International Journal of Nursing Studies 40 (2003) 321332

Peer support within a health care context: a concept analysis

Cindy-Lee Dennis*
Faculty of Nursing, University of Toronto, 50 St. George Street, Toronto Ont., Canada M5S 3H4

Received 22 April 2002; received in revised form 22 April 2002; accepted 10 October 2002

Abstract

Peer support, and the integration of peer relationships in the provision of health care, is a concept of substantial
signicance to health scientists and practitioners today, as the focus shifts from the treatment of disease to health
promotion. If the nursing profession is to effectively incorporate peer relationships into support-enhancing
interventions as a means to improve quality care and health outcomes, it is essential that this growing concept be
clearly explicated. This paper explores the concept of peer support through the application of Walker and Avants
(Strategies for Theory Construction in Nursing, 3rd Edition, Prentice-Hall, Toronto, 1995) concept analysis
methodology. This analysis will provide the nursing profession with the conceptual basis to effectively develop,
implement, evaluate, and compare peer support interventions while also serving as a guide for further conceptual and
empirical research.
r 2003 Elsevier Science Ltd. All rights reserved.

Keywords: Peer support; Concept analysis; Theory development; Nursing science

1. Introduction Recognition of peer supports salutary impact on

The importance of social relationships in the treat-
ment of disease and the maintenance of health and well-
being has drawn the attention of scientists and practi-
tioners across a large number of behavioural science and
health disciplines. Prospective population studies have
established associations between measures of social
relationships and mortality, psychiatric and physical
morbidity, and adjustments to and recovery from
chronic diseases. Furthermore, interventions designed
to alter the social environment and the individuals
transactions within it have been successful in facilitating
psychological adjustment, aiding recovery from trau-
matic experiences, and even extending life for indivi-
duals with serious chronic disease (Cohen et al., 2000).
Theoretically embedded within the social relationship
construct (Fig. 1), peer support is a salient concept for
the nursing profession.
*Tel.: +1-416-946-8608.
E-mail addresses: cindylee.dennis@utoronto.ca
(C.-L. Dennis).
health outcomes (Lakey and Cohen, 2000) is reected in
recent trends where health care has become more health-
promoting and disease-preventing (Stewart and Tilden,
1995). Acknowledging the greater benets of preventing
illness rather than treating it, health promotion not only
encompasses nutrition, weight control, exercise, and
stress management but also the enhancement of
supportive relationships within an interpersonal net-
work (Stewart and Tilden, 1995). To substantiate this
view, the World Health Organization (1998) has
identied strengthening social relationships as a health
promotion strategy, while the augmentation of suppor-
tive resources, through health promotion mechanisms
such as mutual aid and healthy environments, has been
endorsed by the Ottawa Charter for Health Promotion
(Epp, 1986).
While health-promoting strategies continue to under-
pin the contemporary health-care system, nances have
led the delivery of health services in another direction.
Rapidly expanding medical specialization and technol-
ogy, while raising the quality of care for some
individuals, has also led to less desirable effects

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322 C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332
Fig. 1. Social relationship classication.
including upwardly spiralling costs, shortened hospital
stays, limited access to care, and reduced interpersonal
communication between health professionals and their
clients (Eng and Young, 1992). Consequently, during
times of need individuals turn to social relationships for
support in response to barriers or deciencies encoun-
tered in the present health-care system. Accompanying
nancial limitations, changing population demo-
graphics, longer life expectancy, and an increase in
chronic, long-term illness have resulted in the shift of
responsibility for care to communities, again situating
social relationships central to the delivery of health-care
(Stewart and Tilden, 1995). Recognizing that health
professionals alone are unable to address evolving
health needs, consumers have brought the self-help
movement centre stage in the health care arena (Stewart
and Tilden, 1995). This movement specically incorpo-
rates peer lay individuals with experiential knowledge
who extend natural (embedded) social networks and
complement professional health services. In recognition
of the importance of social relationships, a proliferation
of health-care services that incorporate peers in the
delivery of support-enhancing interventions has been
instituted in industrialized countries to meet consumer
demand.
Within this dynamic environment, peer support has
become a signicant element in the delivery of quality
health care (Cox, 1993; Eng and Young, 1992). As such,
it is essential that the nursing profession have a clear and
concise understanding of this concept. Unfortuna-
tely, peer support is a complex phenomenon whose
application is vague and highly variable, although its
benets continue to be sought after as a means for
improving health outcomes. The purpose of this paper is
to provide an enhanced understanding of peer support
using Walker and Avants (1995) concept analysis
methodology as a general guiding framework. In
particular, dening attributes, antecedents, conse-
quences, and related concepts will be discussed following
a wide-ranging literature review. The goal of the analysis
is to provide conceptual renement in order to assist the
nursing profession in the development, measurement,
and evaluation of peer interventions. This analysis will
also promote consistency in the implementation of these
interventions, thereby aiding in the comparability of
research ndings and program evaluations.
