The impact on anxiety and depression of a whole ...

Advances in School Mental Health Promotion

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The impact on anxiety and depression of a whole school approach to health promotion: evidence from a Canadian comprehensive school health (CSH) initiative Wijaya Dassanayake, Jane Springett & Tania Shewring To cite this article: Wijaya Dassanayake, Jane Springett & Tania Shewring (2017) The impact on anxiety and depression of a whole school approach to health promotion: evidence from a Canadian comprehensive school health (CSH) initiative, Advances in School Mental Health Promotion, 10:4, 221-234, DOI: 10.1080/1754730X.2017.1333913 To link to this article: https://doi.org/10.1080/1754730X.2017.1333913

Published online: 29 May 2017.

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Advances in School Mental Health Promotion, 2017 VOL. 10, NO. 4, 221–234 https://doi.org/10.1080/1754730X.2017.1333913

The impact on anxiety and depression of a whole school approach to health promotion: evidence from a Canadian comprehensive school health (CSH) initiative Wijaya Dassanayake, Jane Springett and Tania Shewring School of Public Health, Edmonton Clinic Health Academy, University of Alberta, Edmonton, Canada

ABSTRACT

In this paper, we examine the impact of adopting a comprehensive school health (CSH) approach on reducing anxiety and depression of school-age children. We use the data from 245 schools that received government funding support to adopt a CSH approach in order to build health promoting school environments in Alberta. Using a linear multi-level (hierarchical) model, we compare the average percentage of students with anxiety and depression across the schools that are in three different funding stages: pre-funded, actively-funded, and post-funded. Results show that, all else held constant, the schools that are in the actively-funded stage, relative to pre-funded schools have a lower percentage of students who suffer from anxiety and depression.

ARTICLE HISTORY

Received 18 February 2016 Accepted 13 April 2017 KEYWORDS

Health promoting schools; comprehensive school health; anxiety; depression; multi-level model

Introduction Globally, a shift has been taking place in the use of schools as a setting for Public Health. No longer is the focus solely on teaching health education and delivering short term health related interventions in a school. Rather, the aim is to develop and sustain a health promoting school environment. Based on WHO (1948) definition of health, a health promoting school environment aims to produce students with a state of complete physical, mental and social well-being (Bell & Dyment, 2008; Keshavarz, Nutbeam, Rowling, & Khavarpour, 2010; Kwan, Petersen, Pine, & Borutta, 2005; Lynagh, Knight, Schofield, & Paras, 1999). The shift from the traditional health promoting approaches to establishing health promoting school environments is reflected in the global expansion of organizations and networks to support the whole school approach (Bell & Dyment, 2008). Building a health promoting school environment is often done through a whole school approach in which all school stakeholders are actively and collectively involved in identifying needs relating to the students’ health and implementing actions to meet those needs (Cushman, 2008; Lister-Sharp, Chapman, Stewart-Brown, & Sowden, 1999; Samdal & Rowling, 2011; St Leger, 2000; Stewart-Brown, 2006). Theoretical base for whole school approaches stems from the ‘setting’ approach to health promotion in which the students are treated as a part of the larger social networks in which they live, work and play (Bell & Dyment, 2008; CONTACT Wijaya Dassanayake © 2017 The Clifford Beers Foundation

[email protected]

