Implementing School-Based Mental Health Services: A Scoping Review of the Literature Summarizing the Factors That Affect Implementation

1 Procome Research Group, Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, 171 77 Stockholm, Sweden; es.ik@dnartsennujs.ym (M.S.); es.uu.hbk@hdnarts.eramor.airam (M.R.S.); es.ik@nossah.anneh (H.H.)

2 Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine, Region Stockholm, 171 29 Stockholm, Sweden

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My Sjunnestrand

2 Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine, Region Stockholm, 171 29 Stockholm, Sweden

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Maria Romare Strandh

3 Reproductive Health Research Group, Department of Women’s and Children’s Health, Uppsala University Hospital, 751 85 Uppsala, Sweden

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Henna Hasson

2 Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine, Region Stockholm, 171 29 Stockholm, Sweden

Find articles by Henna Hasson Paul B. Tchounwou, Academic Editor

2 Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine, Region Stockholm, 171 29 Stockholm, Sweden

3 Reproductive Health Research Group, Department of Women’s and Children’s Health, Uppsala University Hospital, 751 85 Uppsala, Sweden

Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

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Abstract

Background: Mental illness in children and youths has become an increasing problem. School-based mental health services (SBMHS) are an attempt to increase accessibility to mental health services. The effects of these services seem positive, with some mixed results. To date, little is known about the implementation process of SBMHS. Therefore, this scoping review synthesizes the literature on factors that affect the implementation of SBMHS. Methods: A scoping review based on four stages: (a) identifying relevant studies; (b) study selection; (c) charting the data; and (d) collating, summarizing, and reporting the results was performed. From the searches (4414 citations), 360 were include in the full-text screen and 38 in the review. Results: Implementation-related factors were found in all five domains of the Consolidated Framework for Implementation Research. However, certain subfactors were mentioned more often (e.g., the adaptability of the programs, communication, or engagement of key stakeholders). Conclusions: Even though SBMHS differed in their goals and way they were conducted, certain common implementation factors were highlighted more frequently. To minimize the challenges associated with these types of interventions, learning about the implementation of SBMHS and using this knowledge in practice when introducing SBMHS is essential to achieving the best possible effects with SMBHSs.

Keywords: implementation, school-based mental health services, mental health, scoping review

1. Background

Mental illness in children and youths has become a public health concern. Symptoms can range from mild and short-term problems, such as mild anxiety or depressive symptoms, to more severe and long-term forms of diagnosed anxiety disorders or major depression [1]. An estimated 12–30% of school-age children suffer from mental illness of sufficient intensity to adversely affect their education [2]. The vulnerability to mental illness is highest during childhood and adolescence [3]. Within the last decade, an increase in diagnoses related to mental ill-health has been noted [4]. An estimated 50% of all mental illnesses begin before the age of 14, and three-quarters of mental ill-health occurs before the age of 25 [5].

Tremendous social costs result from the consequences of leaving mental ill-health in children and youths untreated. These consequences may range from poor educational attainment, compromised physical health, substance abuse, juvenile delinquency, and unemployment to even premature mortality (e.g., suicide [6,7,8]). In line with that, cost-benefit analyses of mental health programs have found these programs result not only in economic productivity gains but also improved health [9,10].

Despite this, mental ill-health of children and youths is often not identified and treated in a timely way. Estimations show that up to 75% of students suffering from mental ill-health receive inadequate treatment or are not treated at all [11,12]. Consequently, mental ill-health often manifests in adulthood [5,13], which is unfortunate because many children and youths have originally mild or moderate symptoms [14]), and thus early identification and prevention can have beneficial effects [12,14,15]. Hence, there is an unmet need for mental health services for children and youth.

2. Mental Health Services Provided in Schools

Education and health are closely interlinked; school is important for one’s social and emotional development, and, therefore, school has an effect on health [16]. Moreover, due to compulsory school attendance, the majority of children and youths spend a considerable amount of time in schools, making schools an ideal environment to provide timely and convenient access to mental health services, including early identification, prevention, and interventions to prevent the escalation of mental ill-health [17]. In addition, providing services related to mental ill-health within the school setting has additional benefits such as cost efficiency and good accessibility to the services [18].

While school-based mental health services (SBMHS) may vary widely in focus, format, provider, and approach [19], they are all united in the fact that schools collaborate with health services to provide support for children and youths who are at risk of or have experienced mental ill-health. An SBMHS encompasses “any program, intervention, or strategy applied in a school setting that was specifically designed to influence students’ emotional, behavioral, and/or social functioning” [20](pp.224).

Even though services related to mental ill-health can be found outside the school setting, these community mental health services are often underutilized. For example, Kauffman, [21], Langer et al. [22], and Merikangas et al. [23] showed only 20% of children and youths received help to address their needs related to mental health, whereas Armbruster and Fallon [24], and McKay et al. [25] showed the help children and youths receive is often prematurely ended. Instead, SBMHS seem to resolve some of the known barriers that prevent access to mental health services for children and youths, such as lack of insurance, shortage of medical or psychological mental health professionals, mental health stigma, or the lack of transportation opportunities [26].

