Exploring the Effectiveness of Mental Health First Aid Program for Young People in South Africa

Abstract

This study explored the effectiveness of a mental health first-aid program on improving young people’s attitudes, knowledge and mental health-related behavior, using qualitative methods. An assessment of the pilot project that was conducted among social science students between age 18 and 34 years revealed a reduction in stigma, increased openness about mental health challenges and increase in utilization of professional services among participants (n-548) of the MHFA program, following the 13-week program. The study found that MHFA intervention projects were considerably more effective in changing attitudes towards mental illness when blended with indigenous concepts, values, language, as well as priorities for various cultures and settings. Based on analysis of course content and focused group discussions, the study concludes that four factors contributed to the overwhelming satisfaction experienced by participants: (1) the utilization of peer tutors in administering the training, (2) the inclusion of mental models and centering participants’ agency in creating and administering training content, (3) the availability of peer mentors and a mobile application which makes referral (social prescribing) and access to professional intervention easy, and (4) the inclusion of friends and family as accountability partners.

1. Introduction

This paper provides an overview of the investigation of the effectiveness of a Mental Health First Aid program hereafter known as MHFA, among young people between the age of 18 and 30 years in South Africa. There is growing evidence of the efficiency of mental health first aid in the Global North, specifically, in the United States of America [1] and the United Kingdom [2]. However, the implementation of MHFA programs in these contexts were embedded within broader national health intervention projects. In this sense, MHFA programs were utilized and implemented within broader social prescribing [3] or community referral systems where trained health professionals referred individuals to various categories of nonclinical services. There is growing evidence that MHFA holds potential for de-stigmatization and improved access to professional services within rural [4] or low-resource settings, even when such programs are designed outside national clinical settings.

It is known that the earlier an individual receives support or intervention, the higher their chances of recovery from a mental illness. Within this context, further studies are required to investigate how effective nonprofit organization (NPO)- or community-led MHFA programs have been in improving attitudes, knowledge, and general mental health-related behavior among young people. Mental Health First Aid (MHFA) is an adaptation of physical first-aid training [5], for emotional or psychological health emergencies. It emerged out of the need to provide immediate support for individuals experiencing mental health crises. Drawing on this, researchers [6] explain that MHFA involves a six-step process of approaching an individual experiencing a mental health crisis: assessing and assisting with the crisis; listening and communicating with them without prejudice or; providing support and information; encouraging the individual to get appropriate professional help; and encouraging other forms of support.

MHFA involves a process of increasing participant’s knowledge of mental wellbeing in order to increase supportive attitude while reducing their negative behavior toward individuals experiencing mental health challenges [7]. Mental health literacy is a broad term that involves reducing negative behaviors and increasing support for people with mental illness. Therefore, as an adaptation of the physical first-aid training which emerged out of the interlinked processes of providing a first point of contact to help individuals with mental health challenges, MHFA is a kind of support offered to an individual experiencing a mental health crisis until the appropriate professional help is received or until the crisis is resolved [8]. This could be individuals who have experienced a major traumatic event or are suicidal.

Mental Health First Aid International [9] notes that this physiological emergency support began in 2000, in Australia, through the collaborative efforts of a researcher and a part-time volunteer who had experienced mental health issues. Jorm and Kitchener [10] note that by 2011, there were over 850 instructors in Australia who had trained over 170,000 adults. As of July 2022, MHFA is being delivered in 24 countries by over 60,000 accredited instructors and over 5 million people who have received training. Within this framework, MHFA targets mostly individuals in professions or environments with high probability of interacting with people experiencing mental health emergencies such as parents, youth group leaders, police officers, coaches, social workers, camp counselors, teachers, family caregivers, and other individuals who work with the youth among others.

Understanding the effectiveness of MHFA involves a process of contextualizing it within and across specific political, cultural, and socioeconomic contexts [11]. However, not much is known about MHFA implementation mechanisms in the Global South. Even though MHFA has been adapted to various disasters and populations in different countries and regions, detailed knowledge of the basic principles surrounding its adaptations by various stakeholders in South Africa remains under-researched and inadequately known. The processes of MHFA implementation such as the duration of implementation, content, for whom it was intended, identity of tutors implementing it, circumstances under which MHFA was administered, where they administered it, and how and at what cost MHFA was administered have not been a subject of research in South Africa. Yet, there exists a substantial body of contextual work in psychology, social work, nursing, pharmacy, and the biomedical sciences on psychological first aid [12, 13, 14]. These studies have been concerned with identifying the characteristics, participants of MHFA programs, and the contexts of their implementation.