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Rowe & Stewart, 2011; Veugelers & Schwartz, 2010). Unlike the traditional health promotion in schools that focus on individual behavioural change, whole school approaches focus on organizational and policy change (Lee, 2009). In most parts of Canada, the Comprehensive School Health approach (CSH) has been the most frequently used whole school approach to health promotion. Like other whole school approaches, the CSH approach focuses a planned, integrated and holistic approach to promoting health within a school community setting (Allensworth & Kolbe, 1987; Allensworth, Wyche, Lawson, & Nicholson, 1995; Deschesnes, Martin, & Hill, 2003). The concept originates from the Ottawa Charter for Health Promotion (OCHP), which established an international framework to contribute to Canadian health in a daily context (World Health Organization, 1986). While the core of the CSH approach remains the same, different provinces in Canada have used different components and means to incorporate CSH into the school environments depending on the local policy, resources and priorities (Beaudoin, 2011). In the context of Alberta, the CSH approach includes four components: (1) policy; (2) social and physical environments; (3) teaching and learning; and (4) partnerships and services (Canadian Association for School Health, 1991; Pan-Canadian Joint Consortium for School Health, 2015). The underpinning idea is that when the CSH approach is applied to a school, the actions in all four components are integrated to provide skills, supports, and improvements. Despite recent increase in the practice, CSH and other whole school approaches lack the empirical evidence to show their impacts (Chen et al., 2010; Veugelers & Schwartz, 2010). This paper aims to narrow this gap by investigating the impact of adoption of the CSH approach on reducing anxiety and depression among school-age children. Previous studies have suggested that higher anxiety and depression among students could negatively impact their academic achievements (e.g. AL-Sagarat, AL-Saraireh, Masa’deh, & Moxham, 2015; Ameringen, Mancini, & Farvolden, 2003; Bernal-Morales, Rodríguez-Landa, & Pulido-Criollo, 2015; Bostani, Nadri, & Nasab, 2014; Huan et al., 2015; Mihailescu, Diaconescu, Ciobanu, Donisan, & Mihailescu, 2016; Sznitman, Reisel, & Romer, 2011). Anxiety and related disorders may also be associated with problematic school absenteeism (e.g. Egger, Costello, & Angold, 2003; Kearney & Albano, 2004). Further, studies find that students with depression could be more likely to drop out of school (e.g. Eisenberg, Golberstein, & Hunt, 2009). Accordingly, prevention of anxiety and depression has increasingly been considered as an integral part of improving students’ health and is central to the CSH and other whole school approaches (Bell & Dyment, 2008; Cushman, 2008; Macnab, Gagnon, & Stewart, 2014; Symons, Cinelli, James, & Groff, 1997; Weare, 2000). We hypothesize that building health promoting school environments by applying the CSH approach may decrease the anxiety and depression among students directly and indirectly. Direct impacts occur when the schools incorporate specific processes and strategies to prevent anxiety and depression and improve mental health of the students through the four components of the CSH approach. For example, some schools may opt to implement a social-emotional curriculum and support ongoing training for the school community. In the case of indirect impacts, the changes may occur, for example, as a result of improvements in students’ physical health. Studies have shown that the improvements in physical health may help to prevent and cope with anxiety and depression (Craft & Perna, 2004; Fox, 1999; Lucas et al., 2011). Our aim of this study is not to separate out these two effects, rather we seek to identify the general pattern of the relationship.

ADVANCES IN SCHOOL MENTAL HEALTH PROMOTION

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We use a unique set of data collected from the schools that received funding from the Alberta Healthy School Wellness Fund (henceforth referred to as Wellness Fund) to apply the CSH approach to build health promoting school environments during 2010–2014. In identifying potential impacts, we pay special attention to both jurisdiction and school level heterogeneity. In addition to quantifying impacts, using qualitative data, we examine the specific actions and strategies that the funded jurisdictions and schools used to prevent and cope with anxiety and depression and improve mental health of the students.

