Mental health literacy among adolescents in Nigeria exposed to a school-based multidimensional intervention

Abstract

Background

It is crucial to prioritize mental health (MH) promotion among adolescents, as the initial onset of mental illnesses commonly occurs during this developmental stage. Adopting a multi-pronged approach to mental health literacy (MHL) may help promote adolescent mental well-being.

Objective

We aimed to determine baseline adolescents’ knowledge and attitudes on mental illness and any changes following a multidimensional MHL program.

Method

A pre-post study was conducted among 600 adolescents in grades 10–12 recruited by multistage sampling in southwest Nigeria. MHL training was implemented using multidimensional tools which included peer-led education, MH booklets, posters, and role plays over a six-week period. Pre- and post-intervention questionnaire data on the knowledge and attitudes of respondents on MH issues were collected and analyzed.

Results

Of 600 students, 594 (99%) [mean age of 14.87 (SD 1.44), a range of 11–21 years, and a female: male ratio of 1.3:1] completed the study. Post-intervention there were significant improvements in some but not all domains assessed. Participants’ views on care seeking and willingness for friendship improved post-intervention with a significant reduction in the concern for personal safety as a reason for unwillingness for friendship. Mean knowledge scores significantly increased from 11.89 (SD 2.56) to 13.51 (SD 2.62).

Conclusions

The findings suggest that school-based multidimensional interventions may improve MHL. However, additional studies are needed to more rigorously assess their impact to inform effective integration of MHL into school curricula to enhance adolescent MHL.

Introduction

Despite the global burden of mental disorders, there continues to be a significant level of neglect and a persistent prevalence of negative attitudes towards individuals with mental disorders, with little observed improvement over several decades in Nigeria (1,2). Adolescents contribute to 45% of the global burden of diseases associated with mental disorders (3). It is estimated that 50% of mental disorders emerge during the adolescence period. This usually follows non-specific psychosocial disturbances that have the potential to develop into various major mental disorders (3). Mental health disorders in adolescents are a major public health concern because of the attendant consequences on their academics, progression to adulthood, poor quality of life, and associated disability (4–6). Common mental disorders among Nigerian adolescents are depression, anxiety disorder, and substance use (7,8). Investing in appropriate strategies to detect MH problems in early adolescence may provide an opportunity to prevent the onset and progression of mental illness.

Interventions focusing on mental health literacy (MHL) show the potential to promote mental health among adolescents. MHL describes the understanding and convictions regarding mental illnesses that support their identification, treatment, or avoidance (9). This construct includes knowledge on how to prevent mental disorders, recognition of when a disorder is developing, knowledge of help-seeking options and treatments available, knowledge of effective self-help strategies for milder problems, and first aid skills to support others who are developing a mental disorder or are in a mental health crisis (10,11). Empirical research suggests that the capacity to identify a mental disease based on symptomatology is positively correlated with favourable attitudes towards formal mental health help-seeking (12–14), as well as the actual utilization of mental health services (15). MHL mostly targets schools, allowing access to a large youth population within an established learning environment. In a comprehensive systematic review, which included 24% of studies involving adolescent participants and 24% of adolescents in the overall study population, notable reductions in stigma were observed following anti-stigma strategies (16). Adolescents exhibited a higher susceptibility to the influence of education and contact strategies (involving interpersonal contact or video contacts), while adults demonstrated a greater responsiveness to only contact strategy in mitigating the stigma associated with mental illness (16).

In the existing health education curricula within the elementary and secondary schools of Nigeria, the predominant emphasis has been on environmental health and hygiene, neglecting substantial coverage of mental health (17). This is compounded by the notable scarcity of mental health practitioners (18,19). This deficiency in mental health education and professional support significantly elevates the risk and concerns associated with the burden of mental disorders, particularly among adolescents in Nigeria. To underscore the critical need for our study, a cross-sectional study conducted among secondary school students (Grade 10–12) in Southeast Nigeria reported that only 4.8% of these students could recognize depression using the ‘friend in need’ vignettes (2,20). This statistic reflects a substantial gap in understanding and addressing mental health issues among this population.

