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Teachers’ views and experiences of student mental health and well-being programmes: A systematic review

Teachers’ views and experiences of student mental health and well-being programmes: A systematic... Copyright © The Authors Journal of Child & Adolescent Mental Health 2023: 1–20 JOURNAL OF Open Access article distributed in terms of the Creative Commons CHILD & ADOLESCENT MENTAL HEALTH Attribution License [CC BY 4.0] ISSN 1728-0583 EISSN 1728-0591 https://creativecommons.org/licenses/by/4.02022 https://doi.org/10.2989/17280583.2023.2229876 Review Article Teachers’ views and experiences of student mental health and well-being programmes: A systematic review 1 2 3 John Goodwin , Laura Behan & Niamh O’Brien Catherine McAuley School of Nursing and Midwifery, University College Cork, Ireland Health Information and Quality Authority, Ireland Department of Education, South East Technological University, Ireland Correspondence: john.goodwin@ucc.ie Background: In schools, teachers are often tasked with implementing mental health and well-being programmes. However, little is known about teachers’ views on and experiences with implementing these programmes. Aim: The aim of this systematic review was to explore teachers’ views and experiences of mental health and well-being intervention programmes developed to promote and protect student mental health. Methods: A systematic review of the empirical literature was conducted using the following databases: Academic Search Complete, APA PsycArticles, APA PsycInfo, British Education Index, Education Full Text (H.W. Wilson), ERIC, Social Sciences Full Text (H.W. Wilson), and SocINDEX with Full Text. Findings: Seven papers met the inclusion criteria. Teachers reported several challenges to the successful implementation of mental health and well-being programmes, including a lack of time allotted in the curriculum, insufficient training, and inadequate interagency support. There was evidence of conflicting opinions regarding the role of teachers in supporting students. Conclusion: It is recommended that mental health and well-being are viewed as central to schools’ ethos and that teachers are adequately prepared to implement programmes. Keywords: mental health; mental illness; students; teachers; well-being; systematic review Introduction Adolescence is a developmental period of immense change when the vulnerability to the experience of mental distress peaks (Hartas, 2021; McCrory et al., 2022; Solmi et al., 2021). Indeed, it has been reported that half of all mental illnesses start by age 14 (World Health Organization, 2021). There is a historical and more recently elevated call to action to urgently respond to the global adolescent mental health crisis (Benton et al., 2021; Goodwin et al., 2016; Kuhn et al., 2021; Solmi et al., 2021; World Economic Forum, 2020). It is widely understood that health and mental health is influenced by a range of determinants from the biological, social, and psychological domains (Engel, 1977; Lehman et al., 2017), meaning both biological and environmental risk factors and protective factors exist within an individual’s dynamic socio-ecological system at which they are the centre (Bronfenbrenner, 1992). This emphasises the importance of social relationships across a range of layered environments such as the microsystem (school, home, community), the mesosystem (interactions between the members of the microsystem), the exosystem (indirect environments), and the macrosystem (shared culture, norms, policies, and values) on adolescent mental health. Therefore, mental health risk factors of adolescents can range from age and gender to learning needs, family stress, relationships, Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Informa UK Limited [trading as Taylor & Francis Group] 2 Goodwin, Behan and O’Brien socio-economic status, school life, and community (Dooley et al., 2019). Mental health protective factors that also exist within the layers of the socio-ecological system, including gender, school connectedness, family support, and the presence of “one good adult” can act as a buffer against mental distress (Dooley et al., 2019). Research determines social support plays a key role in promoting adolescents’ psychological well-being, with teacher social support associated with better psychological well-being for all students (Guo et al., 2018). As a result of the ecological dynamics of adolescent mental health, there is a need to respond to the mental health needs of adolescents across each of the layers of the socio-ecological system (Barry, 2009). Schools are seen as one of the most important settings for the promotion of mental health as they provide ample opportunities to reach the adolescent population to promote and protect good mental health and well-being (Government of Ireland, 2020; Holzer et al., 2021; World Health Organization, 2004). Mental health interventions can be large-scale and part of a whole-school approach or education-specific experiences that aim to promote mental health, prevent mental illness development, and treat diagnosed illnesses through cognitive skills training (Barry, 2009; O’Reilly et al., 2018; Weare, 2000). Mental health interventions that are part of a whole-school approach to well-being promotion deliver positive outcomes when embedded across the whole-school system, producing long-term benefits for young people, including enhanced emotional and social functioning, positive health behaviours, and academic performance (Barry et al., 2013; Clarke et al., 2021; Hoare et al., 2017). Education-specific mental health intervention programmes for schools are diverse in their design but can include themes such as positive psychoeducation (Hoare et al., 2017), mindfulness (Bauer et al., 2019), mental health literacy (Ojio et al., 2015), and health-seeking (Gulliver et al., 2012). Research indicates that students benefit from engagement in education-specific mental health interventions that are tailored to address the key behavioural determinants of mental health for the target population group (Barry, 2009; Barry et al., 2013). Multiple systematic reviews found statistically significant increases in student knowledge and awareness of mental illnesses (Bidik & Sisman, 2021; Gulliver et al., 2012; Ma et al., 2022), resilience, communication skills (King & Fazel, 2021), self-esteem, self-efficacy, emotional competence, life satisfaction, positive body perception, self-awareness, self-regulation, psychological flexibility, sense of belonging to society, social-emotional skills, problem-solving skills and coping skills (Bidik & Sisman, 2021), in addition to reductions in mental health stigma and depressive and anxiety symptoms (Dray et al., 2017). However, although there is good evidence to support the efficacy of mental health interventions in enhancing student knowledge and skills to cope with adversity and mental health risks. O’Reilly et al. (2018) highlight the challenges that still exist for successful mental health promotion. Although teachers often act as gatekeepers to help students with mental health needs, in Ireland, it has been reported that 95% of teachers do not perceive themselves as adequately trained to support students with mental health difficulties (Ni Chorcora & Swords, 2021). Nonetheless, their capacity to appropriately respond to the mental health needs of students through intervention can have a life-long impact on an individual, making teachers’ level of mental health knowledge and skill essential to their efficacy of intervention programme delivery (Byrne & Carthy, 2021). It is generally accepted worldwide that supporting and promoting social-emotional learning is viewed as an important aspect of a teacher’s role to support the learning and mental well-being of students in schools (Ekornes, 2015; Froese-Germain & Riel, 2012; Knightsmith et al., 2013; Mazzer & Rickwood, 2015). However, the extent to which teachers promote, support and respond to student mental health varies widely, with schools in some countries including more involvement of health and mental health professionals than others (Patalay et al., 2017). This indicates that some schools have the provisions for teachers to remain more focused on academic performance, with the support of on-site professionals to promote student well-being (such as school counsellors and nurses), while others might be disproportionately affected by the limited access to trained and/or specialist staff. Increasingly, teachers rather than mental health professionals are the primary delivery agents of mental health interventions, as they are the link between student academic learning and social and emotional competencies and well-being (Cefai et al., 2021; O’Reilly et al., 2018). In addition, embedding mental health into the school curriculum encourages schools and teachers to broaden Journal of Child & Adolescent Mental Health 2023: 1–20 3 their agenda to include mental health and well-being as a shared responsibility and key learning objective of education (Cefai et al., 2021; Hoare et al., 2017). However, there is limited data on teacher involvement in the evaluation process (Franklin et al., 2013). If teachers represent the frontline of opportunity to promote and protect the mental health of young people during the delivery of mental health interventions in school settings, their perceptions of the experience and their roles are vital to ensure that they feel supported and informed to sustain such an initiative. Therefore, this systematic review aims to answer the question: what are teachers’ views and experiences of mental health and well-being intervention programmes developed to promote and protect student mental health? This includes studies where teachers observed the delivery of a mental health and well-being programme, or where teachers facilitated the programme themselves. Studies conducted in schools where mental health and well-being programmes were implemented were also included, whether or not teachers surveyed delivered the programmes. Method This systematic review was guided by the Cochrane Handbook for Systematic Reviews of Interventions (Chandler et al., 2019) and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist (Page et al., 2021). The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42021282864). The PICOS (Population, Intervention, Comparison, Outcomes, Study Design) framework was used to determine study eligibility. Empirical studies of any design (Study Design) were eligible for inclusion provided that they focussed on teachers’ (Population) views on mental health programmes within schools and experiences of observing or facilitating (Outcomes) mental health/well-being education programmes (Intervention) delivered in schools or as part of school-endorsed activity (Setting), with or without comparators (Comparison). Studies were excluded if: (i) they focussed on the experiences of third-level educators; (ii) teacher data could not be distinguished from student data; or (iii) the mental health activity was unconnected to the school. We also excluded intervention protocols, literature reviews, dissertations, conference proceedings, commentaries, and editorials. No geographical limitations were set. Search strategy We searched the following electronic databases for relevant studies: Academic Search Complete, APA PsycArticles, APA PsycInfo, British Education Index, Education Full Text (H.W. Wilson), ERIC, Social Sciences Full Text (H.W. Wilson), SocINDEX with Full Text. We also reviewed the reference lists of potentially eligible studies to identify additional studies. The following keywords were used with all databases, truncated to maximise retrieval, combined using Boolean operators “OR” and “AND,” and searched on title OR abstract: (Teacher*) AND (Experience* OR view* OR opinion* OR issue* OR barrier* OR outcome* OR perception* OR perspective*) AND (OR “well-being program*” OR “well-being initiative*” OR “well-being education” OR “well-being strategy” OR “well-being module” OR “well-being class*” OR “well-being program*” OR “well-being initiative*” OR “well-being education” OR “well-being strategy” OR “well-being module” OR “well-being class*” OR “mental health program*” OR “mental health initiative*” OR “mental health education” OR “mental health strategy” OR “mental health module” OR “mental health class*”). The search was last conducted on 17 April 2023. Study selection Records identified from the search were transferred to Covidence and duplicates were deleted. Titles/abstracts and full texts were screened independently by JG and NOB. Screening conflicts were identified by Covidence (Veritas Health Innovation, n.d.) and resolved by LB (see Figure 1). 