Mental Health First Aid for the Armed Forces Community: evaluation
scope.
Introduction
Mental health problems are common affecting around one in four adults in the UK. It is the
single largest source of burden of disease and no other health condition matches mental
illness in the combined extent of prevalence, persistence and breadth of impact (Centre for
Economic Performance Mental Health Policy Group, 2012). Only a quarter of all those with
mental illness are in treatment, compared with the vast majority of those with physical
conditions (Centre for Economic Performance Mental Health Policy Group, 2012) and many
only seek help after a considerable delay of many years (Wang et al., 2005). Prevalence
studies suggest that we are all likely to know someone experiencing mental ill-health with
thirty to fifty per-cent of the population meeting diagnostic criteria for a mental disorder at
some point in their lives (WHO, 2000; Kessler et al., 2005). Yet community surveys also
reveal that recognition of symptoms and awareness of helpful interventions or treatment
options remains poor across the general population (Jorm et al., 2006).This is despite
evidence that promoting mental health and early intervention when people first display
symptoms can both improve recovery and the quality of people’s lives as well as saving
considerable costs in the longer term (Knapp, M.; McDaid, D.; Parsonage, M., 2011).
Definition of Armed Forces Community
In the context of this document, the Armed Forces Community includes Veterans and
Serving personnel, their families and any charities or health and social care organisations
that work with this group.
Mental health and the Armed Forces Community
Those in the Armed Forces Community experience mental health problems at broadly the
same rate of prevalence as other groups in the community. They are most likely to
experience depression, anxiety and particularly alcohol misuse problems (Fear
2009)(Iversen, et al., 2009).Recently there has been greater focus on the prevalence of
post-traumatic stress disorder (PTSD) among UK military personnel, although prevalence
rates among those returning from Iraq appear relatively low (between 4–6% compared with
8–15% experienced by US counterparts) and are broadly comparable with community
rates.Similar rates of mental illness are also found for ex-Service personnel and their still
serving equivalents(Sundin, et al., 2010).
However, some particular patterns, problems and challenges are noted in the literature
outlining the particular experiences of those with mental health needs in the Armed Forces
community and their patterns of access to mental health interventions. There is evidence
that:

those who do develop mental health problems generally fare quite badly(Fear, et al.,
2009)

military personnel with mental health problems are more likely to leave their Service
compared with those with no problems and are at risk of poorer post Service
outcomes (Fear, et al., 2009).
 Armed Service personnel and veterans often avoid or significantly delay seeking
appropriate help and treatment (Iverson, et al., 2011)(Iversen, et al., 2010)
 Armed Service personnel sometimes do not know where to go (Iverson, et al., 2011)
 Stigma and lack of trust or confidence in providers of mental health services
represent some of the main barriers to seeking help in serving personnel(Britt,
2000)(Langston, et al., 2007)(Rona, et al., 2004)(Greene-Shortridge, et al., 2007).
Admitting a psychological problem was anticipated as much more stigmatising than
admitting a physical health problem among soldiers returning from Bosnia (Britt,
2000).Some stigma has been associated with a reluctance to disclose vulnerability in
a profession which sets great store by physical and psychological resilience in the
face of adversity. Some stigma is also linked to fears of being blamed by their
employer and that that disclosure may have a negative impact on careers(Britt,
2000) (Langston, et al., 2007)(Iverson, et al., 2011).
 Furthermore, access to appropriate treatment services has been historically
problematic. Although treatment rates generally are on a par with those of the
general population (which in itself involves low levels of access to help), one study
noted an overall treatment rate of 13% fora sample of UK Armed Forces personnel,
around half that found for the general population(Iversen, et al., 2010).
Such delays potentially hinder critical opportunities for early intervention and jeopardise
effective recovery.
Relative to other service personnel, the following groups were identified with poorer mental
health prospects in the Armed Services Community:



