Do universal school‐based mental health promotion programmes improve the mental health and emotional wellbeing of young people? A literature review

AIMS AND OBJECTIVES
To examine evidence-using a range of outcomes-for the effectiveness of school-based mental health and emotional well-being programmes.


BACKGROUND
It is estimated that 20% of young people experience mental health difficulties every year. Schools have been identified as an appropriate setting for providing mental health and emotional well-being promotion prompting the need to determine whether current school-based programmes are effective in improving the mental health and emotional well-being of young people.


METHODS
A systematic search was conducted using the health and education databases, which identified 29 studies that measured the effectiveness of school-based universal interventions. Prisma guidelines were used during the literature review process.


RESULTS
Thematic analysis generated three key themes: (i) help seeking and coping; (ii) social and emotional well-being; and (iii) psycho-educational effectiveness.


CONCLUSION
It is concluded that whilst these studies show promising results, there is a need for further robust evaluative studies to guide future practice.


RELEVANCE TO CLINICAL PRACTICE
All available opportunities should be taken to provide mental health promotion interventions to young people in the school environment, with a requirement for educational professionals to be provided the necessary skills and knowledge to ensure that the school setting continues to be a beneficial environment for conducting mental health promotion.

. . .actions to create living conditions and environments that support mental health and allow people to adopt and maintain healthy lifestyles. These include a range of actions to increase the chances of more people experiencing better mental health. (World Health Organisation, 2016 pp. 1) The terms "mental health" and "emotional well-being" are used interchangeably within the literature and are considered to have similar properties. For this review, the terms "children," "adolescents" and "young people" will be used interchangeably as they encompass the age range of the population of interest, 5-18 years old.
This study investigates promotional programmes designed to support MH and emotional well-being (EW) in children. Children's public health embraces physical, social, mental and emotional wellbeing dimensions. MH and EW are defined as: being happy and confident and not anxious or depressed. . .the ability to be autonomous, problem-solve, manage emotions, experience empathy, be resilient and attentive (National Institute for Health and Care Excellence (NICE), 2013 pp. 5).
Because each dimension of health interacts, a positive effect on physical health is likely to also improve a person's MH and EW and vice versa (Ewles & Simnett, 2003). From this perspective, the WHO identifies the need for a holistic approach to the well-being of young people as MH problems can have a negative effect on all areas of development. These include the ability to manage thoughts and emotions, the ability to build social relationships, the aptitude to learn and the subsequent consequences of failure to do so (WHO, 2010).
The burden of MH in young people is substantial (UNICEF, 2013;WHO, 2004), which is a clear motivation for providing MH and EW promotion in additional or alternative environments rather than simply focusing on healthcare settings. In 2016, WHO published further guidance on MH promotion in their fact sheet "Mental Health: Strengthening our response." The fact sheet supports the use of intersectoral strategies and provides specific ways in which MH can be promoted, including the use of school-based MH promotional programmes (WHO, 2016).
Further to this, in a recent report by the Education Policy Institute's Commission (EPIC) there is an acknowledgement of the short falls of current MH services for young people and it is recommended that schools and teachers should be used in the process of transforming young people's MH care. One of the suggested initiatives in the report is the use of joint training for Child and Adolescent Mental Health Services (CAMHS) staff and teaching staff. This initiative is already being piloted in 22 areas of the UK and aims to ensure that all professionals in a position of responsibility have an understanding of the MH needs of young people and how these may be supported. It is expected that initiatives such as the one above would reduce the number of referrals to MH services that specialists in areas such as CAMHS would consider inappropriate. There is often a "disconnect" between what non-MH practitioners or members of the public compared with MH practitioners consider "appropriate." Training non-MH practitioners, such as teachers, in techniques such as listening and mental health first aid (for example) may reduce referrals and reduce MH services waiting times; whilst also enabling education professionals to feel that they are receiving the required training and support for meeting the needs of the young people in their care (Frith, 2016).
According to Marks (2012), schools are the optimal environment to deliver MH programmes for children and young people outside of healthcare settings as they are safe, cost-effective and flexible places in which a diverse range of interventions can be offered. Alexander (2003) states that schools and the education system play an important role in MH promotion as it may contribute to making schools a healthier environment which benefits the pupils, staff and the wider community. Similarly, NICE (2009) identifies that educational establishments can and should provide a safe environment which nurtures self-worth and efficacy. Established relationships between the child and one or more of their teachers, along with regular contact between these two groups, suggest both trust and accessibility.
The Office of National Statistics (2004) suggest a child or young person with impaired well-being is more likely to be excluded from school, to become disengaged from the education process and to experience academic underachievement. It is also clear within a recent report by The Centre for Mental Health that the effect of MH problems for young people will rarely cease to exist for an individual during their school age years, but in fact will continue into adult life. This report also calls for schools to be used as an environment for providing MH promotion and recognises that schools that provide a "whole-school approach" to promoting MH have the best outcomes (Khan, 2016). For a whole-school approach to be engaged, the school must commit to creating a health promoting environment, with all staff supporting the initiative and ensuring that MH and social and emotional well-being is placed throughout the school's curriculum (Weare & Nind, 2011). For each school, the best outcome results in meeting the individual needs of the students, particularly What does this paper contribute to the wider global clinical community?
• Schools have been identified as an alternative or additional environment to the more typical healthcare setting, with this literature review providing further evidence of the effectiveness of school-based mental health interventions.
• This literature review also demonstrates the importance of ensuring that schools are provided with quality evidence-based programmes that can be effectively implemented and sustained.
in terms of the social and emotional well-being and the reduction of any identified risk factors (Khan, 2016). Therefore, if schools are deemed to be an appropriate additional or alternative to healthcare settings for MH and EW programmes, then this focuses the need to answer the research question: Are current school-based MH programmes effective for promoting the MH and EW of young people?
School-based MH and EW programmes can generally be divided into two different categories, universal interventions and targeted interventions. Universal interventions are those that target general population groups; for example, in schools this may be the whole school or all within an age range. Targeted interventions are designed to be delivered to specific groups or individuals who have been identified to need specific support or treatment due to an existing illness, vulnerability or risk factor.
Generally, there is little information about exactly how and where universal interventions are delivered. Provision depends on individual schools and organisations largely rather than national initiatives, and in a recent report by "Young Minds," current provision in schools was referred to as "inconsistent" (Young Minds, 2017).
However, it is noted that one specific form of school-based MH promotion that is more widely undertaken and that has been more thoroughly researched is "social and emotional learning" (SEL). SEL interventions are a form of MH and well-being promotion that have been undertaken in schools across the UK, USA and Europe (Elias et al., 1997).

