School Health Implementation Network in the Eastern Mediterranean Region (SHINE)
To evaluate an enhanced School Mental Health Program in reducing socio-emotional difficulties within school-going children in rural Rawalpindi, Pakistan.
The adaptation and implementation of WHO’s School Mental Health Program through an online training platform and chat-bot for school teachers in Pakistan.
10-20% of children are affected by socio-emotional problems globally, of these, 90% of children and adolescents live in Low and Middle-Income Countries (LMICs)1. Despite the tremendous burden of child mental health problems and widespread recognition of the importance of early identification and intervention for child mental health problems, a large number of these children in LMICs do not receive mental health services2.
Schools offer an excellent opportunity for the early identification and management of children in need for mental health services. There is considerable evidence to suggest that both universal and targeted school-based interventions lead to better social, emotional and academic outcomes for children3-5. Child mental health has also been identified as a priority within the WHO’s Eastern Mediterranean Regional Office (WHO EMRO) informing their development of an evidence-based manualized School Mental Health Program (SMHP).
School Health Implementation Network: Eastern Mediterranean Region (SHINE) is a collaborative network involving four countries in the World Health Organization’s Eastern Mediterranean Region (WHO-EMRO). Its principal focus is scaling up school-based mental health services. An implementation study is taking place in Pakistan, and capacity-building activities are occurring in Pakistan, Egypt, Jordan, and Iran.
The SHINE Program goals include:
- Developing a cross-disciplinary and cross-sectoral collaborative network to inform strategies for scaling-up a school-based mental health program at national and regional levels
- Conducting research into scaling-up the School Mental Health Intervention. This will include testing the effectiveness of a technology-assisted model of delivering the intervention in Pakistan.
- Collaborative learning: To support early-career researchers in evaluating the implementation of the School Mental Health Program (SMHP) using science-based methods, and undertake policy engagement through building skills in effective communication with policy-makers.
The program will gather information on the following indicators:
- Number of teachers trained in the Enhanced School Mental Health Program (eSMHP) using the online training platform
- Reduction in the socio-emotional difficulties scores of children on parent-rated strengths and difficulties questionnaire
- Evaluating the cost-effectiveness of eSMPH with the conventional training model for the management of socio-emotional difficulties of school going children
Child mental health has also been identified as a priority within the WHO’s Eastern Mediterranean Regional Office (WHO EMRO). Following consultations with international and regional experts and stakeholders, WHO EMRO developed an evidence-based manualized School Mental Health Program (SMHP), endorsed by member countries, including Pakistan. WHO SMHP is informed by evidence-based strategies based on behavioural and socio-emotional learning theories6. The evidence on the effectiveness of SMHP in Pakistan supports the administration of this model to train teachers how to promote child mental health in school settings6, 7.
Another goal of the WHO SMHP innovation is to support institutions, researchers, policy-makers, and community stakeholders in the Eastern Mediterranean Region to address child mental health in their respective countries sites in Egypt, Jordan and Iran.
The School Health Implementation Network in the Eastern Mediterranean Region (SHINE) is comprised of multilateral, national and international policy organizations and partners from Pakistan, Jordan, Iran and Egypt, with technical support from universities in the United Kingdom and United States. SHINE will work alongside other global networks working to tackle priority mental health issues in different regions of the world with the following aims:
- Inform strategies for scaling-up mental health programmes to regional/national levels through the knowledge sharing and best-practice
- Embed collaborative learning within the EMRO Framework for regional implementation of the WHO Comprehensive Mental Health Action Plan with a prioritized a focus on child mental health
- Support the technical expertise of researchers from Pakistan, Egypt, Jordan and Iran in evaluating the implementation of the SMHP and of effectively engaging with and communicating findings to policy-makers, and to support their application to the development of evidence-based policy
The technological innovation component within WHO’s School Mental Health Program (SMHP) includes the adaptation and enhancement of the SMHP manual. The program will:
- Include the implementation of an enhanced and more operationalized SMHP manual using the online training platform
- An algorithm based Chat-bot that acts as an aid memoire (to aid memory) to support teachers in identifying and managing the low-intensity mental health problems of students in their class
- The eSMHP will also enable teachers to identify and refer children in need of additional support to specialists
In addition to the phased implementation of WHO SMHP occurring in Pakistan, Egypt, Jordan and Iran, the WHO SMHP is also being evaluated at the Pakistani site to generate the evidence for its effectiveness. Stakeholders from the education section, including teachers, parents and children aged 8-13 years, will participate in a cluster randomized control trial to evaluate the effectiveness of the conventional as well as the technology-assisted model of delivering SMHP. The intervention will be implemented through a task-shifting approach, whereby mental health care to the children will be provided by non-specialist teachers in the public schools of rural sub-district of Gujar Khan, Rawalpindi, Pakistan.
