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

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.

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: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

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.

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.

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.

Study population

The population from which the schools in our sample were recruited was secondary schools in two geographical areas: (1) Bristol and surrounds up to a 30-mile radius, comprising 64 mainstream secondary schools and (2) South East and South Central Wales, comprising 88 mainstream secondary schools. Exclusion criteria were as follows:

• fee-paying schools

• special schools (e.g. for those with learning disabilities)

• pupil referral units

• schools that had been WISE pilot schools

• schools participating in other, similarly intensive, research studies

• schools already delivering MHFA or other mental health training

• schools without available FSM data for stratification purposes

• schools within the same academy chain and local authority as one that had already been selected for participation.

In total, we aimed to recruit 24 schools (i.e. 12 in each area).

Our study population within each school was all teaching staff and all students in year 8 (aged 12–13 years) at baseline. At 24-month follow-up (T2), the same students were year 10 (aged 14–15 years). We assumed that any effect on this year group would be the same for all students, as the intervention was intended to be at the whole-school level.

Recruitment and randomisation

In both England and Wales, the sampling frames were stratified by the proportion of children in each school who were eligible to receive FSM to ensure schools from a wide range of socioeconomic catchment areas were included in the study. In Wales, the sample was divided into two administrative regions (educational consortia), South East and South Central Wales, and schools were stratified into three FSM levels (high, medium and low vs. the national average). Two schools were randomly selected from each stratum in each region, and selected schools were approached via a relevant senior leader (e.g. a deputy head in charge of pastoral care) and invited to participate in the study. Schools that declined were replaced by a randomly selected school from the same stratum and region. In England, the study was advertised to head teachers at all eligible schools and invitations were followed up with relevant senior leaders, identified with the help of local public health teams that worked with the schools. Those who expressed interest in participation were stratified into three levels according to FSM (high, medium and low vs. the national average) and local authority (Bristol/non-Bristol). When more than two schools fitted into one stratum, two were randomly selected.

Within each study area and stratum, selected schools were randomly allocated to a study arm. Sequence allocation was generated by the study statistician, who was blinded to the schools’ identities, using the Stata ralloc command (version 14, StataCorp LP, College Station, TX, USA). Random allocation to study arm took place after baseline data collection.

Primary outcome

The primary outcome was teacher well-being, measured using the Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS). 62 The WEMWBS is comprehensive (incorporating elements of both subjective and psychological well-being), short enough to be used in population-level questionnaires, responsive to change and validated among community samples of adults in the UK. [Licenses to use the WEMWBS are available at https://warwick.ac.uk/fac/sci/med/research/platform/wemwbs/using/ (accessed 11 February 2021).] We selected well-being rather than a measure of mental health difficulty as the primary outcome because it is a broad enough measure to capture changes among staff with a range of mental health needs, including those who have good well-being, but may still benefit from cultural changes at the whole-school level.

The WEMWBS scores can range from 14 to 70, where a higher score indicates better well-being. This outcome was measured at baseline, T1 and T2.

Secondary outcomes

Teacher depression was measured using the Patient Health Questionnaire-8 items (PHQ-8). 64 The PHQ-8 is suitable for measuring levels of depressive symptoms in population-based studies and is short enough to be used in self-complete questionnaires. It was analysed as a continuous variable, but also as an ordinal variable (0–4 indicating no depressive symptoms, 5–9 indicating mild symptoms, 10–14 indicating moderate symptoms, 15–19 indicating moderately severe symptoms and 20–24 indicating severe symptoms) and a binary variable, with a cut-off point of ≥ 10 indicating depression. 64 These cut-off points were established for the Patient Health Questionnaire-9 items, but are the same for the PHQ-8, with the only difference between the two scales being an additional question about self-harm behaviour, which does not contribute to the overall depression score.

Teacher absence was measured by self-report (i.e. the ‘number of days missed from school because of health problems in the past 4 working weeks’) and routine data collected by the schools (i.e. the total number of days of absence over the previous year). Both measures were treated as continuous, but the self-report measure was also treated as binary (any vs. no absence) and ordinal. Based on the distribution of responses in the pilot study, in which the majority of respondents had taken very little absence, categories were 0 days, 1 day, 2–7 days or ≥ 7 days.

Teacher presenteeism was measured by self-report, using the relevant item from the Work Productivity and Activity Impairment questionnaire65 and adapted to fit teachers’ work schedule. Teachers were asked ‘during the last 4 working weeks, how much did health problems affect your productivity while you were working?’ and selected a number between 0 (no effect) and 10 (completely prevented me from working). This measure was treated as continuous, but also as binary (no effect vs. 1–10 effect on work over the previous 4 working weeks) and ordinal. Based on the pilot responses to presenteeism, in which roughly one-third of participants scored 0 and a majority scored < 6, the categories were 0 days, 1–5 days or 6–10 days.

Teacher retirements and leaving for other reasons were collected as total number reported by the schools for the previous year.

Year 8 student well-being was measured using the WEMWBS, which has been validated for use among teenagers from age 13 years. 66 This measure was treated as continuous.

Year 8 student psychological distress was measured using the Strengths and Difficulties Questionnaire (SDQ), a widely used measure among this age group, with well-established norms for a UK population. 67 A total difficulties score was calculated (this can range from 0 to 40, with a higher score indicating greater difficulties) and treated as continuous.

Student attendance was collected as a total proportion for each school from routine data sources for England68 and Wales. 69

Student attainment at the end of year 11 was collected from the same routine data sources as student attendance. 68,69 Exams at the end of statutory school age (key stage 4) are graded and reported differently for the two countries. For English schools, we reported per cent of students achieving grade 5 or above in both English and Maths General Certificates of Secondary Education, and for Welsh schools we reported per cent of students achieving grade C or above in English/Welsh, Maths and Science GSCEs.

The baseline questionnaires are included in Appendices 1 and 2.

Outcome data collection process

Teacher self-report outcome questionnaires were completed during staff meetings at baseline (May–July 2016), T1 (May–July 2017) and T2 (May–July 2018). Those who were absent from the data collection session were offered the option of completion via an online survey. Data on teacher absence, retirement and leaving for other reasons were collected via routine data recorded by the schools.

Student mental health outcomes were gathered via self-report questionnaires at baseline and T2, completed by all students in year 8 (aged 12–13 years at baseline), during tutor groups or lesson time. Where fewer than five students were absent, questionnaires were left with school for those students. Where five or more students were absent, a second data collection was arranged with schools. School-level student absence and attainment were collected using government statistics published online.

Teacher routine outcomes (school-reported absence and leavers data) and all student outcomes were measured at baseline and T2 only. This was for practical reasons, and also because the intervention’s logic model implied that teacher mental health would need to improve before changes to student mental health were maximised.

The study team planned to attend all data collections, introduce the questionnaires, answer any questions and take them away at the end. However, three schools at baseline did not manage to secure meeting time to conduct the data collections. In these schools, the team briefly introduced the questionnaires in a meeting, but left them with staff along with envelopes in which questionnaires could be sealed and then either posted or returned via a box left at the school. Two of these schools followed the same process at both T1 and T2, despite attempts by the study team to organise meeting time.

Compliance and loss to follow-up

We encouraged the schools to set the dates for data collection sessions far in advance to try and ensure maximum attendance. We built in time to follow up those who were absent, either in person or by leaving questionnaires in named envelopes, which the research team collected once completed. We also made an online version of the questionnaire available to teachers who missed the data collection session. We incentivised schools to remain part of the study by providing them with their own school-level data from each time point at the end of the study. We also offered control schools a payment at the end of the study, which they could choose to spend on the intervention if it was found to be effective. This payment was contingent on a response rate of at least 80% at follow-up among teachers and students.

Sample size

The study was powered to detect a mean change of 3 points on the WEMWBS (i.e. the primary outcome measure). This difference was chosen as the minimum meaningful change discussed in a WEMWBS user guide. 70

A change of 3 points was also close to the difference in mean WEMWBS scores between staff in the highest- and lowest-ranked schools in the pilot study.

It was estimated that each school would have approximately 60 teachers and 150 year 8 students, depending on size. The sample size took account of clustering. In the pilot data, the teacher WEMWBS intracluster correlation coefficient (ICC) at baseline was 0.01 (95% CI 0.00 to 0.03) and at follow-up it was 0.00 (95% CI 0.0 to 0.02). We assumed a mean of 50 (83%) teachers followed up per school (with a coefficient of variation of sample size of 0.5) and a standard deviation (SD) for WEMWBS of 8.4 (based on the pilot data). A sample size of 24 schools (i.e. 12 intervention schools and 12 control schools) would achieve 83% power for an ICC of 0.05. This would rise to 98% if the ICC is 0.02, and fall to 65% for an ICC of 0.08. Sample sizes were calculated using the clustersampsi command in Stata. For the tests for interactions (see Main outcomes analysis), we would have 80% power to detect an interaction that is twice as big as the main effect, and 30% power to detect an interaction that is the same size as the main effect. 71

Blinding and breaking of blind

Allocation to study arm took place after baseline data had been collected to ensure blinding among all parties during this first data collection. It was not possible for the schools, teachers or students to be blind to intervention status (although students were likely to be unaware of the intervention). The research assistants/associates leading outcome data collection also collected the process data, which prevented blinding among the study team.

Clustering

All statistical analyses took account of clustering by school using robust standard errors and, where appropriate, by using random-effects models with schools as a random effect. Analyses were conducted using Stata.

Main outcomes analysis

Measurements

The economic analysis took a public sector perspective, calculating the financial and opportunity costs to schools of participating in the WISE intervention. We collected self-reported information on the impact of teachers’ health on absenteeism and presenteeism during the previous 4 weeks at T1 and T2. However, in common with other school-based interventions,76 we elected not to track teacher health-care use at T1 or T2.

