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• Volume 13, Issue 2
• Qualitative Research Methods in Mental Health
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• Sarah Peters
• Correspondence to : Dr Sarah Peters, School of Psychological Sciences, The University of Manchester, Coupland Building 1, Oxford Road M13 9PL, UK; sarah.peters{at}manchester.ac.uk

As the evidence base for the study of mental health problems develops, there is a need for increasingly rigorous and systematic research methodologies. Complex questions require complex methodological approaches. Recognising this, the MRC guidelines for developing and testing complex interventions place qualitative methods as integral to each stage of intervention development and implementation. However, mental health research has lagged behind many other healthcare specialities in using qualitative methods within its evidence base. Rigour in qualitative research raises many similar issues to quantitative research and also some additional challenges. This article examines the role of qualitative methods within mental heath research, describes key methodological and analytical approaches and offers guidance on how to differentiate between poor and good quality qualitative research.

https://doi.org/10.1136/ebmh.13.2.35

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The trajectory of qualitative methods in mental health research

Qualitative methodologies have a clear home within the study of mental health research. Early and, arguably, seminal work into the study of mental illnesses and their management was based on detailed observation, moving towards theory using inductive reasoning. Case studies have been long established in psychiatry to present detailed analysis of unusual cases or novel treatments. Participant observation was the principle method used in Goffman's seminal study of psychiatric patients in asylums that informed his ideas about the institutionalising and medicalising of mental illness by medical practice. 1 However, the 20th century saw the ‘behaviourist revolution’, a movement where quantification and experimentation dominated. Researchers sought to identify cause and effects, and reasoning became more deductive – seeking to use data to confirm theory. The study of health and illness was determined by contemporary thinking about disease, taking a biomedical stance. Psychologists and clinical health researchers exploited natural science methodologies, attempting to measure phenomenon in their smallest entities and do so as objectively as possible. This reductionist and positivist philosophy shaped advances in research methods and meant that qualitative exploration failed to develop as a credible scientific approach. Indeed, ‘objectivity’ and the ‘discovery of truth’ have become synonymous with ‘scientific enquiry’ and qualitative methods are easily dismissed as ‘anecdotal’. The underlying epistemology of this approach chimes well with medical practice for which training is predominately in laboratory and basic sciences (such as physics and chemistry) within which the discourse of natural laws dominate. To this end, research in psychiatry still remains overwhelmingly quantitative. 2

Underlying all research paradigms are assumptions. However, most traditional researchers remain unaware of these until they start to use alternative paradigms. Key assumptions of quantitative research are that facts exist that can be quantified and measured and that these should be examined, as far as possible, objectively, partialling out or controlling for the context within which they exist. There are research questions within mental health where this approach can hold: where phenomenon of interest can be reliably and meaningfully quantified and measured, it is feasible to use data to test predictions and examine change. However, for many questions these assumptions prove unsatisfying. It is often not possible or desirable to try and create laboratory conditions for the research; indeed it would be ecologically invalid to do so. For example, to understand the experience of an individual who has been newly diagnosed with schizophrenia, it is clearly important to consider the context within which they live, their family, social grouping and media messages they are exposed to. Table 1 depicts the key differences between the two methodological approaches and core underlying assumptions for each.

• View inline

Comparison of underlying assumptions of quantitative and qualitative research approaches

It should be cautioned that it is easy to fall into the trap of categorising studies as either quantitative or qualitative. The two traditions are often positioned within the literature as opposing and in conflict. This division is unhelpful and likely to impede methodological advancement. Though, undeniably, there are differences in the two approaches to research, there are also many exceptions that expose this dichotomy to be simplistic: some qualitative studies seek to test a priori hypotheses, and some quantitative studies are atheoretical and exploratory. 3 Hence it is more useful to consider research methodologies as lying along a spectrum and that researchers should be familiar with the full range of methodologies, so that a method is chosen according to the research question rather than the researcher's ability.

Rationale for qualitative methods in current mental health research

There are a number of scientific, practical and ethical reasons why mental health is an area that can particularly benefit from qualitative enquiry. Mental health research is complex. Health problems are multifactorial in their aetiology and the consequences they have on the individual, families and societies. Management can involve self-help, pharmacological, educative, social and psychotherapeutic approaches. Services involved are often multidisciplinary and require liaison between a number of individuals including professionals, service-users and relatives. Many problems are exacerbated by poor treatment compliance and lack of access to, or engagement with, appropriate services. 4

Engagement with mental health research can also be challenging. Topics may be highly sensitive or private. Individuals may have impaired capacity or be at high risk. During the research process there may be revelations of suicidal ideation or criminal activity. Hence mental health research can raise additional ethical issues. In other cases scepticism of services makes for reluctant research participants. However, if we accept the case that meaningful research can be based in subjective enquiry then qualitative methods provide a way of giving voice to participants. Qualitative methods offer an effective way of involving service-users in developing interventions for mental health problems 5 ensuring that the questions asked are meaningful to individuals. This may be particularly beneficial if participants are stakeholders, for example potential users of a new service.

Qualitative methods are valuable for individuals who have limited literacy skills who struggle with pencil and paper measures. For example qualitative research has proved fruitful in understanding children's concepts of mental illness and associated services. 6

How qualitative enquiry is used within mental health research

There are a range of types of research question where qualitative methods prove useful – from the development and testing of theory, to the piloting and establishing efficacy of treatment approaches, to understanding issues around translation and implementation into routine practice. Each is discussed in turn.

Development and testing of theory

Qualitative methods are important in exploratory work and in generating understanding of a phenomenon, stimulating new ideas or building new theory. For example, stigma is a concept that is recognised as a barrier to accessing services and also an added burden to mental health. A focus-group study sought to understand the meaning of stigma from the perspectives of individuals with schizophrenia, their relatives and health professionals. 7 From this they developed a four-dimensional theory which has subsequently informed interventions to reduce stigma and discrimination that target not only engagement with psychiatric services but also interactions with the public and work. 7

Development of tools and measures

Qualitative methods access personal accounts, capturing how individuals talk about a lived experience. This can be invaluable for designing new research tools. For example, Mavaddat and colleagues used focus groups with 56 patients with severe or common mental health problems to explore their experiences of primary care management. 8 Nine focus groups were conducted and analysis identified key themes. From these, items were generated to form a Patient Experience Questionnaire, of which the psychometric properties were subsequently examined quantitatively in a larger sample. Not only can dimensions be identified, the rich qualitative data provide terminology that is meaningful to service users that can then be incorporated into question items.

Development and testing of interventions

As we have seen, qualitative methods can inform the development of new interventions. The gold-standard methodology for investigating treatment effectiveness is the randomised controlled trial (RCT), with the principle output being an effect size or demonstration that the primary outcome was significantly improved for participants in the intervention arm compared with those in the control/comparison arm. Nevertheless, what will be familiar for researchers and clinicians involved in trials is that immense research and clinical learning arises from these substantial, often lengthy and expensive research endeavours. Qualitative methods provide a means to empirically capture these lessons, whether they are about recruitment, therapy training/supervision, treatment delivery or content. These data are essential to improve the feasibility and acceptability of further trials and developing the intervention. Conducting qualitative work prior to embarking on an RCT can inform the design, delivery and recruitment, as well as engage relevant stakeholders early in the process; all of these can prevent costly errors. Qualitative research can also be used during a trial to identify reasons for poor recruitment: in one RCT, implementing findings from this type of investigation led to an increased randomisation rate from 40% to 70%. 9

Nesting qualitative research within a trial can be viewed as taking out an insurance policy as data are generated which can later help explain negative or surprising findings. A recent trial of reattribution training for GPs to manage medically unexplained symptoms demonstrated substantial improvements in GP consultation behaviour. 10 However, effects on clinical outcomes were counterintuitive. A series of nested qualitative studies helped shed light as to why this was the case: patients' illness models were complex, and they resisted engaging with GPs (who they perceived as having more simplistic and dualistic understanding) because they were anxious it would lead to non-identification or misdiagnosis of any potential future disease 11 , an issue that can be addressed in future interventions. Even if the insights are unsurprising to those involved in the research, the data collected have been generated systematically and can be subjected to peer review and disseminated. For this reason, there is an increasing expectation from funding bodies that qualitative methodologies are integral to psychosocial intervention research.

Translation and implementation into clinical practice

Trials provide limited information about how treatments can be implemented into clinical practice or applied to another context. Psychological interventions are more effective when delivered within trial settings by experts involved in their development than when they are delivered within clinical settings. 12 Qualitative methods can help us understand how to implement research findings into routine practice. 13

Understanding what stakeholders value about a service and what barriers exist to its uptake is another evidence base to inform clinicians' practice. Relapse prevention is an effective psychoeducation approach that helps individuals with bipolar disorder extend time to relapse. Qualitative methodologies identified which aspects of the intervention service-users and care-coordinators value, and hence, are likely to utilise in routine care. 14 The intervention facilitated better understanding of bipolar disorder (by both parties), demonstrating, in turn, a rationale for medication. Patients discovered new, empowering and less socially isolated ways of managing their symptoms, which had important impacts on interactions with healthcare staff and family members. Furthermore, care-coordinators' reported how they used elements of the intervention when working with clients with other diagnoses. The research also provided insights as to where difficulties may occur when implementing a particular intervention into routine care. For example, for care-coordinators this proved a novel way of working with clients that was more emotionally demanding, thus highlighting the need for supervision and managerial support. 14

Beginners guide to qualitative approaches: one size doesn't fit all

Just as there is a range of quantitative research designs and statistical analyses to choose from, so there are many types of qualitative methods. Choosing a method can be daunting to an inexperienced or beginner-level qualitative researcher, for it requires engaging with new terms and ways of thinking about knowledge. The following summary sets out analytic and data-generation approaches that are used commonly in mental health research. It is not intended to be comprehensive and is provided only as a point of access/familiarisation to researchers less familiar with the literature.

Data generation

Qualitative data are generated in several ways. Most commonly, researchers seek a sample and conduct a series of individual in-depth interviews, seeking participants' views on topics of interest. Typically these last upwards of 45 min and are organised on the basis of a schedule of topics identified from the literature or pilot work. This does not act as a questionnaire, however; rather, it acts as a flexible framework for exploring areas of interest. The researcher combines open questions to elicit free responses, with focused questions for probing and prompting participants to provide effective responses. Usually interviews are audio-recorded and transcribed verbatim for subsequent analysis.

As interviews are held in privately, and on one-to-one basis, they provide scope to develop a trusting relationship so that participants are comfortable disclosing socially undesirable views. For example, in a study of practice nurses views of chronic fatigue syndrome, some nurses described patients as lazy or illegitimate – a view that challenges the stereotype of a nursing professional as a sympathetic and caring person. 15 This gives important information about the education and supervision required to enable or train general nurses to ensure that they are capable of delivering psychological interventions for these types of problems.

Alternatively, groups of participants are brought together for a focus group, which usually lasts for 2 hours. Although it is tempting to consider focus groups as an efficient way of acquiring data from several participants simultaneously, there are disadvantages. They are difficult to organise for geographically dispersed or busy participants, and there are compromises to confidentiality, particularly within ‘captive’ populations (eg, within an organisation individuals may be unwilling to criticise). Group dynamics must be considered; the presence of a dominant or self-professed expert can inhibit the group and, therefore, prevent useful data generation. When the subject mater is sensitive, individuals may be unwilling to discuss experiences in a group, although it often promotes a shared experience that can be empowering. Most of these problems are avoided by careful planning of the group composition and ensuring the group is conducted by a highly skilled facilitator. Lester and colleagues 16 used focus-group sessions with patients and health professionals to understand the experience of dealing with serious mental illness. Though initially participants were observed via focus-group sessions that used patient-only and health professional only groups, subsequently on combined focus groups were used that contained both patients and health professionals. 16 The primary advantage of focus groups is that they enable generation of data about how individuals discuss and interact about a phenomenon; thus, a well-conducted focus group can be an extremely rich source of data.

A different type of data are naturally occurring dialogue and behaviours. These may be recorded through observation and detailed field notes (see ethnography in Table 2 ) or analysed from audio/ video-recordings. Other data sources include texts, for example, diaries, clinical notes, Internet blogs and so on. Qualitative data can even be generated through postal surveys. We thematically analysed responses to an open-ended question set within a survey about medical educators' views of behavioural and social sciences (BSS). 17 From this, key barriers to integrating BSS within medical training were identified, which included an entrenched biomedical mindset. The themes were analysed in relation to existing literature and revealed that despite radical changes in medical training, the power of the hidden curriculum persists. 17

Key features of a range of analytical approaches used within mental health research

Analysing qualitative data

Researchers bring a wide range of analytical approaches to the data. A comprehensive and detailed discussion of the philosophy underlying different methods is beyond the scope of this paper; however, a summary of the key analytical approaches used in mental health research are provided in Table 2 . An illustrative example is provided for each approach to offer some insight into the commonalities and differences between methodologies. The procedure for analysis for all methods involves successive stages of data familiarisation/immersion, followed by seeking and reviewing patterns within the data, which may then be defined and categorized as specific themes. Researchers move back and forth between data generation and analysis, confirming or disconfirming emerging ideas. The relationship of the analysis to theory-testing or theory-building depends on the methodology used.

Some approaches are more common in healthcare than others. Interpretative phenomenological (lPA) analysis and thematic analysis have proved particularly popular. In contrast, ethnographic research requires a high level of researcher investment and reflexivity and can prove challenging for NHS ethic committees. Consequently, it remains under used in healthcare research.

Recruitment and sampling

Quantitative research is interested in identifying the typical, or average. By contrast, qualitative research aims to discover and examine the breadth of views held within a community. This includes extreme or deviant views and views that are absent. Consequently, qualitative researchers do not necessarily (though in some circumstances they may) seek to identify a representative sample. Instead, the aim may be to sample across the range of views. Hence, qualitative research can comment on what views exist and what this means, but it is not possible to infer the proportions of people from the wider population that hold a particular view.

However, sampling for a qualitative study is not any less systematic or considered. In a quantitative study one would take a statistical approach to sampling, for example, selecting a random sample or recruiting consecutive referrals, or every 10th out-patient attendee. Qualitative studies, instead, often elect to use theoretical means to identify a sample. This is often purposive; that is, the researcher uses theoretical principles to choose the attributes of included participants. Healey and colleagues conducted a study to understand the reasons for individuals with bipolar disorder misusing substances. 18 They sought to include participants who were current users of each substance group, and the recruitment strategy evolved to actively target specific cases.

Qualitative studies typically use far smaller samples than quantitative studies. The number varies depending on the richness of the data yielded and the type of analytic approach that can range from a single case to more than 100 participants. As with all research, it is unethical to recruit more participants than needed to address the question at hand; a qualitative sample should be sufficient for thematic saturation to be achieved from the data.

Ensuring that findings are valid and generalisable

A common question from individuals new to qualitative research is how can findings from a study of few participants be generalised to the wider population? In some circumstances, findings from an individual study (quantitative or qualitative) may have limited generalisability; therefore, more studies may need to be conducted, in order to build local knowledge that can then be tested or explored across similar groups. 4 However, all qualitative studies should create new insights that have theoretical or clinical relevance which enables the study to extend understanding beyond the individual participants and to the wider population. In some cases, this can lead to generation of new theory (see grounded theory in Table 2 ).

Reliability and validity are two important ways of ascertaining rigor in quantitative research. Qualitative research seeks to understand individual construction and, by definition, is subjective. It is unlikely, therefore, that a study could ever be repeated with exactly the same circumstances. Instead, qualitative research is concerned with the question of whether the findings are trustworthy; that is, if the same circumstances were to prevail, would the same conclusions would be drawn?

There are a number of ways to maximise trustworthiness. One is triangulation, of which there are three subtypes. Data triangulation involves using data from several sources (eg, interviews, documentation, observation). A research team may include members from different backgrounds (eg, psychology, psychiatry, sociology), enabling a range of perspectives to be used within the discussion and interpretation of the data. This is termed researcher triangulation . The final subtype, theoretical triangulation, requires using more than one theory to examine the research question. Another technique to establish the trustworthiness of the findings is to use respondent validation. Here, the final or interim analysis is presented to members of the population of interest to ascertain whether interpretations made are valid.

An important aspect of all qualitative studies is researcher reflexivity. Here researchers consider their role and how their experience and knowledge might influence the generation, analysis and interpretation of the data. As with all well-conducted research, a clear record of progress should be kept – to enable scrutiny of recruitment, data generation and development of analysis. However, transparency is particularly important in qualitative research as the concepts and views evolve and are refined during the process.

Judging quality in qualitative research

Within all fields of research there are better and worse ways of conducting a study, and range of quality in mental health qualitative research is variable. Many of the principles for judging quality in qualitative research are the same for judging quality in any other type of research. However, several guidelines have been developed to help readers, reviewers and editors who lack methodological expertise to feel more confident in appraising qualitative studies. Guidelines are a prerequisite for the relatively recent advance of methodologies for systematic reviewing of qualitative literature (see meta-synthesis in Table 2 ). Box 1 provides some key questions that should be considered while studying a qualitative report.

Box 1 Guidelines for authors and reviewers of qualitative research (adapted from Malterud 35 )

▶ Is the research question relevant and clearly stated?

Reflexivity

▶ Are the researcher's motives and background presented?

Method, sampling and data collection

▶ Is a qualitative method appropriate and justified?

▶ Is the sampling strategy clearly described and justified?

▶ Is the method for data generation fully described

▶ Are the characteristics of the sample sufficiently described?

Theoretical framework

▶ Was a theoretical framework used and stated?

▶ Are the principles and procedures for data organisation and analysis described and justified?

▶ Are strategies used to test the trustworthiness of the findings?

▶ Are the findings relevant to the aim of the study?

▶ Are data (e.g. quotes) used to support and enrich the findings?

▶ Are the conclusions directly linked to the study? Are you convinced?

▶ Do the findings have clinical or theoretical value?

▶ Are findings compared to appropriate theoretical and empirical literature?

▶ Are questions about the internal and external validity and reflexivity discussed?

▶ Are shortcomings of the design, and the implications these have on findings, examined?

▶ Are clinical/theoretical implications of the findings made?

Presentation

▶ Is the report understandable and clearly contextualised?

▶ Is it possible to distinguish between the voices of informants and researchers?

▶ Are sources from the field used and appropriately referenced?

Conclusions and future directions

Qualitative research has enormous potential within the field of mental health research, yet researchers are only beginning to exploit the range of methods they use at each stage of enquiry. Strengths of qualitative research primarily lie in developing theory and increasing understanding about effective implementation of treatments and how best to support clinicians and service users in managing mental health problems. An important development in the field is how to integrate methodological approaches to address questions. This raises a number of challenges, such as how to integrate textual and numerical data and how to reconcile different epistemologies. A distinction can be made between mixed- method design (eg, quantitative and qualitative data are gathered and findings combined within a single or series of studies) and mixed- model study, a pragmatist approach, whereby aspects of qualitative and quantitative research are combined at different stages during a research process. 19 Qualitative research is still often viewed as only a support function or as secondary to quantitative research; however, this situation is likely to evolve as more researchers gain a broader skill set.

Though it is undeniable that there has been a marked increase in the volume and quality of qualitative research published within the past two decades, mental health research has been surprisingly slow to develop, compared to other disciplines e.g. general practice and nursing, with relatively fewer qualitative research findings reaching mainstream psychiatric journals. 2 This does not appear to reflect overall editorial policy; however, it may be partly due to the lack of confidence on the part of editors and reviewers while identifying rigorous qualitative research data for further publication. 20 However, the skilled researcher should no longer find him or herself forced into a position of defending a single-methodology camp (quantitative vs qualitative), but should be equipped with the necessary methodological and analytical skills to study and interpret data and to appraise and interpret others' findings from a full range of methodological techniques.

