Level of consensus among participants
Table 1 shows the level of agreement with each of the aims of MHFA in relation to the five-step logic framework used to develop the questionnaire. All the participants agreed that the MHFA program had improved their health and well-being (Aim 7). There was also agreement based on the 80% consensus threshold that the training contributed to ensuring safety when someone's life was at risk due to mental illnesses (Aim 1; 95.24%) and prevented mental health issues from worsening (Aim 2; 95%). Two aims were close to consensus: the training contributed to increasing mental health awareness (Aim 5; 73.68%) and reducing stigma and discrimination (Aim 6; 75%). However, promoting good mental health (Aim 3) and comforting people with mental health issues (Aim 4) did not reach the consensus with agreement rates of 61.5% and 66.7%, respectively.
Consensus analysis for the five-stage logic frameworks shows that the agreement was 100% with the statements on achieving MHFA objectives and developing the knowledge, skills, and attitude required for attaining them. The consensus threshold was also reached for the items on MHFA training (93.6%), first aiders' actions (95.2%), 'general' statements about the
Table 1 Percentage of consensus on Delphi statements (n=111) for MHFA aims and five-stage logic frameworks
|
7 MHFA aims and number of items reached consensus (% of consensus)
|
MHFA training
n=31 (%)
|
Knowledge, skill & attitude of first aiders n=21(%)
|
Actions of first aiders
n=21(%)
|
Demonstrable evidence n=30(%)
|
Objectives achieved n=8 (%)
|
Total
n=111(%)
|
(1) Preserve life where a person may be at risk of harm to themselves or others
|
9 (100)
|
3 (100)
|
4 (100)
|
2 (66.7)
|
2 (100)
|
20 (95.2)
|
(2) Provide help to prevent the mental health issue from becoming more serious.
|
5 (100)
|
5 (100)
|
5 (100)
|
3 (75)
|
1 (100)
|
19 (95)
|
(3) Promote recovery of good mental health
|
1 (100)
|
3 (100)
|
2 (66.7)
|
1 (20)
|
1 (100)
|
8 (61.5)
|
(4) Provide comfort to a person with a mental health issue
|
---
|
1 (100)
|
---
|
0 (0)
|
1 (100)
|
2 (66.7)
|
(5) Raise awareness of mental health issues in the community
|
3 (100)
|
5 (100)
|
4 (100)
|
1 (16.7)
|
1 (100)
|
14 (73.7)
|
(6) Reduce stigma and discrimination
|
8 (80)
|
1 (100)
|
1 (100)
|
4 (57.1)
|
1 (100)
|
15 (75)
|
(7) To improve own health and well-being
|
3 (100)
|
3 (100)
|
4 (100)
|
4 (100)
|
1 (100)
|
15 (100)
|
Total (%)
|
29 (93.6)
|
21 (100)
|
20 (95.2)
|
15 (50)
|
8 (100)
|
93 (83.8)
|
content and objectives of MHFA training (94.9%), and 'I' statements regarding the knowledge, skills, attitude, and actions of the first aiders (97.6%). However, the agreement rate was low (50%) for the 'social impact' statements about MHFA training effects on society. The findings suggest that MHFA Bangladesh has progressed significantly towards its aims. However, 'social impact' demonstrable evidence statements indicated that the training's influence on broader society was limited, with the highest level of disagreements (50%) amongst this group of statements.
Qualitative thematic analysis of the MHFA program in Bangladesh
Two members of the research team (AH and UK) independently coded the comments in Delphi rounds and the expert panel meeting transcript to identify themes from participants' opinions on the MHFA Bangladesh program. The analysis found 12 themes relating to the positive contributions of MHFA training to individuals and society and ten themes explaining low consensus and participants' disagreements with some statements. While explaining the disagreements, participants suggested various initiatives for MHFA and other mental health activities to impact society more. These are described in the section on recommendations.
Themes relating to the positive contributions of MHFA training
Empathy and non-judgmental skills
Participants' learning about empathy and non-judgmental skills in MHFA training helped them to support other people. One participant noted, "After MHFA program, I have become a more sensitive person to empathize with the experiences people go through with mental health issues." Another participant mentioned, "Non-judgmental listening was a huge part of our training; how to listen to people was taught through various activities. I have certainly developed a general attitude to hear people out nonjudgmentally."
Understanding and taking care of own mental health
Participants' understanding of and ability to take care of their mental health improved after attending the MHFA training. A participant commented, "It worked for me like magic as I was suffering from some psychological issues for two long years." Another participant reflected, "I was in a bad situation with my mental health. After the training, I realized that my over-thinking attitude was the problem, and now I can identify my problem and work on it."
