The present study was a qualitative study using conventional content analysis that used a semi-structured in-depth interview and FGD to obtain information from groups of stakeholders. Selected instructors, teachers, principals, and designers of the School Mental Health Promotion Program were the target of the study. Purposeful sampling was used in this study. In this study, a total of 4 group discussion sessions were held with school teachers. The duration of each session was expected to be 45-60 minutes, which was done according to the saturation of the discussions and the desire of the participants to continue the discussion, increased or decreased. The median experience of teaching in these teachers in these 4 groups was 8 years. The average age of the teachers was 33 ± 8 years. 48% of the participants in these group discussion sessions were male and 52% were female. As mentioned earlier, in-depth interviews were also used in another part of the study to collect information. Each interview was conducted only once which lasted from 14 to 60 minutes In-depth interview sessions were conducted with 3 school principals, 3 school counselors, 2 psychologists of the counseling core in the regional education headquarters, as well as 2 school mental health planners. In order for the subjects to be able to fully explain their understanding and experiences, the questions were asked in an open form and then continued according to the discussion process. These open questions allowed the participants to share their opinions, perceptions, and experiences and Express themselves. Interviews were held at the interviewees’ workplaces where calmness and the absence of disturbing factors were observed. Interview questions were compiled according to the goals of the literature review. Some of the main questions include "What are the strengths and weaknesses of this program in your design and implementation stages? “What do you think threatens the implementation and continuation of the program?" and "If you were involved from the beginning in the program design, how would you modify it?
The interviews were all recorded and transcribed and notes were taken during the interviews. The interviews continued until the saturation was reached so that no new code was found. The transcribed text of each interview was considered as an analysis unit and was analyzed in five stages according to the Graham and Landman model: at least 2 authors (MB and MN) read them. Following model 1- they read the text several times to understand its general meaning. 2- They divided the text into semantic units, containing the concepts and meaning extracted from the text. 3- At this stage, the codes, which were the labels of semantic units, were created by condensing and shortening them but maintaining their original core. 4- The codes were put together based on content similarities and then subthemes were created. 5. Finally, classes were created that made the basis for the content that was placed in the next them. Because qualitative analysis requires a circular process, we went back many times to complete the steps (16). The participants did not review the originally transcribed text of the interviews and results, but the researchers considered their final comments and notes from the interview after each meeting, and two people did the whole process. Data was also managed manually without using any software. To clarify the codes and classes, direct quotes from the interviews were provided in the results section.
The accuracy and validity of the data were assessed according to the criteria of Goba and Lincoln (17), which were examined in the following cases: 1. Long term engagement by the researcher with the topic of study, 2. Following the review by a colleague, the coding was done by two people, then, the external check of codes was done by the article authors, and some codes were corrected. Moreover, after performing steps 4 and 5, the analysis was reviewed by the first and corresponding authors. Other authors also monitored all stages and commented when necessary. 3. Triangulation of data sources conducted by interviewing various groups to examine their views. 4- Searching for conflicting evidence using purposeful sampling of those who might suggest conflicting views to give a full description of the subject.
Accordingly, a pilot project, according to the above-mentioned published handbook, has been implemented in schools after translation and customization. This guidebook was initially designed initially for those involved in the learning process, including teachers, administrators, health educators, counselors, and education policymakers. The handbook includes information to increase teachers' awareness about the importance of mental health in schools, the developmental and psychological stages of children, and strategies for managing children's age-appropriate behavior. It also familiarizes teachers with the symptoms of psychiatric disorders in students (mental health literacy) and their distinction from abnormal mood disorders (18).
The pilot project was designed to initially select two instructors from each school who were counselors, health instructors, or other school staff. A total of 6 schools were selected and the age of students was between 6 and 17 years. They took a three-day training course and were trained as trainers of trainers. Then they trained the school teachers who began identifying and referring students with symptoms of emotional, psychological, and behavioral disorders. In cases the teachers themselves could solve a student's problems with a minor intervention, they would not refer them to the selected instructor or school counselor. The selected instructors or school counselor intervened based on their specialty; otherwise, the students were referred to the Education Counseling Center. The center was staffed with experts from various fields to visit these students and refer them to a psychiatrist if needed. The feedback process was based on Figure 1 from the psychiatrist to the counseling core, from the counseling core to the selected instructors, and from the instructor-to-the teacher. The project's ethical considerations included the possibility of withdrawing from the study at any stage, the confidentiality of information, and anonymous dissemination of the results.
The Findings
The findings of the present study were presented in four themes 1) program strengths (Table 1),2) program weaknesses (Table 2), 3) factors preventing the achievement of program objectives (Table, 3) and 4) recommendations for program improvement (Table 4). It is to be noted that 14 subcategories were also devised, and finally, 50 codes were extracted.
1- Strengths
Table 1: The theme of strengths and its subcategories and codes
Code
|
Subtheme
|
theme
|
Useful educational resources
|
Educational benefits
|
Strengths
|
Promoting and correcting teachers' attitudes
|
Conflicts and involvement of school staff
|
Design differentiation
|
Increase counseling demands on education
|
Model of using selected trainers
|
Matching needs
|
Teachers' satisfaction with the plan
|
Design efficiency
|
Comprehensive design
|
Reducing teachers' improving classroom management
|
Increasing individual motivation and creating positive challenges for selected educators counselors
|
Reducing stigma
|
Positive consequences of program implementation
|
Ability to identify psychiatric disorders and refer students to a specialized level
|
* Educational benefits
Teaching mental health topics to help teachers understand the importance of mental health in schools, raise awareness about the developmental stages of children's mental development, provide strategies for managing age-appropriate behavioral management, including mental organization and management of undesirable behaviors, thorough understanding of methods of promoting mental health in schools, familiarizing students with the symptoms of psychiatric disorders and distinguishing them from normal mood disorders, providing appropriate interventions for a variety of mental health problems and psychiatric disorders. One of the events that were expected to take place directly in teacher training was that teachers’ attitudes toward students' mental disorders and behavioral problems changed. In an interview with teachers, they said that education had changed their views.
