1 Background

The prevalence of youth mental conditions is approximately 10–20% globally [1, 2]. In high income countries (HICs), of youth in need of indicated mental health care, defined as talk therapies and/or medications to treat an identified mental health problem, 20% receive it; access in low and middle income countries (LMICs) tends to be poorer, with 1% or fewer of children in need receiving care [3,4,5]. Youth with mental health needs remain critically underserved.

A shortage of trained professionals underlies the care gap, necessitating alternative models of care to bridge it, such as task-shifting [6]. In task-shifted mental health care, non-accredited individuals, “lay counselors”, are trained and supervised by professionals to deliver indicated care, typically talk therapies, to those with clinical levels of need. In LMICs, lay counselors delivering task-shifted care have improved mental health outcomes for adults in need of care, with several studies and reviews supporting their effectiveness, including a 2013 Cochrane review updated in 2021 [7,8,9,10,11,12]. Delivering task-shifted care for children (aged 5–12 years old) has yielded mixed outcomes; community health workers (the most common lay counselor human resource) who have delivered task-shifted child mental health care have not consistently improved children’s symptoms of Post-Traumatic Stress Disorder, Depression, or Anxiety [8]. Such care requires lay counselors to have experience with children’s growing capabilities in cognition and emotion-regulation, often lacking by community health workers [13].

Teachers in LMICs may be positioned to deliver task-shifted child mental health care [13, 14]. They have experience in child development requisite for care delivery, have consistent access to children, and in real time can address children’s mental health needs [13,14,15]. Teachers in HICs have been studied to deliver indicated mental health care on a limited basis, improving symptoms of children with Conduct Disorder and Attention Deficit Hyperactivity Disorder (ADHD) [16,17,18]. By contrast, teachers in LMICs have rarely delivered task-shifted care [5, 8, 16]. Rare teacher delivery of indicated care may be due to teachers expressing: (1) being undertrained to work with students with mental health needs; (2) being overburdened with their teaching duties; and (3) that addressing their students’ mental health may not be their responsibility [14].

These factors may underlie whether teachers find it acceptable to deliver task-shifted care to their students. Acceptability is defined as an individual’s judgments of whether a specific model of care is “appropriate, fair, and reasonable” and is considered a key factor in care adoption and sustainability [19,20,21]. Han and Weiss [22] described 3 domains that affect teacher acceptability of delivering mental health interventions in classrooms, based on work by Elliott [23] and Reimers and colleagues [24]: (1) severity of a student’s target mental health concern; (2) type of care delivered; and (3) required time to deliver care.

The one study that has evaluated teachers’ acceptability of delivering task-shifted care in an LMIC found that teachers considered it acceptable to deliver care to students outside of the classroom setting [25, 26]. No studies have evaluated teacher acceptability of delivering task-shifted mental health care to their elementary school students within classroom settings, where delivering care to their students presents a potential systems-level efficiency given their familiarity with and the consistent time spent with their students [14].

Limited teacher delivery of task-shifted mental health care may also be due to child and family acceptability. To date, however, no published studies have examined the acceptability to children and their families of teacher-delivered, task-shifted mental health care in an LMIC [13]. For adolescents in an LMIC receiving task-shifted mental health care from their teachers, they expressed mixed acceptability of the care [27]. With limited literature on parent acceptability of teacher-delivered care in LMICs, insight may be gained from a relevant HIC study. Parents in this study found it acceptable for teachers to deliver indicated care, citing decreased stigma as compared to outpatient care [28].

To meet the critical global child mental health need with an eye toward implementation outcomes such as acceptability, our group created an alternative system of care called Tealeaf [Tealeaf—Mansik Swastha (Teachers Leading the Frontlines—Mental Health)] for the Darjeeling region of India. In Tealeaf, teachers are trained to deliver transdiagnostic, non-manualized, task-shifted care. As Tealeaf care is transdiagnostic, it applies “the same underlying principles across mental disorders, without tailoring the protocol to specific diagnoses” [29], thus allowing teachers to learn one set of therapeutic skills for all diagnoses. Care in Tealeaf is also non-manualized, allowing teachers to customize the care they deliver, including delivering care within classroom activities or in a more traditional one-on-one (1:1) setting. Early evidence points to teachers delivering Tealeaf care feasibly, with fidelity, and with improved mental health symptoms in children who have received Tealeaf care [30, 31].

