A Qualitative Exploration of mental health peer support provision for racially minoritised people in England

A Qualitative Exploration of mental health peer support provision for racially minoritised people in England | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Qualitative Exploration of mental health peer support provision for racially minoritised people in England Anthony Salla, Rhiannon Foster, Charlotte Crowl, Daniela Lewis, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8337940/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Peer support is being expanded at pace across mental health services in England. Limited research looks at peer support in relation to racially minoritised people in the UK, against a backdrop of longstanding racial inequities in mental health provision. The purpose of this research was to explore the main issues for peer support in responding to diverse populations, and to make recommendations relating to race equity considering the peers support’s integration into mental health services. Methods We conducted an exploratory qualitative study using semi-structured key informant interviews with 18 participants, including supported peers, peer workers and professionals. A lived experience advisory group ensured high levels of lived experience involvement in the conceptualisation, analysis and write up. Interviews were transcribed and analysed thematically. A hybrid approach was used in the data analysis. Results Data are presented below under four themes: peerness and connection, cultural awareness and peer support, cultural responsiveness and peer support, and organisational cultural competence. Important findings around racialised matching surfaced, reflecting various perspectives peer support must embrace. Peer support’s role as being tailored to addressing specific racial inequities was put forward. Themes looking at cultural awareness and responsiveness highlighted the dynamic inter-relation between peer support and race, ethnic and culture differences, and peer support’s agility to respond to diverse needs. Conclusions The introduction of peer support workers is a key part of NHS reform. The considerations in relation to race equity for this new mental health workforce have been unclear in practice and research. As the scope of PSW increases there is a need for greater awareness of the issues they will encounter to support system integration. Our findings highlight key approaches by PSW’s in responding to ethnic diversity. They also highlight the need for appropriate resourcing to help ensure race equity can be central to service delivery. Support for racialised peer support workforce to attend to vicarious racism should be provided, alongside opportunities for ongoing learning and coaching around culture and mental health. Improvements in how to monitor and to appropriately respond to inequities across access, experience and outcomes should also be a priority. Peer support lived experience mental health services race equity implementation health and well-being Background Research has repeatedly rehearsed the unfavourable relationship between racially minoritised people and mental health services (1), alongside evidence of poorer outcomes (2). This relationship has been typified by coercion, retraumatisation, breakdowns in trust, fear, and factors embedded within notions of epistemic injustice, strongly emphasising imbalanced power relations (3). Research has suggested peer support might have potential to bridge across social difference given its capacity to overcome hierarchies (4). Over recent years, there’s been a push to increase the availability of peer support across England, as part of a long-term plan for service expansion (5), matched by a proliferation of peer services internationally, now considered an indispensable feature of mental healthcare (6). Peer-support initiatives vary in how they’re designed, the mode and frequency of contact, the degree of professional training, and the content and structure expected to inform peer interactions. Differences in outcomes or target population are also observed (7). One area less frequently placed in the spotlight of peer support research is the experience of racially minoritised people. Previous research has focused attention on a differential experience for such groups in relation to user involvement (8). Given this, and against a backdrop of racial inequities across other areas of mental health provision peer support’s role in this space warrants ongoing consideration given its implementation across mental health services in England. Race, culture and ‘peerness’ in mental health services Peerness has been described as the experience of living with mental health problems and using mental health services (9), and active use or disclosure of this within the peer support relationship (10). Nevertheless, questions remain about how peerness is defined, measured and evaluated, alongside thoughts about peer worker qualities and experiences (11). Racalised bodies, and the extent of ethnic diversity adds another dimension of consideration to the peerness debate. The term, racialised bodies, encourages us to explore the complex imbrication of social processes through which bodies become recognised in racial terms. As Ahmed (12) contends, the concept pushes us to see bodies as a container of experience, whereby racialised identities are reified, and in themselves sites of racialisation. Racialised bodies, known to influence healthcare expectations have been used as anchors to base peerness (13). A sizeable degree of discourse around racialised bodies comes into play with the notion of racialised matching, the idea or intention of finding congruence by connecting people based on some level of shared racial, ethnic or cultural identity (14). Attempts at racialised matching across other areas of healthcare have produced mixed results (15). Indeed, there’s ambivalence about the benefits of ethnic matching, providing a narrow conception of a person’s holistic need (16). Research in some settings has indicated that the cultural understanding care providers have of patients, and not their racialised identity, was associated with ongoing patient service engagement (17). While this is the situation, for peer support, patient perspectives have indicated matching has been beneficial, bringing similarity in experiences (18). In some situations, the experience of being a Black survivor, providing mutual support with other Black survivors of the UK mental health system, has been a cornerstone to fostering a sense of belonging; in some instances of greater importance than the shared oppression of mental distress (19). A US study reported competing perspectives; African American peer group leaders found being watched by White supervisory staff evoked images reminiscent of plantation enslavement, it also reported how for some, being allocated to work in a group defined by racial or ethnic boundaries made them feel uncomfortable (20). Among the Latino population in the US, peerness was defined by shared cultural, linguistic or migration experience, instead of the experience of mental ill-health, an approach used to alleviate fears about non-engagement from supported peers due to mental health stigma (21). Flowing from this are implications related to peer support workforce diversity and inclusion. Similarly, in a separate study, peer participants echoed a need for peers from culturally and linguistically diverse backgrounds, also underlining a need for peers of colour to provide authentic, culturally aware connections (22). While research has indicated that shared lived experience of mental health challenges can bring a grounding equilibrium (4), potentially mitigating cultural or racial distance between peer support worker and supported peer, as highlighted, peerness is defined in multiple ways according to contextual considerations. Organisational habitude Of course, matters of racialisation within peer support are not limited to peerness; cultural differences have been identified in peer support (23). Research in England attempted to identify culturally distinctive features around peer worker roles, with a particular emphasis on racially and culturally specific organisations (24). The authors found areas of divergence in culturally specific organisations compared with peer support delivered in inpatient settings regarding whether lived experience was necessary, highlighting also different expectations around personal disclosure of mental health history. Culturally specific organisations also placed greater value on informal roles and flexible delivery approaches. This points to differences in practices, sanctioned by organisational habitude, which can translate to differential service experiences. The role of organisational culture has been addressed in the literature and voluntary sector provision is central. The voluntary sector has been recognised as a playing a crucial role in supporting groups who often experience discrimination, offering a source of help that is the least stigmatising (25). An area of provision that has been identified as being particularly suited to racially minoritised people is the black voluntary sector (BVS) (also referred to as ethnocentric support (26). Keating (27) has posited that the BVS offers the most relevant support to racialised groups because their work is based on different conceptual ideas about what it means to experience mental ill-health than do state services. Further, he argues that the BVS embraces the whole person when combating mental health problems rather than other models that narrowly define mental ill-health within a psychiatric framework. Further, Fernando (26) said he was struck by the ‘informality of approach by the staff towards clients’ in the BVS, and also that they brought a greater range of social and political issues of personal significance into provision. Similar sentiments have been noted by Newbigging et al. (28) who suggested BVS services are grounded in different conceptualisations of advocacy with a sharper understanding of the needs of African and Caribbean men. Race, culture and access to peer support A nationwide US survey found racially minoritised people would not access peer groups due to a feeling they would not be accepted or that their concerns would be misunderstood; people who did access peer support reported feelings of disrespect to their cultural beliefs and values, yet they did not want to raise concerns due to a fear of ‘rocking the boat’ (29). Research has shown lower levels of peer support engagement among racially minoritised people (30), while one study reported higher dropout rates for people whose first/main language was not English (31). This raises broader questions about equitable access and experience. Steps have been taken by some peer programmes to embrace cultural competence, making it a feature of peer training (32,33) Peer programmes have been known to implement various cultural modifications to assessment tools, use of colloquialisms and modes of expression, activity location (20), targeted support (34), utilising cultural knowledge (21), and the involvement of healthcare professionals (35). Hence, the literature points towards broader considerations about the delivery of peer support for racially minoritised people. Race, culture and outcomes of peer support Peer support’s role in relation to equitable outcomes for racially minoritised people can also be considered. Two studies in the US indicated peer support resulted in a higher likelihood of positive change in psychiatric symptoms for non-White peers compared to White (36), and authors of another study concluded peer support transitions can reduce disparities for older participants from racially minoritised backgrounds with clinical depression (37). Improvements for homeless African Americans across physical and mental health measures have also been reported in a peer navigator programme. (38). A UK based trial indicated peer support on discharge was more beneficial in reducing readmission compared to control amongst Black participants than for participants from all other ethnic groups (39). However, this study also showed that, for all participants, ongoing engagement with peer support – a key predictor of positive effect – was not associated with being matched with a peer worker of similar ethnicity (40). Hence, peer support can be effective across difference making the case for better idea how people are understanding and experiencing it. Cultural competence in peer support Matters discussed thus far, including racialised peerness, culturally affirming support, organisational habitude, can each be understood in relation to efforts to improve access, experience and outcomes for racially minoritised people. This sits under a broader framework of cultural competence (CC). Though earlier definitions of CC have rightly been critiqued for narrowly focusing on end learning points and individual level knowledge and skills, and failing to have sufficient analysis of power (41), more recent attempts to embed these issues makes the case for it to be retained as a useful framework for contextualising race equity initiatives (42,43). Cultural awareness, historically viewed as a component of cultural competence, focuses on an individual’s basic knowledge about the differences between cultures, including an individual’s awareness of their own views and biases (44). On its own, cultural awareness is recognised as being limited in its scope to transform services. More recently, the term cultural responsiveness has attracted attention, reflecting a substantial step beyond general awareness, encompassing use of individual’s skills and actions, yet importantly including the mindset of practitioners to exhibit sensitivity, self-reflection, and humility (45). It can be seen to entail what Curtis describes as being beyond acquiring knowledge about other cultures to focus on a response embodying cultural safety, an approach focused on recognition of power differentials (41). Cultural competence also acknowledges the significance of organisational functions. Cultural competency is a term used to describe interventions that aim to improve accessibility and effectiveness of health care services for racially marginalised people. This can include service design, organisational polices, training, coaching and supervision structures, and appropriate partnerships (46). Current evidence suggests peer support can offer benefits for people from racialised communities using mental health services, but problems of access remain and it is clear that ‘peerness’ can mean different things for different groups of people; that race and culture might offer limited points of connection that define racialised experiences of peer support. Research is needed to better make sense of how racially minoritised people understand and experience peer support, in order that the opportunity for peer support to address inequalities of experience and outcome of mental health services is optimised. Aims Given the background of racial inequities across mental health service provision, and the limited research looking at peer support in relation to racially minoritised people in the UK, and the significant rollout of peer support in England, this study aimed to build on and test existing research outlined above. We aimed to find out what peer support workers, the people they support (‘supported peers’) and professionals working closely with peer support services thought were the main issues relating to the delivery of peer support for racially minoritised people. Part of the aim was also to understand differential needs of supported peers were in relation to peer support, and whether different delivery models or characteristics of peer support had been successful in responding to diverse populations. Methods This was a qualitative study, using semi-structured interviews with peer support workers and supported peers, and professionals working closely with peer support in National Health Services in England. The study took an exploratory approach across four mental health trusts. Sites were selected based on the peer support initiatives the research team knew were operational. The study was approved by NHS Research Ethics Committee. Participant recruitment Inclusion criteria was: adults age 18+, being able to provide informed consent and English speaking. The sample criteria for supported peers included recruitment based on ethnicity (e.g. self-define as belonging to a racially minoritised group), as well as having experience of being offered or taking part in peer support. Inclusion criteria for peer workers and professionals was based on their experience and knowledge of peer support and with experience of supporting people from racially minoritised groups. Recruitment occurred through four mental health trust sites and via contact with third sector organisations who provided peer support to people using mental health services in those areas. Attention was paid to recruiting diverse participants across gender, ethnicity and age. All potential participants were provided with the participant information sheet and were offered an opportunity to speak with the research team if they had any questions about the study. All participants provided informed consent (written or audio recorded) prior to interviews being conducted. A socio-demographic monitoring form was also completed. Data collection All interviews followed a topic guide and were conducted by AS (researcher in mental health) and RF (lived experience researcher) either in person, by telephone or remotely using video call. Research around peer support, as cited above, informed the development of the topic guide. The topic guide was also co-produced with members of a lived experience advisory group. Questions explored participants general experience of receiving or providing peer support, the relationship between peer support worker and supported peer, and the experience of culture in mental health services and peer support (see supplementary material). Interview length averaged 67 minutes (range = 55-95minutes). Supported peers, and peer support workers doing interviews outside of working hours, were offered £25 as an appreciation of their time and expertise. Interviews were audio recorded and transcribed verbatim initially using software. Prior to analysis, transcripts were corrected by the research team, and changes made for accuracy and participant anonymity. Data collection continued until the target number of interviews was complete. One researcher (AS) was of mixed heritage, but not the same racial identity as participants, and the other (RF) White British, both representing an academic institution. As some interviews were with people who had experienced mental health challenges, the researcher was mindful that participants could be apprehensive about discussing race and their experiences of mental health services. To minimise the possibility of participants feeling uncomfortable, measures were taken to build trust through informal discussions prior to interview. Data analysis Interview transcripts were transferred into Nvivo software for thematic analysis. A hybrid approach was taken to analysis. Initially, a preliminary coding framework was developed from the team’s understanding of existing research, including codes related to race, ethnicity, culture, and service design. Preliminary analysis was undertaken by AS and RF using three transcripts. Two researchers (AS, RF) independently and systematically coded three of the transcripts and discussed the codes and emerging themes, along with SG to develop a provisional coding framework. Members of the Lived Experience Advisory Panel (LEAP) and the Project’s management committee then reviewed the same transcripts and the provisional coding framework was refined. A hybrid approach was used for the remaining transcripts, coding them deductively where data demonstrated fit with the framework, and inductively so that new codes could be added as necessary or existing codes modified in response to the data. This was followed by inductive coding whereby new codes were generated from participant accounts and added to the coding framework. Familiarisation was achieved by the first author reading through the entire data set. The coding framework was applied to the transcripts using line-by-line coding. AS continued coding the data using the revised framework, adding new codes to the framework as more transcripts became available and until no new codes were identified. Codes were then organised into themes corresponding to the research questions and new themes. The research team met weekly to review and discuss codes, themes and developing findings. Members of the LEAP were invited to comment and approve the final report. Sample Description 18 participants were involved in the study from across four sites. This included: Seven supported peers, ages: 30-40 (3); 40-50 (3) and 50+ (1); Gender: female (4) male (3); Ethnicity: Black Caribbean (2), Black other (1), Mixed ethnicity Black and White (1), Asian Pakistani (1), Asian other (1) and other mixed ethnic group (1). Nine peer workers, ages: 29-20(1); 30-40 (3); 40-50 (4) and 50+ (1); Gender: female (6) male (3); Ethnicity: Black Caribbean (2), Black other (2), Black British African (2), Mixed ethnicity Black and White (1), Asian other (1) and White British (1). Two professionals, age 30-40(1), one participant age not recorded; Gender: female(1), male(1); Ethnicity White British(2). Research Findings Data are presented below under four themes: peerness and connection, cultural awareness and peer support, cultural responsiveness and peer support, and organisational cultural competence, and are illustrated by verbatim quotes from the interviews. Interviewee characteristics are indicated in brackets by site number (e.g S1-4), ethnicity, gender and role (e.g. SP=supported peer; PSW=peer support worker; or professional role). 