ARTICLE Year : 2022  |  Volume : 20  |  Issue : 1  |  Page : 36-45

Mental health and psychosocial wellbeing in education: The case to integrate core actions and interventions into learning environments

Ashley Nemiro1, Zeinab Hijazi2, Ruth O'Connell3, April Coetzee4, Leslie Snider5
1 PhD, The MHPSS Collaborative Hosted by Save the Children Denmark, Copenhagen, Denmark
2 MSc, PsyD, UNICEF, New York, USA
3 MA, UNICEF Consultant, New York, USA
4 MA, War Child Holland and University of Amsterdam, Amsterdam, The Netherlands
5 MD, MPH, The MHPSS Collaborative Hosted by Save the Children Denmark, Copenhagen, Denmark

Date of Submission02-Jul-2021Date of Decision07-Nov-2021Date of Acceptance07-Dec-2021Date of Web Publication31-May-2022

Correspondence Address:
Ashley Nemiro
Rosenørns Allé 12, 1634 Copenhagen V
Denmark

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/intv.intv_20_21

Exposure to adversity, particularly in early childhood, can lead to lifelong struggles with learning and adverse physical and mental health. Mental health promotion and prevention, care services and psychosocial approaches can play an important role in mitigating these adversities and improving a range of developmental outcomes for children – including learning, relational and social skills, and health and nutrition. This study explores effective mental health and psychosocial support (MHPSS) programming integrated within education in emergencies (EiE). Core actions developed through a participatory consultation with multisectoral actors are outlined to address the common challenges and barriers associated with MHPSS programming in emergency education. Targeted approaches, resources and case studies from humanitarian settings are highlighted and provide detail on how to address planning, coordination and implementation barriers to effective MHPSS integration. This study explores the social and psychological foundations of MHPSS programming in EiE and how caregivers, teachers and communities can meaningfully participate in creating safe and healing learning environments, forming the critical safety net for children's wellbeing in situations of adversity.

Keywords: EiE, education emergencies, mental health psychosocial, MHPSS, school wellbeing, SEL, social emotional learning

How to cite this article:
Nemiro A, Hijazi Z, O'Connell R, Coetzee A, Snider L. Mental health and psychosocial wellbeing in education: The case to integrate core actions and interventions into learning environments. Intervention 2022;20:36-45
How to cite this URL:
Nemiro A, Hijazi Z, O'Connell R, Coetzee A, Snider L. Mental health and psychosocial wellbeing in education: The case to integrate core actions and interventions into learning environments. Intervention [serial online] 2022 [cited 2022 May 31];20:36-45. Available from: https://www.interventionjournal.org/text.asp?2022/20/1/36/346324
Key implications for practiceIntegrating MHPSS into education services and structures and ensuring holistic learning are imperative to promote mental health and to create a system that is responsive to the unique needs of girls and boys in conflict settings.To create safe, quality learning environments that are responsive to the mental health and psychosocial needs of school aged girls and boys, there must be a paradigm shift away from traditional education systems that rely on rote learning, to more holistic learning methods.Children, teachers, caregivers and community members must be included in the process of making decisions which affect their lives, and in all stages of the MHPSS programme cycle.   Introduction 

Humanitarian emergencies and protracted crises affect millions of children around the world with severe consequences for their ability to learn, grow and develop. In 2019, 420 million children – nearly one-fifth of children worldwide – were living in a conflict zone (Save the Children, 2019). A child's experiences during the earliest years of life have a lasting impact on their physical, mental, social and emotional development. Children in conflict are especially vulnerable, as the combination of exposure to chronic adversity, grave violations of their human rights, insecurity and deprivation can lead to poor mental health and psychosocial outcomes. Children under extreme stress over long periods may show a range of mental health and psychosocial problems such as regression to earlier behaviours, self-harm and suicide, depression, anxiety, aggression and withdrawal, and may experience educational difficulties later in life (United Nations High Commissioner for Refugees (UNHCR), 2015) as well as barriers in accessing opportunities into adulthood.

Research has shown that the interruption of formal education is one of the most significant stressors in post conflict settings, particularly given that schooling is perceived as a route out of poverty and to a more prosperous life by children and their families (United Nations Educational, Scientific and Cultural Organization (UNESCO) & United Nations International Children's Emergency Fund (UNICEF), 2015). Mental health and psychosocial support (MHPSS) approaches and interventions in education services for children in conflict are imperative to overcome the impacts of chronic adversity and loss of learning opportunities and to give children the chance to develop to their full potential. Integrating MHPSS programming into the existing services and structures that support and protect children, such as educational services and systems, is essential to ensure children can access opportunities for healing, recovery and learning at scale.

