Characteristics of the programs
As shown in Table 2, all the studies included were from middle-income countries (MICs); seven were from upper middle-income countries (23-29) and four were from lower middle income countries [22, 30-32], as indicated by the World Bank [52]. Three studies were conducted in South Africa [23, 24, 26], two in Bosnia and Herzegovina [28, 28] and one study each was from India, Kosovo, Nigeria, Mauritius, Thailand, and Palestine [22, 25, 29-32]; Africa accounted for five studies (three from South Africa and one each from Nigeria and Mauritius).
A range of experimental designs was employed across the chosen studies, including quasi-experimental [23, 26, 29], Solomon four group design [24], experimental design (RCTs) [25, 28, 30, 32], mixed study design [26], intervention study [22] and a cross-sectional cohort study [31]. Sample sizes differed significantly: the smallest sample was 12 [26], while the largest was 877 [31]. The quality of the studies also differed based on the GRADE system assessments: two studies were of high quality [25, 28], seven were moderate [22, 23, 28-31], and two were low quality [24, 26]. This suggests that most of the studies had adequate quality ratings.
Practical indices, such as the duration of the programs and who conducted the programs, were also evaluated. The duration of individual sessions of the programs ranged from 45 minutes to 12 hours. The number of weekly sessions per programs ranged from one to three sessions per week. The total duration for implementing the individual programs ranged from three weeks to one year [22-32]. The programs were implemented by a range of professionals, including teachers [23, 25, 29, 32], school counsellors [28, 28, 31], researchers and research assistants [30], consultant psychiatrists, [22] and psychologists [24]. This highlights the culture of the multidisciplinary approach in the provision of mental health interventions in schools.
The involvement of stakeholders in the development of the programs was also highlighted. Out of the 11 programs, one program was developed through needs assessments conducted with multiple stakeholders, including students, parents, non-governmental organizations (NGOs), and policy makers [29]. Others were developed by the researchers [30] or adapted from existing programs [22], while in some others, this was not indicated [23-25, 28, 30-32].
The effectiveness of the 11 programs varied in relation to the individual outcomes of the programs. Five programs [22, 25, 28, 31, 32] were significantly effective across all measured outcomes, and were measured after a period that ranged from three months to four years. The effects of the five programs on adolescent mental health were maintained throughout the measured periods. One [25] of the programs, however, revealed different effects due to the maintenance dose. Improvements in self-esteem and coping skills were maintained at six months’ follow-up, while improvements in depression symptoms and hopelessness were not maintained at six months’ follow-up [25]. Although three of the programs indicated improvements across all the outcomes [26, 28, 30], but they did not measure the effects after the implementation.
The remaining three programs [23, 24, 29] showed varying effects. One of the articles revealed that there was a significant improvement in interpersonal strength, emotional regulation, self-appraisal, and emotional reactivity, and these were also maintained at three months’ follow-up [24]. Also, no significant improvement was reported in family involvement, intrapersonal strength, school functioning, affective strength, sense of mastery, sense of relatedness, family appraisal, or general social support [24]. Another study [23] indicated significant increase in intrinsic motivation, decreased introjected motivation and amotivation in the intervention group. For the control group, there was a sharp increase in recent and heavy use of alcohol and cigarettes. The effects of the programs on alcohol and cigarette use were found to be greater for girls [23]. Significant improvement in self-esteem, perceived self-efficacy, pro-social behavior, and perceived adequate coping was reported. Participants showed significantly better adjustment in respect of teachers, better adjustment in school, and improved classroom behavior. However, no change was observed in adjustment in respect of parents and peers [29].
Description of the program modules
Modules of the universal programs
Universal programs were identified in two of the studies [28, 29]. The modules of these programs included psychoeducation, relationship and communication, cognition, and coping skills modules. The psychoeducation module covered topics such as introduction of participants and areas to be covered in the programs, self-introductions, and building rapport. The second module dealt with relationships and communication, and it covered self-awareness, empathy, learning how to be friendly, and learning how to communicate with friends. The cognition module, which was the third module, covered topics such as problem-solving skills and anger management, decision-making, and critical and creative thinking. The final module was related to coping skills; for example, how to manage emotion and stressful situations. Both programs targeted all the school students and/or parents, but not the teachers [28, 29].
