Introduction
The Universal Mental Health Training for Frontline Professionals (UMHT) was developed in Ukraine1 as an educational programme for police officers, emergency responders, social workers, educators, pharmacists, priests, and other professionals on the first line of service to the general public (Gorbunova et al., 2024). Whereas their professional roles often imply working with people in difficult or unstable life circumstances, a high level of mental health awareness and skills to manage mental health issues are essential. The UMHT aims to equip frontline professionals with knowledge and skills to deliver evidence-based responses to the mental health needs of the population they serve.
The feasibility of such public health programmes as the UMHT is one of the primary requirements for their implementation (Bowen et al., 2009). In every case, a feasibility study answers whether an intervention is appropriate for further development, testing and implementation and identifies if anything needs modification and adjustments. According to the Framework for the Development and Evaluation of Complex Interventions issued by the National Institute for Health and Care Research (NIHR), research-driving policymaking implies feasibility and pilot trials as steps taken immediately after intervention development prior to effectiveness evaluation (Skivington et al., 2021).
Among examples of widespread public mental health programmes for which the feasibility analysis was done in different settings are Psychological First Aid / PFA (Brown et al., 2009; Chandler et al., 2023; Geoffrion et al., 2023) Mental Health First Aid / MHFA (Crooks et al., 2018; Narayanasamy et al., 2018) and Mental Health Gap Action Programme / mhGAP (Mutiso et al., 2019a; Mutiso et al., 2019b; Siddaiah et al., 2022). The main idea of the mentioned studies was to predict the future success of an intervention or to assess the current situation with its implementation in different populational or professional groups, in different countries and under different circumstances. Some studies focused on the feasibility of programme modifications, such as its transition into e-format or cultural adaptation. All measurements of feasibility analyses usually fall into two broad categories: 1) the feasibility of an intervention itself as its ability to be successful in terms of technical and content features and 2) the feasibility of an intervention’s implementation and maintenance in the real world with its risks and unpredictabilities.
Keeping in mind the fact that public MH intervention is not just a scientific product but a scientific product for wide public usage, often linked to policymaking, it needs to be feasible in terms of design and technical features, operational strategy, and finance model, together with established risk management measures. Such qualities let a programme be considered in the public health domain as an instrument able to bridge the gap between a population’s needs and the society's responses.
The present study aims to assess the feasibility of the UMHT as a public mental health promotion and prevention intervention. Feasibility is determined based on various aspects such as UMHT’s demand as well as users’ satisfaction and programme potential to be adjustable for different groups of frontline professionals and to be open to modifications due to design and content features.
Research questions
1. Demand: to what extent is the UMHT likely to be used?
2. Acceptability: to what extent is the UMHT suitable, satisfying and attractive to programme deliverers and recipients?
3. Adaptability: to what extent is the UMHT suitable for adjusting content and procedure to new formats and working with different population groups?
4. Extendability: to what extent can the UMHT be expanded to cover new topics and solve new problems?
Methods
UMHT dissemination and participants
UMHT delivery and data collection was made in Ukraine in collaboration with a team of academics from Zhytomyr State University with support of the “Mental health for Ukraine Project” (MH4U), implemented in Ukraine by GFA Consulting Group GmbH.
The UMHT was disseminated by the Training of Trainers (ToT) approach, highlighted in the mhGAP Operation Guide (WHO, 2018). To assess the feasibility of the UMHT, we surveyed the satisfaction and usability of the programme, its trainers (mental health professionals trained to deliver the UMHT to different groups of frontline professionals), and its recipients, i.e., frontline professionals (FLPs). We analysed the answers of 144 UMHT mental health professionals intended to become UMHT trainers and those of 714 frontline professionals (n = 203 social workers), educators (n = 152), police officers (n = 122), employees of occupation centres (n = 58), emergency responders (n = 52), military volunteers (n = 34), pharmacists (n = 37), librarians and museum workers (n = 29), priests and clerics (n = 27).
To find out which set of mental conditions should be included in the programme for every particular group of FLPs, we run preliminary interviews on age, typical communication pass way, widespread problems and other features of people with whom FLPs work. The distribution of mental health conditions (training modules) with numbers of trained FLPs whose answers were taken into the analysis is reflected in Table 1.
Table 1. Distribution of mental health conditions (training modules) and N of trainees in the trained groups of frontline professionals.
