The current state of international research on the effectiveness of school nurses in promoting the health of children and adolescents: An overview of reviews

OBJECTIVE

School nurses are engaging worldwide to promote and protect children's health. Many researchers who examined the effectiveness of the school nurse criticized the inadequate methodology employed in many of the studies. We therefore carried out an evaluation on the effectiveness of school nurses based on a rigorous methodological approach.

METHODS

In this overview of reviews we performed an electronic databank search and global research results on the effectiveness of school nurses were sought. We identified 1,494 records through database search. Abstracts and full texts were screened and summarized using the dual control principle. We summarized the aspects of quality criteria as well as the significance of the effectiveness of the school nurse. In the first step, k = 16 systematic reviews were summarized and evaluated following the AMSTAR-2 guidelines. In a second step, j = 357 primary studies included in these k = 16 reviews were summarized and assessed following the GRADE guidelines.

RESULTS

Research results on the effectiveness of school nurses show that school nurses play a key role in improving the health of children with asthma (j = 6) and diabetes (j = 2), results on combating obesity are less certain (j = 6). The quality of identified reviews is mostly very low with only six studies of medium quality, of which one identified as a meta-analysis. A total of j = 289 primary studies were identified. Approximately 25% (j = 74) of identified primary studies were either randomized controlled trials (RCT) or observational studies, of which roughly 20% (j = 16) had a low risk of bias. Studies with physiological variables such as blood glucose or asthma labeling led to higher quality results.

CONCLUSION

This paper represents an initial contribution and recommends further evaluation of the effectiveness of school nurses, particularly in the areas of mental health or children from low socioeconomic backgrounds. The general lack of quality standards in school nursing research should be integrated into the scientific discourse of school nursing researchers to provide robust evidence for policy planners and researchers.

The Evolution of the Role of U.S. School Nurses in Adolescent Mental Health at the Individual, Community, and Systems Level: An Integrative Review

School nurses are crucial to addressing adolescent mental health, yet evidence concerning their evolving role has not been synthesized to understand interventions across levels of practice (i.e., individual, community, systems). We conducted an integrative review of school nurse roles in mental health in the U.S. related to depressive symptoms, anxiety, and stress. Only 18 articles were identified, published from 1970 to 2019, and primarily described school nurses practicing interventions at the individual level, yet it was unclear whether they were always evidence-based. Although mental health concerns have increased over the years, the dearth of rigorous studies made it difficult to determine the impact of school nurse interventions on student mental health outcomes and school nurses continue to feel unprepared and under supported in this area. More research is needed to establish best practices and systems to support school nursing practice in addressing mental health at all levels of practice.

Depressive Symptoms Prospectively Predict Peer Victimization: A Longitudinal Study Among Adolescent Females

Research has consistently demonstrated a relationship between peer victimization, a major issue in early adolescence, and depression. However, longitudinal studies examining the relationship between peer victimization and depressive symptoms have yielded mixed results. Thus, the current study examined how specific aspects of peer victimization and subtypes of depressive symptoms are related over a two-year period. Adolescent females (N = 265) completed a questionnaire battery at baseline and two-year follow-up. Results indicated that baseline depressive symptoms prospectively predict peer overt victimization, relational victimization, and decreased prosocial behaviors at follow-up; baseline peer victimization did not predict depressive symptoms at follow-up. Further, results demonstrate the differential predictive value of specific depressive symptoms for overt vs. relational aggression and decreased prosocial behavior. Taken together, this study provides insight into the impact of depressive symptoms on peer victimization and the importance of addressing peer relations in the context of treatment for adolescent depression.

A School-Based Intervention for Mental Illness Stigma: A Cluster Randomized Trial

OBJECTIVES

To determine the effectiveness of a school-based curriculum, Eliminating the Stigma of Differences (ESD), in improving attitudinal and/or behavioral contexts regarding mental illness in schools and increasing the likelihood that youth seek treatment for mental health problems when needed.

