Effectiveness of the Mental Health First Aid programme for general nursing students in Hong Kong: A randomised controlled trial

G Model COLEGN-700; No. of Pages 8 ARTICLE IN PRESS Collegian xxx (2020) xxx–xxx Contents lists available at ScienceDirect Collegian journal homepage: www.elsevier.com/locate/coll Effectiveness of the Mental Health First Aid programme for general nursing students in Hong Kong: A randomised controlled trial Maria S.Y. Hunga,∗ , Meyrick C.M. Chowa , Wai Tong Chienb , Prudence Y.K. Wongc a b c Tung Wah College, Hong Kong Special Administrative Region, China Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China The Mental Health Association of Hong Kong, Hong Kong Special Administrative Region, China a r t i c l e i n f o Article history: Received 6 July 2019 Received in revised form 10 December 2019 Accepted 15 April 2020 Available online xxx Keywords: Nursing students Undergraduate students Mental wellbeing Mental Health First Aid a b s t r a c t Background: Insufficient mental health related knowledge among healthcare professionals and students may lead to higher levels of stigma towards and increased social distance from mentally unwell patients. Moreover, university students enrolled in healthcare programmes are particularly susceptible to stress, depression, anxiety and other mental health problems. Objective: This study evaluated the effectiveness of the Mental Health First Aid (MHFA) Programme for undergraduate general nursing students in improving their mental health literacy, decreasing their social distance from persons with mental health issues, increasing their mental health first-aid intention, and enhancing their confidence in assisting others. The programme was also extended the effectiveness to help students to maintain their own mental wellbeing. Methods: A randomised controlled trial study with a pre-test, post-test, and follow-up research design was conducted. Three hundred and fifty-eight students were recruited. The experimental group comprised 182 students, of whom 168 completed MHFA training and a post-test questionnaire in mid-2017, and 167 students completed a follow-up questionnaire early in 2018. Meanwhile, 175 and 165 of the 176 students in the control group completed the post-test and follow-up questionnaires, respectively. Results: The effectiveness of the MHFA programme was supported by the results of repeated measures analysis of variance with Greenhouse-Geisser correction. Significant interaction effects were found in mental health knowledge in recognition of depression (␩p2 = 0.17; 95% CI: 0.24, 0.42), recognition of schizophrenia (␩p2 = 0.16; 95% CI: 0.33, 0.47), depression social distance (␩p2 = 0.20; 95% CI: −0.41. −0.22), schizophrenia social distance (␩p2 = 0.31; 95% CI: −0.58, −0.37), confidence in helping (␩p2 = 0.04; 95% CI: 0.11. 0.14), mental first-aid actions (␩p2 = 0.08; 95% CI: 1.75, 2.90), and mental wellbeing (␩p2 = 0.15; 95% CI: −0.53, −0.19). Discussion: Mental illnesses present substantial challenges to healthcare professionals worldwide. MHFA training should be promoted locally and integrated within compulsory training and extracurricular activities in curricula developed for healthcare and general university students. Conclusion: This study confirms the benefits of MHFA for general nursing students in developing their professional understanding of and willingness to assist people with mental health problems, and in developing, maintaining, and improving their understanding of their own mental health. © 2020 Australian College of Nursing Ltd. Published by Elsevier Ltd. 1. Introduction and background According to the World Health Organization (World Health Organization, 2017), approximately one in four people worldwide ∗ Corresponding author at: School of Nursing, Tung Wah College, 31 Wylie Road, Homantin, Kowloon, Hong Kong Special Administrative Region. Tel.: +852 34686804. E-mail addresses: mariahung@twc.edu.hk (M.S.Y. Hung), wtchien@cuhk.edu.hk (W.T. Chien). are affected by mental illness during their lifetimes. The WHO recommends global collaborative efforts to promote mental health and prevent mental illness. Most mental health problems first arise during adolescence and are highly prevalent among college and university students, particularly those in the field of healthcare (Eisenberg, Hunt, & Speer, 2012; Kelly et al., 2011). Prolonged academic study, together with a heavy workload and high-pressure clinical practicum, may have adverse effects on the mental and physical well-being of these students (He, Turnbull, Kirshbaum, Phillips, & Klainin-Yobas, 2018; IsHak et al., 2013; Lee, Lee, & Lee, https://doi.org/10.1016/j.colegn.2020.04.006 1322-7696/© 2020 Australian College of Nursing Ltd. Published by Elsevier Ltd. Please cite this article in press as: Hung, M. S. Y., et al. Effectiveness of the Mental Health First Aid programme for general nursing students in Hong Kong: A randomised controlled trial. Collegian (2020), https://doi.org/10.1016/j.colegn.2020.04.006 G Model COLEGN-700; No. of Pages 8 2 ARTICLE IN PRESS M.S.Y. Hung et al. / Collegian xxx (2020) xxx–xxx Summary of relevance Problem • Little is known about the effect of the Mental Health First Aid (MHFA) programme in improving the mental health knowledge, behaviour, attitudes, and wellbeing of general nursing students. What is already known? • The MHFA programme is a psycho-educational training programme that has been shown to enhance mental health knowledge in diverse