PLAIN LANGUAGE SUMMARY

Evidence and gap map finds stronger focus on treating than preventing mental health problems of children and adolescents

Most research on child and adolescent mental health and psychosocial interventions is reactive rather than proactive, with a strong focus on treating rather than preventing mental health problems or promoting mental health.

To access the interactive EGM, visit https://www.unicef-irc.org/evidence-gap-map-child-mental-health/.

What is this evidence and gap map (EGM) about?

Half of all mental health problems originate early in life. Many are preventable, but most remain unrecognised and untreated. Investment in effective child and adolescent mental health prevention, promotion and care is therefore essential.

This EGM provides a visual overview of the existing evidence on the effectiveness of mental health and psychosocial support interventions for children and adolescents aged 0-19 years in low- and middle-income countries (LMICs).

The interventions are divided into four categories: school-based, community-based, individual and family-based, and digital. These are then further filtered by where, how, for what and to whom they are delivered.

What is the aim of this EGM?

This map visually presents evidence from 697 studies and reviews conducted between 2010 and 2021 on the effectiveness of mental health and psychosocial support interventions for children and adolescents in low- and middle-income countries.

What studies are included?

A total of 697 studies and reviews are captured in the EGM, focusing on 78 LMICs.

What are the main findings of this EGM?

Most records cover lower-middle-income countries, with a few covering low-income countries.

Most of the records examine the effectiveness of interventions among adolescents. Most interventions focus on treating mental health problems rather than preventing them or promoting mental health.

School-based interventions are the most studied, followed by community-based interventions, individual and family-based interventions. Digital interventions are the least researched platform.

Most studies investigated mental health conditions, followed by mental health and early childhood development outcomes. Depression was the most frequently researched outcome sub-domain, followed by anxiety disorders, wellbeing, and post-traumatic stress disorder.

What do the findings of this EGM mean?

Research evidence on mental health and psychosocial support interventions for children and adolescents in LMICs is progressively expanding but unevenly distributed among regions and countries and by intervention and outcome domains.

Most of the evidence focuses on treating mental health disorders rather than preventing or enhancing mental health, indicating that current research is more reactive than proactive.

Mental health and psychosocial support research for children and adolescents lacks diversity. It is critical to include certain sub-populations in studies, particularly those that tend to report a higher prevalence of mental health and psychosocial problems and are less likely to have access to mental health care. More evidence is needed on the effectiveness of digital mental health interventions, interventions in humanitarian settings, and interventions for the youngest children.

There are concerns about the quality of the available research. Progress on mental health and psychosocial support is hampered by a lack of investment in robust research on which interventions work to improve child and adolescent mental health.

How up-to-date is this EGM?

All the searches were conducted in December 2021, to retrieve all systematic reviews and primary studies published between January 2010 and December 2021, with no language restrictions.

PLAIN LANGUAGE SUMMARY

Educational interventions for Covid-19 vaccine confidence frequently involved group and individual-based strategies

Many educational interventions were introduced to adult populations during the Covid-19 pandemic, to help build their vaccine knowledge and confidence. These initiatives often involved the use of both formal (e.g., presentations) and informal (e.g., one-on-one conversations) approaches. Community partnerships were often leveraged to develop and facilitate Covid-19 vaccine education.

What is this review about?

There were high levels of hesitancy towards the Covid-19 vaccines when they were first introduced, despite scientific evidence showing their effectiveness in reducing morbidity and mortality from Covid-19. Education about the vaccines was one of the key tools commonly used by public health professionals and healthcare providers to support individuals in their vaccine decisions.

What is the aim of this scoping review?

This scoping review identifies and describes educational interventions delivered during the pandemic to support Covid-19 vaccine confidence in adults. This review also highlights lessons learned that can be applied to support vaccine confidence in adults and priority populations for vaccinations, such as healthcare workers.

What studies are included?

