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Grummitt L, Bailey S, Kelly EV, Birrell L, Gardner LA, Halladay J, Chapman C, Andrews JL, Champion KE, Hunter E, Egan L, Conroy C, Tiko R, Nguyen A, Teesson M, Newton NC, Barrett EL. Refining the Universal, School-Based OurFutures Mental Health Program to Be Trauma Informed, Gender and Sexuality Diversity Affirmative, and Adherent to Proportionate Universalism: Mixed Methods Participatory Design Process. JMIR Pediatr Parent 2024; 7:e54637. [PMID: 39167794 PMCID: PMC11375394 DOI: 10.2196/54637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 07/04/2024] [Accepted: 07/08/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND Mental disorders are the leading cause of disease burden among youth. Effective prevention of mental disorders during adolescence is a critical public health strategy to reduce both individual and societal harms. Schools are an important setting for prevention; however, existing universal school-based mental health interventions have shown null, and occasionally iatrogenic, effects in preventing symptoms of common disorders, such as depression and anxiety. OBJECTIVE This study aims to report the adaptation process of an established, universal, school-based prevention program for depression and anxiety, OurFutures Mental Health. Using a 4-stage process; triangulating quantitative, qualitative, and evidence syntheses; and centering the voices of young people, the revised program is trauma-informed; lesbian, gay, bisexual, transgender, nonbinary, queer, questioning, and otherwise gender and sexuality diverse (LGBTQA+) affirmative; relevant to contemporary youth; and designed to tailor intervention dosage to those who need it most (proportionate universalism). METHODS Program adaptation occurred from April 2022 to July 2023 and involved 4 stages. Stage 1 comprised mixed methods analysis of student evaluation data (n=762; mean age 13.5, SD 0.62 y), collected immediately after delivering the OurFutures Mental Health program in a previous trial. Stage 2 consisted of 3 focus groups with high school students (n=39); regular meetings with a purpose-built, 8-member LGBTQA+ youth advisory committee; and 2 individual semistructured, in-depth interviews with LGBTQA+ young people via Zoom (Zoom Video Communications) or WhatsApp (Meta) text message. Stage 3 involved a clinical psychologist providing an in-depth review of all program materials with the view of enhancing readability, improving utility, and normalizing emotions while retaining key cognitive behavioral therapy elements. Finally, stage 4 involved fortnightly consultations among researchers and clinicians on the intervention adaptation, drawing on the latest evidence from existing literature in school-based prevention interventions, trauma-informed practice, and adolescent mental health. RESULTS Drawing on feedback from youth, clinical psychologists, and expert youth mental health researchers, sourced from stages 1 to 4, a series of adaptations were made to the storylines, characters, and delivery of therapeutic content contained in the weekly manualized program content, classroom activities, and weekly student and teacher lesson summaries. CONCLUSIONS The updated OurFutures Mental Health program is a trauma-informed, LBGTQA+ affirmative program aligned with the principles of proportionate universalism. The program adaptation responds to recent mixed findings on universal school-based mental health prevention programs, which include null, small beneficial, and small iatrogenic effects. The efficacy of the refined OurFutures Mental Health program is currently being tested through a cluster randomized controlled trial with up to 1400 students in 14 schools across Australia. It is hoped that the refined program will advance the current stalemate in universal school-based prevention of common mental disorders and ultimately improve the mental health and well-being of young people in schools.
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Affiliation(s)
- Lucinda Grummitt
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Sasha Bailey
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Erin V Kelly
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Louise Birrell
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Lauren A Gardner
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Jillian Halladay
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
- School of Nursing, McMaster University, Ontario, ON, Canada
- Peter Boris Centre for Addictions Research, St Joseph's Healthcare Hamilton, McMaster University, Ontario, ON, Canada
| | - Cath Chapman
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Jack L Andrews
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Katrina E Champion
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Emily Hunter
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Lyra Egan
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Chloe Conroy
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Raaya Tiko
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - An Nguyen
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Maree Teesson
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Nicola C Newton
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
| | - Emma L Barrett
- The Matilda Centre for Research in Mental Health and Substance Use, The University of Sydney, Sydney, Australia
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McPhail L, Thornicroft G, Gronholm PC. Help-seeking processes related to targeted school-based mental health services: systematic review. BMC Public Health 2024; 24:1217. [PMID: 38698391 PMCID: PMC11065683 DOI: 10.1186/s12889-024-18714-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/25/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND One in seven adolescents globally are affected by mental health conditions, yet only a minority receive professional help. School-based mental health services have been endorsed as an effective way to increase access to mental health support for people at risk, or currently presenting with mental health conditions, throughout adolescence. Despite this, low treatment utilisation prevails, therefore the aim of this review is to contribute insights into the processes related to adolescents' accessing and engaging with essential targeted mental health support within schools. METHODS This systematic review extracted qualitative, quantitative and mixed-methods data to determine what processes affect adolescents seeking help from targeted school-based mental health services (TSMS). Searches were conducted in EMBASE, Medline, PsycINFO, CINAHL, ERIC, Web of Science, in addition to manual searching and expert consultations. Data were synthesised following guidelines for thematic synthesis and narrative style synthesis. RESULTS The search resulted in 22 articles reflecting 16 studies with participant sample sizes ranging from n = 7 to n = 122. Three main themes were identified: 'access-related factors', 'concerns related to stigma', and 'the school setting'. These findings elucidate how help-seeking processes are variable and can be facilitated or hindered depending on the circumstance. We identified disparities with certain groups, such as those from low-socio economic or ethnic minority backgrounds, facing more acute challenges in seeking help. Help-seeking behaviours were notably influenced by concerns related to peers; an influence further accentuated by minority groups given the importance of social recognition. Conflicting academic schedules significantly contribute to characterising treatment barriers. CONCLUSIONS The findings of this review ought to guide the delivery and development of TSMS to facilitate access and promote help-seeking behaviours. Particularly, given the evidence gaps identified in the field, future studies should prioritise investigating TSMS in low- and middle-income settings and through quantitative methodologies. REGISTRATION The protocol for this systematic review was registered on PROSPERO (ID CRD42023406824).
