and integration into society, some participants also expressed concerns about potential additional pressure on peer supporters. They also specified that remuneration should not be the main motivation for becoming a peer supporter. Additionally, participants emphasized the importance of not remunerating all types of peer support. It is, therefore, essential to define remuneration based on the recognition of specific peer support types. Regarding training, participants agreed that training conditions should be defined for peer supporters, but they also emphasized that personal experience is crucial for peer supporters. Indeed, the authenticity of personal experience facilitates establishing connections with the patient. Personal experience is and continues to serve as the foundation for fulfilling the role of a peer supporter. Some participants, therefore, suggest adopting a balanced approach, in which personal experience is valued as much as structured training. Training should mainly focus on practical elements (e.g., communication and group dynamics), with theoretical knowledge (e.g., mental health theories, principles of psychology) addressed by other healthcare professionals. Furthermore, efforts should be made to promote communication and mutual understanding between peer supporters and conventional healthcare professionals by coordinating training in which both groups are present. Limitations The Delphi study has several strengths and limitations. Notable strengths include broad consultation and widespread dissemination of the call, along with the involvement of various target groups. However, the participation rate among certain target groups, particularly patients, was rather limited. As with all iterative research designs, there is a risk of participant dropout. While it is common for 20 to 30% of participants to discontinue between rounds (Chalmers & Armour, 2019 ), our study saw a dropout rate of 39% between rounds 1 and 2, and 32% between rounds 2 and 3, which is slightly above the expected range. Despite this, the proportion of various expert categories was evenly distributed across rounds, suggesting no attrition bias in the outcomes. Additionally, although the interpretation of peer support was clearly defined at the beginning of the survey, it may have led to different interpretations within the diverse group of participants. The use of different terms ("peer supporters," "lived experience experts," and "peer experts") throughout the statements could have prompted varied interpretations and responses, potentially causing confusion about the different roles and types of peer support addressed in this study. Furthermore, the formal scientific approach adopted in the Delphi study, while systematic, may have resulted in some limitations. Research on patient participation in scientific research highlights the value of involvement but also underscores challenges such as the need for training and education before participation, attention to facilitating factors, and potential obstacles like individual and structural barriers and interaction issues between researchers and patients, which were less emphasized in the current study. CONCLUSIONS Recognizing the added value of intentional, asymmetric peer interactions outside clinical settings within mental healthcare is, currently, not a given. A more clear framework and professionally organized structure is needed for peer supporters to be able to attain an equal and complementary position alongside conventional healthcare providers. This framework seems to be comprised of different elements. A clear definition and demarcation of the job will help strengthen the peer support role and clarify how it relates to other professions and/or volunteers active in the healthcare setting. Continued training, intervision and networking - including with healthcare professionals - is needed to uphold the quality of services delivered by the peer supporters and to continue to substantively nourish this emerging field. Durable logistical (facilities) and financial support (transportation or operational expenses) is needed to realize the peer support offer in a professional manner. The insights stemming from this research project lead to the scientifically grounded formulation of specific recommendations for peer support groups, policy-making, the healthcare sector, and society as a whole. ABBREVIATIONS IQR interquartile range WHO World Health Organization Declarations Ethics approval The study was carried out under the supervision of the Belgian Superior Health Council, an independent network of national and international experts. The College is the decision-making body of the Council, and the Ethics Commission is an external and independent group that oversees the management of interests and potential conflicts of interest. Ethical approval was not required. Within a national expert group, experts from the field freely and willingly provided information on their experience with peer support in light of writing policy recommendations and publications. Consent to participate Within a national expert group, experts from the field freely and willingly provided information on their experience with peer support in light of writing policy recommendations and publications. The study had a formal opt-in procedure for participants, explaining the research project, the procedure, the goal of the research (incl. policy advice and publications) and offering the opportunity to opt out at any given moment in time, before being able to participate in the actual Delphi module. Consent for publication Not applicable Availability of data and materials All data generated or analyzed during this study are included in this published article. Supplementary information is readily available from the corresponding author upon request. Competing interests The authors declare that they have no competing interests. Clinical Trial Number Not applicable Funding No funding was received for this study. Authors' contributions GS made substantial contributions to the conception and design of the work, analyzed and interpreted the patient data, and drafted the manuscript. TE analyzed and interpreted the patient data and was a major contributor in writing the manuscript. MF made substantial contributions to the conception and design of the work. VIG made substantial contributions to the conception and design of the work. GP made substantial contributions to the conception and design of the work and substantively revised the manuscript. VDCN made substantial contributions to the conception and design of the work, analyzed and interpreted the patient data, and substantively revised the manuscript. All authors read and approved the final manuscript. All authors agreed to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even those in which they were not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. Acknowledgements This article was written as part of a scientific advisory report by the Belgian Superior Health Council on peer support in mental health care. The authors were members of the ad hoc working group and sincerely thank the other members: Beheydt Lieve, Bol Suzanne, Cephale Sophie, Colemont Patrick, Crew Sarah, Debyser Bart, Delatte Benoit, Delespaul Philippe, Deloyer Jocelyn, Delvaux Jan, Delville Kim, Lamy Dominique, Lejeune Philippe, Nolmans Mattias, Nuhaan Marlene, Ripault Sophie, Simon Yves, Van den Abeele Tom, Van den Broeck Kris, Van Doren Shauni, Van Hal Guido, Van Wanseele Carine, Vilain François, Waha Stéphane. We are also grateful to the participants of the Delphi study for their time and input. References Altheide L, Schneider CJ. Qualitative Media Analysis. SAGE; 2013. Cano Prieto I, Simó Algado S, Prat G. Peer Interventions in Severe Mental Illnesses: A Systematic Review and its Relation to Occupational Therapy. Occup Ther Ment Health. 