Data were collected on the resources used for the following four activities: (1) the HSC MHFA instructor training (which was relevant for Welsh schools only); (2) the 2-day standard MHFA training; (3) the in-service day MHFA training for schools and colleges; and (4) the awareness raising session. In each case, the project team completed a pro forma after the training session, documenting the resources used and expenses claimed.

As noted in Chapter 1, in Wales, Public Health Wales paid for a course to train seven HSCs as MHFA instructors who could then deliver the MHFA training to teachers in Welsh schools. The course included 6 days of training with a MHFA trainer and 2 additional days of independent preparation for the HSC trainees. The costs comprised HSCs’ time (estimated based on salary costs), actual travel expenses incurred, MHFA course fees, MHFA trainer expenses and course refreshments. The venue was provided at no cost by Cardiff University (Cardiff, UK).

The resources used during the 2-day standard MHFA training comprised MHFA trainer fees, trainer travel expenses (in English schools this was sometimes included in the trainer fee), MHFA manuals, refreshments (in most schools) and the time of the teachers being trained as peer supporters (a minimum of five teachers and a maximum of 16 teachers). There were no venue costs for training, as this happened either on the school site or at a university. Several schools provided estimates of the cost of hiring supply teachers to cover the teaching commitments of staff attending the MHFA training. We used these estimates to impute the opportunity cost of staff time at all schools.

The resources used for the 1-day MHFA schools and colleges training comprised MHFA trainer fees, trainer travel expenses (in English schools this was sometimes included in the trainer fee), MHFA manuals and the time of the teachers attending training (a minimum of seven teachers and a maximum of 18 teachers). As training took place during in-service days, no supply teachers were necessary and staff costs were estimated based on anonymised salary information provided by the schools. When salary information was not provided by the school (n = 1), these costs were imputed based on the number of attendees and the mean salaries of attendees from other schools.

The resources used for the 1-hour awareness raising session for all teachers comprised the trainer fees, and travel costs and the staff costs for the teacher and support staff attending. For the English schools, staff costs were estimated from the number of staff attending (a minimum of 31 staff and a maximum of 85 staff) and estimated salaries were based on salary band information provided by schools. The mean school staff costs in England were used to impute the staff costs in Welsh schools, where data on staff attendance was not available.

All resource use was valued in monetary terms using published UK unit costs (Table 2) or participant valuations estimated at the time of analysis (2016/17). Support staff salaries were obtained by asking schools/individuals for this information. Teachers’ salaries were estimated using national pay scales after confirming participants’ pay bands.

Cost–consequence analysis

The economic evaluation is a cost–consequence study that provides evidence on whether or not the incremental costs of the intervention are justified because of improved teacher or student outcomes. The potential benefits of the intervention are multifaceted and affect multiple agents (e.g. staff, students and schools), even those not directly observed in the study (e.g. students in other years). Therefore, a cost–consequence framework that tabulates costs against several outcomes for staff and students is appropriate, rather than a more reductive cost-effectiveness or cost–utility analysis that attempts to summarise efficiency in a single ratio. 77 It provides a more complete analysis for policy-makers than a ‘cost per unit improvement in WEMWBS score’, which has no easy interpretation. Previous research has demonstrated limited correlation and overlap between the WEMWBS well-being scores and health-related utility scores (such as the EuroQol-5 Dimensions, three-level version) used to estimate quality-adjusted life-years. 78 As quality-adjusted life-years are unlikely to be sensitive to small changes in well-being, we did not include the EuroQol-5 Dimensions or other preference-based health-related quality-of-life measures.

Subgroup analysis

Subgroup analysis is reported by country to investigate any differences in findings between England and Wales. This is important, given that the costs and, potentially, the outcomes will differ because of the different use of MHFA trainers in England and Wales.

Aims

A mixed-method process evaluation was integrated into the outcome and economic evaluations,79 following a ‘nested’ design. 80 The primary aim of the process evaluation was to support the interpretation of the outcome data and further refine the programme theory. 81 The process evaluation had five central objectives, which, for the purpose of the study, were categorised as domains of inquiry. These were as follows.

Research questions

Table 3 lists the research questions that the process evaluation addressed and outlines the domain of inquiry to which each one was aligned.

Sample

Four intervention schools and four control schools were purposively sampled to serve as ‘case study schools’, in which more extensive process evaluation was undertaken (e.g. focus groups and observations). To sample the case study schools, all study schools were stratified by trial arm allocation (intervention vs. control), site (England vs. Wales), administrative region (educational consortia vs. local authority) and proportion of students eligible for FSM (high/low vs. the national average). One intervention school within each stratum was then purposively sampled to achieve variation across the cases in school size and assessment ranking by the educational inspectorate. One control school was selected within each stratum to match the intervention cases as closely as possible. Table 4 presents the final sample of case study schools.

Data sources

The process evaluation adopted a mixed-methods approach and used both quantitative and qualitative data sources. The different types of data collected from the study schools, and how they relate to the research questions, are summarised in Report Supplementary Material 3.

Analysis

Process evaluation data were analysed independently of the trial outcome data. Findings were then integrated following the completion of outcome data analysis so that the process evaluation could inform the interpretation of these data, specifically by explaining how the mechanisms of change worked (or did not work) in context and how the intervention had been implemented.

Informed consent

The head teachers at all participating schools were given an information leaflet and had up to 1 month to confirm participation. At this point, they signed an agreement consenting to the school’s participation (or another senior leader signed with the head teacher’s consent), confirming that they would comply with all intervention and data collection requirements. All teachers and student participants were given information sheets at least 2 weeks before each questionnaire data collection, outlining the right to opt out of participation, the purpose of the study, any potential benefits or harms in taking part, details about data storage and details about what the data would be used for. The information sheets also contained contact information for the study team. Letters containing the same information were posted or e-mailed to parents by schools (in accordance with their usual procedures for communicating with parents) at least 1 week before student data collection, accompanied by opt out forms. Any student whose parent returned the opt out form did not take part in the questionnaire data collection. Consent was assumed from participants who completed a questionnaire. Written consent to participate was obtained from all staff peer supporters and from all participants who agreed to take part in an interview or focus group. We attempted to obtain parental written consent for students invited to take part in a focus group, but, where this was not returned, the school contact obtained verbal parental consent over the telephone.

Safety reporting procedures

School contacts and those delivering the intervention (i.e. MHFA trainers, HSCs and those trained as peer supporters) were asked to contact the study team within 2 working days if any untoward incident or adverse event (AE) occurred to a student or member of staff (1) as a direct result of taking part in the WISE study or (2) because of changes that had occurred in the school environment because of participation in the WISE trial (e.g. heightened awareness among staff of mental health problems, leading to inappropriate referrals to specialist help sources for ‘normal’ student behaviour). In these cases, study-specific AE/incident forms were completed, recording information on the event. Members of the research teams in Bristol and Cardiff were also required to complete a form about any incidents or AEs that they encountered during data collections. All AE/incident report forms were discussed with the principal investigator to assess seriousness and to explore causality. All AEs deemed to be ‘serious’ [i.e. a serious adverse event (SAE)] were to be reported to the sponsor within 24 hours. All AEs and SAEs not deemed to be related to the study were reported to the Trial Steering Committee at the next scheduled meeting. There were no SAEs reported that were suspected to be related to the intervention.

All student questionnaires were checked on return to the university for any indication of serious harm. If a student had written something on their questionnaire indicating that they were at risk of serious physical or emotional harm, the principal investigator (Bristol) or study manager (Cardiff) was to be informed and they would contact the child protection officer at the school to report the concern. No such issues arose, possibly because the questionnaire did not directly ask about things indicating risk of serious harm.

If a teacher wrote something on their questionnaire indicating that their life may be in danger (e.g. ‘I would like to bring an end to it all’), the plan was for the study team to break anonymity and write to the individual at their school, in an envelope marked confidential, expressing concern and recommending seeking help. The teacher participant information sheets made clear the circumstances in which we would break anonymity and the action that would be taken. No such action was needed during the course of the study.

Final sample of schools

We recruited one extra school than was needed to allow for school dropout. The final total was, therefore, 25 schools (12 intervention schools and 13 control schools). Not enough schools could be recruited at each geographical site in each FSM level, partly because of the distribution of schools by FSM status in each area. We therefore merged strata for recruitment and randomisation, where necessary, to maintain balance across the study overall. In England, the lower two strata were merged and in Wales, the top two strata were merged.

The final distribution of recruited schools by geographical area and FSM strata is shown in Table 5.

Participant response rates

All 25 schools remained in the trial until the end and participated in all three data collections. Overall, teacher and student response rates at each time point are shown in Table 6.

Participant flow through the trial is shown in the Consolidated Standards of Reporting Trials (CONSORT) flow diagram (Figure 2). As can be seen in Figure 2, teacher response rates were slightly lower in intervention schools at both follow-ups than in control schools. At each time point, a proportion of teachers and students were not eligible for inclusion and, therefore, were not given a questionnaire to complete (e.g. those who were on maternity leave, had left the school, had parental consent withdrawn or were on long-term absence, such that they would not be in school during the intervention period). Reasons for non-completion at each time point were absence from all data collection sessions and returning a blank questionnaire (which those not consenting to participate were asked to do).

FIGURE 2.

The CONSORT flow diagram. 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.

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: https://creativecommons.org/licenses/by/4.0/. The figure includes minor additions and formatting changes to the original figure.

The total number of teachers included in the primary analysis was 1722. This was well above the mean of 50 teachers per school assumed within the power calculation. The total number of teachers in any secondary individual-level analysis ranged from 1533 to 1739. The total number of students included in the analysis with well-being as the outcome was 2700. The total number of students included in any individual-level analysis ranged from 2700 to 2703.