4.1 Peerness and connection Opinions about peerness, and whether this could be matched based on one or more aspects of person’s identity varied. In most situations this was interrelated with notions of connection, understanding and validation. There was an understanding that it’s too simplistic to expect race or ethnicity alone to define all aspects and outcomes of a peer relationship. A belief was shared that among some participants that effective, skilled peer workers can cut across racial and ethnic differences, and that racialised matching would not guarantee a rapport. A Black male peer support worker noted how he preferred peer support from an LGBT charity, explaining that racialised fulfilment was acquired through nourishing connections he had with family, friends and another culturally-specific community organisation. In another peer dyad among two Black females, the religious beliefs of the PSW were imposed onto the SP regarding her sexual orientation, which had an overwhelmingly negative impact bringing an end to that relationship, and reducing their willingness to engage in future peer support. Participants shared how well-meaning efforts to create a bond through racialised matching could have a paradoxical effect in creating and perpetuating a degree of segregation: They could be purple for all I care. They have to that vibe…I think if that [racialised matching] was an option it’s going create the [racial] divide even more. (S1, Black other, Male, SP) And: If it works, it works. I’ve got a client in where I’m working and we’ve referred him to a counselling service, he’s a person of colour, and he asked for a black counsellor. If it works, if that is what some people want, fair enough. I’d ask why because I don’t think we need to get into that whole. That’s not what peer supports about…I do think that perpetuates a thing, black people with black people, that’s segregation, I do not believe in that. I believe that we’re all human and, you know, get over it, essentially that’s my pool of thought. (S3, Black British Caribbean female, SP) Across participants’ accounts there was a consensus that a person’s preferences, wherever possible, should be respected. While there was some caution about matching, several participants described racialised identity bringing advantages. One participant felt his racialised identity alongside interpersonal skills fostered engagement. I would say my identity is a massive advantage, I’m a brown person, which means I can appeal to a lot of brown and black people….There is a value, I’ve noticed that, there is definitely. I am working currently with a 27 year old Pakistani lad, and he hasn’t engaged with anyone on the ward. I walk in and he sees another Pakistani. He’s walking around with me playing table tennis and all the other staff are like, ’why is he opening up to you?’ …I think their assumption is it’s because I’m a Pakistani man, but at the same time, I just ask questions persistently. I just ask him questions until he tells me, gives me a chance. And I’m not sure they understand, it’s like the level of attention I’m giving him for the hour . (S2, Asian British male, PSW) Participants who shared a preference for racialised matching had varying reasons. One Black British female PSW explained how sharing a similar racialised identity created an immediate bond in a predominantly White space during her recovery. A Black British Caribbean male, supported peer, detailed his firm expectation that a Black PSW would resonate with his multiple experiences of racism and social and cultural positions of belonging to a Black family, including the nuances of upbringing in UK. This was to the extent that the racially minoritised identity of his PSW was a central factor in his decision to take up peer support. Either African-Caribbean or mixed parentage….Because they would be able to relate to me properly and get what I needed to get done. Not a Caucasian person, they don’t understand and I don’t think they’ll ever understand. (S1, Black British Caribbean male, SP) Similar sentiments were echoed by a PSW. [T]here are some people that I’ve worked with where I thought well, this could not be done by anybody else but black man, another black man you know, there are times where that is definitely helpful . (S1, Black British African, PSW) Occasions, albeit rare, were also shared when an SP would only speak to someone if they were not White, due to racialised trauma. Preferences were expressed by an Asian female SP who experienced an enhanced relationship with an Indian PSW as result of common ethnic heritage, shared cultural beliefs about mental ill-health, alongside other common recreational interests (e.g. Indian TV, movies). Similar sentiments were recognised as significant by a North African Muslim female peer support worker relating to religion and cultural matters including women’s societal roles. The nuances involved in understanding the merits of racialised matching were further elaborated, giving insight into the specific context, which arguably becomes a precipitating factor in appeals for support of this nature. One Black PSW pointed towards a wider consideration about what racialised connections might offer racially minoritised bodies given their experience in UK society more broadly, and mental health services in particular. I feel like most people that are brown or black gravitate towards me because they’re looking at me like, ‘What are you doing here?’ And then as soon as I am able, without trying to take the light away from what they’re going through to say, ‘I’ve been admitted before, I’ve been sectioned before, the eyebrows are raised’. My demeanour and my willingness to want to help anybody and everybody that’s involved in being admitted to a psychiatric ward, I think it transcends colour. …. [However] I don’t know because we’re kind of like pushed to one side and made to feel inhuman. So sometimes it helps to see someone that looks like you. So it makes it feel like it’s less inhuman that it’s happening to you because we’re already made to feel inhuman as black people anyway. (S3, Black British other female, PSW) 4.2 Cultural awareness and peer support Cultural awareness was a point of enquiry in the research to gauge its importance to practice. All but one participant reflected how they thought cultural awareness had been or could be relevant within peer support. In most instances, having some level of cultural awareness was considered valuable, without pre-judging the beliefs, values or experiences of a supported peer. As one participant shared: An awareness — without reverting to stereotype— of where they’re coming from and where they stand as a person culturally in terms of their identity is always going to help you: Why is it that they can’t go to no one else? Why do they feel that you approaching them is making them feel this way? why is it when if I come they immediately shut down? So is it because of me or is it because of culture? Is it because of identity? (S3, Black British Caribbean female, SP) Various examples were shared about how valuable it was for PSWs to have an understanding about the way faith influenced the decision-making of SPs. In one example, a supported peer decided to discontinue the peer relationship as they preferred to spend more time with the Jehovah Witness community. Additionally, a supported peer expressed the benefits of a PSW being empathetic to culturally situated experiences. My mum’s Indian and she does not tolerate that I’ve got mental health problems, she doesn’t understand it and she thinks it’s for lower caste people,. She’s like, ’Oh, you’ve got a psychiatric problem’, kind of thing. So I think that’s partly cultural that she’s blasé about that, and my PSW, she’s Indian and that’s really helpful to me because I feel like I can share with her and she understands. (S2, Multiple ethnic background, female, SP) Awareness of specific cultural experiences were communicated as being helpful to the peer support role, including different interpretations of mental health and illness, racialised stigma, present and historical experiences of racism (including systemic and vicarious racism), and racialised experiences within the mental health system. One participant elucidated the value of understanding the ongoing pain of societal racism, how this reduces trust and whether people chose to engage in peer support. [B]eing aware how weathered they are by the system and how much trauma they’ve got in their bodies as a result of their experiences probably has a big part to play in how much they trust that they’re going to receive help or how much they trust in institutions generally. (S2, White British female, Occupational Therapist) Understanding that different racialised populations are at increased risk of being exposed to potentially traumatising experiences, such as ruqyah, experiences of war, was also thought to be beneficial. Similarly, insights into cultural differences were thought to be helpful to know why there are different informal rules of engagement. In one such example, a PSW described one of the biggest barriers in their role supporting Somali people to access care was overcoming shame: I think it’s about confidentiality, there’s often mistrust, I think that has been the biggest barrier, people thinking, ‘I’m having suicidal thoughts or depression I’ll get my children taken away…I’ll get all these interventions that can really make my life difficult. (S4, Black British African female, PSW) It was also felt necessary to be aware of cultural beliefs which may cut across race and ethnicity. One PSW alluded to the need for peer workers to accept there will be bias held towards them. This was not only in relation to race, but also how supported peers may prefer professional and technical input, thus seeing the PSW role as peripheral to their care and treatment. I'm a Black man, you can see from my diversity form, Black African. This person was also from a BAME background but a different kind of BAME community…He was well educated…had an undergraduate degree, did a professional job before becoming unwell. I just felt he saw somebody from a Black African background doing a relatively low paid job, low skilled job, you could see kind of the judgments quite present in the kind of interactions, judgments of prejudices or biases about Black people, and obviously the thing in the technical sense, status in terms of the occupation as well. (S1, Black British African male, PSW). While participants did not directly refer to cultural awareness being as much about understanding other people’s backgrounds as much as it was about reflecting on their own sense of self and any sense of power, this dynamic was implicitly present. For instance, a Black male, acknowledged the importance of being abreast of different forms of oppression in his role. There’s a white woman, you know middle-aged white woman, her anger was about actually her position in the family, and being, feeling she was powerless and voiceless as a woman. You know in that family. So you know you have to kind of understand, you know, how she might feel as a woman in that family. (S3, Black and White British male, PSW) At the same time, a lack of current cultural awareness should also not be viewed as a barrier to effective relationships being established. In one account, a supported peer shared how the PSW had no cultural awareness around his experience of racism, yet this was not experienced as problematic as the PSW demonstrated compassion. I saw my parents being treated differently by people of their races negatively and positively and how that affected me. She listened with sympathy and acknowledged, but couldn't really contribute much to that part of the conversation. But I thought that I was listened to and that she was compassionate in her listening. I was happy with that. But I could tell that there wasn't much that she could contribute towards me disclosing that. So I made the presumption that she was white. And then when I met her, my judgment was correct. So I'm not saying… that every white person wouldn't be able to contribute to that conversation. I think having spoken to a Black person or another mixed race person, they would have been able to contribute more to that part of the conversation. So it's not that I felt neglected because I felt that I was being heard, but I could just tell that she didn't really know what to say other than, listen, with sympathy. (S2, Multiple ethnic Black and White British male, SP) 4.3 Cultural responsiveness and peer support Culturally affirming acts were evident in different ways, from interpersonal approaches and adapting practice to attend to cultural nuances. Important questions were raised about the extent to which PSW’s cultural knowledge or belief systems are brought into the peer relationship. One professional felt religion and spirituality, for instance, are not always neutral grounds and felt it was an unresolved dilemma about whether and how PSWs broach such matters. There was no agreement on this point as a PSW described how they used their ongoing judgement, listening skills while offering the space to be guided by the supported peer to decide whether to bring culturally distinct issues into the discussion. This was addressed by PSWs in relation to faith: It's about connecting spiritually. A lot of the women are Muslims and they feel disconnected from their faith, reassuring them they’re not a bad Muslim or bad person for not praying, validating their experiences. The evil eye … for us it’s just so real. It’s really embedded in our faith. I don’t shy away from it. So it’s just about having that space, for me to feel that they’re heard, and that I can bring my experiences because I really feel like I’ve had experiences of that . (S4, Black British African female, PSW) And It was to do with her religion, and we incorporated that in terms of her goals of things to do to try to improve her mood. And I think those things are important because you don’t want to skip over what’s really important culturally or to do with their religion or race. They wanted to spend a bit more time focusing on their religious texts and getting more in tune with their religious side just because of some things that were going on for them at the moment. (S3, Black British Caribbean female, PSW) Another PSW explained how they adopted an approach involving slow progression when engaging with South Asian people on the ward after initially observing they were more reluctant to participate in ward activities. In a similar way, a supported peer expressed how he found it affirming that the PSW used his time to research issues relating to racism and would bring this into their discussions so they could engage in dialogue and shared learning. The SP also detailed how the PSW needs to be perceptive and responsive to sources of anger which can be rooted in oppression. They have to be able to deal with it right, {they} can’t understand your sources of anger and when you’re triggered they don’t want to be there to support you, they have to be able to understand and advise at least a little coping mechanism towards that, you can’t just listen to you and then put down the phone and fuck off. That doesn’t make no sense, that’s not going to help is it. (S1, Black British male, SP). Experiences were shared of PSW de-escalating racial tensions in an inpatient setting, increasing cross cultural understanding in the process by fostering an understanding about why people may make derogatory comments or have prejudiced attitudes while reinforcing an environment of zero tolerance. One PSW demonstrated traits of cultural responsiveness when challenging unhelpful biases among other staff, by drawing on their lived experience: I’m talking to staff, you always hear this, ‘he’s still living at home, he’s 28, he’s got recurring depression, anxiety, psychosis. So he’s 34, he’s living at home…we need to support him to become more independent’. Sometimes I think that people forget, people from an Asian background, we like living with our family, it’s actually almost a mark of pride for our parents to say, (S2, Asian British male, PSW). How PSW operated in culturally responsive ways could also be observed in actions to connect SP people with appropriate services. So there was one individual who was Eritrean, couldn’t speak much English. He was stuck in the hospital recently. He was being aggressive. He was just like ’get lost’. And all I did for him just [to] get through to him a little bit and just got in touch with an Eritrean community group which no one else on the ward had thought of doing. I just thought, hang on, one of my goals is creating social inclusion. So I found out this organization, organized a phone call, hooked him together. That is still peer support. (S4, White British male, PSW) Comparable actions, illustrating humility, were shared when a young Somali lady, dealing with emotions around genital mutilation, was connected with a community group, as the PSW understood limitations of what could be offered by their own service. Another example involved an Irish individual who needed assistance obtaining ID papers for child support for his son. 4.4 Organisational cultural competence Organisational cultural competence was a theme to emerge from the data, drawing on various functions of PSW services aimed at improving access, experience or outcomes for racially minoritised people. This included established conventions, such as celebrating Black History, an activity supported peers who had newly arrived to the UK found helpful for cross-cultural interaction and learning, to topics about workforce diversity and targeted provision. 