The effectiveness of the WHO school mental health package in promoting mental health literacy among secondary school teachers in Qatar: a randomized controlled trial

doi:10.21203/rs.3.rs-2981304/v1

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The effectiveness of the WHO school mental health package in promoting mental health literacy among secondary school teachers in Qatar: a randomized controlled trial

https://doi.org/10.21203/rs.3.rs-2981304/v1

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published 15 Jul, 2024

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Teachers’ mental health literacy (MHL) is fundamental for recognizing and assisting students with mental disorders. The aim of this study was to assess the effectiveness of the World Health Organization School Mental Health Program (WHO-SMHP) in promoting MHL among secondary schools’ teachers in Qatar. We conducted a two-arm randomized control trial. Teachers working in governmental secondary schools were eligible for selection. A total of 16 schools (8 intervention, 8 control) randomly selected and stratified by gender then randomly assigned (1:1). Participants and study team were aware of group assignment. Assessment of teachers’ MHL was at day 0, 3 then 3 months afterward. Bivariant analysis and Generalized Estimating Equations were used in analysis. The primary outcome was teachers MHL. Secondary outcome was the influence of sociodemographic characteristics on the level of MHL. Between October 30, 2018 and March 21, 2019, we randomly assigned 195 teachers from 16 schools to attend training workshop on WHO-SMHP (n = 95) or usual practice (n = 100). Compared with controls, teachers from intervention group demonstrated a significant improvement in the level of MHL at day three (mean difference 19.08, 95% CI 17 to 21.16, Cohen’s d = 2.63; p < 0.001) and after three months (mean difference 16.61, 95% CI 13.96 to 19.26, Cohen’s d = 1.86; p < 001). There were no significant differences related to influence of other variables on MHL. To our knowledge, this is the first trial to prove the effectiveness of the (WHO-SMHP) in promoting teachers MHL, which can be successfully implemented in a wider scale.

Mental Health

Intervention

Literacy

Schools

Teachers

Mental health literacy (MHL) is a crucial element for promoting mental health and wellbeing for individuals and populations overall. This is of high importance especially if we aim to overcome barriers of mental health such as lack of knowledge and presence of stigma [1]. MHL was first defined by Jorm AF as “knowledge and beliefs about mental disorders which aid their recognition, management, or prevention” [2]. Mental disorders are life-long conditions that affect general public including adolescents, and interfere with all aspects of their lives. Adolescents however, are at increased risk for many negative outcomes. Studies reported that lack of attention and inappropriate management of mental disorders during adolescence phase, are strong predictors of poor vocational achievements, interpersonal, and family relationship issues. In addition to decreased life expectancy due to associated medical conditions, such as diabetes, heart diseases and stroke, respiratory conditions, and suicide [3, 4]

The World Health Organization reported that more than half of mental disorders starts to manifest during adolescence, and globally one in five adolescents suffers a form of disabling mental disorder, and when they are not taken in consideration, this could result in lifelong adverse consequences, in addition to decrease in compliance with health regimens, and impaired productivity and safety of societies [4]. A systematic review of data from the Eastern Mediterranean Region, showed a raise of more than 10% for the total burden of mental disorders over the past two decades, which outstand the burden in other regions around the globe, including developing regions such as sub-Saharan Africa [5]. Additionally, the review revealed a wide range of the 12-month prevalence of mental illnesses and psychological distresses, between 11.0% and 40.1%, and 15.6% and 35.5%, respectively [5].

These alarming figures have led to global initiation of efforts by international agencies such as the World Health Organization (WHO) and the United Nations Educational, Scientific, and Cultural Organization (UNESCO) to promote school’s mental health. And over the years, many programs have been designed to deliver preventive mental health services in schools, where the majority of adolescents worldwide spend great part of their days. Hence, schools are considered an ideal place to implement activities focused on mental health promotion, prevention and intervention [6]. Teachers, on the other hand, are at the forefront of the universal effort to promote mental health literacy in schools, starting with students in their classrooms. However, researchers found that teachers often lack the knowledge that enables them to recognize students with mental disorders, and encourage professional help seeking for them [7, 8].