2023;39(3):1-38. Campos F, Sousa A, Rodrigues V, Marques A, Queirós C, Dores A. Practical guidelines for peer support programmes for mental health problems. Rev Psiquiatr Salud Ment. 2016;9(2):97-110. Chalmers J, Armour M. The Delphi Technique. In: Liamputtong P, editor. Handbook of Research Methods in Health Social Sciences. Springer Singapore; 2019. p. 715-735. Davidson L, Chinman M, Sells D, Rowe M. Peer support among adults with serious mental illness: a report from the field. Schizophr Bull. 2006;32(3):443-50. De Meyrick J. The Delphi method and health research. Health Educ. 2003;103(1):7-16. Diamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401-9. Jorm AF. Using the Delphi expert consensus method in mental health research. Aust N Z J Psychiatry. 2015;49(10):887-97. Linstone HA, Turoff M, editors. The Delphi Method. Techniques and Applications. London: Murray Turoff and Harold A. Linstone; 2002. McPherson S, Reese C, Wendler MC. Methodology Update: Delphi Studies. Nurs Res. 2018;67(5):404-410. Thangaratinam S, Redman CWE. The Delphi technique. Obstet Gynaecol. 2005;7:120-125. Von der Gracht HA. Consensus measurement in Delphi studies: Review and implications for future quality assurance. Technol Forecast Soc Change. 2012;79(8):1525-1536. Wang Y, Chen Y, Deng H. Effectiveness of Family- and Individual-Led Peer Support for People With Serious Mental Illness: A Meta-Analysis. J Psychosoc Nurs Ment Health Serv. 2022;60(2):20-6. Wilhelm W. Alchemy of the Oracle: The Delphi Technique. Delta Pi Epsilon J. 2001;43(1):6-26. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4648393","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":330878998,"identity":"1be94066-eefc-46ea-9b7b-0caf598f7e6a","order_by":0,"name":"Gerard Sylvie","email":"data:image/png;base64,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","orcid":"","institution":"Belgian Superior Health Council","correspondingAuthor":true,"prefix":"","firstName":"Gerard","middleName":"","lastName":"Sylvie","suffix":""},{"id":330878999,"identity":"5a42a0d9-8c43-46e0-a610-616ec532a311","order_by":1,"name":"Tobback Els","email":"","orcid":"","institution":"Belgian Superior Health Council","correspondingAuthor":false,"prefix":"","firstName":"Tobback","middleName":"","lastName":"Els","suffix":""},{"id":330879001,"identity":"a2460d9c-1956-48f5-bd8f-38050a75e3ad","order_by":2,"name":"Matthys Frieda","email":"","orcid":"","institution":"Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel)","correspondingAuthor":false,"prefix":"","firstName":"Matthys","middleName":"","lastName":"Frieda","suffix":""},{"id":330879002,"identity":"9cb38d59-8089-4559-ad10-884e6bc1514e","order_by":3,"name":"Van Isterdael Geert","email":"","orcid":"","institution":"Uilenspiegel vzw","correspondingAuthor":false,"prefix":"","firstName":"Van","middleName":"Isterdael","lastName":"Geert","suffix":""},{"id":330879004,"identity":"2bce1662-9f9e-43ea-9957-65f4a460d88e","order_by":4,"name":"Gérain Pierre","email":"","orcid":"","institution":"Université Libre de Bruxelles (ULB)","correspondingAuthor":false,"prefix":"","firstName":"Gérain","middleName":"","lastName":"Pierre","suffix":""},{"id":330879005,"identity":"5b266837-1de7-44c7-a5ab-bcfb39d76ca7","order_by":5,"name":"Van den Cruyce Nele","email":"","orcid":"","institution":"Katholieke Universiteit Leuven (KU Leuven)","correspondingAuthor":false,"prefix":"","firstName":"Van","middleName":"den Cruyce","lastName":"Nele","suffix":""}],"badges":[],"createdAt":"2024-06-27 12:03:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4648393/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4648393/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":61002744,"identity":"f34b9782-702f-466a-8e4b-c4d77dd8eae8","added_by":"auto","created_at":"2024-07-24 13:20:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":197185,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of the Delphi procedure.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4648393/v1/318ea10c254c0dcade9c23ef.png"},{"id":97370392,"identity":"670c2445-40f3-4719-a876-da6cbe9ad042","added_by":"auto","created_at":"2025-12-03 16:27:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":803073,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4648393/v1/ce8dbec8-c8ee-4488-92b5-6f93f7ef2bdc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Recognizing peer support initiatives organized outside of the clinical setting: insights from a Belgian Delphi method with peer supporters, patients and mental health professionals","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eIn recovery-oriented mental health care, peer support is becoming more prevalent. Peers are individuals who share common characteristics with a specific individual or group. Peer support has been shown to improve several indicators and symptoms related to mental and psychosocial health and promote behavioral change and self-care (Cano Prieto et al., 2022; Wang et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). It is, therefore, considered beneficial for many population groups, particularly those with chronic (mental) illnesses. Peer support is endorsed in various best practice guidelines. The World Health Organization (WHO, 2021) also recommends peer support as a care practice that enhances individual-centered, recovery-focused, and rights-based mental health care. Notwithstanding the scientific evidence concerning the benefits of peer support at the individual level (e.g., treatment compliance and adherence, stress, health, quality of life) and societal level (e.g., professional care utilization, frequency/length of hospital stays, socio-professional integration), peer support is not yet fully acknowledged in the current Belgian healthcare system.\u003c/p\u003e \u003cp\u003ePeer support can manifest itself in different types and settings. Davidson et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) propose a continuum of support, ranging from unidirectional approaches (expert-to-non-expert) to reciprocal approaches (friendship, mutual support groups), where all participants are viewed as equals. According to this continuum, peer support is considered asymmetric, with the peer supporter possessing unique insights or experiences compared to the peer who receives support. Indeed, individuals earlier in their recovery process receive support from peer supporters, who are in recovery themselves and have a significant history of mental illness along with notable improvement experience. This kind of peer support is sometimes organized in close collaboration with mental health professionals or even organized in mental health care facilities. However, several organizations in the field also operate outside of this clinical setting. The organizations claim to provide a beneficial and qualitative service to patients, but find it hard to gain recognition for their work. Belgium currently lacks a recognized framework supporting the practical implementation of this kind of peer support in mental health, including job descriptions and training required to be considered a peer supporter. The quality and rigorousness of their work are, therefore, easily questioned, as the local initiatives often operate at will and do not follow clear guidelines. More often than not led by charitable organizations of former patients, this lack of recognition also leads to a lack of funding, which threatens the survival of these initiatives.