Unobtrusive and Acceptable Ways to Gather Participant Perceptions of Community-Based Interventions and Their Effectiveness at Improving Mental Health and Wellbeing: A Literature Review of Peer Reviewed and Grey Literature

In England, approximately 1 in 6 people have a common mental health condition, with certain groups experiencing worsening mental health since the start of the COVID-19 pandemic. Therefore, improving mental health remains a key priority for policy makers and practitioners. Community-based interventions are increasingly used to improve health and reduce inequalities. Evaluation of such interventions is important to ensure they are effective and to maintain financial support for continued delivery. Hesitation to complete administratively demanding evaluative measures by service users, which may not be suited to evaluating low intensity activities, point to the need to identify acceptable, unobtrusive methods of data collection. This review focuses on identifying unobtrusive methods that have previously been used to examine service user's perceptions of community-based interventions and their effectiveness, and the acceptability of the methods. A review of peer reviewed, and grey literature was undertaken in July 2022. Literature was identified via six databases, Google searches, and by contacting experts. Literature was included if it described unobtrusive methods to gather service users' perceptions of an intervention and/or reported the acceptability of such methods. Literature was excluded if it described traditional methods to gather service users' perceptions of an intervention. Our search identified 930 citations from searching databases (n = 886), Google (n = 40), and from contacting 15 experts directly, and over 300 experts indirectly via three e-mail lists (n = 4). No literature met our inclusion criteria. We report an empty review. There is no peer reviewed or grey literature that describes unobtrusive methods of data collection for mental health and wellbeing focused community-based interventions, or their perceived acceptability. The findings from this review indicate the need to develop unobtrusive methods of data collection in the field of public mental health, suitable for low intensity activities, and examine the acceptability and feasibility of such methods.

A qualitative process evaluation of universal free school meal provision in two London secondary schools.

BACKGROUND: In the UK, one in five households with children experienced food insecurity in 2022, defined as a household-level economic and social condition of limited or uncertain access to adequate food. Free school meals are a public health intervention aimed at reducing food insecurity amongst children. The provision of universal free school meals (UFSM) to secondary school-aged children is a novel and untested intervention in the UK. This study is a process evaluation of a pilot of UFSM in two secondary schools in England. The aim was to understand the feasibility, acceptability, cost implications and lessons for the implementation of UFSM. METHODS: 20 parents, 28 students and 8 school staff from two intervention schools participated in online qualitative interviews, as well as 4 staff from non-intervention schools. The Framework Method of thematic analysis was applied. These data were supplemented with student-led observations of school meal times, and school lunch uptake-data and cost information provided by the local authority delivering the pilot. RESULTS: UFSM in secondary schools is a feasible and acceptable intervention, with coherent goals of increased access to a healthy meal, reduced food insecurity and better nutrition. All participants perceived these goals were met. Acceptability was further enhanced by the perception that UFSM were supporting a greater proportion of low-income families than the national, targeted Free School Meal scheme, as well as being easier to implement. Potential barriers to implementation include limited school kitchen and dining infrastructure, meal quality and choice, and increased queuing times. Participants' concerns that UFSM may benefit middle- and high- income families not in need were not as prevalent as the perception that UFSM was an effective way to support all families with secondary-aged children experiencing food insecurity. CONCLUSION: This small-scale pilot study suggests that UFSM in secondary schools is feasible and acceptable, but more evidence is required from larger studies on the impact on long-term health, psychosocial and educational outcomes. Future, larger studies should also include detailed economic evaluations so this approach can be compared with other possible interventions.

The Peer Education Project to improve mental health literacy in secondary school students in England: a qualitative realist evaluation.