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Affiliation(s)
- Lauren McPhail
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
| | - Graham Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Petra C Gronholm
- Centre for Global Mental Health and Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Flodin N, Lejtzen S, Gunnarsdóttir H. The Perceived Power and Powerlessness in School Health Nurses' Mental Health Promotion Practices: A Synthesis of Qualitative Studies. J Sch Nurs 2024:10598405241241212. [PMID: 38602147 DOI: 10.1177/10598405241241212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Abstract
Schools are important arenas for mental health promotion initiatives. School nurses have the opportunity and ability to support and promote students' mental health, but their role and practices have been perceived as somewhat unclear. Therefore, the aim of this study was to explore school nurses' mental health promotion practices. A total of 12 scientific studies were synthesized through a meta-ethnographic approach. The overarching results of the synthesis show that school nurses' mental health promotion practices are largely about balancing and combining the students' needs with different professional perspectives, competencies, and conditions. The school nurses perceived that they had the power to influence their practices through a variety of ways, highlighting the importance of letting the students' needs guide the practices. Yet, at the same time they described feelings of powerlessness because of the different organizational structures that were hindering their mental health promotion practices.
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Affiliation(s)
- Nina Flodin
- Department of Health Sciences, University West, Trollhättan, Sweden
- Lindholmens Tekniska Gymnasium, The Educational Administration, City of Gothenburg, Sweden
| | - Stina Lejtzen
- Department of Health Sciences, University West, Trollhättan, Sweden
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Robinson WL, Whipple CR, Jason LA, Cafaro C, Lemke S, Keenan K. Social Support Coping for African American Adolescents: Effect of a Culturally Grounded Randomized Controlled Trial Intervention. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2023; 24:715-727. [PMID: 36595131 PMCID: PMC10229440 DOI: 10.1007/s11121-022-01484-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 01/04/2023]
Abstract
The effect of the Adapted-Coping with Stress (A-CWS) intervention on social support coping was examined, using a randomized controlled trial design. The participants were 410 ninth-grade students (ages 14 to 16 years and mostly African American) living in low-resourced neighborhoods. Participants were randomly assigned 1:1 to either the A-CWS intervention or a standard care control condition. All participants were assessed at their schools before implementation of the intervention, at intervention completion, and again at 6- and 12-month post-intervention. Engagement in social support coping was examined in both intention-to-treat and treatment-as-received samples (i.e., intervention participants who attended at least 12 A-CWS treatment sessions and participants in the standard care control condition), using latent growth models. In intention-to-treat analyses, no significant treatment effects were identified. In treatment-as-received analyses, results revealed a significant association between social support coping and treatment condition; levels of social support coping decreased over time in the control condition, but they remained relatively stable in the treatment condition. The results indicate adequate intervention adherence and efficacy of the A-CWS to sustain social support coping within a sample of youth at high risk for stress exposure and associated disorders.Clinical Trial Registration: clinicaltrials.gov identifier: NCT0395445.
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Affiliation(s)
- W LaVome Robinson
- Department of Psychology, Center for Community Research, DePaul University, Chicago, IL, 60614, USA.
