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Gavin: Welcome to the Lancet voice. It's February, 2023. I'm Gavin Cleaver, and I'm delighted to be joined by Jessamy Bagnall and Phoebe Ashley Norman. Hello, Jessamy. Hello, Phoebe. 

Jessamy: Hi, we're in the office together. Exciting. 

Gavin: It's very exciting to have two people in one place doing this podcast. 

Jessamy: It's still mind 

Phoebe: blowing.

Yeah, it's a rarity. 

Gavin: So we should say to our listeners, of course, it's The Lancet's 200th anniversary. And if you listen to our first podcast of the year with Richard Orton, you'll have heard us discuss our spotlights for the year, which are areas that we kind of really want to focus on, so we can drive some change in those areas.

For each spotlight, we're going to have four themed podcasts. And so this is spotlight one, episode one. We're here at the very beginning. The first spotlight is Child and Adolescent Health, and Phoebe, who joins us, is part of the team organizing the Child and Adolescent Health Spotlight. She's hosting the interview that you're going to hear today.

Phoebe, for this first podcast, why don't you tell us a little bit, well, first about yourself, and then about what topic you've chosen for this first podcast, and why it's so interesting to you. 

Phoebe: Yeah, sure. So, hi everyone, I'm Phoebe. I work as an editorial assistant in the journal office here at Lancet, and my background's in biochemistry, so I studied for undergrad and master's.

And today we're going to be talking about peer support. We've got three excellent guests from Acrista Globe and all of them have expertise in this field, which really focuses on youth and adolescents in this context, offering support to people who are going through issues that they themselves have gone through and recovered from in the past.

So really offering one to one and community based treatment and help and assistance. in contexts like HIV, the Zeneca, which he'll discuss throughout the podcast, and mental health and suicide prevention as well. So yeah, it's a really interesting podcast and I'm looking forward to you all hearing 

Gavin: about it.

Yeah, it's a really interesting topic, isn't it? What's kind of some of the importance of peer support? 

Phoebe: Yeah, so peer support is a really important first point of call, I think. A lot of young children, adolescents, If they're going through mental health problems or diseases that they don't have that much information about, they find it really hard to go to professionals or to adults as a first contact.

And actually having a peer supporter, someone who's of a more similar age to you, who's gone through this experience recently and has personal lived experience, it creates a really useful bridge between higher up services and professionals and people, especially children and adolescents, who are dealing with those issues on a day to day basis in their lives.

Gavin: I think that's great. Well, we're super happy to have you on board for this, Phoebe. And it's a wonderful interview, which everyone is going to hear next.

Phoebe: Okay, wonderful. So I'd like to introduce you all to the Lancet Child 200 Anniversary. Lancet special podcast on peer support for obviously children and adolescents. And I'm really excited to introduce our panel. And I'll have them introduce themselves. We've got Ramona Hildensberger, Karim Zendi, and Maka Mokwanwa.

So Ramona, would you like to tell us a little bit about yourself to start off with, please? 

Kareem: Of course. Thank you so much. I was really excited to be invited here. So my name is Ramona Hildensperger. I'm a psychologist by profession and I work as a researcher in Ulm University in Germany. My main research interests are peer support in mental health, global mental health and implementation science.

For the past five years now, I've upsides project, which is a large multi center study. That aims to evaluate and scale up peer support interventions for adults with severe mental illness in both low, middle, and high income countries. Wonderful. Thank you. 

Phoebe: Thank you. Kareem, would you like to tell us a little bit about yourself 

Tanaka: now, please?

Sure. So, hello. My name is Kareem Zudi. I'm a second year med student in Florida, in the United States. And I also wanted to start off with just an honor of being here. It's great being in such great company. So, I'm Syrian American, I'm passionate about medical education, about rare diseases, and just improving physical and mental well being for children and adolescents.

I also volunteer as a counselor for the Crisis Text Line, which I can go into a little further. And I'm also on the Youth Advisory Panel for Atlanta's Child and Adolescent Journal. 

Phoebe: Exactly. Wonderful. Thank you. And Tanaka, would you like to introduce yourself quickly? 

Kareem: Hey, my name is Tanaka Mukua from Zimbabwe.

I'm working with Shandiri as a peer supporter and as a peer advisory board member and also a community adolescent treatment supporter working at Zimunya Clinic. I'm also passionate on peer support. And it has led me to being awarded an honorary doctorate in developmental studies on ending child marriages and abuses by the University of London and World Health Organization.

