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Original Paper
Older Adult Peer Support Specialists’ Age-Related Contributions
to an Integrated Medical and Psychiatric Self-Management
Intervention: Qualitative Study of Text Message Exchanges
Mbita Mbao1*, LICSW; Caroline Collins-Pisano2*; Karen Fortuna2*, LICSW, PhD
1Simmons University, School of Social Work, Boston, MA, United States
2Dartmouth College, Lebanon, NH, United States
*all authors contributed equally
Corresponding Author:
Karen Fortuna, LICSW, PhD
Dartmouth College
Department of Psychiatry, Geisel School of Medicine, Dartmouth College
Lebanon, NH
United States
Phone: 1 603 722 5727
Email: karen.L.Fortuna@dartmouth.edu
Abstract
Background: Middle-aged and older adults with mental health conditions have a high likelihood of experiencing comorbid
physical health conditions, premature nursing home admissions, and early death compared with the general population of adults
aged 50 years or above. An emerging workforce of peer support specialists aged 50 years or above or “older adult peer support
specialists” is increasingly using technology to deliver peer support services to address both the mental health and physical health
needs of middle-aged and older adults with a diagnosis of a serious mental illness.
Objective: This exploratory qualitative study examined older adult peer support specialists’ text message exchanges with
middle-aged and older adults with a diagnosis of a serious mental illness and their nonmanualized age-related contributions to a
standardized integrated medical and psychiatric self-management intervention.
Methods: Older adult peer support specialists exchanged text messages with middle-aged and older adults with a diagnosis of
a serious mental illness as part of a 12-week standardized integrated medical and psychiatric self-management smartphone
intervention. Text message exchanges between older adult peer support specialists (n=3) and people with serious mental illnesses
(n=8) were examined (mean age 68.8 years, SD 4.9 years). A total of 356 text messages were sent between older adult peer
support specialists and service users with a diagnosis of a serious mental illness. Older adult peer support specialists sent text
messages to older participants’ smartphones between 8 AM and 10 PM on weekdays and weekends.
Results: Five themes emerged from text message exchanges related to older adult peer support specialists’age-related contributions
to integrated self-management, including (1) using technology to simultaneously manage mental health and physical health issues;
(2) realizing new coping skills in late life; (3) sharing roles as parents and grandparents; (4) wisdom; and (5) sharing lived
experience of difficulties with normal age-related changes (emerging).
Conclusions: Older adult peer support specialists’ lived experience of aging successfully with a mental health challenge may
offer an age-related form of peer support that may have implications for promoting successful aging in older adults with a serious
mental illness.
(JMIR Form Res 2021;5(3):e22950) doi: 10.2196/22950
KEYWORDS
older adults; peer support; self-management; mobile technology
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Introduction
Middle-aged and older adults with mental health conditions
have a high likelihood of experiencing comorbid physical health
conditions, premature nursing home admissions, and early death
compared with the general population of middle-aged and older
adults [1]. Despite challenges associated with mental health and
comorbid physical health conditions in late life, there is a
shortage of trained professionals to address the medical,
psychiatric [2-4], and psychosocial age-related needs of this
vulnerable population. An emerging workforce of peer support
specialists aged 50 years or above is one of the fastest growing
mental health workforces and may be a suitable
community-based workforce to simultaneously support the
mental health, physical health, and aging needs of middle-aged
and older adults with a serious mental illness. A serious mental
illness is defined as a diagnosable mental, behavioral, or
emotional disorder that an adult has experienced in the past year
that causes them serious functional impairment that substantially
interferes with or limits at least one major life activity (ie,
schizophrenia, bipolar disorder, and treatment refractory major
depressive disorder) [5].
Older adult peer support specialists are people with a lived
experience of aging into middle age and older adulthood with
a mental health condition. As people with serious mental
illnesses die up to 32 years earlier than the general population
[1], older age is commonly defined as 50 years or above in this
population of peer support specialists and their service user
counterparts. For Medicaid reimbursement, older adult peer
support specialists are trained and accredited by their respective
state to provide support services that augment the traditional
mental health system. Although accreditation and certification
of older adult peer specialists varies by state, as of 2017, 41
states were billing Medicaid for peer support services [6].
Promising evidence indicates that older adult peer support
specialist services reduce hospitalizations; improve engagement
and treatment adherence; improve feelings of loneliness among
older adults [7,8]; and promote hope, empowerment, and quality
of life [9,10].