Providing mental health support to friends, colleagues, and families
The MHFA training equipped the participants to provide mental health support to their friends, colleagues, and family members. One participant shared, "One of my family members has severe anxiety. Now (as I am trained in MHFA) we all try to help him." Another participant mentioned, "Now I provide mental health support to others if required. I provided MHFA Training to the factory mid-level management. Now they act as mental health first aiders for their workers and families." MHFA helped the recipients as one participant stated: "one of my colleagues is now in a good situation as I tried to help him with some knowledge that I gathered from MHFA."
Providing mental health support during crises
Participants found MHFA useful in supporting people with mental health issues during the coronavirus pandemic. One participant stated, "I started to provide MHFA support to people in March (2020) during the ongoing pandemic. So, what happened is, their coping became better. My MHFA support also helped them to decide whether there was a need for professional help." Another participant mentioned, "When I received the training, I was not very clear. But when I started to practice MHFA, it became more clear to me, and I became more confident to deal with any emergency associated with self-harm or harming others."
Ability to provide mental health support in various settings
Participants viewed the MHFA training enabled them to provide mental health support in various settings. One participant pointed out, "We can effectively apply MHFA training in many areas, such as health and education. It is very effective."
Increased mental health awareness among other people
Participants pointed out that their MHFA activities have positively contributed to mental health awareness at their homes and workplaces. One participant commented, "People are aware nowadays. My friends and relatives ask for information from me regarding mental health services when they require." Another participant mentioned, "I can see that people are more aware, at least around me. And I would say the impact is due to the MFHA training that I had."
Improved social relationships
Participants found that their MHFA initiatives improved the service recipients' social life. One participant said, "After receiving the (MHFA) training and mental health support from our team and me, many married adolescents from Gaibandha, Kurigram, and Nilphamri are now better able to maintain personal and social relationship with friends and family."
Change in attitude about mental health
Participants found that their MHFA activities contributed to change people's perception of mental health. One participant reported, "Now (due to my MHFA initiatives) my surrounding people respect individuals with mental health issues." Another participant shared, "My mother used to say there is nothing called mental health, but now she learns from me and tells her siblings to take care of their children's mental health as they are going through teenage life."
Motivating people to learn about mental health
Participants' MHFA actions encouraged others to learn about mental health. One participant mentioned, "The people who received MHFA support from me are now wanting to take MHFA training. It clearly says they received some good help."
Increased mental health initiatives at work
MHFA training enabled the participants to promote mental health initiatives at work. One participant said, "In our office, we have established a mental health and well-being network. Through that, I am trying to promote mental health issues more systemically. Since I am a certified mental health first aider, it empowered me to negotiate mental health issues with my senior management." Another participant shared, "when the mental health first aiders created the awareness, we had a meeting with the management. We informed them about the importance of mental health and asked them to include some questions about mental health status in the company's quarterly performance survey, and they agreed with us."
A common platform to promote mental health
The training provided a shared understanding and goals to bind the participants together to give MHFA support in society. A participant stated, "This mental health training helps me in two ways. Number one is to get connected with like-minded people and the peer group we have formed, and it allows us to exchange our ideas (about mental health) with each other."
Reaching people at the grass-root level
Participants agreed that the MHFA could potentially help people at the grass-root level. One participant commented, "It (MHFA) is a nice and precious tool that can be applied to reach the people at the grass-root level."
Themes to explain low consensus and disagreements with Delphi statements
Social stigmas are the barriers to mental health initiatives
The majority of the participants disagreed with the 'social impact' statements as they found social stigma a major barrier against changing public perception of mental health issues. One participant commented, "Still, there are stigmas around mental health in all spheres of life…… people are going through harsh treatments as soon as it comes to mental health issues. People take it as a disgrace to talk to a psychiatrist."
Low mental health literacy in society
Low mental health literacy in society was a barrier to advocate MHFA initiatives as one participant stated: "I think a long way to go; people are not aware of the signs and symptoms of distress (associated with mental health issues)."
Inadequate mental health research
Participants disagreed with the statements on providing evidence-based information to promote mental health due to a lack of mental health research in Bangladesh. One participant mentioned, "Yes, we can provide global research-based evidence. The research evidence for our country is insufficient." For the same reason, they disagreed with the statements evaluating MHFA initiatives. One participant commented, "I know I have spread mental health knowledge at my workplace. I am doing it personally, but I cannot claim that people are accepting mental health issues more as a result of my initiatives. I cannot claim it without (research) evidence, no matter how close people in my surroundings are."
Lack of access to mass media to promote mental health
Participants disagreed with the statements about using mass media to advocate mental health to the broader society. One comment pointed out, "I did use my network and workplace to do advocacy for mental health. I did not have access to promote mental health in mass media."
MHFA is not a priority at the policy level
Participants indicated that policymakers are yet to prioritize MHFA. One participant described, "I was present in … meeting. In the mental health part, I explained and proposed MHFA for service providers. They noted it down, but I feel people were not very much interested in it." As policy supports were lacking to promote MHFA initiatives at the societal level, participants disagreed with 'social impact' statements.
