Ma et al.

International Journal of Mental Health Systems (2022) 16:45 International Journal of

https://doi.org/10.1186/s13033-022-00555-6
Mental Health Systems

RESEARCH Open Access

Development of the Mental Health

Peer Support Questionnaire in colleges
and vocational schools in Singapore
QianHui Ma1* , Joseph J. Gallo2, Jeanine M. Parisi3 and Jin Hui Joo4

Abstract
Background: A nation-wide mental health peer support initiative was established in college and vocational schools
in Singapore. The purpose of this cross-sectional study was to develop and validate a 20-item self-report instrument,
the Mental Health Peer Support Questionnaire (MHPSQ), to assess young adults’ perceived knowledge and skills in
mental health peer support.
Methods: We administered the questionnaire to 102 students who were trained as peer supporters, and 306
students who were not trained as peer supporters (denoted as non-peer supporters), in five college and vocational
schools. Exploratory factor analysis and descriptive statistics were conducted. Cronbach’s α was used to assess reliabil-
ity, and independent sample t-tests to assess criterion validity.
Results: Exploratory factor analysis indicated a three-factor structure with adequate internal reliability (discerning
stigma [α = .76], personal mastery [α = .77], skills in handling challenging interpersonal situations [α = .74]; overall
scale [α = .74]). Consistent with establishing criterion validity, peer supporters rated themselves as significantly more
knowledgeable and skilled than non-peer supporters on all items except two: (1) letting peer support recipients make
their own mental health decisions, and (2) young adults’ self-awareness of feeling overwhelmed. Peer supporters
who had served the role for a longer period of time had significantly higher perceived awareness of stigma affecting
mental health help-seeking. Peer supporters who had reached out to more peer support recipients reported signifi-
cantly higher perceived skills in handling challenging interpersonal situations, particularly in encouraging professional
help-seeking and identifying warning signs of suicide.
Conclusions: The MHPSQ may be a useful tool for obtaining a baseline assessment of young adults’ perceived knowl-
edge and skills in mental health peer support, prior to them being trained as peer supporters. This could facilitate tai-
loring of training programs based on young adults’ initial understanding of mental health peer support. Subsequent
to young adults’ training and application of skills, the MHPSQ could also be applied to evaluate the effectiveness of
peer programs and mental health training.
Keywords: Peer support, Mental health, Scale development, Emerging adulthood, School program

Background
Mental illness is a growing public health concern, with
*Correspondence: maqianhui@gmail.com roughly half of all lifetime mental disorders starting by
1
the mid-teens and three-quarters by the mid-20s [24].
Department of Mental Health, Johns Hopkins University Bloomberg School
of Public Health, 624 North Broadway Street, 8Th Floor, Baltimore, MD 21205, Young adults living with serious and distressing mental
USA health problems may refuse to seek help or consider-
Full list of author information is available at the end of the article ably delay seeking professional mental health services

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​
mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Ma et al. International Journal of Mental Health Systems (2022) 16:45 Page 2 of 11

[7, 18], due to concerns such as stigma, embarrassment data [22, 42]. Only two studies on school-based pro-
and confidentiality [19]. This may lead to adverse health grams were found to have collected data from recipients
outcomes, including substance abuse, risky sexual behav- of these peer programs [1, 40]. One review was available
ior, lower quality of adult life and premature death [3, 10, regarding a peer program in the Asian context, but it did
11, 26]). More concerted efforts have to be conducted to not involve any data collection [22]. No studies thus far
improve the mental health well-being and help-seeking have assessed the knowledge and skills of mental health
behaviors of young adults. peer support among young adults in Asia.
Peer support is an intervention that could benefit The purpose of this study was to develop and vali-
young adults facing emotional and mental health distress. date the Mental Health Peer Support Questionnaire
Within the context of a school setting, peer support is (MHPSQ), an instrument intended to assess perceived
defined as a process of assistance whereby trained, super- mental health peer support knowledge and skills among
vised students help other students with personal and young adults in college and vocational schools with peer
school-related problems, offer supportive relationships, support programs. We provide an exploratory factor
clarify peer support recipients’ (denoted as recipients) analysis (EFA) on the underlying structure of the meas-
thoughts and feelings, explore options and help recipi- ured mental health peer support variables, and initial
ents in determining their own solutions [32]. In various evidence of validity and reliability of the MHPSQ for
countries, peer support programs have been extensively potential use in other school-based peer support training
used to supplement traditional approaches to help col- programs.
lege and vocational students, such as school counseling As a check of criterion validity, we analyzed the
services [22]. Training and supervising young adults to responses from both peer supporters and non-peer sup-
reach their peers with health-related information have porters. We took into consideration whether participants
long been used to promote help-seeking behaviors [6]. had been trained to provide mental health peer support,
In Singapore, young adults have the highest 12-month and if they were, their self-reported peer support expe-
and lifetime prevalence of mental illness, as compared to riences. We hypothesized that participants who were
older age groups [43]. A nation-wide survey found that trained to be peer supporters would have higher per-
only 6% of the population and 32% of those with depres- ceived knowledge of and skills in mental health peer sup-
sive and anxiety disorders sought professional help for port, relative to those who were not trained. A second
mental and emotional problems [33]. In 2016, an inter- hypothesis was that among peer supporters, having more
governmental agency taskforce was formed in Singapore, experience in the role would be associated with greater
charged to enhance young adults’ mental health. As part perceived knowledge of and skills in mental health peer
of this initiative, concerted efforts have been made to support.
strengthen peer support networks for young adults in The validated instrument could be used to obtain a
colleges and vocational schools throughout the country. baseline assessment of young adults’ understanding of
This initiative requires all colleges and vocational schools mental health peer support prior to being trained, to
in the country to set up a peer support program. Within facilitate the tailoring of peer support training programs.
each school, some of the students served as peer sup- The instrument may also be used for the evaluation of
porters and some were students who were not part of the peer support programs’ effectiveness subsequent to peer
peer support program (denoted as non-peer supporters). supporters’ training and practice.
All schools provide training for peer supporters on top-
ics such as mental health awareness, listening skills, and Methods
referring other students to professional resources, to help Study sample
these students take on the role [29]. The collaborating institution partnering the schools to
Despite the extensive literature on peer support pro- develop peer support programs, the Health Promotion
grams for individuals with serious mental illness, few Board Singapore, contacted eight colleges and vocational
studies have investigated peer support programs for men- schools in Singapore that had an existing peer support
tal health promotion in colleges and vocational schools. program. Five of the eight schools agreed to participate
Most studies on school-based mental health peer sup- in the study. To maintain confidentiality of the schools,
port were conducted in secondary or high schools [1, 13, the schools will be denoted in the order of how long
15, 20, 21, 38, 41] and one was conducted in a veterinary their peer support program had been established, rang-
school [40]. Out of the four studies found that were con- ing from S1 (longest established program) to S5 (most
ducted among college students, two had small sample recently established program).
sizes of 20 to 30 peer supporters [2, 4], one collected only Participating schools sent emails which contained a
qualitative data [4], and two did not collect any primary brief description of the study and links to the online
Ma et al. International Journal of Mental Health Systems (2022) 16:45 Page 3 of 11

