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Letters to the Editor, Late October 2004

I Introduction

This week we have a number of letters in response to our recent feature articles: OHPE Bulletin 380.1 Self-Help and Peer Support Strategies in Maternal, Newborn, and Family Health (, OHPE Bulletin 382.1 Towards A Bully Free Canada (, and OHPE Bulletin 384.1 Best Practices In Chronic Disease Prevention (

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II Self-Help and Peer Support

A. Distinguishing Between Self-Help, Peer Support, and Peer Education

The September 24, 2004, Ontario Health Promotion E-Maill Bulletin (380.0) contained an interesting synopsis of an environmental scan and needs assessment regarding the use of self-help/peer support strategies in maternal, newborn, and family health promotion. The

study provided worthwhile information about how peer support is perceived (valuable, worthwhile, essential, and distinct from other types), but it had almost nothing to say about self-help.

As a matter of fact the article fails to make any distinction with regards to the differences between self-help, peer support, and peer education. At times the report treats at least peer support and self-help as the same and at other times details results that pertain only to peer support but applies them to both peer support and self-help.

Nowhere in the study do the authors clarify what is meant by either term. Both these approaches are extremely important in the continuum of care and health, but too often they are jumbled together. While the Best Start Resource Centre (BSRC) and the Self-Help Resource Centre (SHRC) are both top-notch organizations, their expertise in the area of peer support is not clear.

Formal peer support is a process whereby trained and supervised volunteers provide a variety of types interpersonal, educational, and practical assistance to others who are perceived to be peers. At times this can be these can be peer volunteers with similar experiences and background to their peers (identical maternal issues, for example) and at other times they may have common characteristics with peers (both mothers, for example) but not similar experiences.

National standards have been created for formal peer support, but my guess is that neither BSRC or SHRC know about these standards and therefore could not use them as a benchmark to assess the success of peer support as a strategy. This does not negate what they did find out about it; that is, the power of peers in influencing the support experience. Turning this on its head, it could even be that informal peer support may be more effective than formal peer support. Some

researchers have expressed the view that "professionalization" of peer support (setting standards, policies, guidelines, delivery requirements, etc.) may actually decrease the influence of peers.

Rey Carr, Ph.D.

B. Response from SHRC

The full report on our needs assessment (available on request) includes a discussion of terminology under "statement of the issue" as well as references to various research studies (which our survey was not) on self-help and peer-support strategies.

In our experience at the Self-Help Resource Centre, the community-based history of self-help/peer support initiatives has made it difficult for professionals to solidify discreet definitions of terms used--these often vary depending on the issue focus (e.g., mental health or physical health), community (e.g., mainstream or aboriginal), organization, and/or country. Sometimes, in both lay and professional circles, self-help means self-care; sometimes it means mutual aid. Sometimes peer support means an informal support group, sometimes it refers to lay peer helpers trained and supervised by professionals. This is a language challenge we face every day.

Since our aim in collaboration with Best Start Resource Centre was to scan the environment and assess needs of those using self-help/peer-support strategies in Maternal, Newborn and Family Health with a broad stroke, we used the term "self-help/peer-support strategies" to encompass a full spectrum of approaches including (as per the survey): member-led support group, referral of clients to self-help groups in the community; promoting strategies on-site (e.g,. flyers on bulletin board), telephone support line staffed by peers, one-to-one counselling by peers, peer "buddy" program, peer workers (paraprofessionals), professionally-led support group, peer educators/mentors, ethno-specific peer support activities, and fostering the development of peer support networks within educational programs. We feel that anyone (lay or professional) using one or more of these strategies is integrating self-help/peer support strategies in their health promotion efforts. These are the community of health promoters we sought to survey and that we hope to better serve.

For those seeking more theoretical definitions, the conceptual model that I find most useful--building on recognized research in the fields of self-help and peer support--is that presented by Cindy-Lee Dennis in her 2003 article "Peer support within a health care context: a concept analysis." Dennis' model focuses on created "peer relationships" and then differentiates between groups or one-to-one strategies with no (or limited) professional involvement and groups or one-to-one strategies with professional involvement. This spectrum of professional involvement highlights the importance of Rey Carr's comments in relation to the "professionalization" debate. At SHRC we encourage and support people to recognize where their work stands on the spectrum of peer versus professional leadership, to understand the complementary strengths and limitations of these elements, and to regularly evaluate and improve on their efforts in relation to their distinct group or program goals.