Similar to peer support specialists of any age, older adult peer
support specialists employ a collaborative approach, in which
caring for others creates an upward spiral of positivity to both
professionals and service users [11]. This approach may be
central to recovery and support bidirectional successful aging
in people with serious mental illnesses and older adult peer
support specialists themselves. Successful aging is defined as
preventing late-life disease and disability; maintaining high
cognitive, mental, and physical function; and being actively
engaged in late life [12]. As such, successful aging cannot exist
without the absence of disease, disability, and impairment, and
thus, may not apply to middle-aged and older adults with serious
mental illnesses, as the majority of this population is also
diagnosed with one or more chronic health conditions [2]. As
such, subjective factors of successful aging for people with
serious mental illnesses may include resilience, optimism,
adaptability, life satisfaction, and physical and mental
health–related quality of life [12,13].
Older adult peer support specialists are increasingly using
technology to deliver peer support services related to addressing
both the mental health and physical health needs of older adults
[9,10], including text messaging, videoconferencing, social
media, and virtual reality. Text messages may be a low-cost
high-reach intervention to support people in the community
between clinical encounters with psychiatrists, social workers,
etc. Clinician-supported text message exchanges have shown
promising evidence of positive outcomes for improving mental
health disorders and cardiac outcomes [14]. Other supportive
clinician-based text message interventions have reported
potential improvements in users with a comorbid diagnosis of
depression and alcohol use [15]. A similar randomized
controlled trial of supportive text messages for users with
depression also reported positive outcomes for depression [16].
Despite evidence of clinician-based text message effectiveness
for people with mental health challenges, limited literature exists
on older adult peer support specialists, and unlike clinicians,
their role is to intentionally disclose their lived experiences of
aging with mental health challenges to support older adults. The
purpose of this study was to explore older adult peer support
specialists’text message exchanges with middle-aged and older
adults with a diagnosis of a serious mental illness and their
nonmanualized age-related contributions to a standardized
integrated medical and psychiatric self-management
intervention.
Methods
Study Design
The study design and recruitment procedures have been
described in a previously published article [17]. Briefly, a
medical and psychiatric self-management intervention enhanced
with the smartphone app “PeerTECH” was offered to 10 older
adults with serious mental illness (ie, bipolar disorder,
schizophrenia spectrum disorder, and persistent major depressive
disorder) and one medical comorbidity (ie, cardiovascular
disease, obesity, diabetes, chronic obstructive pulmonary
disease, hypertension, and/or high cholesterol). All the
participants were over the age of 60 years, and the PeerTECH
intervention was delivered in the participant’s home using
eModules augmented with the smartphone app (ie, it includes
text messaging between older adult peer support specialists and
older service users). Eight of the 10 older service users
completed the intervention and were included in the current
analysis. Three trained older adult peer support specialists
delivered PeerTECH. All procedures were conducted in
accordance with the ethical standards of the Dartmouth College
Institutional Review Board and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical
standards. Written informed consent was obtained from all
participants.
An older adult peer support specialist and a research staff
member met with potential participants in their homes. As part
of the informed consent process, research staff members
provided an overview of the study and discussed the voluntary
nature of study participation and confidentiality issues. If
interested, the potential participant completed written informed
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consent and could ask any questions as needed. This study was
approved by Dartmouth College Institutional Review Board.
After the informed consent form was completed by the
participant, an older adult peer support specialist met with the
participant in his/her home for 1 hour each week over 12 weeks.
A study of PeerTECH text messaging exchanges has been
conducted with the data. The related findings have been
described in detail in a previously published report [17].
Previous research explored how older adult peer support
specialists used text messages to support integrated illness
self-management (ie, via health behavior change,
self-management therapeutic techniques, engagement in health
technology, and peer support) [17]. This study seeks to expand
on prior work by exploring unique older adult peer support
specialists’age-related contributions to a medical and psychiatric
self-management intervention enhanced with a smartphone app.
Older Adult Peer Support Training
Older adult peer support specialists completed their
state-certified peer specialist support training. In addition to
their state credentialing, as part of this study, they were provided
a 4-day training by the third author (20 hours), which included
the following content: (1) information about the interconnected
relationship between aging, physical health, and mental health;
(2) training older adults to use technology and mitigating normal
age-related challenges using technology; (3) older adult mental
health (eg, suicidality in late life, anxiety and depression in late
life, and role of life events in mental health in older adults); (4)
techniques used in PeerTECH (ie, motivational interviewing,
psychoeducation, coping skills training, and behavioral tailoring
for medication adherence); (5) setting personalized goals and
action steps to achieve goals; (6) delivering PeerTECH sessions
in person using eModules on a tablet; (7) structure of the weekly
sessions; (8) using lived experience of successful aging, physical
health, and mental health challenges and role play in teaching
self-management skills; and (9) orientation to the smartphone
app. Each older adult peer support specialist had a two to
three-person caseload and worked a total of 10 hours per week,
including direct care, text messaging participants, and
supervision. Older adult peer support specialists were supervised
by a trained older adult peer support supervisor for 1 hour each
week in person or over the telephone. Verbal informed consent
was obtained from older adult peer support specialists during
the older adult peer support specialist training.
