The effectiveness of the WHO school mental health package in promoting mental health literacy among secondary school teachers in Qatar: a randomized controlled trial | BMC Public Health
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. During the screening of schools, principals of two girls schools and one boys school suggested that the intervention timing should be changed as it was near exams period, hence they declined to response at the time of invitation due to shortage of staff to cover for their colleagues if they planned to participate in either the control or intervention groups. These schools were replaced by 3 other schools, and the response rate was nearly 95%. 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.
We followed the concert statement in this study.
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.
Procedures
The intervention was based on the World Health Organization, Eastern Mediterranean Region (WHO-EMRO) School mental health package manual (SMHP) 2016. The package was extensively studies and developed by a team of experts in the field of school mental health in the middle east region. The manual’s goals include teaching educators about the importance of mental health in schools, familiarizing them with child development stages, providing them with proven behavior management techniques, and encouraging mental health promotion using a comprehensive school approach. It covers topics such as social-emotional development in children, creating mental health-promoting schools, addressing student mental health issues in classrooms (including guidance on when to seek further assistance), and includes case studies for a better understanding of common issues. Additionally, standardized handouts are provided to participants for enhanced learning. 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 psychologist presented the lectures and delivered the intervention afterward to the teachers involved in the study. 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 h 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.
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:
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Knowledge about mental disorders: Ability to correctly identify features of a disorder, a specific disorder or category of disorders.
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Knowledge of risk factors and causes: Knowledge of environmental, social, familial or biological factors that increase the risk of developing a mental illness.
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Skills needed to manage mental disorders: steps and strategies that can be applied to handle students suffering from mental disorders in class.
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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. This tool was newly constructed by experts in the region ensuring the validity and tested in a regional country in Arabic language, with fitting contents to the local context. Regarding the face and content validity, the WHO questionnaire was evaluated locally by a group including; eight psychologists working with governmental schools in Qatar and experts in the area of mental health literacy. Additionally, senior consultants in the field community medicine and mom-communicable diseases, and the national trainer of the WHO-SMHP. These participants assessed difficulty, generality and ambiguity of the items, and they were asked to comment on the were asked to comment regarding the grammar of items, choice of vocabulary, placement of items. All 16 psychologists received a 3 days training on the interventions and the questionnaire and they filled the pre-post survey. 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 (including Hypertension that was defined as any history of diagnosis for the patient with the average of casual systolic blood pressure readings ≥ 140 mmHg and/or diastolic pressure readings ≥ 90 mmHg. And Diabetes Miletus type 2 that was defined persistent hyperglycemia in patients with a history of diagnosis of diabetes using the standard tests like fasting blood sugar, Two-Hour Oral Glucose Tolerance Test, and Glycated Hemoglobin (Hb) A1C), 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).
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 [9, 12], 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 and 15 teachers were selected. Since the ratio of 1:1 was applied first to selected schools as the clustering sample unit, however with selecting teachers we gave a range of 12–14 teachers per participating school from all subjects taught. And the selection was done over two days to get the final list of teachers who will attend the workshop, hence there was a small difference in the total number of subjects in each study arm.
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. Regarding data normality will be tested using kurtosis and skewness tests. The skewness of the teachers scores was found to be -0.116, indicating that the distribution almost normal and only mildly left-skewed. The kurtosis of the scores was found to be -2.01, indicating that the distribution was more moderately tailed compared to the normal distribution.
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