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Mental Health First Aid is an effective public health intervention for improving knowledge, attitudes, and behavior. A meta-analysis

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Abstract

Mental Health First Aid (MHFA) is a standardized, psychoeducational programme developed to empower the public to approach, support and refer individuals in distress by improving course participants’ knowledge, attitudes and behaviours related to mental ill-health. The present paper aims to synthesize published evaluations of the MHFA programme in a meta-analysis to estimate its effects and potential as a public mental health awareness-increasing strategy. Fifteen relevant papers were identified through a systematic literature search. Standardized effect sizes were calculated for three different outcome measures: change in knowledge, attitudes, and helping behaviours. The results of the meta-analysis for these outcomes yielded a mean effect size of Glass’s Δ = 0.56 (95% CI = 0.38 – 0.74; p < 0.001), 0.28 (95% CI = 0.22 – 0.35; p < 0.001) and 0.25 (95% CI = 0.12 – 0.38; p < 0.001), respectively. Results were homogenous, and moderator analyses suggested no systematic bias or differences in results related to study design (with or without control group) or ‘publication quality’ (journal impact factor). The results demonstrate that MHFA increases participants’ knowledge regarding mental health, decreases their negative attitudes, and increases supportive behaviours toward individuals with mental health problems. The MHFA programme appears recommendable for public health action.
Correspondence: Gerg ö Hadlaczky, National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, 171 77, Stockholm,
Sweden. Tel: 46 8 524 870 26. Fax: 46 8 30 64 39. E-mail: Gergo.Hadlaczki@ki.se, Gergo.Hadlaczky@sll.se
(Rece ived 8 May 2014 ; a ccepte d 13 May 2014 )
Mental Health First Aid is an effective public health intervention for
improving knowledge, attitudes, and behaviour: A meta-analysis
GERG Ö HADLACZKY , SEBASTIAN H Ö KBY , ANAHIT MKRTCHIAN , VLADIMIR CARLI
& DANUTA WASSERMAN
National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden
Abstract
Mental Health First Aid (MHFA) is a standardized, psychoeducational programme developed to empower the public
to approach, support and refer individuals in distress by improving course participants knowledge, attitudes and
behaviours related to mental ill-health. The present paper aims to synthesize published evaluations of the MHFA pro-
gramme in a meta-analysis to estimate its effects and potential as a public mental health awareness-increasing strategy.
Fifteen relevant papers were identifi ed through a systematic literature search. Standardized effect sizes were calculated
for three different outcome measures: change in knowledge, attitudes, and helping behaviours. The results of the meta-
analysis for these outcomes yielded a mean effect size of Glass’s Δ 0.56 (95% CI 0.38 0.74; p 0.001), 0.28 (95%
CI 0.22 0.35; p 0.001) and 0.25 (95% CI 0.12 0.38; p 0.001), respectively. Results were homogenous, and
moderator analyses suggested no systematic bias or differences in results related to study design (with or without con-
trol group) or publication quality (journal impact factor). The results demonstrate that MHFA increases participants
knowledge regarding mental health, decreases their negative attitudes, and increases supportive behaviours toward
individuals with mental health problems. The MHFA programme appears recommendable for public health action.
Background
Mental health problems are major contributors to
the global burden of disease, with mental and sub-
stance abuse disorders accounting for 7.4% of the
total disease burden in 2010, as measured by dis-
ability-adjusted life years (DALYs) (Whiteford et al.,
2013). In the European Union (EU) alone, this
number was more than 25% in 2010 for mental and
other brain disorders, which are also the largest con-
tributors to the morbidity burden (Wittchen et al.,
2011). The most frequent mental disorders are
depression, anxiety and substance abuse (Whiteford
et al., 2013). These mental disorders further repre-
sent one of the most important risk factors for sui-
cide, and constitute one of the largest public health
problems in the world (Ferrari et al., 2014).
Although treatment for these disorders exists, only
a minority of individuals experiencing mental health
problems receive it. It has been estimated that in
serious cases of mental disorders alone, only 11% to
62.1% receive treatment over the course of a year
(Wang et al., 2007). There are various putative expla-
nations for this. Individuals with mental health prob-
lems may be unaware that they are experiencing a
diagnosable and treatable condition, or in regions
where professional care is available, they may be
unaware of how it can be accessed. The general public
could be an important asset in these situations. Social
contacts could inform or refer affl icted individuals to
professionals and may even provide actual support
during mental health crises. However, stigmatized atti-
tudes and a general lack of knowledge regarding men-
tal ill-health, including causes, determinants and
treatment options for various illnesses, or how they
might be expressed by affected individuals, constitute
serious obstacles to the prospective benefi ts of social
support (Ahmedani, 2011; Baumann, 2007; Hatzen-
buehler, 2013; Henderson et al., 2013; Kelly et al.,
2007; Rickwood & Thomas, 2012). Thus, it can be
assumed that improving the quality and frequency of
social support may facilitate earlier detection and refer-
ral, which in turn could increase the odds of successful
treatment outcome and reduce individual suffering
(WHO World Mental Health Survey Consortium,
2004; Wang et al., 2005). An important public health
strategy towards a general improvement of the overall
mental health in communities might be widespread
psychoeducation (Dumesnil & Verger, 2009).
