Review articleStigma related to targeted school-based mental health interventions: A systematic review of qualitative evidence
Introduction
One in ten children and young people (CYP) experience mental health problems (Polanczyk et al., 2015), and mental disorders constitute the greatest cause of non-fatal burden of disease for CYP aged 10–24 years (Gore et al., 2011). Early mental health problems often persist or recur in later life: around half of adults with mental disorders identify the first onset before the age of 15 years (Kim-Cohen et al., 2003). Despite the prevalence and negative impacts of mental health problems among CYP, most go untreated (Merikangas et al., 2011). Low levels of specialist service use are reported even by CYP with severely impairing mental disorders (Dey and Jorm, 2017, Merikangas et al., 2011). This unmet need for mental health care is recognised as a global public health concern (Patel et al., 2007, Polanczyk et al., 2015).
School-based mental health services have been recommended as a way to increase access to evidence-based interventions (Thorley, 2016). Despite a substantial number of school-based mental health intervention trials, relatively little consensus has emerged about optimal programme design elements, with particular debate centred around questions of targeted versus universal provision (Rapee et al., 2006). Previous reviews have shown that targeted interventions (i.e., those focused on students who are at risk for, or currently presenting with mental health problems) are associated with stronger and more durable effects on mental health outcomes (Sanchez et al., 2018, Werner-Seidler et al., 2017). On the other hand, universal interventions have been advocated to enable wider coverage for students with diverse needs while ensuring closer integration with school curricula (Fazel et al., 2014).
CYP's service preferences and expectations have been relatively overlooked in discussions about school mental health programming (Dickinson et al., 2003, Segrott et al., 2013). It is notable that many targeted school-based mental health interventions have been transported from clinical settings (Rapee, 2000), with limited involvement of CYP at formative stages of development. This limitation is important because the school environment presents its own distinctive challenges for ensuring acceptable programme delivery.
In particular, issues of mental health-related stigma are crucial to ensuring that interventions are socially acceptable to the intended recipients (Corrigan, 2004, Schomerus and Angermeyer, 2008, Thornicroft, 2008). It has been argued that schools provide a familiar, non-stigmatising service setting, and that school-based services can normalise help-seeking and subsequently increase students’ utilisation of support (Baruch, 2001, Thorley, 2016). Other commentators have countered this view, by suggesting that school-based mental health services risk stigmatising participants by singling them out for attention in various ways, including the use of standardised tools for “screening” students against specified mental health criteria (Lupien et al., 2013, Rapee et al., 2006, Weems et al., 2014, Werner-Seidler et al., 2017).
The empirical evidence on stigma and school-based services is likewise mixed. Some quantitative studies have failed to identify evidence of stigma associated with participation in targeted school mental health provision (Martinsen et al., 2016). However, stigma has also been identified as a common barrier inhibiting students’ help-seeking from school counselling services (Chan and Quinn, 2012). Students have also reported stigma-related concerns due to the visibility of accessing school-based mental health support in proximity to peers and teachers (Baruch, 2001, Buchholz et al., 2015, Gronholm et al., 2017, Segrott et al., 2013).
More systematic and contextualised evidence is needed to reconcile these apparently disparate findings and inform future directions in intervention development and implementation. In particular, qualitative methods have been advocated in mental health stigma research more generally (Link et al., 2004), and may offer important insights into help-seeking processes and the influence of anticipated and experienced mental health stigma in schools (Evans et al., 2015). However, no previous systematic review has directly addressed this topic, and qualitative approaches have been relatively underutilised in school mental health programme evaluations to date.
The current study therefore completed a systematic review of qualitative sources in order to address the following research questions: (1) to what extent do students experience stigma due to screening positively for/participating in targeted school-based mental health interventions (TSMHIs)?; and (2) what are the consequences of potential stigma for students’ engagement with TSMHIs and associated screening?
Section snippets
Methods
This review complies with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement (Moher et al., 2009); see Supplement 1 for the PRISMA checklist. The review protocol was developed a priori, and registered at PROSPERO centre for reviews and dissemination (ID CRD42016039541).
Results
The search produced 3463 non-duplicated results, of which 3396 were excluded following initial screening. Full-text articles were accessed for the remaining 67 results; 59 articles were excluded following assessment against full eligibility criteria. Eight articles met review inclusion criteria. Fig. 1 depicts this article selection process using the PRISMA flow diagram.
The eight articles included in this review were based on seven studies, representing an aggregate participant sample size of n
Discussion
This review aimed to derive systematic evidence about the potentially stigmatising effects of TSMHIs. We searched for and synthesised data on (1) students’ experience of stigma due to screening positively for/participating in TSMHIs, and (2) the consequences of stigma for students’ engagement with TSMHIs. Drawing from seven eligible studies, exclusively based on secondary school samples, we found evidence of negative labelling by peers and others and self-stigma, alongside fears of
Strengths and limitations
To our knowledge, this is the first review to examine potential stigma associated with students’ engagement with TSMHIs, providing an important synthesis of the available qualitative evidence in this area. Critically, our review focused on young people's actual experiences of TSMHIs. It has been remarked that much of the existing literature on mental health service stigma for young people rests on hypothetical actions and attitudes in relation to different mental health care scenarios (
Conclusions
Given the recent push towards school-based services to expand access to mental health care for children and young people, it is essential to understand how stigma-related concerns might compromise such efforts and how these challenges can be overcome. This review of qualitative evidence advances our understanding of stigma in relation to targeted mental health interventions in schools, and thus provides a valuable contribution to the literature which has to date been characterised by mixed and
Authors' Contributions
Authors PCG and DM designed the study. PCG wrote the review protocol, with comments and suggestions from DM and EN. PCG conducted the literature searches. PCG led the results screening and data extraction process, with a proportion of the screening and extraction independently checked by EN. PCG led the results synthesis process, with comments and suggestions from DM and EN. PCG wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
Acknowledgements
None.
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