TeaLeaf-Mansik Swastha (Teachers Leading the Frontlines- Mental Health) is a research-led community-based intervention which sees the “shifting” of mental health care to primary school teachers in the Darjeeling Himalayas of West Bengal using evidence-based therapy techniques. The teachers partake in 2 day and 6 day trainings to deliver therapeutic interventions to selected students in their classroom environment. This is a novel approach in attempting to tackle the care gap in CAMHS by increasing access to community support for children in resource-limited settings, with teachers being a key element. This intervention was found to be feasible in initial assessments (Cruz et al., 2021).
Mental health disorders affect 10-20% of children and adolescents globally (Fazel et al., 2014). In low- and middle-income countries (LMICs), including India, there is a severe lack of support and care services available for youth dealing with mental health concerns. According to the International Labour Organisation, India has the largest youth population in the world with 40% of the country’s population aged between 13 -34 years (International Labour Organisation, 2012). However less than 1% of Indian children and adolescents with mental health struggles are receiving treatment (Hossain & Purohit, 2019). Some of the main barriers are noted as being a shortage of trained mental health personnel, skewed access to care facilities and programmes (e.g. urban versus rural access), early detection and timely intervention of mental health issues (Mehra et al., 2022).
Overall, the Indian Mental health system is recognised as being weak and fragmented. In 2023 reports indicated that India had about 0.7 psychiatrists per 100,000 people, whereas the recommended ratio is at least 3 per 100,000 (Jha, 2023). There is an urgent need to explore more innovative solutions to help bridge the gap between CAMHS and access to care (Mental Health National Survey, 2015-16). Task shifting is one such example of an alternative model which can play an important role in addressing this gap (Kakuma et al., 2011). Task shifting is a process of reallocating resources and skills of specialised professionals to lay individuals, or those with less expertise, to help off load the work burden and to extend access to a larger population (Schalkwyk et al., 2020). In the mental health context this model has been shown to be a promising approach to the delivery of child mental health care with results of increased access and improved mental health outcomes demonstrated in various studies (Patel et al., 2010) (Patel et al., 2017) (Van Ginneken et al., 2013).
“India has the largest youth population in the world with 40% of the country’s population aged between 13 -34 years. However less than 1% of Indian children and adolescents with mental health struggles are receiving treatment.”
TeaLeaf Reimages Mental Health care for primary school children in Darjeeling, West Bengal, India.
TeaLeaf-Mansik Swastha is an intervention run in partnership between DLRPrerna, Darjeeling and Broadleaf Health and Educational Alliance along with the support of Mariwala Health Initiative (MHI) whereby trained professionals’ task-shift their specialised knowledge and skills to primary school teachers in order to deliver cognitive therapy techniques in the classroom. In 2018 a single arm mixed-methods feasibility study was conducted with 19 teachers and 36 children in 5 rural primary schools to ascertain whether teachers can deliver transdiagostic mental health care, to select children-in-need with fidelity to protocol, to assess with therapeutic options teachers chose to use within the protocol and to evaluate for a potential signal of efficiancy. It was found that a majority of teachers met or exceeded quality benchmarks for all intervention activities with a rate of 72% to 100% and that children improved in mental health score percentiles on the Achenbach Teacher Report form, which is a validated scale of measuring type and severity of child mental health symptoms as reported by a teacher.
To reach children with poor access to government services and care, low-cost private primary schools in the tea plantations and farming villages of Darjeeling and Kalimpong were targeted (Cruz et al., 2021). Research by our team revealed that 13% of students in our study area were suffering from depression and 41.6% reported poor mental well-being (Cherewick et al., 2024).
The training material utilised has been carefully developed by a team of international and local experts in child mental health, well-being and development. All the material is contextualised to the local environment and available in both English and Nepali; the local spoken language. This specialised and customised material is then delivered in 2 day and 6-day trainings by our local team in the community. Teachers are trained to identify and provide targeted support to children displaying signs or at risk of mental distress. A key component of the training is to understand the underlying reasons for the “behaviour” of the child. In our experience it is common for teachers to disregard the students as being “lazy” or “dumb” or “hyperactive” without thinking about the reasons behind this behaviour. Understanding the possible “why” helps the teachers to foster more empathy and we can then work together to develop a tailored plan to help the children improve their health and education outcomes based on this “why”. Instead of diagnosing a child, which comes with its own ethical concerns and additional burden on teachers, teachers are trained to understand behaviours through behaviour theory (Cooper et al., 2020). They fit behaviors into categories of children filling a need in: attention, escape, tangible, or sensory. These needs are common across diagnoses and are, in fact, the target of therapies. Tealeaf skips diagnoses and goes directly to the child’s behaviour that demonstrates their need and requires care.
