Mental health literacy of school-going adolescents in sub-Saharan Africa: a regional systematic review protocol.

INTRODUCTION: Assessing mental health literacy has implications for the identification and treatment of mental health problems. Adolescents have been identified as a particularly important target group for initiating and improving mental health literacy. However, much of what we know about adolescent mental health literacy comes from high-income countries. This proposed review seeks to synthesise the available published primary evidence from sub-Saharan Africa on the status and measurement of mental health literacy among school-going adolescents. METHODS AND ANALYSIS: We will perform a systematic review reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA-2020). We will systematically search selected global databases (EMBASE, PsycINFO, PubMed and MEDLINE) and regional electronic databases (African Index Medicus and African Journals OnLine) up to December 2021 for observational and qualitative studies published in English and French. The standard quality assessment criteria for evaluating primary research papers from a variety of fields (QualSyst criteria) will be used to appraise the methodological quality of the included studies. The Petticrew-Roberts 3-step approach to narrative synthesis will be applied to the included studies. ETHICS AND DISSEMINATION: We will not seek ethical approval from an institutional review board, as this is a systematic review of available and accessible literature. When completed, the full report of this review will be submitted to a journal for peer-reviewed publication; the key findings will be presented at local and international conferences with-partial or full-focus on (adolescent) mental health (literacy). PROSPERO REGISTRATION NUMBER: CRD42021229011. © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

The cross-national nature of this review allows for comparisons of findings across and within countries and subregions in sub-Saharan Africa.

We have reported this protocol in keeping with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines.

Significant heterogeneity is expected within and across different domains (eg, understanding of mental health literacy, sampling approaches) and across periods of time.

Expected significant heterogeneity will obviate the conduct of a meta-analysis.

An expected general limited amount of published primary studies on school-going adolescents’ mental health literacy across low-income and middle-income countries (relative to high-income countries) may result in less than enough eligible papers.

Introduction

Mental health literacy—defined as ‘knowledge and beliefs about mental disorders which aid their recognition, management or prevention’1—is a critical determinant of overall mental well-being in individuals across various age groups within the general population.2–5 The concept has several components, including knowledge of how to prevent mental disorders; recognition of when a disorder is developing; knowledge of help-seeking options and treatments available; knowledge of effective self-help strategies for milder problems; and first aid skills to support others showing symptoms of mental health disorders or are in a mental health crisis.1 6 7 Leading scholars have maintained that each component of mental health literacy contributes to (functional) mental health through recognising the need to seek professional mental healthcare or treatment for self or others who may be experiencing mental health problems, thereby facilitating decision-making regarding types of help to seek and correcting negative attitudes and stigma held towards mental illness and treatment.1 5 7–10 Additionally, evidence of a population’s mental health literacy has the potential to inform how mental healthcare systems and professionals could design and shape their practice to meet the care needs of persons struggling with mental health.5 7–9 Information aiming to enhance mental health literacy is provided through community, institutional and social outlets, such as schools (where young people and school staff are usually targeted), mass media and workplaces. Mental health literacy is applied contextually, often involving several related stakeholders, and thus, by necessity, mental health literacy is understood to be developmentally appropriate.2 3 11

Increasing evidence indicates that mental health, ‘a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community’,12 is the most active research area in recent times, particularly due to the global COVID-19 pandemic.13 However, notably, while the COVID-19 pandemic has underscored the need to pay research attention to mental health needs of populations (including children and adolescents),14–17 the pandemic has also shown that low (mental) health literacy continues to remain an underestimated global public health challenge.18 19 Even so, much of what we know about mental health literacy comes from studies conducted in high-income countries, while less than enough attention has been paid to mental health literacy within public health research and action in low/middle-income countries (LMICs), including those in sub-Saharan Africa.5 13 20–23 This is concerning, as the burden of mental health disorders is high in LMICs, while mental health infrastructure and resource access are scarce, in comparison with high-income countries.24–26 Relative to high-income countries, the quality and availability of professional mental healthcare services are poor in most LMICs, and many LMICs (including those in sub-Saharan Africa) have non-existent, inappropriate or deficient mental healthcare policies and lack of national strategies for the prevention of specific public mental health challenges.26–30

