The feasibility and acceptability of an approach to emotional wellbeing support for high school students
Background: Emotional wellbeing of young people has high global and national priority. UK high schools are under pressure to address this but lack evidence-based guidelines.
Method: Students (N=23) (aged 11–16 years) and staff (N=27) from three urban UK high schools participated in qualitative interviews to explore the feasibility and acceptability of an approach to emotional wellbeing support. Key components were: self-referral, guided self-help, and delivery by school pastoral and support staff.
Findings: Confidentiality, emotional support, effectiveness and delivery modes were important to students. Organisational values influenced feasibility.
Conclusions: Understanding a school’s moral and operational framework can enhance the development of suitable emotional wellbeing support.
Key Practitioner Message:
- • It can be acceptable and feasible to deliver a self-referral, guided self-help intervention to promote emotional wellbeing in high school students
- • School support staff appeared to be an appropriate resource for the delivery of the intervention
- • Intervention implementation was affected by contextual factors in the schools
Mental health of young people is a growing public health concern that has been highlighted by the World Health Organisation (WHO) and national policies (Wahlbeck & Taipale, 2006; WHO, 2008). Prevalence estimates of mental disorder in young people (11-16 years) in the UK are 13% for boys and 10% for girls (Green, 2004) but difficulties in recognition and diagnosis have led to higher estimates of around 20% (Macdonald, 2000). Poor mental health in childhood is detrimental to life chances and quality of life in adulthood, increasing the risk of difficulties with employment, relationships, mental health, criminal behaviour and social isolation (Richards et al., 2009). There is therefore an urgent need for effective strategies to improve the mental health of young people in the UK.
‘Emotional wellbeing’ (EWB) is a precursor of mental wellbeing, or positive mental health (WHO Europe, 2005). EWB can incorporate problem-solving skills, self-awareness, emotional self-management and resilience to distressing events (Rickwood et al., 2005; Stallard et al., 2008) and therefore protects long-term mental health. As a building block of mental health, EWB is a valid focus for interventions with non-clinical populations of young people (Burns & Hickie, 2002; National Institute for Health and Clinical Excellence (NICE, 2009). EWB promotion has been a dominant theme in public health research worldwide, with studies in many countries (Patton et al., 2000; Payton et al., 2000; Ravens-Sieberer et al., 2002; World Health Organisation Europe, 2005).
UK policy is consistent with WHO in identifying young people’s EWB as a public health priority (Herrman, Saxena, & Moodie, 2005) and imposes on schools a responsibility for EWB promotion. The evidence favours approaches based on cognitive behaviour therapy (CBT) (Merry et al., 2004), a psychological intervention that has demonstrated effectiveness in depression and anxiety in young people; however, access to traditional CBT is often limited.
School-based EWB approaches tend to be targeted at vulnerable individuals or delivered universally via the curriculum (NICE, 2009). Social, educational or psychological approaches may be combined in strategies that aim to influence the whole school (Department for Children Schools and Families (DCSF), 2008; Adi et al., 2007).
National guidelines for EWB promotion in schools strongly endorse the Social and Emotional Learning in Schools approach (SEAL) (NICE, 2009). SEAL is a high profile programme that comprises resources and strategies for classroom, small group and individual work. The implementation and evaluation of SEAL in secondary schools (students aged 11-16 years) is in early stages. (In the UK, most state funded secondary education takes place in high schools.) However, positive evaluations of acceptability and usefulness are emerging from evaluations in primary school settings (e.g. Lendrum et al., 2009). Process evaluation of SEAL has identified that factors in the setting, such as the availability of suitable physical space, can influence how SEAL is implemented (Humphrey et al., 2009).
Although the emphasis to date has been on primary education (DCSF, 2008), the UK evidence for school-based EWB with older students is emerging gradually. Current guidelines for EWB promotion in school recommend SEAL, but otherwise focus on principles: school EWB strategies should connect with local and national policies, particularly the National Healthy Schools programme and the Every Child Matters agenda (National Institute for Health and Clinical Excellence, 2009). There is therefore scope to develop approaches suited to local need.
