CRITICAL APPRAISAL

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

Disusun dalam rangka memenuhi tugas ujian tengah semester (UTS)

mata kuliah Evidence Based Practice of Nursing

OLEH:
Patricia Mega Sri Y.T
132024153003

PROGRAM STUDI MAGISTER KEPERAWATAN

FAKULTAS KEPERAWATAN
UNIVERSITAS AIRLANGGA
SURABAYA
2021
 LEMBAR PERNYATAAN

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Jika dikemudian hari terbukti adanya ketidakjujuran akademik, saya bersedia mendapatkan
sangsi sesuai peraturan yang berlaku.

Surabaya, 26 Maret 2021

Nama : Patricia Mega Sri Y.T

NIM. 132024153003

1
 LEMBAR PENILAIAN
CRITICAL APPRAISAL

Nama Mata Ajaran : Evidence Based in Nursing

Nama Tugas : Critical Appraisal

Nama Mahasiswa : Patricia Mega Sri Yulianty Tae

NIM : 132024153003

Jumlah Kata :
No Aspek Yang Dinilai Bobot
Kriteria penilaian
1 Pendahuluan 10 %
Menjelaskan topik, tujuan, dan alat yang digunakan
untuk mengkritisi jurnal. Memberikan deskripsi
singkat makalah dan deskripsi singkat jurnal yang
ditelaah secara spesifik da relevan
2 Kritik Artikel 80 % Deskripsi dan kritik jurnal/artikel menggunakan alat
kritik (tool yang tepat):
Analisa tidak logis Sangat Koheren
Pemilihan tool dan logis
Yang tidak sesuai Tool tepat
Ide susah dipahami Ide Lugas
Dan jelas
3 Kesimpulan 10 % Menyimpulkan makalah dan menuliskan refleksi
atas kritik jurnal
4 Pengurangan nilai 5% Nilai akan mendapatkan pengurangan jika kriteria
berikut tidak terpenuhi:
Jumlah kata kurang atau lebih dari batas toleransi
5% dari 1500 Tidak mengikuti aturan penulisan
referensi dengan benar
Penulisan bahasa Indonesia yang tidak baik dan
benar, termasuk tanda baca.
Catatan: Makalah tidak akan dinilai jika terbukti bukan karya sendiri
Nilai Total :
Komentar dosen
......................................................................................................................................................
......................................................................................................................................................
...................................................................................................................................

2
 DAFTAR ISI

Lembar Pernyataan ............................................................................................................ 1

Lembar Penilaian ................................................................................................................ 2
Daftar Isi.............................................................................................................................. 3
Bab 1 Pendahuluan ............................................................................................................. 4
Bab 2 Pembahasan .............................................................................................................. 6
2.1 Apakah penelitian tersebut menunjukka fokus masalah yang jelas ? ..................... 6
2.2 Apakah metode penelitian telah menjawab pertanyaan penelitian? ....................... 6
2.3 Apakah responden pada penelitian sudah cukup sehingga hasil yang didapatkan
bukan hal yang kebetulan? ................................................................................... 6
2.4 Apakah subjek dialokasikan secara acak ke kelompok eksperimen dan kontrol?
Jika tidak, dapatkah ini menimbulkan bias? .......................................................... 7
2.5 Apakah kriteria inklusi / eksklusi yang digunakan? .............................................. 7
2.6 Apakah kedua kelompok sebanding pada awal studi ? .......................................... 7
2.7 Apakah terdapat kriteria hasil yang digunakan untuk menentukan hasil yang
objektif dan tidak bias ? ........................................................................................ 8
2.8 Apakah penelitian telah menggunakan alat yang sudah divalidasi untuk mengukur
hasil ? ................................................................................................................... 8
2.9 Apakah efek yang dihasilkan secara praktik relevan ? .......................................... 8
2.10 Seberapa tepat perkiraan efek yang dihasilkan ? apakah terdapat nilai interval yang
dapat dipercaya ? .................................................................................................. 8
2.11 Apakah terdapat faktor perancu yang tidak dijelaskan ? ........................................ 9
2.12 Apakah hasil yang dihasilkan bisa diaplikasikan ? ................................................ 9
Bab 3 Kesimpulan ............................................................................................................. 10
Daftar Pustaka .................................................................................................................. 11

3
 BAB 1
PENDAHULUAN

Kesehatan mental atau kesehatan jiwa merupakan aspek penting dalam mewujudkan
kesehatan secara menyeluruh. Kesehatan mental juga penting diperhatikan selayaknya
kesehatan fisik. There is no health without mental health, sebagaimana definisi sehat yang
dikemukakan oleh World Health Organization (WHO) bahwa “health as a state of complete
physical, mental and social well-being and not merely the absence of disease or infirmity.”
Kesehatan mental merupakan komponen mendasar dari definisi kesehatan. Kesehatan mental
yang baik memungkinkan orang untuk menyadari potensi mereka, mengatasi tekanan
kehidupan yang normal, bekerja secara produktif, dan berkontribusi pada komunitas mereka.

