Co-creating Norwegian DigiPer: a digital tool including peer support for managing mental, physical, and social health in serious mental illness

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Fortuna, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5806093/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 People with serious mental illness (SMI) often encounter physical health issues, a lack of focus on self-management, and persistent symptoms of mental illness. Strategies to empower people with SMI to self-manage their mental, physical, and social health are needed. The PeerTECH application is an American digital peer support intervention that can help manage health issues and promote self-management skills for people with SMI. This study aims to co-create a Norwegian version of PeerTECH, DigiPer, with service users, peer support workers, and professionals from Norwegian community mental healthcare. Methods This study employs a qualitative design using principles of co-creation to develop the Norwegian DigiPer. We conducted workshops, videoconference demonstrations, and application testing with key stakeholders in the co-creation process. The data collected were analyzed using thematic analysis. Results Five themes and ten subthemes were developed in the data analysis. The first theme reflected feedback and challenges in DigiPer functioning, with the subthemes of Usability in DigiPer and Managing complexity in DigiPer classes. The second theme focused on the peer support worker's role, with subthemes of recognizing and addressing user challenges and balancing self-responsibility and support. The third theme focused on the content of DigiPer in addressing day-to-day challenges, with subthemes of supporting personal growth and goal setting and DigiPer as a tool to build supportive networks . The fourth theme highlighted the use of DigiPer to encourage a healthy lifestyle, with subthemes of addressing substance use and smoking habits and improving sleep and stress management. The fifth theme provided a holistic view of health, with subthemes of connecting users to relevant services and a need for support to overcome financial challenges. Conclusions DigiPer has good usability among community mental healthcare stakeholders and has proper functionality, which is relevant to the Norwegian context. Although challenges exist, all participants perceived DigiPer as a meaningful and promising tool to help people with SMI improve their self-management of their mental, physical, and social health. Future studies should assess the accessibility and feasibility of the Norwegian DigiPer. Co-creation User involvement Peer support Digital mental health Mobile application Self-management Recovery Figures Figure 1 Figure 2 Background Research, technology, and understanding of mental illness are constantly evolving, necessitating innovations in the treatment of overall health ( 1 ). This evolution is particularly relevant for addressing the mental, physical, and social health needs of people with serious mental illness (SMI) ( 2 – 5 ). By the term SMI, we refer to schizophrenia, schizoaffective disorder, psychotic disorders, major depressive disorders, and bipolar disorders ( 6 ). People with SMI are more likely to encounter physical health issues than the general population ( 7 ). A lack of focus on healthy lifestyles and self-management, as well as persistent symptoms of mental illness, are functional issues that often occur when people experience SMI ( 2 , 8 – 10 ). Strategies to empower people with SMI to self-manage mental, physical, and social health are needed ( 2 , 8 – 10 ). Digital health involves the use of information and communication technologies, including wearable devices, mobile health, telehealth, health information technology, and telemedicine, to manage health issues and promote well-being ( 11 ). Digital health interventions can include resources to prevent relapse, strategies to manage mental health symptoms, enhancing physical health, improving medication adherence and physical activity engagement, and promoting self-management skills ( 12 ). Moreover, digital health can reduce disparities in healthcare access for people with SMI by increasing their connection with services ( 13 , 14 ). Gillis et al. (2024) reported that people with SMI appreciate simple digital health interventions that emphasize physical health, healthy lifestyles, exercise, and weight management but view these interventions as complementary to, rather than replacements for, clinical services. Several studies ( 2 , 15 , 16 ) have shown that digital health, when combined with peer support, facilitates the sharing of health information, advice, and lived experience expertise, promoting recovery and engagement in technology. Digital peer support involves interactions with peer support workers, who act as lived experience experts ( 4 ) to promote recovery ( 5 ). This encompasses live or automated peer support services delivered via technological media, peer-delivered interventions through smartphone applications, and both asynchronous and synchronous technologies, with asynchronous methods enabling communication between peer support specialists and service users without requiring real-time interaction ( 5 ). Moreover, digital peer support shows promise for improving psychosocial outcomes, such as hope, social support, medication adherence, and self-management skills ( 5 ). The American PeerTECH application is a digital peer support intervention that integrates technology and peer support ( 17 – 19 ). PeerTECH draws upon integrated illness management and recovery (I-IMR) and self-management for people with SMI and chronic medical conditions ( 19 , 20 ). The objective of self-management is to empower people in their recovery by equipping them with the skills needed to recognize and manage their mental, physical, and social health issues ( 21 ). PeerTECH offers several components to support its service users' mental, physical, and social health by developing self-management skills and personalized goals. PeerTECH helps link individuals to relevant resources in the community to access services and support. Pilot studies in the United States indicate that PeerTECH enhances health literacy, promotes healthy behavior, and provides tools to prevent relapses, maintain health, and improve overall well-being ( 17 , 19 , 22 ). A usability test of the American prototype PeerTECH application with Norwegian service users, peer support workers, and healthcare professionals employed in community mental healthcare revealed that participants were positive toward the application's content, it was user friendly, and they considered it a relevant tool to support self-management of their mental, physical and social health ( 22 ). Thus, translating and adapting PeerTECH into a Norwegian version, DigiPer (digital likeperson, meaning digital peer), was considered appropriate to ensure an optimal fit for the needs of Norwegian service users, peers, and community mental healthcare ( 22 ). Petretto et al. ( 14 ) emphasized that digital health interventions are complex and dynamic and that unintended consequences may lead to inequalities. Difficulties in design and a lack of engagement and motivation pose challenges ( 23 , 24 ). Other barriers include limited opportunities for contact with the helper ( 13 ), inadequate access to mobile phones ( 13 , 22 ), complex login procedures ( 22 ), usability problems ( 23 ), and high attrition rates before intervention effects are achieved ( 5 ). Thus, when designing and implementing digital health interventions, it is essential to consider specific needs, priorities, and unique ethical considerations related to the privacy, confidentiality, and information governance of people with SMI ( 7 , 24 , 25 ). Involving service users in the digital health development process is crucial to ensure that interventions align with the needs and expectations of end users, thereby enhancing acceptance, effectiveness, and uptake in the real world ( 26 ). Co-creation models are suitable for ensuring that digital health interventions are clear, usable, and engaging for people with SMI and tailored to individual needs ( 5 , 24 ). According to Greenhalgh et al. (27 p. 39), co-creation is "the collaborative generation of knowledge by academics working alongside stakeholders from other sectors." Co-creation entails collaborative knowledge production, often centered on local or regional university‒community partnerships, to align research and service development and enhance research and social impact ( 27 ). Co-creation can help address the persistent gap between research and its practical implementation ( 27 , 28 ). This approach involves collaboration through implementation from early stages, such as commissioning and design ( 29 ). In mental health research, co-creation involves diverse stakeholders, including individuals with lived experiences of mental illness, professionals, and those who bring both perspectives ( 29 , 30 ). Participation in co-creation processes can promote personal growth and support career aspirations despite the challenges of mental illness ( 31 ). Greenhalgh et al. ( 27 ) explain that co-creation relies on three key success principles, as co-creation "failures" can often be traced back to not following these principles. The first principle adopts a systems perspective, which assumes emergence, local adaptation, and nonlinearity. By taking a systems perspective, the impact of the collaboration will be more robust and more enduring, enhancing the user experience. The second principle is to frame research as a creative initiative centered on human experience, particularly that of service users and staff. The third principle emphasizes the need for an appropriate leadership style and highlights the importance of program framing, relationship dynamics, facilitation arrangements, interactions, sensemaking, dialog, and outcomes. Greenhalgh et al. ( 27 ) emphasized that co-creation in health services should start with the service user experience, involve collaboration with staff to enhance the user experience, and ensure that health services are tailored to the experiences of service users and carers. This study aims to co-create a Norwegian version of the PeerTECH application, DigiPer, by utilizing workshops, videoconference demonstrations, and application testing with service users, peer support workers, and professionals from Norwegian community mental healthcare. We use the term community mental healthcare when referring to services provided to people with SMI in the municipality. We sought to answer the following research questions: How do community mental healthcare stakeholders perceive the content, classes, and functions of DigiPer? What are their perceived challenges with DigiPer content and functions? What are the perceived roles of peer support workers in DigiPer? Methods Research design This study has a qualitative research design that is suitable for obtaining knowledge of the study participants' experiences and perceptions ( 32 ). We use Greenhalgh et al.'s ( 27 ) principles of co-creation to integrate the experiences and perceptions of key stakeholders in community mental healthcare, including service users, peer support workers, and professionals. This process involves workshops, videoconference demonstrations, and application testing to develop the Norwegian DigiPer application ( 27 ). Study setting: Norwegian community mental healthcare The Norwegian healthcare system comprises municipal health and care services and specialist health services ( 33 ). Municipalities offer mental and physical community-based healthcare, focusing on illness prevention, health promotion, treatment, care, and assistance with daily life ( 34 ). Municipalities must ensure that residents can access general practitioners (GPs), who typically provide initial consultation for healthcare needs and deliver ongoing treatment and care ( 34 ). Specialist health services are responsible for those with the most extensive mental healthcare needs, including inpatient and outpatient care through psychiatric hospitals and community mental health centers ( 35 ). The current study was conducted with participants from community mental healthcare in two municipalities in western Norway. Workshops and application tests were conducted in a Norwegian municipality with approximately 15,000 residents. Additionally, videoconference demonstrations were held with participants from community mental healthcare in a larger Norwegian municipality with approximately 292,000 residents. Recruitment and participants We used purposive sampling to select participants eligible to contribute to co-create the Norwegian DigiPer ( 32 ). Service users, peer support workers, and professionals from community mental healthcare were considered stakeholders with the relevant knowledge and experiences necessary for this study. This diverse range of stakeholders aligns with the co-creation principles described by Greenhalgh et al. ( 27 ). Workshop and application testing participants were recruited through one service leader whom MS contacted via e-mail with information about the study. The leader then provided eligible service users, peer support workers, and professionals with this information and selected participants on the basis of their accessibility, interest, willingness, and experience with digital tools. Workshops were scheduled with two service users, two peer support workers, and two professionals. Among them, five were female, and one was male. For the application testing, three service users, one peer support worker, and two professionals participated. Four of them were female, and two were male. In November 2022, we attended the "Sterkere Sammen" conference in Oslo, Norway, which focused on peer support. Interested participants were invited to participate in a videoconference demonstration of DigiPer. Four peer support workers, two women and two men, were recruited to participate in these demonstrations. PeerTECH intervention The American PeerTECH is a peer-led digital health intervention ( 17 , 36 ). As illustrated in image 1, it combines the expertise of peer support workers with recovery-focused content accessible via mobile phones or tablets. Image 1 PeerTECH application PeerTECH seeks to empower people with SMI to manage stress and reduce vulnerabilities that contribute to the deterioration of mental, physical, and social health. The program focuses on helping users strengthen their self-management skills through 1-hour, in-person meetings with peer support workers conducted once a week over 10 weeks. PeerTECH consists of two applications: one for users and one for peer support workers. The peer support worker's application includes information to guide users during in-person meetings, develop self-management skills, and share lived experiences. It allows them to message assigned users and view their goals, wellness plans, and progress through the PeerTECH intervention. The user application provides access to messaging with their assigned peer support worker, formulating personal goals, developing wellness plans, and a resource library with self-management support classes. The PeerTECH chat feature enables users and peer support workers to communicate between classes. Peer support workers are expected to text users thrice weekly during the intervention. These text messages should follow up on goals and provide support between meetings. Image 2 displays the user application's home screen. Image 2 User application home screen The user application includes a library with resources illustrating mental, physical, and social health interconnections. The library comprises guided tasks designed to teach and reinforce coping skills training for self-management. It features videos of people with SMI sharing their experiences of challenges and successes. The PeerTECH library consists of ten classes that the users and peer support workers will conduct during their weekly meetings. This includes the following classes: ( 1 ) Introductions, Smartphone Orientation, and Recovery and Health; ( 2 ) Good Mental Health Starts With Good Physical Health and Social Health (vice versa); ( 3 ) Recovery is a Daily Process; ( 4 ) How Stress Impacts our Health; ( 5 ) Smoking and Living a Healthy Lifestyle; ( 6 ) Healthy Sleep; ( 7 ) Dental Health; ( 8 ) Exercise; ( 