systematic review of resilience-enhancing, universal ... · their aims, focusing on different...

Fenwick-Smith et al. BMC Psychology (2018) 6:30 https://doi.org/10.1186/s40359-018-0242-3

RESEARCH ARTICLE Open Access

Systematic review of resilience-enhancing,universal, primary school-based mentalhealth promotion programs
Amanda Fenwick-Smith, Emma E. Dahlberg and Sandra C. Thompson*
Abstract

Background: Wellbeing and resilience are essential in preventing and reducing the severity of mental healthproblems. Equipping children with coping skills and protective behavior can help them react positively to changeand obstacles in life, allowing greater mental, social and academic success. This systematic review studies theimplementation and evaluation of universal, resilience-focused mental health promotion programs based in primaryschools.

Methods: A systematic review of literature used five primary databases: PsycINFO; Web of Science; PubMed;Medline; Embase and The Cochrane Library; and keywords related to (a) health education, health promotion,mental health, mental health promotion, social and emotional wellbeing; (b) school health service, student, schools,whole-school; (c) adolescent, child, school child, pre-adolescent; (d) emotional intelligence, coping behavior,emotional adjustment, resilienc*, problem solving, to identify relevant articles. Articles included featured programsthat were universally implemented in a primary school setting and focused on teaching of skills, including copingskills, help-seeking behaviors, stress management, and mindfulness, and were aimed at the overall goal ofincreasing resilience among students.

Results: Of 3087 peer-reviewed articles initially identified, 475 articles were further evaluated with 11 reports onevaluations of 7 school-based mental health promotion programs meeting the inclusion criteria. Evaluation toolsused in program evaluation are also reviewed, with successful trends in evaluations discussed. Encouraging resultswere seen when the program was delivered by teachers within the schools. Length of programing did not seemimportant to outcomes. Across all 7 programs, few long-term sustained effects were recorded following programcompletion.

Conclusions: This review provides evidence that mental health promotion programs that focus on resilience andcoping skills have positive impacts on the students’ ability to manage daily stressors.

Keywords: Mental health, Health promotion, Primary school, Resilience, Universal intervention, Child

BackgroundThis review looks at resilience-boosting mental health pro-motion programs implemented universally at schools forprimary school-aged children (5–12 years). Wellbeing andresilience are important in preventing and reducing the se-verity of mental health problems. The skills of problemsolving, building and maintaining interpersonal relation-ships, and realistic goal-setting are well-established as

* Correspondence: [email protected] Australian Centre for Rural Health, University of Western Australia,167 Fitzgerald St, Geraldton, WA 6531, Australia

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enhancing an individual’s ability to contribute meaningfullyin daily life. There is substantial literature on resilience [1]which is defined as a capacity or set of skills that allows aperson to “prevent, minimize or overcome the damaging ef-fects of adversity” [2] and includes factors that are internaland external to the person - emotions, behavior, biology,development, and context affect mental health [3]. Potentialrisks for poor self-esteem and mental health can be over-come by protective factors, including one’s coping skills,healthy family and social relationships, help-seeking behav-iors, and meaningful activities in interactions [4].

le is distributed under the terms of the Creative Commons Attribution 4.0.org/licenses/by/4.0/), which permits unrestricted use, distribution, andive appropriate credit to the original author(s) and the source, provide a link tochanges were made. The Creative Commons Public Domain Dedication waiverro/1.0/) applies to the data made available in this article, unless otherwise stated.

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Resilience theory states that all children, regardless ofrisk or current mental health status, can benefit fromhelp and support in the development of effective,mentally-healthy strategies and resilience skills [5]. Sup-port for and a focus on the development of children’s re-silience skills does not lead to a risk-free life, but canincrease a child’s ability to seek support while buildingtheir self-worth and self-efficacy. By providing childrenwith skills with which to cope with negative life stressorsthrough the promotion of resilience and protective fac-tors, children can thrive despite obstacles [6]. An argu-ment for a population approach for mental healthstrengthening can be extrapolated from Geoffrey Rose’sargument that the largest number of cases of ill healthhappen not in those at high risk, but in those who havejust some risk, simply because in a normal populationdistribution more people (and hence adverse events) willoccur to them [7]. Since all people experience adversityat some point in their life, teaching strategies for resili-ent thinking would be better applied in advance to thepotential “at risk” population. The positive outcomesand possibilities associated with strengthening children’sresilience universally applied can act as a mitigatingapproach, allowing for early support and strengthen-ing of mental health, rather than requiring interven-tions for acute situations in the future [8]. Theapproach of boosting resilience can enhance children’sabilities to self-protect, as well as being an effectivecounter to offset the effects of maltreatment and po-tential traumatic life events [9–11]. As such, universalapplication of programs to enhance resilience standsas not only useful for those recognized as being atrisk and who require additional mental health supportcurrently, but also as a protective shield for all chil-dren moving through life.

Universal, school-based programingSchool-based mental health promotion programs deliv-ered to all students within a class, grade, or the entireschool are categorized as universal programs. In devel-oped countries, all children are required to attendschool, making it an ideal setting for programs providingkey interventions for children, particularly children fromchallenged families, homes and communities that maynot have easy access to community or home-based inter-vention programs [12]. Mental health promotion pro-grams have been developed and implemented in schoolsusing a variety of different approaches. Many mental ill-ness prevention or intervention programs use a targetedapproach, focusing on children deemed at risk due totheir background, history or signs of mental health prob-lems, usually based upon defined socio-demographic fac-tors or certain behavioral characteristics.

Universal programs vary in their approach and imple-mentation. Some universal programs are class-based,with weekly sessions delivered by classroom teachers orprogram staff to the entire classroom. Another universalapproach is to change the entire school environment tobe friendlier and more supportive of positive mentalhealth messages, and this is often implemented in com-bination with class-based approaches [13]. Class-based,universal mental health promotion programs vary intheir aims, focusing on different elements of cognitive oraffective skills and behaviors, environmental or culturalfactors, while increasing knowledge of mental health andresources.Mental health promotion programs specifically target-

ing resilience may be referred to as social and emotionallearning programs, mindfulness programs, stress man-agement programs, or emotional wellbeing programsand vary in terms of curriculum, length and implemen-tation, and use of different tools and activities to conveykey themes and topics. Methods of delivery vary as well,including the use of clinical tools, educational resources,training of teachers and parents, changes to school sys-tems and resources, and use of narrative tools. As such,the curricula used in these programs vary, although allutilize a pre-established definition of resilience and thedesired outcomes to be achieved from a social andemotional learning program. The most effective socialand emotional learning curricula are highly interactiveand use a variety of educational tools, addressing bothspecific and general skills, and are delivered in support-ive environments [14]. Mental health promotion pro-grams promoting resilience focus on the developmentof coping skills, mindfulness, emotion recognition andmanagement, empathic relationships, self-awarenessand efficacy, and help-seeking behavior. Secondary out-comes often include decreased symptoms of anxiety,depression, and increased academic outcomes.

