Mental Health First Aid for the Armed Forces Community: evaluation scope.

Introduction

Mental health problems are common affecting around one in four adults in the UK. It is the single largest source of burden of disease and no other health condition matches mental illness in the combined extent of prevalence, persistence and breadth of impact (Centre for Economic Performance Mental Health Policy Group, 2012). Only a quarter of all those with mental illness are in treatment, compared with the vast majority of those with physical conditions (Centre for Economic Performance Mental Health Policy Group, 2012) and many only seek help after a considerable delay of many years (Wang et al., 2005). Prevalence studies suggest that we are all likely to know someone experiencing mental ill-health with thirty to fifty per-cent of the population meeting diagnostic criteria for a mental disorder at some point in their lives (WHO, 2000; Kessler et al., 2005). Yet community surveys also reveal that recognition of symptoms and awareness of helpful interventions or treatment options remains poor across the general population (Jorm et al., 2006).This is despite evidence that promoting mental health and early intervention when people first display symptoms can both improve recovery and the quality of people’s lives as well as saving considerable costs in the longer term (Knapp, M.; McDaid, D.; Parsonage, M., 2011).

Definition of Armed Forces Community

In the context of this document, the Armed Forces Community includes Veterans and Serving personnel, their families and any charities or health and social care organisations that work with this group.

Mental health and the Armed Forces Community

Those in the Armed Forces Community experience mental health problems at broadly the same rate of prevalence as other groups in the community. They are most likely to experience depression, anxiety and particularly alcohol misuse problems (Fear 2009)(Iversen, et al., 2009).Recently there has been greater focus on the prevalence of post-traumatic stress disorder (PTSD) among UK military personnel, although prevalence rates among those returning from Iraq appear relatively low (between 4–6% compared with 8–15%experienced by US counterparts) and are broadly comparable with community rates.Similar rates of mental illness are also found for ex-Service personnel and their still serving equivalents(Sundin, et al., 2010).

However, some particular patterns, problems and challenges are noted in the literature outlining the particular experiences of those with mental health needs in the Armed Forces community and their patterns of access to mental health interventions. There is evidence that:

  • those who do develop mental health problems generally fare quite badly(Fear, et al., 2009)
  • military personnel with mental health problems are more likely to leave their Service compared with those with no problems and are at risk of poorer post Service outcomes (Fear, et al., 2009).
  • Armed Service personnel and veterans often avoid or significantly delay seeking appropriate help and treatment (Iverson, et al., 2011)(Iversen, et al., 2010)
  • Armed Service personnel sometimes do not know where to go (Iverson, et al., 2011)
  • Stigma and lack of trust or confidence in providers of mental health services represent some of the main barriers to seeking help in serving personnel(Britt, 2000)(Langston, et al., 2007)(Rona, et al., 2004)(Greene-Shortridge, et al., 2007). Admitting a psychological problem was anticipated as much more stigmatising than admitting a physical health problem among soldiers returning from Bosnia (Britt, 2000).Some stigma has been associated with a reluctance to disclose vulnerability in a profession which sets great store by physical and psychological resilience in the face of adversity. Some stigma is also linked to fears of being blamed by their employer and that that disclosure may have a negative impact on careers(Britt, 2000) (Langston, et al., 2007)(Iverson, et al., 2011).
  • Furthermore, access to appropriate treatment services has been historically problematic. Although treatment rates generally are on a par with those of the general population (which in itself involves low levels of access to help), one study noted an overall treatment rate of 13% fora sample of UK Armed Forces personnel, around half that found for the general population(Iversen, et al., 2010).

Such delays potentially hinder critical opportunities for early intervention and jeopardise effective recovery.

Relative to other service personnel, the following groups were identified with poorer mental health prospects in the Armed Services Community:

  • those deployed to Iraq or Afghanistan with pre Service vulnerabilities
  • those deployed to Iraq or Afghanistan who were exposed to high levels of combat
  • Reservists compared with Regulars; reservists have been noted to have the poorest mental health
  • early service leavers
  • younger male ex-Service personnel (under the age of 24 years); this age group has higher rates of suicide than their general population equivalent.

(Iversen, et al., 2009)(Fear, et al., 2010)(Harvey, et al., 2011)(Buckman, et al., 2012)(Woodhead, et al., 2011a)(Woodhead, et al., 2011b)

When Armed Forces Personnel with a mental health problem seek help, there is evidence that they prefer informal support through a spouse or friend (between 73–85%). Only a quarter of thosewith a diagnosed mental health problem accessed medical help. Similarly, just under aquarter (23%) with alcohol problems had sought professional help, which was lower thanthose with depression and anxiety where 50% sought help. Regulars and Reservists did notdiffer in their help-seeking behaviours. Common treatments included medication and counselling/psychotherapy (Iversen, et al., 2010).