And I'm also, I'm also into various international boards, such as the International Board for Young People's Network on Child Marriages, Abuses and Rights. And also I am a climate change activist mainly focusing on What climate change affects the youth. 

Phoebe: Thank you so much. So just to start off our conversation, I wanted to ask a very general question, which was just what is peer support, especially intensive mental health for young people and why is it important?

Ramona, can I come to you first on this one, please? 

Kareem: Yes. Yes. Yes. So I would say in a nutshell, peer support is when a person in recovery. Offer support to other people currently experiencing mental health problems. And what this may entail now in detail, that can differ a little bit from, from setting to setting.

But overall, peer support workers can be seen as some sort of mentors that promote the recovery journey of their clients. And they do that, for example, in form of providing. Practical help, such as conversations about mental health problems or counseling how to promote recovery. So that would be the basic description that I can offer, but every, every peer support organization has their own definitions and I think that's also a good thing.

It's very flexible and I'm happy to, to hear what my other colleagues here have to add. Thank you. 

Phoebe: Yeah, wonderful. Tanaka, could you talk perhaps about the specific example of Swahili and how peer support is implemented in your setting? 

Kareem: Okay. I will start by the definition of peer support for, I think, mental health.

I think it encompasses a range of activities and interactions between people who share similar experiences. For example, being diagnosed with mental health condition. Substance use disorders and or and so on. And here in Zimbabwe we are offering many Things in peer support we shall, which I shall discuss a bit further when I'm asked the other question.

So here we are offering mental health support, also TB screening, and also adherence support to adolescents, children, adolescents, and young people living with HIV. 

Phoebe: Great. That's wonderful. Could you share your experiences of providing or accessing peer support through the work of Strandiri, potentially?

Kareem: My experience Has been quite good and sometimes hectic because when providing peer support, they are the merits and demerits of it. And especially the demerits comes when the adolescents the children or adolescent is failing to accept what he or she is that is living with HIV and also that the parents may Fail to disclose that to their Children.

So it then becomes a problem when we call for a support group and then they come in large numbers. And then we started discussing on several issues affecting HIV and AIDS affecting adherence. So it becomes a challenge when that child years what others are discussing about how they are coping up with the treatment and then It then becomes a problem when the child knows, which knows that the medication which I'm taking is HIV.

So it then becomes a problem. And also on the advantage side of it I have faced many success stories in providing peer support such that I, I have managed to clear all the. adolescents and youths. We have mental health problems and also referring them to general psychologists who are helping them.

And also that I'm also working with YPIN which is Young People's Empowerment Network to provide and also Zandiri, which is a partner to Zandiri, which is working on drug and substance abuse. And also peer support is very much more important. And needed so that the peers are the other youth know what they really want.

And they feel free to talk with me on several issues and also me being able to provide them with requisite with the requisites they need. And also that such other mentally healthy needs. Which I will provide. 

Phoebe: Wow. That's, that's amazing. Thank you so much for sharing all of that Tanaka. One of the points you made was really interesting talking about how peer support can act as almost a springboard to allow people who are experiencing mental health problems or similar issues to not only have counseling directly with one on one with a peer supporter, but also to access a wider framework of health support and care.

Kareem, could I come to you at this point? Because I'm aware that you have experience working as a counselor on a suicide hotline. I wondered if you could talk a little bit about how that fits into the wider scheme of care and how you can help people to access through peer support, other sources.

Of course. Thank you. 

Tanaka: Yeah. Okay. So, I volunteer for an organization called Crisis Text Line. So, it is basically a 24 7 platform where if someone's in a crisis, if someone has trouble ending their life, if someone is going through relationship problems or substance abuse problems, or you just want someone to talk to, they can text them a number and then here they are, they get access to a crisis counselor, someone who's, who's certified, who was trained, and then they can, how they can help, how, any access to resources, or if they just want someone to hear them, someone to hear their concern, someone who can lend a listening ear.

So, a lot of times, on the platform, there might be an issue that I can't exactly perform, I can't exactly help to the best of my abilities because it's above my pay grade, it's above my knowledge, and there are other people who are more trained in that. So, for example, I remember there was one story where someone said they were overdosing, and they were concerned about telling their mother about, they were concerned about telling their mother about them going to the hospital because they didn't want their mother's anger.