Baseline characteristics

Baseline teacher demographic data (Table 7) were similar between study arms, with the majority being white female participants. This reflects the wider teaching workforce. Figures for 2018 in England showed that 64.3% of full-time state-funded secondary school teachers were female and 82.6% were white. 85 Figures for 2019 in Wales showed that 75.5% of all teachers were female and 90.5% were white. 86 Participating teachers had much poorer well-being than the general working population, whose mean score is 51.4. 62 Similarly, participant median scores on the PHQ-8 suggest a higher level of depressive symptoms than population prevalences reported in other studies. 65,87 Around one-third of participants self-reported experiencing a previous mental health problem, and the vast majority had not received previous mental health training. Most participants reported good relationships between teachers and students and between staff at their school, and just under half had provided support to a colleague more than once a month in the previous academic year.

Baseline student characteristics (Table 8) were well balanced between arms, although the mean total difficulties score was slightly higher among control school students. Students were predominantly white, reflecting the population ethnicity in which the study was conducted. The mean well-being score was lower than the population mean WEMWBS score of 51.7, reported for 11- to 19-year-olds in England in 2017. 1 This difference may reflect poorer well-being among our particular geographic sample, but it may also be partly due to the narrower age range in the current study. The baseline SDQ scores also indicate higher total psychological difficulties than UK norms for 11- to 15-year-olds. 88 Again, this may indicate poorer mental health in this particular sample or it may reflect wider population changes since these norms were established in 2004. The majority of students at baseline reported good relationships between teachers and students in their school, and just under half had never gone to a teacher for help in the previous academic year.

Schools were also well balanced by most baseline characteristics across arms (Table 9). Intervention schools had a considerably higher mean number of teachers leaving during the year leading up the baseline measures for reasons other than retirement, and a higher percentage of schools in this group had equal to or above the national average in student attainment.

Primary analysis

Table 10 shows the teacher WEMWBS scores by arm at each follow-up time point and the results for the primary analysis. There was no evidence of a difference between arms in mean teacher mental well-being (WEMWBS score) over the course of follow-up (adjusted mean difference –0.90, 95% CI –2.07 to 0.27; p-value 0.130).

Secondary analyses

Subgroup and sensitivity analyses

Exploratory analyses

Implementation of Wellbeing in Secondary Education training components

To measure the reach and dosage of the MHFA training, the number of teachers and other school staff attending and completing the courses were recorded. Reach of the 1-hour awareness raising course was measured by recording the number of staff that attended it; however, we could not identify how many of these staff were teachers and how many were other staff, such as teaching assistants or learning mentors. Fidelity to the training delivery plan and quality of the training was measured drawing on the training observations, checklists and evaluation forms completed by training attendees, and trainer interviews (see Chapter 2 for the description of these data sources). Response rates to the checklists and feedback forms were high (Table 30).

Implementation: peer support service

Reach of the peer support service was assessed using information from the teacher questionnaires regarding use of the peer support service, the peer supporter logs recording support given and peer supporter focus group data. As described in Chapter 2, all peer supporters were asked to complete an electronic log each academic term (three times a year). Of the 113 peer supporters trained, an average of 60.6 (53.6%) peer supporters completed logs at each of the five time points, and each supporter completed a mean of 3.1 (SD 1.5) logs. Just over half the peer supporters completed the log at each of the five time points, although 14.5% did not complete one at any time point.

Fidelity of the peer support service delivery was assessed through the peer supporter feedback meetings (described in Chapter 2). A feedback meeting was successfully held in all 12 intervention schools at 6 months, but was held in only 10 schools at the 18-month follow-up, despite multiple attempts to organise this in all the schools.

Summary

The different components of the WISE intervention (i.e. the three different training sessions and the setting up of a peer support service) were delivered in all of the intervention schools. Generally, the training was delivered as planned, although the specified dose was not reached in all schools and the trainers did experience challenges in the school context. The peer support services were variable in their fidelity to the guidelines, with a majority not writing a confidentiality policy or feeling supported by senior leadership in the longer term. The significance of these issues will be returned to in the following section.

Did teachers have access to support and advice?

As a peer support service was set up in each intervention school, all teachers did at least, in theory, have access to increased support and advice. However, as reported in Chapter 4, Reach of peer support service, the teacher questionnaire data indicated that only a small number of teachers actually accessed the peer support service. The questionnaire also asked those who had not used it why they had not accessed the service. At both time points, the most frequent reasons given were help was not needed, a preference for talking to other colleagues and a lack of knowledge about the service (Table 35). Other reasons mentioned by fewer participants were lack of time, having access to support elsewhere, not wanting to talk to the particular individuals involved, believing that it would not help and concerns about confidentiality.

In keeping with the results from the peer supporter logs reported in the previous section (see Table 34), comments from the peer supporter focus groups did indicate that some teachers were using the service:

I rate the project, I think it’s in the forefront of people’s minds to talk to you. The volume at which they’re talking to you and sharing, I think it’s had an impact.

Intervention group, peer supporters, phase 2, school 4N

Yes, and likewise, the staff room, as you said, is really good. Because I had a member of staff who came and sat and spoke to me about quite a difficult thing that was going on, and would come and sit by me every break to talk about, and really, you know, we got to know each other through that, just when she’d started to talk and felt comfortable. And it went on and I followed that process right through. And I think somebody just listening to you and empathising with you, is often really, really powerful, even though they’re going through the most awful situations. And I think that’s where actually, if there is that opportunity to have tea and cake, yes, it’s great, it’s just currently, I don’t think that that, there is any room for people to manoeuvre within that because of everything that’s going on. Hopefully, when we get to a good place, I think that would be a good thing to try and initiate, you know.

Intervention group, peer supporters, phase 2, school 2L

Furthermore, there was evidence that the 2-day standard MHFA training had improved the quality of support that those acting as peer supporters could provide because of a better awareness of mental health problems and how to respond:

Those high-end issues, the signs to look out for, the symptoms, you know, it’s certainly improved my awareness of lots of different areas.

Intervention group, peer supporters, phase 1, school 1D

And as you were doing the sessions you were kind of thinking, oh that conversation I had with that person the other day, that kind of needs to be followed up because of a reason or something like that.

Intervention group, peer supporters, phase 1, school 1D

I think it has changed my language which is a weird way of describing it because you can be supportive without suggesting and I have stopped necessarily suggesting and it is about – what do you think will help you, what do you think your next step is? It is about not trying to solve the problem and I think just the change in language has helped.

Intervention group, peer supporters, phase 2, school 3P

Participants also highlighted the limitations of the service and the potential difficulty of providing the initial support but then having nowhere to signpost the person on to:

The other thing is have you have got the services that help and support and help people to move on to access the right things. Sometimes the right thing is we have had a whinge and it has made me feel better but sometimes it is not enough and it is about making sure that they can access other things. I have had one person talk to me over a period of time about coming back after a long term absence and he still feels that actually people don’t look at him in the same way because of his issues. But he is struggling and he could do with extra support in terms of school but you can’t really do it as well as perhaps you would like to.

Intervention group, peer supporters, phase 2, school 3P

In addition, comments from both peer supporters (focus groups and logs) and other teacher focus groups identified similar barriers to using the peer support service as those identified in the teacher questionnaires (see Table 32). Lack of understanding about how to access support, a general concern about confidentiality, a preference for using other informal or formal supports and a lack of time for both those needing support and the peer supporters themselves were all raised:

I’d struggle to tell you who was involved in it or where to go.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 2, school 3P

So when I did have issues with mental health, I thought about all of the people there that I would speak to. So one was my line manager, I didn’t want to speak to her about it because it felt like a conflict of interest. Several of the people on there I think would have told other people, so I didn’t talk to them.

So you didn’t trust the confidentiality?

No. And then, so I did e-mail one person and we were going to meet but then I was actually worried about people seeing me with her and then being like, well you would never, what reason do you have to speak to her, and putting two and two together, so I just didn’t speak to her.

So you were just worried about other people finding out?

Yes, because I think it’s frowned upon that, you know like for me, if I take my mental health issues to my employer and they kind of fob it off and they’re not bothered, it just left me, that’s what happened, and then it left me in quite an insecure place. So I just felt like I was, and I guess, which is typical of mental health, I felt like I was very much on my own with it and I felt quite paranoid when, you know, like actually, now I’m in a little bit of a better place, that seems even silly saying it, but at the time.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 2, school 1D

I feel I’ve got people I can talk to about things and be honest about, especially my line manager.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 1, school 3P

Yes, like people can’t come because they’re running after school sessions. People are working so hard and I think they just think that’s part of the job now, they just don’t think that coming to talk to us is going to make a lot of difference. I think they all just, people are right up here, aren’t they?

Yes, which is probably the worst time, everyone probably needs more support, but actually, putting your hand up and think, you know, I need that support now but I haven’t got time to do that.

Yes, and I think we haven’t got the time to give them the time that they need really.

Intervention group, peer supporters, phase 2, school 2L

Therefore, although teachers in the intervention schools did have access to a new form of advice and support and some made use of this, there were significant barriers to uptake that appeared to result in relatively few teachers consciously making use of the service.

Did teachers have increased insight into their own mental health and did mental health have a raised profile in schools?

There was evidence of increased mental health awareness and skills among those who had attended the MHFA training. The MHFA evaluation sheets showed improvements following the course in self-assessed personal confidence to help [change to mean scores: 2.8 (1-day MHFA for schools and colleges) and 3.7 (2-day standard MHFA); p < 0.001] and knowledge and understanding [change to mean scores: 3.1 (1-day MHFA for schools and colleges) and 4.1 (2-day standard MHFA); p < 0.001] (Table 36).