Text Messaging Requirements
The smartphone intervention portion of PeerTECH was designed
to reinforce in-person sessions and to provide support to people
in real-world environments. Older adult peer support specialists
were instructed to message participants a minimum of three
times a week. There was no maximum number of text messages
required. Text message exchanges were unstructured and were
to focus on nonmanualized peer support, follow-up of service
users’ goals, and discussions during in-person sessions
facilitated by eModules (eg, “hope you are doing well on your
goals- journaling and walking”). Older adult peer support
specialists were encouraged to text message at times consistent
with the preferences of the service users they were working
with. All text message content was logged, and the time/date
was recorded. Requirements for text messaging were purposely
left unstructured in an effort to examine naturalistic interactions
between older adult peer support specialists and service users
with a diagnosis of a serious mental illness.
Smartphones and data plans were provided free of charge or
service user participants could use their own smartphone.
Participants were not provided incentives to send text messages;
however, they were provided US $20 compensation to complete
baseline, 1-month, and 3-month assessments (total of US $60
over the entire study duration). For this study, incoming and
outgoing text messages were securely stored within the
smartphone app database. Text message transcript data were
extracted into an Excel worksheet and analyzed.
Data Analysis
Transcripts were analyzed for eight participants and three older
adult peer support specialists. The codebook consisted of a priori
older adult peer support specialist and nonpeer researcher–driven
codes, which were derived from text messages, and inductively
derived codes from qualitative data [18]. The first and third
authors read data and incorporated new codes and operational
definitions from transcript coding, which is a validated approach
that allows for multiple perspectives [18]. Codes were assigned
to text, grouped, and checked for themes. Thematic analysis
was used to summarize themes identified in the text message
data [19]. Analyses assessed within-group consensus or
disagreement. Member checking was employed to validate
results and resolve any incongruent findings. As such, the third
author contacted the participating older adult peer support
specialists to discuss the key themes that emerged from the text
message data. This approach helped ensure these findings are
consistent with how older adult peer support specialists intend
to use these text message exchanges. Quantitative data
comprised the frequency of text messages by either older adult
peer support specialists or service users. Frequency data were
captured directly from the PeerTECH app. Frequency data were
integrated at the conclusion of the study.
Results
Study Sample
The sample consisted of eight service user participants and three
older adult peer support specialists. Service user participants
had a mean age of 68.8 years (SD 4.9 years; range 62-77 years)
and were primarily women (7/8, 88%), White (8/8, 100%), and
married (6/8, 75%). The sample included people diagnosed with
major depressive disorder (5/8, 63%), schizophrenia spectrum
disorder (2/8, 25%), and bipolar disorder (1/8, 13%). Older
adult peer support specialists were all aged 55 years or above.
Additionally, 100% (3/3) were female, 66% (2/3) identified as
White, and 33% (1/3) identified as African American.
Text Message Exchanges
Older adult peer support specialists sent text messages to
participants’ smartphones based on participants’ preferences
from 8 AM to 10 PM EST on weekdays and weekends. Over
the course of the 12-week intervention, a total of 356 text
messages were sent. For this study, only the text message
exchanges were analyzed. Five themes emerged including (1)
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simultaneously managing mental health and physical health
issues through empowerment and technology; (2) realizing new
coping skills in late life; (3) sharing roles as parents and
grandparents; (4) wisdom; and (5) sharing lived experience of
difficulties with normal age-related changes.
Using Technology to Simultaneously Manage Mental
Health and Physical Health
The first and most predominant theme was using technology to
simultaneously manage mental health and physical health
(29/53, 55%). Older adult peer support specialists encouraged
participants to take control of their mental health and physical
health needs using technology. For example, an older adult peer
support specialist texted as follows:
You were able to relax enough to get the exercise. It
was amazing what 10 minutes of focused quiet can
do. Take a timer and just do a mental relaxation
exercise for 5 minutes 2x a day. It will be great for
your heart. You can find guided imagery and
meditations videos on YouTube also.
Another older adult peer support specialist texted as follows:
I can feel the stress you are under. In the app, there
are several short videos on stress reduction like deep
breathing, mindfulness, meditation that you can try
to have some peace.