So my job was to help them at that moment to be able to have the courage to tell their mother to walk them through what their health process was. And then later on, it goes to the next step of care where they go to the EMS or they go to the hospital and they can get further care from there. But I think peer support is important as that first step to access other medical care.

But without the peer support, oftentimes the health care goes missing. They don't get to those next steps. 

Phoebe: Great. That's a really wonderful point. Thank you for sharing that. Picking up on your point about training and having people who are certified, and I know that in Zanderi as well, there's a lot of training that goes on to enable counsellors to be to implement peer support and to act as a mentor to people who are suffering problems that they may have experienced themselves in the past and have worked their way through themselves.

One of the concerns about peer support programs is the burden that it places on young people without formal qualifications, they still have training, but without, you know, they may not be doctors. Are there any negative impacts to being a peer support worker and what are the benefits and what kind of training and support can we provide for peer support workers to allow them to do their job to the best of their ability?

Kareem: Yes, I just, I can only second and say it is a very challenging job. Absolutely. And my, my how can I say this? My, my biggest, um, respect to everyone doing this job. It is definitely. In my opinion, and also from my experience now over the past years, it is necessary for peer support workers to receive some sort of training to prepare them for this job.

But what we have found to be even more helpful is for peer support workers to have some sort of network of other peer support workers or mutual support groups. So someone also doing the same job can help and give advice. They share experiences from the day to day life of a peer support worker.

It is also helpful to have for example, supervision by a clinical supervisor. But in my Personal opinion, the mutual support among peer support workers and having a network is even more important. So to help also with the fact that often peer support workers, they work quite alone. So there might be a hospital and this hospital employs one or two peer support workers.

And they're the only one in this hospital with this job description, for example. And it's quite challenging. So we found it very important for peer support workers to have a network and to have some sort of training that prepares them for it. We, we did develop an upsides training manual for peer support workers for adults.

And I was also a trainer and had the honor to train a team over here in Ulm. And yeah, it was a, it was a really interesting adventure and journey over the past years. Yeah. 

Phoebe: Wonderful. I can imagine that training a group like that really does forge strong connections between the members who train together and then who then go off and offer peer support to individuals but still maintain those group bonds from their training themselves.

Tanaka, do you have anything to add here about training potentially for Zwandiri peer supporters? How do you implement that within your organization? 

Kareem: As Zwandiri in Zimbabwe we are training peer supporters and also giving them the necessary Equipments so that they will do their work and also a motivation, which is like a volunteer allowance, which is given to them so that they will really feel appreciated in their work hard to achieve a certain goal.

But the problem then comes on other necessities which are needed by peer supporters, which we really can't provide. very much. But being provided by other organizations. So we have been referring them to other organizations so that they would help. And also that in the, in this one daily program, we are also chaining.

peer supporters and other community members so that they will provide much more information and also for information dissemination and uptake to the adolescents and young people, children, adolescents and young people. And also that we are providing them With necessary data collection tools so that it will be easy for them to collect the data which we want on peer support.

And also that we are, we are, we are, we are also providing them with other transport logistics so that they will, Feel free to move during the week. 

Phoebe: Great. Wow, that's really wonderful. That's great to hear. Thank you. So you're talking about logistics and moving and people getting really one on one direct support within quite close communities.

But as we know, peer support is not only an in person activity, it can also be provided across many different platforms. For example, over phone lines some organizations create apps which allow people to form peer support networks by technology, and I wondered if you think that there's an optimal way of delivering peer support as a form of care to children and adolescents specifically, and what are your experiences of using different methods?

Karim, could we come to you here first, please? 

Tanaka: Yeah, so there is a time and place for every resource and everything has benefits and drawbacks, but here at Crisis Text Line, what I find helpful is that everything is through text. So a lot of it is anonymous. So for instance, if someone is having trouble in school during their lunch break, they can be on their phone and other people might think they're texting friends or texting loved ones, but They could be reaching out to us or let's say a lot of people might have anxiety talking on the phone or seeing someone face to face and then maybe bumping into them at a local store.

So this is completely anonymous. They can reach out. They don't have to worry about having to talk to someone on the phone. That causes them anxiety. So I believe it's very anonymous and helpful platform for those who might benefit from it. 

Phoebe: That's great. Just to follow up a bit obviously we're all aware of how COVID has affected young people and adolescents in particular due to increased isolation and not being able to go to schools and access normal social connections that we usually do.