Many focus group participants who had attended both the 1-day MHFA for schools and colleges and the 2-day standard MHFA training courses discussed increased awareness of the need to look after themselves and how to do this, and also when to seek support. Some reflected that this was important to ensure that they were better equipped to support those around them:

I think you’re a bit more aware of like thinking about yourself, making sure you care about yourself. And that we have such roles that are so, like so demanding and there’s so many different things going on, just to make sure that you yourself are OK and you’re in the right place to support others, because otherwise you can’t. I think that’s, I took that away from it.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 1, school 2L

There’s so much pressure on you as teachers that I think having that awareness of the mental health training from a personal point of view, as well as being able to support each other as a staff is really important, because I think that if we are anxious and we are stressed, and we are finding it difficult to manage or to cope in some way, or we are experiencing mental health issues, then that does impact on the children as well. So having this training is important not only in the way we deal with the pupils, but the way we manage our jobs for ourselves. Because otherwise, if we let things get on top of us . . . It’s nice to know there are people we can talk to about it or there are things that we can do to try and think actually, I need to handle this situation better.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 1, school 3P

The majority of attendees of the 1-hour awareness raising session also reported a small increase in knowledge and understanding in relation to all the topics asked about (Table 37).

Some focus group participants perceived a greater openness to talking about mental health in their schools, although it was not always clear how much this was down to the WISE intervention or how much it was influenced by a perceived growing awareness in society:

It is definitely a conversation that we’re all having. Members of staff are not frightened of using the words and having the conversations. Children are more and more asking for help, and maybe that’s because they need help, maybe that’s because we’re raising awareness.

Intervention group, peer supporters, phase 2, school 1D

I think there’s a better understanding of mental health, certainly, amongst the students, and there’s a lot of work on that, in terms of the knowing what it is and perhaps recognising it. As I say, the next steps now are, can we prevent it, and that side of things. I think there’s certainly an increase in the awareness of it and it’s just much more open, isn’t it I think, not just in schools but nationally as well. So that helps and it’s in the media and things like that, like those case studies and examples to be able to use and talk about when you do . . .

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 2, school 2L

I’d say staff attitudes have changed. I think it’s a lot more acceptable, or accepted from my perspective at any rate. I sort of see some attitudes around the school which before it was like you couldn’t even talk about one individual member of staff and now it’s like, oh he’s doing so much better, he’s come such a long way. From that perspective I think there has been a little bit of a shift.

I’d agree with [P2]. Just in terms of I think you mentioned acceptable versus accepted I think it has become more acceptable to discuss mental health and we are more accepting of mental health and what that involves. I think there is a slight shift that we’re going through that I think is being mirrored to a certain extent in society as well. I think it’s going hand and hand in some ways and at various rates but I think that is happening outside of the school environment as well which will obviously feed into our school culture then.

Intervention group, untrained teachers, school 3P

The teacher questionnaires did not ask about openness to discussing mental health; however, as reported in Chapter 2, they did ask about perceptions regarding how much the school cares about teacher well-being, the quality of relationships among staff and how often participants had given help to a colleague in the past academic year. As Table 23 shows, there was no evidence of a difference in these ratings by study arm at T2. Therefore, it appears that there were no large improvements to the perceived culture around support in the intervention schools as a result of the intervention.

In the student focus groups, participants were asked whether or not there had been any changes in the way that teachers at their school talked about mental health and well-being, to try and capture any increased openness that the students were aware of. Across all case study schools, and regardless of study arm, students reported that little had changed from their perspective:

So have you noticed any change in the way the teachers in this school talk about mental health and well-being over the past sort of year?

[Shaking heads.]

We don’t do much on this.

Intervention group, student focus group, school 1D

. . . Do you think anything’s changed, in terms of things being talked about in school, over the last year? . . .

About the same.

Control group, student focus group, school 2C

Did trained teachers have increased confidence and skills in supporting students?

As already shown in Table 35, the MHFA evaluation sheets showed an increase in self-assessed knowledge and confidence to help among those attending both the 1-day MHFA for schools and colleges and 2-day standard MHFA training courses. Focus group discussions indicated that teachers who had attended either course found that they had been able to provide better one-to-one support to students and were also able to raise their awareness about mental health and well-being (e.g. through using the materials at assemblies and tutor time). Aspects of the course that were particularly highlighted as having been used with students were methods for dealing with anxiety, the concept of the ‘stress bucket’ and being able to identify when a student might need further help:

Some of the techniques and things they talked about, especially with the anxiety I found really useful just coming up, especially with some of the change in this school in the past year it’s been quite unsettling to some of the pupils.

Intervention group, 1-day MHFA training for schools and colleges trained teachers, phase 1, school 3P

Using the stress bucket when supporting them [students] one to one, they really find that they can relate to that. That makes a lot of sense for them. So when they’re trying to articulate how they’re thinking and feeling and why they’re thinking and feeling that, when we refer to that, it just helps them, ‘ah yes, no, that’s exactly what I’m feeling.’ ‘I get that now’ . . .

Intervention group, 1-day MHFA trained teachers, phase 1, school 2L

I have used some of the training skills with a number of kids because I would say it is almost like you have opened a wound and the number of children who are now comfortable with saying – I have issues, has gone up I would say. They come and see us when they are feeling a little anxious or a little of this or a little of that rather than letting it build up and up until there is some sort of explosion. We are seeing kids who are willing to say – I can’t cope right now.

Intervention group, peer supporters, phase 2, school 3P

It’s easier to spot signs of people dealing with anxiety and depression. You can refer with a bit more confidence to the pastoral team, you pick up on the nuance I suppose of dealing with those people.

Intervention group, peer supporters, phase 2, school 4N

One teacher from an untrained teacher focus group commented that they were impressed by the skills they had seen in trained colleagues regarding panic attacks:

I’ve seen different members of staff deal with panic attacks. The ones who are trained are phenomenal, I have full admiration, I’m watching and I’m thinking wow, they’re keeping their composure, erm, taking away the emphasis and working on their breathing and that’s fantastic.

Intervention group, untrained teachers, school 4N

Some participants did not feel that the training had given them new knowledge or skills, but generally still felt that it had reinforced what they were already doing, which helped improve confidence:

I think a lot of us, because we work within the pastoral team, are well aware of some of the aspects of the training. And I think the training basically clarified some of the aspects of what we do on a day to day basis. It’s stuff we undertake on a daily basis anyway.

Do others feel that’s a fair reflection or . . .?

Yes, I think it reinforced things we need to be looking out for. I don’t think I learned anything new per se from the training, but it was definitely a reinforcement of things, to support how you go about supporting young people.

Yes, I’d agree with that, yes.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 1, school 4N

I found it really useful, in terms of validating what you already do and knowing you’re doing it right, and giving me a bit more confidence as well really in having those conversations. And to know that you are sort of like using the right skills and kind of giving them the right tools, so that was quite nice to have that sort of confirmation.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 1, school 2L

Did teachers have trained colleagues to offer advice in supporting students?

Although there was good evidence that those who completed the training had improved skills and confidence, there was little evidence of this learning being shared or of untrained staff asking trained colleagues for advice on supporting students. Only one teacher mentioned being approached by another member of staff for advice in supporting a student and another described being more proactive in supporting colleagues:

I think it just makes you more aware of, for example I knew when I took a pupil back to a class and the teacher was really struggling, and I was really concerned. Then I checked back and said – I was really concerned are you OK? I think that member of staff was quite shocked that I had actually bothered to go and see him to make sure he was OK.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 2, school 3P

The lack of knowledge-sharing may be because of contextual barriers, for example the limited time in schools to share learning and failure to embed any learning in the wider school processes (something that is discussed further in Chapter 4, Contextual challenges to the Wellbeing in Secondary Education intervention).

Did staff and student relationships improve?

Both the teachers and students were asked about teacher–student relationships in the questionnaires. At baseline and T2, the vast majority of teachers in both study arms agreed that their school cares for student well-being and has good teacher–student relationships (Table 38). A similar majority in both study arms reported providing emotional support to a distressed student at least once a month, with this proportion increasing slightly at T2. At T2, there were no strong differences by study arm in these variables.

In the case study, school teachers talked about having good-quality relationships with students in both intervention and control schools, with no obvious differences by study arm and no comments indicating that the intervention had led to improved teacher–student relationships:

I think we’ve got pretty good relationships with most of the students in the school as well, and it’s the sort of nurturing culture that we’ve got here, where we do encourage pupils, if there is an issue, speak up. And I think they’re pretty comfortable in doing that, which I think is the first step towards finding out what the problem is, making that initial contact.

Control group, untrained teachers, school 3O

We’re there for anybody who wants us, we do our job, we listen, and we do our best to help anybody, really. And that’s adults or children, or the pupils, really. And I do feel like they feel comfortable coming to speak to us.

Intervention group, peer supporters, phase 1, school 3P

The logic model was based on the assumption that if teachers have improved support for their own mental health then they would feel better able to then maintain positive relationships with students, a logic endorsed by teachers in both intervention and control schools. Given the lack of improvement in overall teacher mental health following the intervention, it is perhaps not surprising if there is a lack of difference by study arm in the perceived quality of teacher–student relationships by the end of the study.

Turning to the students’ perspective, Table 39 shows that at T2 students in the control arm had more favourable perceptions of the quality of teacher–student relationships and whether or not teachers care about or listen to students than those in the intervention arm. Generally, perceptions had become more negative across both arms for these variables, but this change had been more pronounced among the intervention group. There were no large differences by arm regarding whether or not the school cares for student well-being, whether or not teachers are there when the student needs them and whether or not teachers are interested in the student.

In the student focus groups, observations regarding quality of teacher–student relationships were remarkably similar between study arms. Both groups reported that relationships tended to be variable, with good relationships dependent on the individual teachers and the qualities they exhibited:

Do you think that teachers and students at your school have a good relationship?

