Innovative local authority public health interventions to support the mental health of children and young people

Abstract

Purpose

Mental health champions (MHCs) and young health ambassadors (YHAs) are two innovative public health interventions. MHCs are practitioners who work in schools and other youth settings and aim to be the “go to” person for mental health in these settings. YHAs are a linked parallel network of young people, who champion mental health and advocate for youth involvement, which was co-produced with young people across all stages of development implementation. This paper aims to identify the potential benefits, barriers and facilitators of these interventions.

Design/methodology/approach

Semi-structured qualitative interviews (n = 19) were undertaken with a purposive sample of n = 13 MHCs, and n = 6 YHAs, between June 2021 and March 2022. Interviews were audio-recorded, transcribed, anonymised and then analysed following a thematic approach. Ethical approval was granted by Newcastle University’s Faculty of Medical Sciences Ethics Committee.

Findings

The findings are organised under five key themes: motivating factors and rewards for MHCs and YHAs; outcomes for children and young people (CYP) and others; impact on youth settings and culture; facilitators of successful implementation; and implementation challenges and opportunities.

Practical implications

These findings are intended to be of relevance to practice and policy, particularly to those exploring the design, commissioning or implementation of similar novel and low-cost interventions, which aim to improve mental health outcomes for CYP, within the context of youth settings.

Originality/value

The interventions reported on in the present paper are novel and innovative. Little research has previously been undertaken to explore similar approaches, and the individual experiences of those involved in the delivery of these types of interventions.

Citation

Spencer, L., Redgate, S., Hardy, C., Adams, E.A., Arnott, B., Brown, H., Christie, A., Harrison, H., Kaner, E., Mawson, C., McGovern, W., Rankin, J. and McGovern, R. (2024), "Innovative local authority public health interventions to support the mental health of children and young people", Journal of Children's Services, Vol. 19 No. 3, pp. 173-188. https://doi.org/10.1108/JCS-04-2023-0019

Introduction

Children and young people’s mental health

Worldwide, children and young people (CYP) are experiencing increasing levels of mental health (MH) distress, including high rates of self-harm, increases in substance use, lower educational achievements and poorer interpersonal relationships (Doyle et al., 2015). It was estimated in 2021 that in the UK one in six (16.0%) CYP had a diagnosable MH disorder, increasing from one in nine (10.8%) in 2017 (Ford et al., 2021). MH problems faced by CYP typically persist into adulthood (Kim-Cohen et al., 2003), with approximately half of adult MH disorders emerging during adolescence (Kessler et al., 2005), making this a key time at which to intervene to promote positive MH, and to prevent or reduce later poor MH outcomes. Tackling MH issues early can also improve other outcomes such as better physical health, reduced health risk behaviours, better educational outcomes and increased employability for CYP as they develop into adulthood (Dyakova et al., 2016). However, as many as 70% of CYP who experience significant MH difficulties do not receive appropriate interventions at an early stage (Department of Health, 2015). Efforts from across the whole spectrum of services for CYP’s MH support are required, including MH promotion and prevention of MH problems, alongside interventions for CYP who have existing or emerging MH problems (Department of Health, 2015). The Marmot Review highlighted that giving every child the best start in life and in school years was the most effective means of improving long-term health outcomes, including reducing inequalities in the early development of physical and emotional health, and building the resilience and wellbeing of CYP (Marmot et al., 2010). Subsequently, this was identified as one of the priorities within Public Health England’s five-year strategy (Public Health England, 2021). During the COVID-19 pandemic, child health was placed under additional risk from the unintended consequences of the pandemic response, with impacts on family functioning, access to health care, interruption of education, child poverty and social inequalities (Hefferon et al., 2021).

Local authority and public health approaches to mental health

In England, local authorities (LAs) − the public administration bodies of local government, have a key role to play in early intervention; a public policy approach to identify and support children and their families (Powell, 2019). This is crucial in identifying needs, and targeting preventative and low-level MH support and advice, which could reduce referrals to more costly specialist services (Children and Young People’s Mental Health Coalition, 2021). This is particularly salient in the context of continued austerity (Bhandari, 2019), with a 2019 report revealing that 60% of English LAs saw a real-term spending fall on low-level MH services between 2016 / 17 and 2018 / 19, with wider support such as youth services, children’s centres and extended school services also reduced (Children’s Commissioner, 2019). A range of cost-effective public health interventions exist to prevent MH problems from arising and promote wellbeing. These interventions can improve MH literacy to facilitate early recognition and treatment of MH issues, bolster resilience and reduce stigma (Campion, 2018; Campion et al., 2020). Research also suggests that school is a focal setting for young people to achieve positive MH and emotional wellbeing (Churchman et al., 2019; Carta et al., 2015), with evidence supporting a reciprocal relationship between health and wellbeing and educational attainment (Bonell et al., 2014), and the effectiveness of taking a whole school/college approach to realise positive mental wellbeing outcomes (Langford et al., 2014). A review of MH interventions in schools in high-income countries suggested that MH services embedded within schools can create a continuum of integrative care that improves both MH and education attainment for CYP, through the democratisation of service access coupled with evidence-based practices (Fazel et al., 2014). A review of the sustainability of public health interventions in schools has suggested that sustainability of such initiatives depends upon commitment and support from senior leaders; staff observing a positive impact on students’ engagement and wellbeing; and staff confidence and belief in delivering health promotion (Herlitz et al., 2020).

