School‐Based Mental Health Interventions

Recommendations for Selecting and Reporting Implementation Strategies

Dados Bibliográficos

ID21354119
AutoresGwendolyn M Lawson (0000-0003-4363-3169, Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania Philadelphia PA USA, autor correspondente), Gazi Azad (0000-0003-0395-4355, Heilbrunn Department of Population and Family Health, Mailman School of Public Health Columbia University Irving Medical Center New York NY USA)
Ano2024
Volume94
Fascículo6
Páginas581-585
Data de publicação2024-06-01
Peer ReviewedSim
Open AccessSim
TipoARTICLE
PeriódicoJournal of School Health (JOURNAL)
Identificadores do periódicoISSN: 0022-4391 • E-ISSN: 1746-1561
EditoraWiley (PUBLISHER • GB)
DOI10.1111/josh.13458
PMID38627895
OpenAlexW4394873493
IdiomaEN
Citações recebidas1
Referências citadas38

A key component of student health and well-being is mental health. The rates of diagnosable mental health concerns among students are high—the lifetime prevalence for at least 1 mental health disorder was nearly 50% in a large, nationally representative sample of adolescents from 2010,1 and prevalence has increased among school-age children and adolescents in recent years.2 Notably, only about half of youth with mental health concerns receive treatment,3, 4 and rates of treatment receipt are lower among marginalized or low-income youth.3, 5 When children and adolescents do receive mental health treatment, they frequently access these services through their preK-12 schools.6-8 Compared to clinic-based settings, schools offer many advantages for mental health service provision, including promoting access to care and reducing stigma9 particularly within under-resourced settings.10 Unfortunately, there are significant implementation challenges to the uptake and delivery, as well as the study, of mental health services within schools. The primary mission of schools is academic education, and many schools, particularly those serving marginalized or low-income students, frequently lack the resources to achieve their academic mission. As a result, there are often limited resources left to deliver mental health services, especially if they are not directly aligned with the schools' academic mission.9 Furthermore, school-based mental health practitioners face multilevel barriers when implementing interventions, including characteristics about the intervention itself (eg, usability, contextual fit), the individual (eg, stress and burnout), the team (eg, turnover), and the school (eg, funding for sustainability), as well as factors related to the macro-level community (eg, service fragmentation).11, 12 Applying concepts from the field of implementation science, the scientific study of strategies to facilitate the uptake of evidence-based practices into real-world service delivery,13 has the potential to benefit school mental health research and practice. One way to support successful uptake is to develop and test implementation strategies (ie, the techniques used to enhance the adoption, implementation, or sustainment of interventions), which are key to ensure that school mental health interventions are implemented as intended within schools. The School Implementation Strategies Translating ERIC (ie, Expert Recommendations for Implementing Change) Resources (SISTER) is a compilation of 75 implementation strategies14 for the school context. SISTER provides a taxonomy of strategies (eg, provide consultation/coaching; monitor the implementation effort) to help researchers and school partners select strategies to support evidence-based practices in schools. In implementation science, over 140 theories, models, and frameworks have been developed,15 including those that specify implementation barriers and facilitators, evaluation outcomes, or steps in the implementation process, among other purposes.16 The EPIS framework17 may be particularly relevant for school-based researchers and practitioners because it addresses the key phases (ie, explore, prepare, implement, sustain) that guide the implementation process (ie, steps in translating research to practice). In the Exploration phase, researchers and practitioners use implementation strategies to consider the emerging or existing needs of the school (eg, students', teachers' or other personnel needs), as well as evaluate the potential fit between the intervention and school. During the Preparation phase, it is important to plan for implementation by capitalizing on implementation facilitators and addressing potential barriers to implementation. During the Implementation phase, researchers and practitioners apply implementation strategies and monitor the implementation process. During the Sustainment phase, the structures and processes in schools are considered that would support ongoing implementation.17 The EPIS framework is particularly well-suited for school mental health research and practice because it highlights constructs at the level of the intervention itself (eg, usability, adaptability), the level of the inner context (ie, individual factors such as attitudes about the intervention, and organizational factors such as culture and climate), the level of the outer context (ie, factors such as policies, legislation, and funding), as well as factors that span the inner and outer context (ie, “bridging factors,” such as community-academic partnerships). In this commentary, we draw on the EPIS framework17 to argue that the school mental health field would benefit from explicit consideration of implementation strategies across EPIS phases. Implementation strategies (eg, professional development trainings, coaching) are frequently used in schools to support the delivery of mental health interventions, and therefore, there is growing interest in applying implementation science concepts to school mental health.12, 18, 19 We respond to this call to systematically infuse school mental health service research with critical concepts from implementation science. We make 3 specific recommendations for selecting and reporting implementation strategies to advance school mental health research and practice. First, we urge school mental health researchers and practitioners to recognize the crucial roles of the Exploration and Preparation phases for implementation success. Specifically, we argue that researchers and practitioners should intentionally use and report implementation strategies at these phases. It is imperative that the development of implementation strategies, especially early in the implementation process (ie, Exploration), occurs in close collaboration with community partners who are attuned to the school's emerging or existing needs and contextual fit, as well as barriers and facilitators to the implementation of school-based mental health interventions. For example, researchers and school partners can collaborate to select interventions and implementation strategies that address school priorities and fit within existing structures (eg, schoolwide frameworks, professional development schedules). An example implementation strategy relevant to the Exploration and Preparation phases is to collaboratively develop a needs assessment (eg, with input from parents, teachers, related service providers, administrators, and researchers) to “assess for readiness and identify barriers and facilitators” (which falls under the Evaluative and Iterative Strategies category in SISTER) for the specific prevention or intervention program under consideration. The collaborative interpretation of the needs assessment can inform the co-selection of prevention and/or intervention programs, as well as implementation strategies to support these programs. For example, identifying specific implementation barriers and