• Crawford MJ ,
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• ↵ MRC Developing and Evaluating Complex Interventions 2008
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• Quintana SM
• Schulze B ,
• Angermeyer MC
• Mavaddat N ,
• Lester HE ,
• Donovan J ,
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35 Qualitative research methods in mental health

• Published: July 2011
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In this chapter I set out to introduce the reader to qualitative research in mental health. I describe its main methods of inquiry, and its underpinning foundational and philosophical principles. I give numerous examples of where qualitative research has been fruitfully employed in community psychiatry. I then describe criteria of rigour which can be used to assess the strength and contribution of any qualitative study in mental health. I believe qualitative research continues to offer interesting insights into the prevention, diagnosis, phenomenology, treatment, management, and understanding of psychiatric disorder. It may also assist resolution of current policy imperatives, such as calls for person-centred care, and more thorough evaluations of service effectiveness.

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• Open access
• Published: 11 September 2024

Implementing peer support into practice in mental health services: a qualitative comparative case study

• Steve Gillard 1 ,
• Rhiannon Foster 1 ,
• Sarah White 2 ,
• Rahul Bhattacharya 3 ,
• Paul Binfield 3 ,
• Rachel Eborall 4 ,
• Sarah L Gibson 5 ,
• Daniella Harnett 3 ,
• Alan Simpson 6 ,
• Mike Lucock 7 ,
• Jacqueline Marks 8 ,
• Julie Repper 9 ,
• Miles Rinaldi 10 , 11 ,
• Anthony Salla 1 &
• Jessica Worner 12  

BMC Health Services Research volume  24 , Article number:  1050 ( 2024 ) Cite this article

1 Altmetric

Metrics details

Peer workers are people with personal experience of mental distress, employed within mental health services to support others with similar experiences. Research has identified a range of factors that might facilitate or hinder the introduction of new peer worker roles into mental health services. While there is mixed evidence for the effectiveness of peer worker delivered interventions, there are no studies exploring how implementation might be associated with effect.

This was a qualitative comparative case study using data from interviews with 20 peer workers and their five supervisors. Peer workers delivered peer support for discharge from inpatient to community mental health care as part of a randomised controlled trial. In the trial, level of participant engagement with peer support was associated with better outcome (hospital readmission). Study sites with higher levels of engagement also had higher scores on a measure of fidelity to peer support principles. We compared data from sites with contrasting levels of engagement and fidelity using an analytical framework derived from implementation theory.

In high engagement-high fidelity sites, there was regular work with clinical teams preparing for working alongside peer workers, and a positive relationship between staff on inpatient wards and peer workers. The supervisor role was well resourced, and delivery of peer support was highly consistent with the intervention manual. In low engagement-low fidelity sites peer workers were employed in not-for-profit organisations to support people using public mental health services and in rural areas. Supervisors faced constrained resources and experienced barriers to joint working between organisations. In these sites, peer workers could experience challenging relationships with ward staff. Issues of geography and capacity limited opportunities for supervision and team-building, impacting consistency of delivery.

Conclusions

This study provides clear indication that implementation can impact delivery of peer support, with implications for engagement and, potentially, outcomes of peer worker interventions. Resourcing issues can have knock-on effects on consistency of delivery, alongside challenges of access, authority and relationship with clinical teams, especially where peer workers were employed in not-for-profit organisations. Attention needs to be paid to the impact of geography on implementation.

Trial registration

ISRCTN registry number ISRCTN10043328, registered 28 November 2016.

Peer Review reports

Peer support in mental health services

People with personal experience of mental distress, often referred to as peer workers, are increasingly employed within mental health services internationally to support others with similar experiences. An extensive literature explores a range of implementation issues that might dilute the distinctive qualities of peer support when introduced into public mental health services [ 1 , 2 ]. These include adequate provision of role specific training for PWs, [ 3 , 4 ] support and supervision for PWs, [ 5 ] clarity of expectation around the way in which PWs bring experience-based knowledge to mental healthcare, [ 2 . 6 ] and preparation of clinical teams to work alongside PWs [ 7 ]. It has been argued that ‘over-professionalisation’ or ‘institutionalisation’ of the PW role constrains the distinctive contribution of peer support [ 8 , 9 , 10 , 11 ].

Trials of peer support in mental health services continue to demonstrate inconsistent results, with some studies indicating that peer support might be superior to care-as-usual or a comparator intervention, [ 12 , 13 ] while others indicate no difference in effect [ 14 , 15 ]. Some of this variation might be explained by heterogeneity of interventions, population or outcome, but it is also possible that the quality of implementation of peer support into mental healthcare settings is associated with the effect of peer support interventions [ 16 , 17 ].

It has been noted that peer support is often poorly described in the trial literature, [ 17 , 18 ] with a lack of research assessing association between implementation and outcome. A recent review of one-to-one peer support in mental health services categorised peer support as being well implemented where at least two of the following criteria were reported: dedicated peer support training; clear description of the underlying processes of peer support; well-defined support structures for PWs (e.g. supervision) [ 19 ]. However, only a small number of studies reported sufficient data to conduct an analysis and results were unclear. There is a need for research that explicitly considers the possible relationship between quality of implementation and the outcomes of peer support.

Implementation theory

Implementation science offers a range of frameworks for understanding the facilitators and barriers to successful implementation of healthcare innovation into practice [ 20 ]. There is a clear recognition that the effects of any intervention will always depend on successful implementation [ 21 ]. The well-established Promoting Action on Research Implementation in Health Services (PARIHS) framework conceptualises successful implementation of research-based innovation into healthcare in terms of the nature of the evidence on which the innovation is based, the context or environment into which the innovation is placed, and the method by which implementation is facilitated [ 22 ]. In recent years, the co-design [ 23 ] or coproduction [ 24 ] of new interventions in mental health has gained prominence, with people who use mental health services bringing experience-based knowledge to the process, alongside the professional and practice-based knowledge brought by healthcare professionals. Given that this experiential knowledge is core to peer support, and that a number of members of the research term brought their own experiences of mental distress and/ or of using mental health services to the design and conduct of the research, we adapted the PARIHS framework for the purposes of this study. An earlier scoping review of implementation literature and an empirical case study, [ 25 ] undertaken by members of the team (SG and RF), identified five domains where experiential knowledge might impact research implementation, and we mapped these domains directly onto the framework (Table  1 ).

The ENRICH trial

A trial of peer support for discharge from inpatient to community mental health care indicated that peer support was not superior to care-as-usual (follow up by community mental health services within seven days of discharge) in terms of either the primary outcome – readmission within 12 months of discharge – or a range of secondary outcomes [ 26 ]. PWs received eight days of training focused on individual strengths and connecting to community, met the people they were supporting at least once while still inpatients and then weekly for up to four months post-discharge. Peer support was flexible and collaborative, informed by a peer support principles framework [ 27 ]. PWs received group and individual supervision from an experienced peer worker coordinator (PWC) who had access to an action learning set with other PWCs across study sites. The trial and intervention are described in detail in a protocol paper [ 28 ].

Findings from the trial indicated that 62.5% of participants offered peer support had at least two contacts with their PW, at least one of which was post-discharge, and that those participants were significantly less likely to be readmitted than a similar group of PWs in the care-as-usual group [ 26 ]. There might be many reasons why people chose not to, or were unable to engage with their PW, including the possibility that peer support was not always well implemented into practice in the trial.

This paper aims to explore if and how levels of engagement in a new peer support intervention were associated with implementation of the intervention, and therefore how implementation of peer support in mental health services might be optimised in the future.

Study design

We take a comparative case study approach, informed by case-orientated Qualitative Comparative Analysis [ 29 ] and pattern-matching [ 30 ] techniques, considering the seven sites where the study took place as cases. Sites were National Health Services (NHS) mental health trusts (public healthcare provider organisations) in England, where the new peer support intervention was delivered as part of the ENRICH trial. Sites were selected to provide contrast in urban, town and rural localities, geographical spread across England, and where mental health trusts were committed to introducing new PW roles into mental health services. In most sites PWs were directly employed by the mental health trust, while in others a much smaller, voluntary (not-for-profit) sector organisation was sub-contracted by the trust to employ PWs to provide support to people using mental health trust services. Information about each site is given in Table  2 below.

To inform case selection for the comparative analysis we charted level of engagement at each site – percentage of trial participants offered peer support who had at least two contacts with their PW, at least one of which was post-discharge – against site fidelity score, measured using an index designed to assess fidelity of delivery of peer support at site level against a set of principles articulating what is distinctive about peer support compared to other forms of mental health support [ 31 ] (Fig.  1 ). Fidelity was assessed through a semi-structured interview with PWs, the people they supported and their supervisor, rated by researchers against criteria based on the principles framework. A high fidelity score indicates that peer support had been implemented according to those principles. Fidelity was assessed after peer support had been delivered for at least six months at each site.

Relationship between engagement with peer support and fidelity

Figure  1 is indicative of a direct relationship between engagement with peer support and fidelity, offering rationale for selecting sites with higher or lower levels of both engagement and fidelity as cases for comparative analysis. There was one outlier, site 2, where fidelity was high (11) but engagement was mid-range (51%). We included this site in the comparative analysis as engagement might be explained by implementation issues not related to fidelity of delivery.

We report on the Evidence domain of the framework in a paper describing how experiential knowledge was central to developing the ENRICH peer support intervention [ 32 ]. Our research questions here are based on the Context and Facilitation domains of the framework, with context referring largely to the NHS Trust in which implementation took place (question 1), and facilitators being the PWs and PWCs who delivered the peer support (questions 2–4):

How did the culture of organisations, leadership (including issues of access and authority ) and monitoring and feedback impact implementation of peer support?

How did PWs and PWCs feel that their roles were characterised?

How did PWs and PWCs feel they were able to exercise flexibility while remaining consistent in their approach to delivering peer support?

How did experiential knowledge underpin peer support as it was delivered at each site?

Data sources

Peer worker interviews. Thirty-two PWs delivered peer support in the ENRICH trial and were invited to give written informed consent to participate in the research. All 32 consented and were interviewed after 12 months of delivering peer support. Interviews explored how well training prepared them for the role, their experiences of working as a PW, the support they received in the role and their relationship with clinical teams they worked alongside.

Peer worker coordinator interviews. Eight PWCs supervised PWs in the trial. Seven PWCs were themselves experienced PWs and one was a mental health nurse who shared the role with an experienced PW. All 8 PWCs gave informed consent to participate in the research and were interviewed at the same timepoint as PWs. Interviews explored PWCs’ experiences of supporting PWs, how well they thought the role was supported and organisational issues impacting delivery of peer support.

Interviews were conducted by researchers working from a perspective of having experienced mental distress and/ or having used mental health services, and played a key role in schedule development. Interview schedules can be found in the Supplementary Material file.

Data analysis

Interviews were audio-recorded, pseudonymised at the point of collection and transcribed verbatim.

Interview data were analysed using a framework approach [ 33 ] based on the Context and Facilitation domains of the modified PARIHS framework (see Table  1 ). Data were first coded to the constructs within those domains, with inductive space retained to code factors not related to the framework that participants described as impacting delivery of peer support. Second, a comparative, cross-case analysis was used to look for patterns of implementation that were: A, shared across cases; B, characterised high fidelity-high engagement cases; C, characterised low fidelity-low engagement cases; D, described implementation in the outlier case [ 30 ]. Preliminary analyses were undertaken by the first author and refined through iterative rounds of discussion with the whole team.

Characteristics of included cases

The two high engagement-high fidelity cases (sites 3,5), and the outlier high fidelity-low engagement case (site 2), were in urban areas with PWs directly employed in mental health NHS Trusts (see Table  2 ). The two low engagement-low fidelity cases (sites 4,6) were in areas that were a mix of rural localities with small towns or urban localities respectively. In both the latter sites PWs were employed by voluntary sector organisations outside of the NHS.

Characteristics of participants

A total of 20 PWs were included in the analysis, five each from sites 3 and 4, three each from sites 2 and 5, and two from site 6. Twelve PWs were female, seven were male and one preferred not to say. Three PWs were aged under 35 years of age, 12 aged from 35 to 55 years, one over 55 and four preferred not to say. Eleven PWs were White British, two were White Irish, one White other, one Black/ Black British, one Asian/ Asian British, one Arab, one Mixed White Asian with two preferring not to say.

There were five PWCs, one from each site. Four PWCs were female and one was male; two were aged from 35 to 55 and three over 55; all were White British.

Participant quotes presented below are identified with a site code (e.g. S1 = site 1) and role identifier (PW = Peer Worker; PWC = Peer Worker Coordinator) plus an additional number to distinguish between PWs at each site.

Implementation across cases

A number of implementation features were evident across all five cases, including characterisation of the PW role as largely consistent with the principles that were used to inform development of the intervention; [ 27 , 32 ] taking a non-judgemental approach and sharing experiences to create a safe space, make connections and build relationships:

‘We’re not going to be judgemental so to speak. It’s a safe place really for people to be themselves regardless of what their mental health issues are or mental health diagnoses are.’ (S5PW2). ‘I’m always sharing lived experience, whether that’s just generally or whether that’s personally with mental health … obviously you share when appropriate but you try to match that experience together so you have something in common, and then there is that mutuality and reciprocity and creating that trusting relationship.’ (S3PW3).

On the whole, training – as specified in the ENRICH manual – was consistently delivered and worked well to provide PWs with the range of skills they felt they needed for the role:

‘We did a lot about strengths-based approaches and I think that’s really informed the way that I interact with people, so I think I’m always trying to bring it back to what can you do, what is strong for you … we did a lot about active listening and also about discussing difficult issues … I think it’s been very helpful the stuff we did in training … definitely the boundaries and relationships sessions that we did …’ (S3PW1).

The importance of group supervision facilitated by the PWC, as well as individual supervision where required (both specified in the handbook), was indicated across sites, providing the opportunity for PWs to share experiences and receive feedback from one another as well as from the PWC:

‘I will hold these feelings until supervision and that’s when I let it out, offload it to my colleagues. And it’s been great because we’ve been bouncing it off each other and I’ve noticed that it’s not just me that was going through it, so it’s such a relief …’ (S2PW2). ‘… [PWC] will always ask how I am, if anything has triggered me or anything like that and she’s quite easy to talk to and it’s OK to be open with her.’ (S6PW3).

Participants in all sites described differences between the culture of clinical services in the host trust and the ethos underpinning peer support:

‘…it’s about the values because what I find with the other types of support, it all tends to be clinical and deficits based … very directive and judgemental … some of the clinical teams are stuck in that way of seeing things, that deficit-based thing and they don’t really know too much about peer support.’ (S5PW1).

At all sites, there was a perceived lack of contact with, and feedback from, community mental health teams, sometimes accompanied by a lack of understanding of the PW role:

‘Whenever I got a new service user, I’d email their [Community Psychiatric Nurse] or care coordinator … to give them more information about it and nobody, apart from I think one person, got back to me. So that’s been quite challenging, not really having any communication or contact really with the mental health teams that are working with the service users …’ (S5PW3).

Interviewees in all sites remarked that the timing of the offer of peer support - prior to discharge from hospital - was particularly challenging for some, especially in relation to maintaining contact with the PW following discharge. This represented a barrier to engagement that was related to the clinical context, rather than implementation:

‘… they are being introduced to it as soon as they come out … they are going through a tough period of fear, of not knowing what’s next for them. The last thing they want is to commit to 16 weeks of meeting someone that they don’t even know.’ (S2PW2). ‘I suspect that the post-discharge needs more targeting, that would be my sense. There are people who really get so much out of it, but then there are an awful lot who just disengage. It’s another stress for them I think.’ (S4PWC).

Implementation in high fidelity-high engagement cases

There was evidence of features supporting implementation in the high fidelity-engagement cases which contrasted with low fidelity-lowengagement cases (see below). In high fidelity cases, cultural differences between clinical services and peer support were generally seen as an asset and were valued, rather than as a source of tension:

‘… you need a values-based practice and how important it is, as opposed to the clinical based practice and how helpful that is … I’m not saying the clinical approach is wrong or anything like that, what I’m saying is we need to complement each other, we need to take a holistic approach.’ (S5PW1).

Some aspects of organisational culture were seen as supportive of peer support, including the role of recovery colleges in preparing PWs for the role or providing additional training once in post (recovery colleges employ an adult education model to supporting people with their mental health, often co-delivered by people using mental health services [ 34 ]):

‘… we were in a really fortunate position being linked with a Recovery College, that, where later in their work they then wanted to do specific recovery focused training around diagnosis we were able to provide that for people.’ (S3PWC).

In these cases, staff on the wards (inpatient units) were reported as largely familiar with and valuing the role of peer support:

‘… when I’d go on the ward … they seemed to see great value in the transparency of people being there because they’ve got lived experience. That aspect of it was really nice … good for the culture of the organisation in many ways.’ (S5PWC). ‘… the clinical teams are aware … they’re very excited that we’ve got peer workers on the ward. They’re very positive about it.’ (S3PW3).

PWCs described PW recruitment as having followed the process specified in the intervention handbook, and as such the PWs who were appointed were well equipped to deliver the role:

‘… we had the right people to execute these roles effectively really … we had quite a diverse selection panel … we had the right people that expressed the interest I think …’ (S5PWC).

There was evidence that PWs and PWCs – as intervention facilitators - had worked hard in delivering clinical team preparation sessions, as specified in the handbook, offering repeat sessions where necessary, and that this had supported a good relationship with ward teams:

‘… [in] the early days we went in to talk about ENRICH and then if they’d had significant staff turnover, which is really happening a lot … we’d then go back to the teams just so that they were aware of what ENRICH was about, what their role was … it certainly meant that staff were much more welcoming of the ENRICH peer workers when they came onto the wards.’ (S3PWC).

PWCs reported being well resourced in their leadership role, both in terms of having sufficient time to do the work and having sufficient supervision themselves around any difficult issues that might arise:

‘… [my role] was two days a week and that was plenty of time…’ (S3PWC). ‘I have had unconditional support from my manager … it’s been part of my regular monthly supervision … any kind of difficulties I’ve had or frustrations or whatever that has come up, that has been an ideal time to go through it. But I’ve also been supported to discuss things as and when they come up …’ (S5PWC).

In these sites, there was evidence that delivery of peer support was highly consistent with the manual. There was notable emphasis on flexible application of peer support, especially around pacing support in response to the individual’s needs, spending as much time as necessary alongside the participant to build a trusting relationship:

‘… it doesn’t necessarily follow a linear path a lot of the time. Sometimes, somebody might be having a really bad week and they actually want you to listen to what’s been going on for them … at the beginning, because you are getting to know the person as well, I think the kind of conversation you’d have is a bit more general … and then it might actually take a completely different path however many meetings down the line and they’ll actually go … “I haven’t told anyone about a particular issue, but I want to talk it through with you and see what you think”.’ (S3PW1).

PWs at these sites demonstrated confidence in taking a lead from the person they were supporting, consistent with the principles of choice and control that underpinned the intervention:

‘… I’m kind of getting to know things that they’re interested in and this is influencing where I signpost them to … it’s just about giving them the option and then they can make their own decision then whether they want to go, and again that’s putting them back in control, which is all about helping people to recover really and take control back of their lives.’ (S5PW2).

PWs also described learning from the people they were supporting, and the importance of validating their experiences, consistent with the principle of reciprocity in the underpinning framework:

‘There are people who I’m supporting who … realise that the medication is very important to them and that they will probably always be on it. So, I gain insight from that, just because maybe I found that medication in my own lived experience wasn’t particularly fantastic but for others it’s very important. So, you learn from other things … you’ve got to validate their experience because … they know what works for them and you can’t tell somebody else what will work for them …’ (S5PW1).

Implementation in low fidelity-low engagement cases

There was evidence of barriers to implementation in low fidelity-lowengagement cases. In both, PWs were employed in not-for-profit organisations, resulting in organisational context-related barriers to implementation. Resource issues impacted leadership of the intervention with, in one site, the organisation not having capacity to provide cover or suitable supervision for the PWC:

‘… we’ve had different staff line managing me over the past year because of maternity. But to be fair none of them really knew about ENRICH … there was nobody who could have covered my role here … it’s felt like a bit of pressure to continue doing it because I took a bit of time off … I couldn’t physically go out and do anything when I wasn’t well …’ (S6PWC).

Support for PWCs at these sites, including an Action Learning Set with other PWCs, was difficult to access because of lack of sufficient funding to travel to meetings:

‘I think the action learning sets worked really well … maybe they should have been planned for a bit more financially … because ultimately we had to go back to our Trust and say we need to find more money or I’m not going.’ (S4PWC).