surveys, to both peer supporters and non-peer support- avoid neutral responses while capturing more granular
ers. Research team members also recruited additional differences in rating.
non-peer supporters from public spaces (e.g., hall- Participant characteristics
ways, cafeterias, study rooms) of the five participating The online surveys for both peer supporters and non-
schools to invite them to participate in the online sur- peer supporters gathered information on sociodemo-
vey. Informed consent was obtained through the online graphic characteristics, such as age (in years), gender
survey platform, Qualtrics, before participants could (male, female), self-identified race (Chinese, Malay,
proceed to complete the online surveys. Towels or stress Indian, Caucasian, Other), school and graduation year
balls were given as tokens of appreciation to participants (2019, 2020, 2021, 2022, Other). Age was recoded as
who indicated interest in participating in the online sur- a categorical variable due to small numbers in higher
vey. At the end of the study, each participating school ages. Graduation year and school information were used
received a report of their own schools’ data and students’ to calculate the number of years students had spent in
feedback on their program. The project was reviewed and their school. Peer supporters were also asked questions
approved by the Institutional Review Board of the Johns to assess their level of experience as a peer supporter:
Hopkins University Bloomberg School of Public Health. (1) when they attended training workshop(s) to become
Study procedures a peer supporter (one-month intervals from < 1 month
The online survey for peer supporters, administered ago to > 12 months ago), (2) the number of recipients they
through Qualtrics, included questions about basic demo- had supported since their first training (None, 1 to 5, 6 to
graphics, the participants’ level of experience in the peer 10, 11 to 15, 16 to 20, > 20), (3) the number of recipients
support role and the MHPSQ. For non-peer supporters, they recommended to seek professional help (None, 1 to
the survey included questions about basic demographics 5, 6 to 10, 11 to 15, 16 to 20, > 20), and (4) the number
and the MHPSQ. of recipients who had sought professional help, among
those whom the peer supporters had recommended to
Measurement development seek help (None, 1 to 5, 6 to 10, 11 to 15, 16 to 20, > 20,
Mental Health Peer Support Questionnaire (MHPSQ) Don’t know).
As majority of the participating schools used the peer
supporter training workshops provided by the Health Analytic strategy
Promotion Board, we referred to the training content To assess validity and reliability of the MHPSQ, our
of these peer supporter training workshops to identify data analysis proceeded in six phases. First, data were
major topics that peer supporter trainings had in com- inspected for errors and outliers and cleaned as needed.
mon. Peer supporter training provided by all schools Only participants who completed all 20 items of the
included content reflecting five common training topics: instrument were retained in subsequent analyses. Sec-
(1) fundamental skills of peer support, (2) self-care, (3) ond, exploratory factor analysis (EFA) for all items on
understanding mental health, (4) identifying distress in the scale were carried out to identify underlying rela-
peers, and (5) promoting help-seeking behavior. A pool tions between measured mental health peer support
of items was generated that assessed perceived knowl- variables. The EFA sample size meets the general guide-
edge and skills under each of the common training topics. lines of N = 200 and at least ten participants per indica-
We sought assistance from five consultants in the tor [31, 34]. Scree plots, eigenvalues and parallel analysis
Health Promotion Board who were in charge of designing based on the 20 MHPSQ items were used to determine
the program and collaborating with the schools. This was the number of factors to retain. Two eigenvalues were
to ensure that the topics identified and the MHPSQ items greater than 1, three eigenvalues were greater than 0.70.
generated were coordinated with what was taught to peer Scree plots suggested two factors while parallel analysis
supporters in training programs throughout all the par- suggested three factors. We explored the possibility of
ticipating schools. We circulated drafts of the instrument two or three correlated factors accounting for the data.
to the consultants for comments in an iterative manner. Maximum likelihood procedures were employed and all
Feedback was incorporated into final versions of the solutions were rotated obliquely using oblimin rotation
questionnaire, which enabled us to arrive at a smaller [23]. Maximum likelihood allows for the computation of
number of items. We also edited the item wording to bet- a wide range of goodness of fit indices, factor correlations
ter fit the students’ language and mental health literacy and confidence interval computations [16]. Oblimin rota-
levels. The final version of the MHPSQ included 20 items. tion is preferable when underlying factors could be cor-
Responses to each item were evaluated on a six-point rat- related [36]. Pattern matrices were analyzed using 0.32 as
ing scale ranging from “Strongly disagree” (coded 1) to the cutoff value for a salient factor loading, which corre-
“Strongly agree” (coded 6). A six-point scale was used to sponds to a minimum 10% overlap in variance with other
Ma et al. International Journal of Mental Health Systems (2022) 16:45 Page 4 of 11

