Development and evaluation of a mental health and suicide prevention student leadership training programme for secondary school students in Hong Kong

Abstract

Background

Contributing to the growing need for adolescent school-based mental health interventions in Hong Kong, the “Suicide Help Intervention through Education and Leadership Development for Students” (S.H.I.E.L.D.S.) programme was developed to train secondary school students to become gatekeepers and lay leaders in mental health for their school communities. It involved both education – through mental health and suicide prevention training – and leadership development – through the design and implementation of student-led projects to encourage help-seeking behaviours and promote mental wellbeing to their peers.

Methods

Using a mixed-methods approach, we examined the impact of two rounds of S.H.I.E.L.D.S. that ran between June 2022 and June 2023 on three groups of participants across eight participating schools: 89 student leaders (M_age = 15.2) who underwent training, 33 staff advisors who supported the student leaders, and 423 general students (M_age = 14.3) who participated in student-led project activities. Questionnaires were disseminated to each group of participants before and after relevant programme activities, while interviews were conducted after the conclusion of all programme activities.

Results

Quantitative analyses demonstrated that there were no significant changes in both student leaders’ and general students’ knowledge of and attitudes towards mental health. However, qualitative feedback revealed that leaders did feel that their mental health-related knowledge and ability to help their peers improved. This was supported by the staff advisors, who also developed a greater appreciation for the role of students’ input in co-creating school-based mental health promotion initiatives. General students similarly appreciated the peer-led nature of project activities. General observations on the impact of S.H.I.E.L.D.S. on the schools’ mental health culture are also discussed.

Conclusions

This study highlights the importance of recognising student perspectives and integrating new mental health programmes with existing school efforts, which were instrumental in the successful implementation of S.H.I.E.L.D.S. in the intervention schools. Future implications for the continuity and scaling-up of S.H.I.E.L.D.S. and similar school-based mental health promotion initiatives are also given.

Trial registration

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-025-06461-3.

Background

The mental health of adolescents remains an issue of concern around the world. Globally, the onset of mental disorders has been found to peak at 14.5 years, with around 48.4% of onsets occurring before the age of 18 [1]. Adolescence is characterised by major biopsychosocial changes that have long been associated with an increased vulnerability to mental health problems [2]. Recent societal changes such as increased social exclusion and loneliness continue to undermine adolescents’ wellbeing, and their effects are further compounded by persistent global stigma against young people’s mental health issues, preventing those in need from seeking help [3].

In Hong Kong, there have been similar concerns about adolescents’ mental health in recent years. The suicide rates among children below 15 years and youths aged 15 to 24 years were 1.4 and 10.3 per 100,000 population respectively in 2021 [4], and a territory-wide mental health survey conducted from 2019 to 2022 found that 16.6% of youths had a mental disorder [5]. Cultural stigma around mental health issues also remains a major problem: it was identified as a barrier for help-seeking among undergraduate students even after accounting for other factors such as severity of depressive symptoms [6]. Together, these findings emphasise the urgent need to address the adolescent mental health crisis in Hong Kong.

Academic stress is one of the most commonly identified risk factors correlated with worsening mental health among Hong Kong adolescents [7, 8]. As in many East Asian societies, local secondary students face the pressure of high-stakes public examinations which are crucial in determining university admissions and future opportunities [9], while norms and expectations of family, school, and the wider society surrounding academics can further exacerbate students’ experience of academic stress [10]. This intense academic environment makes adolescents especially susceptible to academic- and school-related stressors, significantly increasing their risk for mental health challenges. Several studies have found that academic pressure, parental expectations, and poor help-seeking behaviours have all been associated with adverse mental health outcomes among Hong Kong youths, including a heightened risk of suicidality in some cases [11–14].

As children and adolescents spend most of their daytime in school settings, schools have become a key environment for implementing mental health interventions. Although school-based interventions have typically been delivered by teachers or other professionals, often as classroom-based psychoeducation talks, students themselves are becoming increasingly engaged in such efforts [15]. Peer education takes advantage of (young) individuals’ ability to influence their peers through their common characteristics, serving as positive role models or trusted and credible sources of information [16]. Given that adolescents tend to value relationships with their peers more than with adults [17], and that youths tend to seek help for their mental health from friends more than from other informal and formal channels [12], it is perhaps not surprising that peer-led education of mental health content has shown promise in improving youths’ knowledge of and attitudes towards mental health [18]. In university settings, gatekeeper trainings to teach students to recognise and respond to peers in distress and refer them to appropriate professional help have also been shown to have positive effects on trainees’ mental health knowledge and readiness to intervene in such situations [19–21]. These trainings have been shown to be similarly effective in secondary school settings, improving students’ knowledge and self-efficacy in providing help to others [22, 23]. However, to our knowledge, no studies have examined the impact of student mental health gatekeeping programmes in Hong Kong.

S.H.I.E.L.D.S. programme overview

“Suicide Help Intervention through Education and Leadership Development for Students” (S.H.I.E.L.D.S.) is a mental health and suicide prevention student leadership training programme that aims to empower secondary students in Form 3 (Grade 9) or above to become gatekeepers and lay leaders in mental health promotion and suicide prevention in their school community. The programme adopts a whole-school approach to school mental health, engaging both staff and students as proactive promoters of mental health for their school communities [24]. Three main groups of participants were engaged during the programme: (1) students leaders who participated in the S.H.I.E.L.D.S. training and were responsible for planning and implementing the student-led projects; (2) school staff who participated in staff workshops, some of whom also served as advisors to oversee the student-led projects; and (3) general students who participated in the leaders’ project activities. More detailed information on the programme implementation can be found in the Methods.