Developing a novel approach

“Alliancing” is an approach whereby services work collaboratively focusing on the “whole-system” (Redgate et al., 2023), aiming to be as cost-effective as possible, by using existing skills of the workforce to improve the lives of a larger number of residents in the area (Local Government Association, 2020). In 2017, a Best Start in Life strategy was launched by a small LA in the North East of England, and an “alliance” was formed, focusing on three key priorities viewed as being critical to the future prosperity and wellbeing of children and families:

1. safer and stronger families;

2. enterprise learning and skills; and

3. healthier communities (South Tyneside Council, 2017).

As part of this approach and following a review of emotional health and wellbeing education programmes for CYP, two new linked (but not inextricable) interventions were launched – mental health champions (MHCs) and young health ambassadors (YHAs). MHCs are a network of practitioners who work in youth settings including schools, and community and voluntary sector organisations and aim to be the “go to” person for MH in these settings. They have four main roles: to keep up to date with MH priorities; share any resources or information with colleagues; be the key point of contact for MH service information to ensure young people and their families know what services they can access; and to offer advocacy for young people. All settings which offer youth provision are encouraged to identify an MHC, with the aim of at least one MHC per 100 CYP. The YHAs are a co-produced linked parallel network, focused on championing MH and advocating youth involvement. Young people chose the name, designed the programme, set their priorities and decided how they wanted to be involved. They have four main roles: to offer formal and informal peer support to their peers about low-level MH issues [defined as mild presentations of common MH issues such as depression and anxiety (NICE, 2011)]; to run health campaigns amongst their peers; to support MH services to become more service user friendly; and to find out how CYP would like to be involved and engaged in specific campaigns and service improvement. YHAs were recruited from a variety of youth settings across the LA.

The present study

Given the fairly recent development of these innovative LA public health interventions, and the drive for early interventions to improve the MH of CYP (Department of Health, 2015; Public Health England, 2019; Children and Young People’s Mental Health Coalition, 2021), this paper aims to identify and better understand factors involved in the implementation of these MHC and YHA interventions. Through qualitative interviews with individuals enacting MHC and YHA roles, we aim to provide a nuanced insight into the potential benefits, barriers and facilitators of these interventions.

Methods

Study design

This study adopted a qualitative research design approach, which offered an effective means of capturing participants’ direct experiences in their natural settings (Patton, 2002); enabling in-depth analysis of socially situated experiences to provide insight into otherwise unknown practices. Research taking this approach can produce evidence to inform public health policy decisions through the identification of optimal opportunities for intervention, prevention and treatment (Maher and Dertadian, 2018). Due to lockdown rules and guidance on physical distancing during the COVID-19 pandemic, online semi-structured interviews with MHCs and YHAs were used, to provide an in-depth understanding of the potential impact of these interventions upon CYP’s MH in the LA. Ethical approval was granted by the Newcastle University Faculty of Medical Sciences Ethics Committee on 7th September 2020 (Ref: 2001 / 4504).

Sample and recruitment

A purposive sampling strategy was adopted to recruit MHCs and YHAs from across the LA area. To be eligible to participate, MHCs must have held the role within the LA during the period of data collection. As YHAs were CYP who undertook the roles for short periods of time (often before moving onto university/work), they were eligible if they had presently or previously held the role within the LA. A public health practitioner, involved with leading both interventions, facilitated recruitment by supplying the research team with contact details of MHCs and YHAs. One researcher (LS) contacted members of both networks by e-mail to explain the aims of the study and invite individuals to express an interest in taking part. All MHCs (n = 13) were aged over 18 years old; nine participants were female, and four participants were male. A breakdown of the gender and youth setting of MHCs has been provided in Table 1. The YHAs (n = 6) were aged between 17 and 21 years old (mean = 19.5 years); five participants were female, and one was male (see Table 2).