The effectiveness of SBMHS has been studied in several reviews and meta-analyses. In general, mental health programs through SBMHS were found to have a positive effect on emotional and behavior problems [20]. Hoagwood and Erwin [27] identified three types of services that had a clear impact (i.e., cognitive behavioral techniques, social skills training, and teacher consultation models). Other studies evaluating multifaceted and multilevel interventions showed improvements to mental health outcomes [28,29]. However, Caldwell et al. [30], focusing on SBMHS at secondary schools for youths with depression and anxiety, found limited evidence for their effectiveness. Fazel et al., [31] suggested these results might be premature and that long-term follow-ups should be applied to investigate effectiveness. Systematic reviews on the effect of SBMHS on specific target groups such as primary school children [32] or elementary school children [33] showed positive effects on their mental health. To conclude, even though these studies generally indicate positive effects of SBMHS, general conclusions are made difficult by the heterogeneity of interventions and evaluation designs used [34].

Besides the different definitions, the variety of programs included under the SBHMS umbrella, and the different designs for evaluation, these programs are complex, which also makes the implementation process potentially challenging. For example, Rones and Hoagwood [20] identified some features associated with the implementation that are important for the maintenance and sustainability of SBHMS programs (e.g., including various stakeholders, using different modalities, and integrating the intervention into the regular classroom curriculum). Without shedding more light on the implementation of SBMHS, there can be a risk of drawing false conclusions about the effectiveness of the programs. For instance, the lack of effects can be due to poor implementation instead of a failure of the theory underpinning the program [35]. In line with this reasoning, there has been a call to provide more clarity on the implementation of SBMHS [20,36].

3. Aim of the Review

This scoping review aimed at synthesizing the literature on the implementation of SBHMS. By doing so, we aim to increase the understanding of the systemic conditions and factors that affect the implementation of SBHMs.

The following research question will be addressed: Which factors are important for the implementation of school-based mental health services (SBMHS)? To systematize the findings, the factors relevant for implementing SBMHS will be structured according to Consolidated Framework for Implementation Research (CFIR) that differentiates between characteristics of the intervention and individuals using the intervention, the inner and outer context as well as the process of implementing.

4. Method

4.1. Study Design

To address the study aim, we performed a scoping review to identify barriers and enablers of the implementation of SBHMs. This method was chosen to provide a broad overview of implementation-related factors for SBHMs [37]. We followed the procedure outlined by Arksey and O’Malley [38]. After identifying the research question we (1) identified relevant studies, (2) selected studies, (3) charted the data, and (4) collected, summarized, and reported the results. Steps 1–3 are described in the Section 4, whereas Step 4 is presented in the Section 5.

4.2. Identify Relevant Studies

The search was conducted on 7 May 2019. The search strategy was developed in collaboration with a team of informatics experts from the university library at Karolinska Institutet. Based on several example papers focusing on SBHMs, and in discussion with representatives from the Swedish Public Health Agency and the Swedish Association of Local Authorities and Regions, potential keywords were identified. The search strategy included conducting searches in four databases: Medline, Eric, PsycINFO, and Web of Science (see Appendix A). Articles published up to May 2019 were included in the search. The informatics team provided a full list of references after duplicates had been removed. Articles were also found and added through manual searches based on recommendations.

Simultaneous with developing the search strategy, eligibility criteria for relevant studies were defined [38]. To be included, studies were required to focus on SBMHS and to have been conducted through a collaboration of school staff together with staff from social services and/or health-care services. The interventions had to address children and youths’ mental health and be published in English or a Scandinavian language. In addition to peer-reviewed journals, reports, and dissertations were included. Mental health was defined broadly and based on a definition by the Swedish Committee on Child Psychiatry [39], where mental ill-health is children’s lasting symptoms that prevent them from optimal functioning and development and that cause suffering. This included internalized mental health symptoms (e.g., anxiety, depressive symptoms, psychosomatic symptoms, eating disorder symptoms, and self-harming behaviors), externalized mental health symptoms (e.g., neuropsychiatric impairment, or behavioral problems), and indicators of psychological problems (e.g., school problems, trauma, or problems at home). Two reviewers tested the eligibility criteria on 40 articles from the final search. Inconsistencies in interpretations were discussed within the research group and with representatives from the Swedish Public Health Agency and the Swedish Association of Local Authorities and Regions, and thereafter modified to clarify the criteria.

4.3. Select Studies

All studies were screened to eliminate those that were not in line with the research question [38]. Rayyan, a software program that facilitates the screening process, was used [40]. Two authors (A.R. and M.R.S.) reviewed articles in addition to two research assistants. First, study titles and abstracts were evaluated based on the eligibility criteria in duplicate by two independent reviewers. Throughout the process, the reviewers met to discuss the eligibility criteria to confirm consensus, and modifications of the criteria were made to increase clarity (see Appendix B for eligibility criteria). The evaluation of titles and abstracts was finished in July 2019. The reviewers’ conflicting decisions were compared after completion. In the cases of inconsistencies in the decisions, the titles and abstracts were re-read and discussed in the reviewers’ group to reach a consensus. In addition, searches of the reference lists from relevant articles were also conducted to find potentially relevant articles (i.e., snowball search). These additional articles were screened in the same way as the original articles.

