Randomised hybrid implementation-effectiveness trial of a school-based mental health program in Australian schools

In this trial all primary schools will receive a universal prevention program known as the PAX Good Behaviour Game [PAX GBG], which is a school-based, classroom intervention used by teachers to teach students self-regulation and prosocial behaviours in the classroom. For teachers to be qualified to deliver the program they must complete the 1-day didactic PAX GBG initial teacher training course. This is a 1-day course, delivered virtually (via Zoom) by master trainers from the PAXIS Institute, USA. The training ensures proficiency in each of the component parts of the program (PAX Kernels). In addition to learning about how to implement the strategies (PAX kernels), teachers learn the importance of a nurturing environment and its effects on trauma, self-regulation, and mental health outcomes throughout the lifespan. The program itself is comprised of nine PAX kernels, which are evidence-based strategies that are designed to improve social-emotional learning and regulation. The main component of the program which teaches these outcomes is ‘Beat-the-Timer’. In Beat-the-Timer, all 9 PAX kernels are designed to be used together – and to do so, students are divided into small teams and a timer is set during which students are expected to work within their teams to engage in on-task/desirable behaviours and focus on their set task until the timer ends. Any off-task or less desirable/unwanted behaviour is tallied, and at the end of the playing period, teams with three or fewer points are rewarded. When the program is first delivered, rewards are given immediately following a ‘beat the timer’ game, and then are increasingly delayed, to teach delayed self-gratification. There is no standard program dosage, although for Beat-the-Timer to be most beneficial, teachers are expected to deliver it up to 3 times per day, for between 10 and 40 minutes. In addition to playing Beat-the-Timer, teachers are expected to deliver each individual kernel daily, and the duration for this can vary for between 1 minute to 20 minutes. The dosage and frequency of the strategies should increase over time, from every two days in the beginning to up to three times per day once students and teachers are comfortable with the program. It should not be played at the same time each day, and any rewards associated with the Beat the Timer component should be increasingly delayed over time to support students’ self regulation. As the overall PAX GBG program is designed to be integrated and to support usual classroom lessons, there is no finite delivery period. The minimum duration to see benefits at the student level would be 12 weeks, however, the longer the duration the greater the benefits. Delivering the PAX GBG program for a minimum of 12 months is ideal. Schools in both the intervention and control conditions will receive the PAX GBG program in this trial. As such, the exposure being tested is a multi-component implementation strategy [PAX Plus] to see if this leads to higher levels of PAX GBG adoption in schools and greater effectiveness in relation to student emotional and behavioural changes. The PAX Plus enhanced implementation strategy was iteratively co-designed by the research team, the NSW Department of Education and an advisory group of teachers and principals. Schools in the PAX Plus condition will have access to all the same resources as in PAX Standard (control condition) and in addition, will have access to our implementation approach which includes the following strategies: 1. Fortnightly e-newsletter: The purpose of the newsletters will be to provide information about specific PAX kernels (why they are important, how to deliver them, and tips to make use easier) to encourage teachers to use the full range of kernels. Between 2 and 3 kernels will be addressed in each newsletter. Newsletters will be emailed out fortnightly across a 4-month period. The newsletters will be between 2 and 3 pages in length, including visualisations, and will be expected to take between 5 and 10 minutes to read. 2. Peer Learning network: School staff will have access to an online peer learning network, hosted on Microsoft Teams. It is a Questions and Answers forum for teachers from different schools to share their experiences with implementation challenges. Questions can be posted anytime, and once a week, a member of the research team will moderate the forum and answer the week’s questions. 3. Promoting PAX Chats: PAX Chats are live discussions between teachers and the PAXIS Institute (program owners) in the USA to resolve common challenges with kernel implementation. The school leadership team will be encouraged to send reminders for teachers to participate in these PAX Chats available once or twice a term. 4. Executive Support: A member of the research team will schedule a 15-minute phone call with the principal of each school every 4 weeks to check in with, and gain an understanding of, their progress. 5. School champions: One teacher or other staff member trained in the PAX GBG program will be nominated as a ‘program champion’. Their role will be to promote the innovation and to identify strategies to enhance engagement within the school. As part of this, the champion may chair weekly meetings with the relevant teachers and staff to share learning, problem solve, and maintain motivation. The school principal will be contacted to identify the most appropriate person for this role in their school. 6. Recognition system: Schools will be provided with certificates of achievement certified by the NSW Department of Education to acknowledge the commitment of staff to the PAX GBG program. Schools will also be provided with a staff 'tootle board' (which is adaptation of one PAX GBG kernel delivered to students) where they can anonymously post positive affirmations about their peers. In addition, the research team will set up an online portal which will publicly recognise teachers and staff doing an outstanding job of program delivery. Schools will be asked to nominate staff for this and to provide a brief background of the staff member. 7. Audit and provide feedback: Schools will be provided with access to an online survey system (using Qualtrics) to use to monitor the outcomes of the PAX GBG for their own school and feedback progress to staff as a motivation tool. Schools will have a unique link to this tool for their own school, and are able to download data directly. PAX Plus schools will be provided a toolkit (manual) describing each of these strategies in detail. Schools will be directed to use these implementation supports for 6 months from when they join the trial. Some strategies have a clear, specified timepoint for implementation (e.g. executive support which occurs every 4 weeks) while others can be used as frequently as suits the needs of individual schools (e.g. recognition system).