Evaluation of the Mental Health First Aid Training in First Nations ...

Section 3 describes the participants and how the data was collected from them. Section 4describes the data collection tools and presents results for each of the evaluationquestions. Section 5 presents final recommendations.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 6 of 40

2. Mental Health First Aid2.1 Development of Mental Health First AidMental Health First Aid is patterned after first aid courses like CPR. It is intended toincrease mental health literacy and provide practical tools for responding to mental healthcrises. The course was developed in Australia in 2000 by Dr. Tony Jorm and Ms. BettyKitchener and has since been adapted in 15 countries.Dr. Jorm had been researching mental health literacy for several years before developingthe course with Ms. Kitchener. In that research 2 , it was apparent that mental healthliteracy is poor for a variety of groups. Mental health literacy is a major part of theMHFA course. It includes:• The knowledge and beliefs that help in recognizing, managing and preventingmental illnesses.• The ability to recognize specific disorders.• Knowing how to find mental health information.• Knowing risk factors and causes.• Knowing self-help strategies and what professional help is available.• The attitudes that promote recognizing mental illnesses.• The attitudes that promote appropriate help-seeking. 3Part of mental health illiteracy is the myths about mental illnesses. Such myths lead tostigmatizing attitudes toward the mentally ill that result in discrimination toward them.Stigma and mental illness has been studied for almost fifty years and has remainedconsistently negative. Debunking the underlying myths of stigma is also a significantcomponent of MHFA. Course materials provide clear information that speak to the manyaspects of stigma.The “first aid” aspect of the course is captured in the acronym ALGEE. The use of anacronym is a frequent tool to aid in knowledge retention. This five-step approach isapplied to each of four disorder groups and the course itself provides the necessaryinformation for graduates to be able to employ the approach.ALGEE includes:• Assess risk of suicide or harm.• Listen non-judgementally.• Give reassurance and information.• Encourage person to get appropriate professional help.• Encourage self-help strategies. 42 For example, see AF Jorm, AE Korten, PA Jacomb, H Christensen, B Rodgers, P Pollitt. 1997. “Mentalhealth literacy”: a survey of the public’s ability to recognize mental disorders and their beliefs about theeffectiveness of treatment.” The Medical Journal of Australia, volume 166: 182.3 Jorm, Korten, Jacomb, Christensen, Rodgers, Pollitt, 1997.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 7 of 40

The course helps graduates to identify signs of crisis for each of four types of disorders.The disorder groups are depression, anxiety, psychosis, and substance abuse. Steps toensure harm reduction are identified, the first step of ALGEE. The second step is to listennon-judgmentally while part of the third step is to give reassurance. Here the course helpsgraduates by using modelling techniques and group activities to learn and practice goodlistening skills.The third step includes giving reassurance, but also to provide information that could bereassuring. Here the course addresses issues related to:• The status of mental illness as an illness.• The disabling effects of mental illness compared with physical illnesses.• The rate of mental illness.The course also discusses treatment options, a source of reassurance to someone in amental health crisis.The fourth step of ALGEE is to encourage the person to get the proper professional helpif needed. In the Australian 2002 manual, this includes mental health and other healthprofessionals as well as the support of family and friends. That manual also brieflydiscusses treatment options available through mental health and health care professionals.Both the Australian and the AMHB websites and course materials make it clear thatgraduates of MHFA receive training in first aid skills only.The fifth and final step is to encourage self-help strategies. The Australian 2002manualdiscusses life style changes, and self-help and holistic strategies for managing more mildforms of mental illness. The AMHB’s fifth step, “encouraging other supports” has aslightly different set of strategies. The AMHB includes life style changes and self-helpand holistic strategies, as well as seeking out the support of lay people such as clergy orelders, or family and friends.2.2 History of ProgramAs noted above, MHFA was developed in 2000 in Australia. Since then, MHFA Australiahas worked with 15 other countries including Canada to establish the course in thesecountries. These countries are diverse in language and culture and include, for example,Scotland, Hong Kong and South Africa. Both Scotland and Australia have made thecourse part of their national mental health strategies. It was introduced to Canada in 2006by the Alberta Mental Health Board but in 2010, the leadership of the program wasassumed by the Mental Health Commission of Canada.It was originally intended for members of the community. The course has been used morewith workforce groups than with the general public 5 . Versions for youth and for different4 AF Jorm, BA Kitchener, R O’Kearney, KBG Dear. 2004. Mental health first aid training of the public in arural area: A cluster randomized trial. BMC Psychiatry, volume 4:33. Available throughhttp://www.mhfa.com.au/evaluation.shtml#uncontrolled_trial_public, downloaded February 26, 2010.5 AF Jorm, BA Kitchener, LG Kanowski, CM Kelly. 2007. Mental health first aid training for members ofthe public. International Journal of Clinical and Health Psychology, volume 7, number 1, pp. 141-151.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 8 of 40

cultural groups have been developed, including two for Aboriginal peoples in Australiaand New Zealand. When adaptations are made, the developers work closely withmembers of the community to assist in the “development and delivery of course contentand in finding the appropriate explanatory models for mental disorder for the respectivecommunities” 6 . Instructors from these communities are trained in the new courses (seeSection 2.4).2.3 EvaluationsFive evaluations of Mental Health First Aid have results that are relevant tounderstanding the impact on Alberta First Nations participants. All five are available athttp://www.mhfa.com.au/evaluation.shtml. Four include pre- and post-course data; thefifth looks at the uptake of the 2008 Australian Aboriginal and Torres Strait IslanderMHFA. Alberta participants were not assessed on referral and response patterns beforethe course. Stigma also was not assessed. One method to compensate for the lack of suchdata is to compare results with other studies. What was unanticipated was how similar theAlberta graduates are to participants in other countries and of other languages.In 2007, Alberta Mental Health Board also evaluated the program. It involved over 600participants in Alberta and Manitoba and was completed in 2007. The evaluation does notprovide a description of the population. It used the same course evaluation form andmental health opinion quiz. It did not include pre-course measures, important indetermining whether key outcomes have changed as a result of the course.MHFA has been evaluated using both qualitative and quantitative methods. It has beenevaluated twice using one of the strongest methods for assessing effectiveness, therandomized controlled trial.2.4 Program FidelityMHFA Australia provides guidelines to maintain program fidelity. When a program hasevidence of effectiveness, keeping the key components of it intact is important inmaintaining program fidelity. But a balance between maintaining the original programand adapting it to local needs has to be struck.As MHFA has been imported to other countries, the manual and accompanying materialshave been adapted to the local needs. How it is taught – using the manual and othercourse materials delivered in a standard format – has been held fairly consistent.Agencies wishing to import MHFA to their countries must sign a Memorandum ofAgreement that outlines the process for adaptation.A key component of any training program is the instructor. Research in teaching methodsindicates this is the component that most influences the implementation of a prescribedteaching method 7 . Mental Health First Aid includes a 5-day course to train instructors6 Jorm, Kitchener, Kanowski, Kelly, 2007.7 SW Smith, AP Daunic, GG Taylor. 2007. Treatment fidelity in applied educational research: Expandingthe adoption and application of measures to ensure evidence-based practices. Education and Treatment ofChildren, volume 30, number 4, pp. 121-134.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 9 of 40