items in the same factor [44]. Crossloading items that p < 0.05). Fewer males and Indians completed the
loaded at 0.32 or higher on more than one factor were MHPSQ.
dropped from the analysis. Third, in conducting descrip- Of 536 non-peer supporters who started the non-
tive data analyses, we investigated the distributional peer supporter questionnaire, 306 completed all items
properties of each demographic (for both peer support- of the MHPSQ (57.1% completion rate). There was also
ers and non-peer supporters) and experience (only for no particular point in the questionnaire where attrition
peer supporters) variable. Pearson’s chi-square [35] was occurred. No statistically significant demographic dif-
used to identify any possible trend among responses ferences were found between non-peer supporters who
that were missing or incomplete. Fourth, we computed completed the MHPSQ (n = 263) and those who did not
Cronbach’s alpha coefficients [12] for the subscales. Fifth, complete the MHPSQ (n = 24), except for the school
we sorted the peer supporter sample into two reference they were enrolled in (χ2 (4, n = 287) = 9.60, p < 0.05). S1
groups based on when they had been trained, as a proxy and S4 had fewer non-peer supporters completing the
for how long they had been active peer supporters in the MHPSQ.
program: above the median (more than eight months The peer supporter and non-peer supporter question-
ago) and at or below the median (eight months or less). naires took an average of 15.2 and 15.6 min to complete,
To assess criterion validity, we compared peer supporters respectively. This calculation excluded durations that
above the median duration as active peer supporters to exceeded 5.5 h, as those participants were likely to not
those below the median, based on individual items and have completed the survey at one sitting.
total scores of the MHPSQ factors. We also sorted the Table 1 shows the demographics of the analytic sam-
peer supporter sample into two reference groups based ple, the 102 peer supporters and 306 non-peer support-
on how many recipients they had supported since their ers who completed the MHPSQ. The mean ages of peer
first training: above the median (six or more recipients) supporters and non-peer supporters were 20.6 years
and at or below the median (fewer than six recipients). (SD = 2.61) and 20.7 years (SD = 2.55) respectively.
We then conducted comparisons on individual items and The mean amounts of time peer supporters and non-
total scores of the MHPSQ factors. We hypothesized that peer supporters had been enrolled in their school were
among peer supporters, having more experience in the 1.34 years (SD = 1.26) and 1.13 years (SD = 1.30) respec-
role would be associated with higher perceived mental tively. Approximately 74.2% of Singapore’s population
health knowledge and peer support skills. Sixth, to fur- is ethnically Chinese [39], thus there was a slight over-
ther assess criterion validity, we compared peer support- representation of Chinese in our peer supporter sample
ers with non-peer supporters, based on individual items (81.2%). More females participated in the peer supporter
and total scores of the MHPSQ factors. We also hypoth- survey than males.
esized that participants who were trained to be peer sup- Factor analysis
porters would have greater perceived knowledge of and The three-factor solution (GFI = 0.92, AGFI = 0.87,
skills in mental health peer support, relative to those RMSR = 0.03, RMSEA = 0.04, CFI = 0.97) had bet-
who were not trained. We used independent sample ter model fit than the two-factor solution (GFI = 0.81,
t-tests [25] to compare item and total factor mean scores AGFI = 0.76, RMSR = 0.06, RMSEA = 0.07, CFI = 0.87).
between high and low experience groups and between Further comparisons with alternative models are shown
peer supporters and non-peer supporters, with an α of in the Additional file 1.
0.05 for statistical significance. All analyses were con- The three-factor solution with 16 items was used for
ducted with the R statistical program, version 3.5.1 [37]. subsequent analyses. The first factor represented items
associated with discerning stereotypes and prejudices
Results (denoted as Discerning Stigma) (1) “Young people with
Sample characteristics mental illness are dangerous;” (2) “People with mental
Of 148 peer supporters who started the peer supporter illness can just get over their emotional problems if they
questionnaire, 102 completed all items on the MHPSQ try;” (3) “Serious mental health problems are obvious;”
(68.9% completion rate). There was no particular point (4) “Stigma does not affect people’s willingness to seek
in the questionnaire where attrition occurred. When help.” The second factor consisted of eight items related
demographic and experience covariates were examined, to personal mastery in one’s peer support abilities and
peer supporters who completed the MHPSQ (n = 101) judgment (Personal Mastery): (1) “Self-care is impor-
and those who did not complete the MHPSQ (n = 14) tant;” (2) “Mental health stigma can be caused by media
were significantly different in terms of gender (χ2 (1, portrayals;” (3) “I am able to understand my peers with
n = 115) = 4.57, p < 0.05) and race (χ2 (3, n = 115) = 9.42, empathy;” (4) “I can talk about ways of coping with my
peers;” (5) “I am confident of letting my peers make their
Ma et al. International Journal of Mental Health Systems (2022) 16:45 Page 5 of 11

Table 1 Demographics of peer supporters and non-peer supporters, Singapore 2018

Peer supporters Non-peer supporters
Total n (%) Total n (%)

Demographic characteristics
Age, in years
  18–20 53 (52.5) 138 (49.6)
  21–24 39 (38.6) 120 (43.2)
  25–30 9 (8.9) 20 (7.2)
Gender
  Male 35 (34.7) 143 (49.7)
  Female 66 (65.3) 145 (50.3)
Race/Ethnicity
  Caucasian 0 (0) 3 (1.1)
  Chinese 82 (81.2) 213 (74.7)
  Indian 3 (3.0) 19 (6.7)
  Malay 9 (8.9) 30 (10.5)
  Other 7 (6.9) 20 (7.0)
School
  S1 35 (36.8) 63 (24.0)
  S2 19 (20.0) 67 (25.5)
  S3 19 (20.0) 40 (15.2)
  S4 13 (13.7) 42 (16.0)
  S5 9 (9.5) 51 (19.4)
Years in school
   < 1 year 35 (38.9) 124 (50.4)
  1–2 years 37 (41.1) 82 (33.3)
  3–4 years 18 (20.0) 40 (16.3)
Peer supporter experience
Duration since attending training workshop
   ≤ 4 months 33 (33.0) –
  5–8 months 18 (18.0) –
   ≥ 9 months 49 (49.0) –
Number of peers supported (since training)
  None 19 (18.6) –
  1 to 5 55 (53.9) –
   > 6 28 (27.5) –
Number of peers recommended to seek professional help (since training)
  None 58 (56.9) –
  1 to 5 39 (38.2) –
   > 6 5 (4.9) –
Number of peers, out of those recommended to seek professional help, actually sought
help (since training)
  None 65 (71.4) –
  1 to 5 24 (26.4) –
   > 6 2 (2.2) –
Number of students who submitted demographics data might not match the total number who completed the MHPSQ, due to incomplete or missing data