Research objectives

This study aims to examine the impact of S.H.I.E.L.D.S., particularly in relation to participants’ acceptability of the programme and achievement of the programme outcomes. Specifically, we hypothesised that, in line with the expected programme outcomes (described in more detail in the Methods):

1. Student leaders would be expected to demonstrate increased mental health knowledge and greater competence and ownership in school mental health promotion.

2. Staff would be expected to demonstrate an improved understanding of student mental health issues and a greater capacity to support mental health student leaders.

3. Hypothesis 3 (H3). General students would be expected to demonstrate increased mental health knowledge and improved help-seeking willingness and behaviours.

Methods

Intervention

The S.H.I.E.L.D.S. programme was locally developed by the Hong Kong Jockey Club Centre for Suicide Research and Prevention and built upon another student-led mental health promotion programme that was first administered in a single school between September 2019 and August 2020 [25]. This pilot programme engaged student leaders and staff advisors who received half-day training workshops on empathic listening skills and responding to peers in distress, then implemented a student-led project within the school. The case study findings suggested that the students benefitted greatly from their proactive role in the project’s design and implementation, through which they gained a sense of ownership and eagerness to help their peers. The staff advisors, on the other hand, experienced key shifts in their mindsets from a top-down approach to a whole-school approach. By shifting their roles from decision-makers to facilitators, they could acknowledge the students’ potential to be co-leaders in mental health promotion, while also developing a more holistic perspective of students’ mental health needs and how to promote mental health at school. Owing to the positive results of this pilot programme, S.H.I.E.L.D.S. was launched in February 2022 to scale up the programme and reach a greater number of schools.

Like the pilot programme, S.H.I.E.L.D.S. includes two main components: training secondary school student leaders on mental health knowledge and gatekeeper skills, then supporting them in designing student-led projects to promote mental wellbeing at school. By participating in S.H.I.E.L.D.S., student leaders were expected to demonstrate greater competence and ownership in school mental health promotion to develop initiatives that contribute to better mental health and wellbeing of the school community. Furthermore, students in the wider school community were expected to benefit from a stronger peer support network in their schools, potentially reflected in improved mental health knowledge and help-seeking willingness and behaviours. Additionally, S.H.I.E.L.D.S. provided training for staff members to enhance their understanding of student mental health issues, and their capacity to support students to develop leadership in mental health promotion.

This study uses survey and interview data collected over two programme rounds: Round 1 took place from June to October 2022, while Round 2 took place from February to June 2023. The total duration of one round of S.H.I.E.L.D.S. was five months. The leaders’ training consisted of one (in Round 1) or two (in Round 2) half-day workshops led by a clinical psychologist and a social worker to learn skills to identify peers in distress, respond to their immediate needs, and assist them to seek professional help. Leaders then had the opportunity to practise these skills at a full-day camp under the supervision of a counselling psychologist and research team members, where they also learned about the importance of self-care for gatekeepers through a music therapy taster workshop led by a music therapist. Staff participated in two, two-hour workshops led by an educational psychologist which focused on the mental health situation of local adolescents, and skills to support student leaders in school mental health promotion efforts. For the student-led projects, students were instructed to design a project that would last two months, including any preparation work. Students were allowed to freely decide the target population, content and format of their projects (e.g., single vs. multiple sessions) based on the perceived needs and interests of their schoolmates, and received guidance from their staff advisors. Each school submitted a proposal which was reviewed by research team members, who provided further suggestions for improvement and subsequently awarded grants of HK$5,000 (~ US$640) to each school to support their project costs. Finally, a graduation ceremony was held, including the issuance of certificates of completion to all leaders and certificates of appreciation to each school. The programme contents were delivered primarily in written Traditional Chinese and entirely in spoken Cantonese (the native language in Hong Kong). All programme activities were held in-person.

Recruitment and participants

Participation in S.H.I.E.L.D.S. was open to all registered public secondary schools in Hong Kong, excluding special schools for children with disabilities. To recruit participating schools, a bulk email was sent to invite all eligible schools to an online briefing session introducing the programme details. Of the 45 schools that attended the briefing sessions across both rounds, eight schools comprising nine cohorts of leaders and staff participated in S.H.I.E.L.D.S. (i.e., one school participated twice, with a different cohort in each round). Two of the participating schools (including the one that participated twice) were girls’ schools while the rest were co-educational.

Schools were recommended to recruit leaders who were in Form 3 or above at the time of training due to the sensitive nature of the training content. Leaders either were directly selected by staff based on their experience with student leadership or interest in mental health-related issues, or expressed their interest to participate via an open call by staff. The exact selection method(s) varied by school and were not controlled by the research team. Over two programme rounds, 89 leaders (23 males, 66 females; M_age = 15.2, SD = 1.0) successfully completed the S.H.I.E.L.D.S. programme. At the time of their respective trainings, leaders included four Form 2 s (all recruited in Round 1, held during the summer before they were promoted to Form 3), 37 Form 3 s, 39 Form 4 s, and 9 Form 5s.

