McPhail et al.

BMC Public Health (2024) 24:1217 BMC Public Health

https://doi.org/10.1186/s12889-024-18714-4

S YS T E M AT I C R E V I E W Open Access

Help-seeking processes related to targeted

school-based mental health services:
systematic review
Lauren McPhail1* , Graham Thornicroft2 and Petra C. Gronholm2

Abstract
Background One in seven adolescents globally are affected by mental health conditions, yet only a minority receive
professional help. School-based mental health services have been endorsed as an effective way to increase access
to mental health support for people at risk, or currently presenting with mental health conditions, throughout
adolescence. Despite this, low treatment utilisation prevails, therefore the aim of this review is to contribute insights
into the processes related to adolescents’ accessing and engaging with essential targeted mental health support
within schools.
Methods This systematic review extracted qualitative, quantitative and mixed-methods data to determine what
processes affect adolescents seeking help from targeted school-based mental health services (TSMS). Searches were
conducted in EMBASE, Medline, PsycINFO, CINAHL, ERIC, Web of Science, in addition to manual searching and expert
consultations. Data were synthesised following guidelines for thematic synthesis and narrative style synthesis.
Results The search resulted in 22 articles reflecting 16 studies with participant sample sizes ranging from n = 7 to
n = 122. Three main themes were identified: ‘access-related factors’, ‘concerns related to stigma’, and ‘the school setting’.
These findings elucidate how help-seeking processes are variable and can be facilitated or hindered depending
on the circumstance. We identified disparities with certain groups, such as those from low-socio economic or
ethnic minority backgrounds, facing more acute challenges in seeking help. Help-seeking behaviours were notably
influenced by concerns related to peers; an influence further accentuated by minority groups given the importance
of social recognition. Conflicting academic schedules significantly contribute to characterising treatment barriers.
Conclusions The findings of this review ought to guide the delivery and development of TSMS to facilitate access
and promote help-seeking behaviours. Particularly, given the evidence gaps identified in the field, future studies
should prioritise investigating TSMS in low- and middle-income settings and through quantitative methodologies.
Registration The protocol for this systematic review was registered on PROSPERO (ID CRD42023406824).
Keywords Systematic reviews, School, Mental Health, Adolescent, Intervention, Help-seeking

2
*Correspondence: Centre for Global Mental Health and Centre for Implementation Science,
Lauren McPhail Health Service and Population Research Department, Institute of
[email protected] Psychiatry, Psychology & Neuroscience, King’s College London, London,
1
Centre for Global Mental Health, Health Service and Population Research UK
Department, Institute of Psychiatry, Psychology & Neuroscience, King’s
College London, London, UK

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McPhail et al. BMC Public Health (2024) 24:1217 Page 2 of 21

Background well-established position in delivering mental health

It is important to understand how adolescents’ access care [21], there has been a notable effort to increase the
and utilise mental health services, particularly the sup- availability of services within this setting. In England, for
port provided in school-based settings. Adolescence is a example, the government has increased funding to more
key developmental period when various health issues and than £17 million between 2021 and 2025 and begun to
mental health concerns can arise [1, 2]. Indeed, approxi- rollout policies such as Mental Health Support Teams in
mately 1 in 7 adolescents globally are affected by mental schools, to improve mental health and well-being sup-
health conditions, with half of all lifetime cases emerging port in schools and colleges [22, 23].
before the age of 14 [2, 3]. During this period, there is a Despite this, a dichotomy exists where, on one hand,
marked increase in disability-adjusted life years (DALYs), it is argued that schools provide a familiar and non-
with depressive disorders, anxiety disorders and conduct stigmatising service setting increasing access for those
disorders accounting for the largest proportion of DALYs who might otherwise not seek help [24]. On the other
throughout adolescence [4]. hand, a systematic review by Gronholm and colleagues
Considering the high prevalence of mental health con- countered this by suggesting that targeted school-based
ditions in adolescents, and the possible consequences of mental health services risk stigmatising adolescents who
suffering and disease burden, many adolescents health- access them [25]. They conclude the widespread and per-
care needs remain unmet [1]. Adolescents experience vasive effects of stigma may limit the increased access
barriers in the form of poor mental health literacy, and to mental health services through targeted school-based
this lack of knowledge about mental health and services provision. Similar findings report on stigma as one of the
may increase sensitivity to confidentiality, stigma, poor most prominent barriers to mental health help-seeking
accessibility of care providers, and adverse community for common mental health conditions among adolescents
attitudes [5–7]. This means fewer than two-thirds of and also among older populations more generally [9, 26].
young people with mental health conditions in England Most commonly, school-based mental health services
receive professional help [5, 8], which can give rise to take either a targeted or universal approach. Targeted
further problematic consequences, such as adverse path- services, whether selective or indicated, are offered in
ways to care and worse outcomes throughout the subse- an individualised or group format [27]. When compar-
quent life course [9, 10]. Despite adolescent service use ing the two approaches, ‘selective’ aim to address mental
increasing in some community settings, such as schools, health concerns among those at risk, whilst ‘indicated’
it remains relatively low, with 23.3% of children and target individuals with more pronounced mental health
young people aged 11 to 16 in England accessing support needs, focusing on treatment [27]. In contrast, univer-
at school for mental health and wellbeing [11]. It is there- sal services take a whole-school, generalised approach,
fore crucial to understand why low rates of treatment regardless of individual risk or need, and have the poten-
utilisation exist. tial to prevent mental health conditions in larger groups
Previous studies have identified parent-reported or cli- [27]. Yet there is little consensus on which is best suited
nician-reported barriers to accessing services for adoles- to address adolescent mental health concerns [28]. Spe-
cent mental health [12, 13]. One study reports from the cific worries have been raised on the potential iatrogenic
perspective of the school guidance counsellor identify- effects of universal services, whereby some students
ing issues around privacy and confidentiality concerning might be taught unhelpful or irrelevant information that
counselling service provision, and underuse of services, may actively cause harm. This could be due to the gen-
even with evident need amongst students [14]. There has eralised and widespread dissemination of information,
been a notable growth of research conducted to explore where individual concerns are unknown, thus potentially
adolescents’ perspectives on perceived barriers and facili- increasing the risk of internalising symptoms [24]. Tar-
tators to accessing formal sources of help from men- geted services, however, hold promise to be more effec-
tal health services [15–17]. However, the extent of this tive in tailoring care [29]. This has been noted during the
research, as reported by adolescents in school settings, is childhood-adolescent transition as a crucial period in
yet to be investigated [18]. which targeted support for mental health should be pro-
Schools have historically been recognised as one of the vided [3].
largest providers of mental health services for young peo- Previous reviews have largely focused on synthesising
ple, and more recently, have been endorsed by the WHO universal and/or targeted school-based mental health
as an effective place to tackle health conditions in adoles- services to establish their effectiveness in preventing or
cence [6, 19]. Schools are especially significant for their treating adolescent mental health [30–34]. To date, only
role in providing equitable access to adolescents from one systematic review synthesises studies reporting on
diverse backgrounds, considering that they spend many accessing and utilising TSMS, however, this is limited to
of their waking hours in these settings [20]. Given their help-seeking influences in terms of stigma, qualitative

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McPhail et al. BMC Public Health (2024) 24:1217 Page 3 of 21