METHODS

We conducted a cluster randomized trial in sixth-grade classes from 14 schools in 2011 and 2012 with follow-up at 6-month intervals through 24 months (2012-2015). Using a fully crossed 2 × 2 × 2 factorial design, we compared ESD to a no-intervention control and to 2 comparator interventions: (1) contact with 2 young adults with a history of mental illness and (2) exposure to antistigma printed materials. We implemented interventions in classrooms in an ethnically and socioeconomically diverse school district. There were 416 youth who participated in the follow-up, and 312 (75%) of these participated for the full 2 years. Outcome measures were knowledge and positive attitudes, social distance from peers with mental illness, and mental health treatment seeking.

RESULTS

Youth assigned to ESD reported greater knowledge and positive attitudes and reduced social distance (Cohen's d = 0.35 and 0.16, respectively) than youth in the comparator interventions and no-intervention groups across the 2-year follow-up. Youth with high levels of mental health symptoms were more likely (odds ratio = 3.51; confidence interval = 1.08-11.31) to seek treatment during follow-up if assigned to ESD than if they were assigned to comparator interventions or no intervention.

CONCLUSIONS

ESD shows potential for improving the social climate related to mental illnesses in schools and increasing treatment seeking when needed. ESD and interventions like it show promise as part of a public mental health response to youth with mental health needs in schools.

Effects of a school teacher-led 45-minute educational program for mental health literacy in pre-teens

AIM

A concise teacher-led program for mental health literacy (MHL), suitable for schools with tight schedules was developed, and its effects were examined in pre-teens.

METHODS

Participants comprised 662 grade 5 to 6 students from nine Japanese elementary schools. The program consisted of a 45-minute session, delivered by school teachers using a 10-minute animated film. Program focuses included: mental health problems are common, can be associated with lifestyle and that seeking help from reliable adults is a key to finding solutions. Participants filled out self-report questionnaires before, immediately after and 3 months post-intervention. Changes in MHL were analyzed using multilevel models.

RESULTS

Knowledge about mental health/illnesses, recognition of mental health state and intention to help peers/seek help when suffering from mental health problems, were significantly improved immediately and 3 months post-intervention.

CONCLUSIONS

Concise teacher-led programs administered in schools can have positive and lasting effects on MHL in pre-teens.

Psychosocial Correlates of Jordanian Adolescents' Help-Seeking Intentions for Depression: Findings From a Nationally Representative School Survey

Little is known about help-seeking for depression among Jordanian adolescents who are a vulnerable population with high rates of depressive symptoms and few mental health services. The purpose of this study was to (1) explore Jordanian adolescents' helpseeking intentions for depression and (2) examine whether depression stigma, depression severity, or their interaction are associated with Jordanian adolescents' willingness to seek help for depression and the type of treatment they would seek. In collaboration with the Jordanian Ministry of Education, we conducted a nationally representative, school-based survey of adolescents aged 12-17 years ( N = 2,349). One fourth of the adolescents reported they would not seek professional help for depression, and those respondents had higher average depression scores. Among those adolescents willing to seek help, the most likely sources included family member (57%), school counselor (46%), psychiatrist (43%), religious leader (39%), and general health practitioner (28%). Lower stigma scores were associated with greater likelihood to seek psychotherapy or visit a psychiatrist, while higher stigma scores were associated with increased likelihood to seek help from a school counselor or a family member. Jordanian adolescents experience significant barriers to seeking professional help for depression. However, even among adolescents with greater depression severity and depression stigma, school counselors were identified as a key resource for help. These findings suggest that school-based interventions may fill a critical service need for adolescents with depression and other mental health problems. School nurses should be leveraged along with counselors to address mental health issues in this vulnerable population.

Early intervention for stigma towards mental illness? Promoting positive attitudes towards severe mental illness in primary school children

Purpose

Stigma towards severe mental illness (SMI) is widespread, exacerbating mental health problems, and impacting on help-seeking and social inclusion. Anti-stigma campaigns are meeting with success, but results are mixed. Earlier intervention to promote positive mental health literacy rather than challenge stigma, may show promise, but little is known about stigma development or interventions in younger children. The purpose of this paper is to investigate children’s knowledge, attitudes and behaviour towards SMI and whether we can positively influence children’s attitudes before stigma develops.

