Peer Support: a Human Factor to Enhance Engagement in Digital Health Behavior Change Interventions

  • Karen L. FortunaEmail author
  • Jessica M. Brooks
  • Emre Umucu
  • Robert Walker
  • Phillip I. Chow


The purpose of this report is to develop a theoretical model based on empirical evidence that can serve as a foundation for the science of peer-support factors that facilitate engagement in digital health interventions for people with serious mental illness (SMI). A review of the literature on how peer-support specialist interaction with consumers with SMI in digital health behavior change interventions enhances engagement. Unlike relationships with other health providers, peer-to-consumer relationships are based on reciprocal accountability —meaning that peer-support specialists and consumer mutually help and learn from each other. Under the recovery model of mental illness, reciprocal accountability suggests autonomy, flexible expectations, shared lived experience, and bonding influence engagement in digital interventions. Separate yet related components of reciprocal accountability in the context of digital health intervention engagement include (1) goal setting, (2) task agreement, and (3) bonding. Hope and sense of belonging are hypothesized moderators of peer-support factors in digital health interventions. Peer-support factors help people with SMI learn to live successfully both in the clinic and community. Peer-support specialists add value and complement traditional mental health treatment through their professional training and lived experience with a mental illness. The proposed model is a pioneering step towards understanding how peer-support factors impact engagement in digital health behavior change interventions among people with a lived experience of SMI. The model presents proposed factors underlying the reciprocal accountability processes in the context of digital health intervention engagement. This model and related support factors can be used to examine or identify research questions and hypotheses.


Peer support Digital health Human factors Science of behavior change 


Compliance with Ethical Standards

Conflict of interest

The authors declare that there is no conflict of interest.


  1. Anttila, M., Välimäki, M., Hätönen, H., Luukkaala, T., & Kaila, M. (2012). Use of web-based patient education sessions on psychiatric wards. International Journal of Medical Informatics, 81(6), 424–433. Scholar
  2. Aschbrenner, K. A., Naslund, J. A., Gorin, A. A., Mueser, K. T., Scherer, E. A., Viron, M., Kinney, A., & Bartels, S. J. (2018). Peer support and mobile health technology targeting obesity-related cardiovascular risk in young adults with serious mental illness: protocol for a randomized controlled trial. Contemporary Clinical Trials, 74, 97–106.Google Scholar
  3. Badcock, J. C., Shah, S., Mackinnon, A., Stain, H. J., Galletly, C., Jablensky, A., & Morgan, V. A. (2015). Loneliness in psychotic disorders and its association with cognitive function and symptom profile. Schizophrenia Research, 169(1–3), 268–273.Google Scholar
  4. Bandura, A. (1994). Self-efficacy. In R. J. Corsini. Encyclopedia of psychology 2 (3),368–369. New York: Wiley.Google Scholar
  5. Bandura, A., & Ramachaudran, V. S. (1994). Encyclopedia of human behavior. New York: Academic Press.Google Scholar
  6. Barnes, A. L., Murphy, M. E., Fowler, C. A., & Rempfer, M. V. (2012). Health-related quality of life and overall life satisfaction in people with serious mental illness. Schizophrenia Research and Treatment, 2012, 1–6. Scholar
  7. Baumeister, R. F., & Leary, M. R. (1995). The need to belong: desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin, 117(3), 497–529.Google Scholar