In 2016, WHO Eastern Mediterranean Regional Office (WHO EMRO) developed the School Mental Health Package (EMRO SMHP), an evidence-based intervention designed for school staff members including teachers and school counselors. This package was developed by a panel of experts in the field of mental health as well as psychiatrists, and revised through series of editions. Topics covered in the training workshop for this intervention included: Normal childhood development, behavior management strategies for schools, life skills training, essential components for healthy schools, recognizing warning signs for common psychiatric illnesses and developmental disorders and school-based interventions for various psychiatric problems. This intervention, however, has not yet been implemented widely in the region (Unpublished). Murphy J and his team identified and evaluated school-based programs that have been implemented over the past years reaching millions of students in several countries. These large-scale trials have presented some promising findings on the effectiveness of such programs in promoting mental health and helping students who are at risk of psychological dysfunctions. Most of these programs were conducted in high-income countries including mainly the US, but encouraging studies were in progress in countries with limited resources in the South American Continent [9].

Yamaguchi and his colleagues conducted a systematic review to analyze interventional studies on implemented programs, that were designed specifically to enhance MHL among schools’ teachers. Results showed significant improvement separately for knowledge, stigma, and confidence to help students; which are the main three attributes for MHL. Yet, when combining all three, the outcomes reported weak evidence. This systematic review also revealed several limitations in the available programs globally, and the inconsistency of the tools used to assess the level of MHL [10]. Additionally, the lack of validity and reliability of available tools in measuring and assessing MHL is considered a major constraint for future cross-cultural studies, and researchers need to work vigorously on this barrier [10]. By improving teachers’ MHL in schools; they would be able to play a more effective role in the identification, assessment, referral, for mental disorders among schoolchildren and provide an appropriate support for them. This will eventually contribute to promoting mental health in schools. So far, no previous study has been conducted to tackle the subject of MHL in school settings in the local or regional context. We aimed to study the effectiveness of the WHO school-based intervention in improving MHL among secondary schools’ teachers in Qatar, in a sustainable and effective manner.

2.1. Study design and participants

We conducted a two-arm randomized control trial (RCT) study design to determine the effectiveness of the WHO SMHP in improving MHL among secondary school teachers in Qatar. The study included governmental secondary schools across the state of Qatar. The study protocol received ethical approval from the institutional review board (IRB) of the medical research center at Hamad Medical Corporation (HMC), as well as approvals from the Ministry of Education and Higher Education (MOEHE) following a vigorous review by the committee and agreed quality assurance for the code of conduct in interventional studies. All methods were carried out in accordance with relevant guidelines and regulations under the IRB. The experimental protocols were approved by the IRB and MOEHE. Additionally, an informed consent was obtained from all subjects and/or their legal guardian(s).

Screening for schools, randomization and allocation were carried by the principal investigator and the informed consent and assessments were collected by assigned and trained data collectors.

The total number of governmental secondary schools in Qatar in 2018 was 57 (29 boys’ schools and 28 girls’ schools), and the student-teacher’s ratio was 9:1. Participants were eligible if they were working in governmental secondary schools. There were no exclusion criteria. Recruitment began on October 30, 2018 and ended on December 10, 2018. Final data were collected on March 21, 2019.

The principal method of recruitment was via sending emails to the principals and administration of selected schools in each study groups, emails included the purpose of the study and schedule of the training workshop for the intervention group, afterward teachers were selected from each school and confirmed their participation to the administration to clear their schedule during the workshop’s days.

2.2. Randomization and masking

To select schools, we used simple randomization (1:1) with an automated online system, ensuring that the research team was unable to affect randomization. Afterward teachers were selected randomly from each school by the principle to represent each class, an average of 12 teachers from each school, using Microsoft excel sheet to generate teachers’ codes. Participants completed all the assessments independently and therefore their responses could not be affected by the study team.