The present study aimed to evaluate, in Darjeeling, India, an LMIC setting, the acceptability to teachers, children, and their families of Tealeaf. By studying acceptability, this study may contribute to the literature by evaluating a key prerequisite for sustainable teacher delivery of non-manualized, transdiagnostic, task-shifted child mental health care to their students, which has the potential to help bridge the wide child mental health care gap [3, 4]. Through a 2019 single-arm mixed-methods pilot pragmatic design with parallel data collection and explanatory sequential analysis (QUAN qual), we evaluated whether teachers would find delivering task-shifted mental health care to their students acceptable on top of and integrated into their regular school responsibilities and whether children and their caregivers would find receiving teacher-delivered, task-shifted mental health care in a classroom setting acceptable [32]. We hypothesized that teachers, children, and their families would find teacher-delivered, task-shifted care, i.e., Tealeaf, acceptable.

2 Methods

2.1 Setting

The study was conducted in Darjeeling, West Bengal, India. The local population is predominantly ethnically Nepali, a minority group in India, and speaks Nepali primarily [33]. A majority of residents work in tea-plantation areas and small-scale agricultural communities, with daily average wages at 176 INR ($2.42 USD) [33]. Despite this economic condition, a majority of rural families with lower incomes prefer sending their children to low cost private (LCP) schools; they perceive LCP schools as providing a high-quality education in English [34]. The number of LCP schools is growing to meet this demand, typically operating without support from the government and leading to enrolled students having poorer access to government services [35]. LCP schools charge a minimal fee and pay their teachers 1500–3000 INR ($23–45 USD) monthly [34]. Child mental health prevalence in Darjeeling is unknown, but a study in a nearby rural area estimated prevalence at 33% [2]. Similarly, access to care in Darjeeling has not been studied; an unpublished needs assessment from our group in 2017 revealed that there were 3 counselors and 1 general psychiatrist available to meet the needs of 100,000 youth. In India more broadly, 1% of children in need receive care [4].

2.2 Participants

Eligible schools were LCP primary schools in the rural areas of the Darjeeling Himalayas and employed at least 3 teachers to allow for a student body size (30–50 students) that was more likely to approximate child psychiatric morbidity estimates [1]. To reach children with the poorest access to care [34], schools were further required to meet the following inclusion criteria: (1) did not receive government aid, (2) charged < 11,500 INR ($180 USD) annual fees, and (3) served families with a daily average income < 725 INR ($10 USD).

To recruit potential schools, we held information sessions for school principals in four communities in rural Darjeeling. Nine of 12 schools attending the information sessions agreed to participate. From participating schools, eligible teachers had prior experience of teaching primary grade levels [1,2,3,4] for at least 1 year to avoid teacher acceptability being moderated by inexperience as a teacher, were aged 18 years or above, and had not been convicted of or under active investigation for child maltreatment or misconduct. All 19 teachers who provided permission to their school’s principal to provide their contact information to our team met inclusion criteria and provided informed consent to be in the study. Thirteen teachers completed all study activities. All 6 teachers who left the study did so prior to the collection of quantitative acceptability ratings. Two teachers expressed not being able to provide time for Tealeaf. Two teachers cited family reasons. Two teachers were enrolled at a school that felt less comfortable engaging with parents.

Tealeaf-trained teachers selected two students each who were in grades 1–4 (5–12 years old) to receive services based on each teacher’s judgment that is grounded in their everyday interactions with students; this method was chosen based on accuracy (as next) and to avoid any additional one-on-one interactions or screenings that may unintentionally identify to others in the classroom or school which children need mental health support. Tealeaf-trained teachers have been shown to select children in need of mental health support with moderate accuracy (72% sensitivity and 62% specificity) [36]. Teachers were pragmatically limited to 2 students each based on teacher preferences in an earlier pilot trial [36].

Based on the timing of teacher dropout, verbal assent for participation was obtained in Nepali from 30 students by study staff. An English version of the assent script is in Additional File 1. Written informed consent was obtained from their parent or guardian (termed “caregiver” for this manuscript) for their child’s participation and their own participation in the study. Twenty-six students and their 29 caregivers completed all study activities; 3 children had 2 caregivers each enrolled, one to provide quantitative data and one to provide qualitative data. For qualitative semi-structured interviews, a purposive sample of 7 teachers, 7 children, and their 7 caregivers were chosen as representative of the study sample. To robustly capture potentially different views on acceptability based on gender, teachers were chosen such that a little over half were female, deviating from female representation in the larger study sample.

The research protocol and consent and assent forms were approved by the University of North Carolina at Chapel Hill Institutional Review Board (Study 17–2608) and a Darjeeling-based Ethics Committee.

2.3 Measures

Quantitative and qualitative data, as below, were collected in parallel (i.e., before either was analyzed) due to resource constraints. As in “Analysis” their integration occurred through an explanatory sequential method [32].