BACKGROUND: Worsening of adolescent mental health and exacerbated health inequalities after the COVID-19 pandemic calls for universal preventative strategies. The Mental Health Foundation's school-based Peer Education Project seeks to improve students' mental health literacy through peer educators (aged 14-18 years) teaching peer learners (aged 11-13 years) to recognise good and bad mental health, identify risk and protective factors, and seek help accordingly. Although previous before and after quantitative assessments have found the intervention to be effective, this realist evaluation aimed to qualitatively develop the theory of change, exploring how the mechanisms played out in different contexts to achieve the desired outcomes. METHODS: Our initial programme theory was developed following expert stakeholder consultation and reviewing the literature. We divided mechanisms into resources and reasoning to explain how the intervention components (ie, resources), experienced within specific contexts, engendered responses in the participants (ie, reasoning), to produce observable outcomes. Data collected from six purposively recruited schools in England comprised staff interviews (n=11), student focus groups (n=15), and observations (n=5). Deductive and inductive analysis was undertaken, using NVivo-informed multiple causal statements represented as context-mechanism-outcome configurations (CMOcs), to test and refine the programme theory. FINDINGS: We created several distinct CMOcs. For example, in learners accustomed to didactic teaching methods (context), conversing with educators having similar life experience (mechanism resource) endorsed and destigmatised help-seeking behaviour (mechanism reasoning) and facilitated a realisation that seeking help was appropriate and acceptable (outcome). Other mechanisms included the following: learners perceiving the information as tailored and relevant, educators feeling empowered, and a cultural shift percolating across the school. INTERPRETATION: Our findings show how peer education can work to improve mental health literacy, which will inform changes to the intervention to maximise its effectiveness in different operational contexts. Future research could test our theory of change in a randomised controlled trial, and examine impacts on inequalities in a more diverse sample. FUNDING: National Institute for Health and Care Research School for Public Health Research.

Adolescent Experiences of the COVID-19 Pandemic and School Closures and Implications for Mental Health, Peer Relationships and Learning: A Qualitative Study in South-West England.

The COVID-19 'lockdown' and multiple school closures disrupted the daily lives and routines of the entire UK population. However, adolescents were likely particularly impacted by such measures due to this time being key for social and educational development. This qualitative study explored young people's experiences of lockdowns and school closures. Fifteen secondary schools within south-west England were initially contacted and three schools participated in recruitment efforts. From December 2020 to March 2021, 25 students aged 14-15 participated in a combination of individual interviews (n = 5) and focus groups (n = 3). Findings revealed diverse experiences of the pandemic and highlighted the complexity of experiences according to individual student contexts. Three main themes were identified: (1) Learning environments; (2) Connection to peers; (3) Transition, adaptation and coping. These findings highlight the value young people place on face-to-face social contact with close friends, and the sense of structure provided by school, with implications for future home-based learning. Further in-depth qualitative research is needed to continue to understand the varied experiences during the course of the pandemic, particularly longer-term impacts on mental health and learning.

Impact of School and Peer Connectedness on Adolescent Mental Health and Well-Being Outcomes during the COVID-19 Pandemic: A Longitudinal Panel Survey.

School closures and social distancing measures during the pandemic have disrupted young people's daily routines and social relationships. We explored patterns of change in adolescent mental health and tested the relationship between pre-pandemic levels of school and peer connectedness and changes in mental health and well-being between the first lockdown and the return to school. This is a secondary analysis of a longitudinal 3-wave panel survey. The study sample included 603 students (aged 13-14) in 17 secondary schools across south-west England. Students completed a survey pre-pandemic (October 2019), during lockdown (May 2020) and shortly after returning to school (October 2020). Multilevel models, with random effects, were conducted for anxiety, depression and well-being outcomes with school and peer connectedness as predictor variables. Symptoms of anxiety decreased from pre-pandemic to during the first UK lockdown and increased on the return to school; anxious symptoms decreased the most for students reporting feeling least connected to school pre-pandemic. Students reporting low levels of school and peer connectedness pre-pandemic experienced poorer mental health and well-being at all time points. Low school connectedness pre-pandemic was associated with a greater increase in anxious and depressive symptoms between lockdown and the return to school when compared to students with medium levels of school connectedness. No associations were found with high school connectedness or with low/high peer connectedness. For adolescents with poor school connectedness, the enforced time away from school that the pandemic caused led to reduced anxiety. Going forwards, we need to consider ways in which to promote connection with school as a way of supporting mental health and well-being.

