The acceptability of instructors providing task-shifted mental health care to their school-aged students is not adequately investigated. In this study, we assess the acceptability of Tealeaf (Teachers Leading the Frontlines) to teachers, students, and caregivers.
Tealeaf is an alternative system of care in which teachers are trained and supervised to provide transdiagnostic, non-manualized task-shifted care to their students.
Are Teachers Considered Caregivers:
Teachers are professionals whose primary role is education: planning lessons, delivering instruction, assessing student progress, and fostering intellectual development. They certainly care for their students and support their well-being, but their main job is teaching.
Caregivers, by contrast, are people whose primary role is to provide personal care and assistance to others who can’t fully care for themselves. This often includes helping with daily living activities, offering emotional support, and ensuring health and safety. Caregiving jobs often include roles such as:
- Home health aides
- Personal support workers
- Childcare providers (especially in early childhood settings)
- Elderly care workers
- Disability support workers
Background:
The global prevalence of adolescent mental conditions is estimated to be between 10 and 20%. In high-income countries (HICs), 20% of youth in need of indicated mental health care, which is defined as talk therapies and/or medications to treat an identified mental health problem, receive it. In low and middle-income countries (LMICs), access to care is typically poorer, with 1% or fewer of children in need receiving care. Youth with mental health needs continue to be severely underserved.
Task-shifting is one of the alternative care models that are necessary to bridge the care divide, which is rooted in a shortage of trained professionals. In task-shifted mental health care, professionals train and supervise non-accredited individuals, known as “lay counselors,” to provide clinically indicated care, typically talk therapies, to individuals with clinical needs.
In low- and middle-income countries (LMICs), the mental health outcomes of individuals in need of care have been enhanced by lay counselors who provide task-shifted care. This has been supported by numerous studies and reviews, including a 2013 Cochrane review that was updated. The delivery of task-shifted care for children between the ages of five and twelve has resulted in inconsistent results.
Community health workers, who are the most prevalent form of lay counselor human resource, have not consistently enhanced the symptoms of Post-Traumatic Stress Disorder, Depression, or Anxiety in children. Community health workers frequently lack the necessary experience to provide this type of care, as informal counselors must be familiar with the developing cognitive and emotional capabilities of children.
Check Also: Alzheimer Caregiver Prayers – Check Here
Setting:
The research was conducted in Darjeeling, West Bengal, India. A minority group in India, the local population is primarily ethnically Nepali and speaks Nepali. The majority of residents are employed in small-scale agricultural communities and tea-plantation areas, with an average daily wage of 176 INR ($2.42 USD).
A majority of rural families with lower incomes prefer sending their children to low-cost private (LCP) schools, despite this economic condition, because they believe that LCP schools provide a high-quality education in English.
Participants:
Eligible schools were LCP primary schools located in rural areas of the Darjeeling Himalayas. These schools were required to employ a minimum of three teachers in order to accommodate a student body size of 30–50 students, which was more likely to approximate child psychiatric morbidity estimates.
Schools were additionally required to satisfy the subsequent inclusion criteria in order to reach children with the least access to care: (3) served households with a daily average income of less than 725 INR ($10 USD), (2) charged annual fees of less than 11,500 INR ($180 USD), and (1) did not receive government aid.
Measures:
As a result of resource constraints, quantitative and qualitative data were collected concurrently (i.e., prior to analysis). Their integration occurred through an explanatory sequential method, as in “Analysis”.
Quantitative assessments:
Acceptability
The selection of quantitative acceptability measures was determined by a panel of experts and research personnel with local expertise, who reviewed the acceptability measures. There are no published surveys that have evaluated the acceptability of teacher-delivered behavioral and mental health interventions by parents in relation to their students.
In the context of Darjeeling, local research staff found surveys that more broadly assessed parent acceptability to be challenging to comprehend. Consequently, the decision was made to evaluate the acceptability of parents qualitatively, as illustrated below, and to proceed with the quantitative assessment of the acceptability of teachers and children, as illustrated below.
Intervention rating profile—15 (IRP)
Teacher acceptability of school-based behavioral and mental health interventions is evaluated by the Intervention-Rating Profile (IRP). A six-point Likert-type scale is used to evaluate the 15 items, with one indicating strong disagreement and six indicating strong agreement. The cumulative score is the sum of all item scores.
