Assessing the Effectiveness of the Mental Health Equity Global Agenda for Low- and Middle-Income Countries  - MHI

ISSUE NO. 6 OCTOBER

THE MARIWALA HEALTH INITIATIVE JOURNAL

Re-Vision

Contesting Global Mental Health

World Mental Health Day, Medicalised Mental Health Awareness, and Psychiatric Subjectivation

Authoritarian Neoliberal Regimes and Global Mental Health

Enough Politeness: Decolonising Mental Health in a Society Oblivious to Its Colonial Wounds

Work with Us, Not against Us

Context

Mental Health in the Time of Genocide

Reshaping Narratives: Reproductive Justice among Women in Kashmir

Mental Health and Marginalisation

Warriors Within: Decoding the Paradox of Strength and Vulnerability among the Naga Tribe

Redefining Queerscapes through Poetry

The Impact of AFSPA on the Mental Health of the Naga People

Engage

Collective Healing and Trauma-Informed Approaches for the Mental Health of Survivors of Trafficking

Assessing the Effectiveness of the Mental Health Equity Global Agenda for Low- and Middle-Income Countries 

Fostering Mental Healthcare in a Postcolonial Continent with Digital Medicine

Tackling Mental Health Inequalities for Roma Communities in the UK

Behind Bars

ENGAGE

13

RESEARCH

Assessing the Effectiveness of the
Mental Health Equity Global Agenda for
Low- and Middle-Income Countries 


Merits of Bottom-Up Approach to
Mental Health Research: A Study in Malawi


Gloria Chirwa, Joel Nyali and Sandra Jumbe

AUTHOR

author’s bio

Gloria Chirwa, Joel Nyali and Sandra Jumbe

Gloria Chirwa is a social scientist from the University of Malawi. With eight years’ experience in youth development work, she aims to understand the challenges faced by Malawian youth and implement evidence-based youth development programmes. Gloria works in mental health research at the School of Health and Social Sciences, Millennium University, Malawi.

Joel Nyali is a development economist by training, currently working on a youth mental health research project at Millennium University, through which he hopes to contribute to improved youth health outcomes in Malawi. He is also an aspiring health economist, hoping to contribute to the country’s health system and policy through his work in youth health programming.

Sandra Jumbe is a health psychologist, trained at UWE Bristol, United Kingdom. As an African Research Initiative for Scientific Excellence, or ARISE, fellow funded by the African Academy of Sciences, she leads the Mental Health Literacy e-Curriculum project at Millennium University. She is also an NIHR Research Support Service Methods Advisor at Queen Mary University.

illustrator’s bio

Amreeta Banerjee

Alice A. Barwa completed her MA in Education from Dr. B.R. Ambedkar Univerity, Delhi (AUD), in 2022, and is from the Oraon Adivasi community, a native of Chhotanagpur Plateau, Chhattisgarh. She has been an advocate for Adivasi rights and voices as a member of an Adivasi youth collective @TheAdivasiPost, and has been an Adivasi youth representative at UN Climate Change Conference in Glasgow, Scotland, in 2021. Her research interests include education, culture, sociology, and linguistics.

Poverty and Mental Health in Low- and Middle-Income Countries (LMICs)

Mental health concerns are prevalent among the poor around the world,1 with mental, neurological, and substance use (MNS) conditions significantly contributing to morbidity and early mortality.2 A systematic review of adolescent substance use in sub-Saharan Africa found a 42% overall prevalence,3 with over 75% of individuals with MNS problems unable to access necessary care or therapy.4 In Malawi, a low-income country, depression is prevalent among adolescents, with rates as high as 20%.5 Globally, disparities in access to healthcare, particularly among youth living in poverty,6 amplify limited treatment access for, poor knowledge of, and negative attitudes towards mental health concerns.7 Poverty significantly impacts mental health, especially during adolescence and early adulthood, where disorders often emerge and impact psychosocial development and adulthood transitions.8 Although the treatment of MNS conditions among youth is a priority for global mental health, its top-down approach does not fully benefit the poor Malawian youth. 

The Mental Health Literacy e-Curriculum (MHLeC) research project in Malawi demonstrates how empowering grassroots organisations in mental health research can shape constructive critiques of the treatment agenda for MNS conditions in LMICs.