Berdasarkan data Riset Kesehatan Dasar (Riskedas) menunjukkan prevalensi

gangguan jiwa berat nasional sebesar 1,7 per mil, yang artinya 1-2 orang dari 1000
penduduk Indonesia mengalami gang-guan jiwa (Badan Penelitian dan Pengem-
bangan Kesehatan, 2013). Prevalensi penduduk yang mengalami gangguan mental
emosional secara nasional pada tahun 2013 sebesar enam persen (37.728 orang dari
subjek yang dianalisis). Fenomena gangguan jiwa di Indonesia meningkat pada
kelompok masyarakat yang rentan terhadap sumber tekanan psikososial yaitu
pengungsi, remaja, dan masyarakat sosial ekonomi rendah (World Health
Organization, 2012).

Menurut Organisasi Kesehatan Dunia ( Organisasi Kesehatan Dunia, 2017 ), kira-kira

satu dari empat orang di seluruh dunia terkena penyakit mental selama hidup mereka. WHO
merekomendasikan upaya kolaboratif global untuk mempromosikan kesehatan mental dan
penyakit pencegahan. Masalah kesehatan yang paling umum pertama kali muncul selama
masa remaja dan sangat lazim di kalangan mahasiswa, terutama mereka di bidang perawatan
kesehatan ( Eisenberg, 2011 ). Studi akademis yang lama, beban kerja yang berat dan
praktikum klinis dengan tekanan tinggi, mungkin memiliki efek buruk pada kesejahteraan
mental dan fisik para siswa ini (Sun dkk., 2016 ). Cheung (2016) mengatakan perntingnya
untuk memberikan dukungan dan bantuan ekstensif untuk masalah ini ( Cheung dkk., 2016).
Selain itu, mahasiswa dan perawat yang menghadapi masalah kesehatan mental mengatakan
dikurangnya penerimaan diri dari sesame kolega di lingkungannya. ( Fokuo dkk).

4
 Pelatihan Pertolongan Pertama Kesehatan Mental (MHFA) dikembangkan di
Australia untuk meningkatkan literasi kesehatan mental di kalangan masyarakat umum dan
juga untuk memberikan keterampilan dalam memberikan bantuan awal kepada orang-orang
dalam situasi krisis kesehatan mental dan bagi mereka yang memiliki masalah kesehatan
mental yang sedang berlangsung. Pelatihan ini mencakup kursus 12 jam di mana pendekatan
pertolongan pertama diajarkan dalam lima langkah: 1: Menilai risiko bunuh diri dan bahaya,
2. Mendengarkan tanpa menghakimi, 3. Memberikan jaminan dan informasi, 4. Mendorong
orang untuk menjadi profesional yang sesuai membantu, dan 5. Mendorong strategi
membantu diri sendiri. ( Kitchener & Jorm, 2002 ). Dalam dekade terakhir, beberapa evaluasi
populasi sasaran yang beragam di berbagai negara, termasuk mahasiswa keperawatan, telah
menunjukkan efek dari pelatihan MHFA ( Bond, Jorm, Kitchener, & Reavley,

Tiga studi kualitatif juga telah dilakukan, dua di Australia dan satu di Inggris,
menemukan bahwa MHFA meningkatan pengetahuan, lebih percaya diri dalam memberikan
bantuan, dan penanganan dalam aspek stigma dan sedikit dukungan untuk peningkatan
bantuan yang diberikan kepada orang lain. Penelitian tersebut merupakan sumber pendukung
terkait dengan penelitian yang bertujuan mengatasi kecemasan pada pasien menggunakan
terapi non farmakologi melalui proses critical appraisal untuk mengetahui validitas, makna,
dan relevansi untuk diterapkan. Instrumen yang digunakan untuk mengkritisi penelitian ini
adalah Center for Evidence-Based Management yang terdiri dari 12 pertanyaan

5
 .

BAB 2
PEMBAHASAN

2.1 Apakah penelitian tersebut menunjukkan fokus masalah yang jelas ?

Penelitian ini telah menunjukkan fokus masalah yang dapat diketahui pada bagian
abstrak penelitian. Analisis PICO. Population (P): responden yang akan dilakukan
Mental Health First Aid (MHFA), Intervention (I): pemberian pelatihan Mental Health
First Aid Programme (MHFA) (C) tindakan memberikan kegiatan belajar mengajar
interaktif kelompok kecil, Outcome (O) berupa hasil peningkatan literasi pada
mahasiswa dan peningkatan niat pertolongan pertama kesehatan mental dengan
intervensi program pertolongan pertama kesehatan mental.

