The Peer-to-Peer Model: A UK Institution’s Approach to Broadening and Embedding the Provision of Peer Learning and Support

Friendship, and wider peer relationships, contribute to young people's sense of safety and wellbeing (Blakemore, 2018; Cossar et al., 2013; Foshee et al., 2014; Roesch-Marsh & Emond, 2021). Moreover, during adolescence the significance and influence of young people's peer relationships have been found to intensify in many countries around the world (Blakemore, 2018; Coleman, 2011). Nevertheless, recognising this has failed to ensure that child protection or wider safeguarding systems and interventions take account of young people's friendships or wider peer relationships when supporting those affected by violence and abuse. On the contrary there is evidence that many social work responses disregard peers, while centring family relationships, in their efforts to safeguard young people (Bracewell et al., 2020; Firmin, 2019, 2020; Johnson, 2017; Rogowski, 2012). Such an absence is notable given the role of friendship, and wider peer relationships, in young people's exposure to risk as well as protection. Multiple studies have found that young people are more, or as likely, to disclose concerns about abuse to their peers than their parents or other adults (Allnock & Atkinson, 2019; Barter, 2018; Brennan & McElvaney, 2020; Cossar et al., 2013). More broadly, positive attitudes can be reinforced through peer relationships. Peer influence can support pro-social behaviours and beliefs, such as healthy living (e.g. healthy eating and avoiding drugs and alcohol), equality, anti-discrimination and ambition (Laursen, 2018; Veenstra et al., 2018). In recognition of this, prevention programmes aimed at reducing rates of bullying, intimate partner violence and sexual harassment in schools have commonly sought to create opportunities for ‘bystander’ interventions, peer mentoring and buddying schemes, in which supportive and protective peer cultures are utilised and nurtured (Banyard et al., 2020; Foshee et al., 2014). Peer relationships also provide wider opportunities and contexts for pro-social activities and skill-building (Ramey et al., 2018; Veenstra et al., 2018). However, as already identified, peers can also be a source of harm. These harms can be perpetrated on and offline and can include a wide range of activities such as bullying, criminal and sexual exploitation and physical and sexual abuse. Peer victimisation is reported to be global problem impacting the welfare of significant numbers of young people around the world (UNICEF, 2019, 2020). In the year ending March 2018 the crime survey for England and Wales estimated that 4.4 per cent of children aged 10 to 15 years (423,000) had been a victim of violent crime in the previous 12 months (Office for National Statistics, 2018). For young people who participated in the survey, 92 per cent knew the person who had instigated violence against them. In 86 per cent of cases, they attended school together, and for 13 per cent, the instigator was identified as a friend (including boyfriend or girlfriend). In this special issue we present papers from Australia, China, Europe, Ghana and North America, which consider the role(s) of friendships and wider peer relationships. Despite their geographical spread, this body of work features numerous shared messages about the opportunities and challenges that come with considering peers in both informal and formal protective responses to young people in need of support and/or protection. They also point to the definitional, methodological, policy and practice gaps that warrant attention, for friendships and peer relationships to be sufficiently considered within child protection and wider safeguarding systems. The papers in this special issue consider the role of both friendship, and wider peer support networks and relationships, in safeguarding young people. The terms friend and peer have distinct but interrelated meanings which have implications for research and practice (Roesch-Marsh & Emond, 2021). Most of the papers contained in this issue illustrate that the different meanings these terms hold for young people and practitioners matter. For example, in Cudjoe et al.'s (2022) paper, young people from Ghana spoke about friends as important people who you have fun with but not necessarily someone to share difficulties with, such as dealing with parental mental health. The voluntary and informal nature of friendship means that young people are often left to deal with these issues alone. As authors Warrington et al. (2023) from the United Kingdom found in their exploration of friendship and peer support following sexual abuse, the support of friends can be vital for some but the sensitivity and understanding of friends can be variable and unreliable. In contrast, Cody et al. (2022) focused on structured peer support for young survivors of sexual violence across Europe and North America, defining peer support as ‘support provided by those with similar experiences’. This formalised peer support system was viewed as an additional or alternative support provision to that of informal friendship networks and ensured that peer supporters receive appropriate training and help. The unique nature of support from friends was described variably but primarily presented as something with potential to feel less emotionally charged, pressured or judgemental. Children commonly think that once their peers get to know about their parent's mental illness, they may cease to enjoy activities together. Therefore, it is important to keep silent about their parents' mental illness when around their peers to continue enjoying relationships with them. Likewise, in studies from the United Kingdom, Daw et al. (2022) identified that young people can feel ‘helpless’ and ‘fearful’ when their friends seek support around domestic abuse, and Warrington et al. found that precarious peer cultures were not always suitable for providing support in the aftermath of sexual violence. The challenges associated with accessing support through informal friendships appeared to be mitigated, at least to some extent, in more formal peer support structures. A study across Europe and North America found that shared peer experiences of sexual violence created a context conducive with peer support groups. Having shared experiences facilitated peer support that was relatable, credible and translatable, where young people were not judged (or fearful of judgement) when turning to peers for support. Similarly, in Ghana it was recommended that young people who shared a traumatic experience could be better placed to support one another and be less likely to bullying or judge. A third type of peer relationship was explored by Zhu (2023) in China. In this scenario, young people were not supported through existing friendships or organised around a shared experience of harm/abuse, but within schools through peer mentoring systems. In this form of peer support, younger pupils are matched with older young people who can then support them with the aim of reducing school bullying. However, the author notes that these hierarchical peer relationships might themselves feature power imbalances, with an age gap introducing the potential for exploitation and bullying. Reflecting other conclusions in this special issue, they point to the importance of education and practical support for young people who are positioned as mechanisms for peer support (be that formal or informal) to ensure that these relationships do not feel burdensome to the young people providing the support and that any help they offer is protective. Clear definitions are therefore crucial. Peer support through existing friendships, shared interest or experience groups or through a shared context all present unique challenges and opportunities, and consequently, the type of relationship being studied requires careful consideration. The best thing that I did was to be there for her [friend]. Not try and pressure her into breaking up with him, because that's, kind of, being just as bad as him, but, like, to just be emotionally there for her and make sure you're there to comfort her whenever she's down. (Young person 13–16) At first glance such a request appears relatively feasible. However, the collection of arguments made across this special issue highlight a range of considerations that would need to be addressed before this request can be met. The articles in this issue suggest that a non-judgemental approach is most reliable when coming from formal peer support structures, rather than informal friendship networks. The fear of shame, or being misunderstood, was mitigated either through shared experiences within the formal