Strengths of the awareness program
The Awareness coordinators from all sites drew attention to the particular design of the program that gave space for discussing important mental-health related topics, which otherwise go unaddressed. In 6 of the 11 participating sites (Austria, Estonia, Germany, Hungary, Italy, Slovenia), the coordinators underscore that talking about mental health problems and emotions is still uncommon, shameful and stigmatised. Figure 3 shows the aspects of the Awareness program that were most appreciated across sites.
From the evaluation results, and as intended, the adolescents used the role-play as an opportunity to discuss their feelings, and they were eager for this kind of experience (Austria). Adolescents particularly appreciated the opportunity to talk about topics such as problem-solving, depression, anxiety, bullying (Austria, Germany, Israel), stress and crisis situations (Spain), pregnancy, conflicts with parents and teachers (Romania), and also suicidal behavior (Slovenia, Israel). The experience in France also showed that it was important that positive aspects of health were addressed. In Estonia, it was noticed that, in schools with a higher proportion of children with social problems, more serious topics emerged during the role-play sessions.
According to the Awareness coordinators, the program successfully promoted social networks in all countries. Pupils often reported that, when they are in distress, they do not have anyone to talk to (Hungary, Israel). The Awareness program addresses this problem in two ways: First, pupils are informed about different kinds of professional support. Second, the Awareness program promotes peer support. The importance of peer support is emphasised directly with guidelines on how to help a friend in need and indirectly by developing empathy. By participating in the program, the youth got to know each other in a deeper way, often realising that they were not alone with their problems, and that classmates, who they often didn’t know very well, shared similar problems (Hungary). Students also learned the importance of offering support to peers, instead of avoiding their problems, and learned how to do it more effectively. All countries report positive outcomes in this regard. In some cases, the Awareness program also contributed to stronger class bonds (Hungary) or an improved general school-climate (Israel) as reported by students to the instructors.
Interactive workshops as a means of prevention
The adolescents and instructors alike appreciated the interactive approach of the Awareness program. The relaxed atmosphere of the role-play sessions proved to be a good point of departure for discussion, and a way to approach the youths’ thoughts and feelings. The instructors often noticed that pupils had difficulties expressing their feelings in words (Austria, Germany, Israel, and Slovenia). The role-play sessions provided them with the opportunity to communicate, express and verbalise their feelings, not only to the facilitator, but also to their peers. They were able to overcome their fears of expression, and open up in a more relaxed way (Austria, Italy). The interactive approach engaged pupils, and they preferred it to the standard classroom set-up, or the ex-cathedra approach, which is still the predominant way of teaching in many schools across Europe. Not only the pupils, but also the instructors, liked the variety of verbal and written materials used in the Awareness program, as well as the more interactive components in contrast to the lectures (Austria). There were reports from all participating countries about students approaching the facilitators after the end of the program, telling them about their problems. Moreover, school counsellors noted that the Awareness program lead to the development of networks with the clinical sector, specifically by providing information on the treatment of pupils in distress, much to the benefit of the perceived quality of care in the schools (Slovenia).
The instructor from the Irish site gave the example of how a young boy actively used the booklet as a means to speak to his mother about his feelings and worries. The mother came to the school after one of the sessions to speak to the instructor; she had noticed a marked change in his mood and was very thankful. The instructor also noticed that the boy had become more vocal as the Awareness sessions proceeded.
Moreover, the instructors reported changes in the adolescents’ behaviors as the 4-week program progressed; it was evident that, from participating in the role-play sessions, the youth developed problem-solving skills when faced with different situations (Ireland). Additional analyses are required to learn how this potentially translates into everyday life and in preventing mental health problems.
The schoolteachers expressed the importance of having a person from outside the school-system to perform the program (Austria), avoiding possible distrust of more familiar instructors. The emotion that they could express their views and emotions in a safe environment, without prejudice and fear of ridicule, was a very powerful aspect (Ireland, Romania). Pupils indicated that they liked that the instructors were open-minded and young, and someone to whom the pupils easily could make a connection with and feel close to. With all of this in mind, it is very important to assemble, train and manage a team able to deliver this kind of program to young people (Ireland, Romania).
The shortcomings of the awareness program and proposals for future modifications
The shortcomings of the Awareness program, as voiced by the instructors, mostly concern the lack of flexibility due to the RCT design and the tight time frame in the implementation of the workshops. It was difficult to assure that the needs of all pupils were met, or that all topics were equally addressed, explained and/or understood with the same depth. Some topics (e.g., serious mental health problems like depression or suicide) were more difficult to comprehend for some adolescents and, thus, a challenge for the instructors to convey in such a brief period of time.
The question of allocating more time for role-play sessions, e.g. 2 h instead of 45–60 min, was raised. The current program included an opening lecture that was considered by some to be too theoretical in nature and, consequently, not as well accepted as the interactive role-play sessions (Austria, Israel). Moreover, pupils thought the time frame for each session was too short (France).
