Running head: MENTAL HEALTH TRAINING

Mental Health Training: Pathway to Early Mental Health Intervention
Elizabeth Mazhuvencherry
Arizona State University

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Abstract

There is an increase in the prevalence of mental health problems in the United States.
Healthy People 2020’s leading mental health indicator is to increase the delivery of care to those
with mental health issues and lower the number of youth who experience a major depressive
disorder. Teachers and non-teaching staff are well placed in the community to identify youth
undergoing emotional distress and facilitate early interventions, yet do not receive adequate
training in mental health. A project was undertaken to determine if a mental health training
intervention affected the community youth mentors knowledge, attitude and self-efficacy
towards helping youth with mental health issues. Three instruments with good validity and
reliability namely Mental Health Literacy Scale (MHLS), Attitudes to Severe Mental Illness
(ASMI) scale, and Gatekeeper Behavior Scale were used in pre intervention, immediately post
intervention and two weeks post intervention questionnaires. The Wilcoxon Signed Ranks test
indicated changes in the pre and post intervention scores as significant in knowledge, and
attitude between pre intervention and immediately post intervention time periods. Cohen’s effect
size value suggested large, medium, small, and minimum clinical significance in the variables
over period of time. Mental health literacy narrows the gap between symptom onset and
intervention. Numerous mental health trainings are currently available worldwide. Schools and
after school clubs in collaboration with hospital mental health and other community agencies are
better equipped to bridge the gap. School staff report better confidence in addressing mental
health and behavioral health issues among youth when equipped with additional resources within
the school in the form of psychologists, social workers, and counselors.
Keywords: non-teaching staff, mental health training, youth mentors, major depressive
disorder

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The World Health Organization defines health as a state of complete physical, mental and
social well- being and not merely the absence of disease or infirmity. It has also identified mental
health as a state of complete wellbeing without psychological distress and impaired functioning
(Delfabbro et al., 2018). Psychological wellbeing is a state in which individual flourishes
emotionally and is able to reach goals, and thrive. An estimated 50% of adults suffering from
psychological syndromes reported having its onset before 15 years of age (O’Reilly et al., 2018).
Problem Statement
Death by suicide is the second leading cause of death among youth aged 10 to 34 and
50% of all lifetime cases of mental illness begin by 14 years of age (National Alliance on Mental
Illness [NAMI]. (2019). The average delay between the onset of illness manifestation and
interventions is 11 years, and only 50.6 % of youth 6 to 17 years of age with mental health
disorder received mental health services in 2016 (NAMI, 2019). Self-harm is a leading public
health issue concerning adolescents internationally with a lifetime prevalence estimated at 16.1%
to 18% in adolescents 11- 18 years of age (Townsend et al., 2018).
Children in Arizona spend an average of 6.43 hours per day and an average of 181 days
per year in school (National Center for Education Statistics [NCES], 2008). Despite the integral
role teachers and non-teaching staff play in mental health services in schools, they receive
limited training to support the mental health of children (Ball et al., 2016). Nationwide, currently
there is shortage of 6.4 percent of the psychiatrists we need and 15,000 behavioral health
practitioner shortages by 2025 (Nenn, 2017). Over one-half of teachers and non-teaching staff
are unable to identify traumatic stress in children (Long, Albright, McMillan, Shockley, & Price,
2018). They also do not possess knowledge regarding the procedures for referral, or obtaining
additional resources, which make them less supportive to traumatized children (Le et al., 2017).

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They feel overwhelmed in handling mental health needs due to their lack of knowledge (Imran,
Rahman, Chaudhry & Asif, 2018).
Purpose and Rationale
Healthy people 2020’s leading mental health indicator is to increase the number of
children with mental health problems who receive treatment and reduce the number of
adolescents 12 - 17 years of age who experience major depressive disorder (Office of Disease
Prevention and Health Promotion [ODPHP], 2014). Teachers and non-teaching staff have an
integral role in school mental health and specific training in mental health literacy will lead to
early detection and referral in mental health of children. Desired outcomes include an increase in
youth mentors and non-teaching staff’s knowledge and beliefs regarding mental health, which
will influence how they respond to children mental health crises. They will not feel overwhelmed
and incompetent from lack of knowledge, and skills in the area of mental health. They will
promote positive mental health and a sense of connectedness among stakeholders. They will
experience reduction of stigma, knowledge improvement and confidence in providing support to
the students.
A project was undertaken to examine if the implementation of an evidence- based mental
health training will impact the knowledge, attitude and self-efficacy of youth mentors at after
school club.
Background & Significance
Children and adolescents fail to receive adequate treatment for disorders related to mental
health, with only 24% of children 6- 11 years of age receiving psychotherapy compared to 33 %
who received psychotropic medications (Long, Albright, McMillan, Shockley, & Price, 2018).
Mental health problems result in truancy, repeating a grade, dropping out of school, suicidal

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thoughts and attempts, and developing internalizing and externalizing mental health disorders
(Schulte-Korne, 2016). In 2019, in the United States, 17% of youth, 6- 17 years of age
experienced a mental health disorder and only 51% received treatment (NAMI, 2019).
Being bullied is often associated with depressive symptomatology, suicidal behaviors,
self-harm, suicide attempt, higher somatization scores, more functional neurological symptoms,
and anxiety (John et al., 2018). There is strong evidence supporting the relationship between
bullying victimization and hospitalization for acute psychiatric illness (Leader et al., 2018).
Environmental triggers along with genetic predisposition lead to emergence of personality
disorders in adolescents. If untreated, adolescents are at risk of experiencing significant social,
educational, employment and financial impairments later in life (Townsend et al., 2018).
Teachers and non-teaching staff are strategically positioned in community settings to
bridge the gap in delay in mental health services. Evidence suggests that teachers do not receive
training to address students’ mental health problems. Lack of training in early detection of
psychological distress contributes to delay in intervention and accessing mental health services
(Ball et al., 2016). Nationwide, there is shortage of behavioral health practitioners, and this
shortage is predicted to nearly double by 2025 (Nenn, 2017). There exists disparities in providing
services, with only 24% of children, aged 6 to 11 receiving psychotherapy compared to 33 %
who received psychotropic medications (Long, Albright, McMillan, Shockley, & Price, 2018).
Teachers and non-teaching staff report lack of adequate training and resource availability in
addressing youth mental health problems (Ball et al., 2016). Youth experiencing psychological
distress will likely experience truancy, repeating a grade, school drop-out, suicidal thoughts and
attempts, developing internalizing, and externalizing mental health disorders (Schulte-Korne,
2016). The ripple effect of mental illness includes higher chances of cardiovascular and

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metabolic diseases, higher rates of unemployment, higher rates of school drop outs, and
substance use disorder. Per data updated in 2020 on NAMI website from CDC (Centers for
Disease Control and Prevention), in the US, the revenue lost in providing care for serious mental
illness were $193.2 billion dollars, and 60% of U.S. counties do not have a single practicing
psychiatrist.
There is an increase in mental health disorders among youth over the last two decades
with greater interest in youth mental health worldwide. The high incidence of onset of mental
health disorders before 25 years of age and its persistent impact results in social and economic
burden. Additional challenges include delay in initial assessment and access to care; lack of
family involvement; youth to adult care transitioning challenges; and high rate of discontinuation
from services (Malla et al., 2018). A recent systematic review shows clear evidence that
adolescents with mental health issues have suboptimal academic performance and
unemployment. Additional factors contributing to poor mental health include social exclusion,
cannabis use, alcohol use and smoking (Hale &Viner, 2018). Mental health training programs
without doubt equip teachers and school staff to recognize mental health difficulties. Mental
health training programs offer a basic understanding to help with children’s mental health issues,
facilitating early identification and intervention. Mental Health First Aid USA and ALGEE
(Assess for risk of suicide; Listen non-judgmentally; Give reassurance and information;
Encourage professional help; Encourage self-help) training notably improves mental health
knowledge, attitude, confidence and skills among teachers and non-teaching staff (Kidger et al.,
2016).
Mental health literacy is foundational for improving access to care and reducing stigma
regarding mental illness (Kutcher et al., 2015). Health literacy which includes mental health

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literacy is recognized globally as a foundation and strong determinant of good health. It is
stronger than income, education level, employment status, and racial or ethnic group (Kutcher et
al., 2016). The four components of mental health literacy are; (1) maintaining positive mental
health; (2) understanding the types of mental health disorders and its treatment; (3) reducing
mental health stigma; (4) knowing when to seek help and developing competencies in improving
mental health (Kutcher et al., 2016). Mental health literacy is the foundation for mental health
promotion, early identification of mental illness, intervention and continuing care. This has led to
the clinically relevant PICOT question: Among youth mentors and non-teaching staff at after
school club, does mental health training affect the knowledge, attitude and self-efficacy of youth
mentors in helping youth with psychological distress over two week time period?
Search Strategy
A database search was accessed through the Arizona State University Library website.
The databases searched were PsycINFO, Grey literature; worldwide services, Cochrane library
and PubMed. The search strategies for each resource were guided by the PICOT question. The
grey literature search initially yielded 942 studies. It did not yield any final studies without
duplicate studies found in other database searches.
The database search involved the use of keywords. The search on the PsycINFO database
included combinations of words ‘mental health training for teachers’, ‘in schools’, ‘ impact on
students mental health’. Each term was linked with the Boolean term ‘AND’. The initial search
yielded 118 results. The same database search with different combinations including, ‘mental
health education’, ‘for teachers’, ‘ mentors’ ‘in schools’, yielded 93 search results. The final
search yields from PsycINFO database were six studies.