The selection of staff to participate in the staff workshops and serve as staff advisors to the leaders also varied by school. All schools had at least one staff member who served as the primary staff advisor to their leaders, liaised with the research team, and recruited other staff to join the workshops. Some schools had multiple staff serving as co-advisors, while other schools’ additional staff only participated in the workshops. Over two programme rounds, a total of 33 staff (10 males, 23 females) participated in the workshops, including 23 full-time subject teachers who concurrently served on the school’s counselling team (or equivalent), 2 counsellors, 3 social workers, 2 special educational needs staff, and 3 vice principals. Of these workshop participants, 14 staff served as (co-)advisors to their leaders.

For the selection of general students to participate in data collection procedures, staff were instructed to select only those who had participated in the leaders’ student-led project activities. The demographic characteristics of the general students from each school therefore differed based on the target audience of the student-led projects. A total of 423 unique general students (66 males, 357 females; M_age = 14.3, SD = 1.3) completed either the pre- and/or post-project evaluation questionnaire over the two programme rounds. However, only 89 students (28 males, 61 females; M_age = 14.7, SD = 1.5) completed both questionnaires and could have their responses matched.

Written informed consent was obtained at the start of the programme at the school level from the school’s principal, and at the individual level from participating staff and participating leaders’ parents. Written informed consent was obtained at the start of the student-led projects from participating general students’ parents. Written assent was obtained from participating leaders and general students. Verbal informed consent or assent was also re-obtained at the start of interviews. In cases where individual focus group participants did not consent to audio-recording, the recording was paused when they spoke, and notes were taken instead. As it was expected that students and staff alike could potentially experience psychological stress or discomfort when asked to think about mental health-related personal issues, all participants were reminded in the consent form, by research team members, and by distributing school staff (for general students) to seek help from a professional if they felt distressed. This study was approved by the Human Research Ethics Committee of the University of Hong Kong (HREC No. EA220215).

Procedures and measures

The evaluation of S.H.I.E.L.D.S. employed a mixed-method approach to examine programme outcomes of all three groups of participants using a combination of questionnaires and interviews. All questionnaires were distributed online in both English and Traditional Chinese. Focus group interviews with leaders and general students were conducted in-person at their schools, while interviews with staff were conducted either in-person or online. All interviews were transcribed into Traditional Chinese and translated into English for data analysis purposes by authors and research assistants fluent in both languages.

Leaders

Two questionnaires were prepared for leaders to examine programme outcomes, each with a pre-post-test design. The first questionnaire was administered before and after participating in the workshops, while the second was administered before and after the day camp. The workshop questionnaire (Additional file 1, Appendix 1) included: (1) demographic characteristics; (2) a four-question multiple-choice quiz developed by the research team to test the leaders’ knowledge of mental health and suicide; and (3) self-reported attitudes and behaviours towards mental health, including the 10-item Attitudes Toward Seeking Professional Psychological Help – Short Form (ATSPPH-SF) [26]. The day camp questionnaire (Additional file 1, Appendix 2) included: (1) demographic characteristics; and (2) a fifth multiple-choice question developed by the research team on responding to peers in distress, and eight self-assessment questions developed by the research team to assess leaders’ ability to handle distressed peers and their own mental health as gatekeepers, including an understanding of their own feelings and the importance of self-care when giving care to others. In addition to these two main questionnaires, leaders completed a four-question online exit survey during the graduation ceremony about their interest in continuing their student-led project activities after their participation in S.H.I.E.L.D.S. ended (Additional file 1, Appendix 3).

Across the two rounds, 10 focus groups with three to five leaders each were conducted after the student-led projects had finished (late September/early October 2022 for Round 1, and June 2023 for Round 2), with a total of 40 leaders participating in the focus groups. During the sessions, leaders were asked about the programme’s effectiveness, including the usefulness of gatekeeping- and self-care-related knowledge and skills gained during the training; experiences with help-giving as newly trained peer leaders; and the potential continuity of S.H.I.E.L.D.S. within their school. The focus group sessions lasted an average of 33.5 min.

Staff

After each of the two staff workshops, participating staff completed a three-question feedback form developed by the research team on whether the workshop could enhance their understanding about the mental health situation of local adolescents (Workshop 1) or skills to support student leaders in school mental health promotion efforts (Workshop 2), whether they found the session useful, and how satisfied they were with the session on 5-point Likert scales, with space for open-ended feedback (Additional file 1, Appendix 4). Staff advisors were also interviewed about mental health programming within their school prior to participation in S.H.I.E.L.D.S.; observed changes in the student leaders’ involvement in mental health promotion; observed changes in their own ability to support student leadership and mental health; and resources needed to support student mental health leadership. After the completion of the student-led projects, a total of eight staff interviews involving one or two staff at a time were conducted, with a total of 12 staff having been interviewed. The interviews lasted an average of 40.5 min.