Burden of the program for the school system
A potential obstacle to successfully implementing the Awareness program is the response of the school authorities, school staff, and their parents. In some cases, teachers and school staff were sceptical about the pupils’ motivation to participate in such a program. Ensuring that the entire teaching body appreciates the benefits and efforts of such a program is beneficial to the implementation (Ireland). As the Awareness coordinator typically was in touch with the school principal and guidance counsellors across their site, many coordinators underscored that it proved to be helpful when the principal and/or guidance counsellor were asked to inform all teaching staff about the program. It also happened that some parents and teachers refused or discouraged pupil participation in the program, because they would miss too many classes (Austria, France, Germany, Hungary, Israel, and Slovenia). It would be helpful therefore to place hand-outs with information about the Awareness program in the staff room in order to ensure familiarity among the entire teaching staff (Ireland). In fact, the benefits of this kind of intervention program may not be obvious to everyone, especially parents (Hungary, Slovenia). In some schools, the Awareness sessions were scheduled after school and since many pupils attend other after-school activities, this could have influenced participation rates in the program.
A more holistic program and a longer time frame
The most important aspects that the coordinators wish to change in the program are shown in Figure 4 below. Many of them mention the short time frame of the program and the value of a more flexible schedule, as well as the advantage of a less rigid approach to the dissemination of content, expressing some reservation regarding the structure of the opening lecture and the somewhat intrusive posters. Instructors and students alike expressed the desire for an Awareness program that would last longer (Germany, Hungary, Ireland, Italy, Slovenia, and Spain), and for the structure of the program to be changed to two longer workshops, instead of three shorter ones (Estonia). Additionally, a wish to address other topics was expressed by the coordinators, such as: sexual behavior (Slovenia), sexual orientation (France), influence of emotions and thoughts on behavior (Romania), practice with behavioral techniques about how to talk to peers in distress (Hungary).
Materials and tools of interaction
In addition to the role-play, discussions and problem solving that were part of the SEYLE Awareness program, adding other kinds of interactive teaching could further strengthen the program. Among these learning from videos (Italy) expressive arts techniques or even action teaching were mentioned (Slovenia).
Moreover, in some countries (Germany, Slovenia) pupils did not like the posters, as their design or style was not appealing and was sometimes considered too intrusive. This issue can be dealt with by minimising the amount of text on them and by giving more attention to the design. One problem with the posters, in addition to their somewhat simple design, was that they were printed locally, and the quality of the prints varied greatly from site to site. The Awareness and instruction booklets were all printed in Sweden at a printing company and, consequently, were of high quality and uniform across sites.
A cross-country comparable awareness program
In the SEYLE study, the Awareness program was implemented in an identical fashion across the 11 countries. According to the SEYLE protocol, the sites were encouraged to, if needed, culturally adjust the content of the role-play examples and to account for these adjustments by keeping a journal at the time of program. In some cases, some of the role-play examples from the instruction manual were not used or, if used, applied in a modified fashion. Nonetheless, all participating sites addressed the same topics, as it is important in a cross-country primary preventive RCT to have well-structured tools and clear guidelines on how to work with pupils, so that the instructors could be easily trained, and the obtained intervention results to be comparable across schools and countries.
Flexibility vs. uniqueness
The short time frame of the program (four weeks) was stipulated because of the SEYLE study research-design, aiming to compare different intervention outcomes. For future implementation of this kind of preventive program, the structure and the time frame of the intervention can also be tested, since it is often difficult to offer it in an identical way in different countries and school-settings. The Awareness program stimulates the pupils’ thoughts and feelings, as such, creating a need for a space for continuous discussion, something that should probably be integrated into the ordinary school curriculum. In the Hungarian case, a group of pupils decided to continue meeting together weekly to discuss their problems among themselves at the end of the program. Moreover, coordinators from most of the sites underscored that the program was more successful in those schools where the number of pupils per session was fewer, as well as when more time was given for discussion. It was interesting to note that, in Austria, girls were more interested and open than the participating boys and, in Ireland, boys offered better advice when taking part in the role-play sessions compared to girls, especially, around the topic of pregnancy. In Romania, pupils from smaller towns were more involved and had a lot of questions during the introductory lecture, whilst pupils from bigger towns had higher expectations, expressing views about mental health that they had read about on the Internet and in other sources. Schools with pupils of lower Social Economic Status (SES) had lower participation rates (Hungary) and some adjustments of the program had to be made according the type of school (Slovenia).
In summary, the key lesson is to uphold flexibility in discussion with the adolescents, taking into consideration the specific context of every classroom. Despite many challenges with the scheduling of the workshops in different schools and classes and other organisational efforts, all site Awareness coordinators reported that these were well worth it in relation to the satisfaction and appreciation expressed by the pupils (see Figure 5).
To overcome logistical difficulties as well as those related to the attitudes of the schools and parents, it is important that stakeholders, politicians, school-principals, teachers and parents understand the importance of such a mental health and Awareness intervention program, including its’ aims and design and that they support it (Israel, Germany, Hungary). It is also important to have close collaboration with other systems (e.g. social and health care system) as specified in the SEYLE protocol, to be able to provide professional help and back-up to adolescents in need.