2.2 Apakah metode penelitian telah menjawab pertanyaan penelitian ?

Tujuan dari penelitian adalah untuk mengetahui pengaruh pemberian pelatihan Mental
Health First Aid Programme (MHFA) dalam meningkatkan literasi kesehatan mental,
mengurangi jarak social dari orang-orang dengan kesehatan mental, meningkatkan niat
pertolongan pertama kesehatan mental, dan meningkatkan kepercayaan diri mereka
dalam membantu orang lain. Penelitan telah menggunakan metode yang tepat yaitu
randomized controlled trial. Rancangan ini mengungkapkan hubungan sebab – akibat
dengan cara melibatkan kelompok kontrol di samping kelompok intervensi. Pada
kelompok – kelompok tersebut dilakukan pengukuran sebelum dilakukan PCI dan
sesudah dilakukan PCI. Hal ini sesuai dengan metode penelitian menurut Nursalam
(2015) yaitu kelompok – kelompok tersebut diawali dengan pra-tes dan setelah
pemberian perlakukan selesai diadakan pengukuran kembali (post-tes).

2.3 Apakah responden pada penelitian sudah cukup sehingga hasil yang didapatkan
bukan hal yang kebetulan ?
Penelitian ini menggunakan 358 mahasiswa keperawatan S1 responden. Yang memenuhi
keriteria yang disediakan. Penelitian ini terdiri dari dua kelompok. Yaitu kelompok
experiment terdiri dari 182 responden dan kelompok control terdiri dari 176 responden.

6
 Peneliti menyebutkan bahwa populasi penelitian terbatas, dan tidak menyebutkan jumlah
populasi, hanya tertuang didalam artikel ini jumlah responden yang harapannya dapat
mewakili keadaan populasi. Hal tersebut sesuai dengan Sugoyono (2016) sampel
merupakan bagian dari jumlah dan karakteristik yang dimiliki oleh populasi tersebut dan
diperoleh sampel yang benar – benar dapat berfungsi atau dapat menggambarkan
keadaan populasi yang sebenarnya atau representatif.
2.4 Apakah subjek dialokasikan secara acak ke kelompok eksperimen dan kontrol?
Jika tidak, dapatkah ini menimbulkan bias?
Desain penelitian yang digunakan ialah randomized controlled trial, yaitu penelitian
untuk mengetahui pengaruh pengaruh pemberian pelatihan Mental Health First Aid
Programme (MHFA) dalam meningkatkan literasi kesehatan mental, mengurangi jarak
social dari orang-orang dengan kesehatan mental, meningkatkan niat pertolongan
pertama kesehatan mental, dan meningkatkan kepercayaan diri mereka dalam membantu
orang lain. Penelitan mengungkapkan hubungan sebab – akibat dengan cara melibatkan
kelompok kontrol di samping kelompok intervensi. Selain itu, pengambilan subjek pada
penelitian ini secara acak, sehingga dapat meminimalkan bias. Pengacakan tersebut
terkomputerisasi (menggunakan situs pengacak) digunakan untuk menetapkan pasien ke
dalam kelompok.

2.5 Apakah kriteria inklusi / eksklusi yang digunakan?

Pasien yang memenuhi kriteria berikut dimasukkan dalam penelitian: (a) berusia minimal
18 tahun, (b) terdaftar dalam program sarjana keperawatan umum dan (3) dapat
memahami materi Bahasa mandarin dan inggris. Peneliti tidak menyebutkan kriteria
eksklusi penelitian. Namun, peneliti menyebutkan bila responden bisa manarik diri dari
penelitian kapan saja tanpa konsekuensi negative

2.6 Apakah kedua kelompok sebanding pada awal studi?

Kelompok kontrol dan kelopok intervensi diambil berdasarkan kriteria inklusi dan
eksklusi, sehingga tidak ada perbedaan terkait dengan karakteristik responden. Perbedaan
yang dilakukan kelompok kontrol tidak diberikan intervensi, dan kelompok intervensi
tetap menjadi satu dan diberikan intervensi berupa pelatihan Mental Health First Aid
Programme (MHFA).

7
2.7 Apakah terdapat kriteria hasil yang digunakan untuk menentukan hasil yang
objektif dan tidak bias ?
Salah satu cara yang dilakukan untuk menghindari bias ialah dengan menentukan kriteria
inklusi dari responden. Kemudian memasuki proses penelitian, yaitu pemberian
intervensi pelatihan Mental Health First Aid Programme (MHFA) pada kelompok
interversi yang diberikan selama 1 bulan serta tetap melakukan pengukuran pada
kelompok kontrol. Pengukuran yang dilakukan ialah pengukuran literasi kesehatan
mental dan pengukuran kesehatan mental. Pengukuran tersebut dilakukan sebelum dan
setelah tindakan MHFA. Hasil tersebut dilakukan analisis supaya tidak memperoleh hasil
yang bias.