Data collection

MHCs and YHAs who expressed an interest in participating were provided with an information leaflet, which detailed the purpose of the study, and outlined their right to confidentiality and anonymity, the voluntary nature of their participation and their right to withdraw from the study at any time. Prior to each interview, informed consent was obtained from all participants. Staff participants (MHCs) did not receive a financial incentive to participate in interviews, as the evaluation was co-hosted by the LA, and interviews were undertaken within work hours. Young participants (YHAs) received a £10 shopping voucher incentive for participating. Two semi-structured interview schedules were developed, which were designed to guide topics of interest covered in the interviews. Interviews were conducted online using Zoom/Microsoft Teams (as per participants’ preferences) by one researcher (L.S.). Interviews were digitally audio recorded and transcribed verbatim by a professional transcription company to facilitate quicker progression of the data analysis process. The transcripts were fully anonymised, with the names of people and places omitted, to protect their anonymity, and an individual identifier was allocated to each transcript. Interviews were conducted between June 2021 and March 2022. Interviews with MHCs lasted between 20 and 42 min (mean = 33 min), and interviews with YHAs lasted between 23 and 59 min (mean = 37 min).

Data analysis

A qualitative thematic content analysis approach was used to analyse the data (Brewster et al., 2014). This approach was chosen as it is theoretically flexible (Braun and Clarke, 2021) and produces a comprehensive category system, identifying the emergent themes in individual interviews, linking these together to enable a description of participants’ shared experiences (Anderson, 2007). Data were coded and organised using NVivo for Mac (release 1.7.1). Initial data coding was undertaken iteratively by L.S. and S.R., using a combination of inductive approaches, guided by patterns, themes and categories that emerged from the data, and deductive approaches, guided by existing literature and our interview topic guides (Braun and Clarke, 2021). Emergent ideas were discussed with other members of the research team (R.M. and E.A.A.), and original codes were organised into five main domains that were considered of significant relevance to policymakers and practitioners working on CYP’s MH within LAs.

Findings

Our findings are organised under five key domains:

1. motivating factors and rewards for MHCs and YHAs;

2. outcomes for CYP, families and practitioners;

3. impacts on youth settings and culture;

4. facilitators of successful implementation; and

5. implementation challenges and opportunities.

Verbatim participant quotations from interviews are used to illustrate the themes below.

Motivating factors and rewards for MHCs and YHAs

MHCs and YHAs did not receive any financial incentives for undertaking these roles, and participants spoke about a range of altruistic factors that motivated them to take on the roles and shared a strong sense of empathy towards those who were struggling with their MH. Participants’ interest in MH was often long-standing, and both MHC and YHAs reported that they saw engaging in these roles as an opportunity to make a positive change, and a way to better support the MH of CYP and others:

I’ve always been interested in mental health, and it has just been highlighted that bit more throughout the pandemic, that it’s absolutely necessary. (MHC_01)

It sounded so interesting. I love knowing that there's a way to go out and help people and make a change. That's why I joined it. (YHA_02)

For MHCs, there was often salience between the role and their day job. This included MHCs who had prior experience or training in roles designed to support young people’s MH and wellbeing, such as counselling and social work, and this vested interest further motivated them to engage. Participants shared that it “made sense” for them to take on the role, as they would be able to bring these relevant skills and experience to the role, as well as the role positively impacting their work:

Children’s wellbeing has been a part of my life since I qualified as a social worker. Because I’m the mental health lead in the school, it was felt that I would benefit from being part of it. (MHC_09)

I trained as a counsellor many years ago, so I do have quite an interest in supporting people. (MHC_05)

The YHA intervention often caught the attention of young people who were passionate about pursuing a career in the health and social care sector or applying to study a related subject (such as psychology), at university. The potential for relevant work experience in the field acted as a motivating factor for them to engage, offering them an opportunity to learn more about health and wellbeing, and gain highly relevant skills and experience:

It caught my eye because I knew that was something I was really passionate about and something I was interested in doing in the future. (YHA_04)

I've always wanted to do more that I can add to my experience, and I love knowing that there's a way to help people and make a change. (YHA_02)

Participants also spoke about the personal rewards they gained as a result of engaging in the MHC and YHA roles. MHCs reflected upon how they felt more equipped to deal with challenges they faced in their workplaces relating to CYP’s MH and emotional wellbeing, primarily due to increased levels of knowledge, a greater sense of compassion and bolstered confidence:

We are getting knowledge about how to improve mental health. I would not have known about those strategies, and those students would not have spoken to anybody if I hadn’t been a MHC. (MHC_11)