populations in various countries. What does this paper add? • The findings show that completing the MHFA programme increases general nursing students’ mental health knowledge, confidence, and intention to help, which will improve their ability to care for patients with mental and physical comorbidities, as well as benefiting their friends, families, and the public. Furthermore, MHFA training has the secondary effect of enhancing general nursing students’ self-awareness and mental wellbeing. The Mental Health Review Report (Food & Health Bureau, HKSAR, 2017) published by the Hong Kong government noted that some forms of psychosis, such as schizophrenia, are typically more evident in late adolescence and early adulthood. Tertiary institutions are thus optimally positioned to organise peer support training to promote and improve adolescents’ mental wellbeing. For nurses, knowledge regarding the early identification of mental health problems and effective interventions, together with a positive attitude and willingness to offer help and support for individuals with mental health disorders, should be a fundamental attribute of patient care. This waitlist-based randomised controlled trial aimed to evaluate the effectiveness of MHFA training for undergraduate nursing students. The objectives were as follows: 1) to increase the participants’ mental health literacy; 2) to decrease the social distance between the participants and people with mental health problems; 3) to increase the participants’ confidence in helping others; 4) to enhance participants’ mental health first-aid intentions; and 5) to improve the participants’ mental wellbeing as a secondary effect of the MHFA programme. 2. Methods 2018; Sun et al., 2016), and indicates the need to provide extensive support for this population (Cheung et al., 2016; He et al., 2018; Mospan, Hess, Blackwelder, Grover, & Dula, 2017; Rotenstein et al., 2016). Moreover, healthcare students and nurses who face mental health problems have expressed concerns about disclosure and lack of acceptance from their colleagues (Fokuo et al., 2017; Knaak, Mantler, & Szeto, 2017). In addition, it has been reported in several studies that insufficient mental health related knowledge among healthcare professionals and students might lead to higher levels of stigma, prejudice, and social distance when these individuals are faced with mentally unwell patients (Bingham & O’Brien, 2018; Chernomas & Shapiro, 2013; Fokuo et al., 2017; Giandinoto, Stephenson, & Edward, 2018; Knaak et al., 2017; Mak et al., 2015). In particular, nurses often spend considerably more time providing patient care than other healthcare professionals. These obstacles likely hinder nurses’ motivation and ability to provide quality holistic care. Accordingly, relevant pre-registration education for nursing students that establishes a holistic and positive view of people with mental disorders may better facilitate the needs of these patients. The MHFA programme is an effective standardised psychoeducational training programme that was established in Australia in 2000. It aims to enhance attendees’ knowledge of general mental health and common mental problems such as anxiety, depression, and psychosis, and the self-harming behaviours that can be triggered by these problems, with the aim of supporting people with mental health problems (Kitchener & Jorm, 2002). In the last decade, several evaluations of diverse target populations in various countries, including nursing students, have demonstrated the effects of MHFA training (Bond, Jorm, Kitchener, & Reavley, 2015; Burns et al., 2017; Davies, Beever, & Glazebrook, 2018; Hung, Lam, & Chow, 2019; Kelly & Birks, 2017; Svensson & Hansson, 2014; Wong, Lau, Kwok, Wong, & Tori, 2017). A recent systematic review and meta-analysis of 18 studies of MHFA training with 5936 participants demonstrated that the training significantly improved the participants’ knowledge and identification of mental illnesses, increased their awareness of effective treatments for these illnesses, and improved their confidence when assisting individuals with mental health problems (Morgan, Ross, & Reavley, 2018). In addition, in a recent qualitative study of nursing students’ experience of MHFA training conducted by the first two authors of this paper, the participants reported gaining a greater awareness of the importance of their own mental wellbeing from the programme (Hung et al., 2019). 2.1. Participants and procedures The eligible participants were all students who (a) were at least 18 years of age, (b) were enrolled in an undergraduate general nursing programme, and (c) could understand both Chinese and English language materials. The study setting was one of the largest tertiary institutions in Hong Kong, which provides several undergraduate general nursing programmes for more than 1600 nursing students. The estimated minimum sample size was 128 per group in a two-group statistical analysis, assuming an effect size of 0.5, a desired power of 0.8 and an ␣ level of 0.05 (Cunningham & McCrumGardner, 2007). 2.2. Ethical considerations After receiving ethical approval for the study from the Research Ethics Sub-Committee of the participating institution, general nursing undergraduate students were invited to join the study through class announcements and emails in April 2017. Three hundred and fifty-eight eligible students were enrolled within one week during May 2017. The participants were supplied with an information sheet that clearly described the purpose, procedure, risks, and benefits of the study, and the voluntary nature of participation. They were also informed of their ability to withdraw from the study at any time without any negative consequences. Informed consent was then obtained from all of the participants. 