\u003c/p\u003e \u003cp\u003eThe objective of this study is to explore how organizations outside of clinical institutions can best organize peer support in order to be recognized as a valuable care approach. As has been done in other countries (e.g., Campos et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), establishing a framework can provide the foundations for the design and implementation of recognized peer support programs outside of the clinical practice. Doing this also provides insights for other countries to develop their own approaches and recommendations for peer support adapted to their specific healthcare settings. Accordingly, this research addresses the following main questions: How should peer support outside of the clinical setting best be organized in order to be recognized as a valid qualitative offer besides traditional care? And can the added value of such peer contact be recognized as a tool in the mental health care system towards patient recovery?\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThe study was conducted in collaboration with the Belgian Superior Health Council and carried out under its supervision. The Belgian Superior Health Council produces scientific advisory reports aimed at guiding policymakers and healthcare professionals (FPS Public Health, 2024). A working group was established within the Superior Health Council, comprising peer supporters and specialized experts from various fields, including psychiatry, psychology, sociology, medicine, and nursing. The group was in charge of the design, conduct, analysis, and reporting of the present study. Members of this group provided a general and ad hoc declaration of interests, which was evaluated by the Ethics Committee of the Superior Health Council (an external and independent body tasked with assessing potential conflicts of interest).\u003c/p\u003e \u003cp\u003eA Delphi method of consensus was conducted to gather insights from peer supporters, mental health professionals, and patients. This systematic and interactive research procedure, first developed by the Rand Corporation in the 1950s, aims to achieve consensus through experts' subjective opinions (McPherson et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Linstone \u0026amp; Turoff, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). Recognized for its effectiveness in structuring group communication, the Delphi technique addresses questions beyond experimental or epidemiological means (Jorm, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) and has been widely utilized in psychosocial research (De Meyrick, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). The process involves asking qualitative questions individually, collecting written responses, summarizing them into statements, and seeking agreement from participants through quantitative evaluation. Statements for which consensus is achieved are reviewed for meaning and importance; statements that are near consensus are reviewed to clarify areas of possible ambiguity and linguistically revised before inclusion in the next Delphi round; and, lastly, statements that do not reach consensus are discarded unless modification and inclusion in the next Delphi round are warranted based on for example qualitative input of the respondents. The iterative nature of the Delphi method structurally translates individual responses into quality-driven conclusions backed by a larger group.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThere is a lack of definitive guidelines regarding the optimal number of respondents needed for Delphi studies (Wilhelm, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Chalmers and Armour, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), with participant numbers ranging widely from 4 to 3000 individuals in different research works (Thangaratinam \u0026amp; Redman, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Typically, Delphi studies involve panels consisting of 10 to 100 respondents, whereby smaller groups tend to reach consensus faster than larger ones. While some argue that Delphi studies with over 25\u0026ndash;30 panel members do not yield new insights, the ultimate panel size is eventually influenced by various practical considerations such as research question complexity, resource availability, and study logistics.\u003c/p\u003e \u003cp\u003eThe quality of respondents engaged in a Delphi study is crucial to the reliability of the research outcomes, whereby this quality surpasses the importance of the quantity of respondents involved. While professional participants are typically utilized in most Delphi studies, there is a growing recognition of the value of diverse expertise, leading to the inclusion of consumer advocates and informal caregivers in Delphi panels (Jorm, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This trend is evident in the present study, where three distinct groups of participants were identified and utilized: mental health professionals, patient representatives, and peer supporters.\u003c/p\u003e \u003cp\u003eThe Belgian Superior Health Council maintains an extensive and active database of Belgian health experts, particularly in the field of psychosocial health, including healthcare professionals, patient associations, and peer supporters. These experts can be consulted whenever specific questions arise. Utilizing this network, an initial invitation for the Delphi was sent to all contacts of the Superior Health Council in the field of mental health (N\u0026thinsp;=\u0026thinsp;2216), inviting them to participate in the study if they were either a) a (mental) healthcare professional collaborating with peer supporters or treating patients assisted by peer supporters for mental health issues; b) a user of mental healthcare services; or c) a former user of mental healthcare services actively involved as an expert through peer support. The invitation specified that the Superior Health Council was seeking participants regarding a study on peer support defined as : a) support in the field of mental health, b) provided by individuals who are or have been affected by mental illness, c) offered by individuals recognized as experts (whether remunerated or not), d) intentionally provided support, and e) organized outside the institutional, clinical framework. The email also requested recipients to disseminate the survey further amongst their contacts. It was also sent to mental health associations, professional associations of psychologists, psychiatrists, and physicians; as well as patient, family, and peer support associations, with a request to share it with their members. The working group members also disseminated the Delphi invitation to their contacts. By using this snowball method, it is believed that the relevant expert base in Belgium was reached.