School staff experiences on involvement in a co-creation process: a Health CASCADE scoping review and thematic synthesis

The right place at the right time

Schools are an ideal setting to deliver public health interventions, yet there are competing obligations that could limit their implementation. This study aimed to examine the decision making process and explore what evidence informs prioritisation of public health interventions in this setting. Semi-structured interviews were conducted with 14 staff in seven UK schools between November 2017 and March 2018. Participants were recruited from schools participating in The Birmingham Daily Mile trial and comprised leadership staff, teachers, and pastoral staff. Analyses used a constant comparison approach to explore the prioritisation process and schools’ use of economic evidence. Teachers felt that they had little decision making influence in regard to public health interventions, with this falling on leadership staff. Participants perceived tension between delivering academic subjects and public health initiatives and thought proven impact was important to justify the opportunity cost. Evidence did not appear to be routinely used, and participants were unaware of cost-effectiveness analyses, but thought it could be a useful tool. This study shows that schools face challenges in balancing the academic, health, and wellbeing needs of children. There is a need for targeted evidence that includes appropriate costs and outcomes and meets school decision makers’ needs.

BackgroundAs youth e-cigarette use has surged in the last several years, teachers and school administrators have reported challenges addressing student use of emerging e-cigarette products on school property. While federal policy prohibits smoking in U.S. schools that receive federal funding, school e-cigarette bans only exist where states or localities have acted. Little is known about school staff experiences with implementing these relatively new policies; this study examines associations between school e-cigarette policies and trainings on school staff awareness and intervention on student e-cigarette use.MethodsA national convenience sample of 1,526 U.S. middle- and high-school teachers and administrators was surveyed in November-December 2018. Among respondents who provided their job title and indicated that they worked in a school rather than a district (n = 1,480, response rate = 97.0%), separate logistic regressions examine associations of school policies and policy training with e-cigarette awareness and intervention on student e-cigarette use.ResultsDespite being the most popular e-cigarette at the time, fewer than half (47.5%) of respondents identified an image of a JUUL device as an e-cigarette. However, respondents reporting the presence of e-cigarette policies in their schools had higher odds of recognizing e-cigarettes (OR = 3.85, p<0.01), including photo recognition of JUUL (OR = 1.90, p<0.001). Respondents reporting e-cigarette policies also had higher odds of reporting intervention on student e-cigarette use (communicating with students about e-cigarette avoidance: OR = 2.32, p<0.001; reporting students had been caught using e-cigarettes at school: OR = 1.54, p<0.05). Among respondents reporting a school e-cigarette policy, those trained on the policy had higher odds of JUUL photo recognition (OR = 1.54, p<0.01). Respondents trained on e-cigarette policies also had higher odds of reporting intervention (communicating: OR = 3.89, p<0.001; students caught using e-cigarettes: OR = 2.71, p<0.001).ConclusionsAs new tobacco products enter the market, school policies may be important tools to raise school personnel awareness of and intervention on emerging e-cigarette product use. However, policy adoption alone is not sufficient; policy training may further aid in recognition and intervention upon student use of e-cigarettes at school.

Mental health interventions in schools

Australian students are experiencing rising well-being concerns in line with global trends. Although schools and youth-focused community organizations are positioned as central sites of well-being promotion, little research examines how well-being is understood and supported by those working with students. This study examined (i) key factors influencing student well-being and (ii) the experiences of high school staff and youth-focused community organizations workers and volunteers in supporting well-being. Forty-two participants took part in semi-structured focus groups. Transcripts were analysed using inductive thematic analysis. Four factors shaped student well-being: mental health, social determinants, school safety, and social connection. Participants described three systemic challenges: fragmented systems, resource shortfalls, and escalating systemic pressures. Significant emotional burden and burnout were reported by school and community organization participants. Findings reveal a gap between well-being policy and frontline practice, highlighting the need for sustainable funding, workforce support, and stronger intersectoral collaboration to improve well-being for young people.

