Effectiveness of School Based Intervention for Promoting Mental Health Literacy Among Teachers

Study Overview
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Brief Summary
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Significantly higher prevalence of emotional and behavioural problems have been reported from Pakistan.This higher prevalence along with stigma of psychiatric problems and limited child & adolescent mental health services in Pakistan means that it is important to consider alternate methods for promoting psychological and emotional well-being of our youth. Schools can thus act as a natural platform for mental health promotion as schools context has almost as much impact on students' emotional health as the family context. Teachers' role in the school mental health initiatives cannot be overemphasized. Teachers own knowledge and beliefs regarding mental health influence the way they respond to students mental health crisis. Recognizing the need for wider implementation of evidence based school mental health interventions in the region and to help in addressing the mental health literacy of educators in resource constrained settings, World Health Organization, Eastern Mediterranean Region (WHO-EMRO) has developed a concise and practical manual of school mental health in December 2014. In the absence of any whole school approach study from Pakistan focusing on teachers training and addressing all the various evidence based components of promotion of positive mental health, Investigators aim to conduct a pilot randomized controlled trial to assess effectiveness of training based on WHO-EMRO manual, in addition to its feasibility & acceptability in improving teachers' mental health literacy and self-efficacy in dealing with students mental health issues. HYPOTHESIS: For teachers: School mental health training intervention will significantly improve teacher's mental health literacy & self-efficacy compared to wait list control group. At 3 months follow-up, control group teachers' mental health literacy will also improve compared to baseline due to contamination of information provided, across groups within the same school. All hypothesis pertains to individual level. For students: Mental health training of teachers would lead to an overall improvement in student's outcome measure (student's emotional and behavioural difficulties) at 3 months follow-up.

Detailed Description
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Pakistan is the 6th most populous country of the world with population over 188 million; Almost 35% of population is under the age of 14. Country cannot afford to ignore mental health of this large group. School experiences are important for children emotional, psychological and social development World Health Organization (WHO) also identifies promotion of emotional health and well- being as a core feature of their Health promoting school initiative. Schools can play an important role in promoting positive mental health, reducing stigma, raising awareness among teachers, parents and children about mental health issues as well as identifying and supporting youth experiencing mental health difficulties. Furthermore, mental health initiatives in schools help teachers to feel less stressed and be more satisfied with their role and save costs. Educational interventions involving teachers have shown significant improvement in teachers knowledge and attitudes regarding mental health & better accuracy of teacher identification of children and adolescents with mental health problems. Although importance of schools for mental health promotion and early identification for mental health problems has been evident for quite some time, it is almost nonexistent in developing countries including Pakistan with only a handful of studies focusing one aspect of health promoting school or on one disorder. World Health Organization, Eastern Mediterranean Region (WHO-EMRO) has developed a concise and practical manual of school mental health in December 2014.This manual is primarily intended for all stakeholders involved in the educational process including teachers. It aims for helping educators to take practical steps that can be implemented at low costs in school settings. OBJECTIVE: To assess the effectiveness of locally adapted WHO school mental health Manual based intervention in improving mental health literacy among school teachers through a randomized controlled trial. Secondary objectives include To assess whether school mental health Manual based intervention leads to better self- efficacy among school teachers. To determine if mental health training of teachers would lead to an indirect improvement in students outcome measure (emotional and behavioural difficulties) and school psychosocial environment. STUDY PHASE 1: Interaction with key stakeholders to do a current situational analysis / identify priority problems.by using WHO Questionnaires & in depth Interviews. STUDY PHASE 2: Randomized controlled trial to assess effectiveness, feasibility & acceptability of the adapted manual delivery in school settings. STUDY PHASE 3: Process Evaluation by feedback from Teachers.

Official Title
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Effectiveness of School Based Intervention for Promoting Mental Health Literacy Among Teachers: A Randomized Controlled Trial

Conditions
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School Mental Health Training of Teachers

Intervention / Treatment
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* Other: School Mental Health training


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All the teachers in the participating schools. Teachers of Grade 1-10 will be approached. Both Genders. Exclusion Criteria: Lack of informed consent. Teachers who are leaving/ not planning to be in the school in 3 months' time. Teachers who have not been involved in active teaching in last 6 months.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: School mental health training<br>Teachers Training workshop Workshop based on local adaptation of WHO-EMRO school mental health manual will be conducted in school. The duration of the workshop will be 3 days. Teachers can decline to participate or withdraw at any stage. | Other: School Mental Health training<br>* School based intervention (Teacher training intervention) is the teachers training program based on World Health Organization, Eastern Mediterranean Region (WHO-EMRO) School mental health manual draft (December 2014). Topics to be covered in training workshop include normal childhood development, behaviour management strategies for schools, life skills training, essential components for healthy schools, recognizing warning signs for common psychiatric and developmental disorders common to children and adolescents & school based interventions for various psychiatric problems<br>* Other names: WHO-EMRO School Mental Health Manual Based Training;|
| No Intervention: Wait list control group<br>Wait list control group of teachers in same schools. Half of teachers in the same school will be the wait list control group. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Teachers' knowledge | Mental health literacy refers to a person's knowledge and beliefs about mental disorders, which in turn increases their ability to recognize, manage, or prevent the development or exacerbation of mental health problems. It has various elements including: 1) enhancing capacity to obtain and maintain good mental health; 2) enhancing understanding of mental disorders and their treatments; 3) decreasing stigma related to mental illness; 4) enhancing help-seeking efficacy. It will be assessed in the study using a self-administered questionnaire based on literature review and addressing various mental health literacy elements. Although main outcome time frame is post workshop but it will be reevaluated at 3 months time to see if change from baseline is seen. | At the end of 3 days workshop | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Teachers' Sense of Self Efficacy | Teachers sense of efficacy scale(TSES) measures teachers assessment of their self-efficacy for teaching tasks as well as their other responsibilities. Efficacy in Student Engagement & Efficacy in Classroom Management subscales will be used to assess self efficacy of teachers. There are 8 statements & each statement is rated on 9 point Likert scale. It will also be reassessed at 3 months after the training workshop to assess if change from baseline is seen. | At the end of 3 days workshop | 
| Students behavioural and emotional Problems | Self- reported Strengths and Difficulties questionnaire{SDQ} (11-16 years) will be used to assess students behavioural and emotional problems. SDQ measures 25 attributes, which are grouped in subscales of five items each, generating scores for conduct, hyperactivity, emotional, peer problems and prosocial behaviour. Statements are rated on a three point likert scale:0(not tue), 1(somewhat true) and 2(certainly true). All scales excluding the last are added to generate a total difficulties score (0-40). Total difficulties and categories scores can be coded in normal, borderline and abnormal categories. | 3 months after the teachers training | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Teachers, mental health literacy, school mental health promotion