| | | | - Leonard A Jason
- Department of Psychology, Center for Community Research, DePaul University, Chicago, IL, 60614, USA
| | - Cori Cafaro
- Department of Psychology, Center for Community Research, DePaul University, Chicago, IL, 60614, USA
| | - Sally Lemke
- Office of Community Health Equity and Engagement, Rush University Medical Center, Chicago, USA
| | - Kate Keenan
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, USA
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Are mental health awareness efforts contributing to the rise in reported mental health problems? A call to test the prevalence inflation hypothesis. NEW IDEAS IN PSYCHOLOGY 2023. [DOI: 10.1016/j.newideapsych.2023.101010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Hörbo M, Johansson C, Garnow T, Garmy P, Einberg EL. Experiences of Stress - A Focus Group Interview Study Among Swedish Adolescents During the COVID-19 Pandemic. J Sch Nurs 2023; 39:189-197. [PMID: 34967254 PMCID: PMC9988619 DOI: 10.1177/10598405211071002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Adolescence can be a stressful period in life. The period contains challenges associated with the transition from childhood to adulthood (body changes, changes in interpersonal relationships, and identity changes). The aim was to investigate experiences of stress among adolescents in addition to stress related to the COVID-19 pandemic. Focus group interviews (n = 8) were conducted with girls (n = 22) and boys (n = 19) aged 13-15 in southern Sweden. The transcribed interviews were analyzed with qualitative content analysis. Analysis of the collected material resulted in two categories with four sub-categories each of which highlights adolescents' experiences of stress. The results show that adolescents' have a variety of experiences of stress, i.e., what they mean are the sources of stress and how stress is manifested. The adolescents experienced how stress was manifested both physically and emotionally. This affected both their sleep and performance. The adolescents reflected on both positive and negative manifestations of stress.
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Affiliation(s)
- Moa Hörbo
- Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
- Equal contribution as first author
| | - Camilla Johansson
- Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
- Equal contribution as first author
| | - Tide Garnow
- Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
| | - Pernilla Garmy
- Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Pernilla Garmy, RN, PhD, Faculty of Health Sciences, Kristianstad University, Elmetorpsvägen 15, Kristianstad 29188, Sweden; Department of Health Sciences, Clinical Health Promotion Centre, Lunds Universitet, Lund, Sweden.
| | - Eva-Lena Einberg
- Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
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Bush R, Upadhyay K, McPeters S. Identification of Anxiety and Depression Among Adolescent Kidney Transplant Recipients: A Cross-Sectional Observational Study. J Pediatr Health Care 2022; 36:270-276. [PMID: 34844818 DOI: 10.1016/j.pedhc.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/30/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Studies demonstrate an association between mental health disorders and organ transplantation, with adolescents five times more likely to experience anxiety and depression than their nontransplant peers. The purpose of this study is to describe the prevalence of anxiety and depression in adolescent kidney transplant recipients using standardized mental health screening tools. METHOD The standardized screening tools, generalized anxiety disorder-7 for anxiety and Patient Health Questionnaire-9 for depression, were administered over 6 months to kidney transplant recipients aged 12-21 years during the transplant clinic visit. RESULTS Mental health screening increased by 74.0%. Patients reported mild to moderate anxiety at 46.4% and depression at 35.7%. DISCUSSION Routine screening for mental health disorders in the transplant clinic allows for early identification of anxiety and depression, prompt referrals to a mental health professional, and improved health outcomes in adolescent kidney transplant recipients.
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Harrison MG. Therapeutic change processes in school-based counselling: the perspectives of students and counsellors in Hong Kong. BRITISH JOURNAL OF GUIDANCE & COUNSELLING 2022. [DOI: 10.1080/03069885.2020.1729340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Vejzovic V, Carlson L, Löfgren L, Bramhagen AC. Early Identification of Mental Illness in Primary School Pupils by School Nurses: A Qualitative Study. SAGE Open Nurs 2022; 8:23779608221081452. [PMID: 35237719 PMCID: PMC8882927 DOI: 10.1177/23779608221081452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/29/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction The World Health Organization has reported that one fifth of all children in the world suffer from poor mental health regardless of cultural differences. Previous studies have shown that working with mental health is an important part of the duties of school nurses in Sweden. Objective The aim of the present study was to describe the experiences of school nurses regarding the identification of mental illness among pupils in primary school. Methods In this inductive qualitative study, interviews were conducted with 11 school nurses in southern Sweden and analyzed using content analysis. Results The results indicate three major themes: (1) the need for shared responsibility, (2) feelings of uncertainty and inadequacy in school nurses, and (3) the importance of establishing relationships. Conclusion This study indicates that school nurses feel responsible for their pupils’ well-being, but also feel that they need support. A lack of guidance in identifying mental illness emerged from the interviews.
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Affiliation(s)
- Vedrana Vejzovic
- Malmö University, Faculty of Health and Society, Department of Care Science, Malmö, Sweden
| | - Lilliann Carlson
- Department of Care Science, Specialist nurse Malmö University, Faculty of Health and Society, Malmö, Sweden
| | - Lisa Löfgren
- Faculty of Health and Society, Department of Care Science, School nurse, Malmö University, Malmö, Sweden
| | - Ann-Cathrine Bramhagen
- Faculty of Health and Society, Department of Care Science, Malmö University, Malmö, Sweden
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Hansson E, Garmy P, Vilhjálmsson R, Kristjánsdóttir G. Bullying, health complaints, and self-rated health among school-aged children and adolescents. J Int Med Res 2020; 48:300060519895355. [PMID: 32054367 PMCID: PMC7105741 DOI: 10.1177/0300060519895355] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective The aim of the current study was to examine whether health complaints and self-reported health were associated with bullying victimization in a large cohort of Icelandic children and adolescents. Methods In this study, we used data from a school-based cross-sectional survey, specifically, the Icelandic contribution to the international research network Health Behavior in School-aged Children (HBSC). The study population included all students throughout Iceland in grades 6, 8, and 10 (mean age 13 years, standard deviation 1.61). The participation rate was 84% (N = 11,018). Participating students completed an anonymous standardized questionnaire in their classrooms. Results Bullying victimization was associated with feeling depressed (odds ratio 2.61), having difficulty falling asleep, dizziness, and low self-reported health. No differences were found between sex and age groups. Conclusions Children and adolescents who are bullied appear to more often experience depression, difficulties falling asleep, dizziness, and poor health; however, health complaints were also relatively high among non-bullied children and adolescents. Bullying prevention measures must be implemented in children’s and adolescents’ social environments. In addition to assessing bullying interventions, further research should focus on methods of enhancing resilience in this population.
