PARTICIPANT EXPERIENCES OF PEER SUPPORT IN A
COMMUNITY-BASED PHYSICAL ACTIVITY PROGRAMME
FOR MENTAL HEALTH SERVICE USERS
Data from the longitudinal study in chapter 3 reported that PA significantly increased among
MHSU in the face-to-face peer support condition. However, PA levels decreased for those
receiving social support via an online community. Variables such as motivation, perceived
social support and mental wellbeing did not change over the duration of the study, nor were
there any differences found between the two social support conditions. These are interesting
findings which cannot be fully explained based on this dataset alone. The complexity of
mental health, and its relationships with motivation, social support and mental wellbeing
were highlighted from these results. Indeed, the chapters that follow attempt to capture the
depth of personalised participant experiences missing from the quantitative dataset presented
in chapter 3. Therefore, chapter 4 considers MHSU participant experiences of peer support
within GStG, both within face-to-face PA sessions and via a pre-existing online community
platform.
Abstract
Community settings are an appropriate environment to promote physical activity (PA) by
facilitating social interaction with similar others (Quirk, Crank, Harrop, Hock, & Copeland,
2017). The aim of the current two study enquiry was to explore participants’ experiences of
peer support within a community-based PA programme for mental health service users
(MHSU), via face-to-face peer support (study 1) and peer support provided via an online
community platform (study 2). Both studies employed a qualitative design; participants who
had registered to either the face-to-face programme or the online platform were recruited
using purposive sampling and had a range of mental health diagnoses. Study one participants
(21 male, 16 female, M age=50.32 years, SD=13.01 years) took part in one of four focus
groups conducted in four regions in England (North West (n=13), North East (n=12), London
(n=5) and West Midlands (n=7). Study two participants (3 male, 18 female, M age=50.32,
SD=13.01 years) took part in either a telephone or online messenger interview. Participant
experiences of peer support within a community-based PA programme were explored. Focus
groups and interviews were transcribed verbatim and thematically analysed using the
approach outlined by Braun and Clarke (2006). Three key themes were developed for study
1; the social environment for physical activity, shared lived experience, and a supported
mental health journey. Two key themes were developed for study 2; a reciprocal relationship,
and a supportive community environment. Strategies such as the inclusion of peer support
within community-based PA programmes are important to capitalise on facilitators towards
PA engagement for MHSU.
Introduction
Physical inactivity is recognised as a contributor to the high prevalence of physical
diseases, such as cardiovascular disease, type 2 diabetes and cancer, in MHSU (Knapen,
Vancampfort, Moriën, & Marchal, 2014). Physical activity (PA) can work to improve both
physical and mental health (Kim et al., 2012). Benefits of PA include a reduction in
symptoms of mental disorders such as depression, anxiety and schizophrenia, helping to
protect against, and manage, negative health outcomes to enhance mental wellbeing
(Carneiro, Fonseca, Vieira-Coelho, Mota, & Vasconcelos-Raposo, 2015; Firth et al., 2016).
Despite the potential for PA to positively influence health and wellbeing, studies indicate that
MHSU still engage in significantly less PA than the general population (Andrew Soundy,
Stubbs, Probst, Hemmings, & Vancampfort, 2014; Stubbs, Vancampfort, et al., 2016) with
small proportions meeting the international PA recommendations for adults of 150 minutes of
moderate PA (e.g. brisk walk or cycle) or 75 minutes of vigorous PA (e.g. running) per week
(WHO, 2014). Research is therefore required to consider how MHSU can be supported to
engage in help-seeking behaviour such as PA (Hom, Stanley, & Joiner, 2015).
