Introduction

Background

Young people’s mental health

Mental disorders among 11- to 15-year-olds in the UK have risen in recent years, particularly among girls experiencing emotional disorders, with 13.6% among this age group identified as having one or more disorders.1 Cohort studies indicate that levels of distress and difficulty in the early teenage years are increasing,2 with 25.7% of teenagers aged 14–15 years, and as many as 37.4% of girls in this age group, reporting high levels of psychological distress.3 There is also evidence that self-harm is increasing among young people in the early to mid-teenage years, particularly among girls.2,4 Intervening early to support young people’s mental health is important to avoid the development of more serious and long-term problems,5 as approximately half of all adult mental disorders begin during adolescence.6

Given that only 25% of children and young people with a diagnosable condition are able to access Child and Adolescent Mental Health Service (CAMHS) support,7 it is vital that non-specialist settings, including schools, where most children and young people spend a great deal of their time, are equipped to engage in early prevention work and support those at risk of developing a mental health problem. A large number of school-based studies seeking to improve children and young people’s mental health focus on developing individual coping skills or mental health literacy. There is mixed evidence as to the effectiveness of such programmes. A recent systematic literature review8 found some effects on prevention or reduction of anxiety and depression for a short time. However, a recent network meta-analysis9 did not find such positive results and concluded that previously observed effects may be driven by differential control group effects.

As well as attempting to develop young people’s own skills and knowledge regarding mental health maintenance, it is important to consider changes to the school environment to ensure that it is supportive of mental health. Research has shown that teachers are the professionals that teenagers are most likely to talk to about mental health difficulties,10 and also that perceived supportive relationships with school staff can be protective of future depression for students in secondary schools.11 Conversely, difficult teacher–student relationships among this age group predict mental health problems and future exclusion.12 Despite the importance of positive relationships with teachers for student mental health, many teachers report a lack of training in how to support students.13,14 In a questionnaire commissioned by the Department for Education in 2015, 52% of respondents working in schools identified training for staff as an important strategy to support student mental health.15 The government’s pledge to train one senior lead on mental health in every secondary school in England16 is unlikely to go far enough in terms of strengthening all teachers’ ability to develop supportive relationships with students, and to know how to help those at risk of poor mental health.

Teachers’ mental health

In addition to a lack of training, another barrier to teachers providing appropriate support to students is their own poor mental health and well-being.17,18 Health and Safety Executive data for Great Britain consistently show teaching professionals to have higher rates of work-related stress, anxiety and depression (recent figures show a rate of 3020 per 100,000 for teaching and education professionals vs. a rate of 1320 per 100,000 for all industries).19 Causes of these heightened levels of work-related stress and distress have been identified as excessive workload, lack of autonomy, poor salary, perceived lack of status, challenging student behaviour, difficult relationships with colleagues and managers, and pressure to ‘perform’ in a context in which schools are increasingly regulated and judged against an array of externally determined targets.20–23 These stressors may be exacerbated by a culture in which teachers feel unable or unwilling to ask for help.3,24 Failure to support teachers experiencing such difficulties may lead to longer-term mental health problems, presenteeism (i.e. going to work when one is mentally or physically ill) and sickness absence or quitting the profession.25–28 Presenteeism for teachers may result in difficulty managing classroom behaviour effectively and supporting vulnerable students,29,30 both of which may impact on student mental health.31

Interventions to improve teacher–student relationships

A small number of previous studies have attempted to enhance teachers’ support of students with the aim of improving student outcomes. The INCLUSIVE study32 found that a whole-school approach to strengthening relationships among students and between students and teachers reduced bullying and psychological difficulties among UK secondary school students. The Supporting Teachers and Children in Schools (STARS) trial33 found that the Incredible Years training, which aims to improve school teachers’ classroom management skills and strengthen teacher–student relationships in UK primary schools, led to a short-term (9-month) improvement in student mental health, although this was not sustained. The Saving and Empowering Young Lives in Europe (SEYLE) trial,34 conducted across 10 European countries, compared the impact of three interventions on suicidal ideation and attempts among secondary school students: (1) training school staff to recognise and support at-risk students, (2) delivering a mental health awareness programme to students and (3) screening and referral of at-risk students by professionals. This trial found that only the awareness raising intervention had an impact on suicide ideation and attempts, although the other interventions showed promise, with the confidence intervals (CIs) overlapping across the three. The authors suggested that the smaller effect of the staff training element may have been because poor teacher well-being reduced teachers' ability to support students.30

