Evaluation of Mental Health First Aid training with members of the Vietnamese community in Melbourne, Australia

The importance of effective response to mental illness has become increasingly acknowledged as a result of epidemiological data showing the high prevalence of mental disorders in many countries, including Australia [1, 2], the large contribution of mental disorders to burden of disease [3], the high economic and social costs of mental disorders [4] and evidence of the personal, social and economic benefits of good mental health [5]. In Australia and elsewhere these realizations have given impetus to a sustained program of mental health system reform [6–8] with the intention of improving population mental health and the performance of mental health systems that have struggled to keep pace with community needs [9]. There is an emerging consensus that several elements are essential for successful reform and for the development of mental health services that are effective, affordable, accessible and equitable. Among these are a population mental health perspective, a whole of government approach [10, 11], genuine stakeholder participation in decision-making [12, 13], and an informed and engaged community [14, 15].

The 12-hour, two-day MHFA training program was advertised widely through community channels in the Vietnamese community in Melbourne, emphasising that all community members were welcome to participate in the program, which was delivered free of charge. Participants in the training programs were general members of the community who registered for the training. There was no specific selection process. An interest in learning about mental health was sufficient. Participants in three training groups were invited by the trainers to participate in the evaluation of the program by anonymously completing the evaluation questionnaire prior to the commencement of the training (pre-test) and at its completion (post-test).

The training was delivered by two qualified MHFA instructors, both mental health professionals (psychology and social work), and both born in Vietnam, who were involved in the cultural adaptation of the MHFA training course and manual. The adapted MHFA manual was translated into Vietnamese by a Vietnamese psychiatrist. The training program was conducted in Vietnamese.

The evaluation questionnaire consisted of the following components:

1) A section seeking brief socio-demographic information.

2) Presentation of four brief vignettes about each of which the following questions were asked:

a) What would you say, if anything, is wrong with John?

b) Imagine John is someone you have known for a long time and care about. You want to help him. What would you do?

c) Has anyone in your family or close circle of friends ever had problems similar to John's?

d) Have they received any professional help or treatment for these problems?'

e) Have you ever had a job that involved providing treatment or services to a person with a problem like John's?

The vignettes were taken from a paper by Griffiths et al. [35] reporting a study of stigma associated with mental disorders. The vignettes described a person with: depression; depression with suicidal ideation; early schizophrenia; and chronic schizophrenia. Each of the disorders depicted in the vignettes satisfied both DSM-IV and ICD-10 diagnostic criteria for either major depressive disorder or schizophrenia.

3) Following the open-ended responses to the questions above, respondents were asked to indicate level of agreement with a number of statements in relation to each vignette on a 5-point scale (1 = Strongly agree, 2 = Agree, 3 = Neither agree nor disagree, 4 = Disagree, 5 = Strongly disagree). The first group of statements asked respondents to "indicate how strongly you agree or disagree with each of the following statements by ticking the appropriate box". This was intended as a measure of personal stigma [35]. The second groups of statements, identical in content to the first, asked respondents to "indicate what you think most other people believe". This was intended as a measure of perceived stigma [35]. The statements concerning which participants were asked to indicate level of agreement were:

a) People with a problem like John's could snap out of it if they wanted

b) A problem like John's is a sign of personal weakness

c) A problem like John's is not a real medical illness

d) People with a problem like John's are dangerous

e) It is best to avoid people with a problem like John's so you don't develop the problem yourself

f) People with a problem like John's are unpredictable

g) If I had a problem like John's I would not tell anyone

h) I would not employ someone if I knew they had a problem like John's

i) I would not vote for a politician if I knew they had a problem like John's

The post-test questionnaire was identical except that the socio-demographic information was excluded. The questionnaires were presented in English, but participants were invited to write their responses to the open-ended questions in either English or Vietnamese. Vietnamese responses were translated into English by a bilingual mental health professional.

The data collected were analysed in two ways. First, data collected at pre-test were analysed to examine participants' recognition of disorders, their mental health first aid responses and the level of personal and perceived stigma. The data collected at post-test were compared with data collected at pre-test to measure change in recognition of disorders, first aid responses and stigma towards people with mental disorders. Only participants who completed both the pre- and post-test questionnaires were included for analysis. From a total of 138 training participants, 114 returned completed pre- and post-test questionnaires (82.6% response rate). Twenty-four questionnaires were excluded because of incomplete data or because the code that was necessary to link pre- and post-test questionnaires was not entered.

For each vignette there were two open-ended questions. (1. What would you say, if anything, is wrong with John? 2. Imagine John is someone you have known for a long time and care about. You want to help him. What would you do?) The first was to assess participants' recognition of the mental disorder described in the vignette and the second inquired about mental health first aid responses. The four diagnoses that were considered correct were: depression (for vignette 1), psychosis or schizophrenia (vignettes 2 and 4) and depression and/or a reference to suicidality (vignette 3). Responses were coded 0 (incorrect diagnosis) or 1 (correct).

In the MHFA training program a structured response, consisting of five actions, is taught. The actions are:

1) A ssess risk of suicide or harm

2) L isten non-judgmentally

3) G ive reassurance and information

4) E ncourage the person to get appropriate professional help

5) E ncourage self-help strategies

The initial letters of these actions constitute the mnemonic ALGEE.