2.3. Procedures

The intervention was based on the World Health Organization, Eastern Mediterranean Region (WHO-EMRO) School mental health package manual (SMHP) 2016. A group of eight experienced locally-based psychologists were recruited and trained on the content of the intervention by the principal investigators; who received the training from the WHO EMRO country representative that underwent WHO training of trainers (TOT) back in Jordan. The workshop was prepared in forms of series of lectures, audiovisuals, case studies and sessions for group discussions. Location and schedule of the workshop was communicated to teachers in the intervention groups prior to starting date.

The intervention was delivered to all teachers in group 1 (intervention) in one venue for 6 hours from 7:30 a.m. to 1:30 p.m., over 3 days (December 17, 19 and 20, 2018). Teachers in the control group received no intervention and carried their work schedule regularly.

Both groups were matched for gender and were assessed at the same time period for their MHL. three points of assessments were; day 0 for baseline assessment (pre-intervention) = T0, day 3 (end of the workshop) = T1, and three months post intervention = T2. All participants signed the informed consents prior to the beginning of intervention. At each point of assessment questionnaires were collected from teachers in sealed coded envelops and handed to the principal investigator to ensure the blinding at the level of data entry and analysis. The code consisted of 4 components; the first letter of the place of birth, the last letter of their fathers’ name, the year of birth, the last two digits of their mobile numbers. All letters were written in English, and Numbers in Arabic numbering

2.4. Outcomes

The primary outcome was teachers’ MHL; which combines attributes of knowledge, skills, and attitude relevant to the school mental health. These attributes are explained as follows:

Knowledge about mental disorders: Ability to correctly identify features of a disorder, a specific disorder or category of disorders
Knowledge of risk factors and causes: Knowledge of environmental, social, familial or biological factors that increase the risk of developing a mental illness.
Skills needed to manage mental disorders: steps and strategies that can be applied to handle students suffering from mental disorders in class.
Attitudes that promote recognition: Attitudes that impact and lead to more recognition of disorders.

Assessment of primary outcome MHL was done through the self-administered tool developed by the WHO to be used in the EMRO region as part of the implementation plan for the WHO EMRO School Mental Health Package. A permission to use the tool was obtained from the WHO regional advisor of Mental Health and Substance Abuse unit. The first section has 30 items, each item in the questionnaire describes an area of knowledge, skill, or attitude relevant to the school mental health literacy. For each item, participants were asked to express their agreement or disagreement. Each item was scored as 0 = No, 1 = don’t know and 2 = yes. In the second section of the questionnaire, participants were presented with six stories about students suffering from a different form of mental disorder. At the end of each case study, teachers were asked to respond on 5 questions. Each question was scored as 0 = No, and 1 = yes. These questions consisted of items related to teachers’ skills and ability to implement certain techniques that will help students with mental issues, in addition to other items about stigma, and beliefs about interventions. Stories covered the most common psychological problems among students which were; depression, post traumatic disorder syndrome (PTDS), fear, conduct disorder, attention deficit hyperactivity disorder (ADHD), and anxiety disorders. Since social and cultural beliefs may influence answering questions, the characters in stories included female and male students. The score ranged from 0 to 90 with higher scores indicating better MHL. The prior cut-off of 75th percentile was used to determine the adequacy level for MHL overall.

The secondary outcomes for the study were determining influencing factors on the level of MHL. For these outcomes we used a self-administered structured questionnaire constituted of 20 questions related to socio-demographic characteristics (including; age, nationality, level of education, marital status, number of children, level of education, years of experience in Qatar and outside Qatar, subjects taught by teachers: during the academic year 2018–2019, past medical history, past diagnoses with mental disorders, family history of mental disorder, sources of information of mental health, and previous exposure to training on mental health). This section was developed based on extensive literature review and discussion with experts in the field of mental health. Each questionnaire was coded to ensure anonymity and link the same teacher at all three points of assessments (T0, T1, T2).