One regional initiative is the UK Resilience Programme; this is a manualised, curriculum-based approach to promoting optimistic thinking, adaptive coping skills, and social problem-solving. A mixed-methods project to evaluate its impact on Year 7 students (aged 11-12 years) in three local authorities in England is currently near completion. An interim report has suggested positive outcomes for students, while highlighting that actions of schools, for instance in changing the programme from a universal to a targeted intervention, can create implementation issues (Challen et al., 2010).
Positive parenting approaches have also been well received. The Incredible Years programme, which stems from the USA, focuses on improving skills of teachers and parents and appears to be a promising intervention with young people in the UK (Hutchings et al., 2009).
Targeted Mental Health in Schools (TaMHS) is a phased, government programme (Department for Children Schools, 2008). TaMHS delivers focused interventions to students aged 5-13 years who have been identified as vulnerable, and sees whole-school and curriculum interventions as complementary to this activity. An underpinning principle is the need to develop a useful and relevant evidence base from ‘real world’ projects (Department for Children Schools, 2008, p.20), and it thus combines concurrent implementation and evaluation. The TaMHS approach reflects the limitations of the evidence base for EWB work in UK schools (Department for Children Schools, 2008). Overall, the evidence to support implementation in UK secondary schools is sparse (National Institute for Health and Clinical Excellence, 2009), has limited generalisability, and focuses on evaluation of process (Weare, 2009).
Recently published national guidelines for EWB promotion in secondary education recognise the potential of both organisational and targeted approaches but identify evidence gaps including short and long term outcomes, effectiveness, the impact of using different professional groups, unintended effects, and evaluation strategies (National Institute for Health and Clinical Excellence, 2009). These limitations in the evidence restrict the support available to schools for decision-making, despite the imperatives placed upon them to deliver EWB promotion.
Low intensity interventions to promote EWB have demonstrated acceptability and effectiveness in non-clinical populations of children (Stallard et al., 2008) and there has been considerable interest in the use of guided self-help (GSH) to deliver low intensity psychological interventions to young people in school (Dalle Grave, 2003). GSH is a mechanism for delivering CBT-based interventions; therapist contact is brief and instead the recipient refers to written or audiovisual materials between sessions (Richardson & Richards, 2006). Through its emphasis on self-help and minimal contact time, this approach may address some of the well-documented barriers to help-seeking in young people, particularly expectations of being judged, lack of privacy, and losing control of the agenda (Gleeson, Robinson, & Neal, 2002; Rickwood et al., 2005).
A feature of GSH that may be helpful in school contexts is that it does not require delivery by mental health specialists. The practice of using appropriately skilled, unqualified, mental health practitioners to provide brief, focused sessions is recognised in mental health services (Lovell et al., 2006) and endorsed in policy and best practice guidelines (Fletcher et al., 2006; National Institute for Mental Health in England, 2004). Precedents exist for the provision of ad hoc support and CBT-based programmes in school without mental health specialists (Allen, 2007; Stallard et al., 2008). There is a workforce of pastoral and teaching support staff in high schools (DfES 2008), potentially available to deliver evidence-based EWB support, but so far there has been little interest in developing this role.
Deploying pastoral and support staff in this way may increase the potential for self-referral mechanisms, which could benefit young people. Self-referral could enhance confidentiality and active engagement, while avoiding problems associated with over- or under-referral by third parties (Kramer et al., 2004). GSH delivered by existing school staff and accessed by self-referral may be a valuable means of delivering effective EWB support in high school.
The current study
This paper reports a study centred on an intervention to promote EWB in high schools: ‘The Change Project’ (the Project). It was developed from a consultation process including students, school and clinical staff (Kendal, 2009) and then piloted in three high schools (A, B, C) located in urban areas of northern England (the same schools whose students had participated in the consultation). In order to tailor the Project for the intended population and setting, the same study populations were involved in both development and implementation (Medical Research Council, 2003). The research reported here aimed to evaluate the Project’s feasibility and acceptability from perspectives of staff and students in those schools.
