Table 3.

Challenges, mitigations and lessons learnt from qualitative data collections

Challenges encountered	How we mitigated these	Lessons learnt
Research phase: appraising the existing need for support and context
Parents/teachers may not recognise anxiety as a problem	Offering universal screening for the Y4 class.	Universal screening offered a way to identify children who may be struggling with anxiety, but difficulties were not previously recognised as such.
Parents may not know how to access help for their child	Integrated pathway for screening and intervention so families are offered help if potential difficulties were identified.	Schools and families were receptive to a screening programme if an intervention to problems found was also being offered.
Formal support may not be easily accessible	Integrated pathway included screening and intervention so families would not need to be referred elsewhere to access support for anxiety problems. Rapid contact with a mental health professional was available to support further signposting to resources and further services if required. Intervention was made available to all families interested in taking it up, not solely those who screened positive for a likely anxiety problem.	An inclusive offer for access to a low level intervention was of interest to families, even those who did not have a child who screened positive for a likely problem. Low level or early mental health interventions may not be sufficient for complex needs cases and team must be prepared to provide resources and make referrals as part of the intervention.
Research phase: engaging schools
School staff are bombarded with offers for mental health interventions	Used university logos on materials, refer to previous evidence, and offer face-to-face meetings with staff to answer questions.	Future studies should take steps to ensure school-based screening/intervention studies are seen as credible and trustworthy to schools.
Schools are under considerable and changing CV-19 pressures to provide children with mental healthcare	Pathway incorporates an efficient intervention to be offered to families in cases where children met criteria for likely anxiety problems and which can be delivered remotely.	There is an increasing demand for schools to offer accessible mental health support to children and young people due to CV-19 and a screening/intervention pathway may be especially welcome as a consequence.
Research phase: participant recruitment
There may be stigma around mental health problems and help seeking. There may be a lack of trust in formal services and interventions where families have had negative previous experiences	Universal screening was offered to Y4 within a supported information session at school. Information was shared with parents and school staff explaining all procedures, including guidance to address data sharing concerns.	‘Opt out’ (rather than ‘opt in’) was considered to be a more inclusive approach for engaging families, that is, all children are included unless parents/carers request for them not to be. Parents/carers are given clear information and opportunities to ‘opt out’.
Schools and families may not have a good understanding of mental health	Training materials were provided to staff about the project which included psychoeducation. Staff training briefing, including in-person meetings, telephone calls and a short information video was offered. Assembly, an in-class lesson and parent evenings were offered to provide psychoeducation to children and parents/carers.	Brief video about the pathway and the steps involved was considered more accessible and engaging than an information sheet. School staff reported not being approached by families to ask questions about the pathway but nonetheless staff appreciated being informed about how the pathway operated. Being able to contact the research team and receive personalised feedback was valued and allayed parents’ concerns.
Parents did not attend information sessions or reported not hearing about the project	Brief information video about the project made and posted online and circulated via school mailing lists.	Delivery of information in a varied and accessible format (eg, information video) is preferred by parents who often have many competing demands on their time.
Research phase: screening
Concerns about the accuracy and content of screening questionnaires	Underpinning work to improve accuracy and content of screening measures (with stakeholder involvement). Clear information was provided to parents and teachers about the content and purpose of the questionnaires in advance. Parents had the option for their child to complete the questionnaire at home with them instead of in class. Screening for likely case criteria was done by encouraging parent, child and teacher completion of the screening questionnaires to provide a more complete picture of the child’s difficulties. Language for communicating about screening developed with stakeholders to ensure sensitivity.	Researchers must be transparent and clear when giving information to families and school to ensure school-based screening/intervention studies are understood and are credible and trustworthy. It is important to stakeholders that multiple views about a child’s anxiety are heard to reflect the different experiences in different contexts.
Schools feel unable to offer a screening session in classrooms	Dedicated team facilitate administration of screening questionnaire session in small groups outside the classroom. Information assembly and in-class lesson provided by research team to explain what the questionnaires were for in context of wider psychoeducation.	Having a dedicated team presence can feel reassuring to teachers who may lack confidence in having mental health-related discussions. This approach may also reduce burden for staff.
Concerns about adequate privacy during screening questionnaire completion	The option of completion of screening questionnaire at home via online/paper was also offered to children. Option to complete in classroom on a tablet was offered.	Participating children ultimately did not report privacy concerns if they completed the questionnaires at school (pre-CV-19). Children enjoyed taking part in the study and feeling 'part of' the pathway. Having the option for their child to complete at home was felt to be reassuring for parents. Tablet option was considered more engaging as well as ensuring privacy.
