Exploring factors shaping positive attitudes of adolescents towards seeking support for mental health issues in schools: a qualitative inquiry

Background: Reflexive thematic analysis is widely used in qualitative research published in Palliative Medicine, and in the broader field of health research. However, this approach is often not used well. Common problems in published reflexive thematic analysis in general include assuming thematic analysis is a singular approach, rather than a family of methods, confusing themes and topics, and treating and reporting reflexive thematic analysis as if it is atheoretical. Purpose: We reviewed 20 papers published in Palliative Medicine between 2014 and 2022 that cited Braun and Clarke, identified using the search term ‘thematic analysis’ and the default ‘relevance’ setting on the journal webpage. The aim of the review was to identify common problems and instances of good practice. Problems centred around a lack of methodological coherence, and a lack of reflexive openness, clarity and detail in reporting. We considered contributors to these common problems, including the use of reporting checklists that are not coherent with the values of reflexive thematic analysis. To support qualitative researchers in producing coherent and reflexively open reports of reflexive thematic analysis we have developed the Reflexive Thematic Analysis Reporting Guidelines (the RTARG; in Supplemental Materials) informed by this review, other reviews we have done and our values and experience as qualitative researchers. The RTARG is also intended for use by peer reviewers to encourage methodologically coherent reviewing. Key learning points: Methodological incoherence and a lack of transparency are common problems in reflexive thematic analysis research published in Palliative Medicine. Coherence can be facilitated by researchers and reviewers striving to be knowing – thoughtful, deliberative, reflexive and theoretically aware – practitioners and appraisers of reflexive thematic analysis and developing an understanding of the diversity within the thematic analysis family of methods.