Method Description of the CSH programme The Government of Alberta has developed an integrated infrastructure to support grassroots efforts to promote CSH across the province over the years. In 2006, Alberta Ministry of Health made a CA$18-million investment to promoting healthy weights in children and young people through the Healthy Weights Initiative (Stolp, Wilkins, & Raine, 2014). One of the five elements of the Healthy Weights Initiative was the Wellness Fund to which school communities can apply for the financial support of health promotion projects.1 The Wellness Fund, initiated in 2007, is the product of a partnership between the School of Public Health, University of Alberta and the Government of Alberta, who provides funding for healthy school initiatives. Over the years, the focus of the Wellness Fund has shifted from its original objective of promoting healthy weights. During last seven years in particular, the Wellness Fund has been involved in developing health promoting school communities across the province. In doing so, the Wellness Fund provides funding support to school jurisdictions and individual schools to apply a CSH approach to improve students’ health. A number of different types of grants were available during the time period considered in this study: general wellness grants, those focusing specifically on high schools, on healthy relationships or on student leadership. The funded jurisdictions and schools are encouraged to self-identify their own needs and decide how to address them. Generally, the schools and jurisdictions need to address three provincial priority areas of health: (1) healthy eating; (2) active living; and (3) positive social environment. However, they can focus more intensely on one or more of the different priority areas according to identified needs, and act independently to use a wide array of strategies and processes to achieve identified needs. Nevertheless, the chosen strategies and processes have to be compatible with the overall whole school approach to health promotion, and related to the four components of the CSH approach.

Sample The overall sample for this study consisted of 245 unique schools which received funding support for CSH at school or jurisdiction level during 2010–2014. These schools represent 45 different projects and 27 of the 61 (44%) of Alberta’s public, separate and francophone school jurisdictions. Since some schools have received funding support in multiple years, the total sample used in the analysis consisted of 427 observations representing about 75,000 students.

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Measures In this paper, anxiety was characterized by having intense feelings of fear, intense nervousness, or worry about particular events or social situations. Depression was characterized by having prolonged periods of feeling sad, discouraged, and inadequate. Two sets of six Likert questions were used to collect the data on anxiety and depression (see Appendix A for the survey questions). These questions investigated the frequency in which the students experience feelings or display symptoms related to anxiety and depression. The data were scaled on a four-point scale: 0 = ‘Never or hardly ever’, 1 = ‘About once a week’, 2 = ‘About 2 or 3 times a week’ and 3 = ‘Every day or almost every day’. The average score across all six questions was calculated for each student. For anxiety, an average score above 2 were considered to be experiencing high levels of anxiety, while those with scores above 1.2 but below 2 are considered to have moderate levels of anxiety. For depression, an average score above 2.4 were considered to be experiencing high levels of depression, while those with scores above 1.6 but below 2.4 are considered to have moderate levels of depression. The cut-off points were aligned with the response stems and their assigned values. Based on consultation with subject matter experts, as well as the psychometric analyses, the cut-off points were determined based on the frequency of behaviour that would be closely aligned with the definition of moderate or high levels of anxiety. For example, a student would only be classified as high anxiety if their average response met the threshold of ‘every day or almost every day’.

Data The data on anxiety and depression were obtained from the Tell Them From Me (TTFM) survey. The data collection is undertaken yearly using an anonymous online survey filled out by students. In this paper, we use school level data on the percentage of students with moderate to high levels of anxiety and depression. In addition, this study used the data on the parental income and school size as measured by the number of students. These data were obtained from the Fraser institute and the Alberta Education respectively. Average school level parental income measured in Canadian dollars included earnings from wages, salaries and from self-employment. We used parental income, school size as explanatory variables in our statistical model discussed below.

Empirical procedure We adopted a unique categorization of schools that allows us to compare the effects of adopting CSH across the schools in identified categories. Based on the time of collection of TTFM data and receiving funding support, we categorized all the schools that were receiving funding into three stages of funding: pre-funded, actively-funded and post-funded. The definitions of these categories are as follows. • Pre-funded schools: Schools that have completed TTFM survey before receiving funding support. • Actively-funded schools: Schools that completed TTFM survey at least six months after receiving funding support and before funding support ended. • Post-funded schools: Schools that completed TTFM survey after funding support ended.


