Mental Health & Prevention 14 (2019) 200164

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Mental Health & Prevention

journal homepage: www.elsevier.com/locate/mhp

Peer counseling for mental health in young people – Randomized clinical T

trial –
Hiroki Nozawaa,b, , Kazunori Ikegamia, Satoshi Michiia,c, Ryosuke Suganoa,d, Hajime Andoa,
⁎

Hiroko Kitamuraa,e, Akira Ogamia

a
Department of Works Systems and Health, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, 1-1, Iseigaoka, Yahata-nishi-
ku, Kitakyushu, Fukuoka 807-8555, Japan
b
Hatano Factory, Stanley Electric Co., Ltd., 400 Soya, Hadano-shi, Kanagawa 257-8555, Japan
c
Suzuka Factory, Honda Motor Co., Ltd., 1907, Hiratacho, Suzuka-shi, Mie 513-8666, Japan
d
Sony Corporate Services (Japan) Corporation, 1-7-1, Konan, Minato-ku, Tokyo 108-0075, Japan
e
Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan

ARTICLE INFO

Keywords:
Peer counseling
Young people
Mental health
Facilitator
Randomized clinical trial

1. Introduction Currently, many schools and workplaces provide support systems

In recent years, Japan has experienced an increase in the prevalence
of impaired mental health in young people. According to participant
surveys implemented by Japan's Ministry of Health, Labour and
Welfare, the proportion of out-patient clinic visitors in their 20 s with
mental disorders increased markedly from 1999 to 2014 compared to
laborers in other age strata among the general population. The pro-
portion increased approximately 3-fold for mood disorders and ap-
proximately 2.5-fold for neurotic disorders, stress-related disorders, and
somatoform disorders (Ministry of Health, Labour, & Welfare, 2014).
Moreover, the number of young employees taking workplace leave due
to psychiatric diseases and the number of recorded labor accidents re-
lated to mental disorders have increased (The Institute of Labour
Administration, 2008). One study reported that many mental health
problems such as depression, anxiety, drug and alcohol use, and sui-
cidal ideation, self-harm, and suicide increase significantly in adoles-
cence and young adulthood (Burns & Birrell, 2014). It is therefore of
paramount importance to take preventive measures against impaired
mental health in young people. Many mental health support measures
such as counseling and mental health training with specialists are
provided as preventive strategies for young people.
for young people with mental health problems, including consultations
with specialists, training on mental health, and consultation liaisons.
Many Japanese employee assistant program (EAP) service providers
also offer services to support those with mental health concerns or
disorders. However, these systems involve recruitment of outside spe-
cialists, increased workloads on internal staff, and high costs associated
with service introduction and operation. Therefore, it is not feasible to
introduce these systems to small schools and business sites with low
management resources.
Peer counseling may be introduced as an alternative approach for
such schools and businesses. Peer counseling is a consultation-support
approach where colleagues and other individuals in similar demo-
graphic positions mutually listen to an individual's problems, feel
sympathy, and offer solutions. Peer counseling was first developed in
the United States in the 1970s as a measure to support disabled in-
dividuals with mental health problems, and was introduced to Japan in
the 1980s. The method was initially used to provide mutual consulta-
tions to disabled individuals and was subsequently used to support their
families (Higashimura, 2006). Thereafter, a number of studies reported
that peer counseling ameliorated mental pain and depressive symptoms
in individuals with breast cancer (Giese-Davis et al., 2006, 2016;

⁎
Corresponding author at: Department of Works Systems and Health, Institute of Industrial Ecological Sciences, University of Occupational and Environmental
Health, 1-1, Iseigaoka, Yahata-nishi-ku, Kitakyushu, Fukuoka 807-8555, Japan.
E-mail address: h-nozawa@med.uoeh-u.ac.jp (H. Nozawa).