The authors included all studies that described an educational intervention on Covid-19 vaccines provided to adult populations, regardless of geography. The interventions had to include an active interaction between an education facilitator and an audience. For example, informational pamphlets about the Covid-19 vaccines were excluded.

The authors found 32 studies from seven countries, published between February 2021 and February 2022. There were two rounds of database and grey literature searches.

What are the main findings of this review?

Group-based educational interventions were used more frequently than individual-based approaches. Formal presentations were the most common type of intervention. Other group-based interventions included community events and small group discussions.

Individual-based interventions included phone calls, in-person consultations and door-to-door communication. Many interventions involved multiple strategies. Often, formal group-based presentations were coupled with additional individual-based interventions, such as one-on-one conversations either in-person or on the phone.

Given the novelty of the Covid-19 vaccines, personalized conversations, question periods, and other opportunities to address misinformation were important components of educational interventions.

Healthcare professionals provided the education in almost all studies. Many of the studies also showed that other community leaders who were familiar to the audience also supported the education. The studies were diverse in their priority populations.

What do the findings of this review mean?

This review identified many lessons that may be relevant to future vaccine education. For example, personal connections and trust between educator and audience is an important theme. Utilizing recognized community leaders could therefore be an important strategy.

Also, working with the audience to understand their preferences for including how the education should be provided (i.e., format and language) and their information needs (i.e., common concerns) helps to ensure relevant and effective interventions.

How up-to-date is this review?

The review authors searched for studies published from the onset of the Covid-19 pandemic to February 2022.

PLAIN LANGUAGE SUMMARY

Montessori education significantly impacts academic and non-academic outcomes

Relative to traditional education, Montessori education has modest but meaningful positive effects on children’s academic and non-academic (executive function, creativity and social-emotional) outcomes. This is indicated by a meta-analysis of 32 studies in which it was possible to compare traditional business-as-usual education to Montessori education.

What is this review about?

How best to educate children is an issue of enduring concern, and Montessori is the most common alternative to the conventional education system. Montessori includes a full system of lessons and hands-on materials for children from birth to 18 years, presented individually, and embedded in a philosophical framework regarding children’s development and its optimal conditions.

The term Montessori is not trademarked, and, therefore, its implementation can vary. We studied the range of variations included in the literature, which likely reflects the range of implementations encountered in the world. We also compared Montessori with a range of control conditions described in the literature as traditional (sometimes referred to as conventional, or business-as-usual), reflecting the implementation of traditional education in the real world.

What is the aim of this review?

This review examined whether children who receive Montessori education have better academic and non-academic outcomes than children who receive traditional education. This review also examined whether certain elements moderate the effects of Montessori education (i.e., grade level, public vs private Montessori settings, random assignment, treatment duration and length of follow-up measurements).

What studies are included?

From a search yielding over 2,000 studies, the review evaluated 32 of the most rigorous Montessori studies, with publication dates ranging from 1970 to 2020.

Study participants were spread across age levels: preschool, elementary school and middle and high school.

The studies took place in eight countries: the USA (18 studies), Turkey (four studies), Switzerland (three studies) and one each in England, France, Malaysia, Oman, Iran, The Philippines and Thailand.

How effective is Montessori education?

On academic outcomes, Montessori students performed about 1/4 of a standard deviation better than students in traditional education. The magnitude of these effects could be considered small when compared to findings obtained in tightly-controlled laboratory studies, but they could be considered to be medium-large to large when compared to studies in real-world school contexts involving standardized tests.

Most (29) of the included studies were conducted in schools implementing Montessori as a full program; the remaining three studies were short-term add-ons to otherwise traditional school curricula.

The effect sizes for academic outcomes are similar to those obtained in other studies that compared “No Excuses” charter schools to business-as-usual urban schools.

The magnitude of Montessori education’s non-academic effects was slightly stronger than its effects on academic outcomes. Montessori students performed about 1/3 of a standard deviation higher than students in traditional education on non-academic outcomes, including self-regulation (executive function), well-being at school, social skills and creativity.