own decisions about their mental health;” (6) “I am aware third factor was associated with skills in handling chal-
of when I am feeling overwhelmed;” (7) “I know the dif- lenging interpersonal situations (Interpersonal Skills): (1)
ferences between self-harm and suicide;” (8) “I am able to “I find it difficult to encourage my peers to seek profes-
encourage my peers to have positive mental health.” The sional help when they need it;” (2) “I find it hard to tell
Ma et al. International Journal of Mental Health Systems (2022) 16:45 Page 6 of 11

my peers concerns in a non-judgmental way;” (3) “I tend were trained; median = 8 months), and those that were at
to focus on myself in conversations with my peers, even or below the median. For the Discerning Stigma factor,
when I don’t mean to;” (4) “I find it difficult to identify the reverse-coded item “Stigma does not affect people’s
warning signs of suicide.” willingness to seek help” (M = 0.58, 95% CI = [0.04, 1.12],
The three-factor model showed good fit (GFI = 0.92, p < 0.05) was significantly higher for peer supporters
AGFI = 0.87, RMSR = 0.03, RMSEA = 0.04, CFI = 0.97), who reported having been active for a longer period of
acceptable internal reliability (α = 0.74) and cumulatively time. There were no statistically significant differences in
explained 36.9% of the variance. Factor loadings of the total factor and item scores for the Personal Mastery and
items, eigenvalues, percent of total variance explained Interpersonal Skills factors.
and scale reliability values (Cronbach’s α coefficient) The same comparison was conducted between peer
for each of the three factors are shown in Table 2. Fac- supporters that reported having supported a number
tor correlations indicated divergent validity (correlation of recipients above the sample median (one to five
between Discerning Stigma and Personal Mastery = 0.06; recipients), and those who supported a number of
correlation between Discerning Stigma and Interpersonal recipients at or below the median. There were no sta-
Skills = 0.50; correlation between Personal Mastery and tistically significant differences in total factor and item
Interpersonal Skills = 0.02). scores for Discerning Stigma and Personal Mastery
factors. For the Interpersonal Skills factor, the reverse-
Criterion validity coded items “I find it difficult to encourage my peers
Comparison among peer supporters, by experience with peer to seek professional help when they need it” (M = 0.70,
support 95% CI = [0.18, 1.22], p < 0.01) and “I find it difficult
Mean ratings for each item and total factor scores were to identify warning signs of suicide” (M = 0.56, 95%
calculated and compared between peer supporters that CI = [0.06, 1.03], p < 0.05) were significantly higher for
reported having been active peer supporters for a period peer supporters who reported having supported more
above the sample median (calculated based on when they recipients. The total score for Interpersonal Skills was

Table 2 Summary of exploratory factor analysis results for the Mental Health Peer Support Questionnaire (MHPSQ), Singapore 2018
Factor loadings
Discerning stigma Personal mastery Interpersonal
(Factor 1) (Factor 2) skills (Factor
3)

Young people with mental illness are ­dangerousa .46 .01 .17
People with mental illness can just get over their emotional problems if they t­ rya .65 .04 .13
Serious mental health problems are ­obviousa .69 − .03 .00
Stigma does not affect people’s willingness to seek ­helpa .68 − .01 − .02
Self-care is important .14 .55 .03
Mental health stigma can be caused by media portrayals .23 .41 − .13
I am able to understand my peers with empathy .12 .67 − .04
I can talk about ways of coping with my peers -.17 .63 .06
I am confident of letting my peers make their own decisions about their mental health -.15 .37 − .11
I am aware of when I am feeling overwhelmed .06 .60 − .05
I know the differences between self-harm and suicide − .04 .53 .05
I am able to encourage my peers to have positive mental health − .12 .63 .04
I find it difficult to encourage my peers to seek professional help when they need i­ta − .03 − .01 .65
I find it hard to tell my peers concerns in a non-judgmental ­waya .04 .04 .64
I tend to focus on myself in conversations with my peers, even when I don’t mean t­ oa .11 − .02 .60
I find it difficult to identify warning signs of ­suicidea − .01 .00 .62
Eigenvalues 1.84 2.49 1.75
Percent of variance 11.0 15.5 10.4
Cronbach’s α (95% CI) .76 (.72, .79) .77 (.73, .80) .74 (.70, .78)
Only factor loadings greater than .32 are presented
a
Items were reverse scored in the questionnaire and for the factor analysis
Bold values indicate salient factor loading for each item
Ma et al. International Journal of Mental Health Systems (2022) 16:45 Page 7 of 11

also significantly higher (M = 1.67, 95% CI = [0.09, Discussion

3.25], p < 0.05) for peer supporters who reported hav- Overview
ing supported more recipients. The purpose of this study was to develop and validate an
Comparison between peer supporters and non‑peer instrument for measuring the perceived knowledge of
supporters and skills in mental health peer support among young
We calculated and compared each item and total factor adults in colleges and vocational schools in Singapore.
scores between peer supporters and non-peer support- In the current study, EFA was used to identify underly-
ers (Table 3). Peer supporters had significantly higher ing relations among measured variables on mental health
mean ratings of total factor and all item scores for all peer support. EFA uncovered three domains: discerning
three factors, except for the items “I am confident of stereotypes and prejudices (Discerning Stigma), personal
letting my peers make their own decisions about their mastery in one’s abilities and judgment (Personal Mas-
mental health” and “I am aware of when I am feeling tery), and skills in handling challenging interpersonal
overwhelmed” in the Personal Mastery factor. situations (Interpersonal Skills). These three domains
differed from the original five training topics that were
used to guide the instrument design, suggesting that the
latent constructs for mental health peer support centered
around young adults’ perception of relative ease and
challenges in applying mental health support to self and