facilitators during a needs assessment can inform the selection of implementation strategies that address barriers and capitalize on facilitators (eg, training or educational materials to address knowledge barriers; identifying champions to facilitate social influence). Additionally, pre-implementation enhancement strategies20, 21 are particularly relevant for the Preparation phase. Pre-implementation enhancement strategies are delivered prior to the active implementation phase, with the goal of enhancing the impact of implementation-phase strategies. For example, the Beliefs and Attitudes for Successful Implementation in Schools (BASIS20) is a brief pre-implementation strategy, designed to target individual-level barriers to behavior change (eg, attitudes) among school mental health clinicians. BASIS is provided prior to the delivery of implementation-phase strategies, such as training and consultation, with the goal of enhancing clinicians' engagement in training and consultation.20 Similar pre-implementation strategies have also been developed for teachers.21, 22 These kinds of pre-implementation strategies are an important example of how implementation strategies can be applied at the Preparation phase to increase motivation to engage in implementation. We argue that an explicit emphasis on applying implementation strategies during initial phases of the implementation process will help set up school-based mental health programming for success. Second, we argue that researchers and their school partners should consider implementation strategies in addition to time- and resource-intensive training and coaching at the Implementation phase. Most of the strategies reported in the extant school mental health literature about the Implementation phase involve intensive (ie, 2 hours to 4 days in length) training and/or ongoing consultation or coaching.23-27 Although there is evidence that the combination of training and coaching or consultation can be effective to support implementation,23, 28 these strategies may not always be feasible or sustainable in school settings where time and funding are constrained, and they do not always directly address the most salient implementation barriers. It is important to additionally consider a broader set of implementation strategies at the Implementation phase. The SISTER compilation highlights strategies appropriate for the Implementation phase in addition to training, consultation, or coaching. For example, the category Change Infrastructure includes strategies such as “change accreditation or membership requirements,” “change/alter environment,” “change record systems,” and “prune competing initiatives.” Moreover, SISTER strategies such as “develop educational materials” and “distribute educational materials” were rated by experts as high in importance and feasibility in school settings,29 suggesting that school mental health research may benefit from adding to the implementation strategies that are used at the Implementation phase. Indeed, leaders in contemporary implementation science have recently argued that the field risks recreating the “research-to-practice gap” by using strategies that are time intensive and ultimately not feasible in practice settings, even if they are effective.30 School mental health researchers and practitioners can avoid this potential pitfall by considering a broad array of strategies at the Implementation phase, identifying and selecting them with key partners, including school personnel who are experts in contextual fit and feasibility,30 and prioritizing pragmatic research.31 Third, we argue for employing and reporting implementation strategies to plan for Sustainment. Currently, there is very little in the extant school mental health literature regarding implementation strategies at the Sustainment phase. This is a critical gap in the field, and we recommend a 2-prong approach to address sustainment. First, we suggest planning for sustainment across the prior EPIS phases (ie, Exploration, Preparation, Implementation) by considering the sustainability of interventions, as well as strategies to support sustainment, throughout the implementation process. Second, it is imperative to explicitly consider and report implementation strategies for the Sustainment phase. In reporting implementation strategies, researchers should follow established guidelines for naming, defining, and specifying implementation strategies.32 For example, 1 strategy under the Adapt and Tailor to Context category in SISTER14 is to “test-drive and select practices” which involves supporting staff to try out various practices in small doses (eg, at the Implementation phase) and then having them select the ones (ie, at the Sustainment phase) that they find the most feasible and acceptable in the school context. School mental health researchers who use this strategy can report key details to operationalize the strategy (eg, who delivers, dosage, temporality) at both the Implementation and Sustainment phase. For sustainment and scale-up, it is important to focus on the practices that are identified as feasible and acceptable through partnerships, such as community-based participatory approaches. Given the lack of consideration for sustainment, especially early in the implementation process, researchers and practitioners are consistently faced with the problem of re-implementation—that is, implementing the same prevention or intervention program again in the same context.33 However, it is important to acknowledge that it can be particularly difficult to plan for sustainability in schools given its inherent challenges, such as high staff turnover, students advancing grades, incoming students mid-year, and families leaving the district.34 Some of these challenges have been addressed in other fields by focusing on organizational implementation. For example, Adam et al.35 examined the implementation of a “cultural change toolkit” to reduce burnout and mitigate turnover with nurses in the emergency department.35 A similar approach may be applicable in schools. In this commentary, we draw on the EPIS framework to argue for the importance of considering and reporting implementation strategies that support school mental health prevention and intervention programs. Specifically, we argue for the need to consider the Exploration and Preparation phases; the importance of Implementation strategies in addition to intensive training and consultation; and the need to focus on Sustainment. We suggest that applying concepts from the field of implementation science, such as the EPIS framework and the SISTER compilation of implementation strategies, has the potential to advance school mental health research and practice, at a time when this is sorely needed to enhance student health. Future work on the implementation of school health programs may also benefit from explicitly considering EPIS constructs, such as the inner context, outer context, and bridging factors. Our recommendations also highlight the critical role of authentic community partnerships and participatory research (ie, shared decision-making, iterative nature of intervention development and implementation, and including partner priorities).36 Indeed, the practice-based expertise of school practitioners are critical in developing and selecting interventions and implementation strategies that are appropriate and feasible across EPIS phases. Moreover, engagement between schools and community organizations, including researchers, is a critical component of overall school health promotion efforts, such as the Whole School, Whole Community, Whole Child model.37, 38 The authors declare that there is no conflict of interest

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