"The course has made us a little more open, a little more focused on some kids." Or another teacher insisted, "My knowledge has increased tremendously, and I've found that in some places, I'm wrong in class after 25 years as a teacher."
* Design presentation model
One of the occasions that were more prominent for the presenters and designers in this project was the selection of instructors as liaisons and counselors in schools. What distinguishes this project from other implemented projects? As the No. 1 designer puts it:
"One of the strengths of empowerment was, raising the sense of responsibility in the selected instructors and their strong commitment, which was the basis for these interventions in schools."
* Effective design
Doing so had increased teachers' skills in identifying and referring students, which in turn led to less energy for behavioral problems and paying more attention to subjects.
"When a student is referred to work with the counselor, this time, our educational efficiency increases as we have to spend less energy on such students."
2- Weaknesses
Table 2: The theme of weaknesses and its subcategories and codes
code
|
subtheme
|
Theme
|
Family education
|
Lack of family training
|
Weaknesses
|
Referring to higher levels
|
Reference and feedback
|
Cores with insufficient power
|
Response structure and feedback
|
Registration and reporting
|
Designing support process
|
Structural problems
|
Coordination between design components
|
Selection of pilot schools
|
Limitations of selected coaches
|
Lack of workforce
|
* Lack of family education
Lack of family education was one of the factors that made it difficult to achieve the project goals. It seems that if educational programs were held for families in the area, in addition to being welcomed, it would encourage them to come back and follow their student’s status.
"I think the issue of families is a gap in this project".
* Reference and feedback
Feedback is not provided in a proper manner, which seems to be due to the performance of the service providers, including overcrowding and lack of mastery. One of the school principals stated that:
"We have to have feedback; we don't get specialized results".
* Structural problems
The project has been hampered by problems such as the selection of pilot schools and low financial support from other agencies and organizations.
* Lack of manpower
It seems that the number of selected instructors should be increased due to the large volume of work. Lack of adequate time and expertise of selected teachers in schools were among their limitations. One of the consultants at the educational counseling center stated that:
"The selected trainers were people who had 1) not enough time, 2) lack of expertise and 3) that, like a social worker, did not have a wide field of work."
3- Factors preventing the achievement of the project goals
Table 3: The theme of factors preventing the achievement of the project goals and its subcategories and codes
code
|
Subtheme
|
Theme
|
Students’ financial problems
|
Beneficiary
|
Factors preventing the achievement of the project goals
|
Lack of follow-up by families
|
Teachers’ workload and increasing their responsibilities
|
Factors related to teachers
|
Teachers’ burnout
|
Teachers’ time limitation
|
Lack of teamwork and cooperation of some teachers
|
Structural problems of the execution field( Ministry of education)
|
Legal limitations
|
The field of mental health requires a general culture that should be implemented in a variety of ways, including public education, the education of influential people, and self-care or other methods. The financial problem of students in paying for counseling fees at the Education Counseling Center was one of the factors that prevented families from following up. Since some of the specialized services at the counseling center were provided by informal forces, families had to pay their fees. The two causes of fear of stigma and financial problems of families were the reason for the lack of referral or non-follow-up treatment. One of the selected instructors said:
"The problem in the treatment process is that the families don't cooperate, or if they do, it's not continuous, and also they don't go for treatment and there is a fear of stigmatization."
4- Recommendations for program improvement
Table 4: The theme of recommendations for program improvement and its subcategories and codes
code
|
Subtheme
|
Theme
|
Educational support
|
Education
|
Recommendations for program improvement
|
Expanding educational resources
|
Teaching how to write reports
|
Teaching students and families
|
Changing the structure of education
|
Continuing education and retraining
|
Applied and need-based training
|
Financing
|
Design and structure of the program
|
Prioritizing primary education
|
Establishing a program and continuing it
|
Special and specific time
|
The need for a school counsellor
|
Integration into school programs
|
School management role
|
The need to pay attention to all levels of education
|
Collaborating with other governmental agencies
|
A comprehensive approach to students' psychological problems
|
Counseling core
|
Empower Specialists
|
Social workers
|
Empowering each teacher
|
Considering incentives for selected educators and teachers
|
To fulfill Expectations
|
Lack of inappropriate behavior by teachers
|
* Training
Regarding teacher training course/methodology, there was a call for a change in the educational structure of the program to empower teachers so that experts can train teachers and not selected instructors to provide more specialized and quality training, as well as training students and families.
"Keep in mind that these teachings are very effective for children and teachers, as well as parents."
* Program design and structure
Currently, in the first year of high school, people are working as counselors to provide services to students. But primary and secondary schools do not have counselling experts. Restrictions on counselling centers and their experts in the Ministry of education require solutions to be devised to meet the students’ needs, especially in primary schools. One of the requests of the school staff was to have a school counsellor.
"We really need to have one person on the subject of psychology in every school."
* Specialists
Although the role of selected instructors is to perform executive work and counselling, and it was intended to track students’ mental status as well as provision of some support services, it seems that rehabilitating the mentally ill as well as supporting them and their families is a specialized task and the presence of a social worker will improve the service.
"First, the specialists must be identified. More specialists must enter the setting to be able to cover services, for example, a social worker."
* Factors of the project success
Considering incentives for selected teachers and educators can be useful in increasing their motivation as well as the results of interventions and project implementation.
"If these efforts are made together, well, they will naturally work better."