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Table 1 shows mean values and standard deviations of the percentage of students with moderate to high levels of anxiety and depression across the schools that are in each funding stage. The schools that are in the actively-funded stage have the highest percentage of students who suffer from anxiety and depression. However, as these are unadjusted means, just by looking at numbers in Table 1 we cannot make claims as to any potential associations or causality between funding for CSH and anxiety or depression. If the factors assumed to affect anxiety and depression such as school size and parental income are systematically different across the schools in the three funding-stages, unadjusted means can yield misleading results. Therefore, in order to understand the relationships between funding for CSH and anxiety and depression further, we adopted a multivariate approach. A multivariate analysis allows us to isolate the impacts of CSH by controlling the potential impacts of the other factors affecting anxiety and depression. Our base-line multivariate model is as follows:

Yst = 𝛽0 + 𝛽Xst + 𝜀st ,

(1)

s = 1, ... , S ≤ 245; t = 1, ... , T ≤ 5

where Yst denotes the dependent variable, the percentage of students with anxiety (or depression) in the school s in time period t. In order to account for potential heteroskedasticity of the data and to be able to interpret the coefficients in percentage terms, we transform the real values of Yst into natural log values. The vector X denotes the explanatory variables, specifically, the funding stage of the school, school size, average parental income of the school,2 school year and the season. The β’s denote a vector of the parameters to be estimated and ε is a vector of error terms of the model. We consider the funding stage of the school as a proxy variable for the adoption of the CSH approach. Funding stage variable is not expected to represent the extent to which a CSH initiative is incorporated into the school settings. Rather, it distinguishes the schools that have adopted CSH, both presently and previously, from the ones that have not adopted CSH during the time period of this study. Accordingly, we include two dummy variables to represent actively-funded and post-funded schools. The schools in pre-funded stage are considered as the base-category. Based on the potential direct and indirect effects mentioned previously, we expect the actively-funded and post-funded schools, relative to prefunded schools to have less percentage of students having anxiety and depression. The number of students influences the quantity and quality of social networks available within schools and thereby may impact the percentage of students having anxiety and depression. We expect a non-linear relationship between the school size and the percentage of students having anxiety and depression, but do not have the a priori expectations on the direction of the relationships. Average parental income is used as a proxy variable to account for the socio-economic factors of students and their families. Based on the findings of the previous studies (e.g. Lefebvre & Merrigan, 1998; Lipman & Offord, 1997; Lipman, Offord, & Boyle, 1994) we expect the parental income to have a negative effect on the percentage of Table 1. Means and standard deviations of the percentage of students with anxiety and depression. Indicator Anxiety (%) Depression (%) Sample size

Total sample 19.76 (5.62) 19.91 (5.46) 427

Pre-funding 18.26 (5.28) 18.48 (5.24) 205

Note: Standard deviations are reported in parenthesis.

Actively-funding 21.83 (6.21) 21.91 (5.86) 112

Post-funding 20.51 (4.76) 20.63 (4.69) 110

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students having anxiety and depression. We use dummy variables for school year and the season of data collection (i.e. Fall or Spring) in order to account for any time related variability of the dependent variables. Year 2013 and the spring season are considered as the base cases. An important statistical modelling issue concerns the potential presence of unobserved heterogeneity in the data that could affect the impacts of the explanatory variables on the dependent variable. These un-observables can make some schools more likely than others to exhibit low (or high) percentage of students with anxiety or depression. Unobserved heterogeneity may arise from sources such as efforts of the school staff and school norms. For example, a school with a staff that is highly dedicated towards improving mental health of the school is more likely to have lower percentage of students with anxiety and depression. There are two potential levels of such unobserved heterogeneity: (1) heterogeneity across jurisdictions; (2) heterogeneity across schools. In order to account for the potential presence of these two types of unobserved heterogeneity econometrically, we adopt a multi-level (hierarchical) linear modelling framework. Multilevel models recognize the existence of unobserved heterogeneity by allowing for residual components at each level in the hierarchy. The hierarchical nature of our data allows formulating a three level model. The level one represents 427 responses that are nested within 245 unique schools at level two, nested within 27 jurisdictions at level three. Accordingly, Equation (1) can be rewritten to include the random intercepts at jurisdiction and school level as follows:

Ysjt = 𝛿0 + 𝛽Xsjt + ud + us + 𝜀sjt ,

s = 1, ... , S ≤ 245; j = 1,... , J ≤ 27; t = 1, ... , T ≤ 5, (2)

where the subscripts s and j denote a specific school and a jurisdiction respectively. δ0 is the non-random intercept at the response level, uj and us are jurisdiction and school level random intercepts respectively. Equation (2) was estimated separately for anxiety and depression by using Stata 14 econometric software.