2.3. Data collection and intervention The first author (HSYM) generated a random allocation sequence table. Two research assistants were responsible for then enrolling and assigning the participants to either the experimental group or a waitlisted control group. Self-administrated questionnaires were used to collect data immediately after randomisation (pre-test), after participation in the 12-hour MHFA programme (post-test), and six months after completion (follow-up). Fig. 1 shows a flow diagram of different stages of the study. During the face-to-face MHFA training sessions (Hong Kong version) conducted by certified MHFA instructors in Cantonese with English supplementation, the participants were given an overview of the main classifications of mental health disorders, such as anxiety, depression, psychosis, and related manifestations, such as substance abuse. Please cite this article in press as: Hung, M. S. Y., et al. Effectiveness of the Mental Health First Aid programme for general nursing students in Hong Kong: A randomised controlled trial. Collegian (2020), https://doi.org/10.1016/j.colegn.2020.04.006 G Model COLEGN-700; No. of Pages 8 ARTICLE IN PRESS M.S.Y. Hung et al. / Collegian xxx (2020) xxx–xxx Fig. 1. The stages of the study. The Chinese version of MHFA manual (Hong Kong 3rd Edition) (The Mental Health Association of Hong Kong, 2015) and an information booklet about local mental health resources were distributed to each participant. Each three-hour training session comprised small-group interactive teaching and learning activities, and four sessions were administered over a one-month period. During these sessions, the participating students learned not only the signs and symptoms, possible risk factors, and crises associated with these mental health problems, but also strategies to help those suffering from these problems. In the experimental group, 168 of the 182 students completed MHFA training and the posttest questionnaire during mid-2017, and 167 students completed the follow-up questionnaire early in 2018. Meanwhile, 175 and 165 of the 176 students in the control group completed the post-test and follow-up questionnaires, respectively. After completing the follow-up questionnaire, the participants in the control group also underwent MHFA training, as this was expected to benefit all the participants. Overall, 20 12-hour MHFA training classes comprising approximately 15–20 students were provided for the experimental and waitlisted groups in this study. 3 tal illness. Their knowledge and beliefs of students regarding the ‘helpfulness’ of different professionals, such as general physicians, clinical psychologists, and counsellors, who can offer assistance to people with mental health problems (i.e., professional consensus) and appropriate treatment decisions (i.e., beliefs about treatment) were also assessed. Each correct answer received one mark, and a higher score indicated better mental health knowledge. For the social distance scale, five types of interpersonal relationship were used to describe the participant’s willingness to have a relationship with a person who has mental health problems, such as living in a neighbourhood or marrying into a family with a person who has mental health problems. These items were scored on a 4point Likert scale ranging from 1 (definitely would) to 4 (definitely would not). A higher mean score indicated greater social distance. The reliability coefficients for the social distance scale ranged from 0.86 to 0.93, which demonstrated good internal consistency. In addition, nursing students were asked about their confidence in their ability to provide assistance to individuals with mental health disorders. They were required to respond to this item on a 5-point Likert scale ranging from 1 (not confident at all) to 5 (extremely confident). For the assessment of mental health first-aid intentions, the participants were asked whether they had observed mental health problems themselves during the past six months, in their family members or friends or anyone else they knew, and if so, what kinds of assistance or MHFA actions they had been able to offer. One mark was given to each action that was based on the ‘ALGEE’ action plan (Kitchener, Jorm, & Kelly, 2017), comprising assessment of the risk of harm or suicidal plan, listening non-judgementally to the person’s problems and encouraging the person to talk with family members or others. A higher score indicated that more MHFA actions had been performed. 2.6. Chinese Health Questionnaire (CHQ) The CHQ was selected to measure the students’ mental health. This tool was developed to screen for minor mental health problems (e.g., symptoms of general psychological distress or minor psychiatric disorders) in the general population, including adolescents in community settings (Cheng, Wu, Chong, & Williams, 1990). It assesses the participant’s mental health status at the time of the interview relative to his or her usual state. The CHQ comprises 12 items, such as ‘Have you been suffering from a headache or pressure in your head?’ Each item is scored on a 4-point Likert scale ranging from 1 (never) to 4 (more than usual), and summed to calculate a mean score. A lower score indicates better mental health, and a higher score represents more psychological distress. The reliability coefficients for the CHQ ranged from 0.83 to 0.86, displaying satisfactory internal consistency. 2.4. Outcome measures 2.7. Data analysis The outcomes were measured in terms of local relevance and application, according to the participants’ self-completed responses to two well-validated questionnaires: the Mental Health Literacy Scale (Chinese version) and the Chinese Health Questionnaire (CHQ). IBM SPSS-Statistics 23 was used for the data analysis, which was conducted on an intention-to-treat basis. The missing data for every outcome measure were imputed by using the last-observationcarried-forward method. 2.5. Mental Health Literacy Scale (Chinese version) 3. Results Mental health literacy was evaluated using the Mental Health Literacy Scale (Chinese version), which comprises two scenarios of major depression and schizophrenia that fulfil the indicative standards in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (Wong, Lam, & Poon, 2010). The scale assessed the participants’ recognition of mental health disorders, awareness of mental health problems, and knowledge of treatments for men- The participants comprised 358 nursing students (63 (17.6%) male and 295 (82.4%) female). Table 1 shows the descriptive statistics for the experimental and control groups, respectively. The 358 students were randomised into either the experimental group (n = 182) or the control group (n = 176). Twenty-five (13.9%) participants in the experimental group and 14 (8%) in the control group had previously undergone mental health training, and 59 Please cite this article in press as: Hung, M. S. Y., et al. Effectiveness of the Mental Health First Aid programme for general nursing students in Hong Kong: A randomised controlled trial. Collegian (2020), https://doi.org/10.1016/j.colegn.2020.04.006 G Model COLEGN-700; No. of Pages 8 ARTICLE IN PRESS M.S.Y. Hung et al. / Collegian xxx (2020) xxx–xxx 4 Table 1 Descriptive statistics for the experimental and control group Experimental group Mean ± SD N Gender Male Female Age Previous training on mental health training Mental health issues in self Control group Frequency Percentage Mean ± SD 182 Frequency Percentage 176 36 146 19.9% 80.1% 25 59 13.9 32.8 20.80 ± 1.91 27 149 15.3% 84.7% 14 68 8.0% 36.8 20.76 ± 1.91 (32.8%) and 68 (38.6%) participants in the experimental and control groups, respectively, had experienced problems with their own mental health. A chi-square test and independent samples t-test found no significant differences between the experimental and control groups in terms of sex [␹ 2 (1) = 1.27, p = 0.26], age [t (354) = 0.27, p = 0.82], or previous training in mental health [␹2 (1) = 3.32, p = 0.07]. A repeated-measures analysis of variance with GreenhouseGeisser correction was used to investigate the effectiveness of MHFA training. Table 2 provides the means, standard deviations, within-subject variances, and effect sizes of the outcome measures. Significant interaction effects were observed across the pre-test, post-test, and follow-up assessments of the depression scenario, including recognition of depression [F (2,355) = 36.56, p < 0.01, ␩p2 = 0.17], professional consensus [F (2,355) = 3.82, p < 0.05, ␩p2 = 0.02], beliefs about treatment [F (2,355) 4.28, p < 0.05, ␩p = 0.02], and social distance [F (2,355) = 47.01, p < 0.01, ␩p2 = 0.20]; the schizophrenia scenario, including recognition of schizophrenia [F (2,355) = 33.94, p < 0.01, ␩p2 = 0.16], professional consensus [F (2,355) = 6.28, p < 0.01, ␩p2 = 0.03], beliefs about treatment [F (2,355) = 7.50, p < 0.01, ␩p2 = 0.04], and social distance [F (2,355) = 81.35, p < 0.01, ␩p2 = 0.31]; confidence in the ability to help [F (2,355) = 7.53, p < 0.01, ␩p2 = 0.04]; mental health first-aid action [F (2,355) = 5.92, p < 0.01, ␩p2 = 0.08]; and mental health status in the CHQ [F (2,355) = 31.69, p < 0.01, ␩p2 = 0.15]. Furthermore, a post hoc Bonferroni correction revealed that the MHFA training improved the participants’ scores between the pre-test and post-test for the depression scenario, including recognition of depression (Cohen’s d = −1.10, p < 0.01) and social distance (Cohen’s d = 0.88, p < 0.01), and the schizophrenia scenario, including recognition of schizophrenia (Cohen’s d = 1.44, p < 0.01), social distance (Cohen’s d = 1.15, p < 0.01), confidence in the ability to provide help (Cohen’s d = −0.34, p < 0.01), and the CHQ score (Cohen’s d = 0.76, p < 0.01). This effectiveness was sustained at the six-month follow-up assessment for all of the measures except the CHQ score. Although no significant differences were observed between the pre-test and post-test in beliefs about treatment for the depression scenario, professional consensus for the schizophrenia scenario, or mental health first aid action, these measures showed significant improvement at the six-month follow-up assessment. In terms of mental health first-aid action, 125 participants (86 [68.8%] in the experimental group and 39 [31.2%] in the control group) reported having had contact with individuals with mental health problems within six months of receiving the MHFA training. Of these students, only ten (four and six students in the experimental and control groups, respectively) revealed that they had not offered any help or support to these individuals. The ALGEE skills commonly used by the study participants included listening to the individual’s problems in a non-judgemental manner (80 in the experimental group; 36 in the control group), encouraging the individual to discuss their concerns (80 in the experimental group; 35 in the control group), encouraging the individual to seek support from their relatives (56 in the experimental group; 21 in the control group) and professionals (51 in the experimental group; 17 in the control group), and accompanying the individual to seek help and advice (30 in the experimental group; 5 in the control group). 