The magnitude of Montessori education’s effects was greater for randomized than non-randomized study designs, greater for preschool and elementary school than for middle and high school, and greater for private Montessori compared to public Montessori settings.

What do the findings of the review mean?

Across a wide range of implementations (likely reflecting the range of Montessori implementations in the real world) and in studies of moderate to high quality, Montessori education has a nontrivial impact on children’s academic and non-academic outcomes.

How up-to-date is this review?

The review authors searched for studies published through February 2020.

PLAIN LANGUAGE SUMMARY

Functional Family Therapy is not consistently more (or less) effective than other services

Functional Family Therapy (FFT) is a family-based intervention for youth with behaviour problems. It is often described as an evidence-based programme with consistent, positive effects. This systematic review finds that FFT does not produce consistent benefits or harms. The positive or negative direction of results is inconsistent within and across studies.

What is this review about?

FFT is a prominent, short-term treatment for families of youth with behaviour problems that has been implemented in 45 states in the USA and in nine other high-income countries.Proponents claim that FFT is consistently more effective than treatment as usual (TAU) and other treatments in improving outcomes for youth and families.

This review assessed the effectiveness of FFT in reducing recidivism, out-of-home placements, youth behaviour problems, delinquency, and substance use; and improving peer relations, self esteem, school outcomes, parent functioning, and family functioning.

What is the aim of this review?

This review synthesized data from the best available studies to assess the effectiveness of FFT compared with other active treatments and with no treatment.

What studies are included?

The review included rigorous evaluations of the impacts of FFT, including: randomised controlled trials and non-randomised studies that used parallel cohorts and statistical controls for between-group differences at baseline.

Eligible studies involved families of young people aged 11-18 with behaviour problems, such as criminal offenses, delinquency, anti-social behaviour, and substance abuse.

What are the findings of this review?

Twenty studies met the review’s eligibility criteria, but only 15 provided valid data for meta-analysis. All included studies had high risks of bias on at least one indicator. Half of the studies had high risks of bias on at least four indicators, and most (75%) had incomplete reporting of outcomes and endpoints.

The review found that FFT is not consistently more or less effective than the other treatments to which it has been compared, including various forms of TAU and individual, family, and group therapies. There is insufficient evidence to draw conclusions about the effects of FFT compared with no treatment.

The direction of FFT effects is mixed, sometimes positive, sometimes negative. Confidence intervals show that almost all pooled estimates of effects of FFT are not statistically different from zero. Prediction intervals indicate that future evaluations of FFT are likely to show a wide range of negative and positive effects.

What are the implications for research and policy?

The best available evaluations of FFT are small controlled trials and quasi-experiments with incomplete reporting of outcomes and some high risks of bias. Future studies should have prospectively registered protocols, use larger samples and more rigorous research methods, and provide full reporting on all outcomes and end points.

Incomplete reporting of results of primary studies may have inflated overall estimates of positive effects of FFT.

Although FFT has been marketed as a “scientifically proven”, effective, evidence-based practice, policymakers and practitioners should be aware that the certainty of the evidence for FFT is very low. The direction of results is inconsistent within and across studies, and there is no empirical support for claims that FFT is consistently more effective than other treatments.

Information on the cost effectiveness of FFT appears to be based on inflated estimates of the effects of treatment. Therefore, claims about the cost effectiveness of FFT are not convincing.

How up-to-date is this review?

The review authors searched for studies that were reported through August 2020.

PLAIN LANGUAGE SUMMARY

Little research evidence exists on the effects of small class sizes in special education

Despite carrying out extensive literature searches, the authors of this review found only seven studies exploring the question of class size in special education. The authors therefore call for more research from quantitative and qualitative researchers alike, such that practitioners and administrators may find guidance in their endeavours to create the best possible school provisions for all children with special educational needs.