In the next step, the full texts of the included studies from the title and abstract evaluation were accessed for final inclusion. Three authors (A.R., M.R.S., and M.S.) and two research assistants reviewed articles in full text. As in the first step, the studies were assessed by two independent reviewers, and conflicting decisions were discussed to reach a consensus about the inclusion or exclusion of the study. The full-text evaluation was finished in November 2020.

4.4. Chart Data

In the next stage, key information from the included studies where charted [38]. The following information was collected from all included studies: (a) authors, (b) year of publication, (c) journal, (d) country of origin, (e) aim of the study, (f) study design, (g) method of data collection, (h) setting, (i) name of the intervention, (j) description of the intervention, (k) target groups for the intervention, (l) collaboration partners involved in conducting the intervention, (m) mental health challenge of the intervention target group, and (n) information about the implementation of the intervention. To test the chart template, all reviewers (A.R., M.R.S., M.S., and two research assistants) charted data from the same five included articles and compared the extracted data. Any inconsistencies were discussed, and the template was modified to increase clarity. Based on the information about the focus of the interventions and their target groups, these interventions were then categorized as universal, selective, or indicated. Universal interventions targeted all children, whereas selective interventions focused on risk groups and indicated interventions were provided to children and youths who were already struggling with their mental health.

To organize and categorize the information related to implementation, the Consolidated Framework for Implementation Research (CFIR, [41]) (for more information, see https://cfirguide.org, accessed on 10 February 2022) was used as a conceptual framework to structure the extracted information. CFIR clusters factors related to the implementation into five categories (intervention characteristics, inner setting, outer setting, characteristics of the individual, and implementation process).

The intervention characteristics describe the source of the intervention (i.e., perceptions of the source of the intervention), the evidence strength and quality that the intervention will have desired outcomes, the perceived advantage of implementing this intervention compared to other interventions (i.e., relative advantage), how complex and adaptable the intervention is as well as if the intervention can be tested small-scale first. The costs associated with the intervention as well as the perception about how the intervention is design, packaged, and presented also describe important intervention characteristics. The outer setting of the organization where the intervention is implemented is described by the prioritization of patient needs and the resources allocated to patient needs by the organization, in how fare the organization is part of a larger network (i.e., cosmopolitanism), if other organizations have implemented the intervention hence, there is peer pressure to also implement the intervention and if there are external policies and incentives that may affect the implementation of the intervention. The organization’s inner setting is described by structural characteristics (e.g., age, maturity or size of the organization), the nature and quality of networks as well as (in)formal communication within the organization as well as the culture (i.e., existing norms, values, or assumptions made by employees). Moreover, implementation climate (i.e., the capacity to implement change) is an important characteristic that is further differentiated in the tension for change (i.e., the perception that the current situation is intolerable and requires change), the compatibility of the intervention with existing workflows and norms, the relative priority the intervention is perceived to have, existing incentives and rewards that exist in the organization that affect the implementation process as well as the existence of a learning climate and clear goals and feedback related to the intervention. Another important factor of the inner context is the organization’s readiness for implementation (i.e., the commitment to the decision of implementing the intervention). Here the involvement and commitment of leaders (i.e., leadership engagement), the amount of dedicated resources for the intervention, as well as access to knowledge and information about the intervention and its implementation are important. Characteristics of individuals is another important factor according to CFIR. It is defined by individuals’ knowledge and beliefs about the intervention (e.g., attitudes towards the intervention), individuals’ belief in their own capacity to execute the intervention (i.e., self-efficacy), the phase of change individuals are in, but also individuals’ identification with the organization as well as personal characteristics such as motivation, value, or learning style (i.e., other personal attributes). The implementation process according to CFIR is categorized in a planning phase (e.g., schemes or methods that are developed in advance), engaging, executing, and reflecting and evaluating phase. Engaging, that is the involvement of appropriate individuals is further differentiated in the engagement of opinion leaders, (in)formally appointed implementation leaders, champions as well as external change agents.

Information from included studies that related to the implementation of SBMHS was extracted, and, in the next step, categorized based on the CFIR domains and their more specific subtopics.

5. Results

5.1. Included Studies

The data search resulted in 4414 studies that were potentially relevant to the research question of this scoping review. After 1006 duplicates were removed, 3408 studies remained and were included in the screening of titles and abstracts, resulting in 360 potentially eligible studies. Of these, 38 studies were included in the review after full-text screening. The PRISMA flowchart ( Figure 1 ) summarizes the screening steps and the numbers of included and excluded studies in each step of the screening.