Protocol for a cluster randomised controlled trial of an intervention to improve the mental health support and training available to secondary school teachers - the WISE (Wellbeing in Secondary Education) study

A mixed-methods project on the impact of the mental health first aid training on French university students' knowledge, attitudes and practices

AIM

University students are increasingly affected by mental health problems and need prompt support. The aim of this project was to assess the impact of the mental health first aid (MHFA) training on students' knowledge, attitudes and practices (KAP) concerning mental health in the short, mid and long-term.

METHODS

Three studies were conducted in Bordeaux, France, from May 2021 to March 2022. The first study collected data from 55 students 1 to 6 months after they had followed the training to examine its efficacy in the mid-long term. The second study collected data immediately before and after the training to evaluate the KAP of 52 students in the short-term (1 to 10 days). The third study consisted of 14 semi-structured interviews with students trained since 2020 to identify the training's long-term impact (3 to 18 months). Descriptive statistics were used for studies one and two, and framework analyses for study three.

RESULTS

Most participants reported that their KAP about mental health had improved after the training. In the first study, 94.2% of students reported being ready to intervene during a psychotic crisis in their peers. In the second study, 75.0% of students reported improved mental health-related knowledge and decreased stigma. All students in the third study reported that they had assisted at least one person after the training.

CONCLUSIONS

These were the first data on the impact of the French MHFA on KAP. While not exhaustive, findings suggest that deploying the training would be beneficial to French students.

The relationship between physical activity and the health of primary and secondary school teachers: the chain mediating effects of body image and self-efficacy

BACKGROUND

Active health is a new concept, model, and system to maintain the state of whole-person health. In the context of the increasingly serious health problems of primary and secondary school teachers, it is of great significance to explore the relationship between physical activity and primary and secondary school teachers' health based on the active health perspective.

METHODS

The survey involving 741 primary and secondary school teachers across representative provinces in China utilized the International Physical Activity Scale, Body Imagery State Scale, and General Self-Efficacy Scale. Data analysis employed SPSS 25.0 and Amos 24.0 software.

RESULTS

While no significant gender disparities were observed in body image and self-efficacy, age groups exhibited a bipartite and "V" shaped distribution. Female teachers demonstrated higher physical activity levels (2456.46) and superior physical fitness compared to males (2297.86). A positive correlation emerged between physical activity, body image, self-efficacy, and health status. Importantly, body image and self-efficacy partially mediated the relationship between physical activity and health status, accounting for 82.31% of the total effect.

CONCLUSIONS

Primary and secondary school teachers have real problems such as teachers' physical activity is generally insufficient, teachers' body image status is generally poor, and teachers' self-efficacy is low; physical activity is an important factor in promoting primary and secondary school teachers' health status, and low, medium, and high levels of activity all have a promoting effect on the health of primary and secondary school teachers, and the more active primary and secondary school teachers are in terms of physical activity, the better their body image, self-efficacy, and health status are, and the more active primary and secondary school teachers are in terms of physical activity, the more positive the physical activity, self-efficacy, and health status are. The more physically active primary and secondary school teachers are, the better their physical intention, self-efficacy and health status are.

SUGGESTIONS

improve the quality and effectiveness, promote the concept of active health among teachers; empower teachers, strengthen the institutional protection of teachers' health; reduce the burden and increase the quantity,and optimise the supply of health services for teachers.

Mental Health First Aid as a tool for improving mental health and well-being

BACKGROUND

The prevalence of mental health problems is high, and they have a wide-ranging and deleterious effect on many sectors in society. As well as the impact on individuals and families, mental health problems in the workplace negatively affect productivity. One of the factors that may exacerbate the impact of mental health problems is a lack of 'mental health literacy' in the general population. This has been defined as 'knowledge and beliefs about mental disorders, which aid their recognition, management, or prevention'. Mental Health First Aid (MHFA) is a brief training programme developed in Australia in 2000; its aim is to improve mental health literacy and teach mental health first aid strategies. The course has been adapted for various contexts, but essentially covers the symptoms of various mental health disorders, along with associated mental health crisis situations. The programmes also teach trainees how to provide immediate help to people experiencing mental health difficulties, as well as how to signpost to professional services. It is theorised that improved knowledge will encourage the trainees to provide support, and encourage people to actively seek help, thereby leading to improvements in mental health. This review focuses on the effects of MHFA on the mental health and mental well-being of individuals and communities in which MHFA training has been provided. We also examine the impact on mental health literacy. This information is essential for decision-makers considering the role of MHFA training in their organisations.

