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Tiêu đề Assessing The Effectiveness Of Teachers’ Mental Health Literacy Training In Cambodia
Tác giả Phoeun Bunna
Người hướng dẫn Dr. Amanda Joan Nguyen, Research Assistant Professor, Dr. Tran Thanh Nam, Lecturer
Trường học Vietnam National University, Hanoi University of Education
Chuyên ngành Child and Adolescent Clinical Psychology
Thể loại Doctoral Dissertation
Năm xuất bản 2021
Thành phố Hanoi
Định dạng
Số trang 169
Dung lượng 1,25 MB

Cấu trúc

  • 1. Context and Background (13)
    • 1.1. Global Burden of Child Mental Health Problems (13)
    • 1.2. Mental Health Situation in Cambodia (15)
  • 2. Statement of the Problem (16)
  • 3. Objectives of the Study (19)
  • 4. Research Questions and Hypotheses (20)
  • 5. Significance of the Study (21)
  • CHAPTER 1 (23)
    • 1. Mental Health literacy in Low-Middle Income Countries (23)
    • 2. Conceptual Framework of Mental Health Literacy (25)
      • 2.1. Mental Health Knowledge (28)
        • 2.1.1. General Population Recognition of Mental Health Problems (29)
        • 2.1.2. Teachers’ Recognition of Mental Health Problems (33)
        • 2.1.3. Students’ Recognition of Mental Health Problems (34)
      • 2.2. Attitudes and Beliefs Toward Mental Illness (36)
        • 2.2.1. Stigma Relates to Cultures and Religious Toward Mental Illness (0)
        • 2.2.2. Stigma Toward Mental Illness Varies by Disorder (39)
        • 2.2.3. Stigma Serves as Barriers to Help Seeking (0)
    • 3. Meaning of MHL in MH Problem’s Prevention and Early Intervention (44)
      • 3.1. Promotion and Prevention Program in General (44)
      • 3.2. Promotion and Prevention to Mental Health Care (46)
      • 3.3. Promotion and Prevention Mental Health Problems in School Setting (48)
    • 4. Role of Teachers in Management of Mental Health Problems (50)
    • 5. Review Literature Supporting MHL Intervention in School Setting (55)
    • 6. Current Study (59)
      • 6.1. Interpreting Study Findings in Terms of Causal Inference (59)
  • CHAPTER 2 (62)
    • 2.1. Overview of Research Design (62)
    • 2.2. MHL Curriculum Guide Overview (64)
    • 2.3. Study Methods (67)
      • 2.3.1. Participants and Sampling Strategy (67)
      • 2.3.2. MHL Intervention for Teachers and Students (69)
      • 2.3.3 Measures (72)
        • 2.3.3.1. Teacher Measures (72)
        • 2.3.3.2. Student Measures (77)
      • 2.3.4. Procedures (78)
        • 2.3.4.1. Data Collection (80)
      • 2.3.5. Data Analysis (80)
  • CHAPTER 3 (84)
    • 3.1. Results of Teacher Analyses (84)
      • 3.1.1. Demographic Data of Teachers (84)
      • 3.1.2. Baseline Scale Scores of Teachers (86)
        • 3.1.2.1. Baseline Scale Scores Between Intervention and Control Groups . 74 3.1.2.2. Aim 1: Evaluate Baseline MHL Scores by Participant’s (86)
        • 3.1.2.3. Demographic Differences in Baseline Scores (88)
        • 3.1.2.4. Mental Health Knowledge Quiz (88)
        • 3.1.2.5. Mental Health Literacy Scale (89)
        • 3.1.2.6. Beliefs toward Mental Illness (90)
        • 3.1.2.7. Summary of Aim 1 (90)
      • 3.1.3. Aim 2: Evaluate the Effectiveness of MHL Intervention at T2 (91)
        • 3.1.3.1. Scale Descriptive (91)
        • 3.1.3.2. Mental Health Knowledge Quiz (92)
        • 3.1.3.3. Mental Health Literacy Scale (92)
        • 3.1.3.4. Beliefs Toward Mental Illness (93)
        • 3.1.3.5. Scale Descriptive for Subscale Measures (93)
        • 3.1.3.6. Subscale of MHLS (94)
        • 3.1.3.7. Subscale of BMI (94)
      • 3.1.4. Aim 3: Evaluate the Effectiveness of MHL Intervention Moderated by Participant’s Demographics (95)
        • 3.1.4.1. Mental Health Knowledge Quiz (95)
        • 3.1.4.2. Mental Health Literacy Scale (96)
        • 3.1.4.3. Beliefs Toward Mental Illness (97)
      • 3.2.1. Demographic Data of Students (98)
      • 3.2.2. Scale Descriptive (99)
        • 3.2.2.1. MHL – Knowledge (99)
        • 3.2.2.2. MHL – Stigma (0)
      • 3.2.3. Aim 1: Evaluate Baseline MHL Scores by Participant’s Demographics (100)
        • 3.2.3.1. Scale Descriptive (100)
        • 3.2.3.2. Knowledge and Attitudes by Age (101)
        • 3.2.3.3. Knowledge and Attitudes by Sex (101)
        • 3.2.3.4. Knowledge and Attitudes by Grade (102)
      • 3.2.4. Aim 2: Evaluate the Effectiveness of MHL Intervention at T2 (102)
        • 3.2.4.1. Scale Descriptive (103)
        • 3.2.4.2. Knowledge and Attitudes (103)
        • 3.2.4.3. Scale Descriptive ANCOVA Fully Adjusted-Model (104)
      • 3.2.5. Aim 3: Evaluate the Effectiveness of Intervention Moderated by Participant’s (105)
        • 3.2.5.1. Scale Descriptive (105)
        • 3.2.5.2. Knowledge and Attitudes by Sex (106)
        • 3.2.5.3. Knowledge and Attitudes by Age (107)
        • 3.2.5.4. Knowledge and Attitudes by Grade (107)
        • 3.2.6.1. Implementation Outcomes (108)
    • 3.3. Discussion (110)
    • 3.4. Strength and Limitations (117)
    • 4.1. Conclusions (119)
    • 4.2. Recommendations (119)

Nội dung

Assessing the effectiveness of teachers’ mental health literacy training in cambodia Assessing the effectiveness of teachers’ mental health literacy training in cambodia

Context and Background

Global Burden of Child Mental Health Problems

Child mental health issues pose a significant global challenge, affecting individuals, families, and public health systems The World Health Organization (WHO) reports that nearly 20% of children worldwide experience mental health disorders, contributing to 15-30% of Disability-Adjusted Life Years (DALYs) lost in early life.

Mental health challenges are particularly severe in low-and-middle income countries (LMICs), where inadequate mental health infrastructure leads to significant treatment gaps Studies indicate that in the poorest nations, as many as 85% of individuals with severe mental illnesses do not receive any treatment, with children facing the greatest disparities in care.

Larger treatment gaps in low- and middle-income countries (LMICs) are largely due to limited resources, with the median number of psychologists and psychiatrists in high-income countries being 180 times higher than in low-income countries (Morris et al., 2012) This disparity highlights the urgent need for improved mental health resources and support in LMICs, as emphasized by the World Health Organization (WHO).

(2014) highlighted the limited number of professional mental health careers in LMICs, suggesting a prevalence of approximately 0.5 psychiatrists per

In high-income countries (HICs), there are 6.6 psychiatrists and over 30 mental health nurses per 100,000 people, highlighting a significant disparity in mental health resources In contrast, low-income countries have only 0.4 psychiatrists and 0.4 mental health nurses per 100,000 individuals, while lower-middle-income countries report 2.5 psychiatrists and 2.5 nurses, and upper-middle-income countries have 7.1 psychiatrists and 7.1 nurses per 100,000 people This stark difference underscores the urgent need for improved mental health care access and workforce development in lower-income regions.

The lack of trained mental health professionals and uncertain financial resources are significant barriers to the development and strengthening of mental health systems in low- and middle-income countries (LMICs).

Malhotra & Padhy, 2015; Morris et al., 2012)

Mental health disorders in low- and middle-income countries (LMICs) often go unrecognized and untreated due to various social factors A significant issue is low mental health literacy, which encompasses a lack of understanding about mental health and mental disorders Additionally, stigma surrounding mental health issues discourages individuals from seeking the necessary support, further exacerbating the problem (D Chisholm et al., 2007; Hossain, 2006; Saraceno et al., 2007; WHO).

Stigma surrounding mental illness significantly impacts individuals' willingness to seek professional help, often leading to delayed treatment and reluctance to share their struggles with family and friends Both internalized stigma, which encompasses feelings of shame, and external stigma, characterized by discrimination from others, stem from cultural and religious beliefs about mental health This stigma contributes to poor mental health outcomes and creates barriers to help-seeking, particularly among children Research indicates that stigma is a critical risk factor linked to negative mental health consequences for individuals across diverse populations In low- and middle-income countries (LMICs), stigma further hinders disclosure and help-seeking behaviors, while even healthcare professionals may possess limited knowledge and negative attitudes towards mental illness.

Mental Health Situation in Cambodia

Mental health disorders in Cambodia pose a significant challenge, with an estimated 40% of the population affected and minimal support available for those in need The scarcity of treatment services has resulted in most individuals receiving little to no assistance (Jong, 2002; Sun, Bun, Pich, & Gschaider-Sassahun, 2019; TPO Cambodia, 2015) A prior study highlighted that only 100 mental health professionals, including psychiatrists and psychiatric nurses, were trained to deliver essential services, and alarmingly, only 20% of these professionals continue to work in the field, leaving over 15 million people underserved.

The Cambodian mental health system faces significant challenges, including a shortage of trained professionals and limited community awareness about mental health issues Additionally, the uncertain allocation of budgets for mental health priorities hampers the effective identification and management of mental health problems, especially in children.

Non-governmental organizations (NGOs) offer some mental health services; however, these are typically short-term programs reliant on funding from international donors Consequently, their services often focus on specific mental health issues prioritized by these funders.

Mental health services for children remain severely lacking in both private and public institutions A 2005 WHO mapping exercise revealed a significant absence of child mental health specialists, and subsequent years have shown little improvement Additionally, there is a notable lack of nationally representative epidemiologic studies on this critical issue.

