"I Think Peer Support Helps to Demystify People Who Have Mental Health Issues and Helps to Remove That Stigma": Exploring the Defining Characteristics and Related Challenges of Youth Peer Support Through Participatory Research.

Despite the emerging body of literature on the benefits of youth peer support, there is also evidence that peer support can have unintended negative impacts on peers themselves. It is important to explore what aspects of the peer role contribute to these difficulties in order to mitigate risks. This paper uses a participatory approach to examine the unique attributes of youth peer practice and the related challenges. We conducted semi-structured interviews and focus groups with both peer and non-peer staff from a community-based youth mental health program that provides peer support services (N = 29). Thematic analyses were completed using QSR NVivo. Analyses capture the defining features and related challenges of the peer support role (self-disclosure, boundaries, role confusion and dynamic recovery), and risk factors that affect peers (stigma, exposure to harm and burnout). This paper contributes to the literature on peer support as well as youth participatory evaluation. The findings will be useful to support the development of improved organizational contexts for peer practice and more effective peer support programming.

"You can create a little bit more closure in your own story when someone really connects with it": exploring how involvement in youth peer support work can promote peer development.

BACKGROUND: Peer support relates to the provision of social/emotional support that is delivered by individuals with lived experience of a key characteristic that is shared with clients. Although the main objective of peer support is to enhance client outcomes, through their involvement, peers derive a secondary benefit to their own personal development. This study applied a hybrid participatory-realist approach to identify what works, for whom, why and in what circumstances within the LOFT Transitional Age Youth (TAY) peer services. This paper presents findings related to the processes and possible benefits of being involved in peer work for the peer supporters themselves. METHODS: Semi-structured interviews and focus groups were completed with peer and non-peer staff from the TAY program. A qualitative analysis applied a retroductive approach that involved both inductive and deductive processes to identify relevant themes. RESULTS: Four program theories and one over-arching context were identified through the analyses. Program theories were related to: (1) enhancing self-efficacy and self-determination through peer involvement in program design, (2) increasing peer resiliency and self-care through effective supervision, (3) developing professional skills and opportunities for career advancement through peer practice and (4) overcoming stigma through the recognition of the value of peer lived experience. CONCLUSIONS: Peer practice holds significant potential for the enhancement of the mental health system as well as to increase our understanding of stigma. The findings from this study offer critical new insights into the dynamics of how professional peer practice can support the personal development of youth peers and how programming can be intentionally designed to enhance these benefits.

Focusing a realist evaluation of peer support for paediatric mental health.

OBJECTIVE: Mental health problems are a leading and increasing cause of health-related burden in children across the world. Peer support interventions are increasingly used to meet this need using the lived experience of people with a history of mental health problems. However, much of the research underpinning this work has focused on adults, leaving a gap in knowledge about how these complex interventions may work for different children in different circumstances. Realist research may help us to understand how such complex interventions may trigger different mechanisms to produce different outcomes in children. This paper reports on an important first step in realist research, namely the construction of an embryonic initial programme theory to help 'focus' realist evaluation exploring how children's peer support services work in different contexts to produce different outcomes in the West Midlands (UK). METHODS: A survey and preliminary semi-structured realist interviews were conducted with 10 people involved in the delivery of peer support services. Realist analysis was carried out to produce context-mechanism-outcome configurations (CMOC). RESULTS: Analysis produced an initial programme theory of peer support for children's mental health. This included 12 CMOCs. Important outcomes identified by peer support staff included hope, service engagement, wellbeing, resilience, and confidence; each generated by different mechanisms including contextualisation of psychoeducation, navigating barriers to accessing services, validation, skill development, therapeutic relationship, empowerment, and reducing stigma. CONCLUSION: These data lay the groundwork for designing youth mental health realist research to evaluate with nuance the complexities of what components of peer support work for whom in varying circumstances.

Stigma as a barrier to early intervention among youth seeking mental health services in Ontario, Canada: a qualitative study.