IRP authors define moderate acceptability as a score of ≥ 70, with greater scores indicating higher levels of acceptability. Pre-intervention (following teacher training and prior to care delivery, “PRE”) and post-intervention (at the conclusion of the academic year after 6–8 months of care, “POST”) were the dates on which the IRP was collected. In order to confirm the accuracy of the Nepali translation, the IRP was translated into Nepali and subsequently translated back into English. In five minutes, participants completed the IRP.
Children’s intervention rating profile (C-IRP)
The Children Intervention Rating Profile (C-IRP) evaluates the acceptability of behavioral and mental health interventions provided by instructors to students. Seven items are evaluated on a six-point Likert scale, with a score of 1 indicating strong disagreement and a score of 6 indicating strong agreement. Three items are reverse-scored.
The total score is the aggregate of the individual item scores. Acceptability was correlated with higher total scores, with a score of 24.5 or higher being considered acceptable by the C-IRP authors. The original C-IRP assessed students’ levels of acceptability of interventions delivered in vignettes (see Additional File 2), which was why an adapted version of the C-IRP was employed to enable students to evaluate their own participation in Tealeaf.
Demographics
PRE was the site of the collection of all demographic data. Age, years of teaching, years at current school, gender, language(s) spoken, level of education completed, and grade levels taught were the demographics of the teachers that were compiled. Age, gender, and relationship to the infant were collected to reduce the research burden on caregivers. Age, gender, language(s) spoken, grade level, mental health symptoms as reported by their teacher in the Teacher Report From (as follows), and membership in a scheduled caste/tribe were all collected from caregivers.
Teacher report form (TRF)
The Achenbach System of Empirically Based Assessment (ASEBA) Teacher Report Form (TRF) is considered the “gold standard” for evaluating mental health challenges as reported by instructors. The form consists of 113 questions that are scored to generate multiple clinical scores. These scores include aggregate scores for Total Problem, Internalizing problems, Externalizing problems, and 14 subdomain scores.
Raw scores are summed and converted into T-scores. TRF authors define “borderline” as likely having symptoms that meet diagnostic criteria for a disorder but would be best confirmed by a professional evaluation to minimize false positive screening, while “clinical” is defined as more confidently having symptoms that meet diagnostic criteria for a disorder.
Total problem T-scores ranging from 60 to 63 are classified as “borderline,” and scores ≥ 63 are classified as “clinical.” Internalizing and externalizing problems, as well as all subdomain T-scores of 65 to 69, are classified as “borderline” and scores of 70 or higher are classified as “clinical.”
Qualitative assessments:
Before conducting quantitative data analysis, semi-structured interviews (“interviews”) were conducted with seven instructors, seven students, and seven caregivers at POST to obtain a qualitative description of acceptability.
The qualitative acceptability objectives were based on the components of acceptability that Proctor and colleagues described: acceptability (Aim 1), facilitators of acceptability (Aim 2), conditions necessary for acceptability (Aim 3), barriers to acceptability (Aim 4), and future directions for acceptability (Aim 5). Interview guides (Additional File 3) were devised iteratively in accordance with these objectives. The guides were subsequently finalized in collaboration with the research team and program personnel.
Audio-recorded interviews in Nepali were conducted by trained research assistants, who also recorded complementary field notes. An independent translator transcribed and translated the interviews into English, and the study personnel reviewed them for accuracy.
Procedures:
Tealeaf is an intervention that involves the task-shifting of the administration of evidence-based, non-manualized, transdiagnostic, indicated child mental health care to teachers. Tealeaf was developed by the three authors (CMC, PG, & MM), community partner non-governmental organizations (Darjeeling Ladenla Road Prerna, Darjeeling-based, and Broadleaf Health and Education Alliance, Darjeeling-focused), and their partner LCP schools and community health workers, in order to address child mental health needs that were considered concerning by the Darjeeling community but for which little care was available (as previously mentioned).