data, and includes multiple informants rather than a Inclusion and exclusion criteria
focus on the adolescents’ perspectives [25]. In this con- The review eligibility criteria are outlined in Table 1.
text, the purpose of this systematic review is to enhance Included studies investigated TSMS containing qualita-
our understanding of help-seeking processes related to tive, quantitative, and/or mixed-methods data on help-
TSMS. One approach to consider help-seeking processes seeking processes, reported by adolescents themselves,
is by examining the interplay between different factors, reflecting their experiences related to accessing and
such as facilitators and barriers, associated with help- utilising these services. Studies focused on help-seeking
seeking. Recognising how these factors interact is cru- processes related to other services (i.e., outpatient clin-
cial to effectively promote help-seeking behaviours and ics) were excluded. This was to ensure services could be
to address the diverse needs of adolescents with mental comparable and prevent significant heterogeneity, since
health concerns. The intended value of this review may services outside of schools typically involve a different
therefore have implications for future research and prac- care setting. TSMS, with the primary aim of support-
tice by identifying key evidence gaps and ways to over- ing adolescents’ mental health, of any form (i.e., in per-
come treatment barriers within the school setting, and son, group or online), were eligible for inclusion. Studies
finally, informing intervention design for TSMS. including both those who had received treatment and
those who had not, or comprised different informants
Study aims and objectives were included if the findings could be separated; this was
The aim of this systematic review is to investigate what mainly relevant for quantitative studies where the overall
help-seeking processes affect adolescents accessing effect between both groups were analysed together. Stud-
and utilising TSMS. We intend to address the overall ies that were both universal and targeted were excluded,
research question: “What processes affect adolescents as well as studies that were both predominantly school-
seeking help from TSMS?” through addressing the fol- based and home-based, or existed in another setting due
lowing objectives: (i) To synthesise adolescents’ reported to their distinct approaches that govern different help-
help-seeking processes in relation to accessing and utilis- seeking processes.
ing TSMS; and (ii) To contrast any subgroup differences A broad approach to mental health was taken with
based on evidence coming from high-income settings no limit to the mental health condition being studied.
(HIS) and low-middle-income settings (LMIS). Hence, school-going adolescents identified as having
mental difficulties, or being at risk of such difficulties
Methods were included. Adolescents were defined as young people
This review adheres to the 2020 Preferred Report- aged 10 years to 19 years [2]. Services including parents
ing Items for Systematic Reviews and Meta-Analyses were excluded, as they may cross the boundary of exist-
(PRISMA) statement (see Supplement 1) [35]. The pro- ing outside the school-setting; therefore, by excluding
tocol for this systematic review was registered on PROS- services that involve parents, this review can better iso-
PERO (ID CRD42023406824). late the processes relevant to the adolescent and school-
setting. In this review, studies were considered to assess
Search strategy help-seeking processes related to TSMS if they explic-
The search strategy was developed in EMBASE, guided itly used quantitative measures such as, the Barriers to
by the aforementioned systematic review on stigma Treatment Participation Session questionnaire [36], self-
related to TSMS, and subsequently translated to 5 elec- reported by the adolescent; or qualitative reflections on
tronic databases – MEDLINE, PsycINFO, CINAHL, accessing or utilising TSMS, for example, as prompted in
ERIC and Web of Science [25]. Each search included semi-structured interviews. Studies reporting on accept-
MeSH terms and keywords related to the following top- ability, satisfaction or attendance of the intervention were
ics: (barriers or facilitators or help-seeking) AND (ado- deemed insufficient to report on help-seeking processes.
lescents) AND (mental health) AND (school-based No restrictions were applied on target populations, coun-
interventions or services) (see Supplement 2 for the full try setting or publication date.
search strategy). In addition to the database search, we
performed manual hand searching by forward and back- Study selection
ward citation tracking of all included papers and related Electronic database searching took place in March and
systematic reviews. Content experts (authors of articles April 2023 to identify articles relevant for inclusion per
identified for inclusion) were contacted for further paper the eligibility criteria (Table 1). All records were exported
recommendations. to reference management software EndNote 20 for de-
duplication and following this, the records were exported
to Rayyan for screening. We screened the initial search
results for relevance based on titles and abstracts, with

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McPhail et al. BMC Public Health (2024) 24:1217 Page 4 of 21

Table 1 Inclusion and exclusion criteria

Help-seeking Processes
Inclusion criteria Exclusion criteria
[1] Studies reporting on adolescent help-seeking processes (barriers and facilitators, help- [1] Studies reporting on such processes concerning
seeking attitudes, intentions, and behaviours) that focus on seeking, utilising and engaging informal sources of help (i.e., family and peers) and
with formal sources of care (i.e., school counsellor, school psychologist) self-help
School-going Adolescents
Inclusion criteria Exclusion criteria
[1] Adolescents attending school-level education [1] Adolescents neither screened for nor participated
[2] identified as having mental health difficulties, or being at risk of such difficulties, by meet- in TSMIs
ing screening criteria for and/or participating in TSMIs (i.e., depression, anxiety) [2] adolescents’ primary health condition is not mental
health (i.e., autism spectrum disorder (ASD), substance
use disorder)
Adolescent Mental Health
Inclusion criteria Exclusion criteria
[1] Measures of mental health, including but not limited to mental health and well-being; [1] Mental health is not the primary outcome
pre-clinical psychological conditions or mental health conditions measured by a validated/ [2] mental health and another non-mental health-
commonly used rating scale, or by a structured psychiatric diagnostic interview related co-occurring disorder/disability (i.e., anxiety
[2] measures of other individual-level domains related to mental health (i.e., cognitive func- and ASD)
tion, self-concept, emotional regulation, coping skills)
[3] identified as at risk (i.e., by teacher/parent referral, self-referral)
School-based Targeted Mental Health Interventions
Inclusion criteria Exclusion criteria
[1] Targeted approach delivered by Tier 2 (selected) or Tier 3 (indicated) programs, as defined [1] Interventions with a universal approach (i.e., whole-
in the Multi-Tiered System of Supports (MTSS*) framework school interventions, interventions without targeting
[2] interventions with the primary aim of supporting adolescents’ mental health, (i.e., psycho- a specific risk/symptom)
therapeutic interventions, social and emotional learning interventions) [2] interventions with the primary objective to sup-
[3] conducted in an individual or group setting port adolescents’ non-mental health-related issues
[4] provided in a school-based setting (in-person or online) (i.e., learning difficulties, physical health conditions,
[5] provided in school-settings below university level alcohol/drug use)
[3] Interventions outside the school setting (i.e., home-
based, residential institutions, juvenile placements)
[4] interventions targeting and/or involving both
adolescents and caregivers (i.e., parents)
[5] interventions that are both targeted and universal
Methodology and Study Type
Inclusion criteria Exclusion criteria
[1] Studies utilising qualitative, quantitative, or mixed-method design [1] Qualitative, quantitative or mixed-methods studies
[2] data-based/primary studies not addressing this review’s research question
[3] studies published in peer-reviewed journals [2] non-data-based/secondary studies; (i.e., reviews,
[4] published in English language meta-analyses or meta-syntheses, editorials, protocols,
[5] full-text studies available commentaries, letters)
[3] non-peer-reviewed work (i.e., conference abstracts,
theses, grey literature)
[4] studies published in another language than English
[5] studies for which full-text cannot be accessed
*MTSS (Arora PG, Collins TA, Dart EH, Hernández S, Fetterman H, Doll B. Multi-tiered Systems of Support for School-Based Mental Health: A Systematic Review of
Depression Interventions. School Mental Health. 2019 Jun;11 [2]:240–64)

15% of the total records screened by two reviewers sepa- independently screened 15% of the total full-text papers.
rately. To ensure both reviewers jointly understood the An initial subset (n = 15) of the full-text papers were
eligibility criteria, a subset of the total records (n = 200) screened to establish screening consistency and any dis-
were initially independently screened by the two review- agreements were discussed and resolved. After we com-
ers, with any conflicts resolved through discussions. pleted screening all full-texts, any remaining conflicts
This was then repeated once all records for independent were resolved through collaborative discussions. All full-
screening by the two raters were complete. LM indepen- texts were available online, therefore we did not need to
dently screened the remaining and the second rater was contact study authors at this stage.
engaged for resolution when necessary. Full-text versions
of studies deemed potentially relevant were retrieved and
screened against inclusion criteria. The second reviewer

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McPhail et al. BMC Public Health (2024) 24:1217 Page 5 of 21