Additionally, an intervention study conducted in Ado-Odo Ota Local Government Area (LGA) of Ogun state demonstrated the potential for positive change among adolescents after MHL. The students were stratified into control and intervention groups from grades 10–12 and were exposed to a 5-hour training that spanned over three days. Training modalities included didactic lectures, group discussions, and role plays. Knowledge, attitude, and social distance questionnaires were used to assess outcome measures at baseline, immediately following the training for both groups 3 weeks post-intervention for the intervention group. Following the intervention, there was a significant improvement in mean knowledge and attitude scores in the intervention group (21). Furthermore, a review of randomized controlled trials involving school-based interventions has shown some evidence suggesting that school-based mental health interventions can be effective in improving MHL and reducing mental health stigma among adolescents (22). However, the evidence on their long-term effectiveness is less robust, primarily due to a lack of follow-up assessments in most studies.

Given these considerations, this study aimed to assess the impacts of introducing a six-week multi-modal MHL intervention program, which incorporates peer-led education, role play, and informational resources, on the comprehension, attitudes, and perceptions of mental health among adolescents in secondary schools lacking prior mental health services. The primary objective of this research was to deliver MHL training to adolescents within these secondary schools after establishing their initial understanding and attitudes regarding mental health and related conditions. A post-intervention evaluation occurred two weeks following the completion of the program.

Methods

Study Design

The study design was a pre-post study.

Study Population

This study was conducted among adolescents in the senior secondary (SS 1–3 equivalent of grades 10–12) of selected secondary schools.

Study Setting

The study setting was in Abeokuta South local government area (LGA) of Ogun State, one of the six states in the southwestern region of Nigeria in sub-Saharan Africa. Ogun State covers a total land area of 16,980.55 sq. km with a population of 3,751,140 and 1.2 million adolescents and young people, who make up nearly one-third (30.7%) of the state’s inhabitants as of the 2006 census (23,24). The populace is mainly of the Yoruba ethnic group. Ogun State has four tertiary hospitals (one of which is a specialist neuro-psychiatric hospital), 39 secondary health facilities (including four community psychiatric centres, - one is situated in Abeokuta South LGA), 450 primary health facilities, and 904 private health facilities. Abeokuta South LGAs stands out as one of the most densely populated among the 20 LGAs in Ogun State (23). The secondary schools are subdivided into junior and senior schools with the senior secondary schools (equivalent to Grades 10–12). There are 109 government-approved secondary schools in the LGA (40 government-funded and 69 privately owned). Three being single-gender (all public) and 106 mixed-gender. The study was conducted in mixed-gender schools.

Inclusion and Exclusion Criteria

Adolescents in senior secondary schools without academic records suggestive of learning disability were included in the study, while exclusion criteria were parental refusal or dissent by students.

Sample Size

Based on the estimation for comparative groups (25) using a previously documented mean difference in knowledge score at baseline compared to postintervention of 5.1 by Oduguwa et al. (21), a desired power of 80% and adjustment for a 15% attrition rate, 600 students were recruited into the study.

Sampling Method

A multi-stage sampling method was used.

Stage 1

From the three senatorial districts in Ogun State (Ogun Central, Ogun West, and Ogun East), Ogun Central was selected through a simple random sampling technique by ballot.

Stage 2

From the list of LGAs in Ogun Central, (Abeokuta North, Abeokuta South, Ewekoro, Ifo, Obafemi owode and Odeda), Abeokuta South LGA was selected by ballot.

Stage 3

The 106 mixed-gender schools in Abeokuta South LGA were stratified into Public (37) and Private (69) schools after excluding single-gender schools. The schools were assigned numbers, and three schools were randomly selected from each by balloting. The number of students sampled from the selected school was equal across the different schools irrespective of their population.