4 Goodwin, Behan and O’Brien Identification of studies via other methods Identification of studies via databases and registers Records removed before Records identified from: Citation Records identified from screening: Duplicate records searching (n = 2) databases (n = 279) removed (n = 110) Records not retrieved Records sought for retrieval Records screened (n = 169) Records excluded (n = 143) (n = 0) (n = 2) Records excluded (n = 1): Records sought for retrieval Records assessed for eligibility Records not retrieved (n = 0) Incorrect study design (n = 26) (n = 2) (n = 1) Records assessed for eligibility Records excluded (n = 20): (n = 26) Wrong study design (n = 7) Wrong intervention (n = 1) Wrong outcomes (n = 6) Wrong setting (n = 2) Wrong population (n = 4) Studies included in review (n = 7) Figure 1. Study identification, screening, and selection process Screening Identification Included Journal of Child & Adolescent Mental Health 2023: 1–20 5 Data extraction and synthesis One reviewer (JG) extracted data from eligible studies using the following headings: author(s) (year) and country; aim of the study; study design, sample and setting; intervention description and context; data collection process; key outcomes and key outcome measures; and key findings (see Table 1). Each extracted study was cross-checked by another reviewer (NOB) to minimise reporting bias. Owing to the heterogeneity in study design and outcome measures, a meta-analysis was not practicable. Instead, a narrative synthesis of findings is presented. Quality assessment Critical appraisal was conducted to ensure the accuracy and consistency of data. The quality of four papers was appraised using standard critical appraisal tools prepared by the Joanna Briggs Institute (JBI) (2019). For the two mixed methods papers (Punukollu et al., 2019; Willis et al., 2019), the Mixed Methods Appraisal Tool was used (Hong et al., 2018). Critical appraisal was completed by JG and cross-checked by NOB. The level of evidence was also assessed using the Scottish Intercollegiate Guidelines Network (SIGN) grading system (Healthcare Improvement Scotland, 2011). Individual studies are given a grade ranging from 1++ (high-quality meta-analyses; systematic reviews of randomised controlled trials) to 4 (expert opinion). An overall grade recommendation is awarded, ranging from A (highest level of evidence) to D (lowest level of evidence). The level of evidence was completed by JG and cross-checked by LB. Results An initial search of the empirical literature identified 253 records (see Figure 1). Following the removal of 108 duplicates, we screened 145 papers on title and abstract and excluded 120 irrelevant papers based on eligibility criteria. The full texts of the remaining 25 papers were screened; 19 papers were excluded. Two further records were identified from reference list checks. A total of seven studies were included in this review. Study characteristics There were two mixed-method studies, two qualitative descriptive studies, one discourse analysis study, one action research study, and one cross-sectional study. Studies were conducted in Australia (n = 2) (Graham et al., 2011; Willis et al., 2019), the UK (n = 2) (Punukollu et al., 2016; Skryabina et al., 2016), Canada (n = 1) (Berg et al., 2018), Greece (n = 1) (Antoniadou & Bibou-Nakou, 2012), and the USA (n = 1) (Nadeem et al., 2011). Sample sizes ranged from 3 (Punukollu et al., 2019) to 508 teachers (Graham et al., 2011). Study characteristics are presented in full in Table 1. Quality appraisal There were no major concerns identified regarding the quality of the mixed methods, action research, and qualitative study designs. There were some concerns regarding the cross-sectional study, as confounding factors were not identified, and validated instruments were not used to collect data. All studies scored 3 on the SIGN level of the evidence grading system (Healthcare Improvement Scotland, 2011), indicating that these studies were descriptive and non-analytic. An overall grade recommendation of “D” was awarded, indicating an overall low level of evidence. Overview of findings Four overarching themes are presented in this narrative synthesis. Under the first theme, “teachers’ overall views of mental health and well-being programmes”, teachers’ awareness of mental health and well-being programmes is addressed, as are their views on the effectiveness of existing programmes. Next, mixed and conflicting views regarding the role of teachers in supporting students with mental health issues are reported under “teachers’ perspective on their role in 6 Goodwin, Behan and O’Brien Table 1: Data extraction and synthesis Intervention Study Design, Data (a) Key Outcomes and Key Level of Article and Country Aim Description Sample and Setting Collection (b) Key Outcome Measures Findings Evidence and Context Antoniadou and Explore teachers’ Discourse Teachers took 14 focus group (a) Teachers’ Teachers commented that, despite 3 Bibou-Nakou reflections analysis. part in a interviews. experiences of positive intentions, the introduction (2012), Greece and dilemmas Primary school 4-day training participating in a PSE of PSE programmes was an by discussing teachers (n = programme with programme. endorsement of the status quo, and experiences 66) participated mental health (b) Responses to focus an extension of the focus on academic with a personal in the specialists, group questions. performance. and social implementation developing Most teachers were uncertain about education (PSE) of mental health their knowledge how to prioritise their caring role, programme. education and skills, and whether caring duties were programmes. and becoming supplementary to teaching duties. familiar with However, many teachers felt they did learning not provide enough care for students. resources. A tension exists between delivery of Teachers then the formal curriculum and the social implement the development of students. programme in The PSE programme reduces a schools. disciplinary system of teaching and promotes a relational approach to good behaviour. It was felt that, owing to a lack of clear policies or procedures for addressing children’s mental health and a heavy focus on academic performance, schools neglect children’s social and emotional lives. Teachers indicated that there was a lack of time to implement PSE due to the demanding curriculum structure. Journal of Child & Adolescent Mental Health 2023: 1–20 7 Table 1: Data extraction and synthesis (cont.) Intervention Study Design, Data (a) Key Outcomes and Key Level of Article and Country Aim Description Sample and Setting Collection (b) Key Outcome Measures Findings Evidence and Context Berg et al. (2018), Evaluate student Action research. “Got Health?” is Focus group (a) The impact of “Got Teachers felt that “Got Health?” 3 Canada and staff Large urban an inquiry-based interviews Health?” on improving enhanced awareness of promoting perceptions school district in student-led (number of awareness around positive mental health and awareness of a student- British Columbia. programme interviews not positive mental health of mental health issues. led health Four schools were aimed at provided). and enhancing mental The programme increased the spread of promotion included in the empowering health and well-being positive messages around the school. programme study out of 12 students. in schools. Posters about mental health were known as “Got invited to apply. Through action (b) Responses to focus present in the school environment Health?” Each school had research, group questions. and there was an increase in visits to a “Got Health?” students ask the mental health resources page on team. Teams questions, school websites. were diverse create initiatives, Teachers also reported the programme and included: examine and had a positive effect on their own students (2–8 re-examine the well-being. student leaders), impact of their at least 1 activities on lead teacher the factors that (to guide and contribute to a support students more positive through the school climate. inquiry process), administrators, and community partners (e.g., parents, guardians and public health nurses). 8 Goodwin, Behan and O’Brien Table 1: Data extraction and synthesis (cont.) Intervention Study Design, Data (a) Key Outcomes and Key Level of Article and Country Aim Description Sample and Setting Collection (b) Key Outcome Measures Findings Evidence and Context Graham et al. Investigate Cross-sectional N/A Surveys (a) Teachers’ Over 25% of teachers did not respond 3 (2011), Australia teacher study. distributed to perspectives on or stated that they were not aware of perspectives on Surveys completed primary and student mental health any mental health initiatives in their student mental by teachers in secondary and mental health schools. Others cited a wide range of health and primary and schools in New education. initiatives. mental health secondary South Wales. (b) Surveys consisted Only 34% of teachers felt very confident education. schools in of author-developed in implementing mental health New South Likert scales, open- programmes, and 37% felt quite Wales. Out of and closed-ended confident. Notably, 6% were not 2 220 surveys questions. confident at all. distributed, n Teachers indicated that they were = 508 were not provided time and funding to returned, with adequately deliver mental health a return rate of education, citing the “crowded 23%. curriculum” (p. 490) as an obstacle. Some teachers commented on the difficulties balancing regular teaching duties with providing mental health support and expressed frustration with the lack of connection between outside support agencies and the school. Some teachers felt that teaching was not a welfare role, maintaining that teachers were largely untrained in supporting students’ mental health needs. Journal of Child & Adolescent Mental Health 2023: 1–20 9 Table 1: Data extraction and synthesis (cont.) Intervention Study Design, Data (a) Key Outcomes and Key Level of Article and Country Aim Description Sample and Setting Collection (b) Key Outcome Measures Findings Evidence and Context Nadeem et al. Examine Qualitative YSPP involves 5 focus groups (a) Staff views on Teachers commented that because 3 (2011), US school staff descriptive training school and 10 individual implementation of they have direct contact with students perspectives research. personnel to interviews with YSSP, particularly regularly, they were well-positioned to of the Study took place identify at-risk middle-school barriers and recognise changes in student mood implementation in one of the students, engage teachers, facilitators. and behaviour. of a district-wide nation’s largest their support administrators, (b) Responses to focus Teachers desired better communication youth suicide school districts. networks, and and other school group and individual with administrators or counsellors prevention 45 participants, refer them for personnel. interview questions. about mental health issues. Although program including 10 appropriate formal referral processes were in (YSPP). administrators, 7 counselling place in schools, teachers valued Research focus counsellors or and treatment. information shared across informal was the role mental health staff, 90 minutes of networks, with teachers providing of teachers 2 nurses, and 26 training provided support for one another. at different teachers. annually to The importance of a culture of safety stages in the schools to was emphasised. gatekeeper support staff in In post-crisis scenarios, teachers model of suicide implementing reported that lack of feedback and prevention. YSPP. training disabled their capacity to support student needs. Teachers who previously completed an embedded school-wide programme, known as the Healthy Start programme, were more adept in identifying students at risk for suicide and other mental health problems and were effective in their response to students. 