2. Methods
Using the concept analysis methodology proposed by
Wilson (1969) and described by Walker and Avant
(1995), several steps are performed beginning with
concept selection and purpose delineation. After all the
uses of the concept are dened within an outlined
context, diverse cases are constructed, antecedents and
consequences are identied, and related concepts are
described. However, according to Walker and Avant
(1995), there are no rules for accomplishing this analysis
and the steps above should been viewed as a guideline
for the intellectual work. Thus, in this concept
analysis, no cases are constructed but rather a detailed
 C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332
description of the literature is presented and an
enhanced discussion of the consequences and related
concepts are offered.
Peer support has been the focus of commentary and
investigation by varied disciplines for several decades.
To delineate the current use of peer support within the
health care arena, only literature published primarily
within the past 1015 years from the social-psychologi-
cal, health-care, and medical domains were reviewed.
Coopers (1982) ve approaches were used to retrieve
the sample of studies for this concept analysis: the
ancestry approach, descendancy approach, on-line
computer search, and to a lesser extent, informal
contacts and abstracting services. The following on-line
databases were searched for the 15-year period:
CINAHL, Medline, Psych Info, and Social Work
Abstract. Due to the vastness of the literature, studies
demonstrating conceptual complexity or intervention
diversity were selected to provide the broadest depiction
of peer support. Moreover, this literature addressed the
concept in relation to several distinct populations, which
were classied into the following three domains:
(a) transitional stressors (e.g. childbirth, bereavement),
(b) situational stressors (e.g. chronic and acute), and (c)
health promotion (e.g. healthy behaviours). Finally,
because peer support has not been explicitly dened in
the literature, specic activity and intervention descrip-
tors are presented.
3. Result
3.1. Defining peer support
Etymological investigation of the noun peer leads to
par, the Latin word for equal. The New Lexicon
Websters Encyclopaedic Dictionary (Cayne and
Lechner, 1988) denes the noun term as follows: a
member of one of the British degrees of nobility: a duke,
marquis, earl, viscount, or baron; a nobleman of any
country; someone having the same status in rank, age,
ability, etc. as another. The Oxford Dictionary of
Current English (Allen, 1991) denes the noun peer as
one who is equal to another in rank, standing, merit,
etc.; member of one of the degrees (duke, marquis, earl,
viscount, baron) of nobility in the United Kingdom. In
addition to lexicon denitions, synonyms for peer
include: equal, equivalent, match, colleague, and com-
peer (Roget, 1990).
Likewise, the term support is etymologically derived
from the Old French word supporter, originally
acquired from the Latin word porto which means to
carry. The New Lexicon Websters Encyclopaedic
Dictionary (1988) notes two uses of the term support:
(a) to carry the weight of; to prevent from falling,
sinking, etc.; to be actively in favour of; to assist or
323
strengthen morally; to be or provide an argument in
favour of or additional evidence for; to bear, endure; to
bear the cost of providing for; to give assistance to; to
act with in a secondary role; to second and (b)
supporting or being supported; someone who or
something which supports; a means of sustenance.
Similarly, the Oxford Dictionary of Current English
(1991) denes support as: (a) carry all or part of
weight of, keep from falling or sinking or falling;
provide for; strengthen, encourage, give help or corro-
boration to; speak in favour of; be actively interested in;
take secondary part to; endure, tolerate and (b)
supporting or being supported; someone who or
something which supports; a means of sustenance.
Similarly, the Oxford Dictionary of Current English
(1991) denes support as: (a) carry all or part of
weight of, keep from falling or sinking or falling;
provide for; strengthen, encourage, give help or corro-
boration to; speak in favour of; be actively interested in;
take secondary part to; endure, tolerate and (b)
supporting or being supported; person or thing that
supports. Synonyms for support include: hold up,
sustain, aid, encourage, fortify, endorse, and advocate
(Landau and Bogus, 1990).
Based on these linguistic denitions, the concept peer
support could be dened as the giving of assistance and
encouragement by an individual considered equal.
However, this rudimentary interpretation is too simplis-
tic to be meaningful, leading to the further exploration
of peer support as dened in the health literature.