Relevant research reviewsGiven the importance and reach of school settings,many reports describe universal, school-based mentalhealth promotion programs. Prior reviews have ex-plored school-based mental health promotion pro-grams in different contexts, countries, applications,and within specific demographic parameters. Thereare many reviews addressing targeted programs aimedat suicide prevention, sexual health, substance abuseand misuse, physical activity and nutrition improve-ment and these often measure as secondary outcomeschanges in self-efficacy, coping and resilience skills [5,15–17]. A number of reviews analyzing mental healthpromotion programs that focus on resilience across arange of age groups have established that school-based in-terventions can have significant impacts on achievement,


social and emotional skills, behavior, and symptomsof anxiety and depressive disorders [12, 16, 18]. Intheir 2017 review, Dray and colleagues looked atcontrol-based trial evaluations of programs of univer-sal resilience-programing in schools spanning all ages,reporting on those that yielded significant results inresilience factor changes. Durlak and colleagues com-pared 213 programs, also targeting all age groups,assessing the outcomes on attitudes, behaviors andacademic performance and analyzing effect size andfactors that moderate program outcomes. Waere andMind assessed the key features that make school-basedcurricula successful as an approach, highlighting theimportance of social and emotional competence aspart of the curriculum within schools [12]. Anotherreview considered studies on mental health promotionprograms solely conducted with control and comparisongroups [19].

The current reviewThis review aims to inform policy, programing andevaluation of universal, resilience-focused mental healthinterventions for primary school-aged children as it fo-cuses on the specific tools and key elements for thepopulation that will benefit the most from increased re-silience in an easy-to-reach setting, aspects which havenot been highlighted in previous reviews. The multi-tude of existing mental health promotion programshighlights the need to establish what specific elementsand evaluations contribute to successful programing.Unlike previous reviews, this review focuses on pro-grams delivered solely to primary school students (aged5–12 years), as there is evidence that the younger theimplementation of mental health promotion and resili-ence programing, the greater the positive effect [3, 20,21]. Rather than focusing on the program curriculum,it considers the criteria for implementation and key ele-ments of programing for a comprehensive intervention,highlighting the elements of that allow for best programfidelity and student engagement. It also describes thecriteria and outcome measures (tools and methods) usedin implementing and evaluating resilience-focused, univer-sal school-based mental health promotion programs.

MethodsStudies eligible for inclusion were published from2002 to 2017, describe mental health promotion pro-grams focusing on resilience and protective factors,and were delivered universally at schools for primaryschool children aged 5–12 years. A universal programis defined as being a program offered for a specificall-inclusive group, whether it be the entire school,grade or classroom. All students within the group

participate in at least one component of the program,regardless of their mental health status and risk fac-tors. Resilience is defined as a capacity or set of skillsthat allows a person to “prevent, minimize or over-come the damaging effects of adversity” [2], throughthe promotion of protective factors including copingskills, peer socialization and empathy building,self-efficacy, help-seeking behaviors, mindfulness andemotion literacy.

Search proceduresA preliminary review of literature revealed key terms re-lated to resilience-focused, school-based, universal men-tal health promotion programs. A broad search strategywas then developed to identify relevant peer-reviewedarticles in five primary databases: PsycINFO; Web of Sci-ence; PubMed; Medline; Embase and The Cochrane Li-brary. The search strategy was modified as necessary foradvanced searches of each database, using keywordsearch criteria: (a) health education, health promotion,mental health, mental health promotion, social and emo-tional wellbeing; (b) school health service, student,schools, whole-school; (c) adolescen*, child, school child,pre-adolescent; (d) emotional intelligence, coping behav-ior, emotional adjustment, resilienc*, problem solving.Searches were conducted in September 2016 and up-dated in May 2018. Articles were initially screened byabstract by the lead author. All full-text articles werereviewed by two reviewers, with additional checks andconsultations with other authors, to ensure consensusaround those articles where eligibility was less clear.Snowball citation was used to identify other relevantarticles.

Inclusion criteriaTo be included in the review, each study had to meetthe following criteria: (a) adhere to the above definitionof a universal program; (b) be based in a primary school;(c) be delivered to children aged between 5 and 12 yearsof age; (d) focus on resilience and protective factors(meeting the above definition); (e) contain a qualitative,quantitative or mixed-methods evaluation of the pro-gram; (f ) be published in English since 2002 in apeer-reviewed journal.

Exclusion criteriaPrograms targeting specific behaviors where resilience isa secondary outcome, or programs primarily focusing onpost-traumatic stress among students affected by naturaldisasters or war were not included. Programs with theultimate goal and outcome measurements relating to aspecific behavior, emotional condition or mental illnesswere not included, even if the tools taught in the inter-vention could be classified as resilience promoting.


Universal programs that sought to change school atmos-phere through teacher resilience training, or increasingschool health services were not included. After-school orrecess resilience programing was not included, even if ittook place at a school. Programs that were available butnot implemented universally were not included, as theself-selecting nature of optional programing is unlikelyto reach the most at-risk children, and such programsdo not insure a comprehensive program for all studentsregardless of risk. Studies where many students wereoutside of the age group and during a transition periodbetween different schools were not included. Resilienceprograming that fits our inclusion criteria but is solelydelivered to a population that has been exposed to highstress situations and is at risk or may develop PTSD arenot included. Unpublished dissertations, grey literatureand reports were not included.