4.4.1 Racialised matching and reflections on implementation While racialised matching has already been discussed, the considerations in how this can occur requires decisions at an organisational level, bringing implications for changes to policies and procedures. One consideration, expressed by several participants, related to the initial process of assessing the needs and wishes of supported peers. [Racialised matching] should be part of assessment process, I would think that would need a more in-depth discussion and not just say, ’do you want a black mentor or black youth?’ Some people, according what their issues have been, may have nothing to do really with ethnicity, might be just being understood as a person who has major depression, whether the person is black, white, Hispanic, doesn’t matter . (S3, Black British Caribbean female, PSW) Although not strictly racialised matching, a supported peer noted how they found it affirming being asked whether they had any cultural or spiritual needs to be respected or acknowledged as part of the assessment process to receiving peer support. The timing at which racialised matching could occur featured strongly for some participants. One participant felt matching could be temporary, functioning in the early stages of the peer relationship to assist with establishing a bond, suggesting this was something which needed ongoing review. This was a point echoed by other participants who felt racialised peer connections could be more beneficial at the point of Mental Health Act detention, when there’s broader scope for misunderstanding and confusion, a consequence of which could be feelings of increased cultural distance. I think definitely at the admission process, most definitely there needs to be a familiar face where they know each other or not that it needs to be a familiar face, … we want them to feel safe ultimately, we want them to feel safe. We don’t want them to be scared. But if you’re turning up with police officers and you see all these nurses, for me personally, that would make me worse. That would make me absolutely worse. So if we could have an advocate, someone they feel like they can talk to, someone that’s familiar with their culture, someone that’s familiar with how they speak or their language. (S1, Black British other female, PSW) There was also sense that racialised matching could be part of a targeted provision which is used to address an identified inequity experienced by racial or ethnic groups. If you think about older Asian women who are quite excluded sometimes from public spaces and from groups, and often there’s been a kind of somatisation of distress, it’s been harder for them to use some of the therapeutic tools. I do wonder if you had some peer support work champions from within that community, whether that could be quite powerful for that group. [S]imilarly, the other obvious group are young, black men who are very excluded from gentle entries into the mental health system and are much more overrepresented coming through the police system and sections, seclusion, medication. So again, it would be really powerful, I think, to have a powerful group of young, male, black peer support workers as well. (S4, White British male, psychiatrist). 4.4.2 Workforce diversity For other participants the benefits of matching would not necessary be achieved through a targeted service but through a PSW workforce more representative of local ethnic profile. There was a strong feeling by a small number of participants that more needs to be done to improve progression of racially minoritised people across the peer workforce, and more specifically to increase peer workforce ethnic diversity. The benefits of the latter were documented (4b & 4c). If we look at the statistics, most of the time it’s black and brown people that will find themselves in psychiatric wards. Whether or not the reasons behind it are just or unjust is another story and a very thick one. But what we really need is more representation in terms of support. If I think back to my time when I was in a psychiatric ward, if there was someone that looked like me, I may have chosen to be unmute. (S3, Black British other female, PSW) 4.4.3 Monitoring for equitable access, outcomes and experiences One area where there was agreement on the need for improvement was in monitoring for equity in relation to access, outcomes and experience. One PSW acknowledged how during the course of the interview it dawned on him that all the potential supported peers who had declined support were Black men. So we have a couple of young lads, both black British also declined support as well….That’s quite depressing isn’t it, black British men. I can only think of four. I would say if I had recorded all of this it would be Black British men. (S2, Asian British male, PSW) Another PSW reflected on the way fewer Black supported peers had requested additional support in contrast to other ethnic groups, which was attributed to privilege. He summarised: People may not feel privileged or to ask and expect and demand that their needs are met, you know, and that might be based on their previous experiences or not having a lifetime of not having their needs met, you know . (S1, Black British African male, PSW). While there are differing perspectives in relation to the privilege people might experience, or be deprived of, participants described how peer support systems are presently not attuned to identifying differential experiences or inequities within service uptake. 4.4.5 Training, support, coaching, and reflective spaces Concerns were raised about the amount of training and support provided to PSW more generally and for racially minoritised PSW in particular. Some participants put forward the need for reflective spaces to encourage PSWs to think about their own biases, stressing that the PSW workforce are as prone to making assumptions about other supported peers, despite the empathy they bring to the peer support relationship. I don't think peer support workers just because they're peer support workers have got a greater understanding, because it's the same assumptions and prejudices… Peer support workers are just as prone to making assumptions as other people just because we foreground our own lived experience and what our idea of empathy is that we're not like special beings that can cross all like realms of experience. (S2, Asian British male, PSW) At the same time, some participants expressed a need for contextualised support which accounts for the triggering environment in mental health institutions where experiences of vicarious racism were thought to be ever-present. Connected to this was the additional burden sometimes placed on racially PSW bodies who received referrals to work with racially minoritised supported peers because of their shared identity when this may not have been what the person needed. 4.4.6 Organisational flexibility and specialist community provision Having organisational flexibility and a commitment to equity was also thought to be progressive for peer support services. This included flexibility to adapt services to the needs of the community, and to work closely with the BVS and other specialist services. A PSW shared an example of culturally adapted practice and targeted provision involving partnerships with community services. We worked with a Somali charity…. we do groups in there as well with women and service uses, often they come from, in that sense they’ve already built up that trust. We used the five ways of wellbeing that NHS England uses and we connected that to the five pillars of Islam. And I think having that connection of faith and of wellbeing, and trying to show how they interlink, I think it was really, it was really helpful for everyone involved, myself included. (S4, White British male, PSW) Specialist services provided by the BVS were thought to be trusted by racialised groups and should be offered as an alternative to NHS provision. A further example was shared of a gender specific community organisation providing an in-reach peer support service on inpatient wards: Here peer support is so important to me and I believe is to the other girls as well because, as I say, the charity have different people and different background people, somebody Korean, somebody White British and everything, so they understand our different culture as well…I think the charity do understand what I need, they do understand how to treat the person with a different religion. (S1, Other Asian background, female, SP) Discussion Peerness, and perceptions about how it could or should be shaped, was often the topic that initially surfaced for participants. Data indicated peerness was about connection, validation and disclosure, each of which are apparent in peer support more generally. However, data points to the need for a separate space of analysis giving consideration to how these concepts have a racialised layer to their understanding. Opinions stretched from suggestions peer support should not be pre-occupied with discussions about racism, nor racialised matching, to thoughts about the practical challenges of implementation, and those who thought in some circumstances racialised matching was essential. Such myriad positions in many ways reflects the diversity PS must embrace. The context within which peer support is provided, both a mental health system and society which are respectively institutionally and structurally racist, must be a consideration in people’s expectations from peer support. A deeper understanding around this is required as it is not possible to conclude that recommendations for racialised matching within peer support were due to an expectation that the cultural needs of supported peers would not be met by the peer support service. Indeed, sometimes this appeared to be borne out of frustration given the frequency at which racially minoritised people are the recipients of unequal and undignified treatment within mental healthcare and society. This must be connected to a separate debate about whether peer support is unintentionally put in a position where it is expected to address institutional racism in mental health services; something which will not be achieved by increasing PSW workforce diversity. Racism’s ongoing presence, connected to racially minoritised people feeling dehumanised, are the intractable conditions providing impetus for racialised connection. It is in large part this context which racialised peerness had value. It influenced engagement, in a small number of cases it was presented as predominate factor, in others more preference, whereas others it was not presented as consideration. There was an expectation it would bring not only cross-cultural understanding but also validation. While there was ambiguity about the extent of racialised matching which could take place, the matter of a supported peer’s preference being respected was encapsulated within a framework of addressing racial inequity by improving service experience. Emerging themes covered elements of cultural humility and awareness, chiming with ideas that the former is required during the process of becoming culturally aware and knowledgeable (47). There was a strong sense that alongside being open to learning, PSWs should be supported to have awareness beyond their own culture, in light of the perceived benefits this could bring to peer support relationships. One element of cultural awareness is the racial weathering racialised bodies encounter. Similar to more common understandings of racial weathering (48), it is based on the idea encountering the frustration of societal disadvantage and discrimination, racialised bodies have reduced trust in peer support. Such cultural differences among specific ethnic populations were thought to influence whether someone takes part in peer support. There was an appreciation that is part of understanding informal rules of engagement in the way belief systems inform what people are likely to accept, fear or reject. While this was the situation, and cultural awareness was considered helpful, emphasis was placed on the need to stay open to learning without making assumptions about a person’s belief system. In this way, PSWs need to strike a balance between developing awareness and knowledge, and remaining self-reflective about personal power and other forms of oppression, with an ongoing openness to cultural interaction. Here parallels can be drawn between cultural responsiveness, the willingness to learn, and values underpinning peer support. For peer support this is characterised by a two-way process of learning, and it may provide an understanding about why it has been shown to function across difference. In very much the same way, Clauss-Ehlers and Garagiola (49) describe similar ideals under the banner of cultural humility in relation to health care professionals, and similarities can be drawn to peer support. They argue for a longstanding commitment to learning from cross-cultural interactions, and in doing so remaining perceptive to power differentials to build relationships. Aligned with notions offered by Stubbe (50) in relation to cultural responsiveness, this theme drew on ideas about providing peer support that was respectful, responding to a supported peer’s preferences, needs or values. Offering a flexible and supportive framework for faith and belief to be part of peer support relationship figured strongly. Addressing racism, challenging hegemonic interpretations of independence, and taking steps to enhance SPs social interaction by creating culturally appreciative connections with community organisations, were various acts shared, illustrating how cultural differences were acknowledged during encounters, appraising power dynamics, underpinning the construct of being culturally responsive (51). Cultural competence addressed some of the organisational considerations which have relevance to supporting racially minoritised people (52). Emerging themes drew on organisational functions including recruitment, partnership arrangements, monitoring for equitable outcomes and workforce development. There was limited evidence of peer support services implementing procedures or encouraging PSWs to actively consider cultural needs at the outset of peer support engagement. Where this did happen it was viewed positively. Similarly, perhaps due to the sample participants, no data was gathered which demonstrated efforts to increase workforce diversity. In a similar way, the generally inconsistent approach to monitoring for equitable outcomes in terms of access limited a circular process of learning whereby underrepresentation of racially minoritised people accessing PSW can be identified, understood and addressed. Therefore, while PSWs can demonstrate cultural awareness and be culturally responsive, whether working across difference or otherwise, each of which assists an organisation to be culturally competent, all PSWs should be fully supported to fulfil their role regarding addressing inequities in access. Evidence was documented, albeit limited, around peer services being targeted towards an identified racial inequity. One initiative appeared to have been successful in engaging under-represented populations in psychological services, and working collaboratively with culturally-specific voluntary sector organisations. On the one hand, understanding the successes of such initiatives could tie into a broader need across peer support to improve monitoring for equity, across experience and outcomes. At the same time, evidence from partnership working, alongside data from participants working or receiving support from BVS or other specialist services were viewed positively. The evidence collected indicates that this has potential to increase engagement as it overcomes any feelings of mistrust supported peers may have with statutory provision. More needs to be known about the experience offered by the BVS or other culturally adapted PS services. It is important to understand more specifically whether the degree of informality attributed to the BVS, approaches and differences in practices, sanctioned by organisational habitude, translate to differential service experiences. Peer support services can be consciously and unconsciously shaped by the norms and priorities of the predominate culture. This can mean that peer support services within statutory settings can be as prone as other health and social care agencies to unreflexively reproduce dominant social values within a service model which can have implications for the prioritisation of race equity. This is an area warranting further enquiry. Strengths and limitations We used a standardised, theoretically informed approach to data collection and analysis. A complete data set was analysed from across four geographic sites, interviews with SP, PSW and professionals. Very few studies explicitly explore race, culture and peer support, with high levels of lived experience involvement. Coproduction was central in generating interview schedules, developing coding and analysis. The study could have benefited from lived experience during data collection. The data sample itself was diverse and benefited from a range of perspectives. A greater timeframe for recruitment and geographic spread may have enabled further data to be obtained from BVS organisations or organisations and initiatives providing targeted support to racially minoritised people. Implications of Police Practice and Research Mental health workforce policy in England has placed emphasis on the expansion of the peer support workers. Study findings indicate that peer workers require appropriate resourcing to help ensure race equity can be central to service delivery. Support for racialised workforce to attend to vicarious racism should be provided, alongside opportunities for ongoing learning and coaching around culture and mental health. Improvements in how to monitor and to appropriately respond to inequities across access, experience and outcomes should also be a priority. Conclusion This study had a broad remit to explore the main issues in relation to peer support for racially minoritised people, and within this, to understand how race, culture and ethnicity are relevant to the delivery of peer support services. A range of insights were gathered from the study about the preferences of racially minoritised people in relation to peer support. Consistent throughout the findings was the way matters of racialisation had implications about whether people engage in peer support. While the topic of racialised matching remains an unresolved dilemma, at times peer support worker’s racialised identities influenced whether supported peers engaged in peer support, and the way services were designed also influenced service access. Themes looking at cultural awareness and responsiveness highlighted the dynamic inter-relation between peer support and race, ethnic and culture differences, and the way peer support in the UK has developed. It also illustrates the high levels of cultural appropriateness with which peer support workers operate, in many ways going beyond expectations of their role. Improvements are nevertheless possible, and organisational efforts to support the workforce and to appraise provision are areas which were found to be undeveloped. Abbreviations BVS Black Voluntary Sector CC Cultural competence NHS National Health Service PSW Peer support worker SP supported peer Declarations The study was approved and conducted to the standard of the UK National Research Ethics Service, which built on, and aligned with the norms of Declaration of Helsinki statement of ethical principles in research. Full ethical approval was granted to City, University of London by Health Research Authority and Health and Care Research Wales (HCRW), to carry out the study. IRAS project ID: 307943. A participant information sheet was made available to all participants, and their consent was recorded prior to data collection, consenting to their interview being recorded, transcribed, analysed and published (in a de-identified format). Consent for publication Not applicable Data availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding Funding was received from the National Institute for Health Research (NIHR). Award ID: NIHR202616 Authors’ contributions AS contributed to the conceptualisation, data curation, formal analysis, methodology, project administration, validation, writing original draft, writing review and editing. RF contributed to the conceptualisation, data curation, formal analysis, methodology, project administration, validation, writing review and editing. SG contributed to the conceptualisation, formal analysis, methodology, supervision, validation writing review and editing. CC, DL and JM contributed to the conceptualisation, formal analysis, methodology, validation writing review and editing. Acknowledgments Not applicable References Kapadia D, Zhang J, Salway S, Nazroo J, Booth A, Villarroel-Williams N. Ethnic Inequalities in Healthcare: A Rapid Evidence Review. NHS 2022. Barnett P, Mackay E, Matthews H, Gate R, Greenwood H, Ariyo K, et al. Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data. Lancet Psychiatry. 2019;6(4):305–31710.1016/S2215-0366(19)30027-6. Bansal N, Karlsen S, Sashidharan SP, Cohen R, Chew-Graham CA, Malpass A. Understanding ethnic inequalities in mental healthcare in the UK: A meta-ethnography. PLoS Med 2022;19(12):1310.1371/journal.pmed.1004139. Solomon P. Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatr Rehabil J 2004 January 01;27(4):392–40110.2975/27.2004.392.401. NHS. The NHS Long Term Plan. 2019. Fortuna KL, Solomon P, Rivera J. An Update of Peer Support/Peer Provided Services Underlying Processes, Benefits, and Critical Ingredients. Psychiatr Q 2022 June 01;93(2):571–58610.1007/s11126-022-09971-w. Valenstein M, Pfeiffer PN, Brandfon S, Walters H, Ganoczy D, Kim HM, et al. Augmenting Ongoing Depression Care With a Mutual Peer Support Intervention Versus Self-Help Materials Alone: A Randomized Trial. Psychiatr Serv 2016 February 01;67(2):236–23910.1176/appi.ps.201400454. Kalathil J. Dancing to our own tunes: reassessing black and minority ethnic mental health service user involvement. 2013. King AJ, Simmons MB. A Systematic Review of the Attributes and Outcomes of Peer Work and Guidelines for Reporting Studies of Peer Interventions. Psychiatr Serv 2018 September 01;69(9):961–97710.1176/appi.ps.201700564. Nicholson J, Valentine A. Defining "peerness": Developing peer supports for parents with mental illnesses. . . Psychiatr Rehabil J 2018;41(2):157–15910.1037/prj0000301. Corrigan PW. Understanding Peerness in Recovery-Oriented Mental Health Care. Psychiatr Serv 2024 June 01;75(6):597–59910.1176/appi.ps.20230392. Ahmed S editor. Racialized Bodies. Palgrave, London: Palgrave; 2002. McKinnon SA, Conner KO, Roker R, Ward CJ, Brown C. The Reduction of Public and Internalized Stigma in Late-Life Depression: A Pilot Study. J Appl Gerontol 2019 March 01;38(3):424–43310.1177/0733464816687079. Healey P, Stager ML, Woodmass K. Cultural adaptations to augment health and mental health services: a systematic review. BMC Health Serv Res 2017;17(8)10.1186/s12913-016-1953-x. Cabral J, Smith T. Racial/ethnic matching of clients and therapists in mental health services: a meta-analytic review of preferences, perceptions, and outcomes. J Couns Psychol. 2011;58(4):537–5410.1037/a0025266. Olaniyan F, Hayes G. Just ethnic matching? Racial and ethnic minority students and culturally appropriate mental health provision at British universities. International Journal of Qualitative Studies on Health and Well-being 2022;17(1):211744410.1080/17482631.2022.2117444. Chu W, Chorpita BF, Becker KD. Race, racial matching, and cultural understanding as predictors of treatment engagement in youth mental health services. Psychotherapy Research 2023;33(5):669–68210.1080/10503307.2022.2150582. Stockwell DW, Roche M, Billings J. Evaluating interventions that have improved access to community mental health care for Black men: A systematic review. Journal of Mental Health 2024:1–1210.1080/09638237.2024.2390381. Faulkner A, Kalathil J. The Freedom to be, the Chance to Dream: Preserving user-led peer support in mental health. . 2012. Tondora J, O'Connell M, Miller R, Dinzeo T, Bellamy C, Andres-Hyman R, et al. A clinical trial of peer-based culturally responsive person-centered care for psychosis for African Americans and Latinos. Clin Trials 2010 August 01;7(4):368–37910.1177/1740774510369847. Siantz E, Henwood B, Gilmer T. Implementation of peer providers in integrated mental health and primary care settings. Journal of the Society for Social Work and Research 2016;7:231–24610.1086/686644. Byrne L, Roennfeldt H, Wolf J, Linfoot A, Foglesong D, Davidson L, et al. Effective Peer Employment Within Multidisciplinary Organizations: Model for Best Practice. Adm Policy Ment Health 2022 March 01;49(2):283–29710.1007/s10488-021-01162-2. Pfeiffer PN, Valenstein M, Ganoczy D, Henry J, Dobscha SK, Piette JD. Pilot study of enhanced social support with automated telephone monitoring after psychiatric hospitalization for depression. Soc Psychiatry Psychiatr Epidemiol 2017 February 01;52(2):183–19110.1007/s00127-016-1288-2. Gillard S, Edwards C, Gibson S, Holley J, Owen K. New ways of working in mental health services: a qualitative, comparative case study assessing and informing the emergence of new peer worker roles in mental health services in England. . NIHR Journals Library 2014. Gray P. Voluntary organisations’ perspective on mental health needs. In: Bhugra DB, V, editor. Ethnicity: an agenda for mental health. London: Gaskell.; 1999. p. 202–210. Fernando S. Multicultural mental health services: projects for ethnic minority communities in England. Transcultural Psychiatry. 2005;42(3):420–36. Keating F. Theorising race, ethnicity and mental health. In: Graig, G., Atkin, K., Chattoo, S. and Flynn, R, editor. Understanding race and ethnicity: theory, history policy, practice. 2012: Bristol: Policy Press; 2012. p. 209–226. Newbigging, K., McKeown, M. and French, B. Mental health advocacy and African and Caribbean men: good practice principles and organizational models for delivery. Health Expectations 2013;16:80–104rg/10.1111/j.1369-7625.2011.00692.x. Jonikas JA, Kiosk S, Grey DD, Hamilton MM, McNulty J, Cook JA. Cultural competency in peer-run programs: results of a web survey and implications for future practice. Psychiatr Rehabil J. 2010;34(2):121–910.2975/34.2.2010.121.129. Chinman M, McCarthy S, Mitchell-Miland C, Bachrach RL, Schutt RK, Ellison M. Predicting Engagement With Mental Health Peer Specialist Services. Psychiatr Serv 2019 April 01;70(4):333–33610.1176/appi.ps.201800368. Stergiopoulos V, Gozdzik A, Nisenbaum R, Durbin J, Hwang SW, O'Campo P, et al. Bridging Hospital and Community Care for Homeless Adults with Mental Health Needs: Outcomes of a Brief Interdisciplinary Intervention. Can J Psychiatry 2018 November 01;63(11):774–78410.1177/0706743718772539. O'Connell MJ, Sledge WH, Staeheli M, Sells D, Costa M, Wieland M, et al. Outcomes of a Peer Mentor Intervention for Persons With Recurrent Psychiatric Hospitalization. Psychiatric Services 2018;69(7):760–767. Smith AM, Stewart K, Baul T, Valentine SE. Peer delivery of a brief cognitive-behavioral treatment for posttraumatic stress disorder: A hybrid effectiveness-implementation pilot study. Journal of Clinical Psychology, ;76(12):2133–2154. Holley LC, Oh H, Thomas D. Mental illness discrimination and support experienced by people who are of color and/or LGB: Considering intersecting identities. Am J Orthopsychiatry 2019;89(1):16–2610.1037/ort0000360. Le PD, Agrest M, Mascayano F, Dev S, Kankan T, Dishy G, et al. Understanding Users' Perspectives of Psychosocial Mechanisms Underpinning Peer Support Work in Chile. Community Ment Health J 2022 January 01;58(1):111–12010.1007/s10597-021-00800-1. Chinman M, McCarthy S, Bachrach RL, Mitchell-Miland C, Schutt RK, Ellison M. Investigating the Degree of Reliable Change Among Persons Assigned to Receive Mental Health Peer Specialist Services. Psychiatr Serv 2018 December 01;69(12):1238–124410.1176/appi.ps.201800118. Conner KO, Gum AM, Schonfeld L, Kosyluk K, Anderson E, Baker-Douglan J, et al. Enhancing care transitions intervention with peer support to improve outcomes among older adults with co-occurring clinical depression: a pilot study. Home Health Care Serv Q 2021 December 01;40(4):324–33910.1080/01621424.2021.1967249. Corrigan PW, Kraus DJ, Pickett SA, Schmidt A, Stellon E, Hantke E, et al. Using Peer Navigators to Address the Integrated Health Care Needs of Homeless African Americans With Serious Mental Illness. Psychiatr Serv 2017 March 01;68(3):264–27010.1176/appi.ps.201600134. Gillard S, Bremner S, Patel A, Goldsmith L, Marks J, Foster R, et al. Peer support for discharge from inpatient mental health care versus care as usual in England (ENRICH): a parallel, two-group, individually randomised controlled trial. The Lancet Psychiatry 2022;9(2):125–136. White S, Bhattacharya R, Bremner S, Faulkner A, Foster R, Gibson S, et al. Predictors of engagement with peer support: analysis of data from a randomised controlled trial of one-to-one peer support for discharge from inpatient psychiatric care. Int J Soc Psychiatry. 2023;69(4):996–100310.1177/00207640221148090. Curtis E, Jones R, Tipene-Leach D. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health 2019;18(174)10.1186/s12939-019-1082-3. Garneau AB, Pepin J. Cultural competence: a constructivist definition. J Transcult Nurs 2015;26(1):9–15. Danso R. Cultural competence and cultural humility: A critical reflection on key cultural diversity concepts. J Soc Work 2018;18:410–3010.1177/1468017316654341. Alizadeh S CM. Cultural competence dimensions and outcomes: a systematic review of the literature.. Health & Social Care in the Community 2016;24(6):117–30. Sadusky A, Yared H, Patrick P, Berger E. A systematic review of client’s perspectives on the cultural and racial awareness and responsiveness of mental health practitioners. Culture & Psychology 2024;30(3):567–60510.1177/1354067X231156600. Truong M, Paradies Y, Priest N. Interventions to improve cultural competency healthcare: a systematic review of reviews. BMC Health Serv Res 2014;14(99). Campinha-Bacote J. Cultural Competemility: A Paradigm Shift in the Cultural Competence versus Cultural Humility Debate . Journal of Issues in Nursing 2019;24(1). Forde AT, Crookes DM, Suglia SF, Demmer RT. The weathering hypothesis as an explanation for racial disparities in health: a systematic review. Ann Epidemiol. 2019;33:1–1810.1016/j.annepidem.2019.02.011. Clauss-Ehlers CS, Garagiola ER. Cultural competence and cultural humility as foundations for meaningful engagement among an educational system of care for school stakeholders. In: S. W. Evans, J. S. Owens, C. P. Bradshaw, & M. D. Weist (Eds.), editor. Handbook of school mental health: Innovations in science and practice. Switzerland: Springer Nature; 2023. p. 265–282. Stubbe DE. Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients. Focus. Am Psychiatr Publ 2020;18(1)10.1176/appi.focus.20190041. Gill GK, Babacan H. Developing a cultural responsiveness framework in healthcare systems: An Australian example. . Diversity and Equality in Health and Care 2012;9:45–55. Danso R. Cultural competence and cultural humility: A critical reflection on key cultural diversity concepts. Journal of Social Work 2016;18(4):410–43010.1177/1468017316654341. Additional Declarations No competing interests reported. Supplementary Files InterviewscheduleSPA.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 31 Jan, 2026 Reviewers agreed at journal 19 Jan, 2026 Reviewers invited by journal 14 Jan, 2026 Editor invited by journal 22 Dec, 2025 Editor assigned by journal 19 Dec, 2025 Submission checks completed at journal 19 Dec, 2025 First submitted to journal 11 Dec, 2025 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-8337940","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":574851470,"identity":"0f0c9ae1-2929-4674-84d0-8358fd5be306","order_by":0,"name":"Anthony Salla","email":"data:image/png;base64,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","orcid":"","institution":"City St George's, University of London","correspondingAuthor":true,"prefix":"","firstName":"Anthony","middleName":"","lastName":"Salla","suffix":""},{"id":574851471,"identity":"45e3cd43-3405-495d-89f7-e513d6c13a7d","order_by":1,"name":"Rhiannon Foster","email":"","orcid":"","institution":"City St George's, University of London","correspondingAuthor":false,"prefix":"","firstName":"Rhiannon","middleName":"","lastName":"Foster","suffix":""},{"id":574851473,"identity":"00348854-c7b8-4511-bf5f-0fea8e75a640","order_by":2,"name":"Charlotte Crowl","email":"","orcid":"","institution":"Independent Researcher","correspondingAuthor":false,"prefix":"","firstName":"Charlotte","middleName":"","lastName":"Crowl","suffix":""},{"id":574851474,"identity":"1587fbcf-7a6a-49b9-9505-59b83467d07a","order_by":3,"name":"Daniela Lewis","email":"","orcid":"","institution":"Independent Researcher","correspondingAuthor":false,"prefix":"","firstName":"Daniela","middleName":"","lastName":"Lewis","suffix":""},{"id":574851475,"identity":"a84306dd-6ad0-4af7-8e88-86456bdbdafc","order_by":4,"name":"Jim Maskell","email":"","orcid":"","institution":"Independent Researcher","correspondingAuthor":false,"prefix":"","firstName":"Jim","middleName":"","lastName":"Maskell","suffix":""},{"id":574851476,"identity":"0b197c37-a0be-4aa1-991b-a5385398921e","order_by":5,"name":"Steve Gillard","email":"","orcid":"","institution":"City St George's, University of London","correspondingAuthor":false,"prefix":"","firstName":"Steve","middleName":"","lastName":"Gillard","suffix":""}],"badges":[],"createdAt":"2025-12-11 14:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8337940/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8337940/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100547084,"identity":"5294b54d-318e-4c63-9cf9-d7d114e4d76f","added_by":"auto","created_at":"2026-01-19 08:14:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":627124,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8337940/v1/ec42d043-bd2c-4e73-b349-9aab75265920.pdf"},{"id":100439090,"identity":"40f1ca46-a3ad-4275-9ae6-438162eb60da","added_by":"auto","created_at":"2026-01-16 16:09:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":192193,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewscheduleSPA.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8337940/v1/1e8d9a5c759612f372867659.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Qualitative Exploration of mental health peer support provision for racially minoritised people in England","fulltext":[{"header":"Background","content":"\u003cp\u003eResearch has repeatedly rehearsed the unfavourable relationship between racially minoritised people and mental health services (1), alongside evidence of poorer outcomes (2). This relationship has been typified by coercion, retraumatisation, breakdowns in trust, fear, and factors embedded within notions of epistemic injustice, strongly emphasising imbalanced power relations (3). Research has suggested peer support might have potential to bridge across social difference given its capacity to overcome hierarchies (4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOver recent years, there\u0026rsquo;s been a push to increase the availability of peer support across England, as part of a long-term plan for service expansion (5), matched by a proliferation of peer services internationally, now considered an indispensable feature of mental healthcare (6). Peer-support initiatives vary in how they\u0026rsquo;re designed, the mode and frequency of contact, the degree of professional training, and the content and structure expected to inform peer interactions. Differences in outcomes or target population are also observed (7). One area less frequently placed in the spotlight of peer support research is the experience of racially minoritised people. Previous research has focused attention on a differential experience for such groups in relation to user involvement (8). Given this, and against a backdrop of racial inequities across other areas of mental health provision peer support\u0026rsquo;s role in this space warrants ongoing consideration given its implementation across mental health services in England.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRace, culture and \u0026lsquo;peerness\u0026rsquo; in mental health services\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePeerness has been described as the experience of living with mental health problems and using mental health services (9), and active use or disclosure of this within the peer support relationship (10). Nevertheless, questions remain about how peerness is defined, measured and evaluated, alongside thoughts about peer worker qualities and experiences (11).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRacalised bodies, and the extent of ethnic diversity adds another dimension of consideration to the peerness debate. The term, racialised bodies, encourages us to explore the complex imbrication of social processes through which bodies become recognised in racial terms. As Ahmed (12) contends, the concept pushes us to see bodies as a container of experience, whereby racialised identities are reified, and in themselves sites of racialisation. Racialised bodies, known to influence healthcare expectations have been used as anchors to base peerness (13).\u003c/p\u003e\n\u003cp\u003eA sizeable degree of discourse around racialised bodies comes into play with the notion of racialised matching, the idea or intention of finding congruence by connecting people based on some level of shared racial, ethnic or cultural identity (14). Attempts at racialised matching across other areas of healthcare have produced mixed results (15). Indeed, there\u0026rsquo;s ambivalence about the benefits of ethnic matching, providing a narrow conception of a person\u0026rsquo;s holistic need (16). Research in some settings has indicated that the cultural understanding care providers have of patients, and not their racialised identity, was associated with ongoing patient service engagement (17).\u003c/p\u003e\n\u003cp\u003eWhile this is the situation, for peer support, patient perspectives have indicated matching has been beneficial, bringing similarity in experiences (18). \u0026nbsp;In some situations, the experience of being a Black survivor, providing mutual support with other Black survivors of the UK mental health system, has been a cornerstone to fostering a sense of belonging; in some instances of greater importance than the shared oppression of mental distress (19). A US study reported competing perspectives; African American peer group leaders found being watched by White supervisory staff evoked images reminiscent of plantation enslavement, it also reported how for some, being allocated to work in a group defined by racial or ethnic boundaries made them feel uncomfortable (20).