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThe Delphi process in this research comprised three rounds (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThis chart presents the three rounds of the Delphi study and the number of eligible participants involved at each stage. Du, Dutch speaking participants; Fr, French speaking participants.\u003c/p\u003e \u003cp\u003eDuring the initial phase, participants were presented with a series of open-ended questions (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), to which each had to respond individually using SurveyMonkey (an online survey site).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eList of open-ended questions round 1\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1) For professionals:\u003c/p\u003e \u003cp\u003e- At what point or for what reasons do you refer a patient to peer support?\u003c/p\u003e \u003cp\u003e- In your opinion, what is the added value of peer support in the recovery process of psychologically vulnerable people?\u003c/p\u003e \u003cp\u003e- What is the added value of peer support in the mental health care system?\u003c/p\u003e \u003cp\u003e- What do you think is needed to organize peer support professionally?\u003c/p\u003e \u003cp\u003e- What are the logistical requirements for organizing peer support?\u003c/p\u003e \u003cp\u003e- What training do you think peer experts need?\u003c/p\u003e \u003cp\u003e- In your opinion, is there a need for a legal and/or ethical framework for peer support?\u003c/p\u003e \u003cp\u003e- What should be included in this framework, and what would the practical implications be?\u003c/p\u003e \u003cp\u003e- Do you have any examples of good (or bad) practice in organizing peer support outside the institutional framework? What have you learned from these practices?\u003c/p\u003e \u003cp\u003e- What are the limits of peer support?\u003c/p\u003e \u003cp\u003e- Is there anything else you would like to add?\u003c/p\u003e \u003cp\u003e2) Peer supporters:\u003c/p\u003e \u003cp\u003eThe same questionnaire as for professionals was distributed, with additional specific questions:\u003c/p\u003e \u003cp\u003e- On what basis do you identify yourself as a 'peer expert'? What defines you as a peer expert?\u003c/p\u003e \u003cp\u003e- As a peer supporter, what difficulties do you encounter?\u003c/p\u003e \u003cp\u003e- As a peer supporter, what resources help you in your practice?\u003c/p\u003e \u003cp\u003e- What do you gain from being a peer supporter? What motivates you to be a peer supporter?\u003c/p\u003e \u003cp\u003e3) Patients\u003c/p\u003e \u003cp\u003e- When and/or for what reasons have you needed or do you think you need peer support?\u003c/p\u003e \u003cp\u003e- In your opinion, what is the added value of peer support in the recovery process of psychologically vulnerable people?\u003c/p\u003e \u003cp\u003e- What are the limits of peer support?\u003c/p\u003e \u003cp\u003e- Do you have any examples of good (or bad) practice in organizing peer support outside the institutional framework? What have you learned from these practices?\u003c/p\u003e \u003cp\u003e- As patients, what difficulties do you encounter in organizing peer support?\u003c/p\u003e \u003cp\u003e- Is there anything else you would like to add?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSubsequently, the eligibility of peer supporters was evaluated by examining their responses to the first question posed (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: On what basis do you identify yourself as a 'peer expert'? What defines you as a peer expert?) compared to the definition of Davidson et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFollowing this first round, the responses of eligible participants were independently and ethnographically analyzed (Altheide \u0026amp; Schneider, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) by three researchers. A French-speaking researcher analyzed the responses in French, and two Dutch-speaking researchers divided the responses in Dutch between themselves. The analyses of each researcher were then consolidated and structured into statements summarizing the answers. The three researchers presented and discussed their findings together during a group session to reach a consensus on a set of collectively approved statements and to enhance the structure and readability of the remaining statements.\u003c/p\u003e \u003cp\u003eTo ensure methodological consistency and validity of the defined research statements, the entire process was presented to the full working group members, who did not participate in the analysis process itself. Members of this group ensured that the methodology was followed properly, that the statements corresponded to the analysis results and that they were formulated unambiguously.\u003c/p\u003e \u003cp\u003eA structured online questionnaire containing these statements was then sent to the eligible participants who supplied their contact email addresses, for the subsequent second and third rounds. For each statement, participants were asked to indicate their level of agreement using a 7-point Likert scale, ranging from \"strongly disagree\" to \"strongly agree.\" They could also provide comments and explanations for their responses, allowing them to offer feedback on any aspect of the statements.\u003c/p\u003e \u003cp\u003eStatements were considered as a consensus if over 70% of participants agreed (i.e., rating 5 or above) and the median was 5 or above, with an interquartile range (IQR) not surpassing 1 (Diamond et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Von der Gracht, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Statements with over 70% rating 1 or 2, or a median below 2 and IQR less than or equal to 1, were rejected. The IQR is a measure of dispersion around the median, which reflects the agreement level. An IQR of zero indicates full consensus, while higher values indicate greater data dispersion, thus revealing the experts' disagreement.\u003c/p\u003e \u003cp\u003eFinally, a synthesis report, including the detailed analysis and the statements for which a consensus was reached, was sent to participants in the second and third phases, allowing them to confirm if they agreed with the conclusions or had anything to add.\u003c/p\u003e \u003cp\u003eThe data collection period and approval of the synthesis extended from June 12, 2023, to November 30, 2023.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA flow chart of the three rounds of the Delphi study is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, detailing the eligible participants by group and language. Initially, 441 participants responded to the first round. After evaluating eligibility, 65 peer supporters were excluded because they did not meet the inclusion criteria (i.e. the definition of peer supporter elaborated for this research), resulting in 376 eligible participants. Of these 376, 99 did not provide email addresses, leaving 277 participants who were invited to the second round. In the second round, 169 participated and were invited to the third round, in which 115 participated.