International Review of Psychiatry, August 2014; 26(4): 467–475
ISSN 0954– 0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry
DOI : 10.3109 /095 40261.2 014.924910
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468 G. Hadlaczky et al.
Mental Health First Aid
Mental Health First Aid (MHFA) is a standardized
educational programme developed to combat men-
tal health problems and suicide in the general public
by increasing mental health literacy, improving atti-
tudes and stimulating helping behaviours (Kitchener
& Jorm, 2002). The programme was originally devel-
oped and implemented in Australia (Kitchener &
Jorm, 2002) but has since then been adopted in 21
other countries around the world and has been eval-
uated in several studies (e.g. Kitchener & Jorm,
2004; Massey et al., 2010). MHFA strategies are
aimed at the general public, using a similar peda-
gogical approach as in somatic fi rst aid programmes
(e.g. cardiopulmonary resuscitation). One of these
is a fi ve-step action plan for mental health fi rst aid,
which describes how to practically assist individuals
in mental health crises.
The course programme aims to increase partici-
pants knowledge about mental health in general as
well as about common disorders (e.g., depression,
anxiety, psychosis, substance abuse, self-harm, sui-
cidal behaviours) and available treatment options.
Another aim is to reduce stigma surrounding mental
disorders, as negative attitudes have an adverse
impact on supportive and help-seeking behaviours
(Kitchener & Jorm, 2006). By teaching proactive
techniques that can facilitate healthy relations and
communication, MHFA aims to equip the partici-
pant with skills to provide help to a person in distress
or someone who is suicidal. Course participants
learn how to recognize psychological distress and
how to approach and provide help to a person devel-
oping mental health problems or those in a mental
health crisis, until appropriate professional treatment
is received or until the crisis is resolved. The standard
version of the MHFA programme targets mental
problems in the adult population, while another ver-
sion is tailored for adults that come in contact with
young people with mental health problems.
The key messages of MHFA and the contents of
each course module are based on scientifi c evidence,
established through comprehensive literature reviews
or, regarding issues where comprehensive evidence
does not exist, on expert consensus achieved using
the Delphi method (Beehler et al., 2013; Berk et al.,
2011; Clyne et al., 2012; Colucci et al., 2010a, 2010b,
2011; Hart et al., 2009, 2010; Hemmings et al.,
2009; Jorm et al., 2008; Kelly et al., 2008a, 2008b,
2009, 2010; Kingston et al., 2009, 2011; Langlands
et al., 2008a, 2008b; McGinn et al., 2012; McIntyre
et al., 2010; Morgan & Jorm, 2009; Norder et al.,
2012; Reavley et al., 2012, 2013; Ross et al., 2012;
Ryan et al., 2011). For an in depth description of the
MHFA programme, its development and roll-out,
see Kitchener and Jorm (2008).
The MHFA public health intervention is spread
using the cascade principle: a small team of MHFA
trainers, highly experienced in training, deliver a
ve-day course for carefully selected individuals,
who are trained to become MHFA instructors. The
selection process emphasizes pedagogical skills and
interest in the topic. Then MHFA instructors deliver
two-day courses open to the general public. The pro-
gramme and all included materials are standardized
to ensure the homogeneity of the delivered informa-
tion. The core of the educational material is the fi rst
aider s manual, which contains all essential parts of
the course content. This is complemented by instruc-
tor guidelines, PowerPoint slides and exercises. On
an international level, the course content is carefully
adapted to each country s specifi c conditions by pro-
fessionals. This adaptation is done in close collabo-
ration with MHFA-Australia in order to ensure that
the standardized educational procedures are fol-
lowed. A literature review by (Kitchener & Jorm,
2006) gives a summary of the results from three
evaluation studies on MHFA, but additional studies
have since been conducted and the results have
never been quantitatively synthesized.
Objectives and hypotheses
The aim of this study is to conduct a meta-analysis
estimating the effects of the MHFA programme,
both for adults and young people, based on results
published up to March 2014 (including non-peer-
reviewed literature) and aims at examining changes
in: (1) mental health literacy, in terms of knowledge
about treatment of common mental health problems
as recommended by mental health professionals,
and recognition of symptoms of mental ill-health,
(2) attitudes towards people suffering from mental
health problems and (3) help-related behaviours
exhibited by participants of the MHFA programme
(i.e. mental health fi rst aiders).