YHAs also spoke about increased awareness, as well as a sense of empowerment from being involved, which enabled them to feel better positioned to support their peers, as well as taking care of their own MH needs. YHAs highlighted how their involvement in the intervention gave them a better understanding of the challenges facing other young people and equipped them with skills and knowledge to make a positive impact. As well as gaining experience relevant to the health and care field, YHAs spoke about the additional transferable skills they gained, including a sense of improved confidence, which was perceived as a valuable addition to their CVs:

I thought I had an awareness before I went into it, but nothing compared to after I finished it and having that insight. (YHA_01)

It taught you different skills that are so handy. It definitely gave me that confidence, and it gave me that extra bit of knowledge. (YHA_05)

Outcomes for CYP, families and practitioners

Engaging as MHCs better equipped individuals to support CYP, with participants describing the importance of a dedicated and visible role which promoted being a listening ear and offering reassurance to CYP who may be struggling with their MH. MHCs were supported to provide a holistic approach to supporting CYP’s MH and emotional wellbeing, through building meaningful relationships and creating safe spaces, both emotionally and physically, for CYP to express themselves:

I have children come and knock. It’s like, a reassurance thing and to know what their day looks like, that there are no surprises. (MHC_02)

School can be very hectic and it's students knowing that you are there, that you’ve got time for them and you’re actively listening to what they’ve got to say. (MHC_05)

YHAs recognised the similarities between their role and that of the MHCs – valuing their presence in youth settings and viewing them as an essential part of the support network for CYP. Participants spoke positively about the perspective and understanding that MHCs brought to settings, as well as their ability to offer practical support, such as signposting CYP to other interventions. They also viewed MHCs as positive role models and appreciated the opportunity to have conversations with them, to learn from them and discover additional resources:

Some MHCs were younger and understood the stresses of being a student. I see huge links between them and the YHAs, in the way they think and the perspective they take. (YHA_01)

The help they give is more practical. If you feel like you really do need some intervention, the people to go to are probably the MHCs because they’ve got those links. (YHA_04)

YHAs viewed their role as important for supporting the MH of their peers. Participants felt that they were “making a difference” by being someone that other CYP could talk to and feel understood by. This was achieved through developing their understanding of MH, and by developing communication, problem-solving and knowledge-based “life skills”, which helped them to better judge situations. YHAs also felt that they contributed to raising awareness about MH issues among their peers – providing relevant information to those who may be curious about these topics:

We did a good job of making people feel like there was somebody to talk to, and that there were young people that understood. (YHA_01)

It made me realise that a lot of people are going through things that you don’t pick up on. I think it really gives you skills to be able to judge situations better. (YHA_04)

Despite not being intended as one of the outcomes of the intervention, MHCs spoke about the importance of supporting the MH and wellbeing of their colleagues, to create a positive and supportive work environment that could benefit both staff members and CYP. Participants highlighted challenges that staff faced in managing their workloads and emphasised the importance of providing wellbeing support to staff. MHCs described how the visibility of the role encouraged colleagues to have open conversations about their own MH:

If you have a positive working team, who feel good about themselves − that will then relay onto the children. (MHC_01)

I find that when people know that you are a MHC, they are more candid with their conversations. (MHC_11)

MHCs also played an important role in supporting the parents and other family members of CYP, and participants felt that they were perceived as a trusted and vital link between home and youth settings. In line with the overarching principles of alliancing, by working collaboratively and building relationships and networks with parents and families, MHCs become a safe and accessible source of support. By providing interventions and signposting support where it was needed, MHCs were able to empower parents to become active participants in their child's wellbeing support network:

I’ve built up that network and relationship with the parents, they wouldn’t go to a class teacher with the things that they come to me with. (MHC_03)

We tell parents we’re a team and it’s not “us and them”. It’s a journey and depending on where the support is needed, that’s where we signpost. (MHC_07)

Impact on youth settings and culture

MHCs shared that they played a significant role in breaking down barriers, reducing stigma and changing the MH culture in their settings. Through their work, they helped to shift the understanding of MH beyond just the negative aspects, raising awareness of the different aspects of MH and encouraging more open discussions, by promoting tolerance and celebrating difference:

It raises the profile around mental health generally. You’re trying to look at both sides of mental health, it’s not just the negative side. (MHC_02)

I think it feeds into the whole ethos of this school. We put a big emphasis on living our lives with tolerance and celebrating difference. (MHC_07)

YHAs also spoke about facilitating positive changes to the MH culture in their settings, through their increased visibility, raising MH awareness and by building the MH profile. YHA participants felt that their work to normalise and de-stigmatise conversations about MH amongst their peers was incredibly important:

It has helped to make more awareness of stuff that people wouldn't talk about before, stuff that was very taboo. (YHA_03)