Excluded studiesIt is worth commenting upon how exclusion criteriawere applied in practice. A number of programs werenot included in this review despite having a resiliencefocus, being universally-delivered and school-based be-cause they have not been reported upon within the pre-ceding 15 years (since 2002). Other excluded programshad an ultimate goal that was not general mental healthpromotion program, but rather aimed at addressing aspecific condition or behavior through the promotion ofcertain resilience skills and protective factors. Notableprograms include the Penn Resilience Program, whichhas been shown to reduce depressive symptoms throughthe cognitive-behavioral therapy programing, includingthe promotion of coping skills [22]. The Good BehaviorGames specifically target behavior control through thepromotion of resilience, but fall outside of the agerange of this review [23]. REACH for RESILIENCEpromotes resilience skills to prevent anxiety problems,and targets very young children [24]. The nation-wideAustralian program, beyondblue, focuses on social andresilience skills to prevent depression, targeting ado-lescents [25]. Evaluations of the FRIENDS programwere not included as it targets childhood anxietythrough the promotion of social-emotional skills [26].Another exclusion was the Aussie Optimism: PositiveThinking Skills Program (AOP-PTS) which promotes so-cial and coping skills to prevent and address depressionsymptoms [27].

Article quality assessmentThe Mixed Methods Appraisal Tool (MMAT) was usedto assess the quality of included studies and provides avalidated method of assessing qualitative, quantitative,and mixed methods studies. After the initial screening,articles were scored based on the criteria for each

respective study [28]. Two researchers independentlyassessed each article [29]. Of note, the tool does not ad-dress the quality of the reporting, but only the quality ofthe reported methods of the study.

ResultsThe initial search strategy shows that of an initial3087 publications identified using the search termsand following abstract assessment of 475 references,34 articles were selected for full-text assessment. Anadditional 7 articles were identified through citationsnowballing and after reading of the full-text so that41 articles were fully assessed for eligibility. A total of11 studies reporting on 7 programs met all the inclu-sion criteria (Fig. 1), with key characteristics includingMMAT scores recorded (Table 1). The most commonreasons for exclusion were: focus on trauma, incorrectage group or target population; not meeting our def-inition of universal programs; and lack of focus on re-silience and protective factors. Included articles. Keyelements of each program’s curriculum and imple-mentation are shown (Table 2).

Aim of the programThe aims of the seven programs (reported on in elevenarticles) included varied in their approach to resilienceand the protective factors they sought to address. All sixprograms sought to increase social and emotional com-petencies with the ultimate aim of increasing mentalwellbeing and future protection from risks. Six articles,addressing 2 different programs, Mindfulness-BasedStress Reduction and Zippy’s Friends, specifically soughtto improve psychological functioning with the goal ofameliorating the negative effects of stress and increasingcoping skills [30–35]. The RALLY program aimed at in-creasing the prevalence of resilience protective factors instudents, with a particular focus on academic outcomesand learning potential [36] while the Up program, a so-cial and emotional competencies program, aimed at en-hancing existing competencies and decreasing inequityin social and emotional competencies across socioeco-nomic lines [37]. The You Can Do It! (YCDI!) Educationprogram sought to ameliorate children’s ability to posi-tively control their emotions in daily life [38]. All pro-grams sought to improve the outcomes of one or moreprotective factors, hypothesizing increased resilience as aresult. A strong emphasis on increased coping skills andstrategies as well as improved relationships was evidentin all the programs.

Target populationUniversal programs demand the application of theprogram to an entire cohort of students, but howthat was done varied from delivering the program to

Fig. 1 Flow diagram of selection process for relevant literature


an entire class, across an entire grade or across mul-tiple schools. As such, sample size varied signifi-cantly between studies. Details of sample populations(Table 1) show all but two studies were implementedand evaluated across multiple schools, with ten ofeleven conducted across multiple classrooms [30–35,37–39]. Age groups varied across the programs, with 4studies addressing populations 10 years and above [30, 36,38, 39], and 6 studies addressing populations youngerthan 10 years of age [31–35, 40]. Socio-demographicprofiles of students varied across studies. Four studiesdescribed programs delivered at socio-economicallydisadvantaged schools [30, 31, 33, 36] whereas fourprograms took place in middle or upper class neigh-borhoods [32, 37, 39, 40]. Dufour et al. (2011) didnot report on socio-demographic data of studentswho received the program [34] whereas the studentsinvolved in the report by Holen et al (2012) werefrom homes where parents had educational attainmentlevels higher than the national average [35]. Yamamotoet al. (2017) delivered the program to students in theTokyo Metropolitan Area, making no demographic dis-tinctions, other than to address the specific contextual

implications of Japanese emotion- and stress-culture asimpactful in their student population [38].

Key elements of programsKey elements of the programs (Table 2) show that Maltiet al (2008) was the only study in which the programcomprised more than one student-focused component[36]. Although only a few components were delivereduniversally, all students were exposed to at least onecomponent of the program [36]. The Up program in-cluded parent and teacher training, and school environ-ment programing [37] and program fidelity andadaptability were identified as key contributing factors tosuccessful implementation with four studies reportinghigh levels of program fidelity and program support[32, 33, 39, 40]. The five studies that implementedand evaluated the Zippy’s Friends program describedno changes in curriculum or delivery, but allowed foractivity adaptability during sessions [31–35]. Teachersdelivering it felt equipped to adapt the program as theysaw necessary to their class while still maintaining highprogram fidelity [34]. Adaptability was also highlightedas being an important program factor for the You Can

Table 1 Summary of Articles Included in the Review

First author, year published Study type ProgramName

Location Study Type Sample Size Aim of Program and Study MMATScore

Malti (2008)[36]Program Evaluation: Relationshipsas key to student development

RALLY UnitedStates

Quasi-experimental,Mixed methods

92 students - Improved resilienceoutcomes, learning interestand decrease risk-taking.

- Assess programimplementation quality

100%

Sibinga (2016)[30]School-Based Mindfulness Instruction: AnRCT

Mindfulness-Based StressReduction(MBSR)

UnitedStates(Baltimore,Maryland)

Randomized,ActiveControlled Trial

Interv: 159students

- Improve psychologicalfunctioning to decreasenegative effects of stress

- Reduce worries about future

50%

Kraag (2009)[39]“Learn Young, Learn Fair”, a stressmanagement program for fifthand sixth graders: longitudinalresults from an experimental study

Learn Young,Learn Fair

Netherlands ClusterRandomizedControlled Trial

Interv: 693students (26schools)Control: 732students (24schools)

- Improve stress managementand coping skills

- Reduce anxiety and depressionsymptoms and incidence

100%

Mishara (2006)[32]Effectiveness of a mental healthpromotion program to improvecoping skills in young children:Zippy’s Friends

Zippy’sFriends

Denmark &Lithuania

Non-randomizedExperimentalTrial

StudentsLithuania:Interv: 314Control: 104Denmark:Interv: 322Control: 110

- Increase ability to cope witheveryday life adversities andnegative events

- Decrease problems that arisefrom stressful situations

- Development of adaptivecoping skills

75%

Clarke (2014)[33]Evaluating the implementationof a school-based emotionalwell-being program: a clusterrandomized controlled trial ofZippy’s Friends for childrenin disadvantaged primary schools