peer relationships in question, or through formal training and advice or professional support structures that equipped peers to be understanding and supportive. When the survivor [peer mentor] goes out and meets them, and they're able to see that their story is similar to theirs, and that they have been able to triumph in their own ways, it really creates the sense of hope for them. (Professional respondent 1, Organisation A) Cody et al. stress, however, that supporting and training these peer mentors requires time and resources and is not a cheap alternative to professional support. While acknowledging the unique value of formal peer support, articles in this issue also show that some young people seem to highly value the informality that came with support from friends. Moreover, various authors noted that support from friends was important due to their temporal proximity to young people during adolescence. Young people are with friends during the day at school, and in various out-of-school settings, creating numerous opportunities for support (Zhu, 2023). Such support included being a point of disclosure, providing comfort or emotional support, or acting as a conduit to professional support (Warrington et al.). However, for young people to provide this type and level of support, they require practical advice from adults; and to an extent, this again introduced a level of formality. Taken collectively, the contributions in this special issue suggest a balance needs to be struck and that both formal and informal pathways of support (likely across a continuum) are required. However, none of the contributions were able to clearly articulate what such a continuum might entail, as each focused on a single element. Nevertheless, this provides an important starting point to consider how this continuum might be conceptualised and provides a basis to understand how a young person's peer support needs might best be met. Recommendations to introduce elements of formality into friendship-support mechanisms largely stems from the identified challenges of integrating peer relationships into child protection and wider safeguarding practices. Young people reported concerns about how to maintain friendships while they were also experiencing safeguarding issues (Daw et al.). Seeking support from friends could result in bullying or isolation, when young people failed to understand how to support each other or judged friends negatively due to what they had experienced (Cudjoe et al., 2022). Friendships during adolescence are also dynamic, changing frequently, and with this comes a level of precarity. Reaching out to people who may not remain your friends over an extended period of time could be perceived as a risky endeavour. Consequently, young people surveyed in Australia stated that they were most likely to disclose abuse to their mother (about concerning behaviour of an adult, 68.7 per cent; or a peer, 63.1 per cent) followed by a friend (64.4 per cent; 57.9 per cent) (Russell & Higgins, 2023). Thus, family relationships remain very important and we should not assume that peers are always the first choice, or indeed best placed, to respond to young people who require support. Finally, there is a risk that some young people will feel (or be) burdened when supporting their friends or peers. Authors noted a need to mitigate any ‘responsibilisation’ that might be an unintended consequence of providing young people with the skills and formal space to support each other with experiences of abuse (Daw et al., 2022). For example, when young people were asked about the possibility of being approached by friends who were experiencing domestic abuse, they reported being concerned that they would feel fearful and helpless. All young people require a certain level of practical advice about the nature of abuse (in all its forms), how it impacts young people and what they can do if a friend approaches them for help. Such advice should not suggest that it is the young person's responsibility to prevent or disrupt harm; but instead ensure they are equipped to respond effectively if situations arise where their friends need support, including where they could go to seek more formal assistance. All the above challenges appeared particularly pronounced in situations of informal peer support, particularly support within existing friendships. Formal peer support structures, particularly for young people who had experienced issues such as sexual abuse, were designed to ensure young people were assisted to support each other and involved young people who all had similar experiences of abuse and therefore reduced the risk of being judged or misunderstood. The stories told in this special issue suggest not only that young people's friendships and peer relationships could play a role in safeguarding responses – but that they already do through both informal and formal routes. Nonetheless, far more work is required to understand the dynamics of this support and the best ways to maximise its potential and minimise its risks. There are methodological challenges and shortfalls with work completed to date. For the most part, researchers rely on gatekeeping organisations to speak to young people about their experiences of peer or friendship-based support and access to such organisations varies. In most countries featured in this special issue, the roles of peers have not been fully considered in practice or policy development, as the forms of peer support identified sit beyond formal response systems. Arguably, greater recognition by, and integration into, wider organisational responses to violence and abuse would provide the practical mechanisms required to safely maximise the potential for peer support. While the papers in this special issue draw upon experiences from a number of countries there remain gaps that warrant attention. First, it appears that gender may impact on the accessibility and availability of support from peers and friends. For example, girls and young women surveyed in Australia were more likely to seek support from peers than boys and young men (Russell & Higgins, 2023). Do we understand these gender differences, and are they reflected for various forms of harm and in different countries? More broadly, an intersectional account of friendship and peer support in safeguarding is required. How do the opportunities and concerns raised in this editorial vary in terms of ethnicity, sexuality, ability and so on? Moreover, what avenues of support do online peer relationships, through for example social media platforms, provide for support and how and in what ways do these online peer dynamics reflect or differ from those factors outlined in the current papers and for whom? The papers in this special issue provide a foundation for raising these important questions, although further research is required to answer them and of course this requires research funding bodies to recognise this as a central aspect of safeguarding for young people. We would like to thank all the authors who contributed to this special issue. We believe it brings together a wealth of knowledge but also raises challenging questions for both practice and policy development on how we can best support young people who are at risk of or are currently experiencing harm. In terms of this special issue two key considerations are established—and we hope that these are taken into account in the design of future research. First, that definitions matter. Work is required to explore support via various peer relationships; pre-existing friendships, specialist peer support groups and temporally or physically proximal support structures (in schools for example); and clarity is needed as to what type of peer relationships are under study on each occasion. Secondly, developing a continuum of formal and informal support to characterise the ways that peer relationships/friendships can be integrated into safeguarding practice/policy might also provide a route for clarifying the types of interventions under study and their implications for service development. Formal peer support structures, that exist outside of young people's established friendships, offer specific benefits and require specific scaffolding; these requirements are different for informal support via pre-existing friendship. Questions might also be asked about what happens in the middle, where friendships form within formalised circles of support; friendships that may persist beyond a peer support intervention. Like my best friend … He's always there day and night. I can ring him at three o'clock in the morning and he'll answer the phone … He's very understanding, and he seems to say the right stuff. (Interview 6, male, 21 years)