9 ) Developing and Maintaining Relationships; and ( 10 ) Getting the Help You Want. Each class follows this structure: (a) introduction of the goals and content of the class; (b) review of home practice; (c) mutuality and co-learning activities; (d) questions to explore together; (e) follow-up on personal goals; (f) feedback; and (g) home practice ideas. Appendix 1 outlines the focus of the ten PeerTECH classes. Co-creating Norwegian DigiPer The Norwegian Digiper application was co-created using the five steps described below, inspired by the co-creation principles of Greenhalgh et al. ( 27 ). This approach ensured that DigiPer was designed to meet the needs of service users and peer support workers in Norway. Step 1: Translating the American PeerTECH application into Norwegian DigiPer With the help of fluent translators to ensure that contextually accurate translations aligned with the application's usage, we translated the PeerTECH application interface and content into Norwegian. This included translating all the user interface strings, such as buttons, labels, and error messages, and adapting culturally sensitive content, such as images, symbols, and colors, to ensure their relevance and appropriateness for the Norwegian end users. Additionally, we made significant changes to Class 10, "Getting the help you want," and Class 7, "Dental health," by adding context-specific content to align with the Norwegian healthcare system. These adaptations reflect a systems perspective, ensuring local relevance and usability (Greenhalgh et al., 2016). Step 2: Workshops with service users, peer support workers and professionals After completing the translation, MS and HMHF held two workshops, bringing together service users, peer support workers, and professionals to engage the key stakeholders early in the co-creation process and to ensure inclusiveness in the data collection process ( 27 , 31 ). The workshops provided a safe space for participants to freely express their views while contributing valuable insights into customizing DigiPer to Norwegian users. We emphasized valuing all the opinions and perspectives of the participants, encouraging them to share their thoughts and experiences, and a shared understanding of the value of the co-creation process for tailoring the DigiPer to the user needs and context of the Norwegian mental health service system. The participants reviewed the translated content to ensure that the translations were accurate and up to date, with a focus on its relevance to the context of mental healthcare in Norway and individuals with SMI. We began the workshops by explaining and demonstrating the applications' functionality. The participants reviewed the content of each DigiPer class. The first workshop covered Classes 1–5 and 10, whereas the second workshop reviewed classes 6–10. Class 10, "Getting the help you need," was examined by participants in both workshops owing to the changes needed to optimize it for Norwegian users. We requested feedback on several aspects of DigiPer, as detailed in Appendix 2. Step 3: Videoconference demonstrations with peer support workers MS conducted four individual videoconference demonstrations, each lasting approximately 30 minutes. During these sessions, MS led the demonstrations and presented the application, its functions, and the DigiPer classes. The peer support workers were then encouraged to provide feedback on its relevance to their peer support work. This feedback informed refinements to improve the user experience and ensure its relevance for individuals with SMI ( 27 ). Step 4: Adaptation of the Norwegian DigiPer In step 4, we used feedback from participants in the workshops and videoconference demonstrations to revise, adapt, and tailor the application's content to the views and experiences of multiple stakeholders ( 27 ). We also replaced videos from the original application with six animated videos relevant to users in Norway. Manuscripts for these videos were developed on the basis of the DigiPer classes. Additional videos were added to three classes: relaxing body scan meditation in Class 4, mindfulness sleep meditation in Class 6, and exercise video in Class 8. The researchers continuously tried the application throughout this process for quality assurance and to ensure that everything worked correctly. This feedback loop included ensuring the proper display of Norwegian text without truncation or layout issues, reviewing translations to ensure cultural and linguistic accuracy, and checking for any functional problems, such as date formatting or keyboard input changes that could have arisen from the language switch. Step 5: Testing the Norwegian DigiPer application with potential end-users MS and JNS facilitated two Norwegian DigiPer application testing sessions to gain feedback on content and functionality on the basis of their individual experiences ( 27 ). Each session began with a demonstration of its functionality, followed by an explanation of the system and content, including key features. Under the researchers' guidance, the participants downloaded, installed, and logged into DigiPer. One participant downloaded the peer support worker application in each session, whereas two downloaded the user application. MS facilitated their entry into the DigiPer system. Before testing, the group reviewed Class 1 on a large TV screen. The participants role-played how the initial meetings and ongoing engagement between users and peer support workers might unfold. Role-playing is a suitable method for integrating peer support into these interactions ( 31 ). Classes 1 and 6 were tested, and the sessions concluded with a facilitated review. Appendix 3 details the focus of this review. Data collection Qualitative data were collected at the workshops, videoconference demonstrations, and application testing ( 32 ). The data material consists of written notes the researchers took to document stakeholders' feedback and perceived challenges related to DigiPer content, classes, and functions. The application testings were also audio recorded and transcribed verbatim by JNS. JNS translated the qualitative notes and transcriptions into English during the data analysis. Data analysis The qualitative data collected were analyzed using thematic analysis ( 37 , 38 ). The thematic analysis consisted of the following six stages: ( 1 ) reading through the material multiple times to become familiar with the data, ( 2 ) identifying and coding meaning units pertinent to the study aim and research questions, ( 3 ) recognizing themes and adding meaning units to the themes, ( 4 ) evaluating each theme critically to ensure that the themes and meaning units sufficiently captured the data, ( 5 ) naming the themes, and ( 6 ) compiling the text into five themes and ten subthemes. In the results section, we present these in detail. Ethics The Norwegian Agency for Shared Services in Education and Research assessed the current study, with project number 769409. The participants received oral and written information about the study and provided their written consent to participate. Participation in the study was voluntary, and the participants were informed about their right to withdraw at any stage without explanation or consequences. Results Below, we present the results from the co-creation process of the Norwegian version of PeerTECH named "DigiPer." This includes feedback from community mental healthcare stakeholders, perceived challenges in application functionality, the roles of peer support workers, relevance in addressing day-to-day challenges, and the use of the application to promote a healthy lifestyle and a holistic view of health. Feedback and challenges in DigiPer functioning Usability in DigiPer The participants expressed their appreciation for the opportunity to test DigiPer, showing their willingness to adopt it and their belief in its usefulness for people with SMI. The clear and organized presentation of essential topics and flexible usage, which allows access from anywhere, were highlighted. One service user commented: The application is relevant. DigiPer is straightforward, allowing users to navigate to their desired content quickly. It covers every day topics that are appropriate for people with SMI. (Service user from the application testing) Some individuals commented that "recovery" is frequently used in DigiPer. They suggested providing information about what "recovery" entails, as it might not be evident for Norwegian users. One said: Not everyone may be familiar with recovery. DigiPer mentions using your definition of recovery, but perhaps one should know a bit about the concept first. (Service user from the application testing) Videoconference demonstrations and testing revealed that the DigiPer classes could facilitate reflections, learning, and meaningful conversations between users and peers, particularly among those motivated to change. They emphasized the application's potential to be a resource and guide in daily life, offering new ideas and insights. The participants stressed the importance of clarifying its purpose during initial meetings between users and peers. A service user stated: As users, we are always curious about the purpose. What do we gain from it? How much time does it take? What can the peer support worker do for you? Can they help us navigate the healthcare system? These are the questions we have. (Service user from the application testing) With respect to DigiPer's suitability for other forms of treatment, opinions varied. While some recommended not implementing the DigiPer intervention under or immediately after treatment, others had a different perspective. One of them said: I was in therapy for a year, and it would have been helpful to have someone to talk to outside of the sessions. Over time, things can pile up, and forgetting what you want to say is easy. With a peer, you could address questions as they arise instead of waiting a week and potentially forgetting them. (Service user from the application testing) Concerns were raised if peer communication between weekly meetings was limited, which could hinder users from receiving timely assistance. During the testing, service users expressed worries about the postintervention period, as the 10-week duration might not be sufficient to achieve full recovery. Managing complexity in DigiPer classes - Even small things can become overwhelming During videoconference demonstrations and testing, there were concerns about whether the number of topics covered might discourage end users from completing the DigiPer intervention, as some classes included extensive information. Service users and professionals shared their experiences with previous digital follow-ups in municipalities, stating that they were too complex and had too many questions, leading to discontinuation. Peer support workers emphasized not overwhelming users, which could lead to a loss of motivation. One peer stated: I know that if there are too many things, things can quickly come to a standstill. Even small things can become overwhelming and create much stress . (Peer support worker at the application testing) Class 1 was highlighted as containing particularly complex information, which was challenging despite its importance. Individuals who tested DigiPer also found Class 9 to have too much text, especially in the section about asking for help, discouraging them from reading. Classes 5, 6, and 7 were deemed essential and more focused, making them more accessible to engage with. The number of topics in each class must determine the required time. All the study participants agreed that ten classes in DigiPer might be too many to address over 10 weeks. They emphasized the need for flexibility, allowing users to choose which classes and topics are important. For example, discussing smoking and dental health may be relevant, whereas others may not. One service user remarked: In the end, this should not become too advanced either. The user group needs it to be manageable . (Service user from the application testing) The peer support worker's role Recognizing and addressing user challenges Peer support workers found the peer role interesting. When testing DigiPer, they suggested that each peer support worker support three users throughout the intervention, considering that peer support workers typically have full-time jobs alongside this role. One peer remarked: It would be nice to be a peer support worker in DigiPer. I have experience from various places and am familiar with the peer role. It is enriching to help others . (Peer support worker from the application testing) Several peer support workers highlighted the difficulty of fully understanding other people' challenges, even with personal experiences of mental illness. They explained that strategies effective for one person may not work for another, as individuals differ in how they invest their energy and manage their well-being. Peer support workers also stressed the importance of advancing their recovery and processing their experiences to better support users' challenges. One service user illustrated this as follows: I have a job and try not to juggle too many responsibilities at once. I already have enough to manage independently, which can quickly become overwhelming. I have been sober for a few years now, but it is still easy to slip back. (Service user from the application testing) During the testing, the participants discussed the challenges that users might face at the beginning of the DigiPer intervention. They emphasized establishing a trusting relationship between the user and the peer when starting. Peers at the videoconferences underlined the importance of meeting in person to discuss DigiPer content, classes, and goals. Another peer support worker said: It is essential to see the face of the person you are talking to, to open up and share, and to establish understanding. (Peer support worker from the application testing) Service users stated that meeting others in a similar situation provides valuable support. They mentioned that peers of similar age and gender can better understand their needs. One person stated: Peer support workers are invaluable. If I had not had an experienced consultant, I would not be here today . (Service user from the application testing) However, several peer support workers provided feedback indicating a lack of clear role descriptions and undefined boundaries for the "peer" role. They suggested that DigiPer could be improved by offering a more detailed role description and clearer guidance for their work. Establishing clear boundaries around the peer support workers' roles within DigiPer was essential to prevent them from becoming overwhelmed with responsibility and to ensure that the burden does not fall solely on them when users struggle. During the testing, a community where peers could meet to receive support, discuss issues, and share experiences was suggested. This would ensure that peer support workers have someone to contact in difficult situations. Balancing self-responsibility and support Service users, peers, and professionals emphasized the importance of a balanced approach between self-responsibility and sufficient support during the DigiPer intervention. The workshop participants highlighted the need for users to address their lives' positive and negative aspects. They also warned against feeling overwhelmed by too many changes and emphasized the need for patience in recovery. The professionals in the tests stressed the importance of asking users specific questions without putting too much pressure on them. A professional said: Many want immediate change, but we must also work on patience. If nothing has changed in two weeks, it is not that the intervention is not helping but that one may need more time. It can be easy to start things, but maintaining them is difficult . (Professional from the application testing) In the videoconference demonstrations, peer support workers talked about how they perceived the DigiPer intervention to be effective in promoting change and recovery among certain users while acknowledging its lesser impact on others. They underscored that while it can be a valuable tool, users must actively contribute to their recovery. One peer support worker stated: DigiPer is not a miracle cure. No one can do the work for you. You must be willing to make changes in your