How school systems can improve health and well-being: topic brief: mental health

1Why are mental health and well-being important for health? Mental health is not simply the absence of illness but a state in which learners realise their own abilities, can cope with normal life stressors, learn well, build meaningful relationships and are able to contribute to their community. Social and emotional well-being can include connection to land, spirituality, ancestry and culture, which also provide foundations for mental health. Mental health and well-being are integral to learners’ overall health. Learners with good mental health and well-being are healthier, more socially connected and more productive. Learners can experience mental health conditions such as anxiety, depression, eating disorders and behavioural problems. Most mental health conditions begin during the school years and can disrupt learners’ growth and development and increase risk for future physical and mental health problems and substance use. Mental health conditions are also associated with experiencing stigmatization, discrimination, violation of human rights, suicide and difficulties in education, work and relationships. TOPIC BRIEF Mental health HOW SCHOOL SYSTEMS CAN IMPROVE HEALTH AND WELL-BEING Background Schools play a key role in providing safe, nurturing learning environments that provide the foundation for learners to grow, learn and become healthy, educated and engaged citizens. What is a health-promoting school? Health-promoting schools (HPS) are schools with strengthened capacity to be healthy settings for living, learning and working. HPS reflect a whole-school approach, comprising healthy school policies, curricula, environments, communities and health services. A comprehensive school health programme aims to make every school a health- promoting school, which can be achieved by building health-promoting education systems. A health-promoting education system is one that, through intentional, planned actions, institutionalizes health promotion in all its functions, i.e. governance of the educational process and its content, resource allocation, educators’ professional development, information systems and performance management. What is new? Although the concept of HPS was introduced by WHO many decades ago, the aspiration of fully embedded, sustainable HPS within educational systems is yet to be achieved; few countries have implemented HPS at scale. To fulfil the vision of “making every school a health-promoting school”, United Nations agencies collaborated on global standards for HPS and systems , implementation guidance and case studies from low- and middle-income countries. These evidence- informed resources are intended to be used by national education, health and associated sectors to strengthen their school health programmes in order to build health-promoting education systems. 2Why are mental health and well-being important for education and learning? Good mental health and well-being are associated with better school engagement, increased attendance and better academic performance. Strengthening learners’ social and emotional skills, such as problem-solving and emotional regulation, is associated with better coping and resilience, reduced symptoms of depression and anxiety and less substance use. Conversely, poor mental health and well-being and the experience of mental health conditions contribute to underachievement, absenteeism, disruptive classroom behaviour, suspension and expulsion from school and school dropout. The global learning crisis is due not only to inadequate investment in teachers and school infrastructure but also to lack of attention to the well-being of children and adolescents, which has been exacerbated by the COVID-19 pandemic. Investing in mental health and well-being will ensure that learners thrive at school, with repercussions into adulthood, including positive impacts on the next generation. Why are schools ideally placed for supporting mental health and well-being? Most children and adolescents spend much of their time at school. The school years are a period of rapid development, during which children and adolescents experience profound physical, social and psychological changes and during which the maturing brain is highly susceptible to environmental influences. Negative experiences at school, such as bullying, violence among peers or experiencing discrimination, contribute to poorer mental health and symptoms of anxiety and depression. Positive experiences such as feeling connected to teachers and peers, engaging with learning and belonging at school are linked to better mental health. Schools are well placed to create conditions that promote learners’ mental health and well-being and prevent mental health problems, increase mental health literacy, develop social- emotional skills and identify risks and early signs and symptoms of emotional distress and other mental health conditions. As required, schools can increase access to mental health and psychosocial support services for learners, their families and teachers. Whole-school approaches have been shown to increase learners’ social, emotional and behavioural adjustment and decrease internalizing symptoms. Schools are also key environments for learners to develop a sense of community, of