It depends who the teacher is.

Yes, it’s all about who it is.

Intervention group, student focus group, school 2L

I know some teachers will ask to see you at the end of the lesson and some do ask if you’re like alright, if you’ve been upset in the lesson . . . but it’s not like all teachers. It’s only like certain teachers you get along with.

Control group, student focus group, school 2C

Some students acknowledged that the quality of relationships is shaped by both parties, highlighting poor student behaviour towards teachers and also the way vicious circles are created:

Some of the students like are hard to handle . . . Like some of them just, they just always act up for no reason . . . It’s only sometimes now but when we were younger, it was more often . . . before, when we was in a class, there was the teacher and this kid went mental at her and she started crying.

Control group, student focus group, school 1K

Some students are really disrespectful, they’ll tell them to ‘f off’ and calling them the ‘c word.’ It’s disgusting the way they talk to them, and I feel bad for them in that sense because they can’t really do much, and they’re too soft on them I think. Fair enough they’ll call down on them and call the head [head teacher], they’ll exclude them for a couple of days for it, but I think there should be more in place for that, because it’s not acceptable.

Control group, student focus group, school 3O

I think it’s just whether you have a good relationship with your teacher or not, you have to have a good relationship to be able to work, like I don’t have a good relationship with him [maths teacher], I don’t like maths whatsoever. I do play up in maths I’ll admit that, because I don’t like him. If I had a better relationship with him, I think I’d do better.

Intervention group, student focus group, school 4N

Some students in both arms described extremely negative relationships with teachers and noted that this would put them off seeking help from a teacher:

Most of us, we’re scared of the teachers.

There’s some people that are, like I am scared.

What are you scared of?

Like, I don’t know, like say in a lesson the teacher asks me a question, like in front of the class, I would always say the wrong answer because I’m like, like would she shout? Like the teacher tells us, guess. And when we do guess then she says it’s wrong and then she makes fun out of us.

Intervention group, student focus group, school 1D

. . . some teachers like, I don’t know, like if they’re like having a bad day . . . they’ll just shout at us for not getting it. And there was one teacher who called another student . . . I wasn’t in the lesson, but they called him a . . . douche or something like that.

Control group, student focus group, school 1K

My tutor scares me. No, like honestly, whatever he says, he actually scares me. Like I wouldn’t go to him whatsoever, he’d be the last person to go to.

Intervention group, student focus group, school 2L

In a number of discussions, students noted their belief that teachers cared much more about their academic performance than their well-being:

I don’t think teachers really, I know it sounds really bad, but care, I don’t think they really care . . .

It doesn’t feel like they care anyway.

They would rather you succeed than have a good mind-set on stuff.

Intervention group, student focus group, school 4N

They just generally don’t listen to the students, like they don’t want to, I don’t know how to explain it, they just don’t want to listen. They only tell us, do your work and, you know, the negatives . . . They don’t care about anything else.

Intervention group, student focus group, school 1D

These perceptions of teachers’ priorities are likely to reflect the wider context in which teachers work, which is considered further in Chapter 4, Contextual challenges to the Wellbeing in Secondary Education intervention.

Did students receive improved mental health support?

Chapter 4, Summary presented evidence that trained staff had improved skills and confidence in supporting students. However, this did not appear to translate into more support being provided in the intervention schools relative to the control schools (see Table 38).

Similarly, results from the student questionnaire showed that the number of students asking a teacher for help with a personal problem and proportion of those students finding the teacher helpful were similar between study arms at T2 (Table 40). In both cases, just under half of all responding students had asked for help and a majority found the interaction helpful when they did.

For students in the intervention schools to be more likely to seek help from teachers, their perceptions regarding teachers as a good source of support would have needed to change. The student focus group data did not show any evidence of this, with a number of examples shared where students felt that appropriate and timely support had not been given:

I can probably count the amount of teachers that would help on like one hand really, because I don’t really feel like they do anything. Someone in this school . . . was very depressed . . . there was always this constant look on his face every single day, literally, screaming, I want someone to talk to, I want someone to help me . . . it took his best friend to run to him to actually talk to him, from helping him to stop something that he would have done. And instead, it was meant to really be a teacher’s job to really make him sit down and say, are you OK, do you need someone to talk to?

Intervention group, student focus group, school 1D

I think they could do better, in acknowledging the signs of it more. Cos’, like, I saw a year 7 girl who’s mum had to physically pick her up and carry her up the stairs, and this was like a month or two into term, if the teachers had noticed ‘why doesn’t she want to come into school’ before, then they could have avoided all of that. Like we were walking to lessons and all we could hear this girl screaming, I felt really bad.

Control group, student focus group, school 3O

Although some students were able to name staff or processes by which they could seek help, barriers to doing so were noted, which had similarities to the barriers teachers cited to using the peer support service:

I’d rather someone who, well who’s never been to the school and no one’s ever really seen because usually, if like a teacher that’s been here for a while decides to take up that job, it would kind of be, people would kind of get the wrong idea and expect, know what they’re going to say, if that teacher has a reputation of maybe shouting at a student. When they sat down there with that teacher, she’ll say, oh you can talk to me. They’ll say, oh obviously not, since, for what you’ve done in the past.

Intervention group, student focus group, school 1D

On the back of everybody, all the teacher’s badges they’ve got numbers and stuff for people but again the people that you’re meant to go to I don’t feel comfortable. There are people, other teachers that I’d feel comfortable going to but not the ones I’m meant to.

Control group, student focus group, school 4W

I wouldn’t talk to my teacher. I feel like they judge you and then they will tell their teacher friends.

Intervention group, student focus group, school 2L

That’s the thing with school I think there’s so many students I don’t think they can just focus on one that has probably the same thing that most students have, because with exams and everything, probably half of the school has like a mental issue, it’s just the way it is these days, most teenagers do.

Intervention group, student focus group, school 4N

On the other hand, there were positive comments made in both intervention and control groups indicating that it could be helpful to talk to teachers in school about mental health. In addition, students felt that they could do this confidentially. Sometimes that person was their tutor, but the most important criterion was that it was someone with whom the student felt that they had a good relationship:

Sometimes when you feel sad or something you just want to tell someone to get it out of the way . . . And so telling a teacher is probably better, like it feels better because you know they’re an adult, and you can trust them but if it’s not really something like that bad, it’s something that’s just blown out of proportion.

Yeah, I’d either go to the head of year, or a teacher that I feel like I can trust, that I have a really good relationship with . . . one that you feel like that you can talk to. It doesn’t matter if you have them for tutorial . . .

Intervention group, student focus group, school 3P

Tutors tend to be like the most understanding and the one you trust the most. I mean, you know, we’ve done like the whole school, every morning you see them in school.

Intervention group, student focus group, school 2L

Was teacher stress related to supporting students alleviated?

As noted by students in Chapter 4, Did staff and student relationships improve?, one source of teacher stress is poor student behaviour; therefore, if support for students were strengthened by the intervention, leading to improved behaviour, then this may reduce this source of work-related stress for teachers. In addition, feeling better equipped to support students (through skills learnt on the training courses and having access to better support for themselves) may also reduce stress.

The teacher questionnaires did not ask specifically about stress relating to student support, but they did ask more generally about stress and satisfaction at work. As shown in Table 6, at baseline, a small majority of teachers were satisfied with their work, and just under half found their work very or extremely stressful. The results of the exploratory analysis comparing these outcomes by arm found no difference between intervention or control schools at follow-up (see Chapter 3, Table 23). Given that there was no strong evidence that support for students at the whole-school level had materially changed, and teacher well-being and mental health had not improved, it is unsurprising that stress or satisfaction levels had not improved in intervention schools.

In the focus groups, there was evidence that teachers found supporting students stressful. Staff talked about a perceived increase in problems among students, which might be expected to lead to increased stress among teachers:

If you’re a counsellor, you have no choice but after a certain amount of time to be supervised by another counsellor in terms of to offload, to clear your own mental health and likewise in the school environment, we’re never given that opportunity and I think especially with the heads of year or pastoral, he does, they can deal with a phenomenal amount of issues ranging from the trivial friendship, to suicidal. Now if it’s a Friday afternoon and they’ve dealt with, I know from experience . . . Friday afternoon they may deal with three suicide attempts, and then it’s right OK, go back to see the kids and off I go, and then all weekend, absolutely fixated on those three students, hoping that in the next 48 hours nothing happens and yet there’s no well-being for those members of staff to actually offload that on someone else, if you see what I mean.

Intervention group, untrained teachers, school 4N

It’s going to become a bigger and bigger and bigger issue in schools for staff and for students. And actually, staff being able to help students is going to become more important because we need students to be more resilient, because what they’re being asked to do is so much more difficult. It’s at a time when curriculums are being squeezed into subjects that are thought of as important and, therefore, you know, expressive arts, things like that, are being squeezed. Everything that’s written in the press. So, you know, I think it’s tough being a student between the ages of 11 and 18, it’s tough being a teacher.

Intervention group, peer supporter, phase 1, school 1D

Yes, and access to people like Off the Record [young person’s mental health charity, Bristol, UK] and stuff, I don’t think it’s that straightforward. I’ve had students that have self-harmed and their parents have tried to contact Off the Record, and there’s another one as well I think, at CAMHS, and they’ve heard nothing back from them. And that’s, I know that it’s, obviously, an organisation that’s voluntary but, you know, there’s only so much that I can talk to a child about that kind of stuff, and they do need some more expert help with that. And sometimes, I think, those organisations, people slip through the cracks I think, and that’s really unfair.

Control group, untrained teachers, school 2C

There was no indication from the data that the WISE intervention was effective in addressing this important source of stress.