life. This process may sometimes be uncomfortable, necessitating support to facilitate change. (Peer support worker from the videoconference demonstrations) Furthermore, during videoconference demonstrations, peer support workers emphasized that people may have encountered past challenges that hinder their ability to embrace new opportunities. While DigiPer may seem promising in theory, translating it into practice presents challenges that often result in frustration. In such instances, peers emphasize the importance of helping users identify individual stressors, breaking them down, focusing on positive aspects, and making tasks more manageable. Content of DigiPer: Addressing day-to-day challenges Supporting personal growth and goal setting All groups of study participants highlighted the challenges individuals with SMI face in managing their daily lives. Providing efficient mental and physical healthcare for these individuals can be difficult. DigiPer could offer valuable structure and advice to help people with SMI achieve their desired life. The workshop participants appreciated the self-reflection questions in class 3, which allowed users to explore difficult past experiences and work toward understanding and accepting their condition. They recognized that their life experiences had provided valuable lessons and shaped them, expressing hope for the future and acknowledging that everyone can achieve their goals with proper support. On the other hand, when testing class 2, the participants answered questions such as "What life do you want?" and "What have you always dreamed of doing?" to be broad and challenging to answer. It could also be difficult to address these questions during class 2, as the service users and peer support workers may not yet be well acquainted. Despite this, the participants acknowledged the relevance of these questions and appreciated the opportunity to articulate their aspirations and set personal goals. One service user expressed the complexity of the task by stating: It is not easy to answer what kind of life I desire. At the very least, it should be a better life than I had. I want a life where I excel socially and am kind to myself. That is what I desire. A peaceful life. (Service user from the application testing) Service users had encountered similar questions in treatment contexts, particularly when planning for the future, including potential reentry into the workforce. One of them felt that he had progressed, stating: I have a job and a stable and meaningful life. Therefore, such questions are no longer crucial. It is not my primary objective; it addresses the more minor aspects of achieving a fulfilled life. Currently, loneliness and social challenges are the primary struggles . (Service user from the application testing) With respect to Class 2, workshop participants recommended avoiding unrealistic goals, which could exacerbate users' situations. They suggested that formulating achievable personal goals and subgoals to combat negative thoughts and enhance well-being can help users complete the intervention. The participants appreciated the emphasis of the application on celebrating small victories, daily progress toward manageable goals, and the ability to set new goals afterward. DigiPer as a tool to build supportive networks All the participant groups emphasized the crucial role of social relationships and networks in maintaining stable health and discussed how DigiPer could be a tool for helping users build supportive networks. The participants highlighted the importance of providing information about community resources and meeting places for network building, such as exercise facilities and activity centers. They expressed concern about avoiding people who negatively influence them and instead connecting with people who understand their experiences and emotions, allowing them to be genuine and receive meaningful support. One peer noted: When you are struggling, you feel like you have no one – using the network maps in Class 1 makes it visible that you have people around you, dispelling the feeling of isolation. (Peer support worker from the videoconference demonstrations) Furthermore, workshop participants highlighted the exercises in Class 9 as potential boosters of social skills and network development. These exercises emphasize connecting with others, engaging in interactions, and initiating activities. The "You and I" exercise resonated positively among the participants. However, it was acknowledged that these exercises may not suit everyone's needs and preferences. Utilize DigiPer to encourage a healthy lifestyle Addressing substance use and smoking habits The study participants had differing opinions on whether substance use should be a focus in DigiPer. While workshop participants saw value in addressing this issue, service users who partook in the testing area felt that it was acceptable to avoid questions about substance use. One of them expressed: It is good to have a place where you do not have to talk about substance use. It can lead to feelings of guilt and disengagement. With DigiPer, there are enough other topics to focus on. You do not need to use substances if all the points are covered. (Service user from the application testing) Peer support workers from the videoconference demonstrations suggested that alcohol or substance use be incorporated into Class 5, "Smoking and Living a Healthy Lifestyle," as addiction is a common issue. Furthermore, peer support workers and service users acknowledged that not everyone necessarily wants to quit smoking and recommended avoiding attempts to stop smoking during high-stress periods and other challenges, as smoking can have a calming effect. Moreover, participants raised concerns about Class 5's primary focus on quitting smoking during the testing of DigiPer. They emphasized that a healthy lifestyle encompasses more than smoking cessation, possibly limiting DigiPer's potential to lead to broader changes in health behavior. One service user said: I do not see anything about a healthy lifestyle in this class, just a lot about smoking. Then, you are left wondering what constitutes a healthy lifestyle. It is more than just smoking or not smoking. Diet is almost the most essential component of everyday life. It can be something people struggle with, such as eating junk food. (Service user from the application testing) Improving sleep and stress management Several study participants noted that many people with SMI struggle with a lack of sleep or oversleep. Professionals who test DigiPer explain that despite attending sleep courses, applying advice remains difficult, leading service users to question the purpose of consistent sleep routines when sleep remains elusive. Breaking the cycle of daytime napping after sleepless nights was considered burdensome, especially without daytime work or meaningful activities. A focus on sleep can sometimes irritate, as one service user shared: I would feel stressed if someone told me what to do. Just relax, and I would be all wound up. When you start having trouble sleeping for consecutive nights, stress sets in. A lack of sleep leads to anxiety and negative thoughts about oneself and others, creating a real mess. (Service user from the application testing) Despite this, the participants believed that the sleep advice provided in class 6 could be relevant. They suggest that users go through the list step by step, and they might discover something they have not tried before. Perhaps combining multiple strategies over time and being patient is necessary. The workshop participants found value in both the reading and listening tasks in class 4, which could help them stay calm. Specifically, they highlighted that the listening tasks were particularly well suited for individuals with dyslexia. At the workshop and when testing DigiPer, people acknowledged that stress can negatively and positively affect the body. Some stress levels were always present, and they agreed that they had to live with it. One peer stated: Breathing is crucial in relation to stress management. I struggle to breathe using my stomach; it only reaches my chest. As a result, my neck becomes stiff, and my body feels locked. (Peer support worker from the application testing) A holistic view of health Connecting users to relevant services The workshop participants emphasized the importance of DigiPer in connecting users to healthcare, dental care, and social services, including NAV (Norwegian Labor and Welfare Administration). While satisfied with Class 2, which comprehensively addresses mental, physical, and social health, all groups of study participants highlighted challenges in collaborating with health and social services. Service users noted a lack of information exchange between community and specialist health services, leading to uncertainty about whom to contact when struggling and how to be referred to specialist health services. During a videoconference demonstration, a peer specified the following: Collaborating with health and social services can be demanding. It may entail interactions with hospitals, community mental health centers, GPs, legal guardians, and NAV. (Peer support worker from the videoconference demonstrations). Service users often contact GPs for healthcare but face barriers such as reluctance or communication difficulties that can lead to untreated pain and deteriorating health conditions. Workshop participants appreciated the continuity of community mental healthcare but faced challenges with their inability to adjust medications. They valued care coordination meetings and suggested better outreach during crises. They also noted that people with SMI may not always recognize the efforts of professionals such as GPs, psychologists, social educators, and nurses when they feel bad. Service users in the workshops suggested that having someone reach out during difficult times or acute needs would be beneficial. The study participants were encouraged to use the wellness plan in Class 3 to input information about assigned services and whom to contact when needed. In Class 7, workshop participants found information about dental health crucial, particularly regarding legal entitlement to free dental treatment in Norway. However, they also experienced challenges in determining eligibility for this treatment, citing dental anxiety and financial constraints as reasons some individuals avoid seeking dental care. Additionally, the participants suggested including information about the right to choose treatment from specialist health services in DigiPer. A need for support to overcome financial challenges All the study participants reported that finances could create challenges for people with SMI, making it difficult to meet their social needs. People can struggle to prioritize their dental health and exercise if they cannot pay their bills, stay awake worrying about financial matters, or are unsure if they have a safe place to live. The study participants emphasized that DigiPer lacked a focus on finances. A service user remarked: Finance is a major stressor that affects many aspects of life, especially those in or seeking treatment. I see people rushing into treatment today. Without proper financial support, people may continue to struggle even after treatment. If they had received financial help during treatment, their problems might not have been so large. (Service user from the application testing) The participants also noted that individuals with SMI often rely on income from NAV, but accessing NAV proves difficult through in-person visits, digital means, or phone calls. This lack of communication leaves service users without funds during weekends, exacerbating their frustration. They can easily express anger, leading to disconnections and blocks from NAV. Consequently, they turn to the study participants for assistance, highlighting their challenges as a third part of relaying messages. One service user said: It is not always easy for peer support workers to advise on everything, but if you are a peer, you have likely gone through those experiences and can recommend who to contact. For instance, NAV can be contacted for financial matters. (Service user from the application testing) Discussion In this qualitative study, we co-created a Norwegian version of the American PeerTECH application named "DigiPer." We tested its function and classes with service users, peer support workers, and professionals from community mental healthcare. All the participants perceived DigiPer as having proper usability and found its focus, classes, and helpful content. All the participants perceived the role of the peer support worker in DigiPer to be meaningful. However, maintaining a clear boundary in such a role when delivering peer support remains challenging. Building a trustful relationship with service users and among peer support workers, as well as addressing financial barriers, was highlighted as significant by all participants. A more user-centered joint effort and holistic recovery approach were expected to be realized in DigiPer by all participants. Promoting co-creation in mental health care offers significant benefits. For people with lived experience, co-creation helps identify and address personalized needs, reduces stigma and bias around mental health challenges, and fosters better health literacy and self-efficacy ( 28 , 39 , 40 ). The co-creation approach of DigiPer in our study supports this notion by bringing together voices from those with lived experience, especially peer support workers with successful recovery experiences and professionals. By providing a dedicated communication platform, DigiPer promotes open dialog and mutual learning between peers and service users, supporting Fortuna's model of "reciprocal accountability" ( 4 ) and the findings of Åkerblom and Ness ( 29 ) on how peer support workers help promote genuine and balanced partnerships. The co-creation approach makes DigiPer particularly valuable for vulnerable and traditionally marginalized groups, who often lack voices in the Norwegian mental healthcare system. Throughout the process, many subtle and underlying stressors experienced by people with SMI, such as housing and financial constraints, mistrust and confusion toward health and social care systems, and dental anxiety, were identified in this study. These challenges often remain "hidden" behind individual struggles, leading to unfair labels such as "mentally unstable" rather than recognizing people as holistic individuals with complex life histories ( 41 ). The co-creation approach in this study empowers service users to actively contribute to their recovery plans in DigiPer, which are more sensitive to individual needs and circumstances. Although DigiPer appears to be a promising tool, our peer support workers voiced concerns about establishing clear boundaries and responsibilities with the delivery of peer support services, which is consistent with results from early studies ( 42 – 44 ). Unlike professionals in mental healthcare, peer support workers often navigate "dual relationships" with their service users, which may include interactions beyond designated support programs, such as after-hours communication ( 44 , 45 ). While blurred work-life boundaries can help achieve certain goals ( 46 , 47 ), they also risk negative emotional impacts on peer support workers, potentially contributing to burnout, work-life conflict, and the drain of one's motivation ( 46 , 48 , 49 ). This can be particularly challenging for a peer-led, digital technology-enhanced tool such as DigiPer. Better boundary management can also foster the co-creation process in real practice and between peer support workers and service users ( 29 ). One boundary management strategy involves integrating DigiPer into peer support work routines. To achieve this goal, DigiPer must establish clear communication goals early on between peer support workers and service users. For example, peer support workers can use chat functions to expand access to hard-to-reach groups through geography. Chat features can also be used to send medication reminders or provide motivational support. The goal-setting function and focus classes of DigiPer can be tailored to align with the individual cases that peer support workers manage within existing support programs. Another approach is to enforce clear time