Table 1
Core intervention components
| Intervention Component | Activity | Description |
|---|---|---|
| Professional development & regular supervision | Training | Training: 10-day interactive training for teachers in identification of children with mental health needs, basic functional behavioral assessments and tenets of CBPT, particularly behavior activation, play, and cognitive restructuringSupervision: Twice monthly discussion with and/or observation of the teacher working with the child to provide concrete guidance and techniqueCase reviews: Monthly case reviews are conducted with a team of local and international mental health experts |
| Assessment | Student identification | After training, teachers observe their students during typical teaching activities through the lens of identifying who may need mental health support. They choose two students to target for care whom they judge to be in most need based on their observations |
| Assessment | Behavior analysis | Observations of targeted students through a behavioral lens for key behaviors using the AABC Chart and the Themes of the AABC Chart. Supplemented by collateral from caregivers for further observations from student’s home lives |
| Tailored instruction; therapeutic interactions & skills practice | Behavior plan | A behavior plan (4Cs) incorporating CBPT and classroom-based therapeutic techniques that target school-specific behaviors (1:1 and during instructional time), to be used daily. Use of plan in student home is highly encouraged |
| Therapeutic interactions & skills practice | 1:1 Student interaction | Per behavior plan students engage in 1:1 interactions with teacher during or outside of class. These interactions include CBPT and relationship-building activities |
| Therapeutic interactions & skills practice | 1:1 Family interaction | With support and guidance from teachers, primary caregivers have roles in behavior analysis, implementation of behavior plans, development of positive parental relationships, and reinforcement of positive behaviors |
CBPT, cognitive behavior play therapy; AABC, activating event, automatic thoughts and/or emotions, behavior, and consequence; 4Cs, “cause, change, connect, cultivate behavior plan”
Data analysis:
In order to determine whether participants found Tealeaf to be acceptable, an explanatory sequential approach was implemented. The objective of the data analysis was to gain a more comprehensive understanding of quantitative measures through qualitative inquiry, despite the fact that data were collected in parallel and appear to be more similar to a concurrent method.
Consequently, we implemented an explanatory sequential approach that was informed by recent mixed methods literature, which emphasized the purpose of the data analysis over the timing of data acquisition. Initially, quantitative data were analyzed to determine the acceptability of both the teacher and the child in a quantitative sense.
Qualitative data analysis was implemented to incorporate the two types of data in order to provide a more comprehensive explanation of the quantitative results and to gain a better understanding of caregiver acceptability, as no quantitative measure was determined to be suitable for measuring caregiver acceptability, as previously mentioned in “Measures.”
Quantitative:
The demographic characteristics of all teachers, pupils, and caregivers enrolled in the study were analyzed using descriptive statistics. The demographics of teachers who completed all study activities were compared to those who did not. The demographics of the teachers, pupils, and parents who participated in interviews were contrasted with those who did not. Continuous variables were subjected to independent sample t-tests, while categorical variables were subjected to Fisher’s exact tests.
The mean scores for the acceptability measurements, C-IRP (Total Acceptability score) and the IRP (Total Acceptability score), were calculated at the PRE and POST time points and compared using paired sample t-tests (two-tailed). One teacher lacked an IRP PRE score, which enabled a comparison of 12 instructors’ scores between the PRE and POST periods. The C-IRP values of 24 children who were targeted for care and had comprehensive demographic and C-IRP data collected were compared pre- and post-treatment. All quantitative analyses were conducted using SAS version 9.4 (Cary, NC).
Qualitative
Luxembourg, renowned for its high standard of living, values quality of life and offers a welcoming environment for people from across the globe. As the demand for caregivers grows due to an aging population, Luxembourg offers numerous opportunities for international workers to take on caregiving roles.
Results:
Demographics
Interviews with instructors, children, and their parents were analyzed using inductive content analysis to acquire a more comprehensive understanding of caregivers’ perspectives on acceptability and quantitative acceptability scores. The goal was to offer a qualitative account. In accordance with Crabtree and Miller’s template coding approach, all of the interviews were coded by two independent analysts using ATLAS.ti version 8.4.15, 2019.
Table 2
Demographics of teachers and comparisons between those who completed all study activities and those who did not, as well as qualitative interviews.