The first part of this study examines the need to strengthen traditional learning environments to be more responsive to children's protection, developmental and wellbeing needs. The second part lays out five core actions that were codeveloped during a multisectoral consultation held in January 2020 on the integration of MHPSS into education in emergencies (EiE). The core actions address the barriers to integrating and promoting mental health and psychosocial wellbeing in EiE, while highlighting programmatic examples through the use of case studies, targeted approaches and forthcoming tools and resources.

  Strengthening Learning Environments 

Exposure to violence is one of the strongest risk factors for mental health conditions among child and adolescent refugees (Reed et al., 2012). In 2019, the World Health Organization (WHO) estimated that 17% of adults living in conflict zones have mild to moderate mental disorders, which would require nonspecialised mental health support (Charlson et al., 2019). About 10–20% of children and adolescents worldwide experience mental disorders and half of all mental illnesses begin by the age of 14 and three-quarters by mid-20s (WHO, n.d.). At the end of 2020, it was estimated that 82.4 million people, of which 42% were under the age of 18, were forcibly displaced due to persecution, conflict, violence, human rights violations or events seriously disturbing public order (UNHCR, 2021). Many children and adolescents impacted by conflict do not have access to the protective environment of learning spaces that can restore a sense of normality for those living otherwise disrupted lives, and to quality education that provides social support and nurturing care through positive interactions with peers and educators (Betancourt et al., 2014; Inter-Agency Standing Committee (IASC), 2007).

Girls living in conflict settings face a unique set of challenges that put their health, education and wellbeing at risk. Research centred on the voices of young girls conducted in South Sudan, the Lake Chad Basin and the Rohingya refugee camps found that girls express a passion to attend school but have no decision-making power and are often kept out due to discrimination and family poverty. In addition, girls expressed that they “have little or no access to information about health, and, particularly in the area of mental health, have extremely restricted access to health services” (Plan International, 2018, p. 3).

To create safe, quality learning environments that are responsive to the mental health and psychosocial needs of school aged girls and boys, there must be a paradigm shift away from traditional education systems that rely on rote learning to more holistic learning methods that teach social and emotional learning (SEL) competencies and promote and protect wellbeing. There is a range of potential outcomes from integration of MHPSS into education programmes – including learning outcomes related to academic achievement, various measures of intrapersonal and interpersonal skills and wellbeing, coping capacity (resilience) and child development, and outcomes related to safe, supportive and healing learning environments. Research on school-based interventions shows that incorporating MHPSS within EiE, including SEL and resilience programming, can “enhance academic achievement and attainment; improve school attendance, engagement and motivation; reduce negative student behaviour in schools and in the community, such as bullying, violence, and juvenile crime; benefit the mental health of staff and students by lowering stress, anxiety, and depression; improve health outcomes by reducing teenage pregnancies and drug abuse; lead to better staff retention and higher morale; and generally help to improve the social and emotional skills of both students and staff” (Durlak et al., 2011; Fleming et al., 2005; Zins et al., 2004, as cited in International Network for Education in Emergencies (INEE), 2016, p. 12).

Although there is wide consensus for this paradigm shift, including from the IASC Reference Group on MHPSS in Emergency Settings (Betancourt et al., 2013), barriers continue to impede the integration of MHPSS programming, inclusive of SEL, in education services and structures, particularly in low-resource settings. In addition, there is a dearth of knowledge on the effectiveness of interventions in improving the mental health and psychosocial wellbeing of refugee children and adolescents in a holistic way, aside from reducing posttraumatic stress disorder symptoms (Purgato et al., 2018).

In order for educational environments to be responsive to children's MHPSS needs, the ecosystem (UNICEF, 2018; [Figure 1]) surrounding the child must be taken into account. The onus cannot reside within the education system alone. Without addressing the wellbeing of caregivers, teachers, education personnel and ensuring enabling communities and environments surrounding children, the goal of quality education and improved learning outcomes cannot be attained. In a recently published landscape review on teacher wellbeing (Falk et al., 2019), the authors stress the importance of addressing teacher's psychological needs before they can be expected to support the psychological and cognitive needs of their students.

