Alwin E. Wagener, Laura K. Jones, J. Scott Hinkle
The global burden of disease related to mental health is astronomical and growing, with underprivileged countries being disproportionately affected. The Mental Health Facilitator (MHF) program was designed by the National Board for Certified Counselors (NBCC) to address the need for greater mental health support within international communities lacking adequate mental health practitioners to provide services. The MHF program trains individuals within communities to provide support and necessary referrals for those struggling with mental health challenges. This study assesses the effectiveness of MHF trainings conducted in a diverse subset of countries and communities. Initial findings from the analyses found significant gains in participants’ knowledge of mental health and mental health facilitation skills across training populations.
Keywords: Mental Health Facilitator, MHF, mental health, NBCC, global
Over 450 million individuals around the world struggle with mental health concerns with 300 million people alone suffering from depression (World Health Organization [WHO], 2018). Mental health is defined as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (WHO, 2014a, para. 1). Mental disorders account for nearly 30% of the global burden of disease (i.e., what kills, injures, and disables people around the world) in terms of years lived with disability (Kessler et al., 2009; Vigo, Thornicroft, & Atun, 2016). In addition to the hardships that mental disorders place on an individual’s social relationships, occupational opportunities, and physical health, nearly 800,000 people a year die by suicide, with 75% of those individuals residing in developing countries (WHO, 2014b). Such staggering statistics include the rank of suicide as the second most common cause of death among young people globally (WHO, 2014b).
In addition to personal struggles, communities also face economic hardships related to mental disorders. The global cost of mental health was estimated at $2.5 trillion in 2010, with estimates of costs expected to reach as high as $6 trillion by 2030 (Bloom et al., 2011). Such costs can be devastating for individuals and communities alike, especially where resources are limited.
Despite the exorbitant number of individuals around the world struggling with mental health concerns and the associated individual, societal, and economic costs, only a small portion of people receive the support they need (Hinkle, 2014; Kohn, Saxena, Levav, & Saraceno, 2004; Wang et al., 2007). It is important to note that only one third to one half of individuals in high-income countries receive mental health care. This gap is even more pervasive in low- to middle-income countries, with a mere 15%–24% of individuals receiving any form of mental health support (Demyttenaere, 2004). Furthermore, according to WHO (2015), most of the world’s population live in areas where there is an average of less than one psychiatrist per 200,000 people and even fewer individuals trained in psychosocial interventions.
This gap in service provision and treatment stems from both attitudinal (e.g., misinformation about mental health such as low perceived need, stigma, and discrimination) and structural-level (e.g., availability of services, financial considerations, and transportation problems) barriers (Andrade et al., 2014; Hinkle, 2014). Although attitudinal barriers appeared to be more pervasive, overall individuals with more severe mental health conditions and those in low- or lower–middle- income countries cited financial and service availability barriers as being especially problematic. In 2011, WHO detailed the scarcity of resources available to treat and promote mental health across the spectrum of high- to low-income countries, which leads to a gap in the provision of treatment as well as the quality of treatment when it is available. For example, within high-income countries, approximately $44.84 USD is spent per person on annual mental health expenditures, a value which drops to $0.20 USD per person in low-income countries (WHO, 2011). Clearly, a strategy to lessen this gap in global mental health service provision is needed.
A Call to Action
Given the pervasiveness and deleterious consequences of mental health disorders paired with the dearth of individuals receiving treatment, there is a global imperative that countries begin prioritizing mental health awareness, education, and treatment and combatting the noted barriers to individuals seeking and receiving adequate care. Enhancing the awareness and education of not only individuals struggling with mental health difficulties, but also members of the community, would be beneficial in addressing attitudinal barriers, while providing additional resources through increasing the number of both service providers and service centers can help to eliminate structural barriers to services. Such solutions are reflected in the WHO’s (2013) Mental Health Action Plan, which outlines the following four objectives:
(1) to strengthen effective leadership and governance for mental health; (2) to provide comprehensive, integrated and responsive mental health and social care services in community-based settings; (3) to implement strategies for promotion and prevention in mental health; and (4) to strengthen information systems, evidence and research for mental health. (p. 10)
Several approaches exist to address these objectives, yet one program in particular is unique in creatively addressing multiple objectives at once. Developed by the National Board for Certified Counselors (NBCC) and initially endorsed by WHO, the Mental Health Facilitator (MHF) program aims to reduce disparities in mental health care by facilitating access to support individuals and mental health services in underserved populations (Hinkle, 2006, 2014; Hinkle & Saxena, 2006). Specifically, the MHF program trains diverse community members (i.e., mental health laypersons) in the knowledge and skills necessary to identify mental health needs, support those in need of care, work with existing care resources, and make referrals to mental health professionals as needed (Hinkle & Henderson, 2007). The program focuses on creating a culturally appropriate curriculum adaptive to community needs and contexts while also providing fundamental information concerning mental health and basic psychosocial interventions. Also, unlike many other programs, the MHF program is only tailored and implemented into specific communities at the community’s request. In this way, the MHF program content aligns with WHO’s Mental Health Action Plan by working to strengthen culturally appropriate information systems, implementing strategies for promoting mental health and decreasing the severity and pervasiveness of disorders, and enhancing responsive and integrated service provision within community-based settings tailored to the needs of that community (Hinkle, 2014).
Content of the MHF Program
The mission of the MHF program is to provide skilled, responsible access to quality mental health interventions. This is usually accomplished through basic first-contact help and referrals to mental health professionals with respect for human dignity and meeting population needs by balancing globally accepted mental health practices within local norms and conditions (Hinkle, 2014). Cross-disciplinary in nature, the MHF program includes competencies from psychiatry, psychology, social work, psychiatric nursing, and counseling, covering topics such as helping skills, diversity, violence and trauma, suicide prevention, and referral and consultation skills. The design of the training emphasizes important considerations and approaches in addressing mental health concerns while allowing for flexibility in implementation. This flexibility is a key strength of the training program and is necessary given the breadth of cultural and contextual factors affecting mental health and mental health care around the globe. Such flexibility allows local stakeholders to identify and adapt the training to local needs and the knowledge gained from the MHF training program to be implemented within existing care settings or to provide a foundation for care in areas where no established system is present. The information contained within the training and flexibility of implementation constitute a population-based mental health care approach to addressing health care needs across a broad range of social, political, economic, and cultural environments (Hinkle, 2014), and one that is growing in its evidence base.
History and Implementation of the MHF Program
The MHF program is a three-tiered, train-the-trainer implementation model that consists of MHF master trainers, MHF trainers, and mental health facilitators. MHF master trainers are selected by NBCC based on specific criteria, most notably the completion of considerable training and experience in mental health and education. MHF trainers are often professionals or paraprofessionals with mental health and teaching experience located in the community who can train community groups. MHF trainees are typically laypersons with an interest in mental health who then become the first line of support for community members with mental health needs. Following training at each of the levels, individuals are registered in the international MHF registry. Currently there are over 4,774 registered MHF master trainers, MHF trainers, and mental health facilitators located around the world.
The MHF program was first established in 2005, when NBCC worked in collaboration with WHO to establish a panel of experts, including mental health professionals from the United States, Canada, Malaysia, Trinidad, St. Lucia, Turkey, Romania, India, Mexico, Botswana, and Venezuela, who would contribute to the development of the MHF training manual, curriculum, and implementation plans. This approach led to content and delivery plans that represented diverse cultures and thus diverse perspectives on mental health, mental health care, and the role of MHF master trainers, MHF trainers, and mental health facilitators. The curriculum and master training guide were completed and piloted in Mexico City in 2007 and 2008. Later in 2008, the first train-the-trainer program was delivered in Lilongwe, Malawi. To date, NBCC has partnered with 26 countries, including eight countries in Africa, five in Asia, four in the Middle East, and eight in Europe, as well as programs in Mexico and the United States. Furthermore, the MHF curriculum has been translated into Arabic, Chinese, Dzongkha (the language of Bhutan), Estonian, German, Greek, Japanese, Malay, Portuguese, Romanian, Russian, Spanish, and Swahili (Hinkle, 2014).
The MHF Curriculum
When developing a partnership with NBCC, communities can choose one of five MHF curricula to best suit their needs, namely the original MHF training, an abridged MHF training, a training for educators (MHF-EE), an abridged MHF-EE, or a version for first responders (i.e., fire, rescue, and police). The five MHF curricula share core content aimed at helping professionals and paraprofessionals improve communication and helping skills, identify local mental health resources, understand important ethical considerations, and connect health providers with individuals within their community who are in need of mental health services (Hinkle, 2014). In addition to the core content, the curricula directed toward educators and emergency personnel contain tailored modules to best support those populations. With trainings ranging from 6 to 30 hours, the curricula can be delivered over consecutive days or divided into its modules and taught over several weeks, depending on community needs (Hinkle & Henderson, 2007).