being valued and belonging within a safe, inclusive environment. Schools are also places to which learners, families and communities can turn for support. What are the current gaps? Some schools already provide mental health interventions; however, fewer schools sustainably embed such programmes or approaches in an HPS and systems framework. Mental health exemplifies the importance of a systems approach, as the multiple determinants of mental health require solutions that span many systems and sectors, including health, education, social protection and justice. Bringing these systems together is the essence of the HPS and systems approach. The advantage of this approach is its potential to amplify benefits for well-being, health and education by harmonizing policies and practices in multiple health areas simultaneously, leveraging not only the school’s resources but also the surrounding environment and community. This brief explores how policies, curricula, environments and services can be better designed and integrated to support good mental health. 2 3 What are health-promoting schools and systems? The eight global standards are a system of interconnected elements (Fig. 1) comprising governance structures (primarily standards 1–4), community partnerships (standard 4) and school operations (primarily standards 5–8). A systems approach ensures that policies, mechanisms and resources for health and well-being are sustainably promoted in all aspects of school life. This involves cross-sectoral collaboration, participatory processes, models of distributed leadership, capacity-building and effective monitoring and evaluation. Fig. 1. The eight global standards for health-promoting schools and systems As in this topic brief, the global standards are designed to be used by various stakeholders involved in identifying, planning, funding, implementing, monitoring and evaluating any whole-school approach (even if the term HPS is not used) at local, subnational, national and global levels, primary and secondary schooling and public and private educational institutions. Activating synergies in interventions What is the relation between mental health and sleep? Insufficient and/or poor-quality sleep is associated with more negative emotions and fewer positive emotions, poorer emotion regulation, higher levels of depressive and anxiety symptoms and suicidal ideation. Sleep problems are also associated with poor school performance and attendance and impaired cognitive performance. Poor sleep increases the risk of future mental health problems, particularly depression. Learners with existing depression and anxiety are also more likely to have problems sleeping. Promoting healthy sleep (including age- specific recommendations for sleep duration) has benefits for learners’ mental health and well-being. What is the relation between mental health and nutrition? Unhealthy diets are linked to poorer development and mental health trajectories in children and adolescents. Food insecurity is associated with behavioural issues and increased rates of anxiety, depression and inattention. Concern about body size and appearance and societal pressures make adolescents vulnerable to eating disorders, which in turn are associated with other mental health problems such as anxiety and depression. Fig. 1. System of global standards for health-promoting schools As in the global standards, the implementation guidance uses the term “HPS” generically, to include other whole-school approaches, such as comprehensive school health and education, éducation pour la santé, école en santé, estrategia or entorno escuela saludable and escuela para la salud. Like the global standards, this implementation guidance is based on two evidence reviews (31, 32), a series of case studies from eight low- and middle- income countries (36) and consultations with a global external advisory group and a wider group of stakeholders. 1. Government policies and resources 2. School policies and resources 3. School governance and leadership 4. School and community partnerships 5. School curriculum 8. School health services 6. School social– emotional environment 7. School physical environment 4 M king every school a health-promoting sch ol: implementation guidance The following are examples of actions, activities or initiatives that can be conducted to strengthen mental health in an HPS and systems approach. The list is not exhaustive; actions will depend on the context (e.g., social, cultural, country specific) and the level of schooling (e.g., primary, secondary) and are ideally generated through engagement with all stakeholders (e.g., teachers, learners, community, caregivers, government, private sector and civil society organizations), based on local data. Solutions that target multiple aspects of education, health and well-being are encouraged as cost–effective ways of amplifying benefits. How can we strengthen mental health using a health-promoting schools and systems approach? 3 School governance and leadership • Establish an HPS committee to plan, implement and evaluate mental health initiatives, comprising education sector staff, learners, parents and carers, community and religious leaders, health staff, civil society organizations. • Promote and recognize diversity in school leadership. • Involve all teachers, school health staff, student representatives, parents and carers in decision-making to promote HPS and mental health. • Appoint school well-being coordinators or focal points to promote whole-school mental health and well-being. 