boundaries, such as limiting chat availability to working hours, with the exception of urgent life events such as suicide risk, as shown in previous studies of American PeerTECH ( 36 , 50 ). When using technology to deliver peer support, it is important to consider how this new delivery approach impacts the mental and physical well-being of peer support workers themselves, such as burnout or trauma triggers. This is a major concern expressed by our participants in the study. Hence, building strong connections within the peer community is essential to strengthen mutual support throughout the implementation of digital health technology programs such as DigiPer ( 51 ). Proactively offering training and supervision is one way to connect peers to mitigate potential risks and scale up the effectiveness of the intervention ( 52 ). For example, providing simulation-based training before deploying a digital health technology program can clarify the program's goal and help peer support workers better coordinate with service users ( 1 ). An early study by Fortuna et al. ( 53 ) revealed that simulation training increased peer support workers' capacity to provide support through the technology program. Additionally, regular supervision and interactions among peer support workers while using digital health technology programs such as DigiPer can facilitate the exchange of user experience and challenges, promoting program fidelity and effective use of the technology ( 53 , 54 ). Compared with community mental health services in the United States, Norwegian community mental healthcare involves multiple stakeholders and complex factors that make the implementation of digital health tools challenging, especially for the most vulnerable groups ( 55 ). Future studies should consider synthesized and implementation-oriented theoretical frameworks such as Greenhalgh's NASSS framework ( 56 ) when assessing the accessibility and feasibility of DigiPer. The role of peer support workers is still relatively new in Norway. While there is potential for peer support communities to benefit from using DigiPer, proper training and supervision on accessibility and digital literacy must be established. Additionally, in this instance, simulation could be used to develop and promote adequate training, supervision, and digital literacy for peer support workers ( 1 ). Future studies could also explore the social impact of adopting digital health technology programs such as DigiPer for both peer support communities and service users and compare Norway and the US. We suggest that future findings could be valuable for better mental health peer support guidelines in Norway. Strengths and limitations A notable strength of the current study was the inclusion of several key stakeholders from community mental healthcare. This helped capture diverse perspectives, ensured that the application aligned with the Norwegian mental healthcare context, and strengthened the transferability of the findings to other settings ( 32 ). Using the co-creation principle ( 27 ) ensured that the application was developed with input from relevant stakeholders, strengthening the relevance of the results to practice. Moreover, collecting data from multiple sources (workshops, videoconference demonstrations, and application testing) helped obtain comprehensive perceptions regarding DigiPer, strengthening the credibility of the findings ( 32 ). The current study also has several limitations that should be considered. Although purposive sampling ensured that relevant participants were included, it may have introduced selection bias, as participants were chosen on the basis of accessibility, interest, and willingness to participate ( 57 ). Their interest could have influenced participants' feedback on the intervention and experience with digital tools. Another study limitation is the small sample size, which may limit the transferability when interpreting the results ( 32 ). Additionally, although we continuously tested the application, the testing period may not capture long-term usability issues. Thus, extended use over time could identify additional recommendations for improvements. To conclude, although efforts have been made to ensure accurate translations, nuances that could affect the application's effectiveness may still be lost in translation. Conclusion In this qualitative study, we co-created a Norwegian DigiPer and tested its functionality with service users, peer support workers, and professionals from community mental healthcare. The findings indicate that DigiPer has appropriate usability and that all participant groups perceive its content and classes as applicable. Input from these relevant stakeholders helped ensure the relevance of DigiPer to the Norwegian context and the health needs of people with SMI. Additionally, the study provided relevant general knowledge about important factors to consider when implementing digital tools in community healthcare and promoting self-management, not only for people with SMI but also for individuals with other health needs. Abbreviations GP General practitioner SMI Serious mental illness Declarations Ethics approval and consent to participate This study was assessed by the Norwegian Agency for Shared Services in Education and Research (project number 769409). Information regarding the study was given to the participants orally and in writing, and written consent was obtained to participate. Participation in the study was voluntary, and the participants had the right to withdraw without explanation or consequences. The data were handled confidentially without personally identifiable information to ensure that no directly identifying information about the participants was revealed. Consent for publication Not applicable. Availability of data and materials Data are available to appropriate academic parties upon reasonable request to the corresponding author. Competing interests The authors declare that they have no competing interests. Funding The University of Stavanger funded the study. Authors' contributions All the authors significantly contributed to the study. The study was designed collaboratively by the authors. MS and HMHF conducted the workshops. MS led the videoconference demonstrations, and MS and JNS facilitated the application testing. JNS and MS performed the data analysis. JNS led the drafting and revision of the manuscript, with contributions from HMHF, KLF, BW, and MS in writing, commenting, refining, and revising the manuscript. All the authors approved the final version. Acknowledgments The authors thank the participants for dedicating their time to participate in the study. Authors' information Jorunn Nærland Skjærpe is a PhD candidate in health and medicine at the University of Stavanger. Her research interests are care coordination, digital health, peer support, responsible innovation, and service user involvement. Hilde Marie Hunsbedt Fjellså is a PhD candidate in health and medicine at the University of Stavanger. Her research interests are care coordination, innovation, eHealth, health service research, and elderly care. Karen Fortuna is an Assistant Professor of Community and Family Medicine and a Co-Founder of the Collaborative Design for Recovery and Health. As an international volunteer collaborative of patients, community health workers, peer support specialists, caregivers, policymakers, and payer systems, the Collaborative uses community-based participatory research to facilitate the development, evaluation, and implementation of tools to develop a workforce of lay providers with lived experience expertise to support similar others through peer support and evidence-based practices. Bo Wang is a PhD fellow at Molde University College and a researcher at the Norwegian Centre for E-health Research. She leads and participates in multiple research projects and grant proposals in digital mental health. Her research interests are digital mental health, capacity building, user involvement, task shifting, social care innovation, and implementation. Marianne Storm is a professor of health science at the University of Stavanger. She is affiliated as a professor at Molde University College and Stavanger University Hospital. She leads the research group PARTAKE and research projects funded by the Norwegian Research Council. Her research interests cover user involvement and participation, digital health, mental health and aging, and social innovation. References Williams B, Reddy P, Marshall S, Beovich B, McKarney L. Simulation and mental health outcomes: a scoping review. Adv Simul. 2017;2:2. https://doi.org/10.1186/s41077-016-0035-9 Bartels SJ, DiMilia PR, Fortuna KL, Naslund JA. Integrated care for older adults with serious mental illness and medical comorbidity: Evidence-based models and future research directions. Psychiatr Clin North Am. 2018;41(1):153–164. doi: 10.1016/j.psc.2017.10.012 Berry N, Lobban F, Bucci S. 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Proc IEEE Glob Humanit Technol Conf. 2021:2021:188–194. doi: 10.1109/ghtc53159.2021.9612411 Bønes E, Granja C, Solvoll T. Implementation of the Flexible Assertive Community Treatment (FACT) Model in Norway: eHealth Assessment Study. J Med Internet Res. 2022;24(1):e32220. doi: 10.2196/32220 . Greenhalgh T, Abimbola S. The NASSS Framework – A Synthesis of Multiple Theories of Technology Implementation. Stud Health Technol Inform. 2019;263:193–204. doi: 10.3233/SHTI190123 . PMID: 31411163. Malterud K. Qualitative research: standards, challenges, and guidelines. The Lancet. 2001;358(9280):483–488. doi: 10.1016/S0140-6736(01)05627-6 . Additional Declarations No competing interests reported. Supplementary Files Appendices.docx 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-5806093","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":401927842,"identity":"ac8061f7-e499-4f69-ae04-6a2ee39b87b7","order_by":0,"name":"Jorunn Nærland Skjærpe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBACxgY4k43BAETxI4sRp0WygYAWJMAGoQwOEFDH3N77TLpwB0MeA/+xhIKPe+7IGd9Ibv7AuMMGt8N6jptJzzzDUMwgkXbAcMazZ8ZmNxLbJBjPpOHWMiONTZq3jSGxQYK9wZjnwOHEbUAtDIxth4nQwn+8wfjPgcP1m2ckAh1GlBaGtAPGDAcOJxhIAG3Eq6XnGLM1b5sE0P1pCYY9B54ZzjjzEMTF7RfD9jbG27xtNon9/MfMDH4cuCPP357++MPHNtwhZtgApiRAscIGjMoDEOEEnBoYGOSR2MwP4FpGwSgYBaNgFCABAFXfUo31+Xz3AAAAAElFTkSuQmCC","orcid":"","institution":"University of Stavanger","correspondingAuthor":true,"prefix":"","firstName":"Jorunn","middleName":"Nærland","lastName":"Skjærpe","suffix":""},{"id":401927843,"identity":"f1d01716-e35e-44ed-88b5-cd1fd6fd33ad","order_by":1,"name":"Hilde Marie Hunsbedt Fjellså","email":"","orcid":"","institution":"University of Stavanger","correspondingAuthor":false,"prefix":"","firstName":"Hilde","middleName":"Marie Hunsbedt","lastName":"Fjellså","suffix":""},{"id":401927844,"identity":"3ece5630-d9f8-4c7d-8ca2-f4a5ead80b79","order_by":2,"name":"Karen L. Fortuna","email":"","orcid":"","institution":"Geisel School of Medicine at Dartmouth","correspondingAuthor":false,"prefix":"","firstName":"Karen","middleName":"L.","lastName":"Fortuna","suffix":""},{"id":401927845,"identity":"8d534abb-cff7-4fd9-ab0e-4a94a8e5123e","order_by":3,"name":"Bo Wang","email":"","orcid":"","institution":"Molde University College","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Wang","suffix":""},{"id":401927846,"identity":"069adf05-4e98-4627-8d97-3eaf5b70f14f","order_by":4,"name":"Marianne Storm","email":"","orcid":"","institution":"University of Stavanger","correspondingAuthor":false,"prefix":"","firstName":"Marianne","middleName":"","lastName":"Storm","suffix":""}],"badges":[],"createdAt":"2025-01-10 20:08:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5806093/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5806093/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73900397,"identity":"0254b510-5714-470d-944f-ab250643df3e","added_by":"auto","created_at":"2025-01-15 17:17:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":75752,"visible":true,"origin":"","legend":"\u003cp\u003ePeerTECH application\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5806093/v1/643ce37a852518ef8719e78f.png"},{"id":73900173,"identity":"4ecd5273-5346-4c48-ba99-3040ff9ceeeb","added_by":"auto","created_at":"2025-01-15 17:09:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":48315,"visible":true,"origin":"","legend":"\u003cp\u003eUser application home screen\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5806093/v1/f03f20107e5bb15275d9335a.png"},{"id":74580985,"identity":"e046e4da-78ed-464e-8ec7-5914cfc71b47","added_by":"auto","created_at":"2025-01-23 15:53:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1364820,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5806093/v1/6f73d37a-9477-4b56-a691-d554f0fb666e.pdf"},{"id":73900174,"identity":"b1c241df-f91d-4d94-85e1-b3ca0e1113d8","added_by":"auto","created_at":"2025-01-15 17:09:30","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18502,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-5806093/v1/b39005cb652b592e38884417.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Co-creating Norwegian DigiPer: a digital tool including peer support for managing mental, physical, and social health in serious mental illness","fulltext":[{"header":"Background","content":"\u003cp\u003eResearch, technology, and understanding of mental illness are constantly evolving, necessitating innovations in the treatment of overall health (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This evolution is particularly relevant for addressing the mental, physical, and social health needs of people with serious mental illness (SMI) (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). By the term SMI, we refer to schizophrenia, schizoaffective disorder, psychotic disorders, major depressive disorders, and bipolar disorders (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). People with SMI are more likely to encounter physical health issues than the general population (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). A lack of focus on healthy lifestyles and self-management, as well as persistent symptoms of mental illness, are functional issues that often occur when people experience SMI (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Strategies to empower people with SMI to self-manage mental, physical, and social health are needed (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDigital health involves the use of information and communication technologies, including wearable devices, mobile health, telehealth, health information technology, and telemedicine, to manage health issues and promote well-being (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Digital health interventions can include resources to prevent relapse, strategies to manage mental health symptoms, enhancing physical health, improving medication adherence and physical activity engagement, and promoting self-management skills (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Moreover, digital health can reduce disparities in healthcare access for people with SMI by increasing their connection with services (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGillis et al. (2024) reported that people with SMI appreciate simple digital health interventions that emphasize physical health, healthy lifestyles, exercise, and weight management but view these interventions as complementary to, rather than replacements for, clinical services. Several studies (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) have shown that digital health, when combined with peer support, facilitates the sharing of health information, advice, and lived experience expertise, promoting recovery and engagement in technology. Digital peer support involves interactions with peer support workers, who act as lived experience experts (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) to promote recovery (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This encompasses live or automated peer support services delivered via technological media, peer-delivered interventions through smartphone applications, and both asynchronous and synchronous technologies, with asynchronous methods enabling communication between peer support specialists and service users without requiring real-time interaction (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Moreover, digital peer support shows promise