Mental Health First Aid training findings
Research objectives one & two: Reach and dosage
Across the 12 schools assigned to the intervention arm, 113 (8.6%) teachers and support staff attended and completed the two-day standard MHFA training, and 146 (11.1%) teachers and support staff completed the one-day MHFA for Schools and Colleges. Six hundred and sixty-six (54.5%) teachers and school staff attended the one-hour awareness raising session. In eight (66.7%) of the 12 intervention schools, the pre-specified intervention dose (at least eight percent of school staff attending the course and becoming a peer supporter) of two-day standard MHFA training was achieved. One additional staff member was required to be trained in each of the remaining four schools to reach sufficient dose. In nine (75.0%) of the intervention schools, the pre-specified eight percent of teachers attended the one-day MHFA for Schools and Colleges training course. Of the three schools not reaching sufficient dose, an average of two additional teachers would have been needed to be trained to achieve the required dose. Reasons for schools not achieving sufficient dose included researcher error in calculating the numbers, nominated staff unable to attend at the last minute, and trained staff leaving the school shortly after training.
Research objectives three & four: Fidelity and quality of training
- Observer assessed
In the four case study schools, observer assessed fidelity and quality of delivery of training was consistently high for each of the items of assessment (instructor knowledge of materials, presentation skills, facilitation and support of the learning, interest from the group, and coverage of content ). There was little variation in mean scores on these items for the one-day MHFA for Schools and Colleges (range: 3.9-4.3 out of 5) and two-day standard MHFA training course (range: 4.1-4.4), although mean scores were slightly lower for the one-hour mental health awareness raising session (range: 3.4-4.1) (Table 2. Observer rated fidelity and quality of delivery of the MHFA training package at case-study schools).
- Participant assessed
One hundred and eighteen of the 146 (80.8%) attendees of the one-day MHFA for Schools and Colleges and 108 of 113 (95.6%) attendees of the two-day standard MHFA training course completed a participant checklist. Most attendees scored trainers highly for knowledge of materials, presentation skills, diversity of learning materials, communication skills, use of a range of teaching approaches, and ability to keep the course focused and relevant. There was little variation in the mean scores for each of the instructor qualities by the one-day MHFA for Schools and Colleges (range: 4.6-4.7) and two-day standard MHFA (range: 4.6-4.7) training courses (Table 3. Participant assessed quality of training and fidelity of the MHFA training package).
One hundred and forty-two of the 146 (97.3%) attendees of the one-day MHFA for Schools and Colleges and 110 of 113 (97.3%) attendees of two-day standard MHFA training course completed a MHFA training evaluation form. In keeping with observer-assessed quality of training, overall mean scores for the one-day MHFA for Schools and Colleges training courses were high (range: 4.4-4.7), with the exception of slightly lower scores for participant rating of environment in which the training was delivered (4.1, SD: 0.7). Mean scores for the two-day standard MHFA course were also high (range: 4.3-4.7), with lower scores observed for participant rating of training course environment (3.8, SD: 0.9) (Table 3. Participant assessed quality of training and fidelity of the MHFA training package).
- Trainer assessed
Despite different levels of experience in delivering MHFA sessions, all six trainers reported high levels of fidelity in terms of ensuring key content was delivered. However, three main factors appeared to present a challenge to fidelity, requiring trainers to deliver the course with flexibility, whilst still ensuring all key content was covered. These factors were: needs of the group, location of the training, and scheduling within the school day.
Needs of the group
Trainers discussed the need to exhibit flexibility in relation to choice of materials or timetabling of exercises depending on the needs of the group: ‘You’re not meant to go off the planned route really but if the room is slumping slightly you can kind of get them sort of re-energised for a little while and get them involved in something’ [Trainer five]. They also used their skill as trainers to note and respond to dynamics within the group, to help ensure more effective participation by attendees: ‘I think it’s a general thing about watching your group, seeing how they’re interacting, and making sure that they are interacting about the subject matter’ [Trainer three].
Location of the Mental Health First Aid training delivery
Delivery of the MHFA training package usually took place on the school site, either during an In-Service Training (INSET) day (for the one-day training course) or usual school day. However, being on-site resulted in interruptions to the delivery of training in some schools, due to competing priorities of school staff, such as resolving student incidents, performance management meetings, and break duties: ‘There was an incident in the school that afternoon, which required several members of staff to have to leave in the afternoon and go and do things and come back. I guess that’s just the nature of life inside a school’ [Trainer two]. In such situations, trainers again discussed being flexible in delivery during such interruptions, to ensure coverage of sufficient content: ‘Frequently I was having to move the day around or rejig, to make sure they covered the most important points’ [Trainer three].