2.5. Statistical analysis

The required sample size was calculated using the sample size calculation OpenEpi® software version 3.01. In testing the null hypothesis at 95% level of confidence Interval (CI), error rate of 5% with power = 80%. For the proportion of exposed with outcome we used 70% based on two studies that showed and improvement of almost 20% in level of mental health literacy after delivering the interventions to teachers [11] [Unpublished], while we used 50% for proportion of unexposed with outcome since no similar studies have been conducted in locally or regionally. Adding a 2.5% non-response rate the total would be 195 teachers. The sample size needed for intervention group would be 95 teachers, and 100 for the control group. From each school between 10–15 teachers were selected.

Data were entered and analyzed using the Statistical Package for Social Sciences SPSS® V24.0. Quantitative variables were described as mean and standard deviations whereas; frequency with percentages were calculated for categorical variables. Student t tests (independent and dependent) were applied to compare mean difference in scores of MHL between Intervention and control group at time0 (T0), time1 (T1), and time2 (T2). Whereas; chi-square test was applied to compare percentages of categorical variables. If the conditions for the test application were not verified, we used the Yates Corrected Chi Square test. We tested for improvement of score within each group using test of repeated measures, Analysis of Variance (ANOVA). Correlation analysis was performed for time0, time1 and time2 to see associations among them. Being correlated data, General Estimating Equation (GEE) was applied to see effect of intervention, time and other important covariates on MHL score. The method has the advantage of implicitly accounting for data missing at random. We calculated standardized effect sizes with Cohen's d, dividing the treatment effect by the shared SD. P value 0.05 (two tailed) was considered for statically significant level.

Between October 30, 2018, and March 21, 2019, we recruited 195 teachers who were recruited from the randomly assigned 16 secondary schools across the state of Qatar, to receive either the workshop training for three days or no intervention (Fig. 1). Results showed that 49.7% (97/195) of were females and the average age was 41.5 (SD 7.2) years old. The Qatari nationality represented 15% (30/195) of participants. About 70% (135) completed university level of education specially among female, compared to 27% (54/195) of teachers that completed postgraduate degree, mostly for men. The mean for years of experience outside Qatar was 7.2 (SD 6.3) years, and average number of years’ experience inside Qatar 10.1 (SD 9.2) years. A history of chronic diseases was present in 28% (55/195) of participants, mainly Diabetes Mellitus 34.5% (19/55), joint problems 32.7% (18/55) and Hypertension 30.9% (17/55). Less than 9% (16/195) of participants were smoking tobacco at the time of the study, and all of them were males. Almost 3% (5/195) of teachers in the study admitted being diagnosed with mental illness, and 4% (8/195) had a family member suffering from mental illness. Furthermore, 1 in every 4 (50/195) teachers reported having a form of mental problems, namely anxiety 19% (37/195), stress 15% (30/195) and depression 7% (14/195). The two randomized groups were well matched at baseline (Table 1).

Table 1

characteristics of teachers in study groups (n = 195)
Variable	Intervention (n = 95) N (%)	Control (n = 100) N(%)
Gender
Male	47(49.5)	51(51.8)
Mean age (SD)	41(± 7.1)	42(± 7.2)
Marital status
Single Married Divorced Widowed	10 (10.5) 83 (87.4) 2 (2.1) 0 (0)	5 (5) 94 (94) 0 (0) 1 (1)
Number of children
0–3 ≥ 4 Missing	61 (64.2) 25 (26.3) 9	53 (53) 31 (31) 16
Level of education
Secondary University Post graduate degree	4 (4.2) 62 29	2 (2) 73 25
Mean total years of experience (SD)	16.8 (12.5)	17.6 (7.4)
Worked in other jobs	28 (29.5)	20 (20)
Previously diagnosed with mental illness	3 (3.2)	2 (2)
Having a family member diagnosed with mental illness
No Yes I don’t know	84 1 (1.1) 10 (10.5)	89 7 (7) 4 (4)
Past medical history (yes)	23 (24)	32 (32)
Diabetes mellitus Hypertension Osteoarthritis Others	4 (4.2) 7 (7.4) 7 (7.4) 7 (7.4)	15 (15) 10 (10) 11 (11) 10 (10)
Currently suffering from mental problem	24 (25.3)	26 (26)
Stress Anxiety Depression Others	17 (17.9) 19 (20) 8 (8.4) 2 (2.1)	13 (13.0) 18 (18) 6 (6) 3 (3)
Ever smoked tobacco	11 (11.6)	10 (10)
Looking for information about mental health	85 (89.5)	82 (82)
Previously trained on mental health	25 (26.3)	33 (33)