10 Goodwin, Behan and O’Brien Table 1: Data extraction and synthesis (cont.) (a) Key Outcomes and Study Design, Intervention Description Data Key Level of Article and Country Aim (b) Key Outcome Sample and Setting and Context Collection Findings Evidence Measures Punukollu et al. Evaluate the Mixed methods “SafeSpot” is Qualitative data (a) Teachers’ opinions Teachers commented positively on 3 (2019), Scotland impact of research. a universal collected from of and experiences the “SafeSpot” programme. They “SafeSpot”, a Teachers (n school-based teachers via with “SafeSpot”. noticed that students were more open pilot mental = 3) from a programme, semi-structured (b) Responses to focus to talking about their mental health health high school peer support, interviews. group and individual following its introduction. programme, on near Glasgow and smartphone questions. However, concerns were expressed students’ mental participated in mobile application. regarding provision of emotional health and the qualitative School-based support while managing other explore teacher phase. programme responsibilities. It was also noted opinions and provides students that teachers did not have requisite experiences. with coping training to address student mental strategies and health needs. mental health It was suggested that the programme information. was pitched at too high a level and Peer support teachers had to spend time adapting addressed content, putting them under pressure. through It was felt that the programme “SafeSpotter” was text-heavy, and that future Scheme in which programmes should take a more older students act interactive approach. as first contacts The peer support scheme was a positive for younger peers addition. Older students acted as during lunchtime mentors, supporting younger students drop-in sessions. and, on several occasions, reported to Smartphone teachers when younger students were application experiencing difficulties. incorporates Teachers had mixed views on the coping strategies, mobile application. It was suggested audio relaxation, that the application would have phone numbers benefited from having young people for crisis support, involved in development, with a view and access to to developing content that sustains mental health student interest. awareness content. Journal of Child & Adolescent Mental Health 2023: 1–20 11 Table 1: Data extraction and synthesis (cont.) Intervention Study Design, Data (a) Key Outcomes and Key Level of Article and Country Aim Description Sample and Setting Collection (b) Key Outcome Measures Findings Evidence and Context Skryabina et al. Explore views Qualitative “FRIENDS” is Focus group (a) Teachers’ views Overall, teachers commented positively 3 (2016), UK of children, descriptive a cognitive interviews. on the “FRIENDS” on the “FRIENDS” programme. It parents and research. behavioural programme. equipped them with skills to deal with school staff on Staff (n = 47) therapy-based (b) Responses to focus children’s problems better. “FRIENDS”, a coordinators programme group questions. Teachers commented positively on universal responsible for focused the workbooks and resource packs school-based the personal, on anxiety which helped them deliver the anxiety social and management. programme. Tools and exercises such prevention emotional Programme as “Red and Green Thoughts” and programme. health curriculum is delivered in “Pizza Massage” were regarded as participated. 45–60-minute beneficial. Participants sessions over However, they felt there was too much included head 9 consecutive content to deliver, and struggled teachers and weeks. to find the time for this. It was principals (n also suggested that the strategies = 15), class employed were too passive, and teachers (n a more practical approach was = 24), and recommended, with more time for personal, discussion. social, health and economic (PSHE) teachers (n = 8). Conducted in 28 schools in South-West England. 12 Goodwin, Behan and O’Brien Table 1: Data extraction and synthesis (cont.) Intervention Study Design, Data (a) Key Outcomes and Key Level of Article and Country Aim Description Sample and Setting Collection (b) Key Outcome Measures Findings Evidence and Context Willis et al. Investigate Mixed methods N/A Data collected (a) Teachers’ views on Teachers felt that such initiatives can 3 (2019), Australia teacher views research. using “Eyes the “nexus between strengthen students’ well-being and of well-being Qualitative data of Teachers” student well-being resilience, which then positively programmes. collected from N Mixed Methods concerns and enhances academic performance, with = 177 teachers Survey, an performance agendas” one teacher noting that “well-being from primary online author- (p. 2652) and underpins all” (p. 2664). (40%) and developed teachers’ “experiences Although several programmes, such secondary (60%) survey using of managing tensions as “MindMatters” and “Kid Matters” schools. Likert scales between performance were cited, only 65% of teachers were and open-ended improvement agendas aware of well-being programmes in questions. and addressing their schools. Teachers with more student well-being knowledge of these programmes had concerns” (p. 2652). significantly more positive responses (b) Likert scales and to these programmes. open-ended questions Teachers acknowledged the impact related to student of wider social systems on student mental health and well-being. well-being. Many teachers questioned the effectiveness of well-being programmes, stating they were superficial and tokenistic. It was also felt that, rather than reducing stress, some programmes added to students’ workload and thus increased stress. Another concern was that teachers lacked training and time to implement programmes and respond to student mental health needs effectively. Journal of Child & Adolescent Mental Health 2023: 1–20 13 addressing students’ well-being and mental health”. Two barriers that teachers have encountered are addressed under the next two themes: “time as a barrier in implementing mental health and well-being programmes” and “a lack of training as a barrier in implementing mental health and well-being programmes”. Finally, under “the need for better agency communication”, teachers’ views on working with mental health services and associated staff are presented. Teachers’ overall views of mental health and well-being programmes Most teachers demonstrated an awareness of available mental health and well-being programmes. However, 25% of teachers in Graham et al.’s (2011) cross-sectional study and 35% of teachers in Willis et al.’s (2019) mixed methods study were not aware of such programmes within their school, indicating that such programmes need to be better promoted within school environments. Teachers had mixed views of mental health and well-being programmes. In Berg et al.’s (2018) action research study, it was felt that the Got Health? initiative promoted positive mental health and enhanced students’ mental health knowledge. There was also an increase in students engaging with the mental health resource pages of the schools’ website. Additionally, it was felt that the programme had a positive effect on teachers themselves. Teachers also felt they benefited from the Healthy Start programme in Nadeem et al.’s (2011) qualitative descriptive study, as they were more adept at identifying at-risk students, and reportedly more effective in how they responded to these students. In both Punukollu et al.’s (2019) mixed methods and Skryabina et al.’s (2016) qualitative descriptive studies, teachers commented positively on the programmes implemented (Safespot and FRIENDS, respectively). The peer support aspect of the Safespot programme was particularly well-evaluated, with younger students’ difficulties reported to teachers through older student mentors. However, it was felt that young people should have been involved in the development of the mobile application element of the programme, with a view towards sustaining user engagement (Punukollu et al., 2019). Teachers felt that the FRIENDS programme equipped them with the skills needed to help young students with their problems; they also commented on the practical aspects of the programme, such as the workbooks and resource packs. Despite these positive comments, teachers felt that FRIENDS could be even more practical in its approach, as some strategies were regarded as too passive (Skryabina et al., 2016). Mixed feedback was also reported in Willis et al.’s (2019) mixed methods study. Although it was noted that well-being initiatives can strengthen students’ well-being and resilience, many teachers questioned the effectiveness of these programmes, viewing them as superficial and tokenistic. It was also felt that the introduction of well-being programmes represented an increase in students’ workloads, which had the effect of elevated stress levels. Less ambiguity was reported in Antoniadou and Bibou-Nakou’s (2012) discourse analysis study. Teachers in this study felt that there was too heavy an emphasis on academic performance in the personal and social education programme. Consequently, students’ social and emotional needs continued to be neglected. Teachers’ perspectives on their role in addressing students’ well-being and mental health There were conflicting opinions regarding the role of teachers in supporting students with mental health issues. Teachers in Nadeem et al.’s (2011) qualitative descriptive study felt that, because they have a lot of direct contact with students, they were well-positioned to identify when students were experiencing distress. Because these teachers reported taking an interest in students’ personal lives, students felt comfortable talking to them about their personal and emotional problems. On the other hand, teachers in Graham et al.’s (2011) cross-sectional study felt that teaching was not a welfare role and that supporting students was not within their remit. In Antoniadou and Bibou-Nakou’s (2012) discourse analysis study, teachers demonstrated greater uncertainty regarding their role in supporting students’ mental health and well-being. These teachers were unsure if caring for students was part of their role or supplementary to their usual teaching duties. However, many acknowledged that they did not provide enough care for their students. 