Examining Mental Health and Well-being Provision in Schools in Europe : Methodological Approach

Editor’s Note This work in progress report (WiP) was developed by the 2013–2014 cohort of the Junior Researcher Programme (JRP), a service supported by the European Federation of Psychology Students’ Associations (EFPSA). During the course of the JRP calendar, the six research groups that are initiated via the European Summer School submit the WiPs of their research to the Journal of European Psychology Students (JEPS). The WiPs are short methodology papers that outline steps undertaken by research groups in developing and carrying out a research project in the context of low-resource, independent, student-driven, cross-cultural research. The WiPs are submitted prior to project completion to enable the authors to improve their research according to the comments resulting from the peer-review process. WiPs also support the dissemination of methods used by student-driven, independent research projects, with the hope of informing others carrying out such work. The 2013–2014 cohort was inducted into the JRP at the European Summer School 2013, held in Voeren, Belgium.


Background
The estimated prevalence of mental health difficulties amongst children and young people ranges from 10-20% (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003;Green, McGinnity, Meltzer, Ford, & Goodman, 2005).Furthermore, longitudinal research indicates that cumulatively up to 80% of children and adolescents experience such difficulties by the time they reach adulthood (Copeland, Shanahan, Costello, & Angold, 2011).Schools are considered an ideal setting where mental health and well-being provision can be targeted in order to identify and overcome difficulties of children and young people.It is also increasingly recognized that schools can play a central and highly effective role in administering early interventions and promoting positive mental health (Weare & Nind, 2011).The main reasons for the suitability of schools include the large amount of time young people spend there and the existence of structures within schools that allow planned provision and interventions to be implemented effectively (Jané-Llopis & Bradick, 2008).The utility of schools as a setting for primary screening and intervention is also being increasingly acknowledged in educational policy, although to a different extent in various countries (Weare & Nind, 2011).
School-based interventions can be classified according to their aims or objectives in terms of whether they focus on promotion, prevention and/or treatment.Promotion based programmes do not address specific problems of pupils, but rather aim to proactively increase their subjective well-being by focusing exclusively on their strengths and competences (Shoshani &

WORK IN PROGRESS REPORT
Examining Mental Health and Well-being Provision in Schools in Europe: Methodological Approach Praveetha Patalay * , Catriona Curtin † , Laura Giese ‡ , Dawid Gondek § , Bettina Moltrecht ‖ , Nataliia Savka ¶ and Miloš Stanković ** journal of european psychology students efpsa Steinmetz, 2013).An example of one such approach is the 'Well-being Programme' (Morris, 2009).Preventative interventions, in turn, aim to prevent problems from occurring by both addressing risk factors and nurturing protective factors (e.g.'Check in/Check out' programme; Crone, Horner, & Hawken, 2004).Additionally, treatment based approaches assess and treat existing difficulties (e.g., brief counselling interventions; Murphy & Duncan, 2007).Such interventions can apply to all pupils within schools (universal approaches) or they can be designed to suit specific individuals who are at risk of or already experiencing difficulties (targeted approaches; Weare & Markham, 2005).Systematic reviews and meta-analyses have supported the efficacy of both universal (Weare & Markham, 2005;Wells, Barlow, & Stewart-Brown, 2003) and targeted approaches (Shucksmith, Summerbell, Jones, & Whittaker, 2007).Recommended approaches include the adoption of both universal and targeted methods combined in a complimentary manner (Green, Howes, Waters, Maher & Oberklaid, 2005).
In spite of the large and growing literature looking into the effectiveness of interventions, only two studies were identified that have investigated existing provision in schools.Vostanis, Humphrey, Fitzgerald, Deighton and Wolpert (2013) examined the nature and extent of a range of specific interventions in primary and secondary schools in England, and aimed to assess the extent of and focus on universal and targeted interventions.One of their findings was that mental health support in England was provided mainly by school staff with no mental health training.A similar study was conducted in the USA, wherein Teich, Robinson and Weist (2007) investigated the types of mental health problems encountered in schools and the kinds of available provision to address such difficulties.They also examined funding mechanisms and their impact on delivery of services, intervention coordination and any potential barriers that might prevent schools from providing mental health and wellbeing support.They reported that almost half of the schools surveyed identified inadequate internal and community mental health resources as a 'serious barrier' to providing adequate support for young people's mental health and well-being.
The current study aims to extend this research and examine the nature of available provision in schools in a series of European countries, taking into account the diverse schooling and community-based mental health support systems in participating countries (Germany, Ireland, the Netherlands, Poland, Serbia, Spain, Sweden, the United Kingdom and Ukraine).This will not only contribute to understanding the extent of existing provision in individual countries, but also allow an examination of cross-national similarities and differences in type, focus and amount of provision in schools.In addition to expanding previous research by engaging with cross-national comparisons of available provision, the present study further aims to investigate perceived barriers to providing mental health and well-being support in schools, and compare them between participating countries in order to identify possible recommendations that could be made to enhance current provision.
Existing studies have focused primarily on psychopathology (prevention and treatment) and not on promotion of well-being (Vostanis et al., 2013;Teich et al., 2007), which the current study also incorporates.Moreover, it is intended to discuss the findings of the current study in the context of national policies and the importance placed on mental health and well-being in the participating countries.By engaging in cross-national comparisons of provision with the corresponding national policies, this research could ascertain whether countries with existing mental health and well-being policies at national and local levels provide greater access to well-being interventions and programmes in their schools.Hence, the key research questions the current study aims to answer include: What mental health and well-being provision is available in schools across different European countries?What factors do schools perceive as being barriers to providing support?Are there differences between participating countries and if so, can differences in the extent of provision be linked to existing policy?