3.2. Literature review
3.2.1. Transitional stressors
A myriad of research has focused on the relevance of
peer support with individuals who have undergone
maturational or developmental life transitions. In
particular, childbearing women have received consider-
able attention centring on the use of peer interventions
to enhance prenatal care among low-income women
(Lapierre et al., 1995) and improve perinatal outcomes
in teenagers (Heins et al., 1987), Hispanic migrant
farmworkers (Warrick et al., 1992), and high-risk
mothers (Snyder, 1988). Integrated into the postpartum
period, the augmentation of social relationships through
general mother-to-mother support groups (Cronenwett,
1980) and telephone interactions (Gosha and Brucker,
1986) have been advocated, while diverse breastfeeding
peer support interventions have been shown to signi-
cantly improve breastfeeding outcomes among middle-
income Caucasian mothers (Dennis et al., 2002) and
low-income Native American (Long et al., 1995),
African-American (Cauleld et al., 1998), Mexican
(Morrow et al., 1999), urban (Kistin et al., 1994) and
rural (Schafer et al., 1998) women. Peer support also has
been employed to facilitate adjustment in women
324 C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332
suffering from postpartum depression (Jones et al.,
1995), enhance coping and behavioural management
skills with mothers of excessively crying infants (Wolke
et al., 1994), and improve the mental health of mothers
and young children by buffering the effects from families
with signicant psychosocial morbidity (Cox, 1993).
Peer interventions also have been applied to indivi-
duals experiencing signicant losses. Community-based
peer support organizations have been developed to
augment embedded social networks and alleviate social
isolation while indirectly reducing the number of
physician visits (Tudiver et al., 1995). For example, an
independent charitable organization entitled Commu-
nity Contacts for the Widowed (Roger et al., 1980)
offered group and one-to-one support through the
employment of peers called widow contacts. Simi-
larly, hospital-based interventions, such as group grief
therapy, have been suggested to promote coping and
surviving strategies in gay men experiencing multiple
losses (Maasen, 1998).
3.2.2. Chronic and acute situational stressors
Facilitating adjustment to long-term disabilities or
chronic diseases, in both individuals and caregivers, is
another area where the benets of peer support have
been advocated (Olsson et al., 1997; Payne, 1995).
Within the traditional self-help/support group setting,
peer interventions have been used with adults managing
diabetes mellitus (Powell, 1988), adolescents experien-
cing chronic renal failure (Gorynski and Knight, 1992),
individuals suffering from head injuries (Schwartzberg,
1994; Schulz, 1994), and couples coping with a cardiac
condition (Stewart et al., 2001). In addition, distinct
programs have incorporated one-to-one sessions be-
tween peers and individuals who have experienced breast
cancer (Rinehart, 1994) and the loss of vision (Kleinsch-
midt, 1996). While peer-based home visits have been
used with individuals who suffer from long-term mental
illness (Bradshaw and Haddock, 1998) and renal disease
(Roy and Atcherson, 1983), telephone-based interven-
tions have been applied to lonely low-income elderly
women (Heller et al., 1991) and individuals aficted with
haemophilia and HIV/AIDS (Stewart et al., 2001). Some
peer interventions are part of a long-term program,
while other are time-limited, such as the school-based
self-management series for youth with chronic health
conditions (Magyary and Brandt, 1996) and the
healthy bladder habits course for seniors suffering
from urinary incontinence (Newman et al., 1996).
Contrary to the familiar volunteer role, peers have been
paid by health professionals to function as team
members. This specic type of peer support has been
applied in the Parent Advocate Program, as part of a
paediatric haematology/oncology service (Carpenter
et al., 1992) and in the Work Incentives and Needs
Study (WINS), where peer counsellor specialists help
individuals with psychiatric disabilities prepare for and
maintain employment (Mowbray et al., 1994, 1996).
Transcending traditional health care delivery settings,
unique peer interventions have been developed to
address distinctive needs such as community-based
HIV walk-in clinics for gay men (Levinson and Miller,
1992) and on-line computer-mediated support groups
for women with breast cancer (Weinberg et al., 1996). In
comparison to client-oriented care, peer interventions
have emerged for caregivers such as family members of
stroke victims and parent-to-parent support programs,
which offers personalized services by incorporating
veteran parents of children with disabilities (Santelli
et al., 1997; DeNardo et al., 1995; Hartman et al., 1992).