who then provide the 12-hour course in their communities. These instructors are trainedby at least one of the Australian developers and must meet the following eligibilityrequirements:• Experience in the field of mental health and mental illness.• Good knowledge of mental health disorders and their treatment.• Experience in delivering training/teaching effectively to adult learners.• Experience in networking with community partners.• Knowledge of the range of mental health services.• Good interpersonal and communication skills.• Positive attitudes towards people with mental health problems.• Enthusiasm to reduce stigma/discrimination associated with mental illness 8 .The tuition for the instructors’ course covers the cost of training, access to the AMHBinstructor’s website, updated materials, ongoing program evaluation, instructor meetings,and support from master facilitators. Currently there is one master facilitator in Canada.The instructors are responsible for arranging, conducting, and financially managing theircourses. The AMHB website provides instructor profiles and schedules of upcomingcourses. A variety of course fees are charged.The other key component is the materials used to deliver the content. The manual wasadapted by the Alberta Mental Health Board and reviewed by Canadian mental healthexperts as well as one of the Australian developers. It includes much of the same materialas the original Australian manual. A PowerPoint presentation was developed toaccompany the manual but the DVDs used in the Canadian course are from Australia. Aswith the original program, the Canadian MHFA is offered over two days in four sessionsand uses a combination of lectures and group learning activities.The version of the course used by Health Canada for the First Nations MHFA initiativewas the adaptation produced by AMHB. Consistent with the cultural competence ofMHFA, one First Nations instructor was trained by Health Canada. The AMHB course isclose to the original version and kept key components. Two changes of note are: (1) theAustralian 2002 manual covers the disorder groups in order of incidence. The AMHBmanual discusses substance abuse first followed by the other three disorders in order ofincidence. The second is the slightly different wording of the fifth step of the ALGEE isbetween the Australian 2002 and AMHB versions, as already noted. The AMHB versionwas reviewed by Canadian mental health experts as well as by Ms. Kitchener.Health Canada’s usual training model is to train people in a central location. The MHFAinitiative was intended to be delivered in the community, to increase participation at thecommunity level as well as to enrich community resources in mental health. HealthCanada also implemented MHFA in keeping with program fidelity. Mental Health FirstAid has been offered in and evaluated with a variety of delivery models. The course has8 AMHB. 2009. Selection Criteria for MHFA Canada Basic Instructors. Available athttp://www.mentalhealthfirstaid.ca/instruct/basic/Documents/Selection%20Critera%20Apr%202009.pdf,downloaded March 1, 2010.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 10 of 40

een offered with members of the public responding individually to publicity, withemployees in workplace settings 9 and in rural Australia 10 . In Canada, the course isoffered in a variety of settings 11 . In this initial round of training, Health Canada onlyfocussed training for community gatekeepers in First Nations communities and not laymembers of the public.9 BF Kitchener, A Jorm, 2002. Mental health first aid training for the public: evaluation of effects onknowledge, attitudes and helping behavior. BMC Psychiatry 2. Available at throughhttp://www.mhfa.com.au/evaluation.shtml#uncontrolled_trial_public, downloaded February 26, 2010.10 Jorm, Kitchener, O’Kearny, and Dear. 2004.11 See AMHB’s “Course Information” athttp://www.mentalhealthfirstaid.ca/COURSE/Pages/FindCourse.aspxAB FN MHFA Final Report,May 11, 2010 (CAZA) Page 11 of 40

3. Description of ParticipantsAs noted above, the Alberta First Nations graduates of Mental Health First Aid weresimilar in key ways to graduates of other courses. Gender, birth year, First Nations status,employment, and level of education were gathered for 28 participants in the follow upevaluation. The majority (61%) were from Treaty 6 First Nations, with 22% from Treaty8 First Nations, and 16% from Treaty 7 First Nations. Six other people attending aconference on indigenous mental illness also completed a part of the evaluation. Theywere similar in age and community of residence as the graduates. Five administrativeinterviews were also completed. The MHFA trainer was interviewed as was a communityorganizer from each of the three Treaty areas and a staff member from Health Canada; nobackground information was gathered from them.Background information was not gathered for the graduates at the time of the course.About 63% provided information about their jobs. Over half worked in health care (30%)or social services (25%). Most (89%) seemed to be women (from the first name). A littleover half (52%) of the 302 graduates came from Treaty 6 First Nations, 30% from Treaty8 First Nations, and 18% from Treaty 7 First Nations.The 28 participants in the follow up were contacted by telephone or by email. About onethird(35%) of the 302 participants were contacted by email with several follow up phonecalls. Almost half of the participants (48%) could not be contacted because the numberprovided was not in service; they no longer worked at the number provided; the emailwas incorrect; or a phone number was not provided and they did not work at thecommunity health centre. Ten participants agreed to an interview but had to cancel theday of the interview and could not reschedule.The course was delivered to first community gatekeepers in First Nations communities,with less than 5% of the participants coming from the general public. The participantsfrom the First Nations communities are similar in many ways to participants from coursesin other countries and from other ethnic groups. Table 3.1 lists key characteristics of thedifferent groups of participants.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 12 of 40

Table 3.1 Comparison of Alberta MHFA Graduates and Other GraduatesSample % of women > 40 years old Indigenous Sector UniversityDegreesAlberta MHFA 89% Unknown Unknown 31% healthUnknownGraduates55% human servicesAlberta Follow Up 62% 60% > 40 68% 73% health or mental 53%healthVietnamese, 2009 12 68% 48 > 40 0% 33% human services 49%Rural public study, 81% 472.6% 43% human services 21%2004 13 (Average age)Workplace study, 78% 51% > 40 1.3% 96% human services 61%2004 14 6% healthGeneral public, 2002 15 84% 75% > 40 0.5% 38% consumers orcarers31% health44%Participants tend to be women over the age of forty, who work in human services andhave a university degree. Unlike the First Nations participants, several of the studiesabove included large percentages of the general public. Several results from these studiesare similar to the Alberta results and since the groups are similar in all ways exceptethnicity, this adds confidence that the Alberta results can be anticipated to be similar forfuture graduates.12 H Minas, E Colucci, AF Jorm. 2009. Evaluation of Mental Health First Aid training with members of theVietnamese community in Melbourne, Australia. International Journal of Mental Health Systems, volume3:19. Available at through http://www.mhfa.com.au/evaluation.shtml#uncontrolled_trial_public,downloaded February 26, 2010.13 Jorm, Kitchener, O’Kearney, Dear, 2004.14 BA Kitchener, AF Jorm. 2004. Mental health first aid training in a workplace setting: A randomizedcontrolled trial. BMC Psychiatry, volume 4:23. Available at throughhttp://www.mhfa.com.au/evaluation.shtml#uncontrolled_trial_public, downloaded February 26, 2010.15 Kitchener, Jorm. 2002.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 13 of 40

4. ResultsThe section on program fidelity ended by noting Health Canada had implemented MentalHealth First Aid as it was intended to be. One purpose for this evaluation is to understandwhether the course is suitable for First Nations communities. Three aspects areconsidered: cultural, educational, and the community-centred training model in Sections4.1 to 4.3. It is not a case that the course is inappropriate. There is a known need forrevision and the results from the evaluation confirm this.AMHB planned to develop an Aboriginal version. Both manual and methods ofinstructing likely would have been reviewed. Because MHFA Australia has a knownprocess for ensuring cultural and educational competence of the course (Section 4.2), it islikely AMHB would have followed this process.A second purpose of the evaluation is to determine whether other community gatekeepersin First Nations communities will benefit in similar ways. Despite known weaknesses ofthe AMHB course, the course was still effective for First Nations graduates. Resultsshow:• Improvements in mental health literacy and first aid skills (Section 4.4).• Changes in behaviour (Section 4.5).• Increases in empathy (Section 4.6).Data sources include:• Course evaluation forms completed by 279 participants in the last session of thecourse (Appendix A).• Mental health opinion quizzes completed by 324 participants (Appendix B).• Interviews completed by 12 participants (Appendix C)• A stigma scale completed by 27 participants (Appendix D).These are explained in more detail in the following sections. Participants were asked fortheir consent, for their permission to record the interview, and were given contactinformation for questions about the study (Appendix E).4.1 Educational AppropriatenessMFHA is appropriately taught and includes information that was new to the participants.It uses lectures and group activities as well as visual aids like PowerPoint and DVDs.About 40% of participants in their course evaluations identified these teaching methodsas strengths. Just over half of participants found the material “easy to understand” (53%),“new to them” (56%) and “relevant” (69%). About 77% of participants made generalcomments about the quality of the course. Responses included remarks like “it wasgood,” or educational, informative, beneficial, and interesting. Another 33% thought thecase studies, exercises, manual, and DVDs were strengths of the course. About twice asmany people found the DVDs useful (41%) than the manuals (20%). Less than 10%AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 14 of 40