Table 3 Results of T-Test and descriptive statistics comparing peer supporters and non-peer supporters for the Mental Health Peer
Support Questionnaire (MHPSQ), Singapore 2018
Peer supporters Non-peer 95% CI
supporters for Mean
Difference
M SD n M SD n t df

Discerning stigma
Young people with mental illness are ­dangerousa 4.15 1.42 102 3.14 1.44 306 (.68, 1.33)*** 6.12 406
People with mental illness can just get over their emotional problems if they 4.34 1.38 102 3.75 1.46 306 (.27, 0.92)*** 3.62 406
­trya
Serious mental health problems are ­obviousa 3.90 1.31 102 3.32 1.47 306 (.26, 0.90)*** 3.56 406
Stigma does not affect people’s willingness to seek ­helpa 4.51 1.40 102 3.67 1.49 306 (.51, 1.17)*** 5.00 406
Total score 16.90 3.97 102 13.88 4.41 306 (2.05, 3.99)*** 6.13 406
Personal mastery
Self-care is important 5.61 .60 102 5.32 .86 306 (.14, .44)*** 3.73 247.75
Mental health stigma can be caused by media portrayals 5.00 .89 102 4.68 1.02 306 (.09, .54)** 2.79 406
I am able to understand my peers with empathy 4.92 .78 102 4.67 .92 306 (.07, .44)** 2.69 202.73
I can talk about ways of coping with my peers 4.87 .71 102 4.43 .99 306 (.26, .62)*** 4.87 240.67
I am confident of letting my peers make their own decisions about their 4.36 .93 102 4.29 .93 306 (-.14, .28) .68 406
mental health
I am aware of when I am feeling overwhelmed 4.95 .92 102 4.77 .93 306 (-.03, .39) 1.66 406
I know the differences between self-harm and suicide 5.10 .91 102 4.72 1.05 306 (.15, .61)** 3.26 406
I am able to encourage my peers to have positive mental health 4.84 .74 102 4.47 .91 306 (.20, .55)*** 4.18 209.37
Total score 39.66 3.56 102 37.36 4.76 306 (1.42, 3.18)*** 5.17 230.43
Interpersonal skills
I find it difficult to encourage my peers to seek professional help when they 3.49 1.22 102 3.08 1.16 306 (.14, .67)** 3.02 406
need it a
I find it hard to tell my peers concerns in a non-judgmental way a 3.83 1.15 102 3.12 1.16 306 (.45, .97)*** 5.39 406
I tend to focus on myself in conversations with my peers, even when I don’t 4.04 1.36 102 3.22 1.12 306 (.52, 1.11)*** 5.49 149.60
mean to a
I find it difficult to identify warning signs of suicide a 3.57 1.12 102 3.00 1.15 306 (.31, .83)*** 4.37 406
Total score 14.93 3.64 102 12.42 3.33 306 (1.74, 3.27)*** 6.42 406
*p < .05. **p < .01. ***p < .001
a
Items were reverse scored in the questionnaire and for the analysis. Larger values indicate higher perceived knowledge/skills
Ma et al. International Journal of Mental Health Systems (2022) 16:45 Page 8 of 11

others in practice, and not how the training content was increased peer supporters’ recognition of suicide symp-
organized by consultants. Each of three identified factors toms [21] and decreased their stigmatizing beliefs [20].
had high internal reliability and criterion validity. As part Peer support training also had positive impacts on gen-
of establishing criterion validity, our study also compared eral communication skills [40, 41] and specific empa-
peer supporters across experience levels, and peer sup- thetic and reflection skills [2, 9, 28]. Peer supporters had
porters to non-peer supporters. We hypothesized that also reported self-development [40], increased confi-
peer supporters with more experience would have more dence in supporting peers [15, 20], decreased nervous-
perceived mental health knowledge and peer support ness and increased self-awareness [1]. A longitudinal
skills than peer supporters with less experience, and that study on secondary school peer supporters’ pre- and
peer supporters would have more perceived knowledge post-peer program participation found significant
and skills than non-peer supporters. improvement in peer support skills and understand-
Criterion validity ing [15], which corroborates the results from our study.
Relation between being a peer supporter and perceived These findings suggest that school-based programs that
mental health peer support knowledge and skills involve young adults in mental health training and sup-
Our study found that peer supporters, as compared to porting their peers could be an effective way to increase
non-peer supporters, were significantly more likely to young adults’ perceived mental health literacy and skills
have higher perceived ability to discern stigma, higher to cope with their own and their peers’ mental health
perceived mastery of peer support abilities and judg- issues.
ment, and higher perceived skills in handling challeng- Relation between peer support experience and perceived
ing interpersonal situations. These findings reveal robust mental health peer support knowledge and skills
criterion validity between being a peer supporter and We also found that young adults who had been peer
almost all aspects of perceived peer support knowledge supporters for a longer period of time were significantly
and skills, as all items were significantly different between more likely to recognize that stigma could affect one’s
peer supporters and non-peer supporters, except per- willingness to seek help, than those who had been peer
ceived confidence in letting peers make their own men- supporters for a shorter duration. Peer supporters who
tal health decisions and perceived awareness of feeling had supported more peers reported significantly higher
overwhelmed. This could possibly be due to deficits in perceived confidence in encouraging their peers to seek
those specific areas of training or those concepts being professional help when necessary, in identifying warn-
more resistant to change through training. In other ing signs of suicide, and in handling challenging inter-
words, despite having received training on respecting personal situations as a whole. These self-rated results
their recipients’ mental health decisions, peer supporters indicate criterion validity between peer supporter experi-
could still believe that it would be better for their recipi- ence and several components of perceived peer support
ents’ long-term wellbeing if their recipients were more knowledge and skills.
strongly encouraged to seek professional mental health Supporting more recipients was associated with sig-
help. Young adults may also either not require training nificantly increased perceived skills in handling a variety
to know when they are feeling burnt out, or the training of challenging interpersonal situations, while being peer
was not effective in improving this skill. Those who were supporters for a longer period of time was not signifi-
selected or volunteered to be peer supporters could also cantly associated with increased perceived skills. There-
be better at self-care, thus less likely to feel overwhelmed fore, these results suggest that the practical application
regardless of training. of peer support skills through interaction with recipients
These results suggest that young adults’ perceived is more strongly associated with increased perceived
mental health knowledge and peer support skills were ability in handling challenges, relative to merely having
positively associated with experience as a peer supporter. been in the peer support program for a longer period of
Strong self-efficacy has been demonstrated to motivate time. The findings also suggest that years of experience
and sustain one’s endeavors for optimal performance, and real-life application of peer support skills might be
increasing one’s attention and efforts to situational more salient than the initial training in improving per-
demands and resilience in the face of obstacles [5]. Our ceived knowledge and skills. This suggests that conduct-
results suggest that peer supporter trainings could build ing ongoing trainings and sharing expertise among peer
young adults’ self-efficacy through increasing perceived supporters could be beneficial program components that
knowledge and skills on specific domains covered in the would facilitate knowledge and skill transfers.
MHPSQ, thus possibly increasing their motivations to
be a positive pillar of support for their peers. In the peer
support literature, studies found that training programs
Ma et al. International Journal of Mental Health Systems (2022) 16:45 Page 9 of 11