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Affiliation(s)
- Erika Hansson
- Faculty of Education, Kristianstad University, Kristianstad, Sweden
| | - Pernilla Garmy
- Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden.,Clinical Health Promotion Centre, Medical Faculty, Lund University, Lund, Sweden
| | - Rúnar Vilhjálmsson
- Faculty of Nursing, University of Iceland, Reykjavik, Iceland.,Landspitali University Hospital, Reykjavik, Iceland
| | - Gudrún Kristjánsdóttir
- Faculty of Nursing, University of Iceland, Reykjavik, Iceland.,Landspitali University Hospital, Reykjavik, Iceland
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Gimba SM, Harris P, Saito A, Udah H, Martin A, Wheeler AJ. The modules of mental health programs implemented in schools in low- and middle-income countries: findings from a systematic literature review. BMC Public Health 2020; 20:1581. [PMID: 33081737 PMCID: PMC7576731 DOI: 10.1186/s12889-020-09713-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 10/15/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Secondary schools in low- and middle-income countries (LMICs) provide health promotion, preventive, and early intervention services. Nevertheless, literature indicates that the modules of these services are either adapted or modified from existing mental health programs in developed countries. The literature also highlights the provision of non-comprehensive services (mental health promotion, prevention, and early intervention), in LMICs. These findings inform the need for undertaking this systematic literature review. The aim of this review was thus to identify the modules of school-based mental health programs (SBMHP) that have been implemented in LMICs to guide the development of a culturally sensitive comprehensive mental health program for adolescents in a LMIC country. METHODS The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was used to guide this review. The following databases were searched in September 2018, to identify the relevant literature: PubMed, CINAHL, Scopus, Web of Science, PsycINFO, and ERIC. The search was conducted by the first author and reviewed by the authors. RESULTS Following the screening process, a total of 11 papers were identified and reviewed for quality. The systematic review highlighted that the mental health programs provided in schools included: an introduction module, a communication and relationship module, a psychoeducation module, a cognitive skills module, a behavioral skills module, establishing social networks for recovery and help seeking behavioral activities and a summary/conclusion module. CONCLUSION This review sheds light on the characteristics of the programs in LMICs. Two programs were found to be universal in nature. Five programs were directed at key risk factors or at-risk groups, and four were early intervention programs. The review also revealed that only one program out of the 11 programs included modules for parents. The synthesis indicated that all the identified programs were adapted or modified from existing programs. The dearth of comprehensive programs in LMICs was also revealed. Lastly, the review revealed seven modules that can be useful for developing a SBMHP.
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Affiliation(s)
- Solomon Musa Gimba
- Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia. .,Department of Nursing Science, University of Jos, Jos, Nigeria.
| | - Paul Harris
- Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia
| | - Amornrat Saito
- School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia
| | - Hyacinth Udah
- Social Work and Human Services, James Cook University, Townsville, Queensland, Australia
| | - Averil Martin
- Academic Engagement Services, Griffith University, Brisbane, Queensland, Australia
| | - Amanda J Wheeler
- Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia.,Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Role of School Health Officers in Mental Health Care for Secondary School Students in Can Tho City, Vietnam. SCHOOL MENTAL HEALTH 2020. [DOI: 10.1007/s12310-020-09386-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractThe objectives of the study were to explore the experiences of school health officers in identifying and managing mental health problems of secondary school students and to gather recommendations from the school officers for improving the effectiveness of mental health care in secondary schools in Can Tho City, Vietnam. We conducted a qualitative study based on in-depth interviews using a semi-structured guideline with 15 school health officers at 15 secondary schools in Can Tho City, Vietnam. Data were analyzed using content-driven analysis to identify recurring themes. The school health officers reported that stress, depression, suicidal ideation, and sexual orientation issues were the most commonly encountered mental health problems among their students. The officers worked with a limited range of interventions for helping these students, such as giving non-narcotic analgesics or advising students to take a short break at school or to go home. Most of them felt that their training was insufficient to deal with mental health problems in an optimal way. They recommended further training to improve their knowledge and skills in recognizing and managing mental health problems in students. They also considered a university-sponsored mental health website a good source of information on mental health care for students. School health officers reported that they did not feel well equipped to manage mental health problems because of insufficient training, lack confidence, and absence of an appropriate network for advice and referral. Updated policies and programs are needed for initial training and refresher courses, which will strengthen the role of school health officers as first line support for secondary school students with mental health problems.