The research focus differs significantly reflecting the heterogeneity of interests, aims, viewpoints, and approach of researchers. For example, a scoping review which was conducted in 2020 [14] focused on mapping MHFA programs to contextualize its implementation mechanisms across various contexts, NG et al. [12] in their systematic review, concentrated on youth and teen MHFA, exploring the body of work that describes its delivery and assessment among university students as well as discipline and participants’ level of study. Another systematic review [13] which focused on summarizing the current evidence for youth and teen MHFA in order to provide direction for future training and research concluded that there was a need for more empirical research in non-Western countries, high-risk populations, and different professional settings. They noted that future interventions could also consider different modes of learning, longer-term follow-up, and the measurement of outcomes that evaluate the quality of helping behavior. These existing bodies of literature that describe the assessment and delivery of MHFA training among college students revealed that while MHFA was not compulsory for most students in healthcare professions, of those enrolled in the program within the United States, Australia, and United Kingdom, majority were pharmacy, healthcare, and social work majors.

Furthermore, disciplines who implemented MHFA training integrated the adult version into their curriculum and made it mandatory for all students across all years of their program, focusing mostly on mental health literacy, confidence, stigma, knowledge, intentions, and application of skills. In addition, while most of these programs assessed participants based on their knowledge of skills related to mental health literacy, only a few focused on self-reported health measurements and direct observation of behaviors. MHFA can be thought of as a first-aid box for the mind, used to recognize symptoms of physiological distress and to provide initial support and treatment. Hart, Jorm, Paxton, and Cvetkovski [15] note that MHFA needs to be situated beyond healthcare and “care” spaces in order to understand its positive impact on participants.

Given the current trend for MHFA certification requirements for adult professionals within care roles and occupation in the Global North, it is not surprising that disciplines within biomedical sciences and public health now integrate MHFA as a compulsory aspect of their programs across all levels. However, the context of the implementation of the tertiary MHFA program among students within the social sciences and its impact on both instructors and students in the Global South is unclear. For example, the full scope and context of MHFA adaptation in South Africa is unclear. In addition, it is not clear whether MHFA programs adapted by nonprofit organizations (NPOs) for social science majors within low-income settings lead to mental health literacy, improved support, de-stigmatization, and access to professional services [16]. Although, mental health issues have significant impact on countries and individual’s financial wellbeing, productivity, and life expectancy, with an estimated economic cost of over USD$ 16.1 trillion from the global economy between 2010 and 2030 [17].

A MHFA training impact assessment study [18] conducted among 166 adult participants who enrolled in classes organized by a community health center in rural Kansas in the United States reported that even though the response rate was low (36%) for the online feedback survey, there was evidence of changed behaviors, attitudes, and improved mental health literacy. However, as with most impact assessments, there were suggestions for additional research to better understand change processes that occur as a result of MHFA across multicultural and diverse settings within and outside the United States. Noltemeyer et al. [19] assessed the impact of a national rollout of Youth Mental Health First Aid (YMHFA) training among adults in Ohio who were trained as first responders to youth in crisis. The pilot study utilized data gathered from over 2180 predominantly White women within the education sector. They found significant improvements in self-confidence, openness to individuals with mental health conditions, willingness to help, and awareness of mental wellbeing resources and support, 3 months after training.

The MHFAI [20] notes that its global presence is currently limited to 26 countries, mostly within the Global North, with the exception of India and Bangladesh. While international uptake for MHFA within the Global South and Africa in particular appears developmental, evaluations of its effectiveness and benefits of current programs among individuals and communities within these contexts are scarce. In fact, proponents of MHFA training suggest the need for further partnership with research (and researchers) as its international uptake and perceptions of its effectiveness depend largely on access to evidence-based evaluative publication. When considered as a body of work, evidence-based evaluative publications on MHFA particularly, within the Global South is scarce and inconclusive. In addition, there is limited empirical work on the effectiveness of MHFA in Africa and its cultural appropriateness.

A Delphi expert consensus study which reviewed guidelines for providing mental health first aid to suicidal individuals in India, against the backdrop of growing suicide, noted that while their target population were mental health professionals, the program could be adapted outside its intended context, for individuals who work in welfare and health settings as well as ethnic minorities. The reviewers [21] suggested that it was imperative to evaluate the impact of such guidelines on the first aider’s helping behavior and on the recipients of the first aid. The evaluation would assist researchers in developing an evidence base for mental health first aid and suicide prevention initiatives. Another Delphi expert consensus study which reviewed a cultural adaptation of the mental health first-aid guidelines for assisting people at risk of suicide in Brazil supported the importance of adapting the guidelines to various cultures. They found that the incorporation of aspects of Brazilian culture such as family and friends and self-care for first-aid providers helped in improving health outcomes.