Method
A cross-sectional survey design is being utilized in the present research to allow for the assessment of mental health and well-being provision in schools across nine European countries.An online survey methodology is being employed to distribute a questionnaire to schools that measures the types, focus and extent of existing interventions, groups of professionals involved, links with local agencies and perceived barriers to providing support.

Participants
Participants in this study are schools from nine European countries including Germany, Ireland, the Netherlands, Poland, Serbia, Spain, Sweden, Ukraine and the United Kingdom.The sample consists of all country-specific types of primary and secondary stage schools, which are either state or privately funded.This study aims to collect data from a minimum of 100 schools per country in order to obtain sufficient data to examine both within country variation and between country differences.

Measure
Representative(s) from schools are being asked to respond to questions relating to different aspects of schoolbased provision regarding mental health and well-being.Questions were informed by the two existing studies with participating schools in England and the USA (Teich et al., 2007;Vostanis et al., 2013) and recent theory in the field, as outlined in the introduction.The survey includes a range of sections as outlined below.
The first section of the survey asks schools to provide information on the school itself (e.g., whether it is a primary or secondary school).Section two requires the participating school to rate on a five-point scale (ranging from 'not at all' to 'very much') the extent to which the school provides a number of interventions to support mental health and well-being of students, parents/carers and school staff.Some examples included in the survey are social skills development and anti-bullying programmes.The third section involves reporting on the approaches schools adopt to mental health services provision.First, it requires schools to identify the aims of the approaches it employs.For example, schools are asked to rate on a five-point scale (ranging from 'not at all' to 'very much') the extent to which their school focuses on targeted groups with identified mental health problems, preventing mental health problems from arising or proactively promoting the well-being of students.It further requests schools to identify target groups for which such approaches are adopted.For instance, schools are asked the following question: 'In supporting student well-being to what extent does your school focus on individuals with specific problems?'.Section four requires participants to state which professionals are involved in mental health and well-being provision in their school such as educational psychologists, social workers and/or school nurses.The fifth section requests schools to rate on a fivepoint scale (ranging from 'no links' to ' excellent links') the level of cooperation between schools and external agencies and institutions.Examples of external agencies and institutions include local mental health services, social services, charities, societies and non-governmental organizations.Section six requires participants to rate on a five-point scale (ranging from 'not at all' to 'very much') the extent to which a series of factors are perceived by schools as being barriers to delivering mental health and well-being support within their school.Examples of such factors include school funding, availability of specialists in the local area, lack of national policy for well-being.Finally, schools are asked to provide information regarding which members of staff were involved in completing the survey.