Scheduling MHFA training within the school timetable
The school timetable presented challenges to fidelity of the MHFA training package. Often trainers reported a reduction in time available due to expectations of delivering the course within a school day, with set break and lunchtimes, and other scheduled school events being prioritised: ‘We couldn’t start at eight thirty because it was an inset day and the Principal wanted staff to come and join the main assembly for a talk. So that pushed it beyond nine o’clock’ [Trainer four]. This required trainers to be adaptive in their delivery style to ensure that key materials were covered within a shorter timescale: ‘We’re not going to be pedantic about timescales…we’ll just go with the flow of the school day and just stop and start when it automatically fits’ [Trainer six].
The trainers reflected on the one-hour awareness raising session and perceived that it was Powerpoint heavy and not necessarily conducted at an optimum time (e.g. at the end of the school day) for the school staff to remember and fully process the messages within the session. However one particular trainer used personal experience to engage the school staff and make the messages less abstract. It was also felt that there was not enough time built in for it to be interactive and allow discussions: “They were struggling a little bit at the end of the day. There was a lot of PowerPoints and quite a lot of actually reading from the PowerPoints. The main bits that actually worked were when I handed out the little sticky post-it notes to get them to do things... I used my own experience of bipolar disorder to cover the stigma section, which completely changed the dynamic in the room” [Trainer one].
The trainers’ reports of high fidelity were corroborated by observers’ feedback forms which confirmed that the core content was covered. The trainers’ descriptions of the skill they used to be flexible and response to the needs of the group and practical considerations of the school context were corroborated by both observers and attendees high rating of trainers’ skills and quality of the sessions.
Research objective five. Fidelity to guidance (peer support service)
At the six month peer supporter feedback meetings, nine (75.0%) of the intervention schools indicated that support had already been provided to colleagues by peer supporters. Peer supporters at the majority (n=9, 75.0%) of schools had met as a group to discuss the set-up of the staff peer service, with some schools indicating they had held regular up-date meetings since then (n=5, 41.7%). Usually peer supporters provided support to each other through an informal ‘buddy’ system (n=11, 91.7%), although one school (8.3%) reported implementing a more formal approach. Five (41.7%) of the schools had set-up a formal confidentiality policy for the peer support service at this point.
All schools used advertising to launch the peer support service. Methods to promote the service included posters provided by the research team (n=10, 83.3%), newsletters (n=1, 8.3%), staff briefings (n=11, 91.7%), staff email (n=4, 33.3%), and posting information in staff pigeon holes (n=1, 8.3%). Half of the schools planned to advertise the service at the start of the following academic year (8 to 11 months after delivery of MHFA training). All schools (n=12, 100.0%) offered service users the choice of which peer supporter they contacted. Most schools offered a confidential space where support could be provided (n=9, 75.0%) and senior leaders had helped to raise the profile of the peer support service (n=8, 66.7%).
The second feedback meeting took place at only ten (83.3%) schools (approximately 18 months after training). Since the first feedback meeting, none (0.0%) of the schools had met as a group, with most (n=9, 75.0%) mentioning just discussing any issues with other peer supporters informally if needed. Three (25.0%) of the schools had re-advertised the service, by email (25.0%), posters (1, 8.3%) and through a staff newsletter (1, 8.3%). Peer supporters in fewer schools indicated that they perceived they had senior leadership support at the second feedback meeting (4, 33.3%). During feedback meetings, peer supporters indicated varied levels of involvement from the senior leadership team. Although the majority indicated that additional support from senior leadership would be advantageous in terms of keeping wellbeing on their agenda, some peer supporters perceived their involvement would be inappropriate.
Qualitative data from trainer interviews and peer supporter focus groups shed light on the challenges in setting up the peer support service. In some cases a short amount of time was found at the end of the second training day for the group to begin to discuss the service, but this was limited: "…it might have prompted a little bit more conversation and discussion about what do we do? But there wasn’t a huge amount of that and the course doesn’t really lend itself, because again, you’ve got to get through this and that" [Trainer four].
Difficulty in finding further time to meet was noted as the reason that some groups failed to meet at all even to set the service up, and no groups were meeting a year on:
Peer Supporter: "If we’ve got half an hour free at all it will be different times in the day."