However, a mixed-methods study [22] of an advocacy program for mental healthcare users in South Africa which evaluated the implementation of a national advocacy program for mental healthcare users, conducted by the South African National Department of Health and the South African Federation for Mental Health, reported that although the programs helped with mental health literacy there was inadequate support from NGOs or the Department of Health (DoH), which impeded sustainability of mental health advocacy efforts. They noted scarcity of professional mental health services in primary care clinics, with acute care limited to provincial tertiary hospitals, where the majority of resources are allocated. The study concluded that limited resource allocation and prioritization of mental disorders within the South African public health system created inequities in access to treatment which has now resulted in human suffering, disability, and economic losses [23].

Globally, young people and women have the highest rate of global emotional disorder [24]. One in six people between 17 to 19 years have a mental disorder with 1 in 16 experiencing more than one mental disorder in 2017. Fifty percent of all lifetime mental illness begins by the age of 14 years and 75% by the age of 24 years [25]. In South Africa, the statistics are similar. A report from the South African Federation for Mental Health (SAFMH) [26] on the state of mental health in the country indicated that in 2o18, 18% of learners in the country (between ages 15 to 19 years) reported having suicide ideation, 18% had attempted suicide, 25% reported experiencing feelings of hopelessness and sadness, and 32% of those who attempted suicide required medical treatment. Yet, the optimal methods of promoting health and the effectiveness of MHFA with young people in South Africa are not clear. However, research and interventions in other areas have shown that more awareness, MHFA, and community participation decrease the stigma and therefore increase the chances of getting help.

The SAFMH and SADAG [27] noted the absence of a national MHFA guide, explaining that even though NGOs, communities, and other nongovernmental agencies were implementing mental health literacy and first-aid interventions within their various communities, the culturally appropriateness of those programs were unclear. They suggested that formulating laws or policies and funding evaluative research efforts that provided specific step-by-step advocacy guidelines on how to mitigate mental health crises or cater specifically for the needs of this demographic would contribute to addressing these health issues in an evidence-based manner. It thus remains to be seen whether MHFA efforts by NGOs in South Africa, in the absence of a national guide, are culturally appropriate and effective among the most vulnerable social groups. In light of growing international uptake of MHFA and the need to understand its full scope and the cultural appropriateness of implementation mechanisms for its tertiary guidelines, among young people, this paper forms part of the broader attempt at investigating the effectiveness of MHFA in South Africa.

It focuses specifically, on MHFA in the Western Cape province of South Africa, to examine the extent and degree to which an NPO (nonprofit organization) has included protective factors in its adaptation of MHFA among social science majors, aged 18 to 34 years in the Western Cape province of South Africa. The paper delimits its focus to self-reported measurements of the impact of MHFA training on both peer trainers and trainees. Within this context, the aim of the current study is twofold: to describe the scope and characteristics of an NPO-led MHFA program in the Western Cape province of South Africa and secondly, to assess the cultural appropriateness and effectiveness of adapted guidelines on participants and the extent to which it is useful in mental wellbeing management (using self-reported health measurement).

2. Methods

2.1 Indima Yethu’s pilot project

Despite its growing popularity as a method of improving mental literacy and wellbeing, national uptake of MHFA in South Africa has been slow, as with other mental health related policies in the country. In the absence of a well-coordinated national MHFA strategy, guidelines, and agenda, the responsibility for mental health literacy has fallen on civil societies and communities. These organizations and communities design and pilot adapted MHFA training nationally, based on assumptions that are drawn from international research from the Global North, which leaves gaps in perceptions and understanding of the cultural appropriateness of MHFA training in South Africa. This paper examines the outcome of a culturally adapted version of MHFA in South Africa (which included spirituality and ubuntu values), implemented by a nonprofit organization, Indima Yethu. The current assessment of outcomes form part of a wider effort at building an evidence base of the utilization of YMHFA in South Africa, through a post-training feedback interview of MHFA participants in Cape Town.

Since 2018, Indima Yethu has been working with children and young people (CYP) in providing participatory health promotion interventions and culturally adapted MHFA training. In view of the complex mental health issues facing the South African youth during and post-lockdown, the NPO developed a 13-week YMHFA program, for over 863 young people aged 18–34 years, across the Western Cape province in South Africa, to enable them serve as first responders to their peers who were in crisis.

The foundation to Indima Yethu’s Youth MHFA program was laid for the first time by a needs assessment survey which revealed that a number of factors put students and young people at risk of writing – anxiety, panic attacks, paranoia, and depression. Among these factors are mismatched expectations, poor socioeconomic status, and uneven ratio of psychologists to students at various universities in South Africa.

Based on these, the goal of Indima Yethu’s MHFA training program is to create an informal peer mentoring and mental health support group to fill the gaps.