General students

One questionnaire was distributed to general students at the start and end of the student-led project activities (Additional file 1, Appendix 5). It was prepared online by the research team and was distributed by staff and leaders during the student-led project activities. The timing of the general students’ pre- and post-project questionnaire responses differed based on the duration of each school’s student-led project, but the research team nevertheless instructed staff to ensure that there was at least a one-week gap between the distribution of the pre- and post-project questionnaires. The questionnaire included two main parts: (1) demographic characteristics; and (2) students’ perception of their school social environment and attitudes towards help-seeking. Perception of the school social environment was measured using the four-item Friends subscale of the Multidimensional Scale of Perceived Social Support [27] on a 7-point Likert scale (Very Strongly Disagree to Very Strongly Agree), with the term “friends” being substituted with “students at my school,” and the nine-item Psychological Sense of School Membership Scale [28, 29] on a 6-point Likert scale (No, Never to Yes, Always). Students’ willingness to seek help for a range of personal issues was measured using a modified Intentions to Seek Counselling Inventory [30], where they were asked to separately rate their willingness to seek help from school adults and peers, respectively, on 14 items on a 4-point Likert scale (Very Unlikely to Very Likely). Since each of the student-led projects covered different topics and had their own objectives, no knowledge questions were included in the questionnaire.

A total of nine interviews with general students were conducted after the completion of student-led projects. As recruitment of participants for these interviews was up to the staff, the number of participants for each interview ranged from one to five, with a total of 25 general students being interviewed. The interviews lasted an average of 16.5 min. General students were asked about their experiences participating in the leaders’ student-initiated projects, including the projects’ ability to raise awareness of mental health among their peers; the leaders’ effectiveness as mental health peer leaders; their own help-seeking willingness and self-care behaviours; and their interest in becoming mental health student leaders.

Analysis

All quantitative data analyses were conducted using IBM Statistical Package for the Social Sciences (SPSS), version 29. Descriptive statistics on demographic characteristics and scores on each of the questionnaire items were presented, along with mean and standard deviation based on the distribution of the data. Comparisons between pre- and post-test results were made using Wilcoxon signed-rank tests as the data were not normally distributed. Comparisons between the leaders’ pre- and post-training knowledge quiz results specifically were made using a z-test in RStudio to compare proportions (rather than counts) of correct answers as the number of respondents was not consistent across all measurement points. In all tests, a two-sided p-value lower than 0.05 was considered statistically significant, and a value lower than 0.10 was considered marginally significant.

All interviews were analysed using the framework approach [31]. Three authors (IDL, TWSL, CLC), all of whom spent their school-aged years studying in Hong Kong schools, were responsible for reading through and coding all transcripts. The authors initially coded one interview from each group of participants (leaders, staff, and general students) together to ensure general consistency in interpretation. They then independently coded a subset of the interviews, with each coding at least one interview from each group of participants to generate independent coding guides. Regular discussions took place to compare the generated codes and associated quotes, including resolving individual uncertainties in coding specific quotes. When disagreements arose, the relevant coders were asked to justify their chosen codes, and all three coders engaged in further discussions until a consensus was reached. Codes were continuously refined until no additional codes were identified. Once initial coding for each group of participants was completed, the independent coding guides were synthesised into one coding index, which were subsequently subjected to second-order analyses to group codes within relevant themes based on the expected programme outcomes for each group of participants.

Results

The evaluation results of the S.H.I.E.L.D.S. programme are presented below first by providing an overview of school-level observations shared by all three target populations (leaders, staff, and general students) during their interviews regarding their acceptance of the programme. Then, specific impacts on each of the target populations will be examined, drawing from both the quantitative and qualitative results.

Programme acceptability

During the interviews, staff explained that prior to participating in S.H.I.E.L.D.S., all of their schools already had some form of mental health programming (e.g., peer mentorship, counselling or guidance prefect training), and staff were eager to use S.H.I.E.L.D.S. to enhance their leaders’ knowledge and ability to be mental health leaders and gatekeepers. For example, one staff advisor from School 4 described their school’s participation in S.H.I.E.L.D.S. as a “pilot scheme to encourage [the younger leaders] to become guidance prefects next year.” However, both leaders and general students noted that their schools tended to conduct more adult-led psychoeducation talks, while attempts to involve students were limited to assisting in staff-led initiatives. With the student-led projects of S.H.I.E.L.D.S., one leader from School 6 shared, “it’s not just about passively listening and absorbing information. Now we get to participate personally, which leads to a deeper and more meaningful understanding.” This would not have been possible without the support of staff advisors and school administrators, who generally helped leaders “feel more secure and confident” (leader, School 3). However, leaders from School 5 faced difficulties in this regard owing to what their staff advisor described as the school culture’s emphasis on academic performance. Regarding the continuity of S.H.I.E.L.D.S., schools whose existing mental health efforts had complementary goals were more confident in integrating S.H.I.E.L.D.S. into their future programming. For example, while School 3 was able to successfully re-introduce a discontinued mentorship programme through S.H.I.E.L.D.S., the advisor from School 5 believed S.H.I.E.L.D.S. would instead compete for student manpower and resources with the existing mentorship programme aimed at easing younger students’ transition to secondary school.

Leaders

After the completion of the S.H.I.E.L.D.S. training, the quantitative results showed that the leaders’ knowledge on and attitudes towards mental health- and suicide-related topics showed slight, generally statistically insignificant improvements. Their mean (SD) scores on the knowledge quiz increased from 2.12 (0.98) to 2.45 (1.16) out of 5 after the end of the training (see Additional file 2, Supplementary Table 1 for the proportion of correct answers for each question). Leaders’ attitudes towards seeking professional psychological help also improved, as evidenced by slight, sometimes marginally significant increases in the mean scores on individual items of the ATSPPH-SF (Table 1). Furthermore, based on their self-assessments (Table 2), there were statistically significant increases in the leaders’ confidence in their ability to evaluate and respond appropriately to peers who are emotionally distressed. They also reported a statistically significant improvement in their understanding of personal wellbeing, including a better awareness of their own feelings when providing help to others, and the importance of self-care when giving care to others.

