Not hurting students’ feelings: The impact of a specialized training on teacher mental health literacy in central Sri Lanka

Background Globally and mental literacy (MHL) of supports early and Aim develop and conduct a training to in and to explore the effect of the intervention on teacher MHL. Method 251 teachers participated in the study. Psychiatrist authors rst facilitated small group discussions on ten case vignettes of common child psychiatry problems and then large group discussions using mini lectures and a handbook. Pre and post-tests were conducted to assess knowledge and attitudes on mental health problems of school children. The scores were analyzed using, Paired T-test in SPSS 17. Results The mean score differences of pre and posttest in both knowledge and attitude components showed statistically signicant differences with p values <0.001 (condence interval of 95%) and Cohen’s d values >0.2 in each, indicating the training had a signicant positive impact on improving both the knowledge and attitude about mental health.


Introduction
World Health Organization (WHO) claims about 20% of children and adolescents will contract an emotional and/or behavioral disorder during their life time 1,2 .They can have a drastic impact on the academics and social life of these children, depriving them from achieving their full potential. 3 Teachers play an important role in the life of children and adolescents as a group who has the unique opportunity to spend a considerable amount of time with them observing their behaviour, academic performance and social interactions during the most wakeful hours of the day. Especially in rural settings of developing countries, teachers play a signi cant role in the community as they usually have a fair awareness of the students' family backgrounds and are capable of advising the family in various issues including health related problems 4 . Therefore, it is of paramount importance that the teachers have high mental health literacy (MHL).
MHL is de ned as knowledge and beliefs about mental disorders that aid their recognition, management and prevention 5 . De ciency in MHL of the public can hinder the evidence based mental health care 6 .
Research conducted worldwide have revealed that there are inadequacies in MHL of teachers 4,7,8 . In a Brazilian study on public school teachers' perceptions about mental health, 80.6% have showed great interest in acquiring knowledge; yet the lack of reliable sources of education created lack of con dence in managing everyday situations involving mental health problems 9 . The same study revealed that the television was the source that provides information in the case of 61.3% of the teachers 9 . The clinician authors of current study come across many children who face adversities in the hands of the teachers due to poor MHL of those teachers.
Studies have shown that the improvement of MHL of the teachers is helpful in early detection of students suffering from mental disorders and aids early referral to professional care 10,11 . School based programs such as Canadian mental health and high school curriculum guide (The Guide) and the African version of the Guide signi cantly improved knowledge, decreased stigma and enhanced help-seeking e cacy among teachers 12,13,14,15 .In a Tanzanian study more than 200 students with potential mental health issues were identi ed and referred for professional care following a training program to improve MHL 12 .
Sri Lankan data shows the prevalence of child and adolescent mental health problems is a considerable health issue in the country. In a national survey, 18.9% of the adolescents aged 13-18 years showed some abnormality in emotional and behavioral parameters16. Out of them 15.5% and 12.4% were severely affected in educational functioning and peer relationships respectively. In central SL, 13.8% of school children aged 7-11 years showed emotional and behavioral problems 17 .
The concept of MHL is not much familiar in Sri Lankan context. The stigma in relation to mental health is high in the country 18 . This probably contributes to poor conceptualization of MHL in general. There are a few published studies on MHL of various stakeholders in mental health 19,20 . However, there are no published studies in SL on evaluation of MHL of teachers. Teachers learn some child psychology principles brie y at the teacher training schools. There are diploma level courses in early childhood and primary education which include social and personality psychology as sub-courses at the only government run open university 21 . A few non-governmental organizations (NGOs) and individual mental health professionals conduct haphazard training programs for teachers on request of individual schools. There are no regular island wide hands on skills training programs for teachers on emotional and behavioural disorders among children and adolescents.
The clinician authors come across school children and adolescents with mental health problems whose teachers have either failed to detect the problem or managed it adversely, over decades, on a regular basis.
That further deteriorates the condition leading to unfortunate circumstances like poor school performance and worsening of the emotional /behavioural problems such as school refusal, withdrawal and irritability. In order to change this on going adversity, a teacher-training program to improve MHL on emotional and behavioural disorders of childhood and adolescents was developed and delivered. The training was named sisu sitha noridawa (SSN) meaning, "not hurting the feelings of the student" in Sinhala, the main language in SL. The phrase was coined based on the famous Sinhala poem guru sitha noridawa which means, "Not hurting the feelings of the teachers" in order to catch the attention of a wider audience of teachers for the training. The effectiveness of the intervention (the training) was evaluated statistically.