14 Goodwin, Behan and O’Brien Time as a barrier to implementing mental health and well-being programmes Several barriers to implementing mental health and well-being programmes were cited, with “time” acknowledged as a barrier in most studies. In Punukollu et al.’s (2019) mixed method study, teachers felt that the content of the Safespot programme was pitched at too high a level for their students. Consequently, time was spent adapting the content, putting teachers under pressure. Teachers in other studies (Antoniadou & Bibou-Nakou, 2012; Graham et al., 2011; Skryabina et al., 2016; Willis et al., 2019) reported a tension between implementing mental health and well-being initiatives and adhering to the existing demanding curriculum structure, indicating that such initiatives are not always viewed as a priority at the policy level. Lack of training as a barrier to implementing mental health and well-being programmes Another commonly cited barrier was a lack of training in delivering mental health and well-being programmes, meaning teachers were not always comfortable acting as mental health facilitators. Teachers in Nadeem et al.’s (2011) qualitative descriptive study and Punukollu et al.’s (2019) mixed methods study felt that a lack of training around mental health precluded them from adequately supporting students in crisis. Although 80% of teachers in Graham et al.’s (2011) cross-sectional study felt that training in delivering mental health and well-being interventions was very or extremely important, it was noted that such training is expensive or nearly non-existent. Only 34% and 37% felt very confident or confident in implementing mental health programmes, respectively. Moreover, 6% of teachers in this study reported that they were not at all confident in implementing these programmes. Teachers in Willis et al.’s (2019) mixed methods study also felt that they lacked sufficient training in delivering interventions. Need for better interagency communication In Nadeem et al.’s (2011) qualitative descriptive study, teachers highlighted the importance of a “culture of safety”. In order to promote such a culture, it was felt that better communication was needed between teachers and counsellors. In Graham et al.’s (2011) cross-sectional study, some teachers expressed frustration with the lack of connection between outside agencies and the school, indicating that teachers are in need of much better resources to assist them in supporting students’ mental health and well-being. Discussion This systematic review aimed to explore teachers’ experiences of mental health and well-being programmes designed for students. Evidence suggests that mental health outcomes for students are enhanced if there is a commitment from staff to foster a positive mental health ethos within schools (Glazzard et al., 2019; O’Reilly et al., 2018). However, we found that 25–35% of teachers demonstrated a lack of awareness about the availability of mental health and well-being programmes within their own schools. This suggests that schools with mental health and well-being programmes in place need to promote further commitment from staff and develop a stronger culture of support. As Hoare et al. (2017) have noted, the first step to achieving this culture of support is to provide individual teachers with the foundational knowledge to support their own well-being to fulfil their implicit obligation to support the well-being of the student body. This also reflects the need for schools to embrace a whole-school approach to well-being and mental health promotion, where student well-being is recognised as everybody’s responsibility in the school setting (Government of Ireland, 2019; Kern & Wehmeyer, 2021; O’Sullivan & Lynch, 2015; Sweeting et al., 2021; White & Kern, 2018). It is recommended that schools aim to facilitate both targeted and universal approaches to promote mental health to obtain optimal positive outcomes (Mackenzie & Williams, 2018). Our review identifies that some of these programmes were not always viewed as student-friendly, meaning adaptations needed to be made to optimise the intervention impact. This indicates that a participatory or co-production approach could be of benefit to enhance programme outcomes. Co-production involves researchers and consumers working together as collaborative partners at all Journal of Child & Adolescent Mental Health 2023: 1–20 15 stages of intervention design (Happell et al., 2021; O’Brien et al., 2020b). Although co-production is more common in higher-level institutions – with positive results for both service users and students (Happell et al., 2020; 2021, O’Brien et al., 2020b) – there is evidence to suggest that co-production approaches are effective for school programmes concerned with language, maths, writing skills (Honingh et al., 2020), and sexual health (Ponsford et al., 2021). Given the success of such school programmes, in addition to the success of co-produced education in higher education institutes, there is scope for school-going students to contribute to mental health and well-being programmes. Co-production in this context would support the development of learner-centric programmes which would sustain student interest. Other key challenges identified by teachers in the current review were a lack of time to deliver programmes and a deficiency of training around mental health. There is evidence to suggest that having state-level (Brenowitz et al., 2020) and national-level (Nohilly & Tynan, 2019) school mental health policies in place can positively impact a population’s well-being. The success of mental health and well-being programmes is predicated on their implementation being supported by policy that emphasises the time and training required (Gobat et al., 2021). However, research suggests that, despite mental health and well-being policies being in place, adequate time is often not provided to implement programmes (Byrne & Carthy, 2021; Nohilly & Tynan, 2019). This indicates the importance of adopting a whole-school approach to addressing mental health and well-being, where the whole school acts as a community, with an emphasis on well-being as central to the school’s ethos (Abrahamyan et al., 2020; Barry et al., 2013; Glazzard et al., 2019;). Although some countries – such as Greece – employ a health education approach (Maria & Afroditi, 2016), whole-school approaches are being embraced internationally (Gobat et al., 2021; Government of Ireland, 2019; Hanna & Minton, 2021; National Council for Curriculum and Assessment, 2021; Wong et al., 2021). Evidence suggests that adopting a whole-school approach can help to mitigate the barriers identified in the current review, with teachers being able to share responsibilities around student well-being with others, in addition to feeling supported regarding their training needs (Wong et al., 2021). Furthermore, leadership and championing of well-being in schools is understood as a prerequisite to successful engagement and impact of mental health and well-being programmes (Hoare et al., 2017; O’Brien et al., 2020a). The view that mental health and well-being programmes are supplemental to student education needs to change, with such programmes becoming embedded in policy and curricula and whole-school approaches employed to ensure that policy recommendations are realised and maximised. Many teachers were also uncertain about their role in supporting the mental health and well-being needs of students. However, it should be noted that the teacher’s welfare role is paramount for the establishment of a supportive environment where students’ learning can be facilitated (Gray et al., 2017; McCallum & Price, 2015; O’Brien et al., 2020c;). Indeed, in countries where health promotion is implemented as an extracurricular activity, there is evidence of weaker teacher-student relations (Ifantu & Kalofonos, 2011; Organisation for Economic Co-operation and Development, 2011). It is established that while various supports – including parental support – are important in enhancing students’ motivations as learners, teachers can play a significant role in responding to students’ psychological needs (Bureau et al., 2021; Dooley et al., 2019). It is also crucial that students’ emotional and psychological needs are considered by teachers, in addition to a focus on their academic needs, as higher levels of student well-being are associated with superior student engagement and academic performance (Kern & Wehmeyer, 2021). Therefore, although teachers may not always have the skill set to address students’ mental health needs comprehensively, they are ideally positioned to provide indirect support, and to provide other professionals with the relevant information to ensure the best outcomes for students (Amai, 2021; Dimitropoulos et al., 2021; Glazzard et al., 2019). It has been recommended that mental health and well-being education should be delivered to teachers during their pre-service training (Byrne & Carthy, 2021; O’Brien et al., 2021). In addition to reducing the burden on teachers to find the time to upskill during their career, delivering this education at the pre-service stage may help to emphasise the importance of students’ mental health and well-being and clarify the teacher’s role and duty of care in supporting students. 16 Goodwin, Behan and O’Brien Teachers also identified that better communication was warranted between schools and mental health professionals, to foster a culture that appropriately protects and responds to mental health concerns. Although it is common for mental health staff to be employed in some schools (Arora & Algios, 2019), such provisions are not universal (Government of Ireland, 2020; Mann et al., 2019). In the absence of such support, there is a need to enhance relationships between school staff and mental health services. In particular, there is a need to enhance knowledge of referral pathways to mental health services, given that both students (Goodwin et al., 2022) and teachers (Baak et al., 2020) have expressed knowledge deficits here. Some countries, such as Ireland, have proposed the development of a joint protocol between the education and health systems with a view towards facilitating early, appropriate intervention for students (Government of Ireland, 2020). Additionally, Sheridan et al. (2019) highlighted the importance of involving families when supporting students’ mental health needs and fostering supportive cultures within schools. The current review has highlighted deficits in maximising positive mental health and well-being intervention programmes within school environments from the perspective of teachers, and it is crucial that the various stakeholders are identified and encouraged to provide support for each other. The results of this review should be interpreted in light of its limitations. We only included papers published in the English language, resulting in potential language bias. There is also potential publication bias, given that grey literature, such as unpublished research, was excluded. Furthermore, there was diversity in the education systems across countries included in the review, meaning comparisons were often difficult to draw. A strength of this paper is the range of professional backgrounds of the authors: education, mental health nursing, and senior researcher. The team met regularly to engage in reflexive conversations about the review and found that the diversity in perspectives and experience helped to minimise bias. Conclusion The school environment is an ideal place to foster positive mental health and well-being in students. It is recommended that mental health and well-being education is made a priority at the pre-service level of teacher education to ensure teachers are well prepared to offer appropriate support to students and are familiar with the content of relevant programmes. These programmes need to be learner-centric, meaning intervention design should be underpinned by a philosophy of co-production. Although teachers are well-positioned to deliver mental health and well-being programmes, it is vital that this education is supported at both school and policy levels, meaning teachers are provided with the requisite training and the time to implement these. This indicates a whole-school approach to education, where mental health and well-being are central to the school’s ethos, and a culture of safety can be adopted. In addition to a whole-school approach, relationships between external community partners, including families and mental health services, need to be established to ensure a shared responsibility in addressing students’ mental health and well-being. The overall level of evidence was low. It is recommended that future research in this area adopts more robust methodological approaches – including longitudinal strategies – to address teachers’ concerns around mental health and well-being programmes. Funding statement This research received no specific grant from any funding agency, commercial or not-for-profit sectors. Conflicts of interest None. Journal of Child & Adolescent Mental Health 2023: 1–20 17 References Abrahamyan, A., Soares, S., Peres, F. S., & Fraga, S. (2020). Exposure to violence and suicidal ideation among school-going adolescents. Journal of Child & Adolescent Mental Health, 32(2-3), 99–109. https://doi.org/10.2989 /17280583.2020.1848849 Amai, K. (2021). 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Teachers’ views and experiences of student mental health and well-being programmes: A systematic review

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Taylor & Francis