Zippy’sFriends

Ireland ClusterRandomizedControlled Trial

Interv: 544studentsControl: 222students




25%

Dufour (2011)[34]Improving Children’s Adaptation:New Evidence Regarding the Effectivenessof Zippy’s Friends, a School Mental HealthPromotion Program

Zippy’sFriends

Canada(Quebec)

ClusterRandomizedControlled Trial

Interv: 310students (16classes)Control: 303students (19classes)




50%

Holen (2012)[35]The effectiveness of a universal school-based program on coping and mentalhealth: a randomized, controlled studyof Zippy’s Friends

Zippy’sFriends

Norway RandomizedControlled Trial

Interv: 686students (47classes, 18schools)Control: 638students (44classes, 17schools)




75%

Clarke (2015)[31]Evaluating the implementation of anemotional wellbeing program forprimary school children usingparticipatory methods

Zippy’sFriends

Ireland ParticipatoryWorkshop ofRandomizedControlled Trial

Interv: 544studentsControl: 222studentsWorkshop:




100%

Nielsen (2015)[37]Promotion of social and emotionalcompetence: Experiences from amental health intervention applyinga whole school approach

Up Denmark Multi-componentIntervention, NoControl Group

589 students(2 schools)

- Enhance social and emotionalcompetencies to improvemental health

- Increase positivity of schoolmental health environment

50%

Caldarella (2009)[40]Promoting Social and Emotional Learningin Second Grade Students: A Study ofthe Strong Start Curriculum

Strong Start UnitedStates(Utah)

Quasi-Experimental,Non-EquivalentControl Group

26 students - Prevent future emotional andbehavioral problems via thepromotion of social andemotional wellbeing

50%


Table 1 Summary of Articles Included in the Review (Continued)

First author, year published Study type ProgramName

Location Study Type Sample Size Aim of Program and Study MMATScore

Yamamoto (2017) [38]Effects of the cognitive behavioral YouCan Do It! Education program on theresilience of Japanese elementary schoolstudents: A preliminary investigation

You Can DoIt! Education

Tokyo Quasi-Experimental,Intervention,Control Group

125 students,interventionn = 78, controlgroup =47

- Evaluate a mental healthpromotion program’s efficacyin enhancing resilience inschools

100%


Do It! Education program in Japan, where program stafftranslated and altered the internationally-implementedprogram with Japan-specific illustrations, examples andexercises to optimize the connection with students[38]. Three studies identified problems with implemen-tation of programming due to teacher perceptions, timeconstraints, participation rates and class literacy levels[32, 33, 38, 40].

Evaluation frameworks, tools and indicatorsStudy evaluation frameworks and indicators (sum-marised in Table 3) are reported with more detail onevaluation tools and methods used for evaluating el-ements of programing reported in Appendix. Studiesvaried greatly on the timing and purpose of theirevaluation although all applied a combination ofpre-assessment, post-assessment, process evaluation,implementation evaluation and follow up assess-ments. Within specific programs, different evalua-tions were used for different implementations andcontexts. The five articles reporting on the Zippy’sFriends program utilized different evaluation methods[31–35]. Mishara and Ystgaard (2006) evaluated the im-plementation of Zippy’s Friends in two countries withsimilar socio-demographic characteristics, Lithuaniaand Denmark, and found similar results in outcomesof students in the intervention groups in both coun-tries. Yamamoto et al. used a semi-experimental de-sign with intervention and control groups and utilizedthree self-report scales to evaluate students [38].Clarke evaluated a randomized-controlled trial imple-mentation of Zippy’s Friends in Ireland using bothstandard measures [33] and a participatory workshopwith a subsample of students. The workshop wassemi-structured around three key themes: lived expe-riences and coping reactions; emotion recognitionand regulation; and program evaluation [31]. In allarticles meeting out inclusion criteria, multiple stan-dardized, validated tools were used for evaluationmeasures, most commonly the Children’s DepressionInventory (CDI, Short or Complete Form) [30, 39],the Strengths and Difficulties Questionnaire [33, 35],the Schoolagers’ Coping Strategies Inventory [32, 34], anda Program Fidelity Checklist [33, 40]. Evaluation methods

commonly included in-class observations [33, 34, 36, 40],researcher-developed questionnaires [34, 36] and sessionreports [32, 34, 35].

OutcomesEach article identified outcomes associated with their re-search question and hypothesis with outcomes followingprogram implementation to assess the impact of theprogram. Table 4 presents a summary of whether majoroutcomes were considered by the article to have chan-ged as a result of programing. In eight studies, re-searchers identified at baseline an overarching need forresilience programing among students, including lowlevels of trust and empathy; problems with emotioncontrol, relationships and help-seeking; or reportedsymptoms [30, 31, 33, 36–40]. Ten out of eleven studiesreported positive outcomes with improvements in stu-dent resilience and protective factors, including fre-quency of use of coping skills, internalizing behaviors,and self-efficacy at post-assessment [30–34, 36–40].Three studies identified shortcomings in outcomes despitepositive results from the overall program implementationand outcomes. Kraag et al. (2009) identified a lack offollow up and social reinforcement for componentstaught in programing, with negative implications onlong-term follow-up outcomes [39]. Clarke and col-leagues (2014) showed limited effects on resilience it-self, but highlighted a marked increase in self-awarenessamong students [33]. Variations in outcomes between in-formants was highlighted in Holen et al (2012) who did notdetermine that resilience itself was an outcome of theprogram [35].

DiscussionThis review examined the program criteria and out-come measures used in the implementation and evalu-ation of resilience-focused, universal, school-basedmental health promotion programs. Eleven publishedstudies based on seven different programs were identifiedand included.