thought the videos were a weakness. About 5% of participants called for moreinformation on child and youth mental illness.Only three of the 11 follow up participants had used the manual in the one- to two-yearssince completing the course. All three found it straightforward and relatively easy tounderstand; the tabs separating the sections were identified as making the manual easy torefer to. One participant specifically stated he had used it only once while the other twoused the internet resources frequently.Most participants who had not used it were able to retain the knowledge from the course.Or they had other references they preferred, or they rarely dealt with mental illness andhad little reason to refer to the manual. One person indicated that if he were a front-lineworker, he would likely use the manual more often.Another person, a teacher in a community school, thought the language was too difficultfor someone without a university degree. There is a difference between the numbers inthe AMHB’s evaluation finding the material easy to understand (68%) and those in theAlberta FN’s evaluation (53%). Several people interviewed for the administrative portionalso indicated concern over its ease of reading for members of their community. Manyparticipants in both their course evaluations and interviews thought the manual wascomprehensive enough.Many of the follow up participants had either university degrees or extensive (> 10 years)experience in human services. The use of jargon is appropriate for this population. Thereare also unanticipated benefits of introducing jargon. For example, one of the follow upparticipants pointed out that the course gave him more confidence in talking with mentalhealth experts precisely because it introduced psychiatric technical terms to him. As aresult of MHFA, he has forged new relationships with mental health experts and is activein bringing training opportunities to his community. Most of the follow up participantsspoke with the confidence that comes with knowledge. When technical terms were used,they were used correctly. Minas and colleagues 16 found also that because MHFAintroduces the correct psychiatric terms, the use of stigmatizing words (e.g., “crazy”) wasreduced in their study of Australian Vietnamese. With two exceptions, none of the followup participants used stigmatizing terms.The AMHB evaluation of 2007 reported similar findings using the same courseevaluation. The way the course was presented and the use of visual aids like the DVDswere frequently mentioned as strengths of the course. Many of their participants thoughtthe material was easy to understand (68%) and relevant (64%). As with the Alberta FirstNations’ community gatekeepers, the AMHB participants felt they learned newknowledge and practical skills.4.2 Cultural AppropriatenessAbout 20% of participants in their course evaluations commented about the lack ofcultural appropriateness of Mental Health First Aid. In addition to including culturally16 Minas, Colucci, Jorm, 2009.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 15 of 40

elevant definitions of mental health, participants specifically pointed out the lack ofstatistics and studies relating to First Nations. Another omission is information onhistorical response trauma in relation to residential school experiences and other groupexperiences of loss.Several participants asked for more culturally relevant material in general, includingvideos that “should be culturally related.” Many pointed out that the videos were difficultto understand because of the accent. Almost as many requested new videos usingCanadian or First Nations actors.One participant noted “there is a difference from the mainstream and traditional way ofmental health” while another noted the course “does not cover First Nations’ culturalvalues regarding mental health.” A follow up participant also suggested including aholistic definition of health. Several follow up participants spoke of using traditionalhealing like sharing circles.Participants in the 2007 AMHB evaluation also identified the need to adapt the course tospecific Canadian sub-populations. MHFA has been adapted in 15 countries with diverselanguages and cultures. In 2008, the Australian Aboriginal and Torres Strait IslandersMHFA manual 17 and course were finalized. The developers worked in consultation with aworking group of Aboriginal people with professional experience in mental health. TheWorking Group adapted the Australian adult MHFA manual 18 and other course materials.The course includes several DVDs to portray common challenges people with mentalillness face. New DVDs using Aboriginal actors were produced. In the one evaluation ofit, Aboriginal trainers thought these changes had made the course more culturallyappropriate. Two chapters are added to the beginning of the manual and are devoted tothe impact of historical losses on contemporary Australian Aboriginal communities.Cultural understandings of mental illness are included as are rituals that may bemisunderstood for mental illness. Follow up participants spoke of the importance offorming a similar working group to ensure the Aboriginal Canadian version is bothculturally and educationally appropriate.4.3 Appropriateness of the Delivery ModelMental Health First Aid was delivered in the community by a First Nations instructor. InSection 2, the eligibility requirements of MHFA instructors were identified. Theinstructor for the Alberta First Nations MHFA appears not only to have been qualified,but to have excelled in the delivery of the course.It was also noted that instructors are responsible for most aspects of course delivery. Theinstructor travelled to the community for the two day course. In addition to facilitatingthe course, she:• Initiated contact with many of the communities and worked with all of them toschedule the workshop.17 Available at http://www.mhfa.com.au/course_manual.shtml#copyright18 Available at http://www.mhfa.com.au/course_manual.shtml#copyrightAB FN MHFA Final Report,May 11, 2010 (CAZA) Page 16 of 40

• Contacted potential participants.• Distributed and tracked course evaluation forms and mental health opinionquizzes.• Completed and distributed certificates of completion before the end of the course.Her work was appreciated on many levels: 16% of participants named her as a strength ofthe course, more than identified the ALGEE as a strength (7%). Most participants (74%)rated the presentation of the course content as very good (a 9 or 10 on a 10-point scale).Participants were also asked to rate how well the trainer presented the course, and most(76%) rated her presentation as a 9 or 10, using a 10-point scale (1, “not at all;” 10, “verymuch”).As with the AMHB 2007 evaluation, many commented on how well the trainer facilitatedlearning. Responses in that evaluation included: “well organized, well-researched,”“enthusiasm of the presenters and the non-judgmental, empathetic delivery,” and “alllearning styles included: variety in presentation” 19 . The Alberta First Nations instructorreceived similar comments: “instructor very entertaining and engaging,” “well taught,”“she made a lot of sense,” and “very knowledgeable.”The course uses a workshop format with case studies, DVD presentations, and lectures.Participants from 9 communities indicated their appreciation for the opportunity to meettheir peers in the community. As noted above (Section 4.1), many participants identifiedgroup work and the visual aids (DVDs and PowerPoint) as strengths of the course.Three community organizers were interviewed for the evaluation. They were from eachof Treaties 6, 7 and 8. This is a very small sample and what they said may or may not betrue of other communities. One organizer asked for help with registration and promotion.He suggested a standard registration process would be helpful as would standardpromotional materials like brochures, posters, or PDF documents that can be easilyemailed. Another organizer initiated the contact with the trainer and was skilled atregistration and promotion. The third was contacted by the trainer but chose to promotethe program to a “captive” audience of people who were not community gatekeepers, butmembers of the general public in receipt of social service payments. All organizersagreed that a set of guidelines for organizing the course might be helpful, even though allwere experienced in event management.The primary target for the Health Canada initiative was community gatekeepers. Thetrainer made several attempts to contact health directors or coordinators. One healthcoordinator declined the training because his staff was already experienced in mentalhealth. Several health centres could not be contacted or did not return messages afterrepeated attempts. No attempts were made to contact directors or coordinators in othersectors by the trainer. At the community level, however, people employed in other human19 Information Management Team, AMHB. 2007. Selected findings from the Mental Health First AidCanada Evaluation for the Course Instruction Period: November 2006 – June 2007. Edmonton, AB:AMHB. Available at http://www.mentalhealthfirstaid.ca/about/Pages/Evaluation.aspx, downloadedFebruary 26, 2010.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 17 of 40

sectors made up about 70% of the participants. This suggests that community organizersused their networks to promote the program to a wider audience.Although standard promotional materials are currently available from the AMHBinstructors’ website, they were unavailable between 2008 and 2009. AMHB maderegistration and evaluation forms available. Instructions on evaluation are vague. Noinstructions are provided on how to match the data collection forms from the participants.The pairing method used by the trainer was ingenious: she asked participants to drawsome symbol on their pre- and post-quizzes which was used to anonymously match thequizzes by participant. Instructors do not have clear directions on how to identifyevaluation forms in a way that both protects participant anonymity and confidentialityand allows for follow up evaluation.Another well-known mental health training course is ASIST. It could provide a model forcommunity organizing. This is training in suicide prevention and was developed inAlberta in the 1980s. Many participants mentioned taking this course both in theirevaluations and in the follow-up. Unlike MHFA, ASIST clearly identifies the roles ofeach of the four stakeholder groups: ASIST, community, instructors and participants 20 .ASIST prints and provides standard evaluation packages as part of the materials providedto participants. These are returned to ASIST by the community organizer. This procedureis more likely to enable follow up evaluation while protecting anonymity andconfidentiality.One of the responsibilities of the community organizer for ASIST is to provide debriefingat the end of the 2 day session. Examples of a need for debriefing can be found in theAustralian evaluations as well as this one.In Alberta, one person referred to recent “tragedies” in their course evaluation form andseveral talked of personal experiences with mental health both in the course evaluationand in the interviews. From the course evaluation forms:• Alexis: This has helped me to come to terms with my son’s suicide.• Beaver Lake: I learned about my own past experiences.• Bigstone: How you cope with close family members dying; how to cope, let yourfeelings out.• Stoney: Before I didn’t know what I was.• Whitefish: That sometimes, even with mental health first aid, suicide may occur.It’s not your fault.• Enoch: No debriefing to ensure everyone is okay before leaving.• Kehewin: I live with someone that has a problem.• North Peace First Nation Community: Only if I knew about it [MHFA] before thetragedy in our community…I would like to see a training workshop about how tocope with losing a loved one…When you lose someone you care for, it affects thebrain, big time.20 See for example, ASIST Organizer Guide available at http://www.suicideinfo.ca/csp/go.aspx?tabid=124or http://www.suicideinfo.ca/csp/go.aspx?tabid=91 orhttp://www.livingworks.net/docs/ASX_OrgnzrsGd.pdf, downloaded March 1, 2010.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 18 of 40