BackgroundThe sustainability of school-based health interventions after external funds and/or other resources end has been relatively unexplored in comparison to health care. If effective interventions discontinue, new practices cannot reach wider student populations and investment in implementation is wasted. This review asked: What evidence exists about the sustainability of school-based public health interventions? Do schools sustain public health interventions once start-up funds end? What are the barriers and facilitators affecting the sustainability of public health interventions in schools in high-income countries?MethodsSeven bibliographic databases and 15 websites were searched. References and citations of included studies were searched, and experts and authors were contacted to identify relevant studies. We included reports published from 1996 onwards. References were screened on title/abstract, and those included were screened on full report. We conducted data extraction and appraisal using an existing tool. Extracted data were qualitatively synthesised for common themes, using May’s General Theory of Implementation (2013) as a conceptual framework.ResultsOf the 9677 unique references identified through database searching and other search strategies, 24 studies of 18 interventions were included in the review. No interventions were sustained in their entirety; all had some components that were sustained by some schools or staff, bar one that was completely discontinued. No discernible relationship was found between evidence of effectiveness and sustainability. Key facilitators included commitment/support from senior leaders, staff observing a positive impact on students’ engagement and wellbeing, and staff confidence in delivering health promotion and belief in its value. Important contextual barriers emerged: the norm of prioritising educational outcomes under time and resource constraints, insufficient funding/resources, staff turnover and a lack of ongoing training. Adaptation of the intervention to existing routines and changing contexts appeared to be part of the sustainability process.ConclusionsExisting evidence suggests that sustainability depends upon schools developing and retaining senior leaders and staff that are knowledgeable, skilled and motivated to continue delivering health promotion through ever-changing circumstances. Evidence of effectiveness did not appear to be an influential factor. However, methodologically stronger primary research, informed by theory, is needed.Trial registrationThe review was registered on PROSPERO: CRD42017076320, Sep. 2017.

Background. Sexual and gender minority youth (SGMY) experience health inequities compared with cisgender heterosexuals, and these inequities are heightened in areas with high structural stigma. Quantitative research shows school assets (e.g., adult support) are associated with better health for SGMY. Though some qualitative studies elucidated how school staff support SGMY, none have triangulated such strategies in a geographically and sociodemographically diverse sample of school staff and SGMY. This paper describes a multi-perspective qualitative study design and offers lessons learned from conducting such a study. Methods. Using a novel stratified sampling frame, we interviewed 60 SGMY and 29 school staff who attended/worked at high schools in U.S. states with low, medium, and high structural stigma. To ensure sociodemographic diversity, we constructed sampling quotas, and recruited SGMY using social media and staff using a multi-pronged approach. Results. The stratified sampling strategy met our goal of enrolling diverse SGMY and staff participants. SGMY participants attended schools in low ( n = 20), medium ( n = 22), and high ( n = 18) structural stigma states. We enrolled 18 cisgender girls, 18 cisgender boys, and 24 gender minority youth. Fifty-three percent of SGMY were youth of color, and 45% attended schools in rural areas. School staff participants worked at schools in low ( n = 11), medium ( n = 11), and high ( n = 7) structural stigma states. School staff participants were 55% heterosexual, 91% cisgender, and had diverse roles (e.g., teacher, principal, librarian, and nurse). Conclusions. This paper describes new methods for collecting qualitative data from diverse SGMY and school staff. Some lessons learned from this study include the importance of using trauma-informed interviewing methods, having a suicidality safety protocol, establishing a priori sampling quotas, and creating tailored social media advertisements. With these data we will explore the heterogeneity of SGMY and school staff experiences across varying structural stigma levels, yielding foundational information for future school-based interventions.

BackgroundDepressive and anxiety disorders affect 20–30% of school-age youth, most of whom do not receive adequate services, contributing to poor developmental and academic outcomes. Evidence-based practices (EBPs) such as cognitive behavioral therapy (CBT) can improve outcomes, but numerous barriers limit access among affected youth. Many youth try to access mental health services in schools, but school professionals (SPs: counselors, psychologists, social workers) are rarely trained adequately in CBT methods. Further, SPs face organizational barriers to providing CBT, such as lack of administrative support. Three promising implementation strategies to address barriers to school-based CBT delivery include (1) Replicating Effective Programs (REP), which deploys customized CBT packaging, didactic training in CBT, and technical assistance; (2) coaching, which extends training via live supervision to improve SP competence in CBT delivery; and (3) facilitation, which employs an organizational expert who mentors SPs in strategic thinking to promote self-efficacy in garnering administrative support. REP is a relatively low-intensity/low-cost strategy, whereas coaching and facilitation require additional resources. However, not all schools will require all three strategies. The primary aim of this study is to compare the effectiveness of a school-level adaptive implementation intervention involving REP, coaching, and facilitation versus REP alone on the frequency of CBT delivered to students by SPs and student mental health outcomes. Secondary and exploratory aims examine cost-effectiveness, moderators, and mechanisms of implementation strategies.MethodsUsing a clustered, sequential multiple-assignment, randomized trial (SMART) design, ≥ 200 SPs from 100 schools across Michigan will be randomized initially to receive REP vs. REP+coaching. After 8 weeks, schools that do not meet a pre-specified implementation benchmark are re-randomized to continue with the initial strategy or to augment with facilitation.DiscussionEBPs need to be implemented successfully and efficiently in settings where individuals are most likely to seek care in order to gain large-scale impact on public health. Adaptive implementation interventions hold the promise of providing cost-effective implementation support. This is the first study to test an adaptive implementation of CBT for school-age youth, at a statewide level, delivered by school staff, taking an EBP to large populations with limited mental health care access.Trial registrationNCT03541317—Registered on 29 May 2018 on ClinicalTrials.gov PRS