Introduction Migration is at the core of today’s professional sport. In football, since 2020, the rate of migrant players has increased by 20% (Poli et al., 2024). Transnational mobility has become a highly valuable commodity making transnational football career an inescapable pathway to either professional level or world-class level. Therefore, understanding cross-borders sports mobility processes is crucial for both players and stakeholders to effectively prepare and negotiate cultural transitions. Transnational career and pathway research in sport psychology is recent, limited, and suggests that maintaining a career as a migratory athlete remains challenging (Book et al., 2021; Ryba & et al., 2016; Storm et al., 2022). By identifying challenges faced, and psychological process involved, those researches highlight at what extent culture frames athletes’ sport and non-sport life experiences. However, no studies focused on neither the first cultural transition nor African athletes. From analysis of some previous studies, it seems that the experience of the first cultural transition shapes the willingness to initiate and the experience of the following migrations (Book et al., 2021; Ryba et al., 2016). On the other hand, African countries are deeply distinct from the most other countries worldwide regarding relevant features shaping people’s life experience: social security, gross domestic product, facilities, governance, and race. Furthermore, African countries are among those displaying the highest growth of expatriate footballers (Poli et al., 2024). Additionally, most of athletic migrations from Africa correspond to forced migration (United Nations Humans Rights Council, 2022), with the difference that it is triggered by a contract. Thus, what characterize the experience of the first cultural transition of African footballers? This study aimed to explore the athletic transnational career of Cameroonian footballers to characterize their experience of the first cultural transition. Methods This study is grounded within Critical Realism philosophy. It is useful to engage causal analysis and explanation of social problems and suggest practical recommendations for social change (Fletcher, 2017). Fourteen Cameroonian former footballers were purposively sampled following three criteria: having spent at least the formative years in Cameroon, did the first cultural transition for athletic career development, and having played professionally for a football club abroad at least one season. The participants’ position in the pitch included all the main positions acknowledged in football (goalkeeper, defender, midfielder, and striker), and the country of their first cultural transition included the four continents (Kingdom of Saudi Arabia, Germany, France, Indonesia, Greece, Côte d’Ivoire, Paraguay, Italy, Switzerland, and Turkey). The semi-structured interviews based on life story and timeline interviews approaches were conducted, focusing on the participants’ experience of athletic transnational mobilities. This included a series of two interview sessions which lasted between 25 and 121 minutes. A total of 26 interviews were audio recorded, transcribed, and reflexively thematically analyzed (Braun & Clarke, 2021). The study applied the four rigorous criteria to ensure qualitative study trustworthiness: credibility, dependability, confirmability, and transferability (Lincoln & Guba, 1985). Results Nine themes (with their sub-themes) and their relationship were identified: Mental Health Issues (MHI), Context of athletic migration and seven challenges related to: Club and Contract, Team, Pitch, Way of life, Geography, Home country, and High Level Athlete status. MHI emerged as output of the context and challenges. MHI were characterized by players’ psychological distress and inability to understand that condition, and inability of the club leading team to understand what they were going through. The context of athletic migration was characterized by unplanned transition, adolescence, club’s facilities, and perception of moving abroad as having succeed their football career and life (satisfaction of achieving the dream). Challenges characterized tough situations players went through like contract disruption (club and team), broken In-group (team), injury (pitch), new mentality (way of life), winter (geography), long-distance relationship (home country), and experience of professionalism (High Level Athlete status). Discussion/Conclusion This research is the first to study the first cultural transition of athletes and to use a sample of athletes from Africa. The results depict main features characterizing the experience of the first athletic migration of young talented Cameroonian footballers. Applying critical realism philosophy, MHI was identified as the effect of the migration context and challenges faced. Those findings are consistent with the holistic developmental and ecological perspectives to talent development (Wylleman & Rosier, 2016), Intersectionality (Book et al., 2021), cultural sport psychology (Schinke & Hanrahan, 2009), and challenges underscored in previous transnational athletic career studies (Book et al., 2021; Ryba et al., 2016; Storm et al., 2022). Most importantly, this study highlights new result patterns enriching literature and providing critical information for African athletes and sport stakeholders: MHI (explicitly underscored), context of athletic migration, challenges related to winter, new mentality, broken In-group, etc. As successful talented footballers, they anticipated migration with professional contract as the guarantee of happiness. Actually, those young talented footballers navigated through the satisfaction of achieving professional level and distress. They struggled with psychological distress by shouldering the acculturation load and some professional football’s drifts in an environment which was not supportive enough, because it does not understand them. They could not seek for help because the lack means to understand their condition. Thus, this study is directly related to two Sustainable Development Goals (the third and eighth) by addressing mental health and decent work (United Nations Humans Rights Council, 2022). The results suggest several practical implications: informed football stakeholders’ action, strengthen coaches’ training, adjust sport psychologists’ intervention, and build solid preparatory foundation for next transnational African footballers. References Book, R. T., Jr., Henriksen, K., & Stambulova, N. (2021). Oatmeal is better than no meal: The career pathways of African American male professional athletes from underserved communities in the United States. International Journal of Sport and Exercise Psychology, 19(4), 504–523. https://doi.org/10.1080/1612197X.2020.1735258 Braun, V., & Clarke, V. (2021). One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative Research in Psychology, 18(3), 328–352. https://doi.org/10.1080/14780887.2020.1769238 Fletcher, A. J. (2017). Applying critical realism in qualitative research: Methodology meets method. International Journal of Social Research Methodology: Theory & Practice, 20(2), 181–194. https://doi.org/10.1080/13645579.2016.1144401 Lincoln, Y., & Guba, E. G. (1985). Naturalistic inquiry. Sage. Poli, R., Ravenel, L., & Besson, R. (2024, May). Origins and destinations of football expatriates (2020–2024). CIES Football Observatory [Monthly Report n°95]. https://football-observatory.com/MonthlyReport95 Ryba, T. V., Stambulova, N. B., & Ronkainen, N. J. (2016). The work of cultural transition: An emerging model. Frontiers in Psychology, 7, Article 427. https://doi.org/10.3389/fpsyg.2016.00427 Schinke, R. J., & Hanrahan, S. J. (Eds.). (2009). Cultural sport psychology. Human Kinetics. https://doi.org/10.5040/9781492595366 Storm, L. K., Book, R. T., Jr., Hoyer, S. S., Henriksen, K., Küttel, A., & Larsen, C. H. (2022). Every boy’s dream: A mixed method study of young professional Danish football players’ transnational migration. Psychology of Sport and Exercise, 59, 1–11. https://doi.org/10.1016/j.psychsport.2021.102125 United Nations Human Rights Council. (2022). Mid-year trends 2022. https://www.unhcr.org/mid-year-trends Wylleman, P., & Rosier, N. (2016). Holistic perspective on the development of elite athletes. In M. Raab, P. Wylleman, R. Seiler, A.-M. Elbe, & A. Hatzigeorgiadis (Eds.), Sport and exercise psychology research: From theory to practice (pp. 270–282). Elsevier Inc.