OBJECTIVES

To examine mental health and well-being, mental health service usage, and adverse effects of MHFA training on individuals in the communities in which MHFA training is delivered.

SEARCH METHODS

We developed a sensitive search strategy to identify randomised controlled trials (RCTs) of MHFA training. This approach used bibliographic databases searching, using a search strategy developed for Ovid MEDLINE (1946 -), and translated across to Ovid Embase (1974 -), Ovid PsycINFO (1967 -), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Common Mental Disorders Group's Specialised Register (CCMDCTR). We also searched online clinical trial registries (ClinicalTrials.gov and WHO ICTRP), grey literature and reference lists of included studies, and contacted researchers in the field to identify additional and ongoing studies. Searches are current to 13th June 2023.

SELECTION CRITERIA

We included RCTs and cluster-RCTs comparing any type of MHFA-trademarked course to no intervention, active or attention control (such as first aid courses), waiting list control, or alternative mental health literacy interventions. Participants were individuals in the communities in which MHFA training is delivered and MHFA trainees. Primary outcomes included mental health and well-being of individuals, mental health service usage and adverse effects of MHFA training. Secondary outcomes related to individuals, MHFA trainees, and communities or organisations in which MHFA training has been delivered DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. We analysed categorical outcomes as risk ratios (RRs) and odds ratios (ORs), and continuous outcomes as mean differences (MDs) or standardised mean differences (SMDs), with 95% confidence intervals (CIs). We pooled data using a random-effects model. Two review authors independently assessed the key results using the Risk of Bias 2 tool and applied the GRADE criteria to assess the certainty of evidence MAIN RESULTS: Twenty-one studies involving a total of 22,604 participants were included in the review. Fifteen studies compared MHFA training with no intervention/waiting list, two studies compared MHFA training with an alternative mental health literacy intervention, and four studies compared MHFA training with an active or an attention control intervention. Our primary time point was between six and 12 months. When MHFA training was compared with no intervention, it may have little to no effect on the mental health of individuals at six to 12 months, but the evidence is very uncertain (OR 0.88, 95% CI 0.61 to 1.28; 3 studies; 3939 participants). We judged all the results that contributed to this outcome as being at high risk of bias. No study measured mental health service usage at six to 12 months. We did not find published data on adverse effects. Only one study with usable data compared MHFA training with an alternative mental health literacy intervention. The study did not measure outcomes in individuals in the community. It also did not measure outcomes at our primary time point of six to 12 months. Four studies with usable data compared MHFA training to an active or attention control. None of the studies measured outcomes at our primary time point of six to 12 months.

AUTHORS' CONCLUSIONS

We cannot draw conclusions about the effects of MHFA training on our primary outcomes due to the lack of good quality evidence. This is the case whether it is compared to no intervention, to an alternative mental health literacy intervention, or to an active control. Studies are at high risk of bias and often not sufficiently large to be able to detect differences.

Wellbeing in Secondary Education (WISE) Study to Improve the Mental Health and Wellbeing of Teachers: A Complex System Approach to Understanding Intervention Acceptability