Workplace interventions to support mental health

No previous studies have evaluated the impact of improving support for teachers’ own mental health alongside improving their skills in supporting students. A number of reviews have examined the effectiveness of workplace interventions that aim to reduce stress or improve mental health, and report that approaches such as cognitive–behavioural therapy, self-help, exercise and mindfulness interventions have all been found to be effective at reducing workplace depression and other common mental disorders.35–38 The only systematic review39 that looked at interventions to support teachers’ mental health specifically investigated the impact of organisational-level change. Of the four studies included in this review, one looked at changing teachers’ tasks (e.g. establishing flexible work schedules) and reported a resultant reduction in work stress and small increase in performance. Two studies evaluated coaching support, but found no effects on anxiety, depression or burnout. The final study found that a multicomponent programme, which included performance bonus pay, job promotion opportunities and mentoring, led to reductions in teacher resignations. However, the authors note that the quality of studies was poor.

Social support has been found to be protective for mental health in the workplace.40 Bricheno et al.,41 in their review of teacher well-being, identified evidence from questionnaires and case studies that teachers themselves view support from colleagues, senior staff and head teachers as an important factor. Workplace peer support has been identified as helpful because of its contribution towards establishing a supportive culture, its basis in shared experience and understanding of workplace challenges, and its avoidance of the perceived stigma attached to more formal help sources.42,43 However, the evidence base is limited and has tended to focus on peer education to engender behavioural change (e.g. increasing screening uptake or healthy eating).44,45 A number of peer support schemes have been set up in occupations requiring emotional labour or that potentially involve traumatic experiences, such as health-care professionals, but these rarely produce published evaluations. One published example of a peer support scheme for health-care workers43 described the following features as important: credibility of peers, immediate availability, voluntary access, confidentiality, emotional first aid (as opposed to therapy) and facilitated access to next level of support. Social support is conceptualised as comprising problem-focused and emotion-focused supportive strategies, both of which have been found to have a positive impact on physical and mental health.46 A review42 of peer support schemes suggests that they provide a combination of informational, emotional and instrumental support.

Mental health first aid training in the workplace

Mental health first aid (MHFA) training has been delivered in the workplace as one way of improving support.47 MHFA is an internationally recognised training package that is designed to improve lay people’s knowledge of the signs and symptoms of developing mental disorders, and their confidence in helping those in mental health crisis.48 Course attendees are taught to follow five steps when approaching another person who requires support: approach the person, assess and assist with any crisis; listen non-judgementally; give support and information; encourage the person to get appropriate professional help; encourage other supports (ALGEE). A number of studies have provided evidence that MHFA training is effective in improving knowledge, confidence in helping others and intention to help others, as well as reducing stigmatising attitudes.49 MHFA delivered in the workplace has been found to provide a number of benefits: encouraging social support,50 increasing self-reported help-seeking from professionals47,50 and improving the mental health of course participants themselves.47 Participants generally express very positive attitudes towards the training, reporting gains in knowledge and skills, and improved ability to provide help to those around them by using that learning.51–53 Despite high participant acceptability, and evidence of improved mental health literacy and intention to help, no study has yet been able to show impact of MHFA training on mental health outcomes.49 However, a shorter training programme that focused on improving knowledge and communication around mental health when delivered to senior managers in a large fire and rescue service did lead to a decrease in absence rates among the staff whom trainees managed.54

Mental health first aid training in schools

A version of MHFA, the youth MHFA, has been designed specifically for adults supporting young people, using the same ALGEE model. Although the full version has not been evaluated, a randomised controlled trial (RCT) tested a shortened version delivered to secondary school teachers in Australia.55 At 6 months’ follow-up, this study reported improvements to teachers’ knowledge and confidence to help students and colleagues, but there were no changes in the actual help that teachers gave to students or in student mental health. However, the intervention did not attempt to improve support for the teachers’ own mental health. We sought to build on this study by addressing teachers’ own support needs, alongside the training in how to support students.