Experiences of and Attitudes Toward Mental Health Services Among Older Youths in Foster Care

Many individuals with mental health conditions avoid, delay, discontinue, or do not seek mental health services and treatments, despite the existence of evidence-based treatments and support methods. Little is known about the barriers to mental health service utilisation for Sri Lankan Australians, and there is no research on factors that facilitate access for this group. Using quantitative and qualitative methods, this study explored the perspectives of Sri Lankan Australians (N = 262) on the facilitators of mental health service utilisation. Participants rated a set of 18-items (Facilitator Set) and 7 public health interventions (Intervention Set) in relation to their capacity to improve the uptake of mental health services. Participants also completed two open-ended questions about the enablers to seeking professional mental health care. Descriptive statistics were used to summarise quantitative findings, while open-text responses were analysed using reflexive thematic analysis. The Facilitator Set demonstrated that trust in the provider and their confidentiality processes, positive relationships with mental health professionals, and the community having positive attitudes towards seeking help were the primary facilitators to seeking professional help. The Intervention Set suggested that raising community awareness of mental health conditions and providing public stigma reduction interventions may increase access to care. Themes identified in the open-ended responses included access to culturally safe and responsive services and clinicians, improved accessibility and affordability of services, trust, and a community-based approach to increasing mental health literacy and addressing stigma beliefs. Within its limitations, the present study’s findings suggest that providing culturally safe and responsive care, dispelling mental health stigma, and increasing knowledge of mental health conditions within Sri Lankan Australian communities are potential facilitating factors that would enable Sri Lankan Australians to seek and use mental health services. Implications for clinical care and future research are discussed.

Needs for and Barriers to Correctional Mental Health Services: Inmate Perceptions

The postnatal period is a critical transition period for first-time mothers, especially adolescents. An indication of maladaptation with this transition is the experience of poor mental health by some adolescent mothers. Social and collective cultural factors have been claimed to influence maternal mental health during the postnatal period; however, there is limited research focusing on cultural and social factors that influence adolescents’ mental health during the postnatal period in rural Malawi. Therefore, we explored the perceived cultural and social factors that influence mental health among adolescent mothers during the postnatal period in rural Malawi. A descriptive qualitative design (DQ) was employed. Data were collected from September 7th, 2021, to March 31st, 2022, from a convenience sample of 395 adolescent mothers. Reflexive thematic analysis was employed using open coding. Codes were grouped into categories and themes derived using inductive thinking. Adolescent mothers’ mental health was found to be influenced by interactions between social and cultural factors within all levels of the Social Ecological Model of Health (SEM). Four main themes, health and mental health awareness, relationships, family support, and rite of passage, explained social and cultural influences for adolescent mothers in Malawi. There is a need for collaborative, coordinated, and co-designed efforts to implement integrated, comprehensive, and culturally appropriate interventions at each level of SEM influence to promote adolescent’ mothers’ mental health. Specifically, policies should focus on the prevention of early marriages, improved access to reproductive health services, and long-term interventions to promote family involvement in the care of mothers. Healthcare systems should offer accessible mental health support for adolescent mothers.

Engaging people with lived experience and their families (PWLE/F) as partners in mental health and substance use research can have a positive impact. One way to understand this engagement process and its impact is by reporting on it in peer-reviewed papers. However, little is known about the experiences of PWLE/F and researchers regarding the reporting of engagement activities in peer-reviewed papers and navigating the writing process for such publications. This qualitative descriptive study aimed to explore the experiences of PWLE/F and researchers with the writing process for engagement in mental health and substance use research. Separate from participants, PWLE/F were engaged in all phases of the study as partners during the research process. Interviews were conducted with 13 PWLE/F and 12 researchers across Canada via Zoom. Interviews were analyzed using reflexive thematic analysis. Three themes captured the experiences of PWLE/F: navigating uncharted territories, the disclosure dilemma, and paving the way for meaningful co-authorship. Four themes represented the experiences of researchers: prioritizing informed co-authorship, frustrations with reporting on engagement, navigating how and when to report on engagement, and finding clarity amidst ambiguity. This study sheds light on the complex experiences of PWLE/F and researchers with the writing process for engagement-focused papers. Overall findings indicate a need for clear guidance for both researchers and PWLE/F involved in mental health and substance use research projects, particularly around what to report on and how to meaningfully collaborate in peer-reviewed papers.