Data extraction synthesis was not planned. Rather, a narrative-style syn-

Using a standardised, pre-piloted form designed in Excel, thesis was intended to combine findings from included
data were extracted on study design (qualitative, quan- quantitative studies [38]. To combine qualitative data we
titative, mixed-methods); study setting (country, school thematically synthesised findings following the steps to
setting); study aims/objectives; intervention character- conduct a thematic synthesis [39]. This process involved
istics (description, delivery method); participant data extracting contextual data from the articles and deriv-
(age, gender, ethnicity, mental health characteristics); ing codes that develop into iterative key themes and
and self-reported data on help-seeking processes (atti- subthemes. We then triangulated qualitative and quanti-
tudes, behaviours, barriers, or facilitators) in relation tative data to discuss the findings together on help-seek-
to intervention participation. The data extraction pro- ing processes related to TSMS in the synthesis. The was
cess was conducted by the first author. Qualitative data led by the first author and collaborative discussions with
were extracted mostly from participant utterances (i.e., the co-authors confirmed accuracy. To address the sec-
interviews and focus groups) as reported in the included ondary review objective (ii) To contrast any subgroup dif-
articles on the topic of help-seeking processes related to ferences based on evidence coming from HIS and LMIS,
TSMS, while content from author’s results narrative and if feasible, we planned to compare study results by their
discussion were extracted too. Relevant quantitative data setting (HIS vs. LMISs) to identify patterns, convergen-
(i.e., survey data on TSMS access predictors) were also ces, or divergences within these data.
extracted.
Results
Quality assessment A total of 8176 non-duplicated records were retrieved
The Mixed Methods Appraisal Tool (MMAT) was from the database search; 7967 of these were excluded
employed to assess the methodological quality of after title and abstract screening. We accessed full-
included articles [37]. The MMAT consists of two generic texts for the remaining 209 records of which 200 were
screening questions (a) clarity of research question(s), excluded. We identified an additional 80 articles via
and (b) appropriateness of the data for addressing the manual hand searching, of which 13 were included in
research questions, and for quantitative and qualitative the review upon meeting inclusion criteria. In total, 289
studies a further five methodology-specific questions full-text articles were reviewed, and 22 articles met the
[37]. For mixed-methods studies, there are three sets of criteria for inclusion. For the content expert consultation,
five methodology-specific questions (qualitive, quantita- we contacted the corresponding authors of each included
tive, and mixed methods), resulting in a total of 15 qual- study, of whom 6 replied. Some provided additional
ity questions [37]. One point was awarded for meeting articles unidentified by the initial search, but none met
the criteria for a given question. For partially met crite- the criteria for inclusion. The article selection process is
ria, half a point was awarded. Where the criteria was not depicted in Fig. 1.
met, or it was not possible to assess whether the criteria The 22 articles included in this review represent 16
was met due to insufficient level of information provided studies, with an aggregate total participant sample size
in the article, no point was awarded [25]. For quantita- of n = 532 – children and adolescents who participated in
tive and qualitative studies, the MMAT score ranged the service.
from 0 to 5 and mixed-methods studies 0–15. An overall The main characteristics of the included studies
percentage was calculated from the total MMAT score are reported in Tables 2 and 3. Most included articles
(dividing an article’s MMAT score with the maximum described a qualitative design (n = 20; 90%); only one
total score) which determined the quality level of each quantitative (5%) and one mixed-methods article (5%)
included study, with 0% indicating low quality and 100% were included. Only the qualitative data presented in
high quality. Included studies were assessed for quality the mixed-methods article were relevant for this review,
by the first author. Studies were not excluded based on as the quantitative data did not measure help-seeking
methodological quality. processes. In terms of school setting, for most of the
included articles this was described as secondary or high
Data synthesis school level (n = 11; 50%) [40–50]. Some articles (n = 9;
The main synthesis addressing review objective (i) To 41%) did not specify the school level but reported the
synthesise adolescents reported help-seeking processes age of participants – for example 12–18 years – there-
in relation to accessing and utilising TSMS, follows schol- fore, by association it was presumed this was secondary-
arly guidance on conducting a narrative synthesis and level schooling [18, 51–58]. Only one article considered
thematic synthesis [38, 39]. Due to expected methodolog- primary school level (n = 1; 5%) [59]. Another article did
ical variation and heterogeneity in the included studies, not specify the school level but provided an age range
owing to the broad nature of this review, a quantitative of students between 6 and 18 years (mean 11.03 years),

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McPhail et al. BMC Public Health (2024) 24:1217 Page 6 of 21

Fig. 1 PRISMA flow diagram summarising the article selection process

this was ultimately presumed to consider both primary manner to a group of adolescents deemed ‘at risk’ [53,
and secondary level schooling (n = 1; 5%) [36]. Regard- 54]. The remaining articles did not specify the service
ing participant characteristics, most included articles had criteria – however, it can be presumed that the students
an age range within the prespecified adolescence period self-referred or were referred due to some perceived risk
between the age of 10–19 years (n = 16; 73%) [1, 18, 40– (n = 6; 27%) [44, 45, 47, 48, 56, 57].
43, 46–50, 53–58]. The age range of the remaining arti- In terms of intervention characteristics, these were
cles did not fully align with the specified range, however, mostly described in general terms as ‘school counsel-
of these, five articles (23%) provided a mean age value ling service’ or ‘school health service’ (n = 11; 50%) [18,
within this range and one article (5%) participants’ ages 42–45, 47, 48, 51, 52, 56, 57]. Two articles (9%) discussed
ranged from 9 to 12 years, which was considered satis- a different version of DISA (‘depression in Swedish ado-
factory for their inclusion [36, 44, 45, 51, 52, 59]. With lescents’), a school-based cognitive-behavioural depres-
the ages of some participants below the adolescence age sion prevention program, with one only targeting girls
range, as defined by the WHO as between 10 and 19, we [54], and the other targeting girls and boys between the
refer to participants as children and young people (CYP) age of 13–15 years [53]. DISA was universally imple-
in the results and discussion herein. Participants’ ethnic- mented as a population-wide intervention with targeted
ity and race when reported was varying. Through their efforts to address the needs of specific groups identified
involvement in the services described in the included as having increased risk of developing depression [60].
studies, adolescents were identified as having mental dif- Another two articles (9%) discussed the same interven-
ficulties, or being at risk of such difficulties. Most ser- tion of a task-shifted psychotherapeutic post-traumatic
vices utilised a screening criterion or a referral process stress disorder (PTSD) intervention composed of sup-
(n = 14; 64%) [18, 36, 40–43, 46, 49–52, 55, 58, 59]. Two ported counselling (SC) and prolonged exposure therapy
interventions (9%) were offered universally in a targeted for adolescents (PE-A) [49, 50]. The remaining articles

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 Table 2 Study characteristics
Study Study Aims Study Country School Setting n ado- Gender Age Ethnicity
Identification Design lescents
(n total
sample)
Dickinson et al. To determine whether the TRAVELLERS programme was an ap- Mixed- Aotearoa, n = 2 secondary n = 34 Females 13–14 Mainly Pakeha/European
(2003) propriate, feasible, acceptable, and promising intervention for young methods New Zealand schools (one rural n = 24 years
people (only and one urban) Males (mean not
qualitative n = 10 reported)
data used
McPhail et al. BMC Public Health

for this
review)
Evans et al. To explore young people’s lived experiences of participating in a Qualitative Wales (UK) n = 4 secondary n = 41 Females 12–14 “White background”
(2015) targeted SEL intervention; to generate new theoretical and empiri- schools (n = 3 in 50% Males years
cal insights into the manifestation of iatrogenic effects within the post-industrial 50% (mean not
educational domain towns, n = 1 in a reported)
rural area)
(2024) 24:1217

Fazel (2015) To explore the role of schools in supporting the overall development Qualitative Glasgow, n = 3 schools lo- n = 40 Females 15–24 not reported
of refugee and asylum-seeking children in the UK Cardiff and cated in Glasgow, n = 11 years
Oxford (UK) Cardiff and Males (mean age
Oxford (n = 1 per n = 29 17 years)
location)
Fazel et al. (2016) To understand the experience of adolescents directly seen by Qualitative as above as above as above as above as above Albania [5]; Somalia [4];
school-based mental health services; concerning their experience of Sudan [3]; Iran/Iraq ‘Af-
being seen within the school location, how they perceived therapy, ghanistan [9]; other Asia
whether it helped them, and finally, any worries that might be [7]; South America [2]
impacting their time at school
Gampetro et al. To explore the perceptions of mental health needs of 18 inner-city Qualitative Chicago (US) n = 1 school n = 18 Females 12–18 African American [12];
(2012) teens diagnosed with behavioural or mental health issues (low resource n = 10 years Hispanic [5]; Native
community) Males n = 8 (mean not American [1]; Caucasian
reported) [1]
Garmy et al. To explore adolescents’ experiences with a school-based cognitive- Qualitative Sweden n = 6 schools (in n = 89 Female 13–15 not reported
(2015) behavioural depression prevention program four municipali- 75% Male years
ties in rural and 25% (mean not
urban areas of reported)
southern Sweden)
Gibson et al. To find out how young clients made sense of their experiences of Qualitative New Zealand n = 2 high schools n = 22 Females 16–18 New Zealanders of Euro-
(2013) counselling and whether this would be similar or different to the n = 15 years pean ancestry [11], Maori
way that the professional literature constructs counselling Males n = 7 (mean not or Pasifika [5], ‘immigrants
reported) from other English-

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speaking countries’ [6]
Gibson et al. To explore how young clients who made use of a school counselling Qualitative as above as above as above as above as above as above
(2014) service understood their counselling experience
Page 7 of 21
 Table 2 (continued)
Study Study Aims Study Country School Setting n ado- Gender Age Ethnicity
Identification Design lescents
(n total
sample)
Harrison (2019) To investigate the processes by which Hong Kong Chinese second- Qualitative Hong Kong, n = 3 second- n = 25 Females 14 years+ Chinese (local Hong
ary school students engage with school counselling services from China ary schools (total n = 16 (mean age Kong)
the perspective of both clients and counsellors, and how the socio- (private and sample Males n = 9 16.7 years)
cultural context and the school setting influence these processes coeducational) n = 33)
McPhail et al. BMC Public Health