Objective: The effectiveness of peer support programs as a means to sustain self-management in patients with type 2 diabetes has been well documented. However, little is known of how gender differences in peer support might influence the provision and receipt of support. This study used the key functions of peer support as a framework to explore gender differences in peer support programs and identified gender-related issues and global cultural contexts that influence peer support. Methods: Qualitative data were generated through telephone interviews and written responses using open-ended questions to nine programs across the globe: Africa (Cameroon and Uganda), Asia (Cambodia, Hong Kong, Thailand, and Vietnam), and the United States (Alabama, California, and Illinois). Qualitative content analysis was done to achieve in-depth exploration of categories. Data were analyzed using INVIVO 10 software. Results: Five themes emerged: 1) Differences in emotional support: female peer supporters reportedly displayed more emotional support than any other form of support; 2) Differences in instrumental support: male peer supporters gave information as their primary form of support; 3) Who is a peer supporter: males dominated as peer supporters in two Asian countries (Cambodia and Hong Kong) and females dominated in African American and Latino peer support programs in the US; 4) Matching by gender: male peer supporters were assigned only male recipients, but female peer supporters could be assigned to either sex; 5) Gender differences in participant availability: there was considerable variety in how gender was manifest in programs and both peer supporters’ and participants’ responses to them. Conclusion: This study provided evidence that substantial gender differences and gender-related issues were present in all the peer support programs and that the manifestation of differences varied considerably across settings and cultures. Gender differences have to be taken into consideration when planning peer support programs.

