Peer Education: Productive Engagement for Older African Americans in Recovery From Depression

Abstract

Background and Objectives

Older adults who have personal experience with the mental health service delivery system gain unique and potentially valuable insight from their treatment experiences. Research suggests that incorporating trained individuals in recovery from a mental illness (i.e., peer educators) into mental health service delivery roles results in substantial benefits for current mental health consumers, particularly for older adults and racial and ethnic minorities who may feel disenfranchised from the traditional mental health service delivery system. However, little research has examined the impact of participating in these activities on the peer educators themselves.

Research Design and Methods

This mixed methods study examines the experiences of 10 African American older adults in recovery from depression currently working as trained peer educators. Peer educators reported feeling more positive, feeling their lives had significantly improved, and feeling better in general due to their peer educator roles.

Results

This qualitative investigation highlights four unique themes that can explain the benefit of serving in this capacity (i.e., Community Engagement, Life Long Learning and Education, Mental Health Recovery and Productive Aging).

Discussion and Implications

This study suggests that serving has a peer educator has a number of beneficial outcomes for African American older adults in recovery from depression.

Increasingly, mental health programs are creating service delivery roles for people who have experienced, or are currently coping with, a mental health condition. Built upon recognized principles of self-help and mutual support, these programs view the establishment of peer educator roles as a strategy for increasing the acceptability and accessibility of mental health and community support services, and for making services more sensitive and responsive to the needs of vulnerable adults with mental illness (Mowbray & Moxley, 1998). Furthermore, research suggests that individuals who have personal experience with the mental health service delivery system can offer a special kind of expertise not normally available from professional service providers, such as concrete and practical skills learned during their own process toward recovery.

Peer education services have an important role in the recovery of individuals with mental health disorders (Solomon & Draine, 2001), and are an important area of research and development in mental health (Davidson et al., 1999). By sharing tangible and practical skills learned during their own experiences seeking mental health treatment and recovery, peer educators can serve as positive role models for individuals currently in a state of mental distress (Champ, 1998). Peer education and support services also offer a mechanism for working with vulnerable populations, such as older adults or racial and ethnic minorities, who are in need of mental health services, but may feel alienated from the traditional mental health system (Segal, Gomory & Silverman, 1998). Peer educators who have shared characteristics with consumers (i.e., race/ethnicity, gender, age, income etc.), live in the same communities, and have personally encountered similar situations with mental illness, may be more effective than mental health professionals in providing relevant information, mitigating stigma, improving attitudes about mental health treatment and engaging consumers in needed mental health services (Mowbray & Moxley, 1998; Solomon & Draine, 2001). In this article, we examine the benefits and challenges of peer education as a venue for productive engagement roles for depressed African American elders.

Productive Engagement

There is no single accepted definition of the term productive engagement, but the term represents a shift in perspective that views older adults not as a burden to society, but rather as contributors, and recognizes the growing human capital among the older adult population that can be harnessed into activities and behaviors that make significant economic and social contributions (Morrow-Howell & Wang, 2013). Productive engagement includes a variety of roles including, but not limited to: providing supportive services, teaching, formal and informal care giving, and civic engagement activities. These roles typically involve a commitment of at least 1 day each week and occur within the context of an organizational setting. The settings through which an older adult can engage in productive roles are extensive and range from faith-based organizations and schools to social service agencies, non-profit community programs, and healthcare settings (Kaskie & Gerstner, 2004).The concept of productive engagement is particularly relevant for older adults as low birthrates and low death rates are transforming the age structure in the United States and globally such that the numbers and proportion of older adults continue to rise. While a growing number of older adults may require support services in late life due to chronic health conditions, a larger number of older adults are highly functioning, with a significant number of years after retirement to be productively engaged (Morrow-Howell & Wang, 2013). For the purpose of this investigation, productive engagement is distinguished from informal volunteering such that it involves discrete activities associated with community engagement and requires a greater commitment than most volunteering activities (Cutler & Hendricks, 2000; Kaskie & Gerstner, 2004).

Older adults have been placed at the forefront of discussions on productive engagement (Hinterlong & Williamson, 2007) and have been identified as a largely untapped social resource. Many researchers suggest that increasing productive engagement opportunities for older adults in this country will subsequently increase its’ social capital (Galston & Lopez, 2006; Harlow-Rosentraub, Wilson & Steele, 2006). National aging organizations such as the American Society on Aging, The National Council on Aging and the Gerontological Society of America have all made productive aging a priority of recent education and programming efforts (Kaskie, Imhof, Cavanaugh & Culp, 2008). Research also suggests that baby boomers indicate a strong interest in continuing life-long learning, personal development, and being engaged in meaningful paid or unpaid work (Wilson & Simson, 2006) and remaining actively involved in their communities (Hart, 1999, Hart, 2002). As a growing number of baby boomers are facing retirement, this is a critical time to begin developing and sustaining meaningful productive engagement opportunities.