Interviewer: "Have you met as a whole group or is it difficult with the time?"
Peer Supporter: "No, not as a whole group. We had a few meetings in the term after the training, but even then it was a real struggle to get people. And once you get the same people over and over, you start to think, well it’s not good" [School 1D, phase two].
This may have impacted the uptake of the intervention as the peer supporters did not have the space to reflect on their practice and the service and discuss any improvements that could be made.
The guidance (Supplementary material 3) was deliberately flexible, to ensure the peer support service could be implemented in a realistic and sustainable way in each school context. But one trainer observed that in at least one group this added an additional complexity to the peer support role that may have been counter-productive to getting the service going: “…they got really bogged down in policy and procedure and then some people said, well I’m not going to be comfortable doing this if, I want to know” [Trainer six].
It was reported by some peer supporters that there was a struggle to find the time and space to meet with staff who wanted support. Some reflected that it is hard to find a confidential space within a school as many of the spaces have staff and students coming and going on a regular basis. This could have had an effect on the staff approaching peer supporters and the quality of the conversation undertaken: "And also, finding a place at that time as well… I was seeing someone after school, and we were chatting, talking about something they were a bit concerned about, and then somebody else just walked in and just stood there. I didn’t want to say, this is a private, a mentoring, this is confidential. So this person doesn’t want me telling somebody else that, so that was difficult……I didn’t know what to do because I didn’t want to embarrass the person that was there, I wanted to be rude to the person who just stood there but I couldn’t, and they still didn’t go, they still didn’t get the message" [School 2L, phase two].
Although most services were delivered on an ad hoc basis, as and when colleagues approached a supporter for help, in one of the case study schools the peer supporters also created a specific space and time that the staff knew they were available to access should they need support, which may have avoided the above problem. However they found this difficult to implement due to the additional demands it placed on their time: "I mean when we first did it, there was talk about having like a drop in, and then we were going to kind of have a rota and do that. But, you know, people are just so busy that it’s hard to ask people to give up their free time" [School 1D, phase two].
A number of comments suggested that to address some of these implementation problems such as lack of time and lack of clarity over policies, stronger support and recognition from senior leadership was needed: "And I think that maybe needs to be addressed because we want to have more of an impact. Then actually, we need to have that recognition, as to the role that we are playing. And perhaps sitting down with the Head and, as a group of people, this is our plan, how will you support us, kind of thing because it is really important" [School 2L, phase 1].
Research objective six. Reach of peer support service delivery
At the 12 month teacher questionnaire follow-up, 34 (6.1%) of 557 teachers indicated they had accessed the peer support service in the previous 12 months. Most frequently, teachers indicated they had used the service once or twice in the academic year (n=16, 47.1%) or once a term (three times a year) (n=9, 26.5%). Similarly, at the 24 month teacher questionnaire follow up only a small proportion (n=30, 5.9%) of 510 teachers indicated they had accessed the peer support service in the previous 12 months (Table 4. Teacher reported use of the staff peer support service at follow-up time-points).
Of the 113 peer supporters trained in the intervention schools, over half (n=60.6, 53.6%) completed logs at each of the five time-points, and each supporter completed a mean of 3.1 (SD 1.5) logs. Sixteen (n=14.5%) peer supporters did not complete a log at any time-point. Ninety-two (81.4%) peer supporters were still employed by the schools at the final data collection time-point. The mean number of logs completed by school varied (range: 2.2 to 10.6) and decreased slightly over time (mean difference between first and last data collection: 0.7).
Across all time-points combined, peer supporters reported that they had supported a mean of 1.7 (SD: 1.8) colleagues in the previous two weeks, of which approximately half (mean 0.7, SD: 0.8) were additional colleagues who they would not have supported prior to being trained. Most often support was provided to each person once (mean number of colleagues helped once at each time-point (23.8, 40.8%) or twice (18.8, 32.2%). The peer supporters reflected that they were unsure about which contacts should be recorded as part of the intervention, and which would have happened anyway outside of their peer support role. This meant that the logs may inaccurately the work of the peer supporters: "The struggle for me is how do you know if they’re coming to you as a peer mentor or, how do you know if they’re coming to you because they would come to you anyway. Measuring that, you know. Quantifying Peer Supporter support versus pretty much we were all doing that anyway" [School 4N, phase 1].