What is the impact of structural and cultural factors and interventions within educational settings on promoting positive mental health and preventing poor mental health: a systematic review

The protocol for this systematic review was registered with PROSPERO on 17^th June 2019 (CRD42019138976) [25].

Relevant studies were identified through systematic searches of the following electronic bibliographic databases: PsychINFO, Embase, ERIC, ASSIA and British Education Index. In addition, reference lists from key studies and relevant systematic reviews were hand-searched. The development of search terms was informed by the analysis of titles, abstract and index words of key publications in the field. We used the combination of terms for educational settings, environmental factors and MH outcomes. For an example search strategy see Table 1 in the Supplementary File. Database searches were conducted between 18/06/2019 and 20/06/2019. Search results were managed using EndNote software, and individual database results were merged with duplicates removed. The merged EndNote file was then uploaded into the online software CADIMA (https://​www.​cadima.​info/​index.​php/​area/​evidenceSynthesi​sDatabase), designed to support evidence synthesis.

In the first selection stage titles and abstracts were screened independently by five researchers (DT, PJ, JA, JK, JW), with 10% of titles double screened and inconsistences resolved by discussion with a third researcher. Full-text screening was undertaken independently by four researchers (JA, DT, PJ and JK); 15% were double screened and inconsistencies resolved by discussion with a third researcher.

Data extraction was conducted by DT, PJ, EGS, LS, SS and PA, and 10% double extracted as a quality and consistency check by JK. The following data were extracted into a spreadsheet:

Critical appraisal of the quality of all quantitative studies was undertaken using the Canadian Effective Public Health Project Practice Quality Assessment Tool for Quantitative Studies (http://​www.​ephpp.​ca/​PDF/​Quality%20​Assessment%20​Tool_​2010_​2.​pdf). This tool was developed to assess the quality of quantitative studies including RCTs, before-and-after studies and case–control studies [27]. The tool doesn’t assess the risk of biased results but rather gives each study a quality rating of strong, moderate or weak. For qualitative studies, we used the Critical Appraisal Skills Programme qualitative checklist which includes two screening questions (aims of the study and appropriateness of qualitative methodology to the aims), and a further eight appraisal items (research design, recruitment strategy, data collection, reflexivity-related issues, ethical issues, rigour of analysis, and the reporting and value of findings).

Each study was critically appraised independently by two members of the research team (DT, PJ, EGS, LS, SS and PA). Ratings were compared, and where there was disagreement, a third appraisal was undertaken by JK. No studies were excluded on the basis of quality appraisal, but quality is considered in the narrative summary of findings.

A flowchart showing the study selection process is shown in Fig. 1 below.

A summary of the characteristics of included studies can be found in Table 2. A majority were published after 2010. Studies were based in a range of countries, with the United States of America (USA) being the most common country (24 studies), followed by the UK (12). There were slightly more studies based in primary than secondary school, with 3 based in pupil referral units (where students have been excluded from mainstream school.

Evidence from two papers suggested that green and outdoor space were associated with reduced problem behaviours, aggression, stress, Attention Deficit Hyperactivity Disorder (ADHD) and depressive symptoms [37] and improved mental, emotional and social health [38]. Sitting on a stability ball compared to a regular classroom chair resulted in a reduction in depressive/anxious symptomatology after eight weeks but not at a five month follow up [39]. Healthy spaces created both inside and outside of the school buildings – in which students and teachers could enjoy healthy snacks, movement breaks, and MH breaks—was associated with an initial decrease in depression and anxiety but these improvements were note sustained at follow up [40].

Only three studies, all of which had reported interventions to be effective, included information about cost effectiveness. Two of these clearly reported a formal cost effectiveness evaluation. The INCLUSIVE cluster randomised controlled study in UK secondary schools [85] reported what was considered a low additional cost of £47-£58 per student over a two year intervention period, which was found to be effective at improving MH outcomes. The STARS cluster randomised controlled study in UK primary schools [54] looked at total economic costs after 30 months including service provision, and found a cost-effectiveness ratio favouring the intervention of approximately -£29.70 per unit improvement on the main outcome measure (Strengths and Difficulties Questionnaire). The final study, the Fast Track randomised controlled trial, aimed to reduce conduct disorders and antisocial behaviour among children identified as ‘high risk’. The authors estimated an intervention cost of $58,000 per young person over 10 years but reported this as potential economic saving compared to the much larger cost to society per young person who commits a crime. However, the authors note as the intervention was only found to be effective for those identified as highest risk, it may only be cost effective if directed to the highest risk group [80].

