Mental Health Literacy in Secondary Schools A Canadian Approach Stan Kutcher, MD, FRCPC, FCAHSa,*, Alexa Bagnell, Yifeng Wei, MEdc
MD, FRCPC
b
,
KEYWORDS Mental health literacy School programs Youth Knowledge translation Mental health promotion KEY POINTS Youth mental health literacy is a key factor in mental health awareness, reducing stigma and improving health-related decision making. Schools are an ideal environment within which to embed mental health and health literacy programs. Programs for youths need to incorporate information in a twenty-first century learning context, with media and electronic accessibility to material and tools, to develop lifelong health literacy skills and improve mental health outcomes. Sustainable and effective mental health literacy knowledge translation programs can be developed for educators using train-the-trainer models with evidence-based materials and tools for use within and beyond the classrooms. In Canada, 2 complementary mental health literacy approaches in secondary schools have been advanced to accomplish this goal and have been widely adopted across the country.
INTRODUCTION: HEALTH LITERACY
The long-term health and well-being of all individuals is inextricably linked with the level of education and literacy that individuals attain over the course of their lifetime, including education around health and mental health.1 The World Health Organization
The authors have nothing to disclose. a Department of Psychiatry, Sun Life Financial Chair in Adolescent Mental Health, IWK Health Centre, Dalhousie University, 5850 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8, Canada; b Child and Adolescent Psychiatry, Department of Psychiatry, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8, Canada; c Sun Life Financial Chair, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8, Canada * Corresponding author. E-mail address: [email protected] Child Adolesc Psychiatric Clin N Am 24 (2015) 233–244 http://dx.doi.org/10.1016/j.chc.2014.11.007 childpsych.theclinics.com 1056-4993/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
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Abbreviations CDC DRSB TDSB WHO
Centers for Disease Control and Prevention Durham Regional School Boards Toronto District School Board World Health Organization
(WHO)2 and national governments, such as Canada, the United States, and Australia, have recognized the importance of enhancing health literacy to improve population health outcomes.3–5 Health literacy has been both narrowly and more broadly defined. The Centers for Disease Control and Prevention (CDC), for example, defines health literacy as “the capacity to obtain, process and understand basic health information and services to make appropriate health decisions”6; other organizations, such as the WHO, have identified health literacy as the knowledge and competencies needed to enhance health care, disease prevention, and health promotion at both individual and population levels.2 Further extension of this construct has recently been suggested by the WHO as comprising 3 components: functional health literacy, conceptual health literacy, and health literacy as empowerment.7 Understood in this framework, health literacy goes beyond the individual competencies that the CDC describes to recognize the need for creating the capacity of individuals to be actively applying evidence-based and contextually informed knowledge so that they can act effectively on their own behalf and also on behalf of their families and communities. Mental health literacy is an integral component of general health literacy and has been gaining increasing attention as an important focus globally for mental health interventions. With about one-fifth of the population being affected by mental illness in their lifetime and the high cost of these illnesses to individuals and society,8 mental health literacy is a critical area for public health intervention. In Canada, youth mental health is increasingly recognized as a key national health concern and has received more focused attention than ever before within our health system.9 Several unique homegrown national initiatives have addressed youth mental health literacy within Canadian schools.
