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The Use of Guided Self Help to Promote Emotional Wellbeing in High School Students
Sarah Elizabeth Kendal
[Thesis].University of Manchester;2009.
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Abstract
Background: The prevalence of mental disorder in children and young people in the UK is estimated at 10-20% (Meltzer et al. 2003). The World Health Organisation advocates urgent preventive measures to reduce the impact of a predicted steep rise in global rates of depression (World Health Organization 2008 ). The mental health of young people is therefore a public health issue, nationally and globally. The UK children's policy agenda proposes that promoting emotional wellbeing is a shared responsibility between children's agencies at the Tier 1 level of Child and Adolescent Mental Health Services (DCSF 2008), but further research is required to develop low intensity, evidence based interventions to promote emotional and mental health. Schools have a remit to address emotional problems in students and evidence exists to support school based interventions to promote emotional wellbeing. However young people encounter barriers to help-seeking in primary care, which need to be understood in order to deliver appropriate support. There is an emerging evidence base for using guided self-help (GSH) to deliver cognitive behaviour therapy-based interventions to adults in primary mental health care (Gellatly et al. 2007). It is not known whether using GSH in high schools to deliver emotional wellbeing interventions to young people would be feasible or acceptable. Aims: To develop an emotional wellbeing intervention for high schools using GSH, and evaluate it for feasibility and acceptability. Methods: The Medical Research Council (MRC) Framework for complex interventions (MRC 2000) provided the conceptual structure of the research. The methodological approach was also strongly influenced by standards for qualitative research proposed by Popay et al (1998), particularly the need to be responsive to the research context. There were three stages: Consultation, Development and Implementation. In the Consultation stage 54 young people aged 11-15 were consulted in 6 focus groups in 3 inner city high schools in the UK. The outcomes supported the development of a GSH intervention, named the 'Change Project', which was the focus of the Development Stage. Pastoral and Special Educational Needs staff in schools received brief training to deliver the intervention, followed by weekly supervision for the duration of the Project. In the Implementation Stage the Change Project was piloted in the same 3 high schools. The Project was evaluated for acceptability and feasibility using qualitative interview methods and a survey of students. Two instruments were incorporated: the PHQ-2 (Kroenke et al. 2003) was included to identify students who would benefit from a referral to the school nurse and the Rosenberg Self Esteem Scale (Rosenberg 1965) was used to explore its suitability as an outcome measure with the target population. Results: Eight Project workers delivered the Change Project. Twenty one students used it. They were aged 11-17 years and included male, female, white and non-white students. Self reported personal outcomes for students were generally positive. Nine sets of baseline and post-intervention RSES scores were collected. There was a general trend for improvement in scores. Presenting difficulties included potentially clinical disorders which were successfully addressed with support from school nurses. Interviews were conducted with 23 students, and 27 school staff and questionnaire data were collected from 140 students. Project worker reports of the Change Project's acceptability and feasibility were mixed, though also generally positive. The acceptability and feasibility of the RSES is discussed. The ethos of pastoral care, support of senior figures and other contextual factors affected implementation quality in each school. Help-seeking in the young people was driven by peer norms of hiding signs of vulnerability. Conclusions: The Change Project intervention was generally felt to be useful and relevant and overall it was welcomed by staff and students. The intervention has potential for further development. Its acceptability and feasibility were co-dependent and strongly influenced the implementation processes, indicating the value of investing time in understanding social and cultural factors in the research context. Understanding organisational and individual barriers and facilitators of help-seeking in young people may encourage use of emotional support in school.