A meta-synthesis of womenʼs perceptions and experiences of breastfeeding support

BackgroundPeer support among family members is important in cases of mental illness, but there has been limited practice or research on individual peer support specific to families taking care of patients with eating disorders (EDs). To conduct peer support activities, it is necessary to clarify the needs of families.ObjectivesThe objective of this study are to identify the needs for group and individual peer support and the characteristics of family members with EDs who are willing to receive and provide individual peer support.MethodA cross-sectional questionnaire survey was conducted for family members with EDs recruited via the Internet. The questionnaires included demographic information on respondents and their patients, questions about the need for family peer support, interest in offering peer support, and social resources. All participants were given the General Health Questionnaire (GHQ-12), the Zarit Caregiver Burden Interview (J-ZBI_8), and the Anorectic Behavior Observation Scale (ABOS).ResultsOut of 314 respondents, 87.3% believed that a group peer support system was necessary, whereas 56.7% believed that an individual peer support system was necessary. As to whether they want to use individual peer support, 70 (22.4%) stated “Extremely YES” and 99 (31.7%) stated “Moderately YES.” Family members who were willing to receive individual peer support used more social resources and had higher scores on the GHQ and J-ZBI_8. Regarding the provision of peer support, 38 (12.2%) responded “very interested and willing to provide it if possible” and 87 (27.9%) responded “interested and willing to study.” Those with a high willingness to provide peer support used more social resources and had lower ABOS scores; however, 38 respondents (45.7%) exceeded the GHQ mental health screening cutoff (3/4).ConclusionFamily members with ED had a strong need for family peer support Those willing to receive individual peer support suffered from poor mental health and high burden of care. Family members willing to provide peer support tended to have patients whose EDs symptoms had already improved, but their own mental health was not necessarily good. Training for potential peer supporters is needed to implement peer support.

Peer support may help improve the wellbeing of informal caregivers, although little work has explored this in the context of multiple sclerosis (MS). This study explored peer support needs and experiences among MS caregivers in Ireland. A cross-sectional mixed methods survey of 27 MS caregivers, designed with public and patient involvement, measured peer support engagement, sociodemographic and care characteristics, caregiver burden, social support, loneliness and wellbeing. Data were analysed using descriptive, correlational and content analysis. Most caregivers expressed a desire for peer support, with few having participated in online or in-person peer support. Barriers to engagement included a lack of promotion of opportunities. While low levels of social support and wellbeing were reported, no clear associations between peer support needs and these variables were identified. Although peer support shows promise, more research and improvements in the provision of MS caregiver peer support are needed.