2.8 Apakah penelitian menggunakan alat yang sudah divalidasi untuk mengukur hasil?
Alat yang digunakan dalam penelitian adalah Mental health literacy dan Chinese Health
Questionnaire (CHQ). CHQ digunakan untuk mengukur kesehatan mental. Instrument
ini, terdiri dari 12 item. Sedangkan Mental health literacy digunakan untuk menilai
pengenalan peserta terhadap gangguan kesehatan mental, kesadaran akan masalah
kesehatan mental, dan pengetahuan tentang perawatan untuk penyakit mental.

2.9 Apakah efek yang dihasilkan secara praktik relevan?

Efek yang dihasilkan secara praktik ialah perbedaan hasil dari kelompok kontrol dan
kelompok intervensi. Pada kelompok intervensi didapatkan hasil yang significant yaitu
adanya perubahan pada mental dan niat yang meningkatkan pada pertolongan pertama
kesehatan mental, namun pada kelompok kontrol mendapatkan hasil niat mahasiswa
untuk memberikan pertolongan pertama lebih menuru dari pada kelompok intervensi.
Sehingga secara praktik dapat dikatakan efek atau hasil yang dihasilkan relevan.

2.10 Seberapa tepat perkiraan efek yang dihasilkan ? apakah terdapat nilai interval
yang dapat dipercaya ?
Efek yang dihasilkan dari intervensi pelatihan Mental Health First Aid Programme
(MHFA) menunjukan pemahaman literasi kesehatan jiwa semakin meningkat hal ini
dibuktikan dengan Hasil tersebut di dapatkan dari hasil pengukuran menggunakan uji ci-
square dan Green House Geiser yang dilakukan pada pelatihan MHFA. Selain itu juga
niat dan kepercayaan diri siswa dalam menawarkan bantuan pada pertolongan pertama
kesehatan mental lebih tinggi dibandingkan dengan kelompok control. Hasil tersebut
8
 didapatkan dengan adanya perubahan significant pada 6 bulan yaitu pada kelompok
intervensi yang lebih banyak melakukan kontak dengan orang dengan masalah mental
dan menawarkan bantuan/dukungan untuk individual.
Pada penelitian ini peneliti mencantumkan nilai interval dari hasil penelitian yang
dituangkan dalam tabel.

2.11 Apakah terdapat faktor perancu yang tidak dijelaskan ?

Penelitian ini terdapat beberapa faktor perancu yang dapat mempengaruhi hasil
penelitian. Salah satunya ialah faktor psikologis dari masing – masing responden.
Sehingga peneliti mengatakan bahwa kelompok intervensi mungkin telah dipengaruhi
secara psikologis karena mereka berfikir bahwa mereka akan mendapat manfaat dari
intervensi yang telah dilakukan.

2.12 Apakah hasil yang dihasilkan bisa diaplikasikan ?

Hasil penelitian memiliki implikasi terhadap keperawatan terkait dengan peningkatan
literasi kesehatan jiwa, kesejahteraan jiwa perawat serta kepercayaan dalam membantu
orang dengan masalah kesehatan jiwa. Baik intervensi MHFA memiliki efek yang sama
dalam meningkatkan literasi kesehatan jiwa. Bukti dari penelitian ini menunjukkan
bahwa pelatihan MHFA harus dipromosikan dan diintegrasikan sebagai pelatihan wajib
dan sebagai bagian dari kegiatan ekstrakurikuler untuk kesehatan dan
mahasiswa/perguruan tinggi umum secara lokal dan global. Penelitian kualitatif lebih
lanjut harus dilakukan untuk menentukan secara lebih rinci bagaimana pengalaman dan
penerapan MHFA memberikan pemahaman mendalam tentang cara terbaik untuk
membantu orang dengan masalah kesehatan mental. Selain itu, lokakarya pelatihan
MHFA disarankan bagi para profesional kesehatan yang belum menerima pelatihan
terkait kesehatan mental.

9
 BAB 3
KESIMPULAN

Penulisan makalah ini digunakan untuk telaah kritis pada suatu artikel untuk menilai
validitas, makna dan reliabilitas penelitian sehingga hasil dari telaah kritis ini dapat
digunakan sebagai evidence based nursing. Artikel ini dapat dipertimbangkan sebagai dasar
penelitian lebih lanjut tentang intervensi non-farmakologis untuk mengurangi kecemasan.