for improving psychosocial outcomes, such as hope, social support, medication adherence, and self-management skills (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe American PeerTECH application is a digital peer support intervention that integrates technology and peer support (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). PeerTECH draws upon integrated illness management and recovery (I-IMR) and self-management for people with SMI and chronic medical conditions (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The objective of self-management is to empower people in their recovery by equipping them with the skills needed to recognize and manage their mental, physical, and social health issues (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). PeerTECH offers several components to support its service users' mental, physical, and social health by developing self-management skills and personalized goals. PeerTECH helps link individuals to relevant resources in the community to access services and support. Pilot studies in the United States indicate that PeerTECH enhances health literacy, promotes healthy behavior, and provides tools to prevent relapses, maintain health, and improve overall well-being (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA usability test of the American prototype PeerTECH application with Norwegian service users, peer support workers, and healthcare professionals employed in community mental healthcare revealed that participants were positive toward the application's content, it was user friendly, and they considered it a relevant tool to support self-management of their mental, physical and social health (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Thus, translating and adapting PeerTECH into a Norwegian version, DigiPer (digital likeperson, meaning digital peer), was considered appropriate to ensure an optimal fit for the needs of Norwegian service users, peers, and community mental healthcare (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePetretto et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) emphasized that digital health interventions are complex and dynamic and that unintended consequences may lead to inequalities. Difficulties in design and a lack of engagement and motivation pose challenges (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Other barriers include limited opportunities for contact with the helper (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), inadequate access to mobile phones (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), complex login procedures (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), usability problems (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), and high attrition rates before intervention effects are achieved (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Thus, when designing and implementing digital health interventions, it is essential to consider specific needs, priorities, and unique ethical considerations related to the privacy, confidentiality, and information governance of people with SMI (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Involving service users in the digital health development process is crucial to ensure that interventions align with the needs and expectations of end users, thereby enhancing acceptance, effectiveness, and uptake in the real world (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Co-creation models are suitable for ensuring that digital health interventions are clear, usable, and engaging for people with SMI and tailored to individual needs (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to Greenhalgh et al. (27 p. 39), co-creation is \"the collaborative generation of knowledge by academics working alongside stakeholders from other sectors.\" Co-creation entails collaborative knowledge production, often centered on local or regional university‒community partnerships, to align research and service development and enhance research and social impact (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Co-creation can help address the persistent gap between research and its practical implementation (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This approach involves collaboration through implementation from early stages, such as commissioning and design (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In mental health research, co-creation involves diverse stakeholders, including individuals with lived experiences of mental illness, professionals, and those who bring both perspectives (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Participation in co-creation processes can promote personal growth and support career aspirations despite the challenges of mental illness (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGreenhalgh et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) explain that co-creation relies on three key success principles, as co-creation \"failures\" can often be traced back to not following these principles. The first principle adopts a systems perspective, which assumes emergence, local adaptation, and nonlinearity. By taking a systems perspective, the impact of the collaboration will be more robust and more enduring, enhancing the user experience. The second principle is to frame research as a creative initiative centered on human experience, particularly that of service users and staff. The third principle emphasizes the need for an appropriate leadership style and highlights the importance of program framing, relationship dynamics, facilitation arrangements, interactions, sensemaking, dialog, and outcomes. Greenhalgh et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) emphasized that co-creation in health services should start with the service user experience, involve collaboration with staff to enhance the user experience, and ensure that health services are tailored to the experiences of service users and carers.\u003c/p\u003e \u003cp\u003eThis study aims to co-create a Norwegian version of the PeerTECH application, DigiPer, by utilizing workshops, videoconference demonstrations, and application testing with service users, peer support workers, and professionals from Norwegian community mental healthcare. We use the term community mental healthcare when referring to services provided to people with SMI in the municipality. We sought to answer the following research questions:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow do community mental healthcare stakeholders perceive the content, classes, and functions of DigiPer?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are their perceived challenges with DigiPer content and functions?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat are the perceived roles of peer support workers in DigiPer?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch design\u003c/h2\u003e \u003cp\u003eThis study has a qualitative research design that is suitable for obtaining knowledge of the study participants' experiences and perceptions (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). We use Greenhalgh et al.'s (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) principles of co-creation to integrate the experiences and perceptions of key stakeholders in community mental healthcare, including service users, peer support workers, and professionals. This process involves workshops, videoconference demonstrations, and application testing to develop the Norwegian DigiPer application (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy setting: Norwegian community mental healthcare\u003c/h3\u003e\n\u003cp\u003eThe Norwegian healthcare system comprises municipal health and care services and specialist health services (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Municipalities offer mental and physical community-based healthcare, focusing on illness prevention, health promotion, treatment, care, and assistance with daily life (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Municipalities must ensure that residents can access general practitioners (GPs), who typically provide initial consultation for healthcare needs and deliver ongoing treatment and care (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Specialist health services are responsible for those with the most extensive mental healthcare needs, including inpatient and outpatient care through psychiatric hospitals and community mental health centers (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe current study was conducted with participants from community mental healthcare in two municipalities in western Norway. Workshops and application tests were conducted in a Norwegian municipality with approximately 15,000 residents. Additionally, videoconference demonstrations were held with participants from community mental healthcare in a larger Norwegian municipality with approximately 292,000 residents.\u003c/p\u003e\n\u003ch3\u003eRecruitment and participants\u003c/h3\u003e\n\u003cp\u003eWe used purposive sampling to select participants eligible to contribute to co-create the Norwegian DigiPer (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Service users, peer support workers, and professionals from community mental healthcare were considered stakeholders with the relevant knowledge and experiences necessary for this study. This diverse range of stakeholders aligns with the co-creation principles described by Greenhalgh et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWorkshop and application testing participants were recruited through one service leader whom MS contacted via e-mail with information about the study. The leader then provided eligible service users, peer support workers, and professionals with this information and selected participants on the basis of their accessibility, interest, willingness, and experience with digital tools. Workshops were scheduled with two service users, two peer support workers, and two professionals. Among them, five were female, and one was male. For the application testing, three service users, one peer support worker, and two professionals participated. Four of them were female, and two were male.\u003c/p\u003e \u003cp\u003eIn November 2022, we attended the \"Sterkere Sammen\" conference in Oslo, Norway, which focused on peer support. Interested participants were invited to participate in a videoconference demonstration of DigiPer. Four peer support workers, two women and two men, were recruited to participate in these demonstrations.\u003c/p\u003e\n\u003ch3\u003ePeerTECH intervention\u003c/h3\u003e\n\u003cp\u003eThe American PeerTECH is a peer-led digital health intervention (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). As illustrated in image 1, it combines the expertise of peer support workers with recovery-focused content accessible via mobile phones or tablets.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eImage 1 PeerTECH application\u003c/p\u003e \u003cp\u003ePeerTECH seeks to empower people with SMI to manage stress and reduce vulnerabilities that contribute to the deterioration of mental, physical, and social health. The program focuses on helping users strengthen their self-management skills through 1-hour, in-person meetings with peer support workers conducted once a week over 10 weeks.\u003c/p\u003e \u003cp\u003ePeerTECH consists of two applications: one for users and one for peer support workers. The peer support worker's application includes information to guide users during in-person meetings, develop self-management skills, and share lived experiences. It allows them to message assigned users and view their goals, wellness plans, and progress through the PeerTECH intervention. The user application provides access to messaging with their assigned peer support worker, formulating personal goals, developing wellness plans, and a resource library with self-management support classes. The PeerTECH chat feature enables users and peer support workers to communicate between classes. Peer support workers are expected to text users thrice weekly during the intervention. These text messages should follow up on goals and provide support between meetings. Image 2 displays the user application's home screen.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eImage 2 User application home screen\u003c/p\u003e \u003cp\u003eThe user application includes a library with resources illustrating mental, physical, and social health interconnections. The library comprises guided tasks designed to teach and reinforce coping skills training for self-management. It features videos of people with SMI sharing their experiences of challenges and successes. The PeerTECH library consists of ten classes that the users and peer support workers will conduct during their weekly meetings. This includes the following classes: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Introductions, Smartphone Orientation, and Recovery and Health; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Good Mental Health Starts With Good Physical Health and Social Health (vice versa); (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Recovery is a Daily Process; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) How Stress Impacts our Health; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Smoking and Living a Healthy Lifestyle; (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Healthy Sleep; (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Dental Health; (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) Exercise; (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Developing and Maintaining Relationships; and (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) Getting the Help You Want. Each class follows this structure: (a) introduction of the goals and content of the class; (b) review of home practice; (c) mutuality and co-learning activities; (d) questions to explore together; (e) follow-up on personal goals; (f) feedback; and (g) home practice ideas. Appendix 1 outlines the focus of the ten PeerTECH classes.\u003c/p\u003e\n\u003ch3\u003eCo-creating Norwegian DigiPer\u003c/h3\u003e\n\u003cp\u003eThe Norwegian Digiper application was co-created using the five steps described below, inspired by the co-creation principles of Greenhalgh et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). This approach ensured that DigiPer was designed to meet the needs of service users and peer support workers in Norway.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eStep 1: Translating the American PeerTECH application into Norwegian DigiPer\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eWith the help of fluent translators to ensure that contextually accurate translations aligned with the application's usage, we translated the PeerTECH application interface and content into Norwegian. This included translating all the user interface strings, such as buttons, labels, and error messages, and adapting culturally sensitive content, such as images, symbols, and colors, to ensure their relevance and appropriateness for the Norwegian end users.\u003c/p\u003e \u003cp\u003eAdditionally, we made significant changes to Class 10, \"Getting the help you want,\" and Class 7, \"Dental health,\" by adding context-specific content to align with the Norwegian healthcare system. These adaptations reflect a systems perspective, ensuring local relevance and usability (Greenhalgh et al., 2016).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStep 2: Workshops with service users, peer support workers and professionals\u003c/h3\u003e\n \u003cp\u003eAfter completing the translation, MS and HMHF held two workshops, bringing together service users, peer support workers, and professionals to engage the key stakeholders early in the co-creation process and to ensure inclusiveness in the data collection process (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The workshops provided a safe space for participants to freely express their views while contributing valuable insights into customizing DigiPer to Norwegian users. We emphasized valuing all the opinions and perspectives of the participants, encouraging them to share their thoughts and experiences, and a shared understanding of the value of the co-creation process for tailoring the DigiPer to the user needs and context of the Norwegian mental health service system.