1 Government policies and resources • Develop national policies to promote and protect learners’ and teachers’ mental health within schools (e.g., alignment with the Safe to Learn standards; school staff mandated to report abuse; schools not permitted to expel learners because of pregnancy; bans on punitive disciplinary methods such as corporal punishment; learners with mental health needs have access to school and additional or complementary support as needed) and/ or ensure alignment with the ministry of education in all relevant sectors for HPS and mental health (e.g. health, community and social services). • Have an equitable budget and human resources to support HPS, including mental health and psychosocial support services, in schools (e.g., partnerships and integration with community-based mental health services). • Make mental health education and social-emotional learning key parts of the comprehensive national health and nutrition curriculum (e.g., teaching learners to take care of their mental health and seek help). • Support training and professional development in whole-school approaches to mental health for pre-service and in-service school staff, including the mental health and leadership team (e.g., online bullying, identifying signs of distress and need for health services, crisis management, suicide prevention, protocol for referring learners/families to mental health services where relevant). • Invest in collection of data on mental health at national and subnational levels and in monitoring and evaluation of mental health and psychosocial support services. 2 School policies and resources • Have school policies that promote inclusion and value diversity. • Develop and communicate relevant policies and standards in all local languages (including, anti-bullying, respectful relationships, child protection policies). • Have clear policies and processes for confidentiality, identification, assessment, management and referral pathways for learners experiencing mental health problems, developed in consultation with learners, and for supporting the mental health and well-being of school staff (e.g., mental health promotion, crisis support, management of “burnout”). EXAMPLES OF ACTIONS, FRAMED WITHIN THE GLOBAL STANDARDS FOR HPS AND SYSTEMS 4 4 School and community partnerships • Engage with local community and cultural groups to promote meaningful social connections (e.g., volunteering at a homeless shelter; helping to run a community event, homework programmes, street art projects, craft groups, parent and carer days) and enhance learners’, parents’ and carers’ mental health literacy (e.g., emotional regulation, non-punitive approaches to discipline). • Create parent and carer learning and support groups (e.g., safe Internet use at home, communicating with your child, child and adolescent development). 6 School social–emotional environment • Set up peer support programmes (e.g., “buddy programme” for learners moving to a new campus or year level). • Provide enjoyable lunchtime and extracurricular activities (e.g., art projects, sports, music activities) to promote wider learning opportunities and foster social connections and healthy relationships among all members of the school. • Ensure that teachers have the skills to build positive relationships between school staff and learners and between learners, including conflict resolution. • Acknowledge and celebrate learners’ success in a variety of pursuits and activities, especially beyond academic or sporting achievements. • Embrace diversity within the school community (e.g., inclusive education programmes for learners with disabilities, cultural programme). 7 School physical environment • Limit learners’ access to hidden spaces where bullying may occur, and supervise all spaces to ensure that learners are physically and emotionally safe. • Ensure that school grounds are fenced and well-lit and that all visitors are registered. • Ensure access to clean, safe, gender-inclusive washrooms. • Ensure that transport to and from school is safe, including free from harassment. • Ensure access to safe, calming spaces that support mental health promotion (e.g., play, access to nature, prayer rooms). 8 School health services • Facilitate access to mental health services (e.g., face-to-face, digital platforms) to address the needs of individual learners (including in mental health crises) and the whole school community. • Ensure that learners and their families understand the means and referral pathways for accessing confidential mental health services, whether at school or in the community (e.g., pathways to affordable mental health services for vulnerable people with limited resources). 