https://doi.org/10.1016/j.mph.2019.200164
Received 18 August 2018; Received in revised form 3 May 2019; Accepted 12 May 2019
Available online 13 May 2019
2212-6570/ © 2019 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
H. Nozawa, et al.
Schover et al., 2006) and decreased smoking in habitual smokers
(Malchodi et al., 2003), suggesting that this approach may be effective
for mental health care for those in similar demographic positions or
with similar troubles. We hypothesized that peer counseling may pro-
mote mental health with minimum support from outside specialists and
financial investment, making it suitable even for small schools and
business sites.
The objectives of the present study were to create a mental health
training tool based on peer counseling to prevent mental health con-
cerns in young individuals and to evaluate the effects of these inter-
ventions on the maintenance and promotion of mental health to de-
crease the risk for psychological distress.
2. Material and methods
2.1. Study design and participants
This study was conducted from August 2015 to February 2016.
Participants were recruited from among third-year university students
in Fukuoka Prefecture, Japan, and given an explanation about the
nature of the study. We targeted third-year students because their lec-
ture curriculum was uniform and less variable, there were fewer factors
that were likely to affect their mental health, such as academic tests or
employment seeking, during the intervention period, and the subjects
were accustomed to university life by this stage. Criteria for partici-
pation in this study were no history of treatment for mental illness or
disorders, and not currently receiving treatment such as medication or
counseling for mental illness or disorders. Medical doctors confirmed
satisfaction of the criteria when obtaining informed consent by asking
each participant whether or not they had a history of treatment for
mental illness or disorders.
A power analysis was performed with an alpha error of 0.05, a
power of 0.08, and an effect size of F = 0.25 for comparison between an
intervention and control group. This analysis indicated that the re-
quired sample size was 34. We therefore sought to recruit a target of 34
or more participants. Participants were recruited based on their ful-
fillment of the inclusion criteria, as confirmed by medical doctors, and
no students were excluded. The recruited students provided consent
and were enrolled in this randomized clinical trial. Despite the power
analysis indicating a target population of 34, we were only able to re-
cruit 27 participants (13 men and 14 women). Because the recruitment
of more participants was considered difficult, we ended the recruit-
ment.
Two facilitators responsible for supporting the peer counseling in-
terventions were randomly selected from among the participants. Both
were typical university students who had not received special training
in mental health or counseling in the past. The remaining 25 partici-
pants were allocated to one of two groups by the research leader, an
intervention group (n = 13) or a control group (n = 12), using the
permuted block randomization method based on a table of random
numbers. The groups to which the participants were assigned will be
published after the study.
2.2. Development of the peer counseling training manual
We prepared a training manual prior to starting the study. In the
development of the training manual, we referred to the “Practical
Manual for Peer Counseling” developed by the Japan Peer Counseling
Study Group (Takamura, 2005) and the basic concepts and listening
methods of counseling in the “Learning the attitude of active listening”
(Mishima, Kubota, & Nagata, 2000). Everyone involved in the devel-
opment of the peer counseling manual is a qualified medical doctor
with research specialization in preventive medicine. One of the devel-
opers is a researcher in mental health and a careers consultant, and two
of the developers have experience working as an occupational physician
at a school. Brainstorming on the structure of the manual and the items
2
Mental Health & Prevention 14 (2019) 200164
for implementation was performed in advance. The key items included
“ability to implement the intervention with little cost burden in a short
time,” “ability to gain basic mental health knowledge and learn the
concept of peer counseling,” “provision of an easy-to-understand defi-
nition for peer counseling,” “provision of a simple peer counseling
procedure and example titles about college life for discussion in peer
counseling,” and “ability to implement the intervention with minimum
support from specialists.” Other considerations included “minimize the
quantity of handouts,” “simplify the contents of handouts, and use ta-
bles, figures, and illustrations to facilitate visual understanding,” “en-
sure applicability to a broad range of personal situations,” and “focus
on lighter themes immediately after the introduction, such as things
that are fun and pleasing, and subsequently on heavier themes that are
more difficult to discuss, such as things that participants find painful
and emotional, after they have become accustomed to the interven-
tion.” A pilot survey was trialed at a small business and the final
training manual comprised a total of 11 pages, including the opinions of
the survey participants. The table of contents of the training manual is
shown in Table A.1.
After development of the peer counseling training manual, the
contents of the peer counseling sessions were reviewed for im-
plementation of the intervention with the manual. The contents of the
sessions were determined based on our preliminary study.
2.3. Training of facilitators
Before starting the interventions with the participants, we trained
two female facilitators on to how to provide lectures and drills using the
peer counseling training manual for about 1 h. The contents of the
training included basic knowledge on mental health, the concept of
counseling, and the objectives and procedures of the peer counseling
sessions.
2.4. Interventions
After the facilitators were trained, a total of 4 sessions of peer
counseling (twice weekly for 2 weeks) were provided to the interven-
tion group. All members of the intervention group, including the fa-
cilitators, received the peer counseling manual. First, the trained fa-
cilitators provided an explanation of the basic knowledge on mental
health and counseling, an outline and the objectives of the peer coun-
seling sessions, and the procedure of peer counseling in accordance
with the training manual. Thereafter, the facilitators answered parti-
cipants’ questions about the contents of the manual and the peer
counseling method.
After the facilitators’ explanations and the question and answer
session, the participants underwent peer counseling in groups of 3 to 4
for about 30 min. In each group, a leader was selected to choose a
theme concerning university life for discussion. The actual themes
discussed in all groups were about club activities because many of the
subjects participated in club activities. Each group member talked
about his or her experience and feelings such as joy, anger, and sadness
towards a subject associated with the theme for about 2 to 3 min, after
which the group members commented on the presenter's experience for
about 1 min. Participants were not to object to any comments, but were
to express sympathy and to agree with the other participants and accept
the ideas of others even if they differed from their own. Once all group
members had presented and commented, the group leader provided
feedback on all of the presentations and ended the peer counseling
session. The facilitators checked the progress in each group during the