those deployed to Iraq or Afghanistan with pre Service vulnerabilities
those deployed to Iraq or Afghanistan who were exposed to high levels of combat
Reservists compared with Regulars; reservists have been noted to have the poorest
mental health
 early service leavers
 younger male ex-Service personnel (under the age of 24 years); this age group has
higher rates of suicide than their general population equivalent.
(Iversen, et al., 2009)(Fear, et al., 2010)(Harvey, et al., 2011)(Buckman, et al.,
2012)(Woodhead, et al., 2011a)(Woodhead, et al., 2011b)
When Armed Forces Personnel with a mental health problem seek help, there is evidence
that they prefer informal support through a spouse or friend (between 73–85%). Only a
quarter of thosewith a diagnosed mental health problem accessed medical help. Similarly,
just under aquarter (23%) with alcohol problems had sought professional help, which was
lower thanthose with depression and anxiety where 50% sought help. Regulars and
Reservists did notdiffer in their help-seeking behaviours. Common treatments included
medication and counselling/psychotherapy (Iversen, et al., 2010).
The policy context
Recent governments haverecognised ex-Service personnel as a group needing support for
potential mental health problems as set out in the Department of Health’s New Horizons
mental health strategy (Department of Health, 2009) and its replacement ‘No health without
Mental Health’ (Department of Health, 2011). In 2010, the Murrison review(2010) produced
a number of recommendations designed to strengthen mental health services for service
personnel and veterans. One recommendation identified the need to test out improved early
intervention approaches and services for serving personnel and veterans. Efforts to improve
provision were further bolstered by the Military Covenant which enshrines in law society’s
obligation to and duty of care for serving personnel for sacrifices made (Forster, 2012). As
part of this Covenant, proposals were introduced for improving mental health care provision,
extending access to mental health care to six months after discharge, increasing the number
of mental health nurses for veterans and establishing a 24-hour helpline and website for
support and advice (Minstry of Defence, 2011). This obligation has recently paved the way
for a ring-fenced healthcare budget supporting veteran mental health care (although the
sustainability of this funding remains uncertain).
Mental Health First Aid for the Armed Services Community
In 2013 SSAFA (the Soldiers, Sailors, Airmen and Families Association) MHFA England
CIC, Combat Stress and the Royal British Legion formed a collaboration to deliver Mental
Health First Aid (MHFA) for the Armed Forces Community which aims to improve early
identification and access to support. The project aims to train approximately 180 instructors
from across 5 target groups - Health & Social Care professionals, voluntary/charitable
services, friends and family, veterans and serving personnel. Once trained, these individuals
will take back and deliver training in their own communities, with an ultimate aim to skill up
approximately 6,600 Armed Forces Community Mental Health First Aiders. Because of the
broad reach of this initiative, trainers and ultimate beneficiaries of identification, support and
referral into services may be in both Armed Service and civilian settings. A small proportion
of trainers and beneficiaries may be stationed abroad.
MHFA seeks to improve mental health literacy,improve identification, improve access to
support and reduce stigma. The intervention seeks to achieve aims through improving
knowledge, attitudes and behaviour of trainees so that they are better equipped to identify
and respond to poor mental health among Armed Forces personnel and their families.
It seeks to achieve change in the following ways.
Improving knowledge
1. Helping those trained up in MHFA:
o
o
recognize the early signs of a mental health problems
know what types of help are available and best suited to the needs of
potential beneficiaries
Improving attitudes
o
o
Helping those trained up in MHFAfeel more confident when helping someone
experiencing mental health problems
Helping reduce the stigma of mental health problems
Changing behaviour
2. Helping First Aiders:
o
o
provide initial help on a ‘first aid’ basis
guide a person towards appropriate professional help
The evidence underpinning initiatives to improve mental health literacy
Mental health literacy is an overarching term describing the beliefs, attitudes and abilities
required to promote mental wellbeing and aid appropriate use of mental health
services(Jorm, et al., 1997)(Jorm, 2000). The evidence base for MHFA-type interventions is
still emerging. Such interventions arenoted to increase knowledge, confidence and skills in
recognising mental health problems. There is also some limited evidence of reductions in