A critical notion supporting the increasing interest in productive engagement is the well documented relationship between productive activities and health status. Research has identified a strong correlation between productive engagement and successful aging (Everard, Lach, Fisher & Baum, 2000; Rowe & Kahn, 1997; Rozario, Morrow-Howell & Hinterlong, 2004). An abundance of empirical evidence suggests that older adults who continue to work, volunteer, or become involved in civic roles will maintain improved physical and mental health as they age compared to their counterparts not engaged in such activities (Glass, de Leon, Marotolli, & Berkman, 1999; Morris & Caro, 1995; Seeman & Crimmins, 2001). Morrow-Howell and colleagues analyzed longitudinal panel data from 1,669 older adults and found that volunteering in late-life is associated with improved physical and mental health, as well as with reduced mortality rates and decreased depressive symptoms among older adults. Musick and colleagues (2000) found that older adult volunteers had a reduced risk of mortality, even after controlling for the impact of social involvement, health, and class. The relationship between volunteering and more life years was observed among volunteers age 70 and older (Luoh & Herzog, 2002; Harris & Thoresen, 2005) as well as in a recent national study of volunteers age 50 and older (Lee et al., 2011). Furthermore, involvement in civic engagement activities has been shown to reduce mortality rates among older adults at the same levels as physical fitness activities (Glass et al., 1999). Older adults’ self-reported physical health and emotional health significantly improved after just 1 year of formal volunteering (Harlow-Rosentraub et al., 2006), and Avlund and colleagues (2004) observed similar results for older adults who provided informal social assistance. In addition to health benefits, Moen and Fields (2002) found that retirees who were engaged in formal volunteering activities reported higher levels of mastery, self-esteem, energy, and greater life satisfaction. These findings suggest that productive engagement is a conceivable pathway to late life health (physical, mental, and social), reinforcing the importance of further research in this area.

Race, Peer Education, and Productive Engagement

Research suggests that productive engagement may vary by race; however the literature is not resolved on this issue. Productive activity typically occurs within the framework of social roles, which are socially constructed and shaped by a multitude of social and cultural factors (Hill & Sanford, 1995). Racial prejudice or discrimination, and lower levels of education and income, can result in unequal access to productive roles for racial/ethnic minorities (Dannefer, 2003; Musick, Wilson, & Bynum, 2000). Research suggests that race affects the amount and range of volunteer and work activities engaged in by older adults. For example, The National Academy on Aging Society (2000) found that older African Americans are more likely to undertake formal paid employment than their white counterparts. Older African Americans are also less likely to engage in formal volunteer activities than their white counterparts (Independent Sector, 2000; Musick et al., 2000). Hinterlong & Williamson (2007) found that older whites report being involved concurrently in a greater number of productive activities and spent more time involved in these activities as compared to their African American counterparts. On the contrary, Hooyman and Kiyak (2005) noted that older African Americans have a higher rate of organizational membership and are more likely to be engaged in informal productive activities (e.g., church). These differences in choice of productive engagement activity highlight the need to explore the impact of explicit productive engagement activities within diverse racial/ethnic groups. The current study begins to address this research gap by examining the benefits and challenges of serving as a peer educator among 10 African American older adults with a history of depression.

Method

Research Design

We utilized a two-phase sequential mixed methods approach to examine benefits and challenges of serving as a peer educator among 10 African American older adults with a history of depression, and to assess the opportunities for productive engagement as a result of serving in this capacity. Utilizing a mixed methods research design can aid researchers in answering a broader and comprehensive range of research questions, provide stronger evidence for a conclusion through convergence and corroboration of findings, and produce more complete knowledge necessary to inform theory and practice (Creswell, 2003, 2009). The first phase of the study involved a cross-sectional survey research design, and the second phase involved individual semi-structured interviews. Survey methodology was utilized to attain a broad understanding of how serving as a peer educator impacted the older African Americans in the current study and whether it provided beneficial and meaningful opportunities for productive engagement. Subsequently, we used semi-structured interviews to collect qualitative descriptive data to identify and explore the unique experiences of these African American elders in recovery and to further probe about the impact of serving as a peer educator on their self-esteem, quality of life, and mental health recovery process.

Setting and Participants

Study participants were recruited from a community-based primary care center located in an urban, largely low-income African American community, within an Eastern city in the United States. Initially, a purposive sampling approach (Strauss & Corbin, 1998) was used to seek out and identify 42 African American older adults (aged 60–93) who self-identified as having a recent depressive episode. We did not utilize any formal depression screening tool. Inclusion criteria included African Americans who: (a) were 60 years of age or older, (b) self-identified as having experienced a depressive episode within the past 5 years, and (c) had sought professional treatment for their depression and self-identified as in recovery. Results from this focus group are presented elsewhere (Conner et al., 2010). From the 42 focus group participants, 10 were selected to be trained as peer educators based on: (1) their willingness to participate in the formal training, (2) their ability to openly share their experience with the mental health service delivery system, and (3) their excellent communication skills. Research team members used observational methods during the focus groups to determine which participants best met these criteria. The current study focuses on these 10 subsequently trained peer educators.