  8. Beckner, V., Vella, L., Howard, I., & Mohr, D. C. (2007). Alliance in two telephone-administered treatments: relationship with depression and health outcomes. Journal of Consulting and Clinical Psychology, 75(3), 508–512.Google Scholar
  9. Beebe, L. H. (2010). What community living problems do persons with schizophrenia report during periods of stability? Perspectives in Psychiatric Care, 46(1), 48–55.Google Scholar
  10. Borkman, T. J. (1999). Understanding self-help/mutual aid: experiential learning in the commons. New Brunswick, NJ: Rutgers University Press.Google Scholar
  11. Borrero, M., Martens, P., & Gubelman Borrero, G. (1979). Toward a theory of accountability. Journal of Sociology & Social Welfare, 6, 876–894.Google Scholar
  12. Bracke, P., & Verhaeghe, M. (2006). The balance of peer support among persons with chronic mental health problems: consequences and antecedents. Paper presented at The 11th international congress of the European Society for Health and Medical Sociology.Google Scholar
  13. Brehm, S., & Brehm, J. W. (1981). Psychological reactance: a theory of freedom and control. New York, NY: Academic Press.Google Scholar
  14. Cabassa, L. J., Camacho, D., Vélez-Grau, C. M., & Stefancic, A. (2017). Peer-based health interventions for people with serious mental illness: a systematic literature review. Journal of Psychiatric Research, 84, 80–89.Google Scholar
  15. Cacioppo, J. T., Hughes, M. E., Waite, L. J., Hawkley, L. C., & Thisted, R. A. (2006). Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses. Psychology and Aging, 21(1), 140–151.Google Scholar
  16. Campbell, S. R., Holter, M. C., Manthey, T. J., & Rapp, C. A. (2014). The effect of CommonGround software and decision support center. American Journal of Psychiatric Rehabilitation, 17(2), 166–180.Google Scholar
  17. Castelein, S., Bruggeman, R., Van Busschbach, J. T., Van Der Gaag, M., Stant, A., Knegtering, H., & Wiersma, D. (2008). The effectiveness of peer support groups in psychosis: a randomized controlled trial. Acta Psychiatrica Scandinavica, 118(1), 64–72.Google Scholar
  18. Chapman, S. A., Blash, L. K., Mayer, K., & Spetz, J. (2018). Emerging roles for peer providers in mental health and substance use disorders. American Journal of Preventive Medicine, 54(6), S267–S274.Google Scholar
  19. Christensen, H., Griffiths, K. M., & Korten, A. (2002). Web-based cognitive behavior therapy: analysis of site usage and changes in depression and anxiety scores. Journal of Medical Internet Research, 4(1), e3.Google Scholar
  20. Christensen, H., Griffiths, K. M., & Farrer, L. (2009). Adherence in internet interventions for anxiety and depression: systematic review. Journal of Medical Internet Research, 11(2), e13.Google Scholar
  21. Cook, J. A., Copeland, M. E., Corey, L., Buffington, E., Jonikas, J. A., Curtis, L. C., Grey, D. D., & Nichols, W. H. (2010). Developing the evidence base for peer-led services: changes among participants following wellness recovery action planning (WRAP) education in two statewide initiatives. Psychiatric Rehabilitation Journal, 34(2), 113–120.Google Scholar
  22. Corrigan, P. W., & Watson, A. C. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry, 1(1), 16–20.Google Scholar
  23. Corrigan, P. W., McCracken, S. G., & Holmes, E. P. (2001). Motivational interviews as goal assessment for persons with psychiatric disability. Community Mental Health Journal, 37(2), 113–122.Google Scholar
