Study Protocol: A Pilot Study Investigating Mental Health in the UK Police Force

Police workers in the United Kingdom suffer from poor mental health, which is exacerbated by stigma associated with mental health problems. Accordingly, this study protocol paper presents a pilot study aiming to appraise direct experiences of mental illness among police officers, and the culture in the police workforce towards officers suffering with a mental health problem, while evaluating the feasibility of a large study. Thematic analysis on semi-structured interviews was designed to capture their first-hand experience. Ethical considerations and dissemination plans were discussed.

Studies show that levels of police stress are probably linked to leadership style and culture (Silvestri, 2017), rather than the nature of the job (Deschênes, Desjardins, & Dussault 2018). These management styles have been shown to play an important role in work-related stress (Cox, Marchionna, & Fitch, 2017). Addressing these issues starts at an organisational level (Bell & Eski, 2016;Bullock & Garland, 2018). Officers may resist disclosing their mental illness, fearing the negative reactions they may receive from colleagues (Bullock & Garland, 2018;Kotera & Sheffield, 2017;Kurtz, 2008). In addition, officers would expect to face stigma if they disclosed that they were experiencing a mental illness (Stuart, 2017). Internal stigma, a culture of dominance and masculinity (Evans, Pistrang, & Billings, 2013), as well as emotional self-control (Bell & Eski, 2016) were identified as playing an essential role in influencing individual reactions to stress (Stuart, 2017) and has been noted as one of the key reasons officers resist seeking help (Stuart, 2017). It is worth mentioning that shame impacts an individual's decision whether or not to disclose their condition (Kotera, Green, & Sheffield, 2019a;Stuart, 2004). This is particularly evident in professions which encourage masculinity (Kotera, Green, & Sheffield, 2019b). Emotional responses to work-related stress are often perceived within police culture as a sign of weakness and not comparable with the masculine perception of policing (Kurtz, 2008), often leading to a distrust of colleagues' work performance (Heffren & Hausdorf, 2016).
The findings from this pilot study will help to determine whether a larger cross-cultural research study is warranted to address this international issue, given that prior research identifies poor mental health in police forces as a cause of concern in other countries (Carleton et al., 2018;Harman, 2019; The Centre for Addiction and Mental Health [CAMH], 2018). There is a need for better understanding of the attitudes towards mental illness and identifying ways of improving mental health management within the police force.

Aims and Objectives
The aim of the pilot study was to acquire a deeper understanding of the direct experiences of mental illness among police officers, and to examine the culture within law enforcement and perceptions towards officers suffering with mental ill health. The research also aimed to examine the feasibility of a larger study.
The objectives of the pilot study were threefold, namely: • To explore whether disclosure of mental illness has affected career prospects; • To explore the types of stigma experienced; • To examine how treatment of mental ill health of police officers could be improved.

Study Design
The study adopted a qualitative research design using thematic analysis (Braun & Clarke, 2006). All interviews were audio recorded and transcribed verbatim. Each transcript was thoroughly checked against the recordings to ensure accuracy. Data were analysed using a thematic approach (Braun & Clarke, 2006) to identify themes from the dataset. We used thematic analysis because this method is appropriate to investigate a relatively unexplored area (Braun & Clarke, 2006). This systematic process of data collection is used for identifying meaningful patterns in participants' accounts (Evans et al., 2013) and areas of particular interest in the dataset (Braun & Clarke, 2006).

Study Setting
Telephone interviews were conducted to allow minimal intrusion and to help participants feel at ease and more open to the discussion of their experiences.

Participants
Participants were British police officers. Those who were most likely to provide rich data on their experience within the police force were recruited. The mean age was 52 (range 43-62) years old, with a male predominance (four males and one female).
The mean length of their time in the police force was 24 years (range 18-30 years). Officer rank included police constable (N = 2) and sergeant (N = 3). Participants had experienced a variety of mental ill health conditions such as stress, anxiety, depression, and PTSD.