A recent meta-analysis reported that MHSU have unique attitudes and barriers
towards PA engagement (Firth, Rosenbaum, Stubbs, Gorczynski, et al., 2016). Typically
cited barriers include side effects of the medication, the mental illness itself, lack of
motivation (a defining symptom of psychotic disorders), lack of support, stigmatisation by
society and limitations of the mental health service (McDevitt, Snyder, Miller, & Wilbur,
2006). Further research has identified psychological, cognitive and emotional correlates of
PA such as symptom severity, motivation and quality of life to understand potential
mechanisms of change (Vancampfort et al., 2016). Understanding individuals’ attitudes and
preferences to PA will better inform intervention design and implementation for this
population. Therefore, more research is needed to develop effective and acceptable PA
programmes specifically tailored for MHSU.
Community-based PA interventions
Community settings are of particular interest in current health promotion research
(Brand et al., 2014) as they have the potential to achieve high impact by reaching a target
population group within their natural living environment (Quirk et al., 2017). Given that
research has shown that MHSU who participate in PA programmes identify with a socially
inclusive environment (Carless & Douglas, 2012), community interventions can help to
increase health and wellbeing on a community-wide scale, with an emphasis on social
interaction rather than the sole focus on the individual (Quirk et al., 2017).
The settings in which social interaction takes place may be the crucial ingredient for
MHSU (Carless & Douglas, 2008a). PA programmes that are not solely focused on the PA
itself have been shown to reduce psychological distress, and highlight the potential of social
support for engaging MHSU in PA (Martin Webber & Fendt-Newlin, 2017a). However, few
studies have explored the attitudes of MHSU towards specific sources of support which may
facilitate social interaction through PA participation (Quirk et al., 2017).
Peer support
Peer support is not a new concept and can exist in different forms, from informal
sharing of experiences to more formalised roles such as peer workers within mental health
services (Davidson, Bellamy, Guy, & Miller, 2012). Research suggests a lack of clarity about
what precisely constitutes peer support that sets it apart from traditional mental health
services (e.g., specific moderating conditions such as type of peer service and service mode
delivery, as well as the effectiveness of peer support as a new form of service delivery)
(Bellamy et al., 2017). Peer support is generally understood to be a relationship of mutual
support where people with similar life experiences offer each other support (Davidson et al.,
2012). Within the field of mental health specifically, peer support has been defined as ‘social
emotional support, frequently coupled with instrumental support, that is mutually offered or
provided by persons having a mental health condition to others sharing a similar mental
health condition to bring about a desired social or personal change’ (Solomon, 2004, pg.
393). Peer support suggests that individuals with a lived experience of mental health
problems are seen as part of the solution and play a role in supporting both their own
recovery and the recovery of others (Davidson et al., 2012; Lloyd-Evans et al., 2014).
Qualitative research exploring mental health recovery has highlighted the value of
peer support. Specifically, support from peers for MHSU provides something different to that
of professional supporting relationships, in that peer support services appear to have more of
a positive impact on levels of hope, empowerment and quality of life (Bellamy et al., 2017).
Peer support services were found to be equally as effective compared to services delivered by
non-peer healthcare professionals on clinical outcomes associated with mental health
(Bellamy et al., 2017). However, a large proportion of research on peer support has included
studies using quantitative methods, such as randomised controlled trials (RCTs) (Bellamy et
al., 2017). Few studies describe the mechanisms of peer support and delivery effectiveness
through qualitative methods. Therefore, research is needed to understand how the values of
peer support and ‘similar lived experiences’ contribute to recovery-orientated and community
related outcomes, within the context of a community-based, PA programme for MHSU
(Bellamy et al., 2017).
Online peer support
Peer support has been achieved using a face-to-face format, and also via online
community platforms (Ziebland & Wyke, 2012). Online social networking represents a
prominent form of communication within Western populations (Naslund, Aschbrenner,
Marsch, & Bartels, 2016). MHSU can experience challenges with face-to-face
communication due to impairments in social functioning, and opportunities available to
generate social interaction with peers (Naslund, Aschbrenner, Marsch, & Bartels, 2016).
Therefore, online peer networks may offer novel approaches for supporting and engaging this
difficult to reach population group (Naslund et al., 2016) and have increasingly been
recognised as a valuable resource for MHSU to proactively manage their mental health and
wellbeing (Melling & Houguet-Pincham, 2011).
