Development of Chinese mental health first aid guidelines for assisting a person affected by a traumatic event: a Delphi expert consensus study

We used the Delphi method to reach consensus on the inclusion of guideline statements. Generally, the Delphi method involves a number of iterations before consensus is achieved. Feedback is given at each round in order to help experts compare their opinions to those of the group. This method has been used in many countries to develop mental health first aid guidelines for a wide range of mental health problems or crises, including depression, psychosis and alcohol problems [38].

This Delphi consensus study involved four steps: (1) questionnaire development, (2) panel recruitment and formation, (3) data collection and analysis, and (4) guidelines development.

First, the Round 1 questionnaire from the redevelopment of the English-language guidelines [39] was translated into Chinese by a professional translator. Then the Chinese working group (YW, YH, WL and SL) checked the Chinese-language version and made several rounds of modifications to the statements and structure of the questionnaire to ensure that it was appropriate for the culture and health service systems in China. All working group members are skilled in both English and Chinese languages and are familiar with mental health system in China.

A total of 168 statements were included in the first round of the questionnaire and they were divided into 6 sections according to the content of the statements, including: (1) Background information, (2) Actions to be taken at the site of a potentially traumatic event, (3) Talking about the trauma, (4) Providing support in the weeks and months following a potentially traumatic event, (5) Experiences of abuse, and (6) Adolescents.

The questionnaire started with informed consent and questions about the demographic characteristics of the participants. This survey was conducted online using a Chinese survey tool, Questionnaire Star. If someone did not agree to participate in the survey, he/she could opt out of the survey page. The survey only continued if he/she chose the “agree” option.

Participants were recruited into one of the two panels: professionals and people with lived experience (either as consumers or carers). Members of the professional panel could be a psychiatrist, psychotherapist, counselor, or a school teacher who was accredited to provide psychological counseling to students. They were required to have some knowledge about trauma issues and to have at least 2 years of occupational experience in mental health related to trauma. Professionals were approached via publicly available contact details or through personal contacts of the Chinese research team. Participants were also encouraged to pass on the invitation to other eligible participants.

Members of the lived experience panel were people who had personally experienced traumatic events, patients with PTSD, or their carers (e.g., volunteers who care for families who have lost their only child). Potential consumers and carers were recruited primarily from outpatient clinics and related support groups (including those for survivors of the Wenchuan earthquake). The members of this panel also needed to meet the following criteria:

To maximize the diversity of the study sample and the validity of the Delphi survey, we aimed to recruit at least 30 members for each panel. When the panel members received the invitation by email or WeChat, they could voluntarily choose whether or not to participate. The panel members were reimbursed100 RMB retail vouchers for completing at least two survey rounds.

A total of three survey rounds were conducted. Following each of the three rounds, panel members were presented with a brief summary of the results from the previous round, listing items to be included, re-rated, or excluded. In Round 1, there was space at the end of each section for panel members to add comments for that section, as well as to suggest new statements that had not been included. These comments and suggestions made by the panel members in Round 1 were carefully reviewed by the working group and used to develop new items for Round 2. Suggestions and statements were accepted and added to Round 2 if they were clear actions and presented a novel idea. Suggestions were rejected if they were covered by statements in the existing questionnaire, if they were too vague and general, or were more appropriate to clinical treatment than first aid.

The Round 3 questionnaire comprised statements that were presented in Round 2 for the first time and that required re-rating in a further round. Statements that still did not achieve consensus after three rounds were rejected from inclusion in the guidelines.

The correlation between the statement endorsement rates from the two panels was measured by Pearson’s correlation coefficient using the SPSS software (version 17.0).

All statements endorsed as either “Very important” or “Important” by ≥80% of both panels were included into the final guidelines. The first author drafted the guidelines by writing the list of endorsed statements into sections of prose based on common themes. Where possible, statements were combined and repetition deleted. The draft guidelines were then presented to the Chinese working group for structural and linguistic polishing to make them more easily understood by the general public in China. After several drafting iterations, the final draft of guidelines was formed, a copy of which was sent to each panel member for review. They could provide feedback on the structure and wording of the guidelines to make the text clearer. The final guidelines are provided in the online supplementary material.

A total of 63 panel members (30.2% male) completed the Round 1 survey, including 32 mental health professionals and 31 consumers and carers. Their basic demographic information is provided in Table 1. The average age of panel members was 37.0 years (SD = 8.7, range 20–62), and 95.2% of them had university education or above.

The 32 mental health professionals included 13 psychiatrists, 11 psychotherapists, 5 psychology teachers (who are also counsellors) and 1 mental health social worker. The lived experience panel included 5 members of people with experience of traumatic events and 26 carers.

