Effectiveness of a Pragmatic School-based Universal

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  Effectiveness of a pragmatic school-based universalintervention targeting student resilience protective factors inreducing mental health problems in adolescents  Julia Dray  a ,  c ,  d ,  * , Jenny Bowman  a ,  d , Elizabeth Campbell  b ,  c ,  d ,Megan Freund  b ,  d , Rebecca Hodder  b ,  c ,  d , Luke Wolfenden  b ,  c ,  d , Jody Richards  a ,Catherine Leane  c , Sue Green  c ,  d , Christophe Lecathelinais  b ,  c ,Christopher Oldmeadow  b ,  d , John Attia  b ,  d , Karen Gillham  c ,  d , John Wiggers  b ,  c ,  d a Faculty of Science and IT, School of Psychology, University of Newcastle, Callaghan, NSW 2308, Australia b Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia c Hunter New England Population Health Research Group, Hunter New England Local Health District, Wallsend, NSW 2287, Australia d Hunter Medical Research Institute, New Lambton Heights, NSW 2310, Australia a r t i c l e i n f o  Article history: Received 15 December 2016Received in revised form 28 March 2017Accepted 29 March 2017 Keywords: AdolescenceUniversal interventionResilienceMental healthSchoolsPrevention a b s t r a c t Worldwide, 10 e 20% of adolescents experience mental health problems. Strategies aimedat strengthening resilience protective factors provide a potential approach for reducingmental health problems in adolescents. This study evaluated the effectiveness of a uni-versal, school-based intervention targeting resilience protective factors in reducing mentalhealth problems in adolescents. A cluster randomised controlled trial was conducted in 20intervention and 12 control secondary schools located in socio-economically disadvan-taged areas of NSW, Australia. Data were collected from 3115 students at baseline (Grade 7,2011), of whom 2149 provided data at follow up (Grade 10, 2014; enrolments in Grades 7to 10 typically aged 12 e 16 years; 50% male; 69.0% retention). There were no signi 󿬁 cantdifferences between groups at follow-up for three mental health outcomes: total SDQ,internalising problems, and prosocial behaviour. A small statistically signi 󿬁 cant differencein favour of the control group was found for externalising problems. Findings highlight thecontinued dif  󿬁 culties in developing effective, school-based prevention programs formental health problems in adolescents. Trial registration:  ANZCTR (Ref no: ACTRN12611000606987). ©  2017 The Authors. Published by Elsevier Ltd on behalf of The Foundation for Pro-fessionals in Services for Adolescents. This is an open access article under the CC BY license(http://creativecommons.org/licenses/by/4.0/). Effectiveness of a school-based universal intervention targeting student resilience protective factors in reducing mentalhealth problems in adolescents.Worldwide, the reported prevalence of mental health problems in adolescents is typically between 10 and 20% (Kielinget al., 2011). Adolescence, commonly de 󿬁 ned as the second decade of life (10 e 19 years) (World Health Organisation, *  Corresponding author. School of Psychology, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia. E-mail address:  Julia.Dray@hnehealth.nsw.gov.au (J. Dray). Contents lists available at ScienceDirect  Journal of Adolescence journal homepage: www.elsevier.com/locate/jado http://dx.doi.org/10.1016/j.adolescence.2017.03.0090140-1971/ ©  2017 The Authors. Published by Elsevier Ltd on behalf of The Foundation for Professionals in Services for Adolescents. This is an open accessarticle under the CC BY license (http://creativecommons.org/licenses/by/4.0/).  