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The Cochrane Library database involved the use of keywords as ‘mental health training’,
‘among teachers OR educators’, and ‘in schools’. Advanced filters were applied to the search
criteria, which included randomized control trials, research articles, peer reviewed, systematic
review, meta-analysis, within the past five years, published in English language only. The final
yield was three studies.
The PubMed database involved the use of keywords, ‘mental health education’, ‘AND’,
‘among school teachers’ ‘youth club leaders’. Advanced search filters were applied which
included meta-analysis, randomized controlled trial, systematic reviews, within five years of
publication, and studies done in English. The initial yield were 46 studies and the final yield was
seven studies.
Critical Appraisal & Synthesis of Evidence
The Melnyk and Fineout-Overholt’s (2011) rapid critical appraisal was used to evaluate
the quality of the 10 articles selected for this literature review. Ten studies included the teaching
staff and teachers both male and female. The studies were published from 2015 to 2019. The
level of evidence ranged from VI to I. The largest sample size was 18, 896 teachers (Appendix
B). The setting was primarily community schools. Among the study groups there were
significant heterogeneity in the use of measurement tools. Two studies by the same author used
similar measurement tools, questionnaires on knowledge, attitude and comfort. The duration of
intervention was from one to three days. There was heterogeneity in the interventions, only two
studies by Kutcher et al., 2015 and Kutcher et al., 2016 used the same intervention tool: Mental
health literacy- African Guide Malawi version (Appendix B). Another study by Kidger et al.,
2016 used the Mental Health First aid (MHFA) and ALGEE training to improve knowledge,
attitude and skills among teachers and school staff. All the above mentioned studies reported

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significant increase in knowledge, attitude, skills and comfort among teachers and non-teaching
staff towards youth with mental health issues. There were significant difference in the sample
size in the above mentioned studies. The Kutcher et al, 2015 & 2016 studies had sample size of
218 and 61 respectively and the setting was specific to Tanzania in Africa. The Kidger et al.,
2016 study had a sample size of 648 staff and setting was secondary schools in the United
Kingdom. A statistically significant increase in teachers and non-teaching staffs’ knowledge of
mental illnesses, confidence in helping students and helping behaviors towards students were
reported. Due to the heterogeneity of interventions no single intervention was superior.
Conceptual Framework
The social cognitive theory, (SCT), developed by Albert Bandura, is a learning theory
that focuses on observational learning, modeling, and self- efficacy (Butts & Rich, 2015).
Principles of modifying behavior to improve health behavior are derived from SCT. Self-efficacy
influences health behavior change by enhancing confidence in one’s ability to act and persist in
the act despite challenges or obstacles when applied to the mental health first aid (Appendix C)
and ALGEE training, the self- efficacy model suggests that staff will experience possible
outcomes of persistence, continued performance and approach challenges instead of avoiding
them. Mental health first aid (MHFA) training significantly improves mental health knowledge,
attitude, confidence and skills among teachers and non-teaching staff (Kidger et al., 2016).
Evidence Based Practice (EBP) Model
The Rosswurm and Larrabee’s evidence based model (Appendix D) was used to guide
the project implementation. The focus is on changing the culture from status quo to
implementation of an EBP process. The model uses six steps which includes assessing the need
for change in practice; link problem, intervention; aid outcomes; synthesize best evidence;

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design practice change; implement and evaluate change in practice (Reavy, 2016). The
Rosswurm and Larrabee model incorporates the self-efficacy model of Bandura to facilitate
practice change. One of the six steps of the EBP model is design practice change, guided by
evidence. Increasing mental health literacy is an evidence based practice change aimed at
improving children’s mental health.
Methods
Increasing mental health literacy through the mental health first aid and ALGEE training
facilitate early identification, intervention and or referral for treatment. A project utilizing the
mental health training and the ALGEE model was implemented among youth mentors at after
school club in East Valley. The key stakeholders of this project included staff and manager of
after school club, club members, families, social workers, behavioral health counselors, case
managers, registered nurses, nurse practitioners, and psychiatrist.
The sample inclusion criteria included youth mentors, office staff and administrative staff
at the after school club. Participants were required to be 18 years of age or older and able to
speak, write, and understand the English language. Individuals who did not meet the inclusion
criteria were excluded. Completion of a pre-education questionnaire and attending the
educational session was considered consent for participation in this project. Participants were
informed regarding no physical risk associated with the training and questionnaires, and to skip
questions if they do not wish to answer. Project site approval was secured prior to project
implementation. Individuals willing to participate in the project attended a 45 minute mental
health training and filled out anonymous questionnaires pre intervention, immediately post
intervention, and 2 weeks post intervention. Each participant created a unique ID, and used it in
the pre and post intervention questionnaires.

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Measures
The measures included sociodemographic data: age of participant, gender, ethnicity, level
of education, experience as youth mentor, and if mental health training received in the past. The
major variables measured were knowledge, attitude and self-efficacy in helping youth with
mental health issues. The project evaluation questionnaire included six questions on the quality
of the educational presentation (Appendix G). Three scales were utilized to measure knowledge,
attitude and self-efficacy at pre intervention, immediate post intervention and two weeks post
intervention.
Mental Health Literacy Scale (MHLS) (O’Connor & Casey, 2015) was used to measure
participants’ knowledge about mental health illnesses. This scale has good reliability,
Chronbach’s alpha (α = .873) and construct validity p < .001 (O’Connor & Casey, 2015). Five
items from this scale was used to measure knowledge (see Appendix F)
Attitudes to severe Mental Illness (ASMI) scale (Madianos et al., 2012) was used to
measure participants’ attitudes toward mental Illness. This scale has good reliability,
Chronbach’s alpha (α = 0.88) and construct validity p < 0.01 (Madianos et al., 2012). Five items
from this scale was used to measure the attitude (see Appendix F).
Gatekeeper Behavior Scale (Albright et al., 2016) was used to measure participants’ selfefficacy in helping youth with mental health issues. This scale has high reliability, (α = .94),
construct validity p < .01, and Cohen’s d= -1.02. (Albright et al., 2016). Four items from this
scale was used to measure self-efficacy (see Appendix F).
Results
Descriptive statistics were used to describe the sample and outcome variables. SPSS
Statistical software was used to analyze data. The sample (n=11) were youth mentors at after

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school club. The sample consisted of 55% (n=6) female and 45% (n=5) male. The age of the
participants ranged from 18 to 46 years, with a mean of 23.6 and (SD= 8.69). The Latino and
Hispanic ethnicity were the largest at 64%, and the African American and Caucasians were 18%
each. The educational level were high school graduate and some college at 91% and only 9% had
a college degree. The years of experience as a mentor ranged from 0- 25 years, with mean of
5.82 (SD= 7.56). The participants with 0- 5 years of experience as a youth mentor were 18 % and
27% had 11 to 15 years of experience. Those with mental health training in the past were 36%
and 64% had no mental health training in the past.
At pre intervention (T0) knowledge score had mean of 15.72 (SD= 1.79), attitude score
had a mean of 7.09 (SD= 1.92), and self-efficacy score had mean of 11.90 (SD= 3.56). At
immediately post intervention (T1) the knowledge score mean was 17 (SD=1.78), attitude score
mean was 6.09 (SD= 1.22) and self-efficacy score mean was 12.36 (SD= 1.29). At two weeks
post intervention (T2) the knowledge score mean was 16.29 (SD= 2.36), attitude score mean was
5.71 (SD= 1.38) and self-efficacy score mean was 11.86 (SD= 0.69). Appendix I, shows the
variables along with their mean and standard deviation. The sum of knowledge, attitude and selfefficacy scores over time are represented in figures 6, 7 and 8 respectively in Appendices J and
K.
A non-parametric test was conducted due to small sample size and Wilcoxon Signed
Ranks test was used to describe key variables and to compare scores over time. Cohen’s effect
size was utilized to determine the clinical significance of the project findings. The Wilcoxon
Signed Ranks test indicated changes in the pre and post intervention scores as statistically
significant in knowledge for T0 and T1 (Z = 2.35, p = .01), and between T0 and T1 attitude
score (Z = 2.07, p = .03). The T0 and T1 self-efficacy scores was not significant (Z = 1.12, p =

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.26). The T1 and T2 knowledge score was (Z = 0.73, p = .46). The T1 and T2 attitude score was
(Z =1.00, p = .00). The T1 and T2 self-efficacy score was (Z = 1.00, p = .31). The T0- T2
knowledge score was not significant (Z = 0.27, p = .8). The T0-T2 attitude and self-efficacy
score were (Z = 1.5, p = .12), and (Z = 1.51, p = .13) respectively.
Cohen’s effect size value suggested large clinical significance in knowledge score
between T0 and T1 (d = .89), small effect size for knowledge between T1 and T2 (d = .28), and
very small effect size for knowledge between T0 and T2 (d = .08) (see Appendix J). There was
medium effect size for attitude scores at T0-T1 (d = .74) and between T0 and T2 (d = .63) (see
Appendix K). There was no clinical significance seen in attitude between T1 and T2. The clinical
significance of self-efficacy score between T0 and T1 was very small (d = .13), between T1 and
T2 the effect size was small (d = .38) and between T0 and T2 the effect size was medium (d =
.63) (see Appendix L).
Descriptive statistics were utilized to examine the evaluation of the mental health training
intervention and 91 % strongly agreed that the content presented was appropriate to address
mentor’s understanding of mental health. 90% agreed with improvement in mental health
knowledge. About 72% agreed with being more comfortable in identifying signs and symptoms
of mental distress, 64% agreed they felt confident in identifying students who may have mental
health problem, 82% reported better understanding about helping student access appropriate
mental health care in the community, and 82% reported they were more comfortable in
supporting students who may have a mental health problem.
Discussion
Several mental health training interventions are available, namely, mental health
awareness training; anti stigma intervention; online anti-stigma video; MHFA; audio-visual

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synchronous podcast related to autism; and many more (Booth et al., 2017). Students of teachers
trained in MHFA reported receiving help and resources regarding mental health problems
compared to students of teachers who did not receive the training. Teachers also reported
increase in confidence and knowledge (Booth et al., 2017).
More recent developments have been in mental health training intervention for school
nurses and other health providers in schools. Recommendations for meeting the barriers include
web based accessible training modules, including a mental health assessment triage flowchart for
step by step guidance for school nurses, and inclusion of resources for crisis management.
Several positive outcomes can be concluded from this project. The project revealed
statistically significant outcomes over time in knowledge and attitude. The result suggested
further on-going training to ensure knowledge and self-efficacy is sustained over time. The
participants were given resources for a one day MHFA and ALGEE training at their nearest
location in order to sustain the outcomes of the project intervention. The participants need further
training in identifying symptoms of psychological distress among youth.
Additional resources within the after school clubs like counselors and social workers
provide linkage of students and families to mental health services in the community. A multitiered system within the school providing prevention, assessment, screening, identification,
intervention and treatment services have been accepted widely by clinicians and educators.
Conclusion
Increasing mental health literacy is a community based preventive measure in
maintaining psychosocial wellbeing among youth. Early intervention in mental health reduces
hospitalization and healthcare expenditure. Even though teachers and non-teaching staff play a
vital role in the early identification of mental illness they admit to high degree of uncertainty in

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assisting children experiencing psychological distress. With the increase in occurrence of
depressive symptoms, suicidal thoughts and attempts among adolescents in Arizona, there is
evidence in literature reviewed and the mental health training project implemented that mental
health training intervention significantly improves knowledge, attitude, and self-efficacy among
staff interacting with youth experiencing mental health issues. This grass-root level preventive
measure facilitates early identification of symptoms of mental health disorders among youth. The
implementation of this practice change will reduce the current gap of onset of behavioral health
symptoms and its therapeutic intervention.