Procedures

This research project was the result of collaboration between the authors and a local community-based health center. Initial discussions with the community-based health center focused on the large number of older African Americans receiving primary care services at the center that were also suffering from depression, but not receiving mental health services. We used community-based participatory research (CBPR) methodology to develop a research project that would benefit the older African Americans at the community health center, which could also be translated and disseminated into other communities. From these discussions emerged the idea of developing a peer support network. Older African Americans who had a history of depression and were currently in recovery, would be trained to be peer educators and would be paired with acutely depressed (i.e., currently diagnosed with a clinical depressive disorder by their primary care provider) study participants (i.e., peers) to provide support, education, information, and serve as a bridge to helping their peers access needed mental health resources. Although including individuals with a recent depressive episode may be risky (e.g., potential for relapse), it was important to train peer educators who could accurately remember and speak to their mental health treatment experiences. We minimized this risk by conducting bi-weekly brief depression screens (PHQ-2: Kroenke, Spitzer & Williams, 2003) to ensure any significant symptoms suggesting potential relapse would be addressed immediately.

Ten peer educators participated in a rigorous, paid, training program that consisted of a five session, 20-h, manualized training protocol comprised of lectures, role play, and group discussion. This training was developed by the lead authors, with the involvement of community stakeholders and community partners, and was provided by the lead authors. While this training is not evidence-based, it was developed specifically for African American older adults, and drew upon the principles of motivational interviewing (Miller, 2012). This training was mental health focused and training topics included: signs and symptoms of depression, depression and aging, co-morbidity, types of depression treatment, barriers, and pathways to depression treatment, role of the peer educator, confidentiality, communication skills, communicating with providers, crisis management, suicidality, mental health resources, problem-solving, and motivational interviewing.

Peer educators met their acutely depressed peers through a referral from the primary care physicians at the community-based health center through the research project. The research team assigned the peer educators a “peer” based upon evaluations of best-fit and preferences of the peer (i.e., gender and age). Peer educators were instructed to contact their peer to set up an initial visit and were required to meet with them at least three times (at least once in person) over a 2-month period. There was no upper limit to the amount of contacts, and all interactions over the three-session minimum were at the initiation of the peer. On average, peer educators met with their assigned peers six times, and the average length of time spent with their assigned peer was 1 h for in-person contacts and 30 min for phone contacts. Meetings took place at the discretion of the peer educator and their assigned peers, but most frequently occurred at the home of the peer, a local coffee shop or a senior center.

Peer educators did not function as mental health counselors, and this was emphasized in the training process. Peer educators provided information about depression, treatments, and the referral process, supported participants as they moved through this process, and helped them initiate and engage in needed mental health services. Peer educators were monitored closely by the lead authors through bi-weekly supervision sessions and critical review of peer educator contact notes to ensure boundaries were maintained and that peer educators were engaging appropriately (e.g., supportively and not clinically) with their assigned peers. Peer educators did not collect any data from their assigned peers, however they did take notes on a standardized form that indicated the main goals of their interactions, resources their peers identified needing, and plans for future interactions. In addition to working directly with their acutely depressed peers, peer educators attended a mandatory bi-weekly supervision meeting with project researchers/clinicians to discuss their current cases, and to receive critical feedback, further information and additional training and education. Peer educators were paid modestly for their interactions with their peers ($25 for in person visit, $15 for telephone contact) and were not paid for completing the survey or interviews discussed in this manuscript. Funding for the current project was supported by a Steve Manners Faculty Development Award, University of Pittsburgh (Pittsburgh, PA), and a Career Development Award from the National Institute of Mental Illness (5K23MH 090151-06).

Cross-Sectional Survey

The survey consisted of 20 items developed by the research team (10 demographic and 10 related to benefits and challenges). The questions were designed to obtain information about the participants’ perspective on the benefits and challenges of serving as a peer educator, the impact of serving as a peer educator on their motivation to volunteer and be productively engaged, and finally the impact of serving as a peer educator on their views of mental health and mental health treatment.

Semi-Structured Interview

Interviews were conducted with all peer educators (N = 10) at 12 months, after the intervention had ended. Interviews were conducted in the homes of each peer educator. Interviews lasted approximately 45 min and followed a semi-structured format. Examples of questions asked included: “What has the experience of being a peer educator been like for you?”; “What have you found to be the most helpful about the training you received?”; “What has it been like working with depressed peers?”; “What challenges have you had to deal with?”; “How has this project personally benefited you?”; and “Has helping others changed how you look at yourself?” Probes were utilized by the facilitator to gain deeper understanding into individual responses.

