Analysis of a Mental Health Literacy Curriculum and Self-Care Resource Database as a Path to Reducing Stigma in Young Adult Population

Abstract

According to the World Health Organization (WHO), mental health is defined as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (World Health Organization 2018). A human being is not a human being without considering both their physical and mental health. Society has bred a stigma encompassing mental illness, prompting numerous individuals to feel as though a conversation about psychological well-being is unusual or unorthodox. The COVID-19 pandemic has witnessed an escalation in mental illness especially in the young adult population (ages 11-24), as a result of social isolation and decreased faceto- face connection with others. The adolescent and young adult population is vulnerable to mental health issues and is being cultivated in a society where conversations are not held. This study will evaluate the implementation of mental health literacy curriculums into several school systems, as mental health promotion should be mainstreamed to mitigate the potential growth of stigma in the future.

Keywords: Mental health; Stigma; COVID-19 pandemic; Mental health literacy curriculum

Introduction

Mental health issues are a large-scale public health concern, notably among the adolescents and young adult population (ages 11-24) worldwide. Studies proclaim that children and adolescents in Rwanda encounter depression-like symptoms locally recognized as agahinda gakabije (persistent sorrow) and kwiheba (severe hopelessness). Several other determinants contribute to the surge in depression levels in Rwanda. Based on previous research, the prevalent mental health disorders in Rwanda were used as the foundation for content analysis and measurement of the efficacy of mental health literacy programs.

Investigations illuminate that school- based mental health literacy intervention is effective in improving mental health awareness and decreasing stigma among the general population. The impact of the Mental Health & High School Curriculum Guide (The Guide), a school-based mental health literacy resource developed in collaboration with mental health experts and the Canadian Mental Health Association (CMHA), was evaluated as a school-based mental health literacy resource [1]. The use of a mental health curriculum in Tanzanian school systems has proven to be effective especially for the promotion of mental health, stigma reduction, and self-care databases. The installment of mental health literacy into established school curriculums can conceivably be effective in reaching adolescents and members of the 11-24 age group worldwide. The goal of such classroom-based programs is to normalize mental health and motivate teachers to become literate in recognizing mental health in students [2].

Currently, there is limited research on classroom-based educational activities in the country of Rwanda. School-supported information that relates to mental health literacy is limited in sub- Saharan Africa [3]. However, studies conducted in Tanzania and Canada illustrate that schools are an ideal venue to instill mental health literacy into the population. Self-care programs and databases addressing conditions specific to the Central African region (e.g., depression, post-traumatic stress disorder, and anxiety) may be useful to improve the general knowledge of mental health disorders and help-seeking efficacy for students in the young adult population.

Methods

Content analysis

Content analysis was performed on secondary data collected from several publications to assess the prevalence of mental health issues, particularly depression, anxiety, and Post-Traumatic Stress Disorder (PTSD), in Rwanda and the interconnectedness of mental health literacy with self-care practices. The research referred to numerous pieces of previous surveys conducted on topics related to mental health and self-care across the globe and Rwanda in particular. Different transcripts were analyzed and notes were gathered on several scholarly articles about mental health disorders, education, stigma, and self-care worldwide. Following analyses of sources, similarities were noted across all of the content to evaluate the mental health issues that are most prevalent in the Rwandan region amongst the 11-24 age group. The most valuable sources were used to construct an effective background to the research conducted. In addition, the information that was gathered about the mental health status among the young adult population was used to create questions for the interview with the clinical psychologist in the study.

Participants

The participants being interviewed in this study included a clinical psychologist that has been employed as a counselor for 9 years providing counseling and advisory services on mental health among the members of the 11-24 age group. She has collaborated mostly with students from higher education institutions in her career.

Materials

An informed consent form was used containing information about being a key informant in the study, the basis of voluntary participation, and the benefits and risks of participating. Multiple open-ended questions were set for in-depth research. The inquiries emphasized the prevalence of mental health in Rwanda, the impact of COVID-19 on the mental health of the young adult population, and the potential implication of a mental health literacy curriculum and self-care resource database into various school systems in the region.

Design and procedure

The research design of this study was non-experimental and descriptive as it examined the presence of mental health in Rwanda and the efficacy of implementing a mental health literacy and selfcare curriculum. After obtaining informed consent, an interview was scheduled with the respondent. The research was conducted virtually on an online application. After the interview was completed, the responses of the participant were recorded for further analysis.