Methods
Identifi cation and selection of studies
PubMed, PsycINFO, Cochrane Library, and Google
Scholar were searched for peer-reviewed articles
related to MHFA interventions carried out at any
point before March 2014. Only papers in the English
or Swedish languages were considered. Search terms
such as mental health fi rst aid , MHFA , mental
health training , mental health gatekeeper training ,
mental health gatekeeper and mental health educa-
tion were used, as were different combinations of
those words. References in relevant articles were also
screened for publications of interest. An additional
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A meta-analysis of the effects of the Mental Health First Aid programme 469
Google search was made to identify possible grey
literature. The aim of this literature search was to
obtain original research reporting outcomes of the
MHFA programme (standard or youth version). It
should be noted that the offi cial length of the pro-
gramme was originally 9 hours and later extended to
12 hours. Both versions were included in the present
meta-analysis.
Studies were included if they met the following
criteria: (1) included the standard MHFA or youth
programme, (2) included the full course programme
(not just a specifi c module), (3) included an evalua-
tion of the programme, (4) the evaluation was quan-
titative, (5) included either the 9- or 12-h programme
and (6) included at least one out of the three out-
come measures used in this meta-analysis (change in
knowledge, attitudes and/or behaviour).
Studies were excluded if they met the following
criteria: (1) included a modifi ed version of MHFA
that was not the standard or the youth version of
MHFA, (2) did not include an evaluation of the
course programme, or (3) presented only qualitative
evaluation data.
Altogether 599 papers were identifi ed, of which 45
met the inclusion criteria on the fi rst round. The
majority of these papers were, however, not evalua-
tions of the MHFA programme but Delphi-consen-
sus papers describing the development of different
parts of the MHFA material. These were excluded.
Two additional evaluations were excluded, one con-
cerning the Internet-based version of MHFA, and
the other on a specifi c eating disorder module.
Another three studies were excluded due to lack of
a pre-test measure or due to missing all three out-
come measures used in this meta-analysis. One paper,
exclusively focused on the description of MHFA, was
also excluded. A total of 15 papers remained after
selection criteria had been applied, and were included
in the present meta-analysis.
Study characteristics
Nine of the fi fteen selected papers described the results
of single-group pre/post studies. The remaining six
reported controlled trials, four of which were random-
ized. In all four randomized control trials, the control
group consisted of participants on a course waiting list.
Five studies involved interim and long-term follow-up
measures, taking place immediately after a course and
six months after course completion. Eight studies
involved long-term follow-up measures between six
weeks to six months and two studies had evaluations
immediately after the course completion but no long-
term follow-up. Four out of the fi fteen studies used
intention-to-treat analysis.
Two of the studies were conducted in Sweden, one
in Canada, and the remaining twelve in Australia, of
which three were early studies that evaluated the 9-h
version of the standard programme. A large propor-
tion of subjects were members of the public partici-
pating in open courses, with varying demographic
characteristics. Nine Australian studies recruited
subjects from more specifi c populations: pharmacy
students, Chinese-speaking individuals, Vietnamese-
speaking individuals, members of multicultural orga-
nizations, employees in government departments
(Health and Ageing, and Family and Community
Services), workers in agricultural-related services,
rural football club leaders, advisory and extension
agents in rural farming communities and high school
teachers. The majority of subjects were female.
Outcome measures
Outcome measures were fairly consistent across
studies. All 15 studies used similar data acquisition
tools and psychometric scales to measure change in
knowledge, attitudes and behaviour. Although most
studies reported a number of different variables for
knowledge , attitudes and behaviour outcomes,
most had used at least one common quantitative
measure of each of the three areas. Qualitative inter-
view data were not considered for the present meta-
analysis. The outcome measures selected for this
meta-analysis are as follows:
Knowledge: Data regarding knowledge were extracted
from two scales then combined for the analysis. The
rst scale assessed participants beliefs about effec-
tive treatment methods of common mental health
problems. Participants answers to test questions in
this scale were compared with correct answers
(obtained through experts consensus in Delphi stud-
ies and systematic reviews). The aim of the question-
naire was to measure the degree of the agreement
between participants answers and the correct
answers, before and after the course. The second
scale was a measure of participants ability to accu-
rately identify a mental health problem experienced
by a person. Background information and symptoms
were described in a vignette.
At least one of these scales was reported in all 15
papers, although the results were sometimes calculated
using different statistical methods. When available,
effect sizes from the two scales were extracted sepa-
rately and pooled through a random effects model.
Attitudes: Data regarding attitudes
were extracted from
studies that had used modifi ed versions of the social
distance scale (Bogardus, 1947). Participants were
asked to read two scenarios: one regarding an individual
suffering from depression, and the other regarding
an individual suffering from schizophrenia. They
were then asked to rate a number of items measuring
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470 G. Hadlaczky et al.
attitudes towards these individuals. Effect sizes were
extracted for the social distance scale. In papers where
a combined effect size was not reported, this was cal-
culated by extracting data separately for each item
and pooling them through a random effects model.
Behaviour: Behaviour-related changes were measured
by several different items within different studies.
Some items focused on the participant s confi dence
to approach and help a person with mental health
problems, while other items regarded the participant s
intent to do so. The variable selected for this meta-
analysis however, was an item used to measure the
actual number of times when help had been provided
to another person during the time between course
completion and follow-up measures (i.e. between 6
weeks to 6 months). This variable was selected because,
among those available, it was considered to be the
most valid measure of actual behavioural change.