• Whitefish: Feeling lonely and sad brings back memories.About 33% of the participants who were interviewed have a history of personal mentalillness and have family members with mental illness. Three spoke of personalexperiences with suicide in the two years since taking the course. Australian evaluationsof the program have also found that people who take the course have experience withmental illnesses. For example, in the workplace study, 21 60% had personal healthproblems and 75% had family members with mental health problems. Mental healthimproved by the end of the course for these participants. The rate of mental illness in thegeneral Australian population is 20% which is far less than the 60% self-reported rateamong Australian MHFA participants. The Alberta participants fall about half-waybetween this rate but are still higher than the estimated rate for non-AboriginalCanadians.Three First Nations communities in Alberta cancelled MHFA because of deaths. SeveralFirst Nations communities have reported higher rates of suicide and homicide over thepast two years than in neighbouring non-Aboriginal communities. Australian Aboriginalinstructors have also faced difficulties in scheduling MHFA because of “communitygrieving” 22 . Debriefing is especially important for communities known to have a historyof community loss.The final issue for a community-centred delivery model is time. Lack of time to cover thecourse materials was an issue noted by about 30% of participants in their courseevaluation forms. Comments like “so much information and not enough time to absorbeverything,” “would be good if we had more days,” and “too short of a time, too muchinfo, and not enough time” are representative of this issue. Several participantsspecifically asked for a longer course. A related issue comes from a participant inKehewin, who suggested the course was “too in depth for the purpose of first aid.” Manyparticipants in both their feedback and in the follow up indicated the need for a“refresher” course. From the community perspective, one organizer pointed out that smallcommunities cannot lose significant numbers of their service providers for training. Hesuggested other forms of delivery be offered. AMHB has completed the on-line versionof MHFA, but it is not currently available.4.4 Changes in General KnowledgeMental Health First Aid aims to increase mental health literacy. This is:• The ability to recognize specific disorders;• Knowing how to seek mental health information;• Knowledge of risk factors;• Knowledge of self-treatments and of professional help;• Attitudes that promote recognition and appropriate help-seeking (Section 4.6).21 Kitchener, Jorm, 2004.22 LG Kanowski, AF Jorm, LM Hart. 2009. A mental health first aid training program for AustralianAboriginal and Torres Strait Islander peoples: Description and initial evaluation. International Journal ofMental Health Systems, volume 3:10. Available at www.biomedcentral.com, downloaded August 1, 2009.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 19 of 40

MHFA is effective in increasing mental health literacy. Graduates indicated in theircomments that they learned about several of these aspects and average scores on a mentalhealth opinion quiz improved.The mental health opinion quiz was completed by 302 graduates in the first and lastsessions of the course. A year to two years later, 22 graduates completed the quiz again.It has 20 questions based on statements in the MHFA manual and asks participants toagree or disagree. It has a maximum score of 20.Statements ask about specific disordersand risk factors. If MHFA is effective in increasing literacy, average scores shouldincrease between the start and end of the course. If MHFA is effective in the long term,we should also see a similar or higher average score.Course evaluation forms were completed by 279 participants at the end of severalcourses. Participants were asked to identify strengths and weaknesses of the course. Ayear to two years after completing the course, 12 graduates took part in an interview ofabout 30 minutes. The interview asked participants to identify a specific disorderdescribed in a story about “John,” as well as what to do to help someone in a crisis.QUALITATIVE RESULTSMany (40%) participants “learned more than what knowledge” they already had.Participants wrote in their evaluation forms that they learned “a lot about mental health”or the course gave them “major information on most aspects of mental disorders.” Somewere a bit more specific, such as the course was “useful in understanding symptoms thatmay be related to mental problems.”Participants in the follow up were asked to identify a disorder based on a story about“John.” The disorders described were depression and early schizophrenia. Most of thefollow up participants correctly identified depression (75%) in that story. One thoughtJohn may have anxiety. Another would assess physical illnesses first before referring to amental health expert. All participants (100%) who were read the story of schizophreniacorrectly identified it. Several participants pointed out that they were not qualified todiagnose and that their answers were a “best guess.”These results are similar to graduates in other countries. For example, in the 2009 studyof Vietnamese Australian MHFA graduates, 85% were able to correctly identifydepression and 66% were able to identify early schizophrenia after the course 23 . Thisimproved from the 54% and 41% who were able to identify the disorders before takingthe Vietnamese adaption of MHFA. In a 2004 study of rural Australians, 24 68% were ableto correctly identify the diagnosis before the course and 81% after the course. In a 2002study of members of the Australian general public, 25 91% were able to correctly identifydepression before the course and 95% after the course. For schizophrenia in the samestudy of the Australian general public, 56% were able to correctly identify it before thecourse and 76% after the course. At six months after the course, recognition droppedslightly for depression (93%) and a little more for schizophrenia (68%).23 Minas, Colucci, Jorm, 2009.24 Jorm, Kitchener, O’Kearney, Dear. 2004.25 Kitchener, Jorm, 2002.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 20 of 40

A central component of the course is the five-step mental health first aid, ALGEE. Only7% of participants identified this as a strength and double this (14%) identified the moregeneric “first aid” as a course strength. This differs from the findings in the AMHB 2007evaluation, where the ALGEE was the “most consistently cited strength listed across allsessions” 26 . Follow up participants were asked to describe ALGEE, but only two could.All participants identified one or more of the ALGEE steps in their responses to twoquestions in the interview. The questions were:• Can you describe how you would help a person in a mental health crisis?• Imagine John is someone you have known for a long time and care about. Youwant to help him. What would you do?The results are combined for these questions. Four participants (33%) mentioned theimportance of assessing the risk of danger to self or others. Ten (83%) knew of theimportance of listening non-judgementally and of being approachable. Eight (67%) knewabout being reassuring and providing information.Nine (75%) would help the person in crisis get professional (42%) or other help (33%).This is a higher number than found in other studies. In the 2004 study of ruralAustralians, 27 only 25% advised professional help after the course compared to 19%before the course. In the 2002 study of members of the Australian general public, 28 beforethe course, about 15% advised professional help compared with 9% after the course.Kitchener and Jorm suggested this may be because participants had encountered fewerincidents of crisis after the course; it may also be because almost 40% of the participantswere mental health consumers or care givers of mentally ill persons.STATISTICAL RESULTSThe average score on the quiz increased between the start and end of the course(Table4.4). It increased by 21%. Between post-MHFA and follow ups more than 1 year aftertaking the course, the average score dropped slightly to 72%. This was still considerablyhigher than the average pre-MHFA score of 58%.Table 4.4 Ranges and Average Scores for QuizzesType of Quiz N Range by Percentage (Raw Average Score, % t-ratioScores)(Raw)Pre-MHFA 302 10% - 95% (2 – 19) 58.3% (12) 17.6 (pre/post)Post-MHFA 302 45% - 100% (9 - 20) 79.4% (16) 22.3 (post/follow)Follow Up 22 40% - 100% (8 – 20) 71.6% (14) 38.0 (pre/follow)The primary reason for calculating statistics is that they tell us how likely is it that thesechanges would be the same for other people living and working in First Nationscommunities. The t-ratio provides the answer. Technical details are found in Appendix F.26 Information Management Team, AMHB. 2007.27 Jorm, Kitchener, O’Kearney, Dear. 2004.28 Kitchener, Jorm, 2002.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 21 of 40