The aim of this study was to explore young people's experiences of resources and strategies for promoting their mental health. Individual interviews with 33 people aged 16-25 years were conducted using a method inspired by cognitive interviewing, which combines think aloud techniques with probing questions. The interviews were based on the young people's reflections of the questions in the Swedish national public health survey. Data were analysed with reflexive thematic analysis. The resources and strategies that the young people in this study described as important for promoting mental well-being are related to societal prerequisites needed to navigate life; to their immediate surroundings, including social interactions; and to the young people themselves. These resources and strategies are presented under the following three themes: prerequisites for navigating life, social interactions on one's own terms, and who I am and what I can do. Young people have a variety of resources and strategies of their own available for promoting mental well-being. However, they cannot promote mental health just on their own; access to social networks and the opportunity to share thoughts and feelings are central. Further, to promote mental health, young people need good social conditions, knowledge, and support from adults so that the existence they struggle to navigate feels comprehensible, manageable and meaningful.

IntroductionProtecting and promoting the mental health of youth under 30 years of age is a priority, globally. Yet investment in mental health promotion, which seeks to strengthen the determinants of positive mental health and wellbeing, remains limited relative to prevention, treatment, and recovery. The aim of this paper is to contribute empirical evidence to guide innovation in youth mental health promotion, detailing the early outcomes of Agenda Gap, an intervention centering youth-led policy advocacy to influence positive mental health for individuals, families, communities and society.MethodsLeveraging a convergent mixed methods design, this study draws on data from n = 18 youth (ages 15 to 17) in British Columbia, Canada, who contributed to pre- and post-intervention surveys and post-intervention qualitative interviews following their participation in Agenda Gap from 2020-2021. These data are supplemented by qualitative interviews with n = 4 policy and other adult allies. Quantitative and qualitative data were analyzed in parallel, using descriptive statistics and reflexive thematic analysis, and then merged for interpretation.ResultsQuantitative findings suggest Agenda Gap contributes to improvements in mental health promotion literacy as well as several core positive mental health constructs, such as peer and adult attachment and critical consciousness. However, these findings also point to the need for further scale development, as many of the available measures lack sensitivity to change and are unable to distinguish between higher and lower levels of the underlying construct. Qualitative findings provided nuanced insights into the shifts that resulted from Agenda Gap at the individual, family, and community level, including reconceptualization of mental health, expanded social awareness and agency, and increased capacity for influencing systems change to promote positive mental health and wellbeing.DiscussionTogether, these findings illustrate the promise and utility of mental health promotion for generating positive mental health impacts across socioecological domains. Using Agenda Gap as an exemplar, this study underscores that mental health promotion programming can contribute to gains in positive mental health for individual intervention participants whilst also enhancing collective capacity to advance mental health and equity, particularly through policy advocacy and responsive action on the social and structural determinants of mental health.

Reflexive thematic analysis (reflexive TA) originated within psychology and the social sciences and has become an increasingly popular qualitative analytic method across a range of disciplines. In this article, we offer a brief methodological guide for researchers hoping to use the method, suitable for beginners through to those experienced in qualitative research. Reflexive TA can be used to analyze data generated via a range of methods. Reflexive TA is highly flexible, and we outline the choices that researchers need to address when conducting their research. These choices relate to the theoretical approach (realist through to relativist/experiential to critical), their orientation to analyzing the data (inductive to deductive), and the depth in which they analyze their dataset (semantic to latent). We offer an accessible but comprehensive discussion of the six phases of reflexive thematic analysis and how best to produce a rigorous analysis. Starting with familiarization of the dataset as a foundation for analysis, data are then coded, before using these codes to generate initial themes. These early themes are then reviewed and developed, before the researcher moves to defining and naming them. The final phase of analysis is the writing up of the research, at which point final changes may still be made to the results. Written from the basis of our experience of using, teaching, and training reflexive thematic analysis within psychology and the social sciences, we see it as useful for those working across a range of disciplines.