Data Analysis

Qualitative techniques suggested by Zemke and Kramlinger (1985) were utilized to ensure the analysis was systematic and rigorous. The semi-structured interviews were audio-recorded and subsequently transcribed by a professional transcription agency and checked for accuracy. Thematic analysis was utilized to analyze the transcribed qualitative data. This qualitative data analysis technique entails developing themes and codes that are observed directly or emerge from the data being studied. Thematic analysis involves observing data, recognizing it and attempting to understand it through encoding and interpretation. The computer software program, Atlas ti (Scientific Software, 1999) was utilized to support the organization and analysis of the qualitative data. This program aided in the process of coding the transcripts and retrieving thematically structured and ordered-text segments. The thematic analysis process involved: (1) producing a comprehensive inventory of important ideas, expressions, terms and phrases that reflect the language and views of participants, (2) generating categories under which identified ideas were placed, and (3) clustering the categories to identify broader themes and patterns that emerged from the data (Zemke & Kramlinger, 1985).

Transcript data were analyzed using in vivo (line-by-line) coding to categorize responses. Each line of text was read and assigned a code. Codes were subsequently clustered to generate categories of data. Subcategories were constructed when needed. An open coding framework was used to aid in the process of code and category development. The lead author and co-investigators independently coded the 10 interview transcripts, and subsequently met on a weekly basis to discuss any differences in the codes assigned to the text and to attain agreement about the coding process style. After a thorough discussion about reasons for coding differences and correcting redundant coding, the research team came to an agreement about the coding assigned to lines of text and a final codebook was created. The final version of the codebook was utilized to re-code all the qualitative data. Categories of data were then combined to create over-arching themes and matrices were utilized to identify broader patterns and recurring themes across the 10 interviews. Despite a small sample size, saturation of the data was met at 10 interviews.

Results

Participants included 10 older adults (mean age of 65) who completed training and served as a peer educator. Nine of the 10 participants were female and all identified themselves as African Americans. All self-reported as having a history of major depressive disorder. All received some sort of treatment for their mood disorder in the past (seven psychosocial intervention and three medication therapy) and identified themselves as currently in recovery. Six of 10 had graduated from high school and attended at least some college. All participants identified themselves as retired, and none was employed outside of their work as a peer educator.

Overall, participants identified a number of clear benefits they and others received based upon their participation as a peer educator. All 10 participants felt it was “very true” that their work with peers had a positive impact on the community, their assigned peer and on themselves. All participants also identified social benefits (e.g., sharing resources with family and friends, increased social circle) and had better perceptions of themselves and their lives (i.e., responses of very or somewhat true). Participants also identified a number of changes in terms of their attitudes toward mental health issues and treatment (Table 1). All 10 reported feeling their views of mental health treatment had become more positive after working as a peer educator (“very true”). Specifically, they were more interested in learning about mental health, and more willing and likely to seek mental health treatment. They also were more likely to volunteer in the future as a peer educator and in other settings.

Table 1.

Survey Responses for Peer Educators (N = 10)

Item	Very true	Somewhat true
Felt their work with peers had a positive impact	10 (100%)	0 (0%)
Participating as a peer educator changed their outlook about mental health treatment in a positive way	10 (100%)	0 (0%)
More interested in learning about mental health	10 (100%)	0 (0%)
More positive about seeking mental health treatment	10 (100%)	0 (0%)
Felt better about themselves because of involvement with the project	8 (80%)	2 (20%)
More likely to seek mental health treatment if they became depressed in the future	8 (80%)	2 (20%)
More likely to volunteer in the future	8 (80%)	2 (20%)
Brought resources, information and new skills back to family and friends	7 (70%)	3 (30%)
Increased their circle of friends and acquaintances	7 (70%)	3 (30%)
Felt their life has improved because of their involvement with the project	7 (70%)	3 (30%)

Note: Survey response options were “very true,” “somewhat true,” “somewhat false,” or “very false”.

Interview Results

Results of thematic analysis yielded four over-arching themes: Community Engagement, Life Long Learning and Education, Mental Health Recovery, and Productive Aging. Table 2 presents descriptions of the four themes and illustrative quotes. The following paragraphs highlight additional key quotes from study participants that reflect the identified themes. Names presented are pseudonyms to protect the anonymity of study participants.

Table 2.