Nine of the fi fteen studies reported these data.
Statistical methods (meta-analyses)
All statistical analyses were made in Meta53 software
(Schwarzer, 1989) and used an alpha level set to
0.05. In studies where t-tests or ANOVA had been
used, standardized effect sizes were extracted using
the method described by Durlak (2009). Odds ratios
were converted to standardized effect sizes using the
method described by Chinn (2000). Effect sizes were
based on the difference between scores obtained at
baseline and the latest follow-up, while interim mea-
sures were ignored.
Although the 15 selected studies involved different
designs (use of control subjects or not), they all used
similar outcome measures and were hence included
in the same primary meta-analysis.
Mixing studies of different designs poses no
statistical problems as long as the methodological
difference itself does not create logical incompara-
bility (Cooper et al., 2009). Nevertheless, two
moderator analyses were carried out to identify
possible systematic biases that may arise from dif-
ferent study designs or study quality. In the fi rst
analysis, studies using a control group were com-
pared with those using a within-subject pre-post
measures design. To assess study quality, papers
published in peer-reviewed journals with an impact
factor higher than 1.28 (i.e. above the median of
the impact factors amongst all the included stud-
ies) were compared with those published in jour-
nals with a lower impact factor, or without peer
review.
A random effects model was used in all analy-
ses, which reduced the effect of large-sample
studies, if there was heterogeneity among effect
sizes in the sample. If studies were homogenous,
studies were weighted similarly to the fixed-effect
model.
Results
Main results
The studies included in the performed analyses are
listed in Table 1.
Table 1. Characteristics of the 15 studies included in the meta-analyses.
Mean sample size used
in analyses (treatment
versus control)
c
Effect size Moderator variables
Study Knowledge Attitudes Behaviours
Control
group
Journal
impact
factor
MHFA
version
Kitchener & Jorm, 2002 210 0.31 0.16 0.18 No 2.23
b Adult
Jorm et al., 2004 753 (416 vs 337) 0.32 0.17 0.17 Yes 2.23
b Adult
Kitchener & Jorm, 2004 301 (146 vs155) 0.22 0.18 0.09 Yes 2.23
b Adult
Sartore et al., 2008 61 0.50 0.71 0.13 No 1.55
b Adult
Hossain et al., 2009 32 1.33 0.28 – No 0.6 Adult
Minas et al., 2009 114 0.75 0.16 – No
a 1.06 Adult
Jorm et al., 2010 327 (221 vs 106) 0.39 0.28 0.20 Yes 2.23
b Youth
Lam et al., 2010 108 0.84 0.42 – No
a 1.06 Adult
Massey et al., 2010 84 (28 vs 56) 1.06 0.31 0.72 Yes 0 Adult
Pierce et al., 2010 23 1.13 – No 1.06 Adult
Kelly et al., 2011 220 0.90 0.43 0.56 No 1.06 Youth
O Reilly et al., 2011 194 (47 vs 147) 0.15 0.55 – Yes 3.29
b Adult
Morawska et al., 2013 402 0.27 0.35 – No 1.29
b Adult & youth
Svensson et al., 2013a 277 (135 vs 142) 0.36 0.20 0.24 Yes 0 Adult
Svensson et al., 2013b 270 0.75 0.18 0.23 No 0 Adult
Mean effect size Glass’s Δ 0.56 0.28 0.25
a The study did not involve long-term follow-up measures.
b Impact factor of the journal in which the study was published exceeds the median value.
c Separate and unequal sample sizes were sometimes reported for different outcomes within the same study. The average sample size is
therefore reported here .
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A meta-analysis of the effects of the Mental Health First Aid programme 471
Knowledge: The outcome variable for knowledge
included 15 studies (a total sample size of 3807 sub-
jects), with a mean effect size of Glass’s Δ 0.56 (95%
confi dence interval (CI) ranged from 0.38 to 0.74),
p 0.001. Heterogeneity among the effect sizes was
indicated: Q14 55.03, p 0.001. Orwin s fail-safe for
critical d 0.20 was 27. (Most but not all studies
reported two separate measures of knowledge . These
were (a) identifi cation of mental health problems; and
(b) knowledge about effective treatments. The result
reported here is the combined effect size. Mean effect
sizes for the individual measures were 0.63 (n 14)
and 0.40 (n 13) respectively, both with p 0.0001).
Attitudes: The outcome variable for attitudes included
14 studies (a total sample size of 3,929 subjects) and
had a mean effect size of Glass’s Δ 0.28 (95% CI
ranged from 0.22 to 0.35), p 0.001. There was no
indication of heterogeneity among the effect sizes:
Q13 16.55, p 0.22. Fail-safe for critical d 0.20
was 6.
Behaviours: The outcome variable for behaviour
included nine studies (a total sample size of 2,502
subjects), which yielded a mean effect size of Glass’s
Δ 0.25 (95% CI ranged from 0.12 to 0.38),
p 0.001. There was no indication of heterogeneity
among the effect sizes: Q8 12.24, p 0.14. Fail-
safe for critical d 0.20 was 2.