MENTAL HEALTH LITERACY
Our understanding of mental health literacy has developed from relatively circumscribed definitions in which mental health literacy was primarily understood as the knowledge needed to be able to identify mental disorders10 to a more nuanced and complex understanding of the requirements for improving mental health outcomes. For example, Jorm,11 expanding on his early pioneering work in mental health literacy, has identified the following components: recognition of developing mental disorders to facilitate early help seeking, knowledge of professional help and effective treatments available, knowledge of effective self-help strategies, knowledge and skills to give mental health first aid and support to others, and knowledge of how to prevent mental disorders. Such direction recognizes that mental health literacy is the foundation for mental health care, prevention of mental disorders, and promotion of good mental health. This perspective is consistent with the wider definition of health literacy as described by the WHO.2 According to Kutcher and colleagues,12 who have further refined this concept, mental health literacy comprises 4 distinct but related components: (1) understanding how to optimize and maintain good mental health, (2) understanding mental disorders and their treatment, (3) decreasing stigma, and (4) enhancing help
Mental Health Literacy in Secondary Schools
seeking efficacy. Although consistent with Jorm’s definition of focusing on the recognition of mental disorders and help sources/strategies for oneself and others, this construct of mental health literacy by Kutcher and colleagues12 extends to emphasize the importance of fighting stigma, maintaining good mental health, and empowering a person to improve their help-seeking efficacy (knowing when to seek help, where to seek help, what to expect when seeking help, and being empowered to receive the best available help). This more complex construct also provides the basis for mental health decision making and can be applied at the individual and population levels, thus, addressing key factors in determining mental health outcomes. As approximately 1 in 5 young people show signs of emotional/behavioral impairment,8,13 the development of mental health literacy (Box 1) could possibly become the foundation for a lifetime of improved mental health and better outcomes for mental disorders. Given that young people begin making decisions about their health during their early adolescent years, there is a credible argument that health decision-making skills should be an integral part of the school curriculum from an early age.14 Accordingly, youths should be a primary audience for whom mental health literacy is provided, ideally as a matter of course and not as add-on or unique events that occur infrequently (such as mental health parades, student assembly for mental health, and so forth). These one-off events may raise initial awareness of mental health concerns but often have little if any lasting or positive value in enhancing mental health literacy in young people.12,15,16 MENTAL HEALTH LITERACY AND SCHOOL
Given the importance of supporting the development of mental health literacy in young people, the reality that most youths attend school, and that schools are the preferred social structures through which literacy (for example, language literacy, mathematic literacy, scientific literacy, and so forth) is taught, it is both reasonable and rational to focus on developing and delivering evidence-based mental health literacy interventions in schools. School-based mental health literacy interventions can be provided through curriculum and through other school-based initiatives. These interventions may be particularly important for junior high and secondary school students who are demographically situated near the beginning of the rapidly ascending curve that marks the onset of diagnosable mental disorders (between 12–25 years of age).8,13 For young people, the development of good mental health literacy during this period of the life cycle may be instrumental in achieving improvements in mental health, mental health care, and the decrease of stigma associated with mental disorders. Globally, however, school-based mental health literacy interventions for this age group have been few and far between. Although there has been substantial interest in mental health promotion in schools17 and whole-school approaches to student well-being, much of this work has been focused on primary grades, and the evidence
Box 1 Mental health literacy is defined as 1. Understanding how to optimize and maintain good mental health 2. Understanding mental disorders and their treatments 3. Decreasing stigma 4. Enhancing help-seeking efficacy
235
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for a substantive and lasting positive impact is not as robust as early expectations.18–20 Other approaches have addressed various models for meeting mental health care needs in schools, either through site-based services or through integration of schools with health care services, either by providing services within schools or linking schools to off-site services.21–25 However, most of these interventions applied an approach in which external resources are brought into school settings. Such approaches require substantial additional investment and may not be sustainable over time. Further, evidence that they are substantially better than mental health literacy activities applied using existing school resources is not available. Indeed, such externally applied approaches may actually not be as effective as those embedded within usual school ecologies, such as curriculum presented by usual classroom teachers.18 Regarding mental health literacy specifically, a recent systematic review26 on the effectiveness of school-based mental health literacy programs identified 27 studies addressing knowledge, attitudes/stigma, and help-seeking behaviors. However, most of these interventions were delivered by noneducators, and programs were not sustained once the intervention was completed. Although some studies demonstrated preliminary positive results in the 3 outcomes, the results are difficult to interpret as most studies lacked scientific rigor in study designs. As general health promotion initiatives, the interventions did not all fully address the 4 domains of mental health literacy as defined earlier and, thus, may not have included the components required improving mental health awareness and decision making. Stigma does not seem to be impacted by one-off interventions,27,28 and teacher beliefs and perceptions regarding mental health problems and mental disorders need to be considered within any training program.29 Mental health literacy needs to be embedded in schools, integrated and led by educators, to facilitate the creation of a school-wide environment of acceptance and normalization of mental illnesses and to facilitate recognition and help seeking in young people. Furthermore, many of the mental health literacy resources described in the literature may not be designed to meet the evolving needs of students. For example, resources such as textbooks or classroom handouts may not be as acceptable to students today. The core concepts of twenty-first century learning are moving from static information to discovery of information and developing skills in managing new and changing information relevant to the individual. In particular, youths today are highly focused on interactive media as a primary resource and generator of information. Initiatives in mental health literacy must prepare youths to cope with an ever-changing and progressing health care landscape and to be able to apply these skills to the decisions they are making.30 Thus, classroom resources that use interactive media opportunities and online resources while concurrently maintaining a high level of evidence-based content may be an appropriate vehicle to help address teaching mental health literacy to young people.31–33 These considerations raise both a challenge and a solution. A natural approach to addressing mental health literacy in schools, building on existing social ecologies of schools and using existing school structures and the professional capacities of educators, could be realized by developing 2 separate but mutually dependent streams. These streams are (1) a mental health literacy curriculum resource designed to be taught in classrooms by usual teachers who are trained in its use and (2) interactive Web-based mental health literacy resources that can be used by both teachers and students in the classroom setting. The authors here describe 2 separate but mutually supportive approaches that address these streams in Canadian schools: the Mental Health and High School Curriculum Guide (the Guide) (http://teenmentalhealth.org/ curriculum/) and MyHealth Magazine (http://www.myhealthmagazine.net).