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Total pages:
320
Table of contents:
TABLE OF CONTENTS
List of Contents 2
Abstract 3
Declaration 4
Copyright 4
Acknowledgements 5
Dedication 5
The Author 6
List of Abbreviations 7
STAGE I: ORIENTATION AND CONSULTATION 21
1 INTRODUCTION: THE CONTEXT OF THE STUDY 22
1.1 BACKGROUND TO THE STUDY 22
1.2 THE CAMHS 4 TIER FRAMEWORK 24
1.3 CONCLUSION 25
1.4 THE STRUCTURE OF THE THESIS 26
1.5 EXPLANATION OF TERMS 27
1.6 AIMS OF THE RESEARCH 28
1.6.1 Principal aim: 28
1.6.2 Secondary aims: 28
2 REVIEW OF THE LITERATURE 29
2.1 THE SEARCH STRATEGY 29
2.2 APPROACH TO REVIEW OF THE LITERATURE 29
2.2.1 Scope of search for relevant studies/identification of relevant studies 29
2.2.2 Parameters of literature search 30
2.2.3 Search Process 30
2.3 FINDINGS OF THE LITERATURE REVIEW 31
2.3.1 The scale of the problem 31
2.3.2 The impact of mental health difficulties in young people 32
2.3.2.1 Associated health concerns 32
2.3.2.2 Long term effects 33
2.3.2.3 Problems with the identification of mental health difficulties 34
2.3.3 Legislation and policy 34
2.3.4 Barriers to help-seeking in young people 36
2.3.4.1 Contextual factors affecting help-seeking 36
2.3.4.2 Internal factors affecting help-seeking 37
2.3.4.3 Problem construction 37
2.3.4.4 Ease of access 38
2.3.4.5 Peer influences 39
2.3.5 Shame and embarrassment 40
2.3.6 The range of health concerns among young people 40
2.3.7 The significance of autonomy in help-seeking 41
2.3.8 Developmental theories of adolescence 42
2.3.9 The role of emotional competence 44
2.3.10 Conclusion 45
2.3.11 Summary 46
2.4 THE POTENTIAL OF GUIDED SELF-HELP (GSH) TO IMPROVE THE DELIVERY OF PSYCHOLOGICAL
INTERVENTIONS TO YOUNG PEOPLE 47
2.4.1 The evidence for CBT based interventions 47
2.4.2 Application of CBT with young people 48
2.4.3 Self-help approaches using CBT interventions 48
2.4.4 The use of self-help approaches to improve access to effective interventions 49
2.4.5 The evidence base for self-help 50
2.4.6 Delivery of interventions by practitioners with brief, focused training 52
2.4.7 The application of GSH 52
2.4.8 Conclusion 53
2.4.9 Summary 54
2.5 PROMOTING EMOTIONAL WELLBEING IN SCHOOLS 55
2.5.1 Example of a school-based emotional wellbeing intervention 55
2.5.2 UK policy for the promotion of emotional wellbeing in schools 57
2.5.3 Role of learning mentors in schools 57
2.6 FACTORS AFFECTING THE IMPLEMENTATION AND EVALUATION OF SCHOOL PROGRAMMES 58
2.6.1 Influence of school leadership on programme implementation in schools 60
2.6.2 Impact of school leadership on pastoral care delivered by teachers 61
2.6.3 Evaluation of pastoral care in school 62
2.6.4 Discussion: the potential of GSH to promote emotional wellbeing in high school 62
2.7 CONCLUSION TO THE REVIEW OF THE LITERATURE 63
2.8 RELEVANCE OF THIS RESEARCH 64
3 METHODOLOGICAL PRINCIPLES UNDERPINNING THE STUDY 65
3.1 INTRODUCTION 65
3.2 THE MEDICAL RESEARCH COUNCIL (MRC) FRAMEWORK 65
3.1 APPLICATION OF THE MRC FRAMEWORK TO THE STUDY 66
3.2 DESCRIPTION OF THE MRC FRAMEWORK 67
3.2.1 MRC Framework: Theory Phase (Phase 0) 68
3.2.2 MRC Framework: Modelling Phase (Phase I) 68
3.2.3 Exploratory Phase (Phase II) 70
3.2.4 Definitive RCT and Long Term Implementation (Phases III and IV) 71
3.3 ETHICAL CONSIDERATIONS 71
3.4 CONCLUSION 71
3.5 DESCRIPTION OF SCHOOLS PARTICIPATING IN THE STUDY 72
3.5.1 Demographic profile 72
3.5.2 Faithschool 72
3.5.3 Girlschool 73
3.5.4 Sportschool 73
3.5.5 Demographic detail 74
3.6 THE STRUCTURE OF THE RESEARCH DESIGN 76
3.7 THE CONTEXT OF THE RESEARCH 77
3.8 STAKEHOLDER MEETINGS 77
3.9 ESTABLISHMENT OF AN ADVISORY PANEL 77