Stage 4

Systematic sampling was used to select the students from each level (1–3) of the senior secondary schools using the level’s register. A sampling interval (k^th) was determined based on the proportion allotted to the level (33 students each in SS1- 2 and 34 students in SS3, i.e., 100 per school). From the sampling frame of the students in the level, the first student in each level was selected using simple random sampling by ballot. Others were selected through the predetermined sampling interval.

Study Stages

The study had three stages: pre-intervention, intervention, and post-intervention.

Pre-Intervention Stage

1. Stakeholders’ meetings were held with Ogun state Ministries of Health and Education and Zonal Education Inspectorate on the need for MHL and its incorporation into the secondary school curriculum.

2. Development of study tools. These included:

   1. Questionnaire on MHL assessment administered to all study participants at the commencement and post-intervention stages. The questionnaire is a modified version developed and published by Dogra and colleagues (26) which had its foundation in a previous study by Pinfold et al. (27) in a school setting. Other additions to the questionnaire were from reports from an MH survey in Nigeria (28). This tool had no previous psychometric assessment but was pretested among students in a private secondary school in Abeokuta North LGA. Following the pre-test, ambiguous questions were reframed or where necessary removed.

   2. Information, Education and Communication Materials: (i) The mental health booklet was developed by the team led by one of the authors, FOO, a senior consultant psychiatrist. The booklet is comprised of two sections, section A (provides general MH education) and section B (provides specific information on MH disorders: seizures, conduct disorder, substance use problems, autism, ADHD, schizophrenia, depression, bipolar affective disorder, anxiety disorder and MH consequences of rape; (ii) Posters highlighting MH problems, prevention, and how and when to seek help were developed and printed.

   3. The research team, including mental health and behavioral physicians, developed scripts for role plays to disseminate MHL information during school assemblies. These scripts focused on three prevalent mental health issues— conduct disorder, depression, and seizures—emphasizing the importance of seeking appropriate care. This was rehearsed and performed by the National Youth Service Corps, Abeokuta South Dance and Drama Community Development Service group.

3. Selection of research assistants: Eighteen research assistants with a Higher National Diploma (the equivalent of a level 5 qualification) assisted with collecting the questionnaires. They were trained on the data collection instrument and the maintenance of ethical standards.

4. Additional activities: This included school entry, meeting school Principals/Teachers, identification of peer educators, sorting of the intervention population from the level’s register, engagement of parent forums, and obtaining parental consent. Peer educators were chosen by the teachers based on the level of social interactions they have with their peers at different levels and their school performance. Two peer educators at each level, male and female, with a total of six per school were identified. These peer educators were trained by the research team using the MH booklet over two weeks, during their school break time. The team also provided information on how the intervention be carried out and the roles and responsibilities of educating their peers during the intervention period. One week before the intervention period, structured intercept (“on the spot”) interviews were conducted for all the peer educators to ascertain their level of understanding and ability to deliver the MHL content. This stage ended with the baseline assessment of the selected students after written assent.

Intervention stage

This stage involved the distribution of the mental health booklet to each of the study students, the pasting of posters at strategic areas in the school environment, ongoing education by the peer educators, and sensitization meetings with the Parents-fora. Role plays were also performed at the different schools in a chosen assembly period. This interventional stage lasted for 6 weeks in each school.

Post-intervention

At the post-intervention stage, two weeks after the 6-week intervention, a post-intervention reassessment was conducted using the same self-administered questionnaire the same selected students, with tallying the post-test to the pretest identification number. Additional post-intervention activities included (i) a stakeholders’ meeting for feedback on the fieldwork report with the Ministry of Health and Education; (ii) a dissemination meeting five months post-intervention to give feedback on the study’s findings to the officials of the Ministry of Health and Education, teachers, and students representatives; and (iii) provision of phone contacts for students who may want to reach out to a mental health practitioner.

Study Instrument

Information was collected from the respondents under the following sections:

• Section A. Socio-demographic characteristics included information on respondent’s age, sex, class, religion, ethnicity, parent’s marital information, parent’s level of education, parent’s occupation, and whom they live with and school performance.