Raising awareness of different aspects, and also just spreading the message amongst young people. (YHA_05)

MHCs actively engaged with their colleagues to share knowledge about new practices and techniques they acquired from the MHC network meetings. Positive changes were supported by the ability of MHCs to bring new resources into settings, such as the introduction of new activities to support CYP’s wellbeing, and up-to-date signposting information. The MHCs were able to build strong relationships with their colleagues and gained a reputation for being reliable sources of information dissemination:

Resources have been shared directly with myself, which has been really positive to share with my staff. I think it has been more active to what it was prior to the pandemic, which is a good thing. (MHC_01)

Being able to give that calibre of information to staff in school, and for it to work, for it to take place. You want to know that the school is equipped with everything that it can be. (MHC_04)

YHAs felt that by including the voice of CYP in decisions about youth settings led to identifiable benefits. Participants spoke about significant changes brought to youth settings, such as changes in the use of language around MH, which were encouraged by including the voices of CYP in decision-making processes with senior leadership figures. Through their role as advocates for CYP, they were able to provide feedback and suggestions to health professionals, supporting them to better understand the needs and concerns of CYP better, and ensure that CYP’s MH and wellbeing was central to the provision being offered:

We had a meeting with the head of mental health and the head of safeguarding. We sat and said, “Look, you're going to have to change this and that in order for young people to feel like you're with them and want to help them”. (YHA_03)

The programme also gave us the chance to see inside the services which people are being offered. Not just seeing the good parts of them but seeing what might need improving. (YHA_04)

Facilitators of successful implementation

MHCs attended monthly network meetings, and spoke positively about these, highlighting the “community of practice” (a group of people who share a common concern, set of problems or interest in a topic) that was formed amongst the MHCs, whereby their shared values and beliefs about how best to support CYP were fostered by the sharing of different thoughts, views and experiences with other like-minded individuals. Participants particularly valued the support and camaraderie that came from being part of a group that consisted of volunteers working towards a common goal. The network meetings provided a space for individuals to discuss ongoing and emerging MH-related issues in their settings, without fear of judgement or stigma, and participants felt they were able to talk openly about their experiences and receive feedback and advice from other MHC colleagues:

To be with like-minded people is the key thing, and I feel able to talk in a network without worrying what other people think. (MHC_02)

There's cohesion there, and you’re safe in the knowledge that there is someone else that you can talk to if you’ve got a particular issue. There's that kind of camaraderie. (MHC_10)

Emotional investment was a key facilitator for YHAs, who spoke about a sense of “belonging” and the importance of being part of a community that included members with different experiences and perspectives. Participants were able to share their ideas about work they wished to undertake to support CYP’s MH, and provide feedback on services they, or others, had accessed. Participants spoke about feeling empowered by the opportunity to make a difference, and this was bolstered by the community that YHAs fostered:

The strength is how the community builds up itself. It's great just to know it’s there, and you can share your feelings and thoughts. It's like a new family. (YHA_02)

It was a great opportunity to bring people together that never would’ve met. It gave us some shared experiences. (YHA_06)

Participants shared positive experiences of how their groups were organised and structured and highlighted the important role that a public health practitioner played. This individual was responsible for facilitating the groups, and the success of both interventions was recognised as reliant on their efforts. Participants described this individual as being very good at circulating information about relevant topics of interest, sharing resources and keeping everyone informed about new opportunities for training. Participants also noted that this individual created a welcoming atmosphere that allowed MHCs and YHAs to feel comfortable about opening up and having conversations with other members in network meetings. Participants also felt that they were treated with respect and professionalism and spoke of feeling valued and appreciated:

It’s headed by [Public Health Practitioner] − it’s really well organised, information is always shared, and resources are always sent out. That’s a really useful part of it. (MHC_07)

I remember [Public Health Practitioner] created a really good atmosphere for us to be able to open up and have good conversations about that kind of thing. (YHA_04)

MHCs highlighted the importance of increased access to resources and relevant training, including being signposted to specific training around MH issues, such as MH first aid training for adults, CYP and staff and suicide awareness training, which helped to improve MHCs’ confidence in responding to need appropriately and their awareness of the availability of support in settings. Some participants also spoke about their confidence in filtering-down and delivering this training to their colleagues. The transfer of knowledge between MHCs at network meetings was seen as hugely important, with participants speaking about being able to pick resources that were relevant to the settings they work in, which had come up in conversations between MHCs from different settings:

I can share resources that fit our service, we’ve had specific training around things that have been highlighted, and I feel confident delivering that with the team. (MHC_01)

Most of the stuff that I have done in the last three years as a MHC has been ideas that have been “stolen” from the network meetings. I find them really useful and really helpful. (MHC_11)