Qualitative data analysis In order to complement the quantitative data, we used qualitative data collected using an open-ended questionnaire from the actively-funded and post-funded schools. The survey was implemented on the individuals (project leads) and teams that were responsible for undertaking CSH initiatives across 170 schools, at the end of each year during 2010–2014. The survey questions elicited the processes and strategies that the funded projects have used prevent and cope with anxiety and depression and improve students’ mental health. We reviewed the content of the responses in order to identify common themes. These themes were then coded into categories. The data was analyzed by using NVivo10 qualitative data analysis software.

Results Quantitative data analysis Table 2 shows the results of the multilevel models. The estimated coefficient on each funding stage refers to the differentials of predicted mean values of anxiety and depression between the particular funding stage and the base category, all else held constant. The base category represents the schools that are in the pre-funded stage, as defined earlier.


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Table 2. Parameter estimates of the 3-level hieratical model. Anxiety Variable Intercept Actively-funded stage Post-funded stage Parental income School Size School Size-squared Season (1=Fall; 0=Spring) Year (1=2010; 0=otherwise) Year (1=2011; 0=otherwise) Year (1=2012; 0=otherwise) Year (1=2014; 0=otherwise) 𝜎d2 𝜎s2 Residual deviance Log pseudolikelihood Wald chi2 (10)

Coefficient 2.862 (.092)*** −.052 (.023)** .007 (.019) .000 (.001) .00053 (.000)*** −.000 (.000)*** −.109 (.116) .045 (.108) −.133 (.117) .059 (.107) .085 (.033)*** .001 (.016) .047 (.020)** .023 (.009)** 10.18 210.78

Depression P value .000 .024 .731 .969 .000 .004 .349 .676 .258 .581 .009

Coefficient 2.641 (.148)*** −.033 (.017)** .006 (.016) .000 (.000) .00052 (.000)** −.000 (.000) −.074 (.108) .095 (.100) .069 (.119) .155 (.104) .199 (.037)*** .006 (.007) .059 (.025)** .011 (.006)* 36.32 1580.81

P value .000 .046 .697 .530 .011 .111 .491 .338 .562 .136 .000

Note: Standard errors are reported in parentheses. Significance levels: * = 10%, ** =5%, *** =1%.

The schools that are in the actively-funded stage, relative to the ones in the pre-funded stage, have lower percentages of students with anxiety and depression. Specifically, the percentage of students that suffer from anxiety and depression are about 5 and 3% less in the actively-funded schools relative to pre-funded schools. The magnitudes of the effects are comparable with the previous findings, although different studies have used different units of measurements (see Calear & Christensen, 2010 for a systematic review intervention programs on depression). Also, since the CSH approach does not focus specifically on preventing and coping with anxiety or depression, rather aims at improving students’ physical and mental health in general, we believe that the magnitudes of effects are considerable. It is also important to note that the coefficients of the funding stage variables, i.e. predicted mean values, show quite a different picture compared with the unadjusted mean values given in Table 1. This discrepancy emphasizes the importance of controlling the other factors that may affect anxiety and depression by using advanced statistical methods. However, we do not find statistically significant differences with respect to anxiety and depression between post-funded schools and pre-funded schools. Most of our control variables have statistically significant effects. The size of the school as measured by the number of students show non-linear impacts on anxiety and linear effects on depression. The percentage of the students with anxiety increases with the total number of students in the school up to about 1500 students, and decreases afterwards. The percentage of students with depression increases with the total number of students in the school. For example, increasing the number of students by 100 students will increase the percentage of students with depression about 5.5%. In addition, the percentages of students that have anxiety and depression issues are higher in 2014 relative to the base year (2013). Further, the random intercepts at school level have statistically significant variances (σ2) in both models, indicating that due to unobserved heterogeneity, the percentage of students with anxiety and depression can change across the schools. This result also justifies our empirical approach, i.e. the multi-level model. However, we do not find statistically significant variability of the indicators across the jurisdictions.