Generally, mental health literacy of young populations and other vulnerable groups, who are known to experience unique difficulties and barriers to professional mental healthcare—has received less research attention.31 Among these vulnerable populations are adolescents, refugees and the aged. Adolescents are the world’s largest cohort,32 but they also represent the greatest proportion (23%) of the regional population of sub-Saharan Africa.33 Notably though, evidence of recent systematic reviews shows that adolescents in sub-Saharan Africa are particularly at elevated risk of mental disorders, but mental healthcare systems are poorly resourced, and policies are unavailable to help deal with them.34–38 Adolescence is a critical stage across the mental health continuum, as about 50% of mental health challenges experienced during adulthood have their first onset during teenagehood.39 40 Although most adolescents do not seek professional help for their mental health issues (eg, due to stigma, lack of mental health knowledge),41 42 there is evidence to suggest that mental health literacy has implications for the identification and treatment of mental health problems in adolescents and other young people.43 Hence, adolescents have been identified as a particularly important target group for initiating and improving mental health literacy.44

Recent review has identified a few published studies reporting evidence on level of community mental literacy, generally among adults in sub-Saharan Africa.45 However, the mental health and mental health literacy of school-going adolescents in sub-Saharan African countries are poorly understood.20 45 46 Thus, a synthesis of the available published primary evidence from sub-Saharan Africa on the status, conceptualisation and measurement of school-going adolescents’ mental health literacy is needed.

Objectives

The objective of this review is to synthesise the available and accessible published literature (from the inception of the selected databases up to 31 December 2021) on mental health literacy of school-going adolescents in sub-Saharan Africa. Specifically, guided by key conceptual literature in the area of mental health literacy,1 6 47 48 this review will synthesise the evidence on:

The three main thematic domains of mental health literacy of school-going adolescents within sub-Saharan Africa: recognition of mental disorders, knowledge about factors related to mental health and attitudes and beliefs about mental disorders. Notably, these three main domains of mental health literacy guiding this review have been drawn from key literature in the area: Jorm et al,1 Jorm,6 7 O’Connor et al47 and Bale et al.48

The conceptualisations and measures of mental health literacy of school-going adolescents in sub-Saharan African countries.

Methods

Before designing this review, we searched relevant systematic review registers, repositories, review electronic libraries and key peer-reviewed journals, including the Cochrane Library, the International Prospective Register of Systematic Reviews (PROSPERO), the Campbell Collaboration, the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, BMC Systematic Reviews and BMJ Open, to identify identical or similarly designed previously published protocols or completed systematic reviews. To the best of our knowledge this prospective review represents the first to be designed and conducted from sub-Saharan Africa, as our initial search found no prospective or completed reviews on the topic.

We have developed this review protocol consistent with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P-2015) guidelines.49 The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA-2020)50 will guide the reporting of the completed review.

Eligibility criteria

Table 1 presents the exclusion and inclusion criteria to guide the selection of potentially eligible articles.

Table 1

Summary of inclusion and exclusion criteria

Criterion	Include	Exclude
Participants	School-going adolescents (aged 10–24 years and attend junior high or senior high school) sampled from any of the 46 countries within sub-Saharan Africa, regardless of gender, religious groupings, sexual or gender orientation or health status. Studies involving participants within broad age range, but the computed mean age falls within the age range 10–24 years.	Studies involving participants aged younger than 10 years or older than 24 years. Studies involving a wide age range but with study results not disaggregated by age groups.
Setting	The 46 countries within sub-Saharan Africa. Primary studies conducted within clinical or non-clinical contexts (ie, general population, community, school-based, households or neighbourhoods) involving school-going adolescents.	Studies focused on mental health literacy among school-going adolescents, but participants are sampled outside sub-Saharan Africa. Cross-national studies involving countries in sub-Saharan Africa but with study results not disaggregated by country or subregion.
Study designs	Primary studies that address at least one of the specified objectives of this review using observational study designs51 or qualitative approaches. Studies involving self-report or direct reporting of mental health literacy by participants.	Systematic reviews and umbrella reviews. Protocols of prospective reviews or primary studies. Full text of identified records unavailable or inaccessible, even after contacting authors. Studies based on the same dataset reported in an earlier publication included in this review. Articles not based on data, non-peer-reviewed publications, including grey literature such as theses, correspondence, editorials, opinion pieces and commentaries.
Language	Peer-reviewed publications in English or French.	Peer-reviewed publications in languages other than English or French.