Further, this training can benefit the class as a whole and extend beyond the classroom into the community. In our prior research we found that family engagement was viewed as important by both teachers and family. For the study, semi structured interviews (SSIs) were conducted with teachers (n=17) and caregivers (n= 21). The SSIs were coded with themes related to family engagement. As a result of this, the programme now contains a formal family element (Vanderburg et al., 2021). By purposefully engaging with parents/caregivers as well as prominent community members we hope to facilitate de-stigmatisation of mental health along with increasing acceptance of our programme.
“Teachers are trained to identify and provide targeted support to children displaying signs or at risk of mental distress. A key component of the training is to understand the underlying reasons for the “behaviour” of the child.”
Teachers As Existing Human Resources
Teachers are specifically chosen to deliver the intervention as they are in the unique position of having child development experience and of being in daily direct contact with the children in a 1:1 capacity. This is a familiar and accessible space for the child. Whether they realise it or not teachers are often already supporting their students with behavioural challenges and mental health concerns. Now they are given the knowledge and therapy tools with which to identify and apply targeted support to encourage mental well-being and resilience. Barriers to teacher -delivered mental health care were examined during semi structured interviews. Teachers unanimously agreed that lack of time to deliver the Tealeaf interventions, most notably during exam time, was one major difficulty they faced. In order to mitigate this, teachers were supported to problem solve time issues by giving one-on-one time to children during recess or before and after school for example. Another barrier included translating theory into practice which proved more of a challenge then the teachers thought it would. Real world behavioural challenges in children presented much more heterogeneously and techniques learned during the training might not work for all situations. The availability of ongoing support and coaching by the team helped teachers to problem solve and adapt (Cruz et al., 2021).
In this model, teachers have the capacity to customise the techniques learned which can then be integrated into their existing workflows. In our mixed methods feasibility study, we found that this type of non- manualised approach may contribute to the emergence of a new therapy modality that we have coined as “education as mental health therapy” (Ed-MH). The teacher-centric techniques of Ed-MH i.e. techniques that only teachers could deliver given their unique role in the child’s life, were chosen by the teachers 80% of the time. This is a type of educational intervention which teachers find feasible and acceptable giving it the potential to be considered on a wider scale (Cruz et al., 2021). In semi structured interviews carried out along with intervention documentation (e.g. fieldnotes and supervision notes), a majority of teachers shared that they underwent significant changes in their perceptions towards mental health and provided examples of being more inclusive of students with mental health difficulties.
Conclusion
The care gap in the need for and in the delivery of child mental health care is a global struggle. However, in LMICs in particular it is a critical concern. This research study re-imagines the approach to addressing this gap by utilizing already available resources in the form of schoolteachers to be trained to deliver evidence-based therapy techniques in the classroom. This type of therapeutic care model meets children’s behavioural needs in real time. It has the benefit of being community based and accessible rather than in a clinical time-restricted distance-inhibited setting.
Our on-going research indicates that teacher-centric transdiagnostic mental health care (Ed-MH) may be a promising approach in helping to support mental health concerns among the youth. Recent findings have shown that 58% of children receiving Ed-MH through TeaLeaf have a lower risk of having severe mental health risk or challenge. We measured this by comparing 28 students in Tealeaf (taught by 13 teachers) to 188 students (taught by 97 teachers) in enhanced usual care. These children were followed pre and post 1 year of intervention. We measured this using the Achenbach Teacher Report Form (Cruz et al. 2023). Furthermore teachers, students and families alike find this type of intervention acceptable and feasible indicating efficiency and sustainability.
While further research is necessary, the results emerging to date indicate a step in the right direction to finding a more sustainable and tangible approach to providing real care in real time to those children exhibiting mental health concerns.
NB this blog has been peer-reviewed
References
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About the author
Catherine Canavan Shrestha BSc, LLM, works with Broadleaf Health and Education Alliance in Darjeeling, India. The focus of the work is on improving health and education outcomes for children of the region. Catherine is specifically involved in the TeaLeaf project; a mental and behavioural intervention whereby child mental health care is task shifted to teachers in the classroom setting. Prior to this she worked as the Overseas Director for another Darjeeling based NGO providing education, health care and rehabilitation to vulnerable and disadvantaged children