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Giombini L, Nesbitt S, Kusosa R, Fabian C, Easter A, Tchanturia K. Adapted emotion skills training group for young people with anorexia nervosa : A mixed-methods evaluation. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT ÖSTERREICHISCHER NERVENÄRZTE UND PSYCHIATER 2020; 35:76-83. [PMID: 32350767 DOI: 10.1007/s40211-020-00347-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 03/25/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Brief interventions focused on emotion processing are needed to support young people (YP) in inpatient treatment programmes to manage emotions. Cognitive Remediation and Emotion Skills Training (CREST) has been found beneficial in adult anorexia nervosa (AN) groups. An initial case series found that CREST is a feasible intervention for YP with AN. Further age-appropriate adaptations were needed to improve YP's engagement. Following qualitative feedback on the original CREST manual, a second case series was conducted in an inpatient unit with age-appropriate adaptations to evaluate its feasibility in a YP inpatient setting. METHODS A mixed-methods methodology was used to evaluate the intervention. A total of 30 YP were asked to write a feedback letter about their experience of the group and to complete the Emotion Skills Scale (ESS), an ad hoc 12-item self-report Likert scale assessing emotional functioning. The ESS was also completed by a member of the multidisciplinary team for an external assessment. RESULTS Quantitative results showed no statistically significant changes in YP's emotional functioning, while qualitative results showed that YP found it helpful to learn about emotion processes, acknowledging their need to be supported to express them and understand the link with AN symptoms. Four high-order themes were identified: Helpfulness of CREST Group for Young People (CREST-GYP), Perception of contents, Challenges of group therapy, Suggestions for improvement. CONCLUSIONS Pilot findings suggest that CREST-GYP is an acceptable intervention for YP with AN. Clinical and research studies are needed to clarify whether CREST-GYP can produce more beneficial treatment results than treatment as usual.
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Affiliation(s)
- Lucia Giombini
- Elysium Healthcare, Rhodes Wood Hospital, Sheperd's Way, Brookmans Park, Hatfield, AL96NN, London, UK.
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Sophie Nesbitt
- Elysium Healthcare, Rhodes Wood Hospital, Sheperd's Way, Brookmans Park, Hatfield, AL96NN, London, UK
| | - Rutendo Kusosa
- Elysium Healthcare, Rhodes Wood Hospital, Sheperd's Way, Brookmans Park, Hatfield, AL96NN, London, UK
| | - Cleo Fabian
- Elysium Healthcare, Rhodes Wood Hospital, Sheperd's Way, Brookmans Park, Hatfield, AL96NN, London, UK
| | - Abigail Easter
- Health Service Research and Population Department, Institute of Psychiatry, Psychology and Neuroscience Health Services, King's College London, London, UK
| | - Kate Tchanturia
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Department of Psychology, Illia University Tbilisi, Tbilisi, Georgia
- South London and Maudsley NHS Foundation Trust, London, UK
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Teng E, Anthony V, Helen W, Shona C. Is Knowledge Enough? The Relationship Between Mental Health Knowledge and Stigmatising Attitudes Among Australian Adolescents. ADOLESCENT PSYCHIATRY 2020. [DOI: 10.2174/2210676609666181204145835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
Young people carry mental health problems disproportionate to the
size of their population, and rates of help-seeking are low. School mental health programs
have been developed to address these issues, founded on an educational approach to target
mental health literacy, and indirectly improve help-seeking. However, it has been suggested
that knowledge does not necessarily predict health behaviour in young people.
Objective/Methods:
A cross-sectional study was conducted to explore whether knowledge
about mental illness was related to attitudes towards mental illness and intentions to seek
help in a sample of adolescent girls (N=327).
Results:
Results indicated a weak negative relationship between knowledge about mental
health and stigmatising attitudes about mental illness, but no relationship between
knowledge about mental health and intentions to seek help for mental health problems.
When mental health was categorised (e.g., optimal vs. poorer mental health), a negative
relationship between knowledge about and stigmatising attitudes toward mental health was
shown in those with poor mental health, but not for adolescents categorised as having
moderate or optimal mental health.
Conclusion:
Findings suggest that while the traditional adage - more information on mental
health equals better attitude to mental health - may be true for those with ‘poorer’ levels of
mental health (e.g., high levels of psychological distress), it may not reduce stigma
associated with mental illness or motivate positive health behaviour in adolescent girls with
‘optimal’ mental health (e.g., low or no levels of psychological distress).