Rationale for the current study

To date, school intervention studies have focused on improving student mental health, with the majority of studies evaluating classroom-based psychological or educational approaches. Very few studies have focused on training teachers to support vulnerable students through their day-to-day interactions, despite the role of teachers in identifying and attending to students’ mental health problems, as demonstrated in the research literature14,56 and recommended in key policy and guidance documents, such as the Department for Education’s Mental Health and Behaviour in Schools.57 Furthermore, no studies have developed and evaluated an intervention that focuses on teachers’ own mental health, despite evidence that they are a group at risk of poor mental health, and that this is likely to influence the health and attainment of those they teach. We therefore developed an intervention in consultation with teachers and public health specialists working with schools, which addressed these gaps and which we planned to evaluate. The Wellbeing in Secondary Education (WISE) trial was the result of this process.

The Wellbeing in Secondary Education feasibility and pilot trial

In line with Medical Research Council guidance for the evaluation of complex interventions,58 we undertook a pilot cluster RCT of the WISE intervention in six secondary schools to explore its feasibility and acceptability.59 The intervention comprised (1) 2-day standard MHFA training for school staff who went on to set up a peer support service for colleagues and (2) 2-day youth MHFA training for school staff to improve the support they were able to provide to students. The pilot trial also enabled us to test the feasibility of key aspects of the trial design, including the collection of outcome measures and the recruitment and retention of schools, and to develop a logic model as to the likely pathways by which the intervention might have an effect on the outcomes of interest (Figure 1). Key findings from this pilot were as follows:

• Schools from a range of socioeconomic catchment areas were able to be recruited and retained, although it was necessary to make personal contact with a relevant member of staff to ensure this.
• Measures of staff and student mental health, and staff presenteeism and absence were able to be collected at baseline and at 12-month follow-up (T1). Data were collected during meetings and not left to individuals to complete in their own time.
• Staff viewed MHFA training as relevant and useful in terms of knowledge gain and opportunities to reflect on mental health, although a shorter version of the youth MHFA course that focused on practical strategies was suggested.
• Staff peer supporters were able to be recruited and trained in each school. A mean of at least two interventions per peer supporter over a 2-week period was reported, and the service was viewed positively by staff. However, barriers to using the service were identified, specifically concerns around confidentiality, a preference for talking to pre-established social networks and lack of knowledge about the service.
• Unlike the earlier study of youth MHFA in schools,55 we found that, at follow-up, students in the intervention schools had higher well-being (WEMWBS score 48.1 vs. 45.8; p = 0.12) and lower levels of mental health difficulties (SDQ total difficulties scale score 11.2 vs. 13.2; p < 0.01) than those in the control schools, once adjusted for baseline measures.
• Staff who received the MHFA training had improved mental health knowledge and well-being, and lower depression than all other staff, as reported in earlier MHFA studies.49
• There were no differences between study arms regarding staff well-being and depression, but we were not powered to detect such changes, nor were we able to examine sustainability as the study only ran for 12 months.

FIGURE 1 Logic model of the WISE intervention. Reproduced with permission from Kidger et al.60 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure. (Figure not reproduced here; see the original article.)

We concluded that the results regarding feasibility and acceptability of the pilot intervention and evaluation were sufficiently positive to justify a full RCT, powered to measure the effect of the intervention on outcomes, and this is the trial reported here.