4. Discussion The results of this study indicate the effectiveness of MHFA training for undergraduate nursing students in terms of enhancing their mental health literacy, confidence in helping others, mental health first-aid action and mental wellbeing, and reducing their social distance from people with mental disorders. This face-to-face MHFA training course, which comprised small-group interactive teaching and learning activities, aroused the participants’ learning interest and active involvement and enhanced their knowledge and practical skills, which echoed the findings of previous studies (Hung et al., 2019; Kelly & Birks, 2017). The feedback from a pilot randomised controlled e-learning MHFA study of UK medical students expressed difficulties in practising new skills via eLearning (Davies et al., 2018); however, another study recommended that a blended strategy that combined face-to-face training with online learning might be more favourable and effective than an approach based only on face-to-face or e-learning (Bond et al., 2015; Liu et al., 2016). 4.1. Mental health literacy Notably, this study demonstrated the ability of MHFA training to increase the mental health knowledge of the participating nursing students, as evidenced by the increased recognition of mental illness (depression and schizophrenia) and improved understanding of the roles of relevant professionals, medication, and treatment available to assist people with mental health problems. The greatest gain was observed in the recognition of mental illness. The improvement was expected because the MHFA programme had been specifically developed to enhance the recipients’ recognition of mental illness. These results are consistent with those of local and foreign studies conducted with healthcare students (Bond et al., 2015; Burns et al., 2017; Davies et al., 2018; Hung et al., 2019; Kelly & Birks, 2017, with the Hong Kong public (Wong et al., 2017) and in Chinese-speaking communities in Australia (Lam et al., 2010). The programme also emphasised the importance of early treatment and clearly delineated the roles of various healthcare professionals in treating people with mental disorders (Wong et al., 2017). However, in line with other studies (Burns et al., 2017; Jorm, Kitchener, Sawyer, Scales, & Cvetkovski, 2010), a slight decrease in knowledge of treatments for mental illness and helpfulness from different professionals was observed in the post-test compared to the six-month follow-up assessment. This attenuation reflects the need for regular refreshment or further professional development to reinforce the learned knowledge. Mental illnesses present substantial challenges to healthcare professionals worldwide, especially in general hospital settings in which patients often present with mental and physical comorbidities (Vasiliadis, Lamoureux-Lamarche, & Guerra, 2017). Although Please cite this article in press as: Hung, M. S. Y., et al. Effectiveness of the Mental Health First Aid programme for general nursing students in Hong Kong: A randomised controlled trial. Collegian (2020), https://doi.org/10.1016/j.colegn.2020.04.006 G Model ARTICLE IN PRESS COLEGN-700; No. of Pages 8 Pre–follow- up Cohen’s d −1.46** −0.10 0.05** 0.78** −1.28** −0.03* −0.09 0.92** −0.28** −1.32** 0.48 Pre– Post Cohen’s d −1.10** −0.26 −0.17 0.88** −1.44** −0.25 −0.21 1.15** −0.34* 0.06 0.76** M.S.Y. Hung et al. / Collegian xxx (2020) xxx–xxx 5 MHFA training is not intended to replace mental health nursing education in the curriculum (Kelly & Birks, 2017; Kitchener & Jorm, 2017), the general nursing students in this study were expected to use mental health first-aid skills after their training to provide assistance and to refer people efficiently and effectively to mental health professionals and local resources. The valuable and relevant information provided in the MHFA programme not only enhanced the mental health knowledge and practical skills of the general nursing students but also helped to consolidate what they had learned during their general nursing training (Hung et al., 2019). 0.04** 0.08** 0.15** 7.53 5.92 31.69 Repeated-measures analysis of variance with Greenhouse-Geisser and post hoc Bonferroni correction were performed. SD, standard deviation. * p < 0.05. ** p < 0.01. 