Teaching staff report poorer mental health and wellbeing than the general working population. Intervention to address this issue is imperative, as poor wellbeing is associated with burnout, presenteeism, and adverse student mental health outcomes. The Wellbeing in Secondary Education (WISE) intervention is a secondary school-based programme aimed at improving the mental health and wellbeing of teachers and students. There are three components: awareness-raising for staff; a peer support service delivered by staff trained in Mental Health First Aid (MHFA); and Schools and Colleges Mental Health First Aid (MHFA) training for teachers. A cluster randomised controlled trial with integrated process and economic evaluation was conducted with 25 secondary schools in the UK (2016-2018). The intervention was largely ineffective in improving teacher mental health and wellbeing. This paper reports process evaluation data on acceptability to help understand this outcome. It adopts a complex systems perspective, exploring how acceptability is a dynamic and contextually contingent concept. Data sources were as follows: interviews with funders (n = 3); interviews with MHFA trainers (n = 6); focus groups with peer supporters (n = 8); interviews with headteachers (n = 12); and focus groups with teachers trained in Schools and Colleges MHFA (n = 7). Results indicated that WISE intervention components were largely acceptable. Initially, the school system was responsive, as it had reached a 'tipping point' and was prepared to address teacher mental health. However, as the intervention interacted with the complexities of the school context, acceptability became more ambiguous. The intervention was seen to be largely inadequate in addressing the structural determinants of teacher mental health and wellbeing (e.g. complex student and staff needs, workload, and system culture). Future teacher mental health interventions need to focus on coupling skills training and support with whole school elements that tackle the systemic drivers of the problem.

Mental health support and training to improve secondary school teachers’ well-being: the WISE cluster RCT

Background

Health and Safety Executive data show that teachers are at heightened risk of mental health difficulties, yet few studies have attempted to address this. Poor teacher mental health may impact on the quality of support provided to young people, who also report increased mental health difficulties themselves.

Objective

To test the effectiveness of an intervention aiming to improve secondary school teachers’ well-being through mental health support and training.

Design

A cluster randomised controlled trial with embedded process and economic evaluations.

Setting

Twenty-five mainstream, non-fee-paying secondary schools in the south-west of England and South Wales, stratified by geographical area and free school meal entitlement, randomly allocated to intervention or control groups following collection of baseline measures (n = 12, intervention; n = 13, control) between May and July 2016.

Participants

All teachers in the study schools at any data collection. All students in year 8 (baseline) and year 10 (final follow-up).

Intervention

Each intervention school received three elements: (1) a 1-day mental health first aid for schools and colleges training session delivered to 8% of all teachers; (2) a 1-hour mental health session delivered to all teachers; and (3) 8% of staff trained in the 2-day standard mental health first aid training course set up a confidential peer support service for colleagues. Control schools continued with usual practice.

Main outcome measures

The primary outcome was teacher well-being (using the Warwick–Edinburgh Mental Wellbeing Scale). Secondary outcomes were teacher depression, absence and presenteeism, and student well-being, mental health difficulties, attendance and attainment. Follow-up was at 12 and 24 months. Data were analysed using intention-to-treat mixed-effects repeated-measures models.

Economic evaluation

A cost–consequence analysis to compare the incremental cost of the intervention against the outcomes measured in the main analysis.

Process evaluation

A mixed-methods study (i.e. qualitative focus groups and interviews, quantitative surveys, checklists and logs) to examine intervention implementation, activation of the mechanisms of change outlined in the logic model, intervention acceptability and the wider context.

Results

All 25 schools remained in the study. A total of 1722 teachers were included in the primary analysis. We found no difference in mean teacher well-being between study arms over the course of follow-up (adjusted mean difference –0.90, 95% confidence interval –2.07 to 0.27). There was also no difference in any of the secondary outcomes (p-values 0.203–0.964 in the fully adjusted models). The average cost of the intervention was £9103 (range £5378.97–12,026.73) per intervention school, with the average cost to Welsh schools being higher because of a different delivery model. The training components were delivered with high fidelity, although target dosage was sometimes missed. The peer support service was delivered with variable fidelity, and reported usage by teachers was low (5.9–6.1%). The intervention had high acceptability, but participants reported low support from senior leadership, and minimal impact on school culture.

Limitations

Participants and the study team were unblinded, self-report for the main outcome measures and inaccurate measurement of peer support service usage.

Conclusions

The Wellbeing in Secondary Education (WISE) intervention was not effective at improving teacher or student well-being, or reducing mental health difficulties, possibly because of contextual barriers preventing it becoming embedded in school life.

Future work

Identification of ways in which to achieve system-level change and sustained support from senior leaders is important for future school-based mental health interventions.