Translation Protocol
The measure was developed in English by the members of the research group and then translated and adapted for use in the participating countries.The items in the first and last section of the survey were tailored to specific countries as the school systems in participating countries vary.For instance, in England primary school is followed by secondary school, whereas in Germany primary school can be followed by different forms of secondary schools, such as Gymnasium, Realschule or Hauptschule, which are specific types of secondary schooling that prepare pupils for different career paths.The questions and items in the remaining sections were translated such that schools from different countries would answer the same questions in identical order and format.However, the examples provided for certain interventions were sometimes tailored to the particular country to aid understanding of the items.
Each translation of the survey for a participating country went through the following iterative steps to ensure optimal understanding of the measure by school staff (target group) while maintaining the equivalence of the measure across translations.First, the translated questionnaire was assessed by 2-3 bilingual people to assess the broad accuracy of the measure.It was subsequently analysed by 1-2 bilingual individuals of the target sample (school teachers, child/youth mental health professionals) to ensure that the specific terminology was used accurately and could be comprehended by the target group as intended.This was followed by one-to-one discussions with individuals from the target group (e.g., teachers or educational psychologists working in schools) to ensure the translation was appropriate.Last, the online version was sent to some individuals to pilot the survey, ensuring it was error-free and easy to read, understandable and complete.

Procedure
The survey was uploaded onto a web-based survey distribution software.Following this, school email addresses were acquired for the participating countries through communication with education departments and accessing online public databases.Once email addresses were obtained, schools within the participating countries were sent an invitation to participate in the study.This email invitation included details of the study and a link to the online survey.Schools were requested to identify the individual(s) best suited to answer questions regarding current provision and interventions to support mental health and well-being in their school to complete the survey.Upon accessing the survey, participating schools were given further information about the nature of the research and were informed to continue and complete the measure if they consented to participate.

Proposed Analysis
Descriptive statistics will be primarily employed in exploring responses to the different sections by schools in different countries.The extent of within-and between-country variation in amount of provision available in schools will first be estimated using a multi-level modelling approach, with schools nested within countries.This will be followed by separate analysis of each of the sections of interest in the survey (e.g., interventions, involved staff, perceived barriers) both to investigate extent and predominant types within and between countries.Additionally, whether or not the extent of available provision differs based on school type (e.g., primary/secondary, state/privately funded) will be examined using analysis within the regression framework.

Ethics
This study was reviewed by the ethics committee of an accredited university.An exemption from full ethical review was granted due to the following characteristics of the study: First, the study does not require the collection of any personal information as all information required is provided by schools as a whole.Second, no identifiable information is collected and all acquired information remains completely anonymous and confidential.

Practical Concerns
The primary practical concern of this research was in relation to the translation of the survey.Despite being well-established, recognized constructs in the English language, terms such as 'well-being' and 'mental health' do not have standardized, widely accepted definitions, and their translation into different languages consequently proved challenging.For example, even though the translation of 'well-being' in Polish is familiar for academics there is arguably no equivalent used by non-social scientists.Furthermore, it also proved difficult to find country-specific examples of certain interventions for section two of the measure as the understanding of such examples often varies from one country to another.For instance, although a 'multi-sensory room' is well known in the Netherlands as being a ' designated space in schools for well-being and mental health', the term is rarely used in Poland.Any potential disparities between translations were substantially reduced by engaging academics and teachers from all participating countries, many of whom were bilingual, in numerous discussions.
Moreover, it was also necessary to account for the different school systems in the participating countries.For instance, the age at which pupils commence their primary education typically differs from country to country, as does when they transition from one class or school to another (e.g., a typically developing child starts school at age four in Ireland, but at age six in Germany).Schools have been asked to provide information regarding the age range of their students so that this can be accounted for when interpreting results.Other practical considerations of conducting this research project have included the wide geographical spread of the research team, lack of funding and managing other existing commitments relating to work and studies.Such difficulties are being overcome through the use of freely available online resources to distribute the survey and regular on-line communication with all research members.

Current Status of Project
At the time of writing, the study has been reviewed by a university research ethics committee and all associated institutions have agreed for the study to proceed.Translations of the measure for use in all participating European countries have been completed and data collection is underway.

Discussion
Given the importance of providing mental health and well-being support to students in schools and the lack of data providing an overview of the existing provision in different countries, the present study aims to obtain a comprehensive overview of the current mental health and well-being services available in participating countries.As with any cross-national research however, it must be noted that any potential differences revealed by our results might to some extent be due to differing interpretations of the survey content by the participating countries.The study design includes an online survey and is therefore cost effective, but potential limitations of this methodology will also have to be considered as this may limit the findings solely to schools with internet access.
Based on the data, it is expected that this research will obtain a comprehensive overview of current mental health and well-being provision across participating countries and make useful comparisons between countries, existing policy and school systems.It is hoped that this investigation, especially of the barriers that impact on the implementation of mental health and well-being provision in schools, will have the potential to inform future policy to improve school and community based initiatives to support mental health and well-being.