Groups of frontline
professionals | educators | emergency responders | librarians and museum
workers | military volunteers | pharmacists | police officers | priests and clerics | social workers | employees of
occupation centres | Total |
|---|
Mental health conditions
(training modules) |
|---|
attention-deficit / hyperactivity
disorder | 75 | | 14 | | | | | 28 | | 117 |
| autism spectrum disorder | 78 | | 15 | | | | | 36 | 29 | 158 |
| delirium | | 24 | | 14 | | 44 | | 27 | | 109 |
| depressive disorder | 43 | | 29 | | 18 | | 27 | 59 | 29 | 205 |
disruptive, impulse-control, and
conduct disorders | 35 | | 14 | | | 44 | | 52 | | 145 |
| elimination disorders | 25 | | | | | | | | | 25 |
| feeding and eating disorders | 34 | | | | | | | | | 34 |
| gambling disorder | | | | 20 | | 30 | | | 29 | 79 |
| illness anxiety disorder | | | | | 37 | | | 71 | 29 | 137 |
| intellectual disability | 36 | | 15 | | | 15 | 27 | 100 | 29 | 222 |
| neurocognitive disorders | | | | | 20 | | | 44 | | 64 |
| panic disorder | 39 | 28 | | 34 | 37 | 15 | 27 | 57 | | 237 |
| post-traumatic / acute stress disorder | 18 | 52 | | 34 | 34 | | 54 | | | 192 |
| separation anxiety disorder | 50 | | | | | | | | | 50 |
| sleep-wake disorders | 17 | | | 28 | 37 | | 27 | 23 | | 132 |
| social anxiety disorder | 43 | | | | | | | 39 | 29 | 111 |
| specific phobias and agoraphobia | 17 | | | | 36 | | | 34 | | 87 |
| substance-related disorders | 53 | 28 | | 68 | | 14 | 54 | | 58 | 275 |
| aggressive behaviour | | | | | | 78 | | | | 78 |
| self-harm behaviour | | | | | | 80 | | | | 80 |
| suicide & life-threatening behaviour | | | | | | 63 | | | | 63 |
| unusual & disorganized behaviour | | | | | | 126 | | | | 126 |
| Total | 563 | 132 | 87 | 198 | 219 | 509 | 216 | 570 | 232 | 2726 |
Research methods and measurements
To answer the research questions, we carried out an analysis of various feasibility focus areas. The demand, acceptability, adaptability and extendability were assessed during the pilot roll-out in 2021-2023 in eight regions of Ukraine (Kyiv, Lviv, Rivne, Chernivtsi, Dnipro, Luhansk, Donetsk, and Zhytomyr oblasts), mainly through satisfaction and usability surveying of programme trainers and trainees (FLPs of different groups). A summary of the research methods and measurements is presented in Table 2.
Table 2. Research methods and measurements.
UMHT’s
feasibility
focus areas | Measurements | Research methods |
|---|
| Demand | Actual use of the programme | Usability statistic |
| Acceptability | Training content and delivery
satisfaction for trainers and FLPs | Satisfaction surveying, accreditation
structured assessment |
| Adaptability | Usability of the programme by
different groups of FLPs | Usability surveying, supervision
reports evaluation, case comparison |
| Extendability | Usability of the new modules
(mental health crisis) | Usability surveying, supervision
reports evaluation, case comparison |
To assess the programme demand, we measured the actual use of the programme with statistics on the number of trainings conducted with donor support in terms of organisation and financing and independently on request of different organisations.
As the programme acceptability measurement, we chose training content and delivery satisfaction by its trainers as deliverers and FLPs as its recipients through satisfaction surveying. All audiences were asked to assess on the 5-grade scales (ranging from 1 to 5) whether training materials were structured and transparent, whether the balance between theory and practice was kept, whether there were enough examples and explanations, whether answers to participants’ questions were full and clear; whether trainers were careful of sensitive topics and mindful of stigma and whether presentations and following material were of high quality and perceptibility.
The same rating scale was applied for self-assessing the ToT participants' post-training boost of preparedness to lead UMHT in terms of knowledge, skills and general readiness: "My understanding of the topic of interactions with people with MH issues has increased"; "My skills to lead UMH training and supervisions was mastered"; "My readiness to lead UMH training and supervisions has increased". FLPs assessed their subjective preparedness to interact with people with MH conditions with the questions: "My understanding of the topic of interactions with people with MH issues has increased"; "My skills to interact with people with MH issues was mastered; "My readiness to work with people with MH issues has increased".
Also, future trainers and FLPs were asked to name knowledge and skills they would like to strengthen and suggest changes in the training materials and process to improve it. Additionally, data from the accreditation assessment of UMHT trainers' knowledge and skills observed in the process of training delivery was taken into account. In particular, we assessed subject knowledge, organisational skills, instrumental skills, motivational skills, and ethical skills.
The adaptability of the programme was measured through its comparative usability among different groups of FLPs, specifically with questions: “Did you work with people with mental conditions after the UMHT?”; “Did you use the knowledge and skills gained during the UMHT?”; “If yes, what knowledge and skills gained during the UMHT you were able to use?” The list of knowledge and skills consists of those needed on each step of the UMHT model and purposely targeted during the training: recognise MH conditions, validate MH conditions with a person / their caregivers, support a person, refer for professional help, and ensure the reference was successful.
Additional information, such as the content of supervision requests from the UMHT trainers, was derived from supervision reports. In general, there were six possible types of supervision: organisational supervision (issues related to the organization of the training process and supervision of training participants), content-related supervision (issues related to the need to expand/deepen knowledge about a specific disorder or other training topic), instrumental supervision (issues related to the need to practice specific skills to lead training), navigational supervision (issues related to the need for additional motivation of participants, management of difficult situations, conflict-solving), technical supervision (issues related to the use of digital applications during training and other technical aspects), motivational supervision (questions related to psychological readiness to lead training, burnout and general need for support).
The comparative usability for modules centred on MH (mental health) disorders and newly developed modules centred on mental health crises (aggressive behaviour, self-harm behaviour, suicide and life-threatening behaviour, unusual and disorganized behaviour) was used as the extendability measurement of the UMHT.
Data analysis
The data analysis was performed using JASP 0.14.3 (GNU Affero GPL v3, open-source license). Descriptive statistics (mean, standard deviation, frequency analysis) were used to describe the general results. The nonparametric Kruskal-Wallis one-way ANOVA was used to analyse multiple differences between independent samples, including Dunn`s Post Hoc Test. The Shapiro-Wilk test was used to analyse the normality of distributions.
Ethics
All participants gave written informed consent to participate in the study. The research team adhered to the Declaration of Helsinki and Model Code of Ethics of the European Federation of Psychologists Associations (EFPA), the Code of Ethics of the National Psychological Association of Ukraine, a member of the EFPA, Inter-Agency Standing Committee (IASC) Recommendations for Conducting Ethical Mental Health and Psychosocial Research in Emergency Settings and British Educational Research Association (BERA) Ethical Guidelines for Educational Research.
