It is no secret that young people’s mental health is a problem with 1 in 8 young people having a diagnosable mental health condition (NHS Digital, 2018). Schools are an obvious place to address the mental health and wellbeing needs of young people and I and other elves have blogged before about ways in which we may improve access to support in schools through intervention programmes and specialist provision in schools for example. Since 2015 (and earlier) the government has been looking at ways to improve mental health support in schools with reports such as Future In Mind (McShane & Rouse, 2015) and there have been efforts to understand what high-quality peer support looks like in this area (Ecorys, 2020) with little success.
Peer-led interventions are a potential way to support the mental health and wellbeing of young people in schools, and there are strong arguments for using this approach:
- Firstly they are cost effective, with tight budgets schools need to be creative about how they support their young people.
- Secondly, compared to time-poor teachers, students have more available time to offer support and at the same times as those needing support are free to seek support such as lunch and break times.
- Thirdly the support can be offered in a range of locations such as libraries, playgrounds and dining halls. The flexibility and low resource cost means that these sorts of interventions are easily scalable should the need arise, another bonus.
- Finally, our greater understanding of the importance of peer relationships during the teenage years and that young people often turn to friends for support further strengthens the argument for these types of interventions.
So what might these peer-led interventions look like? It’s a good question, because there seems to be little homogeneity between studies that look at this. It can be simple universal interventions like buddy benches right through to supporting young people at high risk of suicidality. It can be drop-ins, one-to-one or group sessions. How peer-leaders are identified can vary from school to school. The training peer-leaders receive typically involves basic counselling and communication skills and may include education about how to find further support if needed, but again there appears to be no tried-and-tested evidence-based method.
The outcomes of peer-led interventions that target mental health and wellbeing have had little scrutiny in the research literature and so it is unclear how effective they are. The aim of this review (King & Fazel, 2021) is to address this gap in the literature, specifically to:
- “Conduct a scoping review of the range of peer-led interventions used to address mental health outcomes in schools.”
- “Conduct a systematic review to collate and evaluate the data on the effectiveness of school-based peer-led interventions on mental health outcomes.”
- “Map the range of mental health outcomes that have been identified.”
To identify papers suitable for inclusion in both reviews, 11 databases were searched using 120 search terms, as well as a range of grey literature. This search returned 45,586 articles. Each study was screened for their suitability for either the scoping and/or the systematic review.
Scoping review inclusion criteria:
- Peer-led interventions targeting mental health or wellbeing outcomes
- Taken place within a primary or secondary school
- Predominantly run by students
- Leaders/facilitators were from the school
- No quality or research design restrictions
Systematic review inclusion criteria:
- Randomised controlled trials, observational studies, quasi-experimental methods and pre- and post- test designs
- Must include at least one mental health or wellbeing outcome
- Must be at least partly peer-led
- Set in primary, secondary, special education or FE college for those under 18 years old
- Could be one-to-one or group based
- Not adult facilitated or led
- All peers had to be of school age (4-18 years – though this was expanded slightly in countries where it is not uncommon to stay beyond 18) and a current student at the intervention school
- Qualitative and quantitative studies were included
- Young people with or without a diagnosis were included (as long as they attended the school)
- Minimum sample size of 50 peer pairs in the intervention group or 50 peer leaders/recipients if only one group was reported.
The review was carried out in accordance with the 2009 PRISMA statement and bias was assessed.
The scoping review included 54 studies that cover a wide range of interventions from around the world, 46 studies were from high income countries and half of those from North America.
The scoping review suggests that peer-led interventions are wide ranging from simple universal strategies such as a ‘buddy bench’ to targeting high risk students with suicidal thoughts. The aims of the interventions were again varied, some targeting specific issues such as bullying or others trying to prevent a certain negative outcome such as school drop-out.
From the 45,597 studies identified for the systematic review, 11 met the inclusion criteria for the final analysis, all of which had low risk of bias. These had a range of design, sample size and intervention. A meta analysis was not possible due to the heterogeneity across the studies.
Overall the systematic review found very few significant results. The effects of the interventions on the peer leaders were covered by 7 studies and only two found significant results. In terms of self-esteem and self-confidence only one study found mixed results (e.g. self-esteem of male tutors significantly increased compared to female), other studies found no change. Results from one study showed no change in positive and negative affectivity. One study from China paired top performing pupils with the lowest attaining pupils for study. The results from this showed significant decreases in ‘social stress’ but increases in guilt (suggested this was as a result of not being able to have much impact on tutee), overall however, there was no significant change in overall mental health.