\u003c/p\u003e \u003cp\u003eThe participants reviewed the translated content to ensure that the translations were accurate and up to date, with a focus on its relevance to the context of mental healthcare in Norway and individuals with SMI. We began the workshops by explaining and demonstrating the applications' functionality. The participants reviewed the content of each DigiPer class. The first workshop covered Classes 1\u0026ndash;5 and 10, whereas the second workshop reviewed classes 6\u0026ndash;10. Class 10, \"Getting the help you need,\" was examined by participants in both workshops owing to the changes needed to optimize it for Norwegian users. We requested feedback on several aspects of DigiPer, as detailed in Appendix 2.\u003c/p\u003e\n\u003ch3\u003eStep 3: Videoconference demonstrations with peer support workers\u003c/h3\u003e\n\u003cp\u003eMS conducted four individual videoconference demonstrations, each lasting approximately 30 minutes. During these sessions, MS led the demonstrations and presented the application, its functions, and the DigiPer classes. The peer support workers were then encouraged to provide feedback on its relevance to their peer support work. This feedback informed refinements to improve the user experience and ensure its relevance for individuals with SMI (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eStep 4: Adaptation of the Norwegian DigiPer\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eIn step 4, we used feedback from participants in the workshops and videoconference demonstrations to revise, adapt, and tailor the application's content to the views and experiences of multiple stakeholders (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). We also replaced videos from the original application with six animated videos relevant to users in Norway. Manuscripts for these videos were developed on the basis of the DigiPer classes. Additional videos were added to three classes: relaxing body scan meditation in Class 4, mindfulness sleep meditation in Class 6, and exercise video in Class 8. The researchers continuously tried the application throughout this process for quality assurance and to ensure that everything worked correctly. This feedback loop included ensuring the proper display of Norwegian text without truncation or layout issues, reviewing translations to ensure cultural and linguistic accuracy, and checking for any functional problems, such as date formatting or keyboard input changes that could have arisen from the language switch.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStep 5: Testing the Norwegian DigiPer application with potential end-users\u003c/h2\u003e \u003cp\u003eMS and JNS facilitated two Norwegian DigiPer application testing sessions to gain feedback on content and functionality on the basis of their individual experiences (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Each session began with a demonstration of its functionality, followed by an explanation of the system and content, including key features. Under the researchers' guidance, the participants downloaded, installed, and logged into DigiPer. One participant downloaded the peer support worker application in each session, whereas two downloaded the user application. MS facilitated their entry into the DigiPer system.\u003c/p\u003e \u003cp\u003eBefore testing, the group reviewed Class 1 on a large TV screen. The participants role-played how the initial meetings and ongoing engagement between users and peer support workers might unfold. Role-playing is a suitable method for integrating peer support into these interactions (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Classes 1 and 6 were tested, and the sessions concluded with a facilitated review. Appendix 3 details the focus of this review.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eQualitative data were collected at the workshops, videoconference demonstrations, and application testing (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The data material consists of written notes the researchers took to document stakeholders' feedback and perceived challenges related to DigiPer content, classes, and functions. The application testings were also audio recorded and transcribed verbatim by JNS. JNS translated the qualitative notes and transcriptions into English during the data analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe qualitative data collected were analyzed using thematic analysis (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). The thematic analysis consisted of the following six stages: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) reading through the material multiple times to become familiar with the data, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) identifying and coding meaning units pertinent to the study aim and research questions, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) recognizing themes and adding meaning units to the themes, (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) evaluating each theme critically to ensure that the themes and meaning units sufficiently captured the data, (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) naming the themes, and (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) compiling the text into five themes and ten subthemes. In the results section, we present these in detail.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003eThe Norwegian Agency for Shared Services in Education and Research assessed the current study, with project number 769409. The participants received oral and written information about the study and provided their written consent to participate. Participation in the study was voluntary, and the participants were informed about their right to withdraw at any stage without explanation or consequences.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBelow, we present the results from the co-creation process of the Norwegian version of PeerTECH named \"DigiPer.\" This includes feedback from community mental healthcare stakeholders, perceived challenges in application functionality, the roles of peer support workers, relevance in addressing day-to-day challenges, and the use of the application to promote a healthy lifestyle and a holistic view of health.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eFeedback and challenges in DigiPer functioning\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eUsability in DigiPer\u003c/h2\u003e \u003cp\u003eThe participants expressed their appreciation for the opportunity to test DigiPer, showing their willingness to adopt it and their belief in its usefulness for people with SMI. The clear and organized presentation of essential topics and flexible usage, which allows access from anywhere, were highlighted. One service user commented:\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe application is relevant. DigiPer is straightforward, allowing users to navigate to their desired content quickly. It covers every day topics that are appropriate for people with SMI.\u003c/em\u003e (Service user from the application testing)\u003c/p\u003e \u003cp\u003eSome individuals commented that \"recovery\" is frequently used in DigiPer. They suggested providing information about what \"recovery\" entails, as it might not be evident for Norwegian users. One said:\u003c/p\u003e \u003cp\u003e \u003cem\u003eNot everyone may be familiar with recovery. DigiPer mentions using your definition of recovery, but perhaps one should know a bit about the concept first.\u003c/em\u003e (Service user from the application testing)\u003c/p\u003e \u003cp\u003eVideoconference demonstrations and testing revealed that the DigiPer classes could facilitate reflections, learning, and meaningful conversations between users and peers, particularly among those motivated to change. They emphasized the application's potential to be a resource and guide in daily life, offering new ideas and insights. The participants stressed the importance of clarifying its purpose during initial meetings between users and peers. A service user stated:\u003c/p\u003e \u003cp\u003e \u003cem\u003eAs users, we are always curious about the purpose. What do we gain from it? How much time does it take? What can the peer support worker do for you? Can they help us navigate the healthcare system? These are the questions we have.\u003c/em\u003e (Service user from the application testing)\u003c/p\u003e \u003cp\u003eWith respect to DigiPer's suitability for other forms of treatment, opinions varied. While some recommended not implementing the DigiPer intervention under or immediately after treatment, others had a different perspective. One of them said:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI was in therapy for a year, and it would have been helpful to have someone to talk to outside of the sessions. Over time, things can pile up, and forgetting what you want to say is easy. With a peer, you could address questions as they arise instead of waiting a week and potentially forgetting them.\u003c/em\u003e (Service user from the application testing)\u003c/p\u003e \u003cp\u003eConcerns were raised if peer communication between weekly meetings was limited, which could hinder users from receiving timely assistance. During the testing, service users expressed worries about the postintervention period, as the 10-week duration might not be sufficient to achieve full recovery.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eManaging complexity in DigiPer classes - Even small things can become overwhelming\u003c/h2\u003e \u003cp\u003eDuring videoconference demonstrations and testing, there were concerns about whether the number of topics covered might discourage end users from completing the DigiPer intervention, as some classes included extensive information. Service users and professionals shared their experiences with previous digital follow-ups in municipalities, stating that they were too complex and had too many questions, leading to discontinuation. Peer support workers emphasized not overwhelming users, which could lead to a loss of motivation. One peer stated:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI know that if there are too many things, things can quickly come to a standstill. Even small things can become overwhelming and create much stress\u003c/em\u003e. (Peer support worker at the application testing)\u003c/p\u003e \u003cp\u003eClass 1 was highlighted as containing particularly complex information, which was challenging despite its importance. Individuals who tested DigiPer also found Class 9 to have too much text, especially in the section about asking for help, discouraging them from reading. Classes 5, 6, and 7 were deemed essential and more focused, making them more accessible to engage with. The number of topics in each class must determine the required time.\u003c/p\u003e \u003cp\u003eAll the study participants agreed that ten classes in DigiPer might be too many to address over 10 weeks. They emphasized the need for flexibility, allowing users to choose which classes and topics are important. For example, discussing smoking and dental health may be relevant, whereas others may not. One service user remarked:\u003c/p\u003e \u003cp\u003e \u003cem\u003eIn the end, this should not become too advanced either. The user group needs it to be manageable\u003c/em\u003e. (Service user from the application testing)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eThe peer support worker's role\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eRecognizing and addressing user challenges\u003c/h2\u003e \u003cp\u003ePeer support workers found the peer role interesting. When testing DigiPer, they suggested that each peer support worker support three users throughout the intervention, considering that peer support workers typically have full-time jobs alongside this role. One peer remarked:\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt would be nice to be a peer support worker in DigiPer. I have experience from various places and am familiar with the peer role. It is enriching to help others\u003c/em\u003e. (Peer support worker from the application testing)\u003c/p\u003e \u003cp\u003eSeveral peer support workers highlighted the difficulty of fully understanding other people' challenges, even with personal experiences of mental illness. They explained that strategies effective for one person may not work for another, as individuals differ in how they invest their energy and manage their well-being. Peer support workers also stressed the importance of advancing their recovery and processing their experiences to better support users' challenges. One service user illustrated this as follows:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI have a job and try not to juggle too many responsibilities at once. I already have enough to manage independently, which can quickly become overwhelming. I have been sober for a few years now, but it is still easy to slip back.\u003c/em\u003e (Service user from the application testing)\u003c/p\u003e \u003cp\u003eDuring the testing, the participants discussed the challenges that users might face at the beginning of the DigiPer intervention. They emphasized establishing a trusting relationship between the user and the peer when starting. Peers at the videoconferences underlined the importance of meeting in person to discuss DigiPer content, classes, and goals. Another peer support worker said:\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt is essential to see the face of the person you are talking to, to open up and share, and to establish understanding.\u003c/em\u003e (Peer support worker from the application testing)\u003c/p\u003e \u003cp\u003eService users stated that meeting others in a similar situation provides valuable support. They mentioned that peers of similar age and gender can better understand their needs. One person stated:\u003c/p\u003e \u003cp\u003e \u003cem\u003ePeer support workers are invaluable. If I had not had an experienced consultant, I would not be here today\u003c/em\u003e. (Service user from the application testing)\u003c/p\u003e \u003cp\u003eHowever, several peer support workers provided feedback indicating a lack of clear role descriptions and undefined boundaries for the \"peer\" role. They suggested that DigiPer could be improved by offering a more detailed role description and clearer guidance for their work. Establishing clear boundaries around the peer support workers' roles within DigiPer was essential to prevent them from becoming overwhelmed with responsibility and to ensure that the burden does not fall solely on them when users struggle. During the testing, a community where peers could meet to receive support, discuss issues, and share experiences was suggested. This would ensure that peer support workers have someone to contact in difficult situations.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eBalancing self-responsibility and support\u003c/h2\u003e \u003cp\u003eService users, peers, and professionals emphasized the importance of a balanced approach between self-responsibility and sufficient support during the DigiPer intervention. The workshop participants highlighted the need for users to address their lives' positive and negative aspects. They also warned against feeling overwhelmed by too many changes and emphasized the need for patience in recovery. The professionals in the tests stressed the importance of asking users specific questions without putting too much pressure on them. A professional said:\u003c/p\u003e \u003cp\u003e \u003cem\u003eMany want immediate change, but we must also work on patience. If nothing has changed in two weeks, it is not that the intervention is not helping but that one may need more time. It can be easy to start things, but maintaining them is difficult\u003c/em\u003e. (Professional from the application testing)\u003c/p\u003e \u003cp\u003eIn the videoconference demonstrations, peer support workers talked about how they perceived the DigiPer intervention to be effective in promoting change and recovery among certain users while acknowledging its lesser impact on others. They underscored that while it can be a valuable tool, users must actively contribute to their recovery. One peer support worker stated:\u003c/p\u003e \u003cp\u003e \u003cem\u003eDigiPer is not a miracle cure. No one can do the work for you. You must be willing to make changes in your life. This process may sometimes be uncomfortable, necessitating support to facilitate change.