3.10 IDENTIFICATION OF PROJECT WORKERS TO DELIVER THE PROJECT 78
3.11 CONCLUSION 78
4 METHODOLOGICAL APPROACH TO THE CONSULTATION WITH YOUNG PEOPLE 79
4.1 AIMS OF THE CONSULTATION 79
4.2 RATIONALE FOR CHOICE OF FOCUS GROUP METHOD 79
4.2.1 Conclusion 81
4.3 METHODS USED IN THE FOCUS GROUP CONSULTATION 82
4.3.1 Approach to access and sampling 82
4.3.2 Ethical approval 83
4.3.2.1 Obtaining a focus group sample 83
4.3.2.2 Eligibility 84
4.3.2.3 Assent and consent 84
4.3.3 Approach to data collection 84
4.3.3.1 Strategies to encourage engagement of participants 85
4.3.4 Summary 86
4.4 APPROACH TO DATA ANALYSIS 87
4.4.1 Familiarisation with the data and data reduction 87
4.4.2 Coding with data display 88
4.4.3 Conclusion drawing and verification 89
4.4.4 Identification of conceptual headings 89
4.4.5 Conclusion 90
5 FINDINGS FROM THE FOCUS GROUP CONSULTATION 91
5.1 DESCRIPTION OF THE SAMPLE 91
5.2 DATA COLLECTION: ADAPTATIONS MADE 92
5.3 COMPARISON OF RESPONSES 92
5.3.1 Age group 92
5.3.2 School 93
5.4 YOUNG PEOPLE’S VIEWS ON THE PROPOSED GSH INTERVENTION TO PROMOTE EMOTIONAL WELLBEING 93
5.4.1 Introduction 93
5.4.2 Range of difficulties likely to be encountered 93
5.4.3 Qualities valued in a helper 94
5.4.4 Outcomes relevant to young people 95
5.4.5 Importance of choice 95
5.4.6 Summary 100
5.5 DISCUSSION: THE CHALLENGES OF CONDUCTING HEALTH RESEARCH IN HIGH SCHOOLS 101
5.5.1 Introduction 101
5.5.2 The relevance of context 101
5.5.3 Development of ideas through group interaction 103
5.5.4 Implications for the next step of the research 106
5.6 CONCLUSION OF CONSULTATION STAGE 107
STAGE II: DEVELOPMENT 109
6 THE DEVELOPMENT OF AN IMPLEMENTATION STUDY 110
6.1 INTRODUCTION 110
6.2 AIMS AND OBJECTIVES 110
6.3 PRINCIPLES INFORMING THE DEVELOPMENT STAGE 111
6.3.1 Relevance of the MRC Framework to the study aims 111
6.3.2 Combining findings from the literature review and consultation with stakeholders. 111
6.3.3 Reprise of findings from literature review 111
6.3.4 Summary 114
6.4 METHODOLOGICAL PRINCIPLES INFORMING THE DEVELOPMENT OF THE CHANGE PROJECT 115
6.4.1 Respecting cultural differences 115
6.4.2 Principles underlying recruitment and training of pastoral and SEN staff to
be Project workers 115
6.4.3 Principles underlying risk protocol 116
6.4.4 Preparation of documentation 116
6.4.5 Keeping control of the health agenda 116
6.4.6 Ethical principles 120
6.4.7 Summary 120
6.5 METHODS USED IN THE DEVELOPMENT OF THE CHANGE PROJECT 121
6.5.1 Development of Project documents 121
6.5.2 Development of a set of self-help materials 121
6.5.3 Development of a risk assessment protocol 122
6.5.4 Negotiating access to schools 123
6.5.5 Negotiating access to young people using the Change Project 124
6.5.6 Negotiating access to Project workers from Pastoral and SEN teams 125
6.5.7 Development of Project worker training manual and training programme 125
6.5.8 Summary 126
6.6 OUTCOMES FROM INTERVENTION DEVELOPMENT: COMPONENTS OF THE CHANGE PROJECT INTERVENTION 127
6.6.1 Introduction 127
6.6.2 Self-help materials 127
6.6.3 Delivery of Project worker training 127
6.6.4 Feedback from Project workers concerning Change Project training 128
6.6.5 Format of appointments 129
6.6.6 Access 129
6.6.7 Confidentiality 130
6.6.8 Safety protocol 130
6.6.9 Summary: Change Project components 131
6.7 METHODOLOGICAL PRINCIPLES UNDERPINNING THE DEVELOPMENT OF AN EVALUATION STRATEGY 132
6.7.1 Overview 132
6.7.2 Rationale for use of qualitative interviews 132
6.7.3 Rationale for use of an instrument to measure emotional wellbeing outcomes 132
6.7.4 Criteria for selection of an outcome measure 133