Figure 1: The Social Ecological Model.
Source: UNICEF Organisation Global Multisectoral Operational Framework for Mental Health and Psychosocial Support of Children, Adolescents and Caregivers Across Settings (2021)

Click here to view

Moreover, this shift to more holistic learning and creating protective environments that are responsive to children's mental health and psychosocial needs requires mechanisms in place at all levels to promote and respond to varying and often complex mental health and psychosocial concerns – particularly for children who have experienced conflict, violence and displacement. Of equal importance is the wellbeing of caregivers, such as parents and others in the household and community, and the protective environments they create. Children's wellbeing is significantly affected by caregiver mental health (Meyer et al., 2017). If distressed, caregivers are unable to access MHPSS services and supports, they may be less able to support their children's wellbeing and learning in challenging circumstances.

In summary, integrating MHPSS into education services and structures and ensuring holistic learning are imperative to promote mental health and to create a system that is responsive to the unique needs of girls and boys in conflict settings. Furthermore, this cannot be done in isolation. A functional, multisectoral MHPSS system throughout the humanitarian response must be in place to ensure the mental health and psychosocial wellbeing of children and their caregivers, teachers and education personnel. Case studies that describe promising approaches for promoting wellbeing in education services are presented below, along with recommended core actions to support and address challenges to the integration of MHPSS into education.

  Core Actions 

To enable a shift towards education that is responsive to children's mental health and psychosocial needs and learning requirements, core actions must be taken in humanitarian contexts to address the various challenges that exist which impede the integration of MHPSS within educational services and systems. During a consultation held in January 2020 on the integration of MHPSS into EiE, led by the MHPSS Collaborative, 33 actors across various organisations and regions including interagency coordinators, funders, country level practitioners and global technical advisors, discussed these challenges from their various perspectives. The meeting served to move health, protection and education sectors forward in a more integrated way to better provide a supportive community for children through nurturing education. The following five recommended core actions came out of the consultation process and are grounded in the case studies and targeted approaches outlined below. They include critical actions to address barriers and advance humanitarian programming to create educational systems that promote children's, teachers' and caregivers' mental health and psychosocial wellbeing in humanitarian settings specifically.

1. Engage communities including children and youth meaningfully and safely, in the design, inception and evaluation of any humanitarian programming and research. Specifically, work with existing community structures and ensure youth, caregivers, teachers and other education personnel, and community members inform MHPSS programming in education and beyond.

The importance of meaningful community engagement and accountability is being paid increased attention as a key priority for MHPSS across development and humanitarian contexts. One example is the dedicated track on engaging host and displaced communities in cross-sectoral MHPSS provision during the October 2019 Ministerial Summit on MHPSS hosted by the government of The Netherlands. However, a special feature on communication and community engagement published by the Humanitarian Practice Network states that despite promising progress, humanitarian responses take insufficient account of the views and feedback of affected people (Humanitarian Practice Network, 2019).

The intentional and meaningful engagement of children, youth, teachers and caregivers is essential to define wellbeing, promote safety within schools and support the integration of MHPSS programming in education services. As resources that promote meaningful community engagement in planning and implementation of cross-sectoral humanitarian response activities exist, there is limited evidence on the impact of community-based and participatory interventions on the wellbeing of children and youth. In addition, few existing resources specifically prioritise the role that can be played by children, young people, teachers and their caregivers in the design and delivery of MHPSS services. Strategies to further the participation of children and adolescents who are often marginalised are insufficiently documented or researched, particularly migrant and refugee children, children with disabilities and children who identify as LGBTQI. More attention is needed to understand the unique needs of marginalised children and adolescents to develop inclusive, effective MHPSS interventions. To maximise opportunities for participation for traditionally marginalised groups, it is important to identify the barriers which these children face in making their voices heard. These include stigma, unequal power dynamics and power relations, inaccessible forums for participation and discriminatory practices. Children and adolescents must be consulted on the barriers they face and how to address them, including developing partnerships with the most marginalised and their allies (UNICEF, 2020). The promising approach below will support implementing agencies to meaningfully engage community members, teachers, caregivers, children and youth in the evidence-based delivery of MHPSS services inclusive of education programming to move towards more holistic learning methods.

2. Work alongside caregivers to promote the wellbeing and learning for children early in the life course. Investment in early childhood development (ECD) and the wellbeing of caregivers is critical to mental health, psychosocial wellbeing and learning.

