Effectiveness of the holistic primary school-based intervention MindMatters: study protocol for a cluster-randomised controlled trial

BACKGROUND

The prevalence of mental health problems in childhood and adolescence has increased significantly, not least due to the COVID-19 pandemic in Germany and other countries worldwide. Although holistic school interventions to promote mental health and prevent mental health problems are considered promising, there is currently uncertainty about their effectiveness due to evaluation studies with heterogeneous methodological quality. This paper presents the study protocol for the evaluation of the primary school module of MindMatters.

METHODS

As part of a universal mental health intervention, the MindMatters primary school module 'Learning Together with Emotions' aims to promote social-emotional learning (SEL) in the classroom across five skill areas. In addition to classroom activities, the intervention includes a school development module to help primary schools create structures and processes to maintain and promote mental health. To evaluate the effectiveness of the intervention, a two-arm cluster-randomised controlled trial will be conducted, including schools implementing MindMatters over a 12-month period and a control group with no access to the intervention. Data will be collected before and 18 months after initiation of the intervention. Controlled for baseline conditions, multilevel regression analysis will be used to examine primary intervention outcomes at the pupil level (i.e. reductions in mental and behavioural problems). Further mediation and moderation analyses will examine whether proximal outcomes predict changes in mental health outcomes and whether school-level factors influence the effectiveness of the intervention.

DISCUSSION

This study will contribute to strengthen the evidence base for holistic school (mental) health promotion interventions using a study design with high internal validity. Based on an intervention model, the results will not only provide insights into the relationship between proximal and distal outcomes, but will also allow conclusions to be drawn about how the implementation of the intervention affects its effectiveness. Finally, the findings also address the question of whether improved mental health has a positive effect on primary school pupils' academic performance.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00023762. Registered on 5 January 2021.

Whole-school interventions promoting student commitment to school to prevent substance use and violence: a systematic review

OBJECTIVES

Whole-school interventions that promote student commitment to school are a promising modality to reduce health inequalities through school-level change; however, evidence for the effectiveness of these interventions in improving policy-relevant health outcomes, such as substance use and violence, has not been comprehensively synthesised.

STUDY DESIGN

This was a systematic review and meta-analysis.

METHODS

We searched 20 databases and a range of other sources to identify randomised trials meeting our intervention definition and reporting substance use and violence outcomes. Extracted effect estimates were meta-analysed using robust variance estimation with random effects, separating effects <1 year from baseline and effects at or more than 1 year from baseline.

RESULTS

We included 18 evaluations with varying risk of bias. Pooled effects suggested significant impacts on short-term (odds ratio [OR] = 0.85, 95% confidence interval [CI] 0.76, 0.96) and long-term (OR = 0.79, 95% CI 0.65, 0.98) violence perpetration, short-term (OR = 0.84, 95% CI 0.72, 0.98) and long-term (OR = 0.85, 95% CI 0.73, 0.99) violence victimisation, and short-term (OR = 0.83, 95% CI 0.70, 0.97) and long-term (OR = 0.79, 95% CI 0.62, 0.998) substance use outcomes, with effects relatively stable between short-term and long-term analyses. Stratifying substance use meta-analyses by type (e.g. smoking, alcohol) did not impact results. All meta-analyses had substantial heterogeneity.

CONCLUSION

Although diverse in content, interventions appear effective with respect to the review outcomes and as a form of universal prevention. Future research should consider contextual contingencies in intervention effectiveness, given considerable policy and practice interest in these interventions and the need to support schools in effective decision-making as to intervention choice.

What factors influence implementation of whole-school interventions aiming to promote student commitment to school to prevent substance use and violence? Systematic review and synthesis of process evaluations

BACKGROUND

Whole-school interventions go beyond classroom health education to modify the school environment to promote health. A sub-set aim to promote student commitment to school to reduce substance use and violence (outcomes associated with low commitment). It is unclear what factors influence implementation of such interventions.

METHODS

We conducted a systematic review including synthesis of evidence from process evaluations examining what factors affect implementation. Meta-ethnographic synthesis was informed by May's General Theory of Implementation.

RESULTS

Sixteen reports, covering 13 studies and 10 interventions were included in our synthesis. In terms of May's concept of 'sense-making', we found that school staff were more likely to understand what was required in implementing an intervention when provided with good-quality materials and support. Staff could sometimes wilfully or unintentionally misinterpret interventions. In terms of May's concept of 'cognitive participation', whereby staff commit to implementation, we found that lack of intervention adaptability could in particular undermine implementation of whole-school elements. Interventions providing local data were reported as helping build staff commitment. School leaders were more likely to commit to an intervention addressing an issue they already intended to tackle. Collaborative planning groups were reported as useful in ensuring staff 'collective action' (May's term for working together) to enact interventions. Collective action was also promoted by the presence of sufficient time, leadership and relationships. Implementation of whole-school interventions took time to build. Considering May's concept of 'reflexive monitoring' (formal or informal review of progress), this was important in assessing and enhancing implementation. 'Quick wins' could help maintain collective impetus to implement further intervention activities.

CONCLUSION

We identified novel factors influencing implementation of whole-school elements such as: local adaptability of interventions; providing local data to build commitment; interventions addressing an issue already on school leaders' agenda; collaborative planning groups; and 'reflexive monitoring' as an explicit intervention component.

Using qualitative research to explore intervention mechanisms: findings from the trial of the Learning Together whole-school health intervention

Background

This study reports on qualitative research conducted within a randomised controlled trial to explore possible intervention mechanisms. It focuses on the ‘Learning Together’ whole-school intervention delivered in secondary schools in England from 2014 to 2017 aiming to prevent bullying and aggression and improve student health. Intervention schools received staff training in restorative practice, a social and emotional learning curriculum, and an external facilitator and manual to convene and run a student/staff action group tasked with coordinating the intervention, focusing this on local needs.

Methods

Informed by realist approaches to evaluation, we analysed qualitative data to explore intervention mechanisms and how these might interact with school contexts to generate outcomes. Qualitative analysis drew on 45 interviews and 21 focus groups across three case-study schools and employed thematic content analysis to explore how intervention resources were taken up and used by local actors, how participants described the intervention mechanisms that then ensued, and how these might have generated beneficial outcomes.

Results

The thematic content analysis identified three social mechanisms that recurred in participant accounts: (1) building student commitment to the school community, (2) building healthy relationships by modelling and teaching pro-social skills, and (3) de-escalating bullying and aggression and enabling re-integration within the school community.

Conclusions

Our analysis provides in-depth exploration of possible mechanisms and the contextual contingencies associated with these, allowing refinement of the initial intervention theory of change.

Trial registration

ISRCTN registry 10751359. Registered on 11 March 2014