Table 1.

Leaders’ pre- and post-training attitudes towards seeking professional psychological help

Indicate how you feel about each statement:	Pre-Training		Post-Training		W	Z	r	p
	M	SD	M	SD
1. If I thought I was having a mental breakdown, my first thought would be to get professional attention.	1.62	0.83	1.75	0.76	299.50	1.113	0.14	0.266
2. Talking about problems with a psychologist seems to me as a poor way to get rid of emotional problems. (R)	1.78	0.87	2.00	0.82	204.00	1.704	0.21	0.088†
3. If I were experiencing a serious emotional crisis, I would be sure that psychotherapy would be useful.	2.03	0.67	2.06	0.62	217.50	0.344	0.04	0.731
4. I admire people who are willing to cope with their problems and fears without seeking professional help. (R)	1.16	0.77	1.27	0.81	111.00	1.214	0.15	0.225
5. I would want to get psychological help if I were worried or upset for a long period of time.	2.02	0.85	2.16	0.72	247.00	1.181	0.15	0.237
6. I might want to have psychological counseling in the future.	1.32	0.78	1.59	0.71	100.00	2.543	0.32	0.011*
7. A person with an emotional problem is not likely to solve it alone; he or she is more likely to solve it with professional help.	1.90	0.64	2.06	0.56	100.00	1.890	0.24	0.059†
8. Given the amount of time and money involved in psychotherapy, I am not sure that it would benefit someone like me. (R)	1.84	0.79	1.90	0.78	205.00	0.604	0.08	0.546
9. People should solve their own problems, therefore, getting psychological counselling would be their last resort. (R)	1.41	0.85	1.52	0.78	143.00	1.226	0.15	0.220
10. Personal and emotional troubles, like most things in life, tend to work out by themselves. (R)	1.38	0.85	1.56	0.69	181.00	1.711	0.22	0.087†

Note. n = 63. Statements were rated on a scale of 0–3 (disagree – agree). Reverse-scored items are denoted with an (R). W = Wilcoxon test statistic; Z = Wilcoxon standardized test statistic (z-score)

^†p < 0.10; *p < 0.05; ** p < 0.01; *** p < 0.001

Table 2.

Leaders’ pre- and post-training attitudes on the gatekeeper role

Indicate how you feel about each statement:	Pre-Training		Post-Training		W	Z	r	p
	M	SD	M	SD
1. I know how to appropriately evaluate students who are emotionally distressed.	3.49	0.683	4.01	0.615	27.00	−4.748	0.58	< 0.001***
2. I know how to respond appropriately to students who are emotionally distressed.	3.36	0.667	4.07	0.611	13.00	−5.325	0.65	< 0.001***
3. I know how to handle my own feelings when dealing with students who are emotionally distressed.	3.87	0.548	4.09	0.690	85.00	−2.513	0.31	0.012*
4. I understand what “self-care” is and clearly understand the relationship between it and giving care.	3.55	0.634	4.09	0.596	68.00	−4.780	0.58	< 0.001***
5. When faced with distress and negative emotions, I know how to take care of myself first, such as being kinder to myself, calming down, giving myself a break, etc., instead of blaming myself and focusing on the bad things.	2.90	1.061	3.28	1.084	154.00	−2.988	0.37	0.003**

Note. n = 67. Statements were rated on a scale of 1–5 (strongly disagree – strongly agree). W = Wilcoxon test statistic; Z = Wilcoxon standardized test statistic (z-score)

^†p < 0.10; *p < 0.05; ** p < 0.01; *** p < 0.001

Through the interviews, both leaders and staff reiterated observed improvements in the leaders’ mental health-related knowledge and ability to help their peers. Leaders shared that they had a clearer understanding of mental health problems and warning signs of distress and reported changes in their mindset towards their own mental health. As a leader from School 6 shared, this created not only “a positive impact on other students’ mental health, but also our own.” The staff also echoed these improvements and felt that the knowledge the leaders gained was applicable to their daily lives and their future. Apart from mental health-related knowledge, leaders and staff also highlighted how the design and implementation of the student-led projects benefitted leaders’ project planning and leadership skills, such as problem-solving, public speaking, and teamwork. By the end of the programme, 81% of the leaders who completed the graduation survey said they would be interested in continuing to provide mental health promotion activities to students at their school, with some of them expressing during the interviews that they felt they now had a “level of responsibility to pay more attention to the emotions of those around me” (leader, School 3).

Similarly, the leaders expressed how the training gave them more confidence to respond to peers in need, equipping them with the skills to observe others’ emotional or behavioural cues and respond in a more comforting or empathic manner. Several leaders shared stories of how they were able to apply the knowledge they learned to help their peers dealing with mental health-related issues, including both close friends and unfamiliar classmates at their school, as well as former classmates through social media. As part of this help-giving process, some of them were able to de-stigmatise professional help-seeking to their peers, including one leader from School 1 who shared that by explaining to a reluctant schoolmate what social workers do and clarifying some misconceptions about professional help-seeking, they were able to successfully refer their peer to the school social worker. Finally, leaders were able to recognise their own limits as non-professional gatekeepers, acknowledging that “even though I am currently in a position of responsibility, I do not have to take on everything” (leader, School 7).

