Exploratory Cluster Randomized Controlled Trial (cRCT) of Saving and Empowering young lives in PAKistan (SEPAK)
We aim to conduct an exploratory study for a large-scale cluster randomised controlled trial (cRCT) involving 40 secondary schools and local health and social care services across eight regions in Pakistan.
The aims of the feasibility study are to:
- Develop culturally adapted preventative interventions for self-harm among pupils in secondary schools across Pakistan targeting pupils, parents, teachers and local health practitioners.
- Investigate the feasibility and acceptability of the culturally adapted preventative interventions among participants (pupils, parents/guardians, teachers, health practitioners) and the intervention facilitators including the perceived benefits and adverse or negative experiences.
- Collect baseline and post-intervention assessments of the mental health and wellbeing, alongside demographic data, information about lifestyles, values, risk behaviours and other psychosocial information of Pakistan adolescents and explore the feasibility of compiling a pragmatic trial database as part of a future large-scale cRCT.
Sepak Interventions:
Awareness Training of Pupils: We have used the LEADS (Linking Education and Awareness of Depression and Suicide) for youth. LEADs aims to increase knowledge of depression and suicide, modify perceptions of depression and suicide, increase knowledge of suicide prevention resources, and improve intentions to engage in help-seeking behaviours. This intervention covers depression and its symptoms, the link between depression and suicide, the risk and protective factors associated with suicide, the warning signs of suicide, seeking help and overcoming barriers to seeking help, and school and community suicide prevention resources. Intervention will be delivered over the period of three consecutive days and consists of a two-hour interactive session.
Gatekeeper Training (Teachers and parents): We used manualised programme for (teachers/school staff), the Question, Persuade, and Refer (QPR), which is originally developed in the USA, http://www.qprinstitute.com/. QPR aims to train teachers/school staff to identify the suicide risk in pupils and encourage pupils at risk of suicide to seek professional help. The QPR involves asking pupils questions concerning their behaviour, persuading them to seek help if they are displaying suicidal warning signs and, when appropriate, referring the pupil to a treatment facility. Teachers/school staff in the participating schools are trained by research practitioners that have undergone the official QPR training programme online. Training consists of a two-hour interactive lecture and a one-hour role play session.
Professional Screening: We have used the Screening by Professionals programme (ProfScreen), an indicated or selective intervention which is based on students’ responses to the baseline questionnaires. Participating health practitioners reviewed pupils’ responses to the questionnaires used in the study and pupils whose scores meet pre-established cut-off points will be invited to participate in a professional mental health clinical assessment and if needed, referred to clinical services. This intervention is designed to help health practitioners to identify at-risk adolescents by using cut-off points for positive responses based on specific scales of adolescent mental health in the baseline questionnaire. All pupils with a predetermined cut-off for depression, anxiety, non-suicidal self-injury (NSSI) and suicidality will be referred for professional treatment. Pupils with social problems are referred to an appropriate non-clinical healthy-lifestyle group.
Control group/Minimal intervention: The control group exposed to the six educational posters displayed in their classrooms which display six key points which are also covered in the awareness arm booklet and provide contact details for the local healthcare services and healthy lifestyle groups. Pupils in the control group who self-recognise the need for help are able contact local health practitioners or a healthy lifestyle group. The posters hang in the classroom for four weeks
Cultural Adaptation of SEPAK Interventions
Date | January 21st, 2021 |
Venue | Zoom |
No of Participants: | 8 (2 teachers from public secondary school, 1 principal of a leading private school, 2 students of grade 7, 1 psychiatrist and 2 clinical psychologists) |
Agenda | To explore the stakeholder views on the LEADS intervention
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On Jan 21st, 2021, SEPAK team conducted a PPIE session to discuss an intervention called LEADS: For Youth (Linking Education and Awareness of Depression and Suicide) a universal intervention that aims at increasing the knowledge about depression and suicide and to modify the perceptions related to depression and suicide. This intervention helps adolescents in recognizing suicide prevention resources that are available in the community and thus improves the intentions to engage in help-seeking behaviours.
In this PPIE, one of the team members gave presentation on each module and collected the feedback of key stakeholders on the content of LEADS and suggestions on how we can culturally adapt it for use in Pakistan, as we aim to assess the feasibility of this intervention in some secondary schools in Karachi, Lahore, Rawalpindi and Peshawar.
Objectives of LEADS PPIE session were:
- To explore the stakeholder views on the LEADS intervention
- To discuss the content difficulty level; whether students would be able to comprehend this intervention
- Identify what works (or not), for students and in what circumstances; what can be added or removed
- Explore the burden on participants/students – Are there any barriers to participants taking part? Explore possible ethical issues from a student’s perspective, e.g. emotional and personal safety issues of participants;
- Any issues with school/teacher participation, any burden on teacher workload
- To have a lay perspective in ensuring the study is feasible and practical, answering the question whether participants would agree to take part in the study.
- Improve the planning of future project – evaluating what worked and what did not will help you identify how to plan future projects;
Discussion was audio recorded with participants’ prior consent. A document with brief summary of LEADS intervention and objectives of session was shared with all participants so that they can have a clear idea about this PPIE session. At the start of the session participants were given a brief orientation about the project SEPAK and then a presentation on LEADS content was given by a SEPAK team member.
This intervention is for students aged 12 to 17 years, will be delivered by school teachers (ideally 20 to 80 students in a group setting from each school) and divided into three sessions (one hour for each session): content for each session to be discussed is as below.
Session 1:What is depression? Its signs and symptoms, how depression affects our thoughts, emotions, behaviour and body? Available treatment options for depression.