2.3.1 Quantitative assessments

2.3.1.1 Acceptability

Quantitative measures of acceptability were chosen based on a review of acceptability measures by a panel of experts and research staff with local knowledge. No published surveys assessed parent acceptability of teacher-delivered behavioral and mental health interventions targeting their students. Local research staff considered surveys more generally assessing parent acceptability to be difficult to understand in the Darjeeling context. Thus, the decision was made to assess parent acceptability qualitatively, as below, while proceeding with quantitative assessment of teacher and child acceptability, as next.

2.3.1.2 Intervention rating profile—15 (IRP)

The Intervention-Rating Profile (IRP) assesses teacher acceptability of school-based behavioral and mental health interventions delivered by teachers [37]. Its 15 items are rated on a 6-point Likert-type scale (with 1 indicating strong disagreement and 6 indicating strong agreement). All item scores are added for a total score. Higher scores represent higher levels of acceptability, with IRP authors setting a score of ≥ 70 representing moderate acceptability. The IRP was collected pre-intervention (after teacher training and prior to care delivery, “PRE”) and post- intervention (at the end of the academic year after 6–8 months of care, “POST”). The IRP was translated into Nepali and back translated to English to verify accurate Nepali translation. The IRP took participants 5 min to complete.

2.3.1.3 Children’s intervention rating profile (C-IRP)

The Children Intervention Rating Profile (C-IRP) assesses students’ levels of acceptability of behavioral and mental health interventions delivered by teachers [38]. Seven items are rated on a 6-point Likert rating scale; a score of 1 indicates strong disagreement and 6 indicates strong agreement, with three items reverse scored. Item scores are summed for a total score. Higher total scores indicated higher levels of acceptability, with a score ≥ 24.5 representing acceptability per C-IRP authors [38]. An adapted version of the C-IRP was used to allow students to judge their own participation in Tealeaf as the original C-IRP rated students’ levels of acceptability of interventions delivered in vignettes (see Additional File 2) [39]. The C-IRP was collected PRE and POST in Nepali. C-IRP collection at PRE occurred after: (1) children were chosen by teachers for care, (2) informed consent was provided for their participation by caregivers, (3) study staff discussed Tealeaf with them and that they were chosen to receive Tealeaf care, and (4) they provided verbal assent. The form was translated into Nepali and back-translated to English to ensure accurate translation. The C-IRP took participants 2 min to complete with staff verbal administration.

2.3.1.4 Demographics

All demographics information was collected at PRE. Teacher demographics collected were age, years teaching, years at current school, gender, language(s) spoken, level of education completed, and grade levels taught. To minimize the research burden on caregivers, age, gender, and relationship to the child were collected. Children’s demographics were collected from caregivers and included age, total people living in the household, gender, language(s) spoken, grade level, mental health symptoms as reported by their teacher in the Teacher Report From (as next), and membership in a scheduled caste/tribe (standard terms used in Indian demographic surveys for officially recognized groups of historically disadvantaged peoples by the Government of India and State of West Bengal) [40].

2.3.1.5 Teacher report form (TRF)

The Achenbach System of Empirically Based Assessment (ASEBA) Teacher Report Form (TRF) is a “gold standard” for assessing mental health challenges as reported by teachers [41]. The form includes 113 questions that are scored to produce several clinical scores, with aggregate scores for Total Problem, Internalizing problems, Externalizing problems, and 14 subdomain scores. Raw scores are summed and converted into T-scores. Total problem T-scores from 60 to 63 are classified as “borderline” and ≥ 63 as “clinical”; “borderline” is defined by TRF authors as likely having symptoms that meet diagnostic criteria for a disorder but would be best confirmed by a professional evaluation to minimize false positive screening, where “clinical” is defined as more confidently having symptoms that meet diagnostic criteria for a disorder [41]. Internalizing and Externalizing problem and all subdomain T-scores of 65 to 69 are considered “borderline” and ≥ 70 are “clinical”. The form is available in Nepali and took participants 20 min to complete. For each student, his/her teacher each filled out the TRF at PRE outside of instructional time to protect student confidentiality. The TRF has been validated globally, including in India [42]. However, studies indicate that lower borderline and clinical thresholds than those reported below may be appropriate for the Indian context, leading to a “borderline” score to be the minimum score signaling a need for indicated care [42].

2.3.2 Qualitative assessments

With the goal of qualitative description of acceptability, semi-structured interviews (“interviews”) were collected prior to quantitative data analysis with 7 teachers, 7 students and 7 caregivers at POST [43, 44]. Qualitative acceptability aims were modeled after aspects of acceptability described by Proctor and colleagues: acceptability (Aim 1), facilitators of acceptability (Aim 2), conditions required for acceptability (Aim 3), barriers to acceptability (Aim 4), and future directions for acceptability (Aim5) [21]. Interview guides (Additional File 3) were developed iteratively around these aims. The guides were then finalized with the research team and program staff.