5 School curriculum • Include cooperative learning and strengths- based approaches to build learners’ self-esteem and confidence. • Provide alternative pathways to educational success (e.g., academic, vocational). • Provide strength- and evidence-based programmes for building individual skills and behaviour that support mental health (e.g., problem-solving, self-regulation, relationship-building, anxiety management, resilience-building). • Integrate mental health education into other parts of the curriculum to optimize learning and create synergies with wider educational opportunities (e.g., language texts, science, history, art projects). EXAMPLES OF ACTIONS, FRAMED WITHIN THE GLOBAL STANDARDS FOR HPS AND SYSTEMS 5 6How does a systems approach to mental health work in different contexts? Collaborative for Academic, Social, and Emotional Learning (CASEL) Collaborating Districts Initiative (CDI), United States of America (USA) Background: CASEL is a not-for-profit, multidisciplinary network for establishing high-quality, evidence- based social and emotional learning (SEL) in schools. In 2011, CASEL launched the Collaborating Districts Initiative (CDI) for systematic implementation of SEL in large urban districts across the USA. Approach: Implementation of SEL extends beyond classroom instruction and includes the school climate, staffing, professional learning, district policies, family engagement and increasing the voice of students. Results: High-quality SEL programmes lead to improvements such as better academic performance and classroom behaviour, less emotional distress and a more positive outlook on themselves and others. After 10 years of implementation, districts were able to sustain their commitment to SEL, even as the people and contexts in the district changed. New schools are joining the CDI, professional development in SEL is being extended to more staff, such as security officers and bus drivers, and SEL is being embedded in district policies and hiring practices. Messages: Sustained implementation was attributed to six main factors: strong leadership; core district policies for SEL that connect all stakeholders; school resources and SEL implementation pathways that can be customized to the needs of the school community; staff culture, climate and learning based on SEL; co-creation of SEL with students, families and communities; and communities of practice to strengthen SEL implementation. Reference: https://casel.s3.us-east-2.amazonaws.com/CDI-Ten-Year-Report.pdf Adolescent Mental Health and Suicide Prevention (AMHSP) programme, Kazakhstan Background: The Government of Kazakhstan implemented an intersectoral Adolescent Mental Health and Suicide Prevention (AMHSP) programme with UNICEF (2012–2018) and the Bilim Foundation, with the National Centre of Mental Health, which has scaled up implementation since 2018. Approach: A comprehensive digital monitoring system is used to identify at-risk adolescents and refer them to trained mental health workers. The AMHSP programme also involves building the capacity of school and public health professionals, including strategies to address stigmatization (e.g., parent outreach, distributing awareness- raising materials) and conducting mental health literacy workshops and awareness-raising campaigns in the school community. During the COVID-19 pandemic, an online individual counselling platform for counselling services was launched, including online training sessions for school psychologists. Results: Evaluation of the pilot programme showed that at-risk adolescents experienced significant decreases in suicidal ideation, depression, anxiety and stress after receiving treatment. More than 10 000 adolescents (4.5%) received referrals to additional services. Approximately 116 000 school psychologists and school personnel received training in identifying and responding to adolescents’ mental health issues, and more than 1500 primary health care and mental health workers were trained in managing adolescents with mental health issues or suicidal behaviour. The online training platform for school psychologists has reached more than 25 000 users. Messages: The programme was based on a Government initiative to extend access to services while investing in students and continuously building the capacity of communities and health professional. Leveraging data was essential to influence advocacy and long-term change. Data from the national study on adolescent suicide was key to securing support from the Ministry of Education and Science for implementing the programme. Prioritization of the collection of data during implementation allowed evaluation of the findings for increasing regional advocacy. Capacity-building was an important aspect of preparing for scaling up. The programme’s success led to an influx of referrals, greater demand for professional services and thus greater support for school psychologists. Reference: Mental health promotion and suicide prevention in schools (Kazakhstan). New York City (NY): United Nations Children’s Fund; 2021 (https://www.unicef.org/documents/mental-health- promotion-and-suicide-prevention-schools-kazakhstan). 