Characteristics of effective programsSeveral characteristics of effective programing stood out.The involvement of teachers in the delivery of programs

Table

2Keyelem

entsof

prog

ramsrepo

rted

ininclud

edstud

ies

Prog

ram

FirstAutho

r(yearpu

blishe

d)Summary

Solely

class-based

Chang

esdu

ring

delivery

Prog

ram

Supp

ort

Delivered

byteache

rDelivered

byou

tsider

Sign

ificant

Implem

entatio

nAge

App

ropriate

RALLY

Malti,(2008)

[36]

Multi-compo

nent

prog

ram

with

afew

compo

nents

delivered

universally

intheclassroo

mDuration:scho

olyear

✓✓

✓

MBSR

Sibing

a(2016)

[30]

Basedon

adultmindfulne

sscurriculum

,three

core

sections

focusing

ondidacticmindfulne

ss,

mindfulne

sspractice,applications

tolife

Duration:12

weeks

✓✓

✓

LearnYo

ung,

LearnFair

Kraag(2009)

[39]

Weeklyho

ur-lo

nglesson

swith

optio

nal,additio

nal

fiveweeklybo

ostersessions,hom

eworkassign

men

ts,

daily

exercises

Duration:7mon

ths

✓✓

✓✓

Zipp

y’sFriend

sMishara

(2006)

[32]

Clarke(2014)

[33]

Dufou

r(2011)

[34]

Holen

.(2012)[35]

Clarke(2015)

[31]

24sessions

cond

uctedeach

weekbu

iltarou

nd6storiesof

agrou

pof

childrenandtheirpe

tinsect

Zipp

y;each

mod

ule

focusing

onathem

ewith

participatoryactivities

Duration:24

weeks

✓✓

✓✓

✓✓

Up

Nielsen

(2015)

[37]

Year-lo

ngprog

ram

with

four

them

esfocusing

oned

ucationandactivities

forscho

olchildren,staffskill

developm

ent,parentalinvolvem

entandscho

olinitiatives

Duration:1year

✓✓

Strong

Start

Caldarella

(2009)

[40]

Prog

ramingwith

weeklydirect

instructionsessions

with

scen

arios,roleplays,think/pair/shareactivities,

children’sliteratureandacurriculum

mascot

Duration:6weeks

✓✓

✓✓

✓

YouCan

DoIt!

Education

Yamam

oto(2017)

[38]

8×45

min

interven

tionsessions

focusedon

them

essuch

asem

otions,‘resiliencebo

osters’,and

‘using

your

head’accom

panied

byactivities

that

prom

otethetopicandfoster

resilienceand

emotionalintelligen

ceDuration20

weeks

(program

deliverywas

affected

bytim

econstraintsin

thescho

ol,schoolvacations,and

classroom

obligations.H

ence,a

reducedsm

allernu

mber

ofsessions

werecond

uctedduringthetim

eallotm

entof

20weeks.)

✓✓

✓✓


Table 3 Evaluation frameworks of included studies

First author(Year published)Study

Evaluator Indicators Pre-Asses.

Process/Implmt.

Post-Asses.

FollowUp

Tools (See Appendix)

Malti. (2008) [36]RALLY

Study Researchers Development, resiliencetechniques, symptoms,relationshipsProgram implementation

✓ ✓ ✓ SRM-SF; Researcher-developedresilience scale; YSR

Sibinga (2016)[30]MBSR

Program Staff Mindfulness, psychologicalsymptoms, anxiety, moodand emotion regulation,coping

✓ ✓ CDI-S; SCL-90-R; MASC; PANAS;DES; STAXI-2; CRSQ; CSE

Kraag (2009)[39]Learn Young,Learn Fair

Maastricht Universitystudents

Stress management, coping,anxiety, depression

✓ ✓ ✓ STAIC; DIC-SF; MUSIC; SPSI

Mishara (2006)[32]Zippy’s Friends

Independent researchers Student engagement, mood,behavior and emotionregulation, coping skillsProgram implementation

✓ ✓ ✓ Session reports; interviews;Social Skills Questionnaire;SSQTF; Schoolagers CopingStrategies Inventory; SSQSF

Clarke (2014)[33]Zippy’s Friends

Researcher & HealthPromotion Specialist

Social and emotional literacy,social and emotional behaviorProgram implementation

✓ ✓ ✓ ✓ Emotional Literacy Checklist;SDQ; Program Fidelity Checklist

Dufour (2011)[34]Zippy’s Friends

Undergraduate universitystudents

Coping mechanisms,socio-emotional functioning,perceived social support,classroom climateProgram implementation

✓ ✓ ✓ Observations; Session reports;Schoolagers Coping StrategyInventory; Surveys; Socio-EmotionalProfile; Social Support Scale forChildren; Class Environment ClimateQuestionnaire

Holen (2012)[35]Zippy’s Friends

Teachers & StudyResearcher

Coping skills ✓ ✓ KidCope Questionnaire; SDQ

Clarke (2015)[31]Zippy’s Friends

Study Researcher Coping skills, emotionalliteracyProgram implementation

✓ ✓ ✓ Participatory workshop; draw andwrite technique; vignette responsefeelings activity; brainstorming

Nielsen (2015)[37]Up

Child and AdolescentHealth Research Group atNIPH

Assertiveness, empathy,collaborative skills

✓ ✓ ✓ ✓ Anonymous Surveys

Caldarella (2009)[40]Strong Start

Teachers & ResearchAssistants

Internalizing and externalizingbehaviors, peer-relatedpro-social behaviorProgram implementation

✓ ✓ ✓ SSRS; Observations; Program fidelitychecklist; IRP-15; StudentSelf-Assessment of Social Validity

Yamamoto(2017) [38]You Can Do It!Education

Study Researchers Anxiety, Awareness of SocialSupport, Resilience

✓ ✓ Spence children’s anxiety scale (SCAS),Social support scale for children (SSSC),Resilience in elementary schoolchildren scale (RESC)

assess assessment, implmt implementation


emerged as key. Numerous studies used teachers to de-liver the program, a feature presented positively as pro-viding the opportunity for adaptability of programingand more seamless implementation, if provided withprogrammatic support and training. For example, theZippy’s Friends program uses teachers to deliver thecontent materials [33] and teachers reported receivingsubstantial, helpful program support by research andprogram staff.In their review of factors of success for implementa-

tion, adaptation of programing was identified as a keycomponent of implementation [38, 41]. Teachers of the

Zippy’s Friends Program reported the ability to adapt,add and remove activities relating to thematic contentbased on student literacy, mood and timing, as one ofthe most important parts of program delivery [33].This allowed the maintenance of high program fidelitywhile also involving students in the most effective waypossible. Teachers are an important resource in the de-velopment of children’s resilience, as they already haverapport and an understanding of the students and aremore likely to know their students lived experiences andcurrent coping and help-seeking strategies. Yamamotoet al. credit their successful implementation of the

Table

4Outcomes

trackedandrepo

rted

byeach

includ

edstud

y

Firstauthor,(Pu

blication

Year)