Themes From Semi-Structured Interviews with Peer Educators (N = 10)

Theme 1: Community engagement
Wanting to help, but not knowing how	“I have always wanted an opportunity to give back. To give back to my own community and people. And I never had a good way to do it. I never knew of any opportunities where I could help. Where someone would think what I had to say was actually valuable. This program gave me a way to do that.” (Andrea, female, age 70)
Reducing isolation by helping others	“Before this project I never left my house. I didn’t have a reason to. But now I have a reason to get up in the morning. And it’s a good reason, because I am helping to improve my community. Who would have ever thought I would be able to do that?” (Alice, female, age 80)
Gaining confidence and positive feelings by helping others	“I have gained so much from being involved in my community. From being helpful you know to other people it makes you feel good it really does it makes you feel good. I’d far rather give something to people then for somebody to give me something… it’s just the feeling that you get when you get around a group of people. I used to go nowhere and nobody knew me and now I don’t care where I go, now people know me. Everywhere I go people know me and they know I am here to help. People ask me for advice and people come to me to get information…so it does give you a lot of confidence and a lot of good feelings about yourself”. (Janice, female, age 62)
Opportunity to use existing skills	“I’m a social worker by trade so I know a lot of resources that are out there and even if I don’t I know how to find them you know I know there’s a help line. And a lot of seniors don’t know how to find those resources. By me being active in my community I can connect people to those resources and if I have a question about where to go for this that or the other this program has provided me with a directory of services. It’s like I get a second chance at my career.” (Talise, female, age 62)
Theme 2: Life-long learning and education
Appreciation of learning at any age	“I love to learn so I found there’s some stuff that I can keep on learning you know living and learning.” (Michelle, female, age 63)
Learning communication skills	“Taught me how to listen. And how to be present. And how to really understand someone else’s problems from their perspective. I am a much better communicator now. People in my family call me the family counselor.” (Mike, male, age 60)
Learning about mental health as beneficial to community, family, self	“The [Peer Educator] training for myself was excellent for one …. there is different degrees of depression that I did not know and some do need a pill and some just need someone to talk to. It taught me about all the different kind of treatments for depression. Things I never knew before. Things I didn’t know I was capable of learning at my age. And now I can better help other people in my community, or my own family or even myself if I ever get sick again.” (Marie, female, age 65)
Learning from other peer educators	“Listening also to other people and the stories of how they handled different situations gives you a peek or so of what you can use dealing with your person your peers. I learned a lot from the other group members.” (Alice, female, age 80)
Theme 3: Mental health recovery
Changing views of mental health issues and treatment in self and others	“It’s helped me learn a lot about the mental health field and how even in my own family has different needs and it helps me to see that problems people in my family had maybe were because of a mental illness, so I use the word crazy a lot less now… The training has helped me to deal with a lot of my own shortcomings and my own depression…as well as giving me an opportunity to help someone else figure out where they are in their recovery.” (Jessica, female, age 62)
Giving and receiving social support with other peer educators	“I like the way we just I think sometimes we just get off of the meeting you know and we just really discuss our own lives. I think it’s more of a fellowship then a meeting or whatever (laugh) I just really enjoy it you know and then even coming home when talking with the two ladies that ride with me to this meeting was so good for me you know it’s just so helpful. It helps you to cope with your own situations.” (Jamie, female, age 74)
Theme 4: Productive aging
New sense of value	“I see myself as a valuable member of society and that wasn’t always the case.” (Mike, male, age 60)
New sense of purpose	“By helping other people you get more out of it than you can imagine when I go places people know me and the more you give the more you get you know people so people recognize that plus the fact I really have a new goal in this life that I’m working towards and now I have more of a purpose. Makes me have a reason to get up in the morning.” (Marie, female, 65)
Contributing in a different way than when younger	“This has improved how I look at myself and the respect that everybody has a purpose in life…and it has really made me examine that. As we age our lives it changes it somewhat but not really a whole bunch but it’s like if you’re a type of a person um say a helper your gonna help all your life. Maybe the people will just change and your help will change in a different way. [For] me I’ve always been with children. I’ve always been raising somebody’s kids and so I thought that was my only purpose in life but now I seen that I’m older I’m still helping but it’s a different and its still good…It’s just like I am old, but I still can do something…so I really feel great that now that I’m older I’m still helping…” (Alice, female age 80)

Community Engagement

Study participants were overwhelmingly positive about their experience serving as a peer educator. Many participants identified their involvement as a unique and meaningful way to be involved and actively engaged within their community. Andrea, a 70-year-old woman, elaborated:

“I have always wanted an opportunity to give back. To give back to my own community and people. And I never had a good way to do it. I never knew of any opportunities where I could help. Where someone would think what I had to say was actually valuable. This program gave me a way to do that.”

Participants stated that before this project they were feeling very isolated. Many of their friends had died, their spouses had passed on, and they had few connections to people in their communities. Alice, an 80-year-old woman, stated: “Before this project I never left my house. I didn’t have a reason to. But now I have a reason to get up in the morning. And it’s a good reason, because I am helping to improve my community. Who would have ever thought I would be able to do that?”