6.7.5 Principles informing development of a questionnaire to explore acceptability 134
6.7.6 Ethical principles informing the research 135
6.8 METHODS USED IN EVALUATION DEVELOPMENT 135
6.8.1 Qualitative interviews 135
6.8.2 The concept of self esteem 135
6.8.3 Rationale for choice of the RSES to measure outcomes 136
6.8.4 Construction of Change Project questionnaire 138
6.8.5 Research study documentation 139
6.8.6 Submission to University Ethics Committee 140
6.9 OUTCOMES FROM EVALUATION DEVELOPMENT 140
6.9.1 Selection of an instrument to measure outcomes 140
6.9.2 Change Project questionnaire 140
6.10 DISCUSSION 140
6.10.1 Implications of outcomes of Project worker training 140
6.10.2 Ethical concerns 141
6.10.3 The evaluation strategy 142
6.11 CONCLUSION 142
6.12 SUMMARY 143
STAGE III: IMPLEMENTATION 144
7 METHODS USED IN THE IMPLEMENTATION OF THE CHANGE PROJECT 145
7.1 METHODOLOGICAL PRINCIPLES 145
7.2 AIMS OF THE IMPLEMENTATION STAGE 145
7.3 ACCESS AND SAMPLING 145
7.4 IMPLEMENTATION STRATEGIES 145
7.4.1 Timing 146
7.4.2 Advertising the Change Project 146
7.5 DATA COLLECTION STRATEGIES 147
7.5.1 Background information 147
7.5.2 Approach to interview sampling 147
7.5.3 Summary 148
8 DESCRIPTIVE ANALYSIS OF THE CHANGE PROJECT 149
8.1 INTRODUCTION 149
8.2 PROJECT USER CASE DATA 149
8.2.1 Description of sample 149
8.2.2 Description of case data 150
8.3 MEASUREMENT OF SELF ESTEEM IN CHANGE PROJECT PARTICIPANTS 151
8.3.1 Description of the RSES sample 151
8.3.2 Discussion 153
8.4 THE CHANGE PROJECT QUESTIONNAIRE 156
8.4.1 Methods 156
8.4.2 Results 156
8.4.3 Analysis of postcodes 158
8.4.4 Analysis of questionnaire responses 158
8.4.4.1 Implementation of the project 159
• Impact of advertising routes 159
• Access to the project 159
• Understanding the purpose of the Change Project 159
8.4.4.2 Acceptability 160
8.4.4.3 Free text answers 160
• Reasons not to use project 161
• Reasons to use project 161
• Suggested improvements and comments 161
8.5 DISCUSSION 162
9 IMPLEMENTATION STAGE FINDINGS 164
9.1 QUALITATIVE INTERVIEW DATA 164
9.2 FINDINGS FROM INTERVIEWS WITH YOUNG PEOPLE 165
9.2.1 Missed appointments 165
9.2.2 Description of interview sample 165
9.2.3 Project user sample 167
9.2.4 Non Project user sample 167
9.2.5 Description of interviews 168
9.2.6 Assent 169
9.3 APPROACH TO ANALYSIS OF INTERVIEW DATA. 169
9.3.1 Introduction 169
9.3.2 Analysis method 169
9.4 SUMMARY 171
10 PATHWAYS TO HELP-SEEKING: FINDINGS FROM INTERVIEWS WITH YOUNG PEOPLE 172
10.1 INTRODUCTION 172
10.2 PROBLEMS AND DIFFICULTIES IDENTIFIED BY PARTICIPANTS 173
10.2.1 Problems and difficulties at home 174
10.2.1.1 Family life 174
10.2.1.2 Conflicting messages from home and school 174
10.2.2 Difficulties at school 175
10.2.2.1 Problems in school caused by anger and aggression 175
10.2.3 Relationships with peers 176
10.2.3.1 Effect of anger on friendships 176
10.2.3.2 Experiences of being mocked or bullied 177
10.2.3.3 Managing tensions 179
10.2.3.4 Embarrassment 179
10.2.3.5 Worry 180
10.2.4 Threats from the outside world: Crime and risk taking 181
10.3 SUMMARY: THE NETWORK OF DIFFICULTIES 182
10.4 COPING WITH DIFFICULTIES: CONDITIONS FOR HELP-SEEKING 184
10.4.1 Personal conditions: competence confidence, and courage 184
10.4.1.1 Competence to make decisions 184
10.4.1.2 Courage to ask for help 187
10.4.1.3 Confidence 187
• Confidence in the helper 188
• Self confidence 188
10.4.2 Reasons not to ask for help 189
10.4.2.1 Other people might find out 189
10.4.2.2 Privacy and embarrassment 189
10.4.2.3 Shame 191
10.4.2.4 Talking about problems is boring 191
10.4.2.5 You don’t take the risk 192