Being outside of the NHS also created issues of access and authority for PWCs:

‘I would have thought there should be regular team meetings, but we never seemed to be able to get in on them … an additional disadvantage from being an organisation outside of the Trust …’ (S4PWC). ‘… it’s been difficult with the [NHS Trust], some of the staff there … I don’t want to say too much, but that’s been difficult.’ (S6PWC).

This extended to PWs being able to communicate with clinical teams about the people using:

‘A few times they didn’t want to talk to me because I didn’t have enough information for them … to establish who I was … I just wanted to know whether they were seeing [participant] or whether they’d stopped seeing him, and they wouldn’t tell me.’ (S4PW3).

At these sites there was, generally, a challenging relationship with ward-based clinical staff, potentially impacting on the initial relationship building phase of the peer support:

‘There were certainly, on that site, a lot of suspicious looks and “what on earth is this all about” type conversations. However much we tried to prepare the staff team, and we’d gone in and visited and talked to them all, but there was still that “what’s this all about”? People didn’t get it straight off.’ (S4PWC).

Cultural differences with the host NHS Trust were keenly felt by PWs employed in not-for-profit organisations:

‘… the ward environment is, well obviously it’s clinical. It sometimes feels some staff, but not all staff, who work on the wards are not really sure what my role is or have a vague understanding. There’s perhaps a little bit of a difference in terms of pecking order and me in the pecking order.’ (S6PW2). ‘… they will be looking at the patient’s files … they can build up a judgement before seeing you … when the patient sees the peer support worker they might talk to us because we’re non-judgemental, we don’t feedback unless there is a safeguarding issue or danger to themselves or others … I don’t think peers should be seeing files …’ (S4PW44).

Both sites also combined rural localities with urban areas, with issues of geography hindering timely delivery of peer support at remote hospital sites:

‘… the geography issue was a great challenge in itself in our area because I was one bit of the triangle and the [hospitals] were in two different places … I’d have had an hour or so travelling and then get there and “oh, they’re on leave until 10pm tonight”.’ (S4PWC).

Geography could also impact on building a strong sense of PW team:

‘I did lots of talking to [the PWC] but not so much my fellow peers. There was one fellow peer that I talk quite a lot to … the other two were very close to each other and so they were almost functioning as one … I got on OK with the people at [the other town] … it’s just that we had differences of opinion.’ (S4PW3).

There was some inconsistent delivery of training, with one PW reporting having received a truncated version of the training programme as a result of capacity issues:

‘I didn’t actually do [the full training] … because I was covering a maternity leave it was the girl did all the training. So, I basically had a morning with the coordinator where we went through the whole bumph together … ’ (S6PW3).

While the importance of group supervision was acknowledged in these sites, there was disruption leading to inconsistency with the pattern of weekly group supervision as a result geography in one site, and capacity in the other:

‘We don’t generally do weekly anymore … generally we do monthly although I check in by phone with them.’ (S4PWC). ‘… a lot of the supervision has ended up being one-to-one just because it’s a small team here … sometimes I would be able to meet with them together but often because my day, I’ve only got one a day week, I’d have to fit them in if one of them couldn’t do it that day …’ (S6PWC).

Possibly as a result of disruption to supervision or opportunities to support each other as a team, PWs at these sites at times appeared to lack confidence in delivering peer support:

‘… it made me feel that I was getting it all wrong … she didn’t really talk at all about, and I felt that I couldn’t, I just felt that I had to wait for her to give information to me … because that’s what I understood you are supposed to do, is wait for them to give you information to talk about their problems …’ (S4PW3). ‘… I’m imagining it’s going to be quite hard for a long time because the expression that I’ve used that comes to mind is pulling teeth. It’s going to be probably like that every time we meet … it is frustrating because you want to help them.’ (S6PW2).

Implementation in the outlier high fidelity-low engagement case

The outlier case shared contrasting sets of features with the other cases. Like high fidelity and engagement sites, the outlier case reported feedback from management describing a positive impact of peer support on culture in the NHS trust:

‘… within senior management they’ve seen the power of peer working and they really like it … we’re in discussions on when ENRICH finishes, that we’re going to have a number of peer workers within teams, exactly to try and change the nature and change the culture …’ (S2PWC).

PWs in this site also demonstrated a more confident, patient approach to relationship building:

‘… trying to build that friendly rapport, getting them to trust you, showing them that you understand them in a way … creating that safe space environment for them to be able to talk about how they are feeling or what’s going on for them … just finding out what they want to do for themselves not someone else telling them what to do … ’ (S2PW0).

However, as in the two low fidelity-low engagement cases, in the outlier site barriers to implementation included a challenging relationship with ward staff:

‘… [I feel] looked down upon sometimes, “oh, you’re just a peer support worker” … it’s the environment. The days that I do go for ward meetings are usually the days I need a long break, I’ll be honest with you …’ (S2PW2).

In this site there was also disruption to group supervision, with some PWs needing considerable additional support from the PWC and a challenging team dynamic emerging:

‘I was definitely doing weekly one-to-one supervisions with the peer workers when they first started … it kind of came apparent that it was what people needed … for me it didn’t work very well, I was exhausted … people want one-to-one sessions to talk about colleagues and issues they are having with their colleagues … I think there are two other peer workers who are less, they don’t see themselves as much as part of the team.’ (S2PWC).

The PWC indicated that they would have benefitted from additional support for their role:

‘I feel like we could have done more support around, more training kind of stuff on managing people with lived experience … … maybe one thing would have been more meetings with other peer worker coordinators and just see how other people are doing it … more guidance on what group supervision actually was … ’ (S2PWC).

This study used a qualitative, comparative case study design to explore how implementation of a peer support intervention might be associated with engagement with peer support and, as indicated in results elsewhere, [ 26 ] with outcomes. We noted clear differences related to organisational context between high fidelity-high engagement cases and low fidelity-low engagement cases. Lack of a positive working relationship between PW and ward (inpatient) clinical teams, exacerbated by lack of awareness of the potential role of peer support, is likely to be crucial to engagement where people begin peer support in hospital. Levels of engagement were highest in cases where those relationships were reported as largely positive and where differences in approach (between clinical practice and peer support) were highly valued [ 6 , 35 ].

We note that the two low fidelity-low engagement sites employed PWs in the not-for-profit sector rather than within the NHS. Elsewhere, research has indicated that the principles underpinning peer support might be better maintained within peer-led or not-for-profit organisations, [ 7 ] and that doing so might provide an opportunity to bring a change of culture into statutory services [ 35 ]. However, we observed constraints on resourcing for leadership roles, and lack of access and authority for managers in the not-for-profit sector, compounded, perhaps coincidentally, by the additional challenges of geography. Neither did we observe, in those sites, evidence of leadership for peer support from within the host NHS organisation that might have facilitated better implementation [ 36 ]. In our outlier high fidelity-low engagement case, resourcing for leadership also impacted support for PWs. Proper resourcing for PWCs has been identified elsewhere as crucial to providing good peer support [ 5 , 37 ]. PWCs at sites that struggled with levels of engagement identified the need for a wider network of mutual support beyond their immediate organisation, with work elsewhere highlighting the need to develop communities of practice around lived experience leadership roles in mental health services [ 38 , 39 ]. As such, our findings reinforce the link that has been observed elsewhere between leadership in implementation, and the outcomes of a newly implemented intervention [ 40 ].

At the two high engagement-high fidelity sites, PWCs noted that robust recruitment processes resulted in a PW team that were well equipped to deliver what was a challenging role. An experience of the PW team as mutually supportive, complemented with group supervision led by a PWC bringing experiential knowledge to their role, was identified as important at all five sites included in our analysis, as it is in the wider literature [ 2 , 5 ]. The PW training programme was equally valued across all sites with PWs indicating that it prepared them well for their roles. Again, the importance of training that is specifically tailored to peer support having been widely noted [ 3 , 4 ]. In sites where there were inconsistencies in delivery of supervision and training, this appeared to impact confidence among PWs in offering peer support that reflected the underpinning principles framework. Sites with high fidelity scores were indicative of a clear focus on relationship and trust building, characterised by spending time alongside the individual offered peer support, learning from them, before taking their lead in exploring new possibilities. These values have been identified as fundamental to peer support, [ 41 ] and our own analysis of data from the trial indicated that relationship building at the beginning of the peer support was predictive of ongoing engagement [ 42 ].

It is worth noting here that not all challenges to engaging people with the peer support were attributable to implementation issues. Across sites, interviewees felt that discharge from hospital was a challenging time for some people to consider taking up peer support. Other trials of peer support for discharge have also struggled in this respect, [ 43 ] especially where participants were those with a higher level of need (people with multiple admissions) as they were in our study [ 15 ].

Strengths and limitations

We employed a robust, theoretically informed comparative case study design, with case selection determined by a priori measures of fidelity [ 31 ] and engagement [ 26 ] made independently of this analysis. We analysed a complete data set – interviews of PWs and PWCs – in all sites included in the analysis, although we might usefully have also interviewed NHS clinicians and managers as they also played a role in implementation. Analysis of in-depth interviews exploring the experiences of people offered peer support will be reported elsewhere. Our original interview schedules were not directly informed by the PAHRIS framework [ 22 ] and so may not have elicited a full range of data relating to implementation variables. Other frameworks might have been indicative of different barriers and facilitators of successful implementation. Nevertheless, we note the work adapting the PAHRIS framework to elucidate the role of experiential knowledge in implementation was particularly suited to a study of peer support and informed by lived experience on the research team [ 25 ].

Implications for policy, practice and research

Mental health workforce policy in England, as elsewhere, is encouraging employment of large numbers of PWs into mental health services.[ 44 ]. A range of training programmes have emerged [ 45 ] that, to some degree, share a set of principles similar to those that informed ENRICH. This study suggests that specific supports for PWs need to be properly resourced as integral to the offer of peer support in mental health services. These include supervision from an experienced PW, opportunities for group supervision, and an emphasis on relationship building in PW training that is consistent with a principles-based peer support framework. While it has been suggested that peer support can drive cultural change in mental health provider organisations, [ 46 ] our research suggests that lack of supportive culture can constrain delivery. Peer leadership, provided with sufficient support and authority, is needed to support change work with clinical teams, in hospital and in the community, so that peer support and clinical care are part of a complementary offer.

This study identifies policy and practice implications when peers are employed through not-for-profit organisations to work in partnership with public mental health providers. Research elsewhere highlights the potential challenges and opportunities of this ‘hybrid’ approach, [ 35 , 47 ] indicating a need for strategies that effectively align implementation expectations between the not-for-profit organisation and the mental health provider.

Further research to develop and evaluate the introduction of peer support in mental health might usefully be informed by a change model that incorporates this range of implementation variables to optimise delivery of peer support. We also note that in our study, PWs were employed to, and supervised within a dedicated PW team that provided peer support across several clinical teams, while in many mental health services internationally PWs are employed as embedded members of multi-disciplinary clinical teams. There is a need for research that considers the implications for implementation and outcome of these contrasting organisational configurations.

This study provides clear indication that implementation issues can impact delivery of peer support, with implications for engagement and, potentially, outcomes. Resourcing can impact consistency of delivery, alongside challenges of access, authority and relationship with clinical teams, especially where PWs are employed outside of the mental health service. Attention needs to be paid to the impact of geography on implementation.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

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This study was funded by the UK National Institute for Health Research (NIHR), Programme Grants for Applied Research funding programme (grant number RP-PG-1212-20019). This paper presents independent research funded by NIHR. The views expressed are those of the authors and not necessarily those of the UK National Health Service (NHS), the NIHR or the Department of Health and Social Care.

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SG, SW, SLG, AlS, ML, JR, MR and JW contributed to the conception of the original study. SG, RF, SW, RB, PB, RE, DH, AlS and AnS contributed to the design of the work reported here. SG, RF, SW, RB, RE, AlS, ML, JR, MR and JW contributed to interpretation of the data. SG, RF, SW and JM contributed to the acquisition and analysis of data. SG, RF and SW drafted and substantively revised the work. All authors approved the submitted version of the study.

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Gillard, S., Foster, R., White, S. et al. Implementing peer support into practice in mental health services: a qualitative comparative case study. BMC Health Serv Res 24 , 1050 (2024). https://doi.org/10.1186/s12913-024-11447-5

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“ The peace that I wanted , I got ”: Qualitative insights from patient experiences of SMART DAPPER interventions for major depression and traumatic stress disorders in Kenya

Roles Conceptualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America

Roles Investigation, Project administration, Supervision, Writing – review & editing

Affiliation Department of Psychiatry, University of Nairobi, Nairobi, Kenya

Roles Data curation, Project administration, Supervision, Writing – review & editing

Affiliation Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, California, United States of America

Roles Project administration, Supervision

Affiliation Global Programs for Research and Training, Nairobi, Kenya

Affiliation Kisumu County Hospital Psychiatric Unit, Kisumu, Kenya

Roles Investigation

Roles Data curation, Project administration, Supervision

Roles Conceptualization, Investigation, Methodology, Writing – review & editing

Roles Investigation, Methodology, Writing – review & editing

Affiliation Department of Psychiatry, University of California San Diego, San Diego, California, United States of America

Roles Investigation, Project administration, Resources, Supervision, Writing – review & editing

Affiliation Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya

•  [ ... ],

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Writing – original draft, Writing – review & editing

• [ view all ]
• [ view less ]
• Monica Getahun, 
• Muthoni A. Mathai, 
• Grace Rota, 
• Ammon Allen, 
• Rachel L. Burger, 
• Elizabeth Opiyo, 
• Dennis Oluoch, 
• Josyline Wangia, 
• Raphael Wambura, 

• Published: September 5, 2024
• https://doi.org/10.1371/journal.pgph.0002685
• Reader Comments

SMART DAPPER is an implementation science study responding to mental health treatment gaps for depression and trauma-related disorders in Sub-Saharan Africa (SSA). We report on patient experiences in a study using a Sequential, Multiple Assignment Randomized Trial (SMART) design to test first and second line non-specialist treatment using psychotherapy (Interpersonal Psychotherapy [IPT] or medication (fluoxetine [FLX]), integrated within public sector primary care in western Kenya. An embedded qualitative study conducted in-depth interviews (n = 17) and three (n = 3) focus group discussions with participants (May to October 2021). Audio-recorded interviews were transcribed and translated into English; we deductively and inductively analyzed transcripts guided by grounded theoretical approaches and content analysis. We drew on the health belief model and socio-ecological framework to present findings, including perceived severity (motivations for taking part in the intervention), impacts of the intervention at the individual, interpersonal, and community and health systems levels as well as barriers and facilitators. Participants discussed family and marital conflict, loss of a child, loss of income or a job, and traumatic events such as a death or illness. Impacts at the individual level included reduced headaches, improved appetite and weight management, increased energy, improved sleep, better self-efficacy, and improved concentration, which was reported to lead to increased economic opportunities. At the interpersonal level, participants noted a reduction in conflict, better conflict management and resolution, increased harmony with family and community members, and improved relationships with their partners and children. Perceived challenges included balancing the intervention with livelihoods, preference for traditional medicines, actual or anticipated side effects with medication (FLX), mental health stigma, major life events, and perceived inadequate counseling and challenges with providers. The findings demonstrate the potential of the SMART DAPPER intervention for depression and trauma-related disorder treatments and underscore the challenges and barriers that must be addressed when scaling similar interventions.

Trial registration: ClinicalTrials.gov identifier: NCT03466346 .

Citation: Getahun M, Mathai MA, Rota G, Allen A, Burger RL, Opiyo E, et al. (2024) “ The peace that I wanted , I got ”: Qualitative insights from patient experiences of SMART DAPPER interventions for major depression and traumatic stress disorders in Kenya. PLOS Glob Public Health 4(9): e0002685. https://doi.org/10.1371/journal.pgph.0002685

Editor: Ejemai Eboreime, Dalhousie University, CANADA

Received: December 1, 2023; Accepted: July 26, 2024; Published: September 5, 2024

Copyright: © 2024 Getahun et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Due to confidentiality agreements, supporting data can only be made available to bona fide researchers. Details of the data and how to request access will be made available at https://www.icpsr.umich.edu/web/pages/ICPSR/index.html .

Funding: The study is funded by the National Institutes of Mental Health (NIMH) and the Global Alliance for Chronic Disease (GACD) (R01MH113722 [NIMH, UCSF prime to SM], R01MH115512 [NIMH-GACD, UoN Prime] to MM), which together comprise the Sequential, Multiple Assignment Randomized Trial (SMART) for non-specialist treatment of common mental disorders in Kenya: leveraging the Depression And Primary care Partnership for Effectiveness-implementation Research (DAPPER) project. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Mental disorders are a leading cause of global disability [ 1 , 2 ], largely driven by depression and anxiety [ 3 , 4 ]. Most of the disease burden is in Low and Middle Income Countries (LMICs), where approximately 75% of adults with mental disorders have no access to care—reflective of the widespread and persistent shortages in trained mental health professionals [ 5 – 7 ]. In Sub-Saharan Africa (SSA), many face challenges in accessing treatment due to complex and multifaceted challenges at the individual, health systems, and community levels [ 5 – 10 ]. The burden of mental health illness and unmet need is even higher among vulnerable populations including people living with HIV (PLHIV) [ 11 – 15 ]. In SSA, a region where an estimated 67% of PLHIV reside [ 16 ], rates of depression and post-traumatic stress disorder (PTSD) are elevated, reflective of the complex stigma and vulnerabilities that PLHIV experience [ 12 – 15 ]. Thus, addressing unmet mental health needs, especially among vulnerable populations including PLHIV, is critical public health priority [ 17 , 18 ].

Some efforts are underway to address this burden of mental health illness in the region, including increased training, capacity building, and task shifting of mental health services [ 19 – 23 ]. Interpersonal therapy (IPT), for example, is increasingly used to address depression and PTSD. Studies have underscored the potential of IPT, including non-specialist delivered therapy, to address complex social cultural and personal dynamics which contribute to negative health outcomes [ 21 , 24 – 30 ]. And yet, despite nearly 15 years of efficacy research showing that local non-specialists can provide evidence-based care for depression and anxiety in LMICs [ 31 – 36 ], few studies have advanced to the critical next step and morbidity from mental disorders continues to escalate [ 1 , 37 – 39 ]. Further, not enough is known about how to implement non-specialist treatments at scale [ 38 – 41 ]. It is vital that global mental health treatment researchers now focus on implementation science to inform scale-up of evidence-based care to lower mental health burden. As emphasized by a recent World Health Organization (WHO) initiative [ 42 ], integration of mental health treatment into existing systems of care is critical to achieving public health impact.

In Kenya, specifically, the high prevalence of Major Depressive Disorder (MDD) (26%) and Posttraumatic Stress Disorder (PTSD) (35%) in primary care populations has led to their prioritization in treatment [ 43 , 44 ]. Depression and trauma-related disorders are frequently co-morbid [ 45 – 47 ], and scalable treatment strategies in resource-constrained settings must be capable of treating both conditions using a non-specialist workforce. Kenyan healthcare providers and policy-makers collaborated to pioneer an innovative, government-funded initiative to scale-up treatment for mental disorders in primary healthcare [ 44 , 48 – 50 ]. Data to guide the related scale-up of two essential treatments for depression and PTSD–psychotherapy and second generation antidepressants [ 51 ]—can thus inform Kenyan policy makers’ efforts to improve public sector mental health in the region.

SMART DAPPER provides data to inform evidence-based scale up of non-specialist delivery of treatment for depression and trauma-disorder, a much-needed approach with high potential to address mental health treatment gaps [ 52 , 53 ], led by a team of investigators from several institutions and ministries of health in Kenya, Uganda, and the US. The project partners, together with local, national, and regional mental health stakeholders, evaluated non-specialist delivery of evidence-based depression and PTSD treatment, integrated within existing healthcare centers for “real world” non-specialist treatment to reduce population-level disability caused by depression and PTSD- priority conditions given their prevalence in Kenya. We formed a collaboration with KCRH and Kenyan national and county Ministry of Health (MOH) offices to identify scalable treatment interventions for this implementation research, with two key criteria: (1) interventions had to be first line treatment for both depression and PTSD with strong efficacy data for non-specialist delivery; and (2) had to meet current, global standard of care recommendations. The majority of mental health treatment studies in LMICs test psychotherapy/psychological interventions only, excluding pharmacological strategies. Yet, in many LMICs, psychotherapy and psychopharmacology (Selective-Serotonin Reuptake Inhibiters [SSRIs]) are considered the two essential pillars of first line treatment for depression and PTSD [ 54 , 55 ].