The UMHT delivery and data collection protocol was approved by the Ethics Committee of the Zhytomyr Ivan Franko State University (registered in the Office for Human Research Protections), approval number 01–2905/2020 (29 May 2020). The confirmation of compliance with Ukrainian legislation was issued by the Ethics Committee of the National Psychological Association of Ukraine (member of EFPA).
Results
To assess the programme demand, we measured its actual use in 2021–2023 based on statistics gathered by the MH4U Project, its subcontractor, the NGO2 For Life, responsible for conducting the Trainings of Trainers and trainers’ accreditation and partner organisations supporting the UMHT implementation (Table 3 and Table 4).
Table 3. Statistics on actual use of the UMHT ToTs*.
| Years | UMHT ToTs
(events / persons) | Donors and supporters |
|---|
| 2021 | 1 | 35 | MH4U Project, Ministry of Health |
| 2022 | 1 | 22 |
| 2023 | 4 | 113 |
| 1 | 19 | MH4U Project, Zhytomyr State University |
| 1 | 15 | German Corporation for International
Cooperation |
| 13 | 30 | Friedrich Naumann Foundation for
Freedom |
| 14 | 20 | UNDP Turkmenistan, Ashgabat |
| Total | 10 | 254 | 6 |
Table 4. Statistics on the actual use of the UMHTs.
| Years | UMHTs (events / trained persons) | Donors and supporters | Implementers | Region |
|---|
| 2021 | 12 | 305 | MH4U Project | NGO Mental Health Support | Lugansk, Donetsk |
| 15 | 291 | NGO DeStigma | Lviv |
| 27 | 596 | 1 | 2 | 3 |
| 2022 | 3 | 68 | MH4U Project | NGO Mental Health Support | Lugansk, Donetsk |
| 5 | 101 | NGO DeStigma | Lviv |
| 5 | 96 | NGO "Nevermind" | Chernivtsi |
| 8 | 142 | NGO Mental Health Service | Rivne |
| 2 | 60 | IREX5, Ministry of Social
Affairs, Ministry of Veterans | IREX Ukraine, NGO VeteranHub | Kyiv |
| 1 | 30 | Vinnytsia |
| 1 | 30 | Dnipro |
| 1 | 25 | Uzhhorod |
| 2 | 50 | Lviv |
| 1 | 18 | Ternopil |
| 1 | 25 | Khmelnytskyi |
| 2 | 52 | Without donor support | NGO Healthy Child Space | Rivne |
| 1 | 23 | Pidhorodne City Council,
NGO Source of Support | Dnipro |
| 2 | 59 | NGO Here and Now, Bukovinian State Medical
University | Chernivtsi |
| 35 | 779 | 4 | 10 | 11 |
| 2023 (QI-QIII) | 18 | 170 | MH4U Project | NGO Embrace | Kyiv |
| 10 | 205 | NGO Analytical Platform | Dnipro |
| 13 | 181 | NGO "Nevermind" | Chernivtsi |
| 18 | 365 | NGO Space of your possibilities | Rivne |
| 3 | 75 | Chervonograd Centre of Social Services | Lviv |
| 3 | 75 | Zhytomyr RMA6, Olena
Zelenska Foundation | Zhytomyr State University | Zhytomyr |
| 2 | 20 | GIZ | NGO Vzaemodia | Zaporizhzhia |
| 1 | 10 | FLC | NGO Women's Information Consultative Center | Zhytomyr |
| 9 | 230 | FNF | NGO SmartOsvita | Online for all regions |
| 1 | 30 | IREX, Ministry of Social
Affairs, Ministry of Veterans | IREX Ukraine | Zhytomyr |
| 1 | 30 | Rivne |
| 1 | 30 | Poltava |
| 1 | 30 | Ivano-Frankivsk |
| 2 | 20 | Without donor support | NGOs New social vector, Ukrainian Institute of Anti-
Crisis Management | Kyiv |
| 1 | 5 | NGO MARTIN-club | Dnipro |
| 1 | 11 | Red Cross Ukraine | Rivne |
| 2 | 20 | Department of Education of Zhytomyr City Council | Zhytomyr |
| 1 | 11 | Community Development Fund "Initiative" | Poltava |
| 2 | 30 | NGOs Proliska, Life is | Online for all regions |
| 90 | 1548 | 9 | 18 | 9 + 2 online for all
regions |
| Total | 152 | 2923 | | | |
Within the frame of the original programme, eight training events for trainers were conducted during 2021–2023 (QI-QIII). Among them, six trainings were solely supported by the MH4U Project (170 persons engaged), one in collaboration with a local university in the frame of a master programme (19 persons) and one by the German development agency GIZ (15 persons). Two more trainings for trainers were developed and conducted with a modified version of the programme but with its core 5-step interaction model for Ukrainian teachers (30 persons) and Turkmen MHPSS workers (20 persons).
The UMHT implementation during 2021–2022 covered 15 Ukrainian regions with the biggest numbers of trainees in Lugansk & Donetsk (373), Lviv (517) and Rivne (600). 138 training events were conducted with support from the different donors, while 14 trainings (from data we were able to reach) were run by trainers either voluntarily or with payments from organisations which ordered the training. Altogether, 2923 frontline professionals combined into 152 training groups received skills and knowledge on interaction with people with mental health conditions through the UMHTs. Each year, the number of trained FLPs increased (596 in 2021, 779 in 2022, 1546 in I-III quarters of 2023), as well as the number of donors and supporters (1; 4; 9).