The foundation of the MHF curriculum underscores the shared experiences of stress, distress, and disorder (Desjarlais, Eisenberg, Good, & Kleinman, 1995; Hinkle, 2014; Hinkle & Henderson, 2007). Given these theoretical underpinnings, the core modules cover topics such as basic helping skills, coping with stress, community mental health services, and community advocacy skills, and also introduce trainees to considerations around ethical practice and specifics about interventions such as suicide mitigation and trauma responses (Hinkle, 2014). Participants learn the benefits of investing in mental health, barriers to mental health care, cost-effective interventions, how mental health disorders impact families, confidentiality and privacy, and the broad mission of the MHF program (Hinkle, 2014).
In the basic helping skills section of the training, trainees cover development; diversity; verbal and nonverbal communication; facilitative skills such as listening, asking questions, and providing reflections; assessing for mental health concerns; empathy and understanding human feelings; and how to make referrals and effectively terminate relationships (Hinkle, 2014; Hinkle & Henderson, 2007). This information is followed by a discussion of how to understand problems, coping styles, and ways of effectively managing problems. The training then delves into recognizing stress, distress, and various disorders, including risk factors and mental health in children. The core modules conclude with discussions of suicide and trauma. Being the leading cause of death among young people in low- and middle-income countries, suicide is a pressing concern within all communities (WHO, 2006). Similarly, the pervasiveness of natural and human-born disasters and crises, such as war, forced displacement, human trafficking, typhoons, and wildfires, affects individuals of all demographics around the world and often goes untreated (Hinkle, 2014). A final topic covered in the core MHF training is the importance of self-awareness and self-care for mental health facilitators.
Moreover, the content in any of the five MHF curricula can be adapted to best fit the social, cultural, economic, and political realities and needs of any community, country, or region. For example, countries have chosen to add additional modules on child maltreatment in the Syrian region.
Past and Ongoing MHF Research
Building a strong evidence base is imperative to the development of a sustainable program that addresses the staggering gap that exists in mental health service provision. With limited resources spent on mental health, countries and communities cannot afford to implement programs that lack evidence supporting their projected outcomes and benefits. To this end, NBCC has and will continue to emphasize building a solid evidence base for the MHF program. Qualitative studies published to date (Luke, Hinkle, Schweiger, & Henderson, 2016; Van Leeuwen, Adkins, Mirassou-Wolf, Schweiger, & Grundy, 2016) support the perceived value and effectiveness of the program. Luke et al. (2016) reported that among the value and benefits, participants commented on how the program was culturally congruent and beneficially adapted to the needs of their community as well as how the program filled a need in terms of limited mental health resources. Participants further noted the considerable negative implications if the MHF program were to be discontinued (Luke et al., 2016). Van Leeuwen et al. (2016) also found notable positive perceptions of the MHF program. Participants reported that they gained skills in communication and referral. They also noted how they received important education on mental health and causes of mental health problems, and an enhanced awareness of mental health in communication. Finally, participants reported that there were both personal and community benefits to the program, such as an ability to better understand their own mental health and the mental health of family members as well as a reduction in community mental health stigma (Van Leeuwen et al., 2016).
However, to date no study has reported the quantitative outcomes of MHF trainings. Most trainings include pre- and post-training assessments of participants using a true-false, pencil-and-paper–based assessment. The assessment for the original MHF curriculum had three small adaptations involving changing the wording on several questions in 2009, 2011, and 2013. The adaptations were minimal, so all years were included in this study. This study fills the gap in the MHF literature by reporting on the objective data gathered from the pre- and post-training assessments of the original MHF curriculum.
This study uses a quasi-experimental research design to evaluate whether participants in 88 MHF original trainings demonstrated increased knowledge of mental health issues and approaches to address community mental health concerns. The trainings spanned from 2009–2017 and included all MHF trainings conducted outside of the European Union and the United States. For each MHF training, pre- and post-training assessments were completed by all participants in an effort to evaluate the effectiveness of training. The pre- and post-training assessments contained 50 true-false questions with the pretest administered on the first day of training and the posttest administered at the final training day, 5 days later. The present study analyzed the pretest and posttest evaluations using paired t-tests and a one-way ANOVA.
Participants who completed all items on both the pretests and posttests were included in the study, resulting in 1,392 participants from 15 countries. Of the 1,392 participants, only 735 provided descriptive information. For those participants, 431 were female (59%) and 304 were male (41%). The age range of participants was 17 to 75 years with a mean age of 36 years. The education of participants ranged from elementary school to doctoral (PhD) and professional degrees (MD and JD). There were 14 participants reporting only an elementary school level of education (2%), 150 with high school (20%), 151 with a 2-year degree (21%), 310 with a 4-year degree (42%), 99 with a master’s degree (13%), and 11 with a PhD or professional degree (1%). Given that trainings were conducted in countries within North America, Africa, Asia, and the Middle East, the data included a diverse range of participants in terms of nationality.
There were two primary questions investigated in this study. The questions were prompted by a desire to better understand the effectiveness of the MHF trainings: (1) Does the MHF program training significantly increase overall knowledge of mental health facilitation from pretest to posttest evaluation for participants? and (2) How does performance on the pretest, or initial mental health knowledge, affect possible training gains made between pretest and posttest scores for the participants?
Prior to formal data analyses, the authors examined the data to ensure it satisfied the assumptions of the relevant statistical tests. Upon initial data examination, the authors determined that 77 participants of an initial 1,392 were outliers. The outliers were those with scores 1.5 times the interquartile range, either above the third quartile or below the first quartile. Based on this, the data analyses presented in the following sections were run with and without the outliers removed, and it was determined that the outliers did not significantly affect the results (the only exception to the outliers affecting the results is described in the results section). As such, the data analyses presented are using the remaining 1,315 participants after the removal of the outliers.
As the data set is too large for statistical normality tests to be accurate, skewness and kurtosis values were examined. The data set without the outliers had skewness (.208) and kurtosis (-.018), both values within the normal range. A visual inspection of the descriptive q-q line further supported the conclusion that the data is normally distributed.
Overall Mental Health Knowledge Gain
The first research question, asking whether the MHF program training significantly increased overall knowledge of mental health and mental health facilitation, was assessed using a paired sample t-test. The result of this analysis showed that there was a significant difference (t = -35.90, p = 0.000) between pretest (M = 37.64, SD = 5.58) and posttest (M = 41.17, SD = 5.24) scores. This analysis confirms the hypothesis that the MHF program training significantly increases the scores of participants from pretest to posttest evaluation.
Initial Mental Health Knowledge and Training Gains
The second research question investigated whether the starting knowledge of participants, as measured in the pretest, affected the training gains made between the pretest and posttest. To address this research question, four categories based on pretest scores were generated. A descriptive analysis was conducted to determine the quartiles of the pretest scores, and the quartiles were used to define the categories. The authors determined that quartiles are an effective means of dividing the pretest scores into four groups given that the relationships between the groups are clearly linked to the overall distribution of pretest scores. The pretest scores ranged from 15–50 (the range of possible scores was 0–50), and quartiles were generated in order to better understand the effects of MHF training on participants with low, medium-low, medium-high, and high MHF knowledge going into the training. The quartile scores were as follows: low < 34 (N = 317, M = 5.34, SD = 4.23), medium-low = 34 to 38 (N = 369, M = 4.13, SD = 3.62), medium-high = 39 to 42 (N = 340, M = 3.06, SD = 2.69), and high > 42 (N = 289, M = 1.35, SD = 2.04).
To compare the four groups and answer the second research question, a one-way ANOVA was used. The analysis showed that the differences between the scores of the four categories are significant (F[3, 1311] = 81.05, p = 0.000). A post-hoc Tukey HSD test allowed for a more detailed understanding of the difference between the four groups. The Tukey HSD test results indicated significant differences between all four groups. The details of the differences between means in the post-hoc test are as follows. The low score group showed a significant difference between pretest and posttest scores compared to the medium-low test score group (mean difference = 1.21, p = 0.000), the medium-high test score group (mean difference = 2.28, p = 0.000), and the high test score group (mean difference = 3.99, p = 0.00). The medium-low test score group was significantly different from the medium-high (mean difference = 1.07, p = 0.000) and high (mean difference = 2.78, p = 0.000) test score groups, and the medium-high test score group was significantly different from the high test group (mean difference = 1.71, p = 0.000). When running the one-way ANOVA with the outliers included, the only difference in significance found in the results for any of the analyses occurred between the medium-low and medium-high groups. With the outliers included in the analysis, there was no significant difference between those two groups, although all the other significant differences remained, and the overall trend of pretest to posttest score differences decreasing as the pretest score rose remained unchanged. The results of the analyses confirm that the lower the pretest scores, the larger the gain in knowledge from the training.