Staff also observed how the leaders’ increased confidence in help-giving translated to an increased willingness to do mental health promotion work in school. A staff advisor from School 7 noted that their leaders exhibited “a sense of readiness, confidence and trust in themselves and their abilities.” However, this sentiment was not shared by all staff – an advisor from School 6 felt that the training had “theoretically enhanced [the leaders’] perception on mental health but is not practical,” being unsure “about the results of peer support, such as whether they gave helpful assistance or identified the needs of their peers.”

Staff

Quantitative feedback on the two staff workshops was positive: 96.2% of participants agreed or strongly agreed that the sessions were useful to them, and 92.3% felt satisfied or very satisfied towards the sessions. However, some more experienced teachers and social workers felt that the workshop content was “too general and simplistic” (staff, School 6), while acknowledging that they could be useful for novice staff. As such, they suggested including more practical, case-based examples, or conducting separate workshops catering to the different experience levels of the participating staff. Qualitative feedback on the S.H.I.E.L.D.S. programme as a whole further suggested that staff advisors’ mindsets towards student participation in mental health activities appeared to shift towards a more student-involved, whole-school approach, similar to the findings of the pilot programme. Several staff shared that they were surprised by the leaders’ student-led project ideas, with some admitting they did not believe the activities would be popular at first. The advisor from School 2 remembered thinking, “‘Wow, we can really do this,’ because it turns out [general students] are genuinely interested in this activity.” Through the staff advisors’ more facilitative roles during the student-led projects, they learned how to better support their leaders while also giving them more room to explore their own interests and ideas. Relatedly, some staff advisors chose specifically to engage students who were not stereotypical leaders (e.g., quieter, not as assertive) in their schools and highlighted their potential for more mental health leadership roles in the future, including one advisor from School 3 who shared:

I feel [these leaders] are the ones who are more caring towards others, but they rarely take on the role of a leader, and it’s rare for them to really take the initiative and organize an activity. So, in S.H.I.E.L.D.S., I’ve seen them bring forth their own qualities and step into the role of a leader. It turns out that caring individuals can also be leaders.

General students

The quantitative results from 89 students suggested that there were no changes to perceived social support in school or psychological sense of school membership, and small, though statistically non-significant improvements in general students’ willingness to seek help from school adults and peers, with their mean (SD) scores across 14 personal issues increasing from 2.2 (0.4) to 2.4 (0.3) for school adults, and 2.7 (0.3) to 2.8 (0.2) for peers. At both time points, the general students reported a greater willingness to seek help from peers than from school adults, which was further reinforced in both the general students’ and leaders’ interviews. Although some general students shared that they preferred seeking help from adults due to professional confidentiality or to gain a more mature perspective, others felt that there was a generational gap that prevented adults from truly understanding their perspective, whereas peers provided “a sense of similarity and connection” (general student, School 6) that made them feel more comfortable. Some leaders noted that their peers may not seek help from professionals for fear of being stigmatised or “classified as having problems” (leader, School 5) by others, or they may simply not be aware of the help professionals can provide.

Apart from the general students’ attitudes towards help-seeking, leaders and staff also observed improvements in their knowledge and attitudes towards mental health. For example, some leaders operated social media pages to promote their activities and share basic mental health concepts, which one staff advisor from School 3 noted had translated to real-life conversations about mental health. The general students, in turn, appeared to appreciate the student-led nature of the projects, which can best be summarised by a general student from School 7: “Usually, students have a better understanding of what their peers are thinking and experiencing compared to teachers. So, if the ideas and suggestions come from the students themselves, it may be more effective.”

Most of the general students reported positive experiences participating in the leaders’ student-led projects, though not all of them appeared to understand the purpose of the project activities. When one general student from School 2 was asked about the theme of the project activity, they simply reiterated the leaders’ stated theme of “preventing suicides” without understanding intermediary themes such as enhancing awareness of one’s own emotions, suggesting that there was perhaps a gap in the leaders’ ability to translate their knowledge to others. Despite this, most of the general students reported positive experiences participating in the leaders’ student-led projects, particularly activities with small gifts like snacks or cards which could provide “a sense of encouragement … it feels like you are being cared for by other students” (general student, School 5). A few of the interviewed students also expressed a willingness to become mental health leaders themselves in the future, including one student from School 6 who felt that “one would feel very happy, feeling like they have helped others, and that would bring a sense of satisfaction and happiness, a sense of accomplishment.”

Discussion

This study presents an examination of the impact of S.H.I.E.L.D.S., a leadership training programme for secondary school students in Hong Kong to encourage peer support and promote mental health and wellbeing at a school level. Overall, reception to the programme was positive, and participants self-reported that they felt they were able to achieve the programme outcomes including greater competence and ownership in mental health promotion and suicide prevention in school for leaders, greater understanding of student mental health and suicide issues and greater capacity to support student leaders in school for staff, and improved mental health knowledge for general students. The following discussion will apply the Knowledge, Attitudes, and Practices framework to consider the participants’ knowledge and understanding of mental health and help-giving behaviours; their attitudes towards mental health issues and perceived self-efficacy in being gatekeepers and mental health leaders; and real-life practice in promoting mental health and providing peer support [32].