Cambodian child mental health, several studies point to the potential magnitude of mental morbidity among young people in Cambodia and

4 provide evidence of the imperative to respond to this developing need

Mental health literacy in Cambodia is recognized to be low, with no prior studies confirming this observation This lack of understanding, coupled with a heavy reliance on medication, presents significant challenges in alleviating the burden of mental disorders in the country.

2015 ”) Khmer cultural explanations for mental illness originate from

Buddhist-Hindu beliefs, along with a focus on spirits, luck, and astrology, often lead individuals to seek help through formal health systems only when traditional methods fail (Schunert et al., 2012) Poor mental health literacy fosters stigmatizing attitudes and discrimination against mental illness, contributing to a lack of understanding that many mental disorders are treatable High-profile cases reveal that individuals with mental health issues are often neglected, abused, or isolated by their families and communities Additionally, the failure to recognize early signs of mental health problems delays necessary treatment.

Statement of the Problem

Timely prevention, early identification, and effective intervention can significantly reduce adverse mental health outcomes, particularly in low- and middle-income countries (LMICs) where treatment resources are scarce (Hawton et al., 2012) The potential benefits of these strategies for improving mental health outcomes in children and adolescents are considerable Consequently, there is an urgent need for more research to enhance mental health promotion, facilitate early detection of mental health issues, and create effective interventions for children facing mental health challenges (Levav & Rutz).

Promoting positive mental health and early identification of mental health disorders in low- and middle-income countries (LMICs) can lead to timely diagnoses and effective treatments for young individuals This proactive approach not only helps prevent the escalation of serious mental health issues but also enhances the long-term outcomes for these youth.

& Wilson, 2010; Kutcher, Wei, Mcluckie, & Bullock, 2013; Lund et al.,

In low- and middle-income countries (LMICs) like Cambodia, the scarcity of mental health treatment options highlights the significant potential of a comprehensive prevention and treatment system, as advocated by the U.S Institute of Medicine (IOM, 2009) A public health approach should implement multi-tiered programming that includes universal, selective, and indicated interventions aimed at entire populations, at-risk groups, and individuals displaying signs of mental health disorders These interventions should focus on fostering protective environments for children across various settings, including family, school, and community.

Schools play a vital role in promoting mental health, providing prevention and early intervention services to a large number of children in the community while reducing stigma associated with traditional health services Comprehensive early education programs, effective classroom management strategies, and targeted interventions for issues like anxiety, depression, and post-traumatic stress disorder have demonstrated positive outcomes in a cost-effective way across diverse settings and populations.

In various low- and middle-income countries (LMICs) like Vietnam, teachers are being utilized as a vital resource for promoting early mental health education, identifying issues, and implementing interventions This approach highlights the significant role educators play in supporting student mental well-being and underscores the importance of integrating mental health initiatives within school systems.

A strong and trusting relationship between teachers and students serves as a vital resource for individual students, enabling them to access essential support services This connection is particularly important for identifying distressed students and facilitating timely referrals to specialist treatment, ultimately enhancing their well-being and academic success.

The strong relationship between teachers and students can play a crucial role in promoting mental wellbeing and reducing the stigma associated with mental illness Recognized and respected within their communities, teachers can effectively convey the importance of mental health This connection presents a valuable opportunity to provide mental health services to adolescents, particularly in communities with limited resources (Goel, 2011; Langeveld et al., 2011; Dang et al., 2017; Greenwood, 2008; Miller-Lewis et al., 2014).

Research indicates that enhancing teachers' mental health literacy significantly correlates with their ability to identify and support students facing mental health challenges, ultimately promoting long-term child wellbeing Implementing a school-wide mental health literacy program can serve as a universal prevention intervention, aimed at reducing stigma and improving knowledge about mental health among both students and teachers This approach is expected to foster resilience, create supportive environments, and facilitate early intervention.

Identification and early intervention for students requiring higher-level support is essential, as highlighted by Riebschleger et al (2017) Such programs should be integrated into a broader support system rather than functioning in isolation Enhancing mental health literacy among both youth and the adults who engage with them is crucial for improving access to treatment, reducing stigma, and encouraging students to seek help In low- and middle-income countries (LMIC), there is a pressing need for more research focused on developing and evaluating comprehensive prevention frameworks, moving beyond the current emphasis on individual mental health treatments.

Within schools in Cambodia, although poorly documented, both student and teacher mental health literacy is thought to be very low

There is a significant shortage of research focused on the development and evaluation of school-based mental health interventions for children In environments where there are considerable gaps in mental health treatment for youth and a scarcity of evidence-based services within schools, it is essential to conduct research aimed at creating and assessing preventive interventions that enhance mental health support for children and adolescents.

Objectives of the Study

This study aimed to assess an evidence-based mental health literacy (MHL) intervention for both students and teachers The first objective was to characterize the baseline MHL levels among teachers and students, considering factors such as teacher sex, education, and teaching experience, as well as student age, sex, and grade The second objective focused on evaluating the effectiveness of a mental health literacy training program, where teachers received initial training and subsequently taught a curriculum to their students, measuring the impacts on mental health knowledge for both teachers and students.

8 attitudes, as well as potential moderators of intervention impact, were assessed.

Research Questions and Hypotheses

In this study, we aim to answer seven questions as identified as below:

1 What are the baseline measures of MH knowledge, attitudes and beliefs across secondary and high school teachers? Are these baseline measures influenced by gender, educational background and teacher experience?

2 Does Mental Health Literacy (MHL) Training increase teachers’ knowledge, beliefs, and attitudes toward mental illness as measured post training?

3 Are changes in teachers’ MH knowledge, beliefs and attitudes influenced by the variables of gender, education and experience of teaching?

4 What are the baseline measures of students’ MH knowledge and attitudes across students in High school (grade 7, 8, 10, and 11)? Are these baseline measures influenced by age, sex, and grade?

5 Does a mental health literacy program, taught by teachers an hour per week for six weeks, lead to an increase in students’ MH knowledge and attitudes?

6 Are changes in students’ MH knowledge and attitudes influenced by age, gender, and education (grade)?

7 Is the Guide-VN culturally feasible and acceptable for the Cambodian classroom context?

1 Hypothesis 1: Teachers will have low baseline MH knowledge, and negative attitudes and beliefs about mental illness; these will vary by gender, level of education, and teaching experience

2 Hypothesis 2: Mental health literacy training will increase teachers’

MH knowledge and improve attitudes toward mental illness relative to a control group

3 Hypothesis 3: Demographic characteristics such as gender, education and experience of teaching will moderate the impact of the MHL training on teacher outcomes

4 Hypothesis 4: Students will have low baseline mental health knowledge, more negative attitudes, and their knowledge; attitudes will vary by age, sex, and grade

5 Hypothesis 5: Mental health literacy training for students will increase students’ MH knowledge and improve attitudes toward mental illness relative to a control group

6 Hypothesis 6: Demographic characteristics such as age, gender and education (grade) will moderate the impact of the MHL training on teacher outcomes

7 Hypothesis 7: The Guide-VN MHL intervention will be feasible for Cambodian teachers to implement and acceptable within the

Significance of the Study

This pioneering school-based mental health literacy (MHL) study in Cambodia gathered essential primary data on the knowledge, attitudes, and beliefs of secondary and high school teachers and students Additionally, the project evaluated a locally adapted MHL intervention, contributing valuable insights to the field.

A pilot randomized controlled trial in Cambodian high schools demonstrates the feasibility, acceptability, and effectiveness of a new intervention, offering valuable insights for future adaptations to enhance its impact This project is expected to lay the groundwork for a comprehensive follow-up evaluation of the adapted curriculum's effectiveness in Cambodia.

Mental Health literacy in Low-Middle Income Countries

Inadequate understanding and negative perceptions of mental health and mental illness pose significant challenges globally, particularly in low- and middle-income countries (LMIC) This study emphasizes the urgent need to address the limited awareness regarding the nature and causes of mental disorders, as well as the available resources for seeking help, which is notably lacking in many LMICs.

Explanatory models that do not align with available mental health services can significantly affect how individuals with mental illness seek help and are treated in their communities Even when mental health services exist, they may remain underutilized if the public lacks understanding of how to access them This issue is particularly critical in low- and middle-income countries (LMIC), where mental health services are scarce, and factors such as poverty and conflict exacerbate the prevalence of mental illness Therefore, it is essential to study mental health literacy in LMICs rather than applying existing models from other contexts without further research Cultural influences shape how communities understand and interpret mental illness, making it vital for efforts to enhance mental health knowledge to consider local cultural explanations and service frameworks for effective integration of new care models.

Calls for improving public mental health literacy are prevalent in the literature addressing the expansion of mental health care in low- and middle-income countries (LMIC) A systematic review conducted in Pakistan revealed a significant lack of knowledge regarding mental disorders and their treatments This highlights the urgent need to enhance mental health literacy to foster greater societal acceptance and utilization of evidence-based mental health care.

In Afghanistan, children have grown up in an environment devoid of peace, significantly increasing their risk of developing mental health issues such as PTSD, anxiety, and depression Access to mental health care remains severely limited, compounding these challenges Additionally, low mental health literacy (MHL) has been recognized as a critical barrier to addressing child mental health effectively.

In Bangladesh, up to 25% of children suffer from mental health issues, with those from low educational backgrounds and remote areas facing significant barriers to care (Hossain et al., 2014; Uddin et al., 2019; WHO, 2019) Similarly, despite its rapid economic growth, China exhibits low mental health literacy, revealing that access to care is not solely dependent on availability but also on cultural perceptions and motivation to seek professional help, as many opt for traditional remedies instead (Huang et al., 2019; Wong et al., 2017) In Cambodia, the lingering effects of war and poverty contribute to high rates of mental health problems, compounded by stigma, low mental health literacy, and cultural diversity, which hinder access to necessary care (Jegannathan et al., 2015; Jong, 2002; Parry & Wilkinson, 2020).