And how, how do you think that the hotline has provided a service to those young people who might have experiences of isolation and loneliness? 

Tanaka: Cord. So even before COVID, a lot of the pictures would. They, that they feel isolated, that they don't feel like they have anyone to talk to. And that was a lot of their concerns.

They had a lot of these issues that they wanted to talk to them about, but they didn't feel comfortable with anyone around them. So now with COVID, that's only been exacerbated. A lot of people haven't left their house. They've been in situations where maybe they're around people who they don't want to be around and they feel isolated.

So through this platform, they're able to have someone who is there to listen to them, someone who. No judgment, no, no stigma they can reach out to. And if they don't want to hear from them ever again, they never have to hear from them ever again. If they don't want to see them, they won't see them because it's all purely through tech.

So it's nice that the anonymity and the help and the COVID era, people feeling isolated, people not being connected to others. 

Phoebe: Great. That's wonderful. Thank you so much for that. Ramona, do you have any experience you could share with us about implementing peer support across different platforms as opposed to just in person?

Kareem: Yes. Actually I do. It was not planned to be like this, but due to the COVID pandemic, we had to adjust and adapt our intervention a little bit. And it was quite challenging because our intervention was was implemented as part of a research study. So the participants who have signed up for the study and have agreed to participate in the intervention.

They were prepared to have face to face contacts with peer support workers. So, So they actually wanted this interaction and this human connection. And we also aim to improve the social inclusion of our participants of the clients, and that was challenging in times of but we, we did find ways and what we, what.

Then was one of the best compromise or best things to do was to have meetings if possible, outside our doors. For example, in a public park or somewhere with enough space between, between two people and then maybe do this like once a month and then have two meetings on the phone or, or here via, via zoom, for example.

So our, our peer support workers and clients, they got quite quite creative with solutions to get through this time. But. One of the challenges we were facing was when it was a complete lockdown and personal meetings were really not allowed was hard, especially in the lower income sites that we are implementing to be in touch with the clients because many do not have a phone or a laptop, or it was very hard to stay in contact.

And it was quite challenging. Really at these sites, I would say to, to even stay in touch somehow. So, so clients who are using, for example, their, their family's phone, maybe one of their family members has a phone and yeah, so we had to be very creative and My impression was that both clients and peer support workers were very, very happy when they were finally able to meet again in person or meet for the first time in person.

That was just my impression, but that might be due to the fact that we That we had this how to say that we had announced, this will be a personal contact. Whereas Karim and his project, they officially say it is anonymous and you do not have to be. So it's really what people actually want from the peer support.

And I think that's also where the beauty of peer support lies because it is so flexible. You can implement it in a variety of, of ways. 

Phoebe: Yeah, 100%. I completely agree with the flexibility being a massive advantage of of peer support. Tanaka, I saw you nodding along at one point. Do you have anything to add on this about providing peer support across different platforms and different mediums?

Kareem: We are also, we have the Community Adolescent Treatment Supporters, who act as positive role models to strengthen our existing networks of social protection. And also they do monthly best support that facilitates learning confidence building and socializing and also community outreach teams provide more advanced key in the homes of youth living with HIV.

But it then comes your question that But we want your question and then we have to adapt to the situation, which is one at the end. That is the COVID 19 pandemic, which is limited us. to do home visits for children and adolescents. Thereby, we're using the mobile iHealthy, which is on call.

We call, we text on SMSs, we talk to them on WhatsApp, but the problem then comes with those who are in rural areas, those who doesn't have phones, those who doesn't have laptops, computers to communicate with us. Yeah, and then we had to adapt to a situation that would go there with the healthy personnel also informing the Minister of Health so that would go there and offer our support following COVID 19 protocols and guidelines.

Phoebe: Great. That's, that's, that's amazing to hear. Yeah, it's, it's interesting to hear about the group settings that you guys host as well. Knowing that, knowing that one of the difficulties of peer support can be isolation, the fact that you offer group support is, sounds like a great way to combat those kinds of difficulties.

Thank you so much for sharing that. He mentions briefly about the differences of implementing peer support, especially when using technological methods across urban versus rural environments. And I know that Ramona and Tanaka, you both have experience of implementing peer support systems from your home countries into external nations.