Table 2 shows the continuity of participation across the three rounds. In the end, 92.1% (n = 58) of the participants completed all three rounds of the survey. Non-responders were contacted to remind them to complete the questionnaire up to three times. Some (7.9%) didn’t complete the survey because they were too busy or lost touch.

An overview of the three rounds of the Delphi study is provided in Fig. 1. The Round 1 questionnaire contained 168 statements and 9 new statements were developed from the comments of the panel members in Round 1, resulting in 177 statements being rated across the three rounds. After the three survey rounds, 134 (75.7%) statements were endorsed for inclusion in the final guidelines: 120 statements were endorsed in Round 1, 13 in Round 2 and 1 in Round 3. A total of 43 (24.3%) statements were not endorsed for the guidelines: 27 statements were rejected in Round 1, 14 in Round 2 and 2 in Round 3 (see Additional file 1 for a list of all the statements and their respective rates of endorsement).

One section in the Round 1 questionnaire was about “Providing support in the weeks and months following a potentially traumatic event”. Of this section, 9 statements were about how long the effects of a potentially traumatic event last before the first aider should encourage the person to seek professional help. For example: “The first aider should encourage the person to seek professional help if the post-trauma symptoms are interfering with their usual activities for: 1)2 weeks or more, 2) 4 weeks or more.” Participants were required to rate the importance of each option in the statement. In Round 1 survey, the “4 weeks or more” option for each statement was endorsed by 80% or more of each panel as either very important or important. Therefore, after discussion, we directly included the “4 weeks or more” option for all 9 statements, which was also consistent with the English-language guidelines. The “2 weeks or more” option was excluded directly and not re-rated in the Round 2 survey.

The endorsement rates from the professional panel and the lived experience panel were significantly correlated (r = .68, p < .001) in Round 1, but some differences were also identified. One statement with the greatest difference (29.3%) in endorsement rates between the professional panel (90.6%) and the lived experience panel (61.3%) was “If the person wants to talk about the potentially traumatic event but this is too distressing for the first aider, they should find someone else for the person to talk to” After discussion, the Chinese working group agreed that this action was important in the first aid work, so we didn’t reject it directly. Instead, we revised the statement by adding examples to clarify ‘someone else (e.g. friends, other first aiders or professionals’) and included it in Round 2 for re-rating. However, in the second round, this statement was excluded because the endorsement rate of the lived experience panel still didn’t reach 80%.

As summarized in Table 3, there were some differences in the endorsement of statements between the English-language and Chinese guideline studies. Thirty-three statements that were rejected in the redevelopment of the guidelines for English-speaking countries, but were endorsed in the current study, and 8 statements were endorsed in the English-language Delphi, but rejected in current study. In addition, 6 new statements developed from the comments in the Round 1 questionnaire were added in the guidelines for China.

There were 31 additional statements in the final Chinese guidelines compared to the English-language guidelines. These additional statements included many specific actions that first aiders should take, such as trying to meet the person’s immediate needs, talking to them about the trauma and helping them to deal with issues related to abuse. In the section on “Actions to be taken at the site of a potentially traumatic event”, the statement “if the person has been a victim of crime, the first aider should consider the possibility that forensic evidence may need to be collected (e.g. evidence on clothing or skin) and should encourage the person to preserve such evidence” may reflect the panels’ expectation that first aiders should play an important role and provide more practical help. In addition, two statements related to recommendations that the first aiders should contact the family members or friends of the person who had experienced a potentially traumatic event. This may show the importance of the support of family and friends in the Chinese context. While people in English-speaking countries may be more likely rely on public services (e.g., doctors, crisis intervention teams, mental health professionals), these are less widely available in China [40‐42]. In the section on “Experiences of abuse”, four additional statements related to asking the police for help were included. “If the person discloses any abuse associated with criminal activity” or “if the first aider is concerned that the person is at risk of harm from someone else”, the first aider should (or encourage the person) to report it to the police. It may be that, compared to English-speaking panelists, Chinese health professionals and consumers saw this as less likely to be common practice and therefore as needing to be emphasised in the guidelines. However, these items may also reflect that fact that there are few other organizations or resources in China that can provide help to people who have experienced abuse, or that they are not very effective [43].

However, as in the English-language guidelines, these new Chinese guidelines emphasize that first aiders are not professionals and they should not be a substitute for professional help. Inappropriate intervention by a non-professional may not only fail to help a person, but may also have a negative impact on the person concerned and the first aider themselves [44]. Therefore, an additional statement was added to the guidelines “The first aider should be aware that they can also be influenced by the potentially traumatic event”, emphasizing that first aiders need to be mindful of their own mental health in order to prevent vicarious trauma. This view may be informed by China’s previous experience in psychological first aid [45]. Previous studies have shown that volunteers who have received disaster assistance training have lower levels of vicarious trauma than those who have not. Student volunteers, media workers and other aid volunteers also reported having higher levels of vicarious trauma than mental health professionals [45].