  24. Darkins, A., Kendall, S., Edmonson, E., Young, M., & Stressel, P. (2015). Reduced cost and mortality using home telehealth to promote self-management of complex chronic conditions: a retrospective matched cohort study of 4,999 veteran patients. Telemedicine and e-Health, 21(1), 70–76.Google Scholar
  25. Davidson, L., Chinman, M., Sells, D., & Rowe, M. (2006). Peer support among adults with serious mental illness: a report from the field. Schizophrenia Bulletin, 32(3), 443–450.Google Scholar
  26. Davidson, L., Bellamy, C., Guy, K., & Miller, R. (2012). Peer support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry, 11(2), 123–128.Google Scholar
  27. de Leeuw, J. R. J., van Splunteren, P., & Boerema, I. (2012). Personal control in rehabilitation: an internet platform for patients with schizophrenia and their caregivers. Open Journal of Psychiatry, 2(04), 355–361.Google Scholar
  28. Deci, E. L., & Ryan, R. M. (1985). The general causality orientations scale: self-determination in personality. Journal of Research in Personality, 19(2), 109–134.Google Scholar
  29. Dixon, L. B., Holoshitz, Y., & Nossel, I. (2016). Treatment engagement of individuals experiencing mental illness: review and update. World Psychiatry, 15(1), 13–20.Google Scholar
  30. Eliacin, J., Coffing, J. M., Matthias, M. S., Burgess, D. J., Bair, M. J., & Rollins, A. L. (2018). The relationship between race, patient activation, and working alliance: implications for patient engagement in mental health care. Administration and Policy in Mental Health and Mental Health Services Research, 45(1), 186–192.Google Scholar
  31. El-Mallakh, P. (2007). Doing my best: poverty and self-care among individuals with schizophrenia and diabetes mellitus. Archives of Psychiatric Nursing, 21(1), 49–60.Google Scholar
  32. Eysenbach, G. (2005). The law of attrition. Journal of Medical and Internet Research, 7(1), e11.Google Scholar
  33. Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7, 117–140. Scholar
  34. Finnerty, M., Austin, E., Chen, Q., Layman, D., Kealey, E., Ng-Mak, D., Rajagopalan, K., & Hoagwood, K. (2018). Implementation and use of a client-facing web-based shared decision-making system (MyCHOIS-CommonGround) in two specialty mental health clinics. Community Mental Health Journal, 1–10.Google Scholar
  35. Firth, J., Cotter, J., Torous, J., Bucci, S., Firth, J. A., & Yung, A. R. (2015). Mobile phone ownership and endorsement of “mHealth” among people with psychosis: a meta-analysis of cross-sectional studies. Schizophrenia Bulletin, 42(2), 448–455.Google Scholar
  36. Fortuna, K. L., Lohman, M. C., Batsis, J. A., DiNapoli, E. A., DiMilia, P. R., Bruce, M. L., & Bartels, S. J. (2017). Patient experience with healthcare services among older adults with serious mental illness compared to the general older population. The International Journal of Psychiatry in Medicine, 52(4–6), 381–398.Google Scholar
  37. Fortuna, K., Aschbrenner, K., & Bartels, S. (2018a). Integration of peer philosophy in clinical workflow. Psychiatric Quarterly, 89(4), 795–800. Google Scholar
  38. Fortuna, K., Aschbrenner, K., Lohman, M., Salzer, M., & Bartels, S. (2018b). Text message exchanges between older adults with serious mental illness and older certified peer specialists in a smartphone-supported self-management intervention. Psychiatric Rehabilitation Journal., 42, 57–63. [Epub ahead of print].Google Scholar
  39. Fortuna, K. L., DiMilia, P. R., Lohman, M. C., Bruce, M. L., Zubritsky, C. D., Halaby, M. R., Walker, R. M., Brooks, J. M., & Bartels, S. J. (2018c). Feasibility, acceptability, and preliminary effectiveness of a peer-delivered and technology supported self-management intervention for older adults with serious mental illness. Psychiatric Quarterly, 89(2), 293–305.Google Scholar