The free responses to the second question (What would you do?) were coded on a 0-2 scale according to the quality of the response for each of the ALGEE actions: 0 = no mention or inadequate response, 1 = superficial response, 2 = specific details. The ratings were then summed to give a total score out of 10. Detailed scoring criteria were drawn up for this purpose. A research assistant was trained in the use of the scoring criteria and she rated the responses after their order had been randomized. Randomization of the order ensured that the rater was not told what vignette the response was to, nor whether it was a pre-test or post-test response. In order to assess the reliability of her ratings, the research assistant was also asked to score 40 responses from another data set that had been previously scored using the consensus of four experts in MHFA. Her ratings correlated highly with the expert consensus ratings. Pearson correlations were: A 1.00, L 0.90, G 0.78, E (Professional) 0.81, E (Self-help) 0.87, Total 0.95.

To evaluate the effect of the training, answers to the structured questions and to the coded open-ended questions given at pre- and post-test were compared using McNemar tests for dichotomous values and Wilcoxon tests for other scores. These non-parametric tests were used because the scores did not meet the distributional assumptions of parametric tests. The analysis was carried out using SPSS 16.0. The p < 0.05 significance level was used. Mean scores, standard deviations and p-values are reported in the tables below.

Although this is the first evaluation of MHFA training with an immigrant group in a language other than English, and the results should be regarded as preliminary, they are encouraging. The findings confirmed our hypotheses, that there would be improved knowledge of mental disorders, reduced negative attitudes to persons with mental disorders and improved knowledge concerning appropriate early response to a person.

Vietnam-born members of the Australian community use public mental health services at substantially lower rates than do the Australia-born [20]. This is true also for a large number of other immigrant and refugee communities in Australia and in other countries of immigration. Many possible explanations have been advanced for this consistent observation, including low mental health literacy in immigrant communities, high levels of stigma attaching to mental illness and to seeking hep from mental health services, lack of knowledge about how to gain access to mental health services, difficulties in communication with mental health services, and many others [36–38]. It would appear from the findings reported here that, through the means of a brief and inexpensive training course that is understandable to general members of the Vietnamese community, it is possible to improve knowledge concerning mental disorders, to teach more appropriate responses when mental disorder is present, and to reduce negative and stigmatising attitudes towards mental illness and people with mental illness. This is the first study to demonstrate the value of MHFA training, suitably modified by skilled mental health professionals who are familiar with the relevant cultural issues, with a non-English speaking immigrant community.

The findings from this study are similar to the conclusions drawn from a review of evaluation studies of the immediate impact of MHFA training [25]. However, we do not know whether the changes observed during the course of the training will be sustained, whether the new knowledge and skills will be used appropriately (or at all), and whether assisting in the recommended manner will actually bring benefit to people with mental illness with whom the mental health first aiders come into contact. Reports from evaluations carried out with English speaking populations show sustained benefits to training participants 5-6 months post-training and continued improved confidence in offering assistance. We do not know whether this will be the case in immigrant communities. These are questions awaiting further studies.

The body of evidence that has accumulated about the benefits of MHFA training in English-speaking communities, and the entirely consonant findings from this study in the Vietnamese community, offers a rationale for substantially scaling up such a training endeavour with the Vietnamese community so that it might have a population level impact. It will be necessary to evaluate, using longitudinal studies, whether such a population level program results in improvement in general community mental literacy, reduction in stigma towards people with mental illness, seeking psychiatric treatment and care when it is required, greater demand for and better access to public mental health services, earlier presentation (early in the episode of illness and at an early age - given the findings of under-detection of mental health problems in Vietnamese children and adolescents by their parents [17]), and improved Vietnamese community mental health.

Because Mental Health Matters: Victorian Mental Health Reform Strategy 2009-2019 [11] sets out the major strategic directions for Victorian mental health services over the next 10 years. The strategy pays particular attention to the need to consider cultural and linguistic diversity in developing more effective and appropriate mental health services. ("Reform also requires concerted change in the culture of service delivery to achieve a more welcoming, participatory service environment that is sensitive to diversity." Page 10). A rigorously evaluated program of MHFA training for the Vietnamese community at a scale that could have population level impacts would be fully consistent with each of the six guiding principles of the new Victorian mental health strategy, which are:

Such a population level program, which engages and enables members of the community to contribute directly to community mental health, would contribute to the core elements of the strategy - prevention, early intervention, a focus on recovery, and social inclusion.

MHFA training has been shown to be effective in the Vietnamese community in Melbourne in improving knowledge about mental disorders and knowledge about appropriate helping responses, and in reducing negative stigmatising attitudes towards people with mental illness. The evidence from this study, together with the accumulated evidence of the benefits of MHFA training in the general Australian community, suggests that this approach should be scaled up to a level where it can have an impact on the whole of the Vietnamese community in Melbourne. Such a scaled up population mental health program should be evaluated over time and, if the evidence supports such extension, should be extended to other immigrant and refugee communities that are under-represented in Victorian public mental health services.