4 MENTAL HEALTH LITERACY AS A MENTAL HEALTH PROMOTION TOOL

In this chapter we will respond to the questions “What is Mental Health Literacy?” and “How is mental health literacy applied in different settings?”

4.1 KEY THEMES AND MAIN IDEAS

4.1.1 Introduction

Mental health literacy was originally conceptualized as the “knowledge and beliefs about mental disorders which aid in their recognition, management or prevention” (Jorm et al., 1997 p. 182). More recently, Jorm (2012) revised his original definition to note there is more to mental health literacy than just having the basic skills and knowledge of dealing with mental illness. A more holistic understanding of mental health literacy now includes an individual’s ability to have the knowledge to take action to benefit their mental health as well as the mental health of others (i.e., achieve and maintain positive mental health). Jorm (2012) states that there are several components of mental health literacy which include:

“(a) the public’s knowledge of how to prevent mental disorders, (b) recognition of when a disorder is developing, (c) knowledge of help-seeking options and treatments available, (d) knowledge of effective self-help strategies for milder problems, and (e) first aid skills to support others affected by mental health problems” (p. 231)

This chapter will explore mental health literacy as a population mental health promotion (MHP) tool across various settings (schools, rural communities, university campuses, and the workplace). Next, gaps and limitations within existing literature will provide insight on where researchers should expand in the future studies.

4.1.2 Mental Health Literacy Programs in School

Cunningham and Suldo (2014) discuss how schools have become major providers for mental health services which is due in part to help overcome potential barriers that individuals face when trying to access mental health support within the community. These barriers include transportation, cost, lack of awareness regarding mental health, and lack of awareness of resources. Access to mental health resources within communities are limited and could be alleviated by providing support in places that are easily accessible to the community. That is, most people attend work or school and embedding mental health promoting resources within these settings is an efficient way to improve access and reach the larger population. Loades and Mastroyannopoulou (2010) highlight that 20% of children and adolescents experience mental health problems which present in the form of behavioral and emotional difficulties at school. Specifically, mental health problems increase the likelihood of children experiencing difficulties in school which then result in low academic achievements as they continue through school (Loads & Mastroyannopoulou, 2010). Many young people with mental health challenges could be supported at school through access to mental health literacy and promotion programs. Children who experience internalizing behaviors such as anxiety and depression are less likely to be noticed by teachers as they are not displaying disruptive behaviors, resulting in a lack of referral for treatment or support (Cunningham & Suldo, 2014). As there is typically one teacher present in a classroom with dozens of students, those who cause the most disturbance to the overall flow of the classroom are the ones that receive the most attention. This suggests a lot of the children who are facing mental health challenges and in need of support go unnoticed in school settings.

One way to help identify students who need mental health support is by educating teachers on mental health recognition. For example, Cunningham and Suldo (2014) discuss the effectiveness of teachers’ nomination as a way of identifying students who are exhibiting mental health problems and referring them for further treatment. About half of students who require mental health support were nominated (i.e., identified) by teachers (Cunningham & Suldo, 2014), indicating that that teacher nominations are an initial step in providing mental health support; however, a multi-modal universal strategy needs to be implemented to identify and help more students. This strategy should focus on identifying the internalizing behaviors that often go unnoticed, as previously discussed. A multi-modal assessment is recommended, which could include comprehensive training for teachers in terms of recognizing different mental health challenges in the children they teach. Teacher nominations would be the first step in that process. Once teachers and administrators are educated on identifying mental health challenges in children, programming, and resources can be properly allocated to those in need.

4.1.3 Mental Health Literacy Programs in Rural Communities

Story et al., (2016) discusses how living in a rural community has a greater impact on poor mental health than living within an urban environment. This leads to higher rates of suicide amongst rural communities, especially amongst adolescence. This article also notes that there is limited mental health literacy amongst rural communities compared to more urban environments which can account for the higher rates of suicide. This is influenced by a number of factors such as stigma, geographic isolation as well as limited resources within these communities. Story et al., (2016) discusses the implementation of a training program that was created as a means to educate individuals on how to identify adolescences who are at risk of suicide and how to respond. Results indicated that the Better Todays training program improved the mental health literacy of those involved in the training. Going forward, implementing programs such as this into rural communities will help to mitigate the barriers that rural communities currently face in relation to mental health awareness and going to seek treatment. These programs will also help to reduce stigma around mental health resulting in more people feeling comfortable in reaching out for help.