Contextual challenges to the Wellbeing in Secondary Education intervention

In understanding why the mechanisms in the logic model had or had not been activated, it is important to consider the context in which the WISE intervention took place. Many of the focus group discussions and head teacher interviews in both intervention and control schools highlighted the difficult job that teachers do, and a perception that the profession is becoming more challenging. In addition to the stress caused by student behaviour and concern about student well-being discussed already, another key issue talked about was workload and the consequential impact on teachers’ mental health and well-being:

As times goes on I think people will always say the teaching is becoming more and more stressful I think if you look at lots of public service jobs whether that’s in health care or police or whatever. Resources are being cut, demands are going up, targets are being set left, right and centre. And it’s fair to say that people are finding it more and more difficult.

Intervention group, headteacher one-to-one interview

Workload.

. . . in the last few years we’ve had an increase in workload so we’ve had fewer free lessons. We’ve lost I think three now over 5 or 6 years. Plus more initiatives and bullshit, excuse my French. So it’s just getting worse and worse and worse and next year we’re losing another lesson. Yeah. People are just sort of on the floor.

Intervention group, peer supporters, phase 1, school 4N

Yes, my first year of teaching felt, it was just like, at the end of the day, just like lying on the floor being like, I’ve just had so many battles today, and you don’t battle with anybody anymore. It’s like you put your head on the desk and you collect your pens and now you leave.

Control group, untrained teachers, school 1K

I think the sense of guilt in our job is massive. It’s like we’ve all been there before and dragged ourselves into work barely able to stand and I know for myself I’ve had one period of sickness since I’ve been in this school and that was literally, well my face was out here and there was no way I could come into school, but by the time I came back, the first person I met was like, oh my God, you’re back, thank God for that. You can’t go off on the sick again and I had that all day, because of the kids I work with, that sense of guilt is enormous.

Intervention group, untrained teachers, school 3P

Part of the workload pressure came from teachers being held accountable for students’ results and having to meet unrealistic student attainment targets, often without consideration of the broader context. Teachers were aware that this could be at the detriment of student well-being and offered an explanation as to why, as discussed above, students perceived teachers to be primarily concerned about their performance over and above their mental health:

I think perhaps in the sort of last 10 years or so there’s been an increase in how, yes, it’s not enough just to be a student and do your best. It’s about actually having this very, sometimes quite, well very challenging in many cases, facilitate unrealistically challenging targets to try and attain. And there’s not that wider appreciation of a particular student’s context that can be applied to that data to make it a bit more real. And I think that’s sometimes very, very difficult to balance off as a teacher as well because you’re kind of, I know this child is doing their best, they may well not get this particular grade, but I know that we’re doing all we can, they’re doing all they can, and yet, there’s that kind of relentless expectation to keep on pushing and keep on pushing. And it’s that danger, kind of being aspirational versus being unrealistically, or being unrealistic, isn’t it?

Control group, untrained teachers, school 2C

As described in this chapter, the WISE intervention had high acceptability in this context. The majority of participants who attended the training were enthusiastic about the MHFA training courses and their potential value. Most participants were also positive about the peer support service in principle. A number of head teachers reflected on the dynamism and enthusiasm displayed by training attendees following course completion:

Yes, I mean staff were really excited, they were really bubbly, they were really enthusiastic about it. And they’ve had a couple of meetings as a group of staff to talk about, right, we’ve done the training, it was brilliant, really useful, how are we going to impact on staff, as well as on students?

Intervention group, head teacher one-to-one interview

This high level of initial acceptability could be explained as schools having reached a ‘tipping point’, where they had become increasingly aware of the need to address staff mental health and well-being. A number of participants reflected that schools’ well-being agenda had historically focused on students, whereas the needs of school staff had remained largely invisible. For example, one teacher made this observation about the school’s pastoral support:

I’d like to have access to a counsellor as well. I mean I’ve actually, I’ve suffered from, I’m not ashamed to say, I’m diagnosed with depression, and I actually went to the school nurse and the school counsellor and said, is there any opportunity for me to have some counselling? They were like, oh you can phone this number or such and such, go and see your GP [general practitioner]. But it was, no, you can’t come and talk to me, only the children can. I thought, that’s a shame.

Intervention group, peer supporters, phase 1, school 2L

The emergent prioritisation of staff well-being was not only because of its inherent value, but also because of a perceived link to teachers’ ability to undertake their professional role and mitigating the risk of burnout or absence:

I think the peer training that took place at the start of this term, to have staff in school who are accessible for other staff within school and not members of the leadership team I think gives us a far better conduit to deal with issues than perhaps otherwise would have been the case. It is about making sure that our staff feel valued really and if your staff feel valued, they tend to be happier, if there is such a thing. It can have an impact on staff absence and that, in turn, has an impact on outcomes. You know I don’t think we can divorce the two. We are an outcomes driven organisation but it is about ensuring that the workforce feel valued and if the workforce feels valued and supported, the likelihood is that they are more likely then to fulfil the goals of the organisation aren’t they.

Intervention group, head teacher one-to-one interview

There was specific acknowledgement of the current sociopolitical context of ‘austerity’ that schools were operating in, where sustained and increasing resource cuts were reducing the availability of external support (e.g. youth workers, educational psychologists). The WISE intervention was considered an innovative and necessary approach in strengthening teachers’ resilience so they could shoulder this extra burden:

I’m glad it’s being addressed because I think with services being cut and less options to have to refer students, I can see why they’re making, like putting it in schools because they’re kind of replacing services. And then one thing we do need is to have a replacement for it, so I think that’s really good.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 1, school 1D

. . . how schools move to up-skill staff now is absolutely vital in terms of what we’re talking about, in terms of the mental health, in terms of the well-being of students. Do you know what I mean? It is, you know . . . we’re not going to be able to employ, because we haven’t got the budget, a raft of educational psychologists. So it’s whether or not there are certain interventions or certain training schemes.

Control group, headteacher one-to-one interview

However, some participants reported what they felt was a tokenistic approach to teacher well-being and mental health, as opposed to genuine investment and commitment from senior leadership, with a few hinting that this may have been the approach taken to the WISE intervention:

The one thing I would say in this school context, is it has to be valued by senior management or it’s not going to go anywhere. Quite often things are tick-box exercises and they’re not committed to and they’re not evaluated and they’re not valued and there’s so many initiatives that they’re like, let’s have a go at this, let’s have a go at this. I would hate something as important as this, or potentially as important as this to just be, oh well there we are, we’ve just ticked another box. It’s got to be meaningful.

Control group, untrained teacher, school 4W

I think a lot of the things we do here is a bottom-up approach, rather than a top-down approach, so it is . . . the initiative is taken from staff and maybe for me, I think that should be more the role of leadership or management, and I don’t think that they are that proactive. It comes from the staff body, so it’s always a bottom up approach.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 2, school 4N

Would you recommend other secondary schools to use mental health first aid training?

I would say, yes, I would, but I think you would have to, it would have to be used in such a way that it was something the school genuinely wished to do, rather than something, which might have been just ticking a box and adding on. And I think there’s a danger that, you know, a lot of, not just MHFA but all sorts of things in a similar manner tick a box, which the school management would like to tick and which are under pressure to tick. And whether an initiative is genuinely embraced or not is something quite different to that.

Do you feel that’s the kind of approach this school may have taken, like a tick box?

I’m not really sure I should respond to that.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 2, school 1D

Perhaps not surprisingly in the light of such observations, a number of teachers discussed their frustration that the intervention had not become embedded in school life and ongoing processes:

There’s been no, we’ve talked about it again but there’s been, it hasn’t gone into kind of the whole-school ethos. So there’s been no time to reflect, no time to encourage me to look at like the ALGEE model or how I’ve used it. There’s been no, it hasn’t been linked to my performance management, you know, like it hasn’t gone into the ethos of the school, no time’s been given to it and it hasn’t been reflected on, so, therefore, it just seems like it was a thing we did just for doing sake.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 2, school 1D

Senior leadership were supportive initially but there has not been much interest from them since the set up. None of them have offered time or leniency with other duties to support the running of the peer support, or spoken to the team about uptake or usage.

Intervention group, peer supporter feedback meeting, phase 2, school 4S

Such comments indicated that, for at least some participants, the WISE intervention was seen as a minimally disruptive approach, a tick-box exercise rather than a serious attempt to address the structural determinants of teacher mental health and well-being. This may have diminished its acceptability over time, replacing initial enthusiasm with disappointment.

This failure to instigate meaningful change at the school level meant that the peer support service struggled to really take off, as peer supporters found it difficult to give it the time it needed. Furthermore, a number of participants described their school environment as characterised by a judgemental and punitive culture, which left them reluctant to admit any personal or professional challenges:

I don’t often like to admit when I’m struggling. I do feel in this job it’s a judge culture, and I don’t like to admit when I’m struggling and when I’m finding things really difficult, or difficult to complete, or whether I’m able to keep up on marking. So whilst it’s there, and as [P3] said, it does raise awareness. Again, I always have that in the back of my mind.

Intervention group, 1-day MHFA for schools and colleges trained teachers, phase 1, school 4N

This directly impinged on intervention acceptability, manifesting in fears about whether or not the confidentiality of the peer support service could be retained:

I think it can be good. I think maybe in this instance there were too many. I also think it needs to be, I was a bit worried because when I look at that list, I see some of the biggest gossips in school on that list. And I worry, as a member of staff, if it’s meant to be confidential, how confidential would it be? So I would worry to approach some of the members of staff who are on that list. Now I, obviously, assume, in the training, that they probably would have been informed that this is a confidential service and that they should maintain confidentiality. But I think, when I see that list and I know some of the names on that list, I think, I don’t know if I want to go to that person and give out all of my concerns and issues about my mental health.