Design/methodology/approach

A cross-sectional study investigated mental health schema in 7-11 year olds. An experimental intervention investigated whether an indirect contact story-based intervention in 7-8 year olds led to more positive mental health schema.

Findings

Young children’s schema were initially positive, and influenced by knowledge and contact with mental illness and intergroup anxiety, but were more stigmatising in older girls as intergroup anxiety increased. The indirect contact intervention was effective in promoting positive mental health schema, partially mediated by knowledge.

Social implications

Intervening early to shape concepts of mental illness more positively, as they develop in young children, may represent a more effective strategy than attempting to challenge and change mental health stigma once it has formed in adolescents and adults.

Originality/value

This study is the first to investigate an intervention targeted at the prevention of stigma towards SMI, in young children, at the point that stigma is emerging.

Effectiveness of Universal School-Based Mental Health Awareness Programs Among Youth in the United States: A Systematic Review

BACKGROUND

Stigmatizing attitudes toward mental illness and low mental health literacy have been identified as links to social adversity, and barriers to seeking and adhering to treatment among adolescents suffering from mental illness. Prior research has found that it is possible to improve these outcomes using school-based mental health awareness interventions. The purpose of this study was to review empirical literature pertaining to universal mental health awareness interventions aiming to improve mental health related outcomes among students enrolled in US K-12 schools, especially minorities vulnerable to health disparities.

METHODS

PsycINFO, Cochrane Library, PUBMED, and reference lists of relevant articles were searched for K-12 school-based mental health awareness interventions in the United States. Universal studies that measured knowledge, attitudes, and/or help-seeking pertinent to mental health were included.

RESULTS

A total of 15 studies were selected to be part of the review. There were 7 pretest/post-test case series, 5 nonrandomized experimental trial, 1 Solomon 4-groups, and 2 randomized controlled trial (RCT) designs. Nine studies measuring knowledge, 8 studies measuring attitudes, and 4 studies measuring help-seeking, indicated statistically significant improvements.

CONCLUSIONS

Although results of all studies indicated some level of improvement, more research on implementation of universal school-based mental health awareness programs is needed using RCT study designs, and long-term follow-up implementation.

A Follow-up Study of Former Student Health Advocates

Student health advocates (SHAs) are high school students who, under the supervision of the school nurse, provide health education and health promotion activities to other students via a peer education model. This 3-year follow-up study explored how the SHA experience influences career choice and attitudes of the participants. It also examined what motivates students to become SHAs, the benefits and drawbacks of SHA participation, how SHA involvement influenced career plans, and how SHAs perceive the role of the school nurse. Study results indicate that this innovative health education/promotion experience offered an opportunity for SHAs to express their interest in health and enhanced their sense of belonging, meaningful involvement, connection to learning, and caring relationships in the school setting.

Adolescent Depression in the Arab Region: A Systematic Literature Review

Adolescent depression is a primary cause of global disability and burden with considerable variability across countries in its prevalence, diagnosis, management, and prognosis. No systematic reviews have been published on adolescent depression in Arab countries despite the unique sociocultural background that can play a major role in shaping Arab depressed adolescents' prognosis and response to treatment. The purpose of this study was to provide such a review with the goal of identifying the necessary foundations for culturally competent mental health care practices to address the unique needs of Arab adolescents and their families. We systematically reviewed PubMed, CINAHL, PsycINFO, and available Arabic databases. We adhered to the PRISMA statement to guide the process of identification, selection, and appraisal of the reviewed articles. No restrictions were applied on publication date. The search was completed in December 2015. A total of 199 unique articles met criteria for screening at the abstract level; 47 articles were selected for review in full text; and 27 articles were included in the final analysis. Four emerging themes were identified: (1) few robust prevalence estimates of adolescent depression are available in Arab countries; (2) depression varies based on the individual characteristics of Arab adolescents; (3) context influences Arab adolescents' risk of experiencing depression; and (4) the stigma of depression negatively impacts help-seeking process among Arab adolescents. This review highlights the need for more community-based detection efforts that employ developmentally and culturally appropriate measurement instruments for adolescent depression. Furthermore, findings suggest the need for culturally competent care that integrates indigenous health practices into modern mental health systems. Nurses, who form the greatest proportion of health personnel in all Arab countries, are uniquely situated to help Arab adolescents experiencing depression restore, maintain, and/or promote their mental health and wellbeing.