Post-Hoc Data Analysis
After considering the significant pretest to posttest gains, the authors became curious about whether the content of the pretest and posttest questions might be separated into subscales to better evaluate MHF training effectiveness. The observation that the questions on the MHF pretests and posttests naturally related to either knowledge or skills prompted the authors to separate the questions into the two subscale categories, MHF knowledge and MHF skills.
To generate the two subscales, one author went through the questions independently and categorized them for each of the three test iterations. Then, the second author went through the questions to confirm they fit the subscales. A paired t-test was used to determine whether participants demonstrated equivalent gains in both knowledge and skills.
The results of the analyses showed significant gains on both subscales. The mean gain on MHF knowledge was 1.41 (N = 1315, t = -22.86, p = 0.000), and the mean gain on MHF skills was 2.12 (N = 1315, t = -29.67, p = 0.000). The results of this post-hoc analysis confirm the hypothesis that the MHF program training leads to significant increases in both MHF knowledge and skills.
The results of the present study provide further evidence of the effectiveness of the MHF program. Previous studies have examined qualitative accounts of trainees’ experiences and impressions of the program (Luke et al., 2016; Van Leeuwen et al., 2016). The present data, however, provide objective evidence that the program is indeed enhancing trainee knowledge of mental health and MHF skills. This finding suggests that individuals who complete the MHF program have the requisite knowledge and skills to provide frontline interventions and needed referrals for community members struggling with their mental health.
Interestingly, the results also demonstrate that the documented growth in knowledge and skills is relative to the existing knowledge of the participant prior to training, whereby those with less initial training (i.e., lower scores on the pretest) showed greater gains in knowledge and skill from participation in the MHF training. Although somewhat intuitive, this provides evidence that the program is successful at enhancing the knowledge and skills of participants despite previous training in mental health. It brings all participants up to a similar, requisite baseline level of knowledge to perform mental health facilitation. Participants with little to no information regarding mental health can gain the needed knowledge and skills necessary to support the mental health of others in their community, while those with considerable information and training can refine their skills and knowledge for their new role.
Post-hoc analyses assessed whether the MHF program is equally adept at enhancing knowledge related to mental health and mental health struggles as well as the skills needed in mental health facilitation. Findings revealed that participants demonstrated a significant growth in both knowledge and skills. As such, the MHF program not only provides mental health literacy, but also the skills needed to support those in need. This is notable given the significant disparity of mental health literacy in both the developed and developing world (Ganasen et al., 2008; Jorm, 2000). Among professionals and laypersons alike, the lack of knowledge and understanding of mental health not only contributes to the treatment gap, but also the considerable stigma faced by those who struggle with mental health issues.
Taken together, the results suggest that the researchers and program developers can confidently endorse this program as one that leads to an increase in mental health knowledge and skills associated with mental health facilitation among both professionals and laypersons. In this way, the MHF program furthers the WHO’s (2013) Mental Health Action Plan goals of strengthening information systems surrounding mental health and clearly establishing a requisite foundation for the implementation of strategies and services. In its proposed actions for member states, WHO emphasized the importance of human resource development by “build[ing] the knowledge and skills of general and specialized health workers to deliver evidence-based, culturally appropriate and human rights-oriented mental health and social care services” (WHO, 2013, p. 15).
Our findings also complement the positive evaluation feedback of participants. In particular, Van Leeuwen et al. (2016) found that participants appreciated the increased knowledge they gained, noting that it was beneficial to themselves as well as their community. Participants noted that they had an enhanced ability to better understand their personal and family members’ mental health and that the MHF training helped reduce community stigma. Examined in conjunction with the present data, this suggests that not only are participants objectively gaining knowledge about mental health, they are aware of what they learned and actively and intentionally applying that knowledge to help themselves, other individuals, and their overall community better understand mental health. Given that the present study also demonstrated that participants are gaining an enhanced understanding of MHF-related skills, the researchers are hopeful that with their knowledge of mental health, participants are likewise intentionally putting their facilitation skills into action to support those in need within their communities.
Limitations and Future Research
The present study provides a notable step in further documenting the effectiveness of the MHF program, yet the limitations of this research must be taken into consideration and used for ongoing program planning and research development. Using true-false repeated measures pre- and post-training assessment could lend itself to bias. Within such situations, the trainee may recall, implicitly or explicitly, the questions asked in the pre-training assessment and may be primed for remembering the information needed to respond to those questions. Similarly, although the findings were statistically significant, probability suggests that true-false questions are more accessible to educated guesses rather than a depiction of accurate knowledge. In this way, having a multiple-choice format test with possible case scenarios to assess application in greater depth might provide a richer depiction of the knowledge gained. The present means of assessment also are vulnerable to a ceiling effect, whereby those with the most knowledge around mental health would earn the maximum number of points on both the pre- and post-training assessment. Although the present testing level is the most adaptive to all knowledge levels, perhaps a greater breadth of questioning to assess more nuanced components of the MHF skillset might be more helpful in accurately assessing the knowledge and skills gained by those coming into the MHF program with more extensive mental health training. An additional limitation of the assessments specifically was the post-hoc distinction between the skills and knowledge components assessed in the MHF training. In the future, greater attention to developing questions specifically geared toward these two necessary areas will be more effective in discriminating such gains. One final limitation of the present study and an area well positioned for future research is the lack of specific data regarding how the knowledge and skills are being used following the training.
Prior to this study, there was no formal quantitative data analysis to substantiate the reach of the MHF program. In addition to this research assessing the knowledge and skills gained through participation in the MHF program, there is the equally important next step of assessing how that knowledge is being used to address the goals of the program. Research examining the extent to which the MHF program aides in increasing mental health access for individuals in need of support and thereby decreasing the treatment gap among individuals struggling with their mental health would be especially important in addressing the over 70% of individuals in developing countries who do not receive the mental health care they so desperately need (Demyttenaere, 2004).
The growing number of individuals around the world with mental health challenges, coupled with the lack of knowledge, services, access, and fiscal resources to address the growing need, drives mental health to the forefront of worldwide public health challenges. Countries and communities in both developed and developing countries alike must embrace creative, economical, and culturally appropriate population-based solutions. The MHF program developed by NBCC (Hinkle & Henderson, 2007), initially in coordination with WHO and mental health experts from around the world, provides one such solution. Extant research on the MHF program validates the cultural appropriateness of the tailored programs as well as the extent to which community members believe they have benefited from the trainings (Luke et al., 2016; Van Leeuwen et al., 2016). The present findings further this research by providing quantitative data speaking to the effectiveness of the program at enriching participants’ knowledge and skills in relation to mental health. This burgeoning evidence base moves the MHF program one step closer to becoming a global best practice in addressing the notable and growing gap in mental health care around the world.
Conflict of Interest and Funding Disclosure
The first two authors were reimbursed by NBCC
for expenses related to this manuscript.
The third author is an employee of NBCC who
has developed and conducted MHF trainings.
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Alwin E. Wagener, NCC, is an assistant professor at Fairleigh Dickinson University. Laura K. Jones is an assistant professor at the University of North Carolina Asheville. J. Scott Hinkle is the editor of The Professional Counselor. Correspondence can be addressed to Alwin Wagener, 285 Madison Ave., M-AB2-01, Madison, NJ 07940, firstname.lastname@example.org.
Melissa Luke, J. Scott Hinkle, Wendi Schweiger, Donna Henderson
Mental health research supports the notion that better care management is achieved when people receive education, training and support to carry out the role of informal caregivers (World Fellowship for Schizophrenia and Allied Disorders, 2006). Although the prevalence of mental disorders in Africa is a significant health problem (Jenkins et al., 2010), treatment remains a low priority (Bird et al., 2011; Jacob et al., 2007), placed at the bottom of the public health care agenda. Mental health patients of all ages and their families are too often invisible, voiceless and living at the margins of society, and they are rarely mobilized to advocate for themselves (Saraceno et al., 2007). In Africa, mental health receives less attention due to a plethora of problems with communicable diseases and malnutrition (Gureje & Alem, 2000). Moreover, the contribution of mental distress to morbidity, as well as mortality, largely goes underappreciated (Jenkins et al., 2010).
Skeen, Lund, Kleintjes, Flisher, and the MHaPP Research Programme Consortium (2010) have reported: “Mental health is a crucial public health and development issue in sub-Saharan Africa” (p. 624). At least half of all African countries have no community-based mental health services, and almost as many have no integration of mental health into primary care or training facilities for primary care staff in the treatment of mental health (World Health Organization [WHO], 2005). In low-income countries like Malawi, essential psychotropic medications are not available, and resources for mental health training and care are largely lacking (Becker & Kleinman, 2013; WHO, 2004). Challenging the negative perception of mental disorders, reducing their prevalence and providing adequate care are essential policy goals for most of Africa (Gureje & Alem, 2000), a continent where widespread stigma and discrimination, human rights abuses and poverty are the hallmarks of mental health care (Lund, 2010).