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Affiliation(s)
- Emmelin Teng
- School of Psychology, The University of Adelaide, North Terrace, Adelaide, South Australia 5005, Australia
| | - Venning Anthony
- Faculty of Medicine, Nursing and Health Sciences, Flinders University, Sturt Road, Bedford Park, South Australia, 5042, Australia
| | - Winefield Helen
- School of Psychology, The University of Adelaide, North Terrace, Adelaide, South Australia 5005, Australia
| | - Crabb Shona
- School of Population Health, The University of Adelaide, North Terrace, Adelaide, South Australia 5005, Australia
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Teixeira LA, Freitas RJMD, Moura NAD, Monteiro ARM. MENTAL HEALTH NEEDS OF ADOLESCENTS AND THE NURSING CARES: INTEGRATIVE REVIEW. TEXTO & CONTEXTO ENFERMAGEM 2020. [DOI: 10.1590/1980-265x-tce-2018-0424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
ABSTRACT Objective: to systematize the knowledge produced about nursing performance in the face of adolescents' mental health needs. Method: integrative literature review, submitting the problem: what are the mental health needs of adolescents and the nursing care provided? Data collection was performed in the PubMed databases; CINAHL; SciELO; ScienceDirect; LILACS, in the month of April 2018. Were included 30 articles available in Portuguese, English or Spanish with full access and free of charge. The findings were grouped into thematic categories with review/synthesis of knowledge. Results: the sample consisted of articles predominantly in English and published between 1999 and 2018. The main mental health needs of adolescents are related to depression, anxiety, stress, drug use and dependence, eating disorders, among others. Nursing cares include health education, groups, cognitive behavioral therapy, interpersonal relationships, and activities that involve adolescents, their families, peers and the school environment. It was evidenced that nurses work with different approaches and intervene through the nursing process and physical activity practices, among other tools that are accessible to them. Conclusion: this review allows professionals to formulate new actions that are based on the adolescent's real mental health needs, which are neglected, because they do not attend so much the health services. The need for studies with higher level of scientific evidence is mentioned.
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16
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Gronholm PC, Nye E, Michelson D. Stigma related to targeted school-based mental health interventions: A systematic review of qualitative evidence. J Affect Disord 2018; 240:17-26. [PMID: 30041074 DOI: 10.1016/j.jad.2018.07.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/22/2018] [Accepted: 07/08/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND School-based mental health services have been advocated to increase access to psychological support for children and adolescents. However, concerns have been raised about the potential stigma associated with selection of students and the visibility of school-based service contact. METHODS This review assessed findings from qualitative studies to identify potential stigmatising effects of participation in targeted school-based mental health interventions for students attending primary- or secondary-level education. Eight articles (reflecting seven studies) were identified through electronic database searches (PsycInfo, EMBASE, Medline, CINAHL, ERIC), supplemented by citation and reference searches and expert consultations. Data were synthesised according to established guidelines for thematic synthesis. RESULTS Three overarching themes were identified: "anticipated and experienced stigma", "consequences of stigma" and "mitigating strategies". These findings illustrate how pervasively stigma can compromise efforts to increase access to mental health care through targeted school-based provision, while also outlining strategies endorsed by students for alleviating the risk and/or impact of stigma. LIMITATIONS The findings need to be considered in view of the relative scarcity of surveyed evidence. Furthermore, as all evidence came from high-income and Western countries, the applicability to other contexts is unclear. CONCLUSIONS This synthesis reflects the first overview of qualitative evidence regarding stigmatising experiences and concerns associated with students' engagement with targeted school-based mental health interventions. The findings should inform efforts for mitigating stigma-related barriers to students' engagement in targeted mental health support, and serve to guide future research in this area.
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Affiliation(s)
- Petra C Gronholm
- Personal Social Services Research Unit, London School of Economics and Political Science, UK; Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.
| | - Elizabeth Nye
- Centre for Evidence-Based Intervention, Department of Social Policy & Intervention, University of Oxford, UK
| | - Daniel Michelson
- Centre for Global Mental Health, Department of Population Health, London School of Hygiene & Tropical Medicine, UK
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17
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McKeague L, Morant N, Blackshaw E, Brown JSL. Exploring the feasibility and acceptability of a school-based self-referral intervention for emotional difficulties in older adolescents: qualitative perspectives from students and school staff. Child Adolesc Ment Health 2018; 23:198-205. [PMID: 30197575 PMCID: PMC6120473 DOI: 10.1111/camh.12234] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adolescents with emotional difficulties need accessible, acceptable and evidence-based mental health interventions. Self-referral workshops (DISCOVER workshops) were offered to stressed 16- to 19-year olds in 10 Inner London schools. METHOD Semistructured interviews were conducted with three groups of participants: students who attended a 1-day workshop (n = 15); students who initially showed interest in the DISCOVER workshop programme, but decided not to take part (n = 9); and school staff who helped organise the programme in their schools (n = 10). Students were purposively sampled to ensure that those from Black and minority ethnic (BME) backgrounds were represented. Data were analysed using thematic analysis. RESULTS The accounts generally indicate that the delivery and evaluation of this intervention is perceived as feasible and acceptable. Students, including those from BME backgrounds, described the setting as suitable and reported that the workshop helped them develop new understandings of stress and how to handle it. They expressed a preference for engaging and interactive activities, and valued a personalised approach to workshop provision. School staff felt that the workshop was in line with school values. They described some logistical barriers to providing the workshops in school settings, and expressed a desire for more information about the workshop in order to provide follow-up support. The main reason students gave for nonparticipation was limited time. CONCLUSIONS Findings are discussed in relation to increasing the feasibility of implementing school-based psychological interventions and the value of providing access to mental health support in schools.