SMART DAPPER tested access to both protocol driven psychotherapy and a modern SSRE, fluoxetine. The service-user acceptability of this treatment implementation strategy is crucial to informing scale up of similar interventions. We integrated qualitative interviews and focus group discussions with study participants to assess the acceptability of the treatments. We report on findings assessing the acceptability of treatment, and perceived benefits and/or challenges.

Study setting

The study was conducted in Kisumu County in western Kenya- a region where our team has established research collaborations for over ten years. The region has a high burden of illnesses as compared to other regions in Kenya, including high rates of mental health disorders and co-morbid conditions including HIV [ 56 , 57 ].

Study design and participants

About the parent trial..

SMART DAPPER collaborates with Kisumu County Referral Hospital (KCRH), and its large, public sector, primary care outpatient clinics (~10,000 participants/month). The parent trial recruited outpatient adult participants with current Major Depressive Episode (MDE) and/or PTSD from public health facilities that cater to both primary and specialized care settings. The published study protocol provides additional details about the trial [ 20 ], while the details of the qualitative sub-study are described below.

Qualitative sub-study.

Embedded within the parent trial, the qualitative study sought to document participant experiences with the intervention and interactions with the study team.

Study team.

The qualitative study team comprised of six research assistants (5 female and 1 male) and two study coordinators (GR and AA) trained in qualitative data collection methods; they conducted and documented the in-depth interview (IDIs) and focus group discussions (FGDs). All were degree holders with training in the interview guides, qualitative data collection, and human subjects’ research. The analytical team included the lead author (MG), qualitative research consultant (IM), GR and AA (study coordinators), and study manager (RB); all were trained in qualitative research methods and had prior experience conducting, analyzing, and writing qualitative research papers. IM, GR, and JW are Kenyan female researchers, and AA a Kenyan-male researcher- all are from the communities where the research is conducted. MG is a US-based east African female researcher and RB is a US-based female researcher.

Participants and sampling . Eligible study participants were 18 years or older, primary care participants at KCRH who met the threshold for MDE and/or PTSD on the Mini International Neuropsychiatric Interview (MINI 7.0.2) and new to the study and team. We excluded and referred those who were identified as having a moderate or high risk of suicide, current/previous hypomania or mania, hazardous drug or alcohol use, severe cognitive dysfunction, were pregnant/breastfeeding, lacked capacity to give consent, unable to attend weekly treatment appointments or were receiving outside mental health care. The qualitative study participants were purposively sampled following their parent trial enrollment, balancing for sex (~15% male and ~85% female to reflect the parent study population), intervention arm (IPT/FLX), and for those who completed their treatment, no more than 3 months since their completion. We also sampled those who dropped out of treatment.

Data collection

Six research assistants and two study coordinators (GR and AA) conducted in-depth interviews (n = 17) and three (n = 3) focus groups with an average of 4 participants (a total of n = 12 across all FGDs), between May 2021 to October 2021, in-person and utilizing semi-structured open-ended guides informed by an implementation science framework [ 20 ]. IDIs were conducted between May-September 2021, while FGDs were conducted between May–October 2021. All participants who were approached for the qualitative data collection agreed to participate. The IDIs and FGDs, combined, were adequate to achieve theoretical saturation. Emerging data and interview debriefs were conducted to determine if additional interviews were needed, at various stages of the data collection period. IDIs were conducted to delve into individual experiences with the SMART DAPPER intervention, while FGDs sought to explore group dynamics in discussing the various aspects of the intervention and mental health. The guides focused on the following areas: (1) conditions prior to the intervention start and general impressions about the intervention, (2) specific treatment experiences, (3) positive, negative, and neutral impacts of the intervention, and (4) interactions with the intervention and study team, including dimensions of respect, confidentiality, and care provision. IDIs and FGDs were conducted in the preferred languages of participants (Dholuo [LUO], Swahili, or English). IDIs were conducted one-on-one, while FGDs were conducted with 3–5 people in each group, at the health facility with only the participants and research team members present; FGDs lasted 1.5–2 hrs., while IDIs lasted 45 mins to 1.5 hrs. Audio recordings were directly transcribed and translated into English transcripts. Study team members reviewed transcripts and audio recordings to ensure the accurate capture of data.

Data analysis

Our analytical approach was guided by constructivist grounded theoretical approaches and content analysis [ 58 , 59 ]. The initial coding framework was refined at multiple stages. RB, GR, AA, and SM, along with research consultant IM, were each assigned three transcripts to review and summarize. They then met to compare notes and develop an initial coding framework based on review notes and discussions. IM and GR then applied the coding framework to the transcripts utilizing Dedoose software, discussing emerging themes and iteratively refining the coding framework; inductive codes were added at this stage and discrepancies resolved. The final coding framework included 12 parent codes and 23 child codes. The lead author (MG) queried all codes relating to the intervention impact, patient experiences, barriers, and facilitators. Based on a close reading of the coded excerpts, as well as an in-depth review of all transcripts, MG developed analytical summaries using MS Excel. This summary was reviewed and discussed with GR, AA, RB, and SM for consensus. We developed an analytical memo utilizing the socioecological framework (SE) [ 60 ] and health belief model (HBM) to present findings, including perceived severity (HBM) to describe the reasons for starting the intervention and the onset of depression/PTSD symptoms. We then present the impacts of the intervention utilizing the SE framework, which presents the perceived impacts of the SMART DAPPER intervention at the individual, interpersonal, and community and health systems levels.

Participant compensation

The study provided travel reimbursement for participation in face-to-face study research data collection (not treatment) at 350ksh (~$3) per visit. IDIs and FGDs participants were compensated at this rate.

Ethical approvals

The study was approved by the University of California San Francisco (UCSF) Human Research Protection Program Institutional Review Board (IRB), the Kenyatta National Hospital- and University of Nairobi Ethics and Research Committee (KNH-UoN ERC) and the Kenyan Pharmacy and Poisons Board (PPB), the National Commission for Science, Technology & Innovation (NACOSTI). All SMART DAPPER participants provided written consent to participate.

Among the parent trial cohort, the average age was 34 (ranging from 18 to 85); a majority were female (90.6%) and had at least some primary education (51.7%). At baseline, the majority of participants were diagnosed with major depression (93.2%) while nearly half (46.5%) were diagnosed with both major depression and PTSD. Only 1% reported a history of prior access to mental health care services. Notably, a large proportion (39.4%) of the study participants were living with HIV ( Table 1 ). The qualitative study cohort was similar in overall characteristics. Individual-level participant characteristics are shown in Table 2 .

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https://doi.org/10.1371/journal.pgph.0002685.t001

https://doi.org/10.1371/journal.pgph.0002685.t002

Qualitative findings

We present our findings utilizing aspects of the health belief model: perceived severity as reasons for starting the intervention and discussions of the onset of depression or PTSD symptoms. We then present the impacts of the intervention utilizing the SE framework, including at the individual, interpersonal, and community and health systems levels; the majority of the findings were at the individual and interpersonal levels. We then discuss the cues to action (i.e. the support and facilitators towards the intervention), as well as perceived barriers (challenges towards the intervention).

Perceived severity

Participants discussed the perceived severity of their conditions including detailed accounts of their symptoms as well as the varied circumstances they perceived caused stress including family and marital conflict, loss of a child, loss of income or a job, and a traumatic event such as a death or illness.

Some participants cited family-related conflict:

“I had a problem of land, with my brother and stepbrothers; we have two mothers and the other house. So, it was a serious one [the fight]. All these things- school fees is there, the children want to go back to school, some are going to college, there was no money, and I was really depressed.” 3633, 58, male , IPT, completed, English

Others attributed their symptoms and described the severity of their marital and relationship challenges, including the loss of a child:

“At that particular time, I was having some psychological problems. Such as, at that time I lost my marriage, broke up with my wife, she ran out and somehow again, I came and married another wife. And with her [new wife], I came to lose my child [child died]. So, in that duration, I met the SMART DAPPER [team] members. I was having so much stress in life.” 3276, 28, male , 2nd line combination, completed, English

Some recounted the severity of their condition, including their marital problems which had arisen to a crisis level where they had considered suicide:

“When I came [to SMART DAPPER], I had a problem with my marriage […] it reached to a level of committing suicide but am so grateful to SMART DAPPER for the counseling they gave me. I started getting treatment. I appreciate it so much, because I changed.” 3016, 52, female , IPT, completed , Kiswahili

For others, economic insecurity and income loss were particularly salient:

“Another important challenge that I have is that, at my age, I don’t have my own home. I am still living in a rental house, where I also have rent arrears of eleven thousand and something that I need to give the landlord. Whenever I receive her [landlord’s] call, I get stressed again. It happens because I don’t have money and I don’t know what to say or tell her.” 3578, 41, female, 2nd line combination, completed, Luo

Others were stressed about job losses, including that of their family members, which was also reported to lead to marital problems:

“The business was doing so badly, yet there are loans that I was paying off. So, I had a lot of pressure from the lenders because they kept on calling me. Yet, there was nothing coming out of the business. I was just depressed. I was wondering, ‘where will I get money to pay these people?’ because they will put me to shame, they will come and start repossessing things.” 3023, 26, female, 2nd line, combination, completed, Luo

For others, a traumatic event or a family member’s illness or death was reported to instigate their PTSD:

“It is because of the life I had at that moment. It was a bad life. At that time, I was going through a lot. My mum was in a hospital- she was in a coma and then she died.” 4329, 46, male, fluoxetine, completed, Luo

Impacts of the intervention at the individual, interpersonal and community and health systems levels

Individual level impacts of the intervention..

We use the SE framework to discuss the individual impact of the intervention across somatic and psychological health domains. These include positive changes such as a reduced headache, improved appetite and weight management, increased energy, improved sleep, and better self-efficacy.

Participants reported a reduction in headaches, as compared to their experience prior to the intervention.

“I noticed a difference because, as it was getting to the point where I felt like the headaches subsided. My heart also stopped beating as it used to, as I continued with the treatment. I even started to gain strength.” 4054, 30, female, fluoxetine, completed, Luo

Similarly, participants also noted a change in their heartbeats, in addition to reduced headaches.

“I just encouraged myself to take the drugs and hope for a better result as times goes by. The drugs worked so well, and the constant headaches started reducing; my fast heartbeat also stopped.” 3060, 36, female, fluoxetine, completed, Kiswahili

Others experienced positive impacts on their appetite and weight management. For some, it meant the realization of weight loss goals, while for others, the intervention facilitated weight gain and attainment of a more ideal body size.

"So, at that point, I was 64kgs. And I believe when you’re sad, you don’t want to eat. You don’t have an appetite, so I used not to eat. Like, I used to skip some meals not because they are not there, but I didn’t have the desire to eat. So then after the treatment, I started to develop an appetite, I started eating a lot and currently, I am 75kgs. That’s a gain of 11kgs.” 3060, 36, female, fluoxetine, completed, Kiswahili

This regulated appetite meant increased energy and ability to take on physical activities:

"First, my health was deteriorating, and I didn’t even have energy- eating was a problem. But for now, I appreciate it so much that I have good health, I am taking care of myself; I have tried so hard to lose weight and now I have good health. I can now walk a long distance, even from here to XXX, without any problem.” 3016, 52, female, IPT, completed, Kiswahili

Many participants also reported improved sleep as a positive impact of the intervention, which also led to better functioning in day-to-day activities.

"IPT treatment has improved my life for the better. I didn’t have many friends before, but now I have many friends. I slept well today; initially, I couldn’t sleep even sleeping hours. Working becomes hard because I would feel sleepy during working hours. Currently I sleep well, I do my job well and get home with some cash to support myself. I received much support from SMART DAPPER." FGD3, P4, IPT, Luo "There is a difference , before and after , because during that time my heart was aching . I could not sleep; I could wake up and just sit down . But now I am sleeping , even during the day , I can sleep . ” 3023 , 35 , female , 2nd line combination , completed , Luo

Participants also noted the important benefits of the intervention including improved self-efficacy and ability to manage challenges:

“That I saw that it wasn’t bad or good after I had finished, I understood that I am the one with the problem, so I am the one to decide how I will live. Because they [SMART DAPPER] have really helped me.” 3016, 52, female, IPT, completed, Kiswahili “The treatment that I received changed me and as of now , even if I experience any stress , I know how I can handle it […] if I experience any challenge , I know how I can handle it . ” 4493 , female , IPT , completed , Luo

For others, this improved self-efficacy reportedly led to better self-worth:

“I can say that treatment changed my emotions and life because I used to feel like I was a useless person by asking myself too many questions. But treatment enabled me to know myself better…” 3060, fluoxetine, completed, Kiswahili

Some participants reported acceptance of and normalized reactions to everyday stressors, including their perceived control over some aspects of their lives:

“After being counselled, I was told that there are some things that we can’t control as individuals. So, I also decided to embrace that and accept my future. I also decided to embrace that because the economy was also worsening, there was nowhere to get money from, therefore, it was upon me to work harder […] before treatment, I was easily irritated. Sometimes I could be lonely and just sit by myself and if anyone upsets me, I would really be mad; but now things are just so normal to me. I am not concerned with a lot of things like I used to be. Things are just normal to me." 3023, 35, female, 2nd line combination, completed, Luo

Other participants reported increased concentration, which for some, meant increased productivity:

"Today, my memory is good. I can perform many functions soberly as a human being. I remember immediately, any pending duties, then I make sure I complete it." 4719, 31, female, fluoxetine, dropout, Luo

Participants also reported improved cognitive functions, describing a resumption of routine functions:

"When they see me now, unlike before, I can do a lot of things by just thinking about them alone without asking somebody, which means I am mentally good. Everything in my brain is thinking quickly, as compared to before. I am normal […] you know when you are stressed, you are not even normal. So, it has helped me a lot. As at now I am so active, I can do most of my things, I can think positively all the time, I can do everything I wanted.” 3022, 26, female, fluoxetine, completed, English

Improved health was reported to result in increased economic prospects and capacities. For some, improved social relationships, opened doors to jobs or other opportunities:

“After getting treatment, my economic status has improved a lot, and this is happening because of the friends I have made. Nowadays, I cannot sit at home because I get other work through friends, which is changing my life." 3870, 50, male, IPT, completed, Luo

For others, the positive change and increased energy brought on by the intervention made it possible to resume their daily chores and livelihood activities:

“You know, at first, I wake up and just sit. You don’t feel like doing anything in your house. You don’t feel like doing anything, you just feel tired the whole day. But as I was engaged in this treatment, I’m always very strong. I can do my jobs very early. I even wake up at 4:00am and do everything, wash everything in my house, and go sell these vegetables. When I come back, I can even wash during the night. So as of now, my energy has increased a lot. I am so energetic.” 3022, 26, female, fluoxetine, completed, English

Participants also reported better concentration, and improved cognitive functions, which they reported their ability to complete their duties:

Before I could not concentrate, I used to lose memory, and my thinking was anticlockwise. But when I started on medication, all the depression and stress ended. Now I can concentrate and do my business as usual […] it didn’t end at once, but step-by-step, as I was attending and adhering to my treatment visits. The more I was taking my medication, the less stress and depression, and finally I was cured fully. I can now concentrate and attend to my duties and responsibilities better.” 3044, 35, female, fluoxetine, completed, Luo

Finally, some participants reported a decreased reliance on other medications to manage their symptoms, and thus, decreased expenses.

"At first, I would buy drugs. I was always tired, I would go and buy this one, when I am feeling headache […] I used to spend a lot of money buying drugs. But when I started this treatment, I don’t know but I just got sick in July last year with malaria only. When I compared the money, I was using at first to now, I feel so good. I am not using a lot of money to go and buy so many drugs. This treatment has really helped my life.” 3022, 26, female, fluoxetine, completed, English

Interpersonal level impacts of the intervention

The most salient findings were those relating to positive changes in the relationships with partners, immediate family members, and others within the community. Participants credited the intervention for increasing their ability to stay calm and avoid unnecessary conflicts, increased harmony, better conflict resolution, and improved relationships with friends and family.

A patient reflected on their past quick irritability and conflict-prone approach, noting:

“Just as I have told you earlier, during that time, if I was in the company of other people, I would easily get irritated. Whenever someone would say something, I would think that they never respected me because of this or that. But now I’m okay. Yes, I take things normally. Before, then, I would argue a lot and I would portray arrogance- but now, most of the time, I just keep calm. Yes, it is not very easy for me to have conflict with others.” 4329, 46, male, 2 nd line combination, completed, Luo

Others also reflected on their conflict avoidance, noting a recent shift to focus on reconciliation and harmony:

“I never used to talk to someone if they were in any disagreement with me. In relation to what I learnt through the treatment provider [name], I just reconciled with the person for me to have a peaceful heart. Because before, I used not to do that; but now I am the person who will have the burden [to make peace], and that is helping in reducing stress. I can now go to the person with whom I have grudges and talk to them.” 4493, 44, female, IPT, completed, Luo

Another patient, despite later dropping out of treatment, still describes how encouragement from her intervention therapist led her t resolve a conflict between her and her co-wife:

" I noticed a change. I can even say that I told my therapist that because of stress, I don’t even have a friend. I am in the same home as my co-wife, but we don’t talk. This really caught the attention of my therapist, and she could ask me if there is any change. Indeed, after some time, I noticed some changes because we are only two of us in that home, but we don’t talk. But after that, I noticed some changes between us. I can say that because she used to ask me this again and again, ‘how is it between you and your co-wife?’ I decided that even if she [co-wife] will think I am stupid, I am just going to talk to her.” 5443, 41, female, IPT, drop out, Luo

Others noted improvements in relationships with others outside of their family, including neighbors:

“I like coming [to IPT] because I could heal without taking medication. I don’t adhere well to medication, so I loved IPT so much. Secondly, since I got enrolled in study I had positive change in my life, I said initially that I was short tempered and feel isolated most of the time, but when I started IPT, I changed and become rejuvenated. Even my neighbor would realize that I have improved. Some of my neighbors would want to know which place I go to for support, but I told them I have a provider who supports me […] when I completed treatment, one of my neighbors also enrolled in SMART DAPPER and currently receiving treatment too…" FGD3 P1, IPT, Luo

For some participants, addressing their own depression and stigma meant they were able to encourage others:

“Yes, when we were discussing, I was, initially, I was not very free to tell anybody about my status; we discussed and even after about the fourth week, in fact I manage to counsel about five people.” 3633, 58, male, IPT, completed, English

Cues to action

Facilitators of the intervention..

Participants discussed components of the intervention they perceived to be important for their success. These were credited for motivation to remain engaged in the intervention.

