Routes to Wellness

Co-designing a peer-led community approach to support the mental health of refugees
Hope in Plymouth artwork depicting a boat in the sea heading towards Smeaton's tower in Plymouth UK. 
Project title: Routes to Wellness
Project duration: May 2022–May 2025
Project partners: University of Plymouth, Plymouth City Council, Livewell Southwest, University of Exeter, Students and Refugees Together, Devon & Cornwall Refugee Support, Head Space, Gloucester Action for Refugees and Asylum Seekers
 
Funded by the National Institute for Health Research (NIHR), this study aims to co-design a peer support model for improving refugees’ mental health and wellbeing.
The study will harness the collective skills of refugees, researchers, and service providers to develop and evaluate a peer-led model to support the mental health of refugees.
This approach will use narratives to create a shared language about mental health. Peer support workers (PSWs) will work with refugees and use this shared language to identify health goals and help them access support.
Routes to wellness logo 
Figure 1. Logo
Figure 2. Tanbur 
Figure 2. Tanbur

Project overview

The process of displacement and resettlement often contributes to higher levels of mental distress for refugees. Researchers Debra Westlake, Kristin Liabo and Helen Lloyd met with refugees and service providers to co-design a study on this topic. Together, refugees and providers identified that access to health care could be challenging for displaced people due to language barriers and a lack of understanding of how to access help. These factors contribute to the adverse health outcomes experienced by refugees as one of the most vulnerable groups within the UK. Refugees and providers wanted to know if peer support might improve the mental health of refugees, but the team found a dearth of research from the UK on how to support refugees using these models in the UK.
We will use Experience-based Co-design to develop the PSW model, which will be tested in a 9-month trial in Plymouth and Gloucester using qualitative methods. Interviews, observations, and focus groups with refugees and professionals will provide data to help us identify key issues known as emotional ‘touchpoints’. Touchpoints capture significant personal and subjective experiences in relation to service needs and health concerns. Over a series of eight co-design workshops with providers and users, touchpoint data will be used to help shape the PSW model. These workshops will also develop the PSW training and delivery manuals, refugee-facing materials, and help identify outcome to measures for a future trial.
A workshop will also help us refine the programme theory of how the model will work.
Data collected and evidence from our literature review will inform this process along with refugee and service involvement during the workshops, which will consist of around 20 people. The outputs from these workshops will be presented at a community event to invite further feedback.
Six PSWs will receive training to provide the new support model. The workers will then work with up to 10 refugees each over a 9-month period. PSWs will enter into a narrative dialogue with each refugee to help understand what is contributing to their distress and help them identify mental health goals to improve this. They will also help them identify suitable community activities and services to help them achieve their goals.
We will interview refugees in contact with PSWs at three time points to assess their experiences of the PSW model; if it is acceptable, and if and how it has been helpful. PSWs will be interviewed to garner their experiences of delivering the model and what benefits or disbenefits they might have experienced. Data from interviews and focus groups will inform adaptations to the approach. Tests of the PSW model will run in both Plymouth and Gloucester.
Figure 3. Friendship 

Figure 3. Friendship 

 

Logo design

Art workshop, figure 5. 
Figure 5. Photo from the art workshop
Art workshop, figure 6. 
Figure 6. Tanbur drawing in action

Logo design workshop with public contributors

The logo and images used in this page were designed by the project’s public contributors in an art workshop co-facilitated with Devon & Cornwall Refugee Support. Through drawing and painting, the contributors convey how they make sense of the “Routes to Wellness” project.
The Routes to Wellness logo (Fig.1) was produced by one of the workshop attendees; with the heart shape representing the letter R and cardiogram representing letter “W”. W is combined with the letter “O’’ creating an image of a person which adequately illustrates our person-centred approach to mental health.
Another contributor expresses “Routes to Wellness” by creating an image of representing friendship support (Fig. 3). In addition, traditional Kurdish music instrument “tanbur” (or “buzuq”) was drawn to represent the memory of participating in locally held music events in Devonport (Fig. 2), where there were brown and green colours at the place. The instrument would worn through time, therefore the dry brush of brown in between the green and brown crescents to tell the time and the uses of the instrument.
A contributor painted a woman figure in a boat heading towards Plymouth’s Smeaton's Tower surrounded by a whale which is the contributor’s dream to witness. The women’s heart opens with a hole representing low feelings, nevertheless, a robin emerges symbolising her hope for the future.
 

Workshops

Image of work created during a Routes to Wellness workshop 
Image of work created during a Routes to Wellness workshop

Finding a common language

On 26 April 2023, researchers, public contributors, interpreters came together for the first time! We started by introducing ourselves and the experience around our favourite food. Some very delicious dishes and recipes were shared: biriyani, tacos, dolma, pizza... Through these exercises, we explored the idea of experiences – we shared our own experience and learnt about the experiences of others.
After that, we looked into some of the experiences that were shared with the researchers in the previous phase – touchpoints – which include the contact with services, concerns around interpreting services, helping and supporting each other, and more.
We discussed and reflected on these touchpoints. We shared our thoughts in group discussions. We wrote post-its and collated images to express feeling and ideas.