Description of the Change Project
The Project offered students GSH for emotional difficulties including anxiety, low mood, self esteem, and relationship problems. Any student could self-refer for individual, face-to-face appointments of 15-30 minutes, in which they were supported to clarify and systematically work towards goals, using behavioural and cognitive techniques. The Project was delivered in school by staff recruited from pastoral and teaching support teams (Project Workers (PWs)), who received training, a manual, weekly supervision, and ad hoc telephone support from an experienced mental health clinician (SK).
Appointments took place discretely in school breaks or after school. Various communication routes for making appointments (e.g. post-boxes, e-mail, mobile-phone, direct approach) were created. High value was placed on the privacy of students who used the Project (Project Users (PUs)) and their personal information was protected. The purpose, confidentiality policies, and access routes into the Project were advertised in the schools verbally and on posters and flyers.
Recruitment of the schools to the pilot study was a continuation of their involvement in the Project; this ensured that students could benefit from their earlier input. There was no evidence that the participating schools were involved in additional, similar initiatives, although these were being conducted in other schools in the area. Demographic differences between schools included ethnicity, gender balance and size; similarities included high levels of socio-economic deprivation. School profiles are summarised in Table 1.
Table 1. Profiles of schools participating in the study
|Gender mix (students)||Male/female||Female||Male/female|| |
|Approx number of students 11-18 years||1200||1700||600|| |
|Total students|| || || ||3500|
|Socio-economic status||In top 5% of most deprived wards in England||In top 20% of most deprived wards in England||In top 10% of most deprived wards in England|| |
|Total staff|| || || ||357|
An assessment protocol was devised using the PHQ-2, which is a 2-item questionnaire designed for use by non-mental health specialists (Care Services Improvement Partnership, 2006; Kroenke, Spitzer, & Williams, 2003). A positive screen triggered a referral to the school nurse who could monitor, signpost or refer as necessary. The protocol complemented existing welfare systems and protected staff and students. Ethical approval was obtained in writing from the University of Manchester Ethics Committee (Ref 06/1001/NMSW) and the head teachers. The research aim was to evaluate the feasibility and acceptability of the Change Project.
The study design was qualitative. Consistent with complex interventions development theory, the research was conceptualised as a modelling phase to explore process and develop theory, in order to inform the design of a future trial (Craig et al., 2008). Staff and students were consulted in semi-structured interviews, and data analysis was informed by the Framework method (Ritchie, Spencer, & O’Connor, 2007).
Eligibility and sampling
Twelve pastoral and teaching support staff (2 in School A; 3 in School B; 7 in team C) volunteered to deliver the Project. Two were educated to degree level; none were qualified teachers. The Project operated between November 2006 and July 2007. Between March and July 2007 an interview sample of 23 students (aged 11–16 years) and 27 school staff was recruited using snowballing and purposive methods. Sample characteristics are presented in Table 2.
Table 2. Interview sample characteristics
|Other pastoral or support staff||3||1||2||6|
All students and staff were theoretically eligible to be interviewed. Students were recruited by PWs who invited them to participate, while stressing that this was voluntary. SK recruited staff through internal communication routes, facilitated by the rapport built up during the Project consultation. Interviewees assented (students) or consented (adults) in writing. Assent and consent were treated as ongoing processes. In order to protect their right to privacy, no explanation was sought from individuals who declined to be interviewed. Data collection continued until a representative sample in terms of schools, gender, role in school, and association with the Change Project had been obtained.
Thirty-nine individual interviews and three focus groups were conducted by SK between March and July 2007. Five students in school C, three PWs in School B and three PWs in School C opted for group interviews. Interviews lasted 20-70 minutes and were recorded on audiocassette if the interviewee agreed; otherwise in written notes. They took place at school, except in the case of two students who were interviewed at home. Interviews with PUs took place after their final appointment.
Using a conversational interview style (Hobson, 2000) encouraged interviewees to expand on topics, and topic guides provided a flexible interview structure (Krueger, 1997). Topics were initially informed by the consultation (Kendal, 2009), but evolved in response to themes emerging during concurrent data analysis. Table 3 summarises the topic guides used.