Online peer support promotes opportunities for recovery, increased self-esteem, and
mental and physical wellbeing (Naslund et al., 2016). For MHSU, the decision to reach out
and connect with others to discuss personal health-related issues typically occurs at a time
when facing significant life challenges and an increased level of instability (Perry &
Pescosolido, 2015a). Seeking support and social connection is a critical point where the
decision of who to reach out to can affect an individual’s behaviour (Naslund et al., 2016)
and consequently can influence their personal recovery and wellbeing. Through peer support
specifically, individuals can achieve acceptance of their mental illness which is a vital step in
changing cognitions and behaviour change choices. For example, enhancing the sense of self,
and engaging in healthy behaviours (e.g., PA) all leading to a greater quality of life
(Markowitz, 2015).
Compared to face-to-face communication, online communication allows individuals
to maintain greater control meaning they can choose their own level of engagement and
extent to which they interact with others (Naslund et al., 2016). A systematic review of
individuals with psychosis reported the importance of feeling connected to similar others and
experiencing the benefits of group belonging at the individuals’ own convenience (Highton-
Williamson, Priebe, & Giacco, 2015). The control over their engagement may help MHSU
overcome debilitating effects of their mental illness such as information processing
challenges, social anxiety or social interaction experienced in person (Schrank, Sibitz, Unger,
& Amering, 2014). However, previous research has predominantly focused on individuals
diagnosed with psychosis or schizophrenia, failing to consider individuals with other mental
health diagnoses (Highton-Williamson et al., 2015; Schrank et al., 2014). Additionally,
research looking at online peer support has not considered how the online culture can help
engage MHSU in PA behaviour. Therefore, research is needed to explore how the
characteristics of an online community environment, inclusive of social connections with
peers and feelings of group belonging, can impact MHSU in terms of their mental wellbeing
and engagement in PA.
The current evidence for the benefits of online peer support are mixed, due in large
measure to heterogeneous outcome measures that have been adopted (Easton et al., 2017). A
quantitative systematic review showed no robust evidence supporting online peer support, as
peer support communities were evaluated in conjunction with other components of complex
interventions (Eysenbach, Powell, Englesakis, Rizo, & Stern, 2004). A separate systematic
review of online peer support for young people with mental health problems also reported a
lack of high quality studies (Ali, Farrer, Gulliver, & Griffiths, 2015). When using validated,
clinical outcome measures, little effect was found in support of online peer support for
MHSU. However, when psycho-social outcomes such as social connectedness and quality of
life have been assessed, research demonstrates that peer support is beneficial for MHSU
(Griffiths, Reynolds, & Vassallo, 2015; Naslund, Aschbrenner, Marsch, & Bartels, 2016;
Välimäki, Athanasopoulou, Lahti, & Adams, 2016). Such outcomes are given higher priority
by MHSU to experience peer support (Naslund et al., 2016). This further highlights the need
for qualitative research to determine the effectiveness and impact of online peer support for
MHSU, and to consider what conditions and for who can online peer support be effective.
Qualitative research allows for a better understanding of how MHSU make sense of
their experiences of peer support from an online community and/or face-to-face. It can be
argued that the use of qualitative research methods, rather than quantitative methods, are
more suitable for studying MHSU (Carless & Douglas, 2008b). Qualitative research methods
give MHSU a ‘voice’ so that the data collected are more service user led. Further, qualitative
data provides access to depth in a manner which is not possible in large scale quantitative
studies due to the types of responses attained in each method (Creswell & Poth, 2018).
Qualitative research provides the opportunity to go beyond surface level characteristics of a
phenomena to make sense of the process at play below the surface level (Creswell & Poth,
2018).