Outcomes

Broadly, this prospective review focuses on mental health literacy of school-going adolescents in sub-Saharan Africa. Specifically, potentially eligible studies must have assessed or measured and reported evidence on at least one of the three main thematic components of mental health literacy as outlined in the objectives of this review: recognition of mental disorders, knowledge about factors relating to mental health, and attitudes and beliefs about mental disorders. Table 2 shows the breakdown of the three thematic domains of the major attributes constituting mental health literacy identified in the key literature.

Table 2

Mental health literacy thematic framework

Thematic domain	Attribute	Mental health literacy content
Recognition	Ability to recognise specific disorders	The ability to correctly identify features of a disorder, a specific disorder or category of disorders. The ability to recognise disorders in hindsight. The ability to recognise onset of symptoms of disorders. Awareness of a wide range of symptoms.
	How to seek mental health information	Knowledge of when, where and how to access mental health information and capacity to do so
	Causes and risk factors	Knowledge of environmental, social, familial or biological factors that increase the risk of developing a mental illness.
Knowledge and prevention	Self-treatments (or ‘self-help’/‘coping’ strategies)	Knowledge of typical treatments recommended by mental health professionals. Knowledge of activities that an individual can undertake to obtain professional help or self-care. Understanding how to obtain good mental health and developing competencies for self-care.
	Professional help available	Knowledge of mental health professionals and the services they provide
Attitudes and beliefs	Attitudes that promote recognition and appropriate help-seeking	Decreasing negative attitudes and stigma related to mental disorders and treatments. Improving help-seeking beliefs and intentions.

Table and content adopted from Bale et al,48 O’Connor et al,47 Jorm6 7 and Jorm et al.1

Definition and measurement of outcomes

We will consider for inclusion studies on mental health literacy; studies on health literacy focused on physical/medical health issues will be excluded. Potentially eligible studies must have clearly defined mental health literacy identical to or similar as the definition guiding this review.1 6 Also, specific measurement or assessment of mental health literacy must have been reported by potentially eligible primary studies (ie, general survey scales and programme specific measures).48

Types of study

We will consider for inclusion in this review primary studies that have used observational study designs (ie, cross-sectional studies, case–control studies and cohort studies), qualitative studies and mixed methods designs.51 52 A study will be excluded if the data had been reported by an earlier or recent study based on the same dataset but in a comparatively sufficient detail. Peer-reviewed publications that draw on student dissertations will be considered for inclusion, but the dissertations (where available and accessible) will be referred for detailed methodological information.

Participants and study setting

Potentially eligible studies must involve school-going adolescents (in junior or senior high schools) sampled from any of the 46 countries within sub-Saharan Africa. The 46 countries considered for this review are based on the regional classification and list of 46 countries within the sub-Saharan African region provided by the WHO.28 There will be no restrictions by type of specific setting. Potentially eligible studies could have been conducted within clinical or non-clinical contexts, including schools, households/neighbourhoods, community contexts, rural or urban settings. Participants in potentially eligible studies must be aged 10–24 years, and will be recruited regardless of gender, religious groupings, sexual or gender orientation, or health status. We have adopted the chronological definition of adolescence as 10–24 years, as this represents an expanded and more inclusive definition of adolescence and the age limit aligns more closely with popular understandings of the adolescence life phase and modern patterns of adolescent growth.53 Studies involving participants within broad age range but where the reported mean age of participants falls within the age range 10–24 years will be considered for inclusion. Participants in eligible studies must have self-reported or directly reported mental health literacy (scores).