| Comparison of teachers who did and did not complete all study activities | Comparison of teachers who did and did not complete a qualitative interview | ||||||
|---|---|---|---|---|---|---|---|
| Variable | Enrolled N = 19 | Completed N = 13 | Did not complete N = 6 | T-test p-value^ | Completed N = 7 | Did not complete N = 12 | T-test p-value^ |
| Continuous Variable | Mean (SD) | Mean (SD) | Mean (SD) | Mean (SD) | Mean (SD) | ||
| Age | 28.4 (5.8) | 29.85 (5.9) | 25.17 (4.4) | 0.10 | 27.3 (5.1) | 29.0 (6.3) | 0.55 |
| Years teaching | 6.1 (5.4) | 7.4 (5.8) | 3.33 (3.4) | 0.13 | 4.6 (6.0) | 7.0 (5.1) | 0.38 |
| Years at current school | 4.4 (4.5) | 4.96 (5.0) | 3.33 (3.4) | 0.48 | 4.4 (6.2) | 4.5 (3.6) | 0.95 |
| Categorical variable | N (%) | N (%) | N (%) | Fisher’s exact test p-value^ | N (%) | N (%) | Fisher’s exact test p-value^ |
|---|---|---|---|---|---|---|---|
| Female gender | 16 (84%) | 10 (76.9%) | 6 (100%) | 0.52 | 4 (57.1%) | 12 (100%) | 0.04^ |
| Language | |||||||
| Nepali | 8 (42%) | 5 (38.5%) | 3 (50.0%) | 0.99 | 2 (28.6%) | 6 (50.0%) | 0.63 |
| English | 6 (32%) | 4 (30.8%) | 2 (33.3%) | 0.99 | 2 (28.6%) | 4 (33.3%) | 0.99 |
| Hindi | 4 (21%) | 2 (15.4%) | 2 (33.3%) | 0.56 | 2 (28.6%) | 2 (16.7%) | 0.60 |
| Level of education | 0.54 | 0.10 | |||||
| Some primary | 3 (16%) | 2 (15.4%) | 1 (16.7%) | 1(14.3%) | 2 (16.7%) | ||
| Some senior secondary | 2 (11%) | 2 (15.4%) | 0 (0%) | 0 (0%) | 4 (33.3%) | ||
| Finished senior secondary | 4 (21%) | 1 (7.7%) | 3 (50.0%) | 2 (28.6%) | 0 (0%) | ||
| Some undergraduate | 4 (21%) | 3 (23.1%) | 1 (16.7%) | 1 (14.3%) | 3 (25.0%) | ||
| Finished undergraduate | 2 (11%) | 2 (15.4%) | 0 (0%) | 1 (14.3%) | 1 (8.3%) | ||
| Some graduate/post-graduate | 2 (11%) | 1 (7.7%) | 1 (16.7%) | 0 (0%) | 2 (16.7%) | ||
| Finished graduate/post-graduate | 2 (11%) | 2 (15.4%) | 0 (0%) | 2 (28.6%) | 0 (0%) | ||
| Had formal training | 5 (26%) | 5 (38.5%) | 0 (0%) | 0.13 | 2 (28.6%) | 3 (25.0%) | 0.99 |
| Teaching certificate | 7 (37%) | 6 (46.2%) | 1 (16.7%) | 0.33 | 3 (42.9%) | 4 (33.3%) | 0.99 |
| Grade level taught | |||||||
| Nursery/kindergarten | 8 (42%) | 6 (46.2%) | 2 (33.3%) | 0.99 | 3 (42.9%) | 5 (41.7%) | 0.99 |
| Class I | 15 (79%) | 10 (76.9%) | 5 (83.3%) | 0.99 | 5 (71.4%) | 10 (83.3%) | 0.60 |
| Class II | 14 (74%) | 10 (76.9%) | 4 (66.7%) | 0.99 | 5 (71.4%) | 9 (75.0%) | 0.99 |
| Class III | 12 (63%) | 8 (61.5%) | 4 (66.7%) | 0.99 | 5 (71.4%) | 7 (58.3%) | 0.66 |
| Class IV | 12 (63%) | 7 (53.9%) | 5 (83.3%) | 0.33 | 4 (57.1%) | 8 (66.7%) | 0.99 |
| Class V | 5 (26%) | 3 (23.1%) | 2 (33.3%) | 0.99 | 2 (28.6%) | 3 (25.0%) | 0.99 |
| Class VI + | 3 (16%) | 3 (23.1%) | 0 (0%) | 0.52 | 3 (42.9%) | 0 (0%) | 0.04^ |
Table 3.