To implement the UMHT in Ukraine, the MH4U Project contracted eight NGOs working in the mental health field during 2021–2023. Besides the MH4U’s disseminating strategy, UMHT was implemented by four NGOs with support from other international donors (IREX7, GIZ8, FNF9, FLC10). Alongside international support, the UMHT and the UMHT-based programmes were funded by the Olena Zelenska Foundation and supported by the Ministry of Health, Ministry of Veterans and Ministry of Social Affairs. Additionally, in the process of the UMHT dissemination, around 10 NGOs, two city councils, and two state universities were engaged.
With the aim to understand the acceptability of the UMHT, we measured the satisfaction with training content and delivery as well as a post-training boost of preparedness to lead the UMHT for its trainers and the preparedness to interact with people with MH conditions for the trained frontline professionals (Table 5). The detailed descriptive statistics are available in the Extended Data (Table 1–Table 4) (Gorbunova & Klymchuk, 2024).
Table 5. Satisfaction with UMHT content, delivery and preparedness to lead the UMHT (for UMHT trainers) / to interact with people with mental health conditions (for trained FLPs)*.
| UMHT ToT
participants | UMHT
participants |
|---|
Mean
(0 to 5) | SD | Mean
(0 to 5) | SD |
|---|
| Satisfaction with UMHT content and delivery |
| Training material was structured and clear | 4.910 | 0.311 | 4.791 | 0.511 |
| Balance between theory and practice was kept | 4.806 | 0.477 | 4.769 | 0.525 |
| There were enough examples and explanations | 4.681 | 0.563 | 4.742 | 0.561 |
| Answers to participants’ questions were full and clear | 4.701 | 0.543 | 4.739 | 0.557 |
| Trainers where careful of sensitive topics and mindful of stigma | 4.903 | 0.297 | 4.864 | 0.423 |
| Presentations and following material were high quality and perceptibility | 4.840 | 0.453 | 4.800 | 0.503 |
| Satisfaction mean | 4.807 | 0.291 | 4.784 | 0.434 |
| Preparedness to lead UMHT (for trainers) / to interact with people with mental health conditions (for FLPs) |
My understanding of the topic of interactions with people with MH issues
has increased | 4.715 | 0.550 | 4.573 | 0.652 |
My skills to lead UMH trainings and supervisions was mastered / My skills
to interact with people with MH issues was mastered | 4.410 | 0.596 | 4.366 | 0.767 |
My readiness to lead UMH trainings and supervisions has increased / My
readiness to work with people with MH issues has increased | 4.597 | 0.571 | 4.429 | 0.768 |
| Preparedness mean | 4.574 | 0.438 | 4.456 | 0.650 |
Means for general satisfaction with trainings content and delivery is high in both groups (4.807 [0.291] for UMHT trainers; 4.784 [0.434] for trained FLPs) with a bit lower rate for satisfaction with number of examples and explanations (4.681 [0.563]; 4.742 [0.561]) and answers to participants’ questions (4.701 [0.543]; 4.739 [0.557]). Level of the preparedness to perform the duties participants were trained also is high but lower in comparison with training satisfaction (4.574 [0.438], 4.456 [0.650]). Also, in both cases, higher grades received preparedness in terms of knowledge (4.715 [0.550]; 4.573 [0.652]) and lower grades – preparedness in terms of skills (4.410 [0.596]; 4.366 [0.767]).
Regarding knowledge and skills, the FLPs would like to strengthen in order to interact with people with MH conditions; they mentioned the need to practice everything gained during the training in real workplace situations. Also quite common was a desire to dive deeper into mental health topics and have more information (“learn more psychological stuff”, “know symptoms better”, “to distinguish different kinds of MH conditions”, “how to work with parents of children with MH disorders”). Personal stress resistance, self-care, resilience, emotional stability, and resourcefulness were also named. There were also several feedbacks with unwillingness, caution or worries toward interaction and support for people with MH issues (“I am not sure I am ready”, “I am afraid but willing to try”, “I would like to meet less of such cases”).
Among the skills the UMHT trainers named as those they would like to master more mainly are technical and organisational skills needed to conduct training remotely (e.g., “use different e-applications”; “trainer skills to organise group work online”, “manage difficult situations online”, “work with resistance and group dynamic without being in one physical space”) as well as skills required to lead discussion and answer difficult questions (“readiness to solve difficult situation”; “communicative skills”, “skills to set limits for discussion”). As for necessary knowledge, the trainers mentioned a deeper understanding of some MH conditions (“epidemiology of MH disorders”, “to renew knowledge about MH conditions I am not used often to work with”, “differential diagnostic of MH disorders”).
The main suggestions from both surveyed audiences were to have more time to practice and more particular examples; those trained remotely were often asking to switch to the offline format.
The averaged data from the accreditation assessment of the UMHT trainers’ knowledge and skills observed in the process of training delivery to the different groups of the FLPs show the lowest means exact for the subject knowledge (3.207 [1.090]) and the highest for the ethical skills (3.915 [0.661]). Table 6 shows generalized results for 41 trainers who have undergone the accreditation process, with only 26 persons passing it successfully with an overall and every-skill grade equal to or above 3.5 (Table 6). The detailed descriptive statistics are available in the Extended Data (Table 5) (Gorbunova & Klymchuk, 2024).