How can cultural differences across countries and also within countries influence how peer support is implemented? Ramona, would you like to talk about this with regards to upsides? 

Kareem: Yes, I'm happy to share some of my experiences over the past years that have also now been written up and published in, in two papers.

If you're interested to read more but in a nutshell, I would say that from my experiences and also what we saw in our qualitative studies is that in lower middle income settings, there is a much bigger emphasis on community and to implement peer support as a bridge between community and people experiencing mental health problems.

And also to support workers to be a bridge between patients and mental health staff, for example. I believe this might be largely due to a stronger stigmatization of mental health issues in lower middle income settings. And also there usually you will have a bit of a how to say a bit of a stronger hierarchy between, for example, a doctor and a patient.

So here the role of a peer support worker to be a bridge builder is especially important and this should be reflected in the way you implement it. Also something we have discussed a lot and that. was quite challenging was the role of the peer support worker. For example, in lower middle income settings we talked with staff members in the institutions where we want to implement peer support, and they directly said they will value peer support workers very highly.

And they value especially their contribution to reduce the workload of mental health workers because they're severely understaffed, especially in low and middle income settings. So on the one hand, this made it a bit easier to implement peer support because the other staff members were very happy to have more support from peer support workers now.

But in the same time. We wanted to be very careful not to have peer support workers as, how to say, a cheaper option to to fill gaps in underfunded services, because we believe that peer support has this unique contribution, the unique perspective that they can bring into services. So that was quite a challenge that you will face.

For, and then when you compare it to higher income settings, for example, here in Ulm in Germany, where I was implementing, we had more of a struggle to find clear role description of peer support workers, but also a distinct role description, because there's a quite large variety of services offered. And we needed to find a way to integrate this in a distinct and transparent way.

Those were some of the differences that I observed when implementing in different settings. Great. Thank 

Phoebe: you. That's so interesting. Tanaka, I know that Svenderi has expanded their services outside of Zimbabwe to neighboring nations. Could you talk a little bit about how this process has worked and whether you have faced any cultural differences that has influenced how you implement peer support and how those countries go and take the principles of Svenderi into their own, into their own communities?

Kareem: Okay. As of Chandry expanding in other in other countries. We have seen with much great concern that they want community adolescent treatment support program to be in their countries. And we haven't faced cultural differences yet because we are training the community members, the, the, the, the, The PA the PA advisory and also that the, the community adolescent treatment supporter who are community based will provide the services to the youth.

And also children and adolescents living with HIV to, to make sure that we have an improved access to HIV care. And also that the kids act as a positive role model to strengthen existing natures of social protection. And they are drawn from the community where they live. And that's why we are saying that a community by led by a community.

So we haven't faced any cultural differences. Because these kids, they are coming from the community, which the project is to be implemented. So there is there are no cultural differences, which we have passed yet in regards to expanding our project to, to other countries. 

Phoebe: Okay, that's wonderful.

Yeah, when I was researching Zvendiri, I noticed there were lots of testimonies and people's stories and I read there were many stories where people had access to peer support. They detailed that their passion and their motivation was then to become a peer supporter, to offer the same kind of support to other youths who come up behind them who face similar problems.

And that really struck me as an incredible legacy to have that each peer supporters generating more motivations for their people that they're supporting to go on and become more like them. And yeah, could you, could you talk a little bit about some of the the feelings of, of real hope and motivation that peer support can offer young children and adolescents, especially those who might be suffering with diseases that they've only just been been told about recently.

Kareem: The impact of the community adolescent treatment supporters in the community, they are helping increasing understanding of medication and motivate adherence, providing mental health screening and other and other sort of support which the results confirm that the importance of our home visits, also the home visits which are being done by community adolescent treatment supporters, they are also helping To motivate other young people to then come to Del and say we want to join the peer the community adolescent peer support program and thereby we are really supporting very high on that.

Kareem, how do you 

Phoebe: feel about those issues? Do, do you feel like people are drawn to become peer supporters and to become counselors on networks? what once they've had experiences integrating with the services or how do you, how do you attract people to become their supporters and to become counsellors?

Tanaka: Thank you. So for one, I do really hope so. So a lot of times after a conversation, they fill out a survey and people are like, wow, I'm so happy to exist in the first place. I didn't know something like this happens and this is something that I'm interested in helping myself. So we have heard of things like this and how I heard about it was actually a TED talk.