Methodology
The necessity of a program to improve MHL of teachers in order to facilitate early detection, appropriate class room management and if necessary, referral of children and adolescents with mental health problems was suggested to the local educational authorities and due approval was obtained from them for the study. The training was conducted at the auditorium of the Teaching Hospital, Kandy, SL in collaboration with local ministries of education and health. A convenient sample of 251 primary teachers from 3 educational zones (namely Kandy, Dewinuwara and Katugasthota) out of the 6 educational zones in Kandy district government schools in Central Province, SL was selected for the study. Three one -day workshops on 3 different days were conducted for each group from each zone. The participants completed a bio data sheet of basic information, namely, participant number, age, sex, civil status, nationality, religion, area of living, level of education, name of the current school, total service duration, number of schools served, records of behavioral and emotional problems of own children and those of children in their classrooms.
A days' group was divided into 10 small groups and 10 case vignettes of common childhood behavioral, emotional and neurodevelopmental problems, namely, oppositional de ant disorder, conduct disorder, attention de cit hyperactivity disorder, autism, dyslexia, mental retardation, depression, separation anxiety disorder, anxiety around sexuality and anxiety around bullying (both by students and teachers advertently or inadvertently) were distributed one vignette per one small group. A comprehensive handbook that was prepared for the training was given to each participant. The handbook contained key identifying features of the conditions discussed in the vignettes and guidelines for classroom management of each case with referral process if necessary. First, the teachers were requested to detect the problems and come up with suggested classroom management plan in small groups without consulting the handbook. Then the 3 psychiatrists in the author panel facilitated an interactive comprehensive discussion in the large group setting on each case vignette with references to the handbook and relevant mini lectures on power point. A certi cate of participation was awarded for each participant as an immediate incentive.
The effect of the training program on the MHL was assessed by a pre and post-test through selfadministered written questionnaires on knowledge and attitude in mental health problems in children and adolescents. The questionnaires were prepared based on the clinical experience of the clinician authors and the cultural context. They were in Sinhalese language. The questionnaire of the knowledge component comprised of 35 questions of true-false type while that on attitude comprised of 14 questions with a 5point Likert scale (Tables 1and 2 respectively). The pre and posttest results were recorded and analyzed using SPSS 17.0. The paired T test was used to assess whether there was a signi cant improvement in attitude and knowledge in mental health following the workshop.

Results
Out of the 251 teachers that participated for the study 205 (81.67%) were females and 98.01% were Buddhists while 1.59% and 0.04% belonged to Islam and other religions respectively. The sample consisted of 41.43% of teachers from Kandy zone whereas 30.28% and 28.29% were from Denuwara and Katugastota zones respectively. The participants came from all the different school categories; 1AB with science, arts and commerce streams for Advanced level (A/L) course (28.69%), 1C with no Science for A/L (12.75%), Type 2 with classes from Grade 1 up to Grade 11 (21.91%) and Type 3 (primary) schools with classes from grade 1 to 8 or Grade 1 to 5 comprising the largest individual group from one category (36.65%).
The participant teachers were of a wide variety of educational backgrounds. Most, 48.21% of the sample was A/L educated. Out of the teachers 33.86%, 8.76%, 6.37% and 2.79% owned a basic degree, diploma, PhD and MA respectively. 185 (73.71%) teachers revealed that they have encountered children with emotional and behavioral problems and 12.35% of the participants had their own children suffering from some mental health issue.
The knowledge questionnaire comprised of 35 questions and 1 mark was awarded per each correct answer. In the pretest of the knowledge component (n=251), the mean score was 26.33. This signi cantly improved after the workshop with a posttest mean score of 27.38. (Figure 1) The percentage of accurate responses to most of the components in the knowledge questionnaire was increased following the program. (Table 1) The change of the outcomes is statistically signi cant with a p value of <0.001 (con dence interval of 95%). The Cohen's d, (d=0.29), exceeded the Cohen's condition for a small effect (d=0.2) indicating that there is a signi cant difference between the two means.
Out of 251 participants only 236 participants had correctly lled the attitude questionnaire and hence considered for the study. The pretest in attitude component of the participants (n=236) had a mean score of 55.9364. This improved to a mean score of 59.0678 in the posttest ( gure 2). The percentage of the most favorable response for each sentence was increased following the program ( Table 2). According to the paired T-test, the change of outcomes is statistically signi cant, the p value being <0.001 (con dence interval of 95%) and the Cohen's d value is 0.4 (d > 0.2). The results indicate that the training program had a signi cant positive impact on improving both the knowledge and attitude components of teachers on child and adolescent mental health issues.

