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Background: Improving children and young people’s provision for mental health is a current health priority in England. Secondary school teachers have worse mental health outcomes than the general working population, which the Wellbeing in Secondary Education (WISE) cluster randomised controlled trial aimed to improve. The WISE intervention comprised a Mental Health First Aid (MHFA) training package to at least 16 percent of staff, a short mental health awareness session to all teachers, and development of a staff peer-support service. Twenty-five schools were randomised to intervention or control arms. This paper reports findings regarding the extent of uptake and fidelity of the intervention. Methods: Mixed methods data collection comprised researcher observations of training delivery, training participant evaluation forms, trainer and peer supporter interviews, peer supporter feedback meetings, logs of support provided, and teacher questionnaires. Quantitative data were summarised descriptively, while thematic analysis was applied to the qualitative data. Results: In the 12 schools assigned to the intervention arm, 113 (8.6%) staff completed the two-day standard MHFA training course, and a further 146 (11.1%) staff completed the one-day MHFA for Schools and Colleges training. In seven (58.3%) schools the required eight percent of staff completed the MHFA training packages. A one-hour mental health awareness raising session was attended by 666 (54.5%) staff. Delivery of the MHFA training package was achieved with high levels of fidelity and quality across schools. All schools set up the peer-support service following training, with a majority adhering to most of the operational guidelines developed from the pilot study at the outset. Teachers reported limited use of the peer support service during follow-up. At the one year follow up, only three (25.0%) schools indicated they had readvertised the service and there was evidence of a reduction in support from senior leadership. Conclusion: The MHFA training package was delivered with reasonably high fidelity, and a staff peer support service was established with general, but not complete, adherence to guidelines. In some schools insufficient staff received MHFA training and levels of delivery of the peer support service compromised intervention dose and reach.

Introduction: Complex population health interventions that are effective in one context may not be effective elsewhere, and may even be harmful. As such, an intervention may require adaptation to ensure it fits with a new context. To date, there is no overarching guidance to help researchers to adapt and evaluate interventions in new contexts, and no criteria to support research funders or journals assess proposed or reported adaptations or evaluation. There is limited assistance for policy-makers and practitioners to decide if evidence-informed interventions are appropriate to their context, or if adaptation and further evaluation is needed. This Delphi exercise will contribute to the development of guidance for these communities to support the adaptation, implementation and/or re-evaluation of complex population health interventions in new contexts.\ud \ud Methods: We will conduct a Delphi consensus exercise to gather expert opinion from researchers, research funders, journal editors and policy-makers. Expert opinion will be sought on: appropriate definitions and concepts, identifying key methodological considerations and establishing adaptations and processes to be undertaken during adaptation of complex population health interventions in new contexts.\ud \ud Ethics and dissemination: Ethics approval for the Delphi exercise has been obtained from the University of Glasgow and and the RAND institutional research board. Dissemination of the results of this study will be through peer-reviewed publications, workshops at national and international conferences, and a summary of the guidance developed for key organisations and stakeholders.

Additional file 5. Extent of implementation of the WISE intervention at school-level. Table indicating whether domains of fidelity, reach and dosage were achieved by intervention schools.

Additional file 2. Sample for case study schools. Characteristics of case study schools.

Health inequalities emerge during childhood and youth, before widening in adulthood. Theorising, testing and interrupting the mechanisms through which inequalities are perpetuated and sustained is vital. Schools are viewed as settings through which inequality in young people's health may be addressed, but few studies examine the social processes via which institutional structures reproduce or mitigate health inequalities. Informed by Markham and Aveyard's theory of human functioning and school organisation, including their concept of institutional boundaries, critical theories of marketisation and the concept of micro‐political practices within schools, this paper presents analysis of student survey data (N = 9055) from 82 secondary schools in Wales. It examines the role of socioeconomic composition, social relationships at school and institutional priorities in mitigating or perpetuating health inequality. It finds that affluent schools were most unequal in terms of student health behaviours and subjective wellbeing. In relation to health behaviours, students from affluent families accrue a disproportionate benefit. For wellbeing, students from poorer families reported lower subjective wellbeing where attending more affluent schools. Student–staff relationships appear to be a key mechanism underpinning these effects: poor relationships with staff were predicted by a pupil's position within schools’ socioeconomic hierarchy and associated with worse health outcomes. That is, students from the poorest families reported better relationships with teachers where attending less affluent schools. Universal approaches engaging with these social processes are needed to reduce health inequalities.

