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Transforming the understanding
and treatment of mental illnesses.

SHINE Hub Project Summary

Watch on YouTube.

Transcript

DR. WISSOW: Hello, I'm Larry Wissow in Seattle, Washington, on the Pacific coast of North America. I'm the co-PI of SHINE, the School Health Implementation Network of EMRO, which is the WHO's Eastern Mediterranean Regional Office, along with Dr. Atif Rahman of the University of Liverpool.

SHINE started in 2016 and has been a collaboration of many sites and individuals. Its heart has been at the Human Development Research Foundation in Pakistan and at the University of Liverpool, as well as at Johns Hopkins University, Harvard, and the University of Washington.

SHINE has a research component and a capacity-building component. However, SHINE reframed capacity-building more as capacity-sharing. We built a collaborative learning group across four countries so that we could help each other move as rapidly as possible from an idea for an intervention to a sustainable program at scale. So in addition to hearing about Pakistan, we worked with colleagues in Egypt, Iran, and Jordan, and you'll hear about their work soon.

SHINE's main objective was to take advantage of the regional rollout of a WHO manual that aimed to help elementary and secondary schoolteachers develop skills for detecting and helping with their students' mental health problems. Through a cluster randomized trial in Pakistan, SHINE sought to demonstrate how an electronically enhanced training model tailored to teachers' own socioemotional needs could have broader reach and more student impact than the traditional in-person cascade model for disseminating trainings.

In addition, through the work of the collaborative learning group, SHINE sought to outline steps needed to gain acceptance of and implement a school mental health program across settings that varied very greatly in their political and administrative structures and in the ways that educational and health authorities related to each other.

One of SHINE's first tasks was to create theories of change at local and national levels that would guide the processes of gaining support for the intervention, putting it into place, and evaluating its impact.

At the more macro level, the creation of these theories of change diagrams was critical to understanding factors that would promote reach and sustainability. At the more microlevel, it was critical to making modifications to the original WHO school mental health material so that it could be seen as strongly meeting teachers' needs. This included developing material that addressed teachers' own wellbeing and material that helped them better understand students in the context of their families and communities.

The SHINE trial in Pakistan involved 80 schools and enrolled 960 children ages 8 to 13 selected because both their teachers and parents agreed that they had clinically important problems with mood or behavior. Schools were randomized so that all of their teachers would receive either the electronically enhanced training or the original WHO version. The trial had many goals, but ultimately it aimed to show that students of teachers who had received the enhanced training would have better mental health after a nine-month period of evaluation.

The enhanced intervention had two main components, an online training that could be used in preparation for small group supervision sessions and a chatbot that could be accessed on a smartphone and provide cues for intervention to commonly occurring children's problems. Two versions of the training, the links are at the bottom of this slide, translated into English, are available on the WHO EMRO website.

The initial part of the trial went very well. The full sample of teachers and students was successfully enrolled, and all of the teacher training took place. But more or less, as the observation period for the students was to start, COVID struck and the schools were closed. There were many hopeful moments after that, but eventually by the time schools reopened, students and teachers had been so dispersed and it was so long since the teachers' initial training that following the students was no longer possible.

So there remain a number of study goals that can still be accomplished with analyses currently under way. We'll learn a lot about teacher training by using some of the teacher-related measures as trial outcomes, and through a detailed mixed method assessment of the training process, we'll also be able to understand how best to replicate the training.

SHINE was also able to develop a large dataset. Nearly 10,000 children were screened in the first stage for eligibility, and that dataset will be able to describe the prevalence and correlates of socioemotional problems in Pakistani school aged children. These analyses are currently under way, along with several other papers that will come from the study.

Finally, on the bottom of the slide here are two papers that have already been published. There are a few others as well, but these describe the original trial protocol and the other the theory of change process. So now I'm delighted to turn the presentation over to the collaborative learning group.

DR. CHIUMENTO: Hi, everyone. I am Dr. Anna Chiumento from the University of Liverpool and on behalf of the SHINE Collaborative Learning Group team, I'm going to be sharing some of our activities and reflecting on our model.

The overall aim of the Collaborative Learning Group was to build the capacity of a core group of individuals from eastern Mediterranean countries, namely Egypt, Jordan, Iran, and Pakistan, in implementation science and child mental health. Strategically, our initiative was embedded within the WHO regional scale-up of the school mental health program, which provided that policy grounding for our activities.

We met face-to-face up until COVID-19 struck, at which point we have adjusted to an online format, and just to highlight some key areas of our guiding principles, the importance really of aligning our collaborative learning group activities and the needs of participants at different phases of school mental health program implementation at individual countries was particularly important, and also the model of learning within the collaborative learning group was very much a constructivist model, so seeking to build gradually over time at each of the individual workshop the skills and knowledge of participants, and encouraging that reciprocal learning between the collaborative learning group countries and ensuring we were feeding that back to the WHO for ongoing development of the school mental health program regionally.