Penelitian ini melibatkan 358 responden yang akan dilakukan Mental Health First Aid
(MHFA), sebelum dilakukan MHFA dilakukan pengukuran dengan menggunakan pre-test
Mental health literacy dan Chinese Health Questionnaire (CHQ). Penelitian sebelumnya ada
yang mendukung penelitian ini, yaitu sebuah penelitian menggunakan MHFA untuk perawat
untuk meningkatkan literasi kesehatan mental dan mengurangi stigmatisasi dan jarak sosial
dari orang-orang gangguan mental. Kesimpulan ini sejalan dengan penelitian yang peneliti
lakukan. Kekurangan penelitian ini yaitu kemungkinan ditemukan faktor perancu karena
mahasiswa direkrut dari tahun yang berbeda program keperawatan. Oleh karena itu sedapat
mungkin peneliti dapat menggunakan mahasiswa tahun pertama tanpa pelatihan sebelumnya.

10
 DAFTAR PUSTAKA

Bingham, H., & O’Brien, A. J. (2018). Educational intervention to decreasestigmatizing

attitudes of undergraduate nurses towards people with mentalillness. International
Journal of Mental Health Nursing, 27(1), 311–319.

Eisenberg, D., Hunt, J., & Speer, N. (2012). Help seeking for mental health on
collegecampuses: Review of evidence and next steps for research and
practice.Harvard Review of Psychiatry, 20(4), 222–232.

Fokuo, J. K., Goldrick, V., Rossetti, J., Wahlstrom, C., Kocurek, C., Larson, J., &Corrigan, P.
(2017). Decreasing the stigma of mental illness through astudent-nurse mentoring
program: A qualitative study. Community MentalHealth Journal, 53(3), 257–265.

Farner, J. et al. (2019) ‘Aromatherapy hand massage for test anxiety and self-ef fi cacy in
nursing students : A pilot study’, Teaching and Learning in Nursing. Organization for
Associate Degree Nursing., 14(4), pp. 225–230. doi: 10.1016/j.teln.2019.04.008.

Heidari, F. et al. (2017) ‘European Journal of Integrative Medicine Clinical trial E ff ect of
short-term hand re fl exology on anxiety in patients before coronary angiography : A
randomized placebo controlled trial’, 16(July), pp. 1–7. doi:
10.1016/j.eujim.2017.09.010.

Kala, P. et al. (2016) ‘Depression and Anxiety after Acute Myocardial Infarction Treated by
Primary PCI’, pp. 1–9. doi: 10.1371/journal.pone.0152367.

Kemenkes RI (2018) ‘HASIL UTAMA RISKESDAS 2018’. Jakarta: Badan Penelitian dan
Pengembangan Kesehatan Kementerian Kesehatan RI.

Kitchener, B. A., & Jorm, A. F. (2002). Mental health first aid training for the
public:Evaluation of effects on knowledge, attitudes and helping behavior.
BMCPsychiatry, 2(1), 10.

Nursalam. (2015). Manajemen Keperawatan: Aplikasi Dalam Praktik Keperawatan

Profesional. Jakarta: Salemba Medika

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Ramezanibadr, F. et al. (2018) ‘The impacts of foot reflexology on anxiety among male
candidates for coronary angiography : A three-group single-blind randomized clinical
trial Complementary Therapies in Clinical Practice The impacts of foot re fl exology
on anxiety among male candidates for coronary angiography : A three-group single-
blind randomized clinical trial’, Complementary Therapies in Clinical Practice.
Elsevier, 32(July), pp. 200–204. doi: 10.1016/j.ctcp.2018.07.005.

Smeltzer, S.C. & Bare, B.G. (2013). Buku Ajar Keperawatan Medikal Bedah Brunner &
Suddarth, edisi 8. Jakarta : EGC.

Stuart, W. (2013). Prinsip dan Praktik Keperawatan Kesehatan Jiwa. Edisi Indonesia. Jakarta :
Fakultas Keperawatan Indonesia.

Sugiyono. (2016). Metode Penelitian Kuantitatif, Kualitatif dan R&D. Bandung: PT Alfabet

Sun, F. K., Long, A., Tseng, Y. S., Huang, H. M., You, J. H., & Chiang, C. Y.
(2016).Undergraduate student nurses’ lived experiences of anxiety during their
firstclinical practicum: A phenomenological study. Nurse Education Today, 37,21–26.