Trained research assistants conducted audio-recorded interviews in Nepali and recorded complementary field notes. Interviews were transcribed and translated into English by an independent translator and reviewed by study staff for accuracy.

2.4 Procedures

Tealeaf is an intervention that task-shifts to teachers the delivery of evidence-based, non-manualized, transdiagnostic, indicated child mental health care. To address child mental health needs that were considered concerning by the Darjeeling community but for which little care was available (as above), Tealeaf was developed by the three authors (CMC, PG, & MM), community partner non-governmental organizations (Darjeeling-based Darjeeling Ladenla Road Prerna and Darjeeling-focused Broadleaf Health and Education Alliance), and their partner LCP schools and community health workers. Tealeaf care is unique in that it is non-manualized, allowing teachers to customize the care they deliver, including fitting care tasks into their primary teaching duties. Further, a transdiagnostic approach was chosen to minimize the need for teachers to create differential diagnoses and master individual treatment paradigms for different diagnoses [45]. Tealeaf is implemented over a school year and involves six major components: training and supervision, student nomination for care, behavior analysis, behavior plans, one-on-one interaction with students, and engaging caregivers (Table 1 and Fig. 1).

Table 1 Core intervention components
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Fig. 1
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Tealeaf’s 6 components are illustrated here. First, teachers receive training and supervision from study staff. Second, teachers under supervision identify children in need of mental health support in their classrooms. Third, teachers perform a behavior analysis on students to begin to understand targeted behaviors. Fourth, teachers create a behavior plan, choosing therapeutic techniques to use that target behaviors identified in behavior analysis and ones they feel they can implement during the school day. Fifth, teachers coordinate with parents, informing them of their child’s progress at school, learning of their child’s progress at home, and guiding how Tealeaf techniques may be used at home. Finally, teachers deliver therapy during the school day

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After a 10-day training delivered by a psychiatric social worker with expertise in youth mental health (component 1 in Fig. 1; Additional File 4), teachers choose two students to work with (component 2 in Fig. 1 and as above in “Participants”), and analyze their behavior by completing basic functional behavioral assessments using 2 decision support tools, the Activating Event, Automatic Thoughts and/or Feelings, Behavior, & Consequence (AABC) Chart and the Themes of the AABC Chart (component 3 in Fig. 1; Additional File 5) [46]. Teachers then develop a targeted response using a behavior plan, the Cause, Change, Connect, and Cultivate (4Cs) Plan (component 4 in Fig. 1; Additional File 5). The 4Cs is akin to behavior plans teachers commonly use in HICs to manage a child’s challenging behavior towards the goal of improved learning, but here with the end goal of improving child mental health [28].

In the 4Cs, teachers select Cognitive Behavior Play Therapy (CBPT)-based therapeutic techniques from: (1) a menu of evidence-based therapeutic options, (2) techniques learned in training that were not on the menu, or (3) techniques they adapted under the guidance of study staff (Additional File 6). CBPT was chosen as Tealeaf’s core therapeutic modality as it provided teachers with practical and tangible therapeutic techniques cognitively accessible to children 10 years or under, whereas Cognitive Behavior Therapy (CBT) is effective for those older than 10 years [47, 48].

Through the 4Cs, CBPT tenets can be interwoven into a child’s daily school schedule through the therapeutic choices teachers make, where teachers can choose to deliver care within classroom activities or outside of them in a more traditional 1:1 setting (Additional File 6) [47]. The “dose” of care in Tealeaf is each individual therapeutic interaction between a teacher and targeted child throughout the school day, in contrast to traditional models of task-shifted care where “doses” are number and length of 1:1 sessions [7]. This non-manualized modality of therapy, in which teachers deliver care through their existing interactions with students in the classroom using CBPT-based therapeutic techniques only they can use as teachers, is a novel therapy modality named “education as mental health therapy” (Ed-MH), discussed at length in a separate publication from this author group [30].

The remainder of the school year is dedicated to the delivery of therapeutic interactions and skills practice (component 6 in Fig. 1), collaborating with family (component 5 in Fig. 1), and revising the 4Cs based on each child’s progress. From the psychiatric social worker who trained them, teachers receive monthly on-site supervision that is supplemented by as-needed telephone discussions, averaging to twice monthly supervision.

2.5 Data analysis

An explanatory sequential method was pursued to answer the question of whether participants found Tealeaf to be acceptable. While data were collected in parallel and seemingly more similar to a concurrent method, the intent of the data analysis was to understand quantitative measures further through qualitative inquiry. Thus, we pursued an explanatory sequential method based on recent mixed methods literature calling for emphasizing the intent of the data analysis rather than the timing of data collection [32]. Quantitative data were first analyzed to gain an understanding of teacher and child acceptability in quantitative terms. To integrate the two forms of data, qualitative data analysis was then undertaken to further explain quantitative results, as well as to understand caregiver acceptability as no quantitative measure was deemed appropriate to measure caregiver acceptability, as above in “Measures”.