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the Latino population in the US, peerness was defined by shared cultural, linguistic or migration experience, instead of the experience of mental ill-health, an approach used to alleviate fears about non-engagement from supported peers due to mental health stigma (21). Flowing from this are implications related to peer support workforce diversity and inclusion. Similarly, in a separate study, peer participants echoed a need for peers from culturally and linguistically diverse backgrounds, also underlining a need for peers of colour to provide authentic, culturally aware connections (22). While research has indicated that shared lived experience of mental health challenges can bring a grounding equilibrium (4), potentially mitigating cultural or racial distance between peer support worker and supported peer, as highlighted, peerness is defined in multiple ways according to contextual considerations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOrganisational habitude\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOf course, matters of racialisation within peer support are not limited to peerness; cultural differences have been identified in peer support (23). Research in England attempted to identify culturally distinctive features around peer worker roles, with a particular emphasis on racially and culturally specific organisations (24). The authors found areas of divergence in culturally specific organisations compared with peer support delivered in inpatient settings regarding whether lived experience was necessary, highlighting also different expectations around personal disclosure of mental health history. Culturally specific organisations also placed greater value on informal roles and flexible delivery approaches. This points to differences in practices, sanctioned by organisational habitude, which can translate to differential service experiences.\u003c/p\u003e\n\u003cp\u003eThe role of organisational culture has been addressed in the literature and voluntary sector provision is central. The voluntary sector has been recognised as a playing a crucial role in supporting groups who often experience discrimination, offering a source of help that is the least stigmatising (25). An area of provision that has been identified as being particularly suited to racially minoritised people is the black voluntary sector (BVS) (also referred to as ethnocentric support (26). Keating (27) has posited that the BVS offers the most relevant support to racialised groups because their work is based on different conceptual ideas about what it means to experience mental ill-health than do state services. Further, he argues that the BVS embraces the whole person when combating mental health problems rather than other models that narrowly define mental ill-health within a psychiatric framework. Further, Fernando (26) said he was struck by the \u0026lsquo;informality of approach by the staff towards clients\u0026rsquo; in the BVS, and also that they brought a greater range of social and political issues of personal significance into provision. Similar sentiments have been noted by Newbigging \u003cem\u003eet al.\u003c/em\u003e (28) who suggested BVS services are grounded in different conceptualisations of advocacy with a sharper understanding of the needs of African and Caribbean men.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRace, culture and access to peer support\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA nationwide US survey found racially minoritised people would not access peer groups due to a feeling they would not be accepted or that their concerns would be misunderstood; people who did access peer support reported feelings of disrespect to their cultural beliefs and values, yet they did not want to raise concerns due to a fear of \u0026lsquo;rocking the boat\u0026rsquo; (29). Research has shown lower levels of peer support engagement among racially minoritised people (30), while one study reported higher dropout rates for people whose first/main language was not English (31). This raises broader questions about equitable access and experience.\u003c/p\u003e\n\u003cp\u003eSteps have been taken by some peer programmes to embrace cultural competence, making it a feature of peer training (32,33) Peer programmes have been known to implement various cultural modifications to assessment tools, use of colloquialisms and modes of expression, activity location (20), targeted support (34), utilising cultural knowledge (21), and the involvement of healthcare professionals (35). Hence, the literature points towards broader considerations about the delivery of peer support for racially minoritised people.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRace, culture and outcomes of peer support\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePeer support\u0026rsquo;s role in relation to equitable outcomes for racially minoritised people can also be considered. Two studies in the US indicated peer support resulted in a higher likelihood of positive change in psychiatric symptoms for non-White peers compared to White (36), and authors of another study concluded peer support transitions can reduce disparities for older participants from racially minoritised backgrounds with clinical depression\u0026nbsp;(37). Improvements for homeless African Americans across physical and mental health measures have also been reported in a peer navigator programme. (38). A UK based trial indicated peer support on discharge was more beneficial in reducing readmission compared to control amongst Black participants than for participants from all other ethnic groups (39). However, this study also showed that, for all participants, ongoing engagement with peer support \u0026ndash; a key predictor of positive effect \u0026ndash; was not associated with being matched with a peer worker of similar ethnicity (40). Hence, peer support can be effective across difference making the case for better idea how people are understanding and experiencing it.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCultural competence in peer support\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMatters discussed thus far, including racialised peerness, culturally affirming support, organisational habitude, can each be understood in relation to efforts to improve access, experience and outcomes for racially minoritised people. This sits under a broader framework of cultural competence (CC). Though earlier definitions of CC have rightly been critiqued for narrowly focusing on end learning points and individual level knowledge and skills, and failing to have sufficient analysis of power (41), more recent attempts to embed these issues makes the case for it to be retained as a useful framework for contextualising race equity initiatives (42,43).\u003c/p\u003e\n\u003cp\u003eCultural awareness, historically viewed as a component of cultural competence, focuses on an individual\u0026rsquo;s basic knowledge about the differences between cultures, including an individual\u0026rsquo;s awareness of their own views and biases (44). On its own, cultural awareness is recognised as being limited in its scope to transform services. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMore recently, the term cultural responsiveness has attracted attention, reflecting a substantial step beyond general awareness, encompassing use of individual\u0026rsquo;s skills and actions, yet importantly including the mindset of practitioners to exhibit sensitivity, self-reflection, and humility (45). It can be seen to entail what Curtis describes as being beyond acquiring knowledge about other cultures to focus on a response embodying cultural safety, an approach focused on recognition of power differentials (41).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCultural competence also acknowledges the significance of organisational functions. Cultural competency is a term used to describe interventions that aim to improve accessibility and effectiveness of health care services for racially marginalised people. This can include service design, organisational polices, training, coaching and supervision structures, and appropriate partnerships (46).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCurrent evidence suggests peer support can offer benefits for people from racialised communities using mental health services, but problems of access remain and it is clear that \u0026lsquo;peerness\u0026rsquo; can mean different things for different groups of people; that race and culture might offer limited points of connection that define racialised experiences of peer support. Research is needed to better make sense of how racially minoritised people understand and experience peer support, in order that the opportunity for peer support to address inequalities of experience and outcome of mental health services is optimised.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGiven the background of racial inequities across mental health service provision, and the limited research looking at peer support in relation to racially minoritised people in the UK, and the significant rollout of peer support in England, this study aimed to build on and test existing research outlined above. We aimed to find out what peer support workers, the people they support (\u0026lsquo;supported peers\u0026rsquo;) and professionals working closely with peer support services thought were the main issues relating to the delivery of peer support for racially minoritised people. Part of the aim was also to understand differential needs of supported peers were in relation to peer support, and whether different delivery models or characteristics of peer support had been successful in responding to diverse populations.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was a qualitative study, using semi-structured interviews with peer support workers and supported peers, and professionals working closely with peer support in National Health Services in England. The study took an exploratory approach across four mental health trusts. Sites were selected based on the peer support initiatives the research team knew were operational. The study was approved by NHS Research Ethics Committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant recruitment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion criteria was: adults age 18+, being able to provide informed consent and English speaking. The sample criteria for supported peers included recruitment based on ethnicity (e.g. self-define as belonging to a racially minoritised group), as well as having experience of being offered or taking part in peer support. Inclusion criteria for peer workers and professionals was based on their experience and knowledge of peer support and with experience of supporting people from racially minoritised groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRecruitment occurred through four mental health trust sites and via contact with third sector organisations who provided peer support to people using mental health services in those areas. Attention was paid to recruiting diverse participants across gender, ethnicity and age. All potential participants were provided with the participant information sheet and were offered an opportunity to speak with the research team if they had any questions about the study. All participants provided informed consent (written or audio recorded) prior to interviews being conducted. A socio-demographic monitoring form was also completed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll interviews followed a topic guide and were conducted by AS (researcher in mental health) and RF (lived experience researcher) either in person, by telephone or remotely using video call. Research around peer support, as cited above, informed the development of the topic guide. The topic guide was also co-produced with members of a lived experience advisory group. Questions explored participants general experience of receiving or providing peer support, the relationship between peer support worker and supported peer, and the experience of culture in mental health services and peer support (see supplementary material).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterview length averaged 67 minutes (range = 55-95minutes). Supported peers, and peer support workers doing interviews outside of working hours, were offered \u0026pound;25 as an appreciation of their time and expertise. Interviews were audio recorded and transcribed verbatim initially using software. Prior to analysis, transcripts were corrected by the research team, and changes made for accuracy and participant anonymity. Data collection continued until the target number of interviews was complete.\u003c/p\u003e\n\u003cp\u003eOne researcher (AS) was of mixed heritage, but not the same racial identity as participants, and the other (RF) White British, both representing an academic institution. As some interviews were with people who had experienced mental health challenges, the researcher was mindful that participants could be apprehensive about discussing race and their experiences of mental health services. To minimise the possibility of participants feeling uncomfortable, measures were taken to build trust through informal discussions prior to interview.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterview transcripts were transferred into Nvivo software for thematic analysis. A hybrid approach was taken to analysis. Initially, a preliminary coding framework was developed from the team\u0026rsquo;s understanding of existing research, including codes related to race, ethnicity, culture, and service design. Preliminary analysis was undertaken by AS and RF using three transcripts. Two researchers (AS, RF) independently and systematically coded three of the transcripts and discussed the codes and emerging themes, along with SG to develop a provisional coding framework. \u0026nbsp;Members of the Lived Experience Advisory Panel (LEAP) and the Project\u0026rsquo;s management committee then reviewed the same transcripts and the provisional coding framework was refined. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA hybrid approach was used for the remaining transcripts, coding them deductively where data demonstrated fit with the framework, and inductively so that new codes could be added as necessary or existing codes modified in response to the data. This was followed by inductive coding whereby new codes were generated from participant accounts and added to the coding framework. Familiarisation was achieved by the first author reading through the entire data set. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe coding framework was applied to the transcripts using line-by-line coding. AS continued coding the data using the revised framework, adding new codes to the framework as more transcripts became available and until no new codes were identified. Codes were then organised into themes corresponding to the research questions and new themes. The research team met weekly to review and discuss codes, themes and developing findings. Members of the LEAP were invited to comment and approve the final report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Description\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e18 participants were involved in the study from across four sites. This included: Seven supported peers, ages: 30-40 (3); 40-50 (3) and 50+ (1); Gender: female (4) male (3); Ethnicity: Black Caribbean (2), Black other (1), Mixed ethnicity Black and White (1), Asian Pakistani (1), Asian other (1) and other mixed ethnic group (1). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNine peer workers, ages: 29-20(1); 30-40 (3); 40-50 (4) and 50+ (1); Gender: female (6) male (3); Ethnicity: Black Caribbean (2), Black other (2), Black British African (2), Mixed ethnicity Black and White (1), Asian other (1) and White British (1). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo professionals, age 30-40(1), one participant age not recorded; Gender: female(1), male(1); Ethnicity White British(2).\u0026nbsp;\u003c/p\u003e"},{"header":"Research Findings","content":"\u003cp\u003eData are presented below under four themes: peerness and connection, cultural awareness and peer support, cultural responsiveness and peer support, and organisational cultural competence, and are illustrated by verbatim quotes from the interviews. Interviewee characteristics are indicated in brackets by site number (e.g S1-4), ethnicity, gender and role (e.g. SP=supported peer; PSW=peer support worker; or professional role).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.1 Peerness and connection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOpinions about peerness, and whether this could be matched based on one or more aspects of person\u0026rsquo;s identity varied. In most situations this was interrelated with notions of connection, understanding and validation. There was an understanding that it\u0026rsquo;s too simplistic to expect race or ethnicity alone to define all aspects and outcomes of a peer relationship.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA belief was shared that among some participants that effective, skilled peer workers can cut across racial and ethnic differences, and that racialised matching would not guarantee a rapport. A Black male peer support worker noted how he preferred peer support from an LGBT charity, explaining that racialised fulfilment was acquired through nourishing connections he had with family, friends and another culturally-specific community organisation. \u0026nbsp;In another peer dyad among two Black females, the religious beliefs of the PSW were imposed onto the SP regarding her sexual orientation, which had an overwhelmingly negative impact bringing an end to that relationship, and reducing their willingness to engage in future peer support.\u003c/p\u003e\n\u003cp\u003eParticipants shared how well-meaning efforts to create a bond through racialised matching could have a paradoxical effect in creating and perpetuating a degree of segregation:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThey could be purple for all I care. They have to that vibe\u0026hellip;I think if that [racialised matching] was an option it\u0026rsquo;s going create the [racial] divide even more.\u0026nbsp;\u003c/em\u003e(S1, Black other, Male, SP)\u003c/p\u003e\n\u003cp\u003eAnd:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf it works, it works. I\u0026rsquo;ve got a client in where I\u0026rsquo;m working and we\u0026rsquo;ve referred him to a counselling service, he\u0026rsquo;s a person of colour, and he asked for a black counsellor. If it works, if that is what some people want, fair enough. I\u0026rsquo;d ask why because I don\u0026rsquo;t think we need to get into that whole. That\u0026rsquo;s not what peer supports about\u0026hellip;I do think that perpetuates a thing, black people with black people, that\u0026rsquo;s segregation, I do not believe in that. I believe that we\u0026rsquo;re all human and, you know, get over it, essentially that\u0026rsquo;s my pool of thought.\u0026nbsp;\u003c/em\u003e(S3, Black British Caribbean female, SP)\u003c/p\u003e\n\u003cp\u003eAcross participants\u0026rsquo; accounts there was a consensus that a person\u0026rsquo;s preferences, wherever possible, should be respected. While there was some caution about matching, several participants described racialised identity bringing advantages. One participant felt his racialised identity alongside interpersonal skills fostered engagement. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI would say my identity is a massive advantage, I\u0026rsquo;m a brown person, which means I can appeal to a lot of brown and black people\u0026hellip;.There is a value, I\u0026rsquo;ve noticed that, there is definitely. I am working currently with a 27 year old Pakistani lad, and he hasn\u0026rsquo;t engaged with anyone on the ward. I walk in and he sees another Pakistani. He\u0026rsquo;s walking around with me playing table tennis and all the other staff are like, \u0026rsquo;why is he opening up to you?\u0026rsquo; \u0026hellip;I think their assumption is it\u0026rsquo;s because I\u0026rsquo;m a Pakistani man, but at the same time, I just ask questions persistently. I just ask him questions until he tells me, gives me a chance. And I\u0026rsquo;m not sure they understand, it\u0026rsquo;s like the level of attention I\u0026rsquo;m giving him for the hour\u003c/em\u003e. (S2, Asian British male, PSW)\u003c/p\u003e\n\u003cp\u003eParticipants who shared a preference for racialised matching had varying reasons. One Black British female PSW explained how sharing a similar racialised identity created an immediate bond in a predominantly White space during her recovery. A Black British Caribbean male, supported peer, detailed his firm expectation that a Black PSW would resonate with his multiple experiences of racism and social and cultural positions of belonging to a Black family, including the nuances of upbringing in UK. This was to the extent that the racially minoritised identity of his PSW was a central factor in his decision to take up peer support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEither African-Caribbean or mixed parentage\u0026hellip;.Because they would be able to relate to me properly and get what I needed to get done. Not a Caucasian person, they don\u0026rsquo;t understand and I don\u0026rsquo;t think they\u0026rsquo;ll ever understand.\u0026nbsp;\u003c/em\u003e(S1, Black British Caribbean male, SP)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Similar sentiments were echoed by a PSW.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[T]here are some people that I\u0026rsquo;ve worked with where I thought well, this could not be done by anybody else but black man, another black man you know, there are times where that is definitely helpful\u003c/em\u003e. (S1, Black British African, PSW)\u003c/p\u003e\n\u003cp\u003eOccasions, albeit rare, were also shared when an SP would only speak to someone if they were not White, due to racialised trauma. Preferences were expressed by an Asian female SP who experienced an enhanced relationship with an Indian PSW as result of common ethnic heritage, shared cultural beliefs about mental ill-health, alongside other common recreational interests (e.g. Indian TV, movies). Similar sentiments were recognised as significant by a North African Muslim female peer support worker relating to religion and cultural matters including women\u0026rsquo;s societal roles.\u003c/p\u003e\n\u003cp\u003eThe nuances involved in understanding the merits of racialised matching were further elaborated, giving insight into the specific context, which arguably becomes a precipitating factor in appeals for support of this nature. One Black PSW pointed towards a wider consideration about what racialised connections might offer racially minoritised bodies given their experience in UK society more broadly, and mental health services in particular.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI feel like most people that are brown or black gravitate towards me because they\u0026rsquo;re looking at me like, \u0026lsquo;What are you doing here?\u0026rsquo; And then as soon as I am able, without trying to take the light away from what they\u0026rsquo;re going through to say, \u0026lsquo;I\u0026rsquo;ve been admitted before, I\u0026rsquo;ve been sectioned before, the eyebrows are raised\u0026rsquo;. My demeanour and my willingness to want to help anybody and everybody that\u0026rsquo;s involved in being admitted to a psychiatric ward, I think it transcends colour. \u0026hellip;. [However] I don\u0026rsquo;t know because we\u0026rsquo;re kind of like pushed to one side and made to feel inhuman. So sometimes it helps to see someone that looks like you. So it makes it feel like it\u0026rsquo;s less inhuman that it\u0026rsquo;s happening to you because we\u0026rsquo;re already made to feel inhuman as black people anyway.\u0026nbsp;\u003c/em\u003e(S3, Black British other female, PSW)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.2 Cultural awareness and peer support\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCultural awareness was a point of enquiry in the research to gauge its importance to practice. All but one participant reflected how they thought cultural awareness had been or could be relevant within peer support. In most instances, having some level of cultural awareness was considered valuable, without pre-judging the beliefs, values or experiences of a supported peer. As one participant shared:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAn awareness \u0026mdash; without reverting to stereotype\u0026mdash; of where they\u0026rsquo;re coming from and where they stand as a person culturally in terms of their identity is always going to help you: Why is it that they can\u0026rsquo;t go to no one else? Why do they feel that you approaching them is making them feel this way? why is it when if I come they immediately shut down? So is it because of me or is it because of culture? Is it because of identity?\u003c/em\u003e (S3, Black British Caribbean female, SP)\u003c/p\u003e\n\u003cp\u003eVarious examples were shared about how valuable it was for PSWs to have an understanding about the way faith influenced the decision-making of SPs. In one example, a supported peer decided to discontinue the peer relationship as they preferred to spend more time with the Jehovah Witness community. Additionally, a supported peer expressed the benefits of a PSW being empathetic to culturally situated experiences.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMy mum\u0026rsquo;s Indian and she does not tolerate that I\u0026rsquo;ve got mental health problems, she doesn\u0026rsquo;t understand it and she thinks it\u0026rsquo;s for lower caste people,. She\u0026rsquo;s like, \u0026rsquo;Oh, you\u0026rsquo;ve got a psychiatric problem\u0026rsquo;, kind of thing. So I think that\u0026rsquo;s partly cultural that she\u0026rsquo;s blas\u0026eacute; about that, and my PSW, she\u0026rsquo;s Indian and that\u0026rsquo;s really helpful to me because I feel like I can share with her and she understands.\u0026nbsp;\u003c/em\u003e(S2, Multiple ethnic background, female, SP)\u003c/p\u003e\n\u003cp\u003eAwareness of specific cultural experiences were communicated as being helpful to the peer support role, including different interpretations of mental health and illness, racialised stigma, present and historical experiences of racism (including systemic and vicarious racism), and racialised experiences within the mental health system. One participant elucidated the value of understanding the ongoing pain of societal racism, how this reduces trust and whether people chose to engage in peer support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[B]eing aware how weathered they are by the system and how much trauma they\u0026rsquo;ve got in their bodies as a result of their experiences probably has a big part to play in how much they trust that they\u0026rsquo;re going to receive help or how much they trust in institutions generally.\u0026nbsp;\u003c/em\u003e(S2, White British female, Occupational Therapist)\u003c/p\u003e\n\u003cp\u003eUnderstanding that different racialised populations are at increased risk of being exposed to potentially traumatising experiences, such as ruqyah, experiences of war, was also thought to be beneficial. Similarly, insights into cultural differences were thought to be helpful to know why there are different informal rules of engagement. In one such example, a PSW described one of the biggest barriers in their role supporting Somali people to access care was overcoming shame:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think it\u0026rsquo;s about confidentiality, there\u0026rsquo;s often mistrust, I think that has been the biggest barrier, people thinking, \u0026lsquo;I\u0026rsquo;m having suicidal thoughts or depression I\u0026rsquo;ll get my children taken away\u0026hellip;I\u0026rsquo;ll get all these interventions that can really make my life difficult.\u0026nbsp;\u003c/em\u003e(S4, Black British African female, PSW)\u003c/p\u003e\n\u003cp\u003eIt was also felt necessary to be aware of cultural beliefs which may cut across race and ethnicity. One PSW alluded to the need for peer workers to accept there will be bias held towards them. This was not only in relation to race, but also how supported peers may prefer professional and technical input, thus seeing the PSW role as peripheral to their care and treatment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026apos;m a Black man, you can see from my diversity form, Black African. This person was also from a BAME background but a different kind of BAME community\u0026hellip;He was well educated\u0026hellip;had an undergraduate degree, did a professional job before becoming unwell. I just felt he saw somebody from a Black African background doing a relatively low paid job, low skilled job, you could see kind of the judgments quite present in the kind of interactions, judgments of prejudices or biases about Black people, and obviously the thing in the technical sense, status in terms of the occupation as well.\u0026nbsp;\u003c/em\u003e(S1, Black British African male, PSW). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile participants did not directly refer to cultural awareness being as much about understanding other people\u0026rsquo;s backgrounds as much as it was about reflecting on their own sense of self and any sense of power, this dynamic was implicitly present. For instance, a Black male, acknowledged the importance of being abreast of different forms of oppression in his role.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere\u0026rsquo;s a white woman, you know middle-aged white woman, her anger was about actually her position in the family, and being, feeling she was powerless and voiceless as a woman. You know in that family. So you know you have to kind of understand, you know, how she might feel as a woman in that family.\u0026nbsp;\u003c/em\u003e(S3, Black and White British male, PSW)\u003c/p\u003e\n\u003cp\u003eAt the same time, a lack of current cultural awareness should also not be viewed as a barrier to effective relationships being established. In one account, a supported peer shared how the PSW had no cultural awareness around his experience of racism, yet this was not experienced as problematic as the PSW demonstrated compassion.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI saw my parents being treated differently by people of their races negatively and positively and how that affected me. She listened with sympathy and acknowledged, but couldn\u0026apos;t really contribute much to that part of the conversation. But I thought that I was listened to and that she was compassionate in her listening. I was happy with that. But I could tell that there wasn\u0026apos;t much that she could contribute towards me disclosing that. So I made the presumption that she was white. And then when I met her, my judgment was correct. So I\u0026apos;m not saying\u0026hellip; that every white person wouldn\u0026apos;t be able to contribute to that conversation. I think having spoken to a Black person or another mixed race person, they would have been able to contribute more to that part of the conversation. So it\u0026apos;s not that I felt neglected because I felt that I was being heard, but I could just tell that she didn\u0026apos;t really know what to say other than, listen, with sympathy.\u0026nbsp;\u003c/em\u003e(S2, Multiple ethnic Black and White British male, SP)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.3 Cultural responsiveness and peer support\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCulturally affirming acts were evident in different ways, from interpersonal approaches and adapting practice to attend to cultural nuances. Important questions were raised about the extent to which PSW\u0026rsquo;s cultural knowledge or belief systems are brought into the peer relationship. One professional felt religion and spirituality, for instance, are not always neutral grounds and felt it was an unresolved dilemma about whether and how PSWs broach such matters. There was no agreement on this point as a PSW described how they used their ongoing judgement, listening skills while offering the space to be guided by the supported peer to decide whether to bring culturally distinct issues into the discussion. This was addressed by PSWs in relation to faith:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt\u0026apos;s about connecting spiritually. A lot of the women are Muslims and they feel disconnected from their faith, reassuring them they\u0026rsquo;re not a bad Muslim or bad person for not praying, validating their experiences. The evil eye \u0026hellip; for us it\u0026rsquo;s just so real. It\u0026rsquo;s really embedded in our faith. I don\u0026rsquo;t shy away from it. So it\u0026rsquo;s just about having that space, for me to feel that they\u0026rsquo;re heard, and that I can bring my experiences because I really feel like I\u0026rsquo;ve had experiences of that\u003c/em\u003e. (S4, Black British African female, PSW)\u003c/p\u003e\n\u003cp\u003eAnd\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt was to do with her religion, and we incorporated that in terms of her goals of things to do to try to improve her mood. And I think those things are important because you don\u0026rsquo;t want to skip over what\u0026rsquo;s really important culturally or to do with their religion or race. They wanted to spend a bit more time focusing on their religious texts and getting more in tune with their religious side just because of some things that were going on for them at the moment.\u0026nbsp;\u003c/em\u003e(S3, Black British Caribbean female, PSW)\u003c/p\u003e\n\u003cp\u003eAnother PSW explained how they adopted an approach involving slow progression when engaging with South Asian people on the ward after initially observing they were more reluctant to participate in ward activities. In a similar way, a supported peer expressed how he found it affirming that the PSW used his time to research issues relating to racism and would bring this into their discussions so they could engage in dialogue and shared learning. The SP also detailed how the PSW needs to be perceptive and responsive to sources of anger which can be rooted in oppression.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThey have to be able to deal with it right, {they} can\u0026rsquo;t understand your sources of anger and when you\u0026rsquo;re triggered they don\u0026rsquo;t want to be there to support you, they have to be able to understand and advise at least a little coping mechanism towards that, you can\u0026rsquo;t just listen to you and then put down the phone and fuck off. That doesn\u0026rsquo;t make no sense, that\u0026rsquo;s not going to help is it.\u0026nbsp;\u003c/em\u003e(S1, Black British male, SP).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExperiences were shared of PSW de-escalating racial tensions in an inpatient setting, increasing cross cultural understanding in the process by fostering an understanding about why people may make derogatory comments or have prejudiced attitudes while reinforcing an environment of zero tolerance. One PSW demonstrated traits of cultural responsiveness when challenging unhelpful biases among other staff, by drawing on their lived experience:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI\u0026rsquo;m talking to staff, you always hear this, \u0026lsquo;he\u0026rsquo;s still living at home, he\u0026rsquo;s 28, he\u0026rsquo;s got recurring depression, anxiety, psychosis. So he\u0026rsquo;s 34, he\u0026rsquo;s living at home\u0026hellip;we need to support him to become more independent\u0026rsquo;. Sometimes I think that people forget, people from an Asian background, we like living with our family, it\u0026rsquo;s actually almost a mark of pride for our parents to say,\u003c/em\u003e (S2, Asian British male, PSW).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHow PSW operated in culturally responsive ways could also be observed in actions to connect SP people with appropriate services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo there was one individual who was Eritrean, couldn\u0026rsquo;t speak much English. He was stuck in the hospital recently. He was being aggressive. He was just like \u0026rsquo;get lost\u0026rsquo;. And all I did for him just [to] get through to him a little bit and just got in touch with an Eritrean community group which no one else on the ward had thought of doing. I just thought, hang on, one of my goals is creating social inclusion. So I found out this organization, organized a phone call, hooked him together. That is still peer support.\u0026nbsp;\u003c/em\u003e(S4, White British male, PSW)\u003c/p\u003e\n\u003cp\u003eComparable actions, illustrating humility, were shared when a young Somali lady, dealing with emotions around genital mutilation, was connected with a community group, as the PSW understood limitations of what could be offered by their own service. Another example involved an Irish individual who needed assistance obtaining ID papers for child support for his son.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.4 Organisational cultural competence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOrganisational cultural competence was a theme to emerge from the data, drawing on various functions of PSW services aimed at improving access, experience or outcomes for racially minoritised people. This included established conventions, such as celebrating Black History, an activity supported peers who had newly arrived to the UK found helpful for cross-cultural interaction and learning, to topics about workforce diversity and targeted provision.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.4.1 Racialised matching and reflections on implementation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWhile racialised matching has already been discussed, the considerations in how this can occur requires decisions at an organisational level, bringing implications for changes to policies and procedures. One consideration, expressed by several participants, related to the initial process of assessing the needs and wishes of supported peers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[Racialised matching] should be part of assessment process, I would think that would need a more in-depth discussion and not just say, \u0026rsquo;do you want a black mentor or black youth?