Factors affecting the sustainability of community mental health assets: A systematic review

Abstract Resources and activities offered by Voluntary, Community and Social Enterprise (VCSE) organisations could play a key role in supporting communities with their mental health. Whilst policy makers have become increasingly interested in using such asset‐based approaches to improve mental health and well‐being, the sustainability of these approaches remains underresearched. In this review, we explored the factors affecting the sustainability of community mental health assets. We conducted a systematic review of the literature using keywords based on three key terms: ‘sustainability’, ‘mental health issues’ and ‘service provision’. Our search strategy was deployed in four electronic databases (MEDLINE, Web of Science, ASSIA and IBSS) and relevant websites were also searched. The literature search was conducted in November and December 2020 and yielded 2486 results. After title and abstract screening, 544 articles were subjected to full‐text review. A total of 16 studies were included in a narrative synthesis. Studies included a broad range of community interventions and 30 factors affecting sustainability were identified across three sustainability levels: micro (individual), meso (organisational) and macro (local/national/global). Factors were discussed as barriers or facilitators to sustainability. A key barrier across all sustainability levels was funding (cost to individual participants, lack of available funding for VCSEs, economic uncertainty) whilst a key facilitator was connectedness (social connections, partnering with other organisations, linking with national public health systems). Nearly all articles included no definition of sustainability and the majority of factors identified here were at the meso/organisational level. As funding was found to be such a prevalent barrier, more research into macro level factors (e.g. government policies) is required.

defined, ranging from material resources (e.g. land and buildings), individual or collective psychosocial attributes (e.g. skills, capacity, knowledge and passions) and the networking of these to improve the health and well-being of communities (Foot, 2012;Friedli, 2013;Garven et al., 2016;Munford et al., 2017).
A recent systematic review of the literature on health assets in a global context found that Morgan and Ziglio's (2007) definition of a health asset as 'as any factor (or resource) which enhances the ability of individuals, groups, communities, populations, social systems and/ or institutions to maintain health and well-being and to help to reduce health inequalities' was the most frequently cited (Van Bortel et al., 2019). Van Bortel et al. (2019) note the importance of such community assets for health and well-being. This is pertinent to the UK context, where widening health inequalities are leading to the growth of a range of mental health issues, many of which have been exacerbated by pandemic conditions (Marmot, 2020;Naylor et al., 2012: Suleman et al., 2021. Despite growing investment in mental health (e.g. Improving Access to Psychological Therapies, Big Society), the UK government is still facing an increased demand for mental health support (Cabinet Office, 2015;Suleman et al., 2021). In this con-

text, this research focuses on the resources and activities offered by
Voluntary, Community and Social Enterprise (VCSE) sector organisations to support community mental health as a complementary strategy to support good mental health and tackle mental health difficulties (Foot, 2012;Friedli, 2013). Such support extends to a variety of non-clinical support for mental health and well-being such as leisure, social connection, education and the arts (Munford et al., 2017).
Despite providing key support to local populations in the UK, the financial sustainability of community health interventions is continuously under threat as a result of a dependence on government grants.
Between 2009 and 2019, local authorities experienced 38% cuts in central government grants which has led to the significant decline of community health interventions (Institute for Government, 2021).
The sustainability of these types of health asset is very important for the delivery of mental health interventions at the community level; the more community-based approaches can be sustained, the better the health and well-being of individuals and communities is likely to be. Thus, the investigation of factors affecting sustainability is important in maximising the potential impact of community health interventions.
Whilst there is a broad literature on sustainability of public health programmes, it remains fragmented and underdeveloped (Schell et al., 2013;Wiltsey Stirman et al., 2012). Many studies exploring long-term delivery of interventions and activities provide no definition of sustainability, and there is also a lack of consensus around core constructs (Schell et al., 2013;Wiltsey Stirman et al., 2012). In their review, Wiltsey Stirman et al. (2012) found four overarching factors influencing sustainability across literature on healthcare, mental health studies and public health/health promotion. These were innovation characteristics (e.g. fit, effectiveness, ability to be modified), context (e.g. climate, leadership, system/policy change), processes and interactions (e.g. shared decision-making amongst stakeholders, evaluation and feedback, planning, collaboration) and capacity (e.g. champions, funding, resources). In the field of public health, Schell et al. (2013) aimed to identify the core domains that affect a programme's capacity for sustainability and drew them together Health Impacts and Strategic Planning (Schell et al., 2013). Whilst these factors may also apply to community mental health assets, it is important to understand sustainability in the specific context of resources and activities offered by VCSE organisations.
The growing importance of health assets for policy makers outlined above, along with the limited research on community assets for mental health and the importance of sustainability for such assets, reveals an important gap in the literature. In order to address this, we conducted a systematic review to answer the following question: what factors affect the sustainability of community mental health assets? Through this review, we aimed to identify policy priority areas that may support sustainability of these assets and to highlight gaps in current research.