Mental health literacy measures evaluating knowledge, attitudes and help-seeking: a scoping review

BACKGROUND

Mental health literacy has received increasing attention as a useful strategy to promote early identification of mental disorders, reduce stigma and enhance help-seeking behaviors. However, despite the abundance of research on mental health literacy interventions, there is the absence of evaluations of current available mental health literacy measures and related psychometrics. We conducted a scoping review to bridge the gap.

METHODS

We searched PubMed, PsycINFO, Embase, CINAHL, Cochrane Library, and ERIC for relevant studies. We only focused on quantitative studies and English publications, however, we didn't limit study participants, locations, or publication dates. We excluded non-English studies, and did not check the grey literature (non peer-reviewed publications or documents of any type) and therefore may have missed some eligible measures.

RESULTS

We located 401 studies that include 69 knowledge measures (14 validated), 111 stigma measures (65 validated), and 35 help-seeking related measures (10 validated). Knowledge measures mainly investigated the ability of illness identification, and factual knowledge of mental disorders such as terminology, etiology, diagnosis, prognosis, and consequences. Stigma measures include those focused on stigma against mental illness or the mentally ill; self-stigma ; experienced stigma; and stigma against mental health treatment and help-seeking. Help-seeking measures included those of help-seeking attitudes, intentions to seek help, and actual help-seeking behaviors.

CONCLUSIONS

Our review provides a compendium of available mental health literacy measures to facilitate applying existing measures or developing new measures. It also provides a solid database for future research on systematically assessing the quality of the included measures.

The Role and Impact of Nurses in American Elementary Schools

School nurses are tasked with the critical job of keeping students safe and well. Due to competing demands for resources in schools, the impact of school nurses must be demonstrated to secure their jobs. A systematic review of the literature from 1937 to 2013 was conducted to show the efficacy of school nursing activities in American elementary schools. While some studies of immunization compliance, attendance rates, body mass index screening, vision screening, and follow-up are promising, results are mixed and additional evidence is needed. The impact of school nurses on educational and health outcomes must continue to be evaluated and more rigorous evaluation methods should be explored. Suggestions for future research and collaborations are discussed.

Mental health promotion: guidance and strategies

Public mental health incorporates a number of strategies from mental well-being promotion to primary prevention and other forms of prevention. There is considerable evidence in the literature to suggest that early interventions and public education can work well for reducing psychiatric morbidity and resulting burden of disease. Educational strategies need to focus on individual, societal and environmental aspects. Targeted interventions at individuals will also need to focus on the whole population. A nested approach with the individual at the heart of it surrounded by family surrounded by society at large is the most suitable way to approach this. This Guidance should be read along with the European Psychiatric Association (EPA) Guidance on Prevention. Those at risk of developing psychiatric disorders also require adequate interventions as well as those who may have already developed illness. However, on the model of triage, mental health and well-being promotion need to be prioritized to ensure that, with the limited resources available, these activities do not get forgotten. One possibility is to have separate programmes for addressing concerns of a particular population group, another that is relevant for the broader general population. Mental health promotion as a concept is important and this will allow prevention of some psychiatric disorders and, by improving coping strategies, is likely to reduce the burden and stress induced by mental illness.

School nurses' perspectives on managing mental health problems in children and young people

AIMS AND OBJECTIVES

To explore the views of school nurses regarding mental health problems in young people and their potential for engaging in mental health work with this client group.

BACKGROUND

Mental health problems in children and young people are an important public health issue. Universal children's services play a key role in identifying and managing these problems and, while school nurses have an important function in this work, little is known about their views on this aspect of their role.

DESIGN

A qualitative research design employing focus group methodology.

METHOD

School nurses (n = 33) were purposively sampled from four school nursing teams in two English cities for a series of focus groups. The focus group data were audio-recorded, transcribed and subsequently analysed using 'framework'.