10.4.3 Strategies to manage emotions without help- seeking 193
10.4.3.1 Bottling it up 193
10.4.3.2 Convincing yourself you don’t care 194
10.4.3.3 Wearing a mask 194
10.4.3.4 Being angry 196
10.4.3.5 The impact of anger 196
10.4.4 Summary 197
10.5 FEEDBACK ABOUT THE CHANGE PROJECT FROM PROJECT USERS 198
10.5.1 Introduction 198
10.5.2 Accessibility of the Project 198
10.5.3 The process of self-referral 200
10.5.4 Knowing about the Project 200
10.5.5 The administration and paperwork 201
10.5.6 Views on the Self Esteem Questionnaire 202
10.5.7 Summary 203
10.6 VIEWS ON SEN AND PASTORAL STAFF AS CHANGE PROJECT WORKERS 204
10.6.1 Interventions 204
10.6.1.1 Cognitive strategies 205
10.6.1.2 Behavioural strategies 206
10.6.1.3 Educational strategies 207
10.6.2 Impact of intervention 207
10.6.2.1 Impact on home problems 208
10.6.2.2 Impact on school problems 209
10.6.3 Suggestions for improvements to the Change Project 209
10.6.3.1 Venue 209
10.6.3.2 Modes of communication 210
10.6.3.3 Brief appointments 211
10.6.3.4 Advertising 212
10.7 CONCLUSION 213
10.7.1 Summary 215
11 METHOD AND RESULTS OF INTERVIEWS WITH SCHOOL STAFF 216
11.1 INTRODUCTION 216
11.2 APPROACH TO SAMPLING 216
11.2.1 Approach to interviews 218
11.2.2 Addressing concerns about anonymity 218
12 MESSAGES FROM THE INTERVIEWS WITH SCHOOL STAFF 220
12.1.1 Range of difficulties encountered by young people 220
12.1.2 Spectrum of severity 220
12.1.3 Boundaries and cultural clashes 222
12.1.4 Perspectives on the impact of emotional difficulties 223
12.1.5 External social influences 224
12.1.6 Communication difficulties 225
12.1.7 Tension and ambivalence in the context of pastoral care 227
12.1.7.1 The wrong kind of pastoral care 227
12.1.7.2 Prevention or promotion of dependence 228
12.1.7.3 Questions about the purpose and extent of pastoral care in school 229
• Measuring outcomes of pastoral care 230
• Appropriateness of school as a location for healthcare. 231
• Balance of teaching and pastoral activity in school 232
• How to deliver pastoral care in school 233
12.1.8 Barriers and facilitators to help-seeking: Conditions affecting the implementation
of the Change Project 236
12.1.8.1 Age and gender 236
12.1.8.2 Peer approval 237
12.1.8.3 Familiar territory 237
12.1.8.4 Importance of a Project champion 238
12.1.8.5 Inclusion of teachers in the referral process 239
12.1.8.6 The importance of timing 240
12.1.8.7 Setting the stage 241
12.1.8.8 Quality of help offered 241
12.1.8.9 Capacity of school to host emotional health work 242
12.1.8.10 Potential extra benefits 242
12.1.8.11 Structural factors impacting on the Change Project 243
12.1.9 The Adult Perspective: Summary of Chapter 12 245
12.2 CONCLUSION 245
13 METHODOLOGICAL DISCUSSION 248
13.1 APPLICATION OF THE MRC FRAMEWORK 248
13.1.1 Consultation Stage 248
13.1.2 Development Stage 249
13.1.3 Implementation stage- interviews, survey and self esteem questionnaire 250
13.1.4 Contribution of the MRC framework to the research 250
13.2 STRENGTHS AND LIMITATIONS OF EVALUATION STRATEGIES 251
13.3 BIAS 252
13.4 OBSERVATION 253
13.5 STRATEGIES USED TO ENHANCE RIGOUR 253
13.5.1 Quality standards for qualitative research 253
13.5.2 Reflexivity 254
13.5.3 Observation 254
13.5.4 Credibility 254
13.5.5 Use of technology to support analysis and audit trail 255
13.5.6 Research question-driven methodology 255
13.6 ANALYSIS 255
13.7 CONTEXTUAL INFLUENCES ON THE ACCEPTABILITY AND FEASIBILITY OF THE INTERVENTION 256
13.7.1 School culture 256
13.7.2 Capacity 257
13.7.3 Cultural perspectives on the value of confidentiality 257
13.7.4 Peer group values: The importance of hiding vulnerability 258