Results

The research design was based upon data accumulated from extensive content analysis in addition to a formal interview. Directed search terms were used to aggregate data from Google Scholar and other published platforms. Data were collected from studies that centralized on the statistical evidence of mental health in Rwanda, implementation of Mental Health Literacy (MHL) curriculums into school systems, and self-care databases. In Rwanda, of 367 children and adolescents aged 10 to 17 years, 71.9% report the presence of depression-like symptoms locally known as agahinda gakabije (persistent sorrow) and kwiheba (severe hopelessness).

The prevalence of mental health illnesses in Rwanda, more specifically out of 12 million Rwandan population, a range of 24.8% to 46.4% suffer from Post-Traumatic Stress Disorders (PTSD), 15% are living with depression, and about 58% have anxiety symptoms [4]. Similarly, research conducted on depression ubiquity in Rwanda youth heads of household indicated that of 539 youth heads of household, 80% rated their health as fair or poor and their mean score on the Center of Epidemiologic Studies Depression Scale was 24.4 [5]. Research conducted on depression and anxiety faced by a mother during the perinatal and postnatal period indicates that depression and anxiety can have serious effects on women’s mental health as well as that of their infants, this has been evident in Low and Middle- Income Countries (LMICs) such as Rwanda where according to the research by Marie P et al. [6], 37.6% of the women in the antenatal period had depressive symptoms and 28% had symptoms associated with clinical levels of anxiety.

As per research conducted by Madeleine M. and Geraldine C., they found out that 83.8% of their respondents who were diabetes mellitus patients had depression [7]. According to springer.com, the likelihood of HIV patients suffering from depression is higher with a range from 10 to 37% of children and adolescents with this sort of virus are disproportionately affected by depression compared to their peers. The data indicates that there is a high number of adolescents affected by mental health issues in Rwanda and adults with underlying health issues such as diabetes mellitus and HIV/AIDS. In contrast, studies from the United States and Australia reported symptom based measures of depression and anxiety to increase for both males and females, while Canadian reported either an increase for males alone or no change. In 2019, a study conducted in the United States reported an increase in the past-year prevalence of suicidality (suicidal ideation, plans and attempts) from 2008 to 2017 among 18- 25 years old youth (sex differences were not examined) [8].

In a study conducted in 24 high schools (534 students) in the regional area of Ottawa, Ontario, Canada, researchers discovered the impact of “Healthy Living” courses on mental health knowledge and stigma by implementing a training program for teachers to gain knowledge of the benefits of a mental health curriculum. There was a significant change in knowledge scores over time, which resulted in overall positive attitudes toward mental health [9]. Furthermore, in an initial training program in Tanzanian school systems, 84% of the teachers reported that they had identified students who had a mental health disorder, thus illustrating an improvement in help-seeking efficacy [3].

A one-on-one interview was conducted with a clinical psychologist from a school system in Rwanda. When asked what the level of understanding of mental health that Rwandan university students have, she described that there is the presence of stigma surrounding mental health in the population. The respondent noted that most students “feel as though it is not their issue and end up not seeking help and/or supporting their colleagues”. The most prevalent effects of the mental health disorders that were mentioned in the qualitative research included lack of motivation, extreme sadness, suicidal tendencies, and depression.

The respondent was invited to describe a student’s mental health status amidst the COVID-19 pandemic. The clinical psychologist described that most students exhibit a “lack of support and motivation from peers due to the fact that during the pandemic they could not meet up and socialize with their peers hence fueling loneliness and anxiety.” In addition, she described that the COVID-19 pandemic has “led to financial constraints which increased depression and despair in the young adult population”.

At the respondent’s university, it was discovered that students rarely check-in for mental health due to the prevalence of a culture where individuals do not feel comfortable about “sharing their suffering with others”. She cited a Kinyarwanda proverb that stated “impfura ishenjagira ishira,” which meant that even when an individual is hurting, they have to keep a smile. She emphasized that one must receive training about the importance of mental health to normalize help seeking.