The present trial

The WISE trial is a full cluster RCT with integrated process and economic evaluations.61 It tested the effectiveness of a complex intervention that delivered mental health support for teachers and training in supporting student mental health, with the aim of improving teacher mental health and performance, and subsequently improving student mental health and attainment, through the mechanisms of change identified in the logic model (see Figure 1).

Objectives

The primary objective was to establish if the WISE intervention leads to improved teacher emotional well-being compared with usual practice.

The secondary objective was to answer the following research questions:

• Does the WISE intervention lead to lower levels of teacher depression, absence and presenteeism, improved student well-being, attendance and attainment, and reduced student mental health difficulties, compared with usual practice?
• Do any effects of the intervention differ according to the proportion of children receiving free school meals (FSM) (an indicator of the socioeconomic catchment area) and geographical area, or individual-level baseline mental health, sex, ethnicity and FSM?
• What is the cost of the WISE intervention, and is it justified by improvements to staff and student well-being, and reductions to staff depression and student difficulties?
• Does the WISE intervention work according to the mechanisms of change hypothesised in the logic model?
• Is the WISE intervention sustainable?

The intervention: underlying theory

The WISE intervention is informed by social support theory. Social support can offer problem-focused coping strategies and emotion-focused supportive strategies, both of which can have a positive impact on physical and mental health.46 Based on findings from the pilot trial,59 we hypothesised that peer supporters would provide both emotion-focused support (e.g. by listening non-judgementally) and problem-focused support (e.g. by offering practical suggestions for solutions to work-based difficulties), where appropriate. Perceived availability of social support may be even more important to mental health than actual support,46 and, therefore, the existence of a peer-delivered support service was theorised to have a positive impact on teacher well-being, regardless of actual service utilisation. The programme theory was further informed by an ecological view of school connectedness, which considers the quality of social bonds and interactions within a school to be a characteristic of the whole-school environment or culture.46 Improvement to teachers’ own mental health and well-being via supportive relationships with peers should lead to more positive teacher–student relationships,61 which is associated with improved student mental health.12 Therefore, all teachers and students within an intervention school may benefit, regardless of whether or not they themselves directly engage with the intervention. Furthermore, a change made from the pilot to the full intervention was that all teachers were offered a shorter version of mental health training, with the aim of improving interactions between all teachers and students, and enabling all teachers to have a better insight into their own mental health (see Figure 1).

The intervention: description of components

Each intervention school received the following.

Staff peer support service

Following the methods developed and found to be acceptable in the pilot study, all teachers in the intervention schools were invited to nominate colleagues whom they considered would make good peer supporters, via a confidential, anonymous written questionnaire completed at baseline before randomisation. The study population was teaching staff only, because pilot findings showed that this was the group most at risk of poor mental health and because of practical difficulties collecting data from all staff. However, the peer support service was available to all staff, as our patient and public involvement work with school staff identified that a service for teachers only may prove divisive. A list was compiled of the 8% of staff with the most nominations, ensuring a mixture of sex, years of experience and teaching/non-teaching roles. The one exclusion criterion was being a member of the senior leadership team, as pilot findings indicated that staff might not use a support service that included senior leaders because of concerns about performance management. Those on the list were invited to attend the 2-day standard MHFA training and become a staff peer supporter. The MHFA training was generally delivered on school premises (one school had the training at a university, and one school shared the training with another school and attended it there). Schools were offered reimbursement for cover costs for teaching staff. A short session about setting up the peer support service and expectations around this was included in the 2-day training, either delivered by the MHFA trainer (England) or by a study team member (Wales). Following the training, participants were provided with guidelines for setting up the peer support service, developed from patient and public involvement work and pilot study findings (see Report Supplementary Material 1). These guidelines covered confidentiality, advertising the service, support for the peer supporters, communication with the research team and practical considerations, such as where support would be provided. An example policy document including a confidentiality statement drawn up by a pilot school and posters for advertising the service were also provided.