Interven

tion

Resilience&Cop

ing

Acade

mic&Learning

Motivation

EmotionandBehavior

Self-Regu

latio

nRelatio

nships

&Behavior

Psycho

logical&

Emotional

Symptom

sEm

pathy

+chng

Nochng

n/a

+chng

Nochng

n/a

+chng

Nochng

n/a

+chng

Nochng

n/a

+chng

Nochng

n/a

+chng

Nochng

n/a

Malti(2008)

[36]

RALLY

✓✓

✓✓

✓✓

Sibing

a(2016)

[30]

MBSR

✓✓

✓✓

✓✓

Kraag(2009)

[39]

LearnYou

ng,L

earn

Fair

✓✓

✓✓

✓✓

Mishara

(2006)

[32]

Zippy’sFriend

s✓

✓✓

✓✓

Clarke(2014)

[33]

Zippy’sFriend

s✓

✓✓

✓✓

✓

Dufou

r(2011)

[34]

Zippy’sFriend

s✓

✓✓

✓✓

✓

Holen

(2012)

[35]

Zippy’sFriend

s✓

✓✓

✓✓

✓

Clarke(2015)

[31]

Zippy’sFriend

s✓

✓✓

✓✓

✓

Nielsen

(2015)

[37]

Up

✓✓

✓✓

✓

Caldarella

(2009)

[40]

Strong

Start

✓✓

✓✓

✓✓

Yamam

oto(2017)

[38]

You

Can

DoIt!E

duc

ation

✓✓

✓✓

✓✓

(+chng

positiv

echan

gerepo

rted

,nochng

nochan

gerepo

rted

,n/a

outcom

eno

ttrackedor

notap

plicab

le)



YCDI! Program with the extensive edits to the cur-riculum to adapt it to Japanese culture and relation-ships [38].The length of programing did not appear to im-

pact on the number of outcomes achievable. TheRALLY program ran for an entire school year andprovided consistent resilience outcomes [36], whilethe Mindfulness-Based Stress Reduction program ranfor only 12 weeks and showed positive resilienceoutcomes as well [30]. The YCDI! Program ran for ashorter period of time than most implementations ofthe program but still demonstrated significant results[38]. Importance was placed on the intensity of ses-sions and the content delivered, as opposed to theregularity. However, importantly, if follow up evalua-tions were conducted, they did not reveal that out-comes were maintained in the longer term aftermost programs. This suggests that program lengthmay not alter the ongoing resiliency of students oncethe program ends.

Emergent themes across studiesAlthough all eleven articles presented programs thataimed at fostering the resilience skills and protectivefactors of students, the specific skills and outcomestaught in each program differed. This is consistentwith research highlighting the difficulty that exists indefining resilience and creating programs around thetopic [1]. Not only is the definition difficult and vari-able between studies, but the criteria and skills thatcome with developing resilience differ as well. In theRALLY study, researchers targeted resilience, and theoutcomes evaluated were empathy, trust of others,and emotional regulation skills [36]. On the otherhand, the UP study targeted resilience through socialand emotional competencies that allow students toengage and navigate daily life, social interactions andsociety [37]. Both programs aimed to foster social andemotional development by increasing resilience skillsand protective factors, but were based on differencesin terminology and theory. Evaluations of both pro-grams determined they had a positive outcome on re-silience in students despite these differences.An effect noted by a number of studies included in

this review was the “ceiling effect” since many of thestudents enrolled in universal-based programs havehigh baseline mental health and social and emotionalcompetence [33]. Although individuals within thegroup might suffer from higher risk factors or mentalillness, across the board students present with gener-ally normal levels. As such, when the program is im-plemented, outcomes may be generated but will notbe large as there is little room for change. This is notthe case when providing targeted programs with

students who all generally have much more room forchange, given that they begin the program with lowerscores at baseline. Despite the ceiling effect, researchhas shown that resilience-boosting programing bene-fits at-risk but are not specific for at-risk children.Additionally, properly identifying and screening targetgroups for targeted programing is often unsuccessfuldue to the complexities of mental health, and preventiveapproaches, such as universal resilience-boosting pro-graming, are considered the most all-encompassingmethod [42]. As such, a program promoting resilience willsupport positive changes and growth in both groups ofkids, although with more significant differences in theat-risk group.

Characteristics and methodologies of evaluationsAn element of the evaluations that emerged in many ar-ticles is the removed nature of evaluation when collect-ing data on children’s capacities. Many of the programsseek to foster resilience through the development ofcoping skills, and use scales or observations in order tomeasure outcomes. The Learn Young, Learn Fair pro-gram evaluated a positive effect on emotion-focused,adaptive coping skills using validated questionnaires andscales [39]. This approach is used in all the programevaluations, but does not leave room for lived experi-ences to be factored into the interpretation of outcomes.These traditional evaluation methodologies can be seenas researching on a topic, rather than researching for acause or population, as they do not leave room for ambi-guity or other factors.Additionally, a couple of studies in this review used

evaluation tools that did not take into account theviews of children themselves. The researchers choseto interview and evaluate both teachers’ and the pro-gram deliverers’ perceptions and ratings, rather thaninterviewing or evaluating the children themselves.For example, Caldarella, Christensen et al. (2009) evaluatechildren’s outcomes through pre- and post-assessments ofthe teacher’s perceptions of her students, using validatedassessment tools [40]. However, evaluations like thisintroduce an additional limitation to the outcomeanalysis, as they gather data through secondarysources with the program delivered to children fortheir benefit, but outcomes not gathered directly fromthe children. However, observational data is a keycomponent of a program evaluation with many stud-ies successfully using observations to ensure programfidelity and as part of process evaluations.More insight around outcomes occurs when multiple

evaluation tools and methods are used [43]. Clarke andcolleagues (2015) evaluated the use of a participatoryworkshop determining children’s coping skills whichused draw and write techniques that allowed children to


share their feelings using their own words rather thanthose of researchers [44], as well as vignettes to elimin-ate interview processes [45]. Students from the interven-tion group were found to use more adaptive copingskills in their daily life, both in and out of the classroomthan children in the control group [31]. These resultswere supported by the quantitative data collected on thelarger student sample from which the participatoryworkshop subsample was drawn [33]. A clearer pictureof children’s coping skills and experiences with theZippy’s Friends program was gathered through the useof both qualitative and quantitative evaluation meth-odology. Additionally, children’s lived experiences anddirect insights were gathered through the participatoryworkshop model, allowing for a greater breadth of un-derstanding on the program’s efficiency.