Harrison (2022) To research the change processes experienced by adolescent Hong Qualitative as above as above as above as above as above as above
Kong Chinese clients, considering the voices of service users and
providers
Kendal et al. To evaluate The Project’s feasibility and acceptability from the per- Qualitative England (UK) n = 3 high schools n=9 Not 11–18 not reported
(2011) spectives of staff and students in those schools (located in socio- (total specified years
economically sample for each
deprived urban n = 50) informant
(2024) 24:1217

areas of Northern group

England)
Kit et al. (2019) To explore Singapore Asian primary school children’s experiences Qualitative Singapore n = 1 primary n = 23 Females 9–12 years Ethnic mix of Chinese
of online live chat counselling, to gain insight into their motivations school n = 15 (mean not (n = 17), Malays (n = 9), In-
for engaging in help-seeking behaviours, and the utility of providing Males reported) dians (n = 6) and another
online counselling services to this population n = 18 race (n = 1)
Kvist Lindholm To explore how the programme is constructed through the girls’ Qualitative Sweden n = 6 schools n = 32 All female 12–14 not reported
& Zetterqvist descriptions and arguments, which contradicts the official version (located in a years (no
Nelson (2014) of DISA relatively small mean
municipality in reported)
Sweden)
McKeague et al. To investigate the feasibility of the DISCOVER workshop programme Qualitative London, Eng- n = 10 schools n = 15 Females 16–19 Black British, African [6];
(2018) for students in UK sixth forms compo- land (UK) (inner economi- (total n = 12 years Black British, Caribbean
nent of a cally deprived and sample Males n = 3 (mean [3]; White British [4]; other
cluster RCT ethnically diverse n = 34) age 17.59 BME group [2]
city area) years)
Nabors et al. To investigate student perceptions about program strengths and Qualitative Baltimore n = 3 high schools n = 37 Females 14–19 African American [30];
(1999) weaknesses; barriers to participating in treatment; and treatment City, Con- (inner city area) n = 24 years Caucasian [7]
outcomes. In particular, the study aims to examine gender differ- necticut (US) Males (mean age
ences in response to focus group questions about mental health n = 13 16.4 years)
services for adolescents.
Nabors et al. To explore stakeholder perceptions on the strengths, weaknesses, Qualitative as above as above n = 37 as above as above as above
(2000) and outcomes of the ESMH program (total
sample

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n = 108)
Pella et al. (2018) To examine anxious children’s perceptions of barriers to treatment Quantita- Baltimore Not reported n = 122 Female 6–18 years Non-white (50.9%); Asian
attendance in a school-based setting and their association with tive (RCT) City, Con- 51.6% (mean (2.7%); African-American
demographic factors, child, and parent clinical characteristics, par- necticut (US) Male age 11.03 (35.7%); Hispanic (8%);
enting style and parent service use history 48.4% years) more than one race
(4.5%)
Page 8 of 21
 Table 2 (continued)
McPhail et al. BMC Public Health

Study Study Aims Study Country School Setting n ado- Gender Age Ethnicity
Identification Design lescents
(n total
sample)
Prior (2012a) To analyse young people’s narratives of accessing a school counsel- Qualitative Central Scot- n = 1 school n=8 Females 13–17 Not reported
ling service land (UK) (located in central n = 6 Males years
Scotland) n=2 (mean not
(2024) 24:1217

reported)
Prior (2012b) To elucidate the key features and stages of the help-seeking process Qualitative as above as above as above as above as above as above
as defined by young people accessing school counselling
Segrott et al. To establish Bounceback’s aims, feasibility and acceptability, through: Qualitative Wales (UK) n = 3 schools n=7 Females 14–16 not reported
(2013) [1] exploring the view of young people who used the service in (located in south (total n = 3 Males years
relation to acceptability and perceived outcomes; [2] examining Wales, serving sample n=4 (mean not
Bounceback’s potential to prevent emotional/mental health issues economically n = 16) reported)
in young people in becoming more severe; [3] examining the rela- disadvantaged
tionship between Bounceback and schools in which it operated; [4] city populations
identifying young people’s support needs during the transition from and pupils from
school to adulthood ethnic minority
backgrounds)
Van de Water et To compare the experiences and perceived efficacy of two PTSD Qualita- Cape Town, n = 4 high schools n = 10 Females 13–18 not reported
al. (2018a) interventions by treatment users (adolescents with PTSD) and treat- tive study South Africa (lower income) (total n = 8 Males years
ment providers nested sample n=2 (mean not
within the n = 13) reported)
main RCT
study
Van de Water et To report on the experiences of stigma in adolescents participating as above as above as above n = 10 as above as above not reported
al. (2018b) in the RCT and use this knowledge to inform the wider implementa-
tion of these interventions for PTSD, especially in LMIS’s

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Page 9 of 21
McPhail et al. BMC Public Health (2024) 24:1217 Page 10 of 21

(n = 7; 32%) described unique interventions summarised distinction between them and the counsellor, depicting a
in Table 3 [36, 40, 41, 46, 55, 58, 59]. ‘dominant role’ to themselves and assigning a ‘relatively
The quality appraisal scores as per the MMAT assess- minor role’ to the counsellor [42]. Participants empha-
ment are presented in Table 4. The methodological qual- sised the importance of selecting what they, as ‘clients’
ity rating of included qualitative articles (n = 20; 100% and ‘entitled consumers’, wanted from counselling and
of qualitative studies) ranged from 60 to 100% suggest- tailoring aspects of it to fit their particular needs [42, 56].
ing good overall quality. The quality of the quantitative However, some CYP identify the power imbalance which
article (n = 1; 100% of quantitative studies) scored 30% on may prevent their ability to express agency directly to the
the MMAT and the mixed-methods article (n = 1; 100% of counsellor [42].
mixed methods studies) had good overall quality > 50%. Referral agent. A significant proportion of studies dis-
For this review, the relevant data used within the mixed- cussed some form of referring agent to access the inter-
methods article were qualitative; therefore, we conducted vention. Most CYP describe teachers as important agents
a subsequent MMAT rating for the qualitative aspect of in mediating a referral or support contact with TSMS
this study which also had good methodological quality [50–52]. Yet, a minority thought a self-referral or par-
(60%). Qualitative methodological limitations were asso- ents would be better positioned to make the referral than
ciated with a lack of or insufficient details on analysis and teachers [46, 51]. Some referred to an adult authority in
data collection procedures and linking these methods more general terms – parents, a staff member [42, 46, 49,
back to the research question with reference to relevant 57]. Fewer discussed peers as a significant referring agent
data sources. Quantitative methodological limitations [42]. Interestingly, however, some participants referred
were related to insufficient data reporting, specifically to disclosing their own experiences of therapy to peers
on outcome data. And lastly, the mixed-methods meth- deemed at risk, in the hope this would encourage others
odological limitations were due to the lack of integration to seek help [49]. For minority groups, the importance of
between qualitative and quantitative results (i.e., identify- social recognition and impactful peer interactions were
ing divergences and inconsistencies). acknowledged as important to motivate and instil confi-
dence to seek help [51]. Beyond the initial referral agent,
Thematic synthesis some studies identify a strategy to facilitate adherence
Addressing the primary review objective (i), three key and encourage utilisation for the full duration of the pro-
themes were identified: (a) access-related factors; (b) gram (i.e., incentives). This was specifically reported by
concerns related to stigma; and (c) the school setting, males who suggest the ‘need’ to incentivise or reimburse
which were characterised with subthemes discussed students for participating in the intervention [48].
herein. These themes describe both barriers and facili- Confidentiality and trust. This theme was largely
tators, as help-seeking processes are variable and can be referred to as confidentiality and trust of the ‘counsel-
facilitated or hindered depending on the circumstance. lor’ [18, 44, 49, 50, 57, 59]. This was described both as a
These themes are described below, and corresponding barrier and a facilitator whereby the counsellor’s other
studies are referenced with the main illustrative quotes role within the school heightened students’ awareness
provided in Table 5. to the importance of confidentiality [44]. On the other
hand, the counsellor mediated this by building trust-
(A) Access-related factors ing relationships with students which facilitated par-
This was the most reported theme and reflects barriers ticipants’ engagement in and utilisation of TSMS. This
and facilitators related to accessing school-based ser- was noted to be particularly important in relation to
vices. These experiences are described further through the sociocultural context of Hong Kong, which seemed
the subthemes “individual agency”, “referral agent”, “con- to heighten initial fears and uncertainty when students
fidentiality and trust”, “direct solution to a problem”, and first approached counselling [44]. The authors discuss
“misconceptions of the service”. that this may stem from the relatively lower level of trust
Individual agency. This theme describes CYP’s self- that exists outside the family within this context, com-
agency to seek help from TSMS. Some favoured the pared to Western cultures. Hence, establishing trust was
self-referral route to act on their own awareness of per- deemed as crucial to foster relationships and essential
sonal need [46]. CYP thus conceptualised themselves as for students to disclose information and overcome ini-
autonomous and self-determining identities empowered tial barriers [44]. This extended to some CYP identify-
to seek help, without assuming a passive illness identity ing the counsellor as the most important component in
[57]. Several CYP report receiving information about the process of accessing and utilising TSMS [50]. CYP
TSMS from other sources – for example, parents and seemed to favour an informal and equal relationship
peers – but “emphasised that, in the end, the decision with the counsellor and saw them as reliable, non-judge-
was theirs” [40]. Some went so far as to make a very clear mental and accepting [18, 44, 45, 47–49]. Similarly, CYP