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References

Albright, G. L., Davidson, J., Goldman, R., Shockley, K. M., & Timmons-Mitchell, J. (2016).
Development and Validation of the Gatekeeper Behavior Scale. Crisis, 37(4), 271–280.
Ball, A., Iachini, A. L., Bohnenkamp, J. H., Togno, N. M., Brown, E. L., Hoffman, J. A., & George,
M. W. (2016). School mental health content in state in-service K-12 teaching standards in
the United States. Teaching and Teacher Education, 60, 312-320.
Booth, A., Scantlebury, A., Hughes-Morley, A., Mitchell, N., Wright, K., Scott, W., & McDaid,
C. (2017). Mental health training programmes for non-mental health trained professionals
coming into contact with people with mental ill health: a systematic review of
effectiveness. BMC Psychiatry, 17(1).
Butts, J. B., & Rich, K. L. (2015). Philiosophies and Theories for Advanced Nursing
Practice (second edition). Burlington, MA: Jones and Bartlett Learning.
Delfabbro, P., Stevenson, J., Malvaso, C., Duong, D., Winefield, H., Winefield, A., &
Hammarström, A. (2018). Who is doing well: Age 15 predictors of psychological and
physical health in young adulthood. Australian Psychologist, 54(2), 114–124.
https://doi.org/10.1111/ap.12369
Eustache, E., Gerbasi, M. E., Smith, F. M. C., Fils-Aimé, J. R., Severe, J., Raviola, G. J., Legha,
R., ... Becker, A. E. (2017). Mental health training for secondary school teachers in Haiti:
A mixed methods, prospective, formative research study of feasibility, acceptability, and
effectiveness in knowledge acquisition. Global Mental Health, 4.
Franklin, C., Kim, J. S., Beretvas, T. S., Zhang, A., Guz, S., Park, S., Montgomery, K., ... Maynard,
B. R. (2017). The effectiveness of psychosocial interventions delivered by teachers in

MENTAL HEALTH TRAINING

17

schools: A systematic review and meta-analysis. Clinical Child and Family Psychology
Review, 20, 3, 333-350.
Hale, D. R., & Viner, R. M. (2018). How adolescent health influences education and
employment: investigating longitudinal associations and mechanisms. Journal of
Epidemiology and Community Health, 72(6), 465–470. https://doi.org/10.1136/jech2017-209605
Imran, N., Rahman, A., Chaudhry, N., & Asif, A. (2018). World Health Organization "School
Mental Health Manual"-based training for school teachers in Urban Lahore, Pakistan: study
protocol for a randomized controlled trial. Trials, 19, 1.
John, A., Glendenning, A. C., Marchant, A., Montgomery, P., Stewart, A., Wood, S., Lloyd, K.,
... Hawton, K. (2018). Self-Harm, suicidal behaviors, and cyberbullying in children and
young people: Systematic review. Journal of Medical Internet Research, 20, 4.
Kidger, J., Stone, T., Tilling, K., Brockman, R., Campbell, R., Ford, T., Hollingworth, W., ...
Gunnell, D. (2016). A pilot cluster randomised controlled trial of a support and training
intervention to improve the mental health of secondary school teachers and students - the
WISE (Wellbeing in Secondary Education) study. BMC Public Health, 16, 1.
Kutcher, S., Wei, Y., Gilberds, H., Ubuguyu, O., Njau, T., Brown, A., Sabuni, N., ... Perkins, K.
(2016). A school mental health literacy curriculum resource training approach: Effects on
Tanzanian

teachers’

mental

health

knowledge,

stigma

and

help-seeking

efficacy. International Journal of Mental Health Systems, 10, 1.
Kutcher, S., Gilberds, H., Morgan, C., Greene, R., Hamwaka, K., & Perkins, K. (2015). Improving
Malawian teachers' mental health knowledge and attitudes: An integrated school mental
health literacy approach. Global Mental Health, 2.

MENTAL HEALTH TRAINING

18

Le, B. R., March, S., Triggell, N., Rabaa, C., & Kenardy, J. (2017). Schools and natural disaster
recovery: The unique and vital role that teachers and education professionals play in
ensuring the mental health of students following natural disasters. Journal of Psychologists
and Counsellors in Schools, 27, 1, 1-23.
Leader, H., Singh, J., Ghaffar, A., & de, S. C. (2018). Association between bullying and pediatric
psychiatric hospitalizations. Sage Open Medicine, 6.
Long, M. W., Albright, G., McMillan, J., Shockley, K. M., & Price, O. A. (2018). Enhancing
educator engagement in school mental health care through digital simulation professional
development. Journal of School Health, 88, 9, 651-659.
Madianos, M., Economou, M., Peppou, L. E., Kallergis, G., Rogakou, E., & Alevizopoulos, G.
(2012). Measuring public attitudes to severe mental illness in Greece: Development of a
new scale. The European Journal of Psychiatry, 26(1), 55–67.
Malla, A., Iyer, S., Shah, J., Joober, R., Boksa, P., Lal, S., … Vallianatos, H. (2018). Canadian
response to need for transformation of youth mental health services: ACCESS Open Minds
(Esprits ouverts). Early Intervention in Psychiatry, 13(3), 697-706.
https://doi.org/10.1111/eip.12772
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare:
A guide to best practice. Philadelphia, Pa: Wolters Kluwer/Lippincott Williams & Wilkins.
Mental Health America (2019). Access to care ranking. Retrieved from
http://www.mentalhealthamerica.net/issues/ranking-states
NAMI, SAMHSA, CDC, and U.S. Department of Justice. (2019). Mental Health by the
Numbers. Retrieved from https://www.nami.org/mhstats

MENTAL HEALTH TRAINING

19

National Alliance on Mental Illness (NAMI). (2019). Mental Health by Numbers. Retrieved
from https://www.nami.org/mhstats
National Council for Behavioral Health. (2020). Mental health first aid. Retrieved from
https://www.thenationalcouncil.org/about/mental-health-first-aid/
National Center for Education Statistics. (2008). Retrieved from https://nces.ed.gov/
Nenn. K., (2017). We’re facing a shortage of mental health professionals. Recovery-An American
Addiction Centers Resource.
O’Connor, M., & Casey, L. (2015). The Mental Health Literacy Scale (MHLS): A new scale-based
measure of mental health literacy. Psychiatry Res.
Office of Behavioral & Social Sciences Research. (n.d.). Social and Behavioral Theories.
Retrieved April 25, 2020, from http://www.esourceresearch.org/Default.aspx?TabId=734
Office of Disease Prevention and Health Promotion. (2014). Healthy people 2020. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mentaldisorders/objectives#4813
O’Reilly, M., Adams, S., Whiteman, N., Hughes, J., Reilly, P., & Dogra, N. (2018). Whose
Responsibility is Adolescent’s Mental Health in the UK? Perspectives of Key
Stakeholders. School Mental Health, 10(4), 450–461.
Reavy, K. (2016). Inquiry and leadership: A resource for the DNP project. PA: Davis company.
Schulte-Körne, G. (2016). Mental Health Problems in a School Setting in Children and
Adolescents. Deutsches Aerzteblatt Online.
Swartz, K., Musci, R. J., Beaudry, M. B., Heley, K., Miller, L., Alfes, C., Townsend, L., ... Wilcox,
H. C. (2017). School-Based Curriculum to Improve Depression Literacy Among US

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Secondary School Students: A Randomized Effectiveness Trial. American Journal of
Public Health, 107, 12, 1970-1976.
Townsend, M. L., Gray, A. S., Lancaster, T. M., & Grenyer, B. F. S. (2018). A whole of school
intervention for personality disorder and self-harm in youth: A pilot study of changes in
teachers’ attitudes, knowledge and skills. Borderline Personality Disorder and Emotion
Dysregulation, 5.

MENTAL HEALTH LITERACY

21
Appendix A

Table1
Evaluation Table of Quantitative Studies
Citation

Ball et al.,
(2016). School
mental health
content in state
in- service K-12
teaching
standards in the
United States.
Funding: None
Bias: None.
Country: US

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables
Definitions

Teacher
competency
framework.

Design:
quantitative
content analysis

N= 40
Sample Type: Inservice teaching
standards
documents.
Inclusions:
Documents
describing the
standards for inservice for K-12
teachers that were
passed by
legislation.
Exclusion:
Standards in
debate, in process,
awaiting licensure.

IV: SMH competency
content in state
standards documents
and in InTASC
DV1: TC in policies
and laws.
DV2: TC in provision
of learning support.
DV3: TC in collection
and use of data
measuring student
behavior.
DV4: TC in
communication.
DV5: TC in
engagement in multiple
systems.
DV6: TC in personal
and professional
growth.

Purpose: To
examine the
difference and
similarities in
content across
state standards
for teachers and
the extent to
which state
standards for
teachers include
competencies for
SMH.

&

Measurem
ent

Data
Analysis

Findings/
Results

Level/Quality
Of Evidence; Decision
for
practice/
application to practice

Code
books.

Descriptiv
e statistics

DV1: n = 29
60% of states.

