Mechanisms of school-based peer education interventions to improve young people's health literacy or health behaviours: A realist-informed systematic review.

INTRODUCTION: Peer education interventions are widely used in secondary schools with an aim to improve students' health literacy and/or health behaviours. Although peer education is a popular intervention technique with some evidence of effectiveness, we know relatively little about the key components that lead to health improvements among young people, or components that may be less helpful. This review aims to identify the main mechanisms involved in school-based peer education health interventions for 11-18-year-olds. METHODS: Five electronic databases were searched for eligible studies during October 2020, an updated search was then conducted in January 2023 to incorporate any new studies published between November 2020 and January 2023. To be included in the review, studies must have evaluated a school-based peer education intervention designed to address aspects of the health of students aged 11-18 years old and contain data relevant to mechanisms of effect of these interventions. No restrictions were placed on publication date, or country but only manuscripts available in English language were included. RESULTS: Forty papers were identified for inclusion with a total of 116 references to intervention mechanisms which were subsequently grouped thematically into 10 key mechanisms. The four most common mechanisms discussed were: 1) Peerness; similar, relatable and credible 2) A balance between autonomy and support, 3) School values and broader change in school culture; and 4) Informal, innovative and personalised delivery methods. Mechanisms were identified in quantitative, qualitative and mixed methods intervention evaluations. DISCUSSION: This study highlights a number of key mechanisms that can be used to inform development of future school-based peer education health interventions to maximise effectiveness. Future studies should aim to create theories of change or logic models, and then test the key mechanisms, rather than relying on untested theoretical assumptions. Future work should also examine whether particular mechanisms may lead to harm, and also whether certain mechanisms are more or less important to address different health issues, or whether a set of generic mechanisms always need to be activated for success.

Estimating the effectiveness of an enhanced 'Improving Access to Psychological Therapies' (IAPT) service addressing the wider determinants of mental health: a real-world evaluation.

BACKGROUND: Addressing the wider determinants of mental health alongside psychological therapy could improve mental health service outcomes and population mental health. OBJECTIVES: To estimate the effectiveness of an enhanced 'Improving Access to Psychological Therapies' (IAPT) mental health service compared with traditional IAPT in England. Alongside traditional therapy treatment, the enhanced service included well-being support and community service links. DESIGN: A real-world evaluation using IAPT's electronic health records. SETTING: Three National Health Service IAPT services in England. PARTICIPANTS: Data from 17 642 service users classified as having a case of depression and/or anxiety at baseline. INTERVENTION: We compared the enhanced IAPT service (intervention) to an IAPT service in a different region providing traditional treatment only (geographical control), and the IAPT service with traditional treatment before additional support was introduced (historical control). PRIMARY OUTCOME MEASURES: Patient Health Questionnaire-9 (PHQ-9) Depression Scale (score range: 0-27) and Generalised Anxiety Disorder-7 (GAD-7) Anxiety Scale (score range: 0-21); for both, lower scores indicate better mental health. Propensity scores were used to estimate inverse probability of treatment weights, subsequently used in mixed effects regression models. RESULTS: Small improvements (mean, 95% CI) were observed for PHQ-9 (depression) (-0.21 to -0.32 to -0.09) and GAD-7 (anxiety) (-0.23 to -0.34 to -0.13) scores in the intervention group compared with the historical control. There was little evidence of statistically significant differences between intervention control and geographical control. CONCLUSIONS: Embedding additional health and well-being (H&W) support into standard IAPT services may lead to improved mental health outcomes. However, the lack of improved outcomes compared with the geographical control may instead reflect a more general improvement to the intervention IAPT service. It is not clear from our findings whether an IAPT service with additional H&W support is clinically superior to traditional IAPT models.

Perspectives on an enhanced 'Improving Access to Psychological Therapies' (IAPT) service addressing the wider determinants of mental health: a qualitative study.