  40. Fortuna, K., Barr, P., Goldstein, C., Walker, R., Brewer, L., Zagaria, A., Bartels, S. (2019). Application of Community-engaged research to inform the development and implementation of a peer-delivered mobile health intervention for adults with serious mental illness. Journal of Participatory Medicine, 11(1), e12380.Google Scholar
  41. Frank, A. F., & Gunderson, J. G. (1990). The role of the therapeutic alliance in the treatment of schizophrenia: relationship to course and outcome. Archives of General Psychiatry, 47(3), 228–236.Google Scholar
  42. Gagne, C. A., Finch, W. L., Myrick, K. J., & Davis, L. M. (2018). Peer workers in the behavioral and integrated health workforce: opportunities and future directions. American Journal of Preventive Medicine, 54(6), S258–S266.Google Scholar
  43. Graffigna, G., Barello, S., & Riva, G. (2013). How to make health information technology effective: the challenge of patient engagement. Archives of Physical Medicine and Rehabilitation, 94, 2034–2035. Scholar
  44. Hagborg, W. J. (1998). An investigation of a brief measure of school membership. Adolescence, 33(130), 461–468.Google Scholar
  45. Hales, S. B., Davidson, C., & Turner-McGrievy, G. M. (2014). Varying social media post types differentially impacts engagement in a behavioral weight loss intervention. Translational Behavioral Medicine, 4(4), 355–362.Google Scholar
  46. Hidalgo-Mazzei, D., Reinares, M., Mateu, A., Nikolova, V. L., del Mar Bonnin, C., Samalin, L., Garcia-Estela, A., Perez-Sola, V., Young, A. H., Strejilevich, S., & Vieta, E. (2018). OpenSIMPLe: a real-world implementation feasibility study of a smartphone-based psychoeducation programme for bipolar disorder. Journal of Affective Disorders, 241, 436–445.Google Scholar
  47. Horvath, A. O., Del Re, A., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9–16.Google Scholar
  48. Kaufman, L., Kuhn, W., & Stevens Manser, S. (2016). Peer specialist training and certification programs: a National Overview. Texas Institute for Excellence in Mental Health, School of Social Work, University of Texas at Austin.Google Scholar
  49. Kukla, M., Salyers, M. P., & Lysaker, P. H. (2013). Levels of patient activation among adults with schizophrenia: associations with hope, symptoms, medication adherence, and recovery attitudes. The Journal of Nervous and Mental Disease, 201(4), 339–344.Google Scholar
  50. Lazarus, R. S. (1999). Hope: an emotion and a vital coping resource against despair. Social Research, 66(2), 653–678.Google Scholar
  51. Lerner, J. S., & Tetlock, P. E. (1999). Accounting for the effects of accountability. Psychological Bulletin, 125(2), 255–275.Google Scholar
  52. Linz, S. J., & Sturm, B. A. (2013). The phenomenon of social isolation in the severely mentally ill. Perspectives in Psychiatric Care, 49(4), 243–254.Google Scholar
  53. Maslow, A. H. (1954). The instinctoid nature of basic needs. Journal of Personality, 22, 326–347.Google Scholar
  54. Mead, S., & MacNeil, C. (2006). Peer support: what makes it unique. International Journal of Psychosocial Rehabilitation, 10(2), 29–37.Google Scholar
  55. Melau, M., Harder, S., Jeppesen, P., Hjorthøj, C., Jepsen, J., Thorup, A., & Nordentoft, M. (2015). The association between working alliance and clinical and functional outcome in a cohort of 400 patients with first-episode psychosis: a cross-sectional study. The Journal of Clinical Psychiatry, 76(1), 83–90.Google Scholar
  56. Mohr, D. C., Cuijpers, P., & Lehman, K. (2011). Supportive accountability: a model for providing human support to enhance adherence to eHealth interventions. Journal of Medical Internet Research, 13(1).