Adolescents living with HIV have poor treatment outcomes, including lower rates of viral suppression, than other age groups. Emerging evidence suggests a connection between improved mental health and increased adherence. Strengthening the focus on mental health could support increased rates of viral suppression. In sub-Saharan Africa clinical services for mental health care are extremely limited. Additional mechanisms are required to address the unmet mental health needs of this group. We consider the role that community-based peer supporters, a cadre operating at scale with adolescents, could play in the provision of lay-support for mental health. We conducted qualitative research to explore the experiences of peer supporters involved in delivering a peer-led mental health intervention in Zimbabwe as part of a randomized control trial (Zvandiri-Friendship Bench trial). We conducted 2 focus group discussions towards the end of the trial with 20 peer supporters (aged 18-24) from across 10 intervention districts and audio recorded 200 of the peer supporters' monthly case reviews. These data were thematically analysed to explore how peer supporters reflect on what was required of them given the problems that clients raised and what they themselves needed in delivering mental health support. A primary strength of the peer support model, reflected across the datasets, is that it enables adolescents to openly discuss their problems with peer supporters, confident that there is reciprocal trust and understanding derived from the similarity in their lived experiences with HIV. There are potential risks for peer supporters, including being overwhelmed by engaging with and feeling responsible for resolving relationally and structurally complex problems, which warrant considerable supervision. To support this cadre critical elements are needed: a clearly defined scope for the manageable provision of mental health support; a strong triage and referral system for complex cases; mechanisms to support the inclusion of caregivers; and sustained investment in training and ongoing supervision. Extending peer support to explicitly include a focus on mental health has enormous potential. From this empirical study we have developed a framework of core considerations and principles (the TRUST Framework) to guide the implementation of adequate supportive infrastructure in place to enhance the opportunities and mitigate risks.

IntroductionAdolescents living with HIV have poor treatment outcomes, including lower rates of viral suppression, than other age groups. Emerging evidence suggests a connection between improved mental health and increased adherence. Strengthening the focus on mental health could support increased rates of viral suppression. In sub-Saharan Africa clinical services for mental health care are extremely limited. Additional mechanisms are required to address the unmet mental health needs of this group. We consider the role that community-based peer supporters, a cadre operating at scale with adolescents, could play in the provision of lay-support for mental health.MethodsWe conducted qualitative research to explore the experiences of peer supporters involved in delivering a peer-led mental health intervention in Zimbabwe as part of a randomized control trial (Zvandiri-Friendship Bench trial). We conducted 2 focus group discussions towards the end of the trial with 20 peer supporters (aged 18–24) from across 10 intervention districts and audio recorded 200 of the peer supporters’ monthly case reviews. These data were thematically analysed to explore how peer supporters reflect on what was required of them given the problems that clients raised and what they themselves needed in delivering mental health support.ResultsA primary strength of the peer support model, reflected across the datasets, is that it enables adolescents to openly discuss their problems with peer supporters, confident that there is reciprocal trust and understanding derived from the similarity in their lived experiences with HIV. There are potential risks for peer supporters, including being overwhelmed by engaging with and feeling responsible for resolving relationally and structurally complex problems, which warrant considerable supervision. To support this cadre critical elements are needed: a clearly defined scope for the manageable provision of mental health support; a strong triage and referral system for complex cases; mechanisms to support the inclusion of caregivers; and sustained investment in training and ongoing supervision.ConclusionExtending peer support to explicitly include a focus on mental health has enormous potential. From this empirical study we have developed a framework of core considerations and principles (the TRUST Framework) to guide the implementation of adequate supportive infrastructure in place to enhance the opportunities and mitigate risks.

