Scaling up peer support for mental health recovery globally: The UPSIDES project

The UPSIDES (Using Peer Support In Developing Empowering Mental Health Services) project was initiated to develop, implement, and evaluate structured peer support interventions across high-, middle-, and low-income countries. Between 2018 and 2023, the consortium worked across eight locations in six countries: Germany (Ulm, Hamburg), Uganda (Kampala), United Kingdom (London and Nottingham), Tanzania (Dar es Salaam), Israel (Beer Sheva), and India (Pune).

The project aimed to scale up peer support for adults with severe mental health conditions and assess its effectiveness and implementation pathways. UPSIDES used a mixed-methods design combining a multi-country randomised controlled trial (RCT), qualitative research, process evaluation, and stakeholder engagement.

Local Advisory Boards (LABs) made up of a range of stakeholders such as service user representatives, mental health professionals, policymakers, carers, community or religious leaders were established at each site. The project team engaged with LABs regularly throughout the project including through participatory workshops to co-develop a Theory of Change, biannual LAB meetings at each site and contacting LABs as needed.

The UPSIDES project generated substantial evidence of impact across clinical, social, and systemic domains.

• Improved social inclusion and empowerment: The RCT revealed significant improvements in social inclusion, hope, and empowerment among participants receiving peer support, compared to those receiving usual care.

• Identified mechanisms of change: UPSIDES found that peer support promotes recovery and psychosocial functioning of service users mainly by strengthening two factors: social inclusion and hope. These factors acted as mediators, meaning they explained how peer support led to better outcomes.

• Adaptable training toolbox and manual: UPSIDES developed a flexible training programme and implementation manual for peer support workers. The manuals are applicable to diverse settings with guidance on how to adapt certain elements to fit local needs.

• Stakeholder buy-in and local system integration: Continuous stakeholder engagement via Local Advisory Boards helped ensure that the project was appropriate in each setting and had local support. In several sites, peer support has since been included in routine mental health service structures. For example, in Ulm (Germany), the district hospital in Günzburg employed UPSIDES peer support workers on permanent contracts to provide support on two inpatient wards.

• Knowledge generation and global influence: The project has contributed to over 20 publications and has helped shape global discussions on recovery-focused mental health care in diverse settings. It demonstrated that structured peer support can be both feasible and impactful across many different mental health systems. UPSIDES has helped put peer support into practice as a recovery-oriented intervention globally. It demonstrated that such interventions are scalable, can foster inclusion and hope, and are adaptable across resource settings. It also gave more power and voice to people with lived experience played central roles in service design and delivery.

Key enablers of UPSIDES included co-design with people with lived experience, flexibility in implementation, ongoing supervision for peer workers, and strong local leadership. Challenges included how much peer workers should share about their own experiences, navigating hierarchical systems, and aligning timelines with real-world conditions especially during the COVID-19 pandemic.

A follow-up initiative, UPSIDES-S, has been launched to support partners interested in adapting and piloting peer support interventions in new settings, such as in additional countries and in different areas of healthcare. The UPSIDES training materials and implementation manual continue to serve as a foundation for further scale-up, both within the original project countries and beyond. A key strength of UPSIDES is its successful implementation across diverse contexts, which underlines its adaptability and broad relevance.