YHAs spoke about the value of training that was delivered exclusively to them and was specifically tailored to their needs, with a focus on educational content. Participants felt that during these sessions they held a unique perspective, which allowed them to provide input based on their own experiences as CYP, as well as the opportunity to share reflections from their peers. Participants felt that training helped them to build their knowledge and confidence and encouraged them to develop a shared understanding and common language for discussing MH. This made it easier for YHAs to work together to bring about change, whilst also enabling them to be more effective advocates for CYP's health needs:

The training is focused on the education side of it, of course, you're still going to have input from professionals, but you can have another young person who's a YHA discussing it with you. (YHA_01)

Whilst there were no financial incentives for settings to facilitate MHC roles, there were also no anticipated costs associated. Therefore, engagement with, and support and buy-in from decision-makers and senior leaders in youth settings emerged as a crucial factor in facilitating the enactment of the MHC role in practice. Participants highlighted that having support from individuals such as head teachers and pastoral leads in schools, who were open-minded, willing to take “risks” and demonstrated readiness to listen and take seriously their suggestions, enabled them to bring in new resources and ideas to support MH without resistance. MHCs who had good reputations and established relationships with senior leaders found it easier to gain support and largely had the autonomy to bring in new resources, highlighting that most proposed ideas were accepted and implemented, as long as they were cost and time efficient. The willingness of senior leaders to try these new ideas demonstrated a commitment to supporting MH and the importance placed on the role of MHCs:

The head is really good, and the SEN teacher. You can go to them and they’ll say, “If you think it will work, I don’t mind trying it”. (MHC_06)

The ideas have to go through our senior leadership team, and most of it is absolutely fine. I can’t think of anything that they have said no to. (MHC_11)

For YHAs, engagement and buy-in from senior leaders and decision-makers was crucial in making their voices heard and effecting change. Through their participation, YHAs gained a newfound sense of agency and confidence in expressing their views on issues affecting CYP's MH. They were given the opportunity to engage with senior local authority figures and medical professionals and felt that they were part of a positive movement, in which their ideas and contributions were valued. This had a positive impact not only on the YHAs themselves, but also on the practitioner community, as more and more individuals became aware of the issues affecting CYP's MH:

It was very much young people based. There was widespread awareness and impact across the board. Speaking to nurses and those sorts of people, it did feel like a bit of a community was starting to arise. (YHA_01)

Implementation challenges and opportunities

The COVID-19 pandemic, and associated periods of lockdown, physical distancing and school closures was cited as a major barrier to the implementation of the MHC role during this period. The pandemic also brought about additional challenges for CYP and their families, including family breakdowns, bereavements, financial hardship and heightened levels of stress and anxiety. Participants spoke about more CYP requiring MH support during this period, which was often challenging for MHCs to manage, as they did not have enough capacity. Furthermore, MHCs reported difficulties in maintaining contact with students and providing MH support due to the restrictions imposed by lockdown measures. Despite the obstacles faced, the commitment of MHCs to supporting CYP did not waver:

Families and children that before the pandemic were just ticking along as normal - things have happened. They have been living on the edge. (MHC_02)

It has been really difficult because we just haven’t been as contactable. I think we are seeing a lot more general student anxiety because of the lockdowns. (MHC_11)

Adaptations to the interventions were necessary, as the pandemic acted as a barrier to the normal running of MHC and YHA network meetings, which participants valued so greatly. Physical distancing measures meant that the MHCs were unable to meet face-to-face, and participants felt that virtual/online meetings were not as effective as the in-person meetings they used to hold. The lack of physical presence hindered MHC’s ability to share ideas and connect with each other, and participants missed the in-person interaction, with some finding it difficult to contribute in the same way. YHAs also felt that their meetings were not as successful as they had been pre-pandemic, as they were not able to engage as meaningfully:

The pandemic has been a big barrier because although it's great to be able to still get together and have Zoom calls, nothing beats sitting around a table. (MHC_10)

With all the stuff that was going on, there wasn’t enough time for us really, which is understandable, we're in a pandemic. It feels like we didn't get the full extent of it. (YHA_02)

MHCs faced a number of capacity challenges, including pressures on time, a lack of other staff members taking on the MHC role and difficulties accessing money for resources. Whilst participants were passionate about their role, some progress they wished they had been able to make was hampered, including the implementation of face-to-face initiatives, which had been discussed at network meeting. Participants often found themselves stretched thin and struggling to find the time to implement necessary changes, and some had to be creative and find ways to make things work within limited budgets:

It can be time consuming, but not in a negative way. It's just because you want to do it, but you haven't got enough time within your day. (MHC_05)