Limitations of articles and evidenceConsideration must be given to the ethics and feasibilityof implementing and evaluating programs for mentalhealth promotion. Ethical concerns arise from providinga program that might be highly beneficial for a group ofchildren, and not for another, essentially disadvantagingthem. The ethics are further confounded by the lack ofcomplete or stringent randomization described in thestudies that include a control group. To avoid the di-lemma of disadvantaging students, studies on successfactors have highlighted that in many studies the controlgroups do not receive ‘no intervention’ [41]. For ex-ample, Sibinga et al. (2016) included an active controlgroup. While the intervention group received theMindfulness-Based Stress Reduction program beingstudied, the control group received Healthy Topics, ageneral health program to match the MBSR structure.Thus, while the control group students are not receivinga resilience-focused, mental health promotion program,they still receive a health promotion program but onewhich allows a distinction between control and interven-tion groups around resilience outcomes and mentalhealth [30]. Yamamoto and colleagues, however, did notprovide programing to the control group following theintervention [38].The evidence provided by certain articles must be

weighed with differing criteria. Seven articles evaluated aprogram against a control group, allowing for compari-son of outcomes. These articles present more substantialoutcome evidence than those that do not include a con-trol group for comparison. For example, Nielsen andcolleagues (2015) and Caldarella and colleagues (2009)did not have a control group, decreasing the strength oftheir evaluation. Nielsen et al. (2015) implemented theUP program in kindergarten through grade 9, but onlyevaluated grades 5–9. Such selective evaluation intro-duces potential bias and paired with the absence of a

control group makes it difficult to identify if the increasein social and emotional competencies is due to the UPintervention, or simply a natural developmental progres-sion [37].A limitation of the evaluations in many programs is

the involvement of the person delivering the programas the evaluator. This can be seen in many studies onthe Zippy’s Friends program, where the classroomteacher delivers the program and conducts the processand implementation evaluation themselves. Third-partyobservations are sometimes conducted in addition toverify program fidelity and implementation outcomes.Of note is that observational evaluation and the use ofindependent evaluators have been more extensivelydocumented as reliable than using tools based onself-report [41].We also note that despite gender differences in the

prevalence of mental health problems and the type ofresilience protective factors that children and adoles-cents use, the studies did not generally report resultsby gender [46, 47]. This limitation could be overcomeby encouraging that future studies provide a genderbreakdown or highlight gender-specific results.

ConclusionThis review complements previous reviews on mentalhealth promotion programing for students. Our focuson universally delivered programs in primary schools re-veals key components and strengths of programing thatmake for the most successful delivery and evaluationand enables important conclusions to be drawn.The review confirms that adaptability and teacher in-

volvement are key elements of program delivery, withstudent engagement and use of multiple methodsstrengthening program evaluation. The use of participa-tory methods to engage children allows for greater as-sessment of lived experiences and use of coping skillscompared to self-reporting tools or observations.Adaptability of curriculum to different contexts, seen inthe Zippy’s Friends program, was considered successfulby multiple authors, illustrating that broad program ap-plication across multiple contexts is possible andeffective.This review demonstrates the importance of establishing

key criteria to be measured during delivery and evaluation ofyouth mental health promotion programs, particularly interms of defining resilience and its associated indicators.The successes of the programs detailed by the studiesincluded in this review highlight the need for andbenefits of such programs. Further research onprimary-school, universally delivered mental healthpromotion programs could be conducted in specificcontexts, particularly more difficult settings such asdeveloping countries or conflict zones.


Appendix
Table 5 Evaluation tools and methodologies used in included studi
Criteria Tool First author(Year) ofStudies inwhich Toolwas Used

Purpose

Depression Children’sDepressionInventory, Shortor CompleteFormCDI

Sibinga(2016) [30]Kraag(2009) [39]

Assess depressivesymptoms

Anxiety MultidimensionalAnxiety Scale forChildrenMASC

Sibinga(2016) [30]

Assess anxiety symptoms

Spence Children’sAnxiety ScaleSCAS

Yamamoto(2017) [38]

Assess frequency of anxietysymptoms

Spielberger’sState-Trait Anx-iety Inventory forChildrenSTAIC

Kraag(2009) [39]

Assess anxiety symptoms

Social/CognitiveDevelopment

Socio-moralReflectionMeasure, ShortFormSRM-SF

Malti (2008)[36]

Assess developmental levelsof cognitive-moral skills

Resilience Researcher-developedResilience Scale

Malti (2008)[36]

Measure selected basicresilience factors, emotionalregulation skills, academic sk

Resilience inElementarySchool ChildrenScaleRESC

Yamamoto(2017) [38]

Measure 19 elements relatinto aspects of resilience

Socio-EmotionalProfile(Dumas et al,1997)

Dufour(2011) [34]

Measure social competencieand adaption problems

Mindfulness Children’sAcceptance andMindfulnessMeasure

Sibinga(2016) [30]

Measure of mindfulness

Symptoms Youth Self ReportYSR

Malti (2008)[36]

Assess behavioral andemotional functioning andsymptoms

SymptomsChecklist 90-RSCL-90-R

Sibinga(2016) [30]

Assess paranoid ideation,hostility, somatization

Stress Children’s Post-Traumatic Symp-tom SeverityChecklistCPSS

Sibinga(2016) [30]

Assess stress symptomseverity and frequency

MaastrichtUniversity StressInstrument forChildrenMUSIC

Kraag(2009) [39]

Assess stress symptomseverity and frequency

es

Methodology Timeframe

Self-reported survey Pre- assessmentPost-assessmentFollow up

Self-reported survey Pre-assessmentPost-assessment


Self-reported survey Pre-assessmentPost-assessmentFollow up

Paper and pencil self-reportedsurvey

Pre-assessmentPost-assessment

ills

Self-reported survey Pre-assessmentPost-Assessment

g Self-reported Pre-assessmentPost-assessment

s 80 items on six point scale,self-reported survey


10 item, self-reported survey Pre-assessmentPost-assessment




Self-reported scale surveyDeveloped for study

Pre-assessmentPost-assessmentFollowup

Table 5 Evaluation tools and methodologies used in included studies (Continued)


Purpose Methodology Timeframe

Relationships Social SupportScale for Children

Dufour(2011) [34]Yamamoto(2017) [38]

Measure perceivedsocial support bychildren: social supportfrom parents, teachers,peers in classand intimate friends