Lack of necessary infrastructure
Participants commented that the proper utilization of the MHFA program required adequate infrastructure, such as dedicated mental health clinics, mental health services, qualified workforce, etc., which are scarce in Bangladesh, especially in rural areas. One participant pointed out, "One big problem perhaps is infrastructure. We have better infrastructure for physical health support compared to mental health."
Lack of institutional support
Participants disagreed with the 'social impact' statements as they explained that institutional assistance with logistics and finance was largely unavailable to provide MHFA to more people. One participant mentioned, "We are doing all these (i.e., providing mental health support) as individuals, as personal trainers. We are trying to do something, but institutional support is much needed to do these." Another participant agreed to this view and shared her experience using MHFA in a program supported by her organization. According to her, "it is easier to work in the area of mental health when an organization supports us. In my case, our organization has a program where we (use MHFA to) provide mental health support to married adolescents. From that side, I can say that because I have an organization banner and a specific program, I have managed to reach a large number of young people, and then we were able to train them (in MHFA)."
Low accessibility and availability of mental health services
Some participants viewed that MHFA's impact on society was limited because mental health services were expensive and not easily accessible. One participant commented, "(Mental health facilities are) relatively better than before, but not sure about the quality. The poor people have little access to mental health services." Another comment pointed out, "Mental health care services are available, but sometimes they are not affordable."
Few numbers of MHFAiders
Participants pointed out that the number of first aiders in Bangladesh is too small to impact society. One participant explained, "As Bangladesh is a densely populated country, the number of people trained in MHFA is small compared to the overwhelming population. So more people should be trained in MHFA."
Forgetting MHFA information
Some participants failed to recall whether they learned certain information during the MHFA training and therefore disagreed with some training statements. One participant commented, "I do not recall any information regarding this."
Recommendations for the MHFA Bangladesh program
Incorporating Bangladeshi data and research findings into MHFA training
Participants recommended incorporating more information on psychosocial and medical mental health services and relevant research data in Bangladesh. They commented that "The data of Bangladesh is less" and "(trainees) get a basic idea about the available services but not a total picture of what is available locally."
Establishing a communication network for MHFAiders
Participants suggested establishing a common social and communication platform for all MHFAiders, which would help them share their experiences and facilitate their MHFA contributions. One participant commented, "….regarding the fact that we are not being able to create an impact…….what experiences are we facing on the ground?.....it is not easy to remove stigmas…….if we could have strengthened our network, then we would have a better answer for these questions."
Arranging refresher training
Participants also emphasized the necessity of refresher training as one mentioned, "While training evaluation and feedback are there, there is an absence of refresher course or CPD (continuous professional development)."
Developing MHFA online resources
Some participants advocated for MHFA online resources as one stated: "I will suggest giving separate referral information online so that they can be shared with others easily when required."
Recommendations for mental health initiatives in Bangladesh
In Delphi rounds and consensus workshop, participants made the following suggestions to promote mental health, but these are beyond what MHFA alone can do and influence.
Running more mental health awareness programs
A strong recommendation was to carry out more awareness programs on mental health issues. One participant commented, "I want to emphasize mostly on (mental health) awareness……at the workplace, at the school level, in the media, and raising awareness everywhere… so that people can move forward on their own."
Incorporating mental health topics in the academic curriculum
A way forward can be to include mental health topics in the academic curriculum, as one participant pointed out: "I think we should put special attention on school and textbook curriculum and teachers' training."
Giving mental health social recognition
Participants emphasized the necessity of a shared understanding and recognition of mental health in society. One participant stated, "Unless every actor in society does not share the same value regarding the importance of mental health, it will not achieve its expected results."
More dialogues on mental health
Participants suggested that people need to exchange their views on mental health as a participant pointed out: "We have to have a lot more dialogue regarding this matter."
Mental health initiative requires a collective effort
Participants stressed that well-planned and collective efforts are needed to improve the mental health situation of the country. One participant mentioned, "Different organizations are working in different ways. I think it is high time to stand on the same platform to improve and spread it". Participants viewed that the government's roles are essential in this matter as a participant indicated: "for larger implications, definitely financial commitment is needed from the government. The private sector can also play a big role, and how we can mobilize that might be a strategy which we can do at the policy level."
Research-based mental health initiatives
Participants recommended research to be an integral part of mental health initiative as stated in a comment: "(We) need more capacity building initiatives, materials, and research to create awareness of mental health in society."
Social welfare policies for mental health
Participants emphasized that mental health services should not become a business. One participant commented: "I want to put that, who are working on national mental health policy, they should strengthen people's organizations, not mental health market. Not make it a profit-generating business."