The t-ratio estimates whether these changes are “real,” not due to chance, and typical ofchanges that could be expected for other community gatekeepers in First Nationscommunities (“the population”). In all three comparisons, it is “statistically significant 29 .”Statistically significant does not always mean significant in implications. Although theaverage score decreased between the end of the course and the follow up period (1-2years later), the amount was less than 8%. This is a reasonable decrease after one to twoyears. That it is statistically significant suggests that “the population” likely will show asimilar decrease. The same generalization can be made about the change between the preand post MHFA averages. It is likely that “the population” will show a similar increase inmental health literacy.4.5 Changes in BehavioursFollow up participants were asked about changes in their responses to persons withmental illness. None made formal referrals even though all but two worked directly withclients more likely to have mental health problems. Several indicated because theirawareness of the early signs of mental health crisis had increased, they called in otherexperts more quickly than they had before the course.All but one participant indicated their confidence had increased as a result of taking thecourse. This participant felt some “mixed messages” had been relayed in the course aboutschizophrenia and suicide. It was not until he received confirmation of the appropriateresponses from a mental health expert that his confidence returned. Two otherparticipants said the approach of the course – that it was “first aid,” emphasizing theability of anyone to be helpful – increased their confidence. Others told stories of feelinguncertain about how to respond to actual crises before the course but felt more confidentthat they would handle a similar situation better because of the course. The two examplesof crisis situations encountered since the course were both personal, not work-related. Inboth cases, the graduate was able to provide support by listening and, in one case,accompanying the person in crisis to the hospital. Participants were also asked to recallhow they might have helped “John” before the course and about half said they would nothave known what to do.Participants were asked about community mental health services. All reported theavailability of a psychologist. Psychologists visited communities between 4 times perweek and twice per month and were available by appointment only. Several communitieshad mental health and addictions workers as well as several social service programs.These included FASD mentors, family violence and other abuse programs, andemergency shelters.All but two were familiar with local services and with referral processes for off-reserveservices. This familiarity was a result of their work experience and not due to the course.The two who were not familiar were not providers of direct services. Most others are partof a well-developed network of human services. Two said they were both a resource forand recommended clients to other service providers. None were aware of any directories29 t pre/post =17.6, df 602, p < 0.05; t pre/follow = 38.0, df 322, p < 0.05; t post/follow =22.3, df 322, p < 0.05.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 22 of 40

of local resources, but all thought one would be useful. Such directories would benefit thegeneral public, social services, and local family doctors. All these seem to be outside thehealth and mental health networks the participants were part of. Barriers to services werethe time to travel off-reserve, disputes over coverage under non-insured health benefits,stigmas associated with mental illness, and lack of awareness of the services offered atlocal health centres.4.6 Changes in StigmaImmediate changes in attitudes were reported by 6% of participants in their courseevaluations. These participants said the course helped them become more understandingof people with mental illnesses.Follow up participants expressed similar changes in attitudes that have persisted for oneto two years. The interview asked the following questions about changes in attitudes:1. Do you find yourself paying more attention now when, for example, the newsreports on mental health issues or a television ad speaks of depression, then youdid before you took the course?2. Do you find yourself talking about mental illness with colleagues, friends, orfamily more after taking the course than before?3. Can you give me some examples of how your attitudes toward mental illness havechanged since you took the Mental Health First Aid course?About half of the participants said they were more aware of mental health issues becauseof the course and talked more about them then before the course. The other half said theyhad always had an awareness of these issues. Two participants said the subject was“taboo” and talk of it was not encouraged. Regarding examples of how attitudes changed,many repeated stories of encounters with persons with mental illness before the coursewhere their response was characterized partly by stigma and partly by lack of knowledgeof what to. Several also referred to the emphasis MHFA places on the similaritiesbetween physical and mental illnesses. One pointed out that when people with physicalillnesses forget their medication, no blame is ascribed. Taking the course helped herunderstand this aspect more and allowed her to be less judgemental.A depression stigma scale was completed by 27 people, 21 follow up participants and 6people from a convenience sample. These 6 people were participants in a Health Canada“Life is Valuable Network” Showcase on mental health. They were similar in age andcommunity of residence to the MHFA graduates. None of these 6 people had completedthe course. Fourteen people completed the depression scale and thirteen peoplecompleted the schizophrenia scale. Participants were randomly assigned the scale inadvance of contacting them. It was used with the permission of the developer, Dr.Kathleen Griffiths.This scale begins with one of two vignettes. The first tells the story of John who issuffering from depression. The second story of John is about someone in the early stagesof schizophrenia. Both stories are based on standard characteristics of these disorders asAB FN MHFA Final Report,May 11, 2010 (CAZA) Page 23 of 40

described in authoritative texts 30 . The participant is asked whether he agrees or disagreeswith 9 statements about how other people feel about persons with mental illness(perceived stigma). For the last 9 statements, the participant is asked whether he agrees ordisagrees personally with the statement. The statements are scored from 0 to 4, where 0 is“strongly disagree” and 4 is “strongly agree.” The higher the total score, the higher thelevel of stigma.Table 4.8 compares the average post-course scores by item for personal stigma forAlberta First Nations’ participants and Vietnamese Australians 31 . The higher the number,the higher the level of stigma.Table 4.8 Comparison of Average Scores per Item between Vietnamese Australian and First NationsGraduatesVietnamese (post course) First Nations (post course)Item Depression Schizophrenia Depression Schizophrenia1. People with a problem like John’s 3.64 3.99 2.64 3.20could snap out of it if they wanted.2. A problem like John’s is a sign of 3.59 3.69 3.00 3.30personal weakness.3. John’s problem is not a real3.89 4.12 3.09 3.50medical illness.4. People with a problem like John’s 3.83 3.15 2.09 2.00are dangerous to others.5. It is best to avoid people with a 4.24 4.13 3.27 3.50problem like John’s so that youdon’t develop this problem.6. People with a problem like John’s 3.40 2.93 2.09 1.60are unpredictable.7. If I had a problem like John’s, I 4.02 3.82 2.27 2.60would not tell anyone.8. I would not employ someone if I 3.30 2.69 1.82 2.10knew they had a problem likeJohn’s.9. I would not vote for a politician if Iknew they had suffered a problemlike John’s.2.90 2.30 1.91 2.00In all cases, the average post-course score is lower for the Alberta First Nationsgraduates. Whether these differences are statistically significant cannot be determinedwith Minas and colleagues’ published data. The trend is important, though, becauseAlberta First Nations appear to have lower levels of stigma than Vietnamese Australians.The developer of the scale, Dr. Griffiths, used it to compare stigma in national samples ofAustralians and Japanese 32 . Table 4.9 compares the percentage agreeing or strongly30 These authoritative texts are the Diagnostic and Statistical Manual, 4 th edition (DSM-IV) published by theAmerican Psychiatric Association and widely used by the North American mental health community. Theother widely accepted standard is the International Classification of Diseases (ICD-10) endorsed by theWorld Health Organization and its member countries of which Canada is one.31 Minas, Colucci, Jorm, 2009.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 24 of 40

agreeing with the following items on the personal stigma scale for Australians andAlberta First Nations graduates.Table 4.9 Comparison of the Percentage Agreeing or Strongly Agreeing with the Item for First Nations anda National Sample of AustraliansAustraliansFirst NationsItem Depression Schizophrenia Depression Schizophrenia1. People with a problem like John’s 25% 18% 18% 10%could snap out of it if they wanted.2. A problem like John’s is a sign of 13% 19% 10% 10%personal weakness.3. John’s problem is not a real15% 15% 0% 0%medical illness.4. People with a problem like John’s 12% 25% 27% 30%are dangerous to others.5. It is best to avoid people with a 7% 5% 0% 0%problem like John’s so that youdon’t develop this problem.6. People with a problem like John’s 42% 67% 36% 60%are unpredictable.7. If I had a problem like John’s, I 17% 27% 36% 20%would not tell anyone.8. I would not employ someone if I 22% 25% 45% 30%knew they had a problem likeJohn’s.9. I would not vote for a politician if Iknew they had suffered a problemlike John’s.30% 35% 36% 40%Higher levels of personal stigma for Australians are seen for most items except thehighlighted items. Again, although these differences may or may not be statisticallysignificant, the trend is important, because again Alberta First Nations appear to havelower levels of some types of stigma than non-Aboriginal Australians.For personal depression and schizophrenia stigma, Alberta First Nations graduates mostcommonly agreed that persons with mental illness are unpredictable and that they wouldnot vote for or employ someone with a history of mental illness. This is the same as forAustralians. Both Alberta First Nations and Australians least commonly agreed thatpeople with mental illness should be avoided. Alberta First Nations graduates also leastcommonly agreed that mental illness is not a real illness. Several persons commented thatif the depression or schizophrenia was under control, their answers would differ onwhether to hire or vote for the person. Two people pointed out that avoidance of personswith mental illness is not because of fear of contagion but fear of not being helpful.Little differences are found between personal and perceived stigma in terms of whichitems are most likely to be agreed with. First Nations graduates were more likely to agreethat others would not employ or vote for persons with a history of mental illness and that32 KM Griffiths, Y Nakane, H Christensen, K Yoshioka, AF Jorm, H Nakane. 2006. Stigma in response tomental disorders: A comparison of Australia and Japan. BM Psychiatry volume 6:21. Available atwww.biomedcentral.com, downloaded February 26, 2010.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 25 of 40