Teacher training in mental health first aid for schools and colleges

At least 8% of all teaching staff who had not received the 2-day peer supporter MHFA training received the 1-day MHFA training for schools and colleges. In our pilot study, findings suggested that teachers who have a support role but who have not received prior mental health training, such as tutors or heads of year, would benefit the most. Schools were, therefore, encouraged to select teachers in such roles to attend, but the ultimate decision about who did attend was made by schools. The aim was to train 8% of the teachers, but schools were free to train up to 16 staff, which is the course maximum. The full 2-day youth MHFA course was made available to staff in our pilot schools, but mainstream teachers were often unable to attend because of its length. Partly in response to these findings, the 1-day MHFA for schools and colleges was developed by MHFA England (London, UK). When possible, this training was delivered during in-service training time to ensure that it was as accessible as possible for teachers. Having completed the training, staff were expected to apply the MHFA learning about how to respond to, and support, a student in distress in their day-to-day interactions with students. The decision to train a different 8% (minimum) of staff in each version of the course meant that 16% of staff were trained in total. A previous study using peer influence to address smoking behaviour found an effect when 16% of students were trained as peer educators.62

Mental health awareness raising session for all teachers

A 1-hour training session aimed at raising awareness of mental health and to introduce self-help strategies, ways to support other people and the peer support service, was delivered either during in-service training or during staff meeting time. This session was co-produced with a MHFA trainer and drew on core MHFA content, and was delivered by the same team of MHFA trainers that delivered the rest of the training. All teaching staff were invited to attend and schools were also free to invite other non-teaching staff. This element of the intervention was added in response to pilot findings, which suggested that some staff were unaware of the peer support service in their schools, and to strengthen the whole-school nature of the intervention.

Detailed information about the content of the MHFA courses can be seen in Report Supplementary Material 2, where we provide an outline of the observation schedule (see also Chapter 2, Data sources). Further information about MHFA courses can be found on the MHFA England website (URL: www.mhfaengland.org).

The control

The comparison schools continued with usual practice in terms of teacher support and training. The details of what this entailed in practice were examined via an audit as part of the process evaluation (see Chapter 2) and results are reported in Chapter 4. Schools signed a research agreement, stating that they would not access MHFA training during the study.

Implementation strategy

Different models for implementing the training were deployed in England and Wales because of the intervention funders in Wales (Public Health Wales, Cardiff, UK) wishing to make use of existing resources and infrastructure to ensure sustainability if the intervention was found to be effective.

In intervention schools in England, the standard MHFA, the MHFA for schools and colleges, and the 1-hour awareness training was delivered by local independent trainers who had attended MHFA instructor training and received certification. Learning from the pilot indicated that trainers needed to have awareness of the school context and challenges faced by teachers, and two of the three trainers had extensive experience of delivering training to schools. In Wales, seven healthy schools co-ordinators (HSCs) attended a 6-day bespoke MHFA instructor training course, received certification and went on to deliver the three strands of training in the intervention schools. HSCs are employed by local authorities or Public Health Wales and are responsible for monitoring and accrediting schools participating in the Welsh Network of Healthy Schools Scheme. HSCs are experienced in delivering training to schools; however, because they were new to MHFA training, they delivered the training in pairs as per MHFA England protocol.

Originally, the training was intended to be delivered within a single academic term (September–December 2016). However, a small number of schools completed the training in January 2017 because of their staff training schedule, and one school did not receive the 1-day MHFA for schools and colleges training until June 2017 because of a change of leadership creating a delay. The order in which training components were delivered was not prespecified to accommodate the constraints and needs of each school. All intervention schools received all three training components.

For the establishment of the peer support services, peer supporters were asked to meet within 3–4 weeks of completing the standard MHFA training course to plan the logistics of running the service, and to develop a confidentiality policy and advertising strategy.

Summary of the remaining document

In the following chapter, we outline the methods used for the main statistical analysis, the economic evaluation and the process evaluation. In Chapter 3 we present the main outcomes and economic evaluation findings. Chapter 4 presents the process evaluation findings, and we discuss the findings and implications in Chapter 5.