Post hoc analyses
Although the observed effect sizes among outcomes
regarding knowledge were heterogeneous, it should
be noted that all effects in all outcomes were in the
predicted direction. Outcomes for attitudes and
behaviours were homogenous. Nevertheless explor-
ative moderator analyses were performed to investi-
gate how study design or publication quality may
have affected the results. The results are described in
Table 2.
Moderator analyses compared the effect sizes of
controlled versus uncontrolled studies, and studies
published in journals with high versus low impact
factor (IF). Analyses showed consistently signifi cant
results in all groups for all three outcomes. Effect sizes
for controlled studies were consistently smaller than
for uncontrolled studies in all outcomes, but these
differences were not signifi cant. Effect sizes for lower
IF were also smaller than high IF in knowledge and
behaviours , but not in attitudes , where the sample
of high IF publications was signifi cantly heteroge-
neous. IF in the knowledge outcome was the only
moderator variable for which there was no observed
CI overlap between conditions and thus a signifi cant
difference (Cumming & Finch, 2005).
Discussion
The aim of the present paper was to assess the
effectiveness of the MHFA programme based on pre-
viously reported results using meta-analytic method-
ology. Following a systematic literature search, more
than 590 papers were analysed by three reviewers
independently, and a total of 15 articles were included.
The results indicate that the MHFA programme can
be considered effective in increasing knowledge
regarding mental health problems. The effect is highly
robust and has a moderately high effect size (Glass’s
Δ 0.56). Although the studies were not entirely
homogenous, they consistently showed a highly sig-
nifi cant positive effect, but with varying effect sizes.
Table 2. Results of moderator analyses performed for the main outcome variables attitudes , knowledge and behaviours : Controlled/
uncontrolled study design and impact factor (IF) of the journal in which the article was published (above/below median 1.28).
Moderator
n studies
(subjects)
Glass s
Δ(SE) 95% CI
p-value
(Effects) Q
p-value
(Homogeneity)
Knowledge
Controlled 6 (1875) 0.38 (0.130) 0.13 0.64 0.002 10.60 0.060
Uncontrolled 9 (1932) 0.68 (0.109) 0.46 0.89 0.001 37.72 0.001
a
IF above 1.28 7 (2644) 0.30 (0.040) 0.22 0.37 0.001 2.40 0.879
IF below 1.28 8 (1163) 0.79 (0.091) 0.61 0.97 0.001 16.73 0.019
a
Attitudes
Controlled 6 (1998) 0.23 (0.046) 0.14 0.32 0.001 5.59 0.348
Uncontrolled 8 (1931) 0.33 (0.046) 0.24 0.42 0.001 8.76 0.270
IF above 1.28 7 (2716) 0.31 (0.078) 0.16 0.47 0.001 12.80 0.046
a
IF below 1.28 7 (1213) 0.28 (0.058) 0.17 0.39 0.001 3.75 0.711
Behaviours
Controlled 5 (1742) 0.24 (0.107) 0.03 0.45 0.013 5.84 0.212
Uncontrolled 4 (760) 0.30 (0.087) 0.13 0.47 0.001 5.00 0.172
IF above 1.28 5 (1651) 0.16 (0.050) 0.06 0.26 0.001 0.64 0.959
IF below 1.28 4 (851) 0.39 (0.112) 0.17 0.62 0.001 6.38 0.094
SE, standard error; IF, impact factor.
a Indicates statistically signifi cant (p 0.05) heterogeneity amongst the effect sizes within the sample.
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472 G. Hadlaczky et al.
The moderator analyses suggested no systematic bias
related to study design. Reports that were not peer-
reviewed or were published in journals with a lower
IF were found to report greater effects. The observed
moderate heterogeneity could perhaps be explained by
different scoring procedures of the outcome measures.
An alternative explanation could be that different study
populations had different levels of pre-MHFA knowl-
edge. Populations who knew less about mental health
to begin with, increased their knowledge to a greater
degree.
The analyses also suggest that participating in a
MHFA course effectively decreases negative attitudes
toward individuals suffering from mental health
problems. The observed difference between interven-
tion and control subjects, as well as in pre-post mea-
sures, was highly signifi cant, suggesting a very robust
but moderate effect (Glass’s Δ 0.28). Moderator
analyses further suggest that the results are indepen-
dent of study design and quality of publication.
Finally, the results show that the MHFA interven-
tion is effective in increasing help-providing behav-
iour. Unfortunately, the measure of behavioural
change (i.e. the number of times that the fi rst-aider
had helped another person after completing the
course) is biased toward the null hypothesis because
the answer is contingent on the number of opportu-
nities in which help could be given. Therefore, in this
behavioural measure, participants who had not
encountered any situation in which help could be
offered, are assumed to have undergone no behav-
ioural change. For this reason it is likely that the
mean effect size estimated by this meta-analysis
(Glass’s Δ 0.25) is an underestimation of the true
effect of MHFA on helping behaviours. Moderator
analyses suggest homogeneity among studies and
that these results are independent of study quality
and design.