Bartlett et al., (2006) also focused on mental health literacy within rural communities in which they conducted a survey within a rural community in Australia. This survey consisted of a vignette that describes someone experiencing depression and looked to determine participants ability to recognize and identify certain mental health disorders, the prevalence of these disorders as well as where to access support if needed. Bartlett et al., (2006) concluded that the majority of participants underestimated the prevalence of mental health problems and 37% of participants were unaware of places to access mental health services. Those that were able to identify places to seek help considered them to be poor. This highlights the importance of implementing mental health literacy programs as a MHP tool within rural communities. Implementing mental health literacy programs will educate more people on mental health which will help individuals recognize potential mental health concerns within themselves while also learning about and feeling more comfortable about reaching out for help. Reducing the stigma surrounding mental health and the need for help is a major concern within rural communities and the implementation of educational programs will help to mitigate this and ensure that individuals are seeking the help they need and deserve. This will also break down the barriers for those who may need help in the future.

4.1.4 Mental Health Literacy Programs on University Campuses

Transitioning into university can be a stressful time for students which can result in adverse mental health consequences , particularly when students are getting ready to graduate and enter the workforce (Cage et al., 2021). The university campus is a fertile setting to implement mental health literacy programs, particularly to help students cope during high stress periods (e.g., exam week, graduation). Cage et al., (2021) conducted a study in which a number of university students and staff participated in a day-long event consisting of a number of focus groups. These pertained to various aspects of mental health and the development of the Student Minds Mental Health Charter which looks to support students throughout their time at university. The purpose of this study was to determine whether or not universities across the United Kingdom had an ideal approach to student mental health and if not, what could be done to achieve this. This study also looked to determine at what point they would be able to identify if an approach was successful. Cage et al., (2021) This study found that there are a number of strategies that can be implemented across universities regarding mental health. These include providing students with the coping skills needed to deal with the transitions to and from university life, more information regarding support on campus as well as education on campus life. Cage et al., (2021) also stresses the importance of implementing these interventions prior to students starting school. This will ensure that students are well equipped to handle stressors once they arise and are not left to try and cope after they are immersed in university life.

Chen and Kumar (2010) also focused on mental health amongst universities and examined the mental health literacy of students in Singapore regarding their knowledge of eating disorders as well as services that are available should they be needed. A questionnaire consisting of a vignette of an individual experiencing bulimia nervosa and corresponding questions were distributed throughout campus. After examination of responses, it was determined that students were not very receptive to the idea of going to a psychiatrist and taking medication as a means to help alleviate symptoms. This study emphasized the importance of implementing MHP programs in university settings. Chen and Kumar (2010) also noted that the implementation of such programs should not only target those with eating disorders but family members as well as those who are in a social circle with individuals at risk. This will help to reduce the stigma surrounding eating disorders and help those at risk receive the support they need and gain the confidence to seek help.

The study above stresses the importance of implementing mental health literacy programs within the university environment however, there is little on what specific programs should be implemented as well as the effectiveness of such programs within the study. Lo et al., (2017) discusses several interventions that can be used to promote mental health literacy amongst university students and educators. One such intervention is Mental Health First Aid (MHFA) which is meant to educate individuals on the initial help that should be given when mental health issues arise. MHFA also educates individuals on what to do to help when someone is in a mental health crisis Lo et al., (2017) explains a five-step plan that should be followed when assisting someone experiencing mental health concerns which are as follows,

1. “Assess risk of suicide or harm,

2. Listen non-judgmentally,

3. Give reassurance and information,

4.Encourage person to get appropriate professional help and,

5. Encourage self- help strategies.” (page 162)

This is great knowledge to have when assisting someone who is experiencing a mental health crisis however, it is also a useful tool for teaching individuals on how to recognize mental health symptoms within themselves. Mental Health First Aid is not exclusively designed for university students and educators. It is an important tool for everyone to have, especially for employers to have when in the workplace. This program would be a great step in ensuring that schools, workplaces, and community settings are equipped with knowledge on mental health disorders as well as how to assist someone who may be in crisis.

4.1.5 Mental Health Literacy Programs In the Workplace

Moll et al., (2017) discuss how there is growing concern in relation to mental illness in the workplace, which leads to reduced productivity and performance, tensions amongst co-workers, and absenteeism. Unfortunately, mental health challenges are often not addressed because of poor mental health literacy amongst staff and employers. A key pillar of MHP is early intervention, which is an upstream approach to preventing mental health challenges from becoming mental illness symptoms . By intervening early and mitigating the onset of symptoms, rates of mental illness may decrease, with accompanying decreases in workplace impact. Programming and training to improve mental health literacy at various levels in the workplace is an example of an early intervention, by equipping managers and human resource professionals with the knowledge and tools to identify and support those in need. For example, the Mental Health Literacy Tool for the Workplace (MHLTW) was developed by Moll et al. (2017) to evaluate mental health literacy and identify program gaps that can be filled to increase literacy in particular organizations. The MHLTW is a reliable way to determine when to implement a program and to determine if the program was effective, post-delivery. For example, Mental Health First Aid (MHFA) is a program that can help organizations equip their employees with the knowledge and confidence to help someone who is in crisis (Lo et al., 2017).