Mental Health Literacy in Secondary Schools
The Guide: Development, Application, and Evaluation with Teachers
The Guide was developed in collaboration between one of the authors (Stan Kutcher) and the Canadian Mental Health Association, the largest national organization addressing mental health in Canada. It was created using input from educators and mental health experts nationally in conjunction with national curriculum development organizations and designed to be a resource that could be used to meet curriculum guidelines and outcomes, as they exist in all Canadian provinces. The Guide is a comprehensive and best evidence–created resource available to support curricula across Canada and is available in both hard copy and Web-based formats (www.teenmentalhealth.org). The resources include a teacher’s self-study guide, teacher’s knowledge selfassessment, student evaluation materials, and 6 core modules in which teachers are trained: the stigma of mental illness, understanding mental health and wellness, information about specific mental illnesses, experiences of mental illness, seeking help and finding support, and the importance of positive mental health (Box 2).12 Supplemental resources accompany each module and include animated videos, first voice videos, digital story-telling videos, PowerPoint (Microsoft Corporation, Redmond, WA) slides, in-class handouts, and Web-linked resources. All materials have been vetted and approved by mental health clinicians, educators, parents, and young people who contributed to the development of the Guide. Total duration of in-class time for teaching the modules is between 8 and 12 hours. Because initial pilot studies found that teachers were not comfortable with and did not have comprehensive enough knowledge to teach many components of the Guide, 2 authors developed a 1-day training program, designed to introduce teachers to the Guide, model the teaching of various components of the core curriculum, and provide more detailed information about the material addressed in the curriculum. The developers of the program initially provided this teacher’s training. More recently, the direct training model has changed to a train-the-trainer model whereby the program developers train trainers (usually a combination of teachers, student services providers, and health care providers) within school boards who become a local resource for newteacher training and support of current educators delivering the program. Program evaluations of mental health literacy outcomes for teachers directly trained by developers of the Guide demonstrate significant improvements in teachers’ knowledge and attitudes with effect sizes (Cohen’s d) ranging from 1.4 to 1.8 for knowledge
Box 2 The Guide (www.teenmentalhealth.org) Teacher’s self-study guide Teacher’s knowledge self-assessment Student evaluation materials 6 core modules The stigma of mental illness Understanding mental health and wellness Information about specific mental illnesses Experiences of mental illness Seeking help and finding support Importance of positive mental health
237
238
Kutcher et al
and 0.5 to 1.2 for attitudes.12,34 Recent evaluation of the train-the-trainer model has been conducted in different Canadian sites to ensure the knowledge transfer to teachers remains consistent. In the Province of Nova Scotia, each of the 9 school boards across the province has developed a training team that was trained by the program developers. Each training team consisted of classroom teachers, student services providers, and health/mental health professionals. Results from each train-thetrainer session demonstrated similar highly positive and substantial results with no significant differences between groups noted. Each of the teams applied their training by teaching teachers in the use of the Guide. Results demonstrated highly significant (P
MD, FRCPC
b
,
KEYWORDS Mental health literacy School programs Youth Knowledge translation Mental health promotion KEY POINTS Youth mental health literacy is a key factor in mental health awareness, reducing stigma and improving health-related decision making. Schools are an ideal environment within which to embed mental health and health literacy programs. Programs for youths need to incorporate information in a twenty-first century learning context, with media and electronic accessibility to material and tools, to develop lifelong health literacy skills and improve mental health outcomes. Sustainable and effective mental health literacy knowledge translation programs can be developed for educators using train-the-trainer models with evidence-based materials and tools for use within and beyond the classrooms. In Canada, 2 complementary mental health literacy approaches in secondary schools have been advanced to accomplish this goal and have been widely adopted across the country.