\u003c/p\u003e \u003cp\u003eBased on the first round of open-ended questions, 52 initial statements were produced, addressing both the need for and different elements of a framework helping the organization of peer contact support outside of the clinical setting and the added value of such peer support. When sent to participants for the second round, they reached sufficient agreement for 28 out of 52 statements (53.8%). No statements were rejected (0%) and 24 statements were reformulated (46.2%) based on the feedback received. During that process, one statement was split into two distinct ones, leading to a total of 53 statements, including the 25 reformulated. No major differences were observed between responses from French-speaking and Dutch-speaking participants, nor between patients, professionals, and peer supporters.\u003c/p\u003e \u003cp\u003eFor the third round, the 25 reformulated statements were resubmitted to the participants following the same principle. Sufficient consensus was found for 10 statements (40.0%), with no statements being rejected (0%), and 15 statements still requiring further reformulation (60.0%). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e lists the accepted statements, the Delphi round in which consensus was reached, and the scores obtained.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAccepted statements, with scores obtained and the Delphi cycle during which a consensus was reached and the\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u0026gt;5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eApproval round\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. ADDED VALUE OF PEER CONTACT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeer support can be useful at various stages of the recovery process (at the beginning, continuously, at the end, at the return to work, etc.), in complementarity with clinical care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeer support can meet different patient needs:\u003c/p\u003e \u003cp\u003e\u0026middot; need for hope and perspective;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; need for additional support or contacts;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95,24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; in case of difficulties in coping with the diagnosis, anxiety and (self-)stigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeer support provides a complementary form of support that\u003c/p\u003e \u003cp\u003e\u0026middot; Can approach the patient with a different perspective compared to conventional healthcare providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; has particular legitimacy and credibility thanks to a good understanding of the disease and the difficulties encountered;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; offers a vision of the care pathway that is not purely medical;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; Can be perceived as more horizontal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeer support has added value for the patient, as it\u003c/p\u003e \u003cp\u003e\u0026middot; empowers them through the exchange of tools, best practices, knowledge about the disease, and advice for recovery with appropriate language;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; Facilitates psychoeducation, when the peer support worker is trained in this subject\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; brings hope and perspectives, because it allows them to identify with a patient who has recovered: an example of success, proof that it is possible, that gives confidence, hope;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; Can help break isolation or loneliness;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; Can offer support in the care process, especially when things are not going well, in difficult times (taking into account their own fragilities)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; allows them to speak freely because they feel listened to without judgment, with kindness and empathy (bond of trust).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeer support also has added value for the peer supporter himself, because it\u003c/p\u003e \u003cp\u003e\u0026middot; also promotes their own recovery, in particular by strengthening their self-esteem, providing them with recognition, satisfaction in helping, being useful, giving meaning to their own difficulties;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91. 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; helps them reintegrate, by giving them a place in society (sense of belonging), by giving purpose and meaning to their days, by integrating them into a learning and training path.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII. NEEDS FOR PROFESSIONAL SUPPORT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe peer supporter must benefit from logistical support according to his needs: having offices if necessary, meeting rooms set up in a friendly way, in a safe and accessible place, furniture, equipment for activities, IT tools, etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe peer support worker must have financial support:\u003c/p\u003e \u003cp\u003e\u0026middot; transport and operating costs,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; In some cases (depending on the role), salary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe peer supporter must benefit from support in terms of human resources (socio-professional integration into the teams/organizations in which they are employed)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe peer supporter must be integrated into a network of peer supporters and associations that support peer support (professional associations and support/expertise centers), ensuring availability everywhere and for all mental health disorders.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThis network should support the peer support in terms of communication:\u003c/p\u003e \u003cp\u003e\u0026middot; Raising awareness among the general public (breaking taboos)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; with (mental) health professionals to recognize peer support workers as partners in patient care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026middot; Peer support details should only be shared in accordance with the law on the protection of privacy, i.e. no personal data, only professional data, if available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn order to be professionally organized, the peer supporter must have a status (based on a job description)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThis job description should define\u003c/p\u003e \u003cp\u003eo the rights and duties (e.g. professional secrecy) of the peer supporter,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eo The limits of the function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining should include, but is not limited to, the following:\u003c/p\u003e \u003cp\u003e- practical elements of communication and group dynamics: oral expression, public speaking, motivational interviewing, active listening;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- elements of ethics (professional secrecy, GDPR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- elements relating to the network in which it operates: available functions, place and limits of the function in relation to others, exchanges with other professionals, functioning of a team, etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- elements relating to the well-being of the peer supporter: knowing how to set the limits of his commitment (in particular the limits between a friendly and professional relationship), having sufficient distance from his own experience, keeping a healthy lifestyle (time for himself, listening to his own needs, etc.)