Working as a peer educator provided an opportunity for these elders to be actively engaged in their own community in a relevant and meaningful way and gave them a sense of belonging and pride. For some participants, this community engagement opportunity provided a mechanism for them to utilize skills they attained throughout their years in the professional workforce, and to continue to serve and help others in their community.

Life-Long Learning and Education

In addition to being excited about becoming more active in their community, peer educators were excited about opportunities to continue to learn. Most peer educators in the current study had graduated high school and completed at least some college, and identified an appreciation for education and knowledge. However, since being retired most had not had an opportunity for continued education. The peer educator training and bi-weekly supervision meetings gave them such as opportunity. Michelle, aged 63 stated: “I love to learn so I found there’s some stuff that I can keep on learning you know living and learning”. Alice, an 80-year-old woman stated “It has been decades since I was able to really use my brain and learn some new things. It felt really good to kinda be in school again and come home after each meeting feeling like I had learned something new. Despite what anyone says, I know now you are never too old to learn”. Peer educators talked in great depth about what they learned in the trainings. Mike, a 60-year-old man, stated that the training:

“Taught me how to listen. And how to be present. And how to really understand someone else’s problems from their perspective. I am a much better communicator now. People in my family call me the family counselor”.

Peer educators stated that their increased knowledge about mental health, mental illness, and treatment helped them to better understand their own mental illness as well as the mental health concerns of their friends and family members. Jamie, a 74-year-old woman stated: “I learned a lot of things that I didn’t know about mental health and it helped me with helping my daughter because she’s bipolar and it helped me to really kinda understand her where I didn’t understand it at first till I started getting this education”. Wanda, a 65-year-old woman goes on to state:

“[This training] helped me to understand to cope with my own my own family my own granddaughter you know and especially that one time when we had the session about anger management …a lot I didn’t know I thought she was just being a teenager or whatever but it has helped me to understand her a little bit more and even with my son and with my own family you know there is always something I learn that helps me to help the people around me. Even myself”.

Peer educators also noted that it was not just the training and supervision presentations from the research team that helped them, rather they learned from others in the group who they also identified as their peers. Often, peer educators found that they had been in similar circumstances with other trainees and the peer educator training and supervision sessions offered opportunities for group sharing and learning. These opportunities were also the richest for meaningful learning and support.

When asked how the peer educator meetings and supervisions were helpful, Mike aged 60, responded: “They are helpful to the extent of putting us in contact with other people who are in similar situations that we have been in and so being peer educators and being in some of those situations and discussing those in the group and then learning from one another is crucial. One person might have a situation that they discuss but maybe I wasn’t confronted with it but since say (Janice) had that situation and we discussed it in that meeting I can learn strategies from her to better help the people that I am dealing with.” Alice, aged 80 goes on to say: “Listening also to other people and the stories of how they handled different situations gives you a peek or so of what you can use dealing with your person your peers. I learned a lot from the other group members”.

Mental Health Recovery

Many peer educators identified that the training they received helped them deal with their own mental health symptoms, recovery, and other mental health concerns among their own family members and friends. In fact, the training seemed to change the way some participants look at mental illness. Jessica age 62 stated “it’s helped me learn a lot about the mental health field and how even in my own family has different needs and it helps me to see that problems people in my family had maybe were because of a mental illness, so I use the word crazy a lot less now”. Jessica elaborated:

“The training has helped me to deal with a lot of my own a short comings and my own depression…as well as giving me an opportunity to help someone else figure out where they are in their recovery.”

Michelle, a 63-year-old woman, stated:

“It benefits me from seeing and hearing the struggles that other people are going through and to know that I have been trained to let them know there’s something out there other than institutionalizing them... I’ll know that if I get into any of those predicaments there is something out there for me as well”

Peer educators also discussed the benefit of just attending the meetings and how these trainings became more than education sessions, but also became pseudo support groups. Peer educators in the group became friends and became a source of social support for one another. These relationships extended beyond the scope of the project and continued after the project had ended.

Productive Aging

Peer educators gained more than just education and training from this program. They felt that this program enhanced their self-esteem, their confidence, their self-efficacy, and made them feel like productive members of society. Mike, aged 60, stated: “I see myself as a valuable member of society and that wasn’t always the case.” Alice, aged 80, went on to say: “At my age…It makes me feel pretty good that I’m still able to help somebody else in need you know who is struggling… another senior.” Jamie, aged 74, stated: “Participating in this project has made me feel like I have something to offer, like I have something to give”

Study participants recognized that working as a peer educator gave them the ability to help someone else in their community, and that offering that service helped them in return. Participants felt that they were given a special gift being able to use their knowledge and skills to work with people in need, and that made them feel a boost of self-worth and gave them a sense of new found purpose in their later years of life. Jessica, aged 62, stated: “It gives me a tremendous feeling of self-worth it also makes me feel like you know well we all like to think that we’re smart in certain areas but it gives me the opportunity to help someone else come to this position this circle that I am standing in right now”. Marie, aged 65, stated:

“By helping other people you get more out of it than you can imagine when I go places people know me and the more you give the more you get you know people so people recognize that plus the fact I really have a new goal in this life that I’m working towards and now I have more of a purpose. Makes me have a reason to get up in the morning”.