Participants were modestly reimbursed transport costs to attend in-person research assessment visits with blinded clinical evaluators (9 visits, total of ~$25 distributed over 2 ½ years). The study reimbursement for transport related for data collection was reported to support participants in buying food and alleviating food insecurity:

“I can say that as a business lady, when I go to sell my goods, I can sit there without selling anything. When I come for treatment visits, I know that I will get three hundred to four hundred shillings, which is enough to buy maize flour. I will also get milk to make tea because I have not taken any food. That is all I can say, helped me a lot.” 4493, 44, female, IPT, completed, Luo "Sometimes , because of the situation of COVID-19 , there was no money and when I am called , I could recall that sometimes they [SMART DAPPER] give Ksh . 350 . That was enough for me to eat . Sometimes , that was motivation . I could say that when I go there , I will get Ksh . 350 therefore I will not sleep hungry because sometimes business was not good . " 3023 , 35 , female , 2nd line combination , completed , Luo

Others perceived the warm and welcoming environment, particularly among providers, as a motivating factor:

"What encouraged me most are the good treatment services which I received; I liked the type of counselling I was offered at SMART DAPPER. The treatment improved my life, and I could not miss a session. Secondly, my IPT provider was a very nice lady, she could remind me three days to my treatment visit through phone call, then a day before, she can call to confirm whether I will attend or not. So, my provider’s good attitude and connection was also encouraging me to honor my treatment visits." FGD3- P2, IPT, Luo "What really motivated me was the level of love all SMART DAPPER staff were showing towards participants . You’re given warm welcome and assisted to find your provider […] you would feel happy . " FGD3 P1 , IPT , Luo

A patient notes the flexible and ideal scheduling of IPT sessions as a motivator:

"There were no negative aspects because during treatment, everything was done in a very organized way, and it did not interfere with my schedule. I also had enough time to plan for the appointment date without any challenges, which made my work easier too […] I was able to attend all the treatment sessions in person without missing even one session.” 3870, 50, male, IPT, completed, Luo

This was particularly important when participants felt they were late for their appointments:

"The way they treated me with respect is that there was privacy, at least when you arrived, they take you direct to the room […] then the way they talk to you also. They will not treat you harshly even when you are late maybe for the clinic those…even if you are absent or late but you communicated at least they get to know what happened […] they take you the way you are, they understand why you are late and the reasons, and what can be done so that next time, you don’t come late." 4212, 20, male, fluoxetine, completed, English

Further, participants appreciated the confidentiality provided during intervention participation:

"My treatment provider X would assure me of confidentiality before we start. The provider assures me to keep every talk very private and confidential, unless there is talk of committing suicide, then she may refer to you to another senior provider who will also keep your information confidential […] my provider showed me a lot of respect and I shared all my problems with her until my life improved […] I thank her so much." FGD3, P4, IPT, Luo

For some, the study participation and intervention impacts were so profound that they encouraged others to participate, noting subsequent positive changes among their friends:

" It has changed my life […] it has helped me with my friend. There at the estate, I also picked some of my friends who also had that problem [mental health] and brought them here. I am seeing their lives have changed. Because when they came here, the doctors talked to them, they were counselled, and now I am seeing they are good." 3022, 26, female, fluoxetine, completed, English

Barriers to intervention engagement.

Participants noted some challenges that impacted their participation in the intervention. Some participants reported livelihood and scheduling-related conflicts:

“the only negative experience I had was about time, sometimes I could have limited time to come for sessions at KCRH-Smart DAPPER then I could find my IPT provider X still having session with another participant, I will have to wait for her to finish, by then customers are also waiting for me at my business premise so that’s the only problem I had during my treatment period…” FGD3 P2, IPT, Luo

Others recounted the stigma associated with the physical space where the intervention is implemented, as well as having mental health issues, noting:

"Let us say you are in PSC (patient support center), you can know what the other person is thinking. Like number three had said, he thought they treated mentally challenged people. Another person who has the same mentality will conclude that the people there are mentally challenged." FGD 4 A2, fluoxetine, Luo “ Because let’s say for example , your friend is passing by and he sees you seated at the waiting bay [in clinic] , and it is known that the study is for people with mental health , depression and anxiety . When he goes out there , he’ll start saying; ‘you see so and so has mental problem’ . You see that creates stigma and more depression . So that’s why sometimes I opted to coming in the evening […] the waiting area was kind of uncomfortable […]You could take like 1–2 min as they searched for an empty room . So at least , that was a plus . " 4212 , 20 , male , fluoxetine , completed , English

Some participants also noted major life events or crises that impacted their engagement:

" The challenge that I faced was when I was admitted inpatient. During this time, I was delaying taking medication and the provider would quarrel with me and urge me to let them know when I’m admitted. At some point, I was admitted and forgot to carry my pills." 4719, 31, female, fluoxetine, dropout, Luo “[I had an] accident whereby my house burned , and I also lost a child . That was the thing that made me disappear- not to come back for another re-fill again . So , I got around three months away . But they [study] used to contact me , that’s the best thing that they used to do . They used to contact me and confirm if I’m there or not . I used to tell him that I’m there but right now I’m [not in town] . ” 3276 , 28 , male , 2nd line combination , completed , Luo

A patient also discussed their preference for the use of traditional medicines rather than the prescription study drugs:

"The session [IPT] was good. I am the one who said I don’t take medication and I also don’t like injections; I just use traditional medicine. I like using traditional medicine compared to going to the hospital […] I told them that I cannot take the medication, yet I am not going to use them. Taking the medication yet I am not going to use them will not give me peace.” FGD 5 P3, dropout, Luo

Finally, some participants found difficulty with the study enrollment counseling, the randomization procedures, and subsequent assignment to a treatment arm:

I fell on the Fluoxetine arm and that is where my problems started. I wanted to get a better understanding before the initiation, but the treatment provider was not willing to do so. Not that I refused to take the drugs, even though they are drugs for stress, but I haven’t used it before. I didn’t know the effects of that drug […] I expected to be explained whether the drugs can make someone weak, have headache or diarrhea and the response was ‘you are supposed to ask me the questions after you have started the medication’, I became tired." 5265, 38, female, fluoxetine, drop out, Luo “I asked questions then the procedure was like , I met a psychologist and we talked , she elaborated , she told me like it’s a study […] they developed a software and it’s a study , so it either is ‘you will be taking the drugs , or you will [get therapy]’ . The category you will fall into , the machine is what will determine , so I was not comfortable . ” 6585 , 47 , female , IPT , dropout , English

The study explored user experiences with the SMART DAPPER intervention; narratives about the severity and onset of depression and PTSD recount family and martial conflict, loss of a child, loss of income or a job, and a traumatic event such as a death or illness. We found that impacts of SMART DAPPER reported at the individual, interpersonal and community levels. At the individual level, findings reveal positive somatic and psychological health outcomes including reduced headaches, improved appetite and weight management, and improved sleep. Participants noted increased self-efficacy, mood regulation, improved cognitive functions, and better concentration, which were reported to lead to increased economic opportunities. At the interpersonal level, participants reported an overall reduction in conflict, better conflict management and resolution, increased harmony with family and community members, and improved relationships with their partners and children. Others also discussed perceived challenges included balancing the intervention with livelihoods, preference for traditional medicines, actual or anticipated side effects with medication (FLX), mental health stigma, major life events, as well as perceived inadequate counseling and challenges with providers.

Our participant narratives reveal the severity of events that precipitated depression and/or PTSD including economic insecurity, job loss, marital and family conflict, and loss of family, as previously documented [ 28 , 61 – 64 ]. Marital conflict, lack of partner support, and marital dissolution were all reported to contribute to depression and PTSD, suggesting that relationship conflicts have profound implications for mental health, as demonstrated in similar settings [ 28 , 64 – 66 ]. Further, in SSA, a region where an estimated 67% of PLHIV reside [ 16 ], rates of depression and post-traumatic stress disorder (PTSD) are elevated. A large proportion of our study cohort (~40%) were living with HIV, also underscoring the unique challenges of managing HIV alongside depressive and stress-related disorders, as has been extensively documented by others [ 11 – 15 ].

Impacts of SMART DAPPER were reported at the individual, interpersonal and community levels. At the individual level, participants noted somatic and psychological improvements in their symptoms of depression and PTSD. These gains included increased energy, improved sleep, and fewer headaches. Further, others reported improved mood, cognitive function, and concentration. Concurrent findings have previously been reported in similar settings [ 66 , 67 ]. For example, a study in Uganda demonstrated an improvement in work status and increased functioning following depression treatment [ 68 ]. Many of the reported positive impacts also spilled over to the interpersonal level; participants reported reductions in conflict, better conflict management and resolution, increased harmony with family and community members, as well as improved relationships with their partners and children, as previously documented [ 27 , 66 , 69 ]. A recent study of Kenyan community health workers (CHWs) delivering IPT among adolescents demonstrated how youth were better able to effectively communicate, interact with others, manage their anger, and resume work, also reported by participants in our study [ 70 ]. Similarly, adolescents in Kenya demonstrated increased confidence in speaking up about problems and expanded social networks, following treatment [ 71 ]. Further, our participants, consistent with studies in Ethiopia, South Africa, and Uganda, describe increased social networking opportunities following therapy [ 25 , 28 , 72 ]. Finally, the respect, confidentiality, and transport reimbursement (for assessment, not treatment) offered during study were perceived to facilitate continued engagement. The transport reimbursement offered in our study was reported to offset economic hardship, which is a documented barrier to services [ 73 ]. The tele medicine aspect of SMART DAPPER, i.e., IPT sessions offered via phone, may have alleviated this burden. However, it remains a challenge that must be considered when scaling other programs and interventions. Participants in our study also recommended the program to others, having realized the personal benefits, similar to participants in a recent study of group IPT in Senegal [ 73 ].

However, we also noted several challenges. Among them, participants noted that the stigma associated with mental health services and physical location of the SMART DAPPER facilities. This has been documented by others who have underscored challenges related to patient confidentiality and privacy, as well as the stigma associated with mental health service provision, especially in the context of HIV [ 73 , 74 ]. Further, participants noted conflict with livelihoods, preference for traditional medicine, actual or anticipated side effects with medication, mental health stigma, major life events, as well as inadequate counseling and challenges with providers. Previous studies, including a recent systematic review, have documented similar attitudinal and economic barriers to mental health services including stigma or anticipated stigma, discrimination, mental health literacy, as well as societal beliefs in alternative treatments [ 28 , 73 – 76 ].

Our findings are particularly important in SSA where many patients face challenges in accessing treatment due to many challenges at the individual, health systems and community levels [ 5 – 10 , 77 – 79 ], underscoring the importance of non-specialist delivery of combination treatments such as SMART DAPPER. Our study contributes important qualitative insights about experience with interventions to address the burden of mental health illness in the region; it adds more data to the efforts to expand mental health access including increased training, capacity building, and task shifting of mental health services [ 19 – 23 ]. Our qualitative findings, and the reported perceived benefits show that Interpersonal therapy (IPT) can address mental health challenges. This adds to previous literature showing the utility of IPT in addressing complex social cultural and personal dynamics which contribute to the burden of mental health illness and health outcomes [ 20 , 21 , 24 – 29 ]. Further, SMART DAPPER may contribute to similar studies non-specialist delivered IPT, including in the context of HIV care [ 21 – 25 , 29 , 30 ]. Finally, we demonstrate that fluoxetine (FLX), widely used in other high-income settings and a key pillar of SMART DAPPER, can be utilized to manage depression and stress-disorders, concurrent with previous findings [ 20 , 80 , 81 ]. Our study contributes critical information on the potential impact of combination therapy (IPT and FLX) and provide data on the user acceptability for the management of mood and stress-disorders.

Policy implications

The parent trial also convened an Implementation Resource Team (IRT), a group of key stakeholders who were identified to facilitate the implementation and scale-up of the study findings. The IRT includes clinic staff, patients and providers, local health policy and community leaders, regional stakeholders, and national mental health policy experts as stakeholders; our findings, along with the input and guidance from the IRT, will be key to addressing the challenge of translating evidence-based practices into broader practice and policy. Our qualitative study directly informs policy at the local and national level, including providing critical data on patient acceptability of this treatment implementation strategy as well as barriers that must be overcome to inform the scale up of similar interventions in Kenya and SSA, broadly.

Strengths and limitations

We note several limitations in the study. First, the interview and focus group guides were developed utilizing an implementation science (ImS) framework and thus may not have delved deeply into personal motivations, opportunities, and capabilities of participants. Data were limited to implementation-related domains, including the perceived impact of the intervention. However, we drew on the health belief model (HBM) to explore data to demonstrate these themes (perceived severity). Second, as subjects who were lost to follow up (LTFU) are inherently more difficult to engage, they may not be well-represented in the narratives. However, we note that the number of participants that terminated from the study was very low (6.8%). Third, participants may have been more likely to give favorable feedback due to social desirability bias. However, we implemented several strategies to mitigate these limitations. Participants were interviewed by study staff who were not implementing the intervention and were encouraged to provide their honest feedback. We utilized several differing strategies including conducting both IDIs and FGDs with participants who dropped out of treatment to include the diverse perspectives of those who did and did not successfully complete the intervention. Finally, our analysis and interpretation of findings utilized a group-based approach inclusive of those who collected the data, which strengthens the rigor of our findings.

Conclusions

To our knowledge, SMART DAPPER is the first study in SSA to provide combination psychotherapy and pharmacotherapy for the treatment of major depression and PTSD among participants in Kenya; we documented critical patient experiences with the intervention to inform future scale-up. Data demonstrate the promise of the interventions and highlight the barriers, challenges, and facilitators that must be addressed when scaling similar interventions. Our study contributes critical and timely information to guide the implementation and integration of mental health services using local non-specialists.

Supporting information

S1 checklist. inclusivity in global research smart dapper..

https://doi.org/10.1371/journal.pgph.0002685.s001

S2 Checklist. COREQ checklist.

https://doi.org/10.1371/journal.pgph.0002685.s002

S1 Text. SMART DAPPER study protocol.

https://doi.org/10.1371/journal.pgph.0002685.s003

S2 Text. SMART DAPPER IDI and FGD guides.

https://doi.org/10.1371/journal.pgph.0002685.s004

Acknowledgments

We would like to thank all the SMART DAPPER research participants, staff and investigators who contributed to this study. We wish to also thank Irene Maeri (IM) who coded the data and contributed to the initial analysis. We thank the Government of Kenya, Kenya Medical Research Institute, Kisumu County Hospital, and key stakeholders, including the study Implementation Resource Team (IRT) Members.

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A Qualitative Study Exploring Access to Mental Health and Substance Use Support among Individuals Experiencing Homelessness during COVID-19

Emma a. adams.

1 Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE3 4ES, UK; [email protected] (C.S.); [email protected] (C.M.); [email protected] (A.O.); [email protected] (E.K.); [email protected] (S.E.R.)

Jeff Parker

2 HeathNow, Crisis, City House 1 City Road, Newcastle upon Tyne NE1 2AF, UK

3 Pathway, 4th Floor East, 250 Euston Road, London NW1 2PG, UK

4 Crisis Pie Team, 66 Commercial Street, London E1 6LT, UK

Tony Jablonski

Joanne kennedy.

5 Expert by Experience Network, Fulfilling Lives Newcastle Gateshead, Gateshead NE8 4DY, UK

Fiona Tasker

Desmond hunter, katy denham.

6 Newcastle University Medical School, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; [email protected]

Claire Smiles

Cassey muir, amy o’donnell, emily widnall.

7 Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK; [email protected]

Kate Dotsikas

8 Division of Psychiatry, UCL, London W1T 7BN, UK; [email protected]

Eileen Kaner

Sheena e. ramsay, associated data.

Summaries of the data presented in the study are available on request from the corresponding author. The data are not publicly available due to containing potentially identifiable information about participants.

People experiencing homelessness have higher rates of mental ill-health and substance use and lower access to health services compared to the general population. The COVID-19 pandemic led to changes in service delivery across health and social care services, with many adopting virtual or telephone support for service users. This paper explores the experiences of access to community-based mental health and substance use support for people experiencing homelessness during the COVID-19 pandemic. Qualitative telephone interviews were conducted with 10 women and 16 men (ages 25 to 71) who self-identified as experiencing homelessness in North East England between February and May 2021. With five individuals with lived experience, results were analysed using inductive reflexive thematic analysis. Reactive changes to support provision often led to inadvertent exclusion. Barriers to access included: physical locations, repetition of recovery stories, individual readiness, and limited availability. Participants suggested creating services reflective of need and opportunities for choice and empowerment. Community mental health and substance use support for people experiencing homelessness should ensure the support is personalised, responsive to need, inclusive, and trauma-informed. The findings of this research have important implications for mental health and substance use policy and practice for individuals who experience homelessness during a public health crisis.

1. Introduction

The COVID-19 pandemic has amplified health inequalities and adversity among people who were already facing social and material disadvantage [ 1 , 2 , 3 ]. Indeed, historical evidence indicates that some groups are more susceptible to harm than others during pandemics and comparable crises [ 3 , 4 , 5 ], for example, individuals experiencing homelessness. However, fear of negative impacts from COVID-19 extend beyond having the infection to impacts on mental health (such as anxiety, isolation, and becoming mentally unwell, access to support) [ 6 ]. Early longitudinal evidence suggests that in the general population the prevalence of anxiety, depression, and other psychological impacts remained relatively unchanged [ 7 , 8 ]. For people experiencing homelessness, there is the potential that lockdowns and social distancing measures could negatively impact their mental health due to existing fears around forced incarceration and hospitalization [ 9 ]. The longer-term impacts to mental health from COVID-19 for this population remain unknown [ 10 ]. This is a particular concern since homelessness often co-exists with mental ill-health, substance use, and offending [ 11 ]. This co-occurrence of vulnerabilities is broadly defined as multiple complex needs, multiple exclusion homelessness, and severe and multiple disadvantage [ 12 , 13 , 14 ]. This co-occurrence and their interactions create a mutually reinforcing cycle, leading to further marginalisation and making it harder to access support [ 11 , 15 , 16 , 17 , 18 ].

People experiencing homelessness face disproportionately high rates of substance use and mental ill-health compared to the general population [ 11 , 19 , 20 ], yet have some of the lowest rates of engagement when it comes to accessing support [ 21 , 22 , 23 ]. Although provision is not always integrated, support for mental health and substance use crosses statutory health, social care, and voluntary sectors [ 24 ]. Examples of support may include, but is not limited to: specialist mental health services, assertive outreach, peer support, housing first, street support, assessment, trauma-informed care, psychologically informed environments, psychotherapy, street, support, and detox services [ 24 , 25 , 26 , 27 ]. Despite the variety of services, a survey found that essential mental health and addictions services are often unavailable in most areas and access is becoming increasingly difficult [ 25 ]. Epidemiological data has shown that people with co-occurring mental health and substance use (dual diagnosis) are less likely to access and use treatment [ 28 , 29 , 30 ]. It is likely that these rates would be even lower for homeless people, whose lack of a stable or permanent address can be a barrier to appointment-based care, where letters are sent to addresses or service provision is based on geographical regions [ 31 ].

Evidence demonstrating the disproportionate health and social care need and barriers to access people experiencing homelessness face is abundant [ 11 , 32 , 33 , 34 , 35 ]. An integrative literature review including qualitative and quantitative studies exploring access to treatment among individuals with dual diagnosis found two categories of barriers: personal characteristics and structural factors [ 36 ]. Personal characteristics barriers encompassed personal vulnerabilities (such as diagnosis-related symptoms associated with co-occurring substance use and mental ill health) and personal beliefs (such as lack of institutional trust, cultural beliefs, stigma) [ 37 , 38 , 39 , 40 ]. Whereas structural factors focus on availability, lack of appropriate diagnosis, and structural barriers to service provision (such as long waiting lists and gender-specific treatment options) [ 32 , 36 , 41 , 42 ]. Prior negative care experiences and lack of knowledge about the benefits of accessing health and social care support were continued barriers even after receiving housing accommodation [ 32 ]. However, most studies around barriers to accessing support for mental health and substance use by people experiencing homelessness have been quantitative. There remains a need for qualitative studies to better understand the experiences of homeless people on accessing support for mental ill-health and substance use.

Measures introduced to limit the spread of COVID-19 from March 2020 onwards led to substantial changes to daily life in the UK and elsewhere. Measures included social distancing, mandating people to ‘stay home’, and the closure of non-essential businesses and many face-to-face services. This meant many health and social care providers who traditionally offered support in-person transitioned to reduced capacity [ 43 ], socially distanced and remote support (such as telephone, Zoom, Skype, or Microsoft Teams) [ 43 , 44 , 45 , 46 ], and in some cases stopping services for periods of time [ 46 ]. The creative responses to offer support remotely demonstrated the ability of organisations to recover and adapt to the dynamic situation; effective adaption is essential for resilience with mental health and substance use services [ 47 ]. In cases where service provision was stopped, the organisation lacked resiliency and was ill-prepared/equipped for the changing circumstances.