So the founder was speaking about the Crisis Text Line and what an opportunity it is that Your main qualification, you don't have to be a psychiatrist, you don't have to be a doctor, you don't have to have all these capabilities. While there is training, of course, and there are supervisors, but one of the main qualifications is just lending a listening ear, like being available, having empathy.

And that's something that any of us can have and something that still provides so much value and isn't so much needed these days. In terms of cultural competency, I think that is really important, and I think one of the best things we can do as peer supporters is knowing what resources are out there for other communities, too.

So, for example, for us in our medical school, we recently just hosted a health clinic at our local mall. And in the Arab and Muslim community, mental health is often hushed or not talked about too much. It's often like, okay, just pray it away. And while prayer and, like, respecting people's culture is obviously very, very important, There are other things that can also help.

So while we were there, we were handing out resources for, for example, there are online tech supports that are typically catered towards Muslims or in general, other local resources that might be catered towards them. So I think more local, more focused establishments are always really great for.

Bridging cultural divides and helping reach those who might not realize they have access to the opportunity. 

Phoebe: Very wonderful. Thank you so much for sharing that. Just to finish off this podcast then, I, I wanted to ask you all about the future of peer support and what what would you like the future of peer support to look like and how do you think peer support can be implemented more into the, in the future to really maximize it as a resource for people and young children and adolescents in particular to use?

Ramona, do you want to start with this one? 

Kareem: Oh, right. Well, as a researcher, we always, you know, want to know more. And I, I think we, the, the, the evidence base for the effectiveness of peer support is already quite established. But we need to know more about what is the best way to implement it.

What is the best way to implement it, for example, now, especially for young people. Because I, I'm not quite sure if we should broaden our, our horizon here a little bit and, and not just think about implementation in a healthcare setting, but also think about implementation, for example, in schools or in youth centers and so forth and so forth.

So there's a lot of things you could do, a lot of ideas. And I think at least my colleagues here on the podcast, we're all convinced that peer support does work. So we just need to know a bit better how exactly can we make it work best way and how to implement it in the best way. So I, I do see a lot of implementation science going on in this area, hopefully in the future.

Phoebe: Very wonderful. Tanaka, can I come to you next? 

Kareem: I think what we want in the future for peer support is very crystal clear. We need more peer support programs not only on mental health, but on other problems which are being faced by adolescent children and adolescent young people because they are right now facing many challenges.

Such as suicide and also other things which are affecting the youth. So we, we are, we really need to upscale from mental health and also offering other other services like TB screening and also with something like that. And also we want a peer led support. When I say a peer led support is that for the youth by the youth.

Yes, we are saying that we need the youth to be at the forefront of we helping other youth because right now I don't want to to lie to you, the youth don't want to hear an old person coming to them, telling them that for example, I'm working with children and the adolescent living with HIV and then an older person comes and tell a child the importance of adherence.

They doesn't understand, they doesn't hear, but it needs a a peer a peer supporter who is a youth to then go and support that child that adolescence so that he or she will understand all the things that are needed. 

Phoebe: Great. That's really powerful. Thank you so much Tanaka. Kareem. 

Tanaka: So I think just mirroring what everyone else is saying, more is the answer.

So we already have great foundations and building more organizations, building upon those organizations, just community outreach in general is huge. So getting the youth involved, getting more implementation, I think outreach is also one of those that I believe will make the biggest difference. So because a lot of these resources exist, but people aren't necessarily aware of them or.

I think outreach through social media or through other resources or even just handing out flyers at community centers makes a big difference. So even like among our own circles, it doesn't have to be a community level. It could just be one person who reaches out a hand and offers support and then that continues and continues and people are inspired by that.

And I think just on an individual level and a community level, giving back and Be open. 

Phoebe: Wonderful. And that's such a positive note to end on. Thank you so much. I think the things that you've really drawn out, that all three of you have really drawn out, is that peer support is really built on empathy and connection.

So with those two guiding principles, it can create really lasting change and provides solace to many people especially children, adolescents, and those working through mental health problems and other, other problems. So I'd like to thank you. Thank you all so much for being with us on this podcast.

It's been a pleasure. Thank you. 

Kareem: It was a pleasure hearing the insights from others in peer support, also learning. what they are doing in their countries so that we may reach a certain level of peer support. Thank you so much. 

Phoebe: It's amazing to hear about what's going on in all your corners of the world.