  57. Mueller, N. E., Panch, T., Macias, C., Cohen, B. M., Ongur, D., & Baker, J. T. (2018). Using smartphone apps to promote psychiatric rehabilitation in a peer-led community support program: pilot study. JMIR Mental Health, 5(3), e10092.Google Scholar
  58. Myrick, K., & del Vecchio, P. (2016). Peer support services in the behavioral healthcare workforce: state of the field. Psychiatric Rehabilitation Journal, 39(3), 197–206.Google Scholar
  59. Naslund, J. A., Grande, S. W., Aschbrenner, K. A., & Elwyn, G. (2014). Naturally occurring peer support through social media: the experiences of individuals with severe mental illness using YouTube. PLoS One, 9(10), e110171. Scholar
  60. Naslund, J. A., Marsch, L. A., McHugo, G. J., & Bartels, S. J. (2015). Emerging mHealth and eHealth interventions for serious mental illness: a review of the literature. Journal of Mental Health, 24(5), 321–332.Google Scholar
  61. Naslund, J., Aschbrenner, K., Marsch, L., & Bartels, S. (2016). The future of mental health care: peer-to-peer support and social media. Epidemiology and Psychiatric Sciences, 25(2), 113–122.Google Scholar
  62. Naslund, J. A., Aschbrenner, K. A., Marsch, L. A., McHugo, G. J., & Bartels, S. J. (2018). Facebook for supporting a lifestyle intervention for people with major depressive disorder, bipolar disorder, and schizophrenia: an exploratory study. Psychiatric Quarterly, 89(1), 81–94.Google Scholar
  63. Ordóñez, L. D., Schweitzer, M. E., Galinsky, A. D., & Bazerman, M. H. (2009). Goals gone wild: the systematic side effects of overprescribing goal setting. Academy of Management Perspectives, 23(1), 6–16.Google Scholar
  64. Palmier-Claus, J. E., Ainsworth, J., Machin, M., Barrowclough, C., Dunn, G., Barkus, E., Rogers, A., Wykes, T., Kapur, S., Buchan, I., & Salter, E. (2012). The feasibility and validity of ambulatory self-report of psychotic symptoms using a smartphone software application. BMC Psychiatry, 12(1), 1–39.Google Scholar
  65. Peh, C. X., Kua, E. H., & Mahendran, R. (2016). Hope, emotion regulation, and psychosocial well-being in patients newly diagnosed with cancer. Supportive Care in Cancer, 24(5), 1955–1962.Google Scholar
  66. Polivy, J. (2001). The false hope syndrome: unrealistic expectations of self-change. International Journal of Obesity, 25(S1), 80–84.Google Scholar
  67. Poole, R., Simpson, S. A., & Smith, D. J. (2012). Internet-based psychoeducation for bipolar disorder: a qualitative analysis of feasibility, acceptability and impact. BMC Psychiatry, 12(1), 139. Scholar
  68. Ritterband, L. M., Thorndike, F. P., Cox, D. J., Kovatchev, B. P., & Gonder-Frederick, L. A. (2009). A behavior change model for internet interventions. Annals of Behavioral Medicine, 38(1), 18–27.Google Scholar
  69. Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78.Google Scholar
  70. Salyers, M. P., Fukui, S., Bonfils, K. A., Firmin, R. L., Luther, L., Goscha, R., Rapp, C. A., & Holter, M. C. (2016). Consumer outcomes after implementing CommonGround as an approach to shared decision making. Psychiatric Services, 68(3), 299–302.Google Scholar
  71. Salzer, M. S. (2002). Consumer-delivered services as a best practice in mental health care delivery and the development of practice guidelines. Psychiatric Rehabilitation Skills, 6(3), 355–382. Scholar
  72. Salzer, M. S., Darr, N., Calhoun, G., Boyer, W., Loss, R. E., Goessel, J., Schwenk, E., & Brusilovskiy, E. (2013). Benefits of working as a certified peer specialist: results from a statewide survey. Psychiatric Rehabilitation Journal, 36(3), 219–221. Scholar
  73. Sarason, I. G., Levine, H. M., Basham, R. B., & Sarason, B. R. (1983). Assessing social support: the social support questionnaire. Journal of Personality and Social Psychology, 44(1), 127–139. Scholar