persons with mental illness are unpredictable. Like the Australians, the perception ofstigma was higher than personal stigma among First Nations graduates for both disorders.The average scores for the perceived stigma are almost double that for personal stigmafor both depression and schizophrenia and the difference between the scores aresignificant at the .05 level for both (Appendix F).The 6 people from the LIVN Showcase demonstrated some differences in stigma scores(Appendix F). The only statistically significant difference was for personal stigma inrelation to depression, where the average score (7) was about half of the MHFA graduates(13.7). Although these people completed the scale on the second day of the Showcase andhad just been presented with the preliminary results of the MFHA presentation, theirscores were similar on perceived stigma in relation to depression and for both perceivedand personal stigma in relation to schizophrenia. Why they should vary so much onpersonal stigma in relation to depression is unknown.Because of the lack of pre-course measures of stigma, other than for the 12 participantswho all reported improvements in attitudes toward the mentally ill, we have no othermeans to determine whether the course was effective in reducing stigma. On the basis ofthese comments, it appears it has been effective. Comparisons with other groups ofpeople results in uncertain conclusions: Alberta First Nations graduates were lower onpersonal stigma than Vietnamese Australians, but similar to stigma of other Australians.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 26 of 40

5. Summary and RecommendationsOverall, Mental Health First Aid has accomplished the objectives Health Canadaidentified for the initiative. The course was adapted for Canadian circumstances but notfor First Nations. Despite the lack of content for First Nations people, it still increasedmental health literacy and first aid skills, and decreased stigma.Recommendation 1: Revise the MHFA Manual to Ensure Cultural RelevanceThe current AMHB version should be revised. Content relevant to First Nations, Inuit,and Métis in the Canadian context needs to be included. In particular, the cumulativeeffects of colonization on mental health of First Nations, Inuit and Métis needs to beaddressed, including but not limited to loss of land, loss of traditional sources of identity,and post traumatic effects of residential schools. Recent work by the Aboriginal HealingFoundation identifies “promising practices” of treatment in Aboriginal Canadiancommunities and analyzes the differences between traditional aboriginal conceptions of“wellness” and the biomedical definition of health, both of which could form acomponent of the revised manual.Recommendation 2: Revise the MHFA Youth ManualAbout 5% of participants specifically requested more information on mental illness andchildren. Aboriginal peoples are young, with a median age of 27 compared to 40 for nonaboriginalCanadians 33 . Suicide rates are estimated to be 3 to 5 times higher than amongnon-aboriginal youth. Revising the youth MHFA course and manual to be culturallyrelevant is also recommended.Recommendation 3: Use “Plain English”The use of plain English is strongly recommended in any future revisions of the manual.While most of the participants in the follow up found the manual easy to read, most(53%) had university degrees. About 80% of the Aboriginal peoples and 70% of the non-Aboriginal peoples in Canada do not have post-secondary education 34 , so a “plainEnglish” version would make the course accessible to the majority of Canadians. Mostparticipants found the current delivery of the course materials effective in enablinglearning and appreciated the workshop format as well as the group and experientiallearning opportunities. A “plain English” version of the PowerPoint presentation is,however, still strongly recommended in keeping with any revisions of the manual.Recommendation 4: Increase the Length of the CourseAbout one-third of participants felt the course was not long enough for the amount ofmaterial. The Australian Aborigine course is 14 hours in length, but this is because of theadditional material specific to Aborigine experiences with colonization that is included in33 Statistics Canada. 2008. Canada Year Book Overview: Aboriginal Peoples. Available athttp://www41.statcan.gc.ca/2008/10000/ceb10000_000-eng.htm, downloaded May 4, 2010.34 D Wilson and D Macdonald. 2010. The income gap between Aboriginal peoples and the rest of Canada.Ottawa, ON: Canadian Centre for Policy Alternatives. Available athttp://www.policyalternatives.ca/publications/reports/income-gap-between-aboriginal-peoples-and-restcanada,downloaded April 29, 2010.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 27 of 40

that course’s manual. Regardless of whether the current AMHB manual is revised toensure greater cultural relevance, consideration should be given to increasing the lengthof the course from 12 to at least 14 and possibly 16 hours.Recommendation 5: Consider a Refresher for GraduatesAlthough the knowledge imparted in the course appears to have been retained, allparticipants in the follow up and many in their course evaluations called for a “refresher”course. The follow up participants specifically stated they did not wish to retake the fullcourse. ASIST offers a half-day “tune-up” for its graduates that may provide a model forMHFA.Recommendation 6: Develop a Standard Community Organizing GuideCommunity organizers stated a desire for more detail regarding event management andadministration of MHFA. Several communities cancelled or declined the training andwhile no reason was given, it is not inconceivable that the burden of organizing a 2-dayworkshop was one of the reasons. ASIST provides a detailed guide for communityorganizers that could stand as a model for both Health Canada’s and the MHCCupcoming MHFA training. This guide is available through both the Centre for SuicidePrevention and the Living Works websites. Recommend Health Canada work with eitheror both of these organizations to adapt their Guide to the needs of MHFA and othercommunity-based training for First Nations.Recommendation 7: Develop a Standard Evaluation PackageCurrently, the only instruments used in the evaluation of the Canadian program are acourse evaluation form and a mental health opinion quiz. Neither have been tested forvalidity or reliability and some of the wording of the quiz is in poor taste (Appendix Bprovides alternate wordings). Neither of these instruments assess pre-course responses to,referrals for, or attitudes toward the mentally ill. A standard evaluation package should bedeveloped. Ideally, it should be include the instruments used in the Australianevaluations, such as the Modified Depression Stigma Scale used in this evaluation. TheAustralians have also developed other measures of mental health literacy that may bemore suitable. Again, ASIST provides a model for evaluation that could be adapted toevaluating MHFA. Recommend Health Canada work with MHCC to provide clearerinstructor guidelines for evaluating MHFA and a standard evaluation package andprotocol.Recommendation 8: Consider DebriefParticipants in both the Alberta and Australian MHFA indicated higher than averageincidences of mental health problems. Participants in the Alberta MHFA come fromcommunities with high suicide rates and histories of cultural loss, both indicators of andrisk factors for high rates of mental illness. A set of debrief strategies should bedeveloped by Health Canada for use when communities endure suicide and other mentalhealth crises. The Australian MHFA has developed a series of guidelines that could serveAB FN MHFA Final Report,May 11, 2010 (CAZA) Page 28 of 40

as models 35 Health Canada should also work with MHCC to develop a debriefing protocolto follow the course.Recommendation 9: Continue Using the Community-Based ModelThe community-based delivery model appears to have been well-received. Severalpersons wrote in their evaluation forms of their appreciation for the workshop style andfor the opportunity to meet peers from other agencies. Small communities with smallhuman services staffs may have had difficulty in ensuring sufficient staff were availableto relieve staff missing for training purposes. Health Canada should work with MHCC toensure the on-line version of MHFA is made available to First Nations communities.Other options for the delivery of the program should be contemplated and could includeregional rather than community level training.Recommendation 10: Consider Using a .5 or .75 FTE InstructorTreaty 8 First Nations of Alberta hired a full time instructor to organize and facilitate theworkshops. The cost for a similar workshop, the 2-day ASIST suicide preventionprogram, is approximately $1,700 for 10 participants. Note, however, that the workshopis organized by a community organizer and it is the community organizer who isresponsible for the evaluation materials. The sole responsibility for the ASIST instructorsis to teach the course.35 MHFA.2007. Mental health first aid guidelines project. Available athttp://www.mhfa.com.au/Guidelines.shtml, downloaded May 4, 2010.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 29 of 40

Appendix A: The Course Evaluation Form1. How new was this material to you? Rated from “not at all” (1) to “very new (10).”2. How easy was it to understand? Rated from “very hard” (1) to “very easy” (10).3. How well was the course content presented? Rated from “very poor” (1) to “verygood” (10).4. How well did the trainer present the course? Rated from “not at all” (1) to “verymuch” (10).5. How relevant was the content for you? Rated from “not at all” to “very much.”6. What is your overall response to this course?7. What do you consider to be the strengths of the course?8. What do you consider to be the weaknesses of the course?9. Are there any other issues, which you think should be included in this course?10. How did you hear about this course?11. Additional comments.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 30 of 40