You don’t know where the time is coming from. We have lovely ideas, but then no money there to resource it sometimes. So, we’ve got to be really creative. (MHC_07)

According to YHAs, a lack of awareness of the intervention was a barrier to its success. Participants shared that both CYP and staff were often not fully aware of the intervention and its objectives, and it was suggested that this may be due to inadequate promotion or marketing. Some participants reported that when they wore their YHA lanyards, peers stopped and asked them what they are for. Participants felt that this lack of awareness may hinder the success of the intervention as the messaging may not reach as many people as intended:

It isn't well known, in school when I talked to my teachers about it, they were like, “What's that? What are they?” (YHA_01)

We got lanyards, and people still stop and say, "What's that? What are you doing? What is it?" You have to sit there, and they still don't understand it. (YHA_03)

YHAs also felt that scalability remains a challenge, with limited accessibility to a larger number of CYP. Participants acknowledged that the intervention (network meetings) worked best in smaller groups, but they felt that more CYP need to get involved, to increase the number of YHA who can help others and bring about change:

It might work better in smaller groups, but if there are more young people doing it, there are more YHAs to help young people. (YHA_03)

MHCs outlined a range of recommendations for the future of the intervention. Participants suggested that more staff should be trained to become MHCs to share the workload and ensure that all students' needs are met, with some recommending that in schools there should be MHCs for each specific year group, as the MH needs of CYP differ by age. Some participants emphasised the need for more regular MHC meetings to discuss updates and future plans, especially as the network expands to include more members in other settings, to ensure that all MHCs are able to contribute. It was also suggested that moving forwards, there should be increased links with external agencies, to ensure that MHCs are fully aware of all the varieties of support available for CYP to access across the borough:

I would like to see every year group in a school having a MHC so that load is shared − we know that a child at 11 and a child at 16 can have very different needs. (MHC_09)

I would like to see more links with external agencies. More information being sent directly, rather than us going looking for it. (MHC_07)

YHAs shared their ideas on how to improve and sustain the intervention for the future, highlighting the importance of getting more CYP people involved and expanding the community to include CYP from varied areas and backgrounds, to better diversify the objectives of the intervention. Furthermore, one of the main recommendations was to increase the awareness of the intervention among CYP and staff in all settings, so that a larger number of CYP could benefit. Recognising the potential of the intervention more broadly, participants also expressed a desire to see it expand beyond their local area in the future, with similar programmes implemented in other regions of the country:

It would be nice to expand the community and to have people from different areas who have multiple opinions − a bit more diversity. (YHA_02)

If absolutely everyone in schools knew about it, how there are other programmes that are definitely known about throughout schools, that would be great. (YHA_05)

Discussion

These findings provide valuable insights to commissioners and strategic and operational leads within local authority public health teams, looking to develop low-cost interventions aimed at improving MH outcomes for CYP. Such early interventions may be of particular importance within the context of continued austerity and the high prevalence of MH need, whereby there may be limited resources and capacity to address the MH problems of CYP. The findings will also be of relevance to teachers and other school staff, MH practitioners, youth workers and those working in voluntary and community sector youth organisations. The presence of MHCs and YHAs appears to have had a positive impact on the MH culture within settings, through raising awareness and reducing stigma. Participants were highly motivated to take part in these interventions due to: an interest in MH (and in the case of MHCs, relevance to their role); their own experience of MH; and a desire to help others; with YHAs also citing an interest in developing relevant skills and experience for future opportunities. Participant involvement had a positive impact on their knowledge and awareness of MH issues, through increased levels of MH literacy. Participants also spoke about improved levels of confidence, which supported them to be better able to provide informal MH support to CYP.

Both groups of participants spoke about feeling better able to provide better support for CYP, with MHCs also sharing that they felt in a position to support colleagues, and the parents and families of CYP. Our findings align with a previous study which explored the experiences of MH “befrienders”, identified altruism and personal growth as factors that motivated individuals to volunteer (Cassidy et al., 2019). Whilst exclusively school-based, a study in Greater Manchester piloted similar MHC and YHA roles. They reported that MHCs had increased confidence in engaging with students with MH problems, improved knowledge about how to refer students to specialised services and increased awareness about the importance of staff health and wellbeing. YHAs felt proud and happy about being chosen; enjoyed the training; their understanding of the role was generally good; and they felt empowered and optimistic that they could make a difference in their schools (Yung et al., 2018). As well as the anecdotal perceived positive impacts that the interventions have had on individuals they engaged with, the MHCs and YHAs helped to bring about positive change to the youth settings they occupied, by increasing awareness and reducing stigma. Whilst important, evaluations of programmes which focus solely on reducing stigma have been found to have weak to no significant long-term effects, and concerns have been raised over their possible unintended consequences, as these interventions typically focus on biomedical explanations of mental illness, and the public continue to “other” those with experiences of mental ill-health (Walsh and Foster, 2021). However, in the present study, reducing stigma was just one aspect of the work that the networks engaged in; with both interventions taking a holistic community approach to improve MH cultures in youth settings.