What is this review about?

While research on the relationship between general education class size and student achievement is plentiful, research on class size in special education is scarce, even though class size issues must be considered particularly important to students with special educational needs. This systematic review sought to examine the effects of small class sizes in special education on the academic achievement, socioemotional development and well-being of children with special educational needs.

Furthermore, the review aimed to perform a qualitative exploration of the views of children, teachers and parents concerning class size conditions in special education.

A secondary objective was to explore how potential moderators (e.g. performance at baseline, age, and type of special educational need) affected the outcomes.

What is the aim of this review?

The objective of this Campbell systematic review was to synthesise data from existing studies to assess the impact of small class sizes in special education on students’ academic achievement, socioemotional outcomes and well-being.

What studies are included?

This review included seven studies, of which two were quantitative, four were qualitative, and one was both quantitative and qualitative. It was not possible to perform a meta-analysis, nor a qualitative thematic synthesis. The included studies were critically assessed, coded for descriptive data, and narratively summarised.  

One quantitative study was assessed to be of sufficient methodological quality following risk of bias assessment. Unfortunately, it was not possible to extract an effect size from this study since it did not report the required information and the study authors could not be contacted.

Three qualitative studies were assessed to be of sufficient methodological quality following qualitative critical appraisal.

What are the main findings of this review?

There are surprisingly few studies exploring the effects of small class sizes in special education on any outcomes. The included qualitative studies find that smaller class sizes are the most preferred option among students with special educational needs, their teachers and school principals. This is because of the possibilities afforded in terms of individualised instruction time and increased teacher attention to the needs of each student.

What do the findings of the review mean?

The impact of small class sizes in special education is under-researched both within the quantitative and the qualitative literature.

Future research should aim to fill this knowledge gap from diverse methodological perspectives, paying close attention to the views of parents, teachers, administrators and, most importantly, the children and young people whose everyday lives are spent in the various special education provisions.

How up-to-date is this review?

Searches in bibliographic databases and EBSCO OPEN Dissertations were performed in April 2021, while the remaining searches for grey literature, hand searches in key journals, and citation tracking took place between January and May 2022.

PLAIN LANGUAGE SUMMARY

Flipped classrooms may improve academic performance and satisfaction of undergraduate health professional students

Flipped classroom learning appears to improve academic performance and the evidence suggests student satisfaction with the innovative learning method, but the certainty of the evidence was low.

What is this review about?

Students face several challenges when learning through traditional teaching settings. They need to accumulate huge amounts of factual knowledge from the courses, and to keep up-to-date with the prolific growth in health knowledge.

Lack of awareness about digital technologies and non-exposure to digital-friendly environments have made learning even more challenging. Therefore, an innovative approach to the education delivery system is needed.

A flipped class includes two elements of education: a recorded lecture (off-campus learning as homework) and an active learning session (on-campus learning). Pre-recorded lectures are provided to the students as homework and as an aid to learning which is then interactively discussed later on campus.

This review aims to explore whether there is empirical evidence that supports this method of learning for undergraduate health professional students. Do flipped classrooms improve academic performance and are students satisfied with the flipped class learning method?

What is the aim of this review?

This Campbell systematic review examines the effects of flipped class teaching compared to the traditional method. The review summarises evidence from 45 studies, including 11 randomised controlled trials.

What studies are included?

This review includes studies that have evaluated the effect of flipped classes compared to traditional classes on the academic performance and course satisfaction of health professional undergraduate students.

Forty-five studies were identified, involving 8,426 undergraduate students in medicine, pharmacy, nursing and other health professional courses.

Of these, 44 studies involving 7,813 undergraduate students examined the outcome of academic performance, measured by examination scores/final grade). Only eight studies, involving 1,696 undergraduate students, examined the outcome of students’ satisfaction.

Studies spanned the period 2013 to 2021. Sixteen studies were conducted in the USA, and only three studies were from lower-middle-income countries, including India. All the studies had important methodological weaknesses.