LOE: V

Pilot test.
Agreement
rate of
coders.

DV2: n = 43
89.6% states.
DV3: n= 48
100% of states.
DV4: n = 34
70.8% of states.
DV5: n= 44
90% of states.

Strengths: National
view of requirements of
in service.
Weaknesses:
descriptive quantitative
study.
Conclusions: Study
shows the extent to
which state teaching
standards reflect SMH
competencies.

Feasibility:
Recommended
for
understanding
stateAttrition:
None
standards for teachers in
SMH competency.
Key: AA- African American; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide:
Malawi version; AH-Acute hospitalization; ALGEE- assess risk of suicide, listen non judgmentally, give advice and information; AS- Attitudes and Skills; ASQ- Attitudes and
Skills Questionnaires; BV- Bullying Victimization; CB- cyberbullying; CDC- Center for Disease Control; CG- control group; CI- confidence interval; CMH- Complex Mental
Health; d- Cohen’s; DV- Dependent Variable; F-Female; FGD-focus group discussions; IG- Intervention group; InTASC- interstate teacher assessment and support consortium;
IPP- In- patient pediatric; IV- Independent Variable; KDS- Knowledge of Deliberate Self Harm; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; LOE- Level Of
Evidence; M- Male; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitudes; MHL- mental health literacy; MOE- Ministry of
education; N- Number of participants; OBQ- Olweus Bully/Victim Questionnaire; OR- odds ratio; p- level of significance; PD- Personality Disorder; PHQ- patient health
questionnaire; PI- psychosocial intervention; RCT- randomized control trial; SB- suicidal behaviors; SH- self harm; SIUH- Staten Island University Hospital; SMH- school
mental health; ST- School Teachers; TC- teacher competency; Time 0- baseline; Time 1- immediate post training; Time 2- 6-9 weeks post training; WEMWBS- Warmick
Edinburg Wellbeing scale; WISE- well-being in secondary education; WHO- World Health Organization; YCL- Youth club leaders; y.o.- year old; α – Cronbach’s alpha value.

MENTAL HEALTH LITERACY
Citation

Franklin et al.,
(2017). The
effectiveness
of
psychosocial
interventions
delivered by
teachers in
schools: a
systematic
review and
meta-analysis.
Country: US.
Funding:
None.
Bias: None.

22

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables
Definitions

Response to
intervention
framework.

Systematic
review and metaanalysis of
RCT’s.

E databases= 9
Websites= 19
Experts= 6

IV: PI

Purpose: To
determine the
outcomes of
teacher delivered
psychosocial
interventions on
students
internalizing and
externalizing
symptoms.

Studies published
from 2000 to
2016.
Setting: School
classrooms.
Exclusions:
If
study did not
involve teachers;
study did not
report information
for
calculating
effect size; study
samples were not
independent;
studies that did not
measure

DV1: Internalizing
outcomes.
DV2: Externalizing
outcomes.
Definition: PI is
delivered in a
school setting to
improve students
behavioral,
emotional or social
functioning.
Internalizing
symptoms are
anxiety, depression
and somatic.
Externalizing:
impulsive,
disruptive and
substance use
symptoms.

Measurement

Data
Analysis

Findings/
Results

Hopelessness
scale for
children.

Bivariate
metaregression.

DV1: d= .133
CI= 95%
p < 0.5

&

Children’s
pessimistic
explanatory
style.
Externalizing
outcomes
measures.

DV2: d= .015
CI= 95%
P > .05

Level/Quality
Of
Evidence;
Decision
for
practice/ application
to practice
LOE: I
Strength: Exhaustive
literature search.
Weakness:
Interventions were
not culturally
competent, not
specific for ethnic
minority youth.
Conclusions: School
based PI delivered by
teachers are more
effective with
internalizing
symptoms.
Feasibility: PI by
teachers are effective
in internalizing and
externalizing
outcomes

Key: AA- African American; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide:
Malawi version; AH-Acute hospitalization; ALGEE- assess risk of suicide, listen non judgmentally, give advice and information; AS- Attitudes and Skills; ASQ- Attitudes and
Skills Questionnaires; BV- Bullying Victimization; CB- cyberbullying; CDC- Center for Disease Control; CG- control group; CI- confidence interval; CMH- Complex Mental
Health; d- Cohen’s; DV- Dependent Variable; F-Female; FGD-focus group discussions; IG- Intervention group; InTASC- interstate teacher assessment and support consortium;
IPP- In- patient pediatric; IV- Independent Variable; KDS- Knowledge of Deliberate Self Harm; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; LOE- Level Of
Evidence; M- Male; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitudes; MHL- mental health literacy; MOE- Ministry of
education; N- Number of participants; OBQ- Olweus Bully/Victim Questionnaire; OR- odds ratio; p- level of significance; PD- Personality Disorder; PHQ- patient health
questionnaire; PI- psychosocial intervention; RCT- randomized control trial; SB- suicidal behaviors; SH- self harm; SIUH- Staten Island University Hospital; SMH- school
mental health; ST- School Teachers; TC- teacher competency; Time 0- baseline; Time 1- immediate post training; Time 2- 6-9 weeks post training; WEMWBS- Warmick
Edinburg Wellbeing scale; WISE- well-being in secondary education; WHO- World Health Organization; YCL- Youth club leaders; y.o.- year old; α – Cronbach’s alpha value.

MENTAL HEALTH LITERACY
Citation

John et al.,
(2018). Selfharm, suicidal
behaviors and
cyberbullying
in children and
young people:
systematic
review.
Country: UK
Funding:
None.
Bias: None.

23

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables
Definitions

Inferred to be
the social
cognitive
theory.

Systematic
Review

Articles= 33
N= 156,384

Purpose: To
review evidence
for associations
between CB
involvement and
SH or SB in
children and
young people.

Electronic search
from 01/1996 to
02/2017 across
MEDLINE,
Cochrane and
PsycINFO

IV: Bullying via
electronic
communicationCB.
DV1= SH
DV2=SB
DV3= Suicide
attempt

Inclusion: Studies
that examined any
association
between
CB
involvement and
SH or SB in a
sample aged under
25 years

Measurement

Data
Analysis

Findings/
Results

Critical appraisal
of the paper.

MetaAnalysis

DV1: OR 2.10
CI 95%

Data extraction
sheet.

Forest plot

DV2: OR 2.57
CI 95%

&

Definition:
Bullying is an
aggressive,
intentional act
carried out by a
group or an
individual
repeatedly
overtime against a
victim who
cannot easily
defend himself or
herself
CB is bullying
that occurs via
electronic forms
of contact.

Independent
reviewers.

Der Simonian
and Laird
randomeffects model.

DV3: OR 1.21
CI 95%

Level/Quality
Of
Evidence;
Decision
for
practice/
application
to
practice
LOE: 1
Strengths: Metaanalysis, large pool
of population.
Weakness: No
analysis on
intervention, no
mention of type of
CB, frequency and
gender.
Conclusion: CB
victims have higher
risk of SH and SB.

Key: AA- African American; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide:
Malawi version; AH-Acute hospitalization; ALGEE- assess risk of suicide, listen non judgmentally, give advice and information; AS- Attitudes and Skills; ASQ- Attitudes and
Skills Questionnaires; BV- Bullying Victimization; CB- cyberbullying; CDC- Center for Disease Control; CG- control group; CI- confidence interval; CMH- Complex Mental
Health; d- Cohen’s; DV- Dependent Variable; F-Female; FGD-focus group discussions; IG- Intervention group; InTASC- interstate teacher assessment and support consortium;
IPP- In- patient pediatric; IV- Independent Variable; KDS- Knowledge of Deliberate Self Harm; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; LOE- Level Of
Evidence; M- Male; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitudes; MHL- mental health literacy; MOE- Ministry of
education; N- Number of participants; OBQ- Olweus Bully/Victim Questionnaire; OR- odds ratio; p- level of significance; PD- Personality Disorder; PHQ- patient health
questionnaire; PI- psychosocial intervention; RCT- randomized control trial; SB- suicidal behaviors; SH- self harm; SIUH- Staten Island University Hospital; SMH- school
mental health; ST- School Teachers; TC- teacher competency; Time 0- baseline; Time 1- immediate post training; Time 2- 6-9 weeks post training; WEMWBS- Warmick
Edinburg Wellbeing scale; WISE- well-being in secondary education; WHO- World Health Organization; YCL- Youth club leaders; y.o.- year old; α – Cronbach’s alpha value.

MENTAL HEALTH LITERACY
Citation

Kutcher et al.,
(2016). A school
mental
health
literacy
curriculum
resource training
approach: effects
on
Tanzanian
teachers’ mental
health
knowledge,
stigma and help
seeking efficacy.
Country: The
United Republic
of Tanzania.
Funding: Grand
Challenges,
Canada.
Bias: None.

24

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables
Definitions

Inferred to be the
Social Cognitive
Theory.

Cohort study
Pre and post
study design.

N=61
Setting:
Secondary
school in
Tanzania.

IV: Refresher
training in
AGMv.

Purpose: To
evaluate the
impact of
participating in
the refresher
training exercise
on the mental
health
knowledge and
attitudes of
teachers.

Exclusions:
Teachers
selected by
education
administrative
authorities from
35 schools in
Arusha and
Meru districts of
Tanzania.
Teachers
previously
trained in
AGMv.

Attrition: 18%

Measurement

Data
Analysis

Findings/
Results

Pre and
posttests.

Independent
samples t test.

DV1: p <
0.001
d = 1.14

Knowledge:
Pretest α=0.601
Posttest α=0.435

Paired t test.

&

DV1: Teachers
knowledge
change.
DV2: Teachers
attitude change.
DV3: Teachers
comfort in
addressing the
mental health
needs of
students.

Attitude:
Pretest α=0.661
Posttest α=0.631
Comfort level:
Pretest α=0.667
Posttest α=0.748

Descriptive
statistics

DV2: p<
0.001
d = 0.50
DV3: p > 0.05
d = 0.19

Level/Quality
Of
Evidence;
Decision
for
practice/
application
to
practice
LOE: VI
(Evidence from a
single descriptive
study).
Strength: modest
sample size,
significant
outcomes.
Weakness: Cohort
study, modest
sample size,
participants not
generalized to
Tanzania.
Conclusion: The
AGMv is an
effective tool for
increasing MHL
within the school
system at an
international level.