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 Table 3 Intervention characteristics
Study Intervention Delivery Participants Mental Health Key Themes Related to Help-seeking
Identification Method Processes
Dickinson et al. TRAVELLERS: a school-based early Group-based; Screening procedure (operates as a filter from the first to the last): answering Anticipated stigma; navigating through
(2003) intervention programme helping young in-person no to self-report measure “do you feel good about yourself most of the time?“; stigma
people manage and process change, loss or those who scored 40 and above on the Subjective Experience of Distress
and transition scale; or those who rated four of more life-events with major impact; or those
who had attended 7 or more schools were also included
Evans et al. (2015) The Student Assistance Programme (SAP): group-based; Students experiencing social and emotional problems, particularly within Anticipated stigma; negative labelling;
a targeted school-based SEL intervention in-person school and the family. The SAP stipulates four referral routes for the interven- navigating through stigma
McPhail et al. BMC Public Health

tion: self-referral; teacher referral; parental referral; community services referral

Fazel (2015) School-based mental health services for individual, Refugees or asylum seekers identified as at risk and referred by teachers Referral agent; confidentiality and trust;
refugee children group or negative labelling; anticipated stigma
multimodal; in
person
Fazel et al. (2016) as above as above as above Available and accessible care; anticipat-
(2024) 24:1217

ed stigma; referral agent; confidentiality

and trust; navigating through stigma
Gampetro et al. School-based health clinic individual; in Adolescents with an Axis 1 diagnosis who were seen by the school-based Confidentiality and trust; available and
(2012) person health clinic’s licensed clinical social worker (LCSW). The adolescent also had accessible care
to have received a DSM-IV-TR diagnosis during the one-year period data were
being collected
Garmy et al. (2015) DISA (‘depression in Swedish adoles- Group-based; Adolescents deemed at risk due to their age between 13–15 years olds. This Anticipated stigma; negative labelling;
cents’): a school-based cognitive-behav- in-person age group was chosen because adolescents at this age are considered suf- navigating through stigma
ioural depression prevention program. ficiently mature to grasp the theory of the program and because depression
rates in this age group have been increasing
Gibson et al. School counselling service individual; in Students can self-refer or can be referred to counselling by a friend, teacher, or Individual agency; referral agent
(2013) person other professional.
Gibson et al. as above as above as above A direct solution to a problem; miscon-
(2014) ceptions of the service
Harrison (2019) School counselling service individual; in Not specified Available and accessible care; miscon-
person ceptions of the service; confidentiality
and trust; negative labelling
Harrison (2022) as above as above Not specified Available and accessible care; confiden-
tiality and trust
Kendal et al. “The Change Project” (The Project): an individual; in Students self-referred for emotional difficulties including anxiety, low mood, Individual agency; referral agent; avail-
(2011) intervention to promote EWB in high person self-esteem, and relationship problems able and accessible care; competing
schools academic schedules
Kit et al. (2019) Online counselling portal, part of the iZ individual; Students experiencing socio-emotional distress were identified by teachers Direct solution to a problem; con-

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Hero Challenge online (within through the school’s participation in the iZ Hero Challenge. They identified 228 fidentiality and trust; available and
scheduled after nine- to 12-year-old children in need of help. Through teachers referrals a total accessible care
school hours) of 33 children (18 males, 15 females) aged between 9 to 12 years old agreed to
participate
Page 11 of 21
 Table 3 (continued)
Study Intervention Delivery Participants Mental Health Key Themes Related to Help-seeking
Identification Method Processes
McPhail et al. BMC Public Health

Kvist Lindholm & DISA (‘depression in Swedish adoles- Group-based; Girls at risk of developing depression. Offered to girls specifically; to address Anticipated stigma; negative labelling
Zetterqvist Nelson cents’): a school-based cognitive-behav- in-person concerns about teenage girls’ mental health and is based on the view that this
(2014) ioural depression prevention program. group is ‘at risk’ for developing depression
McKeague et al. DISCOVER: “How to handle stress” work- group-based; Students self-referred owing to self-perceived need for psychological support Available and accessible care; compet-
(2018) shop programme. This is a self-referral in person in managing common adolescent stressors ing academic schedules; confidentiality
school-based group intervention de- and trust; navigating through stigma
signed for stressed students in sixth form
(2024) 24:1217

Nabors et al. Expanded School Mental Health Program individual; in Not specified Competing academic schedules; nega-
(1999) person tive labelling; confidentiality and trust;
available and accessible care
Nabors et al. as above as above Not specified Anticipated stigma; competing aca-
(2000) demic schedules; referral agent
Pella et al. (2018) STARS: School-based treatment for anxiety individual; in DSM-IV primary diagnosis of an anxiety disorder based on the Anxiety Disor- Competing academic schedules; con-
research study person ders Interview Schedule for DSM-IV fidentiality and trust; anticipated stigma
Prior (2012a) School counselling service individual; in Not specified Anticipated stigma; negative labelling
person
Prior (2012b) as above as above as above Anticipated stigma; referral agent; con-
fidentiality and trust; individual agency;
direct solution to a problem
Segrott et al. Bounceback: a school-based support Individual; Teachers referred young people with emotional difficulties/mental health Anticipated stigma; confidentiality and
(2013) service for young people experiencing in-person issues, which had the potential to cause a crisis or have a negative effect on trust
difficulties detrimental to their mental emotional well-being
and emotional well-being
Van de Water et al. Task shifted psychotherapeutic PTSD individual; in Trauma-exposed adolescents with chronic (at least 3 months) full PTSD or Anticipated stigma; negative labelling;
(2018a) intervention composed of two treat- person subthreshold PTSD who were entered into the RCT in the first year (2014) were confidentiality and trust; misconcep-
ments: Supportive counselling (SC) and asked to participate tions of the service; referral agent;
prolonged exposure therapy for adoles- direct solution to a problem
cents (PE-A)
Van de Water et al. as above as above as above Confidentiality and trust; misconcep-
(2018b) tions of the service

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Page 12 of 21
 Table 4 Mixed Methods Appraisal Tool (MMAT) scores per domain and total score, used to assess methodological quality. Scoring key: Y = Yes, criteria met (1 point); N = No, criteria
not met/not possible to assess (0 points); P = criteria partially met (0.5 points); blank cell = scoring criteria not applicable
1. Qualitative design 2. Quantitative (randomised) 3. Quantitative (non-ran- 4. Mixed-methods design MMAT total Score
design domised) design
Study Identification 1.1 1.2 1.3 1.4 1.5 2.1 2.2 2.3 2.4 2.5 3.1 3.2 3.3 3.4 3.5 4.1 4.2 4.3 4.4 4.5 % (points)
McPhail et al. BMC Public Health

Evans et al. (2015) Y Y Y Y Y 100% (5/5)

Fazel (2015) Y P Y Y Y 90% (4.5/5)
Fazel et al. (2016) Y Y Y Y Y 100% (5/5)
Gampetro et al. (2012) Y Y P Y Y 90% (4.5/5)
Garmy et al. (2015) Y Y Y Y Y 100% (5/5)
(2024) 24:1217

Gibson & Cartwright (2013) Y Y Y Y Y 100% (5/5)

Gibson & Cartwright (2014) Y Y Y Y Y 100% (5/5)
Harrison (2019) Y P Y Y Y 90% (4.5/5)
Harrison (2022) Y Y Y Y Y 100% (5/5)
Kendal et al. (2011) Y Y Y Y Y 100% (5/5)
Kit et al. (2019) Y P Y Y Y 90% (4.5/5)
Kvist Lindholm & Zetterqvist Nelson (2014) Y Y Y Y Y 100% (5/5)
McKeague et al. (2018) Y P Y Y Y 90% (4.5/5)
Nabors et al. (1999) Y P P P Y 70% (3.5/5)
Nabors et al. (2000) Y P P P Y 70% (3.5/5)
Prior (2012a) Y Y Y Y Y 100% (5/5)
Prior (2012b) Y Y Y Y Y 100% (5/5)
Segrott et al. (2013) Y P N P Y 60% (3/5)
Van de Water et al. (2018a) Y P Y Y Y 90% (4.5/5)
Van de Water et al. (2018b) Y P P Y Y 80% (4/5)
Pella et al. (2018) P N N N Y 30%(1.5/5)
Dickinson et al. (2003) Y P N Y P Y Y Y N Y N N P N Y 57% (8.5/15)
(1) Qualitative domain questions: Is the qualitative approach appropriate to answer the research question?; 1.2 Are the qualitative data collection methods adequate to address the research question?; 1.3 Are the findings
adequately derived from the data?; 1.4 Is the interpretation of results sufficiently substantiated by data?; 1.5 Is there coherence between qualitative data sources, collection, analysis and interpretation? (2) Quantitative
(randomised) domain questions: (2.1) Is randomization appropriately performed? (2.2) Are the groups comparable at baseline? (2.3) Are there complete outcome data? (2.4) Are outcome assessors blinded to the intervention
provided? 2.5 Did the participants adhere to the assigned intervention? 3. Quantitative (non-randomised) domain questions: 3.1 Are the participants representative of the target population? 3.2 Are measurements
appropriate regarding bout the outcome and the intervention (or exposure)? 3.3 Are there complete outcome data? 3.4 Are the confounders accounted for in the design and analysis? 3.5 During the study period, is the
intervention administered (or exposure occurred) as intended? 4. Mixed-methods domain questions: 4.1 Is there an adequate rationale for using a mixed methods design to address the research question?; 4.2 Are the