The respondent admitted that mental health illiteracy negatively influences adolescents and the members of the 11-24 age group in both an academic and social setting. When asked to describe her experiences, she stated that students who were unable to open up and speak about their issues had increased difficulty in seeking help and beginning the healing process. In an academic sense, productivity levels were affected when students did not seek help and resulted in them failing to perform properly. The respondent mentioned that the universities equipped with mental health institutions and counseling opportunities were more likely to improve the well-being of the students in the population. The example that she used to describe this occurrence was the presence of basketball courts on campus. These were a source of an extracurricular activity for students to have a break from studies and illustrated that the university values the mental well-being of the student population.

The respondent discussed the implication of a self-care resource database into school systems in Rwanda. She talked about practices such as sports activities, playgrounds, libraries, and other activities that bring students together and allow them to share and have fun. She added that all these activities were brought to halt by the COVID-19 pandemic and that the only support that remained available to students were mental health workshops and counseling sessions. However, she made it clear that those online mental health workshops, training, and counseling sessions cannot replace the activities that students used to enjoy together before the pandemic. When asked about the idea of integrating mental health therapy into a school environment to help deal with mental health issues among students and teachers alike, the respondent said “that would be a great solution, actually schools should have that, sometimes I wonder what happens with schools that do not have such mental health services, because how do they deal with suicidal students or depression issues as they rise?” She went on to suggest “I feel like schools should have those facilities to ensure that students’ mental wellbeing is taken into consideration.” The respondent also touched on what she believes a self-care resource database would be useful for, where she said “it would be extremely helpful because the problem that most people have is that they are not aware,” so an informative self-care resource like brochure would very much help educate people on mental health, making it easy to seek support and reduce the surge in mental health illnesses.

Discussion

The impact of a self-care resource database on the young adult and adolescent population (ages 11-24) during the times of the COVID-19 pandemic was evaluated in this study. In line with the research question, qualitative research revealed that a self-care resource database would positively affect the student population at a Rwandan university. The outcomes suggest that the implementation of a classroom-based resource into an existing academic curriculum would be a sustainable way to increase the mental health literacy of students in the region. This has been evident in countries like Canada where a curriculum was integrated into various school grades and “Healthy Living” courses were delivered [1]. An evaluation was carried out and changes in mental health literacy and stigma were measured with the help of pre-test and post-test questionnaires, and as a result, there was a significant change in student knowledge scores over time [10,11].

In the interview conducted with a clinical psychologist from a higher education institution, it was revealed that most students do not feel comfortable seeking help and/or supporting their colleagues. The most prevalent mental health disorders that she encountered in her experiences with counseling included lack of motivation, extreme sadness, suicidal tendencies, and depression. This builds upon the previous research that Rwandan children and adolescents experience agahinda kenshi (persistent sorrow) and kwiheba (severe hopelessness) on a daily basis [12].

An interview was used as a qualitative research technique for this study, which proved to be useful for obtaining the story behind the individual being interviewed. The questions asked during the interview allowed in-depth information to be pursued regarding mental health education [13], mental health stigma, self-care resources, and a mental health literacy curriculum. Data from both secondary analysis and the interview confirmed the need for developing self-care resource databases especially in schools and other institutions that predominantly have a young adult population as members. In the interview, the respondent stressed that instilling self-care practices in these schools and institutions is key when dealing with mental health and that it would help eradicate the stigma attached to mental health and increase the desire to seek professional help. The stigma stems from mental health illiteracy and that is why creating self-care resources such as brochures, podcasts, mental health magazines et cetera, can be very crucial in educating this population about mental health, increasing help-seeking efficacy, thus, reducing the rates of mental health cases [14,16].

There are strengths and limitations to qualitative research interviews that may have impacted the efficacy of this study. Interviews are more personal than questionnaires and can be guided in a more focused direction based upon the information that the respondent provides. The generalizability of the results is limited by time and the virtual format, as a statistical analysis was not able to be conducted. The reliability of this data is impacted by the use of qualitative research techniques. A closed, fixed-response interview or survey where all interviewees are asked the same questions was not able to be conducted due to time constraints and the virtual format. It is beyond the scope of this study to assume the efficacy of a mental health literacy curriculum in the respondent’s Rwandan university; however, one can infer that it would be an effective method to reach the individuals aged 11 to 24. Further research is needed to establish a specific curriculum that would be applicable in each school system.