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Affiliation(s)
- Lynn McKeague
- Department of PsychologyUniversity of WinchesterWinchesterUK
| | - Nicola Morant
- Division of PsychiatryUniversity College LondonLondonUK
| | - Emily Blackshaw
- Department of PsychologyInstitute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK
| | - June S. L. Brown
- Department of PsychologyInstitute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK
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18
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Lapshina N, Crooks CV, Kerry A. Changes in Depression and Positive Mental Health Among Youth in a Healthy Relationships Program. CANADIAN JOURNAL OF SCHOOL PSYCHOLOGY 2018. [DOI: 10.1177/0829573518777154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mental health promotion programming in schools and community settings is an important part of a comprehensive mental health strategy. The goal of this study was to identify and explore meaningful classes of youth based on their pre- and post-intervention depression symptoms scores with 722 youth involved in a 15-week healthy relationships and mental health promotion program. We utilized latent class growth analysis to identify depression class trajectories, controlling for group clustering effects. A three-class solution identified high decreasing, moderate stable, and low stable trajectories. Gender, age, and reported experience of bullying victimization predicted trajectory class membership. The low stable class trajectory was associated with the highest positive mental health, followed by the moderate stable and the high decreasing trajectories. These results suggest that youth with the highest depression scores showed significant improvement in symptomatology over the course of the program.
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19
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Sibeoni J, Orri M, Podlipski MA, Labey M, Campredon S, Gerardin P, Revah-Levy A. The Experience of Psychiatric Care of Adolescents with Anxiety-based School Refusal and of their Parents: A Qualitative Study. JOURNAL OF THE CANADIAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY = JOURNAL DE L'ACADEMIE CANADIENNE DE PSYCHIATRIE DE L'ENFANT ET DE L'ADOLESCENT 2018; 27:39-49. [PMID: 29375632 PMCID: PMC5777690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 07/27/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Anxiety-based school refusal in adolescence is a complex, sometimes difficult to treat disorder that can have serious academic and psychiatric consequences. The objective of this qualitative study was to explore how teens with this problem and their parents experience the psychiatric care received. METHODS This qualitative multicenter study took place in France, where we conducted semi-structured interviews with adolescents receiving psychiatric care for anxiety-based school refusal and with their parents. Data collection by purposive sampling continued until we reached theoretical sufficiency. Data analysis was thematic. RESULTS This study included 20 adolescents aged 12 to 18 years and 21 parents. Two themes emerged from the analysis: (1) the goals of psychiatric care with two sub-themes, "self-transformation" and problem solving; and, (2) the therapeutic levers identified as effective with two sub-themes: time and space and relationships. CONCLUSION Our results show a divergence between parents and teens in their representations of care and especially of its goals. Therapeutic and research implications about the terms of return to school within psychiatric care and also the temporality of care are discussed.
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Affiliation(s)
- Jordan Sibeoni
- Service Universitaire de Psychiatrie de l’Adolescent. Argenteuil Hospital Centre, Argenteuil, France
- ECSTRA Team, UMR-1153, Inserm, Paris Diderot University, Sorbonne Paris Cité
| | - Massimiliano Orri
- University Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR1219, Bordeaux, France
| | - Marc-Antoine Podlipski
- Centre Hospitalier du Rouvray, Fédération Hospitalo-Universitaire de Psychiatrie de l’Enfant et de l’Adolescent, CHU de Rouen - CH du Rouvray
| | - Mathilde Labey
- ECSTRA Team, UMR-1153, Inserm, Paris Diderot University, Sorbonne Paris Cité
| | | | - Priscille Gerardin
- Centre Hospitalier du Rouvray, Fédération Hospitalo-Universitaire de Psychiatrie de l’Enfant et de l’Adolescent, CHU de Rouen - CH du Rouvray
| | - Anne Revah-Levy
- Service Universitaire de Psychiatrie de l’Adolescent. Argenteuil Hospital Centre, Argenteuil, France
- ECSTRA Team, UMR-1153, Inserm, Paris Diderot University, Sorbonne Paris Cité
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20
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Garmy P, Clausson EK, Berg A, Steen Carlsson K, Jakobsson U. Evaluation of a school-based cognitive-behavioral depression prevention program. Scand J Public Health 2017; 47:182-189. [PMID: 29226799 PMCID: PMC6442019 DOI: 10.1177/1403494817746537] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM The aim of this study was to investigate the feasibility and cost-utility of a school-based cognitive-behavioral (CB) depression prevention program. METHODS A quasi-experimental trial with an intervention group and a control group, with follow-up measurements obtained at three and 12 months after baseline, was conducted. The setting was six Swedish municipalities. The participants were students in grade 8 (median age: 14). A total of 462 students (79% girls) were allocated to the school-based CB prevention program, and 486 students (46% girls) were allocated to the control group. The school-based CB prevention program, Depression in Swedish Adolescents (DISA), was presented by school health service staff and teachers once per week for 10 weeks. RESULTS The main outcome measures were self-reported depressive symptoms and self-rated health; the secondary outcome measures were adherence and cost-utility. The intervention group decreased their self-reported depressive symptoms (as measured by the Center for Epidemiological Studies Depression Scale) and improved their self-rated health (as measured by the visual analog scale) at the 12-month follow-up more than the control group ( p < .05). CONCLUSIONS Given the challenges of conducting a study in a complex, everyday school setting with baseline differences between the intervention and control group, it is difficult to make accurate interpretations of the effectiveness of the intervention. However, with these limitations in mind, the results indicate that the DISA program is a feasible school-based prevention program.