• Section B. Common beliefs and treatability of mental illness.

• Section C. Health-seeking behaviours and source of information on mental illnesses.

• Section D. Relationships with the mentally ill and social distance.

• Section E. Attitude and knowledge statements on people living with different mental illnesses.

Mental health-related knowledge assessed their understanding of mental illness, causes of mental illness, where mentally ill people can get help, and who can provide help to a mentally ill person. Attitude, health-seeking behaviour, common beliefs and treatability of mental illness, source of information, relationships with the mentally ill, and social distance were recorded.

Of the 23 questions used in assessing respondent’s knowledge of MH issues, 13 questions on knowledge statements regarding mental health problems were in Likert format with three options of ‘Agree’, ‘Uncertain’ or ‘Disagree’; the first 11 questions were scored ‘1’ if they agree and 0 if neutral or disagree while for the remaining 2 questions, they were scored ‘0’ if they agree and 1 if uncertain or disagree. The remaining 10 questions were scored ‘1’ if their knowledge was right on the behaviours associated with mental illness or likely causes and ‘0’ if not. The total scores for knowledge were generated by adding all the correct responses. The maximum obtainable score was 23.

Study Procedure

In the preceding week before the intervention, the students were assigned specific identification numbers (to ensure that the same students were assessed at the pre- intervention assessment). Pre-intervention assessments using the self-administered questionnaire were conducted among the students. Three research assistants and assigned members of the research team oversaw events in each school. At the beginning of the six-week intervention period, the MH booklets were distributed to the students, and copies were placed in the school libraries. Posters were pasted at strategic areas in the school environment.

The trained peer educators conducted ongoing education of their peers at the school assemblies for ten minutes twice weekly in the different schools and during school breaks (thrice weekly), they conducted talks (contents were based on different mental health issues in the MH booklets) in groups of six. During this period, the researchers provided supportive supervision using a structured report to ensure the peer educators provided the required education to their peers.

A single-day meeting was held with the Parents’ fora of each school with about two-thirds of the parents in attendance. The meetings highlighted the importance of MHL and how to identify mental disorders. Two assigned researchers made presentations on MH and mental illnesses using audiovisual aids in the local and English languages. Parents were allowed to ask questions on mental health-related issues and the available help for care.

Role plays were conducted once at the different schools in a chosen assembly period with all students in attendance. None of the students were absent from the schools during the period of intervention. This intervention stage lasted for 6 weeks in each school.

Data Analysis

Data collected were checked for errors and omissions at the point of collection. Data were analyzed using IBM^® Statistics Package for Social Science (SPSS) version 26 Software packages. Summary statistics were generated using frequency tables. The McNemar test was used to assess the association between categorical variables pre and post-intervention. Where multiple responses were allowed, as in common beliefs and local descriptions of mental illness and sources of MH information, the denominator was the total number of participants. The level of significance was set at p value less than 0.05.

Ethical Considerations

Ethical approval was obtained from the Office of Research, Planning, and Statistics of the Ogun State Ministry of Health (HPRS/381/478). Additionally, permission was obtained from the school authority.

Result

Socio-demography and Academic Performance

Six hundred students participated in the pre-intervention stage of the study but only 594 (99.0%) students completed both baseline and follow-up assessments as paired samples. The mean (SD) age of the participants was 14.87± 1.44 years, and the majority were 15 years of age or older (58.4%). Females made up a slightly larger proportion. Table 1 shows the sociodemographic and academic ratings of the study participants.

Table 1.