Svensson, B., & Hansson, L. (2014). Effectiveness of mental health first aid trainingin
Sweden. A randomized controlled trial with a six-month and two-yearfollow-up.
PLoS One, 9(6), Article e100911.WHO (2012) ‘Prevention and Control of
Noncommunicable Diseases: Guidelines for primary health care in low-resource
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 Collegian 28 (2021) 106–113

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
Tung Wah College, Hong Kong Special Administrative Region, China
b
Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
c
The Mental Health Association of Hong Kong, Hong Kong Special Administrative Region, China

a r t i c l e i n f o a b s t r a c t

Article history: Background: Insufficient mental health related knowledge among healthcare professionals and students
Received 6 July 2019 may lead to higher levels of stigma towards and increased social distance from mentally unwell patients.
Received in revised form Moreover, university students enrolled in healthcare programmes are particularly susceptible to stress,
10 December 2019
depression, anxiety and other mental health problems.
Accepted 15 April 2020
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
Keywords:
distance from persons with mental health issues, increasing their mental health first-aid intention, and
Nursing students
Undergraduate students
enhancing their confidence in assisting others. The programme was also extended the effectiveness to
Mental wellbeing help students to maintain their own mental wellbeing.
Mental Health First Aid 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 activ-
ities 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.

∗ 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).

https://doi.org/10.1016/j.colegn.2020.04.006
1322-7696/© 2020 Australian College of Nursing Ltd. Published by Elsevier Ltd.
 M.S.Y. Hung et al. / Collegian 28 (2021) 106–113
Summary of relevance
Problem or Issue
Little is known about the effect of the Mental Health First Aid
(MHFA) programme in improving the mental health knowl-
edge, behaviour, attitudes, and wellbeing of general nursing
students.
What is Already Known
The MHFA programme is a psycho-educational training pro-
gramme that has been shown to enhance mental health
knowledge in diverse populations in various countries.
What this Paper Adds
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 comor-
bidities, 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.
1. Introduction and background
According to the World Health Organization (World Health
Organization, 2017), approximately one in four people worldwide
are affected by mental illness during their lifetimes. The WHO rec-
ommends 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 aca-
demic 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,
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 men-
tal 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 particu-
lar, nurses often spend considerably more time providing patient
care than other healthcare professionals. These obstacles likely hin-
der nurses’ motivation and ability to provide quality holistic care.
Accordingly, relevant pre-registration education for nursing stu-
dents 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 psycho-
educational 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, depres-
sion, 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 vari-
ous 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,
107
& 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 par-
ticipants demonstrated that the training significantly improved
the participants’ knowledge and identification of mental illnesses,
increased their awareness of effective treatments for these ill-
nesses, 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’ experi-
ence 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).
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 insti-
tutions are thus optimally positioned to organise peer support
training to promote and improve adolescents’ mental wellbeing.
For nurses, knowledge regarding the early identification of men-
tal health problems and effective interventions, together with a
positive attitude and willingness to offer help and support for indi-
viduals with mental health disorders, should be a fundamental
attribute of patient care.
This waitlist-based randomised controlled trial aimed to evalu-
ate the effectiveness of MHFA training for undergraduate nursing
students. The objectives were as follows: 1) to increase the par-
ticipants’ 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
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 under-
graduate 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 & McCrum-
Gardner, 2007).
2.2. Ethical considerations
After receiving ethical approval for the study from the Research
Ethics Sub-Committee of the participating institution, general nurs-
ing 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 dur-
ing May 2017. The participants were supplied with an information
sheet that clearly described the purpose, procedure, risks, and ben-
efits 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
108 M.S.Y. Hung et al. / Collegian 28 (2021) 106–113
Fig. 1. The stages of the study.
enrolling and assigning the participants to either the experimental
group or a waitlisted control group. Self-administrated question-
naires 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) con-
ducted 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 sub-
stance abuse.
The Chinese version of MHFA manual (Hong Kong 3rd Edi-
tion) (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 activi-
ties, 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 associ-
ated 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 post-
test 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.
2.4. Outcome measures
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 Question-
naire (CHQ).
2.5. Mental Health Literacy Scale (Chinese version)
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 stan-
dards 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-
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 relation-
ship 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 4-
point 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 par-
ticipants 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 fam-
ily 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 psychi-
atric 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 pres-
sure 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 cal-
culate a mean score. A lower score indicates better mental health,
and a higher score represents more psychological distress. The reli-
ability coefficients for the CHQ ranged from 0.83 to 0.86, displaying
satisfactory internal consistency.
2.7. Data analysis
IBM SPSS-Statistics 23 was used for the data analysis, which was
conducted on an intention-to-treat basis. The missing data for every
 M.S.Y. Hung et al. / Collegian 28 (2021) 106–113
Table 1
Descriptive statistics for the experimental and control group
Experimental group
Mean ± SD Frequency
N 182
Gender
Male 36
Female 146
Age 20.80 ± 1.91
Previous training on mental health training 25
Mental health issues in self 59
outcome measure were imputed by using the last-observation-
carried-forward method.
3. Results
The participants comprised 358 nursing students (63 (17.6%)
male and 295 (82.4%) female). Table 1 shows the descriptive statis-
tics 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%) par-
ticipants in the experimental group and 14 (8%) in the control
group had previously undergone mental health training, and 59
(32.8%) and 68 (38.6%) participants in the experimental and con-
trol 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 Greenhouse-
Geisser 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 mea-
sures. 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 treat-
ment [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 recog-
nition 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, includ-
ing 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 pro-
vide 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
109
Control group
Percentage Mean ± SD Frequency Percentage
176
19.9% 27 15.3%
80.1% 149 84.7%
20.76 ± 1.91
13.9 14 8.0%
32.8 68 36.8
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 exper-
imental 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’ learn-
ing 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 stu-
dents 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 ill-
ness (depression and schizophrenia) and improved understanding
of the roles of relevant professionals, medication, and treatment
available to assist people with mental health problems. The great-
est 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
110 M.S.Y. Hung et al. / Collegian 28 (2021) 106–113