In the following sections, the construct of mental health literacy as used in this study is further defined in terms of a conceptual framework The

13 literature on each component of this conceptual framework is then examined separately, with discussion of findings from both high-income countries

(where the majority of work has been carried out), and from LMIC

Specifically, this also includes a section discussing cultural and religious influences on knowledge and attitudes toward mental illness.

Conceptual Framework of Mental Health Literacy

Mental Health Literacy (MHL) is a crucial construct derived from health literacy, encompassing key components that can be targeted for intervention, such as recognizing mental health issues, understanding mental health knowledge, and fostering positive attitudes towards mental health conditions (Jorm, 1997 & 2000; O’Connor et al., 2014) Jorm (1997) defined MHL as the knowledge and beliefs about mental disorders that facilitate their recognition, management, or prevention MHL has since evolved to include the ability to identify mental disorders, understand risk factors, recognize self-help strategies and professional support, promote positive attitudes for recognizing mental health disorders, and access mental health information (Jorm, 2012) More recent frameworks by Kutcher and colleagues emphasize the importance of maintaining positive mental health, understanding mental disorders and treatments, reducing stigma, enhancing help-seeking efficacy, and developing competencies for improved mental health care and self-management (Kutcher, Bagnell, & Wei, 2015).

Mental health literacy (MHL) encompasses essential elements crucial for recognizing and addressing mental health issues (Langeveld et al., 2011; Wei & Kutcher, 2014) Recognized as a foundational component for promoting mental health, MHL is particularly significant in school environments (Jorm, 2012; Kutcher et al., 2015; Reavley & Jorm, 2011).

As is described further in the following sections, MHL

MHL training aims to enhance mental health knowledge, which is essential for fostering positive attitudes and beliefs This knowledge enables individuals to recognize when help is needed and understand how to seek it, while also reducing stigma associated with mental health issues The intervention posits that increasing awareness of mental health signs, symptoms, and the impact of mental illness will lead to improved attitudes and self-efficacy in seeking help Ultimately, these improvements are expected to translate into actual behaviors, such as recognizing mental health problems in oneself or others and fostering supportive interactions with individuals facing mental health challenges.

For this paper, we considered the definition of MHL as provided by Kutcher et al (2015) to reflect the key elements of knowledge, attitudes, and

Fifteen beliefs about mental health highlight the importance of mental health literacy (MHL) and its connection to stigma According to SAMHSA (2004), stigma encompasses negative attitudes and beliefs that lead the public to fear, reject, avoid, and discriminate against individuals with mental illness This stigma significantly impacts help-seeking behaviors, emphasizing the need to address these misconceptions to promote understanding and support for mental health issues.

SAMHSA (2004) highlights that the stigma and discrimination associated with mental health issues deter individuals and their families from seeking necessary assistance Consequently, help-seeking self-efficacy, which encompasses the ability to recognize when and where to seek help and to enhance mental health care and self-management skills, is an essential component of the current study's conceptual framework This self-efficacy is influenced by increased knowledge and reduced negative perceptions about mental health, although the study did not measure actual help-seeking behaviors.

The table1 below outlined how the different measures were mapped onto the conceptual framework (knowledge, attitudes and beliefs

Table 1 The conceptual framework and measures relationship

❖ Mental Health Literacy Scale (MHLS) sub-scale2:

Mental health help-seeking/self- efficacy sub-scale3:

Stigma/negative attitudes toward mental illness sub-scale4:

Willingness to interact with people with mental illness

❖ Beliefs Toward Mental Illness (BMI) sub-scale1:

Dangerousness sub-scale2: Poor interpersonal sub-scale3: Social skills, Incurability

Mental health knowledge encompasses the awareness and understanding of various mental health conditions It is a crucial aspect of mental health literacy (MHL) According to Kutcher (2015), mental health knowledge involves recognizing the signs and symptoms of mental health issues and knowing how to respond appropriately.

Maintaining positive mental health involves understanding mental health issues and knowing when and where to seek help It is essential to develop competencies that enhance self-management and mental health care Mental health knowledge encompasses understanding the causes of mental disorders, recognizing signs and symptoms, knowing the treatability of mental illnesses, and understanding their potential impact on social skills This knowledge is crucial for effective mental health promotion and intervention, particularly for early identification and treatment in everyday environments like schools.

2.1.1 General Population Recognition of Mental Health Problems

Mental health disorders frequently go unrecognized and untreated for extended periods, resulting in worsened outcomes, increased relapses, and higher mortality risks A systematic review of 37 studies highlighted significant treatment gaps across various disorders, with severe conditions like schizophrenia having a lower treatment gap of 32.2%, while common disorders such as depression (56.3%), dysthymia (56.0%), and anxiety (57.5%) exhibited much higher gaps Substance-related disorders, particularly alcohol abuse and dependence, showed the highest treatment gap at 78.1% (Kohn et al., 2004) Additionally, Drancourt et al (2013) found that untreated mental health issues, particularly mood disorders, could persist for an average of eight years, with mood disorders often remaining untreated for 13 to 15 years.

A study conducted in Australia revealed that individuals diagnosed with anxiety and mood disorders, including depression and bipolar disorder, took an average of nearly seven years to recognize their conditions (Drancourt et al., 2013) This highlights the significant delay in awareness and diagnosis for mental health issues.

1.3 years between recognition of the problems and actually seeking help (Thompson et al., 2008) A population study (N12), using case vignettes to measure mental health literacy regarding depression, dementia, and schizophrenia revealed about 63% of the sample could identify symptoms of dementia, 55.2% could identify depression, and only 11.5% were able to identify symptoms of schizophrenia from the case vignettes (Barney et al.,

Disorder recognition varies by context and type, with Americans generally more adept at identifying mental health issues; however, significant disparities exist among different conditions A study involving 1,104 American adolescents revealed that while 40% could accurately identify depression, only 1% recognized social anxiety disorder as social phobia or social anxiety (Coles et al., 2016).

A study of 1,393 American adults revealed that approximately 60% could accurately recognize depression, while only 42% identified ADHD (Bernice A Pescosolido et al., 2008) In Canada, recognition of mental health issues was higher, with nearly 70% of 1,004 Canadian adults able to identify disorders such as depression (80%), schizophrenia (50%-60%), and anxiety (50%) (Marcus & Westra, 2012) Similarly, a survey of 370 British young people aged 17-22 showed a strong ability to identify various mental health problems, particularly addiction (65.1%-87.4%) and anorexia (55.8%-81.3%), with lower recognition rates for conditions like bipolar disorder (14.2%-46.2%) and social phobia (10.5%-30.2%) (Furnham et al., 2014) In stark contrast, only about 12.5% of 650 Saudi adults recognized mental health issues, and nearly 60% held negative perceptions about mental illness (Abolfotouh et al., 2019).

A study involving 4,938 Portuguese youth aged 14-24 revealed that only 27.2% could recognize depression in a vignette, with just 5.5% identifying it as a mental disorder; many misclassified it as stress (47.3%), emotional issues (40.8%), or a nervous breakdown (33.8%) (Loureiro et al., 2013) Although recognition of schizophrenia was slightly better, it was still accurately identified by less than half (42.2%), while psychosis was recognized by only 22.2% (Loureiro et al., 2014) In Sweden, a survey of 368 adults aged 20-64 indicated that 66% failed to recognize depression, often mislabeling it as stress or a routine problem (Dahlberg et al.).

2008) Amongst 426 Sweden adolescents, 42.7% and 34.7% could identify depression and schizophrenia (Melas et al., 2013)

A qualitative study involving Hmong, Cambodian, and Thai immigrants in the US highlighted a significant lack of recognition and understanding of depression, primarily due to the absence of a clear definition for the condition (H Lee et al., 2010) Additionally, a non-systematic review of literature in Singapore uncovered a substantial gap in mental health knowledge among the population, revealing that many individuals struggled to identify mental disorders and harbored negative attitudes toward mental illness, which hindered their willingness to seek professional help.

A cross-cultural study involving 440 participants from Britain, Hong Kong, and Malaysia revealed that British individuals excelled in accurately identifying psychiatric diagnoses for conditions such as OCD, schizophrenia, depression, ADHD, childhood depression, and bipolar disorder, with Hong Kong citizens and Malaysians following behind (Tonsing, 2018; Loo et al., 2012) In contrast, a study of 916 Indian adolescents indicated a concerningly low level of mental health literacy, with only 29% able to correctly identify depression and a mere 1.3% recognizing schizophrenia (Ogorchukwu et al.).

2016) In Philippines, amongst 797 first year Filipino college students, 55.2%

20 could identify depression in a given vignette (Ines, 2019) A cross-sectional study involving 285 Nigerian adolescents showed that only 4.8% could correctly identify depression in a vignette (Deborah, Anyachebelu, Anosike,

Meaning of MHL in MH Problem’s Prevention and Early Intervention

Research indicates that attitudes toward mental illness are influenced by culturally specific knowledge and beliefs regarding its causes and effects Consequently, effective prevention and early intervention strategies must address not only structural barriers, like limited service availability, but also the cultural norms and beliefs that hinder recognition, help-seeking, and support for individuals facing mental health issues This underscores the essential importance of understanding cultural contexts in mental health initiatives.

Literacy is essential for enhancing mental health services and support, as various strategies exist to prevent mental, emotional, and behavioral disorders These strategies include mental health promotion interventions, universal preventive interventions, selective preventive interventions, and indicated preventive interventions, which are crucial components of the mental health intervention spectrum (IOM, 2009) Interventions can be implemented in diverse settings such as schools, homes, community agencies, and healthcare facilities, with the goal of improving individuals' developmental competence, mental well-being, social inclusion, and resilience These approaches are particularly beneficial for populations not identified by individual risk factors and are cost-effective, making them suitable for low- and middle-income countries (LMICs) For instance, integrating mental health promotion into school systems serves as an effective strategy, reaching a broad audience, including students and teachers Additionally, universal preventive interventions are advantageous due to their low costs and high acceptability among the population.

Preventive interventions are essential for the early identification of mental disorders and the promotion of mental health treatment, forming a critical part of a comprehensive mental health system Research indicates that promotion and prevention programs that enable timely diagnosis and early intervention at any stage of mental illness can lead to significant improvements in individual well-being, yield positive outcomes for youth, and prove to be cost-effective for communities.