Child demographics and comparison of children who participated in and did not participate in a qualitative interview
| Comparison of children who did and did not complete a qualitative interview | ||||
|---|---|---|---|---|
| Variable | Enrolled (N = 26) | Completed (N = 7) | Did not complete (N = 19) | T-test or fisher’s exact test p-valuea |
| Continuous variable | Mean (SD) | Mean (SD) | Mean (SD) | |
| Age (years) | 8.23 (1.7) | 8.9 (1.2) | 8.0 (1.8) | 0.26 |
| Total Household Members | 3.8 (1.5) | 3.6 (1.1) | 3.8 (1.6) | 0.69 |
| TRF Total problem score at enrollmentb,c | 62.7 (8.6) | 63.7 (10.2) | 63.4 (8.4) | 0.75 |
| Categorical variable | N (%) | N (%) | N (%) | |
|---|---|---|---|---|
| Female gender | 8 (30.77%) | 1 (14.3%) | 7 (36.8%) | 0.37 |
| Scheduled caste/tribed | 7 (26.92%) | 1 (14.3%) | 6 (31.6%) | 0.63 |
| Language | ||||
| Nepali | 26 (100%) | 7 (100%) | 19 (100%) | n/cj |
| English | 24 (92.31%) | 6 (85.7%) | 18 (94.7%) | 0.47 |
| Hindi | 3 (11.54%) | 0 (0%) | 3 (15.8%) | 0.54 |
| Grade | 0.07 | |||
| Class I | 4 (15.38%) | 0 (0%) | 4 (21.1%) | |
| Class II | 6 (23.08%) | 0 (0%) | 6 (31.6%) | |
| Class III | 9 (34.62%) | 5 (71.4%) | 4 (21.1%) | |
| Class IV | 5 (19.32%) | 1 (14.3%) | 4 (21.1%) | |
| Class VI + | 2 (7.69%) | 1 (14.3%) | 1 (5.2%) | |
| TRF behavior type | ||||
| TRF externalizing at enrollmentc,e | 5 (20.0%) | 2 (28.6%) | 3 (16.7%) | 0.60 |
| TRF internalizing at enrollmentc,e | 13 (52%) | 4 (57.1%) | 9 (50.0%) | 0.99 |
| Baseline Student Mental Health Profile per the ASEBA TRF | |
|---|---|
| Symptom category | Number of children with positive symptom T-Score (n = 25)c,f,g |
| Scale Scoresh,i | |
| Total Problem | 16 (64.0%) |
| Internalizing Problems | 13 (52.0%) |
| Externalizing Problems | 5 (20.0%) |
| Syndrome Scale Scoresi | |
| Anxious/Depressed | 10 (40.0%) |
| Somatic Complaints | 4 (16.0%) |
| Thought Problems | 8 (32.0%) |
| Attention Problems | 4 (16.0%) |
| Rule-Breaking Behavior | 2 (8.0%) |
| Aggressive Behavior | 6 (24.0%) |
| Withdrawn/ Depressed | 13 (52.0%) |
| Social Problems | 8 (32.0%) |
| Any syndrome scale item positive | 19 (76.0%) |
| Diagnostic and statistical manual (DSM) oriented scales i | |
| Depressive problems | 10 (40.0%) |
| Anxiety problems | 13 (52.0%) |
| Somatic problems | 1 (4.0%) |
| Attention deficit | 2 (8.0%) |
| Oppositional defiant problems | 3 (12.0%) |
| Conduct Problems | 4 (16.0%) |
| Any DSM oriented scale item positive | 17 (68.0%) |
| Any symptom item positiveh,i | |
| Total Problem, Internalizing, Externalizing, Syndrome, or DSM | 20 (80.0%) |
Table 4.
Demographics of caregivers and comparison of those who participated in and did not participate in a qualitative interview
| Demographic comparison of caregivers who did and did not complete a qualitative interview | ||||
|---|---|---|---|---|
| Variable | Enrolled (N = 29)a | Completed (N = 7) | Did not completeb (N = 19) | |
| Continuous variable | Mean (SD) | Mean (SD) | Mean (SD) | T-test p-value^ |
| Age of caregiverc | 33.6 (11.38) | 29.75 (7.1) | 33.26 (12.2) | 0.59 |
| Categorical variable | N (%) | N (%) | N (%) | Fisher’s exact test p-value^ |
|---|---|---|---|---|
| Female caregiver | 24 (82.8%) | 5 (71.4%) | 17 (89.5%) | 0.26 |
| Relationship to child: | 0.77 | |||
| Mother | 18 (62.1%) | 4 (57.1%) | 13 (68.4%) | |
| Father | 4 (13.8%) | 1 (14.2%) | 2 (10.5%) | |
| Grandparent | 2 (6.9%) | 0 (0%) | 2 (10.5%) | |
| Aunt | 2 (6.9%) | 1 (14.2%) | 1 (5.3%) | |
| Guardian | 3 (10.3%) | 1 (14.2%) | 1 (5.3%) | |
Quantitative acceptability:
Teachers’ IRP scores were, on average, above the moderate acceptability threshold (≥ 70) at PRE (mean = 73.75, standard deviation (SD) = 5.85; n = 12; 75% (n = 9) above acceptability threshold) and POST (mean = 76.92, SD = 5.58; n = 12; 92% (n = 11) above acceptability threshold) (Table 5). Teachers’ scores did not exhibit a statistically significant change from pre- to post-testing (mean difference = 3.17; p = 0.1550; 95% Confidence Interval (CI): -1.40, 7.73).