Most included studies did not explicitly look at the impact of the environmental factors or interventions on reducing or widening inequalities. Six studies specifically targeted CYP who were at risk of poor MH due to socioeconomic circumstances, which, although not providing formal measures of impact on inequalities, do highlight interventions with the potential to prevent or reduce poor MH among those at greatest risk. The wide range of interventions led to mixed results. One study found older peer mentoring did not improve socio-emotional health among economically disadvantaged young people compared to less disadvantaged controls although positive trends were noted [68]. One study reported improvements in anxiety and self-esteem scores but not depression among young people in a low SES area participating in a physical activity programme compared to controls [31]. One study found perceived manifestation of diversity policies improved psychological school adjustment among young immigrants [44]. One study found a multifactor intervention (parent training, child mentoring, home visits and parent–child groups), delivered in schools in areas high in crime and poverty, showed reductions in behavioural problems, with greater improvements among students with higher conduct problems [80]. One study found a culturally sensitive mentoring programme for minority ethnic young people resulted in improved positive MH [64]. One study reported that delivering a yoga intervention to CYP from disadvantaged socioeconomic backgrounds reduced anxiety and stress but not depression overall [30]. Finally, one study reported marginally reduced depression symptoms when financial and health support was offered to orphans at school in Kenya [36].

Of those studies that specifically conducted subgroup analyses, five looked at differences in effect for those at higher risk of poor MH due to social or economic factors, compared to those not at risk. None of the studies provided evidence of an intervention reducing inequalities. One study did not find that their group based mentoring intervention had a greater impact on the MH of CYP who had special educational needs or who had failed at least two classes, although they did see a decline among the at-risk group for absence and slight improvements in life skills (e.g., problem-solving) compared to those not at risk [67]. Similarly, another study found no difference of effect for their school-wide positive behaviour intervention on children with special educational needs compared to those without [48]. One study also found no difference in outcomes by socioeconomic group for their multifactor intervention [85]. One study reported that, following a physical activity intervention, disparities in physical self-worth between those with higher versus lower SES widened among the control group, whereas they remained constant among the intervention group, with everyone’s self-worth improving [28]. Finally, one study found no difference in their mentoring programme on MH outcomes by ethnicity [59].

In total, 13 studies examined differences by sex in their subgroup analyses, of which 8 found no differences in MH outcomes by sex [36, 48, 59, 61‐63, 69, 86]. Two studies reported differences by sex that may have indicated a widening of inequalities. One of them found their multi factor intervention reduced bullying and aggression among early adolescents and had a bigger impact on boys’ MH (SDQ total difficulties score; boys -1.29, 95% CI -1.67, -0.92; girls 0.04, 95% CI -0.30, 0.39, p < 0.0001) and wellbeing outcomes (Short Warwick-Edinburgh Mental Well-Being Scale total wellbeing index; boys 1.32, 95% CI 0.89, 1.74; girls 0.04, 95% CI -0.81, -0.04, p < 0.0001; Pediatric Quality of Life Inventory; boys 3.85, 95% CI 2.89, 4.80; girls -0.41, 95% CI -1.28, 0.46, p < 0.0001). As girls tend to have poorer MH and wellbeing in the teenage years it is possible this finding signals an increase in inequality, but this was not explicitly discussed by the authors [85]. The other study reported a bigger reduction in girls’ conduct (SDQ conduct: B -0.07, p < 0.001) and peer problems (SDQ peer: B -0.05, p < 0.001) and a bigger increase in their prosocial behaviours (SDQ prosocial: B 0.19, p < 0.001), with no sex differences in emotional problems, following a whole school positive behaviour intervention in primary schools. Boys tend to be at increased risk of behavioural problems within this age group, therefore this may indicate the intervention widened inequalities by sex, but again this was not discussed [47]. On the other hand, two studies reported findings that may have indicated a reduction in MH inequalities, or at least prevention of them widening. One of them found boys had higher physical self-worth at baseline (Children’s Physical Self-Perception Profile: p < 0.001), but that following a physical activity intervention, boys and girls in the intervention group improved equally in physical self-worth, whereas this gap by sex widened in the control group (p < 0.05) [28]. The other study in a post hoc analysis report their mentoring programme led to a bigger improvement in positive MH for girls (Mental Health Continuum – Short Form: b = 11.23, p = 0.037). Although they do not report baseline differences by sex, girls generally have poorer wellbeing, pre-intervention [64]. Finally, one study reported a greater reduction in depression among boys than girls, but unusually, boys began with higher baseline depression (three depression items adapted from SDQ; pretest: boys = 1.45, girls = 1.29), therefore in this study MH inequality by sex remained but switched from boys having higher depression to girls having higher depression (posttest: boys = 1.30, girls = 1.23) [30].