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Affiliation(s)
- Pernilla Garmy
- 1 Department of Health Sciences, Kristianstad University, Kristianstad, Sweden.,2 Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden.,3 Department of Health Sciences, Clinical Health Promotion Center, Lund University, Lund, Sweden
| | - Eva K Clausson
- 1 Department of Health Sciences, Kristianstad University, Kristianstad, Sweden
| | - Agneta Berg
- 1 Department of Health Sciences, Kristianstad University, Kristianstad, Sweden
| | - Katarina Steen Carlsson
- 4 Health Economic Unit, Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
| | - Ulf Jakobsson
- 2 Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden.,5 Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
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21
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Exploring Students’ Participation in Universal, Depression and Anxiety, Prevention Programmes at School: A Meta-aggregation. SCHOOL MENTAL HEALTH 2017. [DOI: 10.1007/s12310-017-9230-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Abstract
PURPOSE OF REVIEW The current review aims to provide an update on the recent work in mental health promotion with a special emphasis on emerging evidence and innovations in the field. RECENT FINDINGS Studies reviewed across settings like the home, school, workplace, communities, and internet-based platforms, have indicated a growing evidence base for effective mental health promotion strategies that are holistic, multicomponent, and targeted at both, specific vulnerable groups and whole populations. Innovative approaches involving online delivery platforms, sports and exercise, positive psychology and lifestyle interventions, mobilizing community networks, and mental health first aid, are some exciting and upcoming areas for future research. SUMMARY Mental health promotion interventions are applicable to individuals, groups, and whole populations and can be delivered in many ways, including media and communication technology. They can be applied in low-resource settings by mobilizing existing community resources like opinion leaders, health workers, and peer educators, thereby increasing cost-efficiency, cultural acceptability, and local capacity. There needs to be a greater focus on study designs and variable measures that examine process-factors affecting well being outcomes. Early interventions through intersectorial collaborations may result in improved long-term positive mental health outcomes for individuals, families, and communities.
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23
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The Need for School-Based Mental Health Services and Recommendations for Implementation. SCHOOL MENTAL HEALTH 2017. [DOI: 10.1007/s12310-017-9216-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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24
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Rosvall PÅ, Nilsson S. Gender-based generalisations in school nurses' appraisals of and interventions addressing students' mental health. BMC Health Serv Res 2016; 16:451. [PMID: 27576359 PMCID: PMC5006424 DOI: 10.1186/s12913-016-1710-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 08/25/2016] [Indexed: 11/26/2022] Open
Abstract
Background There has been an increase of reports describing mental health problems in adolescents, especially girls. School nurses play an important role in supporting young people with health problems. Few studies have considered how the nurses’ gender norms may influence their discussions. Methods To investigate this issue, semi-structured interviews focusing on school nurses’ work with students who have mental health problems were conducted. Transcripts of interviews with Swedish school nurses (n = 15) from the Help overcoming pain early project (HOPE) were analysed using theories on gender as a theoretical framework and then organised into themes related to the school nurses’ provision of contact and intervention. The interviewees were all women, aged between 42–63 years, who had worked as nurses for 13–45 years, and as school nurses for 2–28 years. Five worked in upper secondary schools (for students aged 16–19) and 10 in secondary schools (for students aged 12–16). Results The results show that school nurses more commonly associated mental health problems with girls. When the school nurses discussed students that were difficult to reach, boys in particular were mentioned. However, very few nurses mentioned specific intervention to address students’ mental health problems, and all of the mentioned interventions were focused on girls. Some of the school nurses reported that it was more difficult to initiate a health dialogue with boys, yet none of the nurses had organized interventions for the boys. Conclusions We conclude that generalisations can sometimes be analytically helpful, facilitating, for instance, the identification of problems in school nurses’ work methods and interventions. However, the most important conclusion from our research, which applied a design that is not commonly used, is that more varied approaches, as well as a greater awareness of potential gender stereotype pitfalls, are necessary to meet the needs of diverse student groups. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1710-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Per-Åke Rosvall
- Department of Applied Educational Science, Umeå University, Per-Åke Rosvall, TUV plan 4, 90187, Umeå, Sweden.
| | - Stefan Nilsson
- Institute of Health Care Sciences, University of Gothenburg, Gothenburg, Sweden
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