24 items on four point scale Pre-assessmentPost-assessment

School SocialBehavior SkillsSSBS

Caldarella(2009) [40]

Evaluate social competenceand antisocial behavior ofchildren

Norm-referenced,self-reported survey


Social SkillsRating SystemSSRS


Evaluate pro-social skillsand problem behaviorsof students

Six-subscale items,norm-referenced,self-reported survey


Social SkillsQuestionnaireTeacher Form,Elementary LevelSSQTFStudent Form,Elementary LevelSSQSF

Mishara(2006) [32]

Measure frequency ofobserved behaviors andsocial skills;scores determined forcooperation, assertion,self-control

Rating of frequency ofspecific behaviors

Processevaluation

Mood &Emotions

Positive andNegative AffectSchedulePANAS

Sibinga(2016) [30]

Assess mood and emotionregulation


DifferentialEmotional ScaleDES

Sibinga(2016) [30]



Aggression Scale Sibinga(2016) [30]



State-Trait AngerExpressionInventorySTAXI-2

Sibinga(2016) [30]



Strengths andDifficultiesQuestionnairesSDQ

Clarke(2014) [33]Holen(2012) [35]

Assess children’s emotionaland behavioral functioning:emotional symptoms, conduct2problems, hyperactivity, peerrelationship problems,pro-social behavior

Self-reported questionnaire,25 items with five mainsubscale scores

Pre-assessmentPost-assessmentFollow up

Feelings Activity Clarke(2015) [31]

Assess ability to identifyfeelings in response toproblem situations

Part of participatory workshopevaluation: 6 vignettes readaloud and children asked torespond and explain each

ProcessevaluationPost-assessment

Social andEmotionalCompetenceIndex

Nielsen(2015) [37]

Assess assertiveness,empathy and collaborativeskills

Self-reported questionnairewith ranked answers


EmotionalLiteracy Checklist

Clarke(2014) [33]

Assess emotional literacy:self-awareness, self-regulation,motivation, empathy andsocial skills

Self-reported questionnaire, 20 itemsrated on four-point Likert Scale

Pre-assessmentPost-assessmentFollow up

Coping Children’sResponse StyleQuestionnaireCRSQ

Sibinga(2016) [30]

Assess coping ability bymeasuring 3 types ofreactions: rumination,problem solving, destruction



Table 5 Evaluation tools and methodologies used in included studies (Continued)



Brief COPE Sibinga(2016) [30]

Assess coping ability bymeasuring 14 copingapproaches


Coping Self-Efficacy ScaleCSE

Sibinga(2016) [30]

Assess coping ability Self-reported survey with endresult of single variable


Social Problem-Solving InventorySPSI

Kraag(2009) [39]

Measure problem-solving skills Self-reported scales Pre-assessmentPost-assessmentFollow up

SchoolagersCoping StrategiesInventory

Mishara(2006) [32]Dufour(2011) [34]

Gather information aboutactual coping experiencesof children; identify frequenciesof use of coping skills

Self-reported questionnaire,26 items

ProcessevaluationPost-assessment

Draw and WriteTechnique

Clarke(2015) [31]

Gather personal experiencesof how children copedwith problem situations

Part of participatory workshop:children asked to draw pictureabout emotion and draw how they coped


KidCopeQuestionnaire

Holen(2012) [35]

Measure of 10 coping strategies:distraction, social withdrawal,cognitive restructuring, self-criticism,blaming others, problem solving,emotional expression, wishful thinking,social support, resignation

Self-reporting questionnaireswith adaptations for differentage groups


Focus Groups Malti (2008)[36]

Evaluation of programimplementation and process

Multiple students with oneresearcher

ProcessevaluationImplementationevaluationPost-assessment

Researcher-developedquestionnaires

Malti (2008)[36]Dufour(2011) [34]

Assessment of componentsof program; assessment ofchildren’s status by parentsand teachers

Self-reported questionnaires Pre-assessmentProcessevaluationPost-assessmentClimateassessment

Session Reports Mishara(2006) [32]Dufour(2011) [34]Holen(2012) [35]

Assessment of eachcomponent of program

Qualitative, self-administeredreport by program delivererafter each session

ProcessevaluationImplementationevaluation

Interviews Malti (2008)[36]Clarke(2015) [31]

Assessment of componentsof program

One-on-one interviews withresearcher or evaluator

Pre-assessmentProcessevaluationPost-assessmentImplementationevaluation

ProgrammeFidelity Checklist

Clarke(2014) [33]Caldarella(2009) [39]

Report of what portions ofprogram session fully orpartially implemented,which ones omitted

Self-reported checklist andquestionnaire

ProcessassessmentImplementationevaluation

ClassEnvironmentClimateQuestionnaire

Dufour(2011) [34]

Assess climate of classroomand describe teachercharacteristics

Self-reported questionnaire, 36items


Acceptability Student Self-Assessment ofSocial Validity


Assess student perceptionof social validity of program

Self-reported questionnaire, 10 questions:8 with Likert Scale, 2 open ended

Post-assessment


Table 5 Evaluation tools and methodologies used in included studies (Continued)Criteria Tool First author

(Year) ofStudies inwhich Toolwas Used


InterventionRating Profile-15IRP-15


Assess teacher’s perceptionof social validity of program

Self-reported questionnaire with 15 itemson 6-point Likert scale

Post-assessment


AbbreviationsAOP-PTS: Aussie optimism: positive thinking skills program; CDI: Children’sdepression index; MBSR: Mindfulness-Based stress reduction; MMAT: Mixedmethods appraisal tool; WA: Western Australia

AcknowledgementsWe thank Georgetown University, Dr. Helen Fairnie-Jones and staff at the WACentre for Rural Health for assistance that enabled this work to be under-taken. We particularly thank May Doncon for her valuable help in early dis-cussions and highlighting the importance of the topic.

Availability of data and materialsData sharing is not applicable to this article as no datasets were generatedor analyzed during the current study.

Authors’ contributionsAF determined the search strategy, conducted the systematic review of thedatabases, and wrote all parts of the review. AF, ED and ST read all full textarticles and agreed upon inclusion and exclusion of articles. AF and EDconducted independent applications of MMAT to the articles, and came to aconsensus on article strength. ED assisted in writing the results anddiscussion section as well. AF and ST edited the article for content anderrors. All authors read and approved the final manuscript.

Ethics approval and consent to participateNot applicable as all literature is published.

Consent for publicationNot applicable.

Competing interestsThe authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Received: 27 April 2018 Accepted: 14 June 2018

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