There are a variety of qualitative methods which can be used to gather data from
MHSU including phone and online messenger interviews. Synchronous text-Instant
Messaging (IM) is a method which takes on a style closer to that of a conversation, with
continuity of interaction and both the interviewer and participant being online at the same
time (Pearce, Thøgersen-Ntoumani, & Duda, 2014). Research assessing the development of
synchronous text-based IM as an online interviewing tool has found that participants felt
more autonomous over their interview environment, with increased anonymity between the
participant and the researcher (Pearce et al., 2014). The action of typing enabled participants
to give coherent answers, and were able to use the dialogue, via a visual written ‘record’, to
reflect and engage in a process of reflection (Pearce et al., 2014). Synchronous text-IM is a
convenient, flexible and encouraging method to collect qualitative data suitable for MHSU.
Current study
Despite the known benefits of PA for mental illness (Schuch et al., 2017; Stubbs,
Rosenbaum, Vancampfort, Ward, & Schuch, 2016; Vancampfort, Firth, et al., 2017), the
challenge remains of how to best enable MHSU to become physically active, and maintain a
physically active lifestyle. Peer support has been shown to benefit MHSU, particularly
through facilitating social interaction and group belonging (Quirk et al., 2017). However,
little research has considered the role of peer support in facilitating MHSU engagement
within community PA programmes from both an online and face-to-face perspective.
Understanding MHSU experiences of peer support within PA programmes can help
guide the development of appropriate and appealing interventions. Therefore, the aim of the
current study was to qualitatively explore MHSU’ experiences of peer support within a
community-based, PA programme. This was a two-study inquiry to encapsulate two channels
of peer support from the perspective of the MHSU in their individual context. Study 1
explored face-to-face peer support, whilst study 2 investigated experiences of online peer
support through a virtual community platform.
Method
The community-based PA programme
As described in the thesis introduction, Get Set to Go (GStG) was a programme
implemented by Mind, the UK based mental health charity, to encourage MHSU to become
more involved in PA. As part of the programme, eight local charity organisations affiliated
with the national charity across four regions of England (North East, North West, Midlands
and London) organised PA taster sessions for their service users. Peer support and one-to-one
advice was provided to participants by peer volunteers aligned to GStG during group-based
and one-to-one sessions.
As part of GStG, the existing online peer support community was developed to better
support MHSU in sharing stories about getting active and how to overcome barriers to
encourage individuals to engage in PA. Information focusing on being physically active
and ‘getting started’ were provided via short videos to generate discussions among online
members. MHSU members of the online community could interact on the topic of PA and
offer each other advice and share stories of personal experiences.
Study Design
A social constructivist approach was adopted for the current study. Social
constructivism is a theory of knowledge, based on the work of Vygotsky (1978) where
human development is socially situated and knowledge is constructed through interactions
with others (McKinley, 2015). This approach allowed for the necessary qualitative data
analysis to reveal insights on how participants interact with the world, and experience peer
support from their own perspectives (Creswell, 2009). Within the social constructivist
paradigm, this study is rooted within a relativist ontology; the belief that multiple realities
exist. The truth is always relative to a frame of reference (e.g. socially or culturally) and
the belief that reality is a finite subjective experience (Denzin & Lincoln, 2005). With
multiple interpretations of experience come multiple realities. In line with the current
study, the purpose of a relativist ontology is to understand the subjective experience of
reality and multiple truths that exist for the participants (Levers, 2013).
This study is more social constructivist in nature but remains paradigmatic in the way
that it recognises the need for alternative methods to be used within other thesis chapters
(Chapter 3). Thus, a qualitative study design was adopted to explore MHSU experiences of
peer support within the community-based PA programme, GStG. This was a two-study
inquiry; study 1 explored participant experiences of face-to-face peer support through focus
groups, whilst study 2 investigated experiences of online peer support through telephone and
online messenger interviews. Ethical approval was obtained for both studies from a Research
Degrees Board within a University in the East Midlands. Informed consent was provided in
writing before the focus groups (study 1) and verbally or typed for the telephone and online
interviews (study 2).