Does the flipped class method of learning improve students’ academic performance?

Yes, low certainty of evidence shows an overall improvement in academic performance when flipped classroom interventions were implemented compared to traditional lecture-based classes.

Are students satisfied with flipped class learning?

Yes, low certainty of evidence shows that students’ satisfaction with the flipped classroom method of learning is positive. Therefore, further research may change the estimate in either direction (that is, a larger difference, or no difference, in satisfaction).

What do the findings in this review mean?

The review shows that flipped classroom learning may improve academic performance and satisfaction of undergraduate health professional students. Well-designed studies with larger samples that rigorously evaluate the outcomes are needed.

How up-to-date is this review?

The literature searches were last conducted in April 2022.

PLAIN LANGUAGE SUMMARY

Most COVID-19 studies looked at the influence of sex, age and our perception of COVID-19 on social distancing, handwashing and face covering

Over the course of the COVID-19 pandemic there have been huge volumes of research looking at how different factors influence COVID-19 health protective behaviours: social distancing, face covering and handwashing. The majority of this research is focused on factors that cannot be altered through intervention, such as demographics (age and sex).

The interactive evidence and gap map (EGM) is available here.

What is this evidence and gap map (EGM) about?

In the early stages of the COVID-19 pandemic, health protective behaviours such as distancing and handwashing were the first line of defence to help limit the spread of COVID-19. Understanding why people do or do not engage in recommended behaviours is important to developing successful public health messaging, and to increase the number of people engaging in these behaviours.

This EGM summarises studies that measured one or more factors that might influence health protective behaviours, including handwashing, use of face coverings, social or physical distancing, and isolation or quarantine.

What is the aim of this EGM?

The aim of this EGM is to map the current research on different factors and health protective behaviours, such as social distancing, handwashing and face covering.

What studies are included?

The current map includes 1,034 pieces of evidence. This consists of 25 reviews (including 17 systematic reviews) and 1,009 primary studies. Of these, 860 were cross-sectional studies, 68 were longitudinal, and 78 were qualitative studies.

What are the main findings of this EGM?

There was lots of evidence on some behaviours (social distancing, handwashing, face covering) and very little on others (not touching your face, cleaning surfaces).

Social distancing had the most evidence (487 studies), followed by use of face coverings (382 studies) and handwashing (308 studies). Fewer studies looked at behaviours such as avoiding the T-zone (not touching your face), cleaning surfaces and respiratory hygiene practices (coughing into your elbow or tissue).

A large number of studies (333 studies) combined two or more protective behaviours within the one study. This makes it difficult to use these studies to look at how different factors may influence individual behaviours.

Across the studies there are significant differences in how different behaviours are defined. Some studies described social distancing as minimising contacts outside of the home, whereas others used the term to mean physical distancing from others (for example, keeping at least two metres apart).

In relation to the different factors influencing these behaviours, demographics was the most reported (730 studies), followed by cognitive factors (how people might perceive or think about COVID-19; 496 studies).

Fewer studies looked at the influence of factors such as interventions (for example, providing access to hand sanitiser), information on COVID-19 (for example, the different sources of information people received) and the impact of engaging in other protective behaviours (for example, if someone covered their face, would they be more or less likely to also social distance).

What do the findings of the map mean?

This EGM shows the available evidence on the different factors that may influence health protective behaviours such as distancing, face coverings and handwashing.

This EGM can be used to help guide future areas of research and public health policy during the current COVID-19 pandemic and any future outbreaks of respiratory viruses with pandemic potential.

Current evidence is largely focused on social distancing and the use of face coverings; and primarily on the influence of factors such as age or sex (demographics) on these behaviours. There are major gaps in the evidence base on other important health protective behaviours and the influence of factors other than age or sex.

How up-to-date is this EGM?

The authors searched for studies up to October 2021.