Self-harm (self-injury and self-poisoning) is a major global public health concern [1]. The rates of self-harm among young people, particularly those in their mid to late teenage years, has steeply risen [2], with reported prevalence in the United Kingdom at nearly 20% [1]. Early reports suggest that the COVID-19 pandemic is likely to have a long-term, negative effect on young people’s mental health [3], potentially increasing rates of suicide and self-harm [4]. Young people who self-harm are at high risk of adverse outcomes, including poor mental health in adulthood and an elevated risk of suicide [1,5]. Research indicates that approximately 19% of those who self-harm in adolescence are still doing so 10 years later, suggesting that it can be a persistent behavior [6]. Most young people who self-harm do not seek any formal or informal support as they are often unsure of who to speak to, try to cope with their problems alone, or believe that no one can help [7,8].

Schools play an essential role in early detection of students’ mental health difficulties [9] and supporting young people’s mental health [10]. Indeed, school staff are often the first professionals to notice a young person’s self-harm and are well placed to identify early signs and intervene to prevent severe outcomes [11]. However, many staff members report that they do not feel equipped or confident to respond to students who are self-harming and are fearful of responding in the wrong way [12-14]. This can result in negative or dismissive reactions to discovery or disclosure of self-harm, which in turn can increase a young person’s motivation to keep their behavior secret and decreases the likelihood of seeking help [7]. Some schools perceive disclosures of self-harm as a safeguarding concern, and their default response is to inform parents, which, if self-harm is a result of family difficulties, can aggravate rather than alleviate the problem. At worst, this can prevent young people from disclosing at school [15] and limit opportunities for adults to intervene.

Research shows that there is a need for staff training and policies to help schools address self-harm [16-20]. Currently, there are no national-level UK policies outlining how schools should respond to self-harm, and it is up to each school to develop and implement their own policies. There are a few information resources available for schools about self-harm and how to respond [21-23], but the evidence base for these resources is currently lacking.

A recent systematic review looked at the effectiveness, feasibility, and acceptability of training programs and support tools for school staff to respond adequately to young people who disclose self-harm [18]. The review found only 8 studies, which comprised 4 training programs, 2 workshops, a school policy, and a website, and all were based in Australia or the United States. The quality of the included studies ranged from weak to moderate, and there was an absence of randomized controlled trials and scarcity of follow-up data. The poor description of training content, lack of feasibility outcomes, and overall low quality of the included studies limit the suitability of these training programs for implementation in UK schools. Although participation in a training program increased staff confidence and knowledge regarding how to respond to pupils who self-harm, most programs lacked follow-up or refresher sessions. There was a significant decline in school staff’s perceived and objective knowledge over time, and participants expressed the need for additional ongoing support. The current best practice in mental health training stresses the importance of periodic follow-up to ensure appropriate implementation of skills learned [23]. These findings highlight a clear need for staff training and policies to help school staff address student self-harm and the importance of having ongoing access to training to help participants consolidate and sustain acquired knowledge and skills.

In a UK survey, just over half of school staff reported having received some training on self-harm, but only 22% rated the training as good [21]. Staff wanted greater organizational support, knowledge, and skills to effectively support pupils who self-harm [13]. School staff reported that a lack of time, training, and resources are barriers to effectively addressing self-harm and they would like good-quality evidence-based training [18]. Web-based training programs can be developed and maintained at a relatively low cost [24]. The cost of delivery is also very low compared to programs delivered face-to-face [25], and there is evidence suggesting that web-based teacher training is more cost-effective compared to training delivered in person [26,27]. Web-based programs, unlike those delivered face-to-face, are flexible and can be completed at a pace and time convenient for users, which is particularly important for busy school staff [25,28,29]. There is evidence suggesting that low cost and flexibility increase the feasibility and acceptability of school-based programs and contribute to their successful implementation and adoption [30].