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Qualitative data analysis The findings from the qualitative survey allow us to identify some of the processes and strategies that may have created the observed effects on anxiety and depression among actively-funded schools. After analyzing qualitative answers across the 170 schools, five common processes and strategies were identified. These primarily relate to the positive social environment element of the three provincial priority areas to health. However, some processes and strategies may encompass all three priority areas. Further, these processes and strategies also correspond to one or more components of the CSH approach: policy; social and physical environments; teaching and learning; and partnerships and services. It is also important to note that, in this study, we do not pay attention to the strategies and processes that are focused specifically on healthy eating (e.g. Cooking Clubs/Kitchens) and active living (e.g. Physical Activity Clubs). However, as previously mentioned, such strategies and processes may also affect anxiety and depression of students indirectly by improving the physical health of students. The five common processes and strategies are as follows. (1) Mental Health Initiatives: Most of the schools have focused specifically on mental health initiatives. The mental health initiatives range from education sessions, increased distribution of resources, increased training for teachers and support staff to better equip them at handling student mental health issues, presentations and workshops for teachers, students and parents related to anxiety, depression, stress and healthy relationships. Other mental health initiatives centre on anti-bullying campaigns promoted by schools within the jurisdictions. As one project lead stated, We collaborated with professionals in the field to design and deliver a whole staff professional development full day addressing adolescent anxiety/depression, Mindfulness, and adolescent brain development. Mental health strategically embedded through cross collaboration with the PD Committee into all 10 Professional Development days, both whole staff and individual/ team based.

(2) Education Initiatives: Healthy education sessions for students, teachers and parents have been a main source for fostering mental health. These education sessions cover a variety of topics including mental health issues including anxiety and depression, healthy relationships, healthy eating, physical activity requirements for children, proper sleeping behaviours, and general wellness tips. Schools also noted increased attendance in these education sessions throughout the year and received positive feedback from parents, teachers and students. One project lead stated that: Our project focused on developing ‘Positive Social Environments’ in our high schools, with a focus on mental health capacity building and policy development – creating social environments through teaching and learning that enhance students’ social-emotional functioning and academic development.

(3) New class activities: Incorporating new classroom activities has been a common strategy to increase student engagement. Activities included ‘mentality breaks’ which came in the form of short breaks throughout the lesson to re-engage and focus students. Another example is described by the following excerpt: Teachers invited guest speakers into the classroom to bring new expertise to a subject matter in the hope of further interesting and engaging students in the topic. Teachers incorporated stress


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reducing activities such as mediation/relaxation breathing techniques, gardening activities, and healthy eating activities to further spike student interest in healthy living.

(4) Student Leadership Clubs: Some schools have created student leadership clubs in order to promote positive mental health. These leadership clubs were student run and supported by teachers within the schools and held a number of different activities and events in order to promote a culture of wellness. These leadership clubs provided their peers with educational resources about anxiety and depression, bullying, healthy relationships, held events such as family nights (which involved the parents), sport days, anti-bullying events, and events centred on healthy eating. Schools noted these clubs fostered a supportive and positive social environment within the schools, and noticed increased participation and positive feedback from parents, students and teachers. As one project lead stated, Student leadership team will develop and create a policy for students on health and well-being – including anti-bullying, peer pressure, anxiety, healthy eating, and physical activity based on the delivery of the three goals.