peer counseling sessions and provided suggestions and advice to sup-
port the progress of the sessions. Details of the peer counseling proce-
dure are shown in Table A.2.
Among the 12 members of the intervention group, six participated
in all four interventions, while the other six participated in three of the
four interventions. Among the latter six participants, one missed the
H. Nozawa, et al.
first session, two missed the second, two missed the third, and one
missed the fourth. The first intervention was conducted for approxi-
mately 1 h, including the time for the explanation by the facilitator and
the question and answer session. The other three interventions were
conducted for approximately 30 min each.
Instead of peer counseling, the control group was provided with 4
leaflets about general health issues, including the prevention of food
poisoning and infections for 2 weeks.
2.5. Evaluation
We hypothesized that this intervention would promote commu-
nication and improve listening skills, and that, through communication
and listening, this program may be an effective stress-coping strategy to
reduce the stress response. We used the Active Listening Attitude Scale
(ALAS) to evaluate subjects’ communication and listening skills, the
General Self-Efficacy Scale (GSES) to evaluate self-efficacy in stress
coping, and Profile of Mood States (POMS) to evaluate the stress re-
sponse in the intervention group and control group before the start of
the intervention (baseline), immediately after the end of the interven-
tion at week 2, and 7 days after the end of the intervention. In addition,
an originally developed questionnaire survey concerning the peer
counseling method was implemented in the intervention group only,
immediately after the end of the intervention.
2.6. Questionnaire
2.6.1. ALAS (Mishima et al., 2000)
This questionnaire used a 5-level Likert scale and 20 items to
measure how subjects listened to other members’ presentations. It en-
abled measurement under two subscales: “listening attitude” and “lis-
tening skill.” A higher score indicates better listening attitude and skill.
2.6.2. GSES (Bandura, 1977)
This questionnaire used a 2-level (Yes/No)-type response scale and
16 items to measure self-efficacy. This was used as an index of the
participants’ perception of their ability to choose and execute the ap-
propriate action required under certain circumstances, a psychological
representation of why the emotions of the superiority complex and
inferiority complex arise. A higher score indicates better self-efficacy.
2.6.3. POMS (McNair, Lorr, & Droppleman, 1971)
This questionnaire used a 5-level Likert scale and 65 items to
measure the transient moods and emotions among individuals. It en-
abled measurement under six subscales: tension, depression, anger,
vigor, fatigue, and confusion. The subjects were asked to provide re-
sponses to questions regarding their mood state for the previous 1 week.
A lower score indicates improved mood.
2.6.4. Questionnaire for the intervention group
This questionnaire posed five questions: (1) Do you understand the
basis of this intervention? (2) Is the training manual easy to under-
stand? (3) Do you feel that this intervention is effective for self-care? (4)
Do you feel that this intervention is effective for the care of your col-
leagues? (5) Do you want to continue to receive this intervention? The
participants were asked to respond to these questions using the fol-
lowing 5-level Likert scale: (5) strongly agree; (4) agree; (3) neither
agree nor disagree; (2) disagree; (1) strongly disagree.
2.7. Data analysis
Data were evaluated using a repeated measures analysis of variance
with GSES, ALAS, and POMS scores as dependent variables and group
(intervention group and control group), survey time point (baseline,
immediately after the end of the 2-week intervention, and 7 days after
the end of the intervention) and gender as independent variables. When
3
Mental Health & Prevention 14 (2019) 200164
the hypothesis of sphericity was rejected in the repeated measures
analysis of variance, a Greenhouse–Geisser correction for degrees of
freedom was performed. Statistical analysis was performed using IBM
SPSS ver23.0.
2.8. Ethical approval
In the present study, we obtained ethical approval in advance for
the following items: security for free withdrawal of participants at any
time, measures for ensuring the privacy of participants, methods for
obtaining the participants’ understanding and consent, notification of
participants of their study results, prohibiting the use of participants’
data for anything other than the intended purposes, discarding of
survey data after the end of the survey, and risks and detriments to the
participants, and the actions to take in such cases. The contents of the
study were approved by the Ethics Committee of Medical Research,
University of Occupational and Environmental Health, Japan. Given
that the ethics committee considered this a non-invasive study, regis-
tration of this study to the UMIN-CTR was deemed unnecessary.
3. Results
3.1. Number of participants and attributes
One man in the intervention group and one woman in the control
group withdrew from the study for personal reasons during the study
period, leaving 12 members in the intervention group (5 men and 7
women with a mean (standard deviation [SD]) age of 22.7 (1.9) years)
and 11 members in the control group (7 men and 4 women with a mean
(SD) age of 21.8 (1.8) years). The participants underwent counseling
interventions between October 26 and November 30, 2015. This period
was chosen because there were fewer exams and other events likely to
pose a psychological burden on the participants. The study ended as
scheduled, and no participant complained of poor health during the
study period.
3.2. Changes in GSES, ALAS, and POMS scores
There were no significant differences in either within-subject or
between-subject effects by gender and there was no interaction between
gender and group for any of the measured indexes.
The scores of the various measured indexes at the three time points
in the two groups are shown in Table 1. Statistical analysis showed
significant differences in within-subject factors for GSES and POMS
Anger–Hostility (A–H) scores between the two groups (F[2, 42]=3.750,
p = 0.033, F[2, 42]=4.692, p = 0.015). The mean GSES score in the
intervention group increased by 1.0 point from baseline immediately
after the end of the intervention, but returned to baseline 7 days after
the end of the intervention. In the control group, the mean score de-
creased by 1.2 points from baseline immediately after the end of the
intervention, but returned to baseline 7 days after the end of the in-
tervention. The mean POMS score regarding anger–hostility changes in
the intervention group decreased by 0.7 points from baseline im-
mediately after the end of the intervention, and by 1.6 points from
baseline 7 days after the end of the intervention. In the control group,
the mean score increased by 4.0 points from baseline immediately after
the end of the intervention, and remained similar 7 days after the end of
the intervention.
In addition, there were marginally significant differences in within-
subject factors on the ALAS subscale “listening attitude” between the
two groups (F[2, 42]=2.736, p = 0.078). The mean ALAS score for
“listening attitude” in the intervention group increased by 1.2 points
from baseline immediately after the end of the intervention, but ap-
proached the mean baseline score 7 days after the end of the inter-
vention. In the control group, the mean score decreased by 1.2 points
from baseline immediately after the end of the intervention, but
H. Nozawa, et al. Mental Health & Prevention 14 (2019) 200164

