School-based Mental Health Literacy Research Articles

Teachers’ experiences of school-based mental health literacy programmes: a qualitative study of tackling the blues

ABSTRACT Concern about school pupils' mental health has increased globally. Mental health programmes in state schools, including those provided by external partners, have also expanded. However, little research exists which explores the views and experiences of teachers and other school staff on the development of coproduced, contextually tailored, mental health literacy (MHL) programmes delivered with external partners (including academic researchers and community organisations) to support pupil mental health. This paper reports new interview data from 14 teachers and 1 teaching assistant based in 8 primary schools in north-west England who were involved with a sport- and art-based MHL programme (Tackling the Blues, TtB) during the school year 2022/23. Three themes were identifiable in the interviewees' comments: (i) Externality and navigating the constraints of the national curriculum; (ii) “It's opened my eyes”: developing and enhancing mental health literacy; and (iii) Supporting inclusive and proactive mentally healthy schools. Our findings suggest that TtB provided schools and teachers the opportunity to work with external organisations committed to working with, rather than on or for, them over the school year. This collaborative approach helped align TtB to the values, ethos, and strategic priorities of the school, including existing whole-school approaches to mental health within and beyond the curriculum. External partners' complementary expertise helped build capacity for delivering MHL work flexibly in schools, strengthened teachers' confidence, and expanded their understanding of pupils' diverse mental health needs. This further strengthened programme acceptability by fostering more pupil-to-pupil conversations which were perceived to positively contribute to stigma reduction and help-seeking efficacy.

Universal, School-Based Mental Health Literacy Programs for Middle School Students: A Scoping Review.

Universal, classroom-based mental health literacy (MHL) curricula are associated with improved mental health knowledge, attitudes, and help-seeking behaviors. Young adolescents are an ideal target given their need for and receptivity toward MHL education. We conducted a scoping review to identify universal, school-based MHL programs primarily for students aged 10-14 years, with adequate descriptions of curriculum implementation and content, and measured outcomes. Thirty-one articles describing 24 programs met the inclusion criteria. The content and educational strategies varied, with no two programs having the same curriculum. The studies show promising results for improvement in mental health knowledge, attitudes, help-seeking, and student mental health. Collaborative work between educational and mental health professionals, along with rigorous study of outcomes, aiming to reach a consensus on a core MHL curriculum and best implementation practices, will advance efforts to improve MHL. This scoping review confirmed that existing universal, school-based MHL programs for middle school-aged students improve mental health knowledge. The programs are diverse, and their outcomes are often challenging to compare. Ongoing study in this field to optimize design and implementation for improved effectiveness is needed.

Mental health literacy in German teachers – What do they know? What do they need?

Abstract Background Preventing mental health problems and promoting mental wellbeing is the aim of school-based mental health literacy (MHL) programs. Previous research suggests that good MHL (knowledge and skills regarding mental health, resilience, and help-seeking) helps people to take good care of their own and others’ mental health and use support-services. In this context the MHL of teachers is highly relevant, as they act as role models and interact with affected pupils on a regular basis, for which certain knowledge and skills are necessary. In this study, we therefore seek to investigate the level of MHL in German high-school teachers as well as their exposure to impaired students and their desire for further education on pupils’ mental health. Methods The data are collected as part of an effectiveness study of a school-based intervention to strengthen MHL (BEWARE), which was developed by our working group. We collect data from teachers who are involved in BEWARE as coaches as well as from those not directly involved (n ≈ 300). Data collection takes place online at three measurement timepoints (6 months apart each). For the analysis presented here, data of the first measurement timepoint with respect to MHL, skills in handling affected students and wishes for additional education on pupils’ mental health are included. Results As the data collection is still ongoing, statistical analyses are not yet completed. We will present data on the current state of knowledge on MHL in German teachers as well as their abilities to deal with affected pupils and their wish for further education. In addition, we will relate the number of affected pupils they teach to depict the relevance in their daily life at school to the above-mentioned measures. Conclusions The acquired data and respective analyses will give us important insights about the objective and subjective need of MHL training in schoolteachers (based on assessed knowledge and their reported wish of additional education). Key messages • Our study will give us important insights about the objective need of MHL training in high-school teachers based on assessed knowledge. • Our results will depict which formats of training teachers would prefer for additional education on pupils’ mental health, which will be a valuable basis for the development of future programs.