Table 6. Accreditation assessment of UMHT trainers’ knowledges and skills (0 to 5).
| Subject knowledge | Organisational skills | Instrumental skills | Motivational skills | Ethical skills | Skills & Knowledge means |
|---|
| Mean | 3.207 | 3.671 | 3.720 | 3.646 | 3.915 | 3.632 |
| SD | 1.090 | 1.058 | 0.837 | 0.785 | 0.661 | 0.699 |
With the aim of assessing the adaptability of the UMHT to the needs of different frontline professionals, we compared the usability of the programme by different professional groups (Table 7). The highest generalized usability means have educators (0.676 [0.118]), police officers (0.669 [0.098]) and social workers (0.663 [0.113]); lowest – librarians & museum workers (0.578 [0.127]) and emergency responders (0.580 [0.134]). Post Hoc Dunn tests for the same generalized data show significant differences for the mentioned groups with high-low usability means: educators and emergency responders (4.709 [p < 0.001]); educators and librarians & museum workers (4.031 [p < 0.001]; police officers and emergency responders (4.166 [p < 0.001]); police officers and librarians & museum workers (3.631 [p < 0.001]); social workers and emergency responders (4.121 [p < 0.001]); social workers and librarians & museum workers (3.533 [p < 0.001]). The detailed descriptive statistics are available in the Extended Data, Table 6 (Gorbunova & Klymchuk, 2024).
Table 7. Usability of the UMHT by different groups of the FLPs* (0 to 1).
| educators | emergency
responders | librarians &
museum workers | military volunteers | pharmacists | police officers | priests and clerics | social workers | employees of
occupation centres |
|---|
| Recognise (means) | 0.919 | 0.841 | 0.853 | 0.934 | 0.912 | 0.947 | 0.972 | 0.933 | 0.901 |
| SD | 0.167 | 0.267 | 0.263 | 0.142 | 0.147 | 0.141 | 0.106 | 0.181 | 0.224 |
| Validate (means) | 0.842 | 0.817 | 0.776 | 0.926 | 0.905 | 0.869 | 0.935 | 0.872 | 0.819 |
| SD | 0.235 | 0.314 | 0.343 | 0.116 | 0.190 | 0.251 | 0.215 | 0.259 | 0.272 |
| Support (means) | 0.568 | 0.500 | 0.503 | 0.512 | 0.573 | 0.567 | 0.570 | 0.526 | 0.517 |
| SD | 0.216 | 0.215 | 0.182 | 0.185 | 0.227 | 0.231 | 0.190 | 0.206 | 0.168 |
| Refer (means) | 0.454 | 0.378 | 0.391 | 0.373 | 0.414 | 0.418 | 0.309 | 0.433 | 0.414 |
| SD | 0.286 | 0.272 | 0.296 | 0.243 | 0.277 | 0.259 | 0.225 | 0.260 | 0.295 |
| Ensure (means) | 0.596 | 0.365 | 0.368 | 0.529 | 0.387 | 0.544 | 0.506 | 0.552 | 0.489 |
| SD | 0.308 | 0.258 | 0.224 | 0.248 | 0.319 | 0.243 | 0.283 | 0.263 | 0.281 |
| Total (means) | 0.676 | 0.580 | 0.578 | 0.655 | 0.638 | 0.669 | 0.659 | 0.663 | 0.628 |
| SD | 0.118 | 0.134 | 0.127 | 0.086 | 0.097 | 0.098 | 0.094 | 0.113 | 0.099 |
| Did you work11… | 0.980 | 0.904 | 0.862 | 1.000 | 1.000 | 0.975 | 1.000 | 0.966 | 0.983 |
| SD | 0.140 | 0.298 | 0.351 | 0.000 | 0.000 | 0.156 | 0.000 | 0.183 | 0.131 |
| Did you use12… | 0.967 | 0.942 | 0.966 | 1.000 | 1.000 | 0.992 | 1.000 | 0.990 | 0.983 |
| SD | 0.179 | 0.235 | 0.186 | 0.000 | 0.000 | 0.091 | 0.000 | 0.099 | 0.131 |
As for the separate scales, the biggest number of significant intergroup differences according to ANOVA and Dunn`s Post Hoc tests is observed for the question “Did you work with people with mental disorders after the UMHT?” for librarians & museum workers and such FLPs as educators (-3.301 [p < 0.001], military volunteers (-3.088 [p = 0.002]), pharmacists (-3.148 [p = 0.002]), police officers (-3.105 [p = 0.002]), priests & clerics (-2.919 [p = 0.004]), social workers (-2.949 [p = 0.003]) and employees of occupation centres (-3.003 [p = 0.003]) where in each case lowest means are attributed to librarians & museum workers (0.862 [0.351]).
As for the ability to recognize MH condition, Post Hoc Dunn tests show significant differences between emergency responders and such groups as social workers (-3,382 [p < 0.001]), police officers (-3,151 [p = 0.002]) and priests & clerics (-3,059 [p = 0.002]). The most significant differences in the abilities to validate MH condition with a person and to refer for professional help were found between educators and priests & clerics (-2,645 [p = 0.008]). As for the ability to ensure that professional help was reached there are significant differences between educators and such FLPs as emergency responders (4.982 [p < 0.001]), librarians & museum workers (4.080 [p < 0.001]), pharmacists (3.719 [p < 0.001]); emergency responders and military volunteers (-2.687 [p = 0.007]), police officers (-3.788 [p < 0.001]), social workers (-4.306 [p < 0.001]) and finally police officers and librarians & museum workers (3.165 [p = 0.002]).
Considering averages (Table 7), less used among all the groups are knowledge and skills connected with the abilities to refer and be sure that professional help was reached. The detailed results of the ANOVA and Dunn's Post Hoc tests for all variables are available in Tables 7-22 in the Extended Data (Gorbunova & Klymchuk, 2024).
The supervisor reports analysis of 73 supervisions of the UMHT trainers with the requests derived from their work with educators (19 groups); police officers, emergency responders & military volunteers (24), social workers (25) and other FLPs (employees of occupation centres (2), librarians & museum workers (1), priests & clerics (1); pharmacists 5) shows highest demand of navigational (35.62 %) and organisational (30.14 %) supervisions (Figure 1).
Figure 1. Supervision reports analysis.