Table 3. Summary of topic guides
|Common topics - perspectives on:|
| - Accessibility (e.g. timing, venue, referral system) |
| - Value/potential value to students|
| - Content of appointments (helps/could help students) |
|Project user topics:||Project worker topics:|
| - Finding out about the project || - Appointment schedules (e.g. goodness of fit with skill base, timescale) |
| - Making an appointment || - Difficulties in delivery (time, following protocols, administration, ethical issues, etc) Consultations with school nurse|
| - Helpfulness/value || - Personal experience of delivering project e.g. professional development, interest, difficulties|
| - Personal experience of using project || |
| - Recommendations|| |
|Other students topics:||Other staff topics:|
| - Awareness of project and purpose || - Value to whole school |
| - Potential value to self and peers|| - Impact on school |
| - Access barriers and facilitators|| - Difficulties in delivery (advertising, appropriateness, time for Project Workers, etc)|
Data analysis strategy
Audiotapes were anonymised and professionally transcribed. Anonymised interview notes and transcripts were checked by the interviewer (SK) and imported into an NVIVO 7 software file for data management. Group and individual data were treated equally (Krueger, 1997). Analysis processes involved familiarisation with the data, coding, checking, summarising and charting (Ritchie et al., 2007). Validation strategies included checking of the evolving coding framework by three young people and three academic colleagues. Independent coding of anonymous transcripts was undertaken by two young people and one colleague. The ensuing discussions aided data interpretation (Pope, Ziebland, & Mays, 2000). Stages in data processing were photographed to create an audit trail. An example of the coding process is provided in Figure 1.
There was much common ground between the perspectives of staff and students on the acceptability and feasibility of the key intervention components: self-referral, guided self-help and delivery by PWs. Pseudonyms are used in the report; Key Stages 3 and 4 are indicated by KS3 and KS4, respectively.
Uptake of the Change Project
Between November 2006 and July 2007, 21 students used the Project: 2 in School A; 9 in School B and 10 in School C. Of these, there were 19 females; 12 students in Key Stage 3 (11-14 years); 7 in Key Stage 4 (14-16 years); and one in Key Stage 5 (16-18 years). Four PUs were referred to the school nurse following a positive PHQ-2 screen. None were referred out of the Project. PUs made a total of 53 appointments, of which 49 were attended. The number of appointments per student ranged from 1-7 (mean: 2.33; median: 2.00). Duration of students’ contact with the Project ranged from 1-65 days (mean: 16.86; median 7.00).
PUs spoke in favour of the self-referral route to the Project. Most acted independently, prompted by awareness of personal need combined with publicity in school, suggesting that independent self-referral had high acceptability among PUs.
I saw on the wall, a poster I think. It said Miss X was doing it. I asked my teacher how to find Miss X. I didn’t know who she was. I went to see her and she gave me an appointment. [Lily, KS4 PU, School B]
A small proportion of PUs said they had needed support from a parent or trusted member of staff to make their first contact. Students speculated that self-referral might depend on individual confidence and communication skills. Both staff and students suggested that a person with low cognitive ability or low self-awareness would be less likely to self-refer. Staff expressed concerns that, in making unrealistic assumptions about the competence of students, self-referral could actually restrict access to support.
A lot of children whom I work with, you know, lack basic life skills like, you know, making a cup of tea…just being able to write their address on a letter [Sylvester, PW, School A]
Students and staff expressed that giving the students control over their referral, and timing appointments outside lessons, would reduce the risk of overuse of the service for trivial problems.
If you don’t make the appointment, obviously … you don’t want to be taken seriously. [Savannah, KS3 Student, School A]
The ones you’ve got coming… they’re the genuine ones. [Harriet, PW, School C]
These findings suggest that good quality information, self-awareness and low-key encouragement could enhance self-referral without compromising independence or confidentiality.
Students and staff approved of the practical strategies and emotional support offered within sessions, as in this account of help for panic:
You have to learn strategies to calm your panic attack down, and then like, and then talk about it… she picked out specific sheets that she thought would help me, … and if then there was a certain (thing) that I didn’t …understand, she’d go through it. [Nina, KS3 PU, School B]
PWs provided pathways to other support, such as encouragement to attend an after-school social club.