Table 1
Scores obtained for various evaluation indexes at baseline, immediately after the end of the intervention, and 7 days after the end of the intervention.
a
Evaluation index Group n Baseline Immediately after end of intervention 7 days after end of intervention F-value P-value
Mean (SD) Mean (SD) Mean (SD)
ALAS
Listening attitude Control 11 30.6 (3.1) 29.4 (1.9) 30.6 (3.6) 2.736 0.078*
Intervention 12 27.6 (4.5) 28.8 (2.3) 28.1 (3.3)
Listening scale Control 11 30.6 (4.6) 29.2 (3.3) 30.2 (4.3) 0.547 0.583
Intervention 12 29.3 (3.7) 28.9 (3.8) 29.6 (3.3)
GSES Control 11 5.9 (4.3) 4.7 (4.5) 5.8 (4.9) 3.750 0.033**
Intervention 12 6.8 (2.9) 7.8 (3.1) 6.9 (2.7)
POMS
Tension–Anxiety Control 11 12.4 (4.9) 13.4 (5.5) 14.4 (6.4) 0.367 0.641
Intervention 12 11.2 (6.7) 11.4 (6.7) 11.2 (8.7)
Depression–Dejection Control 11 18.7 (15.1) 19.5 (13.6) 20.6 (16.1) 0.914 0.410
Intervention 12 11.7 (10.3) 10.7 (8.9) 9.6 (11.5)
Anger–Hostility Control 11 6.3 (4.7) 10.3 (6.7) 10.3 (8.9) 4.692 0.015**
Intervention 12 8.3 (7.4) 7.6 (4.4) 6.7 (7.0)
Vigor Control 11 12.7 (6.4) 12.6 (5.3) 12.5 (7.5) 0.019 0.826
Intervention 12 11.3 (5.6) 12.0 (5.7) 11.7 (6.4)
Fatigue Control 11 10.6 (7.9) 11.9 (8.0) 12.1 (9.8) 0.367 0.695
Intervention 12 9.7 (7.5) 9.8 (7.8) 9.4 (7.7)
Confusion Control 11 9.6 (4.6) 10.8 (4.5) 9.8 (5.2) 0.763 0.473
Intervention 12 8.7 (5.3) 8.3 (5.8) 7.5 (5.5)

