Exploring the knowledge and attitude of public about mental health problems: A pilot intervention for effective mental health promotion.

CONTEXT: The knowledge about mental health problems among the general public is comparatively quite low. The pilot study was conducted with an aim to increase the knowledge of the day-to-day mental health problems which people can have among the mass. AIMS: The aims of this study are (1) to assess the knowledge and attitude about mental health problems of the selected sample and (2) to build the capacity in providing first aid for mental health to the selected sample through training. SETTINGS AND
DESIGN: A cross-sectional study was used in assessing the knowledge and skills of the participants of the first aid for mental health problems. It was conducted in the institute itself. SUBJECTS AND METHODS: A total of 89 participants were taken to participate in the cross-sectional study. Using a semi-structured self-administered questionnaire, a brief training, and a feedback form, capacity building for first aid for mental health problems was provided. STATISTICAL ANALYSIS USED: The questionnaires were analyzed using descriptive statistics.
RESULTS: The capacity building program for first aid for mental health problems appears to be effective in improving the knowledge and attitude with regard to the mental health problems. The findings from the program indicated lack of knowledge in understanding of mental health, knowledge of causation, and treatment of mental health problems. Feedback of the training program indicated that it improved the ability of the participants in recognizing persons undergoing mental health problems and brought about a change in their beliefs about mental health, attitudes, and need for prompt referral.
CONCLUSIONS: The program was successful in increasing the confidence of the participants in providing help to someone with a mental health problem and referring to appropriate mental health professional. This shows that there is an immediate need for empowering general public with knowledge and skills to provide support to people with mental health problems. Copyright:

Introduction

Mental and behavioral disorders account for about 12% of the global burden of diseases. This is likely to increase to 15% by 2020.[1] As the numbers are spiraling, the community continues to lack awareness when it comes to identifying and intervening when a person is affected with mental health problems.

Studies have shown that not all are able to receive adequate consultations with professional mental health-care services and that there is a long delay between the recognition of the mental disorders and the help provided for those who received a consultation.[23]

Although people widely accept the public knowledge imparted about physical health problems, there is negligence of knowledge acceptance when it comes to mental health literacy.[4] This ignorance adds to the stigma of mental health problems and prevents people from talking and seeking help early, as well as providing help for mental health problems. To address this issue, attempts have been made by some countries to conduct programs at the community level for providing first aid for people having mental illnesses. A typical first-aid program consists of sessions for identifying symptoms of mental health disorders such as acute suicidal thoughts, depressive, anxiety, or psychotic behavior, their possible risk factors, and how to get professional help. One such program which deserves a mention is the young Mental Health First Aid (MHFA) program, conducted in Australia with an aim to help adults learn skills required to recognize early signs of mental illness of adolescents and provide help as and when required.[5] With respect to mental health disorders, mention should be made of training in MHFA which was conducted yet again in Australia, specifically planned for eating disorders. The program yielded quite positive results, thereby facilitating early intervention of the disorder.[6] Based on the positive feedback on these training programs, similar training programs were conducted for the Chinese as well as Vietnamese communities in Melbourne, Australia, to help members of these communities to identify persons with mental illness (depression and schizophrenia) and help in seeking treatment.[78] As culture plays an important part when it comes to disseminating mental health literacy, such training programs were conducted, specifically for various cultural groups within Australia, like for the Australian Aboriginals and Torres Strait Islander people.[9] Such MHFA training programs for identifying mental disorders, after gaining such positive results, have begun to roll out in other countries as they are being accepted world-wide as an excellent method of empowering people at a community level as well as increasing mental health literacy.[10] However, what is crucial to notice is that all these programs concentrate on mental health illness in particular, and not mental health problems faced by almost everyone on a day-to-day basis. To bring out the differences between mental health illness and mental health problems, it can be said that mental health illnesses are those, which are diagnosable as forms of clinical disorders by a psychiatrist, while mental health problems arise out of social, psychological, and physical effects which are not intense enough to be diagnosed as disorders. Mental health problems can occur on a day-to-day basis and should be addressed adequately so that it does not turn into any form of full-blown disorder. In order to be a responsible member of a community, one should not remain ignorant of the signs and symptoms of these mental health problems a person may face community. Efforts should be made in identifying these, as they can act as a predisposing factor to a forthcoming mental illness in an individual. It is thus of utmost importance and need of the hour to find ways for empowering general public with knowledge and skills to provide support to people with mental health problems.

Based on our objective of assessing and increasing knowledge and skills of identifying general mental health problems that an individual can face, we developed a first of its kind, a 3-h capacity building program on first aid for mental health problems for the community. This initiative is quite different from the other first-aid training programs where mental illness is emphasized in particular. The objective of the program was to assess and increase the knowledge of mental health problems and build the skills needed to intervene, assist, and refer individuals experiencing a mental health issue.

Subjects and Methods

Ethics

The study was approved by the Institutional Ethics Committee with the ethical code of National Institute of Mental Health and Neuro Sciences (NIMHANS)/EC (BEH.SC.DIV.)/16th MEETING/2018/5.06.