Intervention group, non-trained teachers, phase 2, school 1D

Summary

Although aspects of the logic model were achieved in the intervention schools (notably staff having access to support and advice, awareness of mental health and self-care being raised and trained staff having improved skills in supporting students), there was little evidence of whole-school change in terms of staff and students feeling more supported, and quality of teacher–student relationships improving. The WISE intervention was delivered against a challenging backdrop of staff feeling overwhelmed with workload and pressure to perform, a perceived lack of genuine care from senior leaders and a culture of fear, and there was little evidence that it had addressed any of these issues. Ultimately, these failures to instigate whole-school cultural change may explain why the intervention did not have a positive effect on the outcomes. They may also explain the finding that by T2, according to some measures, control school participants actually had a more positive view of their school culture relative to the intervention schools, because they had not had their expectations for change raised. The next section explores other possible iatrogenic effects of the intervention.

Did the training cause harm to attendees?

As the training covered many of the common mental health issues and the training’s participatory nature, there was the potential for it to raise sensitive subjects for the participants. There were two comments from study team members during observed sessions that indicated one participant became upset from frustration at the lack of mental health services and another during the section focusing on suicide:

During the discussion around psychosis one participant became slightly upset at the lack of appropriate service available to support young people and the school. She gave a personal example when a young person exhibiting sign of psychosis was referred to inappropriate services and the negative impact on the young person and their family.

Intervention group, 1-day MHFA for schools and colleges training, observation comment, school 4N

In 2-day observation, in one school [1D] a participant left during the section around suicide. One participant went out during one of the trainer’s anecdotes about suicide, upset – another participant followed them to check if OK. Participant then left for the day.

Intervention group, 2-day standard training, observation comment, school 1D

In these cases, the standard MHFA protocol was followed (i.e. trainers ask participants leaving the room to give a thumbs up if they are OK, otherwise the trainer checks with them whether or not they need further support).

No participants reported detrimental effects as a result of the training on the feedback forms. In fact, as noted in Chapter 4, Fidelity to training components and adaptations, the comments on these forms were overwhelmingly positive, in spite of what trainees acknowledged were difficult topics. During focus groups, a small number of participants reported that the training activated past experiences and issues for them, but they were not unduly distressed by this.

Did the peer support service cause harm to peer supporters?

In the peer supporter logs, there were a number of comments indicating that being a peer supporter could engender positive feelings of self-worth. Peer supporters did not record any major negative impacts (to themselves or users of the service), but there were a number of comments about the difficulties in finding time and space to provide support. There were also a smaller number of peer supporters who indicated feelings of powerlessness (when they did not feel that they could help or that anything would be changed in school) and upset (because of a very difficult problem or because they were experiencing something similar themselves):

Just the rushed nature of it; for example one discussion was when I was in the toilet! The colleague needed to talk so I ended up talking in there and had no break as a result. I didn’t mind but there seems to be no time to talk properly.

Peer supporter log, school 4V

I felt a bit helpless as I could see this person was stressed. I spoke to them about practical issues and ways that they may cut the workload. However, they could not see the wood for the trees in this situation and it got worse. They are currently off work.

Peer supporter log, school 4Q

Emotional stress and worry for that individual you are concerned about, that come to see you. Lack of time to spend with staff and follow up.

Peer supporter log, school 2F

Although a buddy system was recommended in the peer supporter guidelines, some peer supporters still commented on a lack of emotional support for themselves when carrying out the role:

Some staff were visibly upset when talking about the pressures that being a member of peer support staff puts upon them, especially when considering their own individual situations. The group expressed concern that with no support ‘above’ them in place (e.g. a counsellor, etc.) to offload upon then the role of PS [peer supporter] becomes very emotionally draining.

Field notes from peer supporter feedback meeting, phase 2, school 4S

It’s an added difficulty when you’ve got a five-period day and suffer with mental health problems yourself. It can be a bit overwhelming. It got to the point where I had to avoid someone sometimes just to get a drink at break. It’s also stressful when a member of staff talks about self harm. While the school business manager has been very supportive, a number of HOD [heads of departments] under great pressure themselves have not been.

Intervention group, peer supporter logs, school 2L

The intention was for peer supporters to receive ongoing support from HSCs (Wales) and CAMHS link workers (England). However, this did not happen because of the trained HSCs not covering the relevant schools in their day-to-day work and a lack of capacity among local CAMHS teams. If the intervention was to continue, finding a sustainable way for peer supporters to receive support would be important.

Did the peer support service cause harm to users?

Unfortunately, we were not able to interview users of the peer support service as planned, despite attempts to recruit through the peer supporters. In addition, through including direct requests in the teacher follow-up questionnaires, we received only one volunteer to take part. Therefore, no data were collected from the user point of view on benefits or harms of using the peer support service. As noted above, the peer supporters did not log any episodes of harm that they perceived had happened to users of the service as a result of taking part in the study, although the lack of time and also lack of safe spaces to provide support may have meant that the experience of using the peer support service had some negative consequences:

Yes. And it’s like that one where we got interrupted and it was really, that was the end of it that time. So I made a point of finding them early the next day and sort of saying, sorry, we were interrupted, you know, I’ve got some time now or we can arrange another time, sort of thing, because I didn’t, because I felt embarrassed by that, I have to say, because it was just like the moment had gone, so to speak. And I think it had taken them a bit of time to sort of build up to.

Intervention group, peer supporters, phase 1, school 2L

One person was so anxious about being seen talking to me by certain members of staff, we had to come up with a cover story so she could feel more relaxed to talk, and then find a remote space where she felt more comfortable talking.

Peer support log, school 1H

One peer supporter described the negative consequence of a line manager suspecting support had been given, showing that concerns about confidentiality described earlier may have been justified in this school at least:

It was quite a tricky situation with a member of staff, it was only one really particularly, and I was trying to talk to her about possible actions because of, you know, line management roles and all the rest of it. And I was making suggestions, which, and it was, and the line manager had a few pops at me, in terms of, well it’s quite clear you’re supporting that member of staff. And I found that quite difficult, I mean I rode it off and said, well, I just ignored it really.

So the line manager knew that they’d spoken to you?

Yes, it was uncomfortable really, that was uncomfortable. I mean it wouldn’t stop me doing what I was going to do and did, because my, because I felt the member of staff was trusting me and I was trying to advise them, not advise them, trying to say, well you could do this, you could do that, and then it’s up to you really what you want to do. But that was awkward and I didn’t enjoy that much.

Intervention group, peer supporters, phase 2, school 2L

Possibly resulting from such concerns, the peer supporters in one school identified that since the formalisation of the support the informal supportive conversations had decreased:

They feel this may impact staff feelings re [regarding] confidentiality and they feel the more informal ‘how you doing’ conversations have decreased since introducing the service.

Intervention group, peer supporter feedback meeting, phase 1, school 2A

The formalising of support from members of staff, therefore, may have had the iatrogenic effect of making staff reluctant to approach them to talk about problems, which may have led to a less supportive environment within the school. However, there were no differences by study arm in perceptions of how much the school cared for teachers, or the extent of support given to or received by colleagues. Therefore, the data did not indicate colleagues becoming less supportive towards each other as a result of taking part in the study.

Usual practice in all schools at baseline

According to the audits, at baseline none of the schools had a specific well-being policy for students, only one had a policy for staff and another had a ‘stress at work’ policy included in their overall health and safety policy. However, most schools had some initiatives to improve staff and/or student well-being, with similar activities featuring in both study arms. For staff, these included mindfulness training, well-being groups, addressing workloads (e.g. new methods of marking), flexible working, regular social times to share food and drink and formal staff support (e.g. through line management and recognition of good work). For students, initiatives included pastoral care and extra support for vulnerable students, special assemblies promoting well-being and raising awareness of mental health, mindfulness lessons, peer mentoring, personal social health and economic education that covered well-being issues. One school had a pupil well-being group.

In the majority of the schools, informants reported that both students and staff had access to support services. For staff, this was mostly off-site via a range of providers and included occupational health, employee assistance programmes and local authority-funded support. For students, counsellors were generally available on site, either employed directly or working for local organisations. Several schools reported that these counsellors were available part-time only.

Did the control schools take up similar interventions to the Wellbeing in Secondary Education study during the study period?

There was no strong evidence in follow-up audits of a large increase in support for staff or students in the control schools. Data from the head teacher interviews and staff focus groups revealed a range of initiatives for staff and students that schools had recently implemented, although it was not always clear whether these had started before or after baseline measures were collected. Those that focused directly on students included mindfulness training for vulnerable students, a writing project for year 11 students (aged 15–16 years), activities to help students manage stress (including exam stress), student peer support and homework clubs. One school mentioned that they were co-operating with an external agency, ‘Kooth’ (London, UK), to provide online mental health support for students:

. . . we’ve got the Kooth pilot . . . which is happening, which has been launched with all our year 7/8/9/10 students at the moment.

Control Group, head teacher one-to-one interview

Some schools described their recent activities to promote student well-being as being big developments:

The well-being facility is the new thing that we’ve got in this school, so we didn’t have it before and its being well used, it’s being well used that it’s a big, big development for us . . .

Control group, head teacher one-to-one interview

It’s increased quite considerably this year . . . we did a big push in terms of assemblies and so on. We had . . . the mental health nurse, talk about the issues surrounding mental health . . . We made the support mechanisms available to pupils and . . . increased the awareness . . .

Control group, head teacher one-to-one interview

There were also new initiatives to promote staff mental health and well-being, although these were smaller in number. Some schools had focused on well-being during in-service training days and some had introduced mindfulness training or activities such as yoga and sports. One had set up a well-being group for staff and conducted a well-being questionnaire to develop an action plan:

. . . there’s a few things that go on, as a result of that [in-service] day . . . it’s good that it’s on the agenda, because it wasn’t on the agenda for, I’ve been here 7 years and you’ve been here longer, and I’m pretty sure it wasn’t on the agenda up until last year, but there’s still quite a lot of work to do with it I think, it’s probably fair to say.