Mental Health Data on Malawian Youth

Even though half of Malawi’s population is aged 18 years or below,9 the youth here are marginalised in mental healthcare.10 For instance, there are no specialist youth-centred mental health services in the only three hospitals providing mental healthcare in the country.11 There is no policy on mental healthcare for children and youth. There is a lack of epidemiological data on MNS conditions among youth in the country, and so knowledge and data about it are limited. Our initial qualitative study involving focus group discussions with youth and youth-led organisations across the country uncovered a vicious circle of mental health concerns and poverty among young individuals in Malawi as well as the shortcomings of the nation’s health system that impede youth-focused mental health support services.12

To assess mental health literacy (MHL) among Malawian youth, we conducted a cross-sectional national survey using a self-reporting MHL questionnaire (MHLq).13 The questionnaire assessed knowledge of mental health concerns, false beliefs/stereotypes, first-aid skills, help-seeking behaviour, and self-help strategies among 682 young adults (16 to 30 years old) in 13 districts of Malawi in both rural and urban communities. We translated the questionnaire into Chichewa, Malawi’s official local language, to increase the participation of people with low English literacy.

The survey found that most responders were either jobless (36%) or enrolled in education (43%).

Among those surveyed, 73% had finished their primary or secondary school.

While 48% knew someone who had experienced mental health concerns, only 14% could name the condition.

The average MHL score for this cohort was comparable to previous European cohorts used to develop the questionnaire. However, Factor 2 (erroneous beliefs/stereotypes) and Factor 3 (first-aid skills and assistance-seeking behaviour) scores of the questionnaire were considerably lower for those with primary and secondary school credentials than for those with higher education. Assessing MHL in Malawian communities helped us identify gaps and informed the development of MHL- and evidence-based interventions. 

The MHLeC Project

To address some of the gaps we identified in MHL, we carried out a pilot study that culturally modified an existing programme14 into an e-course for youth in Malawian universities.15 This was done in several ways.

First, by incorporating key issues raised by our youth respondents – relationship issues, types of mental health concerns, and finding sources of support – into the existing content.

Second, to address language barriers, we translated the names of different mental health concerns into Chichewa.

Third, to target the issue of ‘erroneous beliefs’ and negative stereotyping of mental health concerns and to instead normalise them, we included lived experience videos from Malawian and other African contexts.

Fourth, to tackle the issue of low first-aid skills and help-seeking behaviour, we included a catalogue of vetted local grassroots organisations providing free psychosocial support and counselling to young people. 

We also revised some questions in our pre- and post-evaluation questionnaires to fit the Malawian context.16 For instance, we replaced the word ‘teen’, not commonly used in Malawi, with ‘young person’ or ‘adolescent’.  A key aspect of cultural adaptation was sharing the initial e-course prototype with various grassroots youth groups through stakeholder workshop discussions and revising it based on their feedback. This proactive community engagement enabled us to learn about and incorporate pertinent perspectives that guided the creation of mental health interventions tailored to our target demographic.17 We anticipated three outcomes from the study, namely, enhanced understanding of mental health, decreased stigma, and enhanced help-seeking ability among workshop attendees.18 

Additionally, in our national survey we found that respondents with higher education attainment had higher MHLq scores.19 This suggests that the longer-term effects of rolling out the MHLeC nationally could include a population-level rise in MHL as well as a reduced strain on an already overburdened healthcare system and medical personnel.20 

The Agenda on Treatment of MNS Conditions in LMICs

The World Health Organization recently issued new and updated recommendations on the treatment of MNS conditions, with some of them focusing on youth, women, and girls. These evidence-based recommendations have been commended as essential in helping primary healthcare providers’ treatment of patients with MNS conditions.21 The recommendations are also reported to have been made based on systematic evidence reviews, among other methods, and to have taken into account several factors, including the balance between desirable and undesirable effects; values and preferences of intended users of the intervention; resource requirements and cost-effectiveness; health equity, equality, and non-discrimination; feasibility; and human rights and sociocultural acceptability.22

Although the new and updated recommendations aim to contribute towards equitable mental health for all, it is a top-down approach that may not work for all contexts in the LMICs, despite using systematic evidence reviews to develop them. Malawi, for instance, does not have sufficient data on mental health, specifically on MNS conditions. The systematic evidence reviews presumably used a common measure of mental health in sub-Saharan Africa or Southern Africa, which may not accurately reflect the MNS conditions and the awareness of these among Malawians for them to seek treatment, given the limited data available. For example, mental health concerns in Malawi are fuelled and/or made worse by poverty. This aspect is not considered enough in the current global mental health agenda.