Quantitative results for leaders showed that although there were generally non-significant increases in their knowledge, there were some statistically significant increases in their attitudes regarding their own ability to serve as mental health gatekeepers in their schools, while results for general students showed small, generally non-significant increases in their willingness to seek help from others between the pre- and post-test periods. A systematic mapping review of adolescent mental health promotion interventions found that interventions delivered by external facilitators or mental health professionals (the experience of our leaders) led to more positive findings in mental health literacy and attitudes/stigma than interventions delivered by high school students (the experience of our general students) [15], perhaps explaining the smaller changes in knowledge and attitudes among general students in the present study. Yet, the goal for involving student leaders in S.H.I.E.L.D.S. was to leverage the potential strengths of peer-led interventions, including the relatively higher levels of engagement, trust, and acceptability that have been associated with such interventions [16]. As such, these findings demonstrate that there are important distinctions to be made between the effects of professional- and peer-led delivery modes, and future research may be needed to determine how to best leverage the strengths of both approaches.

Additionally, the generally small changes observed in the present study, as well as the lack of changes in the general students’ perceptions of their school social environments, were likely due to the short time interval between the administration of the pre- and post-tests. It is possible that these shorter follow-up periods were not sufficient to create a noticeable change in adolescents’ knowledge of and attitudes towards mental health [15], therefore longer programme durations for both the leaders’ training and their student-led projects, as well as the collection of more longitudinal data, may be needed to further investigate these potential changes. Similarly, it is possible that the relatively short duration of formal training that the leaders received during the programme was not sufficient for them to develop levels of knowledge and confidence in delivery that could enable greater changes in their peers, especially when compared to professional facilitators with several years of experience in mental health practice and training. It may therefore be possible that a longer training period for the leaders may allow them to further develop their skills as gatekeepers and lay leaders, leading their peers’ outcomes to improve as well.

The qualitative inquiry further demonstrated that although leaders’ knowledge of and attitudes towards mental health and being a gatekeeper were perceived by leaders and staff to have improved after participating in the S.H.I.E.L.D.S. training, it seems that this did not necessarily translate into the practice of being a gatekeeper. Although the goal with the student-initiated project was to allow leaders to apply their knowledge by sharing what they had learned with their peers, some staff advisors saw this as insufficient since they believed the leaders had fewer opportunities to practice help-giving. However, as S.H.I.E.L.D.S. was designed to be a universal intervention benefitting a broad range of students, it is possible that the incidence of help-seeking behaviours in a universal sample is relatively low [15], perhaps explaining why these help-seeking interactions were harder to detect. Although there were fewer opportunities for the leaders to conduct referrals within their school, it is nevertheless encouraging that they were able to exercise skills related to emotional awareness and empathic response for peers both within and outside their immediate school context. Keeping in line with the need for more longitudinal data, future research could consider following up with peer gatekeepers at regular intervals after their initial training to examine if they have had more opportunities to practice these response and referral skills. In particular, it would be interesting to examine if the knowledge and skills the leaders gained as secondary school students might also be useful when they become university students, especially amid ongoing global concerns of university students’ mental health [33].

One aspect of S.H.I.E.L.D.S. that set it apart from other existing programmes in Hong Kong that we are aware of was the emphasis on student autonomy and ownership. Leaders designed and carried out their own mental health promotion activities, based on their own experiences and what they felt would be beneficial for and well-received by their peers, while staff were encouraged to take on a more administrative rather than decision-making role. This emphasis is in line with previous studies which also found the benefit of engaging students in peer leader training interventions to increase acceptance of and promote mental health and help-seeking knowledge among their peers [34–36]. Indeed, the results of the general students’ questionnaire highlighted that they were generally more willing to seek help from their peers rather than school adults, suggesting that peer-led programmes such as gatekeeper training may provide easier avenues to engage other students than traditional adult-led psychoeducation. All three groups of participants also recognised the importance and benefits of students’ perspectives in school-based mental health promotion initiatives, further highlighting the impact of the present study’s bottom-up approach to empowering young people to play a more active role in mental health promotion and suicide prevention in their school communities. Furthermore, by building student leaders’ capacity to provide mental health support, this could create systemic changes within the wider school community, whereby leaders’ positive changes in their knowledge, attitudes, and practices of mental health could spill over to their peers as well. Engaging student leaders as trained gatekeepers who can provide mental health support to their peers could also help to reduce some of the burden on teachers who are struggling to balance being at the front line of identifying at-risk students with their existing administrative and teaching duties [37].

Finally, it is important to recognise the broader school context and the programme’s place in it. Although the majority of leaders demonstrated their willingness to continue their mental health promotion activities, collaboration and commitment across the whole school is needed to sustain this interest and ensure its long-term impact [38]. Staff advisors who believed their school would have a higher level of success in integrating S.H.I.E.L.D.S. into future mental health promotion efforts were the ones who had pre-existing activities or programming which they believed could be complemented or better supported by S.H.I.E.L.D.S., especially those which were aligned with the current programme’s goals of mental health promotion. By leveraging these pre-existing structures and common goals, this may create a more efficient and sustainable avenue for integrating new school-based mental health promotion initiatives. Moreover, staff advisors who qualitatively demonstrated greater changes in their mindset towards a whole-school approach were more optimistic about their leaders’ and other students’ involvement in school-based mental health promotion efforts in the future [25]. This represents a promising first step in the move towards an effective whole-school approach to student mental health.