Pilot evaluation of an innovative school-based mental health literacy program for teachers and students: The Decode Mental Health and Wellbeing Program

Pilot evaluation of an innovative school-based mental health literacy program for teachers and students: The Decode Mental Health and Wellbeing Program

Mental health literacy in Australian schools: evaluation of the Australian adapted youth education and support program

ABSTRACT Objective The prevalence of youth mental illness is increasing, and accessible preventative approaches, such as school-based mental health literacy programs, are needed. Mental health literacy is the ability to understand how to obtain and maintain good mental health. Schools are an ideal and accessible setting to base programs targeting mental health literacy. Method This study used a non-randomised waitlist control design to evaluate the effects of the Youth Education and Support (YES) program on mental health literacy, help seeking, and resilience for 38 Australian youth (12 male, 26 female) aged 12–16 years (M = 14.05, SD = 1.01). Data was analysed using t-tests, frequency analyses, mixed-model repeated measures analysis of variance, and directed content analysis. Results No significant interaction effect on mental health literacy from pre to post intervention was found between participants in the YES condition and control condition. Participants (n = 26) were significantly more likely to seek help from a helpline for suicidal ideation than control (n = 12) postintervention. Participants within the YES condition demonstrated significantly improved mental health literacy from pre to postintervention. Conclusions This study provides initial evidence supporting the inclusion of mental health literacy programs in Australian school environments.

Evaluation of school-based mental health literacy program in high school students: a scoping review protocol

Evaluation of school-based mental health literacy program in high school students: a scoping review protocol

Evaluating the effectiveness of a school-based mental health literacy intervention from a comprehensive demographic and social-cognitive perspective

Childhood and adolescence are a critical period for the onset of mental and neurodevelopmental disorders and a time when many can be first identified. Research demonstrates that mental health literacy applied in school settings may be an effective approach to address these challenges. In contrast to many existing studies conducted in multicultural and multilingual settings that treated subjects’ language as a demographic feature, the present study recognizes English proficiency as a social-cognitive factor and views the school-based mental health literacy (MHL) intervention as a learning process. The present study aimed to assess the effectiveness of school-based mental health literacy intervention and explore how ethnicity and English proficiency as a social-cognitive factor, as a modified, rather than a fixed variable, impacted the intervention outcomes. Grade 9 students (n = 240) from schools in West Canada with diverse social/cultural background received the intervention in the classroom delivered by trained teachers and completed the pre-test and post-test over a 6-month period. The intervention was effective in improving knowledge and help-seeking attitudes among all students. Non-Chinese and native English-speaking students performed the best on all outcomes. Gender demonstrated an association with changes in stigma, stress and wellbeing. English proficiency was linked to knowledge acquisition, while ethnicity was connected to changes of attitude-related outcomes. These findings deepened our understanding of how demographic and social-cognitive factors underlie changes in mental health literacy outcomes, which will facilitate the development of mental health literacy interventions for diverse student populations.

Validation and evaluation of school-based mental health literacy training program "The Guide Cymru" in Iranian adolescent students aged 13–15: study protocol

BackgroundSchools are an ideal setting for enhancing mental health literacy, a crucial strategy for improving adolescents’ mental health knowledge and attitudes and promoting help-seeking. "The Guide Cymru" program is an adaptation of the mental health literacy program" The Guide" that was developed in Canada. The program will be culturally adapted for 13- to 15-year-old Iranian adolescent students in the first secondary schools.MethodsIn this randomized controlled trial, using the stratified random sampling procedure, the whole eighth and ninth grade student body (aged 13 to 15) from Sirjan City's first secondary schools will be included in the study. Twenty first secondary schools will be randomly assigned to one of two groups: control or intervention. Finally, 562 students and 40 teachers will participate in the research. The tools of mental health literacy scale (MHLs), mental health general knowledge and attitudes related to mental disorders/illnesses are employed in this study.DiscussionThis trial aims to be to explore whether "The Guide Cymru", a mental health literacy program offered to students as part of the school curriculum, can decrease the stigma associated with mental health and promote help-seeking behaviors among students.