Information sources

We will search two regional electronic databases (African Journals OnLine, and African Index Medicus) and four global databases (EMBASE, PsycINFO, PubMed and MEDLINE). We will search the references of key papers to identify potentially eligible papers and use Google Scholar to look for relevant forward citations of key papers. Also, we will search the references of eligible papers for the citations of potentially eligible papers. Our searches in Google Scholar will involve the use of tools and functionality recommended for enhanced recall.54 We will use the ‘Cited by’ and ‘Related articles’ functions in Google Scholar to search relevant citations of similar eligible papers. We will contact authors of potentially eligible papers that are inaccessible, requesting for the full text of their articles for eligibility consideration. We will consider only studies published in French or English, as these are the two main languages for publication of scientific works within the subregion.55 56 The searches will be limited to the year of inception of the selected academic databases up to December 2021, but the review is expected to be completed in June 2022.

Search strategy and process

The search strategy would include keywords, Boolean logical operatives, truncation and MeSH terms as appropriate for and relevant to each selected database. Our geographic search filter would include names of the 46 countries and four subregions within sub-Saharan Africa—in both English and languages relevant to the countries. For example, “mental health literacy” OR “depression literacy” OR “anxiety literacy” OR health educat* OR health behav*) AND (adolescen* OR students OR teen* OR “in-school adolescents” OR “school-going adolescents”) AND (Angola OR Benin OR Dahomey OR Botswana OR Bechuanaland OR Burkina Faso OR Upper Volta OR Burundi OR Urundi OR Cameroon OR Cape Verde OR Cabo Verde OR Central Africa OR West Africa OR East Africa OR Southern Africa OR sub-Saharan Africa OR Congo OR Cote d'Ivoire OR Ivory Coast).

A prototype MEDLINE search strategy (see online supplemental material 1) developed by the authors and reviewed by an Information Specialist will be adapted to the syntax and subject headings of the other selected databases (African Journals OnLine, African Index Medicus, EMBASE, PsycINFO and PubMed). Two authors (MM and KOA) will conduct the searches and two authors (EN-BQ and MR-M) will integrate the search results and remove duplicates of records. The selected databases would be searched separately, but the search results will be combined before duplicates are removed. The reporting of the search process will be informed by the Statement for Reporting Literature Searches in Systematic Reviews guidelines.57

Study records

Data management

Consistent with the PRISMA-2020 guidelines,50 a reference manager, EndNote (V.X9.3.3), would be used to collate the results of the database searches, remove duplicates of the records, screen the titles and abstracts of the identified records, and to access the full text of potentially eligible studies.

Selection process

Three reviewers (TS, MM and SN) will independently screen the titles and abstracts of the identified records within the lens of the prespecified inclusion and exclusion criteria. The full text of potentially eligible studies (after title and abstract screening) would be screened for inclusion. The entire review team will resolve discrepancies through consensus for accuracy check of included studies. The reviewers will consult published protocols and associated online supplemental materials (where available) of eligible studies or contact authors of eligible studies—that are inaccessible online—through email correspondence for missing or extra relevant information.

Data collection process and data items

The identified relevant studies will be divided among three reviewers (SN, HM and MR-M) for data extraction. Records will be screened for eligibility and duplicates removed. Relevant data will be extracted into a predesigned extraction form. The following data will be extracted: author, year of publication, country, study setting (school, clinic, community, etc), study design, sample characteristics (will be extracted more broadly depending on the study: sampling method, sample size, gender ratio, mean age, etc), domain of mental health literacy reported (eg, knowledge and prevention, recognition, attitudes and beliefs), outcome measurement (eg, general or specific measurement approaches using a questionnaire, vignette, clinician interview or qualitative interview), key findings, study quality rating. Authors of eligible studies would be contacted for missing or additional relevant information. Three reviewers (SN, JM and MR-M) will extract data independently from the eligible papers; the extractions will be referred to two other reviewers (EN-BQ and TS) for accuracy check and completeness. At planned research meetings, the review team will resolve discrepancies through consensus. Also, we may (if the need be) contact authors of eligible studies for accuracy check and additional information to resolve discrepancies and uncertainties.