Failure to intervene can result in severe and expensive outcomes, including diminished academic performance, increased dropout rates, strained family dynamics, and potential involvement with child welfare or juvenile justice systems Additionally, it may lead to substance abuse and engagement in risky behaviors.

A report by the National Research Council (2009) highlighted that the cost of mental health care services for young people in the United States is approximately $247 billion However, the lack of intervention for this demographic could lead to significantly greater personal, social, and economic repercussions for society (O’Connell et al., 2009).

3.2 Promotion and Prevention to Mental Health Care

Research shows that focusing on mental health care for children and adolescents offers the best opportunities for preventing mental disorders This proactive approach not only yields significant long-term benefits for various aspects of functioning but also generates substantial social and economic advantages.

& Wells, 1997; Jané-llopis et al., 2003; Kessler et al., 2007; Kutcher et al.,

Early intervention for children with autism spectrum disorder (ASD) has been shown to significantly enhance IQ and adaptive behavior (Dawson et al., 2010) Despite the availability of various mental health programs, a limited number of youth actually seek professional help, with studies indicating that 60 to 90 percent of adolescents with mental health issues do not receive the necessary treatment (Chandra & Minkovitz, 2006; David et al., 2008) Key challenges in accessing adolescent mental health services include a shortage of qualified professionals and a lack of capacity and motivation among non-experts to deliver effective care.

35 people, lack of funding, policies and regulations, family background systems, and, as described above, the stigma associated with mental disorders (Chandra

& Minkovitz, 2006; Chen et al., 2014; Clement et al., 2015; Ndetei et al., 2016; Parcesepe & Cabassa, 2013; V Patel et al., 2007; Pescosolido, Perry, Martin, McLeod, & Jensen, 2007; Rickwood, Mazzer, & Telford, 2015; Sercu

To effectively address mental health treatment barriers in low- and middle-income countries (LMICs), it is crucial to implement prevention and promotion programs targeting children and adolescents Schools serve as an ideal platform for these initiatives, as they can efficiently reach a wide audience of students while remaining cost-effective.

A meta-analysis of 29 studies highlights that school-based mental health prevention and intervention programs effectively reduce the early onset of mental health disorders and alleviate persistent symptoms in children and adolescents (Reddy et al., 2009) Research indicates that teachers are willing to support students facing mental health challenges, and they play a crucial role in fostering a positive, safe, and friendly environment while teaching mental health education and recognizing students’ concerns (Mazzer & Rickwood, 2015) Furthermore, studies show that professional development for teachers significantly enhances their knowledge, beliefs, and abilities to identify and support students with mental health issues, facilitating appropriate referrals for professional help (Jorm et al., 2010; Kirchner et al., 2000; Koller & Bertel).

In their 2013 review of school mental health interventions, Barry and colleagues identified 22 evaluation studies, including 14 focused on school intervention programs and seven employing experimental designs Most of these experimental designs aimed to assess the effectiveness of these interventions.

Research highlights the significance of school-based interventions that enhance social, emotional, and problem-solving skills in adolescents, rather than just focusing on mental health improvement Evidence suggests that multicomponent strategies can effectively influence youth mental health and social wellbeing (Barry, Clarke, Jenkins, & Patel, 2013; Weare & Nind, 2011).

A comprehensive prevention model, such as the one proposed by the Institute of Medicine (IOM, 2009), provides a vital framework for alleviating the impact of mental, emotional, and behavioral disorders on the healthy development of children and adolescents In low- and middle-income countries (LMIC), where treatment resources are often scarce, prioritizing prevention and early intervention strategies is essential to mitigate the adverse effects of mental illness on youth, enhance their developmental pathways, and optimize the use of limited resources.

3.3 Promotion and Prevention Mental Health Problems in School Setting

Strengthening existing resources and targeting environments such as schools, health centers, and community programs for at-risk children can significantly reduce mental health issues (Barry et al., 2013; Fazel, Patel, et al., 2014) Kieling et al (2011) emphasize that integrating new interventions into established services may offer a more sustainable approach than creating entirely new models A systematic review indicates that promoting mental health in schools yields positive long-term outcomes (Wells, Barlow, & Stewart-Brown, 2003) In the U.S., the Multi-Tiered System of Supports (MTSS) is recognized as a best practice for addressing diverse needs among school-aged children Aligned with IOM (2009) guidelines, the MTSS framework includes three tiers of prevention: primary, secondary, and tertiary.

Tier 1, or primary prevention, ensures that all students receive essential academic and behavioral support, including the teaching of expected behaviors, implementation of evidence-based academic strategies, and initiatives to enhance school climate, which are designed to meet the needs of approximately 80% of students For those with higher needs, secondary and tertiary prevention strategies are employed, addressing about 15% and 5% of students, respectively By providing varying levels of interventions and supports, educators aim to foster academic and behavioral success for every student The integration of a multi-tiered framework in schools creates a comprehensive system dedicated to supporting all children effectively.

The MHL program serves as a Tier 1 support initiative designed to foster a more accepting and positive school environment while addressing student mental health needs Although the MHL curriculum plays a crucial role in reducing stigma and enhancing awareness of mental health issues, it is insufficient on its own to drive meaningful change To optimize its effectiveness, the MHL curriculum should be integrated into a Multi-Tiered System of Supports (MTSS) framework, which is better equipped to address the diverse mental health requirements of students However, the development of a comprehensive MTSS model in Cambodia faces challenges, including limited human resources, budget constraints, insufficient political support, and cultural differences compared to the US.

Role of Teachers in Management of Mental Health Problems

Teachers play a crucial role in fostering student learning and development, as they have the opportunity to observe and engage with students over extended periods Research indicates that active involvement from teachers is essential in providing the necessary support for students to thrive academically and personally.

39 with mental health problems Kutcher, et al., 2015; Parikh et al., 2016; Woods,

Teachers see supporting students with mental health problems as part of their professional role (Herman et al., 2009; Reinke et al., 2011; Van

Research indicates that educators often feel unprepared to handle mental health issues among students due to a lack of knowledge and skills For instance, a study revealed that nearly half of surveyed teachers were unfamiliar with the term "evidence-based practice," highlighting significant gaps in understanding effective interventions In a Canadian study involving 75 secondary school teachers, while participants acknowledged their responsibility to support students with mental health challenges, many admitted to lacking essential knowledge in this area Although almost all teachers recognized the importance of responding to mental health concerns, only 36% felt confident in their ability to address these issues effectively.

A review of the literature highlights that while teachers are eager to support students with mental health issues, they often feel stressed and underprepared due to a lack of experience in identifying problems and the necessary skills to respond effectively Research by Rothì, Leavey, and Best (2008) further reveals that teachers frequently feel incapable of managing mental health challenges in their students.

Many individuals lack the specific training needed to identify mental health issues, often leading to confusion regarding the terminology used by Child and Adolescent Mental Health Services.

Teacher ability to identify and respond to student needs varies based on the type of problem presented Research by Loades & Mastroyannopoulou (2010) indicates that while teachers can discern the severity of issues from vignettes, they excel more in recognizing clinical symptoms of behavioral disorders than emotional disorders This aligns with Meltzer et al (2003), which found that teachers were more adept at identifying emotional disorders in girls compared to boys Additionally, studies by Jackson & King (2004) and Undheim et al (2016) reveal that teachers are more proficient in classifying externalizing issues like ADHD and conduct disorder rather than internalizing problems Even when teachers can identify mental health issues, concerns about the validity of their assessments persist, and many are unsure how to respond appropriately A study in Nigeria by Ibeziako et al (2009) highlighted that teachers could recognize common mental health problems in children and understand their underlying causes through focus group interviews.

A study conducted in England and Italy indicates that most secondary school teachers can recognize psychotic symptoms and understand their causes, prognosis, and recovery factors However, the research highlights a significant limitation in the teachers' awareness regarding their roles and the appropriate referral pathways for students in need (Lucas et al., 2009; Masillo et al., 2012).

Low teacher mental health literacy not only presents a missed opportunity to intervene, but can also create further challenges for struggling

A study by Bella, Omigbodun, & Atilola (2011) revealed that teachers' inability to identify students with mental health issues can lead to emotional stress and foster negative attitudes towards these children Additionally, the negative perceptions educators have about mental illness can further obstruct treatment efforts, as highlighted in research by Parikh et al.

A 2016 study revealed that Indian secondary and high school teachers possess inadequate knowledge and negative attitudes toward students with mental illness The research involved face-to-face sessions with 520 teachers, utilizing structured questionnaires with 25 items to assess their understanding and perceptions of mental health issues Findings indicated that teachers struggled to identify mental health problems when presented with vignettes, with very few able to correctly answer questions about five common mental illnesses, and a significant percentage failing to answer any questions accurately regarding mental health.

Mental health literacy training has proven effective in enhancing teachers' skills and abilities, as evidenced by studies (Kutcher et al., 2015; Kutcher, Wei, Gilberds et al., 2016) Despite limited research, existing evidence indicates that teachers are confident that such training will improve their knowledge, skills, and self-efficacy in supporting students with mental health concerns (Graham, Phelps).

A review by Whitley et al (2013) highlights the limited research on educators' values, beliefs, and attitudes towards mental health issues in the classroom This gap in mental health literacy among teachers is underscored by earlier studies, such as those conducted by Parikh et al in India, which further emphasize the need for improved understanding and awareness in educational settings.

(2016) revealed lower education has a significant impact on mental health

Research indicates that low mental health literacy contributes to negative attitudes and increased fear of individuals with mental illness, leading to social distancing However, training programs have demonstrated effectiveness in enhancing mental health literacy among educators Studies evaluating the impact of the Guide for teacher mental health literacy training in Canada, as well as its adaptations in Tanzania and Malawi, revealed significant improvements in knowledge about mental health issues, reduced stigma, and increased willingness to seek help (Kutcher, Bagnell, & Wei, 2015; Kutcher et al.).