Challenges

We also asked participants to also identify challenges. However, participants had a very difficult time identifying any. The only challenge specifically identified by the peer educators was the desire to spend more time with their assigned peers and having difficulty pulling away from those relationships once the study had ended. In fact, many peer educators reported staying in contact with their assigned peers long after the study had ended. This suggests that the peer educators had, in fact, started to value their relationship with their assigned peer, and perhaps were also reaping the benefit of mutual aid support often identified in these relationships.

From the perspective of the lead author, other challenges not identified by the peer educators included: identifying and maintaining boundaries between the peer educators and their assigned peers, the continued assessment of peer educators to confirm they had not relapsed back into their depression, and personality conflicts between the peer educators and their assigned peers. Due to having numerous demographic similarities, often maintaining a professional boundary between the role of a peer educator and that of a friend was blurry. Peer educators were typically assigned to individuals who they would likely be friends with outside of this project. There were also additional boundary issues that were unanticipated, for example, a study participant becoming romantically interested in their peer educator. While it was important to train peer educators with recent experiences with the mental health system (within 5 years), this also carries with it a risk of relapse. Therefore, the research team had to consistently evaluate the mental health of the peer educators to determine if they were fit to continue in their work as a peer educator. There were also a few occasions where the personality clashes between the peer educator and their assigned peer, quite often based upon religious differences, made it necessary for the research team to step in and re-assign a case to a different peer educator. The observations of the lead author will be presented in more detail in a future manuscript.

Discussion and Implications

The goal of this study was to examine the experiences of 10 African American older adults in recovery from depression currently working as trained peer educators. Overall, findings from the current study highlighted the benefits of training older adults in recovery from mental illness to become peer educators and to identify peer education roles for them in research projects and clinical programs. The peer educators we interviewed largely felt that their participation in the project was positive. Many identified their work as beneficial to their own family and friends, and themselves. All peer educators felt better about themselves and that their lives had improved as a result of their work. They also reported enhanced knowledge around mental illness and treatment options and felt that they would be more likely to seek professional mental health services if they needed them in the future. They also reported being more willing to volunteer in the future.

The need for interventions to support productive aging is critical for older adults, and for older racial/ethnic minorities in particular. Because we know that older African Americans are less likely to engage in volunteer activities, policies and programs are needed to increase culturally meaningful opportunities for this population, which in turn supports productive aging. (Gonzales, Matz-Costa, & Morrow-Howell, 2015). According to Morrow-Howell and colleagues (2015), solutions to increase productive aging in our society should be guided by principles of choice, opportunity, and inclusion. The peer educator model reported here not only demonstrated the potential to provide a productive engagement opportunity, but it also provided the opportunity with and for older African Americans. Furthermore, it has the potential to decrease mental health service utilization disparities among a population where mental health service utilization is often considered taboo.

Semi-structured interviews yielded four distinct themes. First, participants felt that working as a peer educator gave them an opportunity to be actively involved and engaged within their own communities and give back to their people in a meaningful way. Many older adults can feel isolated and disenfranchised from their communities as they age (AARP Foundation, 2012; Nicholson, 2012) particularly in urban and low income areas, where resources are in short supply and community members may not frequently interact (AARP Foundation, 2012). While services and goods may be in short supply in their relative communities, the peer educators were able to utilize their skills and training to give back something meaningful, making this peer educator role more gratifying than other volunteer roles. Peer educators in this project reported feeling isolated and not knowing how to help, but wanting to contribute to their community. Working as a peer educator gave them a positive reason to be active in their community and made them a resource and point of contact for others in their communities who needed help. This is important because keeping older people involved in their community can substantially reduce the anticipated drain on financial, health care, and housing resources associated with an aging population (Brown, Hoye & Nicholson, 2012).

Second, peer educators were excited to have an opportunity to engage in a late-life learning activity. Many peer educators felt they learned strategies that could help them in their own lives as well as lives of their peers, friends, and family members. They reported improved communication skills as well as knowledge about mental health issues and treatment. It is also important to note that they reported learning from each other, not just the trainers. This learning could have many benefits for these older adults, including protecting or improving their cognitive, social, and emotional functioning. An abundance of empirical literature suggests that learning as an older adult can decrease involvement with government funded services and increase personal and community well-being (Biggs, Carstensen, & Hogan, 2012; Field, 2009).