Gillian Kranias,

Coordinator, Ontario Self-Help Network Program,

Self-Help Resource Centre

Article reference: Dennis, C.L., (2003). Peer support within a health care context: a concept analysis. International Journal of Nursing Studies, 40, 321-332.

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III East End Community Health Centre's Safer Schools Initiative

East End Community Health Centre's Safer Schools Initiative in local elementary schools is in its fifth year of operation. Our main resource has been Bully- Proofing Your School: A Comprehensive Approach for Elementary Schools by Garrity et al., though we have used many other resources to develop the program. Funded initially by the City of Toronto Breaking the Cycle of Violence grants, we are now using core funds for a community health worker to work with each interested school on a whole school approach to bullying.

We began with a two-year program in one school. We did an intensive data gathering exercise at the beginning, the one-year, and the final points. Some of the data has been pulled into an evaluation, but it may be of interest to evaluators to use our data to develop a more in-depth evaluation. The findings suggest that both students and staff underwent a significant shift in their perception of the causes of bullying behaviours and understood the importance of taking action to intervene when bullying occurs. Incidences of bullying decreased in general (with some interesting exceptions) and student bystander intervention increased.

Not all schools are interested in an intensive, evaluated two-year project, so since completing that project, we have continued to work with schools in a variety of ways. With each school we work with, there are three key challenges:

1. The principal has to be on board. We've had teachers, parents, or both approach us to work with their school. When the principal refuses to accept there is a bullying concern or that bullying prevention would be valuable success is impossible, even when they give us the go-ahead.

2. Teachers, parents, and administrators frequently feel that the bullying problem is about the children. We have a policy of refusing to work with the children unless we are also working on one or more of school policy, teacher education about the definition of bullying, a curriculum for teachers to do with the children, and parent and teacher involvement.

3. Our most successful involvement is in schools where the adults are implementing some sort of whole school approach to improving relationships between everyone in the school. This is not always a bullying program but we can bring in elements of anti-bullying when the school is using a whole school approach to anything that impacts on bullying. Sometimes the piece we add is the social skills program for children. From a community agency perspective, we have found that while bullying is a much broader issue than can be resolved with an in-school approach, the most success comes where there is a whole school approach that is sustainable beyond our involvement.

4. From the schools' perspective, there is no point in involving community agencies where there is no commitment to long-term partnership or where there is a Pollyanna belief that an outside program or agency will solve the problem. There is a proliferation of programs that are overwhelming school administrators and teachers and outside involvement that is not sustained or based on school reality is worse than useless.

This is a health care issue. Our clinical team has been very concerned about their clients who have been physically hurt and/or are experiencing depression due to severe bullying at school--the problems are often intractable. Our experience in individual advocacy has not been successful. Board members are unable to impact on individual school difficulties and superintendents are reluctant to confront principals. At the same time, when we approach schools about the general issue of bullying we have found administrators, teachers, and parents who are delighted to have community support to take action on these kinds of concerns in their schools. As in all health issues, in a very concrete way a health promotion approach to bullying is much more successful than intervention after the fact.

Barbara Neuwelt

Program Coordinator

East End Community Health Centre

Toronto ON

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IV Best Practices

A. Seniors and Chronic Disease Prevention

Just a thought...As with so many other studies being undertaken these days, reference is made to the importance of the issue in light of the looming demographics and reality of the aging of the population. I am delighted that, finally, we are voicing this important trend, and certainly chronic disease prevention is an important issue for the older adults of today...and those of us who follow. However, I see no mention of seniors' organizations being included in the Advisory committees and/or as stakeholders in the work done on Best Practices In Chronic Disease Prevention. Perhaps this reference was simply excluded in this summary . In general, I urge all those undertaking research in areas touching on the lives of older folks to include these experiential experts in every stage of your work --your work and your perspective will be greatly enhanced through their valuable contributions.

Randi Fine, Executive Director

Older Persons' Mental Health and Addictions Network of Ontario

Tel- 416-782-1601


B. Additional Web Resources

Anne Lessio forwarded these additional best practices resources. The original list is at

PTCC's Better Practices Toolkit for tobacco control resources

CCO's Review of Nutrition Interventions for Cancer Prevention

Information about the IDM model for best practices and contains numerous resources

A website which promotes discussion regarding best practices ideas and makes the application of best practices easier

Ontario Public Health Research, Edication and Development (PHRED) Program: the effective pubic health practice project

Centre for evidence-based public health policy

USA's CDC's guide to community preventative services

Nova Scotia's best practices approach to health promotion framework