treating people with mental disorders (Wong et al., 2017). How-

Pre–follow- up
ever, in line with other studies (Burns et al., 2017; Jorm, Kitchener,
Sawyer, Scales, & Cvetkovski, 2010), a slight decrease in knowledge
Cohen’s d

−1.46**

−1.28**

−1.32**
−0.28**
−0.03*
of treatments for mental illness and helpfulness from different pro-

0.78**

0.92**
0.05**
−0.10

−0.09

0.48
fessionals was observed in the post-test compared to the six-month
follow-up assessment. This attenuation reflects the need for regu-
lar refreshment or further professional development to reinforce
Cohen’s d
Pre– Post

the learned knowledge.

−1.44**
−1.10**

−0.34*
1.15**
0.88**

0.76**
−0.26
−0.17

−0.25
−0.21
Mental illnesses present substantial challenges to healthcare

0.06
professionals worldwide, especially in general hospital settings in
which patients often present with mental and physical comorbidi-
ties (Vasiliadis, Lamoureux-Lamarche, & Guerra, 2017). Although
MHFA training is not intended to replace mental health nursing
Partial Eta Sq.

education in the curriculum (Kelly & Birks, 2017; Kitchener & Jorm,
2017), the general nursing students in this study were expected to
0.17**

0.16**

0.31**

0.15**
0.20**

0.03**
0.04**

0.04**
0.08**
0.02*
0.02*

use mental health first-aid skills after their training to provide assis-
tance and to refer people efficiently and effectively to mental health
professionals and local resources. The valuable and relevant infor-
mation provided in the MHFA programme not only enhanced the
F (time*group

mental health knowledge and practical skills of the general nurs-

ing students but also helped to consolidate what they had learned
effect)

during their general nursing training (Hung et al., 2019).

36.56

33.94

81.35

31.69
47.01
3.82
4.28

6.28

7.53
5.92
7.50

4.2. Social distance

4.75 (1.68)
5.43 (1.99)

4.25 (1.93)
5.31 (2.37)
2.29 (0.57)

2.13 (0.54)

2.34 (0.58)

2.88 (0.63)

3.87 (0.95)
2.21 (0.47)
3.20 (0.76)
Mean (SD)

Several studies have reported that insufficient mental health

Control

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;
Experimental

Henderson et al., 2014; Giandinoto et al., 2018; Knaak et al., 2017;

5.97 (2.17)

4.89 (1.82)
2.82 (0.41)
5.08 (1.75)

1.74 (0.54)

2.87 (0.33)

6.08 (2.33)
2.21 (0.56)

3.11 (0.68)
4.34 (2.20)
1.82 (0.43)
Mean (SD)
Follow-up

Mak et al., 2015). An Australian survey that compared the atti-

Repeated-measures analysis of variance with Greenhouse-Geisser and post hoc Bonferroni correction were performed.

tudes of healthcare professionals, such as psychiatrists, clinical

psychologists, and general practitioners, with those of the gen-
eral community, found that women and general practitioners were
prone to have more personal stigmatising attitudes about men-
5.49 (1.87)

2.17 (2.67)
2.25 (0.55)
5.04 (1.13)
5.71 (1.40)
2.25 (0.54)

2.32 (0.46)
4.69 (1.50)

2.85 (0.59)

2.94 (0.80)

2.09 (0.49)
Mean (SD)

tally ill patients, and maintain greater social distance from these
Control

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 main-
tained the greatest social distance and social workers maintained
Experimental

6.35 (2.12)

5.23 (1.69)
6.33 (2.25)
2.71 (0.48)
5.30 (1.65)

2.91 (0.28)

3.17 (0.75)
1.18 (2.04)
1.72 (0.36)
1.70 (0.51)