The extendability of the UMHT was measured through a comparison of programme usability by FLPs who were trained and then worked with only disorder-centred modules (636 persons), only with the newly developed modules for the interaction with people with four different mental health crisis behaviours (63) and with both modules, disorders and crises-centred (15) (Table 8).
Table 8. Usability of UMHT with different combination of the training modules.
| Crisis (n=636) | Disorders
(n=63) | Crises
& Disorders (n=15) |
|---|
| Means | SD | Means | SD | Means | SD |
|---|
| Recognise | 0.952 | 0.099 | 0.917 | 0.191 | 0.950 | 0.140 |
| Validate | 0.929 | 0.171 | 0.854 | 0.258 | 0.800 | 0.302 |
| Support | 0.546 | 0.228 | 0.542 | 0.209 | 0.507 | 0.183 |
| Refer | 0.455 | 0.226 | 0.415 | 0.274 | 0.444 | 0.300 |
| Ensure | 0.534 | 0.243 | 0.521 | 0.287 | 0.533 | 0.169 |
| Total | 0.683 | 0.084 | 0.650 | 0.115 | 0.647 | 0.142 |
| Did you work… | 1.000 | 0.000 | 0.965 | 0.183 | 0.933 | 0.258 |
| Did you use… | 1.000 | 0.000 | 0.980 | 0.142 | 1.000 | 0.000 |
According to the obtained data, there is only one significant intergroup difference between FLPs who studied only disorders and only crises for validation MH conditions (Post Hoc Dunn tests 2,185 [p = 0.029]). Detailed descriptive statistics are available in the Extended Data, Table 23 (Gorbunova & Klymchuk, 2024). The detailed results of the ANOVA and Dunn`s Post Hoc tests for all variables are available in Tables 24–38 in the Extended Data (Gorbunova & Klymchuk, 2024).
Discussion
Demand: to what extent is the UMHT likely to be used?
Numbers on the actual use of the UMHT for different groups of FLPs are direct evidence of its demand. Based on reachable data, during 2021-2023 were conducted 152 UMHTs with 2923 persons involved. Every year, the number of events (27, 35, 90), trained FLPs (595, 779, 1548), donors & supporters (1, 4, 9) and implementers (2, 10, 18) grows. Despite decreased training events in the first half-year of 2022 because of the full-scale Russian invasion, demand for the UMHT stabilised and increased. The UMHT dissemination has gained support from new international donors and community-based stakeholders such as city councils, local NGOs, and universities. The Zhytomyr State University has even included the UMHT in the learning curriculum for the Master's Programme in Public Mental Health.
The demand for public mental health prevention programmes is rarely assessed, mainly because of their on-demand development, when a programme is an answer to population needs.
For example, the PFA as a crisis response approach was developed in the so-called post-9/11 era as a quick and effective tool to reduce trauma-related stress, and shortly after, it was included in international treatment guidelines for PTSD and as an early intervention and adopted by such humanitarian organisations as International Federation of Red Cross and Red Crescent Societies (Shultz & Forbes, 2014). There is only a few feasibility research on the FPA demand, for example, among police officers exposed to traumatic events and healthcare workers during the COVID-19 pandemic, where demand was estimated through the programme's capacity to meet the needs of its beneficiaries based on participants' interviews in the first case and on the expression of interest to participate in the programme in the second (Chandler et al., 2023; Geoffrion et al., 2023).
The MHFA started as a workplace-focused intervention to help depressed employees and, in the first place, was run voluntarily by its developers as a service to the local community. The programme evolved into a global movement with a well-established delivery system with 30 licensed providers in 29 countries supported by politicians and celebrities (Kitchener & Jorm, 2008).
The mhGAP Programme was launched, promoted and implemented with the support of WHO regional offices in over 100 countries in response to the gap between the available and needed resources to address the burden of mental disorders in low- and middle-income countries (Hughes & Thomson, 2019; Mills & Hilberg, 2019). The programme follows a detailed guide for implementation, starting from establishing the implementation team and ending with a thorough monitoring and evaluation process (Spagnolo & Lal, 2021).
The UMHT was also developed on demand by a number of stakeholders on different levels, including the Ukrainian ministries of Health, Veterans Affairs, and Social Policy.
The Ministry of Health of Ukraine approved the UMHT and added institutional certification for ToT trainers. The Ministry of Veterans includes the UMHT in the Recommendation guide for the local authorities, "Psychosocial Assistance to War Veterans and Members of their Families" (Ministry of Veterans Affairs of Ukraine, 2021).
The UMHT 5-step model became a base for the IREX Ukraine Veteran Reintegration Programme "Strengthening the Capacity of Social Workers to Provide Mental Health Support for Veterans and their Families" which was implemented in cooperation with the Ministry of Social Policy of Ukraine. The manual for this programme has been viewed over 60,000 times online and requested by over 650 social workers, psychologists, and teachers (IREX, 2022). The biggest Ukrainian NGO, SmartOsvita, working in the field of school education, launched an UMHT-based training programme, “Psychosocial Support for Educators”13, with the plan to engage around 1000 schoolteachers by the end of 2023.
One more adaptation of the UMHT 5-step model was done on request of the UNDP Turkmenistan office to prepare local trainers in the context of MHPSS and peacebuilding.
Such support from different players, as well as adaptation and dissemination even beyond primary schema are sufficient evidence of the programme demand.
Acceptability: to what extent is the UMHT suitable, satisfying and attractive to programme deliverers and recipients?
To answer research question of acceptability, we underwent surveying of two main audiences: programme trainers as its deliverers and frontline professionals as its recipients. In both cases satisfaction with training content and delivery is highly sufficient (4.807 [0.291] for UMHT trainers; 4.784 [0.434] for trained FLPs). It is essential to mention that every satisfaction measurement remained stable in the transition from the UMHT trainers to trained FLPs; this speaks in favour of the proposed ToT model and supervision.