Design

A cross-sectional study was used in assessing the knowledge and skills of the participants of the first aid for mental health problems.

Participants

The program was advertised in the institute website, and participants comprised of college students, lay counselors, and teachers enrolled for it. Eighty-nine participants participated in the program.

Tools

Everybody who got registered were given a 19-item semi-structured self-administered questionnaire developed for the program in order to assess the knowledge and attitude with regard to mental health with ratings of (1) agree, (2) disagree, and (3) not sure. A feedback form was given after the completion of the training. The items were given to the five subject experts for validation. Once validated, the final questionnaire was prepared.

Setting

The program was conducted at the Department of Mental Health Education, NIMHANS, Bengaluru, India.

Intervention

The faculty from the Department of Mental Health Education, Clinical Psychology, and Psychiatry implemented the program. The faculty are experienced and qualified in providing the capacity building programs. Fulfilling the aims of the program and the following steps cited above, the training was implemented. After the registration, the participants were given a 19-item semi-structured questionnaire. The training lasted for 3 h. Using various methodologies such as brainstorming, interactive sessions, role plays, and group activities, the participants were asked to list of crises which could trigger a mental health problem. The participants were split into four groups each and were asked to brainstorm. The group cited sexual assault, bullying, migration, separation from family, health issues, avoiding school, death, loss of any kind, issues related to elderly, accident, etc., The participants were further asked to list how these crises which people experience could manifest as behavioral and emotional issues. The participants through group activities reported manifestations such as being easily tearful; worry and anxious; aggressive and irritated; social withdrawal; refusal to go to school/college/workplace; thoughts of self-blame; and feeling of hopelessness, feeling of helplessness, and many more. Role play was used as an effective medium to know how one can approach the person undergoing mental health problem without being judgmental and communicate effectively. Referring the person to mental health professional and self-help strategies that the participants can implement was discussed and stressed on. The participants were also asked to take care of their mental well-being and health in the process of facing the challenges. After the training, a feedback form was given to all the participants for feedback.

Procedure

As mentioned, 89 participants registered themselves for the training program through the institute website as well as advertisements in department's bulletin board and in social media platforms. As a part of the pilot study, the participants were given the initial assessment questionnaire for the assessment of knowledge and attitude that the public commonly hold toward mental health problems. It was an easy to follow, simple, and self-administered questionnaire which was collected back once filled. Following this, the 3-h training intervention was given to the participants, for a better understanding of the mental health problems, helping them build skills to assist people facing a mental health crisis, as well as referring them to proper channels, thereby fostering treatment procedures. The brief 3-h capacity building program included the following steps [Table 1].

Table 1

Steps to provide first aid for mental health problems

Identify the signs of a mental health problems

Avoid being judgmental

Encourage professional help

Build up coping strategies

The above criteria were met with the help of training using techniques of role play, video demonstration, brainstorming sessions, and group discussions. The steps are applied to various mental health problems that might surface when a person faces crisis such as bullying, ragging, low mood, anxiety, migration, violence, trauma, and death of a near one to name a few. Majority of the studies have focused on providing MHFA focusing on identifying a person at risk for developing psychosis, depression, anxiety disorders, and substance dependence. This training is unique and one of its kind wherein we take a step backward and help participants to identify day-to-day issues that can lead to mental health problems and provide immediate intervention, thereby minimizing the risk of developing mental disorders. The effectiveness of the training program was assessed through the written feedback forms collected from the participants at the end of the program. Initial evaluation questionnaires were assessed to explore the level of knowledge and attitude the participants had before the training program.

Results

The mean (standard deviation) age of the participants was 28 years. Half of the participants were students pursuing their undergraduate or graduate degree and had an experience of either having or knowing someone with mental illness. Majority of the participants were female (73%).

Table 2 is just not problems that “the other” could have but that it could affect them too. Most of the participants (73%) expressed that being mentally healthy means overcoming difficulties and stressful events that we can face at some point.

Table 2

Responses indicating understanding of mental health

Item	Agree (%)	Disagree (%)	Not sure (%)
Mental health problems cannot affect me	11	56	33
Being mentally healthy means overcoming difficulties and stressful events that we can all face at some point	73	16	11
People with mental health problems are violent and unpredictable	23	56	21
Mental health problems are more like a weakness than a real illness	23	48	29
There is very little hope for people with mental health problems	14	58	28
People with mental health problems can snap out of it if they try hard enough	26	41	33

They did not hold (56%) the idea that is quite commonly found in the community that people with mental health problems are violent and unpredictable. Majority (48%) of them held the attitude that mental health problems are more like a weakness than a real illness. Most (58%) of the participants indicated that there is hope for people with mental health problems, but then they were ambiguous on whether people with mental health problems can snap out of it if they try hard enough, with 33% indicating that they were not sure.