BackgroundRecent advances in digital health technology offer the potential to overcome established access barriers to mental health support, such as stigma and geographical location. The World Health Organization recommends integrating digital technologies into mental health care, underscoring the need for countries to develop national digital mental health (DMH) strategies to guide efforts. The rate of development and availability of DMH tools currently outpaces the existing policy or regulatory guidance required to guide their use. In Ireland, a key requirement of the national mental health strategy, Sharing the Vision, was the development of a national DMH strategy. Key stakeholders in DMH research, policy, practice, and lived experience were brought together as part of a focused stakeholder engagement event to develop a shared vision for digital mental health in Ireland.ObjectiveThis study aimed to explore the views of DMH stakeholders to set priorities for the development of a national DMH strategy.MethodsForty-seven stakeholders were each assigned to 1 of 6 focused strategy discussion groups. Invited stakeholders included experts in DMH research, clinical practice, and mental health advocacy and policy, together with those with lived experience of accessing mental health services. Qualitative data were analyzed using a reflexive thematic analysis approach. Researchers followed the 6-step framework proposed by Braun and Clarke. Reflexive thematic analysis emphasizes intentionality and critical thought, highlighting researchers’ deliberate interpretation of data while being aware of how their perspectives shape the conclusions.ResultsA total of 5 major themes were identified: inclusive access, being user-led, trust, education and training, and connectedness. These major themes were related to 15 subthemes. The inclusive access theme comprised inclusivity, accessibility, and early intervention subthemes. The user-led theme encompassed coproduction, choice, and needs-led subthemes. Compelling narrative; regulation, policy, and governance; and evidence base subthemes were identified within the theme of trust. The subthemes of digital literacy, mental health literacy, and transformation were identified within the education and training theme. Finally, the connectedness theme incorporated the subthemes of integration, relationships, and stigma.ConclusionsOverall, delegates viewed digital technology as a potential enabler of accessible and inclusive mental health support. However, it was also seen as a potential barrier to access and inclusion if concerns regarding data privacy, education and training needs, regulation, and the need for a more a robust evidence base were not addressed. Coproduction at all stages was identified as key to reducing access barriers, enhancing inclusion, and maintaining trust. Themes identified informed a follow-on consensus-seeking process to further refine and prioritize the proposed actions of the first national DMH strategy.

Research has highlighted how the plasticity of adolescent brains provides a window of opportunity for positively affecting a child or young person’s internal working model: their trajectory for developing positive attachments in relationships and mental health in their present and future lives.\nIn light of the neuroscientific evidence for brain plasticity for CYP in early adolescence and the positive local authority-wide evaluations of the attachment awareness programme, this research provides a closer examination of the systemic implications of implementing an attachment awareness programme for Key Stages 3 and 4 by providing a case study of a secondary school that has adopted the programme. This was with the intention to look not at the effectiveness of the programme, but rather at the way in which the attachment awareness programme sits alongside other priorities, policies and procedures in the school. In the interest of further developing this particular preventative response to CYP’s mental health issues in schools, this research investigated a ‘real-world’ view of the intricacies involved for school staff when sustaining an attachment awareness programme alongside other school systems.\nThe research was undertaken from a pragmatic perspective and followed an exploratory purpose utilising qualitative methods. 15 individual semi-structured interviews and two focus groups with a total of 24 participating school staff answered questions relating to the systemic implications of the attachment awareness programme. Using thematic analysis, the findings were organised into five overarching themes. Findings suggest that fundamental systemic implications include: changing organisational behaviours around behaviour; developing attachment practice; responsibility for attachment awareness; time and resources; and staff training considerations and priorities.\nWider systemic implications are highlighted as the research considers the interacting influences around schools when implementing the attachment awareness programme. Educational psychologists are ideally situated to work across these systemic factors and could support the implementation of the programme to reach its potential.