There is a paucity of evidence-based programs designed specifically for school staff [13]. To address this need, this study aimed to coproduce a web-based training resource for school staff to respond to students who self-harm that could be implemented in schools. This early prototype development involved collaborative work with different stakeholders, including young people, school staff, and experts in mental health and self-harm. Coproduction ensures that the knowledge generated is shaped by the requirements of the target users and remains relevant within their specific local context [31]. Involving stakeholders at all stages of intervention development aligns with the Medical Research Council guidelines for complex interventions [32], and this approach is particularly important for interventions targeting complex social systems [33]. In this paper, we describe the design and development of the Supportive Response to Self-Harm (SORTS) prototype, which serves as an exemplar of how involvement of stakeholders can inform the development of web-based training programs and optimize uptake and user engagement.

Ethics approval was granted by the University of Cambridge Department of Psychology Ethics Committee (reference: PRE.2022.053). Electronic consent was obtained from participants, and parental consent was obtained for young people aged <16 years. Participants were informed that their data would be kept confidential and that no individuals would be personally identifiable in the data collected in the study. Transcripts were deidentified and each participant was given a unique alphanumeric code. All participants completed a web-based demographic form before the sessions. Young people received a £20 (US $24.74) shopping gift voucher and school staff received a £40 (US $49.48) gift voucher as a thank you for their time.

Considering the sensitivity of the topic in this research, it was important to engage with members of the public from the start of the study to ensure that the study aims, procedures, and public-facing documents were acceptable and accessible. We held meetings with 9 members of the public (young people: n=4, 44%; parents: n=1, 11%; school staff members: n=2, 22%; and members of a young people’s mental health charity: n=2, 22%) to advise on study procedures and steer the project. Members reviewed the study materials (eg, participant information sheets and consent forms) and gave feedback on the proposed methods and topic guides. Early feedback from members of the public helped shape the study design and considerably improved the study materials, ensuring that public-facing documents were easy to read for potential participants.

The theoretical underpinning of the SORTS program is the self-efficacy theory by Bandura and Adams [34]. Bandura and Adams [34] describe self-efficacy as one’s beliefs about their capabilities to plan and execute actions that are required to produce a desired outcome. Studies show that teachers with a high level of self-efficacy are more confident and effective in their teaching as well as in classroom management and are viewed by students as more competent and trustworthy [35]. Teachers’ attitudes and confidence in supporting students’ mental health may be determined by their knowledge, interests, past experience, and self-efficacy [36]. The theory of change hypothesis is that completing the SORTS training program will lead to improved school staff knowledge about self-harm and increased confidence when responding to students who self-harm, which in turn will facilitate student help seeking and earlier access to support. The theory of change will be revised iteratively throughout the project as new findings emerge.

The SORTS training program aims to (1) improve staff knowledge of self-harm, (2) build staff confidence when responding to self-harm, (3) provide resources for schools to support students, and (4) foster a whole-school approach to self-harm. We developed a logic model (Multimedia Appendix 1) based on the literature and relevant theory. This shows how the SORTS training program might lead to an improvement in school staff’s knowledge about self-harm, increase their confidence when responding to students who self-harm, and facilitate student help seeking and early access to support. Moreover, it shows the mechanisms through which the intervention would be expected to work to support staff and improve outcomes for young people and provides a theoretical framework that will be tested in the next evaluation phase.

This study was underpinned by a user-centered design and person-based approach, which uses in-depth qualitative methods to capture the perspectives of potential end users and other relevant stakeholders throughout the stages of intervention development and evaluation [37-39]. Gaining insight into people’s views at the early stage of intervention planning, combined with existing theory and evidence, can inform the aims and key characteristics of the planned intervention and increases intervention acceptability and feasibility [39-41].

We commissioned a technical developer at the start of the project to create a high-fidelity user interface (UI) design and concepts and held a series of coproduction meetings with a panel of subject matter experts to develop the training content. In parallel, we conducted focus groups with young people to understand their expectations of how schools can best support pupils who self-harm. Focus groups are a particularly useful method of data collection in exploratory research because they allow the conversation to move in directions that may not have been anticipated by the researchers [39]. Findings from focus groups with young people were carried forward to the co-design workshops, where we discussed staff’s views and knowledge of self-harm and shared the training content and UI designs. Consultations with staff informed the final prototype specification. Figure 1 shows how the prototype was informed by the literature, focus groups, workshops, and other consultations.