Modelling the Clinical and Economic Impacts of Foundation-Funded versus Staff-Driven Quality Improvement Mental Health Strategies

BACKGROUND Employing a valid and reliable clinical measurement system established in 2002 within our regional Child and Adolescent, Addictions, Mental Health, and Psychiatry Program, we have been able to measure the effect of the general service system, a novel pre-admission initial family group session to orient families to treatment, and an acute at home care service deigned to divert admissions from emergency to in-home support rather than inpatient admission. Additionally, the modelled clinical effect and economic impact of two community programs; one school-based mental health literacy program and one primary care physician training and education program focusing on the management of children's mental health problems. In this paper, we present an established clinical measurement system combined with standardized cost evaluation strategy to assess the respective cost/benefit impacts of four service innovations. METHODS The clinical measurement system has been described in detail, as has its role in measuring the impact of community-level training on the quality of referrals. Our financial department developed standardized per diem cost references for levels of care within our system. The cost references permitted comparison of groups that were exposed and unexposed to the system innovations before and after the initiation of service and community innovations. The school-based mental health literacy program was a regional implementation of a national program (https://mentalhealthliteracy.org/). The primary care physician education was an internationally develop program from the United States (https://thereachinstitute.org). The other two projects were accomplished on a somewhat smaller local scale and at lower overall cost. The pre-admission initial family group session was a bottom-up, staff-designed and developed quality improvement project. The acute at home project, while funded by the children’s hospital foundation as were the two national and international projects. the acute at home project was a top-down director-designed project with one manager and a coordinator. RESULTS The four innovations were evaluated employing the same model. In each case the clinical space created by each innovation was measured in terms of the cost saved comparing the same outcomes (re-admission rates and lengths of stay) over comparable time intervals between and within pre/post exposed and unexposed groups, whilst controlling for clinical effects of exposure and time. The clinical measurement system helped determine group effects to ensure that the target groups were comparable within each initiative’s exposed and unexposed groups and were appropriately distinct between initiatives (eg, appropriate clinical groups were served by each initiative). While four projects were different and served somewhat different patient groups, the pre-admission initial family group session was the most cost effective. The physician training program was both effective and cost neutral. The school-based mental health literacy program was the least evaluable due to the direction of implementation and tended to increase referrals rather than create clinical space for more affected youth, as might be expected. The acute at home project successfully diverted less suicidal patients away from inpatient readmission over the evaluation period. DISCUSSION The main implications for mental health policy derives from linking standardized cost and clinical measurement models permitting economic evaluation of system and community level innovations. Pre and post clinical and cost measurements within and between exposed and unexposed groups for each innovation or project permitted estimation of benefits and cost. CONCLUSIONS The projects varied in focus together with the evaluability of each project, yet this provided important information for health system innovation and renewal within the context of fiscal constraint. The ranking of the projects in terms of their overall benefits and costs may guide decision-making where maximum return on investment makes the most sense.

Australian School Staff and Allied Health Professional Perspectives of Mental Health Literacy in Schools: a Mixed Methods Study

Schools are an ideal setting to base mental health literacy programs as the learning environment is already established. Mental health literacy represents how to obtain and maintain good mental health and should be incorporated into the school curriculum. Collaboration with key stakeholders in youth mental health, such as school staff and allied health professionals, is critical in ensuring needs are addressed, and programs are sustainable. This study aimed to understand the perspectives of school staff and allied health professionals towards mental health literacy within Australian schools. An exploratory qualitative and quantitative survey was completed by 88 participants across Australia. Results indicated that school staff feel less competent to deliver mental health literacy content and perceive their training did not address mental health education compared to allied health professionals. Most mental health programs reported to be implemented within schools were social and emotional learning programs. School staff viewed mental health programs to strengthen academic performance less than allied health professionals. Thematic analysis of qualitative data identified that participants viewed mental health knowledge, where and how to seek help, and coping skills as vital content to cover in a school-based mental health literacy program. This study reveals that school staff need sufficient training and resources to address youth mental health literacy. Though mental health literacy is lacking in the Australian school system, the perspectives of school staff and allied health professionals in this study provide key ideas and considerations for the future development of school-based mental health literacy programs for youth.

School-based mental health literacy training shifts the quantity and quality of referrals to tertiary child and adolescent mental health services: A Western Canada regional study.