The educational experiences and outcomes of care experienced children and young people is of longstanding concern. The pervasive inequalities they face suggest that current policies have been unable to respond fully to the complex causes of the problem. This paper reflects on a qualitative study into the educational experiences and aspirations of children and young people who are looked after in Wales. The project worked with care experienced peer researchers and drew on visual, creative and participatory techniques to explore 67 children’s and young people’s experiences of education and, importantly, their opinions on what could be done to improve it. This multimodal approach allowed space for participants to think through their subjective, mundane, but important, experiences that operate alongside, and interact with, more structural challenges. A range of films, magazines, artwork, and music outputs were developed to ensure that the project recommendations could reach wide and diverse audiences. This paper argues the voices of children and young people need to be given a platform to inform policy and practice. For this to happen researchers need to be creative in their approaches to both fieldwork and dissemination; harnessing the power of the arts to make positive changes in the everyday lives of children and young people.

Background\ud Adolescent self‐harm is a major public health concern. To date there is a limited evidence‐base for prevention or intervention, particularly within the school setting. To develop effective approaches, it is important to first understand the school context, including existing provision, barriers to implementation, and the acceptability of different approaches.\ud \ud Methods\ud A convenience sample of 222 secondary schools in England and Wales were invited to participate in a survey, with a 68.9% (n = 153) response rate. One member of staff completed the survey on behalf of each school. Participants responded to questions on the existing provision of adolescent self‐harm prevention and intervention, barriers to delivery, and future needs.\ud \ud Results\ud Adolescent self‐harm is an important concern for senior management and teachers. However, emotional health and well‐being is the primary health priority for schools. Health services, such as Child and Adolescent Mental Health Services, and on‐site counselling are the main approaches schools currently use to address adolescent self‐harm, with counselling cited as the most useful provision. Fifty‐two per cent of schools have received some staff training on adolescent self‐harm, although only 22% rated the adequacy of this training as high. Where schools do not have existing provision, respondents stated that they would like staff training, specialist student training, external speakers, posters and assemblies, although the latter four options were infrequently ranked as the most useful approaches. Key barriers to addressing adolescent self‐harm were: lack of time in the curriculum; lack of resources; lack of staff training and time; and fear of encouraging self‐harm amongst adolescents.\ud \ud Conclusions\ud Adolescent self‐harm is a priority for schools. Intervention might focus on increasing the availability of training to teaching staff.

Background: Secondary school teachers have low levels of wellbeing and high levels of depression compared with\ud the general population. Teachers are in a key position to support students, but poor mental health may be a barrier to\ud doing so effectively. The Wellbeing in Secondary Education (WISE) project is a cluster randomised controlled trial (RCT)\ud of an intervention to improve the mental health support and training available to secondary school teachers through\ud delivery of the training package Mental Health First Aid and a staff peer support service. We will conduct a process\ud evaluation as part of the WISE trial to support the interpretation of trial outcomes and refine intervention theory. The\ud domains assessed will be: the extent to which the hypothesised mechanisms of change are activated; system level\ud influences on these mechanisms; programme differentiation and usual practice; intervention implementation, including\ud any adaptations; intervention acceptability; and intervention sustainability.\ud Methods: Research questions will be addressed via quantitative and qualitative methods. All study schools (n = 25) will\ud provide process evaluation data, with more detailed focus group, interview and observation data being collected from\ud a subsample of case study schools (4 intervention and 4 control). Mechanisms of change, as outlined in a logic model,\ud will be measured via teacher and student surveys and focus groups. School context will be explored via audits of\ud school practice that relate to mental health and wellbeing, combined with stakeholder interviews and focus groups.\ud Implementation of the training and peer support service will be assessed via training observations, training participant\ud evaluation forms, focus groups with participants, interviews with trainers and peer support service users, and peer\ud supporter logs recording help provided. Acceptability and sustainability will be examined via interviews with funders,\ud head teachers, trainers and peer support services users, and focus groups with training participants.\ud Discussion: The process evaluation embedded within the WISE cluster RCT will illuminate how and why the intervention\ud was effective, ineffective or conferred iatrogenic effects. It will contribute to the refinement of the theory underpinning\ud the intervention, and will help to inform any future implementation.\ud Trial registration: International Standard Randomised Controlled Trial Number: ISRCTN95909211 registered on\ud 24 March 2016.\ud Keywords: Mental health, Wellbeing, Schools, Children, Adolescents, Teachers, Process evaluation, Cluster\ud Randomised Controlled Trial

