Strategies to Enhance the Implementation of Universal Mental Health Prevention Programs in Schools
A discussion of the paper “Strategies for Enhancing the Implementation of Universal Mental Health Prevention Programs in Schools: A Systematic Review” (Baffsky et al., 2022)
Introduction
On a global scale, adolescents are vulnerable to the development of poor mental health, often reaching levels of disorder (e.g. Kieling et al., 2011). In India, there is high prevalence of mental health disorder among adolescents, often leading to severe long term consequences (e.g. Aggarwal & Berk, 2015; Grover et al., 2019). This problem may be partly combatted through the implication of universal mental health prevention programs in schools. The implementation of programmes in schools has been identified as a cost-effective form of prevention, as they are delivered to large cohorts of children in a setting where they spend most of their time (Fazel et al., 2014; Williams et al., 2020), with universal approaches having the ability to benefit all students (Baffsky et al., 2022). However, in order to ensure the success of these programmes in schools, we need to understand what can enhance their implementation. This blog post summarises the findings from a recent systematic review (Baffsky et al., 2022) outlining what strategies work for enhancing implementation of mental health prevention programs in schools. Additionally, we will explore how these findings relate to experiences during the implementations of the SAMA projects in schools.
Overview of the systematic review:
This systematic review, conducted by Baffsky et al. (2022) and published in Prevention Science in 2022, aimed to understand what strategies work for enhancing implementation of mental health prevention programs in schools. A search of 4 electronic databases was conducted between January 2000 and October 2021, identified 21 papers for inclusion. Nineteen of the identified studies (90%) were conducted in the USA, one (5%) in Canada and one (5%) in Australia. Across the 21 papers, 22 strategies were found to be effective at improving program delivery or adoption. Of these strategies, this review found that, when used in combination with other strategies (such as peer-assisted learning and developing school policies), the best strategies for implementation of mental health programs in schools involved (presented in order of importance for success):
1. Monitoring, auditing and provision of feedback
2. Engaging principles as program and local opinion leaders
3. Improving teachers buy-in
4. Organising regular school team program meetings
Of these, monitoring, auditing and provision of feedback proved to be the most promising strategy. Overall, these findings partly supported previous trials of school based physical health programs, where audit and provide feedback and engaging the school leadership team as local opinion leaders increased program adoption when used in combination with other strategies (Sutherland et al., 2021; Wolfenden et al., 2017). However, the findings of improving teachers buy-in and regular meetings was found to be relatively novel, with limited research identifying or including these strategies previously.
This review concluded with recommendations that school-based practitioners use findings from this review during the implementation of programmes in schools. Additionally, based on the limited number of studies included in this review, this review outlined the need for there to be research involving large-scale, randomised controlled trials to develop and trial more robust strategies to enhance the adoption and implementation of these programmes.
How are these findings reflected in project SAMA?
As identified by the authors of the review, the success of these strategies are likely to be context-dependent, with different strategies being more successful for implementation in different situations. As this review was conducted across higher income countries, their finding may not be reflected in LMICS, such as India. Therefore, we explored these findings in relation to experiences of implementing the SAMA project within schools in India.
Overall, it was felt that all identified strategies were valid and important in the implementation of SAMA. However, from the SAMA team’s experience, it was suggested that the order of importance for success would be different within an Indian (or LMIC) context. First, it was identified that the most important strategy would be the development of school policy encompassing the target mental health prevention programme. This is an important strategy within this context as, unlike in higher income countries (HICs) knowledge and understanding of the need for mental health prevention programmes may be low, therefore potentially reducing acceptance at an individual level. If school policy is developed and implemented then individual and collective acceptance of all aspects of the programme is likely to be higher, enabling a smoother implementation.
Secondly, it was identified that for the successful implementation of programmes in the same context as SAMA, engaging principles as programme and local opinion leaders is an important strategy, as reflected in the review. In SAMA it was observed that schools where the principles were engaged in the programme led to greater levels of acceptance; enabling it to be implemented with comparative ease, when compared to schools with a resistant principle, which created many additional barriers in implementation. It was also experienced that the attitudes of the principles had a large impact on the attitudes of others in the school (teachers/ students), with the schools of engaged principles being more accepting in general than those who were not. Similarly, improving teacher buy-in was also identified during SAMA as an important strategy, however it was not deemed as important as the engagement of principles.
Third, monitoring, auditing and provision of feedback was found to help the implementation of SAMA. However, although it was identified in this review as the successful implementation strategy, from the experience of SAMA it is not considered to be as important as the above-mentioned strategies.
Of the top 4 most successful strategies identified in the review, from experiences of implementing SAMA, we identified that organising regular school team program meetings was not a key strategy for enhancing the implementation of the SAMA programme. This is because, although potentially feasible to maintain in HICs, it is deemed that this strategy would be difficult to implement within a LMIC, such as in India. This is due to teaching staff already being placed under large burdens in their working day (e.g. large classes/ intense teaching timetable), making it highly unlikely that they would have regular time to give to programme meetings. Therefore, instead of this, SAMA found that informal meetings at a convenient time for the teaching staff was more effective than regular formal school team programme meetings.
Finally, in addition to the findings identified by the paper, from the experience of SAMA, an additional strategy identified was creating awareness of the purpose of the programme. This consists of providing teaching staff and students with an understanding of the programme, it’s importance, benefits and why it should be implemented. During the implementation of SAMA it was found that once staff and students were aware of the importance of the programme, their acceptance and engagement increased. This may not have been identified in the studies included in the review as they were all conducted in HICs, where knowledge of mental health and the importance of mental health programmes is arguably more wide-spread than in LMICS, resulting in an initial understanding of the need for the project from its offset.
Based on experiences implementing SAMA the most useful strategies for implementing mental health would consist of:
1. Development of school policy
2. Creating awareness of the purpose of the programme in schools
3. Improving teacher buy-in
4. Monitoring, auditing and provision of feedback
Conclusion
Overall, this review provides a useful starting point for understanding and improving the implementation of universal mental health prevention programs in schools through a selection of different implementation strategies. However, as identified by the authors, these strategies are context dependent and, from our experience, although they are applicable to, they do not fully reflect the implementation of mental health programmes in LMICs, such as India, where pre-existing knowledge of such programmes and resources may be lower than in HICs.
References:
Aggarwal, S., & Berk, M. (2015). Evolution of adolescent mental health in a rapidly changing socioeconomic environment: A review of mental health studies in adolescents in India over last 10 years. Asian journal of psychiatry, 13, 3-12.
Baffsky, R., Ivers, R., Cullen, P., Wang, J., McGillivray, L., & Torok, M. (2023). Strategies for Enhancing the Implementation of Universal Mental Health Prevention Programs in Schools: A Systematic Review. Prevention Science, 24(2), 337-352.
Fazel, M., Hoagwood, K., Stephan, S., & Ford, T. (2014). Mental health interventions in schools in high-income countries. The Lancet Psychiatry, 1, 377–387.
Grover, S., Raju V, V., Sharma, A., & Shah, R. (2019). Depression in children and adolescents: A review of Indian studies. Indian journal of psychological medicine, 41(3), 216-227.
Kieling, C., Baker-Henningham, H., Belfer, M., Conti, G., Ertem, I., Omigbodun, O., ... & Rahman, A. (2011). Child and adolescent mental health worldwide: evidence for action. The Lancet, 378(9801), 1515-1525.
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Williams, I., Vaisey, A., Patton, G., & Sanci, L. (2020). The effectiveness, feasibility and scalability of the school platform in adolescent mental healthcare. Current Opinion in Psychiatry, 33, 391–396.
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