However, either UMHT trainers and FLPs would like a bit more clarity and completeness from trainers’ side in answers to their questions and suggest paying more time and attention to practice and examples. The issue with perceived lack of practise and due to it needed skills is also reflected in scoring of personal preparedness to preform expected duties after training. Being in average high for both groups (4.574 [0.438], 4.456 [0.650]) it shows lower grades in terms of skills (4.410 [0.596]; 4.366 [0.767]) in comparison to knowledge preparedness (4.715 [0.550]; 4.573 [0.652]).
It is a typical case when knowledge is the first takeaway from skills-oriented training, as in the instance with the feasibility assessment of FMHA for indigenous peoples in Canada, where the participants emphasised an increase in mental health knowledge as one of the most valuable impacts from the training and the mhGAP feasibility study in India, where a significant increase in the mental health knowledge of healthcare workers was found as one of the main post-training results (Crooks et al., 2018; Siddaiah et al., 2022).
Reports of perceived practical skills being a bit behind the knowledge and general awareness are natural even after balanced training as people need first apply gained skills to real work-life as well as the need to feel resourceful (resilient, stable) to work with mental health topics. To support our UMHT trainers and frontline professionals, we implemented obligatory after-training supervision with the possibility of address any, even personal, issues connected with the UMHT.
To help the UMHT trainers to be more confident while conducting online training with FLPs, detailed instructions were developed on adapting the organisation process and every training exercise to remote mode. During supervision, each trainer could consult with the supervisor on using e-applications and other useful tools for e-learning facilitation. Supervision support was also offered to fill in knowledge gaps of some mental health conditions.
To maintain the quality of training delivery, an accreditation procedure was implemented as permission to enter practice as a UMHT trainer. Such a procedure was caused primarily by the results of the supervision assessment, when the average mean for UMHT trainers’ knowledge and skills was only 3.632 (0.699) out of 5, with the lowest grade for subject knowledge at 3.207 (1.090). To pass through accreditation, a trainer should score no less than 3.5 subject knowledge (how well a trainer knows the training material, is fluent in the topics, and gives correct and comprehensive answers to the questions of the participants); organisational skills (how effectively trainer organizes the process, keeps the timing); instrumental skills (how effectively trainer uses and applies training tools and techniques); motivational skills (how successfully trainer motivates the participants and how effectively works with resistance, complaints and other potential conflicts); and ethical skills (how ethical are trainer’s manner and behaviour in terms of supporting the dignity of the participants and being free of stigma and bias toward mental health, gender, age, profession etc.).
Adaptability: to what extent is the UMHT suitable for adjusting content and procedure to new formats and working with different population groups?
The main evidence of the UMHT adaptability is the high marks for its usability (max mean - 0.676 [0.118] for educators; min mean 0.578 [0.127] for librarians & museum workers) and more or less even distribution of trained skills utilisation among different groups of FLPs (e.g., for ability to recognise MH condition max average mean 0.972 [0.106] is shown for priests & clerics and min 0.841 [0.267] for emergency responders).
The between-group differences (see Extended Data, Table 6) (Gorbunova & Klymchuk, 2024) are well explained by specifics of the FLPs’ professional duties as well as the possibilities and limitations of their daily work. For example, the highest rates of the usability of all UMHT skills are reported by educators (0.676 [0.118]), police officers (0.669 [0.098]) and social workers (0.663 [0.113]) as professionals who have not just one occasional encounter but chances to return and see their clients again. Their answers differ from those of librarians & museum workers, and emergency responders, with average usability means of 0.578 (0.127) and 0.580 (0.134), respectively. The thinkable reasons for such a difference are a lower level of stress people experience visiting a library or museum that smoothens their behaviour in the first case and lack of time for interaction in the second. That is possibly why librarians and museum workers have less reason to speak about mental health despite having time to do so, while emergency responders, on the contrary, lack time to interact with people; however, they can see a lot of signs of mental difficulties. In addition to the lower average usability, data on librarians and museum workers shows that they do not meet people with MH difficulties as often as other FLPs, especially educators, police officers, social workers, military volunteers, pharmacists, priests & clerics and employees of occupation centres.
There are intergroup differences between the separate skills. Thus, the ability to recognize MH condition is less usable by emergency responders who servantly have less time and space to observe people's reactions and behaviour in comparison with social workers (-3,382 [p < 0.001]), police officers (-3.151 [p = 0.002]) and priests & clerics (-3.059 [p = 0.002]. The ability to validate MH condition is most usable by priests & clerics who, because of their duties, sort of, are permitted to speak about mental health; they significantly differ from educators (-2.645 [p = 0.008]) who can be perceived by students and caregivers as not right persons to share mental difficulties with. At the same time, educators are the ones who, most often in comparison with the majority of other studied FLPs, keep track if the referral was successful, probably because they are able to see and check their students on a regular basis.
Analysis of supervision requests from the UMHT trainers shows that the FLPs, first of all, need additional motivation to support people with MH conditions and skills to smooth interaction and prevent possible conflicts. Keeping in mind that among the skills that FLPs would like to strengthen, they often mention those connected with resilience that are not directly included in the UMHT, it is essential to have supervisor support as a mandatory part of the UMHT implementation.
Taking into account the similarity (but not sameness) of the skills trained in the UMHT and the MHFA programmes, it is possible to compare their usability from the side of people who intend to help others. Thus, the MHFA feasibility trial in the workplace in the UK shows high responses to the programme in higher education, construction/engineering and health sectors (Crooks et al., 2018). One more thing to distinguish is the trained audience. The FMHA is developed for peer-to-peer usage in the workplace when the UMHT trains additional skills that are not necessarily required for professional interaction between service providers (i.e., FLPs) and users.