The intervention was generally deemed acceptable by students, as evidenced by their C-IRP scores at PRE (mean 29.96, SD = 3.49; n = 24, 96% (n = 23) above the acceptability threshold) and POST (mean 27.67, SD = 2.32; n = 24, 96% (n = 23) above the acceptability threshold). The average decline in scores from PRE to POST was statistically significant, with a mean decline of -2.20 points (95% CI: -3.53, -1.05).
Table 5.
Acceptability comparisons
| Acceptability Outcome | PRE | POST | POST minus PRE | P-value | ||||
|---|---|---|---|---|---|---|---|---|
| Mean (SD) | Number (%) above acceptability threshold | Mean (SD) | Number (%) above acceptability threshold | Mean (95% CI) | t | df | ||
| IRP (teacher)an = 12b | 73.75 (5.85) | 9 (75%) | 76.92 (5.58) | 11 (92%) | 3.17 (− 1.40, 7.73) | 1.53 | 11 | 0.1550 |
| C-IRP (child)cn = 24d | 29.96 (3.49) | 23 (96%) | 27.67 (2.32) | 23 (96%) | − 2.20 (− 3.53, − 1.05) | − 3.82 | 23 | 0.0009* |
Qualitative acceptability
The universal acceptability of Tealeaf was conveyed by teachers and caregivers (Aim 1; Table 6). The program was generally deemed acceptable by both groups, with some individuals explicitly expressing their desire for it to persist in the future. Teachers also elaborated on the acceptability of the individual components of Tealeaf.
Although they had several years of experience, some of the more experienced teachers expressed that these skills were novel and useful, and training and supervision were perceived as venues for acquiring new, relevant skills. The delivery of care was deemed acceptable and a worthwhile implementation of newly acquired skills, as the efforts were perceived as impactful, as outlined in Aim 2 below.
According to one educator, “I acquired new knowledge and abilities as a result of this program.” The students have experienced positive changes as a result of this program. I am filled with joy when I observe these modifications, and I believe that my time and effort were well spent.
Table 6.
Themes and representative quotations from semi-structured interviews with students, caregivers, and teachers
| Aim | Theme | Participant Group | Quotation | |
|---|---|---|---|---|
| Aim 1: Acceptability | Training | Teachers | “Even though we have had many years of teaching experience, I know that our techniques were sometimes flawed. We learnt a lot of new skills in the training, we learnt how to handle, behave, treat and react to the children.”“We are ready to receive and go through more sessions of training too.” | |
| Supervision | Teachers | “The others (staff) were really nice, they taught us well and they never made us feel that they were teachers. So there was no awkwardness in asking for their help if something was unclear to us or if there was some challenge facing us.” | ||
| Delivering care | Teachers | “Through this program I gained new knowledge and skills, through this program, good changes have come to the children. When I see these changes, I feel happy, and I feel it was worth my time and energy.”“We have learnt a lot of things in the training and have gained a lot of knowledge which is more important than the bookish knowledge that anyone can impart. I try to apply on a daily basis all the things that I have learnt.” | ||
| Overall program | TeachersCaregivers | “I hope the program continues in the future.”“What I feel is that whatever the program has been doing, it is for the benefit of the children and it’s helped the children and it’s good.” | ||
| Aim 2: Facilitators of Acceptability | Belief program was impactful | TeachersCaregivers | Subtheme | |
| Teachers’ beliefs on mental health | “I would want everyone to understand and be a part of this program because it affects the way you think and react. It really makes you think and reconsider your reactions when the child comes to class without completing their homework or forgets to bring their book.” | |||
| Teachers’ skills | “We like the program and we feel happy when we see that we are capable of helping the children.” | |||
| Child’s academics | “When I used to teach him, he would not listen to me, he would get distracted, but now he studies very well with concentration and interest. When I see these changes, I feel it is because of the teacher.” | |||
| Child’s behavior | “My child was disobedient but through the ideas given by you and the teachers my child has changed and started to become obedient.” | |||
| Engagement in program | Teachers | “I am enjoying my time with the kids, getting close to them and learning about child psychology.” | ||
| Ability to make adaptations | Teachers | “I would observe [the selected children] closely but I would never call them separately and conduct special activities because I did not want them to worry and wonder if something was wrong with them.”“I make small groups of children who are of the same standard studies wise. And in that group I make sure that one of the selected children gets included. In this way the selected children get extra guidance and the rest of the class gets included too. So no one feels left out and neglected and no one gets to know about the program.”“Maybe it’s because of the fact that there is no hard and fast rule regarding the work related to the program so I don’t feel it to be difficult.” | ||