Key: AA- African American; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide:
Malawi version; AH-Acute hospitalization; ALGEE- assess risk of suicide, listen non judgmentally, give advice and information; AS- Attitudes and Skills; ASQ- Attitudes and
Skills Questionnaires; BV- Bullying Victimization; CB- cyberbullying; CDC- Center for Disease Control; CG- control group; CI- confidence interval; CMH- Complex Mental
Health; d- Cohen’s; DV- Dependent Variable; F-Female; FGD-focus group discussions; IG- Intervention group; InTASC- interstate teacher assessment and support consortium;
IPP- In- patient pediatric; IV- Independent Variable; KDS- Knowledge of Deliberate Self Harm; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; LOE- Level Of
Evidence; M- Male; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitudes; MHL- mental health literacy; MOE- Ministry of
education; N- Number of participants; OBQ- Olweus Bully/Victim Questionnaire; OR- odds ratio; p- level of significance; PD- Personality Disorder; PHQ- patient health
questionnaire; PI- psychosocial intervention; RCT- randomized control trial; SB- suicidal behaviors; SH- self harm; SIUH- Staten Island University Hospital; SMH- school
mental health; ST- School Teachers; TC- teacher competency; Time 0- baseline; Time 1- immediate post training; Time 2- 6-9 weeks post training; WEMWBS- Warmick
Edinburg Wellbeing scale; WISE- well-being in secondary education; WHO- World Health Organization; YCL- Youth club leaders; y.o.- year old; α – Cronbach’s alpha value.

MENTAL HEALTH LITERACY

25

Citation

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables
&
Definitions

Measurement

Data
Analysis

Findings/
Results

Kutcher et al., (2015).
Improving Malawian
teachers’ mental health
knowledge and attitudes:
an integrated school
mental health literacy
approach.

Inferred to
be the Social
Cognitive
Theory.

Repeated
measures
design

N 218
F 96
M 121
Gender Unknown
1

IV: Educator
training on use
of AGMv

Pretest and
Posttest
Questionnaires
on Knowledge
( α= 0.638)
and Attitude
(α= 0.549).

Paired t
test

DV1:
Knowledge
P = < 0.0001
d = 1.16

Funding: Grand
Challenges, Canada.
Country: The Republic
of Malawi.
Bias: None.

Purpose: To
evaluate the
impact of
training
educators on
the use of
mental health
curriculum in
improving
Educators
positive
attitudes and a
decrease in
stigmatizing
attitudes
towards MH.

Pop. type:
Teachers and YCL
from primary and
secondary schools.
Setting: Semi
urban community
in The Republic of
Malawi.
Inclusions:
Teachers and YCL
selected by the
MOE from both
primary and
secondary school.
Attrition: 11%
lost to postattitude scale.

DV1:
Knowledge of
MH.
DV2: Attitude
towards MH.
Educator
training is a 3
day
training
through
6
modules on LO,
MC, LP, CA
and TR

DV2: Attitude
P = < 0.0001
d = 0.79

Level/Quality
Of Evidence; Decision
for
practice/
application to practice
LOE: IV
Strength: Large N, low
risk, non-invasive
intervention, low
attrition rate.
Weakness: Non
randomized non control
group. Demographic
limitation, funding
needs for program
implementation.
Conclusions: MH
literacy among teachers
reduces stigma of MH
and improves
knowledge of MH
among teachers.
Feasibility: Potential for
reducing the burden of
MH care costs and
improvement in
psychosocial wellbeing
among student.

Key: AA- African American; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide:
Malawi version; AH-Acute hospitalization; ALGEE- assess risk of suicide, listen non judgmentally, give advice and information; AS- Attitudes and Skills; ASQ- Attitudes and
Skills Questionnaires; BV- Bullying Victimization; CB- cyberbullying; CDC- Center for Disease Control; CG- control group; CI- confidence interval; CMH- Complex Mental
Health; d- Cohen’s; DV- Dependent Variable; F-Female; FGD-focus group discussions; IG- Intervention group; InTASC- interstate teacher assessment and support consortium;
IPP- In- patient pediatric; IV- Independent Variable; KDS- Knowledge of Deliberate Self Harm; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; LOE- Level Of
Evidence; M- Male; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitudes; MHL- mental health literacy; MOE- Ministry of
education; N- Number of participants; OBQ- Olweus Bully/Victim Questionnaire; OR- odds ratio; p- level of significance; PD- Personality Disorder; PHQ- patient health
questionnaire; PI- psychosocial intervention; RCT- randomized control trial; SB- suicidal behaviors; SH- self harm; SIUH- Staten Island University Hospital; SMH- school
mental health; ST- School Teachers; TC- teacher competency; Time 0- baseline; Time 1- immediate post training; Time 2- 6-9 weeks post training; WEMWBS- Warmick
Edinburg Wellbeing scale; WISE- well-being in secondary education; WHO- World Health Organization; YCL- Youth club leaders; y.o.- year old; α – Cronbach’s alpha value.

MENTAL HEALTH LITERACY
Citation

et al.,
(2018).
Leader

Association
between
bullying and
pediatric
psychiatric
hospitalizations
Funding: The
Department of
Pediatrics,
SIUH.
Bias: None
Country: USA

26

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables
Definitions

Inferred to
be the
Social
Cognitive
Theory

Correlational
Study

N= 185

IV: Psychiatric
hospitalization in
children
DV1: BV in
public schools

Purpose: To
study
correlation
between BV
and AH for
MH related
problems

Pt. Type: White
46%, Hispanic
29%, AA 10%,
Other 12%.
Unknown
ethnicity 18%.
Enrolled in
Grades 3 to 12.
Setting: Pediatric
Inpatient unit in
SIUH.
Inclusions:
Children in
public or private
schools in grades
3- 12. Capable of
reading and
comprehending
the questionnaire.

Measurement

Data
Analysis

Findings/
Results

OBQ

Fisher’s exact
test

No difference in
DV1 versus DV2
Pr > Z= 0.5064

&

DV2: BV in
private schools
DV3: BV in IPP
admissions.

Extensively
validated and
included in
2011
compendium
by CDC.

Logistic
regression

DV3: Significant
Mean BV Pr > Z
< 0.0001
DV4: Significant
Pr > Z< 0.0001

DV4: BV and
suicidal ideation.

DV5: Significant
Pr > Z < 0.0001

DV5: BV and
psych consult and
social consult.

Location of BV:
hallway 47%,
stairwells 47%,
lunchrooms 42%.

BV is being a
victim of
physical, verbal
and/ or cyber
bullying.

Methods of BV:
Verbal 17%,
Exclusions 16%,
rumors 16%.

Level/Quality
Of Evidence; Decision
for practice/ application
to practice
LOE: IV
Strengths: Elevates the
perception of risk of a
behavior. Low risk, low
attrition rate,
correlational study.
Weakness: OBQ subscores had not been
independently validated.
OBQ intended for school
setting not Hospital.
Conclusions: Pediatric
psychiatric inpatient
status has a serious link
to psychosocial
wellbeing and BV.
Feasibility: Strong
evidence exists between
BV and hospitalization
for acute psychiatric
illness.

Attrition rate:
6%

Key: AA- African American; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide:
Malawi version; AH-Acute hospitalization; ALGEE- assess risk of suicide, listen non judgmentally, give advice and information; AS- Attitudes and Skills; ASQ- Attitudes and
Skills Questionnaires; BV- Bullying Victimization; CB- cyberbullying; CDC- Center for Disease Control; CG- control group; CI- confidence interval; CMH- Complex Mental
Health; d- Cohen’s; DV- Dependent Variable; F-Female; FGD-focus group discussions; IG- Intervention group; InTASC- interstate teacher assessment and support consortium;
IPP- In- patient pediatric; IV- Independent Variable; KDS- Knowledge of Deliberate Self Harm; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; LOE- Level Of
Evidence; M- Male; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitudes; MHL- mental health literacy; MOE- Ministry of
education; N- Number of participants; OBQ- Olweus Bully/Victim Questionnaire; OR- odds ratio; p- level of significance; PD- Personality Disorder; PHQ- patient health
questionnaire; PI- psychosocial intervention; RCT- randomized control trial; SB- suicidal behaviors; SH- self harm; SIUH- Staten Island University Hospital; SMH- school
mental health; ST- School Teachers; TC- teacher competency; Time 0- baseline; Time 1- immediate post training; Time 2- 6-9 weeks post training; WEMWBS- Warmick
Edinburg Wellbeing scale; WISE- well-being in secondary education; WHO- World Health Organization; YCL- Youth club leaders; y.o.- year old; α – Cronbach’s alpha value.

MENTAL HEALTH LITERACY
Citation

Long et al.,
(2018).
Enhancing
educator
engagement in
school mental
health care
through digital
simulation
professional
development.
Country: US
Funding:
Department of
prevention and
community health
at the Milken
institute of school
of public health at
The George
Washington
University.

27

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables
Definitions

Inferred to be
the Social
Cognitive
Theory

Randomized
control trial.

N= 18,896
IG= 9427
CG= 9469

IV: Self-paced
online simulation
for 45 to 90
minutes.
DV1: Gatekeeper
behavior
preparedness.

Population Type:
Teachers in
elementary schools.
Setting:
Elementary school
Inclusion:
Elementary teachers
who completed
some part of the
training and
evaluation.
Exclusion:
Participants who
did not complete all
required parts of the
study.
Attrition = 31%.

Measurement

Data
Analysis

Findings/
Results

Gatekeeper
behavior scale

Multivariate
analysis.

DV1:
Post
training
preparedness
increased
significantly in
CG, p < 0.001

&

DV2: Gatekeeper
behavior
likelihood.
DV3: Gatekeeper
behavior selfefficacy.
Gatekeeper
behavior is the
positive role among
teachers in SMH
on identification
and referral of
students with
behavioral health
issues.