- The task-shifting model empowers teachers with additional skills and the confidence to address mental health problems among students
- Technological innovations allow the SMHP to avoid implementation bottle-necks such as logistical, human resource and financial challenges of in-person training workshops, supervision and monitoring of SMHP
- The program provides a much needed opportunity to explore business models, and evidence-based integration models for rapid replication and scale-up
The potential challenges involved in the successful implementation of innovation include:
- Political instability, security concerns due to war on terrorism, strikes in the civil society, budgeting issues in educational department
- Difficulties in engaging policy makers & other stakeholders in the school mental health program due to restrictive bureaucratic structures of governance and low political buy-in for mental health
The online training platform of eSMHP will be made available to WHO-EMRO to ensure its availability to other Eastern Mediterranean countries. Through the network’s global partnerships, the eSMHP has the potential to be implemented at scale in other LMICs.
- World Health Organisation (WHO) Office for the Eastern Mediterranean Region (EMRO)
- University of Liverpool and the Liverpool School of Tropical Medicine, UK
- John’s Hopkins University, US
- Harvard Medical School / Boston Children’s Hospital, US
- Tehran University of Medical Sciences and Health Services, Iran
- Human Development Research Foundation, Pakistan
- Institute of Psychiatry, WHO Collaborating Centre for Mental Health Research and Training, Rawalpindi
- Ministry of National Health Services Regulation and Coordination, Govt. of Pakistan.
- National Woman’s Health Care Center, Jordan
- General Secretariat of Mental Health and Addiction - Ministry of Health, Egypt, Department of Education, Government of Punjab
- National Institute of Mental Health (NIMH)
The eSMHP will be evaluated through a cluster randomized controlled trial on a number of outcomes for children, teachers and school climate.
- The primary outcome for eSMHP is reduction in total difficulties scores of children on strengths and difficulties questionnaire
- Parent rated Strengths and Difficulties Questionnaire (SDQ) will be used to measure socio-emotional difficulties of children
- The SDQ is a brief, valid8 and reliable measure of socio-emotional competence that is widely used to assess socio-emotional difficulties in childhood and has been culturally adapted and validated in Pakistan9
Some other multilevel contextual components will also be explored to evaluate the large scale clinical and implementation effectiveness of online school mental health program in rural Pakistan, including:
- Outcomes on child level: Data on Psychological Outcome Profiles (PSYCHLOPS-Kids), WHO-Disability Assessment Schedule-child version (WHODAS), Paediatric Quality of life Inventory (PedsQL), annual academic grades and parent-teachers involvement questionnaire will be collected to measure psychosocial wellbeing, functioning, quality of life, academic performance of children and parent–teacher interaction
- Outcomes on teachers’ level: Data on Teachers’ Sense of Efficacy Scale (TSES), Self-reported Questionnaire (SRQ) and Determinants of Implementation Behaviour Questionnaire (DIBQ) will be used to assess self-efficacy, well-being of teachers and change in teacher’s behaviour to implement SMPH after receiving training in eSMHP
- Outcomes on school level: WHO Psychosocial Environment profile will be used to evaluate the climate of schools that are part of SMHP
Data on parents, children, school teachers and staff will be collected on locally-adapted versions of instruments using hand-held devices (tablets) with pre-assigned participant codes. Research data will be collected by trained research assistants.
Cost of implementation
A cost-effectiveness evaluation will be carried out at the end of the research study as part of a detailed economic evaluation with the aim of informing future scale-up and policy.
- School children in the rural sub-district of Gujar Khan will be screened for socio-emotional difficulties
- Referrals for specialist support will be organized at a public tertiary mental health facility where required
- 8 early-career researchers from Pakistan, Iran, Jordan and Egypt will participate in collaborative learning activities, building skills in evaluating complex mental health interventions delivered in community settings, and effective communication of research findings to policy-makers to support evidence-based policy-making
- Kieling C et al (2011) Child and adolescent mental health worldwide: evidence for action. The Lancet, 378(9801): p. 1515-1525. [Link]
- Thapar A et al (2012) Depression in adolescence. The Lancet, 379(9820): p. 1056-1067. [Link]
- Langford R et al (2011) The WHO Health Promoting School framework for improving the health and well-being of students and staff. Cochrane Database Syst Rev, 1. [Link]
- Durlak J A et al (2011) The impact of enhancing students’ social and emotional learning: A meta‐analysis of school‐based universal interventions. Child development, 82(1): p. 405-432. [Link]
- Arango C et al (2018) Preventive strategies for mental health. The Lancet Psychiatry. [Link]
- Fazel M et al (2014) Mental health interventions in schools in low-income and middle-income countries. The Lancet Psychiatry, 1(5): p. 388-398. [Link]
- Imran N et al (2018) World Health Organization “School Mental Health Manual”-based training for school teachers in Urban Lahore, Pakistan: study protocol for a randomized controlled trial. Trials, 19(1): p. 290. [Link]
- Stone L L et al (2010) Psychometric properties of the parent and teacher versions of the strengths and difficulties questionnaire for 4-to 12-year-olds: a review. Clinical child and family psychology review, 13(3): p. 254-274. [Link]
- Samad L.et al (2005) Child and adolescent psychopathology in a developing country: testing the validity of the strengths and difficulties questionnaire (Urdu version). International Journal of Methods in Psychiatric Research, 14(3): p. 158-166. [Link]