We aimed to improve mental health referral quality of young people by helping educators build capacity for early identification of youth at risk of mental illness and facilitate referrals between the education and health systems. We applied the Go-To Educator mental health literacy training for early identification, triage and support in 208 schools in Calgary, Alberta between 2013 and 2016. Students presenting to mental health services during this time were compared on a number of clinical, system, and demographic variables, based on the training status of the school (untrained schools; before and after training schools), using retrospective cohort design. Based on clinical and system data, bivariate and multivariable logistic regression analysis were employed to compare the three school status domains. After training, referrals differed significantly from control and pre-training schools. Students presenting to services from these schools were younger, from single parent families; were referred more because of adjustment and learning/attention problems; had complex social/family issues; thought disturbances, and harmful behavior/thoughts towards others. While they waited longer to be admitted they stayed longer in services; had more provisional comorbid diagnoses and demonstrated positive treatment outcomes. The Go-To Educator training may be an effective intervention helping educators identify students at risk of mental disorders and in substantial need of mental health services, demonstrating improved linkages between education and health sectors.

The Role of Interpersonal Communication in Mental Health Literacy Interventions for Young People: A Theoretical Review

ABSTRACT School-based mental health literacy (MHL) programs can increase knowledge, reduce stigma, and encourage help-seeking behaviors in school-aged children. Yet, MHL intervention effects are inconsistent and unsustainable over time, and scholars have called for more theoretical work to address these limitations. The purpose of this theoretical review is to investigate how theory is utilized in MHL interventions, explore the interpersonal communication processes integrated in MHL interventions, and uncover the theoretical assumptions made in MHL interventions about interpersonal communication. We identified 27 articles for inclusion and utilized both content and interpretive analyses. Findings suggest that very few MHL interventions are based in theory; interpersonal communication is a central component within MHL programming; and numerous assumptions are made about interpersonal communication within MHL interventions that need to be addressed theoretically and empirically. Accordingly, we recommend that MHL intervention content and delivery practices are grounded in interpersonal communication theory related to disclosure and social support (seeking and provision). Additionally, teaching disclosure and social support skills may be a productive way for MHL interventions to help students build self-efficacy in communication about mental health for themselves and others.

Associations between mild depression and anxiety and physical inactivity among school-going Ugandan adolescents aged 14 to 17 years

Objective: The aim of this cross-sectional study was to investigate associations between physical activity levels and emotional and behavioural problems in school-going adolescents aged 14 to 17 years in Uganda. Methods: Two-hundred and five adolescents [median (interquartile range) age = 16.0 (1.0) years; female = 61.9%] completed the interviewer-administered Strengths and Difficulties Questionnaire (SDQ), Patient Health Questionnaire-9 (PHQ-9), the Generalised Anxiety Disorder-7 questionnaire (GAD-7), and the Physical Activity Vital Sign (PAVS) measure. Spearman’s rho correlations and Mann–Whitney U-tests were applied. Results: Among 205 adolescents, 97.1% were physically inactive (PAVS < 420min/week), while 64.4% reported either mild depressive (PHQ-9 ≥ 5) or anxiety (GAD-7 ≥ 5) symptoms. Higher PAVS scores correlated significantly with lower SDQ emotional problems (ρ = −0.23, p < 0.001), lower PHQ-9 (ρ = −0.26, p < 0.001), and lower GAD-7 (ρ = −0.22, p < 0.001) scores. Those with emotional problems (SDQ ≥ 5) (n = 86) were significantly less physically active than those without (n = 119) [30.0 (62.5) versus 60.0 (105.0) min/week, p < 0.001]. Those with depressive symptoms (PHQ-9 ≥ 5) were significantly less physically active than those without [35.0 (70.0) versus 60.0 (120.0) min/week, p < 0.001]. Conclusion: Physical inactivity and mental health problems are related important public health concerns in school-going adolescents in low-income countries such as Uganda. The efficacy and effectiveness of school-based mental health literacy programs, including physical activity promotion, should be explored in these low-resource settings.