Socio-demographic characteristics and academic ratings of the study participants (N=594)

Variable	Categories	% (n)
Age	</=14 years	41.6 (247)
	15 years and above	54.8 (347)
Gender	Male	43.4 (258)
	Female	56.6 (336)
Class a	SS1	33.0 (196)
	SS2	33.0 (196)
	SS3	34.0 (202)
Religion	Christianity	72.6 (431)
	Islam	27.4 (163)
Ethnicity	Yoruba	93.8 (557)
	Igbo	3.5 (21)
	Hausa	0.8 (5)
	Others	1.9 (11)
Living/Residential situation	With both Parents	78.5 (466)
	With one parent	16.3 (97)
	Family members/Others	5.2 (31)
Family Setting (N=466) b	Monogamous	87.8 (409)
	Polygamous	12.2 (57)
Mothers educational level (N=593) c	No formal	3.2 (19)
	Primary	7.6 (45)
	Secondary	29.7 (176)
	Tertiary	59.5 (353)
Fathers educational level (N=592) d	No formal	2.7 (16)
	Primary	6.6 (39)
	Secondary	28.0 (166)
	Tertiary	62.7 (371)
Student report of academic performance	Excellent	37.7 (224)
	Good	46.6 (277)
	Average	15.3 (91)
	Poor	0.3 (2)
Student report of preceding academicd term grades e	Mostly 29 and below	2.2 (13)
	Mostly 30 – 39	3.0 (18)
	Mostly 40 – 59	22.7 (135)
	Mostly 60 – 79	57.6 (342)
	Mostly 80 – 100	14.5 (86)

^aSS1=Senior secondary class 1 (Grade 10), SS2=Senior secondary class 2 (Grade 11) and SS3=Senior secondary class 3 (Grade 12)

^bthose living with both parents

^c1 missing information

^d2 missing information

^eThe preceding term was a third term in their last grade and it gives the cumulative scores in percentages

Common Beliefs about Mental Illness

We collected multiple responses concerning the baseline common beliefs and local descriptions of mental illness. Among the 594 respondents, 480 (80.8%) believed that mental illness is a form of going mad, and 487 (82.0%) believed that it is necessary to know the mental health history of a potential spouse before marriage. Additionally, 236 (39.7%) believed that mentally ill individuals hear things from the spirit world, 277 (46.6%) believed that being studious can lead to mental illness, and 184 (31.0%) believed that having a history of mental illness is a precondition for being wealthy.

Regarding the local descriptions of mental illness, our multilingual team grouped these descriptions by identifying common and equivalent concepts across different language groups, including those in Nigeria. The three most common descriptions were, (i) “Madness”/ “Onyeara”/ “Onyoosi” (the latter two being a reflection of acute psychosis in the local Igbo language) with 426 (71.7%) responses, (ii) “Weere”/ “Alarun opolo”/ “Alagana”/ “Onigoungoun” (which are local Yoruba translation of disease of the brain, mental imbalance, or being “out of one’s mind”) with 269 (45.3%) responses, and (iii) “Crazy”/ “insane”/ “lunatic” (233, 39.2%).

Health-seeking Behaviours, Belief in the Treatability, and Source of Information of Mental Illnesses

Table 2 shows the health-seeking behaviours in the treatability of mental illnesses. In response to the question: “What would you do to the mentally ill?” There was a significant reduction in the proportion of those who will take the person to the prayer house from pre- to post-intervention (49.7% vs 39.7%). In contrast, there was a significant increase in the proportion who will take the person to a traditional healer (12.7% vs 16.7%). There was a significant increase in the proportion who agreed that a doctor, psychiatric nurse or psychiatrist should care for the mentally ill. However, the proportion who agreed that mental illness is treatable did not statistically change. There was also no significant difference in the proportion of people who used MH services pre-and post-intervention. Twenty-six (4%) of the 594 participants had used adolescent MH services before the intervention compared with 41 (7.0%) post-intervention (p=0.06). Finally, the sources of MH information involve multiple responses. Out of 594 respondents, the three highest sources of information were the school (n=253; 42.6%), television/home video (n=228; 38.4%), and family (n=178; 30.0%).

Table 2.