Discussion
There is a growing global interest in bringing MHL into the school setting 22,23 . There are many school friendly interventions that have been carried out to achieve improved school MHL 24.25.26 . In the South Asian middle income setting in SL, the concept of MHL is little heard of and only a few published research on MHL was found 19 . The SSN program was also a venue to introduce the term MHL and highlight the importance of having high MHL amongst teachers. This type of an interactive approach helps to alleviate many self-identi ed yet unanswered questions teachers have, on day-to-day child mental health problems and supports their willingness in enhancing knowledge and ability to manage them better 27 . The SSN training clearly resulted in a signi cant improvement of both the knowledge and attitudes of teachers on child and adolescent mental health. This improvement can be stated as a direct effect of the intervention due to the design of the study where the pre and posttests are done immediately prior and following the program that makes the non-training factors unlikely. To the best of the knowledge of the authors this study is pioneering in SL in exploring the effect of interactive workshop based training on MHL of teachers.
The SSN training program was well received by the participant teachers who actively participated with enthusiasm and lively interactive discussion despite the fact that stigma on mental health is a barrier in achieving mental health promotion in the country. 18 Authors believe SSN program contributed towards reducing stigma too as knowledge improves understanding and acceptance of mental health issues 28 . Enhancing teachers' knowledge and decreasing stigma could also have a long term and a persistent positive impact on students 11,29 .It will facilitate to improve the MHL of the students as the teachers will impart their new knowledge and attitudes to the students in day to day class room setting. This will in turn lead to self-identi cation and help seeking behaviors by students consequently reducing child and adolescent mental health morbidity and mortality 11,30,31 .
There is no organized and regular national teacher-training program to improve MHL in SL. For an intervention to be successful it should be effective, realistic, feasible and contextually speci c 32 . The SSN training program ful lls these requirements and therefore it is a favorable and economically bearable resource that can be implemented in a middle-income, developing country.
The evaluation of results is important in providing information to the clinicians on how to improve the training program. It guides in identifying the areas that the teachers have performed inadequately in knowledge/attitude, posttest and this would be helpful in modifying the training program to address the de ciencies.
Though this study shows outstanding results it was conducted in only 3 educational zones in the Central Province (out of 9 provinces of SL) and it limits our ability to generalize the effects to the whole country. To overcome this the training could be extended to the other 8 provinces with slightly different geographical, social and cultural settings and evaluated for the effectiveness. The SSN training program can be endorsed as suitable to be embedded in the national teacher training curriculum if the central province results are replicated across the country. The worldwide emphasis is to incorporate training in MHL into the existing school curriculum structure 12,30 . It has been shown that including mental health literacy into regular curriculum legitimizes the educational value of the material 25 . Moreover, such embedding of the program in the teacher training curriculum rather than conducting it as a separate course or a training program will prevent sensationalizing mental health problems and in turn stigma around mental health 25 . Booster training programs of SSN at regular intervals within the teacher training curriculum of training colleges and at in-service trainings will be effective in consolidating the new knowledge and attitudes.
The study measures the immediate results of the intervention and does not guarantee a long-term positive impact or an ability to apply achieved effects into real life classroom problems. A few low income countries have conducted studies in collaboration with resource rich countries like Canada where the teachers are trained in application of mental health literacy resource into their classrooms; the outcomes have been promising 22 .The SSN can be upgraded, as the next step to a didactically familiar classroom based training program to improve both the teachers' and students' MHL 12 .

Conclusion
This study was conducted to evaluate the success of the interactive workshop based SSN training program on improving the MHL of teachers. Improving the mental health literacy of teachers will pave the way towards early diagnosis, proper classroom management and referral of the child and adolescent with mental health problems, which is the ultimate goal of this effort. There was a statistically signi cant improvement in both knowledge and attitude component following the training. "Sisu Sitha Noridawa" (Not hurting the students' feelings) is a favorable training program, which is effective and nancially realistic to improve MHL of teachers in the study population. It can be embedded in the teacher training curriculum of Sri Lanka provided the results are replicated in a more representative sample across the country. This study can be improved by adding an arm for evaluation of the sustainability and applicability of the shortterm effects achieved from the training. Finally this could be a stepping-stone to an internationally collaborated interventional study to improve teacher MHL that could be used as a model for middleincome country teacher training on MHL.

Con ict of interest statement:
None of the authors have any con icts of interest. First author and the 5 th author only had access to the study data. The provincial ministry of education sponsored only the training workshop and neither had no involvement with the data collection, analysis and interpretation of data, writing of the report and the decision to submit the paper for publication nor any proprietary or nancial interest in the outcome of the study.
The contribution of each author: 1. The conception of the work Ginige P. Funding: This research did not receive any speci c grant from funding agencies in the public, commercial, or not-forpro t sectors. Ethics/Consent: The study was based on a training program we developed and delivered for teachers. We got the approval to conduct the training from the due educational authorities of the Provincial Ministry of Education, Central Province , SL. The teachers participated willingly in response to the request from the ministry. We got their informed consent to compare and contrast the pre and post training knowledge and attitude on mental health.