INTRODUCTION: HEALTH LITERACY
The long-term health and well-being of all individuals is inextricably linked with the level of education and literacy that individuals attain over the course of their lifetime, including education around health and mental health.1 The World Health Organization
The authors have nothing to disclose. a Department of Psychiatry, Sun Life Financial Chair in Adolescent Mental Health, IWK Health Centre, Dalhousie University, 5850 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8, Canada; b Child and Adolescent Psychiatry, Department of Psychiatry, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8, Canada; c Sun Life Financial Chair, IWK Health Centre, 5850 University Avenue, PO Box 9700, Halifax, Nova Scotia B3K 6R8, Canada * Corresponding author. E-mail address: [email protected] Child Adolesc Psychiatric Clin N Am 24 (2015) 233–244 http://dx.doi.org/10.1016/j.chc.2014.11.007 childpsych.theclinics.com 1056-4993/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
234
Kutcher et al
Abbreviations CDC DRSB TDSB WHO
Centers for Disease Control and Prevention Durham Regional School Boards Toronto District School Board World Health Organization
(WHO)2 and national governments, such as Canada, the United States, and Australia, have recognized the importance of enhancing health literacy to improve population health outcomes.3–5 Health literacy has been both narrowly and more broadly defined. The Centers for Disease Control and Prevention (CDC), for example, defines health literacy as “the capacity to obtain, process and understand basic health information and services to make appropriate health decisions”6; other organizations, such as the WHO, have identified health literacy as the knowledge and competencies needed to enhance health care, disease prevention, and health promotion at both individual and population levels.2 Further extension of this construct has recently been suggested by the WHO as comprising 3 components: functional health literacy, conceptual health literacy, and health literacy as empowerment.7 Understood in this framework, health literacy goes beyond the individual competencies that the CDC describes to recognize the need for creating the capacity of individuals to be actively applying evidence-based and contextually informed knowledge so that they can act effectively on their own behalf and also on behalf of their families and communities. Mental health literacy is an integral component of general health literacy and has been gaining increasing attention as an important focus globally for mental health interventions. With about one-fifth of the population being affected by mental illness in their lifetime and the high cost of these illnesses to individuals and society,8 mental health literacy is a critical area for public health intervention. In Canada, youth mental health is increasingly recognized as a key national health concern and has received more focused attention than ever before within our health system.9 Several unique homegrown national initiatives have addressed youth mental health literacy within Canadian schools.