Study participants’ responses to questions related to health-seeking behaviours and treatability of mental illnesses, pre-and post-intervention (N=594)

Question	Statement	Pre-intervention response	Post-intervention response		McNemar test p value
			Not Certain/Disagree % (n)	Agree % (n)
“What would you do to the mentally ill?”	I will take the person to the hospital	Not Certain/Disagree	3.4 (20)	9.1 (54)	0.484
		Agree	7.7 (46)	79.8 (474)
	I will take the person to a prayer house	Not Certain/Disagree	39.2 (233)	11.1 (66)	<0.001
		Agree	21.1 (125)	28.6 (170)
	I will take the person to a traditional medicine healer	Not Certain/Disagree	79.5 (472)	7.7 (46)	0.008
		Agree	3.9 (23)	8.9 (53)
	I will lock the person up	Not Certain/Disagree	95.0(564)	2.0 (12)	0.701
		Agree	2.5(15)	0.5 (3)
	I will beat the disease out of the person	Not Certain/Disagree	98.4 (585)	0.7 (4)	1.000
		Agree	0.7 (4)	0.2 (1)
“Which professionals should care for the mentally ill”	Psychiatric nurses	Not Certain/Disagree	48.0 (285)	19.2 (114)	0.003
		Agree	12.3 (73)	20.5 (122)
	Psychologists	Not Certain/Disagree	48.3(287)	19.5 (116)	0.843
		Agree	18.9(112)	13.3 (79)
	Psychiatrists	Not Certain/Disagree	22.7 (135)	17.7 (105)	0.001
		Agree	10.4 (62)	49.2 (292)
	Doctors	Not Certain/Disagree	41.1 (244)	19.7 (117)	0.001
		Agree	11.6 (69)	27.6 (164)
	Traditional Healers	Not Certain/Disagree	79.0(469)	7.4 (44)	0.368
		Agree	5.9(35)	7.7 (46)
	Islamic clerics	Not Certain/Disagree	79.5(472)	8.6 (51)	0.035
		Agree	5.2(31)	6.7 (40)
	Pastors	Not Certain/Disagree	53.7 (319)	13.1 (78)	0.683
		Agree	12.1 (72)	21.1 (125)
“Is mental illness treatable?”		Not Certain/Disagree	1.7 (10)	4.7 (28)	0.135
		Agree	2.9 (17)	90.7 (539)

Relationships with the Mentally Ill and Social Distance

Table 3 shows the type of relationship the participants were willing to have with the mentally ill pre- and post-intervention. There was a significant increase in the proportion of participants reporting willingness of friendship and a decrease in the proportion of those not willing to have any relationship with the mentally ill pre- to post-intervention. There was a significant reduction in the proportion of those who cited personal safety as the reason for their unwillingness to have a relationship with the mentally ill from pre- to post-intervention (45.1% vs 33.0%).

Table 3.

Comparison of the relationship the participants were willing to have with the mentally ill, pre- and post-intervention (N=594)

Relationship variable		Pre-intervention responses	Post-intervention responses		McNemar test p value
			Not Certain/Disagree% (n)	Agree
Type of relationship	None	Not Certain/Disagree	35.0 (208)	7.1 (42)	<0.001
		Agree	23.1 (137)	34.8 (207)
	Friendship	Not Certain/Disagree	38.4 (228)	23.1 (137)	<0.001
		Agree	7.4 (44)	31.1 (185)
	Othersa	Not Certain/Disagree	92.9 (552)	3.6 (21)	0.857
		Agree	3.2 (19)	0.3 (2)
Reasons for unwillingness	Fear of contagion	Not Certain/Disagree	92.4 (549)	2.5 (15)	0.200
		Agree	4.1 (24)	1.0 (6)
	Public perception	Not Certain/Disagree	93.9 (558)	1.9 (11)	0.200
		Agree	3.2 (19)	1.0 (6)
	Poor judgement	Not Certain/Disagree	91.9 (546)	4.4 (26)	0.461
		Agree	3.4 (20)	0.3 (2)
	Personal safety	Not Certain/Disagree	44.8 (266)	10.1 (60)	<0.001
		Agree	22.2 (132)	22.9 (136)

^amarital or business relationship

Participants Responses to Attitude, and Knowledge Statements on People Living with Different Mental Illnesses