6 7 Health-promoting schools Making every school a health-promoting school Global standards and indicators Making every school a health-promoting school: global standards and indicators https://www.who. int/publications/i/ item/9789240025059 Implementation guidance Making every school a health-promoting school Making every school a health-promoting school: Implementation guidance https://www.who. int/publications/i/ item/9789240025073 Country case studies Making every school a health-promoting school Making every school a health-promoting school: country case studies https://www.who. int/publications/i/ item/9789240025431 WHO guideline on school health services In partnership with WHO guidelines on school health services https://www.who. int/publications/i/ item/9789240029392 Mental health This report has received funding under an operating grant from the European Union’s Health Programme (2014-2020) Mental health promotion in Schools State of the art SHE factsheet no. 7 Date of document: 15th August 2021 Authors: Catriona O’Toole & Emily Darlington Contributors: Søvold, L., & Paulus, P. Place: Haderslev Mental health promotion in schools: State of the art (Schools for Health in Europe) https://www.schoolsforhealth.org/sites/default/files/ editor/fact-sheets/factsheet-7-mental-health-2021-new. pdf Helping Adolescents Thrive Toolkit Strategies to promote and protect adolescent mental health and reduce self-harm and other risk behaviours Helping Adolescents Thrive Toolkit (WHO, UNICEF) https://www.who.int/publications/i/item/9789240025554 1 to the Magnificent Mei and Friends Comic Series Teacher’s Guide Helping Adolescents Thrive Teacher’s Guide (WHO, UNICEF) https://www.who.int/publications/i/item/9789240026261 GLOBAL MULTISECTORAL OPERATIONAL FRAMEWORK for Mental Health and Psychosocial Support of Children, Adolescents and Caregivers Across Settings Field demonstration version Global Multisectoral Operational Framework for Mental Health and Psychosocial Support of Children, Adolescents and Caregivers Across Settings(Demonstration Version) (UNICEF) https://www.unicef.org/media/109086/file/Global%20 Multisectorial%20Operational%20Framework.pdf The Mental Health and Psychosocial Support Minimum Services Package: For an effective MHPSS emergency response https://mhpssmsp.org/en A GLOBAL YOUTH MENTAL HEALTH ADVOCACY TOOLKIT A RESOURCE TO DRIVE ACTION TO ADDRESS YOUTH MENTAL HEALTH Developed by Orygen as part of the Global Youth Mental Health Partnership project with the World Economic Forum A Global Youth Mental Health Advocacy Toolkit (Orygen) https://www.orygen.org.au/About/Orygen-Global/Files/ Orygen-WEF-advocacy-toolkit.aspx This briefing is intended for policymakers, national governments, mental health and education coalitions and advocates. It outlines key policy recommendations to strengthen education systems to protect and promote the mental health and psychosocial well-being of children and adolescents, including support for their teachers and caregivers Mental health is an integral component of health and well-being and influences academic, social and economic outcomes across the lifespan. Having good mental health means being better able to interact with others, function, cope and thrive. It is a basic human right.1 Mental health exists on a complex continuum, with experiences ranging from an optimal state of well-being to experiencing severe mental health conditions with related suffering and often an important impact on the capacity to carry out daily activities. The first two decades of life is a critical period for the development of foundational competencies that can shape a learner’s mental health trajectories. At this particular stage of rapid development and learning, children and adolescents are highly susceptible to environmental influences. Experiences and environments can harm mental health. Or they can be shaped to promote and protect it.2 Five essential pillars for promoting and protecting mental health and psychosocial well-being in schools and learning environments A BRIEFING NOTE FOR NATIONAL GOVERNMENTS Five essential pillars for promoting and protecting mental health and psychosocial well-being in schools and learning environments: A briefing note for national governments (WHO, UNESCO, UNICEF) https://www.unicef.org/reports/promoting-and- protecting-mental-health-schools-and-learning- environments Resources How school systems can improve health and well-being. Topic brief: mental health ISBN 978-92-4-006475-1 (electronic version) ISBN 978-92-4-006476-8 (print version) © World Health Organization 2023. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. Design and layout by Inis Communication For further information, please contact: Health Promotion Department World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland https://www.who.int/health-topics/health-promotion Acknowledgements Development of this series of topic briefs was coordinated by Dr Faten Ben Abdelaziz, Dr Valentina Baltag, Dr Mervat Nessiem and Ms Audrey Kettaneh at WHO; Mr Yongfeng Liu and Ms Emilie Sidaner at UNESCO; and Ms Deepika Sharma and Ms Joanna Lai at UNICEF. The briefs were written by Professor Susan Sawyer, Centre for Adolescent Health, Murdoch Children’s Research Institute, Royal Children’s Hospital, and University of Melbourne, Australia, a WHO Collaborating Centre for Adolescent Health, in collaboration with Dr Monika Raniti. The lead writers were Dr Monika Raniti (Mental health); Dr Natalie Evans (Nutrition and WASH); Dr Dorothy Dumuid and Associate Professor Carol Maher (Physical activity); and Dr Wing See Yuen and Associate Professor Amy Peacock (Substance use). WHO acknowledges the valuable contributions of technical experts at WHO, UNESCO, UNICEF, WFP and UNODC, including regional advisers and other academic experts who provided feedback. WHO gratefully acknowledges the financial support of the NORAD Fund.