The importance of supportive relationships for MH in educational settings has been reported previously. A previous review that found that successful peer support schemes reported positive outcomes such as increased happiness or wellbeing, improved self-esteem, and confidence. Successful schemes were well run, had a clear focus, good coordinators and received support from throughout the school including from senior school management [90]. This highlights the importance of ensuring discreet interventions are fully embedded within school life to have the most success. Two of our three included studies found mentoring by adults improved MH [66, 67]; other research on school-based adult mentoring found positive effects on prosocial outcomes for at risk youth, but this was dependent on the quality of relationship developed between mentor and mentee [91].

The nine studies that looked at classroom management techniques found predominantly positive results [47‐55]. Techniques broadly focusing on positive behaviour supports, incentives for better behaviour and clear consequences for undesirable behaviour were effective in reducing disruptive behaviours and increasing prosocial behaviours. A review consisting of nine RCTs investigating the effectiveness of one particular classroom management programme—the Incredible Years intervention—reported reduced use of negative classroom management strategies among teachers and reduced conduct problems among high-risk children but no effect on improving prosocial behaviours [92]. These different findings could be due to the extent to which the various interventions focused specifically on prosocial behaviours. Of the nine studies in our review, only one involved students of secondary / high school age [53], despite evidence that good quality relationships with teachers are important for MH among teenagers too [93]. The positive impact reported by Närhi et al. on positive impact on disruptive behaviour, as well as on concentration for learning and time teachers reported spending on behaviour management, highlights the potential value of introducing positive behaviour management programmes into secondary as well as primary settings [53].

Studies that focused on values within secondary school settings (e.g., evaluating school ethos [41], involving student voice to improve school climate [43], changing values through school policies [44]) were largely effective in terms of the number of studies showing improvement in MH outcomes, although the type of study designs and their quality were quite varied. Three qualitative studies in different settings (two in PRUs [81, 83], one in mainstream secondary schools [15]) found that good relationships between staff and students and amongst peers were conducive to positive MH outcomes. This is supported by other reviews in this area that have emphasised the importance of good relationships in school climates and school connectedness, as well as students’ sense of school safety and the academic environment in the promotion of good MH [94, 95].

Fewer studies in our review considered the association between organisational aspects of school life and student MH. Interventions which focused on increasing physical activity in secondary schools were broadly effective at improving MH [28‐31], as reported by others [96]. A review of reviews in school and non-school settings found positive associations between physical activity and improvements in depression, anxiety and self-esteem in children and adolescents. However, there was only a partial case for causality for reductions in depression and no case based on current evidence for improvements in anxiety and self-esteem. Severity of MH symptoms and physical activity intensity, frequency and duration appeared to be important variables in the success of interventions [97]. Further research is needed to accurately tailor physical activity interventions to optimise MH gains in young people. Future studies should focus on assessing physical activity interventions in primary schools to establish what works with regard to improving the MH of children early in their lives. There were very few studies that examined the impact of other aspects of school organisation, for example there were no studies examining the impact of policies relating to behaviour, or the way the curriculum and break times were organised.

Four studies focused on altering the school physical environment [37‐40]. There was some evidence that providing children with access to outdoor, green areas had a beneficial effect on their MH [37, 38] which is in line with other work in this area showing the positive effect on children’s and adolescent’s MH of green space exposure [98]. Exposure to nature in school settings whether it be passively experiencing enhanced green space in the school environment [99] or actively participating in lessons in nature [100] appear to improve child wellbeing. Broadly, evidence suggests that nature exposure is part of a ‘balanced diet’ of childhood experiences that supports healthy child development and wellbeing [101]. More research into how we can incorporate the knowledge of how nature can benefit MH into the school environment is needed. Evidence regarding other aspects of the physical environment of schools was limited to two studies that examined use of stability balls [39] and creation of ‘healthy spaces’ [40]. There were no studies exploring the impact of the condition of buildings, or schools’ layout or facilities.