Data are mean (SD) or n (%).

A total of 189 participants completed the first post intervention assessment (T1) (3.1% dropout), and 174 participants completed the second post intervention assessment (T2) 10.8% dropout). There are 10.5% (10/95) teachers lost to follow-up from the intervention group and 11% (11/100) from the control group at T2 (3 months post assessment). There were no significant differences among dropouts between the two study groups (Table 2).

Table 2

Comparison of demographic characteristics between the lost to follow-up group and the study participants
Variable	Dropouts n = 21 n (%)	Study participants n = 174 n (%)	p-value
Gender (female)	11(52.4)	86 (49.4)	.798
Age mean (SD)	39.6 (5.9)	41.7 (7.3)	.213
Years of experience mean (SD)	19.91 (20.57)	16.97 (7.55)	.205
Having history of chronic diseases	4 (19)	51 (29.3)	.324
Suffering currently from mental problems	5 (23.8)	45 (25.9)	.839
Previously attended training on mental health	8 (38.1)	50 (28.7)	.375

The baseline level MHL among teachers of secondary school in Qatar was found to be 25.6% in our study, and this percentage represents those who scored a total above 63 (the 75th percentile). Any score equal to or above 63 was adequate and any score below 63 was labeled inadequate. The intervention group demonstrated a highly significant improvement in their mean scores of MHL at the end of day three of the workshop (mean difference 19.08, 95% CI 17 to 21.16, Cohen’s d = 2.63; p < 0.001) and also in the second post intervention assessment after 3 months (mean difference 16.61, 95% CI 13.96 to 19.26, Cohen’s d = 1.86; p < 001) (Table 3).

Table 3

Difference in mean score of MHL between study arms at T0, T1, T2
Mental Health Literacy tests	Intervention group			Control group			Mean difference	CI	Cohen’s d	P-value
Mental Health Literacy tests	n	mean	SD	n	mean	SD	Mean difference	CI	Cohen’s d	P-value
MHL-T0	95	57.6	± 7.6	100	56.5	± 7.1	1.08	-1.01–3.17	0.14	0.31
MHL-T1	89	78.0	± 6.8	100	58.9	± 7.3	19.08	17–21.16	2.63	< 0.001
MHL-T2	85	73.9	± 10.3	89	57.3	± 6.7	16.61	13.96–19.26	1.86	< 0.001

The improvement of MHL level in the intervention group from T0 (pre-intervention) to T1 (immediately after) and T2 (three months post intervention) was significant with P value of 0.004; the mean score increased from 57.84 at T0 to 73.96 at T2 (Fig. 2).

One-way analysis of variance was used to test significant associations of a number of variables with mental health literacy within teachers in each group separately. variables showed no significant results of MHL mean score within each study group when comparing different categories (Table 4).