Hotelling’s T2
Internal reliability
for preparedness
.95, for likelihood
.85, for selfefficacy .94

DV2: Likelihood
of IG higher than
CG, p < 0.001
DV3: Selfefficacy of the IG
significantly
higher than CG, p
< 0.001
Knowledge,
attitudes, skills
and confidence
increased
significantly after
training

Level/Quality
Of
Evidence;
Decision
for
practice/
application to
practice
LOE: II
Strengths: Large
sample size.
Randomized
controlled trial,
low risk.
Weakness:
Modest attrition
rate; limited to
elementary
teachers; short
follow up time.
Conclusions:
Virtual
online
simulation
teachers training
increases
preparedness,
likelihood
and
self-efficacy of

Bias: None
Key: AA- African American; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide:
Malawi version; AH-Acute hospitalization; ALGEE- assess risk of suicide, listen non judgmentally, give advice and information; AS- Attitudes and Skills; ASQ- Attitudes and
Skills Questionnaires; BV- Bullying Victimization; CB- cyberbullying; CDC- Center for Disease Control; CG- control group; CI- confidence interval; CMH- Complex Mental
Health; d- Cohen’s; DV- Dependent Variable; F-Female; FGD-focus group discussions; IG- Intervention group; InTASC- interstate teacher assessment and support consortium;
IPP- In- patient pediatric; IV- Independent Variable; KDS- Knowledge of Deliberate Self Harm; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; LOE- Level Of
Evidence; M- Male; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitudes; MHL- mental health literacy; MOE- Ministry of
education; N- Number of participants; OBQ- Olweus Bully/Victim Questionnaire; OR- odds ratio; p- level of significance; PD- Personality Disorder; PHQ- patient health
questionnaire; PI- psychosocial intervention; RCT- randomized control trial; SB- suicidal behaviors; SH- self harm; SIUH- Staten Island University Hospital; SMH- school
mental health; ST- School Teachers; TC- teacher competency; Time 0- baseline; Time 1- immediate post training; Time 2- 6-9 weeks post training; WEMWBS- Warmick
Edinburg Wellbeing scale; WISE- well-being in secondary education; WHO- World Health Organization; YCL- Youth club leaders; y.o.- year old; α – Cronbach’s alpha value.

MENTAL HEALTH LITERACY
Citation

Townsend et al.,
(2018). A whole
of school
intervention for
personality
disorder and selfharm in youth: a
pilot study of
changes in
teacher’s
attitudes,
knowledge and
skills.
Country:
Australia
Funding: New
South Wales
Department of
Education, New
South Wales
Ministry of
Health.
Bias: None

28

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables
Definitions

WHO’s whole
of School
Framework

Design: Pilot
Study- non
randomized non
controlled trial;
Pre and Post
Test.

N= 400

IV: Training for
ST
DV1: KDS

Purpose: To
evaluate the
ability and
confidence of
class teachers to
respond to
students with
CMH and selfharm in the
school setting,
after
participating in
training
provided by
school
counselors.

Mean Age: 42
y.o.

DV2: ADSH
Pt. Type:
Female = 285,
ST from rural
and urban
communities
Setting: Public
Secondary
School in
Australia.
Inclusions: ST
in public schools
in New south
Wales,
Australia.
Attrition: None
discussed

Measurement

Data
Analysis

Findings/
Results

Questionnaire
KDSQ,
ADSHQ,
(α=.83 pre- test)
(α= .89 post- test),
ASQ

Paired
sample ttest

.DV1: d= 0.27
CI= -0.62

&

DV3: AS with
CMH issues
Training is
workshop on PD
theory & skills
training for
identifying and
responding to
young people
with CMH
needs.

DV2: d= 0.55
p value= < .001
CI= -3.29
DV3: Skills &
Confidence
p value= <.001
CI= -1.01, - 0.84
D= 0.67

Level/Quality
Of Evidence; Decision
for practice/ application
to practice
LOE: IV
Strengths: Large
population size, low risk,
non-invasive
intervention. High level
of significance with p
value <0.001
Weaknesses: Public
secondary school
teachers only, reliability
of KDSQ is unknown.
Conclusions: Teachers
training on CMH
improves the knowledge,
attitude, skills and
confidence of teachers
towards adolescent
students.
Feasibility: Effective in
early identification and
intervention in mental
health
issues
in
Adolescents

Key: AA- African American; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide:
Malawi version; AH-Acute hospitalization; ALGEE- assess risk of suicide, listen non judgmentally, give advice and information; AS- Attitudes and Skills; ASQ- Attitudes and
Skills Questionnaires; BV- Bullying Victimization; CB- cyberbullying; CDC- Center for Disease Control; CG- control group; CI- confidence interval; CMH- Complex Mental
Health; d- Cohen’s; DV- Dependent Variable; F-Female; FGD-focus group discussions; IG- Intervention group; InTASC- interstate teacher assessment and support consortium;
IPP- In- patient pediatric; IV- Independent Variable; KDS- Knowledge of Deliberate Self Harm; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; LOE- Level Of
Evidence; M- Male; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitudes; MHL- mental health literacy; MOE- Ministry of
education; N- Number of participants; OBQ- Olweus Bully/Victim Questionnaire; OR- odds ratio; p- level of significance; PD- Personality Disorder; PHQ- patient health
questionnaire; PI- psychosocial intervention; RCT- randomized control trial; SB- suicidal behaviors; SH- self harm; SIUH- Staten Island University Hospital; SMH- school
mental health; ST- School Teachers; TC- teacher competency; Time 0- baseline; Time 1- immediate post training; Time 2- 6-9 weeks post training; WEMWBS- Warmick
Edinburg Wellbeing scale; WISE- well-being in secondary education; WHO- World Health Organization; YCL- Youth club leaders; y.o.- year old; α – Cronbach’s alpha value.

MENTAL HEALTH LITERACY

29
Appendix B

Table 2
Evaluation Table of Mixed Studies
Citation

Eustache et al.,
(2017). Mental
health training
for
secondary
school teachers
in Haiti: a mixed
methods,
prospective,
formative
research study of
feasibility,
acceptability and
effectiveness in
knowledge
acquisition.
Country: Haiti.
Funding:
National Institute
of Mental Health.
Bias:
None

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables
Definitions

Task sharing
Framework.

Prospective
and
convergent

N= 22
Male= 18
Female= 4
Mean age= 40

IV: Two and a
half day SMH
training for
teachers.

Population Type:
Secondary school
teachers in Haiti’s
Central Plateau.

DV1: Feasibility
and acceptability
of teachers
training to
teachers.

Mixed
method.

Measurement

Data
Analysis

Findings/
Results

Likert scales.
Mean scores
Pre- post
training
assessments.

ANOVA

DV1 teachers
participation=
91.7%
Participants
completing
training=
100%

&

Self-report
written openended
responses.

Paired sample t
test
Shapiro- Wilk
test

Level/Quality
Of Evidence; Decision
for
practice/
application to practice
LOE: VI
Strengths: Mixed
methods design.
Weakness: Small
sample size; teachers
selected by principals;
unstandardized measure
with unknown validity.

Purpose:
To
DV2:Increase
determine
in knowledge
teacher’s
Setting: School in
and attitude
role as
rural Haiti
DV2: Knowledge
FGD interview
p< 0.001 &
Conclusions: SMH
‘teacherInclusions: Teachers
and attitude of
MHKA
p= 0.011
training is acceptable,
accompagn nominated by their
teachers to SMH.
Αt Time 0
respectively.
feasible and improves
ateur’ in
principals from public
α= 0.69
knowledge, and attitude
providing
and independent
Teacher
At Time 1
Time 2 scores among teachers towards
students
schools in Haiti’s
‘Accompagnateur’ α= 0.84
higher than
SMH
with
Central Plateau.
is a teacher’s role
At Time 2
pre test scores
guidance
of guidance and
α= 0.81
for
Feasibility: Use of
and support Attrition rate: 8.3%
support.
knowledge
unstandardized
that could
and attitude
measures is not
facilitate
recommended.
Key: AA- African American; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide:
Malawi version; AH-Acute hospitalization; ALGEE- assess risk of suicide, listen non judgmentally, give advice and information; AS- Attitudes and Skills; ASQ- Attitudes and
Skills Questionnaires; BV- Bullying Victimization; CB- cyberbullying; CDC- Center for Disease Control; CG- control group; CI- confidence interval; CMH- Complex Mental
Health; d- Cohen’s; DV- Dependent Variable; F-Female; FGD-focus group discussions; IG- Intervention group; InTASC- interstate teacher assessment and support consortium;
IPP- In- patient pediatric; IV- Independent Variable; KDS- Knowledge of Deliberate Self Harm; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; LOE- Level Of
Evidence; M- Male; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitudes; MHL- mental health literacy; MOE- Ministry of
education; N- Number of participants; OBQ- Olweus Bully/Victim Questionnaire; OR- odds ratio; p- level of significance; PD- Personality Disorder; PHQ- patient health
questionnaire; PI- psychosocial intervention; RCT- randomized control trial; SB- suicidal behaviors; SH- self harm; SIUH- Staten Island University Hospital; SMH- school
mental health; ST- School Teachers; TC- teacher competency; Time 0- baseline; Time 1- immediate post training; Time 2- 6-9 weeks post training; WEMWBS- Warmick
Edinburg Wellbeing scale; WISE- well-being in secondary education; WHO- World Health Organization; YCL- Youth club leaders; y.o.- year old; α – Cronbach’s alpha value.

MENTAL HEALTH LITERACY

30

their access
to local
mental
health
services.

Citation

Kidger et al.,
(2016). A pilot
cluster
randomized
controlled trial
of a support and
training
intervention to
improve the
mental health of
secondary
school teachers
and students –
the WISE study.
Country: UK
Funding:
National
Institute for
Health
Research’s
School for

Unstandardized
written
assessment

Theory/
Conceptual
Framework

Design/
Method

Sample/
Setting

Major
Variables
Definitions

Logic model
of the WISE
Intervention.

Pilot
cluster
randomized
controlled
trial
Purpose:
To provide
support for
staff mental
health and
strengthen
their ability
to support
students.