3.20 (0.76) 3.87 (0.95) 2.21 (0.47) 3.11 (0.68) 4.34 (2.20) 1.82 (0.43) 2.94 (0.80) 2.17 (2.67) 2.09 (0.49) 3.17 (0.75) 1.18 (2.04) 1.72 (0.36) 2.89 (0.85) 1.33 (2.35) 2.04 (0.47) Confidence in ability to help Mental health first aid action Chinese Health Questionnaire 2.94 (0.87) 2.23 (2.70) 2.10 (0.42) 0.16** 0.03** 0.04** 0.31** 33.94 6.28 7.50 81.35 2.34 (0.58) 4.25 (1.93) 5.31 (2.37) 2.88 (0.63) 2.87 (0.33) 4.89 (1.82) 6.08 (2.33) 2.21 (0.56) 2.32 (0.46) 4.69 (1.50) 5.49 (1.87) 2.85 (0.59) 2.91 (0.28) 5.23 (1.69) 6.33 (2.25) 2.07 (0.59) 2.35 (0.47) 4.84 (1.30) 5.89 (1.79) 2.71 (0.52) Schizophrenia scenario Recognition of schizophrenia Professional consensus Beliefs about treatment Social distance 2.24 (0.46) 4.89 (1.23) 5.93 (1.52) 2.72 (0.56) 36.56 3.82 4.28 47.01 2.29 (0.57) 4.75 (1.68) 5.43 (1.99) 2.13 (0.54) 2.82 (0.41) 5.08 (1.75) 5.97 (2.17) 1.74 (0.54) 2.25 (0.55) 5.04 (1.13) 5.71 (1.40) 2.25 (0.54) 2.71 (0.48) 5.30 (1.65) 6.35 (2.12) 1.70 (0.51) 2.15 (0.45) 5.12 (1.04) 6.03 (1.20) 2.15 (0.47) 2.21 (0.42) 4.93 (1.13) 6.06 (1.13) 2.16 (0.53) Depression scenario Recognition of depression Professional consensus Beliefs about treatment Social distance Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Experimental Experimental Mean (SD) Experimental Post-test Control Pre-test Table 2 Comparison of various measurements at pre-test, post-test and follow-up Control Follow-up Control F (time*group effect) 0.17** 0.02* 0.02* 0.20** Partial Eta Sq. 4.2. Social distance Several studies have reported that insufficient mental health related knowledge among healthcare professionals and students might lead to higher levels of stigma, prejudice and social distance when these individuals face mentally unwell patients (Bingham & O’Brien, 2018; Chernomas & Shapiro, 2013; Fokuo et al., 2017; Henderson et al., 2014; Giandinoto et al., 2018; Knaak et al., 2017; Mak et al., 2015). An Australian survey that compared the attitudes of healthcare professionals, such as psychiatrists, clinical psychologists, and general practitioners, with those of the general community, found that women and general practitioners were prone to have more personal stigmatising attitudes about mentally ill patients, and maintain greater social distance from these individuals, than men and psychologists, respectively (Reavley, Mackinnon, Morgan, & Jorm, 2014). A local study of healthcare professionals and students in Hong Kong found that doctors maintained the greatest social distance and social workers maintained the smallest social distance from individuals with mental illness, whereas nursing students maintained less social distance from individuals with bipolar disorder or schizophrenia than social work students (Mak et al., 2015). Despite the differences in the magnitudes of these attitudes, all likely hinder the professional’s motivation and ability to provide quality holistic care. It is therefore the development and implementation of relevant strategies to reduce stigma and social distance in the healthcare system are significant (Knaak et al., 2017). In line with other results, this study demonstrated that MHFA training could decrease the perceived social distance among nursing student participants (Bond et al., 2015; Burns et al., 2017; Hung et al., 2019). In a recent qualitative study that explored nursing students’ experiences three months after MHFA training, the participants reported that the MHFA programme had improved their beliefs and values (Hung et al., 2019). Specifically, they had acquired the belief that nurses should present a neutral, therapeutic attitude towards and become more accepting of people with mental illness. This demonstrates that improvements in mental health literacy can help these students to normalise mental health problems and dispel the myths that surround these problems, thus decreasing stigmatisation and social distancing from people with mental illness. However, the stigma of mental illness, including self-stigma as well as family and public stigma, is deeply rooted in Chinese communities, and those with mental disorders are perceived as dangerous, impulsive and uncontrollable (Lam et al., 2010). Given this cultural background, the individuals and their families are often criticised and blamed because they are believed to be responsible for the illness. This moralising view further frustrates the individuals and their families, who often already experience feelings of shame or guilt when seeking help and treatment, leading to greater social distancing from others (Lam et al., 2010). Thus, local government and healthcare organiszations are optimally positioned to support these families and to promote compassionate and altruistic attitudes and behaviours towards those in society suffering from mental illness. Please cite this article in press as: Hung, M. S. Y., et al. Effectiveness of the Mental Health First Aid programme for general nursing students in Hong Kong: A randomised controlled trial. Collegian (2020), https://doi.org/10.1016/j.colegn.2020.04.006 G Model COLEGN-700; No. of Pages 8 ARTICLE IN PRESS M.S.Y. Hung et al. / Collegian xxx (2020) xxx–xxx 6 4.3. Confidence in the ability to help and mental health first aid action Consistent with the findings of previous studies, the MHFA intervention was effective in increasing medical and nursing students’ confidence in providing help and support to people with mental problems (Bond et al., 2015; Burns et al., 2017; Kitchener & Jorm, 2002; Hadlaczky, Hökby, Mkrtchian, Carli, & Wasserman, 2014). The student participants acquired a greater understanding of mental disorders, including of the associated signs, symptoms, and crises, which may have reduced the stigma and social distance and increased their confidence in communicating and assisting individuals with mental disorders. It was clear that the participants in the experimental group were more willing than those in the control group to identify and offer help to those in need, which is in agreement with the finding of another study that the participants became more competent in identifying ways to help (Hung et al., 2019). The participants learned basic ALGEE engagement skills