Table 4

The associations between the level mental health literacy at baseline and different variables for the intervention and control groups
Variable	Intervention			Control
Variable	Mean (SD)	p-value	Effect size	Mean (SD)	p-value	Effect size
Gender
Male Female
Age
< 42 ≥ 42	57.8 (7.6) 57.1 (7.8)	0.64	0.002	55.2 (7.2) 57.6 (6.8)	0.09	0.028
Level of education
Secondary level University level Postgraduate level	60.3 (4.4) 57.7 (7.7) 57.0 (7.9)	0.68	0.008	57.5 (9.1) 56.5 (7.5) 56.5 (5.8)	0.98	< 0.001
Years of experience
< 16 ≥ 16	57.9 (7.3) 57.3 (8.6)	0.73	0.001	55.6 (7.1) 57.3 (7.0)	0.23	0.014
Past medical history for chronic diseases
Yes No	57.7 (6.8) 57.5 (7.9)	0.92	< 0.001	57.8 (5.4) 55.9 (7.7)	0.21	0.015
Previous diagnosis with mental illness
Yes No	60.3 (6.0) 57.5 (7.7)	0.53	0.004	50.5 (9.1) 56.6 (7.0)	0.29	0.015
Suffering from mental problems at the time of the study
Yes No	58.0 (8.5) 57.4 (7.4)	0.75	0.001	56.8 (8.2) 56.4 (6.7)	0.81	0.001
Looking for information about mental health using different sources
Yes No	58.3 (6.3) 51.5 (13.9)	0.075	0.007	56.5 (6.8) 65.4 (8.6)	0.95	< 0.001
Previously attended training on mental health
Yes No	57.2 (7.6) 57.7 (7.7)	0.80	0.001	56.3 (8.6) 56.6 (6.3)	0.84	< 0.001

Having ANOVA and regression analysis together suggesting that MHL score was significantly different between intervention and control group whereas; effect of time in the form of visits was also found significant. There was strong interaction between visits and group variable. Furthermore, regression analysis showed that the intervention was effective for increasing MHL score in comparison to control group (p = 0.001) with visits (p = 0.001). There was not significant role of gender (p = 0.35) and DM (p = 0.38) for the MHL score in the study as shown in Tables 5 and 6.

Table 5

shows tests of Between-Subjects Effects
Source	Type III Sum of Squares	df	Mean Square	F	Sig.
Corrected Model	62797.382^a	198	317.158	8.889	0.001
Intercept	2122922.740	1	2122922.740	59497.948	0.001
Group	19402.755	1	19402.755	543.790	0.001
visit	12684.858	2	6342.429	177.756	0.001
visit * Group	8639.264	2	4319.632	121.064	0.001
subj(Group)	21046.814	193	109.051	3.056	0.001
Error	12809.337	359	35.681
Total	2316721.000	558
Corrected Total	75606.719	557
a. r² = .831 (Adjusted r² = .737)

Table 6

shows important coefficients after regression analysis
Model	Unstandardized Coefficients		Standardized Coefficients
Model	B	Std. Error	Beta	T value	P value
(Constant)	62.135	1.639		37.910	0.001
Study group	-12.051	0.809	-0.517	-14.889	0.001
visit	4.322	0.489	0.302	8.830	0.001
Gender of participant	-0.748	0.795	-0.032	− .941	0.35
Do you have diabetes mellitus	1.171	1.336	0.030	.877	0.38

This study sought to examine the effectiveness of the WHO SMHP intervention in promoting MHL among secondary school teachers in the state of Qatar. Teachers in the intervention group were trained on the WHO SMHP manual for 6 hours sessions over three days period. Results showed remarkable improvement in the level of MHL among participants from the intervention group when compared with their counterparts from control group.

Only quarter of secondary schools’ teachers had an adequate level of mental health literacy in the baseline assessment. Similar results were found in a study from Africa where secondary schools teachers had low levels of depression literacy (16.3%), hence, they were unable to identify main symptoms of depression among students [12]. Also, a study in Asia showed that Cambodian teachers struggled to identify common mental disorders among students, which reflects poor mental health literacy, and the most notable areas were relatively poor mental health knowledge, low levels of willingness to interact with people with mental illness, and large proportion of the teachers considered mental disorders as being untreatable [13]. Additionally, researches from Europe reported limited levels of MHL among schools’ teachers in the pre-test results, despite the availability of mental health services [14, 15]. In a recent study conducted in four European countries (Hungary, Portugal, Germany and Ireland) on depression literacy among community facilitators; teachers scored very low compared to other professions like nurses [16]. These findings across various scholars may be in part due to the weak role that school mental health programs are imposing in different countries.