2.5.1 Quantitative

Descriptive statistics were used to investigate demographic characteristics of all teachers, students, and caregivers enrolled in the study. Demographics of teachers who completed all study activities were compared with those who did not complete all study activities. Demographics of the teachers, students, and parents who completed interviews were compared with those who did not. Independent sample t tests were used for continuous variables; Fisher’s exact tests were used for categorical variables.

Mean scores were calculated at PRE and POST time points for the acceptability measurements, C-IRP (Total Acceptability score) and the IRP (Total Acceptability score), and compared using paired sample t-tests (two-tailed). The IRP PRE score was missing for 1 teacher, allowing a PRE to POST comparison for 12 teachers. C-IRP values were compared PRE to POST for children targeted for care who had complete C-IRP and demographics data collected (n = 24). SAS version 9.4 (Cary, NC) was used for all quantitative analyses [49].

2.5.2 Qualitative

The interviews from teachers, children, and their parents were analyzed using inductive content analysis with the aim of qualitative description in order to further understand quantitative acceptability scores and caregivers’ perspectives on acceptability [43, 50]. Using ATLAS.ti version 8.4.15, 2019, two independent analysts both coded all of the interviews with a template coding style as per Crabtree and Miller, with one codebook used for all three participant groups [51]. Group consensus was used to resolve discrepancies in coding. Codes were grouped to identify emergent themes alongside key supporting quotations. Results of the analysis were connected to research aims, as in “Measures”, that reflected the aspects of acceptability as described by Proctor and colleagues [21].

3 Results

3.1 Demographics

Teachers who completed the study (n = 13) were 76.9% female and ranged in education levels between some primary and finishing graduate/post-graduate; 38.5% had formal education training and 46.2% obtained a teaching certificate (Table 2). Teachers who completed interviews were different in gender proportions from those who did not, intentionally pursued as previously discussed; otherwise, teachers who completed interviewers were not significantly different in demographics from those who did not.

Table 2 Teacher demographics and comparisons of teachers who did and did not complete all study activities and those who did and did not complete a qualitative interview
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Students (n = 26) were 30.77% female. Those who completed the interview were not different in demographics from those who did not (Table 3). Caregivers enrolled (n = 29) were 82.8% female; 62.1% were mothers (Table 4). Three children had two caregivers each enrolled; only one caregiver per child completed an interview. Those who participated in an interview did not statistically significantly differ from those who did not, though age was not available for the 3 caregivers who completed interviews only. For the three children who had two caregivers each participate in the study, only one caregiver per child (the one who completed an interview) was included in the comparative analysis (n = 26) to allow for balanced representation.

Table 3 Child demographics and comparison of children who did and did not complete a qualitative interview
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Table 4 Caregiver demographics and comparison of caregivers who did and did not complete a qualitative interview
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3.2 Quantitative acceptability

Teachers’ IRP scores were, on average, above the moderate acceptability threshold (≥ 70) at PRE (mean = 73.75, standard deviation (SD) = 5.85; n = 12; 75% (n = 9) above acceptability threshold) and POST (mean = 76.92, SD = 5.58; n = 12; 92% (n = 11) above acceptability threshold) (Table 5). Teachers’ scores did not statistically significantly change PRE to POST (mean difference = 3.17; p = 0.1550; 95% Confidence Interval (CI): -1.40, 7.73). Students’ C-IRP scores, on average, showed acceptability of the intervention (score ≥ 24.5) at PRE (mean 29.96, SD = 3.49; n = 24, 96% (n = 23) above acceptability threshold) and POST (mean 27.67, SD = 2.32; n = 24, 96% (n = 23) above acceptability threshold), with the average decline in scores PRE to POST of -2.20 points (95% CI: -3.53, -1.05) being statistically significant.

Table 5 Acceptability comparisons
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3.3 Qualitative acceptability

Teachers and caregivers universally expressed acceptability of Tealeaf (Aim 1; Table 6). Both groups spoke to the overall program being acceptable, with some explicitly stating wanting it to continue in the future. Teachers further described their acceptability of Tealeaf’s individual components. Training and supervision were viewed as venues for learning new, relevant skills, with some of the more experienced teachers expressing these skills were novel and useful even though they had several years of experience. Care delivery was considered to be acceptable, seen as a worthwhile application of new skills learned as efforts were viewed as impactful, as described in Aim 2 below. One teacher stated, “Through this program I gained new knowledge and skills. Through this program, good changes have come to the children. When I see these changes, I feel happy, and I feel it was worth my time and energy.”