One example of SEL is the programme Social and Emotional
Aspects of Learning (SEAL). It is a programme which aims to enhance personal development of young people by providing a framework and ideas for teaching SEL in pre-existing lessons and across the school curriculum (PSHE Association, 2014). It has been subject to a national evaluation conducted by Humphrey, Lendrun, and Wigelsworth (2010) through a quasi-experimental study that compared the use of SEAL in 22 schools with 19 comparison schools. The evaluative study aimed to assess the impact of SEAL on the pupils receiving and the staff providing it, whilst also examining the implementation of the SEAL programme. In the implementation arm of the study, the authors found a lack of consistency; however, they acknowledged that this showed little effect on the outcomes for the pupils. Most importantly, the impact of SEAL provided in the sample schools was disappointing; data showed that the programme failed to have an impact on the social and emotional skills, MH difficulties, behaviour problems or pro-social behaviours of pupils.
The results of the evaluation above are not encouraging when considering the effectiveness of school-based MH promotion; however, the authors report that the study findings provided an opportunity for review and reflection and did recognise that their study did not follow the trend that had been shown in alternative reviews of SEL programmes (Humphrey et al., 2010).
Most recent published reviews relating to MH and EW interventions in schools focus on targeted rather than universal programmes (Losel & Beelman, 2003;Wilson, Gottfredson, & Najaka, 2001;Wilson & Lipsey, 2007). Only three papers were identified that related to universal interventions (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011;Sklad, Diekstra, De Ritter, Ben, & Gravesteijn, 2012;Wells, Barlow, & Stewart-Brown, 2003). Wells et al. (2003) conducted a systematic review of universal approaches to mental health promotion in schools. Following the review of 17 papers, which considered 16 different school-based interventions the authors found positive evidence that universal school-based interventions were effective, particularly those that used a long-term intervention with a whole-school approach. It should be recognised however that this was a small review and is now dated. Therefore, a need was identified for a review that focused on school-based universal MH and EW programmes that could add to the existing literature provided by Durlak et al. (2011), Sklad et al. (2012 and Wells et al. (2003). It is clear from the previous literature review by Wells et al. (2003) that there is a range of potential outcomes from universal school-based interventions. To gain further clarity, it was deemed reasonable to initially take the widest possible view in this literature review. It should however be noted that with such an approach, the resulting research question and research aim would have limited specificity.

| AIMS
To examine evidence-using a range of outcomes-for the effectiveness of school-based mental health and emotional well-being programmes.

| Research question
Are current school-based MH promotional programmes effective for promoting the MH and EW of young people?

| Search strategy
A systematic search was conducted using the health and education databases CINAHL, Medline, PsycInfo, ERIC and Education Research Complete. The search terms were used as follows: "young people" OR "young person" OR "child*" OR "kid*" OR "adolescen*" OR "youth*" OR "teen*" AND "school*" OR "school-based" OR "college" OR "sixth form" OR "kindergarten" AND "mental health promotion" OR "mental health prevention" OR "social emotional learning" OR "psychoeducation" OR "intervention" OR "emotional well-being" OR "mental health" OR "mental health stigma" OR "coping" OR "resilience" OR "help-seeking" OR "stress management".