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThese trainings can be organized by patient organizations in cooperation with professional organizations (mental health professionals) or training institutes in order to ensure quality.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTo maintain their status, it is recommended that peer experts, like other health care providers, also participate in intervisions, supervision, and continuing education.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThis status would make it possible to:\u003c/p\u003e \u003cp\u003e- to improve the legitimacy, credibility and recognition of the peer supporter among other health professionals (a function integrated into the panel of possible functions) and to better identify his or her place among them;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- protect both the patient and the peer supporter,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- reassure patients, employers and other professionals, and reduce the stigma that may still be experienced by peer supporters;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- to give a fair remuneration to the peer supporter (definition of scales).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: Possible range for agreement score 1\u0026ndash;7.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFor some statements requiring reformulation in this third round, the results indicated differences in acceptance between French-speaking and Dutch-speaking participants and/or between expert groups. For certain statements, the issue lay in the IQR, meaning that they were generally accepted but with a significant diversity in responses. For others, there was a clear rejection of the proposals, particularly concerning the added value of peer support in the healthcare system, which focused on the role of the peer supporter as a facilitator of the connection between the patient and the professional, or as additional support in case of reluctance to enter the care pathway or in case of a waiting list. Additionally, for some statements, agreement was better in the previous stage, with the reformulation being less well-received (these statements had been reformulated negatively: \"it is not the role of the peer supporter to...\"). Given that remarks on these statements expressed highly divergent views that were challenging to reconcile into a single statement, researchers decided not to reformulate them for another round. The various perspectives on these more complex concepts are discussed below.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present Delphi study aimed at providing a framework for the effective implementation of peer support in mental health outside of the clinical setting and to establish whether this kind of peer support is capable of adding value to the recovery process. Consensus was reached for 38 statements in three rounds. The consensus on these statements is noteworthy: with one exception, all statements have a median score of 7 and over 85% of participants gave a score of 6 or 7 to each statement.\u003c/p\u003e \u003cp\u003eAccording to these statements, participants acknowledged that intentional, asymmetric peer interactions organized outside the clinical setting can be beneficial at various stages of the recovery process (at the beginning, continuously, towards the end, when returning to work), complementing clinical care. It can address different patient needs and offers added value for both the patients (empowerment and psychoeducation, hope and perspectives, support in case of difficulty, breaking isolation, empathetic listening) and the peer supporters themselves (self-esteem, reintegration).\u003c/p\u003e \u003cp\u003eHowever, for this kind of peer support to be recognized as a valid resource, participants agreed that a certain framework is needed, including logistical support (facilities), financial support (transportation or operational expenses, salary), and human resources support (integration into teams). Peer supporters should also be integrated into a network that can support them, especially in communication (raising awareness among the general public and healthcare professionals, communicating with patients with respect for privacy).\u003c/p\u003e \u003cp\u003eParticipants found that intentional, asymmetric peer interactions organized outside the clinical setting should also be regulated, based on a job description defining the rights and duties (e.g., confidentiality) of the peer supporter and the boundaries of their role. This would improve the legitimacy, credibility, and recognition of the peer supporter among healthcare professionals (function integrated into the range of possible functions) and better identify their place when working with them. According to the participants, a clearer demarcation would protect both the patient and the peer supporter, reassure patients, employers, and other professionals, and reduce any stigma that peer supporters may still face. Additionally, it would facilitate a discussion on fair remuneration for peer supporters (establishment of pay scales). An important requirement to be able to be recognized as a peer supporter, is the idea that peer supporters should undergo training including practical elements of communication and group dynamics, ethics, networking skills, and elements related to the well-being of the peer supporter (including knowing how to set boundaries and maintain a professional distance from personal experiences). To maintain their recognition, peer supporters should also participate in peer supervision, and ongoing training.\u003c/p\u003e \u003cp\u003eStatements on which there was insufficient agreement highlighted some specifications. For example, it is essential to clearly define the role of the peer supporter, particularly regarding their role in the healthcare system. While participants agreed that peer support can be a complementary resource in the healthcare system, especially in addressing gaps or issues in conventional care (e.g., waiting lists, patient distrust, breakdown of communication), they emphasized that this should not be the primary role of peer supporters. According to the participants, it is the responsibility of the conventional healthcare system to address potential gaps and resolve these issues instead of relaying these problems to peer supporters. The specific added value of peer supporters lies in being a peer and this specificity should be protected.