Trial registration

Current Controlled Trials ISRCTN95909211.

Funding

This project was funded by the National Institute for Health Research Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information. Intervention costs were met by Public Health Wales, Public Health England and Bristol City Council.

An intervention to improve teacher well-being support and training to support students in UK high schools (the WISE study): A cluster randomised controlled trial

BACKGROUND

Teachers are at heightened risk of poor mental health and well-being, which is likely to impact on the support they provide to students, and student outcomes. We conducted a cluster randomised controlled trial, to test whether an intervention to improve mental health support and training for high school teachers led to improved mental health and well-being for teachers and students, compared to usual practice. We also conducted a cost evaluation of the intervention.

METHODS AND FINDINGS

The intervention comprised (i) Mental Health First Aid training for teachers to support students; (ii) a mental health awareness session; and (iii) a confidential staff peer support service. In total 25 mainstream, non-fee-paying secondary schools stratified by geographical area and free school meal entitlement were randomly allocated to intervention (n = 12) or control group (n = 13) after collection of baseline measures. We analysed data using mixed-effects repeated measures models in the intention-to-treat population, adjusted for stratification variables, sex, and years of experience. The primary outcome was teacher well-being (Warwick-Edinburgh Mental Well-being Scale). Secondary outcomes were teacher depression, absence, and presenteeism, and student well-being, mental health difficulties, attendance, and attainment. Follow-up was at months 12 (T1) and 24 (T2). We collected process data to test the logic model underpinning the intervention, to aid interpretation of the findings. A total of 1,722 teachers were included in the primary analysis. Teacher well-being did not differ between groups at T2 (intervention mean well-being score 47.5, control group mean well-being score 48.4, adjusted mean difference -0.90, 95% CI -2.07 to 0.27, p = 0.130). The only effect on secondary outcomes was higher teacher-reported absence among the intervention group at T2 (intervention group median number of days absent 0, control group median number of days absent 0, ratio of geometric means 1.04, 95% CI 1.00 to 1.09, p = 0.042). Process measures indicated little change in perceived mental health support, quality of relationships, and work-related stress. The average cost of the intervention was £9,103 per school. The study's main limitations were a lack of blinding of research participants and the self-report nature of the outcome measures.

CONCLUSIONS

In this study, we observed no improvements to teacher or student mental health following the intervention, possibly due to a lack of impact on key drivers of poor mental health within the school environment. Future research should focus on structural and cultural changes to the school environment, which may be more effective at improving teacher and student mental health and well-being.

TRIAL REGISTRATION

www.isrctn.com ISRCTN95909211.

Evaluating the effectiveness and cost effectiveness of the 'strengthening families, strengthening communities' group-based parenting programme: study protocol and initial insights

Background

Up to 20% of UK children experience socio-emotional difficulties which can have serious implications for themselves, their families and society. Stark socioeconomic and ethnic inequalities in children’s well-being exist. Supporting parents to develop effective parenting skills is an important preventive strategy in reducing inequalities. Parenting interventions have been developed, which aim to reduce the severity and impact of these difficulties. However, most parenting interventions in the UK focus on early childhood (0–10 years) and often fail to engage families from ethnic minority groups and those living in poverty. Strengthening Families, Strengthening Communities (SFSC) is a parenting programme designed by the Race Equality Foundation, which aims to address this gap. Evidence from preliminary studies is encouraging, but no randomised controlled trials have been undertaken so far.

Methods/design

The TOGETHER study is a multi-centre, waiting list controlled, randomised trial, which aims to test the effectiveness of SFSC in families with children aged 3–18 across seven urban areas in England with ethnically and socially diverse populations. The primary outcome is parental mental well-being (assessed by the Warwick-Edinburgh Mental Well-Being Scale). Secondary outcomes include child socio-emotional well-being, parenting practices, family relationships, self-efficacy, quality of life, and community engagement. Outcomes are assessed at baseline, post intervention, three- and six-months post intervention. Cost effectiveness will be estimated using a cost-utility analysis and cost-consequences analysis. The study is conducted in two stages. Stage 1 comprised a 6-month internal pilot to determine the feasibility of the trial. A set of progression criteria were developed to determine whether the stage 2 main trial should proceed. An embedded process evaluation will assess the fidelity and acceptability of the intervention.