13.7.5 Conclusion: The relevance of the context to the feasibility and acceptability
of the Change Project 259
13.8 SUMMARY 260
14 DISCUSSION 261
14.1 INTRODUCTION 261
14.2 FACTORS INFLUENCING HELP-SEEKING 261
14.3 INTERNAL FACTORS AFFECTING HELP-SEEKING FROM THE CHANGE PROJECT 265
14.3.1 Beliefs about the impact of emotional exposure 265
14.3.2 Relationship between acceptability and accessibility 266
14.4 SUMMARY 267
14.5 HELP-SEEKING FROM THE CHANGE PROJECT: THE YOUNG PERSON’S JOURNEY 267
14.5.1 Self awareness 267
14.5.2 Coping through self reliance 268
14.5.2.1 Strategies for self reliance 269
14.5.2.2 Influence of context on self reliance 269
14.5.3 Uncertainties about help-seeking 270
14.5.4 The importance of confidentiality 271
14.5.5 Assessing trustworthiness 272
14.5.6 Potential facilitators of help-seeking 272
14.5.7 Impact of unpleasant consequences on attitudes to help-seeking 274
14.5.8 Long term effect of favourable outcomes from help-seeking 274
14.5.9 The young person’s journey: Summary 275
14.5.10 Conclusion: emotional exposure and competence, confidence and courage 278
14.6 CONTEXTUAL FACTORS AFFECTING THE CHANGE PROJECT 279
14.6.1 Introduction 279
14.6.2 Importance of key roles 279
14.6.2.1 Senior management 279
14.6.2.2 Project Workers 280
14.6.3 Conflict between rhetoric and culture in school 282
14.6.4 Image management 283
14.6.5 Special Features of Faithschool 284
14.6.6 Conclusion 285
14.6.7 Summary 286
14.7 LESSONS LEARNED ABOUT THE INTERVENTION 287
14.7.1 Components of the Change Project intervention 287
14.7.1.1 Defining confidentiality 287
14.7.1.2 Recruitment of Pastoral staff to act as Project workers 287
14.7.1.3 Brief appointments 289
14.7.1.4 Strategies to protect students’ welfare 290
14.7.1.5 The use of instruments 290
14.7.1.6 Supporting materials 291
14.7.1.7 Planning for sustainability 291
14.7.1.8 School context 291
• Visibility and confidentiality: conflict of ethics 291
• Threats to stability of the research project 292
• Tensions between pastoral worker and Project Worker roles 293
• Promotion of the Change Project 294
14.7.2 Summary 295
14.7.3 Ethical considerations in research with young people in school: the potential
of conflicting value systems 295
14.8 FEASIBILITY AND ACCEPTABILITY OF THE CHANGE PROJECT INTERVENTION 296
14.9 REFLECTIONS ON THE STUDY 300
14.9.1 Achievements of the study 300
14.9.2 What this study adds to research knowledge 300
14.9.3 Questions the study has raised 301
14.9.4 Potential developments of the Change Project 301
14.10 CONCLUSION 302
14.11 FINAL CONCLUSION: CONTRIBUTION OF THE STUDY 303
REFERENCES 305
Abstract:
Background: The prevalence of mental disorder in children and young people in the
UK is estimated at 10-20% (Meltzer et al. 2003). The World Health Organisation advocates
urgent preventive measures to reduce the impact of a predicted steep rise in global
rates of depression (World Health Organization 2008 ). The mental health of young
people is therefore a public health issue, nationally and globally. The UK children's
policy agenda proposes that promoting emotional wellbeing is a shared responsibility
between children's agencies at the Tier 1 level of Child and Adolescent Mental Health
Services (DCSF 2008), but further research is required to develop low intensity, evidence
based interventions to promote emotional and mental health. Schools have a remit to
address emotional problems in students and evidence exists to support school based
interventions to promote emotional wellbeing. However young people encounter barriers
to help-seeking in primary care, which need to be understood in order to deliver appropriate