Third, participants felt that participating in this project contributed to their mental health and emotional well-being and aided in their own mental health recovery process. As they learned more about mental health issues, they reported viewing others and themselves in a different light, perhaps more compassionate and less stigmatizing (e.g., “I use the word crazy a lot less now”). They also reported being helped in their mental health recovery by providing and receiving social support from the other peer educators. This finding is critical due to the stigma that still exists about mental health treatment in the African American community (Conner et al., 2010).

Lastly, participants identified that working as peer educator enhanced their self-esteem, self-confidence and self-efficacy resulting in enhanced productive aging. A key issue in aging is social integration, the extent to which a person is actively connected and engaged with their family and community. Cross-cultural evidence shows that older adults are able to maintain a fairly high level of physical and emotional well-being when they have something considered valuable by others in their society, whether it be customs, skills, knowledge, or economic resources (Cook, 2011; Lin et al., 2016; Morrow-Howell & Wang, 2013). Given the historical context of these participants; who may have openly and more explicitly experienced racism, the feeling of being valuable cannot be underestimated. Having an opportunity to be productive in society as we age and to feel good about what we are able to give is a key factor to healthy aging (Brown et al., 2012). Research also suggests that older adults seek novel ways to experience new meaning as they age. Meaning has to do with feeling that your life still matters and that what you do makes sense. It has to do with the conviction that your life is about something more than simply surviving. Volunteer activities, for example, have been found to bring new meaning to the lives of men and women at midlife and beyond by allowing them not only to perform useful services but also to function as mentors (Kim, Koniak-Griffin, Flaskerud, & Guarnero, 2004). Serving as a peer educator offers such an opportunity.

Although the themes from this study indicate that serving as a peer educator has many benefits, this was only one small cross-sectional study, and we were unable to capture different attitudes and beliefs over time. We did not determine, through standardized means, whether peer educators had depression or depressive symptoms. Self-reported depression may have occurred as long as 5 years ago, limiting the currency and recall of illness on the peer educator. In addition, given the small and purposive sample recruited for this study these findings are limited in their generalizability. However, given that there are few previously reported qualitative studies that examine the benefit of community engagement activities for African American older adults, these findings represent an important step in identifying culturally relevant models for community engagement and productive aging for vulnerable populations. The findings also are consistent with results from other studies of productive engagement and volunteerism in older adults (Gammonley, 2009; Moen & Fields, 2002; Thoits & Hewitt, 2001).

Conclusions

This study advances research regarding peer educator roles for older adults with mental health treatment histories by focusing on the benefits of this role for the peer educator. Prior research has demonstrated benefits for older adults with depression receiving services from a peer educator by: reinforcing effective self-management techniques through peer modeling, reducing stigma, and observing the peer educator as a model for community-based depression education and productive engagement. What this study adds is evidence that serving as a peer educator for depression treatment is a satisfying and beneficial role for the peer educator, in multidimensional ways. Peer educators perceived they were contributing to their communities, serving as a resource for friends and family, learning more about mental health, and bolstering their own mental health recovery.

These findings highlight the importance of developing additional beneficial and meaningful productive engagement roles for older adults that can be incorporated into research and mental health practice. There is already a significant need to help the many older adults not receiving depression care, not to mention the growing numbers of older adults that are predicted to overwhelm the health, social service, and mental health systems in a “silver tsunami” (Bartels and Naslund, 2013). Peer educators could be critical to filling this service gap, and there are multiple service systems and community structures through which peer educators could function. For example, the U.S. Administration on Aging (AoA) estimates their networks deliver 900,000 meals per day to older adults across the nation (AoA, 2007). Peer educators could be identified, trained, and supported through the home-delivered meals program or AoA’s many other community- and home-based services. Many other possibilities exist as well, such as other service organizations (e.g., Alzheimer’s Association), health care organizations, religious communities, and volunteer programs for older adults. The utilization of a peer educator framework can be a sustainable community-based health strategy. While peer educators should be paid for their valued activities, the cost to add a peer educator to an intervention team is significantly less costly than a trained mental health professionals. Research findings support the use of peer educators as a cost-effective healthcare delivery strategy promising community-based sustainability over time (Kim et al., 2004). Future research should utilize cost-benefit analysis to examine the benefit of peer educator interventions and identity additional strategies for prolonged sustainability. While there are many challenges to implementing such programs (e.g., financial constraints) we propose that the benefits to mental health consumers, and the benefits to the peer educators themselves, may far outweigh the costs.

Findings from the current study will help to engage older adults as peer educators, because previous peer educators have shown that they can assume this role, be effective in helping other older adults, and benefit themselves. There are many opportunities to engage older adults with depression histories as peer educators, and to conduct research regarding optimal ways to provide peer support, train and supervise peer educators, and implement peer education programs in diverse settings with diverse older adults.

Funding

This work was supported by the National Institute of Mental Health (5K23MH 090151-06) and a Steve Manners Faculty Development Award.