Discussion

In this paper we provide details of the study protocol for this trial. We also describe challenges to implementing the protocol and how these were addressed. Once completed, if beneficial effects on both parental and child outcomes are found, the impact, both immediate and longer term, are potentially significant. As the intervention focuses on supporting families living in poverty and those from minority ethnic communities, the intervention should also ultimately have a beneficial impact on reducing health inequalities.

Trial registration

Prospectively registered Randomised Controlled Trial ISRCTN15194500.

Depressive and anxiety symptoms in early childhood education teachers: Relations to professional well-being and absenteeism

This study investigated how early childhood education teachers' (N = 444) depressive and anxiety symptoms predicted their professional well-being outcomes and absenteeism over the course of one school year in Ghana. Higher anxiety and depressive symptoms predicted lower job motivation and job satisfaction and higher levels of emotional exhaustion at the end of the school year. Increased depressive symptoms were further associated with more days absent over the course of the school year. Findings point to the importance of considering teachers' mental health for early educational quality. Implications for policy and practice are discussed.

Health and Wellbeing in Higher Education: A Comparison of Music and Sport Students Through the Framework of Self Determination Theory

Students in Higher Education report high levels of mental health issues and psychological distress. Paradoxical findings on performance-orientated students, such as athletes and musicians, suggest that the demands of highly skilled vocations may enhance wellbeing while being detrimental to physical and mental health. To provide timely and appropriate help, institutions need to understand what areas of health and wellbeing are compromised in different student groups. In this study, we compared performance-orientated (music and sport) students to other students and the general population on a selection of wellbeing (WHO5, PWS, and WEMWBS), mental and physical health (K10, SF12, and PHQ9), and trait measures (TIPI, LOT-R, and PCS). Through an online survey (N = 273), data were collected from bachelor and master students (n = 135 music, n = 67 sport, n = 71 controls). Students' scores were compared to the general population, where norm values were available, and analyzed within and between groups. Multiple regression was performed to investigate trait measures as predictors of wellbeing. All groups scored significantly below population norms for wellbeing and mental health. One third were classed as having moderate to severe depression. Musicians scored higher openness to experience than athletes. While sport students showed a highly homogenous within-group profile, music students' scores differed significantly across study courses (e.g., performance and composition). Predictors for wellbeing were: optimism and emotional stability (all students); additionally conscientiousness (sport and music); and perceived competence (music only). As expected, students reported more health and wellbeing issues than general population. Distinct profiles of wellbeing were apparent for performance-orientated students. Results are in line with Self Determination Theory and suggest the need for institutions to embed health and wellbeing into a 'living curriculum' to accommodate the needs of different student groups. The WHO5 emerged as a parsimonious yet sensitive measure for mental health and wellbeing in student populations.

Delivery of a Mental Health First Aid training package and staff peer support service in secondary schools: a process evaluation of uptake and fidelity of the WISE intervention

BACKGROUND

Improving children and young people's provision for mental health is a current health priority in England. Secondary school teachers have worse mental health outcomes than the general working population, which the Wellbeing in Secondary Education (WISE) cluster randomised controlled trial aimed to improve. The WISE intervention comprised a Mental Health First Aid (MHFA) training package delivered to at least 16% of staff, a short mental health awareness session to all teachers and development of a staff peer support service. Twenty-five schools were randomised to intervention or control arms. This paper reports findings regarding the extent of uptake and fidelity of the intervention.

METHODS

Mixed methods data collection comprised researcher observations of training delivery, training participant evaluation forms, trainer and peer supporter interviews, peer supporter feedback meetings, logs of support provided, and teacher questionnaires. Quantitative data were summarised descriptively, while thematic analysis was applied to the qualitative data.