School-Based Mental Health Literacy Educational Interventions in Adolescents: A Systematic Review

Background and Objective: Poor health literacy is a major obstacle to seeking help for health problems in adolescents. The purpose of this study was to investigate the effect of school-based educational interventions on improving health literacy (MHL) in adolescents.  Materials and Methods: In this study, a search was conducted in Scopus, PubMed, Web of Science, Google Scholar, Irandoc, Magiran, and SID databases in both Persian and English language for studies published from 2011 to 2021. The keywords adolescent, mental health literacy, depression literacy, intervention, education, and high school were searched in both languages. Out of 191 articles extracted and finally, 6 articles were included in this study.  Results: The results of the study conducted in Norway showed that the individualâ��s health literacy who participated in the all Mental Health program was significantly increased compared to those in the control group; findings of a study conducted in Australia reported that MHL in the intervention group was significantly higher than the control group after intervention (P <0.05). But, attitudes toward seeking help did not change. A Canadian study indicated that the health curriculum significantly increased health knowledge and reduced tagging (P <0.001); furthermore, an Iranian study demonstrated that the mean score of MHL in the intervention group was significantly increased compared to the control group after the educational intervention (P <0.001). In the study, which was conducted in the US, depressive literacy in the intervention group was significantly increased 4 months after the intervention. However, results of one study showed that education intervention is more effective than contact based intervention with an ill person (P <0.001).  Conclusion: Evidence highlights that although studies have used a variety of methods for adolescent health literacy interventions in schools, all studies have had a positive effect on health literacy. Given that studies used self-report assessment to measure MHL outcomes. Thus, coni¬�rmation of these i¬�ndings with objective tools is still needed.

Adaptation of a school-based mental health literacy curriculum: from Canadian to English classrooms.

School-based mental health literacy (MHL) interventions are increasingly trialled outside of the country in which they were developed. However, there is a lack of published studies that qualitatively explore their cultural adaptation. This study investigated the reasons for adaptations made and suggested to a Canadian MHL curriculum (The Guide) within the English school context. Semi-structured interviews were conducted with 11 school staff responsible for the planning and/or implementation of The Guide across three schools in the South East of England, as part of the Education for Wellbeing (EfW) feasibility study. Transcripts were analysed using a hybrid, deductive-inductive thematic analysis. Adaptations made and suggested included dropping and emphasising content, and adapting language, examples and references. Most adaptations were proactive and related to The Guide's implementation methods, including developing more interactive and student-led approaches. Staff Capacity and Expertise, Timetabling, and Accessibility of Resources were identified as logistical reasons for adaptations. Philosophical reasons included Consistency of Messages, Student Characteristics, Reducing Stigma and Empowering Students, National and Local Context, and Appropriate Pedagogic Practices. Overall, recommendations were for immediately implementable lesson plans informed by teachers' knowledge about best pedagogic practices in England. Adequate training, attended by both senior leadership and those implementing, was also emphasised. While ensuring that the core components are clear, MHL interventions should be developed with a necessary level of flexibility to accommodate contextual characteristics. Future research should ensure that adaptations are captured through process and implementation evaluations conducted alongside efficacy trials.

Experimental evaluation of a school-based mental health literacy program in two Southeast Asian nations.

Low mental health literacy (MHL) is a particular challenge in many low and middle-income countries (LMIC). School-based MHL programs hold promise to increase MHL but lack rigorous research assessing their effectiveness in LMIC. The present study evaluated a school-based MHL program, the "Mental Health & High School Curriculum Guide" ("The Guide"), implemented separately in two different contexts in Southeast Asia (Vietnam and Cambodia) following adaptations made by the research team. Participants were 80 teachers and 2,539 students from 20 schools in Vietnam (Study 1), and 67 teachers and 275 students in one school in Cambodia (Study 2). In Vietnam, teachers/classrooms were randomized to either The Guide MHL program or a treatment-as-usual control condition, with teachers in the intervention condition receiving a 3-day training in The Guide and implementing the 6-module curriculum in their classrooms. In Cambodia, school staff were randomized to either receive The Guide training or to the control condition; four teachers who received the training implemented the curriculum in select classrooms. In both studies, teachers' and students' mental health knowledge and attitudes were assessed at baseline and following completion of the classroom curriculum. In Vietnam, 6 of 7 program effects for teachers were significant with some large effects (e.g., teacher Recognition of Mental Health Disorders, R2=.36); effects for both of the student outcomes were significant, but small. Results were similar in Cambodia, with 6 of 9 program effects significant favoring the treatment group; effect sizes in Cambodia were smaller than in Vietnam for teachers/staff but larger for students. Findings suggest that with limited adaptation, a teacher-delivered MHL intervention can produce measurable increases in MHL among teachers and students in two Southeast Asian countries. These results support the value of school-based MHL training provided via an inexpensive and teacher-friendly program, embedding MHL into classrooms. Some small effect sizes suggest the importance of additional development and research targeting these particular components.

