Author
OLIVER S.; HARDEN A.; REES R.; et al;
Young people and mental health: novel methods for systematic review of research on barriers and facilitators.
Journal citation/publication details
Health Education Research, 23(5), 2008, pp.770-790.
Summary
This paper summarises the results of a review published in 2001, which is based on a novel approach to incorporating the results of both qualitative and quantitative studies in a single review. A descriptive mapping of the literature in the area was followed by the in-depth review of three types of study: systematic reviews; high quality outcome evaluations (all from the USA) not included in these reviews; and UK studies of young people’s views about mental health. The principal finding is that the mental health priorities pursued in the high quality outcome evaluations do not match those expressed by young people themselves.
Context
Mental health problems cause significant morbidity and mortality among the young, but previous systematic reviews have tended to focus narrowly on the effects of interventions rather than looking more broadly at the barriers to, and facilitators of, mental health promoting behaviour. This review explores barriers and facilitators, as expressed by young people themselves and as reflected in the priorities of high quality outcome evaluations. In doing so, it discusses an innovative approach to the systematic review of diverse study designs, as compared to the more conventional approach of restricting reviews to a single study design (usually randomised controlled trials).
Methods
For full details of sources, search terms and methods, see the main report of the review, available via http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=256.
What sources were used?
The databases and other sources searched are listed in Figure 1.
What search terms/strategies were used?
The search terms covered three main areas: mental health (e.g. well-being, psychological adaptation) and associated mediators (e.g. self-esteem); generic and specific determinants of mental health or illness (e.g. resilience, risk factors) or the promotion of positive health or prevention; and young people (e.g.; adolescent, juvenile, teenager).
What criteria were used to decide on which studies to include?
Eligible studies were published in English and: addressed mental health promotion or mental illness prevention and/or associated barriers and facilitators; included participants with a mean age between 11 and 21 years; and described an outcome evaluation or systematic review. Studies published before 1990 were excluded ‘to keep the review current’. The resulting descriptive map of literature was presented to a Steering Group to identify the main areas of interest of potential users. These were outcome evaluations of interventions and UK-based studies of young people’s views.
Who decided on their relevance and quality?
Figure 4 summarises the filtering of the 11,638 references identified by the searches to arrive at a preliminary descriptive map of the literature and then two sets of studies for in-depth review: evaluations of intervention effectiveness (trials and systematic reviews); and studies of young people’s views on mental health. Further inclusion criteria applied to both types of study are reported. For example, systematic reviews and outcome evaluations had to focus on the policy priorities of suicide of depression and their antecedents, while studies of young people’s views had to present these directly as data ‘rather than as a rote to generating variables to be tested in a predictive or causal model’.
How many studies were included and where were they from?
Seven systematic reviews, 14 outcome evaluations (all from the USA) and 12 studies of young people’s views (all from the UK) were reviewed.
How were the study findings combined?
A standardised coding strategy was piloted and applied independently by two authors. An ‘abbreviated’ version is set out in Figure 2. Data for each study were entered independently by two authors into a specialised computer database. Structured summaries and evidence tables were prepared to describe the methodological quality and finings of each study, and three syntheses conducted: a narrative synthesis of the effectiveness studies; a theme-based narrative synthesis of the studies of young people’s views; and a cross-study synthesis that juxtaposed the barriers and facilitators identified by young people with descriptions of the intervention evaluations.
Findings of the review
Synthesis 1: systematic reviews
The seven reviews varied in scope, methods and number of included studies, although all addressed intervention effectiveness. Results ‘were mixed and sometimes contradictory’ with the clearest findings being that there is insufficient evidence to recommend universal school-based suicide prevention programmes; and that primary prevention programmes can vary in their impact. One review found that interventions focusing on self-esteem have a greater impact than less focused interventions, while another concluded that self-esteem should be promoted through a whole school approach.
Synthesis 2: outcome evaluations
Outcome evaluations were covered only if they had not been included in one of the systematic reviews. Most were implemented in secondary education and used varying types of intervention with multiple delivery methods. Of the 14, five were judged to be methodologically sound. ‘No clear pattern emerges for effectiveness based on mental health promotion focus, the type of intervention or intervention provider.’ Three of the studies provided clear conclusions but all outcome evaluations were weakened by the lack of integral process evaluations and the fact that ‘young people were rarely consulted for their views on intervention development or impact.’
Synthesis 3: young people’s views
The methodological quality of the 12 studies was ‘variable’, with only two making any attempt to establish the reliability and validity of data analysis. The findings show that young people generally equate the term mental health with mental illness and ‘do not see it as relevant to their own lives’. Barriers to good mental health included physical or material circumstances (e.g. not having a stable home), restrictions on freedom (e.g. attitudes of society or the police) and anxiety caused by the experience of violence. The only positive facilitator of good mental health identified by young people was the ability to cope with the ups and downs of life. Talking about problems was not seen as helpful, and adults were perceived as not understanding what really matters to young people. Coping strategies could be positive (e.g. creative activity such as making music) or negative (e.g. taking drugs, self-harm).
Cross-study synthesis
The results of the integration of results from the first two syntheses are summarised in Table II, which covers four levels at which barriers and facilitators appear to operate: school; physical and material resources; relationships with family and friends; and the self.
Within schools, effective interventions addressed concerns about teachers but none addressed young people’s worries about workload, academic achievement or engagement with school. No intervention in Synthesis 2 considered their concerns about further (un)employment, financial security, access to basic rights or resources, or access to leisure facilities although several potentially promising interventions were identified in the preliminary descriptive mapping of the literature.
There were effective interventions in Synthesis 2 that considered relationships and ‘these need to be built on, particularly to support excluded young people.’ However, there was a lack of interventions that fostered talking to friends, addressed concerns about violence, or considered personal issues such as anxiety or stress although, again, potentially important interventions were identified in the descriptive map.
Authors' conclusions
‘This review reveals a mismatch between the efforts of researchers addressing policy imperatives for mental health with intervention studies and what is known about young people’s views of their own lives.’ The cross-study synthesis identifies several areas of concern to young people that are missing from the interventions evaluated in Synthesis 2, while rigorously conducted evaluations have focused on issues that appear to be of much less importance to them. For example, suicide prevention is a common policy/intervention preoccupation and yet none of the views studies raised suicide as an issue even though some included high risk or marginalised participants. Much of the evaluation research in Synthesis 2 was conducted with middle class, low risk populations and ‘consequently, there is currently little research to guide mental health promotion for socially excluded groups’.
Implications for policy or practice
None are discussedRelated references
Related reference
For the full report of the review, and further details of the methods used, see:
HARDEN A.; REES R.; SHEPHERD J. et al;
Young people and mental health: a systematic review of research on barriers and facilitators.
London: EPPI-Centre, Institute of Education, 2001. 236p.
http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=256