RESULTS

In the 12 schools assigned to the intervention arm, 113 (8.6%) staff completed the 2-day standard MHFA training course, and a further 146 (11.1%) staff completed the 1-day MHFA for schools and colleges training. In seven (58.3%) schools, the required 8% of staff completed the MHFA training packages. A 1-h mental health awareness-raising session was attended by 666 (54.5%) staff. Delivery of the MHFA training package was achieved with high levels of fidelity and quality across schools. All schools set up the peer support service following training, with a majority adhering to most of the operational guidelines developed from the pilot study at the outset. Teachers reported limited use of the peer support service during follow-up. At the 1-year follow-up, only three (25.0%) schools indicated they had re-advertised the service and there was evidence of a reduction in support from senior leadership.

CONCLUSION

The MHFA training package was delivered with reasonably high fidelity, and a staff peer support service was established with general, but not complete, adherence to guidelines. In some schools, insufficient staff received MHFA training and levels of delivery of the peer support service compromised intervention dose and reach.

TRIAL REGISTRATION

ISRCTN 95909211 . Registered on 15 January 2016.

Individual health trainers to support health and well-being for people under community supervision in the criminal justice system: the STRENGTHEN pilot RCT

Background

Little is known about the effectiveness or cost-effectiveness of interventions, such as health trainer support, to improve the health and well-being of people recently released from prison or serving a community sentence, because of the challenges in recruiting participants and following them up.

Objectives

This pilot trial aimed to assess the acceptability and feasibility of the trial methods and intervention (and associated costs) for a randomised trial to assess the effectiveness and cost-effectiveness of health trainer support versus usual care.

Design

This trial involved a pilot multicentre, parallel, two-group randomised controlled trial recruiting 120 participants with 1 : 1 individual allocation to receive support from a health trainer and usual care or usual care alone, with a mixed-methods process evaluation, in 2017–18.

Setting

Participants were identified, screened and recruited in Community Rehabilitation Companies in Plymouth and Manchester or the National Probation Service in Plymouth. The intervention was delivered in the community.

Participants

Those who had been out of prison for at least 2 months (to allow community stabilisation), with at least 7 months of a community sentence remaining, were invited to participate; those who may have posed an unacceptable risk to the researchers and health trainers and those who were not interested in the trial or intervention support were excluded.

Interventions

The intervention group received, in addition to usual care, our person-centred health trainer support in one-to-one sessions for up to 14 weeks, either in person or via telephone. Health trainers aimed to empower participants to make healthy lifestyle changes (particularly in alcohol use, smoking, diet and physical activity) and take on the Five Ways to Well-being [Foresight Projects. Mental Capital and Wellbeing: Final Project Report. 2008. URL: www.gov.uk/government/publications/mental-capital-and-wellbeing-making-the-most-of-ourselves-in-the-21st-century (accessed 24 January 2019).], and also signposted to other options for support. The control group received treatment as usual, defined by available community and public service options for improving health and well-being.

Main outcome measures

The main outcomes included the Warwick–Edinburgh Mental Well-being Scale scores, alcohol use, smoking behaviour, dietary behaviour, physical activity, substance use, resource use, quality of life, intervention costs, intervention engagement and feasibility and acceptability of trial methods and the intervention.

Results

A great deal about recruitment was learned and the target of 120 participants was achieved. The minimum trial retention target at 6 months (60%) was met. Among those offered health trainer support, 62% had at least two sessions. The mixed-methods process evaluation generally supported the trial methods and intervention acceptability and feasibility. The proposed primary outcome, the Warwick–Edinburgh Mental Well-being Scale scores, provided us with valuable data to estimate the sample size for a full trial in which to test the effectiveness and cost-effectiveness of the intervention.

Conclusions

Based on the findings from this pilot trial, a full trial (with some modifications) seems justified, with a sample size of around 900 participants to detect between-group differences in the Warwick-Edinburgh Mental Well-being Scale scores at a 6-month follow-up.

Future work

A number of recruitment, trial retention, intervention engagement and blinding issues were identified in this pilot and recommendations are made in preparation of and within a full trial.

Trial registration

Current Controlled Trials ISRCTN80475744.

Funding

This project was funded by the National Institute for Health Research Public Health Research programme and will be published in full in Public Health Research; Vol. 7, No. 20. See the National Institute for Health Research Journals Library website for further project information.