Table 4 shows the frequency of responses by statements regarding attitude toward MH problems. Post-intervention, a significantly lower proportion of the participants responded that the person who is mentally ill will be difficult to speak with than pre-intervention (56.9% vs 47.0%) and that the mentally ill are weak and should be blamed (28.6% vs 23.6%). In contrast, no significant changes were seen for three other attitude variables. The pre-intervention mean (SD) knowledge score was 11.89 ±2.56 and 13.51±2.62 post-intervention. This difference was statistically significant (t = 10.78, p <0.0001). Of the 594 participants, 393 (66.2%) had an improvement in their knowledge scores from the baseline.

Table 4.

Frequency of responses by statements regarding attitude toward mental health problems, pre- and post-intervention (N=594)

Variable	Pre-intervention responses	Post- intervention responses		McNemar test p value
		Not Certain/Disagree % (n)	Agree % (n)
Difficult to talk to	Not Certain/Disagree	29.5(175)	13.6(81)	<0.001
	Agree	23.6(140)	33.3(198)
Mentally ill may be violent	Not Certain/Disagree	10.8(64)	17.3(103)	0.619
	Agree	16.0(95)	55.9(332)
Mentally ill persons are unpredictable	Not Certain/Disagree	13.0 (77)	14.5 (86)	0.244
	Agree	17.3 (103)	55.2 (328)
Stigma (shame) attached to people with mental health problems	Not Certain/Disagree	17.7 (105)	16.5 (98)	0.717
	Agree	15.5 (92)	50.3 (299)
Mentally ill are weak and should be blamed	Not Certain/Disagree	57.8 (343)	13.6 (81)	0.036
	Agree	18.7 (111)	9.9 (59)

Discussion

Mental health is crucial to overall health and well-being, yet it is often overlooked, especially in developing countries like Nigeria (29,30). Previous studies have shown that negative attitudes and misconceptions towards mental illness and a lack of understanding of its causes are some of the key barriers to seeking and receiving appropriate MH care as well as delivery of quality MH care (31,32). It is, therefore, important to promote accurate knowledge of and a positive attitude towards mental illness to reduce stigma and improve MH outcomes. In this study, the authors evaluated the impact of a multidimensional educational intervention on the knowledge of and attitude toward mental illness among 594 secondary school students aged between 11 and 21 years old. The low percentage of participants who have used adolescent MH services before the intervention is consistent with other studies that have shown low rates of help-seeking behaviours for MH problems among adolescents (33,34). A systematic review reported that adolescents view accessing MH care services as a sign of weakness (35). This highlights the need for more targeted interventions to improve help-seeking behaviours among adolescents and reduce the stigma associated with seeking MH services.

The findings on common beliefs about mental illness among the study participants revealed some misconceptions and stigmatizing attitudes toward mental illness. A significant proportion of participants had negative beliefs about mental illness, such as the belief that mental illness is a form of going mad or that being studious can lead to mental illness. These findings are consistent with previous research in Nigeria that has demonstrated negative attitudes toward mental illness among the general population. These beliefs may reflect cultural and traditional beliefs in Nigeria, where some people still attribute mental illness to spiritual or supernatural causes (36,37). Additionally, approximately one-third of the participants believed that it is necessary to know the MH history of a potential spouse before marriage underscores the cultural significance and the acknowledgement of the importance of MH in relationships. The complexity between marriage and mental illness with its attendant legal and moral dimensions has been highlighted in previous reports; the history of individuals with mental illness is considered a family concern for marriage prospects (38,39). The results of this study on common beliefs about mental illness among Nigerian adolescents are consistent with other studies in the literature, which have also found misconceptions about mental illness to be prevalent among adolescents worldwide (40–42). For example, in Saudi Arabia, adolescents alongside other age groups have been reported to believe that supernatural forces cause mental illness and is a form of punishment from God, bad karma or a curse, and these beliefs negatively impact attitudes towards mental illness (43,44).