BACKGROUND: A new Health and Wellbeing pathway was introduced into the Improving Access to Psychological Therapies (IAPT) service in one geographical area of the UK in 2021 to address the wider determinants of mental health problems. It comprised assisted signposting to wider services and physical health promotion. This qualitative study aimed to understand stakeholders' experiences of implementing and receiving this new support and the barriers and facilitators to its delivery. METHODS: Forty-seven interviews were conducted, with service developers (n = 6), service deliverers (n = 12), service users (n = 22) and community and clinical partners (n = 7), as part of a larger mixed-methods evaluation. Interviews were recorded, transcribed, and analysed using reflexive thematic analysis. RESULTS: Three themes spanned all participant groups and represented key aspects of the service: (1) identifying suitability, (2) a holistic service, and (3) moving forward. The sub-themes represent the barriers and facilitators to processes working in practice, lending insight into potential service improvements. These included strengthening the quality of communication during referral and assessment, tailoring the support and delivery mode, and increasing transparency around continued care to drive sustained benefits. LIMITATIONS: Service users may have been selected due to their positive experiences of IAPT and were not demographically representative of the population, although participants' experiences of the service did suggest variation in our sample. CONCLUSIONS: The Health and Wellbeing pathway was perceived as having a positive impact on mental health and could reduce the burden on therapeutic services. However, service- and individual-level barriers need to be addressed to enhance statutory and community support links, manage service users' expectations, and improve accessibility for certain groups.

Snacking and anxiety during the coronavirus disease (COVID-19) pandemic: A prospective cohort study.

Anxiety and snacking increased during the initial coronavirus disease 2019 (COVID-19) lockdowns, but it remains unknown whether this change in snacking persisted and if it related to anxiety levels. We used prospective data to examine changes in snacking frequency from t1 (eased restrictions in England in May-June 2020) to t2 (national lockdown in December 2020-March 2021), the association of anxiety (assessed by the Generalised Anxiety Disorder-7 questionnaire at t1) with the snacking change, and the mediating and moderating effects of disinhibition and flexible restraint (assessed by the Three Factor Eating Questionnaire in 2016-17). Analyses including 2128 adults (mean age 28.4 y) residing in England from the Avon Longitudinal Study of Parents and Children showed that snacking frequency increased over time (mean change 1.23 (95% CI 0.81, 1.65) snacks/wk). Linear regressions of snacking adjusted for sociodemographic covariates showed that having clinical levels of generalised anxiety at t1, versus not, was associated with 1.22 (95% CI 0.07, 2.37) more snacks/wk at t2. Disinhibition partially mediated the association between Generalised Anxiety Disorder and snacking (ßindirect = 0.15, 95% CI 0.01, 0.32), while there was no evidence that flexible restraint moderated the association (ß = 0.05, 95% CI -0.57, 0.66). Our longitudinal findings highlight a detrimental anxiety-snacking association partly operating via disinhibition, suggesting future research could target mitigating anxiety and disinhibited eating behaviours to benefit diet-related outcomes following the pandemic.

Assessing the Feasibility of a Peer Education Project to Improve Mental Health Literacy in Adolescents in the UK.

Many mental health problems begin in adolescence and occur on a spectrum of severity: early recognition and intervention is important. This study is a quantitative feasibility study of the Mental Health Foundation's Peer Education Project (PEP). Attrition, psychometric properties of questionnaires, indications of improvement on a range of outcomes, and sample size required for a powered trial of effectiveness were assessed. 203 students completed the survey both pre and post-intervention. It was found that existing previously-validated measures had good psychometric properties, with two new questionnaires demonstrating reasonable reliability (self-help confidence alpha = 0.78, mental health knowledge alpha = 0.59). There were indications of improvement in help-seeking intentions, the number of sources likely to seek help from, and mental health knowledge from pre- to post-intervention. A future trial of PEP with a sample of approximately 36 schools, researcher-led data collections, and help-seeking intentions or sources as a primary outcome appears to be feasible.

School-based peer education interventions to improve health: a global systematic review of effectiveness.