For individuals experiencing homelessness, the initiatives introduced during COVID-19 focused on preventing disease transmission and providing temporary accommodation to house individuals sleeping rough [ 48 ]. Low substance use treatment rates coupled with high drug related deaths during COVID-19 suggests initiatives did not address the substance use needs of people experiencing homelessness [ 49 ]. This suggests that the health system was likely ill-prepared/equipped to meet these needs of people experiencing homelessness during the pandemic. Recent COVID-19 studies have highlighted a gap in understanding the depth of experiences for those who were dealing with mental health and substance use and particularly among people experiencing homelessness [ 45 , 46 , 49 , 50 ].

To better understand access to community-based mental health and substance use services, we conducted a qualitative study with people who experienced homelessness in North East England. We explored their experiences during the COVID-19 pandemic with accessing support, perceptions of barriers to access, and on what they might change to make support more accessible. Findings from this study will provide valuable information for building a more resilient healthcare system, which are better able to respond to current and future crises [ 47 ].

2. Materials and Methods

This qualitative study was informed by participatory action research approaches to ensure the study, findings, and recommendations were grounded in the experiences of those who are directly affected by the topic of the research [ 51 , 52 , 53 , 54 ]. Eligibility criteria were lived experience of homelessness, substance use, and/or mental ill-health. Initial interest was by male Experts by Experience, so the lead researcher made a specific request for females. After individuals expressed interest, E.A.A met with each person individually to clarify any concerns, explain expectations, and confirm participation. Experts by Experience then became part of the core project team and assisted in the design of the study, understanding of interviews, and sharing of findings. Approaches were based on best practices for community-based research with vulnerable populations [ 54 ]. To build rapport and reduce power imbalances between the lead researcher (E.A.A) and the Experts by Experience, Experts by Experience suggested the days and location (either Zoom or in-person) for meetings, refreshments (e.g., tea/coffee, cookies, and health snacks) were offered at all in-person meetings, and feedback was encouraged and listened to [ 55 ]. Using a cross-sectional design, semi-structured interviews were conducted over the phone between February and May 2021 during the COVID-19 pandemic.

2.1. Recruitment, Procedures, and Data Collection

Recruitment used purposive sampling through gatekeepers in housing and charity sectors alongside ‘Experts by Experience’ networks, followed by snowballing among participants. Individuals self-identified as experiencing homelessness during the COVID-19 pandemic, over 18 years of age, and wanting to access community mental health and addiction support within the region. Individuals did not need to have engaged with the support over the last year but did need to express an interest in seeking help. A broad definition of homelessness was used, including different types of homelessness, (e.g., rough sleeping, those in temporary accommodations such as hostels, those staying with friends or sofa surfing, and those who approach the local authority for housing) [ 56 ]. Given the frequently changing contexts and complex health and social care needs experienced by individuals within this population, efforts were made to accommodate re-scheduling interviews, calling different telephone numbers, and providing individuals with multiple opportunities to participate if they were initially unresponsive [ 57 ]. Thirty-one individuals expressed interest and a total of 26 participated; 2 could not be reached following multiple attempts to contact via hostels or referrer; 1 passed away before participating; 1 withdrew prior to data collection, and 1 moved on from their current hostel and did not have follow-up contact details. Participant recruitment continued until data sufficiency had been reached, no new themes, and anyone who had expressed interest previously was given an opportunity to participate.

Prior to participating, individuals were given an information sheet, assured anonymity and confidentiality, the option to withdraw at any time, an opportunity to ask any questions, and provided verbal or written consent. E.A.A conducted individual, telephone semi-structured interviews using a topic guide that covered the following areas: types of community-based mental health and addiction and interest in accessing them; experiences of access during the pandemic; and suggestions for improvement. The topic guide was developed with input from Experts by Experience and those who support people experiencing homelessness. Interviews ranged from 20 min in length to 80 min depending on what an individual was willing to share or their personal experiences. Individuals received a £30 voucher for a grocery store as a thank you for participating.

Ethics approval was granted by the Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University’s Research Ethics Committee (ref: 2034/6698/2020.)

2.2. Analysis

Interviews were digitally recorded, transcribed, anonymised, and checked for accuracy. Analysis was informed by Braun and Clarke’s inductive reflexive thematic analysis [ 58 ]. The recursive process and nonlinear stages enabled shared meaning in the data focused on a central concept to be conceptualised as themes early in the analysis [ 59 ]. Led by the lead researcher (E.A.A), the analysis applied participatory approaches to work with five ‘Experts by Experience’ (J.P., T.J., J.K., F.T., D.H.) through a series of 10 Zoom and in-person workshops. We began by reading, listening, and re-reading transcripts followed by initial coding development for each transcript (all were done by E.A.A, and a portion were done by the five ‘Experts by Experience’). Preliminary themes were developed collectively based on initial coding and reviewed to determine patterns of shared meaning across transcripts. Naming and defining of themes and subthemes were refined with ‘Experts by Experience’ and discussed with all co-authors. The participatory approaches enhanced the quality of the research, as the ongoing reflective engagement led to richer and more nuanced understanding of the data and construction of themes [ 60 ]. All participants were given pseudonyms to maintain anonymity.

Sixteen men and 10 women participated in the study, with ages ranging from 25 to 71 years (mean 40.7, standard deviation 11.4). All individuals self-identified as White British. No further demographic information was collected. Individuals reported a combination of mental health challenges (anxiety, depression, and other diagnosed conditions) and alcohol and drug use (cocaine, heroin, synthetic cannabinoids (spice), and marijuana) and diverse and multiple experiences of homelessness (ranging from sleeping on streets (rough sleeping) and staying with friends (couch surfing) to hostels and supported accommodation) during the COVID-19 pandemic. Table 1 presents an overview of the three main themes developed.

Themes and subthemes related to access to community mental health and substance use support for people experiencing homelessness during the COVID-19 pandemic.

3.1. Inadvertent Exclusion

Participants reported that service provision had drastically changed over the course of the COVID-19 pandemic. Changes that were often made reactively to create support, led to inherent forms of exclusion.

3.1.1. Mental Health Is Not 9-to-5

One of the most evident ways people felt overlooked was the fact that many providers only offered support between normal business hours; yet, people frequently felt that late at night was when they most needed support as ‘no one is awake’ and that was often when they hit ‘rock bottom’. Although this was not necessarily unique to COVID-19, individuals explained they wanted to be able to access some type of support during non-business hours; suggesting either a telephone line or texting service to ensure ‘somebody is there’ so you were never alone.

“Aye, it should be open when you are feeling the worst. Sometimes when you are feeling your worst it is very late. Ya know, it’s dark, and it’s that’s when you feel your most loneliness. Like after 10 o’clock at night ya know, when there is no one around. People are in bed”. — Keith, 45

“I want support 24/7”. — Lily, 33

Individuals reflected on a reduction in services during the pandemic and discussed how support they could normally access out-of-hours had been cut.

“There’s an organisation [name removed] who I’ve sought help from in the past, but at this moment in time, they’re only open Monday to Friday, 10:00 a.m. to 4:00 p.m. If you’re having any episodes or if you need support outside of those hours, you can’t turn to them, where you used to be able to. They used to be open all sorts of hours and they even offered an emergency line for the weekends, but that’s all cut off now”. — Mike, 33

3.1.2. Digital Exclusion

When speaking about experiences accessing services, individuals reflected on the pre-pandemic in-person support with general positivity although recognising it was not without its faults. Barriers included balancing the costs of travelling to appointments with having a meal or not feeling confident enough to meet people face-to-face. With social distancing restrictions coming into effect across England in response to COVID-19, there was a rapid transition to remote care provision to prevent services from closing their doors. Although this approach to care suited some people, others expressed frustration around feeling excluded. Exclusion took multiple forms including lack of device access and lack of digital literacy. Individuals expressed frustration around unspoken expectations that were required to access support.

“He rang and went, “Right, if you join this Zoom link.” Obviously, I’m sat there as if to say, “Well what am I supposed to do? I haven’t got credit, I can’t ring up to say I can’t join the Zoom link.” Obviously, after I’d missed the Zoom link meeting, he rang me on the phone and went, “Why haven’t you joined?” I went, “Because I don’t have internet, I don’t have a laptop, I don’t have credit on my phone to get internet to do it.” He went, “Oh right, well we’ll do it over the phone now then.” It’s like, “Well why didn’t you ask about it?””. — Danny, 29

“They expect you all to have these phones that do everything and we haven’t”. — Sam, 37

Across the interviews, conversations around not having access to Wi-Fi, laptops, or smart phones were plentiful. Where organisations provided devices for people experiencing homelessness, they spoke about issues of theft and the need for training to address gaps in digital literacy.

“I dread to think how many phones I’ve had and they’ve been stolen or whatever. You couldn’t leave your phone lying anywhere. Everything goes. If you had a spit, it would be gone before it hit the floor”. — Hannah, 43

“Computer illiterate. I’ve been on courses and that for it, but I get no further forward two weeks later from the first minute. I can’t log any technology in my head”. — Alan, 54

3.1.3. Awareness of What Support Is out There

Knowledge of available care and support and who provides it was one of the most powerful barriers or facilitators to accessing support. Moreover, public spaces like libraries and coffee shops are typical locations to access information, however, COVID-19 lockdown restrictions had presented new barriers to accessing information from these locations. Participants suggested that information about support needed to be shared widely and not solely online, something that was heavily relied on during COVID-19.

“Once you’re in that vicious circle, it can be very hard to access anything, you don’t know who to go to or who to speak to or who to contact, it’s just extremely difficult to know what to do”. — Ian, 53

“Well, I think somebody coming out and actually talking to the girls, somebody being informed that there are services out there. The key is getting out into the hostels and knocking on the doors and saying, “This is what we’re offering, and would you like to be involved in it?” You’re not aware". — Hannah, 43

For those who accessed support, experiences depicted the variety of ways they found out about support (e.g., online, football match adverts, hostel workers, friends, bulletin boards, providers) and the fact that sometimes they were not looking for support when they found information about available support.

“I just googled. Yeah it was um, I was googling how to kill myself and it came up with that. And I ended up using it. I’ve been using it for months”. — Andrea, 25

3.2. Barriers to Recovery

People shared negative experiences and barriers accessing support before and during COVID-19. These experiences shaped their attitudes towards accessing future support.

3.2.1. Lack of Space for Recovery

With a push to house everyone sleeping rough during the pandemic, individuals reflected on their experiences of being provided with accommodation. Group accommodation was often provided to both current and ex-substance users. This group offering was often a negative experience and sometimes resulted in past users being targeted by drug dealers and facing behaviours they had moved on from. Participants also expressed frustration around experiencing this when accessing support in person.

“They knew there was Spice use in this hostel. They shouldn’t have put me there. I was clean for seven months”. — Sam, 37

“[treatment location] It’s not a nice place to go to when you’re trying to recover from drugs. They’re trying to sell you things outside, and inside the building to be honest. There’s always somebody trying to push something onto you. When you’re trying to recover yourself, it’s hard when people are putting things in your face”. — Hannah, 43

“I don’t like going, but you got-you have to. Because, I’ve got away from it all, and yet you’re walking in and seeing people who are still using and they try and get you to buy some and things like that. [contrast to pandemic] While the pandemic is on, it’s all been changed to differently. You can’t go, they keep away and people get in touch with you over the phone. That would make it alright if it was always like that. That way you don’t have to bump into them”. — Alan, 54

These negative environments created further social isolation as individuals would try to isolate themselves from others to maintain their sobriety.

“When I got put into shared accommodation it was quite hard because every one of the neighbours was on hard drugs like heroin and crack and stuff like that. Obviously, I’m no longer using. It’s like they try to pull you in, so I had to pretty much isolate myself when I was in there”. — Danny, 29

During COVID-19, support offered remotely often took place while individuals were in their shared accommodation. Individuals highlighted the importance of space and place during recovery and shared that their ideal location would be reflective of their current recovery stage, have ample space, and be supportive and welcoming.

3.2.2. Disjointed Care and Repetition of Recovery Stories

Many people shared disconnected care experiences and discontinuity of care due to staff turnover, perhaps exacerbated by COVID-19 constraints. The constant need to repeat their stories caused many people to relive experiences.

“I know. I am sick of getting new workers and having to explain again. Explaining me story to workers. You should get one worker. I’m sick. … I have done this for 17 years and I can’t do it anymore. I can’t”. — Clare, 32

You know you get tired of times of saying—you just want to live a normal life again, you know. You explain your situation to one person, then you’ve, I’ve got to do it over and over and over again. It just seems like it’s never ending". — Keith, 45

One of the perceived solutions was creating an integrated system with increased collaboration and co-working across organisations. A few people shared experiences of how the pandemic led to providers working collaboratively to make sure people did not slip through the cracks.

“Before lockdown, it was a bit of a jigsaw puzzle, everything was here, there and everywhere. Nobody was really communicating well enough together. But since lockdown, people have really honed in on their skills and they’ve had to learn to cope with different ways of doing things. I’ve got literally an appointment almost every day now, and I’ve got such a good routine going on, it’s amazing". — Emily, 39

3.2.3. Not Ready for Recovery

Feeling ready to access support was perceived as extremely personal. Many people explained they were not ready to get help for their substance use or mental health as they had other priorities during COVID-19, including getting housed, a job, or their children back if they had been taken into state care. Individuals could not always articulate what could help them become ‘ready’.

“I don’t know if the support is there but I’m not ready to ask for help”. — Clare, 32

“When you’re feeling down like that and you’re wanting to go with stuff…”. — Danny, 29

Many felt they should be given adequate space and time and not be pressured into seeking help as it may lead to disengagement.

3.2.4. Prioritization When Resources Are Scarce

A common thread across interviews was that people often met ‘brick walls’ when trying to access support. This felt even harder during the pandemic where services appeared fewer and farther between. Examples included waiting lists, requirements around referral pathways, not meeting eligibility criteria around ‘being sick enough,’ or being passed around between services.

“I rung the Crisis team a lot. I was on the phone to them nine times in one night before they actually came out. […later explains] the Crisis team is pretty much the wrong name for them I would say”. — Mike, 33

A shared experience across interviews was the fact that accessing support was often challenging.

“If you’re determined to climb to the top of that mountain, you’re going to get there. But it’s really, really difficult. So, you just have to shout and scream and try as hard as you can”. — Emily, 39

Experiences of being ignored or frequently passed from one place to another led to people feeling reluctant to access support.

“They say “ah we can do this, we can do that” but it never seems to come off, or the supports not really that good or it’s bad for you, it’s not good for you. Most of them just leave you to do what you are doing. … Promises, false promises and it doesn’t happen”. — Tommy, 38

3.3. Building a System Responsive to Needs

Across the interviews, participants highlighted that before and during COVID-19, support was frequently offered using a structured approach that was disempowering for people experiencing homelessness.

3.3.1. Disconnect between Service Provision and Needs

Amplified by frustration around the lack of support during COVID-19, people often felt services did not understand their needs. This meant not recognising or understanding the complex interaction of mental health and substance use. One suggestion was to include peer-led or peer supported approaches within services. This was a perceived opportunity to leverage lived experience knowledge to design services to reflect the complex needs faced by people experiencing homelessness.

“Because they say, “Oh, you have to reduce your drinking,” but I can’t. I’ve got deep psychological issues, I can’t- So, I need the therapy in line with the reduction of alcohol. I need them in conjunction, that’s my biggest hurdle at the minute. It’s a vicious cycle, isn’t it?”. — Emily, 39

“…it would have helped because we’d all be in the same boat anyway, so we could help each other with our own experiences. [later goes on to say] Yes, it would be somebody on your own level that has actually been through alcoholism or drug use”. — Glen, 62

Individuals reflected on how the complexity of co-occurring mental health and substance use meant there was uncertainty over when they would need help with mental health or substance use. This was a particular concern during COVID-19 where lives felt dominated by uncertainty around when things would return to ‘normal’. The best experiences of access were when individuals felt that providers recognised this uncertainty and supported individuals with constant reviews and check-ins.

“Just because I’m feeling good this month, it doesn’t mean that in a month or two’s time, I am still feeling great. There are constant reviews and chats and contacts and stuff, which is great”. — Liam, 26

3.3.2. Choice and an Active Voice

During COVID-19 people felt they lost control of their circumstances and were frustrated with being offered limited and no flexibility in options. One of the easiest ways to create a more positive experience of access was through giving individuals choice in their care. In the context of COVID-19, choice was offered by providing support through a variety of mediums; for example, face-to-face, online, in groups, or one-to-one.

“Everyone’s different. So, a lot of people loved the Zoom, a lot of people like going to different meetings, a lot of people need a lot more support than other people. So, it’s about tailoring it or catering for the individual isn’t it, I suppose”. — Andy, 46

One of the key messages shared during interviews was that individuals need to be asked what they want, to be involved in decision making, and to feel empowered to be active participants in their care.

“Like when people are saying, like they don’t want to be here, or anything in the mental health bag—don’t just hoy a prescription in their face. Like sit down with them and look at what they need". — Carlie, 25

“Ask the person, ask the individual how they want to be helped, that’s the way forward for them, what help do they need”. — Darren, 36

4. Discussion

The urgent response to the global COVID-19 pandemic has led to new ways of working, which presented an opportunity to change how mental health and substance use support is provided. This study explored the experiences of access to community-based mental health and substance use support in people experiencing homelessness during the pandemic. The experiences of access shared took place while there were constraints to the mental health and substance use system (such as reduced service provision and staffing) brought about by the pandemic and pre-existing austerity. Although many experiences of access were negative, individuals did share some positive experiences or suggestions for service improvement.

Although this study focused on experiences during the pandemic, our findings illustrated some known barriers to accessing mental health and substance use support that existed prior to the pandemic and align with pre-pandemic research findings. These included services being restricted to business hours, repeating recovery stories, and limited support [ 61 , 62 , 63 , 64 , 65 ], suggesting an opportunity to improve service provision irrespective of times of austerity and crisis. Negative experiences and barriers to access highlight the need for a resilient mental health and substance use system that is responsive to the needs and circumstances of vulnerable groups such as people experiencing homelessness.

Experiences of exclusion took many forms across interviews. Many people felt they could not access mental health support when they needed it most (e.g., in the evening) or in the most suitable form for their needs or abilities. This echoes research prior to COVID-19 [ 61 , 62 ]. During conversations about remote out-of-hours support many discussed access issues surrounding not having smartphones, internet, or feeling uncomfortable accessing support online or transitioning to online support. Remote solutions therefore need to consider these barriers to ensure appropriate and inclusive access [ 46 ], but this also suggests that more creative out-of-hours provision solutions are needed.

Our findings emphasise that when additional needs (such as past negative experiences, dual diagnosis, material disadvantage) are not recognised, people experiencing homelessness are often unable to appropriately access support. Prior research has extensively explored the complex structural and individual circumstances surrounding people experiencing homelessness [ 33 , 34 , 61 , 66 ]. Our findings suggest that the instability around circumstances and needs requires recognition from service providers during times of heightened adversity. Participants’ suggestions of hiring and training people with lived experience could be one way to better target provision; existing evidence demonstrates improved treatment outcomes in mental health and substance use support when lived experience is integrated within care provision [ 27 , 67 , 68 ].

One of the most crucial messages within interviews was the need to have a choice in one’s care, particularly during the pandemic where people felt their loss of autonomy and control had worsened. The notion of rebuilding control has previously been highlighted within trauma-informed care approaches for homelessness [ 69 ]. In line with autonomy and control, our findings highlighted that not everyone is ready to access support but that continuing to increase awareness and knowledge of current support would equip individuals with the necessary information to access support at the right time for them. This knowledge is essential considering knowing where to go to access support is a central issue for people experiencing homelessness [ 70 , 71 ].

Negative environments for accessing support (such as high presence of drugs, lack of safety) were a source of frustration and led to subsequent care avoidance; a consequence seen in other studies [ 23 , 72 ]. Telephone support to accommodate COVID-19 restrictions meant some people finally felt comfortable accessing support as the environment changed. Like existing mental health and homeless literature [ 63 , 64 , 65 ], participants shared frustration around repeating their stories; likely a consequence of a siloed system of care/support. In a few cases, individuals shared how the pandemic was the first time they found services working collaboratively to support them—echoing other emerging evidence [ 66 ]. Lessons from providers on mechanisms for coordination across the system during COVID-19, could allow future approaches to be more bespoke and coordinated to ensure that the specific needs of people experiencing homelessness are addressed [ 73 ]. Finally, our findings highlight that many struggled to access support, particularly with the reduced service provision and increased waiting lists during COVID-19. Recognising that reduced service provision was perhaps unavoidable given the context, it is important to consider the impact these negative experiences have on future access and experiences.