As for mental health support as the partial duty of such service providers as educators, police officers, social workers and other frontline professionals, there is data on the existence of such public and governmental requests in different countries. Still, there is a lack of adequate preparedness to manage people with mental health needs (Aviram, 2002; Jain et al., 2021; Lamb et al., 2002; Mazzer & Rickwood, 2015; Mclean & Marshall, 2010; Rothì et al., 2008). In all cases, authors emphasize the need to develop special educational programmes tailored to the MH support deliverers' needs. The UMHT proposes a three-step scheme of such tailoring, which enhances programme adaptability. The first is the analysis of the needs of a target audience (i.e., a group of FLPs), the second is the needs-adjusted training delivery, and the third is the obligatory supervision support.
Extendability: to what extent can the UMHT be expanded to cover new topics and solve new problems?
The idea of the UMHT extendability was one of the baselines at the stage of the programme development. The training is called universal because of its universal 5-step model that offers a standard frame for interaction with people with mental health conditions and is suitable for different types of frontline professionals. This frame allows the training curriculum to add new modules dedicated to new disorders as any mental health-connected issue. The UMHT steps first imply recognition of MH condition or any connected problem (paying attention, forming hypothesis, getting ready, preparing space), second, validating of MH condition with a person or caregiver (establishing contact, building trust, testing readiness to speak about MH, finding out the awareness), third, supporting a person/caregiver (sharing observations, decreasing stigma, giving simple advice, responding with special techniques, bringing hope), fourth, referring for professional help (describing possibilities of professional help, naming non-evidence based approaches, helping to contact a professional), fifth, ensuring the reference was successful (initiating next meeting, learning more about person’s MH, helping to contact a professional if the first reference did not work).
The research team had a chance to test the extendability of the training in 2022 when two departments of the National Policy of Ukraine in Lugansk and Donetsk oblasts (regions whose territories are currently occupied by Russia or are proximately close to the battlefield) requested to include in the UMHT modules on mental health crisis and adjust the 5-step model to reaction on people behaviours (aggressive behaviour, self-harm behaviour, suicide and unusual & disorganized).
The comparative analysis of the usability data collected for the training groups that studied MH disorders, disorders, and crises and solely crises show no significant intergroup differences. Only statistically proven differences were seen between FLPs who studied only disorders and only crises for validation MH conditions (Post Hoc Dunn tests 2,185 [p = 0.029]). This result can be explained by partial redistribution of skills application in such steps as validation and support. In case of mental crisis, it is often an issue that support, at least responding with special techniques, comes and is used first before or even without condition validation.
Limitations and future research
The main limitation of the performed feasibility research is the absence of the so-called patient outcomes measures as indicators of the programme’s demand and acceptability among its final beneficiaries. The authors are conscious of this limitation, especially in the context of the recently published Cochrane review on the methodologically closest programme MHFA (Richardson et al., 2023). Next steps of the programme’s evaluation require an analysis of referrals for professional help and then scheduled appointments together with mental health monitoring as, for example, in case of the FPA programme implemented for healthcare workers in Arizona, USA during the COVID-19 Pandemic or the mhGAP feasibility analysis done in Makueni County, Nepal and Nigeria (Chandler et al., 2023; Mutiso et al., 2019a; Salisbury et al., 2021).
Conclusion
The feasibility of public mental health interventions is one of the primary requirements for their implementation, especially in countries with low and middle incomes where resources are limited. The UMHT as an educational programme for frontline professionals was developed and piloted in Ukraine in 2021-2023 to support the country's transition from highly institutionalised to community-based MH care when an intersectional collaboration and sustained referral system are crucial.
Assessment of the UMHT feasibility based on its actual use, users’ satisfaction, usability for different groups of frontline professionals, and openness to modifications show the programme’s potential for further development and implementation.
During 2021–2023, even with obstacles connected with the full-scale Russian invasion in Ukraine, 2923 frontline professionals passed the UMHT. Every year, the number of events, trained persons and engaged implementers increased. The UMHT 5-step model became a base for several other public mental health promotional & preventional interventions, in particular the IREX Ukraine Veteran Reintegration Programme “Strengthening the Capacity of Social Workers to Provide Mental Health Support for Veterans and their Families” and the SmartOsvita training programme “Psychosocial Support for Educators”.
Programme trainers as its deliverers and frontline professionals as its recipients reported high satisfaction with the training content and delivery as well as preparedness to apply their gained knowledge and skills in practice.
The main evidence of the UMHT's adaptability and extendability is the high scores for its usability for different groups of frontline professionals and for different mental conditions. Besides, the 5-step model laid in the programme's base offers frontline professionals a universal frame of interaction with people with MH conditions and is suitable for different types of mental health difficulties.
Ethics and consent
All participants gave written informed consent to participate in the study. The research team adhered to the Declaration of Helsinki and Model Code of Ethics of the European Federation of Psychologists Associations (EFPA), the Code of Ethics of the National Psychological Association of Ukraine, a member of the EFPA, Inter-Agency Standing Committee (IASC) Recommendations for Conducting Ethical Mental Health and Psychosocial Research in Emergency Settings and British Educational Research Association (BERA) Ethical Guidelines for Educational Research.
The UMHT delivery and data collection protocol was approved by the Ethics Committee of the Zhytomyr Ivan Franko State University (registered in the Office for Human Research Protections), approval number 01–2905/2020 (29 May 2020). The confirmation of compliance with Ukrainian legislation was issued by the Ethics Committee of the National Psychological Association of Ukraine (member of EFPA).