All focus groups and workshops were recorded, transcribed professionally, and thematically analyzed using the framework method [45]. The transcripts were checked for accuracy, and all identifying information was removed before being entered into NVivo (version 12; Lumivero) for data management. An analysis plan was drawn up in more detail to guide members of the research team through the analysis. It broadly followed the following stages: transcription; familiarization with the interview; coding; and development of a working analytical framework, application of the framework, charting of data into the framework matrix, and interpretation of the data. The team (AMB, PH, and JA) began by familiarizing themselves with a subset of transcripts from each participant group and using a combination of deductive and inductive coding. Team members met to discuss how the codes could be grouped into categories, and these formed 2 initial working analytical frameworks (one for student data and one for school staff data). The working analytical frameworks were entered into NVivo and applied to all transcripts. Once all the transcripts had been coded, Microsoft Excel (Microsoft Corp) framework matrices were generated, which enabled the data to be charted by PH and AMB. This involved creating detailed summaries in each cell of the matrix while retaining key verbatim quotes. Team members met regularly to discuss potential themes and interpret the data.

A total of 11 young people participated in the focus groups; they were aged 14-21 (mean 16.5; SD 2.38) years. All participants lived in the South East England and East of England regions and were of White ethnicity (Table 1). In total, 82% (9/11) of the young people said that they knew someone who had experienced self-harm, and 18% (2/11) reported that they had self-harmed personally.

A total of 16 school staff members (n=11, 69% female and n=5, 31% male) were recruited from 2 schools in the East of England for the workshops. The staff worked in a range of roles, and their experience ranged from 2 months to 23 years (mean 8.7 years; Table 2).

The qualitative findings from the staff workshops informed the design of the final prototype specification. On the basis of participant feedback, the training content was edited to be more concise, and the language was made more accessible. The training content and resource toolkit were finalized (Textboxes 2 and 3).

The research and technical teams worked closely to implement the changes to the website design, and a number of UI features were used to improve the content structure and presentation across both desktop and mobile platforms. Some graphical elements were removed from the UI because they did not match participants’ expectations, and new elements were added to aid navigation (eg, drop-down menus, “call to action” features, and navigation links to show a suggested direction of training modules). In response to feedback, we minimized the scroll length by introducing a carousel feature for project logos, linked the logos to organizational websites, and introduced a “download all” function for the school resource toolkit. Background and accent colors were used to separate the training topics and design elements incorporated to enhance the UI (eg, pull-out quote; 4 special information modules [Facts, Warnings, Recommendation, and Did you know]; expandable accordion for Resources, Download, and Sources; ways to share the page; and quick access to other pages using “Previous or Next” modules; Figure 5). Participants suggested that stand-alone e-learning modules would complement the existing training content, and these will be developed in the next iteration of intervention development.

This paper describes the collaborative design and development of the SORTS training intervention, which aims to increase school staff’s knowledge, skills, and confidence in how to respond to self-harm. We anticipate that by equipping school staff with the skills and strategies to identify and respond to self-harm, this will encourage students to seek help, prompting staff to initiate linking students with appropriate resources and support. Although the SORTS program has been developed for staff in secondary schools, it also has the potential to be integrated into other educational settings, including youth organizations.

The SORTS training program fits with the UK policy drive for schools to have responsibility for identifying students with mental health difficulties and facilitate referrals to appropriate services [10]. School staff are often the first professionals to notice whether a student is self-harming [11] and the first professionals that parents contact about their child’s well-being [46,47]. Therefore, staff are well placed to intervene and prevent escalation [16]. The review that informed this study found very few training programs and support tools for school staff to address self-harm [13]. The review’s findings showed high acceptability of the interventions and tools, improvements related to knowledge about self-harm and how to respond, confidence in responding to disclosures, and change in response to young people who disclose self-harm. However, the training interventions were poorly described, lacked follow-up data, and had limited applicability to the UK context.

The early prototype development described in this paper involved a review of the evidence base and collaborative work with different stakeholder groups, including young people, school staff, and experts. This is an ongoing iterative process, and work will continue with stakeholders in the next stage of intervention development and evaluation [40,48]. This is in line with the Medical Research Council guidance for complex interventions, which specifies that “appropriate users” should be involved at all stages of development [39]. Our framework of coproduction demonstrates how we drew upon the expertise of stakeholders in the development process to address their requirements and maximize acceptability, feasibility, and future uptake of the intervention [49]. This is particularly important for interventions intended for complex social systems such as schools [33].