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© 2023 The Author(s). Co-published by NISC Pty (Ltd) and Informa UK Limited, trading as Taylor & Francis Group
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10.2989/17280583.2023.2229876
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Copyright © The Authors Journal of Child & Adolescent Mental Health 2023: 1–20 JOURNAL OF Open Access article distributed in terms of the Creative Commons CHILD & ADOLESCENT MENTAL HEALTH Attribution License [CC BY 4.0] ISSN 1728-0583 EISSN 1728-0591 https://creativecommons.org/licenses/by/4.02022 https://doi.org/10.2989/17280583.2023.2229876 Review Article Teachers’ views and experiences of student mental health and well-being programmes: A systematic review 1 2 3 John Goodwin , Laura Behan & Niamh O’Brien Catherine McAuley School of Nursing and Midwifery, University College Cork, Ireland Health Information and Quality Authority, Ireland Department of Education, South East Technological University, Ireland Correspondence: john.goodwin@ucc.ie Background: In schools, teachers are often tasked with implementing mental health and well-being programmes. However, little is known about teachers’ views on and experiences with implementing these programmes. Aim: The aim of this systematic review was to explore teachers’ views and experiences of mental health and well-being intervention programmes developed to promote and protect student mental health. Methods: A systematic review of the empirical literature was conducted using the following databases: Academic Search Complete, APA PsycArticles, APA PsycInfo, British Education Index, Education Full Text (H.W. Wilson), ERIC, Social Sciences Full Text (H.W. Wilson), and SocINDEX with Full Text. Findings: Seven papers met the inclusion criteria. Teachers reported several challenges to the successful implementation of mental health and well-being programmes, including a lack of time allotted in the curriculum, insufficient training, and inadequate interagency support. There was evidence of conflicting opinions regarding the role of teachers in supporting students. Conclusion: It is recommended that mental health and well-being are viewed as central to schools’ ethos and that teachers are adequately prepared to implement programmes. Keywords: mental health; mental illness; students; teachers; well-being; systematic review Introduction Adolescence is a developmental period of immense change when the vulnerability to the experience of mental distress peaks (Hartas, 2021; McCrory et al., 2022; Solmi et al., 2021). Indeed, it has been reported that half of all mental illnesses start by age 14 (World Health Organization, 2021). There is a historical and more recently elevated call to action to urgently respond to the global adolescent mental health crisis (Benton et al., 2021; Goodwin et al., 2016; Kuhn et al., 2021; Solmi et al., 2021; World Economic Forum, 2020). It is widely understood that health and mental health is influenced by a range of determinants from the biological, social, and psychological domains (Engel, 1977; Lehman et al., 2017), meaning both biological and environmental risk factors and protective factors exist within an individual’s dynamic socio-ecological system at which they are the centre (Bronfenbrenner, 1992). This emphasises the importance of social relationships across a range of layered environments such as the microsystem (school, home, community), the mesosystem (interactions between the members of the microsystem), the exosystem (indirect environments), and the macrosystem (shared culture, norms, policies, and values) on adolescent mental health. Therefore, mental health risk factors of adolescents can range from age and gender to learning needs, family stress, relationships, Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Informa UK Limited [trading as Taylor & Francis Group] 2 Goodwin, Behan and O’Brien socio-economic status, school life, and community (Dooley et al., 2019). Mental health protective factors that also exist within the layers of the socio-ecological system, including gender, school connectedness, family support, and the presence of “one good adult” can act as a buffer against mental distress (Dooley et al., 2019). Research determines social support plays a key role in promoting adolescents’ psychological well-being, with teacher social support associated with better psychological well-being for all students (Guo et al., 2018). As a result of the ecological dynamics of adolescent mental health, there is a need to respond to the mental health needs of adolescents across each of the layers of the socio-ecological system (Barry, 2009). Schools are seen as one of the most important settings for the promotion of mental health as they provide ample opportunities to reach the adolescent population to promote and protect good mental health and well-being (Government of Ireland, 2020; Holzer et al., 2021; World Health Organization, 2004). Mental health interventions can be large-scale and part of a whole-school approach or education-specific experiences that aim to promote mental health, prevent mental illness development, and treat diagnosed illnesses through cognitive skills training (Barry, 2009; O’Reilly et al., 2018; Weare, 2000). Mental health interventions that are part of a whole-school approach to well-being promotion deliver positive outcomes when embedded across the whole-school system, producing long-term benefits for young people, including enhanced emotional and social functioning, positive health behaviours, and academic performance (Barry et al., 2013; Clarke et al., 2021; Hoare et al., 2017). Education-specific mental health intervention programmes for schools are diverse in their design but can include themes such as positive psychoeducation (Hoare et al., 2017), mindfulness (Bauer et al., 2019), mental health literacy (Ojio et al., 2015), and health-seeking (Gulliver et al., 2012). Research indicates that students benefit from engagement in education-specific mental health interventions that are tailored to address the key behavioural determinants of mental health for the target population group (Barry, 2009; Barry et al., 2013). Multiple systematic reviews found statistically significant increases in student knowledge and awareness of mental illnesses (Bidik & Sisman, 2021; Gulliver et al., 2012; Ma et al., 2022), resilience, communication skills (King & Fazel, 2021), self-esteem, self-efficacy, emotional competence, life satisfaction, positive body perception, self-awareness, self-regulation, psychological flexibility, sense of belonging to society, social-emotional skills, problem-solving skills and coping skills (Bidik & Sisman, 2021), in addition to reductions in mental health stigma and depressive and anxiety symptoms (Dray et al., 2017). However, although there is good evidence to support the efficacy of mental health interventions in enhancing student knowledge and skills to cope with adversity and mental health risks. O’Reilly et al. (2018) highlight the challenges that still exist for successful mental health promotion. Although teachers often act as gatekeepers to help students with mental health needs, in Ireland, it has been reported that 95% of teachers do not perceive themselves as adequately trained to support students with mental health difficulties (Ni Chorcora & Swords, 2021). Nonetheless, their capacity to appropriately respond to the mental health needs of students through intervention can have a life-long impact on an individual, making teachers’ level of mental health knowledge and skill essential to their efficacy of intervention programme delivery (Byrne & Carthy, 2021). It is generally accepted worldwide that supporting and promoting social-emotional learning is viewed as an important aspect of a teacher’s role to support the learning and mental well-being of students in schools (Ekornes, 2015; Froese-Germain & Riel, 2012; Knightsmith et al., 2013; Mazzer & Rickwood, 2015). However, the extent to which teachers promote, support and respond to student mental health varies widely, with schools in some countries including more involvement of health and mental health professionals than others (Patalay et al., 2017). This indicates that some schools have the provisions for teachers to remain more focused on academic performance, with the support of on-site professionals to promote student well-being (such as school counsellors and nurses), while others might be disproportionately affected by the limited access to trained and/or specialist staff. Increasingly, teachers rather than mental health professionals are the primary delivery agents of mental health interventions, as they are the link between student academic learning and social and emotional competencies and well-being (Cefai et al., 2021; O’Reilly et al., 2018). In addition, embedding mental health into the school curriculum encourages schools and teachers to broaden Journal of Child & Adolescent Mental Health 2023: 1–20 3 their agenda to include mental health and well-being as a shared responsibility and key learning objective of education (Cefai et al., 2021; Hoare et al., 2017). However, there is limited data on teacher involvement in the evaluation process (Franklin et al., 2013). If teachers represent the frontline of opportunity to promote and protect the mental health of young people during the delivery of mental health interventions in school settings, their perceptions of the experience and their roles are vital to ensure that they feel supported and informed to sustain such an initiative. Therefore, this systematic review aims to answer the question: what are teachers’ views and experiences of mental health and well-being intervention programmes developed to promote and protect student mental health? This includes studies where teachers observed the delivery of a mental health and well-being programme, or where teachers facilitated the programme themselves. Studies conducted in schools where mental health and well-being programmes were implemented were also included, whether or not teachers surveyed delivered the programmes. Method This systematic review was guided by the Cochrane Handbook for Systematic Reviews of Interventions (Chandler et al., 2019) and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist (Page et al., 2021). The review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42021282864). The PICOS (Population, Intervention, Comparison, Outcomes, Study Design) framework was used to determine study eligibility. Empirical studies of any design (Study Design) were eligible for inclusion provided that they focussed on teachers’ (Population) views on mental health programmes within schools and experiences of observing or facilitating (Outcomes) mental health/well-being education programmes (Intervention) delivered in schools or as part of school-endorsed activity (Setting), with or without comparators (Comparison). Studies were excluded if: (i) they focussed on the experiences of third-level educators; (ii) teacher data could not be distinguished from student data; or (iii) the mental health activity was unconnected to the school. We also excluded intervention protocols, literature reviews, dissertations, conference proceedings, commentaries, and editorials. No geographical limitations were set. Search strategy We searched the following electronic databases for relevant studies: Academic Search Complete, APA PsycArticles, APA PsycInfo, British Education Index, Education Full Text (H.W. Wilson), ERIC, Social Sciences Full Text (H.W. Wilson), SocINDEX with Full Text. We also reviewed the reference lists of potentially eligible studies to identify additional studies. The following keywords were used with all databases, truncated to maximise retrieval, combined using Boolean operators “OR” and “AND,” and searched on title OR abstract: (Teacher*) AND (Experience* OR view* OR opinion* OR issue* OR barrier* OR outcome* OR perception* OR perspective*) AND (OR “well-being program*” OR “well-being initiative*” OR “well-being education” OR “well-being strategy” OR “well-being module” OR “well-being class*” OR “well-being program*” OR “well-being initiative*” OR “well-being education” OR “well-being strategy” OR “well-being module” OR “well-being class*” OR “mental health program*” OR “mental health initiative*” OR “mental health education” OR “mental health strategy” OR “mental health module” OR “mental health class*”). The search was last conducted on 17 April 2023. Study selection Records identified from the search were transferred to Covidence and duplicates were deleted. Titles/abstracts and full texts were screened independently by JG and NOB. Screening conflicts were identified by Covidence (Veritas Health Innovation, n.d.) and resolved by LB (see Figure 1). 