Education does not start the day a child enters school. Children are born ready and eager to learn, and caregivers have an important role to play in fostering their children's education and wellbeing. Substantial evidence from neuroscience to economics indicates that the early years (0–8 years) of a child's life lay the foundation for long-term health, learning and behaviour (Moving Minds Alliance, 2018).

It is essential that the relationship between the community, family and school is harmonious. This is particularly important in contexts where certain children may be excluded, such as girls, adolescent mothers or children with disabilities. The wellbeing of caregivers has a significant impact on the development and psychosocial wellbeing of children, as well as access to and completion of education. Schools and educational structures can be positioned in the community in ways that promote positive relationships. For example, parent–teacher associations, preschool programmes for children under 5 with facilities to encourage mothers and caregivers to attend, and links between schools and community-based child protection mechanisms are methods that foster a positive school–family relationship.

Volunteers or incentive staff from the community may have a lot to contribute to activities in after-school programmes or nonformal learning spaces, and can come from a variety of educational backgrounds, including having little or no formal education. Activities such as sports, games or creative activities when carried out in conjunction with educational activities can be of significant benefit to children, particularly when implemented in transitional settings. Activities linked with schools also may help to identify caregivers with various needs who may benefit from referrals to services. If caregivers can approach teachers from a position of trust, the MHPSS needs of their children are more likely to be met with potential positive impacts on both wellbeing and learning.

[Box 2] below presents a promising approach that aims to address the mental health and wellbeing of caregivers to support in the promotion of healthy child development and mental health for their children. This is in line with research that consistently shows that the emotional wellbeing of young children and educational outcomes are directly tied to the functioning of their caregivers and the families in which they live (Harvard University, n.d.).

3. Work with the national education system, and advocate for the inclusion of MHPSS programming within education services and teacher training, building upon and integrating it into existing mechanisms and programming.

One-off training of teachers in MHPSS approaches, without building in supervision or coaching over time, will result in little to no change in the overall system. Most importantly, buy-in from the national education system is required to ensure consistency and relevance. Systematic change requires working with national education systems to incorporate MHPSS principles and approaches (such as organised psychosocial activities to foster creativity, play and recovery from stressful events) in preservice and in-service teacher training.

Alongside their professional development, teachers need to have strategies and services available to them that address their own MHPSS needs. Strategies to reduce burnout, maintain workable class sizes, provide access to mentoring and coaching opportunities and build capacity to manage classroom conflict are essential for teachers living and working in often extremely harsh conditions. Educators not only aid in creating safe and healing learning environments but also serve as a necessary link to protection and health services. With appropriate training and support, teachers can identify when a referral is needed to a higher level of care and ensure that children and their caregivers have access to appropriate referrals and services for MHPSS. The case study below incorporates MHPSS principles and approaches through teacher training and professional development programmes in crisis contexts with the aim to improve both teachers' wellbeing and their social and emotional competencies.

4. Create national sector plans that are inclusive of MHPSS and link education services to health and social welfare systems. As a cross-cutting approach, MHPSS is linked across all humanitarian action, with functional referrals up and down the layers of the IASC MHPSS pyramid of interventions [Figure 2].

Figure 2: The IASC MHPSS Intervention Pyramid.
Source: UNICEF Organisation Global Multisectoral Operational Framework for Mental Health and Psychosocial Support of Children, Adolescents and Caregivers Across Settings (2021)

Click here to view

The IASC MHPSS intervention pyramid is a framework to outline evidence-informed and evidence-based approaches and interventions that can be delivered within the humanitarian response to support children and families. The pyramid displays four layers, starting with social considerations in basic services and security for the entire population to more specialised care for a subset of the population.

Existing services to address the MHPSS needs of those on the move are implemented by various actors – international nongovernmental organisations, United Nations and local, governmental services. However, they can be constrained, fragmented and lack coordination and referral mechanisms. Services may therefore be disconnected and ineffective in supporting children, caregivers and teachers who face heightened vulnerabilities and require MHPSS services. Creating national sector plans that are inclusive of MHPSS and linking MHPSS services across the humanitarian response will help to ensure functional referral mechanisms from one layer to the next, operating in both directions.

It is imperative that once a child has been referred to a higher level of care, they are then also referred “down” layers of the pyramid to ensure their basic needs are met appropriately and effectively and they have adequate family and community support. For example, if a child is linked to focused care such as a cognitive behavioural group intervention (layer 3), remaining engaged in interventions from layer two is important as well, to foster inclusion with peers, family and community and strengthen social support surrounding the child.