Eligibility Criteria
Inclusion criteria: 1. Participants were over the age of 18 2. Participants were serving officers with mental ill health, have been on sick leave due to mental ill health, or have left the police force due to mental ill health 3. Participants developed a mental illness during their time as a police officer 4. Participants disclosed or did not disclose their mental health condition to their manager/supervisor 5. Participants with English as their first language or have a good level of English language proficiency.
Exclusion criteria: 1. Police workers who did not speak English 2. Police workers who had not been diagnosed with a mental health condition 3. Police workers who had not recently been exposed to a violent crime or traumatic event which impacted their mental health

Informed Consent
Participants meeting the inclusion criteria were contacted and provided with a formal participant information sheet detailing the purpose of the study, what the study would involve for the participant, and what, if any, risks were involved in taking part in the study. They were advised that participation in the study was voluntary and they could withdraw at any time. Participants were also required to sign a consent form to confirm their willingness to participate.

Demographic Outcomes
We collected demographic data from all participants. The data included age, gender, ethnicity, marital status, level of education, officer rank, area of policing, and number of years in the police force.

Data Collection
To gain a deeper insight into the experiences of police officers, a qualitative study using semistructured one-to-one interviews was used. Interviews were conducted via telephone and lasted between 30-60 minutes. Interviews were audio recorded. A semi-structured interview format was chosen because it produces results that unfold the meaning of participant experiences, providing more deeper understanding of their thoughts, feelings, and beliefs (DeJonckheere & Vaughn, 2019).

Procedure
Participants' obligations and right to withdraw from the study was detailed in the information sheet, which detailed what the research was about and why they were invited. After informed consent was granted, participants were asked to complete general demographic information. The interviews were guided using a proposed interview schedule as a basis for open-ended questioning. Following completion of each interview, all participants were thanked for their time and received a formal debrief via email, reiterating the purpose of the study, details on their right to withdraw, and contact information of mental health services and the researchers themselves.  (5).

Risk Assessment
There were no intolerable risks or main areas of ethical concern identified during or following the study. Given the sensitive nature of the topic, it was important to put measures in place to protect participants should the interview cause them any psychological harm. The researchers were responsible for ensuring participant privacy and confidentiality, and providing details of who to contact should the interview cause the participant any undue distress.

Remuneration
Participants received no reward or incentive for taking part in the study.

Data Protection
The research staff ensured the privacy of all participants. Any information collected as part of the study was securely stored and accessible only by the research team. Participants were assigned a unique identification number to ensure anonymity, and processes were put in place to ensure participant confidentiality, which included any mention of names and places.

Study Limitations
The study was limited, notably related to the small sample size. To achieve a larger sample size, a more systematic approach to recruitment should be used, as the original sampling method did not result in a high enough response rate. Cautious interpretation should be given when generalising the findings of this study, due to its modest sample size, until a more comprehensive study has been carried out. In addition, only one participant was female. Future research should appraise police culture in relation to gender differences and the effect of mental health stigma on female officers. Despite its limitations, the study provides important directions for future research of mental health stigma among police workers.

Knowledge Gaps
The study identified one main area where gaps in knowledge exist: the attitudes of police-to-police mental health stigma (Deschênes et al., 2018). This gap in knowledge exists because of limited knowledge and empirical evidence or understanding of mental ill health in British policing (Bell & Eski, 2016). The present study offered useful insights into breaking stigma and barriers to help-seeking in police officers. To break the stigma of mental health problems and care for police officers, it is crucial to tackle the current challenges and demands of policing (Cox et al., 2017). The results of the present study concur with the findings of Gershon, Barocas, Canton, Xianbin Li, and Vlahov (2009), suggesting the importance of improved training and methods of delivery to include the daily challenges and demands of the police profession.

Outcomes and Dissemination
The results of the study will be shared with key audiences who have an interest in police research: • Academics and peer-reviewed journals • Police forces (UK and International) • Police Federation of England and Wales • The Blue Light Programme (set up by a mental health charity, Mind to support the mental health of emergency services personnel) • University researchers, including forensic and mental health departments.
Dissemination of these findings will highlight the lessons learned during the study and inform the design of a more comprehensive study. All participants will receive a summary of the final report. No raw qualitative data will be published.
The study findings will help to: • Raise awareness and improve understanding of the mental health issues and stigma that exists, and the challenges faced by officers • Engage with target groups • Contribute to studies in this underresearched area • Influence police policy and practice to help secure provision of support for officers experiencing mental illness