Chronic conditions are a growing healthcare concern. People living in rural regions are particularly affected because many barriers exist to accessing services and supports. Peer support for chronic condition self-management, where people living with chronic conditions learn about how to care for themselves and maintain their health from people also living with chronic conditions, is one approach gaining recognition. What remains unknown are the unique challenges and strategies associated with peer support for chronic condition self-management in rural contexts. In order to inform the development of peer supports in the authors' local context in rural eastern Canada, a scoping review was undertaken to discover community-based peer support initiatives for adults in rural settings living with chronic conditions. The authors followed established scoping review methods to answer the research question What is known from the existing literature about the key features and potential formats of community-based peer support initiatives for adults living with chronic conditions in rural settings? Six databases (CINAHL, PubMed, Sociological Abstracts, Embase, Cochrane Libraries and PsycInfo) were searched using the following concepts: chronic conditions, peer support, community-based and rural context. Two researchers reviewed the titles and/or abstracts of the 1978 articles retrieved from the initial search to include articles that were in English, published in 2000 to 2014, and that explicitly discussed rural programs/interventions with peers that were community-based. The initial screen excluded 1907 articles, leaving 71 articles, which were read by two research members in light of the inclusion/exclusion criteria. Thirteen articles representing 10 separate programs were included and analyzed using qualitative content analysis. Included programs were from the USA, Australia and Canada. A range of formats (telecommunications only, in-person meetings only, or a combination of both) were used. Peer leaders had varied experiences with chronic conditions and received training in content and facilitation skills. Peer leaders were provided with ongoing support. Program participants received training on chronic conditions, and programs provided opportunities for social support and the development of new skills. Programs focused on creating social connections, reducing stigma, ensuring relevance and promoting empowerment. Of the nine programs that reported outcomes, eight reported positive outcomes and one reported mixed results. Consistent with the extant literature, the programs identified unique issues faced by people with chronic conditions in rural areas that these programs addressed. The key findings of this scoping review are as follows: 1. A combination of telecommunications with some face-to-face meetings can support the accessibility of peer support programs in rural areas. 2. Core elements of these programs are the provision of social support and skill development. 3. Peer leaders benefit from skills training and ongoing support. 4. Sustainability of such programs is complex and requires multiple strategies. Cultural relevance, ongoing support and the use of telecommunications were key features of rural peer support programs. Guiding questions to facilitate a community consultation around these findings are provided. Peer support chronic condition self-management programs require further research.

Postpartum depression peer support: Maternal perceptions from a randomized controlled trial

Purpose – The purpose of this paper is to present findings from an evaluation of a community mental health resilience intervention for unemployed men aged 45-60. The focus is on examining the place of facilitated peer support within a multi-dimensional men’s mental health programme, and exploring implications for resilience building delivery approaches for men. Design/methodology/approach – The paper draws on a mixed methodology design involving before and after survey data and qualitative interviews, to report results concerning effectiveness in changing men’s perceived resilience, to consider project processes concerning peer support, and to situate these within wider community environments. Findings – The programme significantly raised the perceived resilience of participants. Project activities promoted trusting informal social connections, gains in social capital arose through trusting relations and skill-sharing, and peer-peer action-focused talk and planning enhanced men’s resilience. Research limitations/implications – The paper considers facilitated peer support on a programme, rather than on-going informal peer support or more formal peer support roles (a limitation reflecting the boundaries of the funded programme). Practical implications – The paper discusses emerging considerations for resilience building, focusing on gender-sensitive approaches which can engage and retain men by focusing on doing and talking. It highlights the importance of peer support in community interventions which feature a social model of change. There is potential for encouraging further peer mentoring and peer led support beyond facilitated peer support in programme delivery. Social implications – Potential exists for gender-aware programmes to sustain salutogenic change, co-producing social assets of peer support, male-friendly activities, and context sensitive course provision. Originality/value – The paper adds fresh evidence of gendered intervention approaches with a specific focus on facilitated community peer support, including effects on male resilience. Little previous resilience research is gendered, there is little gendered research on peer support, and unemployed middle-aged men are a significant risk group.