Is teachers' mental health and wellbeing associated with students' mental health and wellbeing?

BACKGROUND

Factors within the school environment may impact young people's mental health and wellbeing. The aim of this study was to understand the association between teacher and student mental health and wellbeing. Further, it seeked to identify possible explanations by examining whether the strength of any association is weakened once quality of teacher-student relationships, teacher presenteeism and absence are considered.

METHODS

Cross-sectional data were collected from 3216 year 8 (aged 12-13 years) students and from 1182 teachers in 25 secondary schools in England and Wales. The association between teacher wellbeing (measured by Warwick Edinburgh Mental Wellbeing Scale (WEMWBS)) with student wellbeing (WEMWBS) and with student psychological distress (Total Difficulties Score (TDS)) was assessed using Random Effects Mixed Models. Analyses were repeated using teacher depression (measured by Patient Health Questionnaire) as the explanatory variable.

RESULTS

Better teacher wellbeing was associated with i) better student wellbeing (standardised effect = 0·07, 95% CI = 0·02 to 0·12) and ii) lower student psychological distress (standardised effect = -0·10, 95% CI = -0·16 to -0·04). Teacher presenteeism and the quality of the teacher-student relationship appeared to be on the pathway of these relationships. Higher levels of teacher depressive symptoms were associated with poorer student wellbeing and psychological distress (standardised effect = -0·06, 95% CI = -0·11 to -0·01 & 0·09, 95% CI = 0·03 to 0·15). This association did not withstand adjustment for teacher presenteeism.

LIMITATIONS

Cross sectional in design so unable to establish temporal associations.

CONCLUSIONS

Associations were found between teacher wellbeing and student wellbeing and psychological distress. There were also an association between teacher depression and student wellbeing. Both may be partially explained by teacher presenteeism and quality of teacher-student relationships.

A Transdisciplinary Complex Adaptive Systems (T-CAS) Approach to Developing a National School-Based Culture of Prevention for Health Improvement: the School Health Research Network (SHRN) in Wales

The paper reflects on a transdisciplinary complex adaptive systems (T-CAS) approach to the development of a school health research network (SHRN) in Wales for a national culture of prevention for health improvement in schools. A T-CAS approach focuses on key stages and activities within a continuous network cycle to facilitate systems level change. The theory highlights the importance of establishing transdisciplinary strategic partnerships to identify and develop opportunities for system reorientation. Investment in and the linking of resources develops the capacity for key social agents to take advantage of disruption points in the re-orientated system, and engagement activities develop the network to facilitate new social interactions and opportunities for transdisciplinary activities. A focus on transdisciplinary action research to co-produce interventions, generate research evidence and inform policy and practice is shown to play an important part in developing new normative processes that act to self-regulate the emerging system. Finally, the provision of reciprocal network benefits provides critical feedback loops that stabilise the emerging adaptive system and promote the network cycle. SHRN is shown to have embedded itself in the system by securing sustainability funding from health and education, a key role in national and regional planning and recruiting every eligible school to the network. It has begun to reorient the system to one of evidence generation (56 research studies co-produced) and opportunities for data-led practice at multiple levels. Further capacity development will be required to capitalise on these. The advantages of a complex systems approach to address barriers to change and the transferability of a T-CAS network approach across settings and cultures are highlighted.

Multilevel analysis of personality, family, and classroom influences on emotional and behavioral problems among Chinese adolescent students

Background

The classroom environment plays a potentially important role in shaping the emotions and behavior of adolescents. However, few studies have focused on this factor. The aim of this study was to explore the association between the classroom environment and emotional and behavioral problems among Chinese adolescents while also considering personality-and family-related factors.

Methods

This cross-sectional study was conducted in November and December, 2009. A set of questionnaires, including the Strengths and Difficulties Questionnaire (SDQ), the Eysenck Personality Questionnaire (EPQ), the Family Environment Scale (FES), the Questionnaire on Teacher Interaction (QTI), and the Center for Epidemiological Studies- Depression Scale (CES-D), were distributed to participants. A total of 5,433 Chinese adolescent students (aged 9–18) and 244 classroom teachers in Liaoning Province were ultimately included in the study. Hierarchical linear modeling was used to explore the factors associated with emotional and behavioral problems.