| Inclusion and exclusion criteria
Inclusion criteria were as follows: English language, published 1995-2015, reports of universal interventions, participants aged 5-18 and conducted in the school environment. Exclusion criteria were as follows: reports of targeted interventions and those conducted in nonschool environments, and papers evaluating SEL interventions prior to 2008 that have been included in the two SEL reviews mentioned above (Durlak et al., 2011;Sklad et al., 2012). During the literature review process, it was decided to include the SEL reviews by Durlak et al., 2011 andSklad et al., 2012 to enable synthesis of results. ). An initial 807 papers were identified, and these were reduced to 29 after excluding duplicates or general interest articles that did not report primary research. To ensure thoroughness, citation searches of included articles were conducted. PRISMA guidelines were designed to aid author reporting in systematic reviews and meta-analyses; therefore, the PRISMA checklist has been used during this literature review process (PRISMA, 2017).

| Study characteristics
Twenty-five studies used a quantitative approach, one qualitative and three were mixed methods. The designs of the studies included, two meta-analysis studies, six randomised controlled trials, or cluster randomised control trials, one controlled prospective longitudinal study, one semi-structured interviews, one quasi-experimental design, eight pretest, post-test with control group designs, five pretest, post-test without control group designs and two time series designs. Studies took place across 12 countries. Sample sizes varied from 28-4,443 and children from across the 5-18 age range were involved. The age range of the participants in the studies included, 11 with primary school age children (5-10 years old) and 13 with secondary school age children (11-18 years old). Three of the studies selected participants that crossed both primary school age and secondary school age (7-14 years of age). In the two research papers that conducted a meta-analysis, the studies included both primary school age children and secondary school age children.
The interventions varied, and SEL was the most common (12 out of 29 included studies); however, there were also, stress management interventions, mindfulness interventions, anxiety and coping skills interventions, and MH education and antistigma interventions.
The detail in which the interventions were described also differed, and information regarding the specific elements of the intervention and how it was provided and by whom, was considerably more limited in a small number of the included papers. Of the studies that reported a theoretical underpinning, the most frequent was that of social learning and/or cognitive-behaviour theory.
Due to the heterogeneity of the methods and outcomes in the studies described above, meta-analysis was precluded; however, this still allowed for description of the studies, their results and limitations and for qualitative synthesis. | e415 appraisal took place using checklist points from more than one checklist, such as for the mixed methods research papers. Each study was also appraised in relation to whether the intervention has been theoretically informed as recommended in the Medical Research Council (MRC) guidelines on developing and evaluating complex interventions (Craig et al., 2008). The "Template for Intervention Description and Replication (TIDieR) Checklist" was also used during the appraisal process to determine whether there was sufficient information provided by each author to allow for a true evaluation of effectiveness and the ability to replicate. Particular interest was taken in considering adherence and fidelity of the interventions, and any omissions were noted as exceptions to quality. (Hoffmann et al., 2014). A brief quality appraisal, including exceptions to quality, reported validity of outcome measures and theoretical underpinning of interventions can be found in Table 1.

| Results of individual studies
A brief description of results of the individual studies can be found in Table 1.

| Synthesis of results
Thematic analysis using a process of coding and categorising was completed to identify and analyse patterns within the data. A sixstep process was undertaken: familiarisation with the data; generating initial codes; searching for themes; reviewing themes; defining and naming themes; and producing the report. This process was informed by the Braun and Clarke (2006) method of thematic analysis. It was evident from initial generating of codes and definition of themes that these would be based on the different outcome measures. The final themes were as follows: (i) help seeking and coping; (ii) social and emotional well-being; and (iii) psycho-educational effectiveness. Each is presented in turn.

| Social and emotional well-being
Twenty of the 29 included papers measured one or more aspects of social and emotional well-being. The effectiveness of a MH Promotion programme on the social skills of children was evaluated by five authors (De Wolfe & Saunders, 1995;Harlacher & Merrell, 2010;Kimber, Sandell, & Bremberg, 2008;Kramer, Caldarella, Christensen, & Shatzer, 2009;Mishara & Ystgaard, 2006) et al. (2008) found no differential effect on social skills, and positive results regarding pro-social behaviours (such as showing concern for others or behaving in a way that helps or supports another person) were not indicated by Wigelsworth, Humphrey, and Lendrum (2013) or Jones, Brown, Hoglund, and Lawrence Aber (2010). (2009)  and Kuyken et al. (2013) with the latter study demonstrating sustained improvements at 3-month follow-up.

