Project HASHTAG: Health Action in Schools for a Thriving Adolescent Generation

Adolescents globally are vulnerable to mental disorders, injuries and unhealthy lifestyle choices, and this is heightened in young people who live in adversity. Early intervention programmes for adolescents can promote mental health, prevent mental disorders, and prevent risky behaviours and other unhealthy lifestyle choices. These programmes have the potential to make positive contributions to adolescents' health, and to their health in later life. Since about 80% of young adolescents globally are in school, intervention programmes delivered in the school setting could reach a large proportion of adolescents. We reviewed the evidence for school-based intervention programmes and found that most programmes come from high-income countries, and focus on one issue only, such as tobacco or alcohol use, or violence. Since many risk factors for poor mental and physical health, such as alcohol use and risky sexual behaviour, occur together, a programme targeting a range of factors could be more effective and more cost-effective. Such programmes may be more attractive to policymakers in low resourced settings. However, classroom-based programmes alone are unlikely to impact whole schools and sustain improved health benefits. Combining broader school climate and classroom-based programmes has been effective in reducing bullying and mental health symptoms in previous studies.

The aim of this study is to address the evidence gap by developing and adapting a multilevel, gender-sensitive school intervention programme in low- and middle-income countries (LMICs) targeting a range of negative mental and physical health outcomes by promoting positive mental health; preventing mental disorders (specifically, depression and anxiety); and preventing a range of risk behaviours in young at-risk adolescents. We propose to develop the programme (Project HASHTAG) in two LMICs, South Africa and Nepal, co-producing two strategies: a broader school climate and classroom-based programme with adolescents, parents, teachers and school managers.

For the first strategy, a school-level assessment, planning and action process, Thriving Environment in Schools (TES), will be conducted to improve school climate. School climate is defined as staff and students' perceptions of the school environment, which is influenced by the school organisational structure, relationships among staff and students, and their attitudes and behaviours. School climate improvement strategies support the role of classroom-based interventions by boosting commitment from teachers, staff and students, and by reinforcing content of classroom-based strategies. For the second strategy, adolescents ages 11-12 will participate in a group programme known as Thrive Together (TT), to equip them with skills identified in the evidence review as being effective in promoting mental health, and preventing mental health problems and risky behaviours.

To develop and test these strategies, Project HASHTAG will comprise two phases. In the development phase we will interview stakeholders, and observe school environments and staff-student interactions to: (i) develop an outline of TES and (ii) gather suggestions for TT, with adolescents, parents, teachers, and other stakeholders in two schools per country. These suggestions will inform the work of an intervention development group in producing a TT programme draft. In the feasibility phase, we will assess the students before and after the TES and TT strategies are implemented in four schools per country using questionnaires. We will assess whether the questionnaires capture the necessary information on school climate, mental health and risky behaviours. We will also evaluate whether the processes needed to implement the programme work well. After programme completion, we will interview students and stakeholders about their opinions of the programme and whether it is feasible to implement in schools, and what will hinder or help this implementation.

Background. Adolescents suffer a high burden of disease, mostly injuries and mental disorders. Universal school interventions offer opportunities to address early symptoms and risk factors. We conducted a systematic review and meta-analysis of such interventions, finding that most are 'single-issue' interventions from high-income countries, focused on substances or violence.
Aim. Project HASHTAG aims to address the evidence gap by developing and adapting a multicomponent gender-sensitive intervention in low- and middle-income countries targeting negative health outcomes by promoting positive mental health; preventing common mental disorders; and preventing risk behaviours in young at-risk adolescents.
Methods. Project HASHTAG will comprise two strategies: 1) a school assessment, planning and action process, Thriving Environment in Schools (TES), to improve school climate; and 2) a group psychosocial intervention, Thrive Together (TT), to equip adolescents 11-12 years old with skills identified as effective components in reducing negative health outcomes. The study will be conducted in 2 low-resource settings in South Africa and Nepal. The development phase aims to co-produce a TES outline and TT draft, together with adolescents, parents, teachers, and other stakeholders in 2 schools per country. This will be achieved through focus groups, interviews and observations, to inform the work of an intervention development group. The aim of the feasibility phase is to assess the feasibility and acceptability of the TT and TES strategies, outcome measures, and intervention processes. To achieve this, we will implement and evaluate both strategies in 4 schools per country, using baseline and follow-up quantitative assessments to measure mental health and risk behaviour outcomes. Qualitative interviews and observations will be conducted to assess acceptability, feasibility, fidelity and barriers to the programme. Process data will be collected to assess feasibility.

Since this project involves the development and feasibility testing of a universally delivered psychosocial intervention for adolescents, the initial range of beneficiaries-and associated impact-will be intervention participants and their schools and families in the two study countries. However, since this project is part of a broader UNICEF-WHO initiative, the potential for widespread impact is significant. This project makes an important contribution to a broad range of intended intervention target outcomes, which include risky behaviours, mental health and educational outcomes. Evidence from international literature suggests that multi-component psychosocial interventions can address this range of outcomes effectively. Thus, the proposed intervention has the potential to impact physical and mental health in adolescents in the short- and long-term, and their future productivity and earning potential, influencing the wellbeing and prosperity of individuals and communities.

For this proposed project, 4 categories of potential beneficiaries have been identified: First, other scholars working in the adolescent health, mental health fields and education fields could benefit from this contribution to the body of knowledge on the development and local adaptation of psychosocial interventions for adolescents (see Academic beneficiaries). Second, programme implementers and/or developers in health, education or civil society could benefit from the preliminary evidence emerging from the HASHTAG project. Third, in providing vital information and skills in the development and testing of HASHTAG, local stakeholders, educators and other staff involved in the research (and by extension, their colleagues and organisations) could benefit from developing additional skills, such as expertise in facilitating adolescent psychosocial learning, or in spearheading school climate discussions among teachers, parents, and other staff. Additionally, their involvement in the study activities could build awareness of mental health and health-promoting school climates, and stimulate interest in further research or quality improvement activities in their contexts. At the conclusion of the feasibility testing phase, each school should have a school climate improvement strategy which could be sustained beyond the life of this project. Fourth, adolescents, taking part in the research activities as experts in their own health and psychosocial needs, could benefit by learning skills, such as interpersonal and problem-solving skills. These skills could be applied in their own lives and lead to improved mental health and wellbeing. Moreover, adolescent involvement in improving school climate activities and in the development of the intervention, could motivate adolescents to be advocates for adolescent and mental health.