Although the professional panel and lived experience panel agreed on most of the statements, they differed (difference in the endorsement rates > ±10%) on some of the statements. For example, the lived experience panel rejected the statement ‘If the person wants to talk about the potentially traumatic event but this is too distressing for the first aider, they should find someone else for the person to talk to’ (professional: 90.6%; lived experience: 61.3%) in Round 1. It is possible that the lived experience panel members thought it important to have the first aider’s company and were reluctant to be separated from them to speak to others or they might think they couldn’t talk to anyone else if they couldn’t talk to the first aider. In addition, 90.6% of the professional panel members endorsed that ‘If the person does not wish to talk to the first aider about how they are feeling, they should encourage the person to consider calling a help line or using other community resources’, but only 71.0% of consumers and carers rated this statement as either very important or important in Round 1 (87.1% vs. 76.6% in Round 2). But the two panels were more in agreement (93.8% vs. 96.8%) on another statement ‘The first aider should encourage the person to talk about their feelings, but only if the person feels ready to do so’. These differences may reflect the desire of a person who has experienced a traumatic event for their wishes to be respected. If the person is unwilling to talk, then the first aider should not push them to talk, instead they should wait or offer other help until the person is ready to talk. Similarly, the professional panel rejected (endorsement rate 56.3%) the statement ‘If the person begins to relate details of the abuse that the first aider finds distressing, the first aider should protect themselves by encouraging the person to talk about other things’, while 80.6% of consumers and carers endorsed it. The professional panel may consider that first aiders should care for their own emotions, but the consumers and carers may want their experiences and feelings to be fully respected and understood and not to be interrupted.

Several limitations of this study should be considered. Firstly, only five people with traumatic experiences were included in the lived experience panel. It was difficult to recruit people with traumatic experiences (including, for example, families who had lost their only child), as they were unwilling to participate for fear of recalling their loss. It may also be because this survey was mainly conducted online. In China, many people with mental disorders and their families, or those who have experienced trauma, feel stigmatized for their experiences. For this reason, they may be reluctant to reveal these private experiences to others, particularly in an online survey [46‐48]. In China, most mental-health-related surveys have been conducted face to face, offering respondents with concerns the opportunity to ask questions of an interviewer in person. As it is relatively easy to refuse to participate or drop out of online surveys, face-to-face surveys may increase participation through better explanation of and provision of care and support to people with lived experience. Future studies could use face-to-face interviews to explore these issues. Secondly, most of the participants in this study were recruited from urban areas (mainly from Shanghai and Zigong), which may limit the generalizability of the findings. Due to the diversity of different regions in China, the uneven distribution of mental health resources between urban and rural areas and in the eastern and western regions of China [49], and the wide variation in education levels, the applicability of the guidelines in rural areas and for people with limited education requires further study.

On the other hand, the study has several strengths. Firstly, the number of members of the two panels (32 professionals and 31 consumers and carers), met the minimum panel size of 20 for a Delphi study [27], which ensured the reliability of the results. In addition, the drop-out rate of participants in the second and third rounds was lower than in many previous Delphi studies [29, 34, 50], possibly because experts were more interested in trauma issues. The third round of the survey was conducted during the COVID-19 outbreak when many people suffered from anxiety, stress and other mental problems, therefore, the focus on trauma may have improved engagement in the study. The third round of surveys also included links to reimbursement for participants, which may also have boosted participation.

This study reports on the development of the guidelines for assisting a person affected by a potentially traumatic event in China. For the guidelines to have beneficial impact, they will need to be effectively disseminated and incorporated into practice. The guidelines may be disseminated as a standalone project and will also be used to inform the development of a MHFA training course for China. Both these activities require consideration of the current state of China’s mental health system, resources, and policies. The Chinese government attaches increasing importance to psychological crisis intervention and psychological assistance, offering promising opportunities to develop and implement MHFA training. Policymakers may be encouraged to include MHFA training as part of plans to improve public mental health literacy.

In addition, the last section of the guidelines, which is about how to help an adolescent who has experienced a potentially traumatic event, is an area that has not been emphasized in the other Chinese mental health first aid guidelines (depression, suicide and psychosis) [34‐36]. Consistent with the emphasis in this section, Chinese policy has called for a focus on adolescent mental health to address the lack of trauma interventions for adolescents in China [12, 13]. Many cases of adolescent abuse, school bullying or family violence go undetected, with appropriate interventions even less common [51, 52]. Therefore, help from the public is particularly important.