Mental Health Literacy is made up of many components and flows across many settings; that facilitate a holistic understanding of how mental health affects an individual.

4.2 GAPS AND LIMITATIONS

This section will discuss the gaps in mental health literacy research, including the lack of variety in study methods, and the problems that occur from a small sample size.

4.2.1 Study Methods

There unfortunately is not much variety in the study methods used when conducting research around mental health literacy. Perhaps this means that researchers have discovered the most effective way to conduct research on mental health literacy or it could mean that there hasn’t been enough research done into discovering what methods would work best to obtain the information we are looking for.

Schools

Loades et al 2010 uses a quantitative, cross-sectional design composed of a series of vignettes, followed by a series of closed and open questions. The purpose of this study was to investigate if teachers can distinguish between children presenting symptoms of the same disorder either emotional or behavioral at different levels of severity, if teachers are more concerned with emotional disorders or behavioral disorders, and if other factors including the child’s gender and the teachers experiences of teaching and with mental disorders played a role in a teachers accuracy of identifying these disorders. Cunningham and Suldo, 2014, used both universal screens and teacher nominations to assess teachers accuracy in identifying elementary school students who self-report having at-risk levels of anxiety or depression.

Public

Bartlett et al., (2006) conducted a survey that consisted of a vignette describing someone who was experiencing depression. Questions were asked to determine the participants ability to recognize and identify certain mental health disorders, the prevalence of them, as well as where to access support. Jorm et al 1997, used a cross-sectional study design, with structured interviews using vignettes of a person with either depression or schizophrenia to investigate the public’s recognition of mental disorders and their beliefs about the effectiveness of various treatments.

4.2.2 School Limitations

Findings in the study by Cunningham and Suldo 2014, were limited to a relatively small sample of older elementary school students who attended one of two schools that were included in the study for a total of 275 student participants. Cunningham and Suldo, 2014, state that elementary schools that elect to use a teacher nomination procedure in lieu of universal screening can expect to miss about half of the students who report elevated depressive symptoms, and up to 60 % of children who experience elevated anxiety. It was also stated in this study that at-risk girls were more likely to be missed than their at-risk male peers by teachers, this indicates a problem with teachers’ gender biases. The substantial number of students ‘‘missed’’ and misidentified by teachers in this study indicates that many teachers have some trouble detecting symptoms of internalizing distress in students who experience at-risk levels of problems. No identification training was provided to teachers, and the majority (84 %) reported little to no prior professional development in children’s mental health issues (Cunningham and Suldo, 2014). Given the lack of studies that have evaluated the accuracy of teacher nominations as a method for identifying elementary school children with internalizing problems, replication is needed prior to making definitive conclusions (Cunningham and Suldo, 2014), however, it appears that teachers should also be provided with training in children’s mental health issues.

There were a number of gaps and limitations to the study by Loades et al, 2010, many being the same as those mentioned in the study by Cunningham and Suldo, 2014. Limitations included potential gender bias being present in the study as boys were more likely to be identified as having a problem than girls were, this study only looked at schools in a small geographical location (113 participants total), and 85% of participants were of white British ethnicity. It was determined that teachers in this study were significantly more concerned with behavioral disorders over emotional disorders, this is believed to be due to behavioral problems being more disruptive in the classroom. Loades et al 2010 states that “replication of this current study (with an improved methodology), and extending it to include questions concerning the process by which teachers make decisions about whether or not a child has a problem, would provide further insight into this under-researched area”. Indicating that a quantitative, cross-sectional study design using vignettes was not the ideal research method for this study. These studies were only published 4-years apart and show a shocking difference in a teachers’ ability to identify mental health problems within students, likely this is due to the study design and limitations to the research.

4.2.3 Public Limitations

There are many limitations mentioned in Bartlett et Al’s 2006 study. To recap, Of the 2132 surveys sent out only 666 were completed and sent back. This indicates the possibility that there may have been response bias in this study through the assumption that individuals who have knowledge of or an interest in mental health may have been more likely to respond which could account for the high percentage of accurate recognition of the mental disorder described in the vignette. This was also indicated by the high number of respondents who stated having current or past knowledge of someone experiencing mental health issues. More potential bias comes from the sample selection coming from local phone directories which automatically removes anyone who does not have a phone number from the chance to participate in the study reducing the potential sample size. A final limitation mentioned is the format and phrasing of the survey questions, for example the question ‘Do you know anyone with a mental health problem…’ was asked and could be interpreted in a few different ways, one person could assume that it means someone close to them like a partner or family member, others may interpret it more generalized and assume it means anyone they have ever crossed paths with in their life, no matter how briefly.