The policy context

Recent governments haverecognised ex-Service personnel as a group needing support for potential mental health problems as set out in the Department of Health’s New Horizons mental health strategy (Department of Health, 2009) and its replacement ‘No health without Mental Health’ (Department of Health, 2011). In 2010, the Murrison review(2010) produced a number of recommendations designed to strengthen mental health services for service personnel and veterans. One recommendation identified the need to test out improved early intervention approaches and services for serving personnel and veterans. Efforts to improve provision were further bolstered by the Military Covenant which enshrines in law society’s obligation to and duty of care for serving personnel for sacrifices made (Forster, 2012). As part of this Covenant, proposals were introduced for improving mental health care provision, extending access to mental health care to six months after discharge, increasing the number of mental health nurses for veterans and establishing a 24-hour helpline and website for support and advice (Minstry of Defence, 2011). This obligation has recently paved the way for a ring-fenced healthcare budget supporting veteran mental health care (although the sustainability of this funding remains uncertain).

Mental Health First Aid for the Armed Services Community

In 2013 SSAFA (the Soldiers, Sailors, Airmen and Families Association) MHFA England CIC,Combat Stress and theRoyal British Legion formed a collaboration to deliver Mental Health First Aid (MHFA) for the Armed Forces Community which aims to improve early identification and access to support. The project aims to train approximately 180 instructors from across 5 target groups - Health & Social Care professionals, voluntary/charitable services, friends and family, veterans and serving personnel. Once trained, these individuals will take back and deliver training in their own communities, with an ultimate aim to skill up approximately 6,600 Armed Forces Community Mental Health First Aiders. Because of the broad reach of this initiative, trainers and ultimate beneficiaries of identification, support and referral into services may be in both Armed Service and civilian settings. A small proportion of trainers and beneficiaries may be stationed abroad.

MHFA seeks to improve mental health literacy,improve identification, improve access to support and reduce stigma. The intervention seeks to achieve aims through improving knowledge, attitudes and behaviour of trainees so that they are better equipped to identify and respond to poor mental health among Armed Forces personnel and their families.

It seeks to achieve change in the following ways.

Improving knowledge

  1. Helping those trained up in MHFA:
  2. recognize the early signs of a mental health problems
  3. know what types of help are available and best suited to the needs of potential beneficiaries

Improving attitudes

  • Helping those trained up in MHFAfeel more confident when helping someone experiencing mental health problems
  • Helping reduce the stigma of mental health problems

Changing behaviour

  1. Helping First Aiders:
  2. provide initial helpon a ‘first aid’ basis
  3. guide a person towards appropriate professional help

The evidence underpinning initiatives to improve mental health literacy

Mental health literacy is an overarching term describing the beliefs, attitudes and abilities required to promote mental wellbeing and aid appropriate use of mental health services(Jorm, et al., 1997)(Jorm, 2000). The evidence base for MHFA-type interventions is still emerging. Such interventions arenoted to increase knowledge, confidence and skills in recognising mental health problems. There is also some limited evidence of reductions in stigma occurring after the intervention in various settings(Kelly, et al., 2007)(Jorm, et al., 2010)(Welsh Assembly Health Improvement Initiative, 2012) .Mental health literacy-based training has also sometimes been shown to improve the mental health and wellbeing of those being trained up in the intervention(Kitchener & Jorm, 2004).

Providing knowledge about mental disorders and their treatment has been shown to be a promising way to increase readiness to seek help (Esters, et al., 1998)(Han, et al., 2006)(Wright, et al., 2007)(Jorm, et al., 2003). Intervention studies also show that de-stigmatisation may lead to increased readiness to seek professional help(Schomerus & Angermeyer, 2008). The belief that seeking help for a mental health problem will be helpful has also been shown to be at the core of help seeking intentions and thus offers a promising target of information programmes(Schomerus & Angermeyer, 2008).

There issomeadditional evidence that participants in mental health literacy programmes will intervene when they recognise potential mental health distress but less consistent and convincing evidence that interventions result in improved access to professional services for those identified with mental health problems(Jorm & Kelly, 2007). There is also, as yet, limited evidence of effects lasting beyond 6 months(Welsh Assembly Health Improvement Initiative, 2012). Finally, there is no evidence as yet that widespread mental health first aid training has the potential to impact on population mental health outcomes(Kitchener & Jorm, 2006)(Kelly, et al., 2007)(Welsh Assembly Health Improvement Initiative, 2012).

The scope of this evaluation tender

This evaluation seeks to contribute to the current evidence base on mental health literacy training through evaluating the extent to which MHFA achieves its desired outcomes in the Armed Forces Community. The contractor will be required to design and undertake an evaluation study of MHFA for the Armed Forces Community that answers the following evaluation questions:

  1. To what extent have first aiders used the techniques they have been taught (e.g. the ALGEE tool), with how many people and to what effect?
  2. To what extent does MHFA for the Armed Forces:

a)improve First Aiders’ knowledge

b)reduce First Aiders’ stigmatising attitudes

c)improve First Aiders’ confidence in dealing with MH distress

d)improve First Aiders’ response to mental health distress following training (e.g. either delivering first aid directly and/or referring people in mental health distress on to appropriate services).

