Unpacking post-implementation adaptations to peer support for adults with mental health challenges: qualitative findings

Purpose The integration of paid peer support workers into publicly funded mental health services has gained momentum over recent decades. While research has primarily focused on the effectiveness and early implementation of peer support, limited attention has been paid to how these services evolve and are sustained over time. This paper aims to report on adaptations made to a peer support service following its initial implementation and during its sustainment phase. Although such changes are often necessary throughout the implementation cycle, they remain under-documented, leaving gaps in our understanding of their impact on implementation outcomes, including long-term sustainment. Design/methodology/approach Drawing on qualitative methods, 19 individuals were interviewed. Participants were engaged in implementing and sustaining peer support in an outpatient unit overseeing community housing for adults with mental health challenges. Data collection and analysis were guided by the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME). Findings Participants described seven key modifications made across three levels; micro, meso and macro adaptations based on where they originated and their perceived impact. These were changes to: service delivery mode, peer support workforce, referral processes, support structures, service expansion and peer worker tasks. Most adaptations emerged organically in response to evolving needs, rather than through formal planning. Importantly, none compromised the core principles of peer support, though all had a multimodal impact on the peer support service. Originality/value This study underscores the significance of adaptation in sustaining peer support services. It illustrates the diverse range of post-implementation changes (planned and emergent) and their impact on sustainment. We offer practical guidance for service leaders and practitioners on how to systematically document and assess adaptations over time. By showing how changes can occur without compromising core peer support principles, the analysis supports more responsive and sustainable implementation. Additionally, it demonstrates how FRAME can be applied in real-world settings to guide decision-making during the sustainment phase and highlights the need to examine how specific adaptations influence implementation and sustainment outcomes.