A study conducted in Norway revealed that involvement in a mental health literacy program or information campaign significantly improves the identification of psychotic cases and fosters a more positive outlook on the outcomes of properly treated psychosis (Langeveld et al., 2011).

Teachers play a crucial role in promoting children's mental health and well-being, serving as essential resources within school environments By undergoing mental health literacy training, educators can enhance their understanding and attitudes toward mental health, thereby reducing stigma and misconceptions surrounding mental illness Equipping teachers with this knowledge significantly benefits children's mental health, enabling them to identify issues and provide timely, effective support Integrating mental health literacy programs into schools not only fosters a healthier environment for students but also proves to be a cost-effective strategy for overall well-being.

Review Literature Supporting MHL Intervention in School Setting

Scholarly literature frequently explores various aspects of mental health literacy (MHL) that can be targeted for intervention, while also evaluating the responses of different populations to programs aimed at enhancing MHL Research predominantly focuses on the impact of these interventions on knowledge, stigma reduction, and awareness, with findings suggesting that these elements of mental health literacy can positively change (Wei et al., 2014) Studies on mental health literacy have been conducted across diverse contexts, including various communities (Anthony F Jorm).

Research indicates that mental health interventions within school environments significantly enhance the mental health literacy of teachers (Yoshioka et al., 2014; Mazzer & Rickwood, 2015) These interventions are generally recognized as effective in improving mental health literacy among university students and school populations, highlighting their importance in educational settings.

Evidence-based practices are essential for enhancing knowledge and attitudes in educational settings, as highlighted by various studies (Kutcher et al., 2015; 2016) A review of existing literature emphasizes the critical role of mental health literacy (MHL) in preventing, identifying, and addressing mental health issues within schools This research demonstrates that fostering mental health literacy, coupled with ongoing support and training for educators, significantly contributes to the long-term promotion of positive mental health in educational environments (Whitely et al., 2013).

Research indicates that school mental health interventions can effectively enhance adolescents' mental well-being A notable example is an Australian randomized controlled trial (RCT) of an 8-week mental health education program delivered by personal development, health, and physical education teachers, which resulted in improved student knowledge and attitudes regarding mental health.

A study in Norway implemented a 3-day training program for students, which resulted in increased knowledge about mental illness, improved attitudes, and enhanced help-seeking behaviors after a 6-month follow-up (Skre et al., 2013) Similarly, a cluster-RCT in the UK assessed a peer-led intervention aimed at reducing the stigma surrounding mental illness and promoting mental health literacy In this initiative, young individuals with mental health experiences served as teaching assistants, facilitating discussion sessions with students The findings indicated that this contact-based approach was effective in diminishing discrimination related to mental illness.

A study by Ojio et al (2012) assessed a two-session, 50-minute mental health literacy (MHL) training for secondary school students in Tokyo, revealing enhanced knowledge and positive attitudes towards mental illness The encouraging outcomes led to the implementation of mental health literacy programs in schools (Ojio et al., 2015) Additionally, a similar intervention aimed at improving teacher MHL was conducted in Portugal, focusing on two training sessions.

A study conducted by Campos et al (2014) involved an intervention consisting of 150-minute sessions held at one-week intervals The assessment of teachers' knowledge and attitudes before and after the intervention revealed a significant increase in their understanding of mental health, along with a notable reduction in stigmatizing attitudes towards mental illness.

Mental health literacy (MHL) trainings have shown significant positive outcomes in low- and middle-income countries (LMIC) In Malawi, a study evaluated teachers before and after a 3-day MHL training, revealing notable improvements in their understanding and attitudes towards mental illness (Kutcher et al., 2015) Similarly, a study conducted in Haiti found that after a two-and-a-half-day MHL training, teachers also reported enhanced knowledge and attitudes, although they expressed a desire for further support and resources.

Extending the length of training sessions is crucial for enhancing teachers' mental health literacy, as highlighted by Eustache et al (2017) Imran et al (2018) conducted a randomized control trial with Pakistani teachers using the WHO-School Mental Health Manual, demonstrating that a three-session intervention effectively improved teachers' mental health literacy This study supports the notion that the WHO-EMRO intervention is a practical and low-cost method for building teachers' capacity in mental health Additionally, research by Kutcher et al (2013, 2016) and Wei et al (2014) indicates that mental health literacy training significantly enhances teachers' understanding and attitudes towards mental health issues Notably, Kutcher et al (2016) adapted a Canadian curriculum for Tanzanian teachers, resulting in significant improvements in their knowledge and a reduction in negative beliefs about mental illness.

(2013) to implement a one-day mental health literacy training session among

A training program involving 134 teachers significantly enhanced their knowledge and attitudes regarding mental illness The program effectively addressed the teachers' needs and notably boosted their confidence in managing students' mental health within the school environment.

Teacher-delivered trainings have also been shown to improve student- level outcomes in LMIC For example, Kutcher, et al., (2015) evaluated the

A classroom-based mental health literacy (MHL) intervention significantly enhanced students' school performance, mental health help-seeking behaviors, and social-emotional well-being Prior to the intervention, teachers underwent a week-long mental health training based on the AGMv format Post-intervention, approximately 70% of students approached teachers with mental health concerns, while 94% encouraged peers to seek help (Kutcher et al., 2015) A study by Kutcher et al (2015) revealed substantial improvements in students' knowledge and attitudes toward mental illness, which were sustained at a two-month follow-up (P < 0.001) These findings indicate that integrating MHL resources into classroom curricula can effectively boost student literacy on mental health issues Additionally, MHL training is instrumental in reducing stigma surrounding mental health disorders among students (Mcluckie et al., 2014; Milin et al., 2016; Wei et al., 2014) Wei et al (2014) found that students exhibited a notable decrease in stigmatizing beliefs about mental illness following a one-day teacher training course.

A randomized controlled trial (RCT) demonstrated that the Mental Health Literacy (MHL) curriculum resource significantly improved mental health literacy among students The study involved randomly assigning schools to either an intervention group, which received the MHL curriculum, or a control group The research included a total of 534 students, highlighting the effectiveness of the intervention in promoting better understanding of mental health issues.

A study involving 24 high schools revealed that approximately half of the participants received mental health literacy training from their teachers The intervention featured a comprehensive six-module curriculum spanning 4 to 8 weeks The evaluation of changes in mental health knowledge and attitudes toward mental illness was conducted over time, comparing intervention and control groups Results indicated that students who participated in the mental health program demonstrated significant improvements in both knowledge and stigma reduction regarding mental health issues.

A study by Milin et al (2016) found that students who participated in a curriculum focused on mental health exhibited more positive attitudes towards individuals with mental illness and possessed better mental health knowledge compared to a control group with no intervention Furthermore, research by McLuckie et al (2014) indicated that the positive effects observed in students persisted even two months after the initial exposure to the curriculum.

Current Study

The current research aims to expand the existing literature on mental health literacy training in schools by examining its application within the Cambodian context This study seeks to establish baseline measures of mental health literacy among students, contributing valuable insights to the understanding of knowledge and attitudes related to mental health in this region.

The study aims to evaluate the baseline measures of Cambodian teachers and assess the impact of an intervention on these metrics Cultural beliefs and values related to mental health and education may significantly influence the study's findings.

Currently, there is a lack of research on mental health literacy (MHL) in Cambodian schools, highlighting the need for teacher training due to the absence of school counselors It is crucial to explore how to create culturally sensitive MHL programs that can be effectively implemented within the Cambodian educational system.

6.1 Interpreting study findings in terms of causal inference

This project aims to enhance mental health literacy (MHL) research in Cambodia while addressing gaps in previous MHL intervention studies conducted in low- and middle-income countries (LMIC) A systematic review from 2013, which analyzed 27 articles on school-based MHL interventions for students in LMIC, revealed that many of these studies exhibited a risk of bias regarding their effectiveness in improving knowledge.

Many studies on attitudes and help-seeking behavior face significant limitations, such as the absence of randomization, inadequate control for confounding factors, and the lack of validated measures Most notably, these studies, particularly those conducted in low- and middle-income countries (LMIC), do not establish causal relationships, primarily due to the absence of control groups.

In scientific research, the efficacy of teachers' mental health literacy (MHL) training is defined as the ability to achieve desired outcomes through the training This implies that the methods used in MHL training directly relate to the actual causes of observed phenomena To establish causality, it is essential to operationalize outcomes, utilize valid and reliable measurement tools, and account for changes over time, such as pre- and post-training assessments Additionally, understanding what changes may have occurred without the intervention necessitates the inclusion of a control comparison This approach helps determine the efficacy of the intervention under optimal conditions.

Effectiveness studies assess how well an intervention works in real-world settings, contrasting with efficacy trials that focus on ideal conditions While often seen as opposing concepts, these trials actually exist on a continuum Key features for supporting effectiveness conclusions include real-world implementation, minimal exclusion criteria, and flexibility in intervention delivery This study advances effectiveness research by utilizing teacher implementers to deliver the intervention in actual classroom environments.

This study highlights the limitations of training and support available in a single school setting, which affects the generalizability of the findings Positioned between efficacy and effectiveness research, the study also faces challenges due to the lack of random allocation at the student level, restricting causal inferences related to the results.

Overview of Research Design

This study employed a randomized controlled trial design among teachers and a non-randomized controlled comparison for students to assess the impact of mental health literacy training The research aimed to evaluate a culturally adapted school-based mental health literacy program, originally developed in Canada, for Cambodian high schools Key objectives included adapting the program, assessing baseline mental health literacy among teachers and students, and comparing post-intervention literacy scores between those in the intervention and control groups The hypothesis was that participation in the intervention would lead to increased mental health literacy for both teachers and students.

Teachers were randomly assigned to either a mental health literacy training program or a control group without intervention Their mental health literacy was assessed before and after the training The effects of the training on students were also analyzed, with students assigned to intervention and control groups based on grade level to prevent contamination Additionally, four teachers who completed the training received an extra day of "train the trainer" instruction to enhance their teaching effectiveness.