Delivery by pastoral and support staff
Recruitment of pastoral and support staff to the PW role appeared to reassure students, mainly because of their reputation for trustworthiness.
With it being pastoral (staff) you know you can trust them with pretty much everything, so that helps a lot. [Greg, KS4 Student, School A]
PWs reported difficulties in finding time to conduct sessions and complete research notes while maintaining their core role in school. In schools A and B few concessions were made regarding their other responsibilities. Consequently, PWs had increased workloads, which reduced their opportunities to see PUs and challenged the feasibility of the Project Worker role.
Sometimes we’re rushing to lessons, we haven’t got time. [Susan, PW, School B]
Perceived value of the intervention
As well as acquiring useful strategies and emotional support, the simple reality of available help made a difference for some PUs. Most reported improvements in their presenting problem:
Before all this, before all the Change Project … I didn’t know who to talk to… I was in a fight every day, but now I’m like in a fight every month or something like that. [Tanya, KS3 PU, School C]
The main criticism offered by PUs related to short appointments. Two PUs said they had wanted more time for in-depth discussions. One explained she had not benefited from the intervention because of this; the other acknowledged that lengthy appointments would be difficult to arrange at school but suggested an increase of 5-10 minutes would help. Some PWs pointed out that the GSH model suited the context:
I think it is actually functional to have short appointments, and I think that generally, you know, having short term and long term goals works very, very well with kids this age. [Megan, PW, School A]
There was evidence that subtle factors in the school setting, such as organisational values, influenced the way the Project was promoted and advertised. For example, an interviewee from School A explained that the senior management team had consciously limited the distribution of Project publicity, for fear of damaging the school’s image:
The more things that you publicise in this way, the bigger the perceived problem from those looking in can be, and there’s a sense in which... people looking in are likely to say, well there must be a big problem there. [Oliver, Staff, School A].
PUs approved of the control they had over referral, the session content and the deployment of pastoral and support staff as PWs. Almost all reported subjective improvement in areas such as relationships, confidence, self-esteem and self-worth. Staff were supportive, but tended to express that they should be involved in the referral processes, whereas there was a strong message from the students that having control over help-seeking was highly valued.
You get to do it when you think you need help, not when someone else thinks you need help. [Toby, Student, KS3, School A]
Change Project components were broadly acceptable to participants, but feasibility was strongly influenced by the way the school operated and its organisational values. The study identified organisational and personal factors relevant to acceptability and feasibility in UK high schools, generating new knowledge to inform school-based EWB interventions development.
The fact that three high schools agreed to pilot the Project suggests their Senior Management Teams (SMTs) believed it could enhance pastoral provision. Nevertheless, SMTs appeared to endorse some implementation barriers, consistent with previous observations that organisational factors can block programme delivery (Elias & Weissberg, 2000). For example, School A’s reluctance to advertise the Project suggests that the stance taken by SMTs may have been pivotal to acceptability and feasibility, illustrating the link between implementation and outcomes evaluation and reinforcing the need to evaluate process (Weare, 2009).
Poor advertising may have reduced Project uptake. It could also reflect a more subtle influence: if the school milieu can facilitate help-seeking in young people (Fonagy, 2009), it might also act as a barrier. Ambivalence in the SMT could permeate through the rest of the school, contributing to a culture that discourages help-seeking. It has been observed previously that programme implementation can be adversely affected by difficulties such as accessing suitable space in a school (Humphrey et al., 2009); findings from the present study suggest that resourcing difficulties could also reflect low commitment to EWB promotion at a management level. Alternatively, the modest Project uptake may reflect considerable barriers to making and attending appointments, possibly relating to student confidentiality, trust, self awareness, and skills. This is consistent with literature on help-seeking in young people (Hunter, Boyle, & Warden, 2004; Rickwood et al., 2005) and suggests that there are moral frameworks in schools that react with operational systems to influence EWB promotion.