In interpreting the utility of the MHFA pro-
gramme based on these results, the reality in which
it is to be implemented should be considered. One
of the greatest public health-related obstacles in sui-
cide prevention is the widespread stigmatization of
mental health problems as well as the taboo sur-
rounding suicide and the lack of knowledge regard-
ing the identifi cation of mental health problems, of
suicidal communication, suicide risk and protective
factors and treatment options (Ahmedani, 2011;
Baumann, 2007; Hatzenbuehler, 2013; Henderson
et al., 2013; Kelly et al., 2007; Rickwood & Thomas,
2012; Wasser man et al., 2012; Wasserman & Wasser-
man, 2009). For example, individuals with mental
health problems are often perceived as incompetent
and dangerous, and the general public often exhibit
an unwillingness to socialize with them (Hinshaw &
Cicchetti, 2000). Individuals with mental health
problems also face extensive discrimination and
marginalization in all aspects of their lives, such as
reduced access to healthcare services (Corrigan,
2004) and employment exclusion (Stuart, 2006).
This can lead to unemployment, poverty and home-
lessness. These prejudices can carry signifi cant
adverse effects on those who are affl icted (McDaid,
2008) by reducing their well-being, self-esteem and
quality of life. Prejudice and discrimination against
individuals with mental health problems also has
adverse effects on intimate relationships (Hinshaw,
2005) and for the families and friends of the affl icted
(Corrigan & Miller, 2004).
These problems are interdependent and may have
several consequences: affl icted individuals may
neglect to seek help until the affl iction becomes
unbearable (and more diffi cult to treat). They may
be more likely to conceal their problems from rela-
tives, friends and co-workers, resulting in reduced
peer-support. Also, affl icted individuals may be less
likely to enter the healthcare system. Due to the lack
of knowledge about mental health problems, parents,
other relatives and peers could misinterpret or com-
pletely fail to notice symptoms of mental ill-health,
and in this way further reduce the affl icted person s
treatment opportunities and perhaps even aggravate
the condition.
The results of this meta-analysis suggest that
MHFA ultimately increases mental health literacy of
the general population. As such, it induces a series
of cascading effects, including improvement in self-
recognition, increased insight into one s own and
others emotional well-being, and enhanced mental
health-related vocabulary, thus also counteracting
stigma. All these effects are expected to lead to
increased coping skills and improved confi dence to
render informed peer support.
Importantly, results indicate not only changes in
knowledge and attitudes, but also changes in the
behaviour of those who attend the training. This is
of major importance because it shows a pragmatic
change in trainees who become more active in sup-
porting those with mental health problems and sui-
cidality.
Considering the estimated effects of the MHFA
programme on knowledge, attitudes and behaviour,
this intervention programme seems to be a promising
public health tool for tackling stigma and taboo sur-
rounding people with mental disorders and suicidal-
ity. An important question that remains unanswered,
and perhaps one that is a valid focus of future stud-
ies, is how MHFA actually improves the mental
health of the general public.
Acknowledgements
We would like to thank Jerzy Wasserman for critically
revising the manuscript for important intellectual
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For personal use only.
A meta-analysis of the effects of the Mental Health First Aid programme 473
content, as well as Maria Anna Di Lucca for statisti-
cal consultation.
Declaration of interest: The preparation of the
manuscript was funded solely through the Swedish
National Centre for Suicide Research and Preven-
tion of Mental Ill-Health (NASP) personnel salaries,
acquired from Karolinska Institutet (V.C., D.W.),
and Stockholm County Council (G.H., S.H., A.M.).
Articles included in the analyses were downloaded
via the Karolinska Institutet electronic library. The
institution of the authors, NASP, also constitutes the
scientifi c and educational basis for MHFA in
Sweden. The authors alone are responsible for the
content and writing of the paper.
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Due to the demanding work environment, healthcare workers are often affected by mental health problems. Besides negative effects on individual wellbeing, mental health problems can reduce professional effort and increase turnover rates in healthcare. Those who develop mental health problems often receive necessary treatment with a great time delay. Two reasons for this are low mental health literacy and stigma. However, empirical investigations regarding the role of workplace mental health literacy and stigma on help-seeking and help-outreach intentions of healthcare workers in the workplace are currently missing. To bridge this gap, survey data was collected among trainees of different healthcare professions in Germany. The variables of interest were measured separately with the help of two times of measurement to avoid common method bias and to strengthen the causal interpretability of the hypothesized model. The response rate of the questionnaire was 21% (Nt1 = 525, Nt2 = 112). For measuring subjective mental health literacy at the workplace the MHL-W-G was used. Results of the structural equation modeling (SEM) indicate that workplace mental health literacy increases workplace help-seeking intention and help-outreach intention significantly. Further, it indicates that workplace mental health literacy decreases self-stigma and that personal stigma decreases overall workplace help-outreach intention. In order to uncover underlying mechanisms of the relationship between the mental health literacy and workplace help-seeking intention and help-outreach intention, the mediation of mental health stigma was tested, but could not be confirmed. The present study reduces the lack of empirical information regarding mental health help-seeking and help-outreach in the workplace. Therefore, the research contributes to the relevance of social contacts in the working context as potential gatekeepers to professional mental health support. Further, the study provides important insights into the way that mental health help-seeking and help-outreach intentions at the workplace are affected by mental health literacy and into the role of personal and self-stigma in healthcare profession. The results are of particular importance in light of the increased need for healthcare workers and the rising prevalence of mental diseases.