Journal of Adolescence 57 (2017) 74 e 89  2014), is a time of extensive physical and social development, during which capabilities vital for successful progression intoadulthood are established (Blakemore  &  Mills, 2014). Additionally, adolescence traverses the age range of onset for mostmentalhealthdisordersthatarelikelytopersistintoadulthood(Kessleretal.,2005;Patel,Flisher,Hetrick, & McGorry,2007).Mental healthproblems negativelyimpact youngpeoplebothduringadolescence andintoadulthood.Such negative impactsinclude emotional distress, lower educational achievements, higher likelihood of engagement in health risk behaviours andhigher rates of self-harm and suicide (Fergusson  &  Woodward, 2002). As such, improving mental health in adolescents is arecognised health imperative internationally (Buckley et al., 2011).Previous research has suggested that an approach that strengthens protective factors, often termed building  ‘ resil-ience ’ (Minnard, 2002), may reduce mental health problems in adolescents (Davydov, Stewart, Ritchie,  &  Chaudieu, 2010;Luthar, Cicchetti,  &  Becker, 2000). Protective factors for resilience include both internal factors (e.g. self-ef  󿬁 cacy, effectiveproblem solving); and external factors within the wider social environment (e.g. meaningful participation within home,school or community environments) (Cowen et al.,1996; Fergus  &  Zimmerman, 2005; Lee  &  Stewart, 2013; Sun  &  Stewart,2010). Theoretical models of resilience are centrally concerned with positive adaptation and are commonly based on thepremisethatprotectivefactorsactasmoderatorsthatreducetheimpactofdeleteriousfactorssuchasriskfactorsoradversity,reducing theimpactof negativeoutcomes(such as prevalenceof mentalhealth problems), and promoting positiveoutcomes(such as positive mental health)(Fergus  &  Zimmerman, 2005; Friedli, 2009). This suggestion is supported by results of previous research, which has found high levels of protective factors to be associated with lower levels of mental healthproblems such as anxiety, depression, stress and obsessive-compulsive disorder in adolescents (Bond, Toumbourou, Thomas,Catalano,  & Patton, 2005; Hjemdal, Friborg, Stiles, Rosenvinge,  &  Martinussen, 2006; Hjemdal, Vogel, Solem, Hagen,  & Stiles,2011).As schools provide access to adolescents for prolonged periods and promote student development and wellbeing(Seligman,Ernst,Gillham,Reivich, & Linkins,2009),theyrepresentanopportunesettingforinterventionstargetingresilienceprotective factors as a means of preventing adolescent mental health problems (Brooks, 2006; Greenberg, Domitrovich,  & Bumbarger, 2001). Universal school-based interventions - those that target whole populations or groups of students notidenti 󿬁 ed as having, or being at-risk of, mental health problems (Weisz, Sandler, Durlak,  &  Anton, 2005) - have been rec-ommended and are widely implemented for the promotion of mental health in young people (O'Mara  &  Lind, 2013).In recent decades, many school-based randomised controlled trials have investigated the effect of universal interventionstargeting multiple internal and or external resilience protective factors on mental health outcomes in adolescents. The largemajorityof such trials have measured the effectof interventions on internalising problems including anxiety, depression andcomposite scores of internalising symptoms, with many indicating signi 󿬁 cant positive results on at least one outcome (e.g.Calear, Christensen, Mackinnon, Grif  󿬁 ths,  &  O'Kearney, 2009; Cardemil, Reivich, Beevers, Seligman,  &  James, 2007; Chaplinet al., 2006; Gillham et al., 2007; Horowitz, Garber, Ciesla, Young,  &  Mufson, 2007; Leventhal et al., 2015; Lock  &  Barrett,2003; Merry, McDowell, Wild, Bir,  &  Cunliffe, 2004; Rivet-Duval, Heriot,  &  Hunt, 2011; Rodgers  &  Dunsmuir, 2015; Rose,Hawes,  &  Hunt, 2014; Ruini et al., 2009; Tomba et al., 2010), and others reporting no signi 󿬁 cant effect (e.g. Araya et al., 2013;Bond, Patton,  & Glover, 2004; Burckhardt et al., 2015; Buttigieg et al., 2015; Kindt, Kleinjan, Janssens,  & Scholte, 2014; Pattonet al., 2006; Perry et al., 2014; Possel, Horn, Groen,  &  Hautzinger, 2004; Sawyer et al., 2010). Fewer reported studies havemeasured the effect of such an intervention on externalising problems such as hyperactivity, conduct problems and totaldif  󿬁 culties (Fitzpatrick et al., 2009, 2013) or composite scores of externalising problems (Cutuli et al., 2013; Lowry-Webster, Barrett,  &  Lock, 2003; Petersen, Leffert, Graham, Alwin,  &  Ding, 1997; P € ossel, Seemann,  &  Hautzinger, 2008; Roberts et al.,2010), with the large majority reporting signi 󿬁 cant positive results on at least one outcome (Cutuli et al., 2013; Fitzpatricket al., 2013; Lowry-Webster et al., 2003; Petersen et al., 1997; P € ossel et al., 2008; Roberts et al., 2010).Further, despite