Demographic variables in several studies have shown to influence MHL across different population groups, and this included age, gender, years of experiences, chronic illnesses, mental disorders, and resources for mental health information. Despite the numerous studies discussing possible association between MHL and sociodemographic variables, and interaction between them; in this analysis we found that none of those variables influenced the level of MHL among participants, which is somewhat unexpected. This is possibly due to the limited number of experimental studies on MHL among school teachers. Never the less, Ganasen et al argued that among all factors that were linked to MHL, across different scholars, they found that “literacy skills are a stronger predictor of MHL than age, employment status, ethnic group, or educational level” [17]. Farrer and his team showed that older age was associated with increased level of stigma compared to younger generations, and justifying this finding with the lack of exposure to media as a readily available source of information among older people [18]. Gender variation in MHL was also evident in number of studies. Considering other related factors like age and cultural context, some scholars reported that females are better in identifying mental disorders compared to males [19, 20]. Some studies revealed that relying on teachers’ experience in dealing with mentally disabled students may be ineffective due to the bias effect of culture believes [21, 22]. Agreeing with these finding, Weston and his colleagues denied any assumptions relating teachers’ experience with better ability in recognition and management of mental problems, since continuous professional training may build new knowledge for all teachers regardless of the length of their career, which they can apply differently [22].

In this trial the most common chronic diseases among teachers were diabetes mellitus, however, the analysis revealed no significant association between MHL and chronic illnesses. Karimpour et al in their recent study shown that people with diabetes and limited mental health literacy had significantly more incidence of inadequate glycemic control and lacking care for self [23]. The relationship between MHL and chronic illnesses such as hypertension, diabetes, and chronic pain following injuries; are yet to be studied and explored in more depth. Furthermore, Kutcher and his colleague justified in the earliest stages of conceptualizing mental health literacy; that people who have past history of mental disorders or who were in close contact with mentally ill persons may possess a different level of mental health literacy that is influenced by their conditions and their previous attempts to seek professional help [1]. A study from the US among teachers in schools, found that there was minimal training ever provided to them on mental health and common disorders among school students, despite an average year of experience that exceeded a decade, which was reflected negatively in their poor knowledge and weak self-efficacy in handling students with mental issues. Teachers from that same study justified their poor mental health literacy with the insufficient training [24].

Utilizing a randomized controlled study design, this trial was aimed to provide robust evidence of the program across a large representative sample of teachers from multiple high schools across the country. To date, few trials have been conducted to formally test the effectiveness of similar programs within the region, and to our knowledge WHO-SMHP is the first to show actual significant changes in the level of MHL among secondary school teachers over the period of three months, as opposed to several studies that reported little or no significant difference to teachers MHL after introducing interventional programs as found in the latest systematic review by [10]. Similar findings were found in a study by Kutcher et al, where they found significant improvement of teacher’s knowledge about mental disorders, scoring an average of 58.3% (M = 17.5, S.D. = 4.07) at pre-intervention assessment, then reaching up to 76.3% (M = 22.94, S.D. = 2.89), immediately following completion of the training program (p < 0.001) [7]. Another study from Tanzania showed a statistically significant improvement in teachers’ knowledge about mental health from average of 14.16 (SD ± 2.19) at the pretraining assessment, to an average of 16.68 (SD ± 2.23) at post-training assessment with (p < 0.001) [25]. A Canadian interventional study used the (Guide) curriculum tool to promote teachers MHL in school settings. The intervention was only one session for 8 hours, using number of modules, and results showed a significant increase of knowledge in general MHL with the average score of 15 at pre-test and 18 out of 21 questions at post-test, p value of 0.0001 [26].