MENTAL HEALTH LITERACY
Our understanding of mental health literacy has developed from relatively circumscribed definitions in which mental health literacy was primarily understood as the knowledge needed to be able to identify mental disorders10 to a more nuanced and complex understanding of the requirements for improving mental health outcomes. For example, Jorm,11 expanding on his early pioneering work in mental health literacy, has identified the following components: recognition of developing mental disorders to facilitate early help seeking, knowledge of professional help and effective treatments available, knowledge of effective self-help strategies, knowledge and skills to give mental health first aid and support to others, and knowledge of how to prevent mental disorders. Such direction recognizes that mental health literacy is the foundation for mental health care, prevention of mental disorders, and promotion of good mental health. This perspective is consistent with the wider definition of health literacy as described by the WHO.2 According to Kutcher and colleagues,12 who have further refined this concept, mental health literacy comprises 4 distinct but related components: (1) understanding how to optimize and maintain good mental health, (2) understanding mental disorders and their treatment, (3) decreasing stigma, and (4) enhancing help
Mental Health Literacy in Secondary Schools
seeking efficacy. Although consistent with Jorm’s definition of focusing on the recognition of mental disorders and help sources/strategies for oneself and others, this construct of mental health literacy by Kutcher and colleagues12 extends to emphasize the importance of fighting stigma, maintaining good mental health, and empowering a person to improve their help-seeking efficacy (knowing when to seek help, where to seek help, what to expect when seeking help, and being empowered to receive the best available help). This more complex construct also provides the basis for mental health decision making and can be applied at the individual and population levels, thus, addressing key factors in determining mental health outcomes. As approximately 1 in 5 young people show signs of emotional/behavioral impairment,8,13 the development of mental health literacy (Box 1) could possibly become the foundation for a lifetime of improved mental health and better outcomes for mental disorders. Given that young people begin making decisions about their health during their early adolescent years, there is a credible argument that health decision-making skills should be an integral part of the school curriculum from an early age.14 Accordingly, youths should be a primary audience for whom mental health literacy is provided, ideally as a matter of course and not as add-on or unique events that occur infrequently (such as mental health parades, student assembly for mental health, and so forth). These one-off events may raise initial awareness of mental health concerns but often have little if any lasting or positive value in enhancing mental health literacy in young people.12,15,16 MENTAL HEALTH LITERACY AND SCHOOL
Given the importance of supporting the development of mental health literacy in young people, the reality that most youths attend school, and that schools are the preferred social structures through which literacy (for example, language literacy, mathematic literacy, scientific literacy, and so forth) is taught, it is both reasonable and rational to focus on developing and delivering evidence-based mental health literacy interventions in schools. School-based mental health literacy interventions can be provided through curriculum and through other school-based initiatives. These interventions may be particularly important for junior high and secondary school students who are demographically situated near the beginning of the rapidly ascending curve that marks the onset of diagnosable mental disorders (between 12–25 years of age).8,13 For young people, the development of good mental health literacy during this period of the life cycle may be instrumental in achieving improvements in mental health, mental health care, and the decrease of stigma associated with mental disorders. Globally, however, school-based mental health literacy interventions for this age group have been few and far between. Although there has been substantial interest in mental health promotion in schools17 and whole-school approaches to student well-being, much of this work has been focused on primary grades, and the evidence
Box 1 Mental health literacy is defined as 1. Understanding how to optimize and maintain good mental health 2. Understanding mental disorders and their treatments 3. Decreasing stigma 4. Enhancing help-seeking efficacy
235
236
Kutcher et al
for a substantive and lasting positive impact is not as robust as early expectations.18–20 Other approaches have addressed various models for meeting mental health care needs in schools, either through site-based services or through integration of schools with health care services, either by providing services within schools or linking schools to off-site services.21–25 However, most of these interventions applied an approach in which external resources are brought into school settings. Such approaches require substantial additional investment and may not be sustainable over time. Further, evidence that they are substantially better than mental health literacy activities applied using existing school resources is not available. Indeed, such externally applied approaches may actually not be as effective as those embedded within usual school ecologies, such as curriculum presented by usual classroom teachers.18 Regarding mental health literacy specifically, a recent systematic review26 on the effectiveness of school-based mental health literacy programs identified 27 studies addressing knowledge, attitudes/stigma, and help-seeking behaviors. However, most of these interventions were delivered by noneducators, and programs were not sustained once the intervention was completed. Although some studies demonstrated preliminary positive results in the 3 outcomes, the results are difficult to interpret as most studies lacked scientific rigor in study designs. As general health promotion initiatives, the interventions did not all fully address the 4 domains of mental health literacy as defined earlier and, thus, may not have included the components required improving mental health awareness and decision making. Stigma does not seem to be impacted by one-off interventions,27,28 and teacher beliefs and perceptions regarding mental health problems and mental disorders need to be considered within any training program.29 Mental health literacy needs to be embedded in schools, integrated and led by educators, to facilitate the creation of a school-wide environment of acceptance and normalization of mental illnesses and to facilitate recognition and help seeking in young people. Furthermore, many of the mental health literacy resources described in the literature may not be designed to meet the evolving needs of students. For example, resources such as textbooks or classroom handouts may not be as acceptable to students today. The core concepts of twenty-first century learning are moving from static information to discovery of information and developing skills in managing new and changing information relevant to the individual. In particular, youths today are highly focused on interactive media as a primary resource and generator of information. Initiatives in mental health literacy must prepare youths to cope with an ever-changing and progressing health care landscape and to be able to apply these skills to the decisions they are making.30 Thus, classroom resources that use interactive media opportunities and online resources while concurrently maintaining a high level of evidence-based content may be an appropriate vehicle to help address teaching mental health literacy to young people.31–33 These considerations raise both a challenge and a solution. A natural approach to addressing mental health literacy in schools, building on existing social ecologies of schools and using existing school structures and the professional capacities of educators, could be realized by developing 2 separate but mutually dependent streams. These streams are (1) a mental health literacy curriculum resource designed to be taught in classrooms by usual teachers who are trained in its use and (2) interactive Web-based mental health literacy resources that can be used by both teachers and students in the classroom setting. The authors here describe 2 separate but mutually supportive approaches that address these streams in Canadian schools: the Mental Health and High School Curriculum Guide (the Guide) (http://teenmentalhealth.org/ curriculum/) and MyHealth Magazine (http://www.myhealthmagazine.net).