Study limitations system have been largely influenced by both the East
Before discussing the implications of our results, the and the West. This could facilitate the adaptability of this
limitations of our study should be considered. First, we questionnaire to schools in other countries.
were not able to collect longitudinal data comparing peer
supporters pre- and post-training and after a follow- Implications
up period. Therefore, we were unable to determine that The implications of school-based peer support research
the peer support training and/or program had a causal for public mental health are timely. Critiques of peer
effect on improving perceived mental health knowledge support programs have been centered on the program
and skills. Nevertheless, we had a comparison group of development and implementation procedures, and the
students who did not participate in the peer support pro- program evaluation research methods. Major critiques
gram, which allowed us to examine the validity of our of these programs highlighted problems in providing
instrument and the effectiveness of these programs. We adequate peer supporter training and supervision, and
also made an initial assessment of criterion validity by underlined challenges in defining and limiting peer sup-
comparing self-ratings among peer supporters based on porter roles [8, 14, 17, 27, 30, 32]. Main criticisms of
their experience level, and we found that peer support- research evaluating these programs had centered around
ers with more experience reported higher self-ratings in the predominant use of qualitative methods, where con-
perceived knowledge and skills. Further studies should clusions were mainly based on subjective comments and
be conducted to determine whether the peer support difficult to replicate [14, 30, 41]. The success of peer sup-
training and/or experience improved students’ mental port programs and peer supporters is largely contingent
health knowledge and skills, or students with higher per- on peer supporters’ skill development through train-
ceived knowledge and skills were more likely to volunteer ing and experience in the programs. However, very lit-
or be nominated to join peer support programs. Future tle in the way of quantitatively assessing peer support
studies can administer our instrument to peer support- programs has been reported, and there is a need for an
ers pre- and post-training and at follow-up, to investi- instrument can serve as a guide for peer supporter train-
gate whether peer support training or experience plays a ing and program evaluation. Our study offers a validated
larger role in improving perceived mental health knowl- self-assessment instrument, the MHPSQ, that can be
edge and skills. Second, sample size limitations precluded administered alongside peer support training to meas-
our ability to conduct confirmatory factor analysis (CFA) ure young adults’ mental health understanding and peer
to further verify the factor structure uncovered by EFA. support skills. The MHPSQ may be used to quantitatively
A goal of future research would be to apply the instru- assess peer supporter training and young adults’ skill
ment to a separate sample to test the extent the proposed development with increasing peer support experience. In
factor structure could be replicated. Other knowledge the case of program development, the instrument could
and skill measures can also be applied to examine con- be used to assess peer supporters’ baseline perceived
vergent validity of the instrument. Third, the assessment mental health knowledge and skills, and to guide and
of perceived peer support knowledge and skills was based tailor training programs based on peer supporters’ self-
on self-reports, and young adults’ actual peer support identified needs.
practices could not be objectively verified. While the pre-
sent measures are able to assess the self-efficacy young Conclusions
adults bring to the peer support role, future research can Based on our sample, we have developed an instru-
supplement self-ratings with observational studies or ment measuring core components of peer support pro-
school counsellors’ assessment of young adults’ mental grams, with demonstrated reliability and validity in a
health knowledge and peer support skills. Third, despite nation-wide peer support initiative. The availability of
our sample size being larger than most existing studies the MHPSQ as a brief assessment tool can facilitate the
on peer support, the current study only involved colleges design and evaluation of school-based mental health peer
and vocational schools in Singapore. Thus, our results support programs. A goal of future research would be to
might not be generalizable to different cultures and edu- use CFA and qualitative methods to refine the instrument
cation systems, and the assessment instrument should items, to further validate and improve the tool across var-
be tested with other samples. School-based peer support ious implementation contexts.
programs for young adults deserve attention because of
the limited literature available on this topic, especially
Abbreviations
among countries in Asia. Our results from the Singapore MHPSQ: Mental Health Peer Support Questionnaire; EFA: Exploratory factor
context offer a unique perspective bridging Western and analysis; CFA: Confirmatory factor analysis.
Eastern cultures, as Singapore’s culture and education
Ma et al. International Journal of Mental Health Systems (2022) 16:45 Page 10 of 11