Limitations

The data presented in this article have several important limitations, so the present research should be viewed as exploratory. First, this study employed several instances of non-random sampling, which may have introduced bias into our study and limits the generalisability of the findings. Schools were asked to express their own interest to participate in the programme, which may have created selection bias as schools that already believe in the importance of student mental health and/or have existing programming that would be further supported by participation in S.H.I.E.L.D.S. would be more likely to enrol. During the recruitment stage, several schools that had initially expressed interest in joining the programme eventually withdrew due to misalignment between the programme’s offerings and the needs or desires of the school. Therefore, it is unclear if S.H.I.E.L.D.S. might have a similar positive impact under these different school-level circumstances.

Second, the present study lacked a control group, making it difficult to conclude that the observed changes were entirely due to participation in S.H.I.E.L.D.S. Although we acknowledge that there are studies of school-based mental health interventions that employ a randomised control design by putting control group students or schools on a waitlist for the intervention [39, 40], such an approach was not feasible with S.H.I.E.L.D.S. given its relatively short timeline and the exploratory nature of the study, and we believe the present non-experimental design was sufficient to pilot-test its potential. However, given the promising results of the present study, future iterations of S.H.I.E.L.D.S. could consider employing a randomised controlled design to more rigorously evaluate the programme’s effectiveness.

Third, the present study used several bespoke, non-validated measures to evaluate participants’ outcomes. Specifically, the leaders’ knowledge questions and several of the leaders’ self-assessment constructs regarding their confidence in understanding and assessing others’ mental health risks, responding appropriately to their needs, and handling their own needs when providing care were all measured using questions developed by the research team. Although the aim of such questions was to evaluate whether leaders could retain the knowledge that they learned and achieve the programme outcomes, the lack of psychometric validity for these constructs makes it unclear if the items could accurately measure changes in the leaders’ knowledge or their self-efficacy in being gatekeepers. Future studies and iterations of S.H.I.E.L.D.S. could use validated measures such as the Literacy of Suicide Scale [41] or the Gatekeeper Behavior Scale [42] to improve the accuracy of the results.

Finally, the sample size of the present study was relatively small. The low matching rate on the general students’ questionnaire specifically was perhaps due to the fact that the research team relied on participating leaders and staff to ensure the questionnaire was distributed to their general students at both time points. Furthermore, the short data collection period likely contributed to the overall lack of significant changes in leaders’ and general students’ knowledge, attitudes, and practices of mental health within their school community that could be detected. Despite this, the qualitative data seems to be able to support the quantitative results to allow for greater optimism in the programme’s impacts. Future studies should employ a longer programme duration with a larger sample and a longitudinal design to better establish the patterns of these changes and examine whether they can persist over time.

Conclusions

Despite these limitations, we believe that S.H.I.E.L.D.S. was successful in meeting its objectives and helping participants achieve the programme outcomes. More broadly, our experience with S.H.I.E.L.D.S. suggests that similar school-based gatekeeper training programmes for mental health promotion and suicide prevention have the potential to be effective if they recognise the perspectives of students and can be well-integrated with existing school efforts. Since the duration of one round of S.H.I.E.L.D.S. was quite short, future iterations should employ a longer duration and examine how it would impact student leaders’ knowledge, attitudes and especially practices, as well as incorporate a longitudinal design to assess whether these changes can be sustained over time. Finally, in terms of scaling up the programme in the future, collaborating with school administrators to find where S.H.I.E.L.D.S. could fit within existing structures may help the programme be better received. Overall, the positive outcomes observed serve as a promising direction for expanding student gatekeeper programmes rooted in a whole-school approach in Hong Kong, enabling flexible implementation across more schools, and demonstrating that S.H.I.E.L.D.S. is not merely a standalone initiative, but can serve as a driving force to cultivate a stronger culture of wellbeing in schools.

Abbreviations

ATSPPH-SF

Attitudes Toward Seeking Professional Psychological Help – Short Form

HREC

Human Research Ethics Committee

S.H.I.E.L.D.S.

Suicide Help Intervention through Education and Leadership Development for Students

SPSS

Statistical Package for the Social Sciences

Authors’ contributions

PSFY conceived the study. IDL, TWSL, and WWYS designed the study methodology. IDL and TWSL were involved in the data collection. IDL, TWSL, and CLC were involved in the analysis of the data. They, along with WWYS, participated in the interpretation of the data. IDL and SSYW drafted the primary manuscript, and JL and PSFY provided substantial revisions. All authors critically revised the manuscript and gave final approval for the submission.

Funding

This work was supported by the Mental Health Initiatives Funding Scheme, coordinated by the Advisory Committee on Mental Health under the Health Bureau (formerly the Food and Health Bureau) of The Government of the Hong Kong Special Administrative Region of the People’s Republic of China.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study conformed to the principles of the Belmont Report and the Declaration of Helsinki. Ethical approval for this study was obtained from the Human Research Ethics Committee of the University of Hong Kong (HREC No. EA220215). Written informed consent was obtained at the start of the programme at the school level from the school’s principal, and at the individual level from participating staff and participating leaders’ parents. Written informed consent was obtained at the start of the student-led projects from participating general students’ parents. Written assent was obtained from participating leaders and general students. Verbal informed consent or assent was also re-obtained at the start of interviews.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.