... They can also answer students' questions, reduce stigma about mental illness, and encourage students to seek help [18]. Therefore, the knowledge and attitudes of teachers about mental illness are important components to study and ensure that no shortage that can compromise these important roles is occurring [19]. Previous studies showed that Chines, Indian, and Kenyan teachers have poor knowledge about the signs of mental disease, prevalence, causes, and treatment [20][21][22]; hence, they were unable to detect early warning signs of mental illness in their students. ...
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Aim: The current study aimed to assess and compare the level of knowledge and attitude towards mental illness between secondary school students and their teachers in Oman. Methods: An online survey was carried out to collect data from 400 students and 411 teachers about their knowledge and attitudes toward people with mental illness. Two independent case studies about depression and schizophrenia were also tested. Results: Students have a poor knowledge of mental illness compared with their teachers, as more than half scored less than 60% compared with 16.5% of the teachers. More than two-thirds of the students (80%) and teachers (76.4%) have a low or minor positive attitude toward people with mental illness. The study identifed signifcant diferences in knowledge in favour of teachers, although the opposite was found regarding attitudes. Conclusions: Since students spend a signifcant amount of time in school, bridging the gap between teachers’ and students’ knowledge and attitudes toward mental illness is an essential part in enhancing the knowledge and attitudes of the students. In addition, knowledgeable teachers with positive attitude can assist in early identifcation of mental illnesses and help students when needed. In turn, students who possess knowledge and positive attitude toward mental illness can share their concerns with their teachers. In the presence of such accepting and cooperative environment, the stigma can be decreased and early detection of mental illness and help-seeking behaviour can be promoted
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Objectives Reluctance to seek help is a leading contributor to escalating mental injury rates in Australian workplaces. We explored the benefit of using community organisations to deliver mental health literacy programmes to overcome workplace barriers to help-seeking behaviours. Design This study used a qualitative application of the theory of planned behaviour to examine underlying beliefs that may influence worker’s intentions to participate in mental health literacy programmes delivered by community organisations and manager support for them. Setting This study took place within three large white-collar organisations in the Australian state of Victoria. Participants Eighteen workers and 11 managers (n=29) were interviewed to explore perspectives of the benefits of such an approach. Results Community organisations have six attributes that make them suitable as an alternative mental health literacy programme provider including empathy, safety, relatability, trustworthiness, social support and inclusivity. Behavioural beliefs included accessibility, understanding and objectivity. The lack of suitability and legitimacy due to poor governance and leadership was disadvantages. Normative beliefs were that family and friends would most likely approve, while line managers and colleagues were viewed as most likely to disapprove. Control beliefs indicated that endorsements from relevant bodies were facilitators of participation. Distance/time constraints and the lack of skills, training and lived experiences of coordinators/facilitators were seen as barriers. Conclusions Identifying workers’ beliefs and perceptions of community organisations has significant implication for the development of effective community-based strategies to improve worker mental health literacy and help seeking. Organisations with formal governance structures, allied with government, peak bodies and work-related mental health organisations would be most suitable. Approaches should focus on lived experience and be delivered by qualified facilitators. Promoting supervisor and colleague support could improve participation. Models to guide cross-sector collaborations to equip community organisations to deliver work-related mental health literacy programmes need to be explored.
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BACKGROUND: The Global Burden of Disease Study 2010 (GBD 2010) identified mental and substance use disorders as the 5th leading contributor of burden in 2010, measured by disability adjusted life years (DALYs). This estimate was incomplete as it excluded burden resulting from the increased risk of suicide captured elsewhere in GBD 2010's mutually exclusive list of diseases and injuries. Here, we estimate suicide DALYs attributable to mental and substance use disorders. METHODS: Relative-risk estimates of suicide due to mental and substance use disorders and the global prevalence of each disorder were used to estimate population attributable fractions. These were adjusted for global differences in the proportion of suicide due to mental and substance use disorders compared to other causes then multiplied by suicide DALYs reported in GBD 2010 to estimate attributable DALYs (with 95% uncertainty). RESULTS: Mental and substance use disorders were responsible for 22.5 million (14.8-29.8 million) of the 36.2 million (26.5-44.3 million) DALYs allocated to suicide in 2010. Depression was responsible for the largest proportion of suicide DALYs (46.1% (28.0%-60.8%)) and anorexia nervosa the lowest (0.2% (0.02%-0.5%)). DALYs occurred throughout the lifespan, with the largest proportion found in Eastern Europe and Asia, and males aged 20-30 years. The inclusion of attributable suicide DALYs would have increased the overall burden of mental and substance use disorders (assigned to them in GBD 2010 as a direct cause) from 7.4% (6.2%-8.6%) to 8.3% (7.1%-9.6%) of global DALYs, and would have changed the global ranking from 5th to 3rd leading cause of burden. CONCLUSIONS: Capturing the suicide burden attributable to mental and substance use disorders allows for more accurate estimates of burden. More consideration needs to be given to interventions targeted to populations with, or at risk for, mental and substance use disorders as an effective strategy for suicide prevention.
