Research suggests that up to 50% of mental health problems are established by age 14 [1]. Recent surveys of children and young people in the UK in 2017 and 2020 demonstrate an increase in disorders among 11–16-year-olds, from 12.6% having a probably mental disorder in 2017 to 17.6% identified as having a probable mental disorder in 2020 [2, 3]. A knowledge gap has been identified amongst young people regarding recognition of the signs and symptoms of mental health problems in themselves and others [4]. A lack of awareness of the signs of mental ill health can prevent timely help seeking [5], as can stigmatising attitudes towards mental health problems [6]. Mental health literacy has been conceptualised into four domains: 1) understanding how to obtain and maintain positive mental health; 2) understanding mental disorders and their treatments; 3) decreasing stigma related to mental disorders; and 4) enhancing help-seeking efficacy (knowing when and where to seek help) [7,8,9]. .Studies have highlighted low levels of mental health literacy among adolescents [10].
Schools are increasingly recognised as key to addressing the high prevalence of mental health difficulties among young people [11], particularly through whole-school, preventative approaches that focus on resilience and promotion of wellbeing [4, 12]. There is some evidence that school-based mental health literacy programmes can lead to improvements in knowledge and attitudes [13]. As young people often approach their peers for support with mental health concerns [4], higher levels of mental health literacy may increase the likelihood that young people signpost their friends and classmates effectively, as well as seeking help themselves, leading to improved outcomes [14].
Peer-delivered health education seeks to capitalise on young people’s tendency to turn to peers for support and advice, and has shown promise in fields such as sexual health [15], drug and alcohol misuse and smoking cessation [16]. However, there is still a scarcity of good quality evidence about the effectiveness of youth peers as health educators, particularly in mental health [17], with existing studies often deploying peer education methods because they are relatively cheap and wide-reaching, rather than because they have been established as effective. Models of peer education hypothesise that peers make effective health educators because (i) young people deem their peers more credible messengers of health information, (ii) peer education builds on existing social networks, (iii) peer educators become role models, influencing behaviour and opinions by modelling good practice [18] and iv) adolescents report they are more likely to seek advice from peers than adults at this developmental stage. However, there is limited research on peer-led initiatives related to mental health in schools [19].
The Mental Health Foundation’s Peer Education Project (PEP) aims to improve the mental health literacy of young people and decrease stigmatising attitudes towards mental health. Its focus is on behaviours that promote good mental health, and on risk and protective factors for mental health and help-seeking [20]. This study will contribute in-depth qualitative findings regarding the mechanisms by which the intervention may have an impact, providing perspectives from schools who have delivered the intervention for a number of years, as well as those who are new to the project. In addition, adaptations have had to be made to the intervention delivery during the current COVID 19 pandemic, and this evaluation will examine how acceptable these changes are to students and schools and which should be kept as permanent changes.
Systems theories suggest that both individual behaviour and the context in which these individuals operate are key to successful outcomes. The success of the Peer Education Project is therefore likely to depend on both individuals’ responses and on the wider school context. What works in one school or classroom, may not work in another. One approach that aims to understand both mechanisms of change and the impact of different contexts, particularly in health research, is realist evaluation [21]. Realist evaluation is a form of theory-driven evaluation based on realist philosophy which aims to advance understanding of why complex interventions work, how, who for and in what contexts [22]. The proposed study will therefore be informed by a realist approach to its evaluation in order to further understand the mechanisms of change underlying peer education and the impact of different school contexts.
The PEP intervention
PEP is a school-based mental health education programme co-designed with Year 7 (age 11–12 years) and Year 12 students (age 16–17 years), with the primary aim of improving mental health literacy amongst students.
During the development of PEP, five consultation workshops were held with students in years 7 and 12 to develop the lesson content, which focused on: 1) Shared understanding and direction, 2) Learning outcomes and topic areas, 3) Lesson plans and outcomes and 4) Building competence and confidence for lesson delivery. Six consultation sessions were also carried out with school staff to consider the practicalities and timetabling of the project.
The programme consists of 4 stages, namely staff training, peer educator selection and training, lesson delivery and continuing the conversation (displayed in Fig. 1). The intervention offers an interactive five lesson mental health syllabus, covering basic mental health awareness, risk and protective factors for our mental health, ways to stay well, the importance of seeking help and how to support others. The syllabus is delivered by Peer Educators (older pupils) to Peer Learners (younger students), who are trained and supported by the school staff leading the project. Typically, peer educators are year 12 students, and peer learners are year 7 students.
The original theory of change underpinning the intervention when first developed by the Mental Health Foundation was based on four key components: i) it is peer-led, thereby making the messages potentially more relevant and acceptable to young people [15,16,17], ii) it is schools-based and delivered during Personal, Social, Health and Economic education lessons (PSHE), which are attended by the majority of young people iii) it is universal, thereby providing information to all young people, regardless of their current identified level of need [23], and iv) it is educational, and even short educational interventions have been shown to be effective in improving knowledge and attitudes around mental health, and reducing stigma [17, 24]. Knowledge and attitudes are important precursors of behaviour change, as they influence someone’s intent to perform a behaviour; behavioural intent is the strongest predictor of actual (observable) behaviour.
[20] The Mental Health Foundation have plans to expand the delivery of PEP considerably over the next few years, therefore the findings from this study will allow us to refine the intervention to maximise the public health benefits that could be achieved.
Extending knowledge of PEP in the current study
In a previous evaluation of the programme [20], we have seen encouraging findings suggesting that PEP improved self-reported knowledge of mental health and confidence to discuss it. However, these evaluations have been limited by their lack of control groups, and the intervention content has been modified since this initial study. Before effectiveness can be more robustly tested, we want to ensure that all of the components of the programme are acceptable and feasible, and to understand more about how the intervention works in practice to inform development of a testable logic model. The key innovative feature of the intervention is the peer educators, so we want to understand how this element in particular is perceived by those involved, and any barriers that exist to its implementation. We will also explore how the intervention may lead to wider changes to the school culture around mental health support. In addition, we want to ensure that the programme is accessible to young people at most risk of developing mental health problems, particularly those in deprived areas. The present study will include schools in areas with different socio-economic profiles to help us understand more about how well the programme works, in what circumstances and for whom. The study seeks to understand what intervention components works best in different school contexts and to better understand what activities and contexts are essential for the intervention to be effective and which components are more flexible and could be adapted between schools.
In addition to understanding how the programme works, we will also test a novel mental health literacy questionnaire. Although there are a number of measures of various aspects of mental health literacy in the literature, it has been challenging to find one measure that includes all the domains in which we are interested (knowledge, attitudes, self-help strategies and help-seeking) and that is appropriate for 11–12-year-olds. We will develop and validate a survey that aims to measure all aspects of mental health literacy among this age group.
This study aims to:
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i.
Develop and test a mental health literacy measure for young teenagers
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ii.
Understand how the PEP intervention currently works in schools
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iii.
Understand the mechanisms of change within the PEP intervention
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iv.
Understand how the PEP intervention works in different school contexts
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v.
Identify areas in which the PEP intervention can be improved
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vi.
Test and revise the PEP logic model (Fig. 2)