Table 3 indicates that majority (44%) of the participants think that personality weakness or character flaws cause mental health problems. Majority (87%) indicated that identifying the early signs of distress in a person can be helpful in providing help. The utility of talking about mental health challenges as well as the effectiveness of therapy or counseling in helping someone with mental health problems was endorsed by most (70% and 80%, respectively). There was a greater degree of ambiguity on whether people can treat themselves with positive thought and prayer with 44% agreeing to it.

Table 3

Responses indicating knowledge of causation and treatment of mental health problems

Item	Agree (%)	Disagree (%)	Not sure (%)
Personality weakness or character flaws cause mental health problems	29	44	27
Identifying the early signs of distress in a person can be helpful in providing help	87	4	9
Talking about your mental health challenges is a waste of time	7	70	23
Therapy or counseling is always effective in helping someone with mental health problems	80	11	9
People can treat themselves with positive thought and prayer	44	32	24

Table 4 indicates that majority (62%) of the participants think that mental health problems can be prevented. Most also indicated that they could be of assistance to a person with a mental health problem (65%) as well as that listening is very important when providing help to a person with mental health problems (94%).

Table 4

Responses indicating attitude toward Mental Health First Aid

Item	Agree (%)	Disagree (%)	Not sure (%)
Prevention doesn’t work. It is difficult to prevent mental health problems	6	62	32
I can’t do anything for a person with a mental health problem. Only a doctor can	7	65	28
Listening is very important when we are providing help to a person with mental health problems	94	3	3

Discussion

The aim of the program was to assess and increase knowledge and skills through a 3-h training program on first aid for mental health problems. Participants’ responses toward understanding mental health clearly show that the majority of participants possessed the attitude that mental health problems are more like a weakness and the person does not have a real problem. Most (58%) of the participants indicated that there is hope for people with mental health problems, but then they were ambiguous on whether people with mental health problems can snap out of it if they try hard enough, with 26% agreeing and 33% indicating that they were not sure [Figure 1].

Figure 1

Graphical representation of responses indicating understanding mental health

Participants’ responses toward knowledge of causation and treatment of mental health problems clearly demonstrate that 29% of the participants think that personality weakness or character flaws can cause mental health problems. A majority (87%) of the participants clearly indicated that identifying the early signs of distress in a person is crucial in identifying the mental health problem arising and in seeking timely help. This clearly goes with the objectives for which the training is based on. The results indicated that 44% of participants considered that people can treat themselves with positive thought and prayer [Figure 2].

Figure 2

Graphical representation of responses indicating knowledge of causation and treatment of mental health problems

Participants’ attitude toward psychological first aid reveals that a majority (62%) of the participants think that mental health problems are preventable. Most of the participants also indicated that they could be of help and source of support to a person undergoing a mental health problem (65%) as well as certain skills such as listening is very important when providing first aid to a person with mental health problems (94%). These results could be partially due to the fact that a majority of the participants were working as lay counselors and teachers who were at sometimes exposed to curriculum pertaining to mental health briefly [Figure 3].

Figure 3

Graphical representation of responses indicating attitude toward Mental Health First Aid

The feedback responses obtained from the participants indicated that they benefitted from the training program in terms of improvement in their knowledge and skills:

“Very unique program and knowledge gained”

“Best part is the understanding obtained regarding the meaning of First Aid for Mental Health issues”

“The training helped me in developing skills in identifying persons with mental health problems”

“This training was very useful for me for my career and day to day life”

“It strengthened my skills in dealing with Persons with mental health problems.”

Participants also expressed that the design of the program was useful and concepts were clearly explained with role play and group activities. Suggestions for improving the capacity building program were to make it for a longer duration, organize a follow-up session, and have it online for participants who are unable to physically attend.

Conclusions

The capacity building program for first aid for mental health problems appears to be effective in improving the knowledge and skills with regard to the mental health problems. The findings from the program indicated lack of knowledge in understanding of mental health, knowledge of causation, and treatment of mental health problems. Feedback from the training program indicated that it improved the ability of the participants in recognizing persons undergoing mental health problems and brought about a change in their beliefs about mental health, attitudes, and need for prompt referral. It also was successful in increasing the confidence of the participants in providing help to someone with a mental health problem and referring to appropriate mental health professional. The limitation of the program was that it was carried out with a small group. The same can be replicated onto a larger population with diverse group, and the study appears recommendable for the community at large. Based on the positive results of this interventional study conducted, future plans to conduct training of teachers programs have been thought of. Such programs will be aimed to be beneficial for teachers as they will be able to provide first aid to their students who may be facing a mental health crisis.

Future suggestions

This pilot study was considered effective based on the feedback received from the participants, for increasing knowledge about mental health and building skills to assist people facing a mental health crisis. Based on this finding, the following points for further research are suggested:

Use of standardized questionnaires for assessing the initial knowledge and attitude about mental health and mental health problems in the community

Building of a brief and effective intervention training program, based on the steps used in this pilot study, exclusively for the community with an aim of promoting knowledge with respect to mental health, and skills to assist people facing mental health crisis

Use of standardized questionnaire for objectively assessing the effectiveness of the training program.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.