2.07 (0.59)
Mean (SD)

the smallest social distance from individuals with mental illness,

Post-test

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
Comparison of various measurements at pre-test, post-test and follow-up

magnitudes of these attitudes, all likely hinder the professional’s

4.89 (1.23)
5.93 (1.52)
2.15 (0.45)
5.12 (1.04)

2.15 (0.47)

2.24 (0.46)

2.72 (0.56)

2.94 (0.87)
2.23 (2.70)
6.03 (1.20)

2.10 (0.42)
Mean (SD)

motivation and ability to provide quality holistic care. It is there-

Control

fore 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
Experimental

training could decrease the perceived social distance among nurs-

4.93 (1.13)

5.89 (1.79)

1.33 (2.35)
2.21 (0.42)

6.06 (1.13)
2.16 (0.53)

2.35 (0.47)
4.84 (1.30)

2.71 (0.52)

2.89 (0.85)

2.04 (0.47)
Mean (SD)

ing student participants (Bond et al., 2015; Burns et al., 2017; Hung
Pre-test

et al., 2019). In a recent qualitative study that explored nursing

students’ experiences three months after MHFA training, the par-
ticipants reported that the MHFA programme had improved their
beliefs and values (Hung et al., 2019). Specifically, they had acquired
Chinese Health Questionnaire
Recognition of schizophrenia

Mental health first aid action

Confidence in ability to help

the belief that nurses should present a neutral, therapeutic atti-

Recognition of depression

tude towards and become more accepting of people with mental

Beliefs about treatment

Beliefs about treatment

Schizophrenia scenario
Professional consensus

Professional consensus

illness. This demonstrates that improvements in mental health lit-

SD, standard deviation.
Depression scenario

eracy can help these students to normalise mental health problems

Social distance

Social distance

and dispel the myths that surround these problems, thus decreas-
ing stigmatisation and social distancing from people with mental
p < 0.05.
p < 0.01.

illness.
Table 2

However, the stigma of mental illness, including self-stigma

*

**

as well as family and public stigma, is deeply rooted in Chinese

 M.S.Y. Hung et al. / Collegian 28 (2021) 106–113
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 individ-
uals 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 gov-
ernment and healthcare organiszations are optimally positioned to
support these families and to promote compassionate and altruis-
tic attitudes and behaviours towards those in society suffering from
mental illness.
4.3. Confidence in the ability to help and mental health first aid
action
Consistent with the findings of previous studies, the MHFA inter-
vention 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 men-
tal 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 individ-
uals 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 find-
ing 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 interac-
tive 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 rela-
tive had encountered mental health problems. The skills they had
learned from these experiences had likely bolstered their readi-
ness 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 achieve-
ment 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 sui-
cidal 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, depres-
sion, 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 partic-
ipants in this study (127; 35.5%) had experienced problems with
their own mental health.
111
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 medi-
cal 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 relation-
ships. After the MHFA training, they were more conscious of and
attentive to their own mental status when handling such life chal-
lenges.
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 the-
oretical 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 can-
not 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 physi-
cal 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 impor-
tance of mental health in response to an increase in the
prevalence of mental disorders, especially in youngsters. Local
governments and non-governmental organisations have organ-
ised various health promotion and disease prevention programmes
that target mental health awareness, stigma, suicide preven-
tion, 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 abil-
ity to cope with the stressors of academic life. Furthermore, tertiary
institutions should review their existing curricula and provide ade-
quate 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 insti-
tutions to organise informative and beneficial activities, including
mental health seminars/workshops and counselling sessions, to
nurture an encouraging atmosphere and emphasise the signifi-
cance 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 gen-
eral nursing students. Similar to other recent studies, this study
confirmed the benefits of the MHFA programme for healthcare stu-
112 M.S.Y. Hung et al. / Collegian 28 (2021) 106–113
dents 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
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 pro-
vide an in-depth understanding of the best ways to assist people
with mental health problems. In addition, MHFA training work-
shops 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 popula-
tion, 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 practis-
ing 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 pro-
gramme (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 Sub-
Committee.
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 con-
flicts of interest to disclose. We have no particular preferences
regarding the selection of academic editors and reviewers to handle
this manuscript.
CRediT authorship contribution statement
Conceptualisation 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,
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.
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Maria S.Y. Hung, RN, DHSc, is an associate professor in the School of Nursing at Tung
Wah College, Kowloon, Hong Kong.
Meyrick C.M. Chow, RN, PhD, is a professor in the School of Nursing at Tung Wah
College, Kowloon, Hong Kong.
Wai Tong Chien, RN(Psy), PhD, is a professor in the Nethersole School of Nursing at
The Chinese University of Hong Kong.
Prudence Y.K. Wong, RSW, BSW, is the co-ordinator of Mental Health First Aid
programme of the Mental Health Association of Hong Kong.