It's really great that we've managed to make this happen and have this conversation.

Jessamy: Such a great topic. When you, it's a, it's a really nice podcast, but do you feel that this is a sort of tool that's being integrated and used enough by health systems and by health care professionals? Interestingly, 

Phoebe: I don't know if it is. I don't know if that many people know about it. And that's why I'm really glad we're shedding light on that today.

I think that test support is. well known about in the communities that it serves. But I think that beyond that, it's less widely spread. Snaka about peer support in the HIV context and in the work that Svenduri do. And so I think that in those kinds of contexts, there's a lot of knowledge about peer support because it's really creating those networks between individuals and then working within a community.

Kareem had some really, really good points on this and he talks about connection. And community being two of the most fundamental parts of peer support and really creating strong bonds between individuals who can support each other and then help each other to get higher end services within the kind of wider health service within their community or within their country, or even as nationally, to be honest.

Jessamy: It's interesting, isn't it? Because it's sort of, it really puts into context that kind of health systems thinking of where are the boundaries of health systems and where do they sit in communities and how is that relationship? How does it work? And where are the pressures eased? Because this is obviously, you know, a crucial part for many people.

But, you know, are we really using it to its full effectiveness? I'm not sure. I know that we have published, we obviously, there's a huge focus on schools and the importance of schools in mental health. And within that, there's a lot of sort of peer support, but outside of the school arena, which is obviously just as important community point of view.

I'm not sure about the evidence base there. But was it something that's kind of particularly personal or you know that you have a particular interest in that made you think about it? 

Phoebe: Yeah, well I'm not, I'm not the only person involved in this podcast. Hannah Rowell from eClinicalMed and Pippa from Healthy Longevity have also been really involved in this, so shout out to them as well.

And the three of us kind of came to this topic together but I personally do have experience with peer support. I trained as a peer supporter at university and offered it within a collegiate kind of environment, which was a really useful way of learning how to talk about kind of mental health issues and also just shared experiences.

I think that some of the key aspects of peer support they brought up there were really to not give advice, but to help people to work through their own problems and to act as more of a, in a supporting auxiliary role. So, so yeah, I think that in schools and universities, it's a really useful tool, but also in communities.

It was interesting, Ramona Hildensberger speaks in a podcast about the implementation of peer supports in lower and middle income countries versus higher income countries. And then the lower and middle income countries. There's a bigger focus on community based action, and there's a lot more strength in community bonds that they see.

And the implementation of peer support obviously has to be adapted to the context in which you're working. I think that she's seen that integrating peer support within a community is actually something that's more applicable to those lower and middle income countries, and that some of the interventions that might apply to higher income countries that using technology and peer support don't apply quite so readily to those other contexts, especially in rural environments where phone signal might not be so prevalent.

And so the beauty of peer support is really, I think it's adaptability because it's so based on individuals and people and forming these connections. And, and yeah, and that's, I think that's why it's a nice tool because it's based. in communities with people who have lived experience and they can use their own experience and their own knowledge of their local community and their local geography and their local area to really implement the support that they give to people who are younger than them coming up behind them with similar problems.

Jessamy: And I guess a great example of that is that friendship bench, right? In St. Bartholomew's Pubway where I think it's grandmas or, you know, elderly women that sit there and people can come and you heard that. I mean, it's just an amazing example. I think it kind of happened almost organically, but it now, sort of, a more formalized process where older people can sit on these benches and other people can just come and sit there and, and chat to them about, you know, different issues that they've got going.

No, she is a. You know, it's great role for everyone in that. And I suppose that it's interesting because as we see the burden of mental health increase so much, you know, there's so many conversations about how we're going to deal with that burden. And then that comes into kind of, you know, patient autonomy and people's autonomy and responsibility to each other, but also their ability to cope with some things that don't need medicalization, you know, that just need friendship, talking, working through issues, you know, senses of community, those.

They're seeing this. sometimes difficult for the medical profession to really value. Yeah, and just essentially not being alone in your problems, 

Phoebe: alone in 

Jessamy: your in 

Phoebe: your health issues.

Gavin: Thanks so much for joining us for this episode of the Lancet Voice. This podcast will be marking the Lancet's 200th anniversary throughout 2023. by focusing on the spotlights with lots of different guest hosts from across the Lancet group. Remember to subscribe if you haven't already and we'll see you back here soon.

Thanks so much for listening.