4.1. Strengths and Limitations

A key strength to this study is its application of participatory approaches, which meaningfully brings the voice of people with lived experience to the study design, methodology and interpretation of findings. Involving individuals with lived experience throughout each phase of the data analysis meant that some of the initial codes were created based on their suggestions and theme refinement was influenced by their rich insights. Lived experience involvement also led to an action-oriented interpretation with a desire to improve future experiences of access, provision, and policy around community mental health and substance use support.

The study is limited by its localised recruitment in Newcastle and Gateshead; however, preliminary conversations with providers in other regions suggest the findings echo their experiences. Despite active recruitment effort, we were unable to recruit anyone who did not self-identify as White British, however, the proportion of individuals in North East England who do not identify as White British is less than 8% in the general population [ 74 ]. Discussions with local providers emphasised that contrary to other regions in England, most individuals who experience homelessness in North East England self-identify as White British. The study employed solely remote approaches to data collection due to the COVID-19 restrictions. Although research has shown the acceptability of remote data collection [ 75 ], the potential of sampling bias remains due to not reaching out to those without telephone or internet access or potentially those sleeping rough [ 76 ]. We attempted to mitigate this bias through working closely with hostels to ensure individuals had access to communal phones.

4.2. Implications for Practice and Research

Our findings suggest several actionable solutions for policymakers and providers in health, social care, and housing that are transferable outside the context of pandemics and times of crisis. These include providing choice (e.g., offer someone a choice between service provision online or in-person or offering choices for the time of day for provision), lived experience representation within support, making information about services accessible (e.g., communicating using simple and clear language [ 23 ]), ensuring appropriate and inclusive digital solutions (e.g., working with individuals with lived experience to co-create solutions or providing smartphones with internet access [ 46 ]), creating a safe space for accessing support (e.g., a service that feels safe, private, and is not overly crowded [ 23 ]), and creating bespoke and integrated care pathways. Research is needed to investigate the difference and factors associated with digital confidence and literacy among people experiencing homelessness. In all cases, solutions should be designed, implemented, and delivered with individuals with lived experience to ensure it is acceptable and appropriate for this population. Ensuring that provision is responsive and appropriate to those most in need is vital for integrated care systems across England.

Through working with individuals with lived experience, we were able to better understand the experiences of participants while being open to seeing solutions to challenges. Further research should look to understand the perspectives of those providing support and co-developing solutions that are equally acceptable to providers and those who experience homelessness.

5. Conclusions

COVID-19 presented an opportunity to learn from changes in service provision and has drawn attention to the need for more accessible and bespoke support for people experiencing homelessness. This study provided rich accounts on the (in)accessibility of mental health and substance use support, which have implications for developing future policy and practice responses. These implications are potentially beneficial for post-pandemic efforts to improve access to and increase the resilience of mental health and substance use support for people experiencing homelessness.

Acknowledgments

We would like to thank participants and the community organisations who supported recruitment efforts.

Author Contributions

Conceptualisation, E.A.A., C.S., C.M., A.O., E.W., K.D. (Kate Dotsikas), E.K. and S.E.R.; data collection, E.A.A.; analysis led by E.A.A. with support from J.P., T.J., F.T., J.K. and D.H.; validation of analysis, all co-authors; literature review, E.A.A. and K.D. (Katy Denham); writing—original draft preparation, E.A.A.; writing, reviewing, and editing, all co-authors. All authors have read and agreed to the published version of the manuscript.

This research was funded by the National Institute for Health Research (NIHR) School for Public Health Research (SPHR) development fund for early career researchers (ECRs). E.A.A and Kate D. are supported by the NIHR SPHR Pre-doctoral Fellowship Funding Scheme, Grant Reference Number PD-SPH-2015 and C.M. is being supported by the NIHR SPHR PhD studentship (SPHR-PHD-FUS-002). A.O. is an NIHR Advanced Fellow. E.K. is supported by an NIHR Senior Investigator award and is Director of the NIHR Applied Research Collaboration North East and North Cumbria. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Institutional Review Board Statement

Ethics approval was granted by the Faculty of Medical Sciences Research Ethics Committee, part of Newcastle University’s Research Ethics Committee (ref: 2034/6698/2020 including amendment 2034_1.)

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study, including consent to publish.

Data Availability Statement

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The authors declare no conflict of interest.

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Conducting qualitative research in mental health: Thematic and content analyses

Affiliations.

• 1 Department of Psychological Medicine, University of Otago, Christchurch, New Zealand [email protected].
• 2 Department of Psychological Medicine, University of Otago, Christchurch, New Zealand.
• PMID: 25900973
• DOI: 10.1177/0004867415582053

Objective: The objective of this paper is to describe two methods of qualitative analysis - thematic analysis and content analysis - and to examine their use in a mental health context.

Method: A description of the processes of thematic analysis and content analysis is provided. These processes are then illustrated by conducting two analyses of the same qualitative data. Transcripts of qualitative interviews are analysed using each method to illustrate these processes.

Results: The illustration of the processes highlights the different outcomes from the same set of data.

Conclusion: Thematic and content analyses are qualitative methods that serve different research purposes. Thematic analysis provides an interpretation of participants' meanings, while content analysis is a direct representation of participants' responses. These methods provide two ways of understanding meanings and experiences and provide important knowledge in a mental health context.

Keywords: Qualitative research; bipolar disorder; content analysis; mental health; methodology; thematic analysis.

© The Royal Australian and New Zealand College of Psychiatrists 2015.

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Mental Health Review Journal

ISSN : 1361-9322

Article publication date: 15 May 2009

In 2005, the Qualitative Methods in Psychosocial Health Research Group (QMiPHR) at the University of Nottingham was established as a forum to bring together academics, researchers and practitioners with an interest in qualitative methods. The group has provided colleagues in nutrition, psychiatry, psychology, social work and sociology with a forum for discussion around the question of how qualitative research is able to contribute to understanding mental health and the development of evidence‐based treatment. As a group, we asked ourselves where we stood in relation to the use of qualitative methods in mental health. While we are unified in our view that qualitative research is important and under‐utilised in mental health research, our discussions uncovered a range of views on the underlying philosophical stance of what it means to be a qualitative researcher in mental health. The aim of this paper is to provide an overview of our discussions and our view that as qualitative approaches have become more widely accepted they have largely been assimilated within the mainstream ‘medical model’ of research. In this paper, we call for researchers to re‐engage with the philosophical discussion on the role and purpose of qualitative enquiry as it applies to mental health, and for practitioners and decision‐makers to be aware of the implicit values underpinning research.

• Epistemology
• Evidence‐based treatment
• Medical model
• Qualitative research

Joseph, S. , Beer, C. , Clarke, D. , Forman, A. , Pickersgill, M. , Swift, J. , Taylor, J. and Tischler, V. (2009), "Qualitative Research into Mental Health: Reflections on Epistemology", Mental Health Review Journal , Vol. 14 No. 1, pp. 36-42. https://doi.org/10.1108/13619322200900006

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Maslow and Mental Health Recovery: A Comparative Study of Homeless Programs for Adults with Serious Mental Illness

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This mixed-methods study uses Maslow’s hierarchy as a theoretical lens to investigate the experiences of 63 newly enrolled clients of housing first and traditional programs for adults with serious mental illness who have experienced homelessness. Quantitative findings suggests that identifying self-actualization goals is associated with not having one’s basic needs met rather than from the fulfillment of basic needs. Qualitative findings suggest a more complex relationship between basic needs, goal setting, and the meaning of self-actualization. Transforming mental health care into a recovery-oriented system will require further consideration of person-centered care planning as well as the impact of limited resources especially for those living in poverty.

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Understanding the ups and downs of living well: the voices of people experiencing early mental health recovery, micropolitics of mental health recovery: an assemblage analysis of people’s experiences of becoming well.

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This research was supported by the National Institute of Mental Health (R01 69865).

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Henwood, B.F., Derejko, KS., Couture, J. et al. Maslow and Mental Health Recovery: A Comparative Study of Homeless Programs for Adults with Serious Mental Illness. Adm Policy Ment Health 42 , 220–228 (2015). https://doi.org/10.1007/s10488-014-0542-8

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Home » 500+ Qualitative Research Titles and Topics

500+ Qualitative Research Titles and Topics

Table of Contents

Qualitative research is a methodological approach that involves gathering and analyzing non-numerical data to understand and interpret social phenomena. Unlike quantitative research , which emphasizes the collection of numerical data through surveys and experiments, qualitative research is concerned with exploring the subjective experiences, perspectives, and meanings of individuals and groups. As such, qualitative research topics can be diverse and encompass a wide range of social issues and phenomena. From exploring the impact of culture on identity formation to examining the experiences of marginalized communities, qualitative research offers a rich and nuanced perspective on complex social issues. In this post, we will explore some of the most compelling qualitative research topics and provide some tips on how to conduct effective qualitative research.

Qualitative Research Titles

Qualitative research titles often reflect the study’s focus on understanding the depth and complexity of human behavior, experiences, or social phenomena. Here are some examples across various fields:

• “Understanding the Impact of Project-Based Learning on Student Engagement in High School Classrooms: A Qualitative Study”
• “Navigating the Transition: Experiences of International Students in American Universities”
• “The Role of Parental Involvement in Early Childhood Education: Perspectives from Teachers and Parents”
• “Exploring the Effects of Teacher Feedback on Student Motivation and Self-Efficacy in Middle Schools”
• “Digital Literacy in the Classroom: Teacher Strategies for Integrating Technology in Elementary Education”
• “Culturally Responsive Teaching Practices: A Case Study in Diverse Urban Schools”
• “The Influence of Extracurricular Activities on Academic Achievement: Student Perspectives”
• “Barriers to Implementing Inclusive Education in Public Schools: A Qualitative Inquiry”
• “Teacher Professional Development and Its Impact on Classroom Practice: A Qualitative Exploration”
• “Student-Centered Learning Environments: A Qualitative Study of Classroom Dynamics and Outcomes”
• “The Experience of First-Year Teachers: Challenges, Support Systems, and Professional Growth”
• “Exploring the Role of School Leadership in Fostering a Positive School Culture”
• “Peer Relationships and Learning Outcomes in Cooperative Learning Settings: A Qualitative Analysis”
• “The Impact of Social Media on Student Learning and Engagement: Teacher and Student Perspectives”
• “Understanding Special Education Needs: Parent and Teacher Perceptions of Support Services in Schools

Health Science

• “Living with Chronic Pain: Patient Narratives and Coping Strategies in Managing Daily Life”
• “Healthcare Professionals’ Perspectives on the Challenges of Rural Healthcare Delivery”
• “Exploring the Mental Health Impacts of COVID-19 on Frontline Healthcare Workers: A Qualitative Study”
• “Patient and Family Experiences of Palliative Care: Understanding Needs and Preferences”
• “The Role of Community Health Workers in Improving Access to Maternal Healthcare in Rural Areas”
• “Barriers to Mental Health Services Among Ethnic Minorities: A Qualitative Exploration”
• “Understanding Patient Satisfaction in Telemedicine Services: A Qualitative Study of User Experiences”
• “The Impact of Cultural Competence Training on Healthcare Provider-Patient Communication”
• “Navigating the Transition to Adult Healthcare Services: Experiences of Adolescents with Chronic Conditions”
• “Exploring the Use of Alternative Medicine Among Patients with Chronic Diseases: A Qualitative Inquiry”
• “The Role of Social Support in the Rehabilitation Process of Stroke Survivors”
• “Healthcare Decision-Making Among Elderly Patients: A Qualitative Study of Preferences and Influences”
• “Nurse Perceptions of Patient Safety Culture in Hospital Settings: A Qualitative Analysis”
• “Experiences of Women with Postpartum Depression: Barriers to Seeking Help”
• “The Impact of Nutrition Education on Eating Behaviors Among College Students: A Qualitative Approach”
• “Understanding Resilience in Survivors of Childhood Trauma: A Narrative Inquiry”
• “The Role of Mindfulness in Managing Work-Related Stress Among Corporate Employees: A Qualitative Study”
• “Coping Mechanisms Among Parents of Children with Autism Spectrum Disorder”
• “Exploring the Psychological Impact of Social Isolation in the Elderly: A Phenomenological Study”
• “Identity Formation in Adolescence: The Influence of Social Media and Peer Groups”
• “The Experience of Forgiveness in Interpersonal Relationships: A Qualitative Exploration”
• “Perceptions of Happiness and Well-Being Among University Students: A Cultural Perspective”
• “The Impact of Art Therapy on Anxiety and Depression in Adult Cancer Patients”
• “Narratives of Recovery: A Qualitative Study on the Journey Through Addiction Rehabilitation”
• “Exploring the Psychological Effects of Long-Term Unemployment: A Grounded Theory Approach”
• “Attachment Styles and Their Influence on Adult Romantic Relationships: A Qualitative Analysis”
• “The Role of Personal Values in Career Decision-Making Among Young Adults”
• “Understanding the Stigma of Mental Illness in Rural Communities: A Qualitative Inquiry”
• “Exploring the Use of Digital Mental Health Interventions Among Adolescents: A Qualitative Study”
• “The Psychological Impact of Climate Change on Young Adults: An Exploration of Anxiety and Action”
• “Navigating Identity: The Role of Social Media in Shaping Youth Culture and Self-Perception”
• “Community Resilience in the Face of Urban Gentrification: A Case Study of Neighborhood Change”
• “The Dynamics of Intergenerational Relationships in Immigrant Families: A Qualitative Analysis”
• “Social Capital and Economic Mobility in Low-Income Neighborhoods: An Ethnographic Approach”
• “Gender Roles and Career Aspirations Among Young Adults in Conservative Societies”
• “The Stigma of Mental Health in the Workplace: Employee Narratives and Organizational Culture”
• “Exploring the Intersection of Race, Class, and Education in Urban School Systems”
• “The Impact of Digital Divide on Access to Healthcare Information in Rural Communities”
• “Social Movements and Political Engagement Among Millennials: A Qualitative Study”
• “Cultural Adaptation and Identity Among Second-Generation Immigrants: A Phenomenological Inquiry”
• “The Role of Religious Institutions in Providing Community Support and Social Services”
• “Negotiating Public Space: Experiences of LGBTQ+ Individuals in Urban Environments”
• “The Sociology of Food: Exploring Eating Habits and Food Practices Across Cultures”
• “Work-Life Balance Challenges Among Dual-Career Couples: A Qualitative Exploration”
• “The Influence of Peer Networks on Substance Use Among Adolescents: A Community Study”

Business and Management

• “Navigating Organizational Change: Employee Perceptions and Adaptation Strategies in Mergers and Acquisitions”
• “Corporate Social Responsibility: Consumer Perceptions and Brand Loyalty in the Retail Sector”
• “Leadership Styles and Organizational Culture: A Comparative Study of Tech Startups”
• “Workplace Diversity and Inclusion: Best Practices and Challenges in Multinational Corporations”
• “Consumer Trust in E-commerce: A Qualitative Study of Online Shopping Behaviors”
• “The Gig Economy and Worker Satisfaction: Exploring the Experiences of Freelance Professionals”
• “Entrepreneurial Resilience: Success Stories and Lessons Learned from Failed Startups”
• “Employee Engagement and Productivity in Remote Work Settings: A Post-Pandemic Analysis”
• “Brand Storytelling: How Narrative Strategies Influence Consumer Engagement”
• “Sustainable Business Practices: Stakeholder Perspectives in the Fashion Industry”
• “Cross-Cultural Communication Challenges in Global Teams: Strategies for Effective Collaboration”
• “Innovative Workspaces: The Impact of Office Design on Creativity and Collaboration”
• “Consumer Perceptions of Artificial Intelligence in Customer Service: A Qualitative Exploration”
• “The Role of Mentoring in Career Development: Insights from Women in Leadership Positions”
• “Agile Management Practices: Adoption and Impact in Traditional Industries”

Environmental Studies

• “Community-Based Conservation Efforts in Tropical Rainforests: A Qualitative Study of Local Perspectives and Practices”
• “Urban Sustainability Initiatives: Exploring Resident Participation and Impact in Green City Projects”
• “Perceptions of Climate Change Among Indigenous Populations: Insights from Traditional Ecological Knowledge”
• “Environmental Justice and Industrial Pollution: A Case Study of Community Advocacy and Response”
• “The Role of Eco-Tourism in Promoting Conservation Awareness: Perspectives from Tour Operators and Visitors”
• “Sustainable Agriculture Practices Among Smallholder Farmers: Challenges and Opportunities”
• “Youth Engagement in Climate Action Movements: Motivations, Perceptions, and Outcomes”
• “Corporate Environmental Responsibility: A Qualitative Analysis of Stakeholder Expectations and Company Practices”
• “The Impact of Plastic Pollution on Marine Ecosystems: Community Awareness and Behavioral Change”
• “Renewable Energy Adoption in Rural Communities: Barriers, Facilitators, and Social Implications”
• “Water Scarcity and Community Adaptation Strategies in Arid Regions: A Grounded Theory Approach”
• “Urban Green Spaces: Public Perceptions and Use Patterns in Megacities”
• “Environmental Education in Schools: Teachers’ Perspectives on Integrating Sustainability into Curricula”
• “The Influence of Environmental Activism on Policy Change: Case Studies of Grassroots Campaigns”
• “Cultural Practices and Natural Resource Management: A Qualitative Study of Indigenous Stewardship Models”

Anthropology

• “Kinship and Social Organization in Matrilineal Societies: An Ethnographic Study”
• “Rituals and Beliefs Surrounding Death and Mourning in Diverse Cultures: A Comparative Analysis”
• “The Impact of Globalization on Indigenous Languages and Cultural Identity”
• “Food Sovereignty and Traditional Agricultural Practices Among Indigenous Communities”
• “Navigating Modernity: The Integration of Traditional Healing Practices in Contemporary Healthcare Systems”
• “Gender Roles and Equality in Hunter-Gatherer Societies: An Anthropological Perspective”
• “Sacred Spaces and Religious Practices: An Ethnographic Study of Pilgrimage Sites”
• “Youth Subcultures and Resistance: An Exploration of Identity and Expression in Urban Environments”
• “Cultural Constructions of Disability and Inclusion: A Cross-Cultural Analysis”
• “Interethnic Marriages and Cultural Syncretism: Case Studies from Multicultural Societies”
• “The Role of Folklore and Storytelling in Preserving Cultural Heritage”
• “Economic Anthropology of Gift-Giving and Reciprocity in Tribal Communities”
• “Digital Anthropology: The Role of Social Media in Shaping Political Movements”
• “Migration and Diaspora: Maintaining Cultural Identity in Transnational Communities”
• “Cultural Adaptations to Climate Change Among Coastal Fishing Communities”

Communication Studies

• “The Dynamics of Family Communication in the Digital Age: A Qualitative Inquiry”
• “Narratives of Identity and Belonging in Diaspora Communities Through Social Media”
• “Organizational Communication and Employee Engagement: A Case Study in the Non-Profit Sector”
• “Cultural Influences on Communication Styles in Multinational Teams: An Ethnographic Approach”
• “Media Representation of Women in Politics: A Content Analysis and Audience Perception Study”
• “The Role of Communication in Building Sustainable Community Development Projects”
• “Interpersonal Communication in Online Dating: Strategies, Challenges, and Outcomes”
• “Public Health Messaging During Pandemics: A Qualitative Study of Community Responses”
• “The Impact of Mobile Technology on Parent-Child Communication in the Digital Era”
• “Crisis Communication Strategies in the Hospitality Industry: A Case Study of Reputation Management”
• “Narrative Analysis of Personal Stories Shared on Mental Health Blogs”
• “The Influence of Podcasts on Political Engagement Among Young Adults”
• “Visual Communication and Brand Identity: A Qualitative Study of Consumer Interpretations”
• “Communication Barriers in Cross-Cultural Healthcare Settings: Patient and Provider Perspectives”
• “The Role of Internal Communication in Managing Organizational Change: Employee Experiences”