Conclusion

This research strived to identify ways in which a self-care resource database would positively impact adolescents and young adult populations (ages 11 to 24). Based on the information gathered from both content analysis and interviews, the results imply that the implementation of a classroom-based resource into an existing academic curriculum would be a sustainable way to increase the mental health literacy of students in the region. Therefore, it can be gathered that a self-care resource database is very crucial in helping this population obtain sustainable mental wellness. This research clearly demonstrates the significance of the existing mental wellness strategies for adolescents and young adult populations in schools such as sports activities, libraries, clubs, and other extracurricular activities. However, it also raises the issue of mental health illiteracy, a phenomenon that limits help seeking and increases stigma correlated with mental health. Based on these findings, a school mental health literacy curriculum should be contracted to educate this population about mental health in order to normalize help seeking and alleviate the stigma attached to it. However, further research is necessitated to establish a specific curriculum that would be implemented into focused levels of education and school systems.

Declaration

Availability of data and materials: The data supporting the findings are available in this article.

Authors’ contributions: Both authors (Sam Muhanguzi & Brooklyn A. Bradley) collaboratively worked on each segment of this paper from data collection to data analysis, and writing the final report.

References

1. Mcluckie A, Kutcher S, Wei Y, et al. Sustained improvements in students’ mental health literacy with use of a mental health curriculum in Canadian schools. BMC Psychiatry. 2014; 14: 379.
2. Kutcher S, Wei Y, Gilberds H, et al. A school mental health literacy curriculum resource training approach: effects on Tanzanian teachers’ mental health knowledge, stigma and help- seeking efficacy. Int J Ment Health Syst. 2016; 10: 50.
3. Kutcher S, Wei Y, Morgan C. Successful Application of a Canadian Mental Health Curriculum Resource by Usual Classroom Teachers in Significantly and Sustainably Improving Student Mental Health Literacy. 2016.
4. Heim L & Schaal S. Rates and predictors of mental stress in Rwanda: Investigating the impact of gender, persecution, readiness to reconcile and religiosity via a structural equation model. International Journal of Mental Health Systems. 2014.
5. Neil W & Lisanne A. Depressive symptoms in youth heads of household in Rwanda. JAMA Network. Home of JAMA and the Specialty Journals of the American Medical Association. 2008.
6. Umuziga MP, Adejumo O & Hynie M. A cross-sectional study of the prevalence and factors associated with symptoms of perinatal depression and anxiety in Rwanda. BMC Pregnancy Childbirth. 2020; 20: 68.
7. Mukeshimana M & Chironda G. Depression and associated factors among the patients with type 2 diabetes in Rwanda. Ethiopian Journal of health sciences. African Journals Online. 2019.
8. Wiens K, Bhattarai A & Pedram P. A growing need for youth mental health services in Canada: Examining trends in youth mental health from 2011 to 2018. PubMed Central (PMC). 2020.
9. Milin R & Kutcher S. Impact of a mental health curriculum on knowledge and stigma among high school students: A randomized controlled trial. Science, health and medical journals. 2016.
10. Binagwaho A, Remera E, Bayingana AU, et al. Addressing the mental health needs of children affected by HIV in Rwanda: validation of a rapid depressionscreening tool for children 7-14 years old. BMC Pediatr. 2021; 21: 59.
11. Bolton Paul MB, et al. Prevalence of Depression In Rural Rwanda Based On Symptom And Functional Criteria. The Journal of Nervous and Mental Disease. 2002; 190: 631-637.
12. Galderisi S, Heinz A, Kastrup M, Beezhold J & Sartorius N. Toward a new definition of mental health. World psychiatry: official journal of the World Psychiatric Association (WPA). 2015; 14: 231-233.
13. Munyandamutsa N, Mahoro Nkubamugisha P, Gex-Fabry M, et al. Mental and physical health in Rwanda 14 years after the genocide. Soc Psychiatry Psychiatr Epidemiol. 2012; 47: 1753-1761.
14. Ovuga E, Boardman J & Wasserman D. The prevalence of depression in two districts of Uganda. Soc Psychiat Epidemiol. 2005; 40: 439-445.
15. Sachaal S, Weiestall R, et al. Mental health 15 years after the killings in Rwanda: Imprisoned perpetrators of the genocide against the Tutsi versus a community sample of survivors. Wiley Online Library. 2012.
16. Tomlinson M, Grimsrud A. The epidemiology of major depression in South Africa: Results from the South African stress and health study. South African medical journal. 2019.