\u003c/em\u003e (Peer support worker from the videoconference demonstrations)\u003c/p\u003e \u003cp\u003eFurthermore, during videoconference demonstrations, peer support workers emphasized that people may have encountered past challenges that hinder their ability to embrace new opportunities. While DigiPer may seem promising in theory, translating it into practice presents challenges that often result in frustration. In such instances, peers emphasize the importance of helping users identify individual stressors, breaking them down, focusing on positive aspects, and making tasks more manageable.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eContent of DigiPer: Addressing day-to-day challenges\u003c/h2\u003e \u003cdiv id=\"Sec24\" class=\"Section4\"\u003e \u003ch2\u003eSupporting personal growth and goal setting\u003c/h2\u003e \u003cp\u003eAll groups of study participants highlighted the challenges individuals with SMI face in managing their daily lives. Providing efficient mental and physical healthcare for these individuals can be difficult. DigiPer could offer valuable structure and advice to help people with SMI achieve their desired life.\u003c/p\u003e \u003cp\u003eThe workshop participants appreciated the self-reflection questions in class 3, which allowed users to explore difficult past experiences and work toward understanding and accepting their condition. They recognized that their life experiences had provided valuable lessons and shaped them, expressing hope for the future and acknowledging that everyone can achieve their goals with proper support.\u003c/p\u003e \u003cp\u003eOn the other hand, when testing class 2, the participants answered questions such as \"What life do you want?\" and \"What have you always dreamed of doing?\" to be broad and challenging to answer. It could also be difficult to address these questions during class 2, as the service users and peer support workers may not yet be well acquainted. Despite this, the participants acknowledged the relevance of these questions and appreciated the opportunity to articulate their aspirations and set personal goals. One service user expressed the complexity of the task by stating:\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt is not easy to answer what kind of life I desire. At the very least, it should be a better life than I had. I want a life where I excel socially and am kind to myself. That is what I desire. A peaceful life.\u003c/em\u003e (Service user from the application testing)\u003c/p\u003e \u003cp\u003eService users had encountered similar questions in treatment contexts, particularly when planning for the future, including potential reentry into the workforce. One of them felt that he had progressed, stating:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI have a job and a stable and meaningful life. Therefore, such questions are no longer crucial. It is not my primary objective; it addresses the more minor aspects of achieving a fulfilled life. Currently, loneliness and social challenges are the primary struggles\u003c/em\u003e. (Service user from the application testing)\u003c/p\u003e \u003cp\u003eWith respect to Class 2, workshop participants recommended avoiding unrealistic goals, which could exacerbate users' situations. They suggested that formulating achievable personal goals and subgoals to combat negative thoughts and enhance well-being can help users complete the intervention. The participants appreciated the emphasis of the application on celebrating small victories, daily progress toward manageable goals, and the ability to set new goals afterward.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eDigiPer as a tool to build supportive networks\u003c/h2\u003e \u003cp\u003eAll the participant groups emphasized the crucial role of social relationships and networks in maintaining stable health and discussed how DigiPer could be a tool for helping users build supportive networks. The participants highlighted the importance of providing information about community resources and meeting places for network building, such as exercise facilities and activity centers. They expressed concern about avoiding people who negatively influence them and instead connecting with people who understand their experiences and emotions, allowing them to be genuine and receive meaningful support. One peer noted:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWhen you are struggling, you feel like you have no one \u0026ndash; using the network maps in Class 1 makes it visible that you have people around you, dispelling the feeling of isolation.\u003c/em\u003e (Peer support worker from the videoconference demonstrations)\u003c/p\u003e \u003cp\u003eFurthermore, workshop participants highlighted the exercises in Class 9 as potential boosters of social skills and network development. These exercises emphasize connecting with others, engaging in interactions, and initiating activities. The \"You and I\" exercise resonated positively among the participants. However, it was acknowledged that these exercises may not suit everyone's needs and preferences.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eUtilize DigiPer to encourage a healthy lifestyle\u003c/h2\u003e \u003cdiv id=\"Sec27\" class=\"Section4\"\u003e \u003ch2\u003eAddressing substance use and smoking habits\u003c/h2\u003e \u003cp\u003eThe study participants had differing opinions on whether substance use should be a focus in DigiPer. While workshop participants saw value in addressing this issue, service users who partook in the testing area felt that it was acceptable to avoid questions about substance use. One of them expressed:\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt is good to have a place where you do not have to talk about substance use. It can lead to feelings of guilt and disengagement. With DigiPer, there are enough other topics to focus on. You do not need to use substances if all the points are covered.\u003c/em\u003e (Service user from the application testing)\u003c/p\u003e \u003cp\u003ePeer support workers from the videoconference demonstrations suggested that alcohol or substance use be incorporated into Class 5, \"Smoking and Living a Healthy Lifestyle,\" as addiction is a common issue. Furthermore, peer support workers and service users acknowledged that not everyone necessarily wants to quit smoking and recommended avoiding attempts to stop smoking during high-stress periods and other challenges, as smoking can have a calming effect.\u003c/p\u003e \u003cp\u003eMoreover, participants raised concerns about Class 5's primary focus on quitting smoking during the testing of DigiPer. They emphasized that a healthy lifestyle encompasses more than smoking cessation, possibly limiting DigiPer's potential to lead to broader changes in health behavior. One service user said:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI do not see anything about a healthy lifestyle in this class, just a lot about smoking. Then, you are left wondering what constitutes a healthy lifestyle. It is more than just smoking or not smoking. Diet is almost the most essential component of everyday life. It can be something people struggle with, such as eating junk food.\u003c/em\u003e (Service user from the application testing)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eImproving sleep and stress management\u003c/h2\u003e \u003cp\u003eSeveral study participants noted that many people with SMI struggle with a lack of sleep or oversleep. Professionals who test DigiPer explain that despite attending sleep courses, applying advice remains difficult, leading service users to question the purpose of consistent sleep routines when sleep remains elusive. Breaking the cycle of daytime napping after sleepless nights was considered burdensome, especially without daytime work or meaningful activities. A focus on sleep can sometimes irritate, as one service user shared:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI would feel stressed if someone told me what to do. Just relax, and I would be all wound up. When you start having trouble sleeping for consecutive nights, stress sets in. A lack of sleep leads to anxiety and negative thoughts about oneself and others, creating a real mess.\u003c/em\u003e (Service user from the application testing)\u003c/p\u003e \u003cp\u003eDespite this, the participants believed that the sleep advice provided in class 6 could be relevant. They suggest that users go through the list step by step, and they might discover something they have not tried before. Perhaps combining multiple strategies over time and being patient is necessary.\u003c/p\u003e \u003cp\u003eThe workshop participants found value in both the reading and listening tasks in class 4, which could help them stay calm. Specifically, they highlighted that the listening tasks were particularly well suited for individuals with dyslexia. At the workshop and when testing DigiPer, people acknowledged that stress can negatively and positively affect the body. Some stress levels were always present, and they agreed that they had to live with it. One peer stated:\u003c/p\u003e \u003cp\u003e \u003cem\u003eBreathing is crucial in relation to stress management. I struggle to breathe using my stomach; it only reaches my chest. As a result, my neck becomes stiff, and my body feels locked.\u003c/em\u003e (Peer support worker from the application testing)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eA holistic view of health\u003c/h2\u003e \u003cdiv id=\"Sec30\" class=\"Section3\"\u003e \u003ch2\u003eConnecting users to relevant services\u003c/h2\u003e \u003cp\u003eThe workshop participants emphasized the importance of DigiPer in connecting users to healthcare, dental care, and social services, including NAV (Norwegian Labor and Welfare Administration). While satisfied with Class 2, which comprehensively addresses mental, physical, and social health, all groups of study participants highlighted challenges in collaborating with health and social services. Service users noted a lack of information exchange between community and specialist health services, leading to uncertainty about whom to contact when struggling and how to be referred to specialist health services. During a videoconference demonstration, a peer specified the following:\u003c/p\u003e \u003cp\u003e \u003cem\u003eCollaborating with health and social services can be demanding. It may entail interactions with hospitals, community mental health centers, GPs, legal guardians, and NAV.\u003c/em\u003e (Peer support worker from the videoconference demonstrations).\u003c/p\u003e \u003cp\u003eService users often contact GPs for healthcare but face barriers such as reluctance or communication difficulties that can lead to untreated pain and deteriorating health conditions. Workshop participants appreciated the continuity of community mental healthcare but faced challenges with their inability to adjust medications. They valued care coordination meetings and suggested better outreach during crises. They also noted that people with SMI may not always recognize the efforts of professionals such as GPs, psychologists, social educators, and nurses when they feel bad. Service users in the workshops suggested that having someone reach out during difficult times or acute needs would be beneficial. The study participants were encouraged to use the wellness plan in Class 3 to input information about assigned services and whom to contact when needed.\u003c/p\u003e \u003cp\u003eIn Class 7, workshop participants found information about dental health crucial, particularly regarding legal entitlement to free dental treatment in Norway. However, they also experienced challenges in determining eligibility for this treatment, citing dental anxiety and financial constraints as reasons some individuals avoid seeking dental care. Additionally, the participants suggested including information about the right to choose treatment from specialist health services in DigiPer.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eA need for support to overcome financial challenges\u003c/h2\u003e \u003cp\u003eAll the study participants reported that finances could create challenges for people with SMI, making it difficult to meet their social needs. People can struggle to prioritize their dental health and exercise if they cannot pay their bills, stay awake worrying about financial matters, or are unsure if they have a safe place to live. The study participants emphasized that DigiPer lacked a focus on finances. A service user remarked:\u003c/p\u003e \u003cp\u003e \u003cem\u003eFinance is a major stressor that affects many aspects of life, especially those in or seeking treatment. I see people rushing into treatment today. Without proper financial support, people may continue to struggle even after treatment. If they had received financial help during treatment, their problems might not have been so large.\u003c/em\u003e (Service user from the application testing)\u003c/p\u003e \u003cp\u003eThe participants also noted that individuals with SMI often rely on income from NAV, but accessing NAV proves difficult through in-person visits, digital means, or phone calls. This lack of communication leaves service users without funds during weekends, exacerbating their frustration. They can easily express anger, leading to disconnections and blocks from NAV. Consequently, they turn to the study participants for assistance, highlighting their challenges as a third part of relaying messages. One service user said:\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt is not always easy for peer support workers to advise on everything, but if you are a peer, you have likely gone through those experiences and can recommend who to contact. For instance, NAV can be contacted for financial matters.\u003c/em\u003e (Service user from the application testing)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this qualitative study, we co-created a Norwegian version of the American PeerTECH application named \"DigiPer.\" We tested its function and classes with service users, peer support workers, and professionals from community mental healthcare. All the participants perceived DigiPer as having proper usability and found its focus, classes, and helpful content. All the participants perceived the role of the peer support worker in DigiPer to be meaningful. However, maintaining a clear boundary in such a role when delivering peer support remains challenging. Building a trustful relationship with service users and among peer support workers, as well as addressing financial barriers, was highlighted as significant by all participants. A more user-centered joint effort and holistic recovery approach were expected to be realized in DigiPer by all participants.\u003c/p\u003e \u003cp\u003ePromoting co-creation in mental health care offers significant benefits. For people with lived experience, co-creation helps identify and address personalized needs, reduces stigma and bias around mental health challenges, and fosters better health literacy and self-efficacy (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The co-creation approach of DigiPer in our study supports this notion by bringing together voices from those with lived experience, especially peer support workers with successful recovery experiences and professionals. By providing a dedicated communication platform, DigiPer promotes open dialog and mutual learning between peers and service users, supporting Fortuna's model of \"reciprocal accountability\" (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and the findings of \u0026Aring;kerblom and Ness (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) on how peer support workers help promote genuine and balanced partnerships. The co-creation approach makes DigiPer particularly valuable for vulnerable and traditionally marginalized groups, who often lack voices in the Norwegian mental healthcare system. Throughout the process, many subtle and underlying stressors experienced by people with SMI, such as housing and financial constraints, mistrust and confusion toward health and social care systems, and dental anxiety, were identified in this study. These challenges often remain \"hidden\" behind individual struggles, leading to unfair labels such as \"mentally unstable\" rather than recognizing people as holistic individuals with complex life histories (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). The co-creation approach in this study empowers service users to actively contribute to their recovery plans in DigiPer, which are more sensitive to individual needs and circumstances.