Thus, working from an asset-based theoretical and a participatory health research framework, the MHFA training program provides a space where students and other participants are able to improve their writing skills and manage their mental health and that of their peers who have no access to professional support through shared narrative therapy or mental health first aid. The methods and intervention tools utilized by Indima Yethu are underpinned by research-backed philosophy that writing, journaling, and narrative therapy give coherence and increase mindfulness, while peer support is cathartic and eases anxiety. Thus, Indima Yethu’s MHFA trainings were held online and offline (onsite at their Cape Town office) once a week for 2 hours each, over a 13-week period per session. The broader goals were summarized thus:

1. Creativity—to help unlock the student’s creativity and let it flow by learning self-expression.

2. Self-discipline and willpower—To help students solve problems by tracking personal patterns of behavior, being honest with themselves about what they feel per day, why and to become their first critic in a safe environment—their journals.

3. Improve problem solving abilities—Through journaling, writing personal narratives and peer support, students can take the edge off toxic emotions and gain clarity on future steps they need to take, while looking back on their writing to see progress made—how far they have come, how they handled challenges, and what personal patterns become roadblocks in their personal and professional life.

4. Stress reduction and improved memory—For students to stop letting their thoughts control them negatively. For them to be goal-oriented and let their goals drive them toward taking little steps that would culminate in success in any aspect of their lives.

5. Self-awareness and mindfulness—For the students to come to terms with the things they can control and those outside their control and through that recognize the sources of their anxiety and dissatisfaction with life.

2.2 Research design and procedures

The context for the current research was an NPO, Indima Yethu, located in Cape Town, whose work focuses on youth mentoring, capacity development, health promotion, and advocacy. Working with Indima Yethu, the data for this study were collected from the Indima Yethu Youth Mental Health First Aid program with ethics number HS21/5/65 from the University of the Western Cape. The data were collected from an analysis of records, intensive observation, and focused group interviews administered between October 2021 and June 2022, by a researcher from the University of the Western Cape. The sampling area was the Western Cape province, and sampling was a three-stage process. In the first stage, all trainees who had participated in the Indima Yethu 13-week Youth Mental Health First Aid program were selected based on a convenience sampling (n = 862). In the second stage, individuals who had participated in the program and utilized the referral system via the mental health app (sentinel) or through a mental health first-aid instructor were included. In the final stage, participants were selected from the second sample, including people who had trained, completed, and graduated from the 13-week course before, during, and after the lockdown as well as those who had lived experience of any form of mental illness.

I used broad categories to cover each group discussion as well as specific open-ended and closed-ended questions that focused on mental literacy and other determinants of wellbeing such as security, health, safety, employment, living conditions, housing, economy, leisure, civic activities, and social relationships. The reason for exploring these broad themes was to ensure that significant aspects of the research were covered during group discussions. In line with my grounding in these frameworks, I adopted a collaborative, consultative, and unstructured approach to the group discussions. As noted by Chevalier & Buckles [28], participatory approaches to research have the potential to facilitate solutions and avert conflicts between individuals in a group setting. They note that aside enhancing data reliability and validity, these approaches also increase researcher’s ability to identify and highlight assets within communities while helping them find solutions and develop strong partnerships.

Participants were required to respond to survey questions which were emailed by the program organizers. The email contained a cover letter, a link to the survey, and an invitation to participate in the FGDs workshop where the group discussions were held. The weekly workshops were conducted face to face and online. The weekly focused group discussions were facilitated by the author due to her experience in the pilot and cross-cultural study. I took notes during the weekly workshop sessions to document thought patterns and encourage reflexivity. Participants were divided into 4-hour sessions twice a week, over 13 weeks. They were required to participate in at least one session per week. The total number of hours spent facilitating discussions with participants was 104 hours. The categories for the lines of inquiries for the group discussions were generated from an extensive reading of literature and focused on each aspect of the surveys as well. Informed consent was obtained from participants after the aims of the study were explained to them.

2.3 Post-MHFA course survey

As earlier indicated, online surveys and focused group workshops were the primary data collection tools. These data collection tools were designed to assess participants’ perceptions, behaviors, knowledge, and attitudes toward mental illness, spirituality, level of empathy, coping mechanisms, and other protective factors for mental wellbeing. The assessment survey for participants took 10 minutes to complete on Google doc form and included 20 MCQs and other demographic data-related questions that required short responses. Although the lines of inquiry and survey questions were teased out from a review of MHFA literature and in consultation with instructors at Indima Yethu, in order to establish content validity, they were submitted to participants of the Indima Yethu MHFA course and other MHFA program organizers for feedback. Feedback from participants and experts were particularly important to me as I was working from an evaluative ubuntu, asset-based, participatory and decolonial epistemological and theoretical framework.