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different components of the study effectively integrated to answer the research question?; 4.3 Are the outputs of the integration of qualitative and quantitative components adequately interpreted?; 4.4 Are divergences
and inconsistencies between quantitative and qualitative results adequately addressed?; 4.5 Do the difference components of the study adhere to the quality criteria of each tradition of the methods involved?
Page 13 of 21
McPhail et al. BMC Public Health (2024) 24:1217 Page 14 of 21

liked the online-based intervention and this format may by medical professionals [49]. Previous disappointing
indeed enhance the process of facilitating access to an attempts to seek help from other services can translate
intervention producing a sense of “psychological safety” to school-based services, forming a barrier to TSMS
with counsellors portrayed as trustworthy, encourag- [43]. These misconceptions were also described as a form
ing and a solution provider [59]. Considering most of of ambivalence within the cultural context [44, 49, 59],
the interventions were in-person, the counsellors dual as some CYP conceptualised this by comparing TSMS
role within the school setting left some students feeling to the non-biomedical healing context [49]. While the
confused about the nature of their relationship [44]. This sociocultural context and minority status appeared to
was further depicted as awkward and embarrassing, with increase sensitivities for some CYP seeking help [44, 51,
some describing a form of barrier indicating that it was 52, 55].
difficult to establish an alliance with new therapists due
to frequent staff turnover [47]. This subtheme was also (B) Concerns related to Stigma
conceptualised in relation to the school environment as This theme captures the prevailing stigma that exists
it was suggested a different location might be beneficial, in the school setting, acting as a significant barrier for
as privacy and confidentiality might not be fully assured CYP to seek help. This theme was characterised by the
within schools [55]. Also expressed in relation to the subthemes: “anticipated stigma”, “negative labelling”, and
importance of creating a ‘safe space’ of trust, where stu- “navigating through stigma”.
dents can attend the intervention without disclosing their Anticipated stigma. Anticipated stigma was described
reason for leaving class, ensure flexible appointments to as a prominent barrier to accessing TSMS. This appeared
not draw attention to absences, and be located in private, to be exacerbated for interventions targeting more severe
non-visible locations to other students [58]. As such, symptoms “through the already present marginalisa-
trust with the teacher was identified as a facilitator [49, tion that came from the manifestations of PTSD symp-
51]. And on the whole, lack of trust and unsupportive toms” [49]. Likewise, for services targeting minority
networks were a barrier to accessing TSMS [49]. groups, such as refugees, who may be managing the dual
Direct solution to a problem. This was firstly described stigma-related burdens associated with both aspects of
as a barrier, with a higher SCARED (Screen for Child their identity, with general settling issues (i.e., language
Anxiety Related Disorders) total score being significantly problems, asylum issues), and navigating access to and
associated with a higher number of children’s perceived utilisation of TSMS [51]. This is depicted in quantita-
barriers [36]. However, when previous coping strategies tive findings with a significant effect for minority status
no longer worked, this facilitated CYP to seek help from (p < 0.05) associated with a higher number of children’s
school-based care [43]. The author described how the perceived barriers to school-based anxiety treatment
progressive worsening of symptoms, whereby they “did [36]. Some studies described how CYP negotiated and
not resolve on their own, and distraction techniques were managed stigma through a socially mediated process by
no longer effective”, led students to describe the interven- reframing their experiences of accessing and utilising
tion as “their last remaining hope” [49]. As such, students services [56, 57]. This was also described through var-
approached the intervention with pre-existing problems ied disclosure to friends and family based upon calcu-
for which they sought care for [59]. Normalising con- lated decisions and relational dynamics [49]. Schools also
structions, such as viewing their difficulties as ‘ordinary made a conscious effort to construct a positive targeting
problems’ in adolescent development and help-seeking as experience – by framing the intervention as ‘care’ and
a ‘problem-solving action’, accordingly assisted in man- ‘additional support’, rather than a focus on problematic
aging stigmatisation concerns [57]. The duration of the behaviours – which seemed to avoid potential stigma
intervention was thus perceived by some as short-term to [40, 41]. Some students suggested some form of adver-
meet immediate needs [43]. tisement within the school would be a useful mitigating
Misconceptions of the service. This theme exists along- strategy to overcome stigma-related concerns [47, 48].
side poor mental health literacy as many students were Negative labelling. Individuals who typically face stigma
familiar with the counselling service, but “had little or no also encounter negative labelling as seen with the DISA
concept of what counselling was” nor did they consider it intervention when offered to girls only, making them feel
as an option for themselves [44]. As such, some described negatively targeted, as though the school expected them
‘counselling’ as different from what they expected [50]. to have problems that boys did not [53]. These findings
Lower parental education was also associated with more were similarly reported when both genders used the
perceived treatment barriers [36]. Misconceptions were intervention, again feeling positioned as having problems
also framed around the concept of who is ‘sick’, imply- they did not perceive themselves to have, and separated
ing that physical illness i.e. bleeding or coughing, rather a distinction between those who need the interven-
than mental illness, could only be effectively treated tion versus those who do not [54]. Several other articles

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 Table 5 Illustrative quotes per theme/subtheme
Key theme and Illustrative quotes
subtheme
a. Access-related Factors
a.1 Individual agency “I certainly want to work out what’s best for me without someone else telling me” [participant] (Gibson & Cartwright, 2013)
McPhail et al. BMC Public Health

“If I think I need help I’ll go get help” [participant] (Prior, 2012a)
a.2 Referral agent “It was actually from Mrs Smith, one of the guidance teachers [that I first heard about counselling]” [participant] (Prior, 2012b)
“when I joined the high school yeah. I tell my the teacher… I have this problem which can make me not concentrate… and she advised me to see X” [participant] (Fazel et al., 2016)
a.3 Confidentiality “[the counsellor is] someone you can trust” [participant] (van de Water, et al., 2018)
and trust “yes I feel safe because instead of sharing with my friends who might spread it around, I can just talk to online counsellors” [participant] (Kit et al., 2019)
“I just feel really trusted with him [counsellor]” [participant] (Segrott et al., 2013)
(2024) 24:1217

a.4 Direct solution to “I don’t talk to somebody about my past. But I knew I needed help” [participant] (Prior, 2012a)
a problem “if I didn’t go to the iZ Hero counselling, I would probably still not know how to handle my problems” [participant] (Kit et al., 2019)
“I thought Jan could maybe help me with my problem. just help like she’d gie me options on what to dae[do]” [participant] (Prior, 2012a)
a.5 Misconceptions “I thought I knew something about what to expect but it turned out to be quite different” [participant] (Harrison, 2019)
of the service “the clinic is only for people who are physically ill (e.g., bleeding, coughing, etc.), which implies that both participants and clinic employees did not believe PTSD to be an illness
that could be effectively treated by medical professionals ” [author] (van de Water et al., 2018)
b. Concerns Related to Stigma
b.1 Anticipated “If people found out you were there then some people can be a bit spiteful” [participant] (Prior, 2012a)
stigma “yes, there is [a need for a course like DISA], but it is strange that it takes for granted that girls will feel bad” [participant] (Garmy et al., 2015)
b.2 Negative “Yes, they bring up negative thoughts all the time and everything and then it feels like as if, then apparently I have low self-esteem or something like that” [participant] (Kvist Lind-
labelling holm & Zetterqvist Nelson, 2015)
“People would “[not] talk to them. They make fun of them,” “say, ‘you are crazy’ and ignore them”, or “judge them” [participant] (van de Water et al., 2018)
“they would laugh at me; think I am stupid” [participant] (van de Water et al., 2018)
b.3 Navigating “I could relate to TRAVELLERS… I hadn’t thought about life’s a journey before the group. I talked to my friends and told them that we talked about things going on in our lives and
through stigma my friends thought I was lucky. There was no shame and no teasing” [participant] (Dickinson et al., 2003)
“… since it was a small group, we wouldn’t feel intimidated to just tell people stuff. It was more confidential in a sense” [participant] (McKeague et al., 2018)
c. The School Setting
c.1 Available and “You know usually like whenever I’m sick, I could come down here and… they help me get better, and I then could go back to class. So that’s convenient you know” [participant]
accessible care (Gampetro et al., 2012)
“well all the other services I did… you know the NHS, and… it was all very clinical and it wasn’t comfortable. I mean [bounceback] made the effort sort of thing; it was little things
like, you know, you could sit and you could eat with them… it’s like you go in and they know how to make you feel warm and welcome” [participant] (Segrott et al., 2013)
“I think in the school is better” [participant] (Fazel et al., 2016)
c.2 Competing aca- “I think it just took a lot of time. It took a whole school day and for me that’s really a lot of information that I missed and had to catch up on” [participant] (McKeague et al., 2018)