Information Technology

• “User Experience Design in Augmented Reality Applications: A Qualitative Study of Best Practices”
• “The Human Factor in Cybersecurity: Understanding Employee Behaviors and Attitudes Towards Phishing”
• “Adoption of Cloud Computing in Small and Medium Enterprises: Challenges and Success Factors”
• “Blockchain Technology in Supply Chain Management: A Qualitative Exploration of Potential Impacts”
• “The Role of Artificial Intelligence in Personalizing User Experiences on E-commerce Platforms”
• “Digital Transformation in Traditional Industries: A Case Study of Technology Adoption Challenges”
• “Ethical Considerations in the Development of Smart Home Technologies: A Stakeholder Analysis”
• “The Impact of Social Media Algorithms on News Consumption and Public Opinion”
• “Collaborative Software Development: Practices and Challenges in Open Source Projects”
• “Understanding the Digital Divide: Access to Information Technology in Rural Communities”
• “Data Privacy Concerns and User Trust in Internet of Things (IoT) Devices”
• “The Effectiveness of Gamification in Educational Software: A Qualitative Study of Engagement and Motivation”
• “Virtual Teams and Remote Work: Communication Strategies and Tools for Effectiveness”
• “User-Centered Design in Mobile Health Applications: Evaluating Usability and Accessibility”
• “The Influence of Technology on Work-Life Balance: Perspectives from IT Professionals”

Tourism and Hospitality

• “Exploring the Authenticity of Cultural Heritage Tourism in Indigenous Communities”
• “Sustainable Tourism Practices: Perceptions and Implementations in Small Island Destinations”
• “The Impact of Social Media Influencers on Destination Choice Among Millennials”
• “Gastronomy Tourism: Exploring the Culinary Experiences of International Visitors in Rural Regions”
• “Eco-Tourism and Conservation: Stakeholder Perspectives on Balancing Tourism and Environmental Protection”
• “The Role of Hospitality in Enhancing the Cultural Exchange Experience of Exchange Students”
• “Dark Tourism: Visitor Motivations and Experiences at Historical Conflict Sites”
• “Customer Satisfaction in Luxury Hotels: A Qualitative Study of Service Excellence and Personalization”
• “Adventure Tourism: Understanding the Risk Perception and Safety Measures Among Thrill-Seekers”
• “The Influence of Local Communities on Tourist Experiences in Ecotourism Sites”
• “Event Tourism: Economic Impacts and Community Perspectives on Large-Scale Music Festivals”
• “Heritage Tourism and Identity: Exploring the Connections Between Historic Sites and National Identity”
• “Tourist Perceptions of Sustainable Accommodation Practices: A Study of Green Hotels”
• “The Role of Language in Shaping the Tourist Experience in Multilingual Destinations”
• “Health and Wellness Tourism: Motivations and Experiences of Visitors to Spa and Retreat Centers”

Qualitative Research Topics

Qualitative Research Topics are as follows:

• Understanding the lived experiences of first-generation college students
• Exploring the impact of social media on self-esteem among adolescents
• Investigating the effects of mindfulness meditation on stress reduction
• Analyzing the perceptions of employees regarding organizational culture
• Examining the impact of parental involvement on academic achievement of elementary school students
• Investigating the role of music therapy in managing symptoms of depression
• Understanding the experience of women in male-dominated industries
• Exploring the factors that contribute to successful leadership in non-profit organizations
• Analyzing the effects of peer pressure on substance abuse among adolescents
• Investigating the experiences of individuals with disabilities in the workplace
• Understanding the factors that contribute to burnout among healthcare professionals
• Examining the impact of social support on mental health outcomes
• Analyzing the perceptions of parents regarding sex education in schools
• Investigating the experiences of immigrant families in the education system
• Understanding the impact of trauma on mental health outcomes
• Exploring the effectiveness of animal-assisted therapy for individuals with anxiety
• Analyzing the factors that contribute to successful intergenerational relationships
• Investigating the experiences of LGBTQ+ individuals in the workplace
• Understanding the impact of online gaming on social skills development among adolescents
• Examining the perceptions of teachers regarding technology integration in the classroom
• Analyzing the experiences of women in leadership positions
• Investigating the factors that contribute to successful marriage and long-term relationships
• Understanding the impact of social media on political participation
• Exploring the experiences of individuals with mental health disorders in the criminal justice system
• Analyzing the factors that contribute to successful community-based programs for youth development
• Investigating the experiences of veterans in accessing mental health services
• Understanding the impact of the COVID-19 pandemic on mental health outcomes
• Examining the perceptions of parents regarding childhood obesity prevention
• Analyzing the factors that contribute to successful multicultural education programs
• Investigating the experiences of individuals with chronic illnesses in the workplace
• Understanding the impact of poverty on academic achievement
• Exploring the experiences of individuals with autism spectrum disorder in the workplace
• Analyzing the factors that contribute to successful employee retention strategies
• Investigating the experiences of caregivers of individuals with Alzheimer’s disease
• Understanding the impact of parent-child communication on adolescent sexual behavior
• Examining the perceptions of college students regarding mental health services on campus
• Analyzing the factors that contribute to successful team building in the workplace
• Investigating the experiences of individuals with eating disorders in treatment programs
• Understanding the impact of mentorship on career success
• Exploring the experiences of individuals with physical disabilities in the workplace
• Analyzing the factors that contribute to successful community-based programs for mental health
• Investigating the experiences of individuals with substance use disorders in treatment programs
• Understanding the impact of social media on romantic relationships
• Examining the perceptions of parents regarding child discipline strategies
• Analyzing the factors that contribute to successful cross-cultural communication in the workplace
• Investigating the experiences of individuals with anxiety disorders in treatment programs
• Understanding the impact of cultural differences on healthcare delivery
• Exploring the experiences of individuals with hearing loss in the workplace
• Analyzing the factors that contribute to successful parent-teacher communication
• Investigating the experiences of individuals with depression in treatment programs
• Understanding the impact of childhood trauma on adult mental health outcomes
• Examining the perceptions of college students regarding alcohol and drug use on campus
• Analyzing the factors that contribute to successful mentor-mentee relationships
• Investigating the experiences of individuals with intellectual disabilities in the workplace
• Understanding the impact of work-family balance on employee satisfaction and well-being
• Exploring the experiences of individuals with autism spectrum disorder in vocational rehabilitation programs
• Analyzing the factors that contribute to successful project management in the construction industry
• Investigating the experiences of individuals with substance use disorders in peer support groups
• Understanding the impact of mindfulness meditation on stress reduction and mental health
• Examining the perceptions of parents regarding childhood nutrition
• Analyzing the factors that contribute to successful environmental sustainability initiatives in organizations
• Investigating the experiences of individuals with bipolar disorder in treatment programs
• Understanding the impact of job stress on employee burnout and turnover
• Exploring the experiences of individuals with physical disabilities in recreational activities
• Analyzing the factors that contribute to successful strategic planning in nonprofit organizations
• Investigating the experiences of individuals with hoarding disorder in treatment programs
• Understanding the impact of culture on leadership styles and effectiveness
• Examining the perceptions of college students regarding sexual health education on campus
• Analyzing the factors that contribute to successful supply chain management in the retail industry
• Investigating the experiences of individuals with personality disorders in treatment programs
• Understanding the impact of multiculturalism on group dynamics in the workplace
• Exploring the experiences of individuals with chronic pain in mindfulness-based pain management programs
• Analyzing the factors that contribute to successful employee engagement strategies in organizations
• Investigating the experiences of individuals with internet addiction disorder in treatment programs
• Understanding the impact of social comparison on body dissatisfaction and self-esteem
• Examining the perceptions of parents regarding childhood sleep habits
• Analyzing the factors that contribute to successful diversity and inclusion initiatives in organizations
• Investigating the experiences of individuals with schizophrenia in treatment programs
• Understanding the impact of job crafting on employee motivation and job satisfaction
• Exploring the experiences of individuals with vision impairments in navigating public spaces
• Analyzing the factors that contribute to successful customer relationship management strategies in the service industry
• Investigating the experiences of individuals with dissociative amnesia in treatment programs
• Understanding the impact of cultural intelligence on intercultural communication and collaboration
• Examining the perceptions of college students regarding campus diversity and inclusion efforts
• Analyzing the factors that contribute to successful supply chain sustainability initiatives in organizations
• Investigating the experiences of individuals with obsessive-compulsive disorder in treatment programs
• Understanding the impact of transformational leadership on organizational performance and employee well-being
• Exploring the experiences of individuals with mobility impairments in public transportation
• Analyzing the factors that contribute to successful talent management strategies in organizations
• Investigating the experiences of individuals with substance use disorders in harm reduction programs
• Understanding the impact of gratitude practices on well-being and resilience
• Examining the perceptions of parents regarding childhood mental health and well-being
• Analyzing the factors that contribute to successful corporate social responsibility initiatives in organizations
• Investigating the experiences of individuals with borderline personality disorder in treatment programs
• Understanding the impact of emotional labor on job stress and burnout
• Exploring the experiences of individuals with hearing impairments in healthcare settings
• Analyzing the factors that contribute to successful customer experience strategies in the hospitality industry
• Investigating the experiences of individuals with gender dysphoria in gender-affirming healthcare
• Understanding the impact of cultural differences on cross-cultural negotiation in the global marketplace
• Examining the perceptions of college students regarding academic stress and mental health
• Analyzing the factors that contribute to successful supply chain agility in organizations
• Understanding the impact of music therapy on mental health and well-being
• Exploring the experiences of individuals with dyslexia in educational settings
• Analyzing the factors that contribute to successful leadership in nonprofit organizations
• Investigating the experiences of individuals with chronic illnesses in online support groups
• Understanding the impact of exercise on mental health and well-being
• Examining the perceptions of parents regarding childhood screen time
• Analyzing the factors that contribute to successful change management strategies in organizations
• Understanding the impact of cultural differences on international business negotiations
• Exploring the experiences of individuals with hearing impairments in the workplace
• Analyzing the factors that contribute to successful team building in corporate settings
• Understanding the impact of technology on communication in romantic relationships
• Analyzing the factors that contribute to successful community engagement strategies for local governments
• Investigating the experiences of individuals with attention deficit hyperactivity disorder (ADHD) in treatment programs
• Understanding the impact of financial stress on mental health and well-being
• Analyzing the factors that contribute to successful mentorship programs in organizations
• Investigating the experiences of individuals with gambling addictions in treatment programs
• Understanding the impact of social media on body image and self-esteem
• Examining the perceptions of parents regarding childhood education
• Analyzing the factors that contribute to successful virtual team management strategies
• Investigating the experiences of individuals with dissociative identity disorder in treatment programs
• Understanding the impact of cultural differences on cross-cultural communication in healthcare settings
• Exploring the experiences of individuals with chronic pain in cognitive-behavioral therapy programs
• Analyzing the factors that contribute to successful community-building strategies in urban neighborhoods
• Investigating the experiences of individuals with alcohol use disorders in treatment programs
• Understanding the impact of personality traits on romantic relationships
• Examining the perceptions of college students regarding mental health stigma on campus
• Analyzing the factors that contribute to successful fundraising strategies for political campaigns
• Investigating the experiences of individuals with traumatic brain injuries in rehabilitation programs
• Understanding the impact of social support on mental health and well-being among the elderly
• Exploring the experiences of individuals with chronic illnesses in medical treatment decision-making processes
• Analyzing the factors that contribute to successful innovation strategies in organizations
• Investigating the experiences of individuals with dissociative disorders in treatment programs
• Understanding the impact of cultural differences on cross-cultural communication in education settings
• Examining the perceptions of parents regarding childhood physical activity
• Analyzing the factors that contribute to successful conflict resolution in family relationships
• Investigating the experiences of individuals with opioid use disorders in treatment programs
• Understanding the impact of emotional intelligence on leadership effectiveness
• Exploring the experiences of individuals with learning disabilities in the workplace
• Analyzing the factors that contribute to successful change management in educational institutions
• Investigating the experiences of individuals with eating disorders in recovery support groups
• Understanding the impact of self-compassion on mental health and well-being
• Examining the perceptions of college students regarding campus safety and security measures
• Analyzing the factors that contribute to successful marketing strategies for nonprofit organizations
• Investigating the experiences of individuals with postpartum depression in treatment programs
• Understanding the impact of ageism in the workplace
• Exploring the experiences of individuals with dyslexia in the education system
• Investigating the experiences of individuals with anxiety disorders in cognitive-behavioral therapy programs
• Understanding the impact of socioeconomic status on access to healthcare
• Examining the perceptions of parents regarding childhood screen time usage
• Analyzing the factors that contribute to successful supply chain management strategies
• Understanding the impact of parenting styles on child development
• Exploring the experiences of individuals with addiction in harm reduction programs
• Analyzing the factors that contribute to successful crisis management strategies in organizations
• Investigating the experiences of individuals with trauma in trauma-focused therapy programs
• Examining the perceptions of healthcare providers regarding patient-centered care
• Analyzing the factors that contribute to successful product development strategies
• Investigating the experiences of individuals with autism spectrum disorder in employment programs
• Understanding the impact of cultural competence on healthcare outcomes
• Exploring the experiences of individuals with chronic illnesses in healthcare navigation
• Analyzing the factors that contribute to successful community engagement strategies for non-profit organizations
• Investigating the experiences of individuals with physical disabilities in the workplace
• Understanding the impact of childhood trauma on adult mental health
• Analyzing the factors that contribute to successful supply chain sustainability strategies
• Investigating the experiences of individuals with personality disorders in dialectical behavior therapy programs
• Understanding the impact of gender identity on mental health treatment seeking behaviors
• Exploring the experiences of individuals with schizophrenia in community-based treatment programs
• Analyzing the factors that contribute to successful project team management strategies
• Investigating the experiences of individuals with obsessive-compulsive disorder in exposure and response prevention therapy programs
• Understanding the impact of cultural competence on academic achievement and success
• Examining the perceptions of college students regarding academic integrity
• Analyzing the factors that contribute to successful social media marketing strategies
• Investigating the experiences of individuals with bipolar disorder in community-based treatment programs
• Understanding the impact of mindfulness on academic achievement and success
• Exploring the experiences of individuals with substance use disorders in medication-assisted treatment programs
• Investigating the experiences of individuals with anxiety disorders in exposure therapy programs
• Understanding the impact of healthcare disparities on health outcomes
• Analyzing the factors that contribute to successful supply chain optimization strategies
• Investigating the experiences of individuals with borderline personality disorder in schema therapy programs
• Understanding the impact of culture on perceptions of mental health stigma
• Exploring the experiences of individuals with trauma in art therapy programs
• Analyzing the factors that contribute to successful digital marketing strategies
• Investigating the experiences of individuals with eating disorders in online support groups
• Understanding the impact of workplace bullying on job satisfaction and performance
• Examining the perceptions of college students regarding mental health resources on campus
• Analyzing the factors that contribute to successful supply chain risk management strategies
• Investigating the experiences of individuals with chronic pain in mindfulness-based pain management programs
• Understanding the impact of cognitive-behavioral therapy on social anxiety disorder
• Understanding the impact of COVID-19 on mental health and well-being
• Exploring the experiences of individuals with eating disorders in treatment programs
• Analyzing the factors that contribute to successful leadership in business organizations
• Investigating the experiences of individuals with chronic pain in cognitive-behavioral therapy programs
• Understanding the impact of cultural differences on intercultural communication
• Examining the perceptions of teachers regarding inclusive education for students with disabilities
• Investigating the experiences of individuals with depression in therapy programs
• Understanding the impact of workplace culture on employee retention and turnover
• Exploring the experiences of individuals with traumatic brain injuries in rehabilitation programs
• Analyzing the factors that contribute to successful crisis communication strategies in organizations
• Investigating the experiences of individuals with anxiety disorders in mindfulness-based interventions
• Investigating the experiences of individuals with chronic illnesses in healthcare settings
• Understanding the impact of technology on work-life balance
• Exploring the experiences of individuals with learning disabilities in academic settings
• Analyzing the factors that contribute to successful entrepreneurship in small businesses
• Understanding the impact of gender identity on mental health and well-being
• Examining the perceptions of individuals with disabilities regarding accessibility in public spaces
• Understanding the impact of religion on coping strategies for stress and anxiety
• Exploring the experiences of individuals with chronic illnesses in complementary and alternative medicine treatments
• Analyzing the factors that contribute to successful customer retention strategies in business organizations
• Investigating the experiences of individuals with postpartum depression in therapy programs
• Understanding the impact of ageism on older adults in healthcare settings
• Examining the perceptions of students regarding online learning during the COVID-19 pandemic
• Analyzing the factors that contribute to successful team building in virtual work environments
• Investigating the experiences of individuals with gambling disorders in treatment programs
• Exploring the experiences of individuals with chronic illnesses in peer support groups
• Analyzing the factors that contribute to successful social media marketing strategies for businesses
• Investigating the experiences of individuals with ADHD in treatment programs
• Understanding the impact of sleep on cognitive and emotional functioning
• Examining the perceptions of individuals with chronic illnesses regarding healthcare access and affordability
• Investigating the experiences of individuals with borderline personality disorder in dialectical behavior therapy programs
• Understanding the impact of social support on caregiver well-being
• Exploring the experiences of individuals with chronic illnesses in disability activism
• Analyzing the factors that contribute to successful cultural competency training programs in healthcare settings
• Understanding the impact of personality disorders on interpersonal relationships
• Examining the perceptions of healthcare providers regarding the use of telehealth services
• Investigating the experiences of individuals with dissociative disorders in therapy programs
• Understanding the impact of gender bias in hiring practices
• Exploring the experiences of individuals with visual impairments in the workplace
• Analyzing the factors that contribute to successful diversity and inclusion programs in the workplace
• Understanding the impact of online dating on romantic relationships
• Examining the perceptions of parents regarding childhood vaccination
• Analyzing the factors that contribute to successful communication in healthcare settings
• Understanding the impact of cultural stereotypes on academic achievement
• Exploring the experiences of individuals with substance use disorders in sober living programs
• Analyzing the factors that contribute to successful classroom management strategies
• Understanding the impact of social support on addiction recovery
• Examining the perceptions of college students regarding mental health stigma
• Analyzing the factors that contribute to successful conflict resolution in the workplace
• Understanding the impact of race and ethnicity on healthcare access and outcomes
• Exploring the experiences of individuals with post-traumatic stress disorder in treatment programs
• Analyzing the factors that contribute to successful project management strategies
• Understanding the impact of teacher-student relationships on academic achievement
• Analyzing the factors that contribute to successful customer service strategies
• Investigating the experiences of individuals with social anxiety disorder in treatment programs
• Understanding the impact of workplace stress on job satisfaction and performance
• Exploring the experiences of individuals with disabilities in sports and recreation
• Analyzing the factors that contribute to successful marketing strategies for small businesses
• Investigating the experiences of individuals with phobias in treatment programs
• Understanding the impact of culture on attitudes towards mental health and illness
• Examining the perceptions of college students regarding sexual assault prevention
• Analyzing the factors that contribute to successful time management strategies
• Investigating the experiences of individuals with addiction in recovery support groups
• Understanding the impact of mindfulness on emotional regulation and well-being
• Exploring the experiences of individuals with chronic pain in treatment programs
• Analyzing the factors that contribute to successful conflict resolution in romantic relationships
• Investigating the experiences of individuals with autism spectrum disorder in social skills training programs
• Understanding the impact of parent-child communication on adolescent substance use
• Examining the perceptions of parents regarding childhood mental health services
• Analyzing the factors that contribute to successful fundraising strategies for non-profit organizations
• Investigating the experiences of individuals with chronic illnesses in support groups
• Understanding the impact of personality traits on career success and satisfaction
• Exploring the experiences of individuals with disabilities in accessing public transportation
• Analyzing the factors that contribute to successful team building in sports teams
• Investigating the experiences of individuals with chronic pain in alternative medicine treatments
• Understanding the impact of stigma on mental health treatment seeking behaviors
• Examining the perceptions of college students regarding diversity and inclusion on campus.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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