BACKGROUND: Stigma associated with mental health challenges is a major barrier to service seeking among youth. Understanding how stigma impacts service-seeking decisions from the perspectives of youth remains underexplored. Such research is necessary to inform effective stigma reduction. OBJECTIVE: This study aims to understand how stigma influences service seeking among youth with mental health challenges. METHODS: Qualitative inquiry was taken using youth engagement, underpinned by pragmatism. Data were collected via 4 virtual focus groups with 22 purposively selected youth participants with lived experience of mental health challenges in Ontario, Canada. Focus group guides were developed collaboratively among research team members, including youth co-researchers. Data were analyzed inductively using reflexive thematic analysis. RESULTS: Three main themes were constructed from the data: point of entry into the system, being biomedicalized or trivialized, and paving the way for non-stigmatizing services. Initial contact with the mental healthcare system was seen to be affected by stigma, causing participants to delay contact or be refused services if they do not fit with an expected profile. Participants described a constant negotiation between feeling 'sick enough' and 'not sick enough' to receive services. Once participants accessed services, they perceived the biomedicalization or trivialization of their challenges to be driven by stigma. Lastly, participants reflected on changes needed to reduce stigma's effects on seeking and obtaining services. CONCLUSION: A constant negotiation between being 'sick enough' or 'not sick enough' is a key component of stigma from the perspectives of youth. This tension influences youth decisions about whether to seek services, but also service provider decisions about whether to offer services. Building awareness around the invisibility of mental health challenges and the continuum of wellness to illness may help to break down stigma's impact as a barrier to service seeking. Early intervention models of care that propose services across the spectrum of challenges may prevent the sense of stigma that deters youth from accessing and continuing to access services.

Implications of time and space factors related with youth substance use prevention: a conceptual review and case study of the Icelandic Prevention Model being implemented in the context of the COVID-19 pandemic.

PURPOSE: This research examines the implementation of the Icelandic Prevention Model (IPM) in Canada to identify opportunities revealed by the COVID-19 pandemic to re-design our social eco-system to promote wellbeing. This paper has two objectives: 1) to provide a conceptual review of research that applies the bioecological model to youth substance use prevention with a focus on the concepts of time and physical space use and 2) to describe a case study that examines the implementation of the IPM in Canada within the context of the COVID-19 pandemic. METHOD: Study data were collected through semi-structured qualitative interviews with key stakeholders involved in implementing the IPM. RESULTS: Findings are organized within three over-arching themes derived from a thematic analysis: 1) Issues that influence time and space use patterns and youth substance use, 2) Family and community cohesion and influences on developmental context and time use and 3) Opportunities presented by the pandemic that can promote youth wellbeing. CONCLUSION: We apply the findings to research on the IPM as well as the pandemic to examine opportunities that may support primary prevention and overall youth wellbeing. We use the concepts of time and space as a foundation to discuss implications for policy and practice going forward.

Building engagement to support adoption of community-based substance use prevention initiatives.

BACKGROUND: System-level approaches that target social determinants of health are promising strategies to support substance use prevention, holistic youth development and wellbeing. Yet, the youth services system is largely based on individual-focused programs that do not adequately account for social determinants of health and place the responsibility for wellness on the individual. There is a need to understand how to enhance adoption of complex system-level approaches that support comprehensive youth development. The Icelandic Prevention Model (IPM) represents a collaborative initiative that takes an ecological, system-level approach to prevent substance use and promote wellness in youth. This research was designed to examine key stakeholder perceptions to better understand social motivations and contextual complexities that influence stakeholder support to garner community-level adoption of the IPM in a rural Canadian community. METHODS: This research applies a case study approach using qualitative interviews to explore strategies to support uptake in the early stages of IPM adoption associated with developing community buy-in and acceptance. A thematic analysis was applied using QSR NVivo. RESULTS: Nine interviews were conducted with community partners leading the implementation of the IPM. Three over-arching themes emerged from the data: 1) Motivating influences 2) Strategies to develop buy-in, and 3) Resistance to the adoption of the IPM. Findings reflect issues that affect behaviour change in system transformation in general as well as upstream prevention and the IPM, in particular. CONCLUSIONS: The findings from this research describe critical insight derived from implementing community-driven initiatives that are designed to support health promotion. It contributes new scientific knowledge related to implementation of complex system-level innovations and practical information that is useful for communities interested in implementing the IPM or following similar approaches to prevent substance use.