Secondary school staff are often tasked with delivering mental health content to students, yet there has been little research on staff confidence to do so. Given the responsibility placed on staff to support student mental health, reliable and valid measures are needed to facilitate assessment of teacher confidence in the classroom and evaluation of the impact of interventions designed to enhance teacher confidence and ultimately support the delivery of mental health interventions in schools. This study aimed to examine the psychometric properties of the Teacher Confidence Scale for Delivering Mental Health Content (TCS-MH) and the What Worries Me Scale (WWMS), both developed by Linden and Stuart (2019) and previously tested on a sample of elementary school teachers. Within this paper we examine the factor structure, reliability, and validity of these measures in a large sample (N = 644) of secondary school staff. Exploratory factor analysis suggested that each scale had a single factor structure with all original items retained. This was further supported with confirmatory factor analysis. Examination of the reliability of both scales found that they had good internal consistency. Finally, through correlation analyses, both measures demonstrated satisfactory convergent and discriminant validity from mental health knowledge, mental health stigma, general anxiety, and teacher efficacy. Both the TCS-MH and the WWMS show great promise as measures of secondary school staff confidence to deliver mental health content.

Legislation has been passed that holds schools increasingly accountable for the proficiency of all students, including those with mental health problems. A critical obstacle impeding the ability of schools to effectively support students is the lack of access to quick, pre-screened, and organized information about scientifically-supported interventions that effectively address youth mental health problems. A new mental health best practices database was developed and made available online that provides access to free and user-friendly information about evidence-based interventions for use in schools. School staff will be better able to meet accountability demands of legislation and to effectively respond to student mental health problems.

Purpose– The purpose of this paper is to explore the process of involving students and staff on school action groups, and staff and student experiences of reviewing local data and initiating school-level changes, to address bullying and other aggression.Design/methodology/approach– The authors draw on qualitative, process data collected at four purposively sampled pilot intervention schools in England via semi-structured interviews with school managers, action group members and facilitators (n=33), focus groups with students (n=16) and staff (n=4), and observations.Findings– School staff used multiple methods to recruit a diverse range of students onto school action groups. Locally tailored data reports were an important catalyst for action groups to identify priorities and plan whole school change – both through the process of “validation” (whereby existing concerns were confirmed) and “discovery” (whereby new problems were identified). An unexpected benefit of providing schools with these data was that it triggered analyses of other data sources, including routine monitoring data. External facilitators were important in promoting student voice and ensuring the intervention retained integrity as a whole-school restorative approach.Practical implications– It was feasible to involve young people using action groups, and there was evidence of school-level actions led by students, including in disadvantaged school contexts. Future Health Promoting Schools interventions could incorporate this approach to support locally appropriate, school-level change.Originality/value– The micro-level processes that were observed, whereby action groups interrogated feedback reports and collected additional data, suggest the responsiveness of such youth-involvement interventions to local needs. Contrary to many public health interventions, implementation appeared to befacilitatedrather than hindered by features of the secondary-school “market” whereby parents have some choice between schools.

Background: Optimized treatment regimens have improved the survival of children/youth living with HIV (YLH) allowing them to pursue career goals. More YLH are now spending time in schools, but evidence points to adherence challenges in schools. We explored school staff experiences with YLH in the school environment. Methods: Four focus group discussions included 32 school staff from 32 high/secondary schools in Kenya. Inclusion criteria included having health responsibilities. Interview data were analyzed using directed content analysis. Results: The median age of participants was 35 (IQR: 31–45) years and over half were women (56%). The majority (91%) had both teaching and health roles, and half were staff at boarding schools. School staff reported YLH expressing feelings of hopelessness that resulted in medication nonadherence and demotivation to excel in school. Sometimes, YLH HIV status was only disclosed when YLH were referred for disciplinary action due to behavioral problems. Parent/caregiver psychological challenges and difficult home environments made it difficult for schools to work with families to support YLH. School staff often stepped in to offer psychological support to YLH, but this created significant time demands. School staff felt they were not adequately trained to provide the services that YLH needed and advocated for school-wide training on HIV and management of common psychological problems. Conclusions: To support YLH to achieve their full potential, there is a need to support school staff to gain the skills needed to support YLH health. Future work on addressing psychological and social health challenges in schools is warranted.