The lack of actual words in the native language to describe MH conditions has been reported in some settings (45). The local descriptions of mental illness in the present study are also consistent with previous studies that have identified common local terminologies used to describe mental illness in Nigeria and other settings including England (46,47). The most common local descriptions reported by the study participants were “madness/ onyeara/ onyoosi,” “crazy/ insane/ lunatic,” and “weere/ alarun opolo/ alagana/ onigoungoun” all of which relate to local languages of Igbo and Yoruba respectively and depicts problems affecting the brain. These findings suggest that these terminologies may significantly influence how mental illness is perceived and interpreted in the study setting. Further research is needed to explore how these local terms impact the community’s understanding and response to mental health issues.

The schools and television/online videos were the most common sources of MH information reported by the participants highlighting the importance of the school and these other platforms in MH education and awareness-creation among adolescents in Nigeria. This finding is consistent with other studies. For example, a study conducted in Japan, China and South Korea found that the most common source of MH information for adolescents was television/movies and school (48). Another study conducted in India found that television/media was a common source of MH information for adolescents with the attendant concern for misinformation (49,50). However, the relatively low proportion of participants who reported friends as a source of MH information suggests a need to explore other informal sources among adolescents.

There was a mix of changes in the post-intervention responses of the participants in the social distance and attitude domain. Post -intervention, the participants’ willingness to have a relationship with mentally ill individuals was higher. This finding suggests that targeted interventions may improve attitudes toward mental Illness and reduce stigma (51). However, the lack of significant changes in the reasons for avoiding relationships with mentally ill individuals (except for personal safety concerns) may suggest the need to address other stigmatizing beliefs and attitudes toward mental illness. In addition, the study did not find a significant increase in the proportion of participants who believed that mental illness is treatable post-intervention. This finding highlights the need for ongoing mental health education and awareness campaigns to improve knowledge about mental illness and its treatability. It also underscores the necessity for more targeted interventions to address specific misconceptions about mental illness and to reduce stigma.

There was a significant increase in participants’ knowledge about mental illness, as measured by higher post-intervention scores compared to pre-intervention scores. These findings are consistent with previous studies showing the feasibility and effectiveness of MH interventions for adolescents (10,17,52,53). However, these various studies accomplished the interventions by different means. It is important to note that the efficacy of such interventions may vary depending on various factors, such as the content, duration, and delivery of the intervention, as well as the characteristics of the participants (such as age, education level, and cultural background). Daniele et al. (54) in a scoping review of different educational intervention called for more genuine ‘educational’ interventions, involving experiential and interactive activities such as discussion groups, role-play, and art-based activities as against less participatory and more ‘information-based’ activities, such as lectures. The present study focused on understanding mental disorders, available treatments, decreasing stigmatization, and enhancing health-seeking behavior through multidimensional interventions. However, some studies have reported mixed results regarding the effectiveness of MH interventions for adolescents (55).

Overall, the results of the present study are consistent with other studies that demonstrate that school-based interventions may improve MH literacy and reduce MH stigma among adolescents in at least some domains. However, it is important to note that the specific interventions used in different studies may vary, and the effectiveness of interventions may depend on various factors, such as the cultural context, the specific population being targeted, and the methods of implementation. The study demonstrates the potential of targeted interventions to improve attitudes towards mental illness and increase willingness to have a relationship with mentally ill individuals.

Limitations

The study assessed the short-term impact only two weeks after the intervention, leaving unclear the sustainability of the intervention’s effects over time. Additionally, the study did not use an experimental design, relied on self-report measures, and faced the possibility of social desirability bias in responses. In addition, our sampling approach of an equal number of students sampled across schools regardless of population size, may lead to the overrepresentation of schools with smaller populations. This could limit our findings generalizability to schools with larger populations. Furthermore, the chosen measures may not have adequately captured all relevant constructs related to mental health literacy and its impact.

Conclusion

Integrating mental health literacy into the school curriculum may create a lasting impact of mental health interventions on adolescents. This strategy could help maintain the positive effects observed in the short term.