"You can kind of just feel the power behind what someone's saying": a participatory-realist evaluation of peer support for young people coping with complex mental health and substance use challenges.

BACKGROUND: Youth peer support, as a practice that aligns youth engagement and participatory approaches, has become increasingly popular in the context of youth mental health services. However, there is a need for more evidence that describes how and why youth peer support practice might be effective. This study was designed to examine a peer support service for youth experiencing complex challenges with mental health, physical health and/or substance use to better understand key features and underlying mechanisms that lead to improved client outcomes. METHODS: We applied a hybrid realist-participatory approach to explore key issues and underlying theoretical assumptions within a youth peer support approach for young people (age 14-26) experiencing complex mental health and substance use challenges. We used semi-structured interviews and focus groups with staff, including peers (N = 8), clinical service providers and administrative staff (N = 15), to develop the theories and a client survey to validate them. Our qualitative thematic analysis applied a retroductive approach that involved both inductive and deductive processes. For the client survey (N = 77), we calculated descriptive statistics to examine participant profiles and usage patterns. Pearson correlations were examined to determine relationships among concepts outlined in the program theories, including context, mechanism and outcome variables. RESULTS: Our analyses resulted in one over-arching context, one over-arching outcome and four program theories. Program theories were focused on mechanisms related to 1) positive identity development through identification with peers, 2) enhanced social connections, 3) observational learning and 4) enhanced autonomy and empowerment. CONCLUSIONS: This study serves as a unique example of a participatory-realist hybrid approach. Findings highlight possible key components of youth peer practice and shed light on the functional mechanisms that underlie successful peer practice. These key components can be examined in other settings to develop more comprehensive theories of change with respect to youth peer support and can eventually be used to develop guidelines and standards to strengthen practice. This research contributes to an expanding body of literature on youth peer support in mental health and connects peer practice with several social theories. This research begins to lay a foundation for enhanced youth peer support program design and improved outcomes for young people experiencing complex mental health and substance use challenges.

Engaging young people within a collaborative knowledge mobilization network: Development and evaluation.

BACKGROUND: It is critical that mental health systems place a focus on prevention and early intervention focused on young people while integrating youth voice to guide priority directions. OBJECTIVE: This study was designed to better understand how youth advisories can be utilized to influence strategic directions within integrated knowledge mobilization networks operating within the youth mental health system. DESIGN: To support this objective, we reviewed the detailed stages of development in establishing a youth advisory within a national network designed to support the integration of youth services. We also engaged the advisory in a participatory evaluation process that examined the extent to which the network had created processes to include youth voice in decision-making. RESULTS: Results from the surveys identified moderate to high levels of individual engagement as well as strong development of processes and procedures that support the inclusion of youth voice across the network. DISCUSSION: Major successes and challenges are presented and discussed with respect to the development of the advisory. The findings are useful for youth advocates and adult allies working to support youth engagement (YE) in knowledge mobilization to enhance the mental health services system. This study also contributes to research and evaluation efforts examining YE and represents an exemplar methodology for evaluating YE efforts at the system level. PATIENT OR PUBLIC CONTRIBUTION: Young people as mental health service users and youth mental health advocates were involved in the design, data collection, analysis and interpretation of the data as well as the preparation of this manuscript.

INNOVATE Research: Impact of a workshop to develop researcher capacity to engage youth in research.