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Background The Global Burden of Disease Study 2010 (GBD 2010) identified mental and substance use disorders as the 5th leading contributor of burden in 2010, measured by disability adjusted life years (DALYs). This estimate was incomplete as it excluded burden resulting from the increased risk of suicide captured elsewhere in GBD 2010's mutually exclusive list of diseases and injuries. Here, we estimate suicide DALYs attributable to mental and substance use disorders. Methods Relative-risk estimates of suicide due to mental and substance use disorders and the global prevalence of each disorder were used to estimate population attributable fractions. These were adjusted for global differences in the proportion of suicide due to mental and substance use disorders compared to other causes then multiplied by suicide DALYs reported in GBD 2010 to estimate attributable DALYs (with 95% uncertainty). Results Mental and substance use disorders were responsible for 22.5 million (14.8–29.8 million) of the 36.2 million (26.5–44.3 million) DALYs allocated to suicide in 2010. Depression was responsible for the largest proportion of suicide DALYs (46.1% (28.0%–60.8%)) and anorexia nervosa the lowest (0.2% (0.02%–0.5%)). DALYs occurred throughout the lifespan, with the largest proportion found in Eastern Europe and Asia, and males aged 20–30 years. The inclusion of attributable suicide DALYs would have increased the overall burden of mental and substance use disorders (assigned to them in GBD 2010 as a direct cause) from 7.4% (6.2%–8.6%) to 8.3% (7.1%–9.6%) of global DALYs, and would have changed the global ranking from 5th to 3rd leading cause of burden. Conclusions Capturing the suicide burden attributable to mental and substance use disorders allows for more accurate estimates of burden. More consideration needs to be given to interventions targeted to populations with, or at risk for, mental and substance use disorders as an effective strategy for suicide prevention.
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Poor mental health has substantial personal and economic impacts across the European Union. Stigma and discrimination exacerbate these impacts. Consistently, the evidence points towards strongly negative attitudes towards people with mental health problems: in particular there is an inaccurate view that they represent a danger to the community, a view strongly reinforced in the media. Negative attitudes are not only found among the general public and media, but even among mental health professionals. These and other elements of stigma increase social distance and lead to social exclusion: they, for instance, reduce the likelihood of an individual becoming employed or accessing health care services. It is important that strategies to counter stigma are evidence-based. To date evidence on both their effectiveness and cost effectiveness is highly limited. Anti-stigma campaigns are difficult to evaluate but the limited evidence available suggests that campaigns targeted at specific population groups such as the police or school children may be more effective than those for the general population. Other measures to consider include investment in schemes to help individuals reintegrate into employment, schemes to increase the empowerment of people with mental health needs to choose the services that best meet their needs, and better enforcement and exchange of information on the use of legal instruments to tackle discrimination. This Research Note has been produced for the European Commission by David McDaid from the Health and Living Conditions Network of the European Observatory on the Social Situation and Demography. The views expressed are those of the authors and do not necessarily represent those of the European Commission
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A systematic review may encompass both odds ratios and mean differences in continuous outcomes. A separate meta-analysis of each type of outcome results in loss of information and may be misleading. It is shown that a ln(odds ratio) can be converted to effect size by dividing by 1.81. The validity of effect size, the estimate of interest divided by the residual standard deviation, depends on comparable variation across studies. If researchers routinely report residual standard deviation, any subsequent review can combine both odds ratios and effect sizes in a single meta-analysis when this is justified. Copyright © 2000 John Wiley & Sons, Ltd.
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Objective: To review studies evaluating mental health first aid (MHFA) training. Method: Review of three published trials: one uncontrolled with members of the public in a city, one randomized controlled efficacy trial in a workplace setting and one cluster randomized effectiveness trial with the public in a rural area. Results: Most mental health first aiders tend to be middle-aged women whose work involves people contact. All trials found the following statistically significant benefits 5 6 months post-training: improved concordance with health professionals about treatments, improved helping behaviour, greater confidence in providing help to others and decreased social distance from people with mental disorders. Only one trial evaluated the mental health benefits to participants and this found positive effects. Conclusions: Although MHFA training has been found to change knowledge, attitudes and helping behaviours, and even benefit the mental health of participants, there has not yet been an evaluation of the effects on those who are the recipients of the first aid.