Table 6 Themes and representative quotes from semi-structured interviews with teachers, caregivers, and students
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Most teachers and caregivers expressed that the belief that the program was impactful for students’ behavior and/or academics was a facilitator of acceptability (Aim 2; Table 6). As exemplified in the previous quote, this impact appeared to justify the effort exerted to deliver care, i.e., making the effort acceptable. Further, for teachers, the ability to adapt Ed-MH techniques facilitated acceptability as they could choose techniques as they saw fit rather than adhering to a strict protocol, making the delivery of care seemingly less burdensome and more acceptable. Caregivers’ trust of and communication with teachers facilitated their acceptability as caregivers appeared to use teachers’ endorsement of the program as a proxy for its potential benefit to their child.

A condition required for teacher and caregiver acceptability was having an understanding of the program’s intent (Aim 3; Table 6). Notably, teachers spoke more to the mental health benefits of the program while caregivers emphasized the potential for academic benefits. This discrepancy may stem from teacher communication with caregivers; teachers conditioned acceptability on emphasizing academics over mental health to caregivers and students given their concerns about mental health stigma (Table 6). Teachers also conditioned acceptability on caregiver involvement and support from the project team. Teachers viewed caregivers as being extensions of themselves by supporting child mental health in the home, while support from the project team allowed them to divide care tasks, such as coordinating with parents, and problem-solve on therapy delivery.

Both caregivers and teachers expressed that a perception of stigma was a barrier to acceptability (Aim 4; Table 6). Both were reluctant to identify children, including to the child his or herself, as having a mental health condition for fear of the untoward negative reputation the child could develop in light of mental health being highly stigmatized locally. Both caregivers and teachers also cited a lack of caregiver engagement and understanding as barriers to acceptability (Table 6). Some caregivers did not understand the effects of mental health on daily functioning, such as on academics or behavior, and this may have prevented them from understanding the full benefits of the program. Instead, they may have superficially understood Tealeaf to target those with mental health concerns such that the identification of their child as needing mental health support appeared to lead only to stigmatization without clear benefit for such identification. Still, as caregivers universally expressed acceptability of Tealeaf, as earlier, this barrier may have played a role in differing levels of acceptability. Some teachers cited a lack of time to deliver the intervention as an acceptability barrier. They reported having school schedules filled with teaching activities, but some reported adapting Ed-MH techniques into whole class activities, for example, to overcome this barrier.

Teachers and caregivers expressed that a future direction (Aim 5; Table 6) could include program continuation in their schools or expansion to either older grades or other schools, implying their acceptability of the program. Some teachers expressed that improving caregiver engagement could enhance future teacher acceptability as teachers viewed caregivers as extensions of themselves within Tealeaf in supporting child mental health in the home.

By contrast, interviewed students universally did not know they were receiving care from their teachers (as in “Not understanding role in program” in Aim 4, Table 6). This limited the ability to directly assess their acceptability of teacher-delivered task-shifted mental health care. In one exchange between study staff (labelled as “Interviewer (I)”) and an enrolled child (labeled as “Student (S)”), the child expressed not receiving any additional attention from the teacher.

“Interviewer (I): Oh, so he taught you in the same old way. Hmmm... Does he care for you and look after you? Does he give you the extra attention or does he treat you like the rest of the class and everyone gets the same treatment?

Student (S): Everyone equally.”

A theme of trust of teachers was expressed by some students (Aim 2; Table 6) while others expressed a distrust of teachers (Aim 4; Table 6). One student stated of his or her teacher, “he is very nice and is not strict with us. He loves all of us.” Trust of teachers may be an intermediary in the pathway to student acceptability of teacher-delivered care [27].

4 Discussion

This study is the first to explore whether teachers, school-aged students, and their caregivers in an LMIC find teachers delivering task-shifted, transdiagnostic, non-manualized mental health care to their students acceptable, a key factor in care adoption and sustainability. Its findings provide evidence for the acceptability of such care for teachers and children, and interview themes indicate acceptability for the 7 interviewed caregivers. This study is in line with evidence in HICs supporting teacher delivery of indicated mental health care structured similarly to Tealeaf and Ed-MH.

Reasons for teacher acceptability are in line with 3 domains determining teacher acceptability of mental health care delivery that Han and Weiss [22] consolidated from the publications of Elliott [23] and Reimers and colleagues [24]. In the first domain of acceptability, the severity of the student’s target mental health concern affects teacher acceptability. Many teachers centered their acceptability around a belief that Tealeaf was impactful regarding changing children’s behavior and academics, implying a change in function and symptom severity from a previously more severe state. Accordingly, children receiving care, on average, had improved mental health symptoms outcomes on the TRF, as in a separate publication from this author group [31]. Further, teachers in studies in HICs expressed similar sentiments of acceptability, citing witnessed improved mental health symptoms of students in their classroom, which also implied previously more severe states [16,17,18].