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demic schedules
[participant]: utterances by adolescent participants who have accessed and utilised TSMIs, reported in the findings; [field notes]: ethnographic field notes reported in the findings documenting additional observations;
[author]: content from author’s results narrative
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McPhail et al. BMC Public Health (2024) 24:1217 Page 16 of 21

describe experiencing negative labelling, or the perceived report they would not have otherwise had the opportu-
risk of this negative label as a barrier to accessing TSMS nity for nor actively pursued mental health support [45].
[41, 44, 47, 49, 56]. Quantitative findings report a strong Care provided in the school was further characterised as
association between teacher-rated externalising behav- convenient and familiar [52, 55], which led to improve
iours and higher perceived children’s barriers [36]. Par- access to other medical care too [18]. The embedded,
ticipants expressed privacy concerns, in particular with familiar nature of TSMS therefore provided easier access
not wanting to be seen by peers – or their parents find- and more opportunities for students to engage [44]. To
ing out – and risk certain questioning [36, 44, 52]. This the extent that by embedding counsellors within the
raised concerns on judgement and extended to worry school setting, the integration of the counselling service
how teachers viewed not just CYP, but how this reflected with other school activities works to normalise engage-
on other family members too [51]. Others resented being ment with mental health services [57]. That being said,
teased or “labelled as crazy by peers” due to participat- the school environment was identified as busy and hectic,
ing in TSMS [47]. In quantitative findings, over a third so “appointments outside of school would probably be
of students did not want other children to ask questions calmer” and govern greater privacy with fewer interrup-
(36.9%) or know that they were visiting the counsellor tions [48, 52]. This similarly relates to restricted interven-
(37.3%) [36]. Several consequences were associated with tion session times and sessions clashing with academic
this negative labelling, such as social exclusion, and some commitments [36, 46–48, 55, 58].
CYP adopted measures to hide or excuse their atten- Competing academic schedules. A conflict was
dance at the intervention – this extended beyond the described between attending intervention sessions and
school-setting and for parents too [44, 49]. On the other missing lesson time [36, 46–48, 55, 58]. This was a promi-
hand, labelling was seen as a coveted process that offered nent concern for the ‘DISCOVER’ workshop lasting a full
a desirable label of anti-authoritarian attitude within day; which was perceived as too time consuming [55]. It
the school context (due to the intervention appearing was therefore important for CYP to ensure the same class
to target ‘naughty’ students based upon a large number was not missed each week, with some suggesting that
of a discrete friendship group, governed by misbehav- teachers and peers provide copies of missed work during
iour, being identified) which brought ‘intervention capi- intervention sessions to prevent poor academic outcomes
tal’ – serving a powerful commodity to strengthen their [48, 49]. These findings characterised concerns of miss-
position within peer groups [41]. The authors further ing classwork, which was the most commonly endorsed
reported this label may carry iatrogenic effects as the treatment barrier (45.3%) [36].
label can only sustain through resistance to the interven-
tion, as engagement risks losing the elevated status [41]. High-income settings/Low-middle-income settings subgroup
Navigating through stigma. Some studies however analysis
report on positive experiences where no stigma was For review objective [2], the majority of the included
attached to participating in the intervention. Students studies (n = 15; 94%) were conducted in high-income set-
from ‘TRAVELLERS’ describe there was “no shame and tings, with only one study from a middle-income setting
no teasing” and key constructs of the programme and (n = 1; 6%) [49, 50], and no studies from low-income set-
metaphors of ‘life as a journey’ were further favoured as tings. As such, no subgroup analyses between HIS and
they did not “jump to conclusions” [40]. Similarly with LMIS were conducted, as a single study does not provide
‘DISCOVER’ the group-based format was perceived as a sufficient, or valid source of information.
beneficial for realising that people shared experiences
and reduced feelings of isolation [55]. Some went so far Discussion
to identify the school-setting as less stigmatising than This review examined evidence on processes that affect
other service settings being the preferred location for CYP seeking help from TSMS. We have provided a com-
CYP to receive care [52]. prehensive synthesis of help-seeking processes reported
by CYP in relation to accessing and utilising TSMS. The
(C) The School setting thematic synthesis thus draws on 16 eligible studies total-
Our last theme reflects the influence of the school setting ling 22 articles of school-based samples and reflecting
itself in acting as both a barrier and a facilitator in the data reported by CYP themselves.
process of seeking targeted supports within schools. The Similar ideas recurred throughout each article form-
subthemes include “available and accessible care” and ing several key themes. We found evidence of self-agency
“competing academic schedules”. and autonomy being important for CYP in the help-seek-
Available and accessible care. The school setting for ing process. As reported in previous research, this may
mental health care provision was identified as available reflect the active role CYP adopt during this develop-
and accessible [18, 44–46]. Insofar as, some students mental period to ascertain their agency to seek help for

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McPhail et al. BMC Public Health (2024) 24:1217 Page 17 of 21

mental health conditions and self-advocate their unique school-setting for mental health care can be stigmatising
needs [1, 5]. Yet many still alluded to a crucially required and peer-related concerns govern help-seeking actions
referring agent, most often in the form of a significant [71, 73]. Some indicated stigma-related concerns not
adult. This is consistent with key CYP help-seeking mod- only affect the labelled individual, but extend to family
els that discuss the special feature of CYP help-seeking members too [51]. Labels can thus be collective and pre-
is that a key adult, generally a parent, plays a central vail to a group identity which can perpetuate harmful ste-
role in the help-seeking process throughout this period reotypes and discrimination [72]. Hence, some students
[61–64]. Help-seeking was thus constructed as a dichot- distance themselves from potentially needed support due
omous relationship with CYP framed as ‘active agents’ to these stigma-related concerns and to avoid possible
versus ‘passive recipients’ [25, 56]. This may resonate stigmatising labels. Some studies identified several miti-
with previous research that identifies how contradictory gating strategies on an individual and structural level that
societal pressures and social norms influence the type are employed out of stigma-related concerns, which have
of referral – self or other. This may form an ambivalence been extensively researched from the perspective of peo-
towards help-seeking for CYP, with a positive attitude ple with lived experience (PWLE) of mental health condi-
for some, and a more negative attitude for others [65]. tions and accordingly devised key components of stigma
A facilitator was also described as a strategy to utilise reduction programmes [72]. While other literature pro-
TSMS (i.e., incentives), however, such strategies risk not vides suggestions from CYP on ways to be discreet and
only affecting the validity of the results, but it is difficult sensitive to vulnerability when it comes to wellbeing
to draw accurate conclusions about the underlying pro- support within schools [74]. Even with a comprehensive
cesses associated with service use when utilising these exploration of help-seeking processes, the findings indi-
strategies. cate that stigma is a core concern, persisting prominently
Confidentiality and trust were essential to access even when considering a broad range of influences.
TSMS, whist also relevant in the process of making The findings from this review did show promise of
optimal use of the service (i.e., through disclosing infor- navigating through stigma with interventions using
mation to the counsellor). Previous literature reports non-stigmatising mental health language – a widely dis-
how ‘conditional disclosure’ can offer a framework for seminated notion to counteract stigma [72, 75]. As such,
understanding the help-seeking processes of CYP. Their using empowering language and normalising concepts
insights into the circumstances under which they feel may avoid undesirable stigmatisation and crucially reject
comfortable disclosing their difficulties could inform internalised stigma. Similarly, prominent studies have
strategies to facilitate CYP access to care [66]. As such, also recommended ways that schools can improve mental
a noteworthy amount of the help-seeking process was health literacy to reduce the barrier of stigma to access-
governed by trust in a formal ‘counsellor’. The importance ing school mental health services [7, 76]. On a structural
of both concepts of confidentiality and trust has been level, it is thus essential for schools to employ these strat-
emphasised within the broader literature [14, 61, 66–69]. egies to attempt to promote help-seeking behaviours.
Interestingly, only one intervention was online, which One study identified the school-setting as less stigmatis-
was deemed to produce a sense of “psychological safety” ing than other locations, being CYP preferred location to
[59]. This finding has been depicted in a scoping review receive care [52]. This finding offers a positive and aus-
focused on identifying evidence-informed uses of tech- picious outlook on TSMS which may indeed resonate
nology for mental health service provision which found with previous findings that the familiarity of schools may
young people are more open and confident when online, make treatment more acceptable [77]. Further, a group-
and anonymity is an important aspect of the technology based format seemed to be favoured leading to enhance
that engages young people [70]. Despite aligning with peer support and potentially extending beyond the inter-
previous findings, we cannot draw definitive conclusions vention itself and counteract stigmatising beliefs in the
on online-based TSMS as only one unique study was school more generally. This was even described with
included in this review and may therefore not be highly some CYP disclosing their own experiences of utilis-
representative or widely applicable. ing TSMS to encourage others to seek help. This shows
Stigma-related concerns were pervasive, acting as a potential for ways to increase help-seeking through col-
form of barrier in the process of seeking care, which is lective shared experience and peer relations [49, 78], and
concordant with findings from previous reviews inves- recognises the importance of PWLE as agents to counter-
tigating mental health-related stigma [9, 71, 72]. This act stigma [72].
review provides further evidence that many CYP antici- In general, TSMS were considered available and acces-
pated stigma develops because of concerns of acquir- sible and facilitated pathways to other services of care.
ing a negative label, primarily centred on peers in the In particular, CYP favoured informality when utilising
school-setting. This resonates with the idea that the TSMS which is consistent with the broader literature [63,