SD: standard deviation, GSES: General Self-Efficacy Scale, ALAS: Active Listening Attitude Scale, POMS: Profile of Mood States.
a
Within-subject factors were compared by repeated measures analysis of variance. When the hypothesis of sphericity was rejected in the repeated measures
analysis of variance, a Greenhouse–Geisser correction of degrees of freedom was performed.
⁎
p < 0.1.
⁎⁎
p < 0.05.

returned to baseline 7 days after the end of the intervention. 4. Discussion

A simple main effects test in the control group showed marginally
significant differences in GSES scores among the surveyed time points
(p = 0.078). A simple main effects test found marginally significant
differences in GSES scores between the intervention group and the
control group immediately after the end of the intervention
(p = 0.091). A simple main effects test in the control group found sig-
nificant differences in POMS A–H scores among the surveyed time
points (p = 0.021), and a multiple comparisons test showed significant
differences between scores at baseline and immediately after the end of
the intervention and between baseline and 7 days after the end of the
intervention (p = 0.020 and p = 0.049, respectively). A main effects
test showed no significant difference in POMS A–H scores between the
two groups at the surveyed points (Fig. 1).
3.3. Questionnaire for the intervention group
The results of the questionnaire survey performed immediately after
the end of the intervention in the intervention group are shown in
Table 2. The median score for understanding the nature of the inter-
vention and comprehensibility of the manual was 4.5 (out of a max-
imum of 5), and the median score for the efficacy of the intervention for
self-care was 4.0. The median score for the efficacy of the intervention
for the care of others was 4.0. The median score for the question “Do
you want to continue to receive this intervention?” was 4.0. One subject
answered “Disagree.”
Major comments provided in the free-answer section included po-
sitive comments on peer counseling; e.g., “It's good to know what other
students feel is worth doing in their student life.” There were also
comments on the procedure, including those praising the facilitators;
e.g., “The progress was smooth because my facilitator provided good
support.” In contrast, some comments suggested improvements to the
procedure; e.g., “I think that the procedure would be more under-
standable if a demonstration video of the peer counseling session was
available in addition to the manual.”
In the present study, self-efficacy and listening attitude scores in-
creased, while anger–hostility scores decreased immediately after the
end of the peer counseling intervention. In addition, there were no
significant differences in Depression–Dejection and Confusion, al-
though the intervention group had lower scores after the peer coun-
seling intervention. Therefore, peer counseling may be effective for
reducing mental stress, and the intervention had an effect on mental
health by improving listening attitude and self-efficacy and reducing
anger and hostility in young people.
The training manual included an explanation of the basic elements
of counseling and how to practice listening. From this, the participants
expected that understanding how to listen empathically and positively
would improve communication skills, facilitate dialogue between par-
ticipants, and consequently improve the effectiveness of peer coun-
seling intervention. Some studies have reported that group training on
listening improves not only participants’ listening attitude and listening
skills, but also mental health (Kubota, Mishima, & Nagata, 2004;
Shimizu, Mizoue, Kubota, Mishima, & Nagata, 2003; Ikegami, Tagawa,
Mafune, Hiro, & Nagata, 2008). The listening attitude and psycholo-
gical susceptibility of participants in the present study may have im-
proved due to the incorporation of listening methods based on basic
principles of counseling (Rogers, 1957, 1971) and conversation
methods that complemented the training manual, and the provision of
repeated sessions by referencing the manual. In particular, the observed
improvement in self-efficacy and anger–hostility may be attributable to
the admiration and positive understanding obtained by participants
from others throughout the intervention, and the skills they gained to
objectively understand their own emotions and those of others. How-
ever, self-efficacy and listening attitude returned to baseline levels 7
days after the end of the intervention. This may be due to the fact that
the peer counseling on self-efficacy was short, given that the approxi-
mately 30-min sessions were provided for the low frequency and short
period of 4 sessions in 2 weeks. In many prior studies, interventions