| ME THODOLOGY
Amongst the types of systematic reviews that can be undertaken the 'systematic map' is useful to describe the existing research literature on a broad topic area (i.e. sustainability and community mental health assets; Gough et al., 2017). In undertaking this, we followed

What is known about this topic?
• There is a growing reliance on and need for community assets to support public mental health • Such community assets may help to address health inequalities and improve mental health outcomes • Changing social and political influences have resulted in a landscape where the sustainability of community health activities is continuously under threat What this paper adds?
• A synthesis of the available literature and a list of factors affecting sustainability of community mental health assets • Detailed list of sustainability factors could inform planning for sustainability, both at the organisational and regional/national level • Recommendations for future research, such as improving definitions and evaluations of sustainability, and exploring cost-effectiveness of interventions in community settings the guidance from SCIE (Clapton et al., 2009) and registered this review with PROSPERO (CRD42021233171).

| Inclusion and exclusion criteria
In order to explore this research question, we developed a range of inclusion and exclusion criteria (see Table 1 for details) around the key constructs of this research including 'mental health or mental wellbeing', 'community assets' (Garven et al., 2016;Munford et al., 2020) and factors affecting 'sustainability'. Of the numerous definitions and frameworks used to conceptualise the term 'sustainability ', Wiltsey Stirman et al. (2012) found that the most commonly cited definition in the literature was proposed by Scheirer (2005). This defines sustainability on three different levels: (i) Individual Level: continuing to deliver the desired outcomes or benefits for individual community members; (ii) Organisational Level: an organisation maintaining the programme or intervention in an identifiable form, even if modified; (iii) Community Level: maintaining the capacity of a community/region/nation to deliver programme activities after an initial implementation period is over (Scheirer, 2005). In this paper, we drew on this definition and searched for papers discussing sustainability at any of these levels.
We used the 'mental health or mental well-being' and 'community assets' inclusion and exclusion criteria at the Title and Abstracts screening stage. We then introduced the 'sustainability' criteria at the Full-Text screening, as discussions concerning this theme were less likely to be mentioned in the title or abstract of each article and were instead expected to require reading the full document (see

| Search strategy
With the support of an information specialist, we identified a wide range of keywords based on the key terms: 'sustainability' (e.g. maintenance, durability), 'mental health issues ' (e.g. anxiety, depression) and 'service provision ' (e.g. interventions, programmes, therapies). A full list of these terms can be found in Appendix S1. These keywords and associated combinations were searched in the following databases for the period 2010-2020: MEDLINE (Ovid), Web of Science, ASSIA Social Care Online (mental health and community) and IBSS.
We also searched a number of relevant websites for grey literature (e.g. King's Fund, Mind, Wellcome Collection) and a full list of websites can also be found in Appendix S1. All searches were carried out between November 1 and December 20, 2020.

| Screening
All identified studies were imported into the data management software EPPI-Reviewer Web (Thomas et al., 2020). A two-stage process was undertaken for screening. The first stage involved screening article titles and abstracts, during which all reviewers (AM, DH, MB and CF) independently screened the same 5% of records.
The remaining records were then split between the reviewers and screened on title and abstract. Full-text copies of the remaining articles were retrieved, and all four reviewers again screened an initial 5% before meeting to finalise inclusion and exclusion criteria. Each reviewer then independently screened a portion of the full texts.
The second stage consisted of full-text screening in which the same process was repeated. Studies where there was uncertainty were discussed in the research team until a consensus was reached.

| Quality assessment
Two authors (AM and AH) conducted quality assessment of the included articles, using the Mixed Methods Appraisal Tool (MMAT; Hong et al., 2018). This tool, designed to help appraise the methodological quality of research studies, allows for simultaneous evaluation of all empirical literature (i.e. qualitative, quantitative and mixed methods studies), which was deemed appropriate for this review. The MMAT has high intraclass correlation and has been shown to be efficient and user-friendly (Pace et al., 2012). Both AM and AH independently scored all of the included articles and then met to finalise the scores. Quality scores for each article ranged from 'low' meeting none of five criteria (zero) to 'high' meeting all five criteria (five).

| Data extraction
A data extraction table was designed by the study team specifically for this review, drawing on best practice guidance (Centre for Reviews and Dissemination, 2008). Extracted variables included: geographical location; study aim and design; study population; description of community intervention; data collection methods; and sustainability definition and factors. Extracted sustainability factors included barriers and facilitators at any level included in Scheirer's (2005) definition. We decided, however, to use the terms micro, meso and macro here (instead of Scheirer's (2005) individual, organisational and community levels) as we wanted to convey the breadth of the highest level (macro) in this work, which covers regional and national influences rather than only the immediate community.