Breastfeeding conveys significant health benefits to infants and mothers yet in many affluent nations breastfeeding rates continue to decline across the early months following birth. Both peer and professional support have been identified as important to the success of breastfeeding. What is not known are the key components or elements of support that are effective in increasing the duration of breastfeeding? The aim of this meta-synthesis was to examine women's perceptions and experiences of breastfeeding support, either professional or peer, in order to illuminate the components of support that they deem 'supportive'. A secondary aim was to describe any differences between components of Peer and Professional support. Both primiparous and multiparous women who initiated breastfeeding were included in the study. Studies that included a specific demographic sub-group, such as adolescents, were included. Studies focused on a specific clinical sub-group, such as women post-caesarean, were not included. This meta-synthesis focused on maternal experiences of breastfeeding support. The meta-synthesis included both formal or 'created' peer and professional support for breastfeeding women but excluded studies of family or informal support for breastfeeding. Primarily qualitative studies were included in the review. Studies such as large scale surveys were also included if they reported in sufficient detail the analysis of qualitative data gathered through open ended responses or included in depth interviews. Only studies published or available in English, in peer reviewed journals and undertaken between 1990 and December 2007 were included. Key data bases were searched. The following search terms were individually added to the main keyword - breastfeeding: qualitative research, breast feeding support, peer support, professional support, postnatal support, post-natal support, volunteer support, lay support, breastfeeding counsellors, lactation consultants, social support, health education, breastfeeding education and lactation. Delimiters applied were humans, English language and years 1990-2007. JBI-QARI (Qualitative Assessment and Review Instrument) was used to assess the quality of 38 articles selected for full review. Seven were excluded primarily because they included little qualitative data relevant to the review focus. The studies reviewed were generally of reasonable quality in terms of clarity, appropriate methodology, credibility and evidence cited to support the conclusions drawn. However, most included relatively limited discussion of theoretical or conceptual perspectives, discussion of relevant literature and reflection on the roles of the researchers. JBI-QARI was used to manage and appraise textual data, Meta-ethnographic methods were used to develop 'interpretive explanations and understanding of breastfeeding support. Each study was systematically reviewed, reading and re-reading papers to create a list of themes through 'reciprocal translation'. Both first order and second order constructs were used to create the themes and these were then synthesised into four interpretive categories. The meta-synthesis resulted in four categories comprising a total of 20 themes. The synthesis indicates that support for breastfeeding occurs along a continuum from authentic presence at one end, perceived as effective support, to disconnected encounters at the other, perceived as ineffective or even discouraging and counter productive. Second, the synthesis identified a facilitative approach, versus a reductionist approach as contrasting styles of support women experienced as helpful or unhelpful. The findings of this meta-synthesis emphasise the importance of person-centred communication skills and of relationships in supporting a woman to breastfeed. Authentic presence is best supported by building a trusting relationship, demonstrating empathy, listening and being responsive to a woman's needs. Organisational systems and services that facilitate continuity of care/r and time spent with the woman, for example continuity of midwifery care or peer support models, are more likely to facilitate an authentic presence. The findings suggest the need to increase opportunities to offer women across all social groups access to peer support. The review indicates several changes in direction for practice to foster provision of support that women consider helpful and enabling, rather than disabling. These include service design that facilitates effective relationships to be established between supporters and the woman, including greater continuity of carer, Midwives need to work in service models that enable them to provide more individualised, rather than standard care and advice, to spend time and provide practical help to those women who need it. Antenatal education needs to be more learner-centred, using pedagogic models based on adult-learning principles, and should provide women with information that is realistic, detailed and positively encouraging. Midwifery education needs to integrate sufficient focus on developing midwives' communication and information giving skills. Schemes to offer peer support should be developed further, using a pro-active approach, including home visits and support groups. Further research is warranted on schemes to develop peer models of support. Research is also needed to investigate in more depth the service models and conditions that are conducive to midwives' ability to offer effective support for breastfeeding.

This research investigated how peer victimization and support are reciprocally related and how Cooperative Learning (CL) can reverse the progressive cascade that, unchecked, can culminate in youth mental health problems. The sample (N = 1890; 53% male) was derived from a randomized trial of CL in 15 middle schools in the United States. Students were recruited in the 7th grade. Structural Equation Modeling (SEM) was used to fit our cross-lag difference score model across four waves of data. The results indicated a reciprocal relationship between peer support and victimization across time, suggesting the potential for negative experiences with peers to become amplified over time in a "vicious cycle," negatively impacting mental health. Students in intervention schools reported significantly higher levels of peer support and lower levels of victimization, suggesting that CL can intervene in this cycle, with salutary effects on mental health; CL also demonstrated direct effects on mental health. The present study indicates that low peer support can be both a precursor to and an outcome of victimization, serving to maintain a vicious cycle that compounds negative effects on student mental health. Further, results demonstrate how CL can reverse this cycle. We conclude that CL can be of particular importance to the prevention field as a universal mental health program that does not require the associated stigma of identifying youth at elevated risk for referral to treatment programs.