Results

Multilevel analyses revealed that adolescent emotional and behavioral problems significantly varied among classrooms. Although personality and family characteristics exerted the greatest influence on adolescents’ emotions and behavior at the individual-level, interactions between classroom teachers and students increasingly affected adolescents with respect to age at the class-level. A mild positive association was found between adolescents’ mental health problems and the mental health of teachers.

Conclusion

This study focused on the classroom environment in order to understand Chinese adolescent mental health problems, the findings of which highlight important implications for policymakers and educators. The results underscore the importance of establishing a comfortable classroom climate by improving teacher-student interactions and meeting specific needs at different school stages, thus promoting a climate of positive mental health among Chinese adolescents.

A cluster randomised controlled trial of the Wellbeing in Secondary Education (WISE) Project - an intervention to improve the mental health support and training available to secondary school teachers: protocol for an integrated process evaluation

BACKGROUND

Secondary school teachers have low levels of wellbeing and high levels of depression compared with the general population. Teachers are in a key position to support students, but poor mental health may be a barrier to doing so effectively. The Wellbeing in Secondary Education (WISE) project is a cluster randomised controlled trial (RCT) of an intervention to improve the mental health support and training available to secondary school teachers through delivery of the training package Mental Health First Aid and a staff peer support service. We will conduct a process evaluation as part of the WISE trial to support the interpretation of trial outcomes and refine intervention theory. The domains assessed will be: the extent to which the hypothesised mechanisms of change are activated; system level influences on these mechanisms; programme differentiation and usual practice; intervention implementation, including any adaptations; intervention acceptability; and intervention sustainability.

METHODS

Research questions will be addressed via quantitative and qualitative methods. All study schools (n = 25) will provide process evaluation data, with more detailed focus group, interview and observation data being collected from a subsample of case study schools (4 intervention and 4 control). Mechanisms of change, as outlined in a logic model, will be measured via teacher and student surveys and focus groups. School context will be explored via audits of school practice that relate to mental health and wellbeing, combined with stakeholder interviews and focus groups. Implementation of the training and peer support service will be assessed via training observations, training participant evaluation forms, focus groups with participants, interviews with trainers and peer support service users, and peer supporter logs recording help provided. Acceptability and sustainability will be examined via interviews with funders, head teachers, trainers and peer support services users, and focus groups with training participants.

DISCUSSION

The process evaluation embedded within the WISE cluster RCT will illuminate how and why the intervention was effective, ineffective or conferred iatrogenic effects. It will contribute to the refinement of the theory underpinning the intervention, and will help to inform any future implementation.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number: ISRCTN95909211 registered on 24 March 2016.

A Mental Health Survey of Different Ethnic and Occupational Groups in Xinjiang, China

Poor mental health has become a serious social and public health-care burden. This cross-sectional study used multistage stratified cluster random sampling to gather mental health information from 11,891 adults (18-60 years) employed in various occupations categorized according to the Chinese Standard Occupational Classification. Mental health was measured by the General Health Questionnaire, and participants exceeding the cut-off score were defined as having poor mental health. The overall prevalence of poor mental health was 23.8%. The prevalence of poor mental health was significantly higher in the Han ethnic group than Kazak ethnic group and in health-care workers, teachers, and civil servants compared to manual workers. Females (odds ratios (OR) = 1.139, 95% confidence intervals (CI): 1.012-3.198) and knowledge workers (1.697, 1.097-2.962) were risk factors for poor mental health, while Kazak ethnicity (0.465, 0.466-0.937), other minority status (non-Han) (0.806, 0.205-0.987), and working ≥15 years in the same occupation (0.832, 0.532-0.932) were protective (p < 0.05). We concluded that the general level of mental health in Xinjiang, China, is higher in the Kazak ethnic group than the Han ethnic group. The prevalence of poor mental health is higher among knowledge workers than in manual workers due to high incidences of poor mental health in civil servants, health-care workers, and teachers.