The survey items included four broad themes: the first theme covered the demographic profile of participants such as educational background, age, gender, ethnicity/race, socio-economic status, mental health lived experience, coping mechanism, etc.; the second theme assessed changes in participant’s knowledge by focusing on their ability to gain and utilize newly acquired mental literacy information upon completion of the MHFA training; the third theme focused on change in attitude and helping behavior toward others; the fourth theme assessed Indima Yethu YMHFA 13-week module-related outcomes which asked questions related to spirituality, confidence, and self-esteem. For questions that fell within themes two and three, participants were required to rate statements using a five-point Likert scales (The response scale for items in categories 2 to 4 were 1 (strongly disagree), 2 (agree), 3 (neutral), 4 (agree), 5 (Strongly agree), and 6 (other).

Each item was meant to indicate the response that best captured the effectiveness of the MHFA program and participants attitudes toward applying the ALGEE action plan:

1. Assess for risk of suicide or harm.

2. Listen non-judgmentally.

3. Give reassurance and information.

4. Encourage appropriate professional help and

5. Encourage self-help and other support strategies

Most of the questions were adapted from existing literature and previous studies on the outcome assessment of MHFA training, and some of the statements participants rated include “I remember ALGEE,” “I have utilized and applied ALGEE action plan,” “I remember the MHFA course content and can teach my peers,” “I have utilized and applied the MHFA course content for myself,” “I have utilized and applied the MHFA course content for my family,” “I have utilized and applied the MHFA course content in my community,” “I have applied the YMHFA training content in my everyday life,” “I learned new information about mental disorders in the YMHFA course,” “I am now confident in helping an individual experiencing a mental health challenge as a result of the YMHFA course,” “My behavior towards mental disorders has changed as a result of the MHFA course,” “My attitude towards mentally ill people has changed as a result of the MHFA course,” “I am more eager to help my community destigmatize mental illness”, etc.

Items that fell within theme four which focused on Indima Yethu’s specific resources such as spirituality, self-confidence, de-stigmatization and self-esteem, and participants were required to circle the responses that indicate how the 13-week MHFA course from Indima Yethu impacted their wellbeing, that of their loved ones and their openness to spirituality. The response scale for these items were rated as positive or negative using a 5-point scale: 1 (very favorable), 2 (favorable), 3 (very unfavorable), 4 (unfavorable), and 5 (NA). Furthermore, participants were asked to indicate how often they were in contact with other individuals experiencing mental health crises and to describe how they supported them as well as their level of confidence in their ability to support others. If they indicated that they had helped someone while taking the course or after, they were asked to list the number of times and under what circumstance they made referrals using Indima Yethu’s in-house mobile app. Participants used the focused group workshop platforms to unpack all responses provided in the surveys.

2.4 Participants

Overall, a total of 548 young people aged 18 to 34 years participated in the study, having completed the YMHFA program through Indima Yethu between December 2019 and June 2022. Of all participants, the general response rate was 98%. Overall, 76.3% of participants were females (n = 418), with a median age of 21.5 years, 87.2% were single, and 57.7% were colored (n = 316) with 38.3% Black Africans (n = 210) and approximately 1.8% (n = 10) Whites. Seventy-nine percent (n = 426) of participants had high school diplomas at the time they underwent the training, and others were mostly social science and humanities undergraduate majors enrolled at various universities in the Western Cape with no prior training in healthcare. Almost all participants had experienced one form of mental illness or had a close family member or friend who had. Approximately 62.2% (n = 341) of participants reported that their annual household income was below R100,000 (equivalent to 6116 US Dollars when controlled for inflation).

2.5 Data analysis

Considering the prevalence of quantitative research on MHFA, the current study will prioritize qualitative insights in order to unpack, enrich, and add the much-needed depth to this emerging topic. All focused group discussions were audio-recorded, transcribed, and coded manually. The process of coding and content analysis enabled us to highlight similarities in experiences. It also enabled us to link quantitative data with qualitative insights and patterns that were generated as well as explain them. This process allowed one to generate major patterns, themes, and concepts [29]. Descriptive statistics are used to categorize and summarize demographic data from participants, and content analysis was used to summarize qualitative data emerging from the FGD on the perceived outcomes of the ALGEE action plan, changes in attitudes and knowledge, supportive behavior, mental health literacy, and spirituality. The pilot study (Obuaku-Igwe, 2020) that preceded the current one generated baseline information on protective factors for mental wellbeing among young people in South Africa. It is anticipated that the current study will yield further information on the effectiveness of MHFA as a protective factor in mental wellbeing management among young people in informal settlements in the Western Cape, for further studies of the social welfare and social protection of CYP in South Africa.