Risk of bias in individual studies

Three reviewers (EN-BQ, JM and TS) will use the standard quality assessment criteria for evaluating primary research papers from a variety of fields (QualSyst criteria)58 to appraise independently the methodological quality of the included studies. The QualSyst criteria is a standardised generic quality checklist designed for quantitative and qualitative studies; it includes 14 criteria for quantitative studies and 10 criteria for qualitative studies. Each included study will be assessed for the extent to which it meets each criterion (no=0, yes=2, partially=1, not applicable=N/A). A sum of all the scores will be calculated and divided by the total possible highest score on the criteria—but items considered non-applicable will be excluded. For ease of understanding, the total score will be converted into a percentage of score available. Discrepancies related to the quality appraisal will be resolved through consensus. No study will be excluded based on quality appraisal rating. However, it is hoped that the quality appraisal ratings will inform recommendations to help improve the methodological quality of future primary studies in the area from sub-Saharan African countries.

Data synthesis

We will use qualitative content analysis—‘a method for the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns’59—for preliminary synthesis of the extracted data. Although the expected significant heterogeneity across the included studies will obviate meta-analysis, we will use tables and figures (including forest plots, where necessary) to aid the synthesis.60 For example, reported scores on mental health literacy will be described qualitatively, due to possible significant heterogeneity across included studies. The formal analysis will follow the three-step approach to narrative synthesis (by Petticrew and Roberts60) would be followed to synthesise the evidence drawn from the included studies: ‘(i) organizing the description of the studies into logical categories; (ii) analyzing the findings within each of the categories; and (iii) synthesizing the findings across all included studies’. While we anticipate the synthesis to be informed by the aims of the review and the identified domains of mental health literacy, the categorisation within and across the included studies will depend mainly on the key emergent patterns of the findings. The authors will jointly synthesise the data.

Patient and public involvement

No patient involved.

Discussion

The aim of this review is to collate, synthesise and report findings of previously published primary studies on the status, conceptualisation and measurement of mental health literacy of school-going adolescents within and across countries in sub-Saharan Africa. Thus, on successful completion, this will be the first regional-level systematic review to report synthesised evidence on school-going adolescents’ mental health literacy in sub-Saharan Africa.

The interpretation of the synthesised evidence in this review is likely to draw on how adolescents in sub-Saharan Africa view mental illness. There is a evidence to suggest that young people in the subregion are less aware of the multi-causal nature of mental health issues, and their primary views equate mental illnesses to brain disorders, with strong supernatural and cultural undertones.61 In other words, the explication of our findings will reference the African worldview and cosmological ideas related to the aetiology of mental illness, and spiritual and religious interventions.23 62

We anticipate that evidence reported by this review will provide a useful point of departure for both initial and continuous primary research efforts on adolescent mental health literacy across the subregion. This anticipated usefulness can be seen in four ways: (1) synthesised evidence on the status of school-going adolescents’ mental health literacy will inform a need for initial and further studies, including intervention and evaluative studies aimed at promoting and improving the mental literacy of school-going adolescents within and across the subregion; (2) evidence on the conceptualisation and measurements of mental health literacy of school-going adolescents within sub-Saharan Africa will potentially inform a need for age-appropriate and context-specific meaning-making or definitions of mental health literacy as a concept, and a need for the development and application of culturally sensitive measures for the assessment of adolescent mental health literacy in the subregion; (3) the methodological quality appraisal of the included studies could have implications for designing future primary research in the area and (4) the application of the three-thematic-domain mental health literacy framework47 48 in this review can, potentially, facilitate the identification and mapping out of specific components of mental health literacy of school-going adolescents that require initial or further research attention across the subregion.

Broadly, it is expected that this review’s findings will be of interest and relevant to the work of researchers, school and family mental health professionals, adolescent mental health professionals and (mental) health policymakers across the subregion. However, we anticipate that the general relatively limited amount of published primary studies on school-going adolescents’ mental health literacy across LMICs may result in less than enough papers for eligibility consideration in this review. This limitation can also underscore a critical need for the initiation and expansion of research in the area, particularly, in countries within the subregion that have yet to contribute any evidence to the topic. Also, significant heterogeneity is expected within and across different domains (eg, understanding of mental health literacy, sampling approaches) and across periods of time; this expected significant heterogeneity will obviate the conduct of a meta-analysis.

Amendments

We do not anticipate amendments to the review methods described in this protocol, but if this becomes necessary, we will describe in the Amendments section of this protocol the needed changes and their justification, and include the date of each change made. All corresponding amendments will also be made in the PROSPERO registration. All the authors will agree on and approve the amendments.