Mental Health Literacy in Secondary Schools
The Guide: Development, Application, and Evaluation with Teachers
The Guide was developed in collaboration between one of the authors (Stan Kutcher) and the Canadian Mental Health Association, the largest national organization addressing mental health in Canada. It was created using input from educators and mental health experts nationally in conjunction with national curriculum development organizations and designed to be a resource that could be used to meet curriculum guidelines and outcomes, as they exist in all Canadian provinces. The Guide is a comprehensive and best evidence–created resource available to support curricula across Canada and is available in both hard copy and Web-based formats (www.teenmentalhealth.org). The resources include a teacher’s self-study guide, teacher’s knowledge selfassessment, student evaluation materials, and 6 core modules in which teachers are trained: the stigma of mental illness, understanding mental health and wellness, information about specific mental illnesses, experiences of mental illness, seeking help and finding support, and the importance of positive mental health (Box 2).12 Supplemental resources accompany each module and include animated videos, first voice videos, digital story-telling videos, PowerPoint (Microsoft Corporation, Redmond, WA) slides, in-class handouts, and Web-linked resources. All materials have been vetted and approved by mental health clinicians, educators, parents, and young people who contributed to the development of the Guide. Total duration of in-class time for teaching the modules is between 8 and 12 hours. Because initial pilot studies found that teachers were not comfortable with and did not have comprehensive enough knowledge to teach many components of the Guide, 2 authors developed a 1-day training program, designed to introduce teachers to the Guide, model the teaching of various components of the core curriculum, and provide more detailed information about the material addressed in the curriculum. The developers of the program initially provided this teacher’s training. More recently, the direct training model has changed to a train-the-trainer model whereby the program developers train trainers (usually a combination of teachers, student services providers, and health care providers) within school boards who become a local resource for newteacher training and support of current educators delivering the program. Program evaluations of mental health literacy outcomes for teachers directly trained by developers of the Guide demonstrate significant improvements in teachers’ knowledge and attitudes with effect sizes (Cohen’s d) ranging from 1.4 to 1.8 for knowledge
Box 2 The Guide (www.teenmentalhealth.org) Teacher’s self-study guide Teacher’s knowledge self-assessment Student evaluation materials 6 core modules The stigma of mental illness Understanding mental health and wellness Information about specific mental illnesses Experiences of mental illness Seeking help and finding support Importance of positive mental health
237
238
Kutcher et al
and 0.5 to 1.2 for attitudes.12,34 Recent evaluation of the train-the-trainer model has been conducted in different Canadian sites to ensure the knowledge transfer to teachers remains consistent. In the Province of Nova Scotia, each of the 9 school boards across the province has developed a training team that was trained by the program developers. Each training team consisted of classroom teachers, student services providers, and health/mental health professionals. Results from each train-thetrainer session demonstrated similar highly positive and substantial results with no significant differences between groups noted. Each of the teams applied their training by teaching teachers in the use of the Guide. Results demonstrated highly significant (P