evidence that internalising and externalising problems differ by gender in adolescents (Dray et al., 2016;Lawrenceetal.,2015;Mellor,2005;Muris,Meesters, & vandenBerg,2003;Rescorlaetal.,2007),trialsthathaveassessedtheeffect of protective factor interventions by gender have variably reported either differential effect by gender on at least oneoutcome (Calear et al., 2009; Lock  &  Barrett, 2003; Petersen et al.,1997; P € ossel et al., 2008) or no differential effects (Araya etal.,2013;Buttigiegetal.,2015;Chaplinetal.,2006;Horowitzetal.,2007;Kindtetal.,2014;Merryetal.,2004;Robertsetal.,2010; Sawyer et al., 2010; Tak, Lichtwarck-Aschoff, Gillham, Van Zundert,  & Engels, 2016; Tomba et al., 2010; Trudeau, Spoth,Randall,  &  Azevedo, 2007).Additionally, the large majority of trials that have assessed the effect of universal, school-based protective factor in-terventions on mental health outcomes in adolescents have included implementation of a manualised resilience-focussedprogram into the school curriculum. Whilst such an approach lends itself to evaluation of intervention ef  󿬁 cacy undertightly controlled research conditions, a key area of challenge to policymakers is the availability of evidence regarding theeffectiveness of programs when delivered by schools in a manner that is tailored to their local circumstances (Wolpert et al.,2015). Related reviews of challenges in implementation science note: the need for further research adopting approaches thatcombine the use of high quality study designs with intervention designs that are tailored to re 󿬂 ect local and real-worldoperational environments such as schools; aid community capacity to implement and sustain complex programs; andsupport local ownership of such approaches (Greenhalgh, Robert, Macfarlane, Bate,  &  Kyriakidou, 2004; McCall, 2009).Pragmatic intervention trials e de 󿬁 ned as research trials designed to test the effectiveness of an approach in  ‘ real world ’ conditions (Thorpe et al.,2009) - typicallyadoptanapproach thatgives 󿬂 exibility toparticipantstoselectelementsof careorprogramstoimplement whichbestmeet theirindividualorlocalneeds (Hawkins,Oesterle, Brown,Abbott, & Catalano,2014;Spoth  &  Greenberg, 2005; Thorpe et al., 2009; Wolpert et al., 2015). For example, Promoting School-Community-University  J. Dray et al. / Journal of Adolescence 57 (2017) 74 e 89  75  Partnerships to Enhance Resilience (PROSPER) is a delivery system utilising a community-university partnership model tofostertheuptakeandimplementationoflocallyselectedevidence-basedprogramsrelatingtointernalandexternalprotectivefactorsinadolescents(Spothetal.,2015).EvaluationsofthePROSPERtrialindicatesigni 󿬁 cantpositiveinterventioneffectsforsubstance use outcomes (such as tobacco, alcohol and illicit substance initiation and use)(Spoth et al., 2007, 2013), conductproblems (Spoth et al., 2015), and a range of outcomes related to internal and external protective factors (such as problemsolving, parent-child attachment and family environment)(Redmond et al., 2009; Spoth  &  Greenberg, 2005). No furthermental health problem outcomes (e.g. internalising problems or total dif  󿬁 culties) were assessed across the PROSPER trials.Toaddresslimitationsofpaststudies,thepresentstudywasconductedtoevaluatetheeffectivenessofauniversal,school-based, pragmatic intervention targeting resilience protective factors in reducing four mental health problem outcomes (totalSDQ; internalising problems; externalising problems; and prosocial behaviour) in adolescents. The secondary study aim wasto evaluate the effectiveness of the intervention in improving internal and external resilience protective factors, and toinvestigate differential intervention effects by gender and baseline mental health problem levels for primary outcomes. Inaddition to student outcome data, process data to describe the extent of intervention implementation were collected andresults of this are described. Methods Study design, setting and sample A cluster randomised controlled trial, was conducted in 32 secondary schools within the Hunter New England region of New South Wales (NSW), Australia. The study was approved by relevant ethics committees (HNEH: Ref no. 09/11/18/4.01;UoN: Ref no. H-2010-0029; and