In Africa, alternative explanations for mental distress, such as bewitchment, taboos and the belief that it runs in families, reduce the chances of access to mental health care (Bird et al., 2011; Wright, Common, Kauye, & Chiwandira, 2014). Moreover, attitudes about mental illness are strongly influenced by traditional beliefs (e.g., supernatural causes) and remedies. Public education that dispels notions that mental disorders are incurable and nonresponsive to typical care is needed (Gureje & Alem, 2000) as well as an effective strategy to decrease stigma (Bird et al., 2011). To accomplish these goals, governments, as well as nongovernmental organizations, need to bring community mental health services to scale (Hinkle, 2014; Patel, 2013; Patel et al., 2007). In 2006, Murthy reported that a global community mental health blueprint does not exist in order to achieve mental health access, and that national community workforce strategies need to be linked to each country’s unique situation. Relatedly, Hinkle (2012a, 2014), among others, has advocated for a radical shift in the way mental disorders are managed, including increasing the numbers of trained community-based workers who can be effectively utilized via informal non-health care sectors, as well as formal health care systems (Bradshaw, Mairs, & Richards, 2006; Gulbenkian Global Mental Health Platform, 2013; Petersen et al., 2009; Saraceno et al., 2007).
About 70% of African countries spend less than 1% of their budgets on mental health, with most of these monies going toward large psychiatric hospitals rather than cost-effective, community-based care (WHO, 2005). Mental health services are basically focused on emergency management (Petersen et al., 2009), with minimum long-term planning within the community. Resources for assisting people with mental stress, distress and disorders are insufficient, constrained, fragmented, inequitably distributed and ineffectively implemented (Becker & Kleinman, 2013; Chen et al., 2004; Gulbenkian Global Mental Health Platform, 2013; Hinkle, 2014; Hinkle & Saxena, 2006; Jenkins et al., 2010; Saraceno et al., 2007), especially in low-income African countries like Malawi, where there is a clear link between the lack of human resources and population ill health (Hinkle, 2014). Unfortunately, mental health services continue to be inequitably distributed, with lower-income countries having fewer mental health resources than higher-income countries (Coups, Gaba, & Orleans, 2004; Demyttenaere et al., 2004; Hinkle, 2014; WHO, 2005), as well as inefficient use of and decentralization of existing resources (Petersen et al., 2009). In summary, one of the major barriers to increased mental health care is the lack of people trained to provide care (Saraceno et al., 2007).
Historically, developing and promoting population-based mental health services at the grassroots level has been a difficult task (Hinkle, 2014). In less-developed countries like Malawi, 75–85% of people with mental disorders have received no treatment in the 12 months preceding a clinical interview, and this statistic does not account for the countless subthreshold cases (Demyttenaere et al., 2004; WHO, 2010a, 2010b). Furthermore, when people with mental disorders are identified, there is often no adequate resource to refer them to (Petersen et al., 2009).
Hinkle (2014) has reported the following:
Most mental disorders are highly prevalent in all societies, remain largely undetected and untreated, and result in a substantial burden to families and communities. Although many mental disorders can be mitigated or are avoidable, they continue to be overlooked by the international community and produce significant economic and social hardship. (p. 2)
Existing mental health care in Africa is under-resourced and overburdened (Bradshaw et al., 2006), with enormous gaps between the degree of mental suffering and the number of people receiving care (Becker & Kleinman, 2013; Hinkle, 2014; Saraceno et al., 2007; Weissman et al., 1997; Weissman et al., 1994; Weissman et al., 1996; WHO, 2010a, 2010b).
Chorwe-Sungani, Shangase, and Chilinda (2014), as well as Pence (2009), have indicated that mental health problems in Malawi “are often not identified and treated, because health professionals do not believe they are sufficiently competent to provide mental health care” (Chorwe-Sungani et al., 2014, p. 35). Unfortunately, mental health professionals might not have the “requisite public health skills for effective national advocacy” regarding mental health (Jenkins et al., 2010, p. 232). The numbers of primary care and specialist mental health workers are in general decline because of training costs and migration from frontier or rural settings to urban areas, and from low-income countries like Malawi to higher-income countries (Jenkins et al., 2010). In general, collaborations between mental health organizations and health agencies are weak (Gureje & Alem, 2000).
Low salaries and poor working conditions, as well as lack of training and recognition, are major demotivating factors for existing health workers’ involvement in mental health care (Bach, 2004; Manafa et al., 2009). Higher salaries in the private sector have resulted in few incentives for health care workers to work in rural areas where most people live in low-income countries (Saraceno et al., 2007). Overreliance on medical solutions to address psychosocial issues has a disempowering impact on communities (Jain & Jadhav, 2009), including their schools.
Furthermore, primary health care providers cannot adequately intervene with the numbers of mental health cases confronting communities, and medicine has not yet developed sufficient answers for chronic mental health and lifestyle problems (Swartz, 1998). Depending exclusively on medicine to deliver mental health care services risks an overreliance on a medical model and its medications, and less reliance on psychosocial interventions and influences, such as talking with people and problem solving (Patel, 2002; Petersen, 1999), especially for school children. Ten percent of children are considered to have mental health problems, but pediatricians are not generally equipped to provide effective treatment (Chisholm et al., 2000; Craft, 2005). The evidence reveals significant psychopathology among sub-Saharan children, with one in seven children and adolescents experiencing significant difficulties. The most common mental health problems among this age group include depression, anxiety, post-traumatic stress disorder and behavior issues.
In addition to a general lack of mental health workers (Chorwe-Sungani et al., 2014), one psychiatrist served the entire country of Malawi (Chorwe-Sungani et al., 2014), only 2.5 psychiatric nurses were available for every 100,000 people (WHO, 2005), and only one psychiatric unit was available, but not always open or at full capacity. A variety of settings must be used in Malawi, and not all of them are within formal health care. For far too long, the concentration has been on an overburdened medical system and not on the development of local community mental health care (Becker & Kleinman, 2013; Hinkle, 2014; Patel, 2013). For a review of the global impact of untreated mental health problems, see Hinkle (2014).
Recognizing the importance of community and family support and using general lay workers equipped with fundamental mental health skills can have positive outcomes (Gureje & Alem, 2000; Saraceno et al., 2007; Swartz, 1998). Saraceno et al. (2007) have reported, “Non-formal community resources will need to be recognized and mobilized to ensure access to care” (p. 1172). Likewise, in low- to middle-income countries, community workers are often the first line of contact with the health care system (Anand & Bärnighausen, 2004; Hinkle, 2014; Hongoro & McPake, 2004).
Communities in developing countries have historically lacked opportunities for mental health training, skill development and capacity building (Abarquez & Murshed, 2004). However, Hinkle (2014) also has indicated that “long years of training are not necessary for learning how to provide fundamental help for people who are emotionally distressed” (p. 4). International health care organizations have demonstrated a need to develop innovative uses of informal mental health assistants and facilitators to establish community mental health services (Hinkle, 2014; Warne & McAndrew, 2004). Hinkle (2006, 2009, 2014) and Eaton and colleagues (Eaton, 2013; Eaton et al., 2011) have indicated that if the gap in mental health services is to be closed, it must include the use of non-specialists to deliver care. Such non-specialized workers should receive Mental Health Facilitator training in order to identify mental stress, distress and disorders; provide fundamental care; monitor helping strategies; and make appropriate referrals (Becker & Kleinman, 2013; Hinkle, 2014; Hinkle, Kutcher, & Chehil, 2006; Hinkle & Schweiger, 2012; Jorm, 2012; Saraceno et al., 2007). According to Hinkle (2014), the “data speaks loudly to the need for accessible, effective and equitable global mental health care. However, a common barrier to mental health care is a lack of providers who have the necessary competencies to address basic community psychosocial needs” (p. 5).
Informal community mental health care is characterized by community members without formal education or training in mental health providing much-needed services. MHF training has been used to bridge the gap between formal and informal mental health care (Hinkle et al., 2006). Murthy (2006) has indicated that informal community care, including self-care, is critical. Moreover, promotion of community mental health increases understanding of mental health problems and decreases mistrust of people suffering from mental health concerns (Kabir, Iliyasu, Abubakar, & Aliyu, 2004; Wright et al., 2014).