Facilitators of success identified focused on the development of communities of practice formed within the respective network meetings; guidance from a key leadership individual; engagement and buy-in from senior leaders; and improved access to relevant training and resources, although there was some tension between a preference for small network groups, and the potential of larger-scale efficiency supporting wider need. A systematic review of barriers and facilitators to the implementation of evidence-based “task-sharing” MH interventions (the redistribution of care typically provided by those with more specialised training) in low- and middle-income countries identified similar facilitating factors, including community engagement; task-sharing and task-shifting; availability of resources; and involvement of stakeholders (Le et al., 2022). From the perspective of CYP, a systematic review of interventions targeting help-seeking for common MH problems revealed that social support, positive attitudes towards help-seeking and access to information and resources were beneficial, also highlighting the benefit of school-based, MH literacy and peer support programmes (Aguirre Velasco et al., 2020). Barriers identified as part of the present study were interruptions brought about as a result of the COVID-19 pandemic; strained resources in terms of staff time and capacity, and financial budgets; and a perception of limited awareness and potential for increased scalability. A combination of these factors could impact on how “embedded” these types of interventions become within settings, impacting upon future sustainability. Le et al. identified a lack of resources as a barrier to success (Le et al., 2022), however the other barriers they identified (MH stigma, a lack of knowledge and training and lack of political support) were factors that were explicitly focused on as part of the present MHC and YHA interventions.

Strengths and limitations

The qualitative design of this study enabled exploration of the experiences and perspectives of the participants, with the use of semi-structured interviews allowing participants to share their thoughts and feelings in their own words, providing a nuanced understanding of their experiences. There has been limited qualitative research to date on similar interventions, due to their recent innovation and delivery, and as such, these findings are of timely practical relevance. The findings include a range of views from a varied sample, particularly in terms of the diversity of roles encompassed by MHCs. Whilst the majority of participants were female, this may reflect a wider outdated trend in caring roles where males are the minority (Pease, 2017). Invitations to participate in the present study were shared with a large number of MHCs and YHAs, however it is worthwhile considering the potential impact of bias; participants may have had a vested interest in portraying the interventions positively, and as a result the findings may not have captured a more critical perspective. The study did not include the perspectives of those who received the interventions, such as young people and their parents/families, and the colleagues of MHCs, which limits the understanding of the impact on those who directly benefitted from them. These interventions were delivered in one LA area in the North East of England, and it is important to consider that different areas may have varying levels of need and require different approaches. It is also important to note that the study was conducted during the COVID-19 pandemic, which impact the future generalisability of the findings.

Conclusions

Innovative public health interventions such as MHCs and YHAs can be developed at a financially low cost by harnessing the interests and goodwill of volunteers in accordance with an “alliancing” approach, providing actual benefits for CYP in youth settings. LAs should ensure that collaborative, productive and community-focused networks can be formed, and positively facilitated. Adequate and realistic capacity to manage the need for support is necessary, through securing engagement and buy-in from senior leaders in youth settings. It is important that where possible, a lack of time or limited funds should not inhibit motivated individuals from pursuing the implementation of resources and support for CYP. It is also important that publicity of such interventions is increased, to improve awareness amongst both CYP, and practitioners. Future research should explore delivery in a post-pandemic world, whereby rules on physical distancing have been relaxed. It would also be advantageous to include the perspectives of those in receipt of the delivery of such interventions, and to attempt to better understand and evidence the mechanisms involved in facilitating positive impact.

Table 1

Mental health champions

Participant ID	Gender	Setting
MHC_1	Male	Care service
MHC_2	Female	Primary school
MHC_3	Female	Primary school
MHC_4	Female	Secondary school
MHC_5	Male	Secondary school
MHC_6	Female	Primary school
MHC_7	Female	Primary school
MHC_8	Female	Primary school
MHC_9	Male	Specialist school
MHC_10	Male	Emotional resilience service
MHC_11	Female	Secondary school
MHC_12	Female	Nursery school
MHC_13	Female	Nursery school

Source: Table by author

Table 2

Young health ambassadors

Participant ID	Gender
YHA_1	Female
YHA_2	Female
YHA_3	Female
YHA_4	Male
YHA_5	Female
YHA_6	Female

Source: Table by author