\u003c/p\u003e \u003cp\u003eAlthough DigiPer appears to be a promising tool, our peer support workers voiced concerns about establishing clear boundaries and responsibilities with the delivery of peer support services, which is consistent with results from early studies (\u003cspan additionalcitationids=\"CR43\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Unlike professionals in mental healthcare, peer support workers often navigate \"dual relationships\" with their service users, which may include interactions beyond designated support programs, such as after-hours communication (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). While blurred work-life boundaries can help achieve certain goals (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), they also risk negative emotional impacts on peer support workers, potentially contributing to burnout, work-life conflict, and the drain of one's motivation (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). This can be particularly challenging for a peer-led, digital technology-enhanced tool such as DigiPer. Better boundary management can also foster the co-creation process in real practice and between peer support workers and service users (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne boundary management strategy involves integrating DigiPer into peer support work routines. To achieve this goal, DigiPer must establish clear communication goals early on between peer support workers and service users. For example, peer support workers can use chat functions to expand access to hard-to-reach groups through geography. Chat features can also be used to send medication reminders or provide motivational support. The goal-setting function and focus classes of DigiPer can be tailored to align with the individual cases that peer support workers manage within existing support programs. Another approach is to enforce clear time boundaries, such as limiting chat availability to working hours, with the exception of urgent life events such as suicide risk, as shown in previous studies of American PeerTECH (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhen using technology to deliver peer support, it is important to consider how this new delivery approach impacts the mental and physical well-being of peer support workers themselves, such as burnout or trauma triggers. This is a major concern expressed by our participants in the study. Hence, building strong connections within the peer community is essential to strengthen mutual support throughout the implementation of digital health technology programs such as DigiPer (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Proactively offering training and supervision is one way to connect peers to mitigate potential risks and scale up the effectiveness of the intervention (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). For example, providing simulation-based training before deploying a digital health technology program can clarify the program's goal and help peer support workers better coordinate with service users (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). An early study by Fortuna et al. (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e) revealed that simulation training increased peer support workers' capacity to provide support through the technology program. Additionally, regular supervision and interactions among peer support workers while using digital health technology programs such as DigiPer can facilitate the exchange of user experience and challenges, promoting program fidelity and effective use of the technology (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCompared with community mental health services in the United States, Norwegian community mental healthcare involves multiple stakeholders and complex factors that make the implementation of digital health tools challenging, especially for the most vulnerable groups (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Future studies should consider synthesized and implementation-oriented theoretical frameworks such as Greenhalgh's NASSS framework (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e) when assessing the accessibility and feasibility of DigiPer. The role of peer support workers is still relatively new in Norway. While there is potential for peer support communities to benefit from using DigiPer, proper training and supervision on accessibility and digital literacy must be established. Additionally, in this instance, simulation could be used to develop and promote adequate training, supervision, and digital literacy for peer support workers (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Future studies could also explore the social impact of adopting digital health technology programs such as DigiPer for both peer support communities and service users and compare Norway and the US. We suggest that future findings could be valuable for better mental health peer support guidelines in Norway.\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eA notable strength of the current study was the inclusion of several key stakeholders from community mental healthcare. This helped capture diverse perspectives, ensured that the application aligned with the Norwegian mental healthcare context, and strengthened the transferability of the findings to other settings (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Using the co-creation principle (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) ensured that the application was developed with input from relevant stakeholders, strengthening the relevance of the results to practice. Moreover, collecting data from multiple sources (workshops, videoconference demonstrations, and application testing) helped obtain comprehensive perceptions regarding DigiPer, strengthening the credibility of the findings (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe current study also has several limitations that should be considered. Although purposive sampling ensured that relevant participants were included, it may have introduced selection bias, as participants were chosen on the basis of accessibility, interest, and willingness to participate (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). Their interest could have influenced participants' feedback on the intervention and experience with digital tools. Another study limitation is the small sample size, which may limit the transferability when interpreting the results (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Additionally, although we continuously tested the application, the testing period may not capture long-term usability issues. Thus, extended use over time could identify additional recommendations for improvements. To conclude, although efforts have been made to ensure accurate translations, nuances that could affect the application's effectiveness may still be lost in translation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this qualitative study, we co-created a Norwegian DigiPer and tested its functionality with service users, peer support workers, and professionals from community mental healthcare. The findings indicate that DigiPer has appropriate usability and that all participant groups perceive its content and classes as applicable. Input from these relevant stakeholders helped ensure the relevance of DigiPer to the Norwegian context and the health needs of people with SMI.\u003c/p\u003e \u003cp\u003eAdditionally, the study provided relevant general knowledge about important factors to consider when implementing digital tools in community healthcare and promoting self-management, not only for people with SMI but also for individuals with other health needs.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003eGP General practitioner\u003c/p\u003e \u003cp\u003eSMI Serious mental illness\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was assessed by the Norwegian Agency for Shared Services in Education and Research (project number 769409). Information regarding the study was given to the participants orally and in writing, and written consent was obtained to participate. Participation in the study was voluntary, and the participants had the right to withdraw without explanation or consequences. The data were handled confidentially without personally identifiable information to ensure that no directly identifying information about the participants was revealed.\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\u003eData are available to appropriate academic parties upon reasonable request to the corresponding author.\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\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe University of Stavanger funded the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors significantly contributed to the study. The study was designed collaboratively by the authors. MS and HMHF conducted the workshops. MS led the videoconference demonstrations, and MS and JNS facilitated the application testing. JNS and MS performed the data analysis. JNS led the drafting and\u0026nbsp;revision of the manuscript, with contributions from HMHF, KLF, BW, and MS in writing, commenting, refining, and revising the manuscript. All the authors approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the participants for dedicating their time to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eJorunn N\u0026aelig;rland Skj\u0026aelig;rpe\u003c/em\u003e\u003c/strong\u003e is a PhD candidate in health and medicine at the University of Stavanger. Her research interests are care coordination, digital health, peer support, responsible innovation, and service user involvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHilde Marie Hunsbedt Fjells\u0026aring;\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eis a PhD candidate in health and medicine at the University of Stavanger. Her research interests are care coordination, innovation, eHealth, health service research, and elderly care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eKaren Fortuna\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eis an Assistant Professor of Community and Family Medicine and a Co-Founder of the Collaborative Design for Recovery and Health. As an international volunteer collaborative of patients, community health workers, peer support specialists, caregivers, policymakers, and payer systems, the Collaborative uses community-based participatory research to facilitate the development, evaluation, and implementation of tools to develop a workforce of lay providers with lived experience expertise to support similar others through peer support and evidence-based practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBo Wang\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eis a\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003ePhD fellow at Molde University College and a researcher at the Norwegian Centre for E-health Research. She leads and participates in multiple research projects and grant proposals in digital mental health. Her research interests are digital mental health, capacity building, user involvement, task shifting, social care innovation, and implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMarianne Storm\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eis a professor of health science at the University of Stavanger. She is affiliated as a professor at Molde University College and Stavanger University Hospital. She leads the research group PARTAKE and research projects funded by the Norwegian Research Council. Her research interests cover user involvement and participation, digital health, mental health and aging, and social innovation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWilliams B, Reddy P, Marshall S, Beovich B, McKarney L. Simulation and mental health outcomes: a scoping review. 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Qualitative research: standards, challenges, and guidelines. The Lancet. 2001;358(9280):483\u0026ndash;488. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(01)05627-6\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(01)05627-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\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":"Co-creation, User involvement, Peer support, Digital mental health, Mobile application, Self-management, Recovery","lastPublishedDoi":"10.21203/rs.3.rs-5806093/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5806093/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePeople with serious mental illness (SMI) often encounter physical health issues, a lack of focus on self-management, and persistent symptoms of mental illness. Strategies to empower people with SMI to self-manage their mental, physical, and social health are needed. The PeerTECH application is an American digital peer support intervention that can help manage health issues and promote self-management skills for people with SMI. This study aims to co-create a Norwegian version of PeerTECH, DigiPer, with service users, peer support workers, and professionals from Norwegian community mental healthcare.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study employs a qualitative design using principles of co-creation to develop the Norwegian DigiPer. We conducted workshops, videoconference demonstrations, and application testing with key stakeholders in the co-creation process. The data collected were analyzed using thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFive themes and ten subthemes were developed in the data analysis. The first theme reflected feedback and challenges in DigiPer functioning, with the subthemes of \u003cem\u003eUsability in DigiPer\u003c/em\u003e and \u003cem\u003eManaging complexity in DigiPer classes.\u003c/em\u003e The second theme focused on the peer support worker's role, with subthemes of \u003cem\u003erecognizing and addressing user challenges\u003c/em\u003e and \u003cem\u003ebalancing self-responsibility and support.\u003c/em\u003e The third theme focused on the content of DigiPer in addressing day-to-day challenges, with subthemes of \u003cem\u003esupporting personal growth and goal setting\u003c/em\u003e and \u003cem\u003eDigiPer as a tool to build supportive networks\u003c/em\u003e. The fourth theme highlighted the use of DigiPer to encourage a healthy lifestyle, with subthemes of \u003cem\u003eaddressing substance use and smoking habits\u003c/em\u003e and \u003cem\u003eimproving sleep and stress management.\u003c/em\u003e The fifth theme provided a holistic view of health, with subthemes of \u003cem\u003econnecting users to relevant services\u003c/em\u003e and \u003cem\u003ea need for support to overcome financial challenges.\u003c/em\u003e\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eDigiPer has good usability among community mental healthcare stakeholders and has proper functionality, which is relevant to the Norwegian context. Although challenges exist, all participants perceived DigiPer as a meaningful and promising tool to help people with SMI improve their self-management of their mental, physical, and social health. Future studies should assess the accessibility and feasibility of the Norwegian DigiPer.\u003c/p\u003e","manuscriptTitle":"Co-creating Norwegian DigiPer: a digital tool including peer support for managing mental, physical, and social health in serious mental illness","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-15 17:09:26","doi":"10.21203/rs.3.rs-5806093/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":"bafb61aa-cf24-41af-ae52-669f19226ded","owner":[],"postedDate":"January 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-23T15:53:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-15 17:09:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5806093","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5806093","identity":"rs-5806093","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}