Simply put, community workers are a large untapped volunteer resource for people suffering from problems associated with poor mental health (Hinkle, 2014; Hoff, Hallisey, & Hoff, 2009), and data have shown that the delivery of psychosocial-type interventions in non-specialized care settings is feasible (WHO, 2010a, 2010b). Hinkle (2014) has reported that “enhancing basic community mental health services, both informally and formally, is a viable way to assist the never-served” (p. 4). He elaborated that the “MHF program is part of a grassroots implementation trend that has already begun in communities around the globe” (p. 4). In straightforward terms, the demand for the strategic increasing of community mental health services in low-resource settings (Wright et al., 2014) needs to be simplified, locally contextualized, available where people live, affordable and sustainable (Patel, 2013). This plan includes offering services to school children and their families. Wright et al. (2014) have reported that “brief structured psychotherapies, delivered by non-specialist health workers, have been successfully trialed” (p. 156), but the benefits have not necessarily translated into everyday practice. However, this paper reports on one such translation.
Overview of the Mental Health Facilitator Curriculum and Training
The National Board for Certified Counselors (NBCC) International developed the MHF curriculum as well as an implementation method that is making a global impact (Hinkle, 2006, 2007, 2009, 2010a, 2010b, 2012a, 2012b, 2012c, 2013a, 2013b, 2014; Hinkle & Henderson, 2007; Hinkle & Schweiger, 2012). The MHF training program addresses the need for population-based mental health training that can be adapted to reflect the social, cultural, economic and political realities of any country (Hinkle, 2014). Hinkle (2014) described the MHF program as follows:
The MHF training program draws on a variety of competencies derived from related disciplines, including but not limited to psychiatry, psychology, social work, psychiatric nursing, and counseling. Because MHF training is transdisciplinary, traditional professional helping silos are not reinforced; skills and competencies are linked instead to population-based mental health needs rather than professional ideologies. Thus, individuals with MHF training (MHFs) can effectively identify and meet community mental health needs in a standardized manner, regardless of where these needs are manifested and how they are interpreted. Mental health and the process of facilitating it is based on developing community relationships that promote a state of well-being, enabling individuals to realize their abilities, cope with the normal and less-than-normal stresses of life, work productively, and make a contribution to their communities. (p. 6)
The MHF training program has been taught in 25 countries and augments specialized mental health services, where they exist, by functioning within the community to provide targeted assistance, referral and follow-up monitoring (Paredes, Schweiger, Hinkle, Kutcher, & Chehil, 2008). The MHF curriculum consists of information ranging from basic mental health knowledge to specific, local, culturally relevant, first-contact approaches to helping, including mental health advocacy, monitoring, and referral, all of which meet local population needs and respect human dignity (Hinkle, 2014). Nonclinical forms of mental health care such as emotional support or strategic problem solving utilized within the community and schools are emphasized.
Mental health training programs must have a practical component in order to become successful (Saraceno et al., 2007). Accordingly, Hinkle (2014) has stated, “the MHF program is designed to be flexible so local experts can modify components of the training to reflect the realities of their situation; so consumers and policymakers ensure that MHF trainings provide culturally relevant services to the local population” (p. 6). Such a contextual approach connects the MHF program to the principle that mental health care is a combination of universally applicable and context-specific knowledge and skills (Furtos, 2013; Hinkle, 2012a; Paredes et al., 2008; Swartz, 1998).
The diverse backgrounds of MHF trainees enhance the possibilities of addressing gaps in local mental health care. This factor in turn assists local educators, policymakers, service providers and volunteers to meet mental health needs without costly infrastructural investments. Local, contextualized MHF training further facilitates the development and delivery of school- and community-based care consistent with WHO recommendations for addressing the gap in mental health services (Hinkle, 2014), especially among school children.
More specifically, the fundamental features of the MHF curriculum include first-responder forms of community mental health care such as basic assessment, social support and referral. The standard training consists of approximately 30 hours, and a brief one-day version is available (Hinkle & Henderson, 2007). The curriculum includes a focus on the universality of mental stress and distress, as well as mental disorders (Desjarlais, Eisenberg, Good, & Kleinman, 1995; Hinkle & Henderson, 2007), basic helping skills, community mental health services, and advocacy, in addition to specified interventions such as suicide mitigation and responses to child maltreatment. Hinkle (2014) has indicated: “In general, MHFs are taught that negative and unhealthy assumptions about life and living contribute to additional mental and emotional stress” (p. 9). Investing in mental health, cost-effective interventions, the impact of mental disorders on families, and barriers to mental health care also are included. Hinkle and Henderson’s (2007) curriculum also encompasses understanding perspectives regarding feelings, effective communication (e.g., listen, listen, listen) and using questions effectively in the helping process, as well as how to assess problems, identify mental health issues and provide support (e.g., assess, identify, support, refer).
Hinkle (2014) has reported that MHF “trainees concentrate on the abilities, needs and preferences that all people possess and how these are integrated in various cultures,” as well as “how to solve problems and set goals with people experiencing difficulty coping with life” (p. 11). Similarly, trainees learn specific information about basic mental disorders (e.g., anxiety, posttraumatic stress disorder, depression and mania, psychosis and schizophrenia, substance abuse and dependence, intellectual disability, autism, epilepsy).
In view of the vast burden of mental disorders in low- and middle-income countries, as well as the lack of resources for such care in these countries, more research and services are desperately needed (MacLachlan, Nyirenda, & Nyando, 1995; Saxena, Maulik, Sharan, Levav, & Saraceno, 2004). The MHF curriculum has been applied in public schools in Malawi, prompting an initial investigation of its effectiveness.
An applied ethnographic research design (Pelto, 2013) was selected to explore how MHF stakeholders in the schools experienced the program in Malawi. As a constructivist research tradition, ethnography explores cultural patterns within a group (Hays & Wood, 2011). Accordingly, it has been argued that ethnographic methods can enhance education-related research conducted within multicultural communities, as well as provide a contextual understanding of diversity; consequently, ethnography has been purported as effective in giving a voice to those who have been underrepresented in research (Quimby, 2006).
Several steps were taken to strengthen the methodological rigor of this study, specifically efforts to increase trustworthiness through establishing credibility, dependability, transferability and confirmability (Lincoln & Guba, 1985). To demonstrate the credibility or believability of the current findings, we used prolonged community engagement and triangulation (Hays & Singh, 2012). Two of the four researchers were involved in data collection through interviews and focus groups over a five-day period, and a three-person coding team (one author and two advanced doctoral students) were employed for the analysis. As another form of triangulation, and consistent with past research, those involved in data collection and analysis intentionally maintained different degrees of familiarity with the MHF program itself, the research methodology and the related literature (Goodrich, Hrovat, & Luke, 2014). To demonstrate dependability, or consistency of study results, researchers kept detailed accounts of the data collection and analysis processes undertaken, including the steps used to collapse codes, reduce data and represent relationships between themes. To address transferability, or how well findings apply to other students and educators, the researchers used purposeful maximum variance sampling to solicit participants across differing MHF stakeholder groups and used persistent observation while collecting data until saturation was reached (Hays & Singh, 2012). Lastly, to address confirmability or assurance that findings reflect the participants in the study, the researchers utilized prolonged engagement with research participants, bracketing and participant member checking as part of data analysis. Finally, thick description was used when reporting the findings (Lincoln & Guba, 1985).
Participants in this study were working and living in three different regions of Malawi (i.e., Lilongwe, Michinji and Salima) and included various stakeholders—five MHF master trainers, twelve MHF trainers, seven MHFs, seven MHF beneficiaries and nine MHF community member stakeholders, who included parents, school personnel and government officials. Twenty-four participants were males and sixteen were females; seven of the participants were children or adolescents. Researchers did not ask participants to identify their ages in order to be culturally responsive to customs in Malawi.
Master trainers are the highest level of trainers in the MHF program. They are required to have a minimum of a master’s degree in a mental health field and significant teaching experience, or they can be included in the Malawi program if they have significant experience with the MHF program. Master trainers are required to take part in additional training, which includes a teaching demonstration and receiving feedback on their subject matter knowledge and interactive skills. In addition, in order to be fully vested in the MHF program, they are required to take part in a co-training exercise. All master trainers were highly placed administrators in the Malawian Ministry of Education or were upper-level staff at an institution dedicated to working with youth and the school system.
MHF trainers have a bachelor’s degree or its equivalent in a mental health-related field, experience as trainers, and are required to attend additional instruction that includes a teaching skills demonstration. MHF trainers in the current study were teachers, guidance teachers and head teachers
(Malawian reference to school principals) who worked in schools participating in the MHF program.
Lastly, MHFs have been instructed in the full MHF curriculum and completed all curriculum requirements. MHF beneficiaries in this study were learners (Malawian reference to students) in schools that incorporated the MHF program. MHF community stakeholders were parents or village leaders who were familiar with the MHF program and able to discuss its effects on their children and communities.