support. There is an emerging evidence base for using guided self-help (GSH) to deliver
cognitive behaviour therapy-based interventions to adults in primary mental health
care (Gellatly et al. 2007). It is not known whether using GSH in high schools to
deliver emotional wellbeing interventions to young people would be feasible or acceptable.
Aims: To develop an emotional wellbeing intervention for high schools using GSH,
and evaluate it for feasibility and acceptability.
Methods: The Medical Research Council (MRC) Framework for complex interventions (MRC
2000) provided the conceptual structure of the research. The methodological approach
was also strongly influenced by standards for qualitative research proposed by Popay
et al (1998), particularly the need to be responsive to the research context. There
were three stages: Consultation, Development and Implementation. In the Consultation
stage 54 young people aged 11-15 were consulted in 6 focus groups in 3 inner city
high schools in the UK. The outcomes supported the development of a GSH intervention,
named the 'Change Project', which was the focus of the Development Stage. Pastoral
and Special Educational Needs staff in schools received brief training to deliver
the intervention, followed by weekly supervision for the duration of the Project.
In the Implementation Stage the Change Project was piloted in the same 3 high schools.
The Project was evaluated for acceptability and feasibility using qualitative interview
methods and a survey of students. Two instruments were incorporated: the PHQ-2 (Kroenke
et al. 2003) was included to identify students who would benefit from a referral to
the school nurse and the Rosenberg Self Esteem Scale (Rosenberg 1965) was used to
explore its suitability as an outcome measure with the target population.
Results: Eight Project workers delivered the Change Project. Twenty one students used
it. They were aged 11-17 years and included male, female, white and non-white students.
Self reported personal outcomes for students were generally positive. Nine sets of
baseline and post-intervention RSES scores were collected. There was a general trend
for improvement in scores. Presenting difficulties included potentially clinical disorders
which were successfully addressed with support from school nurses. Interviews were
conducted with 23 students, and 27 school staff and questionnaire data were collected
from 140 students. Project worker reports of the Change Project's acceptability and
feasibility were mixed, though also generally positive. The acceptability and feasibility
of the RSES is discussed. The ethos of pastoral care, support of senior figures and
other contextual factors affected implementation quality in each school. Help-seeking
in the young people was driven by peer norms of hiding signs of vulnerability.
Conclusions: The Change Project intervention was generally felt to be useful and
relevant and overall it was welcomed by staff and students. The intervention has
potential for further development. Its acceptability and feasibility were co-dependent
and strongly influenced the implementation processes, indicating the value of investing
time in understanding social and cultural factors in the research context. Understanding
organisational and individual barriers and facilitators of help-seeking in young
people may encourage use of emotional support in school.
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Manchester eScholar ID:
uk-ac-man-scw:68379
Created by:
Kendal, Sarah
Created:
23rd October, 2009, 11:28:12
Last modified by:
Kendal, Sarah
Last modified:
11th August, 2015, 12:25:46