Another older adult peer support specialist provided tools for
reducing anxiety as follows:
Doing slow deep breathing and short meditations can
relax you and dissipate anxiety more effectively than
cigarettes. Think about it. I will look for some
YouTube videos on relaxation and/or smoking
cessation.
Realizing New Coping Skills in Late Life
The second most predominant theme was realizing new coping
skills in late life (8/53, 15%). Older adult peer support specialists
purported that they are learning new skills in late life related to
coping skill development. For example, an older adult peer
support specialist texted as follows:
Since I have been in recovery, I am learning new skills
to cope with stressful days, weeks, and months.
Another older adult peer support specialist texted as follows:
I do a lot of journaling (writing). It helps me in many
ways- when I am upset; when I don't have someone
to talk to and I need to get it out of my head; when I
have to make a big decision...Writing has been a
blessing for me especially in tough times.
Sharing Roles as Parents and Grandparents
The third most predominant theme was sharing roles as parents
and grandparents in late life (7/53, 13%). For example, an older
adult peer support specialist texted as follows:
Being (Grandma...) means so much to me. I know you
love your grandchildren and in time we can work
through all of this with grace and ease.
Another older adult peer support specialist texted as follows:
We as parents and women tend to put everybody first.
Now it is our time to take care of ourselves.
Older adult peer support specialists used their shared experiences
to help participants solve the challenges they were having with
their families, which were impacting service users’ mental
health. Older adult peer support specialists and older adults with
mental health conditions shared similar experiences, for
example, an older adult peer support specialist texted as follows:
We grandmothers can't hold back our sheer joy and
love we have for our grandchildren. I wish I had a
video of your “grandmother moment.” Your smile lit
up the room as you shared about your excitement
from hearing from your granddaughter (that's is tears
of joy smile).
Wisdom
The fourth theme was wisdom (6/53, 11%). Wisdom, for the
purpose of this manuscript, was defined as advanced-level
knowledge that leads to good judgment [20]. Older adult peer
support specialists and older adults with mental health conditions
both offered each other wisdom regarding aging successfully.
For example, one older adult peer support specialist texted as
follows:
We form habits without knowing it and once we
identify the “bad” habits, we can turn those unwanted
habits around in 14-21 days. We just have to be
persistent.
Another older adult peer support specialist texted as follows:
What you resist, persist what we focus on, we also
get... as a man thinketh, so is he... What the mind can
conceive and believe, it can achieve... In other words,
instead of focusing on what you don't want, put your
focus on what you do want. … What can you do to
transform your thinking? What actions can you take
to feel better today? What do you want to be focused
on? WORDS HAVE POWER and so do we. We have
a saying “Be, Do, Have” ex: Be Happy, Do things
that make you feel happy and you will have Happiness
in your life.
Sharing Lived Experience of Difficulties With Normal
Age-Related Changes
The fifth emerging theme was sharing lived experience of
difficulties with normal aging (3/53, 6%). An older adult peer
support specialist texted as follows:
Sleep is a challenge for me too. It is a process; we
will work on it. I added the Sleep module. I hope you
can get some good tips on getting a good night sleep. I
get home so late at night it’s hard for me to wind
down. Let me know what works best for you, so I can
try it too.
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Discussion
Principal Findings
This exploratory qualitative study examined older adult peer
support specialists’ text message exchanges with middle-aged
and older adults with a diagnosis of a serious mental illness and
their nonmanualized age-related contributions to a standardized
integrated medical and psychiatric self-management
intervention. The following themes emerged: (1) simultaneously
managing mental health and physical health issues through
empowerment and technology; (2) realizing new coping skills
in late life; (3) sharing roles as parents and grandparents; (4)
wisdom; and (5) sharing lived experience of difficulties with
normal age-related changes. Older adult peer support specialists’
lived experience of aging successfully with a mental health
challenge may offer an age-related form of peer support that
may have implications for promoting successful aging in older
adults with serious mental illnesses.
The age of older adult peer support specialists and their
experiences with multimorbidity led to text message exchanges
that focused on the management of mental health and physical
health challenges using technologies outside of the PeerTECH
platform (eg, smartphone apps, YouTube, and social media
platforms). Older adults in the general population with
multimorbidity are often faced with burdens of managing
treatment, such as increased health care visits, refilling
prescriptions, managing diet concerns, and self-managing care
[14], and this is compounded by functional and structural
challenges (eg, lack of transportation) associated with serious
mental illnesses in late life [2]. As increasing numbers of older
adults with serious mental illnesses are using technologies [21],
technologies may be viable tools to support late-life
self-management of mental health and physical health
challenges. Further, older peer support specialists’ personal
experience of coping with multimorbidity using technologies
may influence service users to engage with these new
technologies to support their own medical and psychiatric
self-management skill development. Prior research has found
that clinician [22] and peer support interactions [23] within
digital mental health services facilitate engagement with
technologies. As such, older adult peer support specialists’
shared experience may have a role in influencing engagement
in digital interventions among older adults with serious mental
illnesses.