Appendix B: The Mental Health Opinion QuizQuestion Answer From the MHFA manualQ1. Schizophrenia is one of the most commonmental disorders in Canada.FalseSection 1, p5: From table ofprevalence, psychotic disorders =0.73%Q2. Mental disorders are in general less disabling FalseS1, p6: Section entitled “how disablingthan physical disorders.Q3. It is not a good idea to ask someone if they arefeeling suicidal in case you put the idea in theirhead.RECOMMEND statement be changed:Q3. It is a good idea to talk with someone who isfeeling suicidal so you can help them.Q4. It is common for people to have a mixture ofboth anxiety and depression.Q5. Feeling tired all the time is a common symptomof depression.Q6: Although women attempt suicide more often,men are more likely to die by suicide.Q7: A person is at less risk of suicide if someonethey know has died by suicide.RECOMMEND statement be changed:Q7. A person is at greater risk of suicide if someonethey know has died by suicide.Q8. Heavy drinking of alcohol increases a depressedperson’s risk of suicide.Q9. A Mental Health First-Aider can distinguish apanic attack from a heart attack.Q10. Exercise can help relieve depression andanxiety disorders.FalseTrueTrueTrueTrueFalseTrueTrueFalseTrueare mental health problemsS3, p8: “Contrary to common belief,asking someone if they are havingthoughts of killing themselves will notmake them suicidal.”S4, p1: “More than 70% of individualswith anxiety disorders have one ormore other diagnosable mental healthproblems [including] depressive mooddisorder.”S3, p3: In table of symptoms: “Lack ofenergy, chronic tiredness.”S3, p7: “Although more women thanmen attempt suicide, more men die bysuicide, perhaps due to the more lethalmeans they choose. Men die 3.5 timesmore often by suicide than women.”S3, p8: “People are at greater risk fsuicide if … anyone close to them hasever attempted or died by suicide.”S2, p9: If a person is thinking ofsuicide, alcohol will increase thechances that they will harm themselvesor die by suicide.’S4, p7: “Mental health first aiders areunable to tell the difference between aheart attack and a panic attack, as manyof the signs and symptoms are thesame.”S3, p13: In table of treatments thatwork for depression.S4, p10: In table of treatments thatwork for anxiety disorders.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 31 of 40

Question Answer From the MHFA manualQ11. If a person has a panic attack, the best way to FalseS4, p7: “Help to calm the person byhelp is to get them to jog on the spot.encouraging slow, relaxed breathing inQ12. If someone has a traumatic experience, it is bestto make them talk about it as soon as possible.Q13. People with agoraphobia aren’t so much afraidof leaving home as of having a panic attack.Q14. It is best not to try to reason with people havingdelusions.Q15. It is important that people with mental healthproblems receive support and help fromfamily members.Q16. It is best to agree with a psychotic person’sdelusions, so they don’t get upset with you.Q17. People with schizophrenia commonly hearvoices that are not real, which they can findfrightening.RECOMMEND statement be changed:Q17. People with schizophrenia are often afraid ofvoices that are not real.Q18. It is a myth that using cannabis increases risk ofpsychosis.RECOMMEND statement be changed:Q18. Using cannabis may increase risk of psychosis.Q19. It is safe for women to drink up to 4 standarddrinks a day on average.Q20. A 1.5 ounce shot of hard liquor has less alcoholthan a 12 ounce can of beer.FalseTrueTrueTrueFalseTrueTrueFalseTrueFalseunison with your own.”S4, p8: “Let the person tell the story ifthey wish. Do not push them to talk ifthey do not want to.”S4, p3: “Agoraphobia is the fear ofhaving a panic attack or symptoms in asituation or place where help may notbe available, and where the person maybecome embarrassed or escape isdifficult.”S5, p7: “Do not argue with a personabout their delusions andhallucinations. Accept that they are realfor them”Mentioned throughout the manual aspart of ALGEE.S5, p7: “do not pretend that thesehallucinations or delusions are real toyou. Instead, respond to commentsabout the person’s delusions bysincerely saying ‘that must be horriblefor you’… ”S5, p3: “Even though thehallucinations are not real, they seemvery real to the person experiencingthem and can be very frightening.”S5, p5: “In people who are vulnerable,cannabis may contribute to thedevelopment of psychotic illnesses,such as schizophrenia.”S2, p3: In table of low risk drinkingguidelines.False S2, p3: “One standard drink = 13.6grams of alcohol … = 1.5 oz ofspirits.”AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 32 of 40

Appendix C. Interview Questions1. Have you used the manual since completing MHFA?[If no, skip to Q4]2. Can you tell me which parts are difficult to understand?Include the section andpage numbers if you like.3. The MHFA manual provided references at the end of each section – have youused these?a. How have you used these references?b. Did you know about them before taking MHFA?c. About how often have you used them since the course?4. If you haven’t used the manual, why not?5. The manual covered several mental illnesses. What other mental illnesses orproblems would you like to learn more about?6. Would a list of contacts and referral procedures for local services be helpful?7. Can you describe how you would help a person in a mental health crisis?8. Can you describe ALGEE?9. Do you feel more confident now about being able to help someone in a mentalhealth crisis than before taking the course?10. Since completing the course, have you helped in a situation where someoneappeared to have a mental health problem? [If no, go to Q11]a. Please describe the situation and the problem you think the person wasexperiencing.b. Please describe what you did. If you were not able to help, please describewhy.c. Please describe how you would have handled a similar situation beforetaking MHFA?11. If you have not assisted in a situation where someone was in a mental healthcrisis, is this what you would have expected? Or are your surprised at not comingacross such a situation?12. Do you have any other comments about how MHFA has helped you respond in ahelpful way to mentally ill persons?13. Please tell me about any person or program or agency in your community that ishelping mentally ill persons.14. Can you tell me about any barriers you have faced in making referrals?15. Would any of the following help you make proper referrals. [Participants wereasked to indicate if the item is in the community or what distance it is from thecommunity.]a. Mental health professionals.b. Mental health clinics.c. Hospitals with beds for persons with mental illness.d. Family doctors who are comfortable managing mental illness.e. Teleconferences with mental health professionals about specific clients.f. Regular inter-agency meetings about general problems and solutions.g. Help lines with First Nation people as first responders.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 33 of 40

16. Since completing MHFA have you made more referrals?17. Do you keep records of referrals? [As no participants made referrals, this questionwas never asked].18. Do you have any other comments about how MHFA has helped you makeappropriate referrals?[As no participants made referrals, this question was neverasked].19. Do you find yourself paying more attention now when, for example, the newsreports on mental health issues or a television ad speaks of depression, then youdid before you took the course?20. Do you find yourself talking about mental illness with colleagues, friends, orfamily more after taking the course than before? For example, do you findyourself correcting common myths about mental illness?21. Can you give me some examples of how your attitudes toward mental illness havechanged since you took the Mental Health First Aid course?[Participants were read one of the two stories about John. See Appendix D.]22. What would you say, if anything, is wrong with John?23. Imagine John is someone you have known for a long time and care about. Youwant to help him. What would you do?24. Can you describe how you might have responded to John before completingMHFA?25. Is there anything else you would like to say about stigma and mental illness ingeneral?26. Has anyone in your family or close circle of friends ever had problems similar toJohn’s? [If yes,] Did they receive any professional help or treatment for theseproblems?27. Have you ever had problems similar to John’s?28. Have you received any professional help or treatment for these problems?29. Have you ever had a job that involved providing treatment or services to a personwith a problem like John’s?AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 34 of 40