Study 1
Participants
A purposeful criterion-based recruitment process was employed. Thirty-seven (21
male, 16 female) participants who registered on the GStG programme aged between 21 and
72 years (M age=50.32 years, SD=13.01 years) were recruited from GStG across four regions
of the UK (Midlands n=7, London n=5, North East n=12 and North West n=13). Participants
had a range, and in some cases multiple, mental health diagnoses including depression
(n=18), anxiety (n=14), bipolar (n=5), personality disorder (n=5), post-traumatic stress
disorder (PTSD) (n=2), obsessive-compulsive disorder (OCD) (n=1) and schizophrenia
(n=5). The length of time as a GStG participant ranged from 6 weeks to 12 months. Two out
of 37 participants lapsed from the programme, with the remaining 35 adhering to GStG
throughout the duration of the study.
Study 1 procedure
All individuals who had registered as a participant on the GStG programme were
invited to participate in research as part of the programme. Individuals who agreed received
an email inviting them to attend a focus group at their nearest local mental health charity who
ran the GStG programme. Alternatively, if participants were unable to attend the focus group,
or did not feel comfortable doing so, they were given the option to have a one-to-one
telephone interview. However, no participants chose this option.
A semi-structured interview schedule was designed to explore participants’
experiences of peer support within GStG. Questions were developed in consultation with a
Lived Experience Panel representing a variety of mental health backgrounds. Such a
collaborative approach is consistent with the ethical standards for research for individuals
with mental health problems (Phillips, 2006). The interview questions explored participants’
experiences of peer support within the programme, how they had been supported
(participants were asked to provide examples), facilitators and barriers towards engaging in
the programme, as well as the impact of GStG had on their wellbeing and general life. The
questions were designed to be open-ended and non-leading.
Each focus group was conducted by the same two interviewers and lasted between 45
and 100 minutes. Digital audio recorders were used with participants’ permission and field
notes were collected. Field notes allowed the researcher to record both descriptively
(observations, behaviours and facial expressions) and reflectively (researcher’s thoughts,
concerns, ideas) providing further meaning and understanding to the context being explored
(Emerson, Fretz & Shaw, 2001). Focus groups were transcribed verbatim, ensuring that any
identifiable information, such as participant names, were replaced with ID numbers.
Study 2
Participants
Twenty-one (3 male, 18 female) participants who were members of the existing
online community aged between 22 and 62 years (M age=50.32 years, SD=13.01 years) were
recruited using a purposeful criterion-based recruitment process. Mental health diagnoses of
participants included depression (n=11), anxiety (n=11), bipolar (n=2), personality disorder
(n=7), post-traumatic stress disorder (PTSD) (n=6), obsessive-compulsive disorder
(OCD) (n=1) and de-personalisation disorder (n=1). Engagement with the online
platform varied and ranged from participants who logged on daily, used the online
platform four to five times a week, or more sporadically every few months.
Study 2 procedure
All members of the online community platform were invited to participate in
either a phone interview or an online messenger interview depending on
individuals’ preference.
Sixteen chose a phone interview whilst the remaining five preferred to be
interviewed via a social media online messenger tool. Participants who chose this
option were asked to add the researchers account for the purpose of the data
collection. This account was then deactivated post data collection.
A semi-structured interview schedule was designed to explore participants’
experiences of receiving peer support from an online community. As with study 1,
questions were developed in consultation with a Lived Experience Panel. The
interview questions asked participants how best they would describe the online
community environment, how they engaged with the online platform, who, if
anyone, supported them when they exercised (participants were asked to provide
examples of how they had been supported) and how did that make them feel.
Phone interviews lasted between 20 and 40 minutes. Online messenger
interviews lasted between 90 and 150 minutes. Phone interviews were fully
transcribed and as with study 1, any identifiable information was removed, and
participant names were replaced with ID numbers. Online messenger transcripts
were saved using a participant ID number to ensure anonymity.
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