during training via interactive teaching and learning activities, such as role-playing. A possible explanation for this observation may be that the participants were future ‘helping professionals’ and were therefore more inclined to feel compassion and care for others. In addition, nearly half of the study’s participants (173; 48.3%) reported that a friend or relative had encountered mental health problems. The skills they had learned from these experiences had likely bolstered their readiness to encounter and interact helpfully with individuals in society or patients in their future workplace suffering from mental health problems. Furthermore, it was notable that an enhanced sense of achievement and satisfaction was reported by the nursing students after practising their skills and providing help for their peers or relatives (Hung et al., 2019). They found that performing MHFA for family members and friends was a positive and valuable experience. The members of other helping professions, such as teachers, have also reported gaining confidence in their ability to assist students and colleagues after completing the MHFA course (Jorm et al., 2010). 4.4. Students’ mental health Evidence suggests that healthcare students both locally and globally often experience high levels of mental distress (Cheung et al., 2016; He et al., 2018; Sun et al., 2016) and may have suicidal ideation due to the high academic and social demands of their professional training (Mospan et al., 2017; Rotenstein et al., 2016). In Hong Kong, 20.0%, 24.3%, and 39.9% of nursing students reported modest to exceptionally severe levels of stress, depression, and anxiety, respectively (Cheung et al., 2016), and the most common stressor was a lack of professional knowledge and skills (Chan, So, & Fong, 2009). Similarly, more than one-third of participants in this study (127; 35.5%) had experienced problems with their own mental health. The initial evidence from this study, gleaned from repeated use of the CHQ, demonstrated that the MHFA training improved the student participants’ mental health as a secondary effect that was maintained for six months. These results are consistent with international evaluations of MHFA training, which have reported its positive effects on the mental health of teenagers and medical and nursing students (Bond et al., 2015; Davies et al., 2018) and its potential to intensify nursing students’ self-awareness of their personal mental health (Hung et al., 2019). The student participants mentioned that they encountered various kinds of stressors each day, including study workload and peer relationships. After the MHFA training, they were more conscious of and attentive to their own mental status when handling such life challenges. In Hong Kong, general nursing and psychiatric nursing are the two predominant registration streams in the field. This study mainly targeted general nursing students, who receive limited theoretical mental health education (a minimum of 40 hours) and clinical practicum (a minimum of 60 hours) during their nursing training (The Nursing Council of Hong Kong, 2017). Although recent studies have aroused concerns and discussion regarding the role of MHFA training in Australian undergraduate mental health nursing education (Happell & McAllister, 2015; Kitchener & Jorm, 2017), the advantages of MHFA for local general nursing students cannot be underestimated. MHFA training is not intended to replace mental health education in the pre-registration nursing curriculum (Happell & McAllister, 2015; Kitchener & Jorm, 2017), but it clearly can enrich the mental-health knowledge of future general nurses, and thereby help them provide holistic care for patients with physical and mental comorbidities in Hong Kong. In addition, we suggest that MHFA could be promoted as a compulsory subject for junior healthcare students, who lack sophistication in caring for people with mental health issues. In recent years, the WHO has globally promoted the importance of mental health in response to an increase in the prevalence of mental disorders, especially in youngsters. Local governments and non-governmental organisations have organised various health promotion and disease prevention programmes that target mental health awareness, stigma, suicide prevention, and school-based mental health promotion (World Health Organization, 2017). Thus, MHFA training could be introduced as an elective subject or extracurricular activity for all students at local colleges/universities, to improve their mental wellbeing and ability to cope with the stressors of academic life. Furthermore, tertiary institutions should review their existing curricula and provide adequate rest and leisure time with social and extracurricular activities for students, to further enhance their students’ physical and mental health (Legislative Council, HKSAR, 2017). According to a local government report, adolescents with poor mental health may achieve a low level of academic success, leading to poor employment and social adaptation (Food & Health Bureau, HKSAR, 2017). It is therefore in the interests of educational institutions to organise informative and beneficial activities, including mental health seminars/workshops and counselling sessions, to nurture an encouraging atmosphere and emphasise the significance of an environment that supports mental health, and enhances their students’ academic achievement (Legislative Council, HKSAR, 2017). 