The study by Jorm et al, 1997, while it does not indicate what results they were expecting to see, the results stating that only 39% of participants accurately labeled the depression vignette and only 27% of participants correctly labeled the schizophrenia vignette, indicates that mental health literacy is lacking in the general public. It’s also stated that “information on this topic is limited and is derived from national surveys on depression alone, or on depression and schizophrenia” (Jorm et al 1997). Indicating that a major gap in the research on mental health literacy is that there is simply a lack of research which has been a common theme throughout the research presented.

These studies were published almost 10-years apart which could indicate an increase in public knowledge on mental health disorders, specifically depression, which is likely part of it but may also indicate limitations in the research which we will look at next.

Despite its extensive use, Lucas, Collins, and Langdon (2008) illustrated the limitations of vignettes. They found that staff attributions about a child’s behavior presented in a real situation differed significantly from their attributions about the same behavior, presented in a vignette at a later date. Therefore, it is important to acknowledge that vignettes are limited in terms of ecological validity and that teachers may not necessarily respond to real incidents of children with mental health problems in the same way that they responded to vignettes (Lucas, Collins, and Langdon, 2008). While this statement is discussing teachers and students in particular, it can be true for anyone in any situation, we don’t always respond in/to situations in a way that we have previously said we would.

Existing research in mental health literacy shows limitations in research methods and sample selection, which impacts the generalizability of results.

4.3 FUTURE RESEARCH DIRECTIONS

In this section we will uncover the need for future research in the mental health literacy of minority populations, in developing countries, and in schools.

A prime area for future research is identifying how mental health literacy can be improved in people of different socio-demographic groups (e.g., cultures, genders). For example, early on, Jorm (2000) showed that lack of mental health literacy hinders the public’s acceptance of evidence-based practices in the mental health care system.

4.3.1 Cross-Cultural Mental Health Literacy

If there are to be greater gains in prevention, early intervention, self-help, and support of others in the community, then we need a mental health literate society in which basic knowledge and skills are more widely distributed (Jorm, 2006). A consequence of poor mental health literacy is that the task of preventing and helping mental disorders is largely confined to professionals working downstream in mental illness treatment. [sentence on how MHL is a MHP tool (upstream). While mental health literacy is an important part of mental health care, knowledge of MHL is limited in some cultures and regions in the world. Future studies should identify how, when, and where to focus mental health literacy education efforts. For example, research could explore the cultural-specific barriers to positive mental health that exist due to culturally-influenced beliefs or attitudes. Of course, barriers in developing countries will be qualitatively different than in developed countries. Thus, research should also consider regional differences in the resources required to promote mental health literacy. Finally, a relatively simple way to streamline future research efforts to create a cohesive evidence base would be to encourage the use of standardized assessments tools when surveying populations. For instance, wide use of the Mental Health Literacy Scale (MHLS) would help develop statistically robust norms that can be used to guide future design and delivery of programming. According to Anderson and Burns (2022), in order to better understand whether mental health literacy programs are effective in improving population mental health, future research should be guided by a standardized definition of mental health literacy to inform how to best operationalise and measure mental health literacy outcomes, which is essential for reliable and valid assessment of the effectiveness of the programs.

4.3.2 School-Based Mental Health Literacy Programs

Future studies should consider ways in which teachers can be trained to identify mental health challenges without affecting the educational quality of the children. The support provided to children also depends on their parents’ mental health literacy, which is shaped by parental beliefs and socio-economic standing . Studies should identify barriers to educating both teachers and parents on children’s mental health, in order to better equip these adults to support children’s mental health. Teachers could benefit from further training in terms of their ability to identify and act upon children’s mental health problems in a timely manner, thus minimizing the need for future intervention (Loades & Mastroyannopoulou, 2010). An educational training program for teachers about identifying common symptoms of common disorders may be useful to illustrate how internalizing symptoms manifest and what to look for in the classroom. Such training could include group discussions regarding the range of challenges students encounter due to depression and anxiety, and video demonstrations of young children depicting internalizing symptoms in various school settings (Cunningham & Suldo, 2014). Additional studies are needed to determine the unique features of students who repeatedly report poor mental health but are disproportionately unidentified by teachers (e.g., across genders).

A mental health literate population across all settings is vital for having an upstream approach to mental health promotion.