In presenting ethnographic results, it is imperative to discuss the researchers’ characteristics due to their potential to influence data collection and analysis. One outside researcher had no prior experience with the MHF curriculum and was intentionally included in an effort to reduce researcher bias. All four researchers identified as Caucasian doctoral-level counseling professionals from the United States. Two female researchers identified as doctoral-level school counselor educators with previous experience working as school counselors, and two researchers (one male and one female) identified as employees of NBCC International (a division of NBCC). All four researchers had professional experiences focused on the development of counseling within an international context and shared an interest in better understanding how the MHF program impacted stakeholders in Malawi. Two of the researchers had previous professional relationships with the partnering organization in Malawi where the MHF training took place.
As part of the research development, all four researchers met to discuss their respective positions and how their experiences might impact beliefs and perceptions related to the study. Intentional efforts were made to bracket and triangulate perspectives throughout the research process for the purpose of identifying and mitigating biases that could interfere with the project (Hays & Singh, 2012).
Sampling and Data Collection
The sole inclusion criterion for the project was for participants to be MHF stakeholders in Malawi since each stakeholder group could provide a unique perspective. The researchers used purposeful sampling to identify potential participants in two different ways. Prior to leaving the United States, the research team contacted the partnering MHF organization in Malawi to discuss the project and make arrangements for the research visit. During these contacts, the partnering organization agreed to review their records of the MHF master trainers, MHF trainers and MHFs to identify potential participants. Additionally, the partnering organization worked with collaborating schools to solicit potential MHF beneficiary and MHF community member stakeholder participants. Convenience sampling was used based on participant availability at schools (both parents and children) and related organizations. One quarter of the participants (n = 10) were interviewed individually to encourage open dialogue. Three quarters of the participants (n = 30) took part in both individual interviews and focus groups. As noted above, the partnering MHF organization solicited participants for this project and scheduled potential participants during the five-day research visit. Potential participants were provided with information about the research and an informed consent or assent and asked if they would participate in an audiotaped interview about their experiences with the MHF program. As part of the signed consent, all participants were informed of the voluntary nature of this research and their right to withdraw from participation at any time.
All interviews and focus groups were conducted in person by one or two of the researchers using a semi-structured research protocol. Interviewees were selected by their availability and convenience. Focus groups were conducted at either a convenient administrative building or classrooms at MHF-participating schools. Each of the 10 interviews began with one of the researchers asking the following open, general question: “Can you please describe what it was like to train/provide/receive MHF services?” After this question, the researchers followed up with probes from the semi-structured research guide that consisted of five areas, including the first question, with follow-up questions (probes) for each area. Another example of a question later in the interview was the following: “What has surprised you about MHF services?” If time permitted, the researchers ended the interview with a question that allowed individual interviewees or focus groups to address anything not discussed in the five areas; for example: “Is there anything additional that you thought we would ask that we did not?” There were between six and nine potential probes that could follow each of the five areas. The following is an example of a probe following the initial question: “On a scale of 1 to 10, how satisfied were you with your MHF experience?” Probes also were open-ended, such as, “What might have made your experience with MHF implementation better?” Consistent with the institutional review board-approved research protocol, researchers tried to use probes from all five areas outlined, but consistent with qualitative research design, not all questions were asked of all participants in the same order. This flexible interview style has been used in past research, permitting researchers to probe and follow topics introduced by participants (see Goodrich et al., 2014).
Focus groups were used as a culturally responsive strategy to facilitate the sharing of multiple perspectives and to promote conversations about a topic which, given customs and cultural practices, might be more challenging to discuss in an individual interview (Bogdan & Biklen, 2006). Focus groups were scheduled based on the participants’ availability and generally delineated by stakeholder group (i.e., other MHF trainers, MHFs, MHF beneficiaries, and community stakeholders). The number of participants in each of 10 focus groups ranged from three to 12 participants, with an average of five per focus group. The total number of focus groups was dependent on the combined schedules of participants and the need to balance the overall schedule with the necessity of researcher travel to conduct interviews in locations most convenient and appropriate for the participants. The use of a semi-structured focus group research guide also allowed researchers to ask specific questions that focused on predetermined key topics related to the study, while also maintaining flexibility to follow up on topics that emerged from participants. Similarly, the 10 focus groups all began with the question, “As you reflect on your own experiences as MHF stakeholders, what is significant?” and then proceeded with probes based on the semi-structured research guide. Both interviews and focus groups were audiotaped in their entirety and conducted in English. Individual interviews averaged 35 minutes, ranging from approximately 20–60 minutes in length. Focus groups averaged 50 minutes, with a range of approximately 30–75 minutes. All individual interviews and focus groups were transcribed verbatim by a team of transcriptionists associated with the study.
Data analysis began on site in Malawi during the data collection process, with the on-site researchers debriefing about patterns and themes as well as their reflections at the end of each day of data collection. After interviews and focus groups were transcribed, the outside researcher created a consensus coding procedure (Hays & Singh, 2012) similar to that used in past studies (Goodrich et al., 2014; Luke & Goodrich, 2013) in which she and two advanced doctoral students trained in ethnographic research each performed the initial coding independently. The process began with each coding team member reading and rereading the data to become familiar with the content and then conducting initial coding using constant comparative methods (Bogdan & Biklen, 2006). Therefore, throughout the initial stage of the analysis, all three coders used line-by-line open coding (e.g., Fassinger, 2005) and compared codes within and across transcripts. This process ensured triangulation, as three different individuals viewed all data.
Although the coding team moved back and forth between the coding stages, the second stage of coding involved the coding team meeting weekly during the coding process. Consensus meetings were conducted using a modified Miles and Huberman (1994) approach to discuss the emergent codes, clarify questions and identify key quotes and reflections on the data, as well as refine the next steps in the research process. Once all transcripts were coded and discussed, the third coding stage began. During the third stage, axial coding was utilized to group and collapse the initial codes, and to form larger categories or themes (Bogdan & Biklen, 2006). The final step of analysis involved developing operational definitions for each theme (Hays & Singh, 2012) and soliciting feedback through peer debriefing and member checking. The feedback received through both peer debriefing and member checking was considered and incorporated into the findings.
In general, the results revealed that the 40 MHF participants in Malawi all agreed that the MHF program was valuable. Participants unanimously noted appreciation for the MHF program and the vital educational role it served in their communities. For example, one adult participant noted, “I am very satisfied with [the] MHF program: It’s a 10 [on a scale of 1–10, with 10 being the best].” Participants also described what made the MHF program implementation successful, with one adult participant stating, “MHF is contributing positively, not only to the access of education, but [to] the quality of education.” Additionally, participants reported that there would be negative consequences should the MHF program discontinue. Illustrating the significance of the MHF program and his appreciation for it, another adult participant stated, “It is our prayer that this program should continue. I know sometimes resources are limited, but I know God is going to help us.”
More specifically, four interrelated themes emerged to illustrate the MHF participants’ appreciative beliefs about and experiences with the MHF program. The first theme, Malawian cultural history and context, served as grounding for three additional themes: resources and needs, processes and outcomes. Participants explained how these themes interacted with and influenced each other.
Malawian cultural history and context. One adult participant described how the MHF program was culturally congruent as follows:
There is a culture of working together. . . . This program . . . has some of the components such as stress, distress, disorders . . . it helps people to identify the signs and symptoms which show that this person is stressed [or] distressed. . . . African culture says, “We are because you are,” meaning that we belong to each other . . . meaning that if you see a person showing signs of sadness, you must quickly go in and help.
Another adult participant echoed the idea that the MHF program was interacting within the unique Malawian educational context by saying, “We have packed classes. . . . It’s very difficult for a teacher to reach out. . . . Together with the MHF program and the training of teachers . . . they can respond.” Still another adult participant explained that before the MHF trainings,
they [teachers] didn’t know that a learner goes through a lot of experiences, right from their homes and on their way to school. . . . They have experiences that need MHF. So the teacher is now aware of handling the learner as a human being, as somebody . . . that is available for their assistance.
Participants also described how the MHF program was adapted to contextual needs in Malawi. One adult participant noted the realism in the MHF training, saying, “Everything that we do and say in trainings, or everything around [the] MHF program, is based on real-life issues.” One of the strongest features of the MHF program is its adaptability to cultural contexts. MHF clubs were created in Malawian schools by guidance teachers, teachers, and administrators who had completed MHF training. The clubs are a place where MHFs teach mental health skills to learners and provide a safe place for learners to talk about school and family concerns. Several of the clubs have organized performances for other students and the community using song and dance, an important contextual part of Malawian culture, to illustrate common concerns and the use of MHF skills in addressing these matters.
Participants also discussed specific cultural meanings and social practices as well as context-specific activities within the schools and communities where MHF was implemented. A focus group of learners described the activities they did in their MHF club, and one learner began by saying:
My poem is based on [a] true story of my friend who [was] . . . always stressed when we had class, wasn’t concentrating, always feeling down . . . so, I tried to ask him what his problem was and then I went to a teacher. . . . The patron helped him . . . and now he is doing pretty well. . . . I tried to give him . . . some tips how he could manage stress on his own, like telling him to sometimes listen to some music, do some physical exercises . . . and then after that . . . I referred him to the teacher.