BACKGROUND: Engaging youth in research provides substantial benefits to research about youth-related needs, concerns and interventions. However, researchers require training and capacity development to work in this manner. METHODS: A capacity-building intervention, INNOVATE Research, was co-designed with youth and adult researchers and delivered to researchers in three major academic research institutions across Canada. Fifty-seven attendees participated in this research project evaluating youth engagement practices, attitudes, perceived barriers, and perceived capacity development needs before attending the intervention and six months later. RESULTS: The intervention attracted researchers across various career levels, roles and disciplines. Participants were highly satisfied with the workshop activities. Follow-up assessments revealed significant increases in self-efficacy six months after the workshop (P = .035). Among possible barriers to youth engagement, four barriers significantly declined at follow-up. The barriers that decreased were largely related to practical knowledge about how to engage youth in research. Significantly more participants had integrated youth engagement into their teaching activities six months after the workshop compared to those who were doing so before the workshop (P = .007). A large proportion (71.9%) of participants expressed the need for a strengthened network of youth-engaged researchers; other future capacity-building approaches were also endorsed. CONCLUSIONS: The INNOVATE Research project provided improvements in youth engagement attitudes and practices among researchers, while lifting barriers. Future capacity-building work should continue to enhance the capacity of researchers to engage youth in research. Researchers notably pointed to the need to establish a network of youth-engaged researchers to provide ongoing, sustainable gains in youth engagement.

Assessing the impacts of the Agenda Gap intervention for youth mental health promotion through policy engagement: a study protocol.

BACKGROUND: Mental health challenges are a leading health concern for youth globally, requiring a comprehensive approach incorporating promotion, prevention and treatment within a healthy public policy framework. However, the broad enactment of this vision has yet to be realized. Further, mental health promotion evidence specific to youth is still emerging and has not yet focused at a policy level. This is a critical gap, as policy is a key mental health promotion lever that can alter the social and structural conditions that contribute to shaping youth mental health outcomes for all youth, across the full spectrum of need. Responsive to this research and intervention priority, our prototype study intervention-the Agenda Gap-is comprised of an innovative, multi-media engagement intervention, developed in collaboration with youth. This intervention aims to equip youth and build capacity for them to lead meaningful policy change reflective of the mental health needs of diverse communities of youth, including those who experience structural vulnerability and who would not typically have had their voice represented in policymaking processes. METHODS: This study will use a multiple case study design and mixed methods grounded in a realist approach and will be conducted in three sites across two Canadian provinces (British Columbia and Alberta). In an earlier phase of this research, we collaboratively designed the prototype intervention with youth, community and policy partners. In this phase of the study, the intervention will be implemented and further tested with new groups of youth collaborators (n = 10-15/site). Outcome data will be collected through realist qualitative interviews, validated questionnaires [i.e., Child and Youth Resilience Measure (CYRM-12), General Self-Efficacy (GSE) Scale, and the Critical Consiousness Scale (CCS)] and additional survey items developed by our study team. Analysis will focus on identification of key context-mechanism-outcome configurations to provide comprehensive insights into how this intervention works, for whom, and in what context. DISCUSSION: This study is unique in its "upstream" focus on youth-engaged policymaking as a tool for improving the social and structural conditions that influence youth mental health across socioecological levels. Through the implementation and testing of the Agenda Gap intervention with diverse youth, this study will contribute to the evidence base on youth-engaged policymaking as a novel and innovative, mental health promotion strategy.

Examining the implementation of the Icelandic model for primary prevention of substance use in a rural Canadian community: a study protocol.

BACKGROUND: The Icelandic Prevention Model (IPM) is a collaborative upstream model that was designed to influence risk and protective factors related to substance use within the community, school, peer and family contexts. By engaging whole communities, the IPM has been found to be effective in reducing youth substance use behaviours across Iceland. As an extension to the IPM's participatory approach, this research will examine how youth involvement can enhance outcomes. In addition, this research will evaluate whether the IPM approach is beneficial for mental health promotion and general youth wellbeing. METHODS: The present research protocol applies the bioecological model within a participatory mixed-method case study design to examine the implementation of the IPM in a rural community in Canada. This study was designed to identify whether the Icelandic substance use prevention model is effective in reducing substance use and promoting mental health and development for Canadian youth. It will also explore how to engage youth within the approach and how this adaptation influences implementation and outcomes. DISCUSSION: The findings from this study will contribute to our understanding of upstream prevention of youth substance use and will be used to support scaling of the IPM across Canada.