the AHMRC: Ref no. 776/11) and prospectively registered (ANZCTR: Ref no.ACTRN12611000606987). Full details of the trial methodology have been described elsewhere (Dray et al., 2014). Secondary schools School eligibility criteria were: at least 400 student enrolments (Grades 7 to 12); enrolments in Grades 7 to 10 (typicallyaged12 e 16years);andlocatedwithinasocio-economicallydisadvantagedLocalGovernmentArea(LGA;schoolpostcodeinaLGA with a score of   < 1000 using the Socio-Economic Indexes for Areas (SEIFA)) (Trewin, 2003). A national database of Australian schools (Australian Curriculum Assessment and Reporting Authority, 2010) was used to identify 172 Governmentand Catholic secondaryschools in the studyarea,of which 47 met the eligibilitycriteria. The 47eligible schools wereorderedby an independent statistician using a random number function, and approached in that order until 32 consented. Randomisation of schools Consenting schools were strati 󿬁 ed by school size (medium-size 400 to 800 students, or large schools  > 800) and byengagement in a national government funding initiative directed at schools in disadvantaged areas (yes/no) (NSWDepartment of Education and Communities, 2011). Schools were then randomised in Microsoft Excel using a randomnumberfunctionina20:12blockdesignratio(20 intervention;12control)priortobaselinedatacollection.Schools, enrolledstudents and parents of students were not blind to treatment allocation. Student sample Students were eligible to participate if they were in Grade 7 ( 󿬁 rst year of secondary school) in 2011. Signed parentalconsent for student participation was obtained through mailing of study information packs and consent forms. Studentoutcome assessments were undertaken via online surveys conducted during class time, with students in Grade 7 at baseline(August to November 2011) and in Grade 10 at follow-up (July to November 2014). School staff  Selected staff from each participating school (deputy principal, head teachers for student welfare and  󿬁 ve key subjectareas, and the Absrcinal Education Coordinator or other nominated Absrcinal staff member) were invited to complete asurvey at follow-up. Intervention An intervention was developed to increase the provision of universal strategies targeting multiple internal and externalresilience protective factors in intervention schools during Grades 8 to 10, from 2012 to 2014. The intervention involved aframeworkofsixteeninterventionstrategiesacrossthethreeHealthPromotingSchoolsdomains(WorldHealthOrganisation,1991) (see Table 1). Each strategy was designed to address one or more internal (cooperation/communication, empathy, goals/aspirations, problem solving, self-awareness, self-ef  󿬁 cacy) or external resilience protective factor (school support,schoolmeaningfulparticipation,peercaringrelationships).Apragmaticinterventionapproachwasused(Thorpeetal.,2009).Intervention schools were asked to meet the same prescribed set of strategies in Table 1, however schools were given the 󿬂 exibility to select which speci 󿬁 c programs or resources to implement to address each of the strategies. Additionally, theorderandmannerbywhichthesewereimplementedwithineachinterventionschoolvariedtoaligntothecontextandneeds  J. Dray et al. / Journal of Adolescence 57 (2017) 74 e 89 76  of each schoolcommunity. A stepped approachwas used wherebythenumberof strategiestoimplement ineach schoolyearincreased starting at two strategies in 2012; 14 in 2013; and 16 in 2014 (Table 1).Curriculum, teaching and learning strategies focussed on the provision of resilience-focussed content inside and outsidetheclassroom.Schoolswererequiredtoimplement 9h ofresilience-focussed contentinaminimumof threeof thefollowingkey learning area's (KLAs): English; Math; Science; History and Geography, or; Personal Development, Health and PhysicalEducation (PDHPE) (Board of Studies Teaching and Educational Standards NSW, 2016). Head teachers of each subject areareviewedtheexistingprogrammedcurriculumcontentandembeddedcontenttargetingresilienceprotectivefactorswhereitwas contextuallyrelevant.Inaddition, schoolswererequiredtoembed afurther9h of contenttargetingresilienceprotectivefactors into school activities (e.g. school assemblies, camps, welfaredays). Intervention