See table one below for further details about participants’ mental health experiences and coping mechanisms before the MHFA training (Table 1).

Mental illness	n	%
Anxiety/depression	365	70.6
Bipolar	99	18.1
Eating disorder	62	11.3
Coping mechanism for mental illness prior to enrollment in MHFA at Indima Yethu
Coping mechanism	n	%
Music	273	49.8
Weed	129	23.5
Energy drink	109	19.9
Alcohol	37	6.8

Table 1.

Participants lived experience of mental disorder and coping mechanism before MHFA (N = 548).

2.6 Results

Content analysis of focused group discussions utilized a bottom-up [30] approach where I tried to identify phrases that were related to broad categories linked to changes in behavior due to utilization of new knowledge, helping behavior, and increase in self-confidence. Afterward, I organized all relevant statements into repetitive themes below the broader categories of changes in behavior, helping behavior, and increase in self-confidence.

2.6.1 Knowledge retention and utilization

Questions under the first theme assessed the extent to which participants’ attitudes changed due to acquisition and utilization of new knowledge through the YMHFA training program. 75.5% of the participants (n = 414) reported that upon completion of the training that they remembered and have utilized aspects of the ALGEE course content and a few people (24.5%, n = 134) indicated that they did not remember much. Of those who remembered the YMHFA course content, majority (81.6%, n = 447) indicated that they utilized the knowledge gained in recognizing signs of mental health issues and instability in their lives and among friends and family members and 17.9% (n = 98) utilized the knowledge of ALGEE in helping colleagues at work.

Overwhelmingly, participants with lived experiences of anxiety/depression who used weed, energy drink, and alcohol as coping mechanisms reported a decline in their utilization of substances after taking the MHFA training. They had accepted the construction of their illness and stigma attached to it by family regardless of how it made them feel, but the training helped in changing their perception of mental illness. Most notably, those with lived experiences of bipolar disorder journaled more during the 13-week training and viewed music as a good coping mechanism each time they felt overwhelmed. The participants with eating disorders differed greatly from other participants, noting that the module on embodied experiences changed their mental models and helped them in overcoming fears about eating and overall construction of selfhood.

2.6.2 Changes in helping attitude due to mental health literacy

The range of questions within this category assessed various ways in which participants’ helping behavior has changed post-training. A good number of participants 75.7% (n = 415) indicated that prior to the training sessions, they did not know about MHFA and only 22.8%(n = 125) said they were familiar with MHFA as a concept. Majority of participants (84.8%, n = 465) indicated that they acquired new knowledge from the training which changed their behavior toward mentally ill people as well as their perceptions of mental disorders. 75.9% (n = 416) indicated that the training they received improved their understanding of the risks associated with untreated mental illness; 16.6% (n = 91) were neutral and only 7.5% (n = 41) said they did not know the risk factors. 87% (n = 477) indicated that upon completing the training, they have become more aware of the prevalence of mental illness among their peers and have experienced individuals with emotional distress whom they supported through referrals and other ALGEE strategies. Of those who provided some form of support for individuals with mental illness, 65.4% (n = 358) indicated that they were confident that liaising with psychologists and getting therapy were the most significant support one could get for psycho-social stressors and early signs of mental health challenges. All participants indicated that they used Indima Yethu’s six-step approach—“reach out, offer emotional support; offer affirmations and appraisal; offer informational support, offer instrumental support and share points of view” in helping people.

2.6.3 Outcome of Indima Yethu’s six-step approach

Items that fell within theme four focused on specific aspects of Indima Yethu’s 13-week training resources which emphasized “self-concept, mentoring at least one person in their community (post training) and enabling peer access to social support through a six-step approach - ‘reach out, offer emotional support; offer affirmations and appraisal; offer informational support, offer instrumental support and share points of view” among others. All participants but 2.6% (n = 14) reported that aspects of the course offering such as practicing active and empathetic listening during week 9 were very favorable. Many participants (98.7%, n = 541) indicated that taking the course helped them in finding their voice via blogging, defining what success and peace meant to them, taking baby steps toward it, and celebrating themselves. 52.7% (n = 289) of those who found the program very favorable indicated that they engaged in at least 30 minutes of moderate physical activity on most days of the week, journaling and telling instructors how they felt before and after each practice, 24.6% (n = 135) journaled but did not engage in any physical activity, and 22.6% (n = 124) did not journal nor engage in physical activity but reported observing their breath for 10 minutes each day and conducting energy mapping by observing when they were most productive each day and doing one little thing that pushed them out of their comfort zone.