We also embedded some research capacity-building type activities as you can see here, and these are very much in response to requests for particular skills building from our partners in country, and finally to highlight some outputs, we have had a couple of papers published that were very much collaborative outputs between collaborative learning group members.

We are also ongoing support to the WHO for the adaptation of the school mental health program training program to an online format that's been informed by the adaptation at country levels, and also policy engagement, particularly in Jordan and Egypt, with some very high-profile social media campaigns around child mental health needs.

That concludes the brief overview that I'm providing of the CLG, and we are go on to here from two of our CLG partners in Egypt and Jordan about their school mental health program implementation and engagement with the collaborative learning group.

DR. ARAJ: Hello, I'm Rana Araj from the Royal Health Awareness Society in Jordan, and I'm the program coordinator for the school mental health project. The growing burden of mental health conditions, such as depression and anxiety, has changed the global health and development agenda and has affected all populations everywhere around the world. Especially now, post the pandemic, post-COVID, there's an urgent need to support the most vulnerable segments of the population and in specific, youth and children.

The school mental health program. SHINE is a regional collaboration aimed at addressing the conflict in regard to implementing mental health-focused school programs. It also aims at early detection of mental health conditions among school students through a set of activities to promote mental health, focusing on training school counselors and teachers on early detection of children's mental health, and the project also focuses on mental health awareness among the local community through conducting a social media campaign focusing on raising awareness and reducing stigma in regard to mental health.

First, we have conducted training of trainers, which focused on equipping the trainers on understanding the importance of mental health in the school environment, the importance of early detection, child development, age-appropriate strategies for managing behavior, and assessing disruptive behavior. The training was conducted by a specialist and psychiatrist, certified in training school mental health program.

So first we conducted a training of trainers for 18 heads of counseling departments at the Ministry of Education directorates. The head of the counseling departments at the UNRWA schools also joined the training. These trainers, in turn, have trained 105 counselors and teachers at 105 schools, building their capacity on school mental health topics, mental health challenges, stigma reduction, provision, support, and referral.

Additionally, we have conducted a social media campaign focusing on stigma reduction and spreading awareness about mental health issues. The mental health campaign also strokes the effect of COVID on the community's emotional and social wellbeing. The campaign tackled mental health issues, risk factors, symptoms, stigma reduction, coping mechanisms, and also had some calls for action. It conveyed a reach above 250,000 people.

We have also organized a celebration celebrating World Mental Health Day. It took place on the 28th of October in the presence of Our Steps Organization, Ministry of Health, Ministry of Education, World Health Organization, and Greater Amman Municipality.

Finally, we have built the capacity of beneficiaries at Our Steps Organization. Now, Our Steps Organization is a nonprofit organization that supports beneficiaries who have suffered from mental health and their (inaudible). We have collaborated with Our Steps Association as part of this project and we have trained 25 female beneficiaries on income-generating activities. There was a total of six vocational training sessions to support those female beneficiaries who have been identified to have signs and symptoms of mental illness.

Now we're striving to implement and to come up with a referral pathway, a national referral pathway, to be used at schools for those who have been identified with red flag symptoms. Here in Jordan, we don't have a proper referral mechanism that could be utilized by school counselors. So we're aiming to establish that for proper diagnosis and effective treatment of mental health issues within schools.
Thank you.

DR. GABER: Our journey in Egypt started by EMRO School Mental Health Training in Jordan 2016. After this, we tried our first implementation trial, and this was done in May 2016 in cooperation with Ministry of Education. Our training of 20 teachers and 20 psychiatrists. Unfortunately, this training was not cascaded because of lack of funding and overburdened teachers.

After this, we had the chance to join SHINE and CLG group and to learn more about implementation research and theory of change. And we learned that we need to do more work about policy engagement, not just with Ministry of Education, but also Ministry of Health and NGOs and Egyptian universities and community advocacy.

One of the main challenges was that although we have human resources inside schools, doctor, nurses, social workers, psychologists, however, still we have a main problem that they all, everyone has its own system. More integration needed, and we work to update our theory of change and to do our second implementation by collaboration with Save the Children to avoid lack of funding. Trained the psychologists who have much time and establish a full psychological support students, parents, and teachers.

And we do a qualitative study to understand the acceptability about this program.
In COVID, after the closing of the schools by the support of our colleagues, we do online school mental health program adaptation, and we do a lot of policy engagement and advocacy. That facilitates a lot of work after the (inaudible) decree, and now school mental health program is implemented in Elmenia, Port-Saied, Aswan, and another trial of training of undergraduates of the social solidarity and psychology was done in Alexandria and was much appreciated.

Thank you.