Concerns about the ability of families to take part when schools moved to remote learning due to CV-19	Schools were provided with information sheets and envelopes to mail home to families as schools reported that families were inundated with emails and postal communication was preferred (although this was not taken up by families). Online questionnaires were delivered via a user-friendly and secure platform. The dedicated teams were available and responded quickly to teacher/parent questions about the study and accessing the questionnaires.	Responding to parental needs, such as being overwhelmed by emails and delivering information via other channels, helped to disseminate accessible information about the study. Responding quickly to concerns helped to continue families’ and staff interest and trust in the project. Families found that due to increased remote working and school work, completion of online questionnaires for the study was not challenging and they did not have concerns about data being stored online. Postal response rate was low (during CV-19 restrictions).
Research phase: feedback of screening outcomes
School staff have considerable pre-existing demands on their time	Dedicated team delivers feedback to families about screening questionnaires directly.	Families found feedback from the CWP directly to be acceptable as the practitioner was seen as a neutral party, independent of the school, and could answer their queries.
Parents may find the feedback surprising or may be distressed to hear that their child has possible anxiety problems	Stakeholders gave input into the content of the feedback letter to families. This letter was followed up by a phone call to discuss any concerns and answer questions.	Feedback of screening questionnaire scores may be a shocking (or validating) moment for families and research teams should be prepared to approach the subject sensitively.
Parents of children who screen positive for likely anxiety problems may choose not to take up the intervention	Future help seeking is encouraged by making it clear that treatment is potentially accessible. Resources are provided which could be useful in future. A psychoeducation lesson is provided to all children including simple guidance on managing anxiety.	Future studies should consider what appropriate steps can be taken to support child anxiety problems where parents are not able to participate in the intervention for any reason.
Parents of children who screen positive for a likely problem may feel they are being forced to take up the intervention	Important to highlight that the intervention is optional and that the school/other services will not be informed whether or not they choose to be involved in the intervention.	It is essential that clear information is given about confidentiality (and its limits) and data sharing to reassure families. Researchers should be conscious and sensitive that not all families may have positive supportive relationships with their child’s school/services.
School staff feel they should be informed about the children meeting criteria for potential anxiety problems to fulfil their duty of care	School staff are copied in to feedback letters that are sent to families where parents consented.	School will have procedures in place to fulfil their duty of care to children that must be considered when identifying potential child anxiety problems.
Research phase: delivery of online intervention
Parents feel they would benefit from peer support	This potential add on was explored with parents and what format this would be preferred given CV-19 social distancing restrictions (eg, WhatsApp, Facebook group).	Future studies should bear in mind the context in which parents engage with mental health interventions and that they may find informal peer support valuable for themselves as well.
Lack of school attendance due to CV-19 removed many sources of children’s anxieties	Information highlighted that skills learnt in the parent intervention will be applicable for the future. Responses to routine parent questionnaires needed to be interpreted in the context of CV-19 circumstances (eg, children not attending school).	It is essential to be prepared to adapt or respond when measures are not applicable to the context.
Parents may not feel an online intervention is acceptable as opposed to more traditional face-to-face support	Families were informed that the intervention that was being delivered online was based on a widely used treatment.	Parents found the online intervention to be acceptable and it often fitted better around their schedules than face-to-face support. Weekly phone calls from the CWP were felt to be essential to personalise the experience and maintain momentum.
Parents are concerned about next steps to support their child once the intervention modules are completed	CWP highlighted that referrals would be made for further support if needed after the intervention. A phone call from well-being practitioner was delivered at 4-week follow-up to embed learning and offer guidance.	It will be important to be prepared to support making referrals on to other local services if the intervention offered does not entirely resolve child’s difficulties.
Research phase: assessing secondary impacts of pathway
Concern that involvement in the study may lead to children being labelled or bullied	Clear information provided to teachers, children, and families via school assembly, in-class lesson and information sheets which includes psychoeducation about mental health. Confidentiality is explained to families, including what data will and will not be shared with the school.	It is important to be mindful that mental health stigma is an endemic issue but providing psychoeducation as part of the school-based screening/intervention represents an opportunity to improve language around and understanding of mental health.
Ensuring that the pathway maximises potential for wide and long-term benefits, for example, through increased mental health literacy in school context	Psychoeducation provided about mental health in several stages, including during teacher training about the project, parent information sheets and feedback, as well as during the assembly and class lesson for children.	There is the potential for school communities to have improved emotional and mental health literacy via the dissemination of linked psychoeducation. Future evaluations should aim to track changes over time in mental health stigma in schools—such as before and after study implementation—and tailor their psychoeducation and information sheets accordingly.

CV-19, COVID-19; CWP, children’s well-being practitioner; Y4, year 4.