Another learner described a story he developed based on MHF content. He explained that he had a friend who had failed a test and who was worried about going home and telling his father, whom he believed would be angry. The learner stated that he referred his friend to a teacher who successfully met with the parents and his friend about the test score.
Resources and needs. Bird et al. (2011) have shared that African health workers believe that mental health resources are desperately lacking. Participants discussed examples of invested individuals and MHF programming, and articulated specific ideas about the materials and adaptations desired for the MHF program in the future. One adult participant spoke about MHFs as an asset, saying, “MHFs are creative, [and] like [using a] curriculum that is more simplified [the MHF curriculum is now offered in 1-day formats for communities and schools].” Participants also described the receptivity of people and educational communities as a significant resource. For example, one adult participant said, “The schools are very interested and communities are eager to be involved. They are open to . . . MHF.” Another adult participant described something similar within the community, saying, “So far, we
engaged the traditional leaders in communities to say there’s this program. . . . We have talked to them and I think they would be interested in the training . . . because this time we talked to the chiefs.” Expanding on this idea, another adult participant noted,
I am sure this program is even extending [beyond] the learners. Even the parents also benefit from the program. Because we can tell the learner, and the learner goes to their parent. But if the parent has no idea about it, it would be so difficult. So, also looking at even the parent and community should be synthesized . . . so they know actually what we mean when we talk about mental health. . . . The teachers, the learners and the parents . . . join together [and] they will be able to assist the learner.
Participants also described how their experience of the MHF program was influenced by the need for more tangible resources (e.g., materials, personnel, transportation). One adult participant reported,
Because the whole program is . . . 19 modules, we ask the office to at least produce one for the school so that we can have it in the building. . . . We have loaded them all on our computers, but access isn’t possible by every teacher.
In addition, many participants expressed a desire for the MHF program to incorporate transportation as one of the provided services, to improve communication between MHFs, and to increase dissemination of MHF information. For example, an adult participant suggested, “If other zones [regions or geographic districts] also [had] mental health facilitation, that could assist [with] ideas.” Another adult participant commented similarly, “More and more teachers are getting [MHF] and it’s very helpful. Maybe to travel to see one another or meet, to talk about what we are each doing—that would be good.” Adult participants explained the purpose of travel for MHF collaboration, stating that it would be helpful if the schools involved with MHF could meet at both the district and regional levels to share ideas and that this would benefit not only those involved, but also those outside of the program’s current involvement.
Additionally, even though all MHF participants expressed a desire for more MHF programming, participants described how less tangible resources and needs (e.g., mental health and education status, service demands and credentials) influenced their experience of MHF. For example, an adult participant noted that language fluency was one such resource that could expand access to the MHF trainings, commenting, “The other thing that I think you should know in order for your project to benefit . . . you [MHF program] should learn our language . . . so that you can communicate with those village headmen because most of them do not speak English.” (The MHF curriculum has been translated into 11 languages, including Swahili.)
Several participants also explained the importance of religious institutions in Malawi, offering recommendations for their involvement in MHF service delivery. One adult participant said, “You should take it [to] religious institutions because they understand there [are] some religious beliefs which prohibit children from going to school. So, by targeting these religious institutions you can easily reach the minds of the young ones.”
Processes. Participants distinguished various MHF-related processes as those consisting of psychoeducational helping, those linked to larger community development efforts, and those focused on specific strategies for spreading the MHF message more broadly. One child participant said, “In the MHF club we learn about how we can . . . advise our friends or how we can . . . [have] good behavior.” A second child participant added, “We are supposed to talk, to show people who are drinking or smoking to stop this bad behavior.” A third child participant offered, “We learn more about having good friends who have good behavior.”
Participants also noted additional educational processes related to MHF. One adult participant stated, “So, the program is developing leadership. It is helping people to grow as individuals and helping society to grow, and when it comes to the learners the program has . . . increased . . . access to education.” Another adult participant described the processes of MHF service delivery as follows: “They [beneficiaries] feel as if they are in control because they are decision makers. We just listen, we just guide and they come up with the decision . . . because we cannot make decision[s] for them.” Yet another adult participant described MHF activities, including the ability to make referrals, in the following way: “. . . helping people individually [and] referring people to other sources of assistance. I can do that, because I know . . . many systems that can offer assistance.”
Relatedly, participants also discussed MHF efforts that were incorporated into educational communities. One child participant described the community process of singing and sharing MHF messages as follows: “I feel good . . . when . . . we sing songs. Songs are more about what MHF [is], so people can remember what we sing and if people drink or smoke they can stop because of the song.” Other child participants demonstrated something similar, singing an MHF song they had created and performed. One child participant described how social role modeling was an important process in MHF service delivery, saying, “You become a model to other people and because of that, even those people that we talk to, those people that we teach . . . become recognized in the communities.” Other adult participants described how the MHF program used relational implementation processes, stating, “The MHF program addresses critical thinking, good planning . . . in addition to mental health because now we are looking at the whole person.”
Lastly, participants described the importance of the use of technology when it came to marketing strategies for the MHF program. One adult participant described how “t-shirts with anti-suicide messages” could be produced to serve two aims, indicating that “learners would feel a sense of belonging” and they could “spread the MHF messages to others.” Another adult participant described how communication of the MHF message was important by saying, “We share information about the availability of MHF now by word of mouth, but it could be broken down by different media, like using radio or TV programs.” Another adult participant offered the following perspective on MHF results:
[People] are able to discuss . . . mental health whereas before they could not. Some topics weren’t discussed, now they air [them] out. . . . This [is a] very important topic, because once you air [it] out on the radio and in the media or in the newspaper, the ability to discuss [mental health] spreads.
Outcomes. It is of note that participants only identified positive outcomes of the MHF program, without any negative impacts. Participants described the positive global impact by saying, “Every time, every year the MHF training comes and goes, it leaves [the] facilitator, it leaves the community, it leaves the learner, and even the teachers better off than they were before.” Another adult participant described the change of perspective provided through the MHF program as follows: “It’s an eye opener. . . . It’s really a new way of thinking.”
Participants also identified manifestation of MHF-related growth and development as personal change, community welfare and larger systemic influences. One child participant described the personal impact as follows: “Personally I have benefitted a lot, because [MHF] touches what I go through on a daily basis.” In addition, an adult participant reported, “In my family there is a big improvement. I do respect other people’s views and even have to promote my decision-making skills.” Another adult participant described a similar change:
I’ve got two children who are in the [MHF] club. . . . Previously, the boy was very, very, very troublesome. But I’ve . . . noticed some changes in . . . him and I’ve never heard about any fight against his friends up to now, so I was wondering what is happening to this child now that he has changed. . . . I came to understand that . . . it is because of this program, the Mental Health Facilitator.
Likewise, a participant described the community benefit when he offered, “The whole school is changing because they are . . . teaching [MHF]. . . . Children as a group . . . are changing. . . . There’s no violence . . . as it was before.” Still another adult participant described the community outcomes in the following way: “One of the teachers was telling me [that] now [learners] trust him even more than their own parents.” Participants identified how the MHF program has been able to shift some community inequities as well. For example, one adult participant indicated the following:
They [MHFs] are able to identify people’s problems at the early stage and they are able to give them personal data and some assistance [so] that these people might be healthy. . . . What happens [when people drop out of school] you find out . . . in fact there are more girls [dropping out] than boys . . . because of stressful situations that they have at home or . . . in the schools. So [MHF] programs have [provided] assistance [in] ways [so] teachers can give some guidance.
At times, participants distinguished direct from indirect outcomes. One adult participant offered the following example of direct impact: “The teachers [and] the learners are directly able to understand and know how to handle . . . life challenges.”
Participants in this study expressed engagement in and appreciation for the MHF program in Malawi schools. Interview responses indicated similarities between the interconnectedness encouraged in the training and the strong interpersonal relationships within the local culture. Participants also recognized the adaptability of the curriculum and credited the MHF program with dealing with real issues. Indeed, they discussed the ways that the MHF training transformed them and provided examples of the influence that the school MHF clubs had on teachers and students. One goal of the MHF program involves culturally appropriate, grassroots efforts to address mental health concerns in resource-poor countries. Based on the comments delivered by the participants, we have initial evidence of meeting that goal in Malawi.
The appropriateness of the research method used in this study provides an important implication. The focus groups allowed researchers to uncover a depth of description about the impact of the MHF project. Had the investigation proceeded with a survey instrument or a more structured interview, the results likely would have been limited. With an ethnographic design, more was uncovered about not only the similarities of the MHF participants’ experiences, but also their particular voices and variations on these similarities. Thus, the applied research design (Pelto, 2013) allowed for a constructivist investigation that provided a contextual understanding of the participants in Malawi and their experiences with MHF.