51 intervention condition then participated in a 6-week classroom-based mental health training program delivered by these teachers Mental health literacy of students was evaluated before and after the intervention

1 Aim 1: evaluate whether baseline MHL scores vary according to participant demographics for a) teachers; and b) students

2 Aim 2: evaluate whether the MHL intervention significantly improved MHL scores relative to a control group for a) teachers; and b) students

3 Aim 3: evaluate whether intervention impacts were moderated by demographic characteristics for a) teachers and b) students

4 Aim 4: evaluate feasibility and acceptability of the Guide-VN as adapted to Cambodian context

2 nd assessment (Quiz, BMI MHLS)

1 st assessment (student evaluatioin- 36items

MH classroom application (1h/week for six modules)

2 nd assessment (student evaluatioin-36items

MHL Curriculum Guide Overview

The Mental Health Curriculum Guide features six modules aimed at enhancing teachers' classroom programs by improving students' mental health literacy Key areas covered include understanding mental health and illness, adolescents' experiences with mental disorders, strategies for addressing these issues, promoting help-seeking behavior, and emphasizing positive mental health The self-study module offers in-depth insights into common adolescent mental disorders and practical strategies for teachers Each module includes core materials, suitable for all students, and supplementary materials for those seeking further knowledge This comprehensive guide provides ready-to-use lesson plans, activities, and resources, all available at www.teenmentalhealth.org/curriculum.

In each module provides several key features include overview of module, learning objective, major concepts, teacher background, activity, and preparation (i.e., required materials to conduct for each activity)

Topic and key concepts of each module are described below:

Figure 3 Modules and major concepts

The stigma of mental illness

- Stigma acts a barrier to people seeking help for mental health problems and mental illness

- Learning the facts about mental illness can help dispel misconceptions and stigma

- People’s attitudes about mental illness can be positively influenced by exposure to accurate information

- We all have a responsibility to fight the stigma associated with mental illness

Understanding mental health and mental illness

- Everyone has mental health regardless of whether or not they have mental illness

- The brain controls our thinking, perceptions, emotions, physical activities, behaviour and provides us with cues about how to adopt our environment

- A mental illness is a heath condition arising from changes in usual brain functioning that causes person substantial difficulty in functioning

Mental illnesses arise from complex causes, including biological factors, making them similar to other health conditions Timely access to effective treatment is crucial, as it significantly improves outcomes for individuals facing mental health challenges.

- All mental illnesses reflect difficulties in thinking, perception, emotions, physical activities, behaviour

54 specific mental illness and signalling (response to environment)

- The exact cause of mental illness is not yet known, but complex interactions between a person’s biology and his environment are involved

- Like illnesses that affect other parts of the body, mental illnesses are treatable and the sooner people receive proper treatment and support, the better the outcomes

- Mental illnesses are diseases that affect many aspects of a person’s life

- With appropriate support and treatment, most people with a mental illness can function effectively in everyday life

- Getting help early increase the chance that a person will make a full recovery from mental illness

- Mental illnesses, like physical illnesses, can be effectively treated

Seeking help and finding support

- There are many ways of seeking help for mental health problems and mental illnesses, and resources are available within schools and within the community;

- Knowing the signs and symptoms of mental illness helps people know how to distinguish the normal ups and downs of life from something more serious

- Recovery from mental illness is possible, when a range of supports, beyond formal treatment, are available

- Everyone has mental health that can be supported and promoted, regardless of whether or not they also have a mental illness

The importance of positive mental health

- Positive coping strategies can help everyone maintain and enhance their mental health

- There are skills and strategies that we can learn to help us obtain and maintain good mental health.

Study Methods

In a study, teachers were randomly divided into two groups: an intervention group and a control group The intervention group underwent a two-day mental health literacy training and an additional day of "train the trainer" sessions to implement the guide in their classrooms Observations indicated that intervention teachers showed significant changes in knowledge, beliefs, and attitudes compared to the control group Students in grades 7 and 11 were assigned to the intervention group, receiving mental health literacy (MHL) interventions, while grades 8 and 10 were in the control group, following the standard curriculum The intervention students demonstrated notable improvements in knowledge and attitudes compared to their counterparts Descriptive analysis highlighted differences in mental health literacy based on demographic factors, and Analysis of Covariance (ANCOVA) was employed for both teacher and student data evaluation.

A study was conducted at a private high school in Phnom Penh, Cambodia, which aims to provide quality education and promote moral values for underprivileged children The school offers a comprehensive education program from kindergarten through high school, enrolling approximately 1,300 students across two classes per grade, each with 45 to 50 students With around 108 full-time and part-time staff members, the Catholic institution maintains an educational environment similar to both public and private schools, despite having a more selective enrollment process Students are required to apply and undergo interviews based on specific selection criteria, with a focus on those from impoverished backgrounds who may not have the means to attend other educational institutions.

In this study, teacher participants were randomly assigned to either the intervention or control group based on the evenness of their consent form numbers, with intervention teachers receiving training in mental health literacy curriculum Four teachers were specifically selected and trained to implement the curriculum in classrooms, a decision made in consultation with the school director to ensure alignment with governmental requirements for English, Library, and Khmer language classes The control group consisted of teachers on a waiting list who did not receive any intervention Additionally, purposeful sampling was employed for student selection, with careful grade-based assignments to minimize spill-over effects.

In a recent study, 57 students in grades 11 and 8 students in grade 10 were designated to an intervention group and a waiting list, respectively The intervention group participated in six module sessions led by their regular classroom teachers, while the control group did not receive any intervention.

A total of 100 staff were contacted for recruitment N = 73

(intervention: n = 36; control: n = 37) consented and returned the baseline assessment Of those, 67 provided complete data for analysis (intervention: n

= 34, 94%; control: n = 33, 89%); reasons for staff loss to follow up were unrelated to the project (e.g., change of employment) Students from grade 7,

8, 10 and 11 were invited to participate in the study Students at grade 7 and

In this study, 11 students were assigned to the intervention group, which received mental health literacy training from their usual classroom teachers, while students in grades 8 and 10 were placed in the control group, either on a waitlist or not receiving any intervention At baseline, a total of 302 students completed the assessment (158 in the intervention group and 144 in the control group) Ultimately, 275 students (145 from the intervention group and 130 from the control group) provided data for analysis, after excluding 27 students due to mismatched assessments between Time 1 (T1) and Time 2 (T2).

2.3.2 MHL Intervention for Teachers and Students

To enhance teachers' mental health literacy and support the implementation of the Mental Health Curriculum Guide, a two-day face-to-face training was conducted by a researcher and clinical psychologist with over ten years of experience in the mental health field This training aimed to improve mental health literacy and offer specific guidance for effectively integrating the Mental Health Curriculum Guide into classroom settings The content of the training was designed to align with best practices in mental health education.

The Mental Health Curriculum Guide consists of six modules that delve into essential concepts of adolescent mental health The training covers the context of mental health in adolescents, the connection between brain function and mental well-being, and specific concepts related to mental disorders It also clarifies psychological terms, differentiating between stress and distress, classifies mental disorders, addresses the stigma surrounding mental illness, and provides an overview of how to effectively implement the Guide in the classroom.

During the 3-day training process, various teaching methods were employed, including case studies, group discussions, group reflections, and PowerPoint presentations A total of ten case studies were developed, covering mental health topics such as schizophrenia, depression, bipolar mood disorder, social anxiety, general anxiety, panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, eating disorders, and attention deficit disorder.

Hyperactivity Disorder Case studies were adapted from existing case studies developed by senior psychiatric consultant Dr Sotheara Chhim, TPO

The Executive Director facilitated interactive learning through various discussion formats, including small group discussions and self-reflection, to enhance understanding of adolescent mental health Participants engaged in case studies to identify symptoms and determine appropriate support and treatment strategies Teachers collaborated in pairs to share their knowledge on mental health, focusing on its definition, recognition of mental health issues, and community perceptions This was followed by a comprehensive presentation on the relationship between brain function and mental health, delivered by the trainer Additionally, teachers were organized into small groups to analyze case studies, pinpointing signs and symptoms, contributing factors, and potential solutions.

The training program focused on enhancing participants' knowledge and attitudes towards mental illness through engaging discussions and video clips depicting youth experiences Trainers utilized slide presentations to support these discussions, addressing common myths and facts about mental health Emphasizing dynamic teaching strategies, the program aimed to equip educators with practical methods for implementing the Mental Health Curriculum Guide in their classrooms Each participant received a copy of the guide, a teacher self-study module, and training materials from the two-day workshop.

The four teachers assigned to implement the Mental Health Curriculum Guide participated in a one-day training session aimed at enhancing their understanding of the materials and accessing the recommended online resources To prepare for delivering the curriculum in their classrooms, teachers were instructed to study essential materials, including the Teacher Knowledge Update and complete a pre-post quiz Additionally, they received guidance on effectively utilizing the Guide alongside the existing school curriculum.

Teachers assigned to implement the Mental Health Literacy (MHL) program in the classroom received instructions on accessing essential training guides and materials These resources include a teacher knowledge self-test, updates, student evaluations, and downloadable modules, all available through the provided link: http://teenmentalhealth.org/schoolmhl/school-mental-health-literacy/mental-health-high-school-curriculum-guide/about-the-guide/.

Teachers received training to effectively utilize online resources, such as the materials available at www.teenmentalhealth.org, specifically designed for classroom application They learned to implement a structured curriculum through six modules, focusing on key concepts and activities outlined in each For instance, in module one, teachers guided students to conduct community attitude surveys, fostering group analysis and interpretation of results Additionally, educators were trained to integrate various resources and teaching methods to enhance the classroom environment It was also emphasized that a research assistant, a clinical psychologist, would observe their teaching practices to provide feedback.

This section describes about the measure that used in the current study both teachers and student measure including the process of adaptation and validation in Cambodia context

Teacher pre-post outcomes were assessed using the Mental Health Knowledge Quiz (MHKQ), Mental Health Literacy Scale (MHLS), and

Beliefs toward Mental Illness (BMI) These assessments were translated,

61 adapted and also piloted with 10 staff before beginning the study The Guide Lesson Fidelity Rating and Teacher Survey were used to observe teacher implementing the guide in classroom

The MHKQ, developed by Kutcher in 2016, is an assessment tool designed to evaluate knowledge based on the curriculum guide It features 30 true/false questions, such as “a phobia is an intense fear about something that might be harmful, like heights or snakes.” Each question is scored with incorrect answers receiving 0 points and correct answers receiving 1 point, while missing responses are also counted as incorrect The results are expressed as a proportion of correct answers, ranging from 0 to 1, where higher scores reflect greater knowledge It is important to note that internal consistency was not assessed, as the items do not aim to measure a single underlying construct.