Enhancing researcher capacity to engage youth in research: Researchers' engagement experiences, barriers and capacity development priorities.

BACKGROUND: There is increasing emphasis on engaging youth in research about youth, their needs, experiences and preferences, notably in health services research. By engaging youth as full partners, research becomes more feasible and relevant, and the validity and richness of findings are enhanced. Consequently, researchers need guidance in engaging youth effectively. This study examines the experiences, needs and knowledge gaps of researchers. METHODS: Eighty-four researchers interested in youth engagement training were recruited via snowball sampling. They completed a survey regarding their youth engagement experiences, attitudes, perceived barriers and capacity development needs. Data were analysed descriptively, and comparisons were made based on current engagement experience. RESULTS: Participants across career stages and disciplines expressed an interest in increased capacity development for youth engagement. They had positive attitudes about the importance and value of youth engagement, but found it to be complex. Participants reported requiring practical guidance to develop their youth engagement practices and interest in a network of youth-engaged researchers and on-going training. Those currently engaging youth were more likely to report the need for greater appreciation of youth engagement by funders and institutions. CONCLUSIONS: Engaging youth in research has substantial benefits. However, skills in collaborating with youth to design, conduct and implement research have to be learned. Researchers need concrete training and networking opportunities to develop and maximize these skills. They also need mechanisms that formally acknowledge the value of engagement. Researchers and those promoting youth engagement in research are encouraged to consider these findings in their promotion and training endeavours.

Frayme: Building the structure to support the international spread of integrated youth services.

AIM: Frayme is a Canadian-based international network designed to accelerate the adoption and scaling up of integrated youth services (IYS). This is done through the synthesis of evidence from a variety of sources and a commitment to integrated knowledge mobilization (KMb) to inform research policy and practice. Frayme is utilizing innovative approaches to stakeholder engagement (youth, families, policy makers, funders, researchers and practitioners) and KMb in order to co-design system change. The purpose of this article describes the overall Frayme strategy and presents findings from a participatory needs assessment implemented to inform policy-related priorities. METHODS: The Frayme leadership team facilitated a participatory needs assessment with major stakeholder groups that applied a modified problem-solving activity. The needs assessment was on a designed to support diverse stakeholder perspectives on ways to improve knowledge mobilization of IYS. Qualitative data were analysed using a thematic analysis. RESULTS: The four themes identified through the needs assessment were: (a) traditional scientific practices, (b) organizational obstacles, (c) change aversion, and (d) pre-established stakeholder hierarchies. CONCLUSIONS: Through the recognition of these challenges, Frayme has developed a set of major objectives to inform projects, opportunities for knowledge sharing, implementation of evidence and scaling up of efforts. The Frayme integrated KMb model represents a unique applied example of an evidence-informed approach to practice collaboration in KMb to promote system change. The findings from this research also contribute to the expanding knowledge base with regard to complex evaluation and system transformation.

Trends in mental health system transformation: Integrating youth services within the Canadian context.

The current mental health services system in Canada is fragmented and transitions between the youth and adult mental health systems have been identified as needing significant improvement. Integrated Youth Services (IYS) are designed to be adaptable and developmentally appropriate as well as to promote seamless transitions, including during emerging adulthood. This article provides an overview of recent developments in Canadian mental health system transformation to promote the integration of services and the holistic promotion of youth well-being. We offer an overview of the current state of knowledge related to best practices in IYS in Canada and highlight areas for future development. We also introduce Frayme, a Canadian-based international knowledge translation platform designed to connect organizations working in the youth services system to accelerate the implementation of IYS.

Examining Integrated Youth Services Using the Bioecological Model: Alignments and Opportunities.