4
H. Nozawa, et al.
Fig. 1. Changes over time in GSES, ALAS (listening attitude), and POMS (an-
ger–hostility) scores at baseline, immediately after the end of the intervention,
and 7 days after the end of the intervention in the intervention group versus the
control group Intervention group: university students (5 men and 7 women)
receiving 4 sessions of mental health training using peer counseling for 2 weeks.
Control group: university students (7 men and 4 women) provided with 4
leaflets about general health issues for 2 weeks GSES: General Self-Efficacy
Scale, ALAS: Active Listening Attitude Scale, POMS: Profile of Mood States
Scores are expressed as mean ± standard error. For ALAS, a higher score in-
dicates better listening attitude and skill. For GSES, a higher score indicates
better self-efficacy. For POMS, a lower score indicates improved mood.
#1. For items for which the repeated measures analysis of variance revealed a
major effect or significant trend of the peer counseling intervention, a sub-
sequent statistical test was performed to compare the scores of the various in-
dicators between the groups at each evaluation time point.
were provided for about 6 to 12 months, much longer than that pro-
vided in the present study (Giese-Davis et al., 2006, 2016;
Schover et al., 2011). Therefore, the transient improvement in self-ef-
ficacy following such a short period and low frequency of sessions in-
dicates the potential of this intervention method. When performed
5
Mental Health & Prevention 14 (2019) 200164
Table 2
Questionnaire results from the intervention group.
Question Score
Do you understand the basis of this intervention? 4.5 (4–5)
Is the manual easy to understand? 4.5 (4–5)
Do you feel that this intervention is effective for self-care? 4 (4–4.25)
Do you feel that this intervention is effective for the care of your 4 (4–5)
colleagues?
Do you want to continue to receive this intervention? 4 (3–4)
Data indicate median (interquartile range)
Scores were based on a 5-level Likert scale (5: strongly agree, –1: strongly
disagree).
repeatedly, this method is expected to contribute to the continued
maintenance and promotion of mental health in young people.
The questionnaire conducted in the intervention group immediately
after the end of the intervention showed that most subjects had positive
impressions of the intervention method and learned the subjective ef-
fects of self-care. This method is characterized by participatory sessions
led by facilitators who received brief prior training, rather than direct
intervention by medical or psychological specialists. Participants in-
dicated that the facilitators were helpful in supporting the progress of
the peer counseling sessions. Similarly, Schover et al. (2006), who
provided lay participants with information on the history of breast
cancer and brief training on medical knowledge and counseling con-
cerning breast cancer before they served as peer counselors, found
improved mental health in their participants. Together, the present and
prior studies suggest that spontaneous mutual support from colleagues
may be effective for maintaining and enhancing mental health.
In obviating direct intervention from healthcare specialists, our
mental health training tool based on a peer counseling approach can be
employed voluntarily by universities and work colleagues. In addition,
the duration of each session is so short that subjects can continue to
receive the training by voluntarily extending the period of training. Our
findings suggest that this method may have an effect on mental health
by improving listening attitude and self-efficacy and reducing anger
and hostility in young people.
4.1. Limitations and future directions
This study had some limitations. First, peer counseling intervention
was only conducted among students in one faculty of one university.
Because the efficacy was not investigated in a more diverse population,
these findings may not be applicable to the general population. Second,
there may have been considerable type II errors because of the small
sample size. Third, members of the control group received health in-
formation on the prevention of food poisoning and infections, which are
unlikely to have a direct impact on mental health. Therefore, strictly
speaking, this study compared the effects of peer counseling and health
information provision on mental health, rather than verifying the effect
of peer counseling on mental health. Fourth, we did not examine fa-
cilitators’ evaluation of the intervention or facilitator training and
materials. The facilitators also formed part of the target group that
received mental health care by peer counseling. Facilitators’ view of the
intervention should therefore be evaluated to improve the training
methods and materials. Fifth, the intervention in this study was de-
veloped for implementation in schools and workplaces, and brain-
storming for the intervention content emphasized ease of delivery ra-
ther than identifying effective interventions to elicit changes in
psychosocial indicators. However, the intervention group showed im-
proved mental health, as reflected by increased listening skills and
H. Nozawa, et al. Mental Health & Prevention 14 (2019) 200164