The Mental Health Literacy Scale (MHLS), developed by O’Connor and Casey in 2015, is a comprehensive tool designed to evaluate an individual's mental health literacy (MHL), identify areas needing further support, and assess the effectiveness of interventions aimed at enhancing MHL This original 35-item scale encompasses six subscales and demonstrates strong internal consistency (α = 87) and test-retest reliability (r = 80), confirming its validity for measuring the outcomes of mental health literacy training programs.

2015) The MHLS was adjusted for this current study by removing those seven items due to low reliability and lack of evidence these occur in

Cambodia No epidemiology studies that addressed the severity of illness between genders are available All deleted items and scales are included below:

Question 9 To what extent do you think it is likely that in general in

Australia, women are MORE likely to experience a mental illness of any kind compared to men

Very unlikely Unlikely Likely Very Likely

Question 10 To what extent do you think it is likely that in general, in

Australia, men are MORE likely to experience an anxiety disorder compared to women

Very unlikely Unlikely Likely Very Likely

Results of Teacher Analyses

In this study, 73 staff participants were initially involved, with 36 assigned to the intervention group and 37 to the control group at time one (T1) By time two (T2), 67 participants remained, as six were lost to follow-up Specifically, 34 participants continued in the intervention group, while 33 remained in the control group Notably, two participants from the intervention group and four from the control group were unable to provide follow-up data due to reasons unrelated to the study, such as leaving the school or taking family leave.

The majority of participants were female (79%), with a median age of

Over half of the individuals surveyed (66%) were teaching staff, with the majority holding either a bachelor's degree (53%) or a master's degree (3%) Additionally, 24% had a high school education, while 15% completed junior high school The remaining participants were employed in administrative or other non-teaching positions.

The mean scores, standard deviation of participant’s characteristics was outlined in Table 2

Table 2 Descriptive statistic summary of participant’s background information

Variables Overall Treatment Control p-value

Experience 5.43 ± 4.282 5.47 ± 4.515 5.35 ± 3.93 0.929 less than 5 years 28 (57.1%) 19 (59.4%) 9 (52.9%) 0.665 5-year/more 21 (42.9%) 13 (40.6%) 8 (47.1%)

3.1.2 Baseline Scale Scores of Teachers

This section addresses research question one by assessing the baseline measures of mental health (MH) knowledge, attitudes, and beliefs among secondary and high school teachers The findings support hypothesis one, which posited that teachers possess low baseline MH knowledge along with more negative attitudes and beliefs toward mental illness.

MHKQ, MHLS, and BMI regarding the research question and hypothesis

3.1.2.1 Baseline Scale Scores Between Intervention and Control Groups

The mean scores, standard deviation of T1 were outlined in Table 3 There were no significant differences between groups on any of the baseline scores, all p > 05

Table 3 ANCOVA – Difference participant’s T1, mean scores, standard deviation, and p-value by groups

F test, for effect of Group

3.1.2.2 Aim 1: Evaluate Baseline MHL Scores by Participant’s

The study aimed to investigate whether baseline measures were influenced by gender, educational background, and teaching experience Hypothesis one proposed that these baseline measures would differ based on gender, education level, and teaching experience.

3.1.2.3 Demographic Differences in Baseline Scores

The mean scores, standard deviation, and p-value by sex, education, and experience of scale score T1 were outlined in Table 4 below

At baseline, female teachers scored an average of 53.9% on the mental health knowledge quiz, compared to an average of 51.0% among male teachers This difference was not statistically significant [F (1, 65) = 1.508, p

Teachers with a high school education or lower scored an average of 53.9% on the mental health knowledge quiz, while those with higher education scored slightly lower at 52.7% However, this difference was not statistically significant (F(1, 61) = 0.290, p = 0.592) Additionally, teachers with less than four years of experience achieved an average score of 54.2% on the same quiz.

Table 4 ANCOVA-Differences (T1) Mental Health Knowledge Quiz on participants’ sex, education, and experiences

The study revealed that teachers with less experience scored an average of 77% on the mental health knowledge quiz, compared to 52.6% for those with five years or more experience; however, this difference was not statistically significant (F (1, 47) = 0.438, p = 0.511) Additionally, demographic factors such as sex, education level, and teaching experience did not significantly influence mental health literacy among participants, indicating that variations in gender, educational attainment, and experience did not affect teachers' understanding of mental health.

At baseline, female teachers scored an average of (M = 3.26, SD 258), compare to an average score of (M = 3.43, SD = 241) among male teachers This difference was not statistically significant [F (1, 65) = 4.970, p

Teachers with higher education levels demonstrated a mean mental health literacy (MHL) score of 3.31 (SD = 233), while those with lower education scored 3.23 (SD = 279), showing a statistically significant difference In terms of experience, teachers with five or more years scored an average of 3.35 (SD = 237), compared to 3.32 (SD = 279) for those with less than five years, with no statistically significant difference found Additionally, female teachers exhibited better mental health literacy than their male counterparts, although no significant differences were observed based on education level or years of experience, suggesting that these factors do not significantly influence teachers' mental health literacy.

At baseline, male teachers had an average score of 2.64 (SD = 618), while female teachers averaged 2.47 (SD = 610), resulting in a mean difference of 0.174, which was not statistically significant (F(1, 65) = 893, p = 348) In contrast, teachers with higher levels of education scored an average of 2.35 (SD = 592), compared to 2.67 (SD = 629) for those with lower education, indicating a statistically significant mean difference of 0.315.

A study revealed that education levels significantly influenced beliefs about mental illness, with teachers having five or more years of experience scoring an average of 2.53 (SD = 713), compared to 2.36 (SD = 630) for those with less experience However, the mean difference of -0.167 was not statistically significant (F(1, 47) = 755, p = 389), indicating that neither sex (male vs female) nor experience level (less vs more) significantly impacted beliefs toward mental illness.

Baseline measures revealed a concerning lack of mental health (MH) knowledge among teachers, with the intervention group scoring an average of 52.6% and the control group at 53.9% out of a possible 100% Additionally, both groups demonstrated low willingness to engage with individuals experiencing mental illness, as indicated by the MHLS sub-scale scores: the intervention group averaged 3.09, while the control group averaged 2.83 on a scale where the maximum score is 5 Furthermore, there were prevalent negative beliefs about mental illness, highlighting the need for improved education and awareness in this area.

A study on the dangerousness and incurability of mental disorders revealed a significant association between education level and attitudes toward mental illness Specifically, individuals with higher education demonstrated a more positive attitude compared to those with lower education, as indicated by a total BMI score analysis (F (1, 61) = 4.093, p = 047) Other demographic factors, such as sex and work experience, did not show a positive correlation with the baseline scale scores.

3.1.3 Aim 2: Evaluate the Effectiveness of MHL Intervention At T2

This study aimed to assess the impact of Mental Health Literacy (MHL) training on teachers' knowledge, beliefs, and attitudes toward mental illness The results indicated that the intervention group exhibited significant improvements in these areas compared to the control group after the training This suggests that MHL training effectively enhances teachers' understanding and perceptions of mental health issues.

The F test, mean scores, standard deviation, and p-value of T2 were outlined in Table 5 below

Table 5 ANCOVA – Difference participant’s T2, mean scores, standard deviation, and p-value by groups

F test, for effect of Group N M (SD) N M (SD)

The ANCOVA analysis, after adjusting for T1 scores, revealed that the intervention group achieved an average score of 64.66% on the mental health knowledge quiz, significantly higher than the control group's average score of 51.37% This resulted in a mean difference of 13.3%, indicating a statistically significant difference between the two groups.

The intervention significantly improved teachers' knowledge of mental health, as evidenced by a statistical result of [F(1, 64) = 22.22, p < 001] A subsequent analysis, which adjusted for key demographic variables such as sex, education level, teacher status, and income, revealed that these factors significantly impacted the results, with an adjusted effect of [F(1, 37) = 8.450, p = 006] This indicates that demographic differences between the treatment and control groups influenced teachers' mental health knowledge quiz outcomes.

In our analysis, we investigated the presence of a statistically significant difference in mental health literacy scores between the treatment and control groups at follow-up, while adjusting for baseline scores After accounting for the initial T1 scores, we assessed the impact of the intervention on mental health literacy.

Discussion

Understanding mental illness is crucial for the early identification and referral of children needing support This preliminary study aimed to explore the knowledge, attitudes, and beliefs surrounding mental health and evaluate the feasibility of the mental health literacy program, The Guide (Kutcher, 2016), among teachers and students in Cambodia The findings indicate that with minimal adaptations to the original curriculum, a 2-day training for teachers can effectively enhance mental health literacy among both educators and students This highlights the potential for a sustainable, low-cost approach to training teachers in mental health literacy.

99 and teacher-optimized resource and embedding the mental health literacy program into existing standard curriculum in classroom

To our knowledge, this is the first study assessing teacher and student mental health literacy in Cambodia

The study hypothesized that both teachers and students would exhibit low baseline mental health (MH) knowledge, along with negative attitudes and beliefs about mental illness, which would vary based on demographic factors The findings confirmed this hypothesis, revealing that both groups possessed limited knowledge and held prejudiced perceptions of mental illness Prior to any intervention, there were no significant differences in baseline scores between the intervention and control groups (p > 05) While demographic factors such as sex and teaching experience did not affect teachers' MH knowledge and attitudes, education level influenced beliefs about mental illness for both teachers and students Higher education levels correlated with less negative beliefs and attitudes, suggesting that knowledge is a crucial factor in reducing stigma Additionally, cultural influences, particularly in a context where Buddhist-Hindu beliefs and traditional practices prevail, contribute to stigmatizing attitudes, as help-seeking often occurs only after traditional methods fail.