Consistent with previous research, our participants reported that there is limited training for staff about self-harm [13,16-18] and some feel ill-equipped to manage a disclosure [17]. Our participants were concerned that a poor response from a staff member could potentially escalate the situation and deter students from engaging or that staff lacking in confidence may avoid responding at all, which could delay putting support in place. This resonates with previous research, which has found that staff lacking in knowledge and confidence may respond negatively [14,17,20]. Moreover, students are often reluctant to seek help because they worry about receiving a negative response [14,20,48,50]. Overall, the school staff in our study would like universal in-service training to build capacity to recognize and refer students who are self-harming and facilitate effective communication with students and parents.

Our findings also indicate that staff think that the SORTS training intervention will be acceptable and practical for schools. Staff provided feedback on the training content and UI design, which included improvements to the intervention and its implementation. In addition, they recommended developing separate scenario-based e-learning modules for future work. In line with the usability heuristics by Nielson [51], staff wanted a simple, neutral UI design and “chunking” of textual information so that it was easier for users to read and comprehend [52,53]. In response to stakeholder feedback, UI elements that did not match participants’ expectations were removed, and navigation functionality was added. We made the resources more prominent because participants highlighted that staff may need to access information quickly. Similarly, Bakker et al [54] emphasized the importance of quick access to information about crisis support in technology-based interventions.

In terms of implementation, senior staff suggested that the training could be embedded within new staff induction programs or within staff protected time for CPD. Developing scenario-based e-learning modules would provide schools with more flexibility for integrating the training into the school context. Time and cost may be potential barriers to implementing training in schools [55]; however, web-based training programs can provide flexibility and overcome these potential barriers [30].

The SORTS training program was discussed as part of a broader culture that would encourage a whole-school approach to self-harm, including psychoeducation for students and parents and developing a school policy tailored to the school context. Similarly, a recent study recommended a whole-school approach and that staff be provided with training, resources, and guidance to respond effectively to students who self-harm [56]. In our study, young people discussed how the stigma surrounding self-harm may prevent help seeking. Students are most likely to disclose to a member of staff whom they trust and feel connected to and within an environment that fosters a supportive culture for mental health. Young people felt that it was important for schools to train staff, include self-harm in the curriculum, and develop a policy so that students understand what the process will be if they disclose. On the basis of these findings, we propose that the SORTS training program be implemented as part of a whole-school approach to self-harm, which is illustrated in Figure 6.

User-centered and person-based approaches offer rich information about stakeholders’ perspectives, which helps ensure that new interventions are meaningful, acceptable, and feasible. These strengths notwithstanding, there are several limitations to consider in relation to the findings. School staff were recruited from schools located in 2 towns in the East of England, and their views may differ from the views of staff in other areas of the United Kingdom and in schools situated in more rural or urban areas. Staff participants were contacted and selected by the mental health leads in each school, so it is possible that many of the staff members we spoke to had a specific interest in mental health training. A range of school staff members were included in the sample, although members of the administrative team were not represented, and their views were not captured in this study. We acknowledge that our sample of staff and young people lacked diversity in terms of ethnicity, and future work should be conducted in more ethnically diverse schools.

Our study highlights the importance of involving multiple stakeholders in the early stages of intervention development. In response to feedback from staff, the next stage of prototype development will involve the development of 2 scenario-based e-learning modules to be incorporated in new staff inductions and staff CPD time. The design and development of the e-learning modules will be coproduced with school staff and experts. Once intervention development is complete, we will conduct user testing of the SORTS prototype to identify and fix any usability problems. Furthermore, we will carry out a mixed methods pilot evaluation to explore acceptability, feasibility, and effectiveness of the SORTS program with specific emphasis on recruiting schools from diverse areas to explore the impact on marginalized ethnic minority groups; lesbian, gay, bisexual, transgender, and queer youth; and young people with special educational needs. Should the intervention prove effective in further evaluation, we hypothesize that school staff’s improved knowledge and confidence will lead to more appropriate responses that will encourage pupil disclosure and facilitate access to available on-site and external support. In line with a whole-school approach, the SORTS program will be expanded to provide information and resources for young people, families, and community partners.