| Data synthesis
A narrative synthesis (Popay et al., 2006) was used to provide a critical evaluation of evidence on factors affecting sustainability of community assets for mental health, examining factors at the micro, meso and macro levels. AM led on the data synthesis, coding line-byline data from the included studies that discussed factors affecting sustainability. Preliminary factors were created and shared with the study team. These were refined through discussion and then split into the three sustainability levels (micro, meso and macro). The narrative synthesis examined similarities and differences across the levels and explored overarching themes across the studies.

| Search results
As depicted in Figure 1, database and wider website searches returned 2486 records and the first stage of screening (titles and abstracts) resulted in the exclusion of 1899 records (see Table 1 and Section 2.1 for exclusion criteria). The second stage of screening (full text) resulted in the exclusion of 528 records. In total, 16 articles were identified that met inclusion criteria and provided extractable information on factors affecting sustainability.

| Study characteristics
The countries with the most included articles, both with five stud-

| Defining sustainability
Only one article discussed different conceptualisations of sustainability, highlighting current uncertainty in the literature regarding

| Quality assessment
Quality of the studies was generally good (scores on the MMAT of 4 to 5), although some of the mixed methods studies did not fully integrate qualitative and quantitative components or address any divergences and inconsistencies between the two (Fan et al., 2018).
Two of the included studies could not be assessed using the MMAT as they were 'lessons learned' pieces and not empirical studies (Ferré et al., 2010;Witte et al., 2019). A summary of study design, data collection methods, intervention characteristics and quality appraisal is provided in Table 2.

| Factors affecting sustainability
For a list of the factors affecting sustainability that were discussed in each article see Table 3. Results are organised here according to the three sustainability levels outlined the methods (Scheirer, 2005): (i) Micro level: factors related to individual participants continuing to receive the desired outcomes or benefits of the intervention; (ii) Meso level: factors related to an organisation's ability to maintain the programme or intervention in an identifiable form; (iii) Macro level: factors related to the capacity of a community/region/nation to continue delivering programme activities after the end of an initial implementation period.

| Micro level factors (individual)
Some of the most prominent factors at the individual level were perceived benefit of the intervention and the opportunity to form social connections (Atif et al., 2019;Coll-Planas et al., 2017;Donnelly et al., 2020;Gorman et al., 2018;Grant et al., 2017;MHF, 2017;Palinkas et al., 2019). Participants experiencing increased satisfaction and wellbeing, learning new techniques or skills, and establishing and maintaining social contacts were all described as facilitators to the sustainability of community interventions. Only one study referenced a perceived lack of benefit as a barrier at the individual level (Fleisher et al., 2020).
Logistical challenges were described as key barriers to sustainability, with participants in some cases struggling to fit the intervention into their week or unable to attend sessions at specific times (MHF, 2017). Transport to where the intervention takes place (and sometimes the associated financial burden placed on participants) was also a barrier, along with the difficulty of using and managing local venues (Atif et al., 2019;Fleisher et al., 2020;Foster et al., 2020;MHF, 2017MHF, , 2018. In contrast, one study highlighted the benefit of a local walking group as an intervention with minimal barriers to participation (Grant et al., 2017).

| Meso level factors (Organisational)
Availability of funding and staff skills and capacity to make grant appli- High staff and volunteer turnover, combined with low morale and burnout, also posed considerable issues for sustainability at the organisational level. These barriers were heightened in certain contexts, for example, in remote or rural populations (Kelly et al., 2019) and where there was uncertainty about the programme's future (Atif et al., 2019;MHF, 2018).  were described as working best when there were clear responsibilities laid out from the start (Fan et al., 2018;Shields-Zeeman et al., 2017).
Another facilitator was the flexibility and adaptability of the intervention at varying levels, from small-scale walking groups that can be adapted for participants' fitness levels to wider interventions making use of Community Partnered Participatory Research (CPPR) to build a programme of activities (Ferré et al., 2010;Grant et al., 2017). A number of studies also highlighted the importance of planning for sustainability at the early stages of a project or intervention, along with allocated staff time for sustainability work, regular progress monitoring and the involvement of VSCE organisation leadership (Fan et al., 2018;Gorman et al., 2018;MHF, 2017;Palinkas et al., 2019;Witte et al., 2019).