Our findings align with previous research in Vietnam, indicating that teachers possess limited knowledge of mental health issues (Dang et al., 2018) Additionally, earlier studies reveal that educators struggle to identify and assess the severity of mental disorders, highlighting a concerning lack of mental health literacy among teachers (Deborah Oyine Aluh et al., 2018; Mendonsa, R D Shihabuddeen).

2013) Further, research across multiple settings such as United States,

Canada, Malaysia, and Nigeria have identified a pressing need to enhance students' understanding and awareness of mental health issues, as well as to address the associated stigma (Mcluckie et al., 2014; Mustafa et al., 2015; Omi Jack ide et al., 2016; Wahl et al., 2012) These findings highlight significant challenges in mental health literacy within contexts that often overlook the mental health care system, where inadequate mental health literacy poses substantial barriers to accessing care (McLaughlin & Wickeri, 2012; TPO Cambodia, 2015).

Hypothesis 2 & 5: It was assumed that mental health literacy training will increase teachers and students’ MH knowledge, beliefs and attitudes toward mental illness amongst intervention group compared to control group Our second finding of this current study confirms the mental health literacy program -The Guide was effective at increasing teachers and students’ mental health literacy (knowledge, beliefs, and attitudes) The finding was supported by previous literature that underpinned the effectiveness of mental health literacy programs for training teachers and MHL program that taught by usual classroom teachers has positive impact on students’ MH knowledge and attitudes toward mental illness (Kutcher, Wei, & Morgan, 2015; Ojio et al.,

Hypothesis 3 & 6: It was assumed that demographic characteristics such as gender, education and experience of teaching would affect teachers’

The study on MHL training revealed that participants' demographics, including sex, education, occupation, experience, and income, did not significantly impact their knowledge, attitudes, or beliefs regarding mental illness Notably, teachers exhibited the most significant changes in their willingness to engage with individuals facing mental health challenges and their perceptions of dangerousness This may be attributed to an enhanced understanding of mental illness, fostering greater empathy Specifically, presenting a bio-psycho-social framework that frames mental illness as a neurobiological condition can diminish the stigma associated with spiritual interpretations, which often imply moral failings Prior research indicates that individuals who perceive mental illness as a medical issue tend to have less stigmatizing attitudes compared to those who view it solely through a neurobiological lens (Lebowitz & Ahn, 2014; Loughman & Haslam).

Increased understanding of the causes of mental illness, along with the recognition that the majority of individuals with mental health issues are not dangerous, can help reduce fear of social or spiritual contamination and direct physical harm This reduction in fear is likely to enhance people's willingness to engage with those experiencing mental health challenges.

Demographic factors, including age, sex, and grade, were examined for their impact on students' responses to Mental Health Literacy (MHL) training The results revealed that while age and grade did not significantly affect knowledge and attitudes, sex had a notable influence on mental health knowledge (p = 007) This aligns with previous research indicating that males tend to have lower mental health knowledge and attitudes compared to females, with studies showing that males exhibit poorer mental health literacy skills.

Research indicates that individuals are often less likely to recognize the seriousness of mental health symptoms and perceive greater personal control over them, leading to a decreased endorsement for treatment (Gibbons et al., 2015) Notably, girls tend to demonstrate a higher level of mental health knowledge compared to boys, potentially due to their greater psychological awareness and introspection This increased awareness may result in more active participation in mental health literacy (MHL) programs, enhanced discussions about emotional challenges, and greater access to mental health resources Furthermore, the general public often holds stigmatizing attitudes towards mental illness, largely stemming from misinformation Promoting accurate information can effectively reduce stigma and foster positive interactions with individuals experiencing mental health issues These insights underscore the need for targeted improvements in mental health education initiatives.

Hypothesis 7: The Guide-VN MHL intervention will be feasible and acceptable for Cambodian teacher implementation Likewise, although we observed statistically significant effects at the student level, their low scores – particularly in knowledge – indicate room for additional improvement These findings are not atypical; a previous study of The Guide reported about 14% improvement among students receiving the intervention (Mcluckie et al.,

A comparison of studies shows that teacher mental health literacy (MHL) training is a promising strategy for enhancing children's mental health care within the school system, yet its effectiveness can differ significantly depending on the specific methodology and context used Research indicates that while such training is beneficial, variations in its implementation may influence outcomes.

In the current study, various factors that may influence student outcomes are examined, focusing on both implementation factors and the cultural or contextual fit of educational practices.

The cascading training model implemented for Cambodian teachers involved a brief 3-day program, which included only one day of train-the-trainers instruction This limited training, derived from the North American curriculum, may not adequately equip inexperienced teachers to effectively deliver mental health lessons Observations during the training revealed significant gaps in mental health literacy and the skills necessary for classroom instruction, as reflected in pre-post quiz scores Teachers struggled to grasp the conceptual framework essential for teaching the curriculum Similar findings in Canada indicate that teachers require more extensive preparation to address mental health issues (A L Andrews, 2012), and studies in both Canada and Haiti highlight the need for longer and more frequent training sessions to improve training outcomes (Eustache et al., 2017; Kutcher, Gilberds).

Teachers often experience stress and a lack of confidence, indicating a need for additional support beyond initial training for effective curriculum delivery (Udedi et al., 2015; Daniszewski, 2013; Udoba, 2014) Implementing ongoing professional development, supervision, or consultation can enhance outcomes for both teachers and students This aligns with existing research that emphasizes the importance of supervision in facilitating behavioral changes in teaching and learning processes (Evans et al., 2017; Kikegbusi, Gloria & Eziamaka, 2016).

104 among Canadian teachers have also showed that supervision was important during delivering curriculum in classroom (Daniszewski, 2013)

The current one-hour weekly dosage for delivering the six modules in Cambodia may be inadequate, as prior research indicates a need for six hours of classroom time or a 4-8 week intervention (Milin et al., 2016) Since the curriculum was originally designed for Western students, adaptations are necessary to accommodate Cambodian students, who may have lower baseline mental health literacy and require more exposure to the material Additionally, larger classroom sizes in Cambodia compared to Canada or the US necessitate modifications to enhance teacher-student interactions Therefore, each module should ideally consist of two sessions, totaling two hours, to foster greater engagement and interaction between teachers and students.

Lack of motivation (intrinsic motivation) may also be a factor

Strength and Limitations

This study's strengths include a randomized experimental design within a real-world context, the involvement of both teaching and non-teaching staff, and a low dropout rate among participants However, significant limitations exist, such as the study being conducted in only one private school, raising questions about the generalizability of the findings to other Cambodian schools In this private setting, teachers and students receive more support compared to public schools, including better salaries for teachers and more attention for students, who also benefit from free part-time courses Additionally, not all staff were involved in curriculum delivery, leading to less training and potential motivation issues regarding The Guide's implementation The single-school design also hindered randomization, as control group students may have interacted with trained staff Furthermore, while assessment tools were validated in Vietnam, they lacked separate validation in Cambodia, and adaptations were limited to pre-defined mental health syndromes, excluding local conditions that may be more relevant to Cambodians.

Due to resource constraints, a long-term follow-up to assess the sustained impacts of the program on knowledge and attitudes was not feasible, and direct measurement of behavior was lacking The reliance on self-reported data introduces limitations, particularly the risk of social desirability bias However, knowledge and attitudes are considered intermediate outcomes that can lead to improved identification of mental health needs, service connections, and enhanced functioning Our findings are encouraging and indicate the need for a more comprehensive evaluation of the Mental Health Literacy (MHL) curriculum in Cambodia, including further adaptation and implementation studies.

Conclusions

The recent study revealed significant enhancements in knowledge and attitudes towards mental health among teachers and students in Cambodia after implementing a classroom-based mental health literacy program Integrating such programs within school settings presents a viable solution to address the critical mental health needs of children and adolescents in resource-limited environments like Cambodia, aligning with the growing emphasis on mental health initiatives in low- and middle-income countries (LMICs).

The task-sharing approach empowers teachers to actively promote mental health within schools, enhancing accessibility to services and reducing stigma associated with seeking care (Dang et al., 2017; Milin et al., 2016) However, many low- and middle-income countries (LMICs) face challenges due to low mental health literacy among both teachers and students This highlights the urgent need to improve understanding of mental health, disorders, and treatments, which is essential for decreasing stigma and encouraging help-seeking behaviors.

Recommendations

• Findings from this pilot RCT support the potential benefits of school- based MHL training in Cambodia, where there is substantial stigma, prejudice and discrimination toward mental illness

• Integrate MHL training into standard curriculums in Cambodia

• Include MHL training as only one of a multi-tiered system of supports

As MHL increases, there also needs to be clear routes of accessing care and support within schools

• Consider revise curriculum to be more in accordance with cultural context (e.g., Khmer culture) and extend the length of teaching for each module (e.g., two hours/sessions for each module)

• Replicate study in larger, multi-school sample to address methods limitations of single school design

• Mixed methods research – more qualitative understanding of how teachers/students experienced the program, would recommend it be improved

• Future research should conduct longer follow-up period to look at long- term impact

• Include measures of behavior change, help-seeking to seek if MHL intervention by usual classroom teacher is effectiveness to increase students’ MHL

• Hybrid research to understand necessary supports for teachers to deliver the program with better outcomes for students, greater fidelity

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The study by Kim et al (2010) investigates the stigma and barriers to mental health care faced by active duty and National Guard soldiers following combat It highlights the significant challenges these soldiers encounter in accessing mental health services, emphasizing the impact of stigma on their willingness to seek help The findings underscore the need for improved mental health support and awareness initiatives to encourage service members to utilize available resources effectively This research contributes to understanding the complexities surrounding mental health care access in military populations.

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In their analytical review, Kutcher, Hampton, and Wilson (2010) examine the mental health policies and plans for children and adolescents in Canada, highlighting key strategies and frameworks The authors emphasize the importance of addressing mental health issues early in life to improve overall outcomes They identify gaps in current policies and advocate for a comprehensive approach that includes prevention, early intervention, and access to services The review underscores the need for collaboration among stakeholders to create effective mental health strategies tailored to the unique needs of young populations in Canada.

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