Although not as targeted as the chronic domain,
health professionals have investigated the effects of peer
support on acute stressors. For example, Taylor and
Bledsoe (1986) examined the efcacy of peer support, in
combination with other treatments, on health outcomes
of women experiencing premenstrual syndrome. Peer
interventions also have been applied to address social
problems such as substance abuse and homelessness
(Galanter et al., 1998) and retention in a cocaine
aftercare program for recovering women (Coughey
et al., 1998). Henderson (1995) examined abused women
and the effect of both individual and group peer-
provided social support in a crisis setting. It is
noteworthy to mention that while the division into
stressor types is useful, it is important to consider that
some problems have various stages to resolution. For
example, substance abuse could be a transitional (e.g.
transition to sobriety), acute (e.g. drug rehabilitation),
or chronic (e.g. as per the AA model) stressor.
3.2.3. Health promotion
Health promotion interventions embody a unique
application of peer support. Within such interventions,
peer roles are immensely diverse with typically a
heightened emphasis on the diffusion of information
and positive encouragement and a diminished accent-
uation on emotional counselling. While Albrecht and
Peters (1997) integrated peers as case managers to
address an extended array of health problems ranging
from substance abuse to gang violence, the majority of
health promotion interventions focus on a specic health
behaviour. Of particular interest is the use of peers in
AIDS and STD prevention among African-American
drug-dependent women (Harris et al., 1998), middle
school youth (Kirby et al., 1997), adolescent females
(Guthrie et al., 1996), and prison inmates (Vaz et al.,
1996). Cancer screening and prevention are other
prevalent health promotion interventions that incorpo-
rate aspects of peer support. Within these community-
based programs, peers have been utilized to increase
colorectal cancer screening among socio-economically
disadvantaged elderly individuals (Weinrich et al., 1993),
 C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332
mammography use among women aged 65 and older
(Janz et al., 1997), and cancer-screening examinations
among Latinos (Navarro et al., 1995). Peer interventions
with adolescent and school age populations are also
prevalent; these programs have addressed the develop-
ment of healthy coping patterns (Carty, 1991), conict
resolution skills (Giuliano, 1994), and injury prevention
attitudes (Tenn and Dewis, 1996), and facilitated
comprehensive violence (Kelder et al., 1996) and drug
prevention interventions (Dorsch, 1997; Klepp, 1986).
3.2.4. Summary
The preceding literature review highlights the multi-
faceted nature of peer interventions. Peer support can be
provided through multiple modes of interaction (e.g.
individual one-to-one sessions, self-help/support groups,
on-line computer-mediated groups, or within an educa-
tional milieu), in diverse settings (e.g. home, hospital,
walk-in clinic, community organization, school, prison,
or via telephone/computer) through various providers
(e.g. community- or hospital-based professional pro-
grams or volunteer organizations), and incorporate a
variety of roles (e.g. educator, advocate, leader, coun-
sellor, mediator, linking agent, or cultural translator)
with varying degrees of involvement (e.g. as the primary
intervention or part of a comprehensive program) and
structure (e.g. highly formalized versus informal indivi-
dualized interventions). In addition, peer interventions
extend across numerous demographic variables and
encompass disease-related, illness-preventive, and
health-promoting topics. Even though there are multiple
applications, the actual provision of peer support
comprises of specic common attributes that span all
settings, structures, and modes of delivery.
3.3. Defining attributes
Through an in-depth examination of the literature,
three critical attributes emerged repeatedly in the
descriptors of peer interventions: emotional, informa-
tional, and appraisal support (Fig. 2). These attributes
are the supportive functions of peer relationships and
Fig. 2. Conceptual distinctions of peer support.
325
may be differentially useful for various stressors and
health outcomes. For example, peer interventions with a
health promotion focus typically have a stronger
informational component originally and later integrate
appraisal and emotional support for reinforcement,
while programs for newly diagnosed individuals provide
increased emotional support initially. Despite the
various combinations, all peer interventions include
some degree of informational, appraisal, and emotional
support. It is noteworthy to mention that instrumental
support (e.g. the provision of practical help or tangible
aid) (Wills and Shinar, 2000) does occur rarely as a
supportive function in peer relationships but due to its
infrequency it is not a dening attribute. In particular,
the literature clearly demonstrated that peer support
primarily occurs without the provision of instrumental
support.
3.3.1. Emotional support
During the course of life, individuals encounter
threats to ones self-esteem that raise doubts about
ability, social attractiveness, or career performance
(Wills, 1985). The availability of an individual to discuss
personal difculties with is a strong interpersonal
resource to counteract the effects of self-esteem threats;
this supportive function has been termed emotional or
esteem support (Wills and Shinar, 2000). While the
specic mechanisms through which emotional support
assists to enhance or restore self-esteem is uncertain,
researchers suggests that emotionally supportive inter-
actions generally include expressions of caring, encour-
agement, attentive listening, reection, reassurance, and
commonly avoid criticism or exhortatory advice-giving
(Helgenson and Gottlieb, 2000). Such exchanges foster
the experience of feeling accepted, cared for, admired,
empathized, respected, and valued despite profound
personal difculties (Cronenwett, 1983; House, 1981;
Norbeck et al., 1981; Cobb, 1976).