Schools= 6
Staff= 648
Setting: Secondary
schools in English
administrative areas.
Exclusion: Fee
paying schools
outside the local
English
Administrative areas.

p < 0.001 & p
= 0.002
respectively

Measurement

Data
Analysis

Findings/
Results

IV: WISE
intervention for
teachers.
DV1: Will staff
participate in
RCT?

Strength and
difficulties
questionnaire

Linear and
Logistic
regression.

Interviews and
audio recording.

Qualitative data
analysis.

DV2: Is MHFA
training
appropriate and
does it improve
MH knowledge
and attitude
among staff?

Inspection of
transcripts

DV1: Total
648 staff
Attrition
greater in
control
schools vs,
intervention
schools.
74.5% vs,
55.9%
DV2: Those
who received
training had
better
knowledge,
less
stigmatizing
attitudes and
greater
tendency to
use ALGEE

DV3: Is a peer
support service
feasible and
sustainable?

&

WEMWBS
PHQ-9 for
assessing staff
depression.

Level/Quality
Of Evidence; Decision
for
practice/
application to practice
LOE: IV
Strength: qualitative
and quantitative
findings indicate that
both adults and youth
MHFA were effective
in improving
knowledge, attitude,
confidence and skills in
supporting others
Weakness: Imbalance
between CG and IG.
CG had low staff
response rate.
Conclusion: MHFA
and ALGEE training
increases the
knowledge, attitude,
confidence and skills

Key: AA- African American; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide:
Malawi version; AH-Acute hospitalization; ALGEE- assess risk of suicide, listen non judgmentally, give advice and information; AS- Attitudes and Skills; ASQ- Attitudes and
Skills Questionnaires; BV- Bullying Victimization; CB- cyberbullying; CDC- Center for Disease Control; CG- control group; CI- confidence interval; CMH- Complex Mental
Health; d- Cohen’s; DV- Dependent Variable; F-Female; FGD-focus group discussions; IG- Intervention group; InTASC- interstate teacher assessment and support consortium;
IPP- In- patient pediatric; IV- Independent Variable; KDS- Knowledge of Deliberate Self Harm; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; LOE- Level Of
Evidence; M- Male; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitudes; MHL- mental health literacy; MOE- Ministry of
education; N- Number of participants; OBQ- Olweus Bully/Victim Questionnaire; OR- odds ratio; p- level of significance; PD- Personality Disorder; PHQ- patient health
questionnaire; PI- psychosocial intervention; RCT- randomized control trial; SB- suicidal behaviors; SH- self harm; SIUH- Staten Island University Hospital; SMH- school
mental health; ST- School Teachers; TC- teacher competency; Time 0- baseline; Time 1- immediate post training; Time 2- 6-9 weeks post training; WEMWBS- Warmick
Edinburg Wellbeing scale; WISE- well-being in secondary education; WHO- World Health Organization; YCL- Youth club leaders; y.o.- year old; α – Cronbach’s alpha value.

MENTAL HEALTH LITERACY
Public Health
Research
Bias: None

31
DV4: What
sample size is
required for a full
cluster RCT with
score on
WEMWBS as the
primary outcome?

p < 0.01
DV3: peer
support
service
utilization
6.3%
Those finding
it helpful
73.7%

towards mental health
among teachers.

DV4: Sample
size of 24
schools

Key: AA- African American; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide:
Malawi version; AH-Acute hospitalization; ALGEE- assess risk of suicide, listen non judgmentally, give advice and information; AS- Attitudes and Skills; ASQ- Attitudes and
Skills Questionnaires; BV- Bullying Victimization; CB- cyberbullying; CDC- Center for Disease Control; CG- control group; CI- confidence interval; CMH- Complex Mental
Health; d- Cohen’s; DV- Dependent Variable; F-Female; FGD-focus group discussions; IG- Intervention group; InTASC- interstate teacher assessment and support consortium;
IPP- In- patient pediatric; IV- Independent Variable; KDS- Knowledge of Deliberate Self Harm; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; LOE- Level Of
Evidence; M- Male; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitudes; MHL- mental health literacy; MOE- Ministry of
education; N- Number of participants; OBQ- Olweus Bully/Victim Questionnaire; OR- odds ratio; p- level of significance; PD- Personality Disorder; PHQ- patient health
questionnaire; PI- psychosocial intervention; RCT- randomized control trial; SB- suicidal behaviors; SH- self harm; SIUH- Staten Island University Hospital; SMH- school
mental health; ST- School Teachers; TC- teacher competency; Time 0- baseline; Time 1- immediate post training; Time 2- 6-9 weeks post training; WEMWBS- Warmick
Edinburg Wellbeing scale; WISE- well-being in secondary education; WHO- World Health Organization; YCL- Youth club leaders; y.o.- year old; α – Cronbach’s alpha value.

MENTAL HEALTH LITERACY

32
Appendix C

Table 2
Synthesis Table

Author
Year
Design/LOE

Sample size/
Studies
Community
setting
Measurement
tools

Duration of
Intervention

Ball
2016
V

22

Eustache
2017
VI
(mixed
study)

24

Franklin
2017
I

24

John
2018
I

33

X
CB

LS,
CDI, HSC,
PPTA,
CPES
SRWOR,
FGD,
MHKA
2.5 days

CA,
DES,
IR

Literature
Review
Kidger
2016
IV
(mixed study)

Kutcher
2016
VI

Kutcher
2015
IV

Leader
2018
IV

Long
2018
II

Townstead
2018
IV

Study
Characteristics
648

61

218

185

18,896

400

X

X

X

X

X

SDQ, WEMWBS

Questionnaire Questionnaire OBQ

GBS

KDSQ,
ADSHQ,
ASQ

2 days

3 days

3 days

1 day

Interventions
Key; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide: Malawi version; ALGEEassess risk of suicide, listen non judgmentally, give advice and information; ASQ- Attitudes and Skills Questionnaires; BV- Bullying Victimization; CA- critical appraisal; CBCodebook; CDI- children depression inventory; CMH- chronic mental health; CPES- Children’s pessimistic explanatory style; DES- data extraction sheet; DV- Dependent
variable; FGD- Focus group discussion; GBS- gatekeeper behavior scale; HSC- Hopelessness scale for children; IR- independent reviews; LOE- Level of evidence; LS- Likert
scale; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitude; MHLmental health literacy; MI- Motivational interviewing; OBQ- Olweus Bully/Victim Questionnaire; PPTA- Pre post training assessment; SA- suicide attempt; SB- suicidal
behaviors; SDQ- strength and difficulties questionnaire; SH- self harm; SI- suicidal ideation; SMH- School mental health; SRWOR- Self- report written open ended responses;
WEMWBS- Warmick Edinburg Wellbeing scale; WISE- well-being in secondary education; ▲- Increase; *- Statistically significant with p ≤ 0.050

MENTAL HEALTH LITERACY
WISE
SMH
TAPS
Training
Psychosocial
MHFAALGEE
MHL-AGMv
Simulation MI
CMH
Training

33
X

X
X
X
X
X

X
X
X

DV
Skills
Behaviors
Professional
growth
Acceptability
Knowledge
and Attitude
Internalizing
SH/SB/SA
Comfort
BV & SI

▲*
▲*
▲
▲*

▲

▲*

▲*

▲*

*
▲
▲*
▲*

Key; ADSH- Assessment towards Deliberate Self Harm; ADSHQ- Assessment towards Deliberate Self Harm Questionnaire; AGMv – African Guide: Malawi version; ALGEEassess risk of suicide, listen non judgmentally, give advice and information; ASQ- Attitudes and Skills Questionnaires; BV- Bullying Victimization; CA- critical appraisal; CBCodebook; CDI- children depression inventory; CMH- chronic mental health; CPES- Children’s pessimistic explanatory style; DES- data extraction sheet; DV- Dependent
variable; FGD- Focus group discussion; GBS- gatekeeper behavior scale; HSC- Hopelessness scale for children; IR- independent reviews; LOE- Level of evidence; LS- Likert
scale; KDSQ- Knowledge of Deliberate Self Harm Questionnaire; MH- Mental health; MHFA- mental health first aid; MHKA- mental health knowledge and attitude; MHLmental health literacy; MI- Motivational interviewing; OBQ- Olweus Bully/Victim Questionnaire; PPTA- Pre post training assessment; SA- suicide attempt; SB- suicidal
behaviors; SDQ- strength and difficulties questionnaire; SH- self harm; SI- suicidal ideation; SMH- School mental health; SRWOR- Self- report written open ended responses;
WEMWBS- Warmick Edinburg Wellbeing scale; WISE- well-being in secondary education; ▲- Increase; *- Statistically significant with p ≤ 0.050

MENTAL HEALTH LITERACY
34

Appendix D
Figure 1
Bandura’s Social Cognitive Theory

(Social and Behavioral Theories. Retrieved from http://www.esourceresearch.org/Default.aspx?TabId=734).

MENTAL HEALTH LITERACY
35

Appendix E
Figure 2
Rosswurm and Larrabee evidence based practice model

(Reavy, 2016)

MENTAL HEALTH LITERACY
36
Appendix F
Figure 3
Pre-Training Questionnaire (T0)
FORM T0
This survey is anonymous, meaning none of your identifiable information (e.g., name, birthday, social security
number etc.) will be asked. Please create a unique ID below so we can link your data collected at different
time. Pick the first three letters of your mother’s first name and the last 3 digits of your cell phone
number. For example, if your mother’s first name is Debbie and your phone number is 123-456-7890,
your ID= deb890

ID_______________

Date: ________________

Demographics:
Age (Birth Year only): ___________
(Mark ‘X’ where applicable)
Ethnicity:

_______African American

________Caucasian

_______Native American

________Hawaiian/Pacific Islander

_______Asian

________Mixed Race

_______Other (Please specify) ____________
Gender: ___________Male

____________Other (please specify) ____________

___________Female
Educational Background: ___________Less than high school

_______________

Technical

degree
___________High School

_______________

College degree

___________Some College

_______________

Professional/

Graduate
Years as a Mentor: ___________ (In years)
Ever Received Mental Health Training in the past?

MENTAL HEALTH LITERACY
37
___________YES (Pleases specify) _____________________________________.
___________NO.