Supplementary Information 4. Badura AS, Millard M, Johnson C, Stewart A, Bartolomei S. Positive

outcomes of volunteering as a peer educator: A qualitative study
The online version contains supplementary material available at https://​doi.​
(Report No. CG 032-187). Creighton University. (ERIC Document
org/​10.​1186/​s13033-​022-​00555-6.
Reproduction Service No. ED 473426). Retrieved from EBSCOHost ERIC
database. 2003
Additional file 1. EFA model comparison statistics. 5. Bandura A. Self-efficacy mechanism in human agency. Am Psychol.
1982;37(2):122–47. https://​doi.​org/​10.​1037/​0003-​066X.​37.2.​122.
6. Barker G. Adolescents, social support and help-seeking behaviour: an
Acknowledgements international literature review and programme consultation with rec-
We would like to acknowledge the support from the Health Promotion Board, ommendations for action. Geneva: World Health Organization; 2007.
Singapore for contacting schools, reviewing the study materials and providing 7. Biddle L, Donovan JL, Gunnell D, Sharp D. Young adults’ perceptions of
tokens of appreciation. We would also like to acknowledge the participat- GPs as a help source for mental distress: a qualitative study. Br J Gen
ing schools and the school counselors for helping to coordinate the data Pract. 2006;56(533):924–31.
collection. 8. Black DR, Tobler NS, Sciacca JP. Peer helping/involvement: an effica-
cious way to meet the challenge of reducing alcohol, tobacco, and
Author contributions other drug use among youth? J Sch Health. 1998. https://​doi.​org/​10.​
QM was involved in (1) the conception and design of the study, obtaining IRB 1111/j.​1746-​1561.​1998.​tb034​88.x.
approval, acquisition of data, and analysis and interpretation of data, (2) draft- 9.  Brenton, Kelly Lynn . Report of a counselling internship at Eugene
ing the article and revising it critically for important intellectual content, (3) Vaters Academy and Junior High, St. John’s, Newfoundland, including
final approval of the version to be submitted. JG and JJ were involved in the a research project: implementation and evaluation of the effectiveness
analysis and interpretation of data, revision and final approval. JP was involved of a peer helping training program at the Junior High. Masters thesis,
in obtaining IRB approval, revision and final approval. All authors read and Memorial University of Newfoundland, 1999
approved the final manuscript. 10. Brindis C, Hair E, Cochran S, Cleveland K, Valderrama L, Park M. Increas-
ing access to program information: A strategy for improving adoles-
Funding cent health. Matern Child Health J. 2007;11(1):27–35. https://​doi.​org/​
This research did not receive grant funding from agencies in the public, com- 10.​1007/​s10995-​006-​0143-6.
mercial, or not-for-profit sectors. 11. Brindis C, Park MJ, Ozer EM, Irwin J, Charles E. Adolescents’ access to
health services and clinical preventive health care: Crossing the great
Availability of data and materials divide. Pediatr Ann. 2002;31(9):575–81. https://​doi.​org/​10.​3928/​0090-​
The datasets analysed during this study are available from the corresponding 4481-​20020​901-​10.
author on reasonable request. 12. Cronbach LJ. Coefficient alpha and the internal structure of tests.
Psychometrika. 1951;16:297–334.
13. Diver-Stamnes AC. Assessing the effectiveness of an inner-city high
Declarations
school peer counseling program. Urban Educ. 1991;26(3):269–84.
https://​doi.​org/​10.​1177/​00420​85991​02600​3002.
Ethics approval and consent to participate
14. Downe AG, Altmann HA, Nysetvold I. Peer counseling: More on an
The project was reviewed and approved by the Institutional Review Board of
emerging strategy. Sch Couns. 1986;33(5):355–64.
the Johns Hopkins University Bloomberg School of Public Health. Informed
15. Eisenstein C, Zamperoni V, Humphrey N, Deighton J, Wolpert M, Rosan
consent was obtained through the online survey platform, Qualtrics, before
C, et al. Evaluating the peer education project in secondary schools. J
participants could proceed to complete the online surveys.
Public Ment Health. 2019. https://​doi.​org/​10.​1108/​JPMH-​07-​2018-​0048.
16. Fabrigar LR, Wegener DT, MacCallum RC, Strahan EJ. Evaluating the
Consent for publication
use of exploratory factor analysis in psychological research. Psychol
Not applicable.
Methods. 1999;4(3):272–99. https://​doi.​org/​10.​1037/​1082-​989X.4.​3.​272.
17. Fennell R. A review of evaluations of peer education programs. J Am
Competing interests
Coll Health. 1993. https://​doi.​org/​10.​1080/​07448​481.​1993.​99363​36.
The authors declare that they have no competing interests.
18. Goodman R, Ford T, Meltzer H. Mental health problems of children in
the community: 18 month follow up. BMJ. 2002;324(7352):1496–7.
Author details
1 https://​doi.​org/​10.​1136/​bmj.​324.​7352.​1496.
Department of Mental Health, Johns Hopkins University Bloomberg School
19. Gulliver A, Griffiths KM, Christensen H. Perceived barriers and facilita-
of Public Health, 624 North Broadway Street, 8Th Floor, Baltimore, MD 21205,
tors to mental health help-seeking in young people: a systematic
USA. 2 Department of Mental Health, Johns Hopkins University Bloomberg
review. BMC Psychiatry. 2010;10(1):113. https://​doi.​org/​10.​1186/​
School of Public Health, 624 North Broadway Street, Baltimore, MD 21205,
1471-​244X-​10-​113.
USA. 3 Department of Mental Health, Johns Hopkins University Bloomberg
20. Hart LM, Morgan AJ, Rossetto A, Kelly CM, Mackinnon A, Jorm AF.
School of Public Health, 624. North Broadway Street, Baltimore, MD 21205,
Helping adolescents to better support their peers with a mental health
USA. 4 Department of Psychiatry and Behavioral Sciences, Johns Hopkins
problem: a cluster-randomised crossover trial of teen mental health
University School of Medicine, Johns Hopkins Bayview Medical Center, 5300
first aid. Aust N Z J Psychiatry. 2018;52(7):638–51. https://​doi.​org/​10.​
Alpha Commons Dr, Baltimore, MD 21224, USA.
1177/​00048​67417​753552.
21. Hennig CW, Crabtree CR, Baum D. Mental health CPR: Peer contract-
Received: 10 December 2020 Accepted: 25 August 2022
ing as a response to potential suicide in adolescents. Arch Suicide Res.
1998;4(2):169–87. https://​doi.​org/​10.​1080/​13811​11980​82604​46.
22. Hsi T, Chung YLA. Peer helpers: Bridging the gap between the student
community and the university’s counseling service. Paper presented at
the 12th Asia--Pacific Student Services Association Conference 2010.
References
2010.
1. Abu-Rasain MHM, Williams DI. Peer counselling in Saudi Arabia. J Adolesc.
23. Jackson JE. Oblimin rotation. In: Armitage P, Colton T, editors. Encyclo-
1999;22(4):493–502. https://​doi.​org/​10.​1006/​jado.​1999.​0243.
pedia of biostatistics. Chichester: John Wiley and Sons Ltd.; 2005. p.
2. Aladag M, Tezer E. Effects of a peer helping training program on helping
3800.
skills and self-growth of peer helpers. Hague. 2009. https://​doi.​org/​10.​
24. Kessler R, Amminger G, Aguilar-Gaxiola S, Alonso J, Lee S, Üstün T. Age of
1007/​s10447-​009-​9082-4.
onset of mental disorders: a review of recent literature. Curr Opin Psychia-
3. Anderson JE, Lowen CA. Connecting youth with health services: System-
try. 2007;20(4):359–64. https://​doi.​org/​10.​1097/​YCO.​0b013​e3281​6ebc8c.
atic review. Can Fam Physician. 2010;56:778–84.
Ma et al. International Journal of Mental Health Systems (2022) 16:45 Page 11 of 11

