Reducing LGBTQ+ adolescent mental health inequalities: A realist review of school-based interventions

Background: Globally, research indicates that LGBTQ+ young people have elevated rates of poor mental health in comparison to their cisgender heterosexual peers. School environment is a key risk factor and is consistently associated with negative mental health outcomes for LGBTQ+ adolescents, suggesting a need to intervene to affect change within the school environment. The aim of this review was to examine how, why, for whom and in what context school-based interventions prevent or reduce mental health problems in LGBTQ+ adolescents?Method: A realist review was conducted utilizing the seven-step published protocol (1, 2). The review focused on all types of school-based interventions that impacted on LGBTQ+ adolescent mental health. All study designs were included. The search strategy involved comprehensive electronic database searches and additional complementary search strategies (hand searching, citation tracking). Studies were subject to an inclusion criteria and quality appraisal. Those included in the review where subject to data extraction under defined fields of context, mechanism and outcome and synthesized to produce a programme theory.Results: In total, 4,911 titles and abstracts were screened, and 125 full papers reviewed, with 17 studies included in the final review. The review found 8 intervention components were necessary for school-based interventions to address LGBTQ+ pupil’s mental health: affirmative visual displays; external signposting to LGBTQ+ support; stand-alone input; school-based LGBTQ support groups; curriculum-based delivery; staff training; inclusion policies; trusted adult to talk to. Explaining how an intervention worked is complex and the programme theory developed emphasises the multiple causal pathways (e.g., psychological, behavioural, emotional, environmental, social) that operate to reduce poor mental health.Conclusions: We identified relatively few school-based interventions for this population group. The developed programme theory indicates that ‘to work’ school-based interventions must have a ‘whole-school’ approach that addresses specifically the dominant cis-heteronormative school environment and hence the marginalisation, silence, and victimization that LGBTQ+ pupils experience. We require more research on school interventions to reduce the inequalities in mental health in LGBTQ+ youth. We need to understand the underlying mechanisms that produce this inequality to design successful school public mental health interventions.