Control group, untrained teachers, school 1K

. . . our well-being group for staff has probably been new, we are about to look at the findings of our well-being survey and look at what we need to do and how the staff action plan related to that.

Control group, head teacher one-to-one interview

One head teacher reported that during the intervention period there had been a shift in the way that the school thought about staff mental health, resulting in greater consideration of teachers’ well-being with regard to workloads:

. . . what I would say is I think it’s been far more intrinsic. We’ve been thinking about staff mental health and well-being in a far more pro-active way, shall we say, in terms of when we’re introducing things, the work/life balance thing, in terms of what we’re expecting them to do.

Control group, head teacher one-to-one interview

The motivations for the implementation of the different student and staff initiatives by schools were not clear, apart from an apparent concern to improve well-being of students and staff in the school, which presumably had motivated the school to sign up to the WISE study.

Is the Wellbeing in Secondary Education intervention differentiable from ‘usual practice’?

As already noted, ‘usual practice’, as identified in the baseline audits, did entail some activities to support staff and student well-being/mental health. However, components of the WISE intervention were quite different from the usual practice reported by schools. Post-intervention audits in the intervention schools revealed some new activities, specifically the employment of a pastoral support officer to work with year 7 and 8 students (aged 11–13 years), a relaunch of the school council for students, focus on antibullying and the introduction of a student peer support service. Like the control schools, some head teachers reported changes that had been instigated recently and, in these cases, they explicitly put this down to participation in the WISE trial:

. . . during some of the initial [WISE] meetings, it transpired that well-being, because we had a pupil well-being group but it emerged that there was possibly a staff well-being issue. Issue is perhaps too strong a word but staff well-being perhaps as an area that wasn’t having enough overt focus as perhaps was needed.

Intervention group, head teacher one-to-one interview

We’re trying to do things, so for instance, we had the staff who were involved in the project [WISE], who’ve been trained, we’re now running drop-ins every day after school in the staff room. So there’s free tea and coffee available every day, there’s posters around the school saying, come along and have a chat . . .

Intervention group, head teacher one-to-one interview

. . . out of that group of people that have been trained to be peer mentors [through WISE], one of them came up and said, do you know what, we don’t do enough around staff voice. OK, great, what shall we do? Well could we have a drop box? So we do . . .

Intervention group, head teacher one-to-one interview

What major events occurred in each study arm?

In many of our study schools, major events and changes that had occurred during the course of the study were reported in the follow-up audit. Major events were described on the audit forms as things ‘that could have affected teacher and/or student well-being’. Of the 18 schools that provided data for the follow-up audit, 14 reported at least one major event or change (8/10 control schools and 6/8 intervention schools). The types of incidents are reported in Table 41.

Schools in both the control and intervention groups experienced some significant events that will have undoubtably had an impact on staff and student well-being. Schools in both groups experienced most of the issues, including student deaths, changes in management and staff, and changes to school premises and structure. However, there were some incidents that were reported in one arm only. In the control group, three schools reported staff deaths and one school reported two serious incidents where staff had to intervene to save the life of a student, whereas no such events were reported by intervention schools. In the intervention group, two schools reported negative feedback from the relevant inspectorate [Office for Standards in Education, Children's Services and Skills (Ofsted) or Estyn]. One school was given a ‘requires improvement’ assessment and another was placed in special measures. None of the schools in the control group reported negative assessments during the study period.

Summary of contamination and differentiation from usual practice

Although the audits indicated that ‘usual practice’ already entailed a certain amount of activity to support student and teacher mental health, this was broadly similar across both arms. The components of the WISE intervention were different from usual practice and the control schools did not introduce components similar to the intervention during the study period. There were a similar number of major events reported in both study arms, although there were a small number specific to one or other arm. The possible significance of this is considered in Chapter 5.

Strengths

To our knowledge, this was the first RCT to evaluate the clinical effectiveness and cost-effectiveness of an intervention aiming to improve teacher mental health. The prospective collection of cost data allowed us to evaluate the trade-off between the investment (i.e. of time and money) required of schools against the potential for improved staff and student health and well-being.

The high response rates from both teachers and students, and the retention of all recruited schools ensured that the study had sufficient statistical power to identify important differences in mental health outcomes between study arms. In addition, high response rates and the use of multiple imputation in our analysis helped limit the risk of reporting bias due to missing outcome data. Collecting baseline data before randomisation helped to further mitigate risk of bias. The stratified approach to recruitment and sampling helped ensure that samples were balanced across study arms at baseline, with the exception of student attainment and teachers leaving for reasons other than retirement, both of which were higher in the intervention schools. An extensive process evaluation enabled us to answer important questions about how the intervention was delivered, participants’ experiences of the intervention and the context in which the intervention was delivered, which helped to shed light on why it did not lead to improvements in teacher or student outcomes. We successfully achieved delivery of all intervention components in all intervention schools and, to the best of our knowledge, no control schools took up the intervention during the study.

Limitations

The lack of blinding of participants was a limitation, as we cannot be sure that knowing they were in an intervention school did not affect their responses. Indeed, there were signs that some teachers in the intervention schools became frustrated by the lack of whole-school change, which may have led to reporting bias, particularly given that a self-report questionnaire was the main source of outcome data. A second problem with using self-report measures of well-being and mental health is the risk that gaining knowledge about mental health may affect how individuals then report their own mental health. This problem has been discussed in the mindfulness literature, in which those who are more experienced at mindfulness may paradoxically report themselves as less mindful because of this greater insight. 92

An important potential limitation for our economic analysis is that we did not directly collect information on school staff or student use of mental health services during the follow period. Direct measurement at 12 months (teachers) and 24 months (teachers and students) would probably have resulted in recall bias,93 and potentially differential bias between study arms in an unblinded study. An effective peer support intervention might either increase (because of signposting) or reduce (because of addressing distress early) health-care use. We know from the log reports that peer supporters discussed available services in approximately 23% of cases (see Table 31). However, we do not know how many of these cases were acted on or which help sources were involved. If the trial had demonstrated that the intervention was effective and efficient from the school’s perspective, it would be less efficient from an NHS perspective if the peer supporters signposted many more teachers on to general practitioner and other NHS services. Given that we found no improvement in staff well-being, schools are unlikely to invest in or sustain the intervention regardless of any possible impact on health services.

Regarding limitations of the process evaluation, it was difficult to confidently measure use of the peer support service because of the informal way in which it operated, in the context of pre-existing relationships. It is, therefore, hard to be sure of how extensively the service was used. Furthermore, because we did not manage to identify enough users of the peer support service willing to take part in an interview, we were unable to evaluate the quality of the support provided beyond a closed question in the teacher questionnaire. We did not manage to collect all intended data from all schools; specifically, we did not collect peer supporter feedback from all schools 1 year after service set up and we did not manage to complete a T2 audit for all schools.

There were aspects of the intervention that did not go to plan. We did not manage to train the specified number of teachers in all schools, and numbers reduced further in some cases because of staff leaving. We were unable to build in more formal external support for the peer supporters from local CAMHS link workers or HSCs, which may have led to the peer supporters finding the role more challenging and may also have contributed to the sense that this new role had not been properly acknowledged. Finally, as discussed above, we were also unable to ensure that the peer support service was delivered as intended, including, crucially, with support from senior leadership, and with a clear confidentiality policy.

How to fully engage senior leaders in mental health interventions

This may include focusing on training for the leaders themselves, addressing the pressures that they experience and ways in which these pressures can be alleviated, and identifying facilitators that would enable them to prioritise mental health. The inclusion of assessment of mental health support for staff and students in Ofsted inspections may be one way to incentivise senior leaders to give such interventions the status and investment they require.

How to address the structural determinants of poor teacher mental health, such as high workload and pressure to perform

The application of systems thinking to public health improvement has become increasingly popular, in which stakeholders map aspects of the system that influence the outcome of interest and where change is required. Such an approach could be applied to the school system, with subsequent evaluation of system-level changes. One characteristic of the system identified in this study is the culture of silence and stigma around mental health that still pervades much of teachers’ working lives. Research to understand how this culture is perpetuated and how it can be challenged would be an important aspect of such system-level work.

How to strengthen relationships within schools (between staff, staff and students, and staff and senior leaders)

Introducing mental health training to a small group of staff was not enough to see a change in these relationships. It may be that whole-school changes involving policy and practice are needed to create more positive and supportive interactions as the norm.

How to build support for schools within the wider mental health services system

In this study, we explicitly planned to set up support for the peer supporters via CAMHS and HSC teams that were already working in schools, but this proved too challenging in practice. The introduction of education mental health practitioners to certain local authorities as a consequence of the government’s Transforming Children and Young People’s Mental Health Provision: A Green Paper16 may provide a model in which this can be achieved, although the focus here is on student mental health and not staff mental health. In the absence of sufficient specialist provision for children and young people’s mental health, expectations are likely to continue to fall on schools to support ‘low-level’ mental health needs, creating further stress for busy teachers. One important avenue for future research could be to examine the feasibility of external services providing formal supervision for school staff to support them in this role.

Whether mental health first aid or other mental health training does have a place within schools alongside system-level change

The training delivered as part of the WISE intervention was well received by teachers, but there was evidence that not all knowledge was retained and dosage may not have been sufficient. Future studies could investigate whether or not the impact increases with a higher dosage and regular top-up sessions. Consideration could also be given to whether or not particular teachers would benefit most, for example those who are still in training or newly qualified, and whether or not learning should be more formally cascaded to colleagues. In addition, ways to more formally recognise the contribution of those who have received the training to supporting mental health should be explored, for example releasing staff for a set amount of time each week to engage in support work, although this would add to the costs of the intervention.