98.7% (n = 541) of the participants who reported that the programs were very favorable indicated that the most positive aspects of were those that involved supporting their peers, pairing up with an established accountability partner to help them along the journey of achieving their set goals, practicing self-expression and coherence through daily journaling, identifying key areas of development related to career, academics, spirituality, and relationships and working on them, enlisting the support of family and friends in answering questions on self-awareness using a weekly prompt that was provided by Indima Yethu. The few participants (1.3%, n = 7) who found the program less favorable indicated the negative aspects were those that involved setting personal short- and long-term goals, and pairing up with an accountability partner who will hold them accountable. They reported that it put further strain on their mental health and did not help. Table 2 presents examples and summaries of statements from participants.

Theme Example statements

Utilization of Knowledge We Black people do not like going for therapy and the older generation dismiss us as lazy when we complain but since I took this course, I have been able to encourage my cousins and I wish it could be translated it into Isizulu for my mom and aunties aunties.; In all honesty, I live with extended family members who use alcohol to numb their pain but I used some of my knowledge to encourage them to seek help for their trauma.; My living situation has been very volatile due to older siblings who are dealing with relationship issues and transferring aggression on others, but after taking the course, I have learned to listen non-judgmentally and give reassurance.; Since I took the course, I have been the strong one for my family through all the losses we suffered during COVID-19. I have been listening to them and encouraging therapy.; Since the day my grandmother started getting sick and even now, I have been the one facing it all, fighting it all through the help of ALGEE, to help encourage self-help support for my family.; The course has helped me to the point where even my mother tells me things because she knows I will not judge her.

Change in helping behavior; Black communities see this as a taboo when one is suffering from mental health, and we are either told we sick and we need prayers. I think that what really draws people who suffer from it to commit suicide. Taking the YMHFA course helped me to recognize and adopt a more tolerant attitude toward mentally ill people. I am now comfortable talking to and helping them.; I never liked the idea of being friends with or working with someone with a mental health problem, but ALGEE has helped me in starting conversations about how they can get help.; I come from a community where people pray about mental illness or see a spiritualist who oftentimes tells them that it is a sign of spiritual calling. The course taught me a six-step approach I can use in persuading them to get help.; To be honest, I used to be afraid of mentally ill people and thought they should be excluded, but now I know that no one is Immune to stressors. I mean, people can always get help if we apply the right strategies by educating them, not judging and referring them for professional help. This is humanity to me

Self-confidence they began with an “asset mapping” instead of “needs analysis” in their course and that really helped us in learning about what is important to young people when it comes to applying ALGEE or making referrals.; I think people with mental illness also value being involved in meaningful things that they also enjoy, including educational achievement, material wellbeing, housing, career success, and positive relationships.; Indima Yethu’s training enlightened me about self-consciousness, self-concept, and self-definition which also helped me in setting healthy boundaries and dealing with the stigma attached to having schizophrenia. People used to call me “schizo” but I am Now able to talk about my experience more openly and help others.; Apart from the ALGEE plan, I benefited mostly from the mobile application and the breathing exercises which I’ve taught my family. It connects me to my higher self and grounds me.; The course taught me a lot about myself and that has changed how I talk to people within my circle. I have referred over 20 people from my class for therapy since I completed the training and I am now working with primary schools.

Table 2.

Statements from participants showing broad spectrums and themes of MHFA impact.

2.7 Discussion

This study examines the effectiveness of a youth-focused Mental Health First Aid training program, within the context of an adapted adolescent guideline implemented by a nongovernmental organization in the Western Cape province of South Africa. It presents a preliminary attempt at building an evidence base for MHFA in South Africa by assessing the perceived impact on individuals who underwent training. The sample included young people between the age of 18 and 35 years who are resident in the Western Cape. Overall, the study findings indicate that MHFA is emerging in South Africa as a protective factor. Preliminary evaluation indicates wide acceptance which corresponds with findings from a systematic review [31], of mostly quantitative studies which found that MHFA is an effective intervention for trainees exposed to the curriculum. They also indicated that the largest effect sizes were found for the knowledge and confidence outcomes, while “attitude and behavior-only” effect sizes were within the small range.

Participants in the current study indicated positive outcomes for MHFA training for them and their friends and family. Majority of the participants indicated that acquiring new information about mental health during their training changed their perception of mental illness and strengthened their confidence in supporting other people within their social network. Even though most of the samples are social science majors who did not participate through a compulsory university-based program, they reported using the knowledge gained to support their friends at school. Statements from participants suggested that adapted and culturally appropriate MHFA training guidelines for young people de-centered neediness and a token system which made communities heavily dependent on specialist services. Within this context, they noted that MHFA focused on identifying, building, and utilizing existing social capital capacities which contributed to improving the health of their communities.