| Trust | CaregiversStudents | “The thought that came to my mind was that this program would help my child. There was never any doubt or fear in my mind when I got to know about the program. I took the news as good news because I told myself that the program would help my child in class, especially during studies.”“He is very nice and is not strict with us. He loves all of us.” | ||
| Communication & relationships | Caregivers | “It’s very easy to find her and talk to her (teacher). Talking to her was extremely easy and comfortable.” | ||
| Aim 3: Conditions Required for Acceptability | Understanding of program | TeachersCaregivers | “Earlier we would treat all the children in the same way in class. We would teach and expect all of the students to get a hang of it. We never considered that the academically weaker students needed more attention. These things were brought into our awareness during the training… When we started doing thing this way, it helped the students.”“I have come to understand that this program is here to help the children who have behavioral issues and are weak in their studies. This is a good program and it is here to help our children. They tell us and teaches us how to handle disobedient children and teaches them to cooperate.” | |
| Emphasis on academics over mental health to caregivers | Teachers | “They were happy when they got to know that their child was chosen for the program because we approached the parents with academics and avoided using the term ‘mental health’ because it is a stigma and still frowned upon. The parents would definitely get anxious and would feel a bit low knowing their child out of all the children in the class had some mental health issue. To avoid this with the parents we told them that we had chosen their child to help them get better at their studies and to help them with their overall development. The caregivers were more than happy to know about this selection and were very supportive.” | ||
| Caregiver involvement | Teachers | “I have had no challenging instances with the parents. The parents come and talk to me about their children. They share their thoughts with me and give me suggestions on how their child can be helped or what else could be done for their child.” | ||
| Support from the project team | Teachers | “Things were a bit easy for us because we did not have to initiate this talk on this topic by ourselves. The teachers from the NGO have organized an awareness program, and it included parents of the students of class 4.” | ||
| No observations of negative impact | Caregivers | “I don’t have much knowledge about this program, but what I have come to understand is that they get to know what knowledge my child has, and whatever issues my child has with studies, this program will help my child handle it | ||
| Aim 4: Barriers to Acceptability | Lack of time | Teachers | “Since I am multitasking, I have not been able to give proper time to the children and the program. I am not giving my 100% to the children because it is very difficult for me.”“Interviewer (I): Did the teachers always help them complete their work or was it a recent thing that they started to do after learning about the children and the program?Teacher (T): This usually does not happen with the children that I have chosen. It’s only during rare moments when they are unable to complete their work or don’t know how to complete their work that they get assistance from the teachers. They don’t always do it for them because all the teachers come with a 40-min lesson plan and they are more focused on completing their lesson plan and have very little time to spare to do these kinds of activities for the two children.”“I was unable to give extra time to the two children and could not meet them separately and spend time with them but I was able to give them time when they were working collectively with the entire class. It’s not possible to give those two children extra or special attention in a 45-min class.” | |
| Perceptions of stigma | TeachersCaregivers | “They obviously did not take it positively. The guardians came to me and said my child isn’t mentally challenged so I don’t think my child should do this program.”“I was sure that there were many weak students in his class and wondered why were they not chosen and why was he only chosen for this program.” | ||
| Lack of caregiver engagement and understanding | TeachersCaregivers | “Every parent thinks their child is good; no one wants to consider that their child might be a bit weaker and require help. I just feel they haven’t tried to understand.”“Of course my mind and heart had a lot of questions. I would often wonder what would happen to my child. I wondered what would they make my child do, etc.” | ||
| Not understanding role in program | Students | “I: Oh, so he taught you in the same old way. Hmmm… Does he care for you and look after you? Does he give you the extra attention or does he treat you like the rest of the class and everyone gets the same treatment?Student (S): Everyone equally.” | ||
| Distrust of teachers | Students | “I: Do you feel scared to ask sir for help?S: (silence)I: huh? Yes or no? Are you scared of him?S: YesI: But why do you feel scared?S: (long silence)I: You can tell meS: (silence again)I: Are you afraid of him?S: YesI: Why are you scared of him?S: (Again silence) | ||