Standardisation of intervention delivery, staff training and support could be required both for quality assurance across sites and for comparative testing of outcomes in further research. Notwithstanding, no interviewee expressed concerns about PWs’ skills for delivering the intervention as planned, suggesting that brief training plus ongoing supervision was sufficient. This provides some contrast with findings from an evaluation of SEAL, which recommended improvements to facilitator training (Humphrey et al., 2009). Potentially, appropriately supported pastoral and support staff may be a particularly suitable group to deliver EWB interventions. The recruitment, preparation and support of pastoral and support staff to deliver structured, measurable EWB interventions has not been explored in the research or practice literature, and there is a lack of consistency in the interpretation of many pastoral roles in school (DfES, 2008). Given the positive responses from young people to this aspect of the Project, it may be worthwhile to explore this topic further.
As part of a GSH model, short appointments may be instrumental in facilitating planned, structured and confidential EWB support within a crowded school day. Brief contact may be a functional and palatable option for students. Furthermore, research proposals that threaten to disrupt school routines may not win access to schools in the first place (Inchley, Muldoon, & Currie, 2007). It is therefore ethical and pragmatic to prioritise feasibility and acceptability over tradition in EWB interventions development. Reports from primary care suggest that reservations about GSH may be a temporary reaction to an unfamiliar model (Lovell et al., 2006), so acceptability may increase with experience; however, there is scope to improve acceptability through a greater focus on time management when training staff.
Simple and low intensity interventions are a recognised starting point in mental health care (National Collaborating Centre for Mental Health, 2005), being clinically and economically sensible and potentially more acceptable to service users. The Change Project reflected this principle and offered a new level of help between informal and formal support systems for young people. This was consistent with recommendations from previous studies asserting the value of choice in help-seeking (Ginsburg et al., 2002).
Self-referral appeared to reassure PUs that help offered was confidential. The link between confidentiality and help-seeking echoes findings from studies of help-seeking in young people (Farrand, Parker, & Lee, 2007; Rickwood et al., 2005), although as accountability for mental health is a relatively new responsibility for schools (Reid, 2005) conflicting attitudes to transparency and confidentiality in schools could challenge development in this area.
Observations and reflections of the interviewees have illustrated how social processes work in three schools and highlight a need for a detailed understanding of context in EWB interventions development. The data suggest that the lack of authority and status of pastoral staff limits their ability to deliver interventions without the wholehearted support of managers, an issue that could be explored with staff in early stages of recruitment to future studies. The Project’s feasibility and acceptability could reflect social cultures that discourage students from help-seeking for emotional difficulties (Farrand et al., 2007), so it may be timely to develop a discourse on the tensions between confidentiality and openness in school settings, and the implications of this for supporting student EWB.
This study was located in the exploratory stage of complex interventions development (Craig et al., 2008). It focused on working with the same school populations from the start of the preliminary work, to develop an intervention tailored specifically for them. Each step informed the next, and as the research progressed it became increasingly clear how much the social and organisational context was influencing the research. The data suggested that the schools’ social cultures were crucial influences at each stage and are consistent with research theory that highlights the importance of context to feasibility and acceptability (Craig et al., 2008).
Involving the participants so closely in the research produced the highly contextualised data that are the natural output of qualitative inquiry. This is consistent with previous studies (e.g. Humphrey et al., 2009; Schachter et al., 2008). Humphrey et al. (2009) argued that the rapport between school staff and children could enhance outcomes from SEAL; the present study suggests other contextual factors in school-based research that may influence both implementation and evaluation of an EWB approach.
These study findings can inform the design of larger studies aiming to produce generalisable data on relationships between setting and outcomes. This could include the impact of demographic characteristics of PUs and PWs and previous experience of school-based emotional support.
This research identified self-referral, guided self-help and delivery by support staff as valued components of a high school-based EWB intervention. It generated insights into how prevailing values in schools may influence the treatment of a pilot study, and the need to secure cohesive management support. This knowledge can inform further development of feasible and acceptable school-based EWB interventions that can be evaluated for effectiveness and sustainability.