Integrated youth service (IYS) is a collaborative approach that brings practitioners together from across disciplines to provide comprehensive services including mental health care for youth and their families. IYS models serve as an advancement in practice as they go beyond the capacity of individual programs and services to reduce the fragmentation of care. Yet, there continue to be opportunities to expand on this perspective and promote health beyond the scope of formalized services. The bioecological model is a theoretical model that examines individual development within multiple systems of influence as well as through interactional processes between the individual and their environment. This paper provides an overview of the bioecological model and the major components of the IYS model, describing alignment and complementarity. The bioecological model provides some explanations for why IYS models may be effective and helps to provide direction to expand applied practice toward a more holistic perspective.

Results of a utilization-focused evaluation of a Right To Play program for Indigenous youth.

This paper presents an evaluation of the Promoting Life Skills for Aboriginal Youth (PLAY) program that is operated by Right to Play (RTP). The focus of the program is to help youth develop a variety of life skills and become leaders within their communities. Piloted in 2010 with 2 communities, the program is now implemented in 88 communities in Ontario, Manitoba, British Columbia, and Alberta. This study applies a utilization-focused evaluation to examine staff perceptions related to program implementation. Data were collected using semi-structured interviews and a thematic analysis was performed. Themes emerged related to: 1) Integrating program flexibility to help facilitate community ownership, 2) Building capacity through skills training for Community Mentors (CMs), 3) Having a motivated staff and organizational learning, 4) Balancing the integration of culture and 5) Challenges related to adapting to multiple stakeholders and program pace. Findings are discussed in relation to relevant literature and recommendations for program improvements are provided. We also describe program improvements that were made as a result of applying the findings. This research contributes to the expanding literature related to programming for youth and evaluation practice within Indigenous communities.

Putting program evaluation into practice: enhancing the Girls Just Wanna Have Fun program.

In recent years there has been a call for increased community physical activity and sport programs for female youth that are deliberately structured to foster positive developmental outcomes. In addition, researchers have recognized the need to empirically evaluate such programs to ensure that youth are provided with optimal opportunities to thrive. This study represents a utilization-focused evaluation of Girls Just Wanna Have Fun, a female-only physical activity-based life skills community program. A utilization-focused evaluation is particularly important when the evaluation is to help stakeholders utilize the findings in practice. The purpose of this study was twofold: (a) to gain an understanding of the ongoing successes and challenges after year two of program implementation and (b) to examine how the adaptations made based on feedback from the first year evaluation were perceived as impacting the program. From interviews with youth participants and program leaders, three main themes with eight sub-themes emerged. The main themes were: (a) applying lessons learned can make a significant difference, (b) continually implementing successful strategies, and (c) ongoing challenges. Overall, this evaluation represents an important step in understanding how to improve program delivery to better meet the needs of the participants in community-based programming.

Girls Just Wanna Have Fun: a process evaluation of a female youth-driven physical activity-based life skills program.

INTRODUCTION: Integrating a positive youth development framework into physical activity programming has become popular as it is believed that this integration can create the development of both physical and psychosocial skills. However, there has been a lack of intervention fidelity research within the field of positive youth development. CASE DESCRIPTION: The Girls Just Wanna Have Fun program was designed in response to increased calls for physical activity programs for female youth and is a theoretically-grounded physical activity-based life skills program that aims to empower female youth. The purpose of this paper was to provide a detailed description of the program and a process evaluation of the first year of program implementation. From interviews with youth and leaders, as well as documentation from the leaders' weekly online log of each implemented session, themes emerged regarding the successes. DISCUSSION AND EVALUATION: Findings from this study indicated that program goals were attained and it appears that the program was implemented, for the most part, as designed. The themes related to successes included using activities to facilitate relational time, providing intentional opportunities for leadership, having communicative program leaders who supported one another, and engaging youth in different types of physical activity. The themes related to challenges included difficulties with facility and transportation, some activities being too much like schoolwork, and social distractions and cliques. Included in the paper is a discussion of practical implications and recommendations for community programmers, as well as future directions for the program. CONCLUSIONS: Overall, this process evaluation represents an important step in responding to calls for increased evaluation in community-based programs and aids in understanding the process in which positive youth development programs can be effectively implemented.