Immigrant families and their children experience isolation after migration to Canada. Inadequate income, unemployment, and underemployment have all been identified as primary challenges to the mental health of immigrant families. This study qualitatively explored the perceptions of six Middle Eastern immigrant caregivers regarding their children’s post-migration mental health. The research was situated in the constructivist paradigm, and qualitative descriptive design was used to explore participant experiences. Interviews were conducted in English with three Farsi-speaking and three Arabic-speaking caregivers. Reflexive thematic analysis was performed. Three themes were developed: (a) parents feel their children are isolated and lonely; (b) caregivers’ limited access to resources impacts their children’s mental health; and (c) community connections enhance families’ mental health. Findings suggest children’s experiences with family separation and exposure to racism contributed to children’s loneliness. Children’s isolation was exacerbated by caregivers’ limited access to resources to support their children’s transition into Canada. Caregivers identified social support as an asset to their families’ mental health. This research highlights the importance of culturally responsive health, employment, and education policies, together with programs to provide resources for immigrant families to support their children’s mental health after migration.

BackgroundPeople with mental health conditions have been identified as particularly vulnerable to poor mental health during the coronavirus disease 2019 (COVID-19) pandemic. However, why this population have faced these adverse effects, how they have experienced them and how they have coped remains under-explored.AimsTo explore how the COVID-19 pandemic affected the mental health of people with existing mental health conditions, and to identify coping strategies for positive mental health.MethodsSemi-structured qualitative interviews with 22 people with mental health conditions. Participants were purposively recruited via social media, study newsletters and third sector mental health organisations. Data were analysed using reflexive thematic analysis.ResultsParticipants were aged 23–70 (mean age 43), predominantly female (59.1%) and of white ethnicity (68.2%). Fifty percent were unable to work due to illness and the most frequently reported mental health condition was depression. Five pandemic-related factors contributed to deteriorating mental health: (i) feeling safe but isolated at home; (ii) disruption to mental health services; (iii) cancelled plans and changed routines; (iv) uncertainty and lack of control; (v) rolling media coverage. Five coping strategies were identified for maintaining mental health: (i) previous experience of adversity; (ii) social comparison and accountability; (iii) engaging in hobbies and activities; (iv) staying connected with others; (v) perceived social support.ConclusionsChallenges were identified as a direct result of the pandemic and people with severe mental illnesses were particularly negatively affected. However, some found this period a time of respite, drew upon reserves of resilience and adapted their coping strategies to maintain positive well-being.

The phenomenon of perinatal distress in terms of depression, anxiety, bipolar, and psychotic disorders is well-explored in the West but barely investigated in South Asia; particularly research evidence highlighting the cultural expression of couples’ mental health with respect to Pakistan is rare. The purpose of this research is to focus on the exploration of psycho-socio-cultural expression of couples’ perinatal distress and coping strategies used in the Pakistani context in relation to maternal and paternal mental health, with implications for the wellbeing of their unborn or born progeny. The research design focused on qualitative interpretative approaches. In data triangulation, reflexive thematic analysis and interpretative phenomenological analyses were applied on the verbatim of the semi-structured interviews conducted with the mental health professionals (n = 9) and the couples (n = 8), screened positive for perinatal distress. Four couples were screened out of 325 perinatal women visiting the gynaecological ward of Aziz Bhatti Shaheed Teaching Hospital, Gujrat. Edinburg Postnatal Depression Scale, Generalized Anxiety Disorder-7 and Washington Early Recognition Center Affectivity and Psychosis Screen are the standardized instruments considered to be used for screening perinatal distress among couples. The Urdu version of WERCAP Screen was developed by a standardized forward-backward translation procedure. The rest of the four couples were purposively selected from the psychiatric ward of the same hospital. The Simplified Negative and Positive Symptoms Interviews were administered to the couples after getting approval for the Urdu version form. All couples were probed with an indigenously developed Structured Clinical Interview Schedule for DSM Disorders based on DSM-5-TR. The triangulation carried out with reflexive thematic analysis and interpretative phenomenological analysis revealed cultural conception of perinatal distress as perceived by the mental health professionals and experienced by the couples during the antenatal and postnatal period of their lives. They were enlightened with a constructive view aimed at promoting transformational change in terms of their mental health care and coping. The implications suggested implementation of a psychotherapeutic intervention for reduction in the level of distress and subsequent enhancement of well-being in couples during the perinatal period.