  74. Schutt, R. K., & Rogers, E. S. (2009). Empowerment and peer support: structure and process of self-help in a consumer-run center for individuals with mental illness. Journal of Community Psychology, 37(6), 697–710.Google Scholar
  75. Shorey, H. S., Snyder, C. R., Rand, K. L., Hockemeyer, J. R., & Feldman, D. B. (2002). Authors’ response: somewhere over the rainbow: hope theory weathers its first decade. Psychological Inquiry, 13(4), 322–331. Scholar
  76. Skovholt, T. M. (1974). The client as helper: a means to promote psychological growth. The Counseling Psychologist, 4(3), 58–64. Scholar
  77. Snyder, C. R., Harris, C., Anderson, J. R., Holleran, S. A., Irving, L. M., Sigmon, S. T., Yoshinobu, L., Gibb, J., Langelle, C., & Harney, P. (1991). The will and the ways: development and validation of an individual-differences measure of hope. Journal of Personality and Social Psychology, 60(4), 570–585. Scholar
  78. Solomon, P. (2004). Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatric Rehabilitation Journal, 27(4), 392–401.Google Scholar
  79. Sue, D. W., & Sue, D. (1990). Counseling the culturally different: theory and practice. Oxford, England: John Wiley & Sons.Google Scholar
  80. Teo, H.-H., Chan, H.-C., Wei, K.-K., & Zhang, Z. (2003). Evaluating information accessibility and community adaptivity features for sustaining virtual learning communities. International Journal of Human-Computer Studies, 59(5), 671–697. Scholar
  81. Todd, N. J., Jones, S. H., & Lobban, F. A. (2013). What do service users with bipolar disorder want from a web-based self-management intervention? A qualitative focus group study. Clinical Psychology & Psychotherapy, 20(6), 531–543. Scholar
  82. Torous, J., Staples, P., Shanahan, M., Lin, C., Peck, P., Keshavan, M., & Onnela, J.-P. (2015). Utilizing a personal smartphone custom app to assess the Patient Health Questionnaire-9 (PHQ-9) depressive symptoms in patients with major depressive disorder. JMIR mental health, 2(1), e8. Scholar
  83. Tracey, T. J., & Kokotovic, A. M. (1989). Factor structure of the Working Alliance Inventory. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1(3), 207–210. Scholar
  84. Tyler, T. R. (1997). The psychology of legitimacy: a relational perspective on voluntary deference to authorities. Personality and Social Psychology Review, 1(4), 323–345. Scholar
  85. Vance, K., Howe, W., & Dellavalle, R. P. (2009). Social internet sites as a source of public health information. Dermatologic Clinics, 27(2), 133–136. Scholar
  86. Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270–277.Google Scholar
  87. World Health Organization. (2018). Guidelines for the management of physical health conditions in adults with severe mental disorders. Geneva: World Health Organization.Google Scholar
  88. Wright, D. (1997). Getting out of the asylum: understanding the confinement of the insane in the nineteenth century. Social History of Medicine, 10(1), 137–155.Google Scholar
  89. Zhao, L., Lu, Y., Wang, B., Chau, P. Y. K., & Zhang, L. (2012). Cultivating the sense of belonging and motivating user participation in virtual communities: a social capital perspective. International Journal of Information Management, 32(6), 574–588. Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Karen L. Fortuna
    • 1
    • 2
    Email author
  • Jessica M. Brooks
    • 3
  • Emre Umucu
    • 4
  • Robert Walker
    • 5
  • Phillip I. Chow
    • 6
  1. 1.The Geisel School of Medicine at DartmouthConcordUSA
  2. 2.CDC Health Promotion Research Center at DartmouthLebanonUSA
  3. 3.James J. Peters VA Medical Center, Geriatric Research, Education and Clinical CenterThe BronxUSA
  4. 4.Department of Rehabilitation SciencesUniversity of Texas at El PasoEl PasoUSA
  5. 5.Massachusetts Department of Mental HealthBostonUSA
  6. 6.Department of Psychiatry and Neurobehavioral SciencesUniversity of VirginiaCharlottesvilleUSA

Personalised recommendations