\u0026rsquo; Some people, according what their issues have been, may have nothing to do really with ethnicity, might be just being understood as a person who has major depression, whether the person is black, white, Hispanic, doesn\u0026rsquo;t matter\u003c/em\u003e. (S3, Black British Caribbean female, PSW)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough not strictly racialised matching, a supported peer noted how they found it affirming being asked whether they had any cultural or spiritual needs to be respected or acknowledged as part of the assessment process to receiving peer support. The timing at which racialised matching could occur featured strongly for some participants. One participant felt matching could be temporary, functioning in the early stages of the peer relationship to assist with establishing a bond, suggesting this was something which needed ongoing review. This was a point echoed by other participants who felt racialised peer connections could be more beneficial at the point of Mental Health Act detention, when there\u0026rsquo;s broader scope for misunderstanding and confusion, a consequence of which could be feelings of increased cultural distance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think definitely at the admission process, most definitely there needs to be a familiar face where they know each other or not that it needs to be a familiar face, \u0026hellip; we want them to feel safe ultimately, we want them to feel safe. We don\u0026rsquo;t want them to be scared. But if you\u0026rsquo;re turning up with police officers and you see all these nurses, for me personally, that would make me worse. That would make me absolutely worse. So if we could have an advocate, someone they feel like they can talk to, someone that\u0026rsquo;s familiar with their culture, someone that\u0026rsquo;s familiar with how they speak or their language.\u0026nbsp;\u003c/em\u003e(S1, Black British other female, PSW)\u003c/p\u003e\n\u003cp\u003eThere was also sense that racialised matching could be part of a targeted provision which is used to address an identified inequity experienced by racial or ethnic groups.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf you think about older Asian women who are quite excluded sometimes from public spaces and from groups, and often there\u0026rsquo;s been a kind of somatisation of distress, it\u0026rsquo;s been harder for them to use some of the therapeutic tools. I do wonder if you had some peer support work champions from within that community, whether that could be quite powerful for that group. [S]imilarly, the other obvious group are young, black men who are very excluded from gentle entries into the mental health system and are much more overrepresented coming through the police system and sections, seclusion, medication. So again, it would be really powerful, I think, to have a powerful group of young, male, black peer support workers as well.\u0026nbsp;\u003c/em\u003e(S4, White British male, psychiatrist).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.4.2 Workforce diversity\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor other participants the benefits of matching would not necessary be achieved through a targeted service but through a PSW workforce more representative of local ethnic profile. There was a strong feeling by a small number of participants that more needs to be done to improve progression of racially minoritised people across the peer workforce, and more specifically to increase peer workforce ethnic diversity. The benefits of the latter were documented (4b \u0026amp; 4c).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf we look at the statistics, most of the time it\u0026rsquo;s black and brown people that will find themselves in psychiatric wards. Whether or not the reasons behind it are just or unjust is another story and a very thick one. But what we really need is more representation in terms of support. If I think back to my time when I was in a psychiatric ward, if there was someone that looked like me, I may have chosen to be unmute.\u0026nbsp;\u003c/em\u003e(S3, Black British other female, PSW)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.4.3 Monitoring for equitable access, outcomes and experiences\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne area where there was agreement on the need for improvement was in monitoring for equity in relation to access, outcomes and experience. One PSW acknowledged how during the course of the interview it dawned on him that all the potential supported peers who had declined support were Black men.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo we have a couple of young lads, both black British also declined support as well\u0026hellip;.That\u0026rsquo;s quite depressing isn\u0026rsquo;t it, black British men. I can only think of four. I would say if I had recorded all of this it would be Black British men.\u0026nbsp;\u003c/em\u003e(S2, Asian British male, PSW)\u003c/p\u003e\n\u003cp\u003eAnother PSW reflected on the way fewer Black supported peers had requested additional support in contrast to other ethnic groups, which was attributed to privilege. He summarised:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePeople may not feel privileged or to ask and expect and demand that their needs are met, you know, and that might be based on their previous experiences or not having a lifetime of not having their needs met, you know\u003c/em\u003e. (S1, Black British African male, PSW).\u003c/p\u003e\n\u003cp\u003eWhile there are differing perspectives in relation to the privilege people might experience, or be deprived of, participants described how peer support systems are presently not attuned to identifying differential experiences or inequities within service uptake.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.4.5 Training, support, coaching, and reflective spaces\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eConcerns were raised about the amount of training and support provided to PSW more generally and for racially minoritised PSW in particular. Some participants put forward the need for reflective spaces to encourage PSWs to think about their own biases, stressing that the PSW workforce are as prone to making assumptions about other supported peers, despite the empathy they bring to the peer support relationship.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI don\u0026apos;t think peer support workers just because they\u0026apos;re peer support workers have got a greater understanding, because it\u0026apos;s the same assumptions and prejudices\u0026hellip; Peer support workers are just as prone to making assumptions as other people just because we foreground our own lived experience and what our idea of empathy is that we\u0026apos;re not like special beings that can cross all like realms of experience.\u0026nbsp;\u003c/em\u003e(S2, Asian British male, PSW)\u003c/p\u003e\n\u003cp\u003eAt the same time, some participants expressed a need for contextualised support which accounts for the triggering environment in mental health institutions where experiences of vicarious racism were thought to be ever-present. Connected to this was the additional burden sometimes placed on racially PSW bodies who received referrals to work with racially minoritised supported peers because of their shared identity when this may not have been what the person needed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e4.4.6 Organisational flexibility and specialist community provision\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHaving organisational flexibility and a commitment to equity was also thought to be progressive for peer support services. This included flexibility to adapt services to the needs of the community, and to work closely with the BVS and other specialist services. A PSW shared an example of culturally adapted practice and targeted provision involving partnerships with community services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe worked with a Somali charity\u0026hellip;. we do groups in there as well with women and service uses, often they come from, in that sense they\u0026rsquo;ve already built up that trust. We used the five ways of wellbeing that NHS England uses and we connected that to the five pillars of Islam. And I think having that connection of faith and of wellbeing, and trying to show how they interlink, I think it was really, it was really helpful for everyone involved, myself included.\u0026nbsp;\u003c/em\u003e(S4, White British male, PSW)\u003c/p\u003e\n\u003cp\u003eSpecialist services provided by the BVS were thought to be trusted by racialised groups and should be offered as an alternative to NHS provision. A further example was shared of a gender specific community organisation providing an in-reach peer support service on inpatient wards:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHere peer support is so important to me and I believe is to the other girls as well because, as I say, the charity have different people and different background people, somebody Korean, somebody White British and everything, so they understand our different culture as well\u0026hellip;I think the charity do understand what I need, they do understand how to treat the person with a different religion.\u0026nbsp;\u003c/em\u003e(S1, Other Asian background, female, SP)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePeerness, and perceptions about how it could or should be shaped, was often the topic that initially surfaced for participants. Data indicated peerness was about connection, validation and disclosure, each of which are apparent in peer support more generally. However, data points to the need for a separate space of analysis giving consideration to how these concepts have a racialised layer to their understanding. Opinions stretched from suggestions peer support should not be pre-occupied with discussions about racism, nor racialised matching, to thoughts about the practical challenges of implementation, and those who thought in some circumstances racialised matching was essential. Such myriad positions in many ways reflects the diversity PS must embrace. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe context within which peer support is provided, both a mental health system and society which are respectively institutionally and structurally racist, must be a consideration in people\u0026rsquo;s expectations from peer support. A deeper understanding around this is required as it is not possible to conclude that recommendations for racialised matching within peer support were due to an expectation that the cultural needs of supported peers would not be met by the peer support service. Indeed, sometimes this appeared to be borne out of frustration given the frequency at which racially minoritised people are the recipients of unequal and undignified treatment within mental healthcare and society. This must be connected to a separate debate about whether peer support is unintentionally put in a position where it is expected to address institutional racism in mental health services; something which will not be achieved by increasing PSW workforce diversity. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRacism\u0026rsquo;s ongoing presence, connected to racially minoritised people feeling dehumanised, are the intractable conditions providing impetus for racialised connection. It is in large part this context which racialised peerness had value. It influenced engagement, in a small number of cases it was presented as predominate factor, in others more preference, whereas others it was not presented as consideration. There was an expectation it would bring not only cross-cultural understanding but also validation. While there was ambiguity about the extent of racialised matching which could take place, the matter of a supported peer\u0026rsquo;s preference being respected was encapsulated within a framework of addressing racial inequity by improving service experience.\u003c/p\u003e\n\u003cp\u003eEmerging themes covered elements of cultural humility and awareness, chiming with ideas that the former is required during the process of becoming culturally aware and knowledgeable (47). There was a strong sense that alongside being open to learning, PSWs should be supported to have awareness beyond their own culture, in light of the perceived benefits this could bring to peer support relationships.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne element of cultural awareness is the racial weathering racialised bodies encounter. \u0026nbsp;Similar to more common understandings of racial weathering (48), it is based on the idea encountering the frustration of societal disadvantage and discrimination, racialised bodies have reduced trust in peer support. Such cultural differences among specific ethnic populations were thought to influence whether someone takes part in peer support. There was an appreciation that is part of understanding informal rules of engagement in the way belief systems inform what people are likely to accept, fear or reject.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile this was the situation, and cultural awareness was considered helpful, emphasis was placed on the need to stay open to learning without making assumptions about a person\u0026rsquo;s belief system. In this way, PSWs need to strike a balance between developing awareness and knowledge, and remaining self-reflective about personal power and other forms of oppression, with an ongoing openness to cultural interaction. Here parallels can be drawn between cultural responsiveness, the willingness to learn, and values underpinning peer support. For peer support this is characterised by a two-way process of learning, and it may provide an understanding about why it has been shown to function across difference. In very much the same way, Clauss-Ehlers and Garagiola (49) describe similar ideals under the banner of cultural humility in relation to health care professionals, and similarities can be drawn to peer support. They argue for a longstanding commitment to learning from cross-cultural interactions, and in doing so remaining perceptive to power differentials to build relationships.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAligned with notions offered by Stubbe (50) in relation to cultural responsiveness, this theme drew on ideas about providing peer support that was respectful, responding to a supported peer\u0026rsquo;s preferences, needs or values. Offering a flexible and supportive framework for faith and belief to be part of peer support relationship figured strongly. Addressing racism, challenging hegemonic interpretations of independence, and taking steps to enhance SPs social interaction by creating culturally appreciative connections with community organisations, were various acts shared, illustrating how cultural differences were acknowledged during encounters, appraising power dynamics, underpinning the construct of being culturally responsive (51).\u003c/p\u003e\n\u003cp\u003eCultural competence addressed some of the organisational considerations which have relevance to supporting racially minoritised people\u0026nbsp;(52). Emerging themes drew on organisational functions including recruitment, partnership arrangements, monitoring for equitable outcomes and workforce development.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere was limited evidence of peer support services implementing procedures or encouraging PSWs to actively consider cultural needs at the outset of peer support engagement. Where this did happen it was viewed positively. Similarly, perhaps due to the sample participants, no data was gathered which demonstrated efforts to increase workforce diversity. In a similar way, the generally inconsistent approach to monitoring for equitable outcomes in terms of access limited a circular process of learning whereby underrepresentation of racially minoritised people accessing PSW can be identified, understood and addressed. Therefore, while PSWs can demonstrate cultural awareness and be culturally responsive, whether working across difference or otherwise, each of which assists an organisation to be culturally competent, all PSWs should be fully supported to fulfil their role regarding addressing inequities in access.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEvidence was documented, albeit limited, around peer services being targeted towards an identified racial inequity. One initiative appeared to have been successful in engaging under-represented populations in psychological services, and working collaboratively with culturally-specific voluntary sector organisations. On the one hand, understanding the successes of such initiatives could tie into a broader need across peer support to improve monitoring for equity, across experience and outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the same time, evidence from partnership working, alongside data from participants working or receiving support from BVS or other specialist services were viewed positively. The evidence collected indicates that this has potential to increase engagement as it overcomes any feelings of mistrust supported peers may have with statutory provision. More needs to be known about the experience offered by the BVS or other culturally adapted PS services. It is important to understand more specifically whether the degree of informality attributed to the BVS, approaches and differences in practices, sanctioned by organisational habitude, translate to differential service experiences. Peer support services can be\u0026nbsp;consciously and unconsciously shaped by the norms and priorities of the predominate culture. This can mean that peer support services within statutory settings can be as prone as other health and social care agencies to unreflexively reproduce dominant social values within a service model which can have implications for the prioritisation of race equity. This is an area warranting further enquiry.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used a standardised, theoretically informed approach to data collection and analysis. A complete data set was analysed from across four geographic sites, interviews with SP, PSW and professionals. Very few studies explicitly explore race, culture and peer support, with high levels of lived experience involvement. Coproduction was central in generating interview schedules, developing coding and analysis. The study could have benefited from lived experience during data collection. The data sample itself was diverse and benefited from a range of perspectives. A greater timeframe for recruitment and geographic spread may have enabled further data to be obtained from BVS organisations or organisations and initiatives providing targeted support to racially minoritised people.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications of Police Practice and Research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMental health workforce policy in England has placed emphasis on the expansion of the peer support workers. Study findings indicate that peer workers require appropriate resourcing to help ensure race equity can be central to service delivery. Support for racialised workforce to attend to vicarious racism should be provided, alongside opportunities for ongoing learning and coaching around culture and mental health. Improvements in how to monitor and to appropriately respond to inequities across access, experience and outcomes should also be a priority.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study had a broad remit to explore the main issues in relation to peer support for racially minoritised people, and within this, to understand how race, culture and ethnicity are relevant to the delivery of peer support services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA range of insights were gathered from the study about the preferences of racially minoritised people in relation to peer support. Consistent throughout the findings was the way matters of racialisation had implications about whether people engage in peer support. While the topic of racialised matching remains an unresolved dilemma, at times peer support worker\u0026rsquo;s racialised identities influenced whether supported peers engaged in peer support, and the way services were designed also influenced service access.