Assessing the Effectiveness of Teachers’ Mental Health Literacy Training in Cambodia: A Randomized Controlled Trial

School-based mental health literacy (MHL) programs are used to reduce stigma and promote help-seeking among students and teachers. This study aimed to adapt and evaluate a teacher-delivered MHL program in Cambodia, where the impact of MHL programs has not previously been evaluated. 67 teachers and 275 students from a high school in Phnom Penh voluntarily completed the study. School staff were randomly assigned, and classrooms purposively assigned, to either a 2-day MHL training program or a control condition. Four teachers in the intervention condition were also pragmatically selected to deliver a 6-week classroom MHL curriculum to students; these teachers receive an extra day of implementation training. Teacher and student MHL were assessed before and after the intervention. Results showed significant improvements in all indicators of teacher and student knowledge and attitudes about mental illness; largest improvements were in teachers’ perceptions of dangerousness and willingness to interact. This pilot RCT supports the potential benefits of school-based MHL training in Cambodia, where there is substantial mental health stigma and discrimination. However, small to moderate effect sizes, particularly for students outcomes, suggest a need for further refinement and testing of the curriculum to optimize impact, including further consideration of implementation strategies and supports.

A Missed Opportunity: Universal School-Based Mental Health Literacy Programs

A Missed Opportunity: Universal School-Based Mental Health Literacy Programs

Mental Health Literacy of Youth That Have a Family Member With a Mental Illness: Outcomes From a New Program and Scale

A program evaluation examined mental health literacy levels and coping outcomes for youth (ages 10–16), before and at the end of their participation in a manualized, school-based mental health literacy program called Youth Education and Support (YES). Most of the youth reportedly had a parent or other family member with a mental health disorder such as depression, anxiety, and/or substance abuse. The mental health literacy levels of program participants from pre to post were evaluated with the developing Knowledge of Mental Illness and Recovery (K-MIR) scale. This scale was validated using item-response theory, demonstrating good psychometric properties. Youth answered two coping questions about their use of positive coping during the program and coping skills compared from pre to post intervention. Findings revealed that youth levels of mental health literacy increased significantly from pre to post program participation. Over 90% of the youth reported an improved use of positive coping strategies from pre to post intervention. The program appeared to deliver enhanced levels of literacy and coping for this sample of youth. The scale appeared to be appropriate to measure youth mental health literacy. Recommendations for practice, policy, and research are offered.

Is It Possible to "Find Space for Mental Health" in Young People? Effectiveness of a School-Based Mental Health Literacy Promotion Program.

Lack of knowledge regarding, and the stigma associated with, mental disorders have been identified as major obstacles for the promotion of mental health and early intervention. The present study aimed to evaluate the effectiveness of a school-based intervention program focused on the promotion of mental health literacy (MHL) in young people (“Finding Space for Mental Health”). A sample of 543 students (22 classes), aged between 12 and 14 years old, participated in the study. Each class of students was randomly assigned to the control group (CG; n = 284; 11 classes) or the experimental group (EG; n = 259; 11 classes). MHL was assessed using the Mental Health Literacy questionnaire (MHLq), which is comprised of three dimensions—Knowledge/Stereotypes, First Aid Skills and Help Seeking, and Self-Help Strategies. The scores on these dimensions can also be combined to give an overall or total score. Participants from the EG attended the MHL promotion program (two sessions, 90 min each) delivered at one-week intervals. Sessions followed an interactive methodology, using group dynamics, music, and videos adapted to the target group. All participants responded to the MHLq at three points in time: pre-intervention assessment (one week prior to the intervention), post-intervention assessment (one week after the intervention) and follow-up assessment (six months after the intervention). The intervention effectiveness and the differential impact of sociodemographic variables on the effectiveness of the program were studied using a Generalized Estimation Equation (GEE). Results revealed that participants from the EG demonstrated, on average, significantly higher improvement in MHL from pre-intervention to follow-up when compared to participants from the CG. Different sociodemographic variables affected the effectiveness of the program on distinct dimensions of the MHLq. Overall, “Finding Space for Mental Health” showed efficacy as a short-term promotion program for improving MHL in schools.