25. Kim TK. T test as a parametric statistic. Korean J Anesthesiol.

2015;68(6):540–6. https://​doi.​org/​10.​4097/​kjae.​2015.​68.6.​540.
26. Laski L. Realising the health and wellbeing of adolescents. BMJ. 2015.
https://​doi.​org/​10.​1136/​bmj.​h4119.
27. Lewis MW, Lewis AC. Peer helping programs: helper role, supervisor train-
ing, and suicidal behavior. J Couns Dev. 1996;74(3):307–13. https://​doi.​
org/​10.​1002/j.​1556-​6676.​1996.​tb018​71.x.
28. Martin AA, II. The effectiveness of Christian adolescent peer counselor
training: a controlled study. Available from ProQuest Dissertations &
Theses Full text: the humanities and social sciences collection. 1998.
29. Ministry of Health Singapore, Ministry of Education Singapore. NurtureSG
action plan report. Singapore: Ministry of Health Singapore & Ministry of
Education Singapore; 2016.
30. Morey RE, Miller CD, Rosén LA, Fulton R. High school peer counseling: the
relationship between student satisfaction and peer counselors’ style of
helping. Sch Couns. 1993;40(4):293–300.
31. Myers ND, Ahn S, Jin Y. Sample size and power estimates for a confirma-
tory factor analytic model in exercise and sport: a Monte Carlo approach.
Res Q Exerc Sport. 2011;82(3):412–23. https://​doi.​org/​10.​1080/​02701​367.​
2011.​10599​773.
32. Myrick RD, Folk BE. The power of peervention: a manual for the trainers of
peer facilitators. Minneapolis: Educational Media Corporation; 1999.
33. Ng TP, Jin AZ, Ho R, Chua HC, Fones CSL, Lim L. Health beliefs and help
seeking for depressive and anxiety disorders among urban Singaporean
adults. Psychiatr Serv. 2008;59(1):105–8. https://​doi.​org/​10.​1176/​appi.​ps.​
59.1.​105.
34. Norman GR, Streiner DL. Biostatistics: the bare essentials. 4th ed. Shelton:
PMPH USA; 2014.
35. Pearson K. On the criterion that a given system of deviations from the
probable in the case of a correlated system of variables is such that it can
be reasonably supposed to have arisen from random sampling. Philos
Mag Series. 1990;50(302):157–75.
36. Pett MA, Lackey NR, Sullivan JJ. Making sense of factor analysis: the use of
factor analysis for instrument development in health care research. Los
Angeles: SAGE Publications Inc.; 2003.
37. R CoreTeam. R: A language and environment for statistical computing.
Vienna: R Foundation for Statistical Computing; 2018.
38. Robinson SE, Morrow S, Kigin T, Lindeman M. Peer counselors in a high
school setting: Evaluation of training and impact on students. Sch Couns.
1991;39(1):35–40.
39. Singapore population. 2018. http://​world​popul​ation​review.​com/​count​
ries/​singa​pore-​popul​ation/. Accessed 13 Dec 2018.
40. Spielman S, Hughes K, Rhind S. Development, evaluation, and evolution
of a peer support program in veterinary medical education. J Vet Med
Educ. 2015;42(3):176–83. https://​doi.​org/​10.​3138/​jvme.​1114-​115R.
41. Steinbauer L. The effects of a high school peer counselor training pro-
gram on the self-appraisal skills and the interpersonal skills of the trained
peer leader. ProQuest Dissertations & Theses Full text: the humanities and
social sciences collection. 1998.
42. Stokes DR, Gonzales M, Rowe D, Romero D, Adams M, Lyons S, Rayfield
GE. Multicultural peer counseling: a developmental perspective and
rationale. J Couns Dev. 1988;67(1):55–6. https://​doi.​org/​10.​1002/j.​1556-​
6676.​1988.​tb020​12.x.
43. Subramaniam M, Abdin E, Vaingankar JA, Shafie S, Chua BY, Sambasivam
R, et al. Tracking the mental health of a nation: prevalence and correlates
of mental disorders in the second Singapore Mental Health Study. Epide-
miol Psychiatr Sci. 2019. https://​doi.​org/​10.​1017/​S2045​79601​90001​79.
Ready to submit your research ? Choose BMC and benefit from:
44. Tabachnick BG, Fidell LS. Using multivariate statistics. Boston: Allyn and
Bacon; 2001.
• fast, convenient online submission
• thorough peer review by experienced researchers in your field
Publisher’s Note • rapid publication on acceptance
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations. • support for research data, including large and complex data types
• gold Open Access which fosters wider collaboration and increased citations
• maximum visibility for your research: over 100M website views per year

At BMC, research is always in progress.

Learn more biomedcentral.com/submissions