(5) Creation of ‘Healthy Spaces’: The healthy spaces were created both inside and outside of the school buildings, and provided a space for students and teachers to take a healthy break to enjoy healthy snacks, movement breaks, and mental health breaks. Some schools also referred to these spaces as ‘wellness spaces’ and the idea was to give students and teachers a place to re-connect with themselves and their peers in a supportive and stress-free environment (often outdoors). An example is described by the following excerpt: The interior plans for the school include a number of student gathering areas. Students have been encouraged to provide input into the planning for these areas. The … team has been researching, planning and making presentations to community groups about exterior planning (i.e. natural playground, outdoor classroom space and gathering spaces). … administrators continue to support safe spaces in schools and creating environments where students can gather for social networking.

Discussion Overall, the findings of this study may indicate adoption of the CSH approach to develop healthy school communities is associated with lesser percentage of students with anxiety and depression among the actively-funded schools. Post-funded schools not being statistically different from pre-funded schools with respect to the percentage of students with anxiety and depression might imply that the schools and jurisdictions need to have a steady focus on the CSH approach for a longer period, especially after funding support ends. During the actively-funded stage, such focus is generally expected due to frequent communication between the Wellness Fund and project leaders as part of ongoing monitoring and evaluation. Unless the schools and jurisdictions take efforts to incorporate the CSH into their cultures, the benefits are likely to disappear after the facilitations from the Wellness Fund support end. Previous research has indicated the success of mental health initiatives within schools is highest when fully incorporated into the school culture and further supported by the curriculum (Rooney, Hassan, Kane, Roberts, & Nesa, 2013). Furthermore, research has indicated that schools will be most successful in their education mission when an integration between

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promoting students’ academic, social and emotional wellbeing (Dix, Slee, Lawson, & Keeves, 2012; Zins, Weissberg, Wang, & Walberg, 2004). Mental health initiatives that are developed to work within the school community are optimally designed to take advantage of the multitude of resources already in place to promote the welling being of students and strengthen the school community as a whole, fostering a sense of belonging (Wyn, Cahill, Holdsworth, & Rowling, 2000). Given school-aged children and youth are at a high risk for the development of depression and anxiety (Bond et al., 2004); incorporating mental health initiatives within the school curriculum through the use of educational resources may be beneficial in addressing student’s mental health concerns. Previous studies have also found educational resources offer significant reductions of anxiety and depressive symptoms in the short term (Sawyer et al., 2010); however, long term effectiveness requires a combination of educational resources, community involvement and positive environments, further strengthening the use of a CSH approach (Wyn et al., 2000). The creation of healthy spaces for students to use within the school, new class activities, and student run leadership clubs gives support to the relation between student’s health and the quality of the physical and social environments at school (World Health Organization, 1995). Further research has also indicated the school climate and a focus on how connected a student feels to their school may be more beneficial than single issue focused education packages (Bond et al., 2004). In this regard, schools that are actively fostering positive social and physical environments, in addition to offering educational and mental health resources, may be more successful in reducing the instances of depression and anxiety in their students. Ensuring students feel supported and have space available to unwind and relax within the school itself through the use of these healthy spaces foster a positive and supportive physical and social environment within the school. Furthermore, fostering a supportive school environment and school culture through the active inclusion of students in positions of leadership may further support student confidence and trust in the initiatives. CSH approaches, similar to other comprehensive programs, may be one avenue in promotion of mental health and wellbeing among students. Therefore, creating an interactive and supportive environment that involves the entire school community may strengthen their ability to effectively address the mental health and wellbeing of their students. Nevertheless, focusing on a more effective means of mental health promotion within schools requires a strong connection between mental health and education on a multitude of levels. The findings of this study supports the idea of a multi-faceted approach to mental health among students, highlighting a combination of positive physical and social environments, education and school community involvement, rather than focusing on specific, one-off education programs. It is clear the complexity of mental health disorders, such as depression and anxiety, require a broader approach, such as those seen with CSH in order to be successful in reaching students. For schools to reduce the levels of depression and anxiety among students, understanding mental health initiatives are not short term interventions is critical. Commitment to CSH models through the incorporation of education, supportive community involvement and fostering positive environments have the potential to improve the school climate and mental health of students. It is clear, mental health promotion is more than simply inserting appropriate educational materials within the school curriculum (Wyn et al., 2000). Schools committed to offering the most successful mental health programs to their students understand collaboration and support between the entire