stigma occurring after the intervention in various settings(Kelly, et al., 2007)(Jorm, et al.,
2010)(Welsh Assembly Health Improvement Initiative, 2012) .Mental health literacy-based
training has also sometimes been shown to improve the mental health and wellbeing of
those being trained up in the intervention(Kitchener & Jorm, 2004).
Providing knowledge about mental disorders and their treatment has been shown to be a
promising way to increase readiness to seek help (Esters, et al., 1998)(Han, et al.,
2006)(Wright, et al., 2007)(Jorm, et al., 2003). Intervention studies also show that destigmatisation may lead to increased readiness to seek professional help(Schomerus &
Angermeyer, 2008). The belief that seeking help for a mental health problem will be helpful
has also been shown to be at the core of help seeking intentions and thus offers a promising
target of information programmes(Schomerus & Angermeyer, 2008).
There issomeadditional evidence that participants in mental health literacy programmes will
intervene when they recognise potential mental health distress but less consistent and
convincing evidence that interventions result in improved access to professional services for
those identified with mental health problems(Jorm & Kelly, 2007). There is also, as yet,
limited evidence of effects lasting beyond 6 months(Welsh Assembly Health Improvement
Initiative, 2012). Finally, there is no evidence as yet that widespread mental health first aid
training has the potential to impact on population mental health outcomes(Kitchener &
Jorm, 2006)(Kelly, et al., 2007)(Welsh Assembly Health Improvement Initiative, 2012).
The scope of this evaluation tender
This evaluation seeks to contribute to the current evidence base on mental health literacy
training through evaluating the extent to which MHFA achieves its desired outcomes in the
Armed Forces Community. The contractor will be required to design and undertake an
evaluation study of MHFA for the Armed Forces Community that answers the following
evaluation questions:
1. To what extent have first aiders used the techniques they have been taught (e.g. the
ALGEE tool), with how many people and to what effect?
2. To what extent does MHFA for the Armed Forces:
a) improve First Aiders’ knowledge
b) reduce First Aiders’ stigmatising attitudes
c) improve First Aiders’ confidence in dealing with MH distress
d) improve First Aiders’ response to mental health distress following training (e.g.
either delivering first aid directly and/or referring people in mental health distress
on to appropriate services).
3. To what extent do any changes persist over time?
4. How useful do First Aiders find the training they receive and what improvements
would they recommend?
5. To what extent does MHFA improve access to support and treatment for those with
poor mental health among the Armed Forces Community?
6. What effect does first aid training have on the wellbeing of those trained up in MHFA
and on the ultimate beneficiaries of the intervention?
7. How much do beneficiaries value the help they receive and what improvements
would they recommend?
8. How effectively is the MHFA intervention being implemented?
The evaluation study will collect and analyse primary and secondary data and triangulate
and analyse a range of quantitative and qualitativedata. The team will have access to MHFA
in the Armed Forces Community pre and post training course evaluation data (see Appendix
one) but will also need to introduce additional pre and post data collection methods to
measure outcomes. Where additional data requirements are required by the contractor,
these will need appropriate approvals and data collection processes to be identified.
There is a need to understand the longevity of effect of training on the attitudes and
behaviour of First Aiders. The contractor would be expected to build into the design of the
methodology the ability to track and measure longer term mental health outcomes resulting
from the intervention on those trained. It would also aim to explore the effect of the
intervention on those assisted through the scheme.
Finally, during the process of this study, the evaluation should examine aspects of
implementation of the programme and, based on findings, provide recommendations to
improve the quality and efficiency of delivery in Armed Forces settings.
Time scale and reporting requirements
The start and termination date of this contract will be confirmed once the suitable partner
has been identified and proposal agreed. On initiation, progress reports will be expected
quarterly.
A publishable evidence-based full evaluation report will be produced describing the findings
from this evaluation by end 2015. The report will also include analysis of the process of
delivery, making recommendations for the improvement of its effectiveness.
Requirements
The contractor will be required to:

design an evaluation study that measures the extent to which MHFA achieves its
desired outcomes.

in conjunction with the Evaluation Programme Manager and the MHFA for the
Armed Forces Steering Group:
o identify, draw together and embed in practice a suite of measurement tools
which can reliably track pre and post training outcomes and shifts in
knowledge, attitudes, behaviour and wellbeing.
o

ensure that all ethical approvals and information governance requirements
are met, and that data is held securely in line with appropriate regulations.
oversee and co-ordinate data collection and analysis across all sites and capture and
analyse all MHFA pre and post evaluation data for new trainees over a 6 month
period.

develop a project plan that will enable the contractor to meet the required deadlines
for the specified outcomes and budget

triangulate quantitative and qualitative data on First Aiders and beneficiaries to
answer the evaluation questions

assess the extent to which any shifts in knowledge, attitudes and behaviour persist
over time

provide information on the process of implementation and delivery contributing to
continuous improvements in implementation effectiveness

establish an expert reference group incorporating a range of stakeholders (including
the views of mental health service users).

introduce a system, with MHFA for the Armed Services Community, for seeking
consent and following up any beneficiaries of those trained up in MHFA
competencies.

complete qualitative interviews with a small cohort of those who have been helped
by or referred onto support through the MHFA.

hold overarching responsibility for the delivery and quality assurance of progress
reports and a full evaluation report prepared using an agreed template. The final
reports should also have a clear and concise Executive Summary.

agree with the Evaluation Programme Manager risk management and issue
resolution mechanisms

ensure that a consistent methodology is used throughout.
The specific skills and knowledge required from the contractor should include:
 Project Management
 Competencies in:
o the design and analysis of mixed methods evaluations
o the design and analysis of process evaluation methodologies
o data collection and data analysis
o maximising service user participation
o report writing with particular skills in translating academic findings into a
format that supports policy and practice development

Knowledge and understanding of:
o Young adult and adult mental health
o health promotion and the prevention of poor mental health
o help-seekingand stigma in the field of mental health
o early intervention approaches in mental health
o programme implementation theory
o thepolicy and mental health service landscape for those linked with the
Armed Services including demonstrating an understanding of public sector
services and voluntary sector roles.
o Understanding differential impact of service provision in terms of age,
gender, BME, sexuality and transgender issues, etc
Process and responsibilities
1. MHFA for the Armed Services Community The Authority will:
 Identify and secure the cooperation of the cohort of MHFA intervention sites and
trainees to take part in the study.
 Identify representatives from MHFA for the Armed Forces Community, including
an Evaluation Project Manager to work with the contractor as part of the MHFA
Steering Group.
2. The Contractor will:
 Attend the MHFA Steering Group
 Perform quality assurance on all aspects of the programme
 Provide MHFA for the Armed Services Community with timely and ongoing
evaluation and quality assurance information relating to the programme
Contract management and monitoring
The key performance indicators for this Contract shall include, as a minimum:
 That work is of an acceptable quality and delivered to agreed timescales
 The work is consistent with any other policy developments taking place
 That work is cleared through any particular Ministry of Defence requirements or
clearances.
The Contractor shall:



Monitor the quality of service provision to ensure customer satisfaction in accordance
with the key performance indicators outlined in the Contract, unless otherwise
approved by the Evaluation Programme Manager.
Provide a report on progress to the Evaluation Programme Manager as agreed.
Attend any agreed meetings?
Budget
MHFA for the Armed Service Community has made available a total of £49,000 inclusive of
VAT over the course of 18 months for the completion of this evaluation.
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Version 1: May 2014