\u003c/p\u003e \u003cp\u003eWhile some sort of regulation of the term peer supporter is deemed necessary by the respondents, overly stringent requirements for becoming a peer supporter also form a potential risk. Some participants voiced the concern that stringent requirements may also lead to the exclusion of people with valuable experience. They, therefore, emphasized the importance of striking a balance between the need for regulation (especially to protect patients and peer supporters) and the preservation of the informal and accessible nature of peer support. A solution that was brought up, is to explicitly distinguish peer supporters who play an explicit role in the healthcare system from other forms of support that operate independently outside of that framework (e.g., self-help groups). All kind of support (individual or group) naturally exist and do not all need to be regulated. It is, particularly, asymmetric peer interactions organized outside the clinical setting that would benefit from regulation.\u003c/p\u003e \u003cp\u003eThere were also divergent views regarding remuneration and training conditions. While study participants agreed that remuneration adds value and can motivate peer supporters contributing to their sense of recognition and integration into society, some participants also expressed concerns about potential additional pressure on peer supporters. They also specified that remuneration should not be the main motivation for becoming a peer supporter. Additionally, participants emphasized the importance of not remunerating all types of peer support. It is, therefore, essential to define remuneration based on the recognition of specific peer support types. Regarding training, participants agreed that training conditions should be defined for peer supporters, but they also emphasized that personal experience is crucial for peer supporters. Indeed, the authenticity of personal experience facilitates establishing connections with the patient. Personal experience is and continues to serve as the foundation for fulfilling the role of a peer supporter. Some participants, therefore, suggest adopting a balanced approach, in which personal experience is valued as much as structured training. Training should mainly focus on practical elements (e.g., communication and group dynamics), with theoretical knowledge (e.g., mental health theories, principles of psychology) addressed by other healthcare professionals. Furthermore, efforts should be made to promote communication and mutual understanding between peer supporters and conventional healthcare professionals by coordinating training in which both groups are present.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe Delphi study has several strengths and limitations. Notable strengths include broad consultation and widespread dissemination of the call, along with the involvement of various target groups.\u003c/p\u003e \u003cp\u003eHowever, the participation rate among certain target groups, particularly patients, was rather limited. As with all iterative research designs, there is a risk of participant dropout. While it is common for 20 to 30% of participants to discontinue between rounds (Chalmers \u0026amp; Armour, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), our study saw a dropout rate of 39% between rounds 1 and 2, and 32% between rounds 2 and 3, which is slightly above the expected range. Despite this, the proportion of various expert categories was evenly distributed across rounds, suggesting no attrition bias in the outcomes. Additionally, although the interpretation of peer support was clearly defined at the beginning of the survey, it may have led to different interpretations within the diverse group of participants. The use of different terms (\"peer supporters,\" \"lived experience experts,\" and \"peer experts\") throughout the statements could have prompted varied interpretations and responses, potentially causing confusion about the different roles and types of peer support addressed in this study. Furthermore, the formal scientific approach adopted in the Delphi study, while systematic, may have resulted in some limitations. Research on patient participation in scientific research highlights the value of involvement but also underscores challenges such as the need for training and education before participation, attention to facilitating factors, and potential obstacles like individual and structural barriers and interaction issues between researchers and patients, which were less emphasized in the current study.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eRecognizing the added value of intentional, asymmetric peer interactions outside clinical settings within mental healthcare is, currently, not a given. A more clear framework and professionally organized structure is needed for peer supporters to be able to attain an equal and complementary position alongside conventional healthcare providers. This framework seems to be comprised of different elements. A clear definition and demarcation of the job will help strengthen the peer support role and clarify how it relates to other professions and/or volunteers active in the healthcare setting. Continued training, intervision and networking - including with healthcare professionals - is needed to uphold the quality of services delivered by the peer supporters and to continue to substantively nourish this emerging field. Durable logistical (facilities) and financial support (transportation or operational expenses) is needed to realize the peer support offer in a professional manner. The insights stemming from this research project lead to the scientifically grounded formulation of specific recommendations for peer support groups, policy-making, the healthcare sector, and society as a whole.\u003c/p\u003e"},{"header":"ABBREVIATIONS","content":"\u003cp\u003eIQR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;interquartile range\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was carried out under the supervision of the Belgian Superior Health Council, an independent network of national and international experts. The College is the decision-making body of the Council, and the Ethics Commission is an external and independent group that oversees the management of interests and potential conflicts of interest.\u003c/p\u003e\n\u003cp\u003eEthical approval was not required. Within a national expert group, experts from the field freely and willingly provided information on their experience with peer support in light of writing policy recommendations and publications.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWithin a national expert group, experts from the field freely and willingly provided information on their experience with peer support in light of writing policy recommendations and publications. The study had a formal opt-in procedure for participants, explaining the research project, the procedure, the goal of the research (incl. policy advice and publications) and offering the opportunity to opt out at any given moment in time, before being able to participate in the actual Delphi module.