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school community, including students, teachers and parents will strengthen their ability to decrease the instances of mental health disorders including anxiety and depression. Overall, creating healthy school communities through the CSH approach may be the key to addressing the mental health of students.

Limitations of the study Generalization of the findings of the study beyond the sample of schools that we used may be limited if the selected sample does not represent the true population. Theoretically, if the schools or jurisdictions that received funding support are systematically different based on unobserved attributes from the jurisdictions or schools that were not selected, the impacts of the CSH approach on anxiety and depression cannot be generalized globally. However, practically, we can preclude the presence of any selection bias when selecting schools for receiving funding as about 95% of schools and jurisdictions that apply for funding are successful. Further, the funding applications are normally rejected due to the mismatch between the proposed approach to improving school health and the CSH approach which is unlikely to be correlated with unobserved heterogeneity. Selection bias that may occur at the stage of applying for funding is also unlikely. The qualitative data collected by the Wellness Fund show that the schools and jurisdictions that apply for funding represent a wide range of different school cultures, needs, and perceptions of school administrators.

Conclusion In this study, we investigated the impact of adopting a CSH approach on anxiety and depression of school-age children. Our sample consisted of the schools that received funding from the Alberta Healthy School Wellness Fund and we used the funding stage as the proxy measure for adoption of a CSH approach. This is one of the first studies that use a multi-level modelling framework in order to account for unobserved heterogeneity in the context of health promoting schools. The study demonstrated the positive effects of adopting CSH in reducing anxiety and depression among actively-funded schools. The study also identified some processes and strategies such as mental health initiatives and student leadership clubs that are likely to cause the observed effects. Further, study demonstrated the importance of accounting for observed and unobserved heterogeneity across the schools when analyzing quantitative school level data. Overall, CSH seems a promising approach in building health promoting school environments in Alberta.

Notes 1. The other four elements are: (1) school health promotion coordinators (HPCs) or school health facilitators (SHFs) employed by Alberta Health Services (AHS); (2) nutrition guidelines for children and youth; (3) healthy school community award; and (4) healthy weights social marketing campaign. 2. Due to data limitations, we use the average parental income for the year 2013 across all the years for a given school.

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Acknowledgements The authors gratefully acknowledge the support of the Alberta Ministry of Health, Alberta Ministry of Education, Alberta Healthy School Community Wellness Fund, Wellness Fund projects, and Alberta Health Services. The authors would like to thank the Alberta Ministry of Education (education.alberta. ca), the Learning Bar (thelearningbar.com), and the Fraser Institute (www.compareschoolrankings. org) for providing data used in this study. The views and opinions expressed in this paper are those of the authors and do not necessarily reflect those of Alberta Ministry of Health or Alberta Ministry of Education.

Disclosure statement No potential conflict of interest was reported by the authors.

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Appendix A: Questions used to collect data on anxiety and depression Anxiety We would like to know how you think and feel about certain things. For each statement below, please tell us how often you feel this way. I worry about what other students think about me. I am too fearful or nervous. I worry about people laughing at me. I worry about a teacher asking me a question. I worry more than most kids. I am afraid that other students will think I am stupid.

Depression We would like to know how you think and feel about certain things. For each statement below, please tell us how often you feel this way. I feel sad or depressed. A lot of things seem to bother me. I feel lonely. I cry without a good reason. Other students seem to have more fun than me.

I have trouble falling asleep at night.