INTRODUCTION: Peer education, whereby peers ('peer educators') teach their other peers ('peer learners') about aspects of health is an approach growing in popularity across school contexts, possibly due to adolescents preferring to seek help for health-related concerns from their peers rather than adults or professionals. Peer education interventions cover a wide range of health areas but their overall effectiveness remains unclear. This review aims to summarise the effectiveness of existing peer-led health interventions implemented in schools worldwide. METHODS: Five electronic databases were searched for eligible studies in October 2020. To be included, studies must have evaluated a school-based peer education intervention designed to address the health of students aged 11-18-years-old and include quantitative outcome data to examine effectiveness. The number of interventions were summarised and the impact on improved health knowledge and reductions in health problems or risk-taking behaviours were investigated for each health area separately, the Mixed Methods Appraisal Tool was used to assess quality. RESULTS: A total of 2125 studies were identified after the initial search and 73 articles were included in the review. The majority of papers evaluated interventions focused on sex education/HIV prevention (n = 23), promoting healthy lifestyles (n = 17) and alcohol, smoking and substance use (n = 16). Papers mainly reported peer learner outcomes (67/73, 91.8%), with only six papers (8.2%) focussing solely on peer educator outcomes and five papers (6.8%) examining both peer learner and peer educator outcomes. Of the 67 papers reporting peer learner outcomes, 35/67 (52.2%) showed evidence of effectiveness, 8/67 (11.9%) showed mixed findings and 24/67 (35.8%) found limited or no evidence of effectiveness. Of the 11 papers reporting peer educator outcomes, 4/11 (36.4%) showed evidence of effectiveness, 2/11 (18.2%) showed mixed findings and 5/11 (45.5%) showed limited or no evidence of effectiveness. Study quality varied greatly with many studies rated as poor quality, mainly due to unrepresentative samples and incomplete data. DISCUSSION: School-based peer education interventions are implemented worldwide and span a wide range of health areas. A number of interventions appear to demonstrate evidence for effectiveness, suggesting peer education may be a promising strategy for health improvement in schools. Improvement in health-related knowledge was most common with less evidence for positive health behaviour change. In order to quantitatively synthesise the evidence and make more confident conclusions, there is a need for more robust, high-quality evaluations of peer-led interventions using standardised health knowledge and behaviour measures.

The Peer Education Project to improve mental health literacy in secondary school students in England: a qualitative realist evaluation.

BACKGROUND: Worsening of adolescent mental health and exacerbated health inequalities after the COVID-19 pandemic calls for universal preventative strategies. The Mental Health Foundation's school-based Peer Education Project seeks to improve students' mental health literacy through peer educators (aged 14-18 years) teaching peer learners (aged 11-13 years) to recognise good and bad mental health, identify risk and protective factors, and seek help accordingly. Although previous before and after quantitative assessments have found the intervention to be effective, this realist evaluation aimed to qualitatively develop the theory of change, exploring how the mechanisms played out in different contexts to achieve the desired outcomes. METHODS: Our initial programme theory was developed following expert stakeholder consultation and reviewing the literature. We divided mechanisms into resources and reasoning to explain how the intervention components (ie, resources), experienced within specific contexts, engendered responses in the participants (ie, reasoning), to produce observable outcomes. Data collected from six purposively recruited schools in England comprised staff interviews (n=11), student focus groups (n=15), and observations (n=5). Deductive and inductive analysis was undertaken, using NVivo-informed multiple causal statements represented as context-mechanism-outcome configurations (CMOcs), to test and refine the programme theory. FINDINGS: We created several distinct CMOcs. For example, in learners accustomed to didactic teaching methods (context), conversing with educators having similar life experience (mechanism resource) endorsed and destigmatised help-seeking behaviour (mechanism reasoning) and facilitated a realisation that seeking help was appropriate and acceptable (outcome). Other mechanisms included the following: learners perceiving the information as tailored and relevant, educators feeling empowered, and a cultural shift percolating across the school. INTERPRETATION: Our findings show how peer education can work to improve mental health literacy, which will inform changes to the intervention to maximise its effectiveness in different operational contexts. Future research could test our theory of change in a randomised controlled trial, and examine impacts on inequalities in a more diverse sample. FUNDING: National Institute for Health and Care Research School for Public Health Research.