For these functional referral mechanisms to take place, sector plans must be linked – for example, across health, protection and education sectors – so that MHPSS is truly cross-cutting and not sitting solely in one sector. The case study below provides an overview of a cross-cutting MHPSS approach responding to the MHPSS needs of children, caregivers and teachers.

5. Advocate for access to flexible, multiyear and multisector funding geared towards integrated learning and wellbeing outcomes in all humanitarian response.

Long-term flexible funding is necessary to integrate MHPSS into the education system, including funding for multisectoral implementation and monitoring and evaluation. As mentioned previously, one-off training without supervision or coaching and time-limited interventions are unlikely to impact learning and wellbeing outcomes for children in humanitarian settings. In addition, without multiyear funding, it will be impossible to carry out the core actions mentioned above to ensure a functional, multisectoral MHPSS system throughout the humanitarian response to address the mental health and psychosocial wellbeing of children, teachers, caregivers and the community that surrounds them.

The MHPSS programming requires time to implement and demonstrate impact, and requires a shift in approach and attitudes at various levels of the education system. Transitioning from traditional learning to more holistic learning methods that teach SEL competencies and promote and protect wellbeing, requires long-term investments aligned with the national education system. Stand-alone programming divorced from a whole child approach (Figure 1) will only limit the impact of education programming and humanitarian programming as a whole. The targeted approach below highlights a package that will support implementing agencies to deliver multisectoral MHPSS services and advocate for flexible multiyear funding through the use of specific and costed MHPSS actions to be implemented across sectors.

  Conclusion 

A solid evidence base supports and encourages the integration of MHPSS into education services and systems. The negative impact of conflict on the wellbeing of children and families is broadly known, as is the benefit of access to the protective and promotive effects of education, and teacher and caregiver wellbeing in supporting MHPSS wellbeing and positive outcomes for children into adulthood. However, multiple challenges exist that impede the integration and promotion of MHPSS services and approaches within the education system, and these need to be addressed in order to ensure that children can live healthy lives, learn and access holistic, linked supports that enable them to prosper.

Outlined in the core actions, a principle of integrating MHPSS into EiE is the need to strengthen traditional learning environments to be more responsive to children's protection, learning, development and wellbeing needs. This requires investment in teachers' social and emotional wellbeing and professional development to build their capacity to create holistic, creative and responsive learning environments that encourages both children and teachers to thrive. In addition to the investment in ECD and the wellbeing of caregivers which is critical to mental health, psychosocial wellbeing and learning.

Furthermore, children, teachers, caregivers and community members must be included in the process of making decisions which affect their lives, and in all stages of the MHPSS programme cycle. The process of participation not only benefits the relevance and quality of programming, it also restores a sense of agency and control to children, teachers and caregivers affected by emergencies. As part of this process, it is essential to engage children, teachers, caregivers and community members in defining wellbeing according to their context and culture, and in determining how education can support their view of wellbeing and ensure every child can benefit.

A phased approach to integrating MHPSS within education, from the onset of an emergency to long-term recovery and development, is essential and requires flexible multiyear and multisector funding. Ultimately, it is important that the education system and the larger humanitarian MHPSS system functions well so that children with higher level needs can benefit from targeted, contextualised referrals to specialised MHPSS services when necessary. In order for an MHPSS system to function successfully, services must be available at all layers of the pyramid, as highlighted in the case study on the SPOT consortium. Collaborative work across sectors and agencies can reduce many of the barriers to access care, and better address the mental health and wellbeing of children and families affected by emergencies.

Targeted approaches and tools such as the WHO, UNICEF and UNHCR MSP will provide essential support to the integration of MHPSS into education. The MSP will outline a series of specific and costed actions to be implemented by appropriately trained staff in a coordinated manner through education services and systems. In turn, these actions provide a systematic response to the mental health and psychosocial needs of children, caregivers and communities in humanitarian emergencies.

Although barriers continue to impede the integration of MHPSS programming into education, we unequivocally know the long-term value of creating learning environments that are safe and protective and that promote and integrate mental health and wellbeing approaches. The core actions outlined in the article demonstrated by the MHPSS in EiE programmatic examples, show promising innovations and tools specific to humanitarian settings. These innovations and tools address the socioecological system surrounding the child and take into account the researched links between caregiver mental health, teachers' wellbeing and the healthy development of the child.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

1See more information at: https://mhpssmsp.org/en

 

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  [Figure 1], [Figure 2]