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThemes looking at cultural awareness and responsiveness highlighted the dynamic inter-relation between peer support and race, ethnic and culture differences, and the way peer support in the UK has developed. It also illustrates the high levels of cultural appropriateness with which peer support workers operate, in many ways going beyond expectations of their role. Improvements are nevertheless possible, and organisational efforts to support the workforce and to appraise provision are areas which were found to be undeveloped.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBVS Black Voluntary Sector\u003c/p\u003e\n\u003cp\u003eCC Cultural competence\u003c/p\u003e\n\u003cp\u003eNHS National Health Service\u003c/p\u003e\n\u003cp\u003ePSW Peer support worker\u003c/p\u003e\n\u003cp\u003eSP supported peer\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe study was approved and conducted to the standard of the UK National Research Ethics Service, which built on, and aligned with the norms of Declaration of Helsinki statement of ethical principles in research. Full ethical approval was granted to City, University of London by Health Research Authority and Health and Care Research Wales (HCRW), to carry out the study. IRAS project ID: 307943. A participant information sheet was made available to all participants, and their consent was recorded prior to data collection, consenting to their interview being recorded, transcribed, analysed and published (in a de-identified format).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding was received from the National Institute for Health Research (NIHR). Award ID:\u0026nbsp;NIHR202616\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAS contributed to the conceptualisation, data curation, formal analysis, methodology, project administration, validation, writing original draft, writing review and editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRF contributed to the conceptualisation, data curation, formal analysis, methodology, project administration, validation, writing review and editing. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSG contributed to the conceptualisation, formal analysis, methodology, supervision, validation writing review and editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCC, DL and JM contributed to the conceptualisation, formal analysis, methodology, validation writing review and editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKapadia D, Zhang J, Salway S, Nazroo J, Booth A, Villarroel-Williams N. Ethnic Inequalities in Healthcare: A Rapid Evidence Review. NHS 2022.\u003c/li\u003e\n \u003cli\u003eBarnett P, Mackay E, Matthews H, Gate R, Greenwood H, Ariyo K, et al. Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data. Lancet Psychiatry. 2019;6(4):305\u0026ndash;31710.1016/S2215-0366(19)30027-6.\u003c/li\u003e\n \u003cli\u003eBansal N, Karlsen S, Sashidharan SP, Cohen R, Chew-Graham CA, Malpass A. Understanding ethnic inequalities in mental healthcare in the UK: A meta-ethnography. PLoS Med 2022;19(12):1310.1371/journal.pmed.1004139.\u003c/li\u003e\n \u003cli\u003eSolomon P. Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatr Rehabil J 2004 January 01;27(4):392\u0026ndash;40110.2975/27.2004.392.401.\u003c/li\u003e\n \u003cli\u003eNHS. The NHS Long Term Plan. 2019.\u003c/li\u003e\n \u003cli\u003eFortuna KL, Solomon P, Rivera J. An Update of Peer Support/Peer Provided Services Underlying Processes, Benefits, and Critical Ingredients. Psychiatr Q 2022 June 01;93(2):571\u0026ndash;58610.1007/s11126-022-09971-w.\u003c/li\u003e\n \u003cli\u003eValenstein M, Pfeiffer PN, Brandfon S, Walters H, Ganoczy D, Kim HM, et al. Augmenting Ongoing Depression Care With a Mutual Peer Support Intervention Versus Self-Help Materials Alone: A Randomized Trial. Psychiatr Serv 2016 February 01;67(2):236\u0026ndash;23910.1176/appi.ps.201400454.\u003c/li\u003e\n \u003cli\u003eKalathil J. Dancing to our own tunes: reassessing black and minority ethnic mental health service user involvement. 2013.\u003c/li\u003e\n \u003cli\u003eKing AJ, Simmons MB. A Systematic Review of the Attributes and Outcomes of Peer Work and Guidelines for Reporting Studies of Peer Interventions. Psychiatr Serv 2018 September 01;69(9):961\u0026ndash;97710.1176/appi.ps.201700564.\u003c/li\u003e\n \u003cli\u003eNicholson J, Valentine A. Defining \u0026quot;peerness\u0026quot;: Developing peer supports for parents with mental illnesses. .\u0026nbsp;. Psychiatr Rehabil J 2018;41(2):157\u0026ndash;15910.1037/prj0000301.\u003c/li\u003e\n \u003cli\u003eCorrigan PW. Understanding Peerness in Recovery-Oriented Mental Health Care. Psychiatr Serv 2024 June 01;75(6):597\u0026ndash;59910.1176/appi.ps.20230392.\u003c/li\u003e\n \u003cli\u003eAhmed S editor. Racialized Bodies. Palgrave, London: Palgrave; 2002.\u003c/li\u003e\n \u003cli\u003eMcKinnon SA, Conner KO, Roker R, Ward CJ, Brown C. The Reduction of Public and Internalized Stigma in Late-Life Depression: A Pilot Study. J Appl Gerontol 2019 March 01;38(3):424\u0026ndash;43310.1177/0733464816687079.\u003c/li\u003e\n \u003cli\u003eHealey P, Stager ML, Woodmass K. Cultural adaptations to augment health and mental health services: a systematic review. BMC Health Serv Res 2017;17(8)10.1186/s12913-016-1953-x.\u003c/li\u003e\n \u003cli\u003eCabral J, Smith T. Racial/ethnic matching of clients and therapists in mental health services: a meta-analytic review of preferences, perceptions, and outcomes. J Couns Psychol. 2011;58(4):537\u0026ndash;5410.1037/a0025266.\u003c/li\u003e\n \u003cli\u003eOlaniyan F, Hayes G. Just ethnic matching? Racial and ethnic minority students and culturally appropriate mental health provision at British universities. International Journal of Qualitative Studies on Health and Well-being 2022;17(1):211744410.1080/17482631.2022.2117444.\u003c/li\u003e\n \u003cli\u003eChu W, Chorpita BF, Becker KD. Race, racial matching, and cultural understanding as predictors of treatment engagement in youth mental health services. Psychotherapy Research 2023;33(5):669\u0026ndash;68210.1080/10503307.2022.2150582.\u003c/li\u003e\n \u003cli\u003eStockwell DW, Roche M, Billings J. Evaluating interventions that have improved access to community mental health care for Black men: A systematic review. Journal of Mental Health 2024:1\u0026ndash;1210.1080/09638237.2024.2390381.\u003c/li\u003e\n \u003cli\u003eFaulkner A, Kalathil J. The Freedom to be, the Chance to Dream: Preserving user-led peer support in mental health.\u0026nbsp;. 2012.\u003c/li\u003e\n \u003cli\u003eTondora J, O\u0026apos;Connell M, Miller R, Dinzeo T, Bellamy C, Andres-Hyman R, et al. A clinical trial of peer-based culturally responsive person-centered care for psychosis for African Americans and Latinos. Clin Trials 2010 August 01;7(4):368\u0026ndash;37910.1177/1740774510369847.\u003c/li\u003e\n \u003cli\u003eSiantz E, Henwood B, Gilmer T. Implementation of peer providers in integrated mental health and primary care settings. Journal of the Society for Social Work and Research 2016;7:231\u0026ndash;24610.1086/686644.\u003c/li\u003e\n \u003cli\u003eByrne L, Roennfeldt H, Wolf J, Linfoot A, Foglesong D, Davidson L, et al. Effective Peer Employment Within Multidisciplinary Organizations: Model for Best Practice. Adm Policy Ment Health 2022 March 01;49(2):283\u0026ndash;29710.1007/s10488-021-01162-2.\u003c/li\u003e\n \u003cli\u003ePfeiffer PN, Valenstein M, Ganoczy D, Henry J, Dobscha SK, Piette JD. Pilot study of enhanced social support with automated telephone monitoring after psychiatric hospitalization for depression. Soc Psychiatry Psychiatr Epidemiol 2017 February 01;52(2):183\u0026ndash;19110.1007/s00127-016-1288-2.\u003c/li\u003e\n \u003cli\u003eGillard S, Edwards C, Gibson S, Holley J, Owen K. New ways of working in mental health services: a qualitative, comparative case study assessing and informing the emergence of new peer worker roles in mental health services in England.\u0026nbsp;. NIHR Journals Library 2014.\u003c/li\u003e\n \u003cli\u003eGray P. Voluntary organisations\u0026rsquo; perspective on\u003cbr\u003e\u0026nbsp;mental health needs. In: Bhugra DB, V, editor. Ethnicity: an agenda for mental health. London: Gaskell.; 1999. p. 202\u0026ndash;210.\u003c/li\u003e\n \u003cli\u003eFernando S. Multicultural mental health services:\u003cbr\u003e\u0026nbsp;projects for ethnic minority communities in England. Transcultural Psychiatry. 2005;42(3):420\u0026ndash;36.\u003c/li\u003e\n \u003cli\u003eKeating F. Theorising race, ethnicity and mental\u003cbr\u003e\u0026nbsp;health. In: Graig, G., Atkin, K., Chattoo, S. and Flynn, R, editor. Understanding race and ethnicity: theory, history policy, practice. 2012: Bristol: Policy Press; 2012. p. 209\u0026ndash;226.\u003c/li\u003e\n \u003cli\u003eNewbigging, K., McKeown, M. and French, B. Mental health advocacy and African and Caribbean men: good practice principles and organizational models for delivery. Health Expectations 2013;16:80\u0026ndash;104rg/10.1111/j.1369-7625.2011.00692.x.\u003c/li\u003e\n \u003cli\u003eJonikas JA, Kiosk S, Grey DD, Hamilton MM, McNulty J, Cook JA. Cultural competency in peer-run programs: results of a web survey and implications for future practice. Psychiatr Rehabil J. 2010;34(2):121\u0026ndash;910.2975/34.2.2010.121.129.\u003c/li\u003e\n \u003cli\u003eChinman M, McCarthy S, Mitchell-Miland C, Bachrach RL, Schutt RK, Ellison M. Predicting Engagement With Mental Health Peer Specialist Services. Psychiatr Serv 2019 April 01;70(4):333\u0026ndash;33610.1176/appi.ps.201800368.\u003c/li\u003e\n \u003cli\u003eStergiopoulos V, Gozdzik A, Nisenbaum R, Durbin J, Hwang SW, O\u0026apos;Campo P, et al. Bridging Hospital and Community Care for Homeless Adults with Mental Health Needs: Outcomes of a Brief Interdisciplinary Intervention. Can J Psychiatry 2018 November 01;63(11):774\u0026ndash;78410.1177/0706743718772539.\u003c/li\u003e\n \u003cli\u003eO\u0026apos;Connell MJ, Sledge WH, Staeheli M, Sells D, Costa M, Wieland M, et al. Outcomes of a Peer Mentor Intervention for Persons With Recurrent Psychiatric Hospitalization. Psychiatric Services 2018;69(7):760\u0026ndash;767.\u003c/li\u003e\n \u003cli\u003eSmith AM, Stewart K, Baul T, Valentine SE. Peer delivery of a brief cognitive-behavioral treatment for posttraumatic stress disorder: A hybrid effectiveness-implementation pilot study. Journal of Clinical Psychology, ;76(12):2133\u0026ndash;2154.\u003c/li\u003e\n \u003cli\u003eHolley LC, Oh H, Thomas D. Mental illness discrimination and support experienced by people who are of color and/or LGB: Considering intersecting identities. Am J Orthopsychiatry 2019;89(1):16\u0026ndash;2610.1037/ort0000360.\u003c/li\u003e\n \u003cli\u003eLe PD, Agrest M, Mascayano F, Dev S, Kankan T, Dishy G, et al. Understanding Users\u0026apos; Perspectives of Psychosocial Mechanisms Underpinning Peer Support Work in Chile. Community Ment Health J 2022 January 01;58(1):111\u0026ndash;12010.1007/s10597-021-00800-1.\u003c/li\u003e\n \u003cli\u003eChinman M, McCarthy S, Bachrach RL, Mitchell-Miland C, Schutt RK, Ellison M. Investigating the Degree of Reliable Change Among Persons Assigned to Receive Mental Health Peer Specialist Services. Psychiatr Serv 2018 December 01;69(12):1238\u0026ndash;124410.1176/appi.ps.201800118.\u003c/li\u003e\n \u003cli\u003eConner KO, Gum AM, Schonfeld L, Kosyluk K, Anderson E, Baker-Douglan J, et al. Enhancing care transitions intervention with peer support to improve outcomes among older adults with co-occurring clinical depression: a pilot study. Home Health Care Serv Q 2021 December 01;40(4):324\u0026ndash;33910.1080/01621424.2021.1967249.\u003c/li\u003e\n \u003cli\u003eCorrigan PW, Kraus DJ, Pickett SA, Schmidt A, Stellon E, Hantke E, et al. Using Peer Navigators to Address the Integrated Health Care Needs of Homeless African Americans With Serious Mental Illness. Psychiatr Serv 2017 March 01;68(3):264\u0026ndash;27010.1176/appi.ps.201600134.\u003c/li\u003e\n \u003cli\u003eGillard S, Bremner S, Patel A, Goldsmith L, Marks J, Foster R, et al. Peer support for discharge from inpatient mental health care versus care as usual in England (ENRICH): a parallel, two-group, individually randomised controlled trial. The Lancet Psychiatry 2022;9(2):125\u0026ndash;136.\u003c/li\u003e\n \u003cli\u003eWhite S, Bhattacharya R, Bremner S, Faulkner A, Foster R, Gibson S, et al. Predictors of engagement with peer support: analysis of data from a randomised controlled trial of one-to-one peer support for discharge from inpatient psychiatric care. Int J Soc Psychiatry. 2023;69(4):996\u0026ndash;100310.1177/00207640221148090.\u003c/li\u003e\n \u003cli\u003eCurtis E, Jones R, Tipene-Leach D. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health 2019;18(174)10.1186/s12939-019-1082-3.\u003c/li\u003e\n \u003cli\u003eGarneau AB, Pepin J. Cultural competence: a constructivist definition. J Transcult Nurs 2015;26(1):9\u0026ndash;15.\u003c/li\u003e\n \u003cli\u003eDanso R. Cultural competence and cultural humility: A critical reflection on key cultural diversity concepts. J Soc Work 2018;18:410\u0026ndash;3010.1177/1468017316654341.\u003c/li\u003e\n \u003cli\u003eAlizadeh S CM. Cultural competence dimensions and outcomes: a systematic review of the literature.. Health \u0026amp; Social Care in the Community 2016;24(6):117\u0026ndash;30.\u003c/li\u003e\n \u003cli\u003eSadusky A, Yared H, Patrick P, Berger E. A systematic review of client\u0026rsquo;s perspectives on the cultural and racial awareness and responsiveness of mental health practitioners. Culture \u0026amp; Psychology 2024;30(3):567\u0026ndash;60510.1177/1354067X231156600.\u003c/li\u003e\n \u003cli\u003eTruong M, Paradies Y, Priest N. Interventions to improve cultural competency healthcare: a systematic review of reviews. BMC Health Serv Res 2014;14(99).\u003c/li\u003e\n \u003cli\u003eCampinha-Bacote J. Cultural Competemility: A Paradigm Shift in the Cultural Competence versus Cultural Humility Debate\u0026nbsp;. Journal of Issues in Nursing 2019;24(1).\u003c/li\u003e\n \u003cli\u003eForde AT, Crookes DM, Suglia SF, Demmer RT. The weathering hypothesis as an explanation for racial disparities in health: a systematic review. Ann Epidemiol. 2019;33:1\u0026ndash;1810.1016/j.annepidem.2019.02.011.\u003c/li\u003e\n \u003cli\u003eClauss-Ehlers CS, Garagiola ER. Cultural competence and cultural humility as foundations for meaningful engagement among an educational system of care for school stakeholders. In: S. W. Evans, J. S. Owens, C. P. Bradshaw, \u0026amp; M. D. Weist (Eds.), editor. Handbook of school mental health: Innovations in science and practice. Switzerland: Springer Nature; 2023. p. 265\u0026ndash;282.\u003c/li\u003e\n \u003cli\u003eStubbe DE. Practicing Cultural Competence and Cultural Humility in the Care of Diverse Patients. Focus. Am Psychiatr Publ 2020;18(1)10.1176/appi.focus.20190041.\u003c/li\u003e\n \u003cli\u003eGill GK, Babacan H. Developing a cultural responsiveness framework in healthcare systems: An Australian example.\u0026nbsp;. Diversity and Equality in Health and Care 2012;9:45\u0026ndash;55.\u003c/li\u003e\n \u003cli\u003eDanso R. Cultural competence and cultural humility: A critical reflection on key cultural diversity concepts. Journal of Social Work 2016;18(4):410\u0026ndash;43010.1177/1468017316654341.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Peer support, lived experience, mental health services, race equity, implementation, health and well-being","lastPublishedDoi":"10.21203/rs.3.rs-8337940/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8337940/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePeer support is being expanded at pace across mental health services in England. Limited research looks at peer support in relation to racially minoritised people in the UK, against a backdrop of longstanding racial inequities in mental health provision. The purpose of this research was to explore the main issues for peer support in responding to diverse populations, and to make recommendations relating to race equity considering the peers support’s integration into mental health services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted an exploratory qualitative study using semi-structured key informant interviews with 18 participants, including supported peers, peer workers and professionals. A lived experience advisory group ensured high levels of lived experience involvement in the conceptualisation, analysis and write up. Interviews were transcribed and analysed thematically. A hybrid approach was used in the data analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are presented below under four themes: peerness and connection, cultural awareness and peer support, cultural responsiveness and peer support, and organisational cultural competence. Important findings around racialised matching surfaced, reflecting various perspectives peer support must embrace. Peer support’s role as being tailored to addressing specific racial inequities was put forward. Themes looking at cultural awareness and responsiveness highlighted the dynamic inter-relation between peer support and race, ethnic and culture differences, and peer support’s agility to respond to diverse needs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe introduction of peer support workers is a key part of NHS reform. The considerations in relation to race equity for this new mental health workforce have been unclear in practice and research. As the scope of PSW increases there is a need for greater awareness of the issues they will encounter to support system integration. Our findings highlight key approaches by PSW’s in responding to ethnic diversity. They also highlight the need for appropriate resourcing to help ensure race equity can be central to service delivery. Support for racialised peer support workforce to attend to vicarious racism should be provided, alongside opportunities for ongoing learning and coaching around culture and mental health. Improvements in how to monitor and to appropriately respond to inequities across access, experience and outcomes should also be a priority.\u003c/p\u003e","manuscriptTitle":"A Qualitative Exploration of mental health peer support provision for racially minoritised people in England","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 16:09:27","doi":"10.21203/rs.3.rs-8337940/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-31T12:13:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187655869088971581426067357483379930375","date":"2026-01-19T14:34:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-14T10:39:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-22T09:52:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-19T18:52:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-19T18:51:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-12-11T14:39:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"79d90252-496c-4997-a870-3a92598277ab","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-16T16:09:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 16:09:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8337940","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8337940","identity":"rs-8337940","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}