Appendix D. Modified Depression Stigma Scale[Introductory Remarks:] The person described here is not a real person, but there arepeople who are very like him. If you happen to know someone who is exactly like him,then that is a coincidence.[Participants were read one of the following stories:]John is 40 years old. He has been feeling unusually sad and miserable for the last fewweeks. Even though he is tired all the time, he has trouble sleeping nearly every night.John doesn’t feel like eating and has lost weight. He can’t keep his mind on his work andputs off making any decisions. Even day-to-day tasks seem too much for him. This hascome to the attention of John’s boss who is concerned about his lowered productivity.John is 24 years old and lives at home with his parents. He has had a few temporary jobssince leaving school but is now unemployed. Over the last six months he has stoppedseeing his friends, and has begun locking himself in his bedroom and refusing to eat withthe family or to have a bath. His parents also hear him walking about in his bedroom atnight while they are in bed. Even though they know he is alone, they have heard himshouting and arguing as if someone else is there. When they try to encourage him to domore things, he whispers that he won’t leave home because he is being spied on by theneighbours. They realise he is not taking drugs because he never sees anyone or goesanywhere.[Participants were then asked:] I’d like you to tell us what you think most OTHER peoplebelieve. Please indicate how strongly you agree or disagree with the followingstatements. [Answer choices were strongly agree, agree, neither agree nor disagree,disagree, strongly disagree.]1. Most other people believe that people with a problem like John’s could snap out ofit if they wanted.2. Most people believe that a problem like John’s is a sign of personal weakness.3. Most people believe that John’s problem is not a real medical illness.4. Most people believe that people with a problem like John’s are dangerous to others.5. Most people believe that it is best to avoid people with a problem like John’s sothat you don’t develop this problem.6. Most people believe that people with a problem like John’s are unpredictable.7. If they had a problem like John’s most people would not tell anyone.8. Most people would not employ someone they knew had suffered a problem likeJohn’s.9. Most people would not vote for a politician they knew had suffered a problem likeJohn’s.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 35 of 40

[Participants were also asked about their own stigma.] The next few questions containstatements about John’s problem. Please indicate how strongly YOU personally agree ordisagree with each statement.10. People with a problem like John’s could snap out of it if they wanted.11. A problem like John’s is a sign of personal weakness.12. John’s problem is not a real medical illness.13. People with a problem like John’s are dangerous to others.14. It is best to avoid people with a problem like John’s so that you don’t develop thisproblem.15. People with a problem like John’s are unpredictable.16. If I had a problem like John’s, I would not tell anyone.17. I would not employ someone if I knew they had a problem like John’s.18. I would not vote for a politician if I knew they had suffered a problem like John’s.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 36 of 40

Appendix E: Consent FormThank you for agreeing to take part in this evaluation of Mental Health First Aid. HealthCanada, First Nations and Inuit Health has asked meto conduct the evaluation.In 2007, Health Canada, First Nations and Inuit Health, Alberta Region offered trainingin Mental Health First Aid to rural and remote Alberta First Nations communities. Thepurpose of the evaluation is:• to assess how appropriate the course was for participants;• to assess its effectiveness in increasing general knowledge about mental illness;and• to assess its effectiveness in decreasing stigma about mentally ill persons.You may recall completing a course evaluation form and a brief mental health opinionquiz. Results from these suggest the course is effective. This part of the evaluation looksat long-term effectiveness.You may decide to withdraw from the evaluation at any point or not answer anyparticular question. If you chose to withdraw, any data collected from you will bedestroyed. All data collected from you will be kept private and confidential. Your nameand any identifying characteristics will not be used in connection with the evaluation.Numerical data and responses to open-ended questions will be summarized with those ofother participants. I will ask your permission to use any direct quotes from your interviewif they best represent an issue. Circulation of the results of the evaluation will be limitedto Health Canada, participants in the evaluation, and to scholarly venues in accordancewith privacy, confidentiality, and anonymity.Do I have your consent to participant?May I record this interview?If you have any questions about this evaluation, you may contact Ms. SelenaSchmidt, Health Canada, First Nations and Inuit Health Branch, Alberta Region byemail (selena_schmidt@hc-sc.gc.ca) or by telephone at 780-495-5417. MichelleCaza can be contacted by email (mmcaza@hotmail.com) or by telephone at 780-428-1926.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 37 of 40

Appendix F: T-test Results and AssumptionsAll statistical models have underlying assumptions that need to be met for the results tobe valid and reliable. For the t-test, the first assumption is that the population the samplecame from is approximately normal. For the pre and post-test sample, the central limittheorem argues that large samples (>30) are normally distributed. The follow up samplewas drawn randomly from the pre/post-test sample and can be assumed to be normallydistributed. The second assumption suggests that the true population standard deviation isunknown and this is true of the pre/post/follow up samples. The final assumption is thatthe observations should be random and for the follow up sample, persons were selectedrandomly to re-do the quiz.T-Test Calculation for the Mental Health Opinion QuizStatistic Used in Pre-test (x 1 ) Post-test (x 2 ) Follow-up (x 3 )Calculation:∑x 3,522 4,796 315n 302 302 22Mean = ∑x/n 11.66 15.88 14.32∑x 2 44,400 78,352 4,767(∑x) 2 12,404,484 23,001,616 99,225(∑x) 2 /n] 41,074.5 76,164.3 4,510.2∑d 2 = ∑x 2 – [(∑x) 2 /n]* 3,325.5 2,187.7s 2 = ∑d 2 /(n-1) σ 2 X1 = 11.0 σ 2 x2 = 7.3s 2 = [∑(x j - 1) 2 +∑(x j - 1) 2 ]/n 1 + n 2 – 2The variance between….… pre and follow up means = 0.10… post and follow up means = 0.10s = the square root of the variance and thestandard deviation between…… pre and follow up means = 0.32… post and follow up means = 0.32s 2 d = s 2 1 /n 1 + s 2 2 /n 2…pre and post means = 0.06The variance of the difference between…s d = the square root of the variance and the …pre and post means = 0.24standard deviation of the difference between…Critical t = ( 1 - 2)/ s dfor pre and post means 17.6Critical t = ( 1 - 2)/s 2 (1/n 1 + 1/n 2 ) for pre andfollow up and post and follow up…for pre/follow up = 38…for post/follow up = 22.3Degrees of freedom = n 1 + n 2 – 2 (df)602 (pre and post)322 (pre/post and follow up)Table value of t, p=0.05 with either 602 or 322 df 1.96*The pre and post samples are the same size and the same individuals and use the paired t-ratio. The follow up sample is much smaller and, while it is made up of the same individualstheir quiz scores could not be matched with any of their other scores. It uses the unpaired t-ratio. There are corrections for each t-test to how variability is measured and may not beapplicable to a sample. In this case, the cell is left empty.AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 38 of 40

T-Test Calculation for the Stigma Scale – DepressionStatistic Used inCalculation:PerceivedStigma,MHFAOwnStigma,MHFA∑x (sum of quizPerceivedStigma, Non-MHFA255 151 50 21scores)n (sample size) 11 11 3 3Mean = ∑x/n 23.2 13.7 16.7 7∑x 2 6,117 2,353 934 153(∑x) 2 65,025 22,801 2,500 441(∑x) 2 /n] 5,911.4 2,072.8 833.3 147∑d 2 = ∑x 2 – [(∑x) 2 /n] 205.6 280.2 100.7 6σ 2 = ∑d 2 /(n-1) 20.56 28.02 50.35 3σ d 2 = σ x1 2 /n 1 + σ x2 2 /n 2The variance of thedifference between…σ d = square root of the2variance, σ dCritical t = 1 -2)/ σ dDegrees of freedom(df)= n 1 + n 2 – 2Table value of t withdf, p=0.05Perceived andown stigma,MHFA= 4.42Perceived stigma,MHFA and non-MHFA= 18.672.10 4.32 2.014.5 1.5 3.3320 12 122.9 2.18 2.18Own Stigma,Non-MHFAOwn stigma, MHFAand non-MHFA= 4.05AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 39 of 40

T-Test Calculation for the Stigma Scale – SchizophreniaStatistic Used inCalculation:PerceivedStigma,OwnStigma,PerceivedStigma, Non-MHFA MHFA MHFA216 122 66 38Own Stigma,Non-MHFA∑x (sum of quizscores)n (sample size) 10 10 3 3Mean = ∑x/n 21.6 12.2 22 12.67∑x 2 5,012 1,654 1,470 486(∑x) 2 46,656 14,884 4,356 1,444(∑x) 2 /n] 4,665.6 1,488.4 1,452 481.33∑d 2 = ∑x 2 – [(∑x) 2 /n] 346.4 165.6 6 4.67σ 2 = ∑d 2 /(n-1) 38.5 18.4 3 2.34σ d 2 = σ x1 2 /n 1 + σ x2 2 /n 2The variance of thedifference between…σ d = square root of the2variance, σ dCritical t = 1 -2)/ σ dDegrees of freedom(df)= n 1 + n 2 – 2Table value of t,p=0.05Perceived andown stigma,MHFA= 5.34Perceived stigma,MHFA and non-MHFA= 4.852.31 2.20 1.624.07 0.18 0.2919 11 112.09 2.20 2.20Own stigma, MHFAand non-MHFA= 2.62AB FN MHFA Final Report,May 11, 2010 (CAZA) Page 40 of 40