5. Conclusions In this study, we aimed to determine the effectiveness of MHFA training and explore the mental wellbeing of university-level general nursing students. Similar to other recent studies, this study confirmed the benefits of the MHFA programme for healthcare students in Hong Kong and other countries. The students’ awareness of their own mental wellbeing was also enhanced after training. We therefore suggest that the local promotion of MHFA training will empower adolescents to develop good mental health status and mental wellbeing, to optimise their potential and strengthen their ability to overcome later hardships in life. 6. Implications The evidence from this study shows that MHFA training should be promoted and integrated as compulsory training and as part of extracurricular activities for healthcare and general college/university students locally and globally. It would also be Please cite this article in press as: Hung, M. S. Y., et al. Effectiveness of the Mental Health First Aid programme for general nursing students in Hong Kong: A randomised controlled trial. Collegian (2020), https://doi.org/10.1016/j.colegn.2020.04.006 G Model COLEGN-700; No. of Pages 8 ARTICLE IN PRESS M.S.Y. Hung et al. / Collegian xxx (2020) xxx–xxx interesting and important to evaluate the effects of MHFA training on the mental wellbeing of general university/college students. Further qualitative research should be conducted to determine in greater detail how the experience and application of MHFA provide an in-depth understanding of the best ways to assist people with mental health problems. In addition, MHFA training workshops are suggested for existing healthcare professionals who have not received mental health related training. 7. Limitations Finally, several important limitations must be considered. First, the study population is not representative of the general population, as general nursing students usually possess better healthcare knowledge than other students at university do. Second, some may have had prior theoretical and practical mental health nursing inputs, because the students were recruited from different years of undergraduate general nursing programmes. It may thus be wise to invite junior year students without prior training to take part in a future study. Third, the study had a higher sex ratio (63 [17.6%] male, 295 [82.4%] female) than the active registered nurses practising locally (1505 [12.2%] male, 10,812 [87.8%] female) (Department of Health, HKSAR, 2015). However, in terms of the effects of sex and previous training on mental health, no significant differences were found between the experimental and control groups. All the nursing students were recruited from a single tertiary institution, so study contamination may have occurred, although the students were also instructed to avoid disclosing any study information to their peers. Since 2005, the Mental Health Association of Hong Kong was authorised to develop the local version of MHFA Manual and to translate the manual based on the Australia MHFA training programme (The Mental Health Association of Hong Kong, 2015). However, a minor limitation is that the validity and reliability of the translated training manual had not been conducted. Funding The study was fully supported by the Competitive Research Funding Schemes for Local Self-financing Degree Sector, Research Grants Council of the Hong Kong Special Administrative Region, China (<GN1>UGC/FDS17/H01/16<GN1>). Ethical statement The study involved human research and obtained ethical approval from the Tung Wah College’s Research Ethics SubCommittee. Conflict of interest This manuscript is the authors’ original work. It has not been published and is not under consideration for publication elsewhere. The authors have accepted the copyright terms and conditions of Elsevier and the Australian College of Nursing. We had no initial contacts with Collegian regarding the manuscript. We have no conflicts of interest to disclose. We have no particular preferences regarding the selection of academic editors and reviewers to handle this manuscript. Author contribution Conceptualization and design of the study, M.S.Y.H., M.C.M.C., W.T.C., P.Y.K.W.; data curation, M.S.Y.H.; literature review and manuscript draft writing, M.S.Y.H.; manuscript review and editing, 7 M.C.M.C., W.T.C., P.Y.K.W.; funding acquisition, M.S.Y.H., M.C.M.C., W.T.C., P.Y.K.W. All authors have read and agreed to the published version of the manuscript. Acknowledgements The authors would like to thank 1) all of the nursing students who participated in this study; 2) the Mental Health Association of Hong Kong for approving the use of the Mental Health Literacy Scale (Chinese version); and 3) Dr Cheng, Andrew Tai Ann for approving the use of the CHQ. References Bingham, H., & O’Brien, A. J. (2018). Educational intervention to decrease stigmatizing attitudes of undergraduate nurses towards people with mental illness. International Journal of Mental Health Nursing, 27(1), 311–319. Bond, K. S., Jorm, A. F., Kitchener, B. A., & Reavley, N. J. (2015). 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Prudence Y.K. Wong, RSW, BSW, is the co-ordinator of Mental Health First Aid programme of the Mental Health Association of Hong Kong. Please cite this article in press as: Hung, M. S. Y., et al. Effectiveness of the Mental Health First Aid programme for general nursing students in Hong Kong: A randomised controlled trial. Collegian (2020), https://doi.org/10.1016/j.colegn.2020.04.006