Notably, these teachers were targeting children with Conduct Disorder and ADHD, diagnoses consider to be “externalizing”, or manifesting in symptoms and behaviors that affect a child’s external world [41]. Children with externalizing symptoms have been more frequently targeted by teachers in HIC studies because of their involvement of the environment versus those with “internalizing” diagnoses, or those that predominantly manifest in the child’s internal psychological world [41, 52,53,54]. By contrast, baseline student mental health profiles in this study indicate that the children selected for care varied in terms of which categories of diagnoses their struggles were consistent with (Table 3). This finding supports that the transdiagnostic nature of Ed-MH may widen Tealeaf-trained teachers’ reach compared to others delivering traditionally-structured care that typically targets single diagnoses [7]. That the care teachers could provide through Tealeaf was transdiagnostic and applicable to all categories of diagnoses may have further contributed to teacher acceptability. One teacher noted wanting other teachers to be part of the program as it affected the way he or she thought and reacted, especially towards children who may forgot a book or not complete assignments, implying a reconceptualization of commonly overlooked internalizing symptoms (Table 6) [41, 52,53,54].

The ability to: (1) choose familiar therapeutic techniques with behavioral or academic actions, (2) make adaptations to these techniques, and (3) not have to adhere to a strict protocol for care, as is the structure of Tealeaf, addresses the second domain of teacher acceptability, where the type of care delivered matters [22,23,24]. By including the choice to use academic and behaviorally based therapeutic techniques, Tealeaf was structured to target the improvement of children’s mental health symptoms through methods tangible to, familiar to, and usable by teachers. Such a connection was made through careful choices in the design of therapeutic techniques to target both behavior and mental health. Teacher-delivered efficacious care in HICs targeting Conduct Disorder and ADHD have been similarly flexible and smoothly integrated into teacher workflows, such as teaching of coping skills in a group classroom setting for Conduct Disorder or teacher use of a classroom behavior report card for ADHD [16,17,18]. Care structured traditionally, as one-on-one sessions, has been mixed in its acceptability across LMIC and HIC settings, potentially due to its structure being less familiar to teachers and more aligned with traditional mental health care, the delivery of which teachers may see as being separate from their teaching duties [10, 22, 25].

Of note, teachers adapted Ed-MH techniques to avoid singling out children receiving care, and such an ability to adapt techniques facilitated their Tealeaf and Ed-MH acceptability. Further, a condition of acceptability for both teachers and caregivers was an understanding of Tealeaf as a program; tasked to work with caregivers and explain the care as it occurred, teachers took the liberty they were given to explain Tealeaf in an understandable and acceptable way to caregivers, ultimately under-emphasizing the mental health benefits of the care and speaking instead to its academic and behavior benefits. These findings highlight that teachers chose to be discrete to optimize the acceptability of Tealeaf to caregivers and children, and that having the choice to be discrete (i.e., flexible with care delivery) in turn facilitated their acceptability of Tealeaf and Ed-MH.

Their acceptability may have been further facilitated by the care including support and supervision from the project team, a required condition for acceptability. This finding is in line with literature that implicates supervision as crucial to lay counselors’ acceptability of delivering task-shifted care across LMICs and HICs [14, 55,56,57,58]. While caregivers were not specifically cited as an additional resource to overcome a lack of time, many teachers discussed the importance of caregiver involvement, whether as a condition for or lack thereof as a barrier to acceptability, similar to mental health professionals’ views [59].

Regarding the third domain, time, some teachers expressed a lack of time to deliver care [22,23,24]. Teachers’ described their time being consumed by primarily focusing on the knowledge transfer process of education, consistent with other LMIC and many HIC contexts [14, 60]. Some teachers described being unable to give “100%” to the children in Tealeaf because of having to balance care delivery and teaching duties. The reported lack of time for some may thus underlie why IRP scores did not change on average PRE to POST. This concern, however, did not appear to significantly affect average teacher acceptability as POST scores remained above the moderate acceptability threshold on average. For some, the additional time needed to deliver care may have been acceptable in return for their stated benefits. One teacher stated,“through this program I gained new knowledge and skills, through this program, good changes have come to the children. When I see these changes, I feel happy, and I feel it was worth my time and energy.” For others, they may have adapted Ed-MH techniques to minimize the additional time needed to deliver them, such as utilizing them during instructional time as per one teacher’s description. “I was unable to give extra time to the two children and could not meet them separately and spend time with them but I was able to give them time when they were working collectively with the entire class. It’s not possible to give those two children extra or special attention in a 45-min class.”