4 Goodwin, Behan and O’Brien Identification of studies via other methods Identification of studies via databases and registers Records removed before Records identified from: Citation Records identified from screening: Duplicate records searching (n = 2) databases (n = 279) removed (n = 110) Records not retrieved Records sought for retrieval Records screened (n = 169) Records excluded (n = 143) (n = 0) (n = 2) Records excluded (n = 1): Records sought for retrieval Records assessed for eligibility Records not retrieved (n = 0) Incorrect study design (n = 26) (n = 2) (n = 1) Records assessed for eligibility Records excluded (n = 20): (n = 26) Wrong study design (n = 7) Wrong intervention (n = 1) Wrong outcomes (n = 6) Wrong setting (n = 2) Wrong population (n = 4) Studies included in review (n = 7) Figure 1. Study identification, screening, and selection process Screening Identification Included Journal of Child & Adolescent Mental Health 2023: 1–20 5 Data extraction and synthesis One reviewer (JG) extracted data from eligible studies using the following headings: author(s) (year) and country; aim of the study; study design, sample and setting; intervention description and context; data collection process; key outcomes and key outcome measures; and key findings (see Table 1). Each extracted study was cross-checked by another reviewer (NOB) to minimise reporting bias. Owing to the heterogeneity in study design and outcome measures, a meta-analysis was not practicable. Instead, a narrative synthesis of findings is presented. Quality assessment Critical appraisal was conducted to ensure the accuracy and consistency of data. The quality of four papers was appraised using standard critical appraisal tools prepared by the Joanna Briggs Institute (JBI) (2019). For the two mixed methods papers (Punukollu et al., 2019; Willis et al., 2019), the Mixed Methods Appraisal Tool was used (Hong et al., 2018). Critical appraisal was completed by JG and cross-checked by NOB. The level of evidence was also assessed using the Scottish Intercollegiate Guidelines Network (SIGN) grading system (Healthcare Improvement Scotland, 2011). Individual studies are given a grade ranging from 1++ (high-quality meta-analyses; systematic reviews of randomised controlled trials) to 4 (expert opinion). An overall grade recommendation is awarded, ranging from A (highest level of evidence) to D (lowest level of evidence). The level of evidence was completed by JG and cross-checked by LB. Results An initial search of the empirical literature identified 253 records (see Figure 1). Following the removal of 108 duplicates, we screened 145 papers on title and abstract and excluded 120 irrelevant papers based on eligibility criteria. The full texts of the remaining 25 papers were screened; 19 papers were excluded. Two further records were identified from reference list checks. A total of seven studies were included in this review. Study characteristics There were two mixed-method studies, two qualitative descriptive studies, one discourse analysis study, one action research study, and one cross-sectional study. Studies were conducted in Australia (n = 2) (Graham et al., 2011; Willis et al., 2019), the UK (n = 2) (Punukollu et al., 2016; Skryabina et al., 2016), Canada (n = 1) (Berg et al., 2018), Greece (n = 1) (Antoniadou & Bibou-Nakou, 2012), and the USA (n = 1) (Nadeem et al., 2011). Sample sizes ranged from 3 (Punukollu et al., 2019) to 508 teachers (Graham et al., 2011). Study characteristics are presented in full in Table 1. Quality appraisal There were no major concerns identified regarding the quality of the mixed methods, action research, and qualitative study designs. There were some concerns regarding the cross-sectional study, as confounding factors were not identified, and validated instruments were not used to collect data. All studies scored 3 on the SIGN level of the evidence grading system (Healthcare Improvement Scotland, 2011), indicating that these studies were descriptive and non-analytic. An overall grade recommendation of “D” was awarded, indicating an overall low level of evidence. Overview of findings Four overarching themes are presented in this narrative synthesis. Under the first theme, “teachers’ overall views of mental health and well-being programmes”, teachers’ awareness of mental health and well-being programmes is addressed, as are their views on the effectiveness of existing programmes. Next, mixed and conflicting views regarding the role of teachers in supporting students with mental health issues are reported under “teachers’ perspective on their role in 6 Goodwin, Behan and O’Brien Table 1: Data extraction and synthesis Intervention Study Design, Data (a) Key Outcomes and Key Level of Article and Country Aim Description Sample and Setting Collection (b) Key Outcome Measures Findings Evidence and Context Antoniadou and Explore teachers’ Discourse Teachers took 14 focus group (a) Teachers’ Teachers commented that, despite 3 Bibou-Nakou reflections analysis. part in a interviews. experiences of positive intentions, the introduction (2012), Greece and dilemmas Primary school 4-day training participating in a PSE of PSE programmes was an by discussing teachers (n = programme with programme. endorsement of the status quo, and experiences 66) participated mental health (b) Responses to focus an extension of the focus on academic with a personal in the specialists, group questions. performance. and social implementation developing Most teachers were uncertain about education (PSE) of mental health their knowledge how to prioritise their caring role, programme. education and skills, and whether caring duties were programmes. and becoming supplementary to teaching duties. familiar with However, many teachers felt they did learning not provide enough care for students. resources. A tension exists between delivery of Teachers then the formal curriculum and the social implement the development of students. programme in The PSE programme reduces a schools. disciplinary system of teaching and promotes a relational approach to good behaviour. It was felt that, owing to a lack of clear policies or procedures for addressing children’s mental health and a heavy focus on academic performance, schools neglect children’s social and emotional lives. Teachers indicated that there was a lack of time to implement PSE due to the demanding curriculum structure. Journal of Child & Adolescent Mental Health 2023: 1–20 7 Table 1: Data extraction and synthesis (cont.) Intervention Study Design, Data (a) Key Outcomes and Key Level of Article and Country Aim Description Sample and Setting Collection (b) Key Outcome Measures Findings Evidence and Context Berg et al. (2018), Evaluate student Action research. “Got Health?” is Focus group (a) The impact of “Got Teachers felt that “Got Health?” 3 Canada and staff Large urban an inquiry-based interviews Health?” on improving enhanced awareness of promoting perceptions school district in student-led (number of awareness around positive mental health and awareness of a student- British Columbia. programme interviews not positive mental health of mental health issues. led health Four schools were aimed at provided). and enhancing mental The programme increased the spread of promotion included in the empowering health and well-being positive messages around the school. programme study out of 12 students. in schools. Posters about mental health were known as “Got invited to apply. Through action (b) Responses to focus present in the school environment Health?” Each school had research, group questions. and there was an increase in visits to a “Got Health?” students ask the mental health resources page on team. Teams questions, school websites. were diverse create initiatives, Teachers also reported the programme and included: examine and had a positive effect on their own students (2–8 re-examine the well-being. student leaders), impact of their at least 1 activities on lead teacher the factors that (to guide and contribute to a support students more positive through the school climate. inquiry process), administrators, and community partners (e.g., parents, guardians and public health nurses). 8 Goodwin, Behan and O’Brien Table 1: Data extraction and synthesis (cont.) Intervention Study Design, Data (a) Key Outcomes and Key Level of Article and Country Aim Description Sample and Setting Collection (b) Key Outcome Measures Findings Evidence and Context Graham et al. Investigate Cross-sectional N/A Surveys (a) Teachers’ Over 25% of teachers did not respond 3 (2011), Australia teacher study. distributed to perspectives on or stated that they were not aware of perspectives on Surveys completed primary and student mental health any mental health initiatives in their student mental by teachers in secondary and mental health schools. Others cited a wide range of health and primary and schools in New education. initiatives. mental health secondary South Wales. (b) Surveys consisted Only 34% of teachers felt very confident education. schools in of author-developed in implementing mental health New South Likert scales, open- programmes, and 37% felt quite Wales. Out of and closed-ended confident. Notably, 6% were not 2 220 surveys questions. confident at all. distributed, n Teachers indicated that they were = 508 were not provided time and funding to returned, with adequately deliver mental health a return rate of education, citing the “crowded 23%. curriculum” (p. 490) as an obstacle. Some teachers commented on the difficulties balancing regular teaching duties with providing mental health support and expressed frustration with the lack of connection between outside support agencies and the school. Some teachers felt that teaching was not a welfare role, maintaining that teachers were largely untrained in supporting students’ mental health needs. Journal of Child & Adolescent Mental Health 2023: 1–20 9 Table 1: Data extraction and synthesis (cont.) Intervention Study Design, Data (a) Key Outcomes and Key Level of Article and Country Aim Description Sample and Setting Collection (b) Key Outcome Measures Findings Evidence and Context Nadeem et al. Examine Qualitative YSPP involves 5 focus groups (a) Staff views on Teachers commented that because 3 (2011), US school staff descriptive training school and 10 individual implementation of they have direct contact with students perspectives research. personnel to interviews with YSSP, particularly regularly, they were well-positioned to of the Study took place identify at-risk middle-school barriers and recognise changes in student mood implementation in one of the students, engage teachers, facilitators. and behaviour. of a district-wide nation’s largest their support administrators, (b) Responses to focus Teachers desired better communication youth suicide school districts. networks, and and other school group and individual with administrators or counsellors prevention 45 participants, refer them for personnel. interview questions. about mental health issues. Although program including 10 appropriate formal referral processes were in (YSPP). administrators, 7 counselling place in schools, teachers valued Research focus counsellors or and treatment. information shared across informal was the role mental health staff, 90 minutes of networks, with teachers providing of teachers 2 nurses, and 26 training provided support for one another. at different teachers. annually to The importance of a culture of safety stages in the schools to was emphasised. gatekeeper support staff in In post-crisis scenarios, teachers model of suicide implementing reported that lack of feedback and prevention. YSPP. training disabled their capacity to support student needs. Teachers who previously completed an embedded school-wide programme, known as the Healthy Start programme, were more adept in identifying students at risk for suicide and other mental health problems and were effective in their response to students. 