decreased hostility and anger. Future studies should target young
company employees to evaluate the efficacy of this intervention method
at small to medium-sized companies, which have difficulty investing in
mental health support. To improve the intervention method, future
studies should examine the usefulness of demonstration videos of peer
counseling before the start of the interventions and web-based ap-
proaches (Fukkink, 2011), as suggested by participants in the ques-
tionnaire. Future studies should also evaluate facilitators’ satisfaction
with the intervention, training and materials.
5. Conclusions
Peer counseling improved participants’ scores in indexes associated
with mental health immediately after the end of the intervention,
suggesting that it may be effective for promoting mental health.
However, that these scores returned to baseline levels 7 days after the
end of the intervention suggests that the length of intervention was not
sufficient to maintain these effects. In addition, providing brief prior
training to a few facilitators to enable them to instruct and advise
participants in the counseling sessions was effective for the smooth
progress of peer counseling. Future studies should examine the effects
of longer duration interventions and the usefulness of demonstration
videos of peer counseling before the start of interventions and other
means of improving the intervention method.
the order of authors has been approved by all those listed.
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We confirm that we have given due consideration to the protection
of intellectual property associated with this work and that there are no
impediments to publication, including the timing of publication, with
respect to intellectual property. In so doing, we confirm that we have
followed the regulations of our institutions concerning intellectual
property.
Ethics
The contents of this study were approved by the Ethics Committee
of Medical Research, University of Occupational and Environmental
Health, Japan. Given that the ethics committee considered this a non-
invasive study, registration of this study to the UMIN-CTR was deemed
unnecessary.
Acknowledgments
We thank the university students and staff members who took part
in this study for their cooperation.

Funding Availability of protocol

This research received no specific grant from any funding agency.
Conflict of interest
The authors declare no conflict of interest concerning this study.
Authorship
The protocol used during the current study is available from the
corresponding author upon reasonable request.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.mph.2019.200164.

We confirm that the manuscript has been read and approved by all Appendix
named authors and that there are no other persons who satisfied the
criteria for authorship other than those listed. We further confirm that Tables A.1 and A.2.

Table A.1
Contents of the peer counseling training manual.
1. Mental health
1.1. About psychological stress
1.2. What is mental health disturbance?
1.3. Promotion of mental health care
1.4. What is stress coping?
2. What is peer counseling?
3. Elements of counseling
4. Basic rules of peer counseling
5. How to conduct peer counseling interventions
5.1. Procedure of peer counseling practice (explanatory text and figures)
5.2. Worksheets for peer counseling practice

6
H. Nozawa, et al.
Table A.2
Procedure of peer counseling practice.
Items for implementation
1. Understanding of the outline and objective of peer counseling (15 min)
2. Grouping and selection of leaders (5 min)
3. Selection of presentation themes (5 min)
4. Theme presentation and comments (about 2 to 3 min for presentation per
member, and about 1 min for comments per member)
5. Feedback (5 min)
6. Selection of a new leader and theme
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Description
The peer counseling manual will be dispensed to each participant prior to the start of the
intervention.
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counseling, an outline and the objectives of the peer counseling sessions, the procedure of peer
counseling, and the leader's roles with regards to the participants in accordance with the
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Peer counseling participants will form groups of 3 to 4 and select a leader for their group. This
grouping should be random, and grouping of participants with their friends only should be
avoided. Likewise, the leaders should be randomly selected.
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have been experienced at least once by all members should be considered. Initially, until the
members become accustomed to the intervention, themes that are easy to discuss, such as things
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