The effect of school and peer connectedness on adolescent mental health outcomes during the COVID-19 pandemic: a longitudinal panel survey

Background The COVID-19 pandemic, school closures, and social distancing measures have disrupted young people's daily routines, learning, and social relationships. We examine the changes in adolescent mental health over time and explore the relationship between how connected students felt to their school and peers before the pandemic and how this affected their mental health during school closures and on return to school. Methods This is a longitudinal three-wave panel survey with students aged 13–15 years in 17 secondary schools across the South West of England. Students completed a self-report survey before the pandemic (October, 2019), during the first UK lockdown (May, 2020), and shortly after returning to school (October, 2020). Matched data across all three waves were available for 603 students. Anxiety and depression were measured using the Hospital Anxiety & Depression Scale (HADS). School connectedness was measured using six items adapted from the Psychological Sense of School Membership (PSSM) scale. Peer connectedness was measured using a seven-item subscale as published by Jose, Ryan, and Pryor (2012). The study was approved by the University of Bristol Medical School ethics committee (reference 84883). Findings There was an overall decrease in anxiety score from before the pandemic (median 7, IQR 4–11) to during the first UK lockdown (median 6, IQR 3–10). Wilcoxon signed-rank tests indicated that this difference was statistically significant (z=–7·061, p<0·0001). Anxiety levels then increased on return to school (median 8, IQR 4–11), which was also statistically significant (z=6·983, p<0·0001). No changes were observed for levels of depression over the three timepoints. Low school connectedness at baseline predicted a significant increase in anxiety when students returned to school (β 1·33, 95% CI 0·55–2·11;p=0·001). No significant association was found between low peer connectedness before the pandemic and anxiety levels on return to school (β 0·53, 95% CI –0·24 to 1·30;p=0·175). Interpretation Our findings suggest that most students adapted well to school closures, and in fact experienced less anxiety than before the pandemic. Students who reported feeling poorly connected to school before the pandemic are likely to experience higher levels of anxiety on return to school. This study highlights the need for routine mental health and wellbeing monitoring in schools to identify key areas of support and to inform school-based public health interventions. Funding The National Institute for Health Research (NIHR) School for Public Health Research (SPHR).

Reducing COVID-19 risk in schools: a qualitative examination of secondary school staff and family views and concerns in the South West of England.

Objective: To investigate student, parent/carer and secondary school staff attitudes towards school COVID-19 mitigation measures. Methods: Recruitment used school communication, community organisations and snowball sampling in South West England. Audio recorded online or phone individual/group semi-structured interviews were conducted in July-Septtember 2020 and lasted 30-60 min. Interviews focused on views towards social distancing, hand hygiene and testing. Framework analysis was performed on interview notes/transcripts. Results: Participants were 15 staff, 20 parents and 17 students (11-16 years) from 14 diverse schools. Concerns about COVID-19 risk at school, especially to vulnerable individuals, were outweighed by perceived risks of missed learning. Some staff felt guilt around being a potential 'spreader' by teaching multiple classes. Findings highlighted a wide variety of school COVID-19 mitigation measures being deployed due to ambiguous government guidance. Participants generally saw mitigation measures as an acceptable and pragmatic solution to the perceived impossibility of social distancing in crowded schools, although anticipated challenges changing habitual behaviour. Participants supported school COVID-19 testing but identified the need to consider data security and stigma around COVID-19 diagnosis. Staff were concerned about unintended consequences of risk-reduction strategies on student behaviour, learning and pastoral care, particularly for those with Special Educational Needs or mental health issues who may find the measures especially challenging, and resultant widening inequalities. Conclusion: Families and staff supported COVID-19 mitigation measures in schools and would welcome the roll out school COVID-19 testing. Clear messaging and engendering collective responsibility are important for compliance and success of COVID-19 mitigation measures. However, schools and policy-makers should consider unintended consequences of measures, providing extra support for vulnerable students and those with additional needs, and consider ways to avoid widening educational and health inequalities. Findings demonstrate the acceptability of school COVID-19 infection control measures is likely to be influenced by the balance of risks and benefits to students.