| Macro level factors (local/regional/national/ global)
Funding and economic uncertainty were the most cited factors affecting sustainability at the higher level, including shifting research priorities, austerity and an over-reliance on voluntarism in public health systems (Grant et al., 2017;MHF, 2017;Witte et al., 2019).
Facilitators to sustainability include working closely with regional or

| DISCUSS ION
In the current climate, with the persistence of health inequalities, and the importance of community assets for improving quality of life, the aim of this research was to review systematically the factors affecting sustainability of community mental health assets.
We aimed to examine how community assets can provide further support to tackling mental health issues, support that could complement the current delivery of statutory mental health services.
The search retrieved articles on a broad range of international community interventions, which in turn include a range of barriers and facilitators to sustaining community activities or services.
Whilst we found a number of factors at the micro and macro levels, the majority of sustainability factors discussed in the included articles were found at the meso level referring to the sustainability factors of organisations.
Some of the themes identified here recurred across levels. The schools have greater 'core' staff resources to facilitate delivery that are not as affected by hostile funding climates where limited, competitive funding is available. In the case of community assets, policy makers and those evaluating interventions should take note of this and plan for ways to link into wider systems prior to starting the intervention.
As a review of asset-based approaches noted, the term connectedness at the micro individual level also refers to the involvement of service users in the design, implementation and evaluation of community interventions as a way to encourage greater sustainability at the micro/individual level (Hopkins & Rippon, 2015). The World Health Organization and a number of countries, including the UK government, have promoted the involvement of service users in the design of mental health services. However, more progress has been made in terms of involving individuals in decisions around their personal health rather than at the wider organisational level (Cheng et al., 2017;Storm et al., 2011). It is also important to note that there are several levels of involvement of service users ranging from manipulation to citizen control (Arnstein, 1969). Increasing sustainability for community assets therefore requires greater attention to ensure that service users' views and opinions are valued.
Funding was found also to be a factor affecting sustainability at all levels, highlighting the importance of financial security and continued support for these types of community health assets. At the micro level, individual participants struggled with the cost of travelling to attend activities, whilst at the meso level, limited funding was described as a key barrier to sustaining VSCE programmes (Atif et al., 2019;Ferré et al., 2010;Fleisher et al., 2020;Kelly et al., 2019;Witte et al., 2019). The lack of available funding was found to limit organisational activities and also had an impact on staff capacity, as already-stretched staff were required to redirect energy to applying for bids and grants (MHF, 2017;Witte et al., 2019). In some instances, the uncertainty around future funding was also found to have a negative effect on workforce morale (Atif et al., 2019).  The role of funding in the sustainability of interventions is consistent with previous reviews (Schell et al., 2013;Wiltsey Stirman et al., 2012). Many community assets depend on their financial sustainability from local authorities, and in the UK, local authorities have seen their funding decline by 38% in the last 10 years (IfG, 2021 It remains to be seen whether greater autonomy will be accompanied by greater funding transfer to local areas. In their framework for the sustainability of public health programmes, Schell et al. (2013)

| Strengths
This review used a broad definition of sustainability (Scheirer, 2005) and therefore enabled an exploration of factors influencing sustainability at all levels in society, from individual participants (micro) to VSCE organisations (meso) and regional, national and international policy (macro). Through its search strategy, this review cap- This research also focussed on mental health outcomes and interventions, an area of public health that is currently under significant pressure. Consequently, identifying factors that affect sustainability of the work of VSCE organisations could be an important contribution to help alleviate pressure on the system.

| Limitations
Whilst an information specialist was utilised and a broad and inclusive approach was taken to the search terms for the construct of sustainability, it is possible that some records were not picked up in the search strategy and thus not included in this review. character of sustainability and learning or of the continuous adjustments that shape the sustainability process' (Pluye et al., 2004, p. 124). Similarly, Lennox et al. (2018) suggest that sustainability should also be viewed as a change process involving adaptations and developments in response to the emerging needs of a system. Future research into sustainability of community mental health assets would benefit from exploring both definitions; planning research involving multiple timepoints would be a particularly important step to understanding more about sustainability as a process.
Given that most of the articles included in this review reported findings at the meso level (VSCE organisations), it would be useful to conduct further research into the micro and macro levels. Exploring some of the macro level factors that influence sustainability, such as higher level policies and funding is particularly important. Similarly, although this research provides insight into funding as a factor that affects sustainability, the cost-effectiveness of community mental health assets has not been explored. With such a focus on funding, the cost-effectiveness of these assets and their activities is a key part of the picture that requires further investigation.

| CON CLUS IONS
The sustainability of community mental health assets is not yet well

ACK N OWLED G EM ENTS
The authors would like to thank Sylvia Potter and Caroline Frostick for their work in the literature search and the first stages of screening for this review.

FU N D I N G I N FO R M ATI O N
This research was commissioned and funded by the MARCH Network, a national network funded by UK Research and Innovation (UKRI). The views expressed are those of the authors and not necessarily those of the MARCH Network.

CO N FLI C T O F I NTE R E S T
The authors state that there are no conflicts of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as no new data were created or analysed in this study.