The duration of MHL interventions also varied greatly in the literature. The WHO-SMHP program lies somewhat in the mid-range of durations reported for interventions on MHL. Some interventions continued over few days [26]. Others for few hours [27]. Only few programs lasted for weeks [28]. Majority of mentioned studies shared a common limitation which is the large numbers of dropouts, this factor may have affected the validity of their results. Additionally, choosing a mid-range program to deliver interventions within the busy schedule of schools’ teachers is not only feasible but may be more appealing to many participants to undertake the training, apply it and benefit from it.

The multiple assessments conducted in the study reflected the possibility of retained knowledge when using the WHO SMHP, which is an advantage over majority of interventional studies in the field of school mental health. Another strength in this trial is being the first study to assess and report promising results using the newly constructed WHO SMHP in the Arabic and local context. In this study, we did not assess the change in teacher’s behavior or engagement with students with mental disorders to get appropriate help through strategies that were discussed in the intervention.; such as referral to psychologists. Although this would have been self-reported but it can show a positive outcome toward improving student mental health in school’s environment. Moreover, randomization of schools would have occurred ideally after baseline assessment. However, this was not feasible because schools needed to know in advance whether they were in the intervention or wait list group so that they could schedule their staff training at the start of the school year.

In summary, while majority of teachers showed limited MHL at baseline assessment, participation in the WHO school-based intervention has shown to be effective in improving mental health literacy for secondary school teachers in Qatar compared to no intervention. In doing so, it is likely to equip teachers with the knowledge and skills to not only support their students who suffer mental disorders and challenges, but also their fellow colleagues. These findings highlight the value of providing skills-based programs which can be successfully implemented in a wider scale.

Ethics Approval and consent to participants

The study protocol received ethical approval from the institutional review board (IRB) of the medical research center at Hamad Medical Corporation (HMC), as well as approvals from the Ministry of Education and Higher Education (MOEHE) following a vigorous review by the committee and agreed quality assurance for the code of conduct in interventional studies. All methods were carried out in accordance with relevant guidelines and regulations under the IRB. The experimental protocols were approved by the IRB and MOEHE. Additionally, an informed consent was obtained from all subjects and/or their legal guardian(s)." The study protocol received ethical approval from the institutional review board (IRB) of the medical research center at Hamad Medical Corporation (HMC), as well as approvals from the Ministry of Education and Higher Education (MOEHE) following a vigorous review by the committee and agreed quality assurance for the code of conduct in interventional studies. All methods were carried out in accordance with relevant guidelines and regulations under the IRB. The experimental protocols were approved by the IRB and MOEHE. Additionally, an informed consent was obtained from all subjects and/or their legal guardian(s).

Authors contribution

RE was the principal investigator, conceived the study, led the design, and drafted the paper. NA and MB were the supervisors and contributed to the design. RS contributed to the design and was responsible for the main statistical outcome analyses. AM carried out the training of psychologists and literature contribution. KS contributed to intervention provision. RE conducted and oversaw the statistical analysis. All authors commented upon and approved the final manuscript.

Data Availability

The dataset(s) supporting the conclusions of this article is(are) included within the article (and its additional file(s))."

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

This work was Funded by Hamad Medical Corporation as an internal grant (MRC01-18-146). The fees for publication are funded by Qatar National Library. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Acknowledgements

We want to thank the Ministry of Education and Higher Education in Qatar, the participating schools, the administrative staff. And special thanks to the teachers.

Consent for publication

Not applicable

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The effectiveness of the WHO school mental health package in promoting mental health literacy among secondary school teachers in Qatar: a randomized controlled trial

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1. Introduction

2. Methods

2.1. Study design and participants

2.2. Randomization and masking

2.3. Procedures

2.4. Outcomes

2.5. Statistical analysis

3. Results

4. Discussion

5. Conclusion

6. Declarations

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