Title: The Identification and Adaptation of an Effective Mental Health and Wellbeing Intervention for Implementation with Welsh Secondary School Students aged 11-18
Funder: Health and Care Research Wales (Welsh Government)

Abstract: The aim is to identify and adapt an effective secondary school-based mental health intervention to Wales. Addressing the high [5] and rising [7-9] levels of adolescent mental health issues at a population level, and amongst at-risk populations, is a Welsh priority [12-18]. Schools and teachers are situated as key to addressing this. At a teacher level, delivering support is difficult due to their own elevated levels of mental health issues [19], limited time and expertise [20], and as adolescents prefer other delivery agents [21]. At a school level, it is problematic to select UK interventions as evaluations show modest, short-lived, and sometimes detrimental effects [22-24]; and delivering non-evaluated interventions can waste resources. This shows a need to adapt interventions to Wales, particularly as adapting interventions is less resource intensive than developing new ones [33], resulting in a cost -effective use of finite resource to relieve pressure on the mental health system [6]. Scoping for interventions that meet Welsh needs shows a growing effective evidence base from LMICs [25-27]. They show promise as transdiagnostic models can be effective for anxiety and depression [28], the most prevalent disorders in Wales [6]. Moreover, lay delivery agents [28, 29] can decrease the burden on teachers; and stepped care architectures [28, 30, 31], with universal components followed by higher-intensity targeted steps, are resource efficient. The study is structured through Adaptation guidance [32] with two phases. The Context and Implementation of Complex Interventions model [34] will be embedded to conceptualise the intervention, contexts, and implementation domains. Phase 1: To assess the rationale for intervention and consider intervention-context fit RQ1 What are the likely elements associated with effective and scalable anxiety and depression promotion and prevention for Welsh secondary school students? RQ2 What is the most appropriate effective intervention for adaptation to Wales, and its theory of change? This has three methods. First, a case study of Welsh policy and research evidence, and stakeholder focus groups and interviews will locate the elements likely to affect adolescent anxiety and depression in schools. Secondly, using the elements as search criteria, a rapid review will locate interventions with selection dependent on effectiveness and accessibility. Lastly, a case study of the selected intervention will provide an understanding of the intervention model, context, and implementation. Phase 2: To plan adaptations to the intervention RQ3 What are the differences and similarities between the current delivery context and the Welsh context? RQ4 Are the intervention elements feasible to implement in Welsh secondary schools? If not, what adaptations are needed? RQ5 Are the adapted intervention elements acceptable to most school stakeholders, practitioners, and policymakers? This has two methods. A cross-case analysis comparing the Welsh context and the intervention will elaborate a set of draft intervention adaptations, and outline implementation considerations. Next, through a participatory adaptation process, the theory and implementation considerations will be modified by school students and staff, and practitioners and policymakers. This will result in adaptation recommendations and an intervention model outlining the pathways which lead to improvements in adolescent mental health.

Lay abstract: Aim: To understand what is needed to address adolescent mental health in schools in Wales, select an effective intervention which fits these needs, and make recommendations on how to adapt it to Wales. Background: In Wales, 19% of adolescents report elevated mental health symptoms, with anxiety and depression increasing since the COVID pandemic. Secondary school students also face problems accessing specialist mental health care and they are ‘bounced’ between services when seeking help. The Welsh Government recognises these problems and made it statutory for schools to embed a Whole-School Approach (WSA) to mental wellbeing in 2021. Schools must offer a range of support including programmes to increase all students’ mental health knowledge and targeted programmes for those at risk of more severe problems. Meeting these requirements is difficult for schools because there is no clear evidence that UK programmes make a long-term difference to mental health. Also, whilst the WSA implicates teachers as key agents, their own high levels of anxiety and depression, their limited time and mental health expertise, and adolescents not wanting teachers to deliver sensitive health information makes this difficult. Globally, interventions do exist which decrease secondary school students’ mental health problems, and these could be adapted to Wales. They have potential as they: target symptoms for both anxiety and depression, and many adolescents experience both; use lay individuals to deliver programmes, decreasing the load on teachers; and use a model which meets the WSA’s focus of supporting all students’ mental health, as well as targeting those showing symptoms. Design: The study has two phases. In phase 1, there are three methods. First, a case study analysing relevant Welsh policy and research, and including focus groups with students and school staff, and interviews with health practitioners and government personnel will be undertaken. This will show what could make a difference to adolescent anxiety and depression in schools. Secondly, using this information as criteria, a rapid review will produce a list of interventions which will be scored (based on the strength of their evidence), with the final intervention selected depending on negotiations with developers about the possibility for adaptation. Lastly, a case study of relevant documents, observations in the original context, and interviews with those that developed and delivered the intervention will provide a model of it, and how it is delivered. Phase 2 involves two methods. First, a comparison of the two case studies will produce a draft of how the intervention could work in Wales and any potential issues which need addressing. Subsequently, a participatory process of consultations with the same stakeholders as in phase 1 will be conducted. Participants will be informed about the draft intervention and potential issues, and their ideas on the changes needed to fit to Wales will be incorporated. This will result in recommendations of the adaptations needed to deliver the intervention in Wales, and a comprehensive intervention model. Public involvement: Four sessions each with two youth advisory groups (one for mental health service users and a general population group) are positioned at important decision-making points. Dissemination: Three academic articles, a professional and a young person’s report, a blog, webinar and conference presentations will be produced.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: MENTAL HEALTH