Self-harm among young people is a major public health concern, and whilst schools are well placed to identify and intervene with students who self-harm, the literature shows that school staff lack training and confidence in this area. This systematic review investigated the effectiveness, feasibility and acceptability of training interventions and support tools intended to equip school staff with skills and knowledge to adequately respond to students' disclosure of self-harm. References for this review were identified through systematic searches of Medline, Embase, PsycINFO, Child Development & Adolescent Studies, ERIC, ASSIA and British Education Index on with search terms 'self-harm', 'training', 'school staff' and 'young people'. Thematic synthesis was used to analyse qualitative data. We found that all eight included studies evaluated interventions/tools that were highly effective in terms of an increase in knowledge, skills and confidence of staff in responding to self-harming youth. Acceptability was good with high levels of satisfaction and perceived benefit by staff, though data on feasibility of the interventions were lacking. Limitations of the studies included a paucity of follow-up data, and lack of data relating to student outcomes and actual changes in staff practice in schools. The findings from this review indicate that more evidence is needed to determine the effectiveness, acceptability and feasibility of interventions/tools for school staff addressing self-harm. Further studies should focus on maintaining knowledge, confidence and comfort levels over time, and determine the feasibility of interventions/tools with different staff cohorts and across school settings, as well as address outcomes for students.

Effective school-based mental health promotion and prevention interventions in low-and middle-income countries (LMICs) can positively impact the mental health and well-being of large numbers of young people. This scoping review aimed to investigate the implementation of effective mental health promotion and prevention interventions in LMIC schools. A scoping review of the international literature was conducted and followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews guidelines. Medline, PsycInfo, Scopus, Embase, CINAHL and Cochrane were searched for peer-reviewed literature published from 2014 to 2022. PsycExtra, Google Scholar and the websites of key organisations were searched for relevant grey literature. Study selection focussed on mental health promotion interventions, including the development of social and emotional skills and mental health literacy, and prevention interventions, including anti-bullying and skill-based interventions for “at-risk” students. Twenty-seven studies evaluating 25 school-based interventions in 17 LMICs were included in the review. Fifteen interventions were developed in the implementing country and 10 were adapted from high-income countries (HICs) or other settings. Findings from the studies reviewed were generally positive, especially when interventions were implemented to a high quality. Universal life-skills interventions were found to increase social and emotional skills, decrease problem behaviours and positively impact students’ mental health and well-being. Mental health literacy interventions increased mental health knowledge and decreased stigma among students and school staff. Outcomes for externally facilitated anti-bullying interventions were less positive. All 19 effective studies reported on some aspects of programme implementation, and 15 monitored implementation fidelity. Eleven studies outlined the programme’s underpinning theoretical model. Only four studies reported on the cultural adaptation of programmes in detail. Including young people in the adaptation process was reported to facilitate natural cultural adaptation of programmes, while input from programme developers was considered key to ensuring that the core components of interventions were retained. The review findings indicate increasing evidence of effective mental health interventions in LMIC schools. To facilitate the sustainability, replication and scaling-up of these interventions, greater attention is needed to reporting on intervention core components, and the processes of implementation and cultural adaptation in the local setting.

Effective school-based mental health promotion and prevention interventions in low-and middle-income countries (LMICs) can positively impact the mental health and well-being of large numbers of young people. This scoping review aimed to investigate the implementation of effective mental health promotion and prevention interventions in LMIC schools. A scoping review of the international literature was conducted and followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews guidelines. Medline, PsycInfo, Scopus, Embase, CINAHL and Cochrane were searched for peer-reviewed literature published from 2014 to 2022. PsycExtra, Google Scholar and the websites of key organisations were searched for relevant grey literature. Study selection focussed on mental health promotion interventions, including the development of social and emotional skills and mental health literacy, and prevention interventions, including anti-bullying and skill-based interventions for “at-risk” students. Twenty-seven studies evaluating 25 school-based interventions in 17 LMICs were included in the review. Fifteen interventions were developed in the implementing country and 10 were adapted from high-income countries (HICs) or other settings. Findings from the studies reviewed were generally positive, especially when interventions were implemented to a high quality. Universal life-skills interventions were found to increase social and emotional skills, decrease problem behaviours and positively impact students’ mental health and well-being. Mental health literacy interventions increased mental health knowledge and decreased stigma among students and school staff. Outcomes for externally facilitated anti-bullying interventions were less positive. All 19 effective studies reported on some aspects of programme implementation, and 15 monitored implementation fidelity. Eleven studies outlined the programme’s underpinning theoretical model. Only four studies reported on the cultural adaptation of programmes in detail. Including young people in the adaptation process was reported to facilitate natural cultural adaptation of programmes, while input from programme developers was considered key to ensuring that the core components of interventions were retained. The review findings indicate increasing evidence of effective mental health interventions in LMIC schools. To facilitate the sustainability, replication and scaling-up of these interventions, greater attention is needed to reporting on intervention core components, and the processes of implementation and cultural adaptation in the local setting.