The shared lived experience of parenting and grandparenting
between older adult peer support specialists and service users
may have facilitated the development of a supportive alliance.
Older adult peer support specialists’practice principles, unlike
those of clinicians, encourage sharing of their lived experiences
(or self-disclose) to support the recovery of individuals. The
use of intentional self-disclosure may have facilitated the
development of a supported alliance between older adult peer
support specialists and older adult service users.
Through sharing of experiences, older adult peer support
specialists offered wisdom related to navigating some of the
challenges resulting from age, illness, and life experiences.
Wisdom is a prototype of successful aging [24] and has been
found to enhance mental health and promote well-being in older
adults (without serious mental illnesses) [25]. Possibly, through
bidirectional sharing of knowledge of aging, illness, and life
experiences, both older adult peer support specialists and older
service users may assist one another in navigating some of the
challenges of aging successfully with a serious mental illness,
which could support older adults between clinical encounters.
This is also an important area for future inquiry. As peer support
is a nonmanualized form of support [26], peer support specialists
aged 50 years or above may offer different lived experience
expertise than their younger adult peer support specialist
counterparts, based on their level of expert knowledge (ie,
wisdom).
This study is not without limitations. First, it is not known
whether we met saturation. Qualitative interviews are conducted
until there is saturation of data (ie, saturation means that
researchers reach a point in their analysis where sampling more
data will not lead to more information related to their research
questions) [27]. By drawing from grounded theory design [18],
saturation would generally occur with 20 to 30 participants in
total [28]; however, the sample size was small because the
primary study was conducted to assess feasibility [9]. It is
important to note that findings cannot be generalized; however,
the themes identified can be used to guide the development of
peer support text-messaging services as an adjunct to
evidence-based interventions [9]. Further, we were unable to
stratify our data by demographic characteristics owing to the
sample size. For example, one peer had a master’s degree in
social work, and this advanced educational background likely
influenced the person’s delivery of services. Second, peers met
in person with participants over a 12-week time frame, and
in-person follow-up discussions from text messages are not
reported. Third, the sample involved a heterogeneous group of
people with psychotic disorders and mood disorders that
predominately included those with major depressive disorder.
Fourth, the participants in this study were all receiving mental
health services, and therefore, our findings cannot be generalized
to individuals with serious mental illnesses not enrolled in care
or without access to mental health services. Finally, the results
elucidate text message themes between older adult peer support
specialists and older adults with serious mental illnesses and
chronic health conditions; however, it is not known whether the
peer-to-participant text message exchanges can improve
self-management and other clinical outcomes.
Conclusion
Older adult peer support specialists are an emerging part of the
service delivery system for older adults. Older adult peer support
specialists offered text message–based age-related experiential
contributions to support aging successfully with a mental health
and physical health condition. Through older adult peer support
specialists’ wisdom, sharing of new late-life coping skills and
similar age-specific roles in life and encouragement to use
technology to support medical and psychiatric self-management
may promote engagement in nontraditional support services (ie,
YouTube) and support for older adults with serious mental
illnesses in the community between clinical encounters.
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Acknowledgments
KF was funded by a K01 award from the National Institute of Mental Health (K01MH117496)
Conflicts of Interest
KF provides consulting services through Social Wellness and discloses interest with Trust and InquisitHealth. The other authors
have no conflicts to disclose.
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Edited by G Eysenbach; submitted 27.07.20; peer-reviewed by J Urff, M Wasilewski; comments to author 17.11.20; revised version
received 26.12.20; accepted 17.01.21; published 02.03.21
Please cite as:
Mbao M, Collins-Pisano C, Fortuna K
Older Adult Peer Support Specialists’ Age-Related Contributions to an Integrated Medical and Psychiatric Self-Management
Intervention: Qualitative Study of Text Message Exchanges
JMIR Form Res 2021;5(3):e22950
URL: https://formative.jmir.org/2021/3/e22950
doi: 10.2196/22950
PMID:
©Mbita Mbao, Caroline Collins-Pisano, Karen Fortuna. Originally published in JMIR Formative Research
(http://formative.jmir.org), 02.03.2021. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction
in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete
bibliographic information, a link to the original publication on http://formative.jmir.org, as well as this copyright and license
information must be included.
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