3.3.2. Informational support
If difculties cannot be readily resolved, individuals
frequently seek information (Wills, 1985). Through the
326 C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332
mechanisms of advice, suggestions, factual input, and
feedback (Burleson et al., 1994), informational support
is the provision of knowledge relevant to problem-
solving and includes (a) availability of relevant re-
sources, (b) independent assessments regarding problem
aetiology, (c) alternative courses of action, and (d)
guidance about effectiveness (Wills and Shinar, 2000).
3.3.3. Appraisal support
Many life stressors are not effortlessly resolved, have
considerable future implications, and necessitate persis-
tence and endurance. Appraisal support, also referred to
as afrmational support, involves the communication of
information that is pertinent to self-evaluation and
encompasses expressions that afrm the appropriateness
of emotions, cognitions, and behaviours (House, 1981;
Kahn and Antonucci, 1980). Specic mechanisms include
motivational aspects such as encouragement to persist in
problem resolution, reassurances that efforts will result in
positive outcomes, assistance to endure frustration, and
communication of optimism (Wills, 1985). Together,
these interactions generate positive future expectations.
3.4. Antecedents
Prior to the provision of peer support, specic
activities are required to transpire. Due to the diverse
application of peer support in various health situations,
antecedent specicity has been kept sufciently broad to
facilitate generalizability. For a peer relationship to
ensue at least two individuals are united in a health-
related situation and willing to participate in, and have
the ability to receive and respond to, a social interaction
involving personalized symbolic, dialogic, and non-
verbal communications (Stewart, 1990). The peer is a
created source of support, internal to a community (Hill
et al., 1996), who shares salient target population
similarities (e.g. age, ethnicity, health concern, or
stressor) (Giblin, 1989) and possesses specic knowledge
that is concrete, pragmatic, present-oriented, and
derived from personal experience rather than formal
training (Borkman, 1976). This experiential knowledge
and target population representation determine peer
appropriateness and selection is based on self-referral or
assessments by health professionals/program develo-
pers. Training is structured to orient the peer to program
objectives and the promotion of skills that enable the use
of experiential knowlege and peers unique understand-
ing of the target population. While program-specic
training is essential, minimization should be practiced to
ensure the preservation of peerness (Giblin, 1989).
3.5. Consequences
The rationale for incorporating peers in support-
enhancing interventions rests on the notion that peers
understand the target populations situation in a way
that naturally embedded social networks may not.
Researchers suggests that in distressing times, social
network members may not respond positively, partly
from an inability to appreciate the stressful experience
and partly from feeling threatened (Helgesson and
Gottlieb, 2000). Furthermore, assimilating new knowl-
edge and appraisals through the mutual exchange of
wisdom (Borkman, 1976) occurs more effectively when
presented by peers with whom individuals identify with
and share common experiences. As research has
demonstrated, the more homogeneous the peer relation-
ships are, the more likely the support will lead to
understanding, empathy, and mutual help (Helgesson
and Gottlieb, 2000). These peer interventions give
credence to personal involvement and experiential
knowledge, which in turn facilitates a cathartic and
empathetic dimension to the interventions (Stewart,
1990). Founded on this mutual identication, shared
experience, and sense of belonging, there is evidence to
suggest that peer support positively affects psychological
and physical health outcomes (Cohen et al., 2000;
Helgesson and Gottlieb, 2000) via direct, buffering,
and mediating effect models.
3.5.1. Direct effect model
This model posits that peer support directly inuences
health outcomes through various mechanisms. One such
method is social integration and the extent to which an
individual participates in a broad range of social
relationships. Incorporation into peer relationships can
enhance social integration, which has been linked to
improved longevity and survival from myocardial
infarction and breast cancer and decreased depression,
reoccurrence of cancer, and susceptibility to infectious
illnesses (Berkman, 1985; Helgeson et al., 1989; Seeman,
1996). Similarly, peer relationships may reduce feelings
of isolation, a condition associated with increased
negative affect and sense of alienation and diminished
feelings of control and self-esteem (Cohen et al., 2000).