school teachers were provided with aone-day MindMatters training workshop in promoting the development of social and emotional skills during lessons and  Table 1 Intervention strategies and implementation support strategies. Intervention strategies by Health Promoting Schools Domain Curriculum, teaching and learning  1. Age-appropriate lessons (9 h) on protective factors across a minimum of three of the following key learning area's (KLAs): English; Math; Science;HistoryandGeography,and/or;PersonalDevelopment,HealthandPhysicalEducation(PDHPE)(BoardofStudiesTeachingandEducationalStandardsNSW, 2016). For example, MindMatters (MindMatters, 2000; Wyn et al., 2000) or school-developed curriculum resources  a,c 2. Non-curriculum programs (9 h) targeting protective factors outside the classroom (e.g. the Resourceful Adolescent Program (Queensland Universityof Technology, 2013))  a,b 3. Additional program targeting protective factors for Absrcinal students  a,b,c Ethos and Environment  4. Rewards and recognition programs  a,b 5. Peer support or peer mentoring programs  a,b 6. Anti-bullying programs  a,b 7. Empowerment/leadership programs  a,b 8. Additional empowerment/leadership/mentoring programs for Absrcinal students  a,b,c 9. Absrcinal cultural awareness strategies  a,b,c Partnerships and Services 10. Promotion and engagement of local community organisations, groups and clubs in the school (e.g. charity organisations)  a,c 11. Additional or enhanced consultation activities with Absrcinal community groups  a,b,f  12. Promotion and engagement of health, community and youth services in the school  a,b,c 13. Additional or enhanced Absrcinal community organisations promoted or engaged  a,b,f  14. Referral pathways to health, community and youth services developed and promoted  a,b,c 15. Strategies to increase parental involvement in school (e.g. school events, and effective parent communication strategies)  b,c 16. Information regarding student protective factors provided to parents via school newsletter. a,b,c Implementation support strategies 1. Engagement with school community including presentations at school staff meetings regarding planned intervention  d 2. Embedded support staff: B  School intervention of  󿬁 cer one day a week to support program implementation B  Project coordinator to liaise with school sectors and support school intervention of  󿬁 cers  e 3. School intervention team formed (new team or re-alignment of existing team, inclusive of school intervention of  󿬁 cer and school executive member)to implement intervention4. Structured planning process to prioritize and select appropriate resources/programs: B  Needs assessment of student protective factors (when study sample in Grade 7) B  Two school community planning workshops and one strategy review workshop  e B  School plan to address intervention strategies endorsed by the school executive5. Intervention implementation guide that described the intervention, planning process, available resources and programs, tools and templates forintervention implementation.6. Staff mental health training (minimum of 1 h per school during staff meetings)7. AUD $2000 per year each for:o Teacher release time for intervention implementation or professional developmento Strategies speci 󿬁 cally for Absrcinal students  c 8. Feedback reports regarding student substance use, protective factors (following baseline and Grade 9) and intervention implementation (termly)  e 9. An Absrcinal Cultural Steering Group was formed comprising of Absrcinal staff from local Absrcinal community organisations and GovernmentDepartments to provide Absrcinal cultural advice and direction regarding the study design, implementation, evaluation and disseminationNB. Following publication of the trial protocols (Dray et al., 2014; Hodder et al., 2012) and based upon advice received from Absrcinal Cultural Steering Group intervention strategies 3,8,11,13 were added. a To target internal protective factors. b To target external protective factors. c Implemented in Years 2 and 3 only. d Year 1 only. e Years 1 and 2 only. f  Year 3 only.  J. Dray et al. / Journal of Adolescence 57 (2017) 74 e 89  77
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