Looking to the Future

The MHLeC project is a good example of how if more people from grassroots organisations in LMICs are empowered or enabled to be more directly involved in mental health research, it can shape constructive critiques of treatment agendas in LMICs with a better understanding of their unique cultural contexts. This in turn will foster more effective interventions that feed into the goal of equitable mental health for all. Solutions on MNS therefore need to be developed from a bottom-up approach that allow an in-depth analysis of each country’s landscape. Needless to say, this bottom-up approach could be more effective with the LMICs’ political will and sufficient government resources for mental health research. For instance, Malawi has perpetually kept the budget for mental health services at 1% of the total national health budget.23 With such meagre resources and investment, the ability of programmes like the MHLeC project to be able to challenge or influence structures of power at the top remains questionable.

Cite this Article View all References

references

  • Wang, Linxi, and Frank Schilbach. Improving Mental Health in Low- and Middle-Income Settings: Key Findings from Rigorous Research. Abdul Latif Jameel Poverty Action Lab, 2023. 
  • UNICEF and WHO Joint Programme on Mental Health and Psychosocial Well-Being and Development of Children and Adolescents. World Health Organization, 2022. 
  • Jumbe, S., et al. ‘Determinants of Adolescent Substance Use in Africa: A Systematic Review and Meta-Analysis Protocol.’ Systematic Reviews, vol. 10, no. 1, 2021, pp. 1–6; Ogundipe, O., et al. ‘Substance Use among Adolescents in Sub-Saharan Africa: A Systematic Review and Meta-Analysis.’ South African Journal of Child Health, no. 1, 2018, pp. s79–s84.
  • WHO Issues New and Updated Recommendations on Treatment of Mental, Neurological and Substance Use Conditions. World Health Organization, 2023.
  • Kim, M.H., et al. ‘Prevalence of Depression and Validation of the Beck Depression Inventory-II and the Children’s Depression Inventory-Short amongst HIV-Positive Adolescents in Malawi.’ Journal of the International AIDS Society, vol. 17, no.1, 2014, p. 18,965.
  • Jumbe, S., et al. ‘“We Do Not Talk about It”: Engaging Youth in Malawi to Inform Adaptation of a Mental Health Literacy Intervention.’ PLOS ONE, vol. 17, no. 3, 2022, p. e0265530; Youth Well-Being Policy Review of Malawi: A 60 Seconds Guide. OECD, 2018. 
  • Jumbe, et al. ‘“We Do Not Talk about It.”’ 
  •  Patel, V., et al. ‘Mental Health of Young People: A Global Public-Health Challenge.’ Lancet, vol. 369, no. 9,569, 2007, pp. 1,302–1,313.
  • 2018 Malawi Population and Housing Census. N.S. Office, Editor, 2018.
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  •  Jumbe, S., et al. ‘Translation of the Mental Health Literacy Questionnaire for Young Adults into Chichewa for Use in Malawi: Preliminary Validation and Reliability Results.’ International Journal of Mental Health Systems, vol. 17, no. 1, 2023, pp. 1–9.
  • Kutcher, S., et al. ‘Creating Evidence-Based Youth Mental Health Policy in Sub-Saharan Africa: A Description of the Integrated Approach to Addressing the Issue of Youth Depression in Malawi and Tanzania.’ Front Psychiatry, vol. 10, 2019, p. 542.
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  • Jumbe, et al. ‘Translation of the Mental Health Literacy Questionnaire’; Wei, Y., et al. ‘Mental Health Literacy Development: Application of Online and In-Person Professional Development for Preservice Teachers to Address Knowledge, Stigma, and Help-Seeking Intentions.’ Canadian Journal of Behavioural Science/Revue Canadienne des Sciences du Comportement, vol. 52, no. 2, 2020, p. 107.
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  • WHO Issues New and Updated Recommendations.
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