Improving mental health peer support for children and young people: A mixed methods realist modelling study

Background Mental health problems are a leading cause of health-related burden across the world. Since 2017 in England, rates of mental health problems in children have increased by as much as 50%.

Between 2019 and 2020, 144,384 children had their referral closed before treatment, and 64% of children referred had not received treatment within a year due to high demand despite the known benefit of early intervention.

Peer support is increasingly used to address this unmet need using the lived experience of people with a history of mental health problems.

Peers are widely regarded to improve hope for recovery, empowerment, and access to services, with downstream impact on symptom reduction and inpatient stays. However, peer support does not appear to work for everyone.

Research using conventional methods offers mixed findings depending on what outcomes are measured, and the diversity in peer support provision for different problems.

Multiple systematic reviews of mental health peer support have called for a more nuanced approach to evaluation, including an exploration of the mechanisms of effect.

An approach informed by complexity science and realism would enable more targeted and efficient use of peer support resource.

Aims I aim to understand how and when peer support for children and young people (up to 25-years) with different mental health problems in different contexts generates personal recovery-oriented (e.g., hope & empowerment) and downstream clinical outcomes (symptom remission).

My research questions include: How do children and young people's clinical and recovery-oriented outcomes co-evolve over time during peer support (identifying 'trends')? What trends exist where clinical outcomes and recovery-oriented outcomes change independently of one another?

What combination of sociodemographic, clinical characteristics, and peer support exposure account for trends in outcomes?

What works and does not work in peer support for children and young people with mental health problems, how, for whom and when?

What are the key components of guidance and resources for services and peer support workers to implement and evaluate peer support? Methods A mixed methods action realist evaluation with case-based computational modelling (CBCM) will be used.

This will involve: CBCM of peer support programmes in children and young people's mental health services to explore recovery-oriented and clinical outcome trajectories.

Realist interviews and observations with patients, carers, peers, and clinical staff to evaluate how contextual components of peer support work to produce an outcome due to underlying mechanisms.

Co-design with peer support workers, patients and peer support programme leads to develop guidance, training and outcome prediction resources for services and peers.

Impact and Dissemination We will publish guidance, training, and resources for (1) services and peer support workers to implement targeted peer support, and for (2) children and peers to evaluate their local service.

These outputs will address a key evidence gap for and with children and young people by robustly evaluating heterogeneity across peer support interventions.

We will work with services to implement new co-designed theory-based care and quality improvement for the benefit of children and young people.