In addition, the majority of the participants noted that YMHFA did not only connect people to others but helped in reconnecting them with their higher self and humanity. These findings strongly suggest that MHFA can be situated within a broader asset-based approach to mental health education. There is evidence of favorable outcomes such as new knowledge and de-stigmatization due to the inclusion of specific youth-friendly information and emphasis on social capital. Within the general pattern among the sample, findings suggest that MHFA is a protective factor which could potentially act at several different levels, including the individual, the family, the community, the structural, and the population levels when implemented in a culturally appropriate manner. Findings indicate that the observed positive changes in behavior and attitudes after MHFA training point to the role of effective health communication strategies in influencing intervention outcomes.

Due to the historical trajectories of South Africa, its long history of racial and economic inequality appears to have significantly influenced perceptions of mental illness among vulnerable social groups and access to coping resources that could protect or mitigate the impact of stressors as well as provide a buffer against risks. Since the end of apartheid, the new democratic government has struggled to sustain inclusive policies despite introducing social welfare packages for historically marginalized groups.

Reflecting on what is working well within a particular social group so that it can be included in training guidelines, considering what makes them strong or healthy as well as including other culturally appropriate items that make them more able to cope in times of stress, as the current study indicates, appears to increase positive outcomes for MHFA.

There was general satisfaction with the implementation of the 13-week program by Indima Yethu among those surveyed due to their emphasis on social determinants of general wellbeing and considerations for concepts, language, and priorities for various cultures and settings. To the majority of participants, the changes in their behavior stemmed from the cultural competence of the course and instructors which helped them and their loved ones in navigating relationships with professional service providers. There was evidence among all respondents of including information that addressed physical barriers to access, such as the sentinel mobile app which made referrals easier by connecting individuals to first responders. Based on surveys and FGD data, participants felt that one of the most favorable aspects of the ALGEE training program was individuation, which made them aware of their specific stereotypes and biases against themselves and others.

3. Conclusion

This study examined the effectiveness of MHFA within the context of its growing popularity post-pandemic, and in particular, within regions without access to professional resources such as South Africa. Participants who had lived experiences of mental illness reported a higher satisfaction with the MHFA training due to their “embodied experiences and their desire to be understood by friends and family. As noted in the literature review, some existing body of work has shown that while MHFA had positive impacts on participants, it was more impactful on high-risk populations. In contrast to previous studies, the sample for the current research included individuals who had been diagnosed with and have experienced a particular mental illness and have lived with the ‘stigma’ of being misunderstood and misjudged by society (which is further reinforced by other participants who had not experienced mental illness of any kind, noting stigmatization and lack of empathy and support for youth living with mental illness. I believe that the positive feedback from participants is directly related to the emphasis on mindfulness, social capital, self-concept and the management of ‘embodied experiences” in the course content.

This study suggests that MHFA plays a significant role in mental wellbeing management, health literacy, and de-stigmatization of mental health. Based on analysis of course content, focused group discussions, and direct observation, I conclude that four factors contributed to the overwhelming satisfaction experienced by participants: (1) the utilization of peer tutors in administering the training; (2) the inclusion of mental models and centering their agency in training content; (3) the availability of peer mentors and a mobile application which makes referral and access to professional intervention easy; and (4) the inclusion of friends and family as accountability partners.

To summarize, MHFA has the potential for positive outcomes when culturally and linguistically adapted. For example, within a global context, Black Africans, young people, females, the LGBT community, and others from marginalized social groups have a higher risk of mental illness, poor access to professional services, and acceptability-related challenges when the services are available; within most capitalist countries, this social group also suffers disproportionately more than others but are less likely to access MHFA, particularly, when such services lack cultural competence [32]. At the same time, while most MHFA training programs target vulnerable populations, some of the programs rarely reach them due to the exclusive focus on medicalization and specialized services [33]. The implication is that they tend to ignore such training [34]. The impact of cultural incompetence in the implementation of MHFA has had a significant effect on vulnerable individuals attempting to access mental health information or education through the public sector in imperialist states. This has implications for health outcomes over a life course.

The present study excluded most predictors of outcomes and changes in attitudes such as gender, age, and other measurable variables. The study also made no attempt at exploring the relationship between most variables and standard deviation. These have implications for future research. Further research is needed to cover these obvious limitations of the present study. In future research endeavors, caution must be applied in utilizing the result of this study to assess racial, gender, or SES-related disparities in MHFA effectiveness. Future research should consider the impact and relationship of gender and education on identified outcomes in the current study. Existing patterns from positive MHFA training outcomes in the global north suggest that most MHFA trainees are more likely to be female, employed in care jobs that involve working with people, middle-aged than young, or males, and these measures matter.

Notes/thanks/other declarations

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