In answering the following questionnaire, select the answer by CIRCLING.
Very unlikely= I am certain that it is NOT likely; Unlikely = I think it is unlikely but am not certain; Likely= I
think it is likely but not certain; Very likely= I am certain that it IS very likely.

1.

If someone experienced excessive worry about a number of events or activities where this level of
concern was not warranted, had difficulty controlling this worry and had physical symptoms such as
having tense muscles and feeling fatigued, to what extent do you think it is likely they have Generalized
Anxiety Disorder?
Very unlikely

2.

Unlikely

Likely

Very Likely

To what extent do you think it is likely that the diagnosis of Agoraphobia includes anxiety about
situations where escape may be difficult or embarrassing?
Very unlikely

3.

Unlikely

Likely

Very Likely

If someone experienced a low mood for two or more weeks, had a loss of pleasure or interest in their
normal activities and experienced changes in their appetite and sleep, to what extent do you think it is
likely they have Major Depressive Disorder?
Very unlikely

4.

Likely

Very Likely

To what extent do you think it is likely that Personality Disorders are a category of mental illness?
Very unlikely

5.

Unlikely

Unlikely

Likely

Very Likely

To what extent do you think it is likely that the diagnosis of Bipolar Disorder includes experiencing
periods of elevated (i.e., high), and periods of depressed (i.e., low) mood?
Very unlikely

Unlikely

Likely

Very Likely

MENTAL HEALTH LITERACY
38
In answering the following questionnaire, select the answer by CIRCLING.
Agree=4; Rather agree= 3; Rather disagree=2; Disagree=1; Don’t know=0
6.

People with severe mental illness have to take medication for the rest of their lives
Agree

7.

Don’t know

Rather disagree

Rather agree

Disagree

Don’t know

Rather agree

Rather disagree

Disagree

Don’t know

Disagree

Don’t know

Disagree

Don’t know

Severe mental illness is caused by bad luck
Agree

10.

Disagree

People with severe mental illness are failures
Agree

9.

Rather disagree

People with severe mental illness are not able to acquire new skills.
Agree

8.

Rather agree

Rather disagree

Rather agree

People with severe mental illness are dangerous
Agree

Rather agree

Rather disagree

In answering the following questionnaire, select the answer by CIRCLING.
Strongly agree=4; Agree=3; Disagree= 2; Strongly disagree=1
11.

I feel confident in my ability to discuss my concern with a student exhibiting signs of psychological
distress.
Strongly agree

12.

Agree

Disagree

Strongly disagree

I feel confident in my ability to recommend mental health support services to a student exhibiting signs
of psychological distress.
Strongly agree

13.

Disagree

Strongly disagree

I feel confident in my ability to help a suicidal student for mental health support
Strongly agree

14.

Agree

Agree

Disagree

Strongly disagree

I feel confident that I know where to refer a student for mental health support.

MENTAL HEALTH LITERACY
39
Strongly agree

Agree

Disagree

Strongly disagree

Appendix G
Figure 4
Immediate Post- Training Questionnaire
FORM T1
This survey is anonymous, meaning none of your identifiable information (e.g., name, birthday, social security
number etc.) will be asked. Please create a unique ID below so we can link your data collected at different
time. Pick the first three letters of your mother’s first name and the last 3 digits of your cell phone
number. For example, if your mother’s first name is Debbie and your phone number is 123-456-7890,
your ID= deb890
ID: _______________
Please tell us what you think of this presentation by checking the boxes that you think best applies.
Evaluation outcome

Strongly Disagree
Disagree

Not
sure

Agree Strongly
Agree

The content presented was appropriate
to address mentor’s understanding of
mental health.
My knowledge about mental health and
mental illness have improved.
I am more comfortable in identifying
signs and symptoms of mental distress.
I am confident in being able to identify
students who may have a mental health
problem.
I have better understanding about how
to help student access appropriate
mental health care in my community.
I am more comfortable in supporting
students who may have a mental health
problem.

What was the most useful learning that you obtained through the presentation?

Do you think all mentors at the club should have the opportunity to access the training for knowledge and
awareness?
______________________________________________________________________________

MENTAL HEALTH LITERACY
40
Thank you for your time. We appreciate your invaluable input

Appendix H
Figure 5
Two weeks post training questionnaire
FORM T2
This survey is anonymous, meaning none of your identifiable information (e.g., name, birthday, social security
number etc.) will be asked. Please create a unique ID below so we can link your data collected at different
time. Pick the first three letters of your mother’s first name and the last 3 digits of your cell phone
number. For example, if your mother’s first name is Debbie and your phone number is 123-456-7890,
your ID= deb890

ID: ___________________

DATE: __________________

In answering the following questionnaire, select the answer by CIRCLING.
Very unlikely= I am certain that it is NOT likely; Unlikely = I think it is unlikely but am not certain; Likely= I
think it is likely but not certain; Very likely= I am certain that it IS very likely.

15.

If someone experienced excessive worry about a number of events or activities where this level of

concern was not warranted, had difficulty controlling this worry and had physical symptoms such as having
tense muscles and feeling fatigued, to what extent do you think it is likely they have Generalized Anxiety
Disorder?
Very unlikely
16.

Unlikely

Likely

Very Likely

To what extent do you think it is likely that the diagnosis of Agoraphobia includes anxiety about

situations where escape may be difficult or embarrassing?
Very unlikely

Unlikely

Likely

Very Likely

MENTAL HEALTH LITERACY
41
17.

If someone experienced a low mood for two or more weeks, had a loss of pleasure or interest in their

normal activities and experienced changes in their appetite and sleep to what extent do you think it is likely they
have Major Depressive Disorder?
Very unlikely
18.

Likely

Very Likely

To what extent do you think it is likely that Personality Disorders are a category of mental illness?
Very unlikely

19.

Unlikely

Unlikely

Likely

Very Likely

To what extent do you think it is likely that the diagnosis of Bipolar Disorder includes experiencing
periods of elevated (i.e., high), and periods of depressed (i.e., low) mood?
Very unlikely

Unlikely

Likely

Very Likely

In answering the following questionnaire, select the answer by CIRCLING.
Agree=4; Rather agree= 3; Rather disagree=2; Disagree=1; Don’t know=0
20.

People with severe mental illness have to take medication for the rest of their lives
Agree

21.

Don’t know

Rather agree

Rather disagree

Disagree

Don’t know

Rather agree

Rather disagree

Disagree

Don’t know

Disagree

Don’t know

Disagree

Don’t know

Severe mental illness is caused by bad luck
Agree

24.

Disagree

People with severe mental illness are failures
Agree

23.

Rather disagree

People with severe mental illness are not able to acquire new skills.
Agree

22.

Rather agree

Rather agree

Rather disagree

People with severe mental illness are dangerous
Agree

Rather agree

Rather disagree

In answering the following questionnaire, select the answer by CIRCLING.

MENTAL HEALTH LITERACY
42
Strongly agree=4; Agree=3; Disagree= 2; Strongly disagree=1
25.

I feel confident in my ability to discuss my concern with a student exhibiting signs of psychological

distress.
Strongly agree
26.

Agree

Disagree

Strongly disagree

I feel confident in my ability to recommend mental health support services to a student exhibiting signs
of psychological distress.
Strongly agree

27.

Disagree

Strongly disagree

I feel confident in my ability to help a suicidal student for mental health support
Strongly agree

28.

Agree

Agree

Disagree

Strongly disagree

I feel confident that I know where to refer a student for mental health support.
Strongly agree

Agree

Disagree

Strongly disagree

MENTAL HEALTH LITERACY
43
Appendix I
Table 3
Descriptive statistics of variables over time
Variable
T0 knowledge score
T1 knowledge score
T2 knowledge score
T0 attitude score
T1 attitude score
T2 attitude score
T0 self-efficacy score
T1 self-efficacy score
T2 self-efficacy score

Participants
11
11
7
11
11
7
11
11
7

Minimum
14.00
15.00
13.00
5.00
5.00
3.00
7.00
11.00
11.00

Maximum
19.00
20.00
19.00
10.00
9.00
7.00
21.00
16.00
13.00

Mean
15.7273
17.0000
16.2857
7.0909
6.0909
5.7143
11.9091
12.3636
11.8571

Std. Deviation
1.79393
1.78885
2.36039
1.92117
1.22103
1.38013
3.59039
1.28629
.69007

MENTAL HEALTH LITERACY
44
Appendix J
Knowledge score and effect size over time
Figure 6
Sum knowledge score over time

Sum Knowledge Score over time
17.5
17
16.5
16
15.5
15
T0

T1

T2

Table 4
Cohen’s effect size on knowledge

Effect size for T0-T1
knowledge
Effect size for T1-T2
knowledge
Effect size for T0-T2
knowledge

mean (pre-post)
1.27

SD
1.42

Effect Size
0.890

Effect
large

0.43

1.51

0.280

small

0.14

1.77

0.080

very small

MENTAL HEALTH LITERACY
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Appendix K
Attitude score and effect size over time
Figure 7
Sum attitude score over time

Sum Attitude Score over time
8
7
6
5
4
3
2
1
0
T0

T1

T2

Table 5
Cohen’s effect size on attitude

Effect size for T0-T1 ATTITUDE

mean (pre-post)
1

SD
1.34

Effect Size
0.75

Effect
medium

Effect size for T1-T2 ATTITUDE

0

1.15

0

none

Effect size for T0-T2 ATTITUDE

0.71

1.11

0.64

medium

MENTAL HEALTH LITERACY
46
Appendix L
Self-efficacy score and effect size over time
Figure 8
Sum self-efficacy score over time

Sum Self-efficacy score over time
12.4
12.3
12.2
12.1
12
11.9
11.8
11.7
11.6
T0

T1

T2

Table 6
Cohen’s effect size on self-efficacy

Effect size for T0-T1 Self-efficacy
Effect size for T1-T2 Self-efficacy
Effect size for T0-T2 Self-efficacy

mean (prepost)
0.45
0.14
1.29

SD

Effect Size

Effect

3.59
0.38
2.06

0.13
0.37
0.63

very small
small
medium