Abstract
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.
Contributors
Declaration of interests
Acknowledgments
Acknowledgments
This study was funded by the National Institute for Health and Care Research (NIHR) School for Public Health Research (grant reference number PD-SPH-2015). The views expressed are those of the authors and not necessarily those of the NIHR or the UK Department of Health and Social Care. This study was approved by the University of Lancaster's Faculty of Health and Medicine Research Ethics Committee (reference number FHMREC19105).
Acknowledgments
JK and ML were responsible for study conceptualisation and funding acquisition. JK, ML, and EW planned the study design and methodological approach. ELC and EW led data collection. ELC and SD conducted the formal data analysis. JK, ML, and AER advised ELC and SD on the data analysis. ELC and SD have directly accessed and verified the underlying data reported in the manuscript. ELC led the writing (original draft) and all authors provided input to ELC on the reviews and edits of the manuscript. All authors have seen and approved the submitted version of this manuscript.
RS is employed by the Mental Health Foundation, serving as the research lead for the Peer Education Project. All other authors declare no competing interests.