Social and emotional learning (SEL) has predominantly been conceptualised as a neurological process, which has precluded understanding of how social, cultural and material discourses inform the expression of emotional experiences. Gender remains a notable omission. This article explores the micro-practices through which gender structures the development of young people’s emotional subjectivities within the context of a school-based SEL intervention. Particular emphasis is placed on the gendering strategies utilised by educational professionals during the course of their emotional pedagogy. Three strategies are considered: the overt coercion of girls to demonstrate their learning; the permission of boys’ passivity, with their docile bodies being indicated as a signifier of participation; and the restricting of occasions for emotional expression in accordance with perceived gender norms. Efforts to inculcate students with a gendered emotional subjectivity mean that differential learning opportunities are on offer, raising concerns about the introduction of new forms of gendered educational inequalities.

Background Evidence reports that schools influence children and young people’s health behaviours across a range of outcomes. However there remains limited understanding of the mechanisms through which institutional features may structure self-harm and suicide. This paper reports on a systematic review and meta-ethnography of qualitative research exploring how schools influence self-harm and suicide in students. Methods Systematic searches were conducted of nineteen databases from inception to June 2015. English language, primary research studies, utilising any qualitative research design to report on the influence of primary or secondary educational settings (or international equivalents) on children and young people’s self-harm and suicide were included. Two reviewers independently appraised studies against the inclusion criteria, assessed quality, and abstracted data. Data synthesis was conducted in adherence with Noblit and Hare’s meta-ethnographic approach. Of 6744 unique articles identified, six articles reporting on five studies were included in the meta-ethnography. Results Five meta-themes emerged from the studies. First, self-harm is often rendered invisible within educational settings, meaning it is not prioritised within the curriculum despite students’ expressed need. Second, where self-harm transgresses institutional rules it may be treated as ‘bad behaviour’, meaning adequate support is denied. Third, schools’ informal management strategy of escalating incidents of self-harm to external ‘experts’ serves to contribute to non-help seeking behaviour amongst students who desire confidential support from teachers. Fourth, anxiety and stress associated with school performance may escalate self-harm and suicide. Fifth, bullying within the school context can contribute to self-harm, whilst some young people may engage in these practices as initiation into a social group. Conclusions Schools may influence children and young people’s self-harm, although evidence of their impact on suicide remains limited. Prevention and intervention needs to acknowledge and accommodate these institutional-level factors. Studies included in this review are limited by their lack of conceptual richness, restricting the process of interpretative synthesis. Further qualitative research should focus on the continued development of theoretical and empirical insight into the relationship between institutional features and students’ self-harm and suicide.

Teaching staff report poorer mental health and wellbeing than the general working population. Intervention to address this issue is imperative, as poor wellbeing is associated with burnout, presenteeism, and adverse student mental health outcomes. The Wellbeing in Secondary Education (WISE) intervention is a secondary school-based programme aimed at improving the mental health and wellbeing of teachers and students. There are three components: awareness-raising for staff; a peer support service delivered by staff trained in Mental Health First Aid (MHFA); and Schools and Colleges Mental Health First Aid (MHFA) training for teachers. A cluster randomised controlled trial with integrated process and economic evaluation was conducted with 25 secondary schools in the UK (2016–2018). The intervention was largely ineffective in improving teacher mental health and wellbeing. This paper reports process evaluation data on acceptability to help understand this outcome. It adopts a complex systems perspective, exploring how acceptability is a dynamic and contextually contingent concept. Data sources were as follows: interviews with funders (n = 3); interviews with MHFA trainers (n = 6); focus groups with peer supporters (n = 8); interviews with headteachers (n = 12); and focus groups with teachers trained in Schools and Colleges MHFA (n = 7). Results indicated that WISE intervention components were largely acceptable. Initially, the school system was responsive, as it had reached a ‘tipping point’ and was prepared to address teacher mental health. However, as the intervention interacted with the complexities of the school context, acceptability became more ambiguous. The intervention was seen to be largely inadequate in addressing the structural determinants of teacher mental health and wellbeing (e.g. complex student and staff needs, workload, and system culture). Future teacher mental health interventions need to focus on coupling skills training and support with whole school elements that tackle the systemic drivers of the problem.