RESULTS

Four principal themes emerged from the data. In these themes, school nurses were found to value their involvement with the mental health of young people, recognising this as an important area of practice. Several obstacles to their work in this area were identified: heavy workloads, professional rivalries, a lack of confidence and limited education and training opportunities. The importance of support from local specialist mental health teams was emphasised.

CONCLUSIONS

School nurses can be engaged in mental health work though, as public health specialists, their role should focus on health promotion, assessment, signposting and early intervention activities. To facilitate mental health work, school nurses are able to draw on established interpersonal skills and supportive networks; however, workload and a lack of confidence need to be managed and it is important that they are supported by constructive relationships with local specialist mental health teams.

RELEVANCE TO CLINICAL PRACTICE

This study has implications for nurses and healthcare practitioners interested in enhancing the mental health of children and young people in school settings.

Feasibility, acceptability, and initial efficacy of a knowledge-contact program to reduce mental illness stigma and improve mental health literacy in adolescents

The purpose of this school-based cluster-randomized trial was to determine the initial acceptability, feasibility, and efficacy of an existing community-based intervention, In Our Own Voice, in a sample of US adolescent girls aged 13-17 years (n = 156). In Our Own Voice is a knowledge-contact intervention that provides knowledge about mental illness to improve mental health literacy and facilitates intergroup contact with persons with mental illness as a means to reduce mental illness stigma. This longitudinal study was set in two public high schools located in a southern urban community of the U.S. Outcomes included measures of mental illness stigma and mental health literacy. Findings support the acceptability and feasibility of the intervention for adolescents who enrolled in the study. Findings to support the efficacy of In Our Own Voice to reduce stigma and improve mental health literacy are mixed. The intervention did not reduce mental illness stigma or improve mental health literacy at one week follow up. The intervention did not reduce mental illness stigma at 4 and 8 weeks follow up. The intervention did improve mental health literacy at 4 and 8 weeks follow up. Previous studies have assessed the preliminary efficacy In Our Own Voice among young adults; rarely has In Our Own Voice been investigated longitudinally and with adolescents in the United States. This study provides initial data on the effects of In Our Own Voice for this population and can be used to further adapt the intervention for adolescents.

Young people's views of mental health education in secondary schools: a Scottish study

BACKGROUND

This exploratory study used mixed methods to investigate young people's preferences in the delivery of mental health education and to investigate possible age and gender differences.

METHOD

Information was gathered about the delivery of mental health education in three secondary schools. Nine pupil focus groups were carried out to identify key themes which were then further developed and administered through questionnaires to a larger sample of 773 pupils.

RESULTS

Gender and age differences were found in young people's preferences about who should deliver mental health education, and what, when, where and how this should be delivered.

CONCLUSION

Mental health education should reflect the needs of young people. Age and gender preferences should be considered when designing these programmes.

Medication management in primary and secondary schools: evaluation of mental health related in-service education in local schools

An increasing number of students are taking medications while they are in school or are under the influence of medication during school hours. In a novel effort, clinical pharmacists and mental health therapists worked together to provide "mini-in-service" educational programs on psychological disorders and medications used to treat these disorders. The purpose of this study was to implement and evaluate the effectiveness of these educational programs presented to school nurses, teachers, school administrators, and other personnel. The study compared participant responses before and after attending a medication in-service session on a psychological disorder and its related medications. Results indicated that in-service education on attention deficit/hyperactivity disorder (ADHD) and depression improved the knowledge and confidence levels of school personnel regarding medications and symptoms. Feedback indicated school personnel wanted longer educational sessions and more information on these disorders and treatments. School nurses working with health professionals can improve education for staff, families, and students about mental health disorders and their treatment.

Mental health and academic achievement: role of school nurses

PURPOSE

This article discusses how school nurses promote mental health and subsequent academic achievement by screening and referral for children demonstrating mental health problems. Nursing interventions are discussed at the individual, systems, and community levels.

CONCLUSION

Mental health problems can affect school performance and academic achievement. When mental health problems are not recognized, students may be unable to reach their academic potential. School nurses are in a key position to provide interventions to address mental health and academic achievement.

PRACTICE IMPLICATIONS

The role of school nurses and examples of mental health collaborative activities are provided.