This is the first systematic review of the evidence regarding the impact of all structural and cultural aspects of educational environments on the MH and wellbeing outcomes of CYP. A strength of our review is the rigour and transparency of the review process evidenced by the publication of the review protocol prior to the selection and screening of studies. The population, intervention, outcome, and comparator of interest were clearly stated as well as our exclusion and inclusion criteria. Our review included quantitative and qualitative studies which allowed us to summarise the evidence from a broader range of studies and triangulate our findings. By only including studies that examined objective changes or features of the environment, we avoided the potential for reporting bias inherent in self-report measures. Further, our review offered an international perspective from 17 countries, however these were concentrated in higher income countries, and our findings may not generalise to low and middle income settings.

Limitations included the limited number of quantitative studies that were high quality; 70% scored a moderate or weak quality rating. Common methodological shortcomings were failure to blind participants to intervention condition and biases in selecting participants. The quality of qualitative studies was also variable with a lack of reporting on recruitment strategies and data analysis methods quite common. Studies with long-term follow up were also in the minority in this review. Less than half of the included studies conducted subgroup analyses by socioeconomic factors to enable evaluation of the effect of interventions or environmental factors on MH inequalities, and the number of studies that evaluated the cost effectiveness of interventions was low (3 studies) [54, 80, 85]. As this review included studies predominantly published in peer-reviewed journal, publication bias may skew findings in favour of positive/effective outcomes. The review included papers in the English language exclusively, excluding relevant studies in other languages. Finally, only 10% of abstracts and 15% of full texts were double-screened, and although we achieved high inter-rater agreement (ƙ = 0.91 and ƙ = 0.93 respectively), it is possible that some papers that fulfilled inclusion criteria might have been missed.

Some of the factors within educational environments likely to be important for student MH outcomes did not feature in our review, or only featured in one or two studies. This is likely because many studies exploring aspects of school life do not explicitly look at the impact on student MH. Notably, evidence regarding the impact of school leadership and management strategies was lacking, and there were only three included studies assessing the impact of school policies on student MH [44‐46]. The impact of these aspects of governance on MH should be explored in future studies; the downstream effects of leadership and policy changes on student MH have the potential to be substantial given their role in establishing and maintaining rules, processes, and a particular culture within schools.

Only two studies in our review looked at the impact of training teachers in MH support [71, 72]. Concern over a lack of training and support for teachers as part of a school’s overall approach to MH support was highlighted in a survey of over 600 UK schools [102]. A more recent survey also showed low levels of teacher training in MH, with 12% of teachers surveyed having received MH first aid training and 11% received training on common MH conditions [103]. In England, there has been recent commitment to providing training in MH support in secondary schools, creating MH champions, and creating better link up with Child and Adolescent Mental Health Services. Mental Health Teams will also be funded who will support schools to audit aspects of how schools prevent poor MH and promote wellbeing [104, 105]. Teachers involved in these initiatives may be able to act as strategic leads for implementing MH interventions and focus on making organisational and cultural aspects of school life more supportive of MH. These schemes also have the potential to allow cross-learning between these two groups of professionals to raise the standard of MH support in schools. It remains to be seen if these schemes will have a positive effect on organisational and cultural aspects of school life, and ultimately on student MH outcomes. In addition, lack of support for teachers’ own MH remains a concern, with a recent survey (October 2020) of education professionals across the UK showing low rates of wellbeing compared to the general population, and high workload the main reason given by those who were considering leaving the profession [106]. These issues may be currently exacerbated due to extra responsibilities in making schools COVID-19 safe and providing additional support for students whose MH or learning has suffered during the pandemic.

Studies exploring the impact of student voice on MH were lacking, with only one included in our review [43]. The co-development of interventions with student involvement should become standard practice in order to ensure a student-centred and inclusive approach [84, 107]. The impact of the physical school environment on student MH is also an under researched area in school-based research, despite the likely implications for student wellbeing and safety. Human Scale Education is a movement interested in the re-design of schools’ physical space to be more relationship focused (https://​www.​humanscaleeducat​ion.​com/​our-principles), but the evidence base for this is currently lacking.

Studies set in further education (FE) colleges (i.e., educational settings that provide technical and professional education and training for young people typically aged between 15–18), were absent from the review. Given that young people with learning difficulties, those from poorer backgrounds and those who struggled to engage with school are overrepresented in FE colleges, and these groups are also at risk of poorer MH, increasing the evidence base regarding MH supporting environments in this setting would be an opportunity to reduce MH inequalities. Finally, evidence of the impact of involving parents in school life seems to be limited to training programmes on behaviour management and parenting skills, which generally took place away from the school environment (i.e., taking place in the parent’s home). Future studies could better integrate parents into interventions taking place in school to ensure a joined-up approach that could enhance the impact on their children’s MH.