Themes of caregiver acceptability centered on the school focus and setting of Tealeaf and appeared to underlie caregivers’ universal positive acceptability of Tealeaf, with sentiments similar to those from a 2018 study exploring caregiver experiences in Tealeaf in a separate publication [61]. Such a setting may have been less stigmatizing, similar to findings from studies in HICs showing that caregivers’ acceptability of care was predicated on experiencing less stigma in schools compared to clinic settings and that teacher communication was highly valued [18, 28]. Some caregivers did cite perceptions of stigma as a barrier to acceptability of Tealeaf, similar to other studies where stigma was a barrier to caregivers seeking mental health care for their children [62].

Stigma may also underlie why the interviewed students universally did not know they were receiving care. While Tealeaf already prioritizes student confidentiality during the identification process, teachers further addressed stigma with children by avoiding singling out students receiving care, an adaptation to Tealeaf some chose to pursue that was not a listed therapeutic option in Tealeaf. Teachers expressed that delivering Tealeaf individually may have made the selected children feel negatively about themselves and labeled them as outsiders to others [63].

It is also possible that stigma may underlie why children’s acceptability scores decreased PRE to POST. No interview themes directly addressed stigma, but exploring themes around trust of teachers may allow for insight. Some students distrusted their “strict” teachers. There is a local cultural expectation that teachers are supposed to be “strict”, and children with mental health struggles are traditionally subject to even more “strictness” from teachers [60]. For students whose C-IRP scores fell PRE to POST, they may have had teachers who were consistently “strict”. Being the recipient of such strictness may have been considered stigmatizing and may have identified them as having more struggles than others. Regardless of whether they knew they were receiving mental health care, students may have used the C-IRP to rate their perceptions of their teachers’ behaviors towards them (i.e., strictness) and how it made them feel (potentially stigmatized), leading potentially to decreasing acceptability scores PRE to POST for these students.

C-IRP scores should be interpreted in the context of interviewed children (n = 7) universally expressing not knowing they were receiving care from their teachers. It is possible that the children not interviewed were more aware of their participation. However, as purposive sampling was pursued, more likely students on average may have been less aware of their participation. As the 7 C-IRP items appear to address program acceptability in the context of a child’s functioning and relationship with their teacher (Additional File 2), children may have rated these aspects on the C-IRP whether or not they were aware of their participation in Tealeaf.

4.1 Limitations

With a small, pragmatic sample, results are exploratory, not definitive, and potentially may not occur across a broader sample of teachers, students, and their caregivers. Further, though using statistical tests least sensitive to small sample sizes, the statistical comparisons were conducted with small sample sizes; this potentially could have led to skewed results. Caregivers’ acceptability was not quantitatively measured as no measure was considered appropriate for the situation and context; quantitative caregiver acceptability findings could differ from qualitative findings if collected in the future. We were unable to collect quantitative acceptability ratings and qualitative data from teachers who left the study.

Due to limited resources to interview participants, interviews were limited for teachers (7 of 13), caregivers (7 of 29) and children (7 of 26); qualitative views from the remaining participants may have yielded different findings. In addition, as only a handful of participants from each stakeholder group (teacher, caregiver, and student) participated in the qualitative interviews, saturation was not assessed for, making it uncertain as to whether it was achieved. This limits the generalizability of the qualitative results. Also, interviewees may have wanted to play the “good-participant role” as a demand characteristic and subconsciously or consciously provided positive acceptability answers.

5 Conclusion

The positive acceptability teachers, caregivers, and students expressed increases the potential of teacher-delivered, task-shifted child mental health care to be a viable alternative option for care delivery. A teacher’s ability to adapt the intervention and frame it as care that improves behavior and academics without having to emphasize its mental health purpose enabled caregiver acceptability and care delivery without students’ knowledge. Such flexibility is at the heart of Tealeaf through having Ed-MH as its therapeutic modality [64]. With teachers being able to disguise care as an educational intervention, Ed-MH may be a feasible option for delivering care where mental health stigma is widespread.

Given the acceptability findings presented here and previous findings showing that teachers can identify children with mental health needs with moderate accuracy [36], a logical next step is to definitively assess the ability of Ed-MH and Tealeaf to improve child mental health outcomes. Should evidence support that Ed-MH within Tealeaf improves child mental health outcomes, teachers may prove to be practical, ubiquitous, and experienced human resources who can take significant steps to bridge the wide child mental health care gap in LMICs through delivering education repurposed for mental health, even and especially in settings with high levels of mental health stigma.