  1. To what extent do any changes persist over time?
  2. How useful do First Aiders find the training they receive and what improvements would they recommend?
  3. To what extent does MHFA improve access to support and treatment for those with poor mental health among the Armed Forces Community?
  4. What effect does first aid training have on the wellbeing of those trained up in MHFA and on the ultimate beneficiaries of the intervention?
  5. How much do beneficiaries value the help they receive and what improvements would they recommend?
  6. How effectively is the MHFA intervention being implemented?

The evaluation study will collect and analyse primary and secondary data and triangulate and analyse a range of quantitative and qualitativedata. The team will have access to MHFA in the Armed Forces Community pre and post training course evaluation data (see Appendix one) but will also need to introduce additional pre and post data collection methods to measure outcomes. Where additional data requirements are required by the contractor, these will need appropriate approvals and data collection processes to be identified.

There is a need to understand the longevity of effect of training on the attitudes and behaviour of First Aiders. The contractor would be expected to build into the design of the methodology the ability to track and measure longer term mental health outcomes resulting from the intervention on those trained. It would also aim to explore the effect of the intervention on those assisted through the scheme.

Finally, during the process of this study, the evaluation should examine aspects of implementation of the programme and, based on findings, provide recommendations to improve the quality and efficiency of delivery in Armed Forces settings.

Time scale and reporting requirements

The start and termination date of this contract will be confirmed once the suitable partner has been identified and proposal agreed. On initiation, progress reports will be expected quarterly.

A publishable evidence-based full evaluation reportwill be produced describing the findings from this evaluation by end 2015. The report will also include analysis of the process of delivery, making recommendations for the improvement of its effectiveness.

Requirements

The contractor will be required to:

  • design an evaluation study that measures the extent to which MHFA achieves its desired outcomes.
  • in conjunction with the Evaluation Programme Manager and the MHFA for the Armed Forces Steering Group:
  • identify, draw together and embed in practice a suite of measurement tools which can reliably track pre and post training outcomes and shifts in knowledge, attitudes, behaviour and wellbeing.
  • ensure that all ethical approvals and information governance requirements are met, and that data is held securely in line with appropriate regulations.
  • oversee and co-ordinate data collection and analysis across all sites and capture and analyse all MHFA pre and post evaluation data for new trainees over a 6 month period.
  • develop a project plan that will enable the contractor to meet the required deadlines for the specified outcomes and budget
  • triangulate quantitative and qualitative data on First Aiders and beneficiaries to answer the evaluation questions
  • assess the extent to which any shifts in knowledge, attitudes and behaviour persist over time
  • provide information on the process of implementation and delivery contributing to continuous improvements in implementation effectiveness
  • establish an expert reference group incorporating a range of stakeholders (including the views of mental health service users).
  • introduce a system, with MHFA for the Armed Services Community, for seeking consent and following up any beneficiaries of those trained up in MHFA competencies.
  • complete qualitative interviews with a small cohort of those who have been helped by or referred onto support through the MHFA.
  • hold overarching responsibility for the delivery and quality assurance of progress reports and a full evaluation report prepared using an agreed template. The final reports should also have a clear and concise Executive Summary.
  • agree with the Evaluation Programme Managerrisk management and issue resolution mechanisms
  • ensure that a consistent methodology is used throughout.

The specific skills and knowledge required from the contractor should include:

  • Project Management
  • Competencies in:
  • the design and analysis of mixed methods evaluations
  • the design and analysis of process evaluation methodologies
  • data collection and data analysis
  • maximising service user participation
  • report writing with particular skills in translating academic findings into a format that supports policy and practice development
  • Knowledge and understanding of:
  • Young adult and adult mental health
  • health promotion and the prevention of poor mental health
  • help-seekingand stigma in the field of mental health
  • early intervention approaches in mental health
  • programme implementation theory
  • thepolicy and mental health service landscape for those linked with the Armed Services including demonstrating an understanding of public sector services and voluntary sector roles.
  • Understanding differential impact of service provision in terms of age, gender, BME, sexuality and transgender issues, etc
Process and responsibilities
  1. MHFA for the Armed Services Community The Authority will:
  • Identify and secure the cooperation of the cohort of MHFA intervention sites and trainees to take part in the study.
  • Identify representatives from MHFA for the Armed Forces Community, including an Evaluation Project Manager to work with the contractor as part of the MHFA Steering Group.
  1. The Contractor will:
  • Attend the MHFA Steering Group
  • Perform quality assurance on all aspects of the programme
  • Provide MHFA for the Armed Services Community with timely and ongoing evaluation and quality assurance information relating to the programme
Contract management and monitoring

The key performance indicators for this Contract shall include, as a minimum:

  • That work is of an acceptable quality and delivered to agreed timescales
  • The work is consistent with any other policy developments taking place
  • That work is cleared through any particular Ministry of Defence requirements or clearances.

The Contractor shall:

  • Monitor the quality of service provision to ensure customer satisfaction in accordance with the key performance indicators outlined in the Contract, unless otherwise approved by the Evaluation Programme Manager.
  • Provide a report on progress to the Evaluation Programme Manager as agreed.
  • Attend any agreed meetings?
Budget

MHFA for the Armed Service Community has made available a total of £49,000 inclusive of VATover the course of 18 months for the completion of this evaluation.