| Aim 5: Future Directions for Acceptability | Program expansion | TeachersCaregivers | “I can tell you that if the other teachers are trained like the way we are then it is a beneficial program. It will benefit everyone.”“It would be fantastic if the program could touch the higher classes of 5, 6, 7.” | |
| Improving caregiver engagement | Teachers | “I feel we are lagging behind in the area concerning the meeting with the parents of the children. The NGO comes to school and manages to conduct monthly meetings with the teachers, but I have observed that the parents of the selected children get ignored. There was one meeting with the parent right at the beginning of the program but after that there has been no such meeting with the parents.” | ||
| Leaving program as is | Caregivers | “I would like it if the program continued in the coming year as well… because this program brought changes in his behavior. I think there would be more changes if the program continued next year, which would be helpful and beneficial to him.” | ||
The majority of educators and caregivers indicated that the program’s perceived impact on students’ academics and/or conduct was a factor in its acceptability (Aim 2; Table 6). This impact, as illustrated in the preceding quotation, seemed to justify the effort required to provide care, thereby rendering the effort acceptable.
Additionally, the adaptability of Ed-MH techniques for teachers facilitated acceptability, as they were able to select techniques that aligned with their preferences rather than adhering to a rigid protocol. This reduced the perceived burden and increased the acceptability of the care delivery process. The program’s acceptability was facilitated by the trust and communication between caregivers and teachers, as caregivers appeared to use the teachers’ endorsement of the program as a proxy for its prospective benefits to their child.
Discussion:
This study is the first to investigate whether teachers, school-aged students, and their caregivers in an LMIC find the delivery of task-shifted, transdiagnostic, non-manualized mental health care to their students acceptable, a critical factor in the adoption and sustainability of care. Its results offer evidence of the acceptability of this type of care for both instructors and children, and the interview themes suggest that the seven caregivers interviewed also find it acceptable.
This study is consistent with the evidence from HICs that supports the administration of indicated mental health care by teachers, which is structured in a manner similar to Ed-MH and Tealeaf.
The pupils who were interviewed universally were unaware that they were receiving care, which may be attributed to stigma. Despite the fact that Tealeaf already prioritizes student confidentiality during the identification process, teachers further addressed stigma with children by avoiding singling out students receiving care.
Limitations:
Results from a small, pragmatic sample are exploratory, not definitive, and may not be replicated across a broader sample of instructors, students, and their caregivers. Furthermore, the statistical comparisons were conducted with small sample sizes, despite the fact that the statistical tests used were least sensitive to small sample sizes. This could have resulted in skewed results.
Caregivers’ acceptability was not quantitatively assessed, as no measure was deemed suitable for the circumstances and context. If quantitative caregiver acceptability findings are gathered in the future, they may differ from qualitative caregiver acceptability findings. We were unable to obtain quantitative acceptability ratings and qualitative data from instructors who withdrew from the study.
Conclusion:
The potential of teacher-delivered, task-shifted child mental health care to be a viable alternative option for care delivery is increased by the positive acceptability that teachers, caregivers, and students expressed. The intervention’s acceptability and care delivery were facilitated by the teacher’s capacity to modify it and present it as care that enhances academics and behavior without the need to emphasize its mental health purpose.
The subsequent logical step is to definitively evaluate the capacity of Ed-MH and Tealeaf to enhance child mental health outcomes, in light of the acceptability findings presented here and prior research demonstrating that teachers can identify children with mental health needs with moderate accuracy.
Frequently Asked Questions:
Is caregiving part of a teacher’s job description?
Yes, though the term “caregiving” may not appear explicitly. Duties related to pastoral care, student welfare, or classroom management involve caregiving functions.
Are teachers considered caregivers?
Yes, in many ways. While teachers are primarily educators, they also perform significant caregiving roles, such as ensuring students’ well-being, supporting emotional needs, and creating a safe environment for learning.
Are teachers trained in caregiving skills?
Teachers receive training in areas like child development, classroom management, mental health awareness, and safeguarding, all of which involve caregiving knowledge and skills.