Modules of the selective programs
A total of five programs were selective in nature [23-25, 28, 31]. The modules of the selective programs were described based on the target population. The target population categories included: 1) children predisposed to or experiencing mild cognitive, emotional, and behavioral problems; 2) children at risk for sexual behavior and substance abuse; 3) children who were victims of war; and 4) children living in conflict-prone areas.
- Mild cognitive, emotional, and behavioral problems
The modules of the program targeted children predisposed to or experiencing mild cognitive, emotional, and behavioral problems. The program included the introduction, relationship and communication, behavioral and cognitive modules for students and the behavioral module for teachers. The introduction module introduced participants to the areas to be covered in the programs [24]. The second module, viz., the relationship (intra- and interpersonal relationship) and communication skills, included developing a strong sense of identity, developing and maintaining realistic self-esteem, identification of emotions, expression of emotions and basic communication skills. Cognition, the third module, covered topics like conflict management, assertiveness, and tolerance regarding diversity [24]. Behavioral skill was included in the fourth module, and it dealt with teaching students successful time management and adaptability [24].
- Sexual behavior and substance abuse
The program modules included drug-related psychoeducation and sexual relationship and cognition modules [24]. Drug-related psychoeducation covered topics around the definition of drugs, signs and symptoms. The relationship module, the second module, covered topics such as self-awareness and leisure activities. The third module was cognitive skills, which included problem-solving activities, decision-making activities, and coping skills activities [23].
- Victims of war
The programs targeting children who were victims of war included modules on relationship and communication, trauma related psychoeducation and training topics, cognitive, social support for recovery, and behavior. The first module covered topics like self-awareness and self-esteem activities, building trust and sharing concerns [28, 31]. The second module was trauma-related psycho-education and training, which covered the following topics: learning about emotions, how to control emotions via bodily and verbal processes and regulating breathing, and somatic problems [28, 31]. The cognitive module was third and included problem identification and problem-solving skills. Examples of problem identification skills included writing about and drawing traumatic events (frightening, disturbing experiences; dreams or memories). Problem-solving skills, such as talking about traumatic events to third parties, storytelling, and exploration of emotions were also included. Other activities included coping skills, relaxation and breathing exercises, sleep, and role playing [29, 31]. The fourth and fifth modules covered topics such as help-seeking behavior and recovery process activities [29, 31].
- Conflict-prone areas
The programs that targeted children living in conflict-prone areas covered topics related to students and their parents. The modules for children included psycho-educational topics and relationship-building activities, cognition, and social networks. The psycho-educational topics and relationship-building activities related to family harmony and avoiding the escalation of conflicts [25]. The third module covered cognition-related topics and problem-solving skills (stress inoculation techniques, trauma processing through narrative drawings, and reactions during and after times of danger) [25]. Establishing social networks was part of the fourth module [25].
This program also included activities for parents. Session one involved identification of existing parental strengths and stressors, followed by management of stress to enhance calm and effective parenting; session two offered information about normal adolescent development and strategies for promoting self-esteem and balancing independence and attachment issues; and session three provided strategies to promote family harmony and manage conflicts [25]. The modules covered by all five selective programs included introduction, psychoeducation, relationships and communication, cognition, behavior, and social support systems. These modules resembled those of the indicated programs (see below).
Modules of the indicated programs
Four programs [22, 26, 30, 32] were indicated, which targeted adolescents with depression, learning disabilities, and negative thinking. The modules covered in these programs included an introduction, psychoeducation, intra-communication, and relationships, cognition, and a conclusion. The first module focused on introductory activities, such as exchanging pleasantries [22, 30, 32]; the second focused on psychoeducation, such as signs and symptoms of depression [22]; the third on intra-communication and relationship activities, such as stabilization, self-actualization, and self-esteem-related activities [26, 30]. The fourth module covered cognitive activities, for example, identification and listing of daily pleasurable activities, identification of emotions, controlling emotions via coping skills, relaxation activities, and problem-solving activities such as boosting self-esteem, storytelling trauma narrative activities, and resilience activities [22, 26, 30]. The conclusion, summary and revision made up the fifth module [22, 26, 30].
The systematic review highlighted that the mental health programs provided in schools were made up of the following modules: an introduction module, a communication and relationship module, a psychoeducation module, a cognitive skills module, a behavioral skills module, establishing social networks for recovery and help seeking behavioral activities module and a summary/conclusion module.