10 Goodwin, Behan and O’Brien Table 1: Data extraction and synthesis (cont.) (a) Key Outcomes and Study Design, Intervention Description Data Key Level of Article and Country Aim (b) Key Outcome Sample and Setting and Context Collection Findings Evidence Measures Punukollu et al. Evaluate the Mixed methods “SafeSpot” is Qualitative data (a) Teachers’ opinions Teachers commented positively on 3 (2019), Scotland impact of research. a universal collected from of and experiences the “SafeSpot” programme. They “SafeSpot”, a Teachers (n school-based teachers via with “SafeSpot”. noticed that students were more open pilot mental = 3) from a programme, semi-structured (b) Responses to focus to talking about their mental health health high school peer support, interviews. group and individual following its introduction. programme, on near Glasgow and smartphone questions. However, concerns were expressed students’ mental participated in mobile application. regarding provision of emotional health and the qualitative School-based support while managing other explore teacher phase. programme responsibilities. It was also noted opinions and provides students that teachers did not have requisite experiences. with coping training to address student mental strategies and health needs. mental health It was suggested that the programme information. was pitched at too high a level and Peer support teachers had to spend time adapting addressed content, putting them under pressure. through It was felt that the programme “SafeSpotter” was text-heavy, and that future Scheme in which programmes should take a more older students act interactive approach. as first contacts The peer support scheme was a positive for younger peers addition. Older students acted as during lunchtime mentors, supporting younger students drop-in sessions. and, on several occasions, reported to Smartphone teachers when younger students were application experiencing difficulties. incorporates Teachers had mixed views on the coping strategies, mobile application. It was suggested audio relaxation, that the application would have phone numbers benefited from having young people for crisis support, involved in development, with a view and access to to developing content that sustains mental health student interest. awareness content. Journal of Child & Adolescent Mental Health 2023: 1–20 11 Table 1: Data extraction and synthesis (cont.) Intervention Study Design, Data (a) Key Outcomes and Key Level of Article and Country Aim Description Sample and Setting Collection (b) Key Outcome Measures Findings Evidence and Context Skryabina et al. Explore views Qualitative “FRIENDS” is Focus group (a) Teachers’ views Overall, teachers commented positively 3 (2016), UK of children, descriptive a cognitive interviews. on the “FRIENDS” on the “FRIENDS” programme. It parents and research. behavioural programme. equipped them with skills to deal with school staff on Staff (n = 47) therapy-based (b) Responses to focus children’s problems better. “FRIENDS”, a coordinators programme group questions. Teachers commented positively on universal responsible for focused the workbooks and resource packs school-based the personal, on anxiety which helped them deliver the anxiety social and management. programme. Tools and exercises such prevention emotional Programme as “Red and Green Thoughts” and programme. health curriculum is delivered in “Pizza Massage” were regarded as participated. 45–60-minute beneficial. Participants sessions over However, they felt there was too much included head 9 consecutive content to deliver, and struggled teachers and weeks. to find the time for this. It was principals (n also suggested that the strategies = 15), class employed were too passive, and teachers (n a more practical approach was = 24), and recommended, with more time for personal, discussion. social, health and economic (PSHE) teachers (n = 8). Conducted in 28 schools in South-West England. 12 Goodwin, Behan and O’Brien Table 1: Data extraction and synthesis (cont.) Intervention Study Design, Data (a) Key Outcomes and Key Level of Article and Country Aim Description Sample and Setting Collection (b) Key Outcome Measures Findings Evidence and Context Willis et al. Investigate Mixed methods N/A Data collected (a) Teachers’ views on Teachers felt that such initiatives can 3 (2019), Australia teacher views research. using “Eyes the “nexus between strengthen students’ well-being and of well-being Qualitative data of Teachers” student well-being resilience, which then positively programmes. collected from N Mixed Methods concerns and enhances academic performance, with = 177 teachers Survey, an performance agendas” one teacher noting that “well-being from primary online author- (p. 2652) and underpins all” (p. 2664). (40%) and developed teachers’ “experiences Although several programmes, such secondary (60%) survey using of managing tensions as “MindMatters” and “Kid Matters” schools. Likert scales between performance were cited, only 65% of teachers were and open-ended improvement agendas aware of well-being programmes in questions. and addressing their schools. Teachers with more student well-being knowledge of these programmes had concerns” (p. 2652). significantly more positive responses (b) Likert scales and to these programmes. open-ended questions Teachers acknowledged the impact related to student of wider social systems on student mental health and well-being. well-being. Many teachers questioned the effectiveness of well-being programmes, stating they were superficial and tokenistic. It was also felt that, rather than reducing stress, some programmes added to students’ workload and thus increased stress. Another concern was that teachers lacked training and time to implement programmes and respond to student mental health needs effectively. Journal of Child & Adolescent Mental Health 2023: 1–20 13 addressing students’ well-being and mental health”. Two barriers that teachers have encountered are addressed under the next two themes: “time as a barrier in implementing mental health and well-being programmes” and “a lack of training as a barrier in implementing mental health and well-being programmes”. Finally, under “the need for better agency communication”, teachers’ views on working with mental health services and associated staff are presented. Teachers’ overall views of mental health and well-being programmes Most teachers demonstrated an awareness of available mental health and well-being programmes. However, 25% of teachers in Graham et al.’s (2011) cross-sectional study and 35% of teachers in Willis et al.’s (2019) mixed methods study were not aware of such programmes within their school, indicating that such programmes need to be better promoted within school environments. Teachers had mixed views of mental health and well-being programmes. In Berg et al.’s (2018) action research study, it was felt that the Got Health? initiative promoted positive mental health and enhanced students’ mental health knowledge. There was also an increase in students engaging with the mental health resource pages of the schools’ website. Additionally, it was felt that the programme had a positive effect on teachers themselves. Teachers also felt they benefited from the Healthy Start programme in Nadeem et al.’s (2011) qualitative descriptive study, as they were more adept at identifying at-risk students, and reportedly more effective in how they responded to these students. In both Punukollu et al.’s (2019) mixed methods and Skryabina et al.’s (2016) qualitative descriptive studies, teachers commented positively on the programmes implemented (Safespot and FRIENDS, respectively). The peer support aspect of the Safespot programme was particularly well-evaluated, with younger students’ difficulties reported to teachers through older student mentors. However, it was felt that young people should have been involved in the development of the mobile application element of the programme, with a view towards sustaining user engagement (Punukollu et al., 2019). Teachers felt that the FRIENDS programme equipped them with the skills needed to help young students with their problems; they also commented on the practical aspects of the programme, such as the workbooks and resource packs. Despite these positive comments, teachers felt that FRIENDS could be even more practical in its approach, as some strategies were regarded as too passive (Skryabina et al., 2016). Mixed feedback was also reported in Willis et al.’s (2019) mixed methods study. Although it was noted that well-being initiatives can strengthen students’ well-being and resilience, many teachers questioned the effectiveness of these programmes, viewing them as superficial and tokenistic. It was also felt that the introduction of well-being programmes represented an increase in students’ workloads, which had the effect of elevated stress levels. Less ambiguity was reported in Antoniadou and Bibou-Nakou’s (2012) discourse analysis study. Teachers in this study felt that there was too heavy an emphasis on academic performance in the personal and social education programme. Consequently, students’ social and emotional needs continued to be neglected. Teachers’ perspectives on their role in addressing students’ well-being and mental health There were conflicting opinions regarding the role of teachers in supporting students with mental health issues. Teachers in Nadeem et al.’s (2011) qualitative descriptive study felt that, because they have a lot of direct contact with students, they were well-positioned to identify when students were experiencing distress. Because these teachers reported taking an interest in students’ personal lives, students felt comfortable talking to them about their personal and emotional problems. On the other hand, teachers in Graham et al.’s (2011) cross-sectional study felt that teaching was not a welfare role and that supporting students was not within their remit. In Antoniadou and Bibou-Nakou’s (2012) discourse analysis study, teachers demonstrated greater uncertainty regarding their role in supporting students’ mental health and well-being. These teachers were unsure if caring for students was part of their role or supplementary to their usual teaching duties. However, many acknowledged that they did not provide enough care for their students. 