**2.2 Research design and procedures**

The context for the current research was an NPO, Indima Yethu, located in Cape Town, whose work focuses on youth mentoring, capacity development, health

#### *Exploring the Effectiveness of Mental Health First Aid Program for Young People in South Africa DOI: http://dx.doi.org/10.5772/intechopen.108303*

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

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

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

#### **2.3 Post-MHFA course survey**

As earlier indicated, online surveys and focused group workshops were the primary data collection tools. These data collection tools were designed to assess participants' perceptions, behaviors, knowledge, and attitudes toward mental illness, spirituality, level of empathy, coping mechanisms, and other protective factors for mental wellbeing. The assessment survey for participants took 10 minutes to complete on Google doc form and included 20 MCQs and other demographic data-related questions that required short responses. Although the lines of inquiry and survey questions were teased out from a review of MHFA literature and in consultation with

instructors at Indima Yethu, in order to establish content validity, they were submitted to participants of the Indima Yethu MHFA course and other MHFA program organizers for feedback. Feedback from participants and experts were particularly important to me as I was working from an evaluative ubuntu, asset-based, participatory and decolonial epistemological and theoretical framework.

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

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


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

Items that fell within theme four which focused on Indima Yethu's specific resources such as spirituality, self-confidence, de-stigmatization and self-esteem, and participants were required to circle the responses that indicate how the 13-week MHFA course from Indima Yethu impacted their wellbeing, that of their loved ones and their openness to spirituality. The response scale for these items were rated as positive or negative using a 5-point scale: 1 (very favorable), 2 (favorable), 3 (very unfavorable), 4 (unfavorable), and 5 (NA). Furthermore, participants were asked to *Exploring the Effectiveness of Mental Health First Aid Program for Young People in South Africa DOI: http://dx.doi.org/10.5772/intechopen.108303*

indicate how often they were in contact with other individuals experiencing mental health crises and to describe how they supported them as well as their level of confidence in their ability to support others. If they indicated that they had helped someone while taking the course or after, they were asked to list the number of times and under what circumstance they made referrals using Indima Yethu's in-house mobile app. Participants used the focused group workshop platforms to unpack all responses provided in the surveys.

#### **2.4 Participants**

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

#### **2.5 Data analysis**

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

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

#### **2.6 Results**

Content analysis of focused group discussions utilized a bottom-up [30] approach where I tried to identify phrases that were related to broad categories linked to


#### **Table 1.**

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

changes in behavior due to utilization of new knowledge, helping behavior, and increase in self-confidence. Afterward, I organized all relevant statements into repetitive themes below the broader categories of changes in behavior, helping behavior, and increase in self-confidence.

#### *2.6.1 Knowledge retention and utilization*

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

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

#### *2.6.2 Changes in helping attitude due to mental health literacy*

The range of questions within this category assessed various ways in which participants' helping behavior has changed post-training. A good number of participants

#### *Exploring the Effectiveness of Mental Health First Aid Program for Young People in South Africa DOI: http://dx.doi.org/10.5772/intechopen.108303*

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

#### *2.6.3 Outcome of Indima Yethu's six-step approach*

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

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

#### **2.7 Discussion**

This study examines the effectiveness of a youth-focused Mental Health First Aid training program, within the context of an adapted adolescent guideline implemented by a nongovernmental organization in the Western Cape province of South Africa. It presents a preliminary attempt at building an evidence base for MHFA in South Africa by assessing the perceived impact on individuals who underwent training. The sample included young people between the age of 18 and 35 years who are resident in the Western Cape. Overall, the study findings indicate that MHFA is emerging in South Africa as a protective factor. Preliminary evaluation indicates wide acceptance

#### Theme Example statements

*Utilization of Knowledge* We Black people do not like going for therapy and the older generation dismiss us as lazy when we complain but since I took this course, I have been able to encourage my cousins and I wish it could be translated it into Isizulu for my mom and aunties aunties.

Since the day my grandmother started getting sick and even now, I have been the one facing it all, fighting it all through the help of ALGEE, to help encourage self-help support for my family.

The course has helped me to the point where even my mother tells me things because she knows I will not judge her.

*Change in helping behavior*

Black communities see this as a taboo when one is suffering from mental health, and we are either told we sick and we need prayers. I think that what really draws people who suffer from it to commit suicide*.* Taking the YMHFA course helped me to recognize and adopt a more tolerant attitude toward mentally ill people. I am now comfortable talking to and helping them.

I never liked the idea of being friends with or working with someone with a mental health problem, but ALGEE has helped me in starting conversations about how they can get help.

I come from a community where people pray about mental illness or see a spiritualist who oftentimes tells them that it is a