A further implication involves an unforeseen benefit of the MHF curriculum. Participants in this study reported a community of helpers. They credited the MHF training with providing a platform for a shared language and a common desire to support students, families and communities. Furthermore, they discussed how that language and mission have a ripple or multiplier effect that extends the benefits of the MHF curriculum to strengthen various groups.
Participants in this study confirmed that the mission of the MHF training in Malawi’s schools was fulfilled—members of a community can learn to help each other. The findings of this study suggest positive results from a compressed training period designed to prepare participants to adapt basic mental health responding skills and knowledge to their community. Current responses to the lack of mental health resources would be augmented significantly by supporting this type of community and school peer assistance preparation, an economical answer to a persistent need for mental health care.
Participants learned the MHF concepts and integrated the information into their daily living. Their explanations incorporated the terms (e.g., “stress, distress, disorder”) and the phrases (e.g., “We just listen, we just guide”). The limits of what an MHF can do also were reported as follows: “. . . helping people individually, referring people to other resources of assistance. I can do that.” Participants have written songs about mental health and have become role models and leaders in schools and the community since the completion of the MHF training. They demonstrated improvements in their confidence levels and competence in the information they shared; it seems reasonable to acknowledge these improvements as evidence of the positive impact the project has had on their knowledge and skills, as well as their influence on the people they encounter. This study outcome reflects a multiplier effect with which the project was designed. Therefore, based on these interviews and the resultant themes, we conclude that the participants in the MHF program in Malawi exemplify the ideals of the project.
The Study and General Limitations
Although this study used maximum variation sampling to identify a diverse group of MHF stakeholders, all participants were ultimately self-selected. Therefore, it is possible that the experiences of participants agreeing to be part of the study might reflect something outside the scope of this study and as of yet not identified (Bogdan & Biklen, 2006). Additionally, as all interviews were conducted in English, the design may have privileged participants with more formal education. Accordingly, the convenience sample may not be representative of the perspectives of all MHF stakeholders in Malawi. Also, cross-cultural research can present unique challenges (Goodrich et al., 2014); therefore, it is conceivable that the level of comfort and openness of participants, as well as decisions about the content shared, may have been different had the two researchers who collected data not been Caucasian American women. Although the research team included an independent member not affiliated with NBCC-I or the MHF program in Malawi, it is possible that the positionality of the research team influenced the participants’ reported experiences. That said, as noted elsewhere, intentional efforts were undertaken to strengthen the trustworthiness of the study; however, as with results of any single qualitative study, findings should be interpreted with caution (Kline, 2008).
Participants were proud of the designation of being an MHF and saw themselves as assets to their communities, schools and families. But they also pointed out barriers to expansion of the MHF program and shared solutions to some of their concerns. Population-based mental health risk management helps reduce vulnerabilities to stress (see Bradshaw et al., 2006). However, Hinkle (2014) has pointed out the following limitation:
For the MHF program to proliferate, it will take not only training, education and implementation in often less than optimal working conditions, but also savvy negotiation of often poorly managed political systems that experience some level of corruption and inability to impact the universal stigma that plagues mental illness. (p. 12)
The efforts to give mental health the prominence it deserves in Africa in general, and in Malawi in particular, will continue to be a political as well as an intervention-related battle (Dawes, 1986) that needs budgets and services that are adequately translated from policies (Bird et al., 2011).
Although the MHF program in Malawi appears to have positive outcomes to date, political support will be needed to realize the program’s full potential impact on mental health care (Saraceno et al., 2007). As long as mortality rather than morbidity is the basis for funding for any health problem, mental health will consistently receive less attention (i.e., less funding and fewer services; Bird et al., 2011). Thus, identifying the various levers and entry points (Jenkins et al., 2010) is critical to the sustainability of programs like MHF, in Malawi and elsewhere. Jenkins and colleagues (2010) have reported that mental health “recognition by international donors and the African Union of the importance of mental health to the [sub-Saharan] region would be extremely helpful in eliciting and pooling resources for this crucially underfunded area” (p. 233). Moreover, it is important that mental health policies (Gureje & Alem, 2000) and population-based mental health training not sit on the proverbial shelf gathering dust. Hinkle (2014) has reported that “unfortunately, not even the laudable efforts of the WHO or United Nations have been able to bring countries that are in desperate need of basic mental health care together effectively,” which “underscores the need for urgent development of grassroots community mental health programs” (p. 12).
Unfortunately, we did not collect specific data as to how many guidance teachers and head teachers participated in the study. Future researchers could find that differences among these two groups of teachers exist.
The MHF program is community-based training that includes basic, universally applicable and context-specific skills. All 40 adult and child MHF stakeholders in Malawi suggested that the MHF program had a positive impact in their lives, schools and communities. Participants’ identification of four interrelated themes—the responsiveness to the Malawian cultural history and context, the availability and limitations of resources, the processes involved in the implementation of the MHF program, and the varied outcomes—begin to illustrate the ways in which the MHF program has been incorporated into school and community contexts, and identify participants’ beliefs about what might be necessary to strengthen and expand the MHF program in this country. Because the MHF program was originally developed to address the unmet mental health needs of individuals in an international context, and trainings have been conducted in 25 countries to date, studies such as this, as well as future quantitative research, can be conducted elsewhere to better understand the ways in which the program is meeting its objectives and to identify the types of support that could be provided to MHFs and human services-related advocacy efforts around the world (Hinkle, 2014; Lee, 2012).
Mental health resource allocations are often haphazard in African countries (Lund & Flisher, 2006); however, Patel et al. (2007) have indicated that the evidence supports the cost-effectiveness of mental health intervention, and the current study reports this potential in the schools in Malawi. Mental health cost-effectiveness also is reflected by a select number of other sub-Saharan countries (e.g., Tanzania, Kenya) that have integrated mental health into basic health service delivery and have set an admirable example of systematic implementation of community mental health service delivery (Jenkins et al., 2010). Community caregiving for mental stress, distress and disorders is often uncompensated and has tremendous public health value, since such caregiving can offset expensive services and assist shorthanded healthcare professionals (Viana et al., 2013). This reality has been demonstrated thus far in the schools in Malawi.
Future Directions in Malawi
More traditional healers should be incorporated into mental health services in Malawi (MacLachlan et al., 1995), a perspective that is reflected by some of the participants’ comments. Integrating traditional health care (i.e., indigenous healers) can impact people in ways that Western approaches do not (Gureje & Alem, 2000; Swartz, 2006). Community mental health care should take into account the beliefs of those being served, and both traditional and more modern progressive strategies need to be integrated. Tropical tolerance, or entertaining competing explanations of mental illness, is imperative when Westerners are assisting with the implementation of intervention programs (MacLachlan et al., 1995), using the emic, or worldview of the person, approach.
In Africa, a large proportion of the population does not receive mental health services for four basic reasons—first, few services are available (resources and needs); second, when services are sought out they are inadequate (outcomes); third, people often prefer self-care and traditional healers (processes); and lastly, stigma leads people to hide their mental health problems (processes and outcomes; Bird et al., 2011). These reasons are all relevant to school children and communities in that mental health can no longer be ignored as a building block of population health as well as social, educational and economic development (Lund, 2010). This study demonstrates that the MHF program addresses many of these concerns and is making at least a modest impact in Malawi. It would be short-sighted not to acknowledge that mental health problems are related to poverty, marginalization, social disadvantage, reductions in economic productivity and the interruption of educational processes (Alonso, Chatterji, He, & Kessler, 2013; Baingana & Bos, 2006; Bird et al., 2011; Breslau et al., 2013; Friedman & Thomas, 2009; Hinkle, 2014; Patel et al., 1997). These factors are even more worrisome in countries like Malawi that have seen poverty levels rise in recent years (Mattes, 2008). Although the MHF strategy is clearly challenged by these factors, the program has demonstrated an impact on Malawian school children that cannot be denied.
Conflict of Interest and Funding Disclosure
The author reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Melissa Luke, NCC, is an Associate Professor at Syracuse University. J. Scott Hinkle, NCC, is the Editor of The Professional Counselor. Wendi Schweiger, NCC, is Vice President at NBCC International, Greensboro, NC. Donna Henderson, NCC, is a Professor at Wake Forest University. Equal authorship is intended. This article is dedicated to Professor Kenneth Hamwaka, Executive Director of the Guidance, Counselling and Youth Development Centre for Africa and Vice Chancellor of the Africa University of Guidance, Counselling and Youth Development. Correspondence can be addressed to Scott Hinkle, 3 Terrace Way, Greensboro, NC 27403, email@example.com.