How will this work?

Our 'How will this work' workshop took place on 26 May 2023. We started with a warm up activity of sharing our favourite music – see our playlist of the songs and artists mentioned by the participants. Beyond this list, rock, reggae, classic, upbeat and salsa dancing music are some of our favourite genres!
We worked in five small groups on themes of faith and beliefs, connection, contact with services, health and language. We started with playing the “if-then-because” cards where we discussed the potential outcomes of certain experiences. For example, the card “if I can talk to someone” prompted the response of “then I learn something and get experiences and ideas” which matches to a because card: “I feel that someone also shares the same experiences and I am not alone.”
From this exercise, we came up with valuable insights on how some interactions help people to feel better and be more willing to share while others don’t. The importance of trust and active listening were also highlighted.
Routes to Wellness workshop
Routes to Wellness workshop - notes and photos on a board

How will this work? II

After the ‘How will this work?’ workshop, we reflected on the previous two workshops: what was working and what topics might have been missed. We found that although the methods of using images, drawing and card games worked well, the figure of a peer-support worker needed to be more personalised and embodied.
We came up with a few ideas around scenario acting—simulating interactions between a peer support worker and the person recieveing support. We discussed with public contributors and decided that we could naturally read out scripts instead of acting the scenarios, which could make some feel uncomfortable.
The scripts covered some of the themes that had not been highlighted before, but which are crucial to peer support work and refugees’ context, including boundaries, uncertainty and worry about finding work, communicating with family back home, assumptions about cultural or religious preferences.
In each of the four groups, we had two ‘actors’, one facilitator and a group of public contributors as the directors. We used a camera to record the scenario reading and we paused to ask ourselves the questions: What might the peer support worker do next? How will that help? Many challenging but important discussions followed. Participants’ contributions and suggestions continued to shape the design of Routes to Wellness’ peer support worker programme.

‘How to become a peer support worker?’

At the end of July 2023, public contributors gathered once again to dive into a series of complex issues around peer support workers recuritment, training, support, supervision and mentoring.
In groups, contributors created several journey maps as they discussed steps required to become a peer support worker, and a method of ‘crazy 8’ was used in the service providers’ group to prompt ideas and discussions around training for peer-support workers.
Some of the key ideas which emerged, along with implications requiring consideration: Do we provide training as part of the recruitment process? Is role play suitable in the recruitment stage? Where do peer support workers get the support from?
We are carrying on with the co-design process and the contour of a peer-support worker programme is slowly emerging.
Peer-support-worker toolkit mapping
Measuring the outcome of peer support work

Peer-support-worker toolkit mapping

In September, we held the fifth workshop in Plymouth. Using textile and yarns, public contributors and researchers delved into the details of terms of engagement between peer support worker and refugees.
We kicked off with a fun and challenging game of writing a word together using only one marker. We had to constantly communicate with one another and negotiate our stength in moving the pen in the right direction.
In groups, public contributors jotted down on a piece of cloth what they might be able to share as a conversation starter with a peer support worker. We then connected the common topics together with yarns across the room. Topics such as children’s issues, GP access, racism, feeling lonely and missing family were shared across the room. These topics could be what peer support workers look out for when they start to engage with people they support.
We also explored the tools of communication between a peer support worker, service providers and service users. The contributors emphasised the importance of partnership working, knowledge of how local services work, boundaries-setting, and effective signposting.

Finding out if our peer support model is working

In this sixth workshop, contributors in Plymouth came together to think about how we might measure the outcome of the peer support work. In groups with topics of stigma, social support and resilience, we discussed the potential ways of knowing whether persons who receive support have improve in different aspects of their wellbeing.
We went through some existing questionnaires and the “I-statements” we wrote, and discussed whether they made sense, what could be useful and what to avoid. We gathered important suggestions about the language and wording used in the questionnaires and statements and the pros and cons of face-to-face conversations as a way to evaluate. We also ranked the tools that can be used to complete a questionnaire.
Service providers raised the concern that evaluation might affect peer support worker’s motivation as some outcomes are not within their control. However, contributors agreed that regular communication and a mix of formal and informal follow-ups could help. In the third phase of the project as we trial the model, ways of evaluation will be an ongoing development.
 

Collaborators

Adele Owen
Gloucestershire Action for Refugees and Asylum Seekers (GARAS)
Dr Al-Noor Abdullah
Coventry University
Yeshi Adhanom
Students and Refugees Together (START)
Celia Edwards
Livewell Southwest
Professor Glenn Robert
Kings College London
 

Research team

Funding

NIHR Health and Social Care Delivery Research
*The funded project is titled ‘Forced to Flee: Co-designing a peer-led community approach to support the mental health of refugees’, however, with the input of public contributors, the public-facing title is “Routes to Wellness”.
 

Relevant links

Routes to Wellness newsletters

Hope in Plymouth artwork depicting a boat in the sea heading towards Smeaton's tower in Plymouth UK.