| Psycho-educational effectiveness
The third theme apparent within eight studies was relating to providing the participants with an increased knowledge of MH and illness and changing negative attitudes and beliefs. Four authors (Economou et al., 2012;Essler, Arthur, & Stickley, 2006;Rickwood et al., 2004 2014) reported that a psycho-educational intervention increased knowledge of MH. Economou et al. (2012), andEssler et al. (2006) also explored whether a psycho-educational intervention would change negative attitudes and beliefs. Economou et al. (2012) identified results that showed that the number of participants using positive terms increased after the intervention; however, Essler et al. (2006) noted that following their intervention there was some evidence of an increase in negative attitudes associated with MH stigma. Merrell et al. (2008) Harlacher andMerrell (2010) and Whitcomb and Merrell (2012) reported increased knowledge about emotional health and situations.

| DISCUSSION
This literature review considered the effectiveness of school-based universal MH and EW programmes for young people. Three themes were generated from the literature: help-seeking and coping, emotional and social well-being and psycho-educational effectiveness.
The principle findings are that most studies reported that schoolbased MH and EW programmes have some positive effect on young people; however, three studies noted either a negative effect or no effect at all (Essler et al., 2006;Jones et al., 2010;Wigelsworth et al., 2013). studies (Barnes et al., 2012;Collins et al., 2013;Kimber et al., 2008;King et al., 2011). Differing biases in the studies should be acknowledged. For example, Kramer et al. (2009) acknowledge that children and their families were recruited from schools that had already agreed to implement the programme, suggesting that the school already had some confidence in its effectiveness whilst Mishara and Ystgaard (2006) (Craig et al., 2008). The level of detail provided regarding each individual intervention varied, from very specific information relating to the different elements of the intervention, to a simple brief description. The theoretical underpinning of the included studies was also considered further in relation to the specific results or overall success of the interventions; however, no pattern was found.
The inclusion of studies other than RCTs has enabled a wider and richer review. As with other literature reviews regarding MH and EW programmes, (Durlak et al., 2011;Sklad et al., 2012;Wells et al., 2003) a large number of studies were excluded at each stage of the process and only 29 papers met the inclusion criteria. However, a distinct difference in this review to those previously conducted (Kutcher & Wei, 2012;Losel & Beelman, 2003;Tenant, Goens, Barlow, Day, & Stewart-Brown, 2007;Wilson & Lipsey, 2007;Wilson et al., 2001) is that it has focused solely on universal interventions.
The findings of this literature review and the recognition of its strengths and weakness have highlighted research questions that need to be addressed to build the evidence base for universal school-based MH and EW interventions including: • What is the comparative effectiveness of different theory based interventions in the short and longer term?
• What are the most appropriate outcomes measures for measuring the effectiveness of different types of intervention?

| CONCLUSION
We tentatively conclude that school-based universal MH and EW programmes are of value for young people but further evaluative studies are necessary before implementation.
This literature review has synthesised the available evidence concerning the effectiveness of school-based interventions in improving the MH and EW of young people. Three areas of effectiveness were identified: (i) help seeking and coping; (ii) social and emotional wellbeing; and (iii) psycho-educational effectiveness. This review has identified the need for further evaluative studies to provide the necessary evidence base to inform nurses, educationalists and public health practitioners.

| RELEVANCE TO CLINICAL PRACTICE
The purpose of this review was to determine whether school-based MH promotion is effective and therefore could be used as an alternative or addition to typical healthcare settings. It has already been recognised that the healthcare sector alone is not sufficient if we are to improve the MH and EW of young people and there has been acknowledgement that schools can play a vital role in transforming MH provision for young people (Frith, 2016;Khan, 2016;WHO, 2016).
The findings of the review have shown positive effects of school-based MH promotion on such areas as coping skills, helpseeking skills, social skills, emotional regulation and reduction of symptoms associated with low level depression and anxiety. Any improvements to MH and emotional well-being will reduce the likelihood of MH problems developing or improve the ability to cope with MH problems in the future, whether that be through such things as stress management or positive help seeking. Considering this, it is essential that all available opportunities are taken to provide MH and EW promotional interventions to young people in the school environment particularly through a whole-school approach.
Furthermore, this review identifies a requirement for educational professionals and all other school staff to be provided with the necessary skills and knowledge to be able to ensure that the school setting continues to be a beneficial environment for providing MH and EW promotion. This highlights the need for multi-agency working and strong links between the education and healthcare professions.
If joint training is provided to MH professionals and school staff as recommended in the 2016 EPIC report, then there is a greater chance of improving the MH support provided to young people and reducing the amount of inappropriate referrals to MH teams which in turn reduces waiting lists. This training would also enable school staff to be better equipped to provide school-based promotion programmes such as those reviewed in this literature review.