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article. Supplementary information is readily available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGS made substantial contributions to the conception and design of the work, analyzed and interpreted the patient data, and drafted the manuscript. TE analyzed and interpreted the patient data and was a major contributor in writing the manuscript. MF made substantial contributions to the conception and design of the work. VIG made substantial contributions to the conception and design of the work. GP made substantial contributions to the conception and design of the work and substantively revised the manuscript. VDCN made substantial contributions to the conception and design of the work, analyzed and interpreted the patient data, and substantively revised the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript. All authors agreed to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even those in which they were not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article was written as part of a scientific advisory report by the Belgian Superior Health Council on peer support in mental health care. The authors were members of the ad hoc working group and sincerely thank the other members: \u0026nbsp;Beheydt Lieve, Bol Suzanne, Cephale Sophie, Colemont Patrick, Crew Sarah, Debyser Bart, Delatte Benoit, Delespaul Philippe, Deloyer Jocelyn, Delvaux Jan, Delville Kim, Lamy Dominique, Lejeune Philippe, Nolmans Mattias, Nuhaan Marlene, Ripault Sophie, Simon Yves, Van den Abeele Tom, Van den Broeck Kris, Van Doren Shauni, Van Hal Guido, Van Wanseele Carine, Vilain François, Waha Stéphane. We are also grateful to the participants of the Delphi study for their time and input.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAltheide L, Schneider CJ. Qualitative Media Analysis. SAGE; 2013.\u003c/li\u003e\n \u003cli\u003eCano Prieto I, Sim\u0026oacute; Algado S, Prat G. Peer Interventions in Severe Mental Illnesses: A Systematic Review and its Relation to Occupational Therapy. Occup Ther Ment Health. 2023;39(3):1-38.\u003c/li\u003e\n \u003cli\u003eCampos F, Sousa A, Rodrigues V, Marques A, Queir\u0026oacute;s C, Dores A. Practical guidelines for peer support programmes for mental health problems. Rev Psiquiatr Salud Ment. 2016;9(2):97-110.\u003c/li\u003e\n \u003cli\u003eChalmers J, Armour M. The Delphi Technique. In: Liamputtong P, editor. Handbook of Research Methods in Health Social Sciences. Springer Singapore; 2019. p. 715-735.\u003c/li\u003e\n \u003cli\u003eDavidson L, Chinman M, Sells D, Rowe M. Peer support among adults with serious mental illness: a report from the field. Schizophr Bull. 2006;32(3):443-50.\u003c/li\u003e\n \u003cli\u003eDe Meyrick J. The Delphi method and health research. Health Educ. 2003;103(1):7-16.\u003c/li\u003e\n \u003cli\u003eDiamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401-9.\u003c/li\u003e\n \u003cli\u003eJorm AF. Using the Delphi expert consensus method in mental health research. Aust N Z J Psychiatry. 2015;49(10):887-97.\u003c/li\u003e\n \u003cli\u003eLinstone HA, Turoff M, editors. The Delphi Method. Techniques and Applications. London: Murray Turoff and Harold A. Linstone; 2002.\u003c/li\u003e\n \u003cli\u003eMcPherson S, Reese C, Wendler MC. Methodology Update: Delphi Studies. Nurs Res. 2018;67(5):404-410.\u003c/li\u003e\n \u003cli\u003eThangaratinam S, Redman CWE. The Delphi technique.\u0026nbsp;Obstet Gynaecol. 2005;7:120-125.\u003c/li\u003e\n \u003cli\u003eVon der Gracht HA.\u0026nbsp;Consensus measurement in Delphi studies: Review and implications for future quality assurance. Technol Forecast Soc Change. 2012;79(8):1525-1536.\u003c/li\u003e\n \u003cli\u003eWang Y, Chen Y, Deng H. Effectiveness of Family- and Individual-Led Peer Support for People With Serious Mental Illness: A Meta-Analysis. J Psychosoc Nurs Ment Health Serv. 2022;60(2):20-6.\u003c/li\u003e\n \u003cli\u003eWilhelm W. Alchemy of the Oracle: The Delphi Technique. Delta Pi Epsilon J. 2001;43(1):6-26.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"mental health, peer support, Delphi study ","lastPublishedDoi":"10.21203/rs.3.rs-4648393/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4648393/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Peer support in mental health involves individuals with lived experience of mental illness providing assistance and encouragement to others facing similar challenges. This care practice is endorsed in best practice guidelines and has been shown to enhance individual-centered, recovery-focused, and rights-based mental health care, according to the World Health Organization (WHO).\u003c/p\u003e\n\u003cp\u003eIn Belgium, there is currently no well-defined framework supporting the practical implementation of peer support in mental health practice, including role descriptions and training needs. Moreover, the added value of peer support compared to formal care is not thoroughly examined at individual and societal levels. This research aims to explore the role and organization of peer support in the mental health care system, focusing on intentional, asymmetric peer interactions organized outside the clinical setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The Delphi method gathered insights from peer supporters, mental health professionals, and patients. Three rounds of data collection and analyses achieved consensus on key statements regarding the added value of peer support and the requirements for a framework enabling peer support as a valid care practice outside clinical settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Participants agreed that peer support can play a significant role in various stages of the recovery process, complementing clinical care. They agreed that peer support offers benefits for both patients and peer supporters. Requirements for a framework include logistical, financial, and human resources support, as well as training and status recognition. Consensus emerged on many statements, but divergent views surfaced on the peer supporter’s role limitations in the healthcare system, the balance between regulation and preserving the informal nature of peer support, and the roles of remuneration and training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: This study achieved consensus on 38 statements, outlining requirements to optimize the organization of intentional, asymmetric peer interactions organized outside clinical settings. It underscores the added value of such peer support in Belgian mental health care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eEthical approval was not required as experts freely shared their experiences on peer support within a national expert group, contributing to policy recommendations and publications.\u003c/p\u003e","manuscriptTitle":"Recognizing peer support initiatives organized outside of the clinical setting: insights from a Belgian Delphi method with peer supporters, patients and mental health professionals","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-24 13:20:05","doi":"10.21203/rs.3.rs-4648393/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ba18fe1e-c9a2-452d-b8aa-f6414107458c","owner":[],"postedDate":"July 24th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-26T20:23:39+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-24 13:20:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4648393","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4648393","identity":"rs-4648393","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}