Five studies looked at outcomes for those receiving the intervention. Again the results were mixed with evidence of improved ‘quality of life’ and some non-significant improvements in ‘life satisfaction’. An American suicide prevention programme showed some non-significant decrease in students reporting ‘some suicidal ideation’. An Australian study found no effect on self-esteem or self-confidence except in the 12-13 year old sub-group who showed significant positive effects at the follow-up. The Chinese study found a significant increase in ‘Learning stress’ and worse overall mental health.
The training peer leaders received varied greatly in terms of content, duration and intensity. Content tended to focus on psychosocial skills and basic counselling skills (e.g. active listening, creating a non-judgemental environment) and interactive elements were embedded in the training such as games and role-plays. No study reported that there was an evidence base for the training.
The role of the peer leaders tended either to be to promote healthy behaviours – role modelling positive behaviour and sharing information on wellbeing – or to provide support for others who were struggling with poor mental health and were essentially lay counsellors. It appears that the extent to which the peer leaders were involved in the intervention is unclear and so the mechanisms by which peer-led interventions may work are also unclear.
The study conducted in China suggests that there may be some concerns around the risks associated with peer-led interventions. However this may be due to one group being labelled as low achieving and the peer mentors feeling unable to help them. There is little other evidence to enable the researchers to draw conclusions about the potential risks of peer-led interventions, but serious consideration must be given to these risks especially around confidentiality and safeguarding.
The review highlights the need for further high-quality research in this area to fully understand the impact of peer-led interventions for mental health and wellbeing within schools. This is of particular concern given the widespread use of peer-led interventions and the potential risks that may arise.
Given the heterogeneity of the research, it would also appear that no ‘best practice’ has been established and therefore developing a clear rationale for the key elements of peer-interventions should be paramount, however, very little evidence exists as to what this might look like. Across the studies there was little rationale given to key design decisions such as what training was given or who was selected as leaders within the intervention.
The review also highlights the lack of young people’s voice in the literature included, particularly around who was chosen to be a peer-leader. Peer-leaders appear to have been chosen based on set criteria applied by teachers or researchers with little consideration as to what the young people felt a ‘peer’ is.
Strengths and limitations
This review is clearly an important start in understanding how peer-led interventions for mental health and well-being are used in school settings and highlights a serious lack of high quality, systematic research.
One of the key issues for the review was the fluidity of the language used in the search terms. The reviewers clearly worked hard to ensure that their search was as comprehensive as possible but acknowledged issues with the process that may have resulted in some studies being missed, for example excluding some studies based on sample size being too small.
Implications for practice
So I guess my first question is should we stop doing this? My gut reaction is no – there are some strong arguments for using peer-led interventions. However, we do need to think carefully about exactly what peer interventions look like and we need to find out what works and what doesn’t. Whilst we don’t have that data (as this review suggests) we perhaps need to consider if it is harmful and only one study which was not a specific wellbeing intervention suggested negative effects, though we do need to be cautious about the conclusions we draw from such little evidence.
In thinking about harmful effects we do perhaps need to investigate who steps into the role of peer-leader and the effects on them. From this review there are mixed findings, however, anecdotally those who volunteer seem often to have lived experience of mental health struggles and teachers do raise concerns about their suitability but are reluctant to turn them down for a whole host of reasons – not least because they feel they may actually benefit from being a peer leader. However, from my experience of working with schools, teachers overseeing these programmes are well aware of any potential risks and as a consequence many of these programmes will involve an element of safeguarding training so that peer-leaders know how to support peer-recipients safely and when to escalate an issue to a teacher or other safe adult, as well as the opportunity for some sort of supervision.
The next step is clearly to design evidence-based interventions in collaboration with young people and monitor the outcomes of the wellbeing of both peer- leaders and recipients.
Statement of interests
King T, Fazel M (2021) Examining the mental health outcomes of school-based peer-led interventions on young people: A scoping review of range and a systematic review of effectiveness. PLOS ONE 16(4): e0249553.
Ecorys UK. Evaluation of the Peer Support for Mental Health and Wellbeing Pilots: research report. London: Great Britain. Department for Education; 2020. 131 p.
NHS Digital (2018). Mental Health of Children and Young People in England, 2017. Summary of key findings. Department of Health and Social Care. London.
McShane M, Rouse J. (2015) Future in Mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing. London: NHS England.