Session 2: Risk and protective factors for suicide, warning signs of suicide, suicidal behaviour and self-harm, stress and anxiety, dealing with stress and anxiety, healthy living strategies.
Session 3: What can students do if they are concerned? Challenges and benefits of help seeking, available school and community resources.
Following are some suggestions and comments given by SEPAK key stakeholders on LEADS;
Student’s Comments: All training material must be in simple local language i.e. urdu. Content shall be simple, easy to understand and we must ensure that slides don’t contain too much information as some of the students might not be able to absorb all the information at once. Moreover, short stories and videos (in local language) on depression, suicide and warning signs will help to engage students.
Teacher’s Comments: Mental health and depression is still a taboo in Pakistan. We know that depression is common in children and young people in the form of fears and worries but our parents and teachers don’t acknowledge this as most people think of depression as an adult illness. In this way many children with depression go untreated because adults don’t recognize they’re depressed. First of all we need to address this issue because it is important for parents, teachers, and other adults to learn about childhood depression. When they will understand the symptoms of depression in children and the reasons children develop it, they can intervene in a helpful manner. In this regard an awareness session on Depression in Children and adolescents can be planned for parents and teachers before delivering this intervention.
Due to academic pressure, there is a possibility that training content of this intervention can create boredom or recall issues. It would be helpful for the students to have either more than 3 days and also we can reduce the training written material or slides instead we can add more videos on depression sign and symptoms, suicide warning signs and verbal direct and indirect cues. Day 2 training content need to be concise and must be divided into 2 days.
Mental Health Professional’s comments: Before implementing this intervention we must need to take on board both parents and school administration and then we can raise awareness on childhood depression, suicidal behavior and suicide. Lack of interest and poor concentration are symptoms of depression that can lead to poor recall and low grades/failing exams. If we highlight these symptoms parents may pay more attention and take interest in this school based suicide preventive intervention. Student must be provided with information on alcohol and other drugs such as LSD and also must inform them how dangerous these are for their health. This will be a good step in reducing the drug use rate in students.
Date | March 25th, 2021 |
Venue | Zoom |
No of Participants: | 7 General Physicians |
Agenda | To explore the stakeholder views on the Professional Screening intervention |
On March 25th, 2021, SEPAK team conducted a PPIE session to discuss an intervention called Professional screening of at-risk students (ProfScreen): This is a program that includes screening of students aged 12-17 years at baseline by using questionnaire’s that have been used previously with young people and have pre-established cut-off points for identifying psychopathology symptoms and risk behaviours. Students that are identified as at risk of suicide will be referred for specialist assessment. This therefore is a programme of assessment and referral of young people using questionnaires that will be used to identify at risk students. The questionnaires are described below:
Assessment Scales |
1. Global School-Based Student Health Survey (GSHS) |
2. Deliberate Self-Harm Inventory (DSHI) |
3. Kessler Psychological Distress Scale (K10) |
4. Beck Scale for Suicidal ideation (BSSI) |
5. EQ-5D |
6. Client services receipt inventory |
7. Client satisfaction questionnaire |
In this PPIE, one of the team members gave presentation on each questionnaire and collected the feedback of key stakeholders on ProfScreen measures and suggestions on how we can culturally adapt it for use in Pakistan, as we aim to assess the feasibility of this intervention in some secondary schools in Karachi, Lahore, Rawalpindi, Peshawar and Quetta.
Objectives of ProfScreen focus group session were:
- To explore the health professionals views on the Professional Screening questionnaires- are these questionnaires useful or not in screening the at risk students?
- To discuss the content level; whether students would be able to comprehend these questionnaires.
- Identify what works (or not), for students and in what circumstances; what can be added or removed.
- Explore the burden on participants– Are there any barriers to participants taking part? Explore possible ethical issues from a student’s perspective, e.g. emotional and personal safety issues of participants.
- To have a lay perspective in ensuring the study is feasible and practical, answering the question whether participants would agree to take part in the study.
- Improve the planning of future project – evaluating what worked and what did not will help you identify how to plan future projects;
Discussion was audio recorded with participants’ prior consent. A document with brief summary of ProfScreen intervention and objectives of session was shared with all participants so that they can have a clear idea about this PPIE session. At the start of the session participants were given a brief orientation about the project SEPAK and then a presentation on LEADS content was given by a SEPAK team member.
Following suggestions has been given by participants:
- Parents and Schools involvement: First we have to take parents’ consent and school’ permission; they must be explained the study objectives so that health professional can refer at risk students for further clinical assessment and treatment. Here we can provide some awareness sessions on mental health due to that parents and school staff would be able to know about student’s mental health issues. These awareness sessions will encourage then to intervene in a helpful manner.
- Scales: As far as administration is concerned, there will be no issues as such because all these scales will be administered in school setting and Pill researchers will be there to assist students so in case student faces any difficulty in completing the questionnaire, they can take help from researchers. If GP have to use these scales to screen a student, then it is a bit difficult because GP can hardly give 5-10 minutes each patient. If possible, we can use 2-3 main scales which can evaluate the student’s mental health properly.
- GP/health professional training: If GP have to administer the screening measures, there should be intensive training on administration of these scales first. Apart from that, some probing techniques must also be taught to GP, which can be use with young people. There should be some training on counseling skills as well so that parents and youngster can be guided regarding mental health and possible ways to treat them.
- Mental Health Interest: Not all health professionals or GPs can get involved in mental health related awareness campaigns, we need to figure out who really want to work with people with mental health difficulties.