IntroductionLow rates of viral suppression among adolescents living with HIV (ALHIV) indicate that more effective support is urgently required at scale. The provision of peer support has generated considerable enthusiasm because it has the potential to ameliorate the complex social and relational challenges which underpin suboptimal adherence. Little is known about the impact on young peer supporters themselves, which is the focus of this paper.MethodsWe present qualitative findings from the Zvandiri trial investigating the impact of a peer support intervention on the viral load for beneficiaries (ALHIV, aged 13 to 19 years) in Zimbabwe. The Zvandiri peer supporters aged 18 to 24 years, known as community adolescent treatment supporters (CATS), are themselves living with HIV. Individual in‐depth interviews were conducted in late 2018 with 17 CATS exploring their experiences of delivering peer support and their own support needs. Interviews were analysed iteratively using thematic analysis.ResultsThe CATS reported that being peer supporters improved their own adherence behaviour and contributed to an improved sense of self‐worth. The social connections between the CATS were a source of comfort and enabled them to develop skills to manage the challenging aspects of their work. Two substantial challenges were identified. First, their work may reveal their HIV status. Second, managing the emotional labour of this caring work; given how commonly the complexity of the beneficiaries’ needs mirrored the circumstances of their own difficult lives. Both challenges were ameliorated by the support the CATS provided to each other and ongoing supervision from the adult mentor. There was variation in whether they felt their roles were appropriately valued through the remuneration they received and within the health system. There was a consensus that their experience meant that they would graduate from being a CATS with transferable skills that could enhance their employability.ConclusionsTheir experiences illustrate the advantages and opportunities of being a CATS. To minimize potential harms, it is vital to ensure that they feel valued in their role, which can be demonstrated by the provision of appropriate remuneration, recognition and respect, and that there is continued investment in ongoing support through ongoing training and mentoring.

To explore peer support and whether it can have an effective role in a multidisciplinary team approach to supporting a patient with a spinal cord injury. This was an independent evaluation that used an online survey, a focus group and telephone interviews to elicit the views of respondents about the Spinal Injury Association (SIA) peer support service in England and Wales. There were four groups of respondents: people with a spinal cord injury; their family and friends; peer support officers; and nurse specialists and other healthcare practitioners. It was identified that peer support officers were valued for their ability to provide a positive role model for people with a spinal cord injury. Healthcare practitioners involved in the care of people with a spinal cord injury also appreciated the training and support they received from peer support officers. This evaluation demonstrated that peer support officers were regarded as an important element of a multidisciplinary team approach to managing the care of those who had experienced a spinal cord injury. Peer support officers were also considered a valuable source of information and education, particularly for healthcare practitioners working in settings where spinal cord injury was not a common presentation.

BackgroundPrevalence of self-harm In England is rising, however contact with statutory services remains relatively low. There is growing recognition of the potential role voluntary, community and social enterprise sector (VCSE) organisations have in the provision of self-harm support. We aimed to explore individuals’ experiences of using these services and the barriers and facilitators to accessing support.MethodsQualitative, online interviews with 23 adults (18+) who have accessed support from VCSE organisations for self-harm in the Yorkshire and the Humber region were undertaken. Interviews were audio recorded and transcribed verbatim. Thematic analysis was undertaken using NVivo software.ResultsParticipants described how a lack of service flexibility and the perception that their individual needs were not being heard often made them less likely to engage with both statutory and VCSE organisations. The complexity of care pathways made it difficult for them to access appropriate support when required, as did a lack of awareness of the types of support available. Participants described how engagement was improved by services that fostered a sense of community. The delivery of peer support played a key role in creating this sense of belonging. Education and workplace settings were also viewed as key sources of support for individuals, with a lack of mental health literacy acting as a barrier to access in these environments.ConclusionsVCSE organisations can play a crucial role in the provision of support for self-harm, however, pathways into these services remain complex and links between statutory and non-statutory services need to be strengthened. The provision of peer support is viewed as a crucial component of effective support in VCSE organisations. Further supervision and training should be offered to those providing peer support to ensure that their own mental health is protected.