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McPhail et al. BMC Public Health (2024) 24:1217 Page 18 of 21

79]. However, considerable concerns were raised in many review must be interpreted with specific limitations.
articles on competing academic schedules within schools. Firstly, despite employing a thorough search strategy,
These concerns are reflected in previous research identi- screening several databases, and carrying out extensive
fying the importance of receiving buy-in from all school manual methods for citation tracking and expert con-
personnel, whilst also involving them in the co-design of sultations, we cannot guarantee that we have captured
interventions which may minimise disruption to school all the relevant articles for inclusion. This should be con-
routine, and to further enhance their sustainability [28, sidered in conjunction with the narrow inclusion and
80]. Recent research extends on these ideas identifying exclusion criteria whereby only published, peer-reviewed
the importance of including CYP themselves in the deci- journal articles were eligible for inclusion. Nonetheless,
sion making for wellbeing provision within schools to it seems implausible that publication status would gen-
achieve a desired integrated systems approach [74]. erate substantial bias for the topic of enquiry. Another
This review found most CYP sought help once they limitation is the absence of a quantitative assessment
fully exhausted all methods to manage their symptoms of inter-rater reliability; however, consistent screening
themselves. The literature reports similar findings that was ensured through discussions and agreement among
CYP preference to self-manage their symptoms was a raters. Most included studies were from HIS, so it was
significant barrier to seeking help for mental health [66, impractical to contrast subgroup differences based on
81–83]. Another focal barrier was based upon miscon- evidence from HIS and LMIS. This further warrants a
ceptions of TSMS, based upon poor mental health liter- limitation on the scope of this review restricting the gen-
acy. These barriers are widely discussed in literature that eralisability and applicability of the findings to other con-
impact CYP engaging with TSMS [10, 14, 84]. texts. There should, however, be caution in considering
Ambivalence was also discussed in relation to cultural the lack of potential differences between settings. It may
values; TSMS may therefore require a culturally sensi- also still be argued that the focus on low-resource areas
tive approach and in some settings may even require in HIS in some of the included articles increases the rep-
collaboration with community stakeholders to success- resentativeness of the population of interest, due to cap-
fully implement interventions in schools. Interestingly, turing various settings in high-income contexts. It should
several studies specified the school setting within HIS be noted that only one quantitative study was included,
in low-resource areas and delineated how barriers may thus the review consists of predominantly qualitative
be exacerbated in these settings. Therefore, the school data which posed hindrance to conducting a narrative
setting may be the only place where underserved and synthesis as we set out to do. This further affected the
hard-to-reach CYP receive care [18, 55]. Despite being representativeness of the perspectives of CYP for whom
unable to contrast findings from different settings, these this review reflects, with the relatively small, aggregated
findings reiterate previous research that help-seeking sample of CYP included in this review. Lastly, not all CYP
is not homogenous and help-avoidance behaviours are are enrolled in schools, even in some HIS [86]. Hence,
more acute among certain groups (i.e., low socioeco- CYP facing significant health inequities may not be rep-
nomic, minority ethnic), which perpetuates inequities for resented in studies conducted in schools.
accessing mental health support [49, 85]. Consequently,
it is crucial school-based services are flexible to the stu- Implications
dent’s needs, especially in ethnically and economically Research. With the limited quantitative studies included
diverse contexts. The reported findings are enduring, in this review, researchers should prioritise efforts to
far-reaching and underscore the inherent need for wid- increase quantitative research to benefit from improved
escale education on mental health, services available, and generalisability and a balanced evidence-base to inform
treatment. decision-making. An integrated approach with quantita-
tive and qualitative data may be more pervasive and carry
Strengths and limitations substantial importance in the process of decision-making
To the best of our knowledge, this is the first review to in policy and practice for TSMS. It may also seem plau-
synthesise all available data on help-seeking processes sible that going forward much support for young people
related to TSMS, based upon evidence coming from might be offered online, so it is important to carry out
CYP who engaged with and utilised TSMS. Prior stud- further research to understand more about influences
ies not only derive from hypothetical scenarios [65], but for accessing and utilising that form of support. Lastly,
frequently report from another informant – namely the researchers should prioritise conducting more research
provider or parent – rather than CYP. As such, the lived in LMIS, as they are currently significantly under-rep-
experience of CYP provides enriched data uncovering resented in studies investigating help-seeking processes
authentic experiences on the processes that affect access- related to TSMS.
ing and utilising TSMS. However, the findings from this

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McPhail et al. BMC Public Health (2024) 24:1217 Page 19 of 21

Clinical practice in schools. The findings of this review Supplementary Material 1

should inform future intervention design for TSMS in
line with the processes that facilitate intervention partici- Acknowledgements
pation. Most significantly this should be centred on pro- We thank the librarians at LSHTM and KCL for reviewing the search strategy
moting mental health literacy and mitigating the risk of and Irine Prince for supporting the screening process.
stigma and negative labelling that pertain CYP help-seek- Author contributions
ing in the school. As most of these stigma-related con- LM conceived and designed the study, screened, extracted and interpreted
cerns are seen in conjunction with peer-related concerns, data from studies and wrote the manuscript. PCG and GT made substantial
contributions to the conception, design and drafting of the work. All authors
schools must ensure they have a referral pathway that is read and approved the final version of the manuscript.
deemed private and confidential. Namely, schools should
support self-referral pathways and ensure appropriate Funding
PCG is supported by the UK Medical Research Council (UKRI) for the Indigo
adult referring agents are linked to school-based services Partnership (MR/R023697/1) award. GT is supported by the National Institute
that are informal and trustworthy – critical in the help- for Health and Care Research (NIHR) Applied Research Collaboration South
seeking process for CYP [63]. London (NIHR ARC South London) at King’s College Hospital NHS Foundation
Trust. The views expressed are those of the author(s) and not necessarily those
of the NIHR or the Department of Health and Social Care. GT is also supported
Conclusion by the UK Medical Research Council (UKRI) for the Indigo Partnership (MR/
The growth of TSMS to broaden pathways for CYP to R023697/1) awards. For the purpose of open access, the author has applied
a Creative Commons Attribution (CC BY) license (where permitted by UKRI,
receive essential mental health support underscores the ‘Open Government Licence’ or ‘Creative Commons Attribution No-derivatives
importance of understanding the processes of engage- (CC-BY-ND) license’ may be stated instead) to any Author Accepted Author
ment with these services from the perspective of CYP Manuscript version arising from this submission’.
themselves. This systematic review of qualitative, quan- Data availability
titative and mixed-methods evidence uncovers the All data generated or analysed during this study are included in this published
dynamic interplay between various factors that contrib- article and its supplementary information files.
ute to the help-seeking process of accessing and engaging
with TSMS, an important contribution to the literature Declarations
yet to be integrated. This should guide the delivery and Ethics approval and consent to participate
development of TSMS to facilitate access to this kind of Ethics application was submitted to and assessed by the LSHTM Research
support, promote help-seeking behaviours, and lastly, Governance and Integrity Office (ref: 29065).
the gaps identified should direct researchers to investi- Consent for publication
gate TSMS in LMIS and prioritise increasing quantitative Not applicable.
studies.
Competing interests
Abbreviations The authors declare no competing interests.
TSMS Targeted School based Mental Health Services
WHO World Health Organisation Received: 16 January 2024 / Accepted: 25 April 2024
DALYS Disability-adjusted life years
HIS High-income settings
LMIS Low-and-middle- income settings
PRISMA Preferred Reporting Items for Systematic Reviews
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