14 Goodwin, Behan and O’Brien Time as a barrier to implementing mental health and well-being programmes Several barriers to implementing mental health and well-being programmes were cited, with “time” acknowledged as a barrier in most studies. In Punukollu et al.’s (2019) mixed method study, teachers felt that the content of the Safespot programme was pitched at too high a level for their students. Consequently, time was spent adapting the content, putting teachers under pressure. Teachers in other studies (Antoniadou & Bibou-Nakou, 2012; Graham et al., 2011; Skryabina et al., 2016; Willis et al., 2019) reported a tension between implementing mental health and well-being initiatives and adhering to the existing demanding curriculum structure, indicating that such initiatives are not always viewed as a priority at the policy level. Lack of training as a barrier to implementing mental health and well-being programmes Another commonly cited barrier was a lack of training in delivering mental health and well-being programmes, meaning teachers were not always comfortable acting as mental health facilitators. Teachers in Nadeem et al.’s (2011) qualitative descriptive study and Punukollu et al.’s (2019) mixed methods study felt that a lack of training around mental health precluded them from adequately supporting students in crisis. Although 80% of teachers in Graham et al.’s (2011) cross-sectional study felt that training in delivering mental health and well-being interventions was very or extremely important, it was noted that such training is expensive or nearly non-existent. Only 34% and 37% felt very confident or confident in implementing mental health programmes, respectively. Moreover, 6% of teachers in this study reported that they were not at all confident in implementing these programmes. Teachers in Willis et al.’s (2019) mixed methods study also felt that they lacked sufficient training in delivering interventions. Need for better interagency communication In Nadeem et al.’s (2011) qualitative descriptive study, teachers highlighted the importance of a “culture of safety”. In order to promote such a culture, it was felt that better communication was needed between teachers and counsellors. In Graham et al.’s (2011) cross-sectional study, some teachers expressed frustration with the lack of connection between outside agencies and the school, indicating that teachers are in need of much better resources to assist them in supporting students’ mental health and well-being. Discussion This systematic review aimed to explore teachers’ experiences of mental health and well-being programmes designed for students. Evidence suggests that mental health outcomes for students are enhanced if there is a commitment from staff to foster a positive mental health ethos within schools (Glazzard et al., 2019; O’Reilly et al., 2018). However, we found that 25–35% of teachers demonstrated a lack of awareness about the availability of mental health and well-being programmes within their own schools. This suggests that schools with mental health and well-being programmes in place need to promote further commitment from staff and develop a stronger culture of support. As Hoare et al. (2017) have noted, the first step to achieving this culture of support is to provide individual teachers with the foundational knowledge to support their own well-being to fulfil their implicit obligation to support the well-being of the student body. This also reflects the need for schools to embrace a whole-school approach to well-being and mental health promotion, where student well-being is recognised as everybody’s responsibility in the school setting (Government of Ireland, 2019; Kern & Wehmeyer, 2021; O’Sullivan & Lynch, 2015; Sweeting et al., 2021; White & Kern, 2018). It is recommended that schools aim to facilitate both targeted and universal approaches to promote mental health to obtain optimal positive outcomes (Mackenzie & Williams, 2018). Our review identifies that some of these programmes were not always viewed as student-friendly, meaning adaptations needed to be made to optimise the intervention impact. This indicates that a participatory or co-production approach could be of benefit to enhance programme outcomes. Co-production involves researchers and consumers working together as collaborative partners at all Journal of Child & Adolescent Mental Health 2023: 1–20 15 stages of intervention design (Happell et al., 2021; O’Brien et al., 2020b). Although co-production is more common in higher-level institutions – with positive results for both service users and students (Happell et al., 2020; 2021, O’Brien et al., 2020b) – there is evidence to suggest that co-production approaches are effective for school programmes concerned with language, maths, writing skills (Honingh et al., 2020), and sexual health (Ponsford et al., 2021). Given the success of such school programmes, in addition to the success of co-produced education in higher education institutes, there is scope for school-going students to contribute to mental health and well-being programmes. Co-production in this context would support the development of learner-centric programmes which would sustain student interest. Other key challenges identified by teachers in the current review were a lack of time to deliver programmes and a deficiency of training around mental health. There is evidence to suggest that having state-level (Brenowitz et al., 2020) and national-level (Nohilly & Tynan, 2019) school mental health policies in place can positively impact a population’s well-being. The success of mental health and well-being programmes is predicated on their implementation being supported by policy that emphasises the time and training required (Gobat et al., 2021). However, research suggests that, despite mental health and well-being policies being in place, adequate time is often not provided to implement programmes (Byrne & Carthy, 2021; Nohilly & Tynan, 2019). This indicates the importance of adopting a whole-school approach to addressing mental health and well-being, where the whole school acts as a community, with an emphasis on well-being as central to the school’s ethos (Abrahamyan et al., 2020; Barry et al., 2013; Glazzard et al., 2019;). Although some countries – such as Greece – employ a health education approach (Maria & Afroditi, 2016), whole-school approaches are being embraced internationally (Gobat et al., 2021; Government of Ireland, 2019; Hanna & Minton, 2021; National Council for Curriculum and Assessment, 2021; Wong et al., 2021). Evidence suggests that adopting a whole-school approach can help to mitigate the barriers identified in the current review, with teachers being able to share responsibilities around student well-being with others, in addition to feeling supported regarding their training needs (Wong et al., 2021). Furthermore, leadership and championing of well-being in schools is understood as a prerequisite to successful engagement and impact of mental health and well-being programmes (Hoare et al., 2017; O’Brien et al., 2020a). The view that mental health and well-being programmes are supplemental to student education needs to change, with such programmes becoming embedded in policy and curricula and whole-school approaches employed to ensure that policy recommendations are realised and maximised. Many teachers were also uncertain about their role in supporting the mental health and well-being needs of students. However, it should be noted that the teacher’s welfare role is paramount for the establishment of a supportive environment where students’ learning can be facilitated (Gray et al., 2017; McCallum & Price, 2015; O’Brien et al., 2020c;). Indeed, in countries where health promotion is implemented as an extracurricular activity, there is evidence of weaker teacher-student relations (Ifantu & Kalofonos, 2011; Organisation for Economic Co-operation and Development, 2011). It is established that while various supports – including parental support – are important in enhancing students’ motivations as learners, teachers can play a significant role in responding to students’ psychological needs (Bureau et al., 2021; Dooley et al., 2019). It is also crucial that students’ emotional and psychological needs are considered by teachers, in addition to a focus on their academic needs, as higher levels of student well-being are associated with superior student engagement and academic performance (Kern & Wehmeyer, 2021). Therefore, although teachers may not always have the skill set to address students’ mental health needs comprehensively, they are ideally positioned to provide indirect support, and to provide other professionals with the relevant information to ensure the best outcomes for students (Amai, 2021; Dimitropoulos et al., 2021; Glazzard et al., 2019). It has been recommended that mental health and well-being education should be delivered to teachers during their pre-service training (Byrne & Carthy, 2021; O’Brien et al., 2021). In addition to reducing the burden on teachers to find the time to upskill during their career, delivering this education at the pre-service stage may help to emphasise the importance of students’ mental health and well-being and clarify the teacher’s role and duty of care in supporting students. 16 Goodwin, Behan and O’Brien Teachers also identified that better communication was warranted between schools and mental health professionals, to foster a culture that appropriately protects and responds to mental health concerns. Although it is common for mental health staff to be employed in some schools (Arora & Algios, 2019), such provisions are not universal (Government of Ireland, 2020; Mann et al., 2019). In the absence of such support, there is a need to enhance relationships between school staff and mental health services. In particular, there is a need to enhance knowledge of referral pathways to mental health services, given that both students (Goodwin et al., 2022) and teachers (Baak et al., 2020) have expressed knowledge deficits here. Some countries, such as Ireland, have proposed the development of a joint protocol between the education and health systems with a view towards facilitating early, appropriate intervention for students (Government of Ireland, 2020). Additionally, Sheridan et al. (2019) highlighted the importance of involving families when supporting students’ mental health needs and fostering supportive cultures within schools. The current review has highlighted deficits in maximising positive mental health and well-being intervention programmes within school environments from the perspective of teachers, and it is crucial that the various stakeholders are identified and encouraged to provide support for each other. The results of this review should be interpreted in light of its limitations. We only included papers published in the English language, resulting in potential language bias. There is also potential publication bias, given that grey literature, such as unpublished research, was excluded. Furthermore, there was diversity in the education systems across countries included in the review, meaning comparisons were often difficult to draw. A strength of this paper is the range of professional backgrounds of the authors: education, mental health nursing, and senior researcher. The team met regularly to engage in reflexive conversations about the review and found that the diversity in perspectives and experience helped to minimise bias. Conclusion The school environment is an ideal place to foster positive mental health and well-being in students. It is recommended that mental health and well-being education is made a priority at the pre-service level of teacher education to ensure teachers are well prepared to offer appropriate support to students and are familiar with the content of relevant programmes. These programmes need to be learner-centric, meaning intervention design should be underpinned by a philosophy of co-production. Although teachers are well-positioned to deliver mental health and well-being programmes, it is vital that this education is supported at both school and policy levels, meaning teachers are provided with the requisite training and the time to implement these. This indicates a whole-school approach to education, where mental health and well-being are central to the school’s ethos, and a culture of safety can be adopted. In addition to a whole-school approach, relationships between external community partners, including families and mental health services, need to be established to ensure a shared responsibility in addressing students’ mental health and well-being. The overall level of evidence was low. It is recommended that future research in this area adopts more robust methodological approaches – including longitudinal strategies – to address teachers’ concerns around mental health and well-being programmes. Funding statement This research received no specific grant from any funding agency, commercial or not-for-profit sectors. Conflicts of interest None. Journal of Child & Adolescent Mental Health 2023: 1–20 17 References Abrahamyan, A., Soares, S., Peres, F. S., & Fraga, S. (2020). Exposure to violence and suicidal ideation among school-going adolescents. Journal of Child & Adolescent Mental Health, 32(2-3), 99–109. https://doi.org/10.2989 /17280583.2020.1848849 Amai, K. (2021). 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Journal

Journal of Child and Adolescent Mental HealthTaylor & Francis

Published: Sep 2, 2021

Keywords: mental health; mental illness; students; teachers; well-being; systematic review

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