Participation in peer relationships also provides ex-
panded access to multiple sources of information,
thereby increasing the probability of receiving appro-
priate information to inuence health behaviours while
subjecting individuals to social controls and pressures
that induce normative behaviours through the regula-
tion of responses and prevention of extreme reactions
(Rook; 1990; Rook et al., 1990). Finally, peer relation-
ships may offer informal health care, which may prevent
minor illnesses from developing into more serious
diseases, encourage help-seeking behaviours, ensure
adherence to medical regimes, and increase motivation
for self-care (Brissette et al., 2000; Cohen et al., 2000;
Cohen, 1988). In summary, within the direct effect
model, peer support can inuence health outcomes
by: (a) decreasing isolation and feelings of loneliness,
 C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332
(b) swaying health practices and deterring maladaptive
behaviours or responses, (c) promoting positive psycho-
logical states and individual motivation, (d) providing
information regarding access to medical services or the
benets of behaviours that positively inuence health
and well-being, and (e) preventing the risk for, progres-
sion of, and recovery from physical illness.
3.5.2. Buffering effect model
The buffering effect model proposes that peer support
either protects individuals from potentially harmful
inuences of stressful events or determines individual
responses to potentially stressful events (Cohen et al.,
2000; Cohen and Syme, 1985). This model is guided by
Lazarus and Folkmans (1984) theory where coping
involves the changing of cognitive and behavioural
efforts to manage specic external environmental and/or
internal demands that are appraised as taxing or
exceeding the resources of the individual. The coping
process incorporates the dual goals of problem-resolu-
tion and emotion-regulation while employing affective,
cognitive, and behavioural response systems.
Chronologically, the cognitive system is rst engaged
when the individual is exposed to a stressor. Here, the
individual attempts to discern the signicance of the
stressor for their well-being, interpreting it as either a
source of harm, threat, or challenge. This primary
appraisal process precedes secondary appraisals where
an individual assesses the availability of coping
resources, both personal and environmental. It is here
that peer support may play a pivotal role in moderating
the individuals behaviour, and thus, their ability to
master stressor demands. Peer relationships may inu-
ence the primary appraisal process not only through
direct responses, such as the provision of information
about the nature of the stressor and active efforts to
alleviate or diminish it (e.g. the suggestion of problem-
solving techniques), but also indirect responses involving
social comparison. In particular, comparison of emo-
tional responses may augment or diminish an indivi-
duals condence in their ability to overcome a threat
depending on how the reference group reacts. For
example, if a peer responds calmly, it increases the
chance that the stressor will be interpreted more
benignly; however, if the peer shows signs of arousal it
is probable that the stressor will be subjectively
interpreted as more threatening. Within this model,
peer support can buffer the inuence of stress on health
by: (a) redening and reducing the potential for harm
posed by the stressor, (b) broadening the number of
coping resources, (c) discussing coping strategies,
problem-solving techniques, and counter-responses
thereby moderating the initial appraisals of the stressor,
(d) highlighting norms through social comparison which
prescribe adaptive behaviour, (e) inhibiting maladaptive
responses, and (f) counteracting the propensity to blame
327
oneself for causing the stressor or adversity thus
preventing active coping efforts to be hampered by
self-recriminations (Cohen and Syme, 1985; Gottlieb,
1985; Lakey and Cohen 2000; Thoits, 1995).
3.5.3. Mediating effect model
The mediator model predicts that peer support acts as
an intervening variable indirectly inuencing health
through emotions, cognitions, and behaviours (Stewart
and Tilden, 1995). One way to clearly demonstrate the
health enhancing effects of this model is to analyse the
self-efcacy concept. Based on Banduras (1977, 1986)
social cognitive theory, self-efcacy is dynamic cognitive
process in which individuals evaluate their perceived
ability to perform a specic task or behaviour. This
perception is a salient variable in that it predicts (a)
whether an individual chooses a particular behaviour,
(b) how much effort they will expend, (c) whether they
will have self-enhancing or self-defeating thought
patterns, and (d) how they will emotionally repond to
difculties encountered. As such, highly efcacious
individuals are more likely to master behaviours due
to increased initiation and perseverance in attempts than
those individuals with low self-efcacy who tend to
avoid situations that stress their capabilities (Bandura,
1977).
In choosing, performing, and maintaining a beha-
viour, individuals weigh four sources of self-efcacy
information: (a) performance accomplishments (e.g.
previous attempts), (b) vicarious experiences (e.g. ob-
servation of others), (c) verbal persuasion (e.g.
encouragement from inuential others), and (d) physio-
logical responses (e.g. fatigue, stress, anxiety) (Bandura,
1986). Peer relationships can modify an individuals self-
efcacy through inuencing these sources of self-efcacy
information.
Personal experiences are often the most immediate
and powerful source of efcacy information as success-
ful performances increase self-efcacy, whereas repeated
failures diminish it (Bandura, 1986). However, the effect
of actual experience on self-efcacy is modied by
individuals interpretations of their performance and the
desired outcome. Attention to successful or improved
aspects of performance or outcomes tends to enhance
perceptions of self-efcacy, whereas observance to
unsuccessful aspects of the performance has a diminish-
ing effect (Bandura, 1986). As such, performance
appraisals from peers can have a colossal effect on
self-efcacy perceptions.
The impact of observational learning is contingent on
role model attributes as well as on the manner in which
demonstrations are performed. The most effective role
models are those who are most similar yet more
competent at the modelled behaviour (Perry and
Furukawa, 1986). In particular, individuals more readily
assimilate new knowledge when presented by peers in a
328 C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332
context where there is the promotion of mutual
identication and shared common experience (Stewart,
1990). This vicariously derived information can alter
perceived self-efcacy not only through social compar-
ison but also through teaching effective coping strategies
and conveying information about the ability to control
and predict behaviour performance. Furthermore, in-
dividuals often accept appraisals and verbal persuasion
from similar others as valid assessments of their own
abilities (Bandura, 1986); the more credible the indivi-
dual providing verbal persuasion, the greater the
potential to affect perceptions of self-efcacy. Finally,
individuals make inferences about their abilities from
emotional arousal and other physiologic cues experi-
enced while enacting a behaviour or anticipating its
performance (Bandura, 1986). Positive interpretations of
arousal, such as excitement or satisfaction, enhance self-
efcacy while negative interpretations, such as pain,
fatigue, anxiety, or stress, can reduce ones sense of self-
efcacy. Through anticipatory guidance and normal-
izing specic arousals, peers can positively inuence
individuals interpretations.
Within the mediating effect model, peer relationships
can indirectly inuence health by: (a) assisting in the
interpretation and positive reinforcement of perfor-
mance accomplishments, (b) providing vicarious experi-
ence and observational learning through role modelling,
(c) offering opportunities for social comparisons to
promote self-evaluations and motivation, (d) teaching
coping strategies and conveying information about
ability, (e) positively interpreting emotional arousal,
and (f) encouraging cognitive restructuring through
anticipatory guidance.
3.5.4. Adverse outcomes
While peer support has numerous favourable con-
sequences, modest attention has been paid to the
potential adverse outcomes. These negative results may
incorporate conict, criticism, failed social attempts,
emotional over-involvement resulting in contagion
stress, reinforcement of poor behaviors, diminished
feelings of self-efcacy, lack of stability, and shadow
work in which an informal, parallel economy supports
the formal, market-based economy (Heller et al., 1991;
Illich, 1981; Marshal et al., 1990; Rook, 1984; Stewart
and Tilden, 1995). Furthermore, while potentially a
cost-effective intervention, the possibility of exploitation
or overburdening exists through the inappropriate
use of peers as a replacement for professional services.
Pragmatic issues are also of consequence as poor
work habits, such as assignment neglect, inadequate
communication, and short notice of vacations or
resignations, have been reported (Giblin, 1989).
However, selection of peers should not be based on
middle-class work ethics, which may be compatible
with meeting program objectives but antagonistic
to indigenous qualities or target population repre-
sentation.
3.6. Related concepts
The foregoing discussion describes multiple facets of
peer support, contextual factors salient for its occur-
rence, and potential health consequences. However,
conceptual discrepancies are apparent in the literature
particularly in relation to the provision of peer support.
While the two following conceptsnatural lay helpers
and paraprofessionalseach comprise of a specic type
of social relationship, there is no proffering of peer
support. To clarify any misconceptions, these two
related concepts will be described and the conceptual
differences delineated.
3.6.1. Natural lay helpers
Natural lay helpers are individuals to whom others
naturally turn for advice, emotional counselling, and
tangible aid (Eng and Smith, 1995). In most commu-
nities, these individuals have a reputation for good
judgment, sound advice, a caring ear, and discretion.
People often turn to such individuals embedded in their
social network as a rst contact person when
addressing health concerns prior to, or in lieu of,
seeking professional help and accessing the formal
health-care system. Often a neighbour, friend, or co-
worker, these natural lay helpers are different from peers
in that (a) experiential knowledge or mutual idenitica-
tion are not dening attributes of the support provided,
(b) they are not created social networks, and (c) they
generally do not work in professional programs or
community organizations, extend existing services, or
reach and motivate the population to use and comply
with existing regimens of care (Eng and Smith, 1995). As
noted by Israel (1985), their usual helping is so
embedded in their daily lives that it is often an
unrecognised function. An example of the use of natural
lay helpers can be found in the Save Our Sisters
Project (Eng, 1993), which aimed to reach older, black
women through existing kin, friendship, and job net-
works to inuence breast cancer screening.
3.6.2. Paraprofessionals
When developing interventions, the training of peers
is a necessary condition that requires caution in order to
avoid professionalisation and the subsequent creation of
paraprofessionals. When peers are professionalized,
their talents and accountability to the target population
are shifted to the health-care system, diminishing their
mutual identication, credibility, and commonality with
clients (Eng and Smith, 1995). Unfortunately, the
amount of training required to create a paraprofessional
is uncertain, necessitating additional research. An
example is McFarlane and Wiists (1997) mentor
 C.-L. Dennis / International Journal of Nursing Studies 40 (2003) 321332
mother program to prevent abuse during pregnancy
where experienced mothers from the community were
hired and an initial 23-h training session consisted of
three parts: (a) advocacy preparation, (b) counselling
and crisis intervention, and (c) philosophy and process
of peer advocacy. Following this classroom training
were weekly educational seminars and eld trips to
referral agencies and organizations. In addition, the
experienced mothers received specialized domestic vio-
lence instructions by the district attorneys ofce and
police department to learn how to assess protective
orders, magistrates orders, and implications of the
states new spousal exemption law. With all this training
were these experienced mothers still peers or were they
now paraprofessionals?
4. Conclusion
This paper highlights one possible strategy towards an
enhanced understanding of the peer support concept.
However, some reection on the results of this analysis
should be presented. While determining the dening
attributes of peer support was not overly difcult, as
those proposed occurred frequently both explicitly and
implicitly, regularity is no guarantee that a concept is
more precise and less ambiguous. Several criticisms of
Walker and Avants (1995) methodology have been
highlighted (Morse, 1995; Paley, 1996) suggesting that
simplifying the complexity of concepts produces a trivial
result. Therefore, the analysis presented here was
performed using both a quantitative (denitions of peer
support) and an interpretive (description of peer support
interventions and their contexts) approach, allowing for
the internal dialogue and the re-analysis originally
described by Wilson (1969) that Hupcey et al. (1996)
suggests is lost using Walker and Avants (1995) analysis
methods.
Apart from the method described by Walker and
Avant (1995), several other approaches have been
developed to conduct a concept analysis (Chinn and
Kramer, 1991; Morse, 1995; Rodgers, 1993; Schwartz-
Barcott and Kim, 1993). It is important to emphasize
that using the concept analysis method is just one
strategy to explore a concept and is not sufcient for a
full understanding. Therefore, the description of the
proposed antecedents, dening attributes, and conse-
quences should be seen as constituting a rst, general
understanding, which could form the basis for further
conceptual and empirical research.
Within the dynamic health care environment, peer
support has become a signicant element in the delivery
of quality care. However, it has been rarely dened in
the extant literature and its diverse application presents
serious methodological issues including difculties
in interpretation and comparability. If the nursing
329
profession is to effectively incorporate peer relationships
into support-enhancing interventions as a means to
improve quality care and health outcomes, it is essential
that this concept be clearly explicated. To address this
need, the preceding concept analysis was conducted and
the following denition has been determined: peer
support, within the health care context, is the provision
of emotional, appraisal, and informational assistance by
a created social network member who possesses
experiential knowledge of a specic behaviour or
stressor and similar characteristics as the target popula-
tion, to address a health-related issue of a potentially or
actually stressed focal person. Antecedents of peer
support have been delineated and the potential positive
health consequences have been explored through direct,
buffering, and mediating effect models. While the
benets of peer support have been highlighted, attention
was also given to the possible adverse effects. Finally, it
was noted that conceptual inconsistencies in the
literature have led to diverse applications of peer
support interventions. As such, conceptual clarity has
been established between the provider of peer support
and the related concepts of natural lay helpers and
paraprofessionals. This concept analysis presents the
nursing profession with the conceptual basis for
improving the development, implementation, evalua-
tion, and comparison of peer interventions and their
impact on health, health behaviours, and health-service
utilization.
Acknowledgements
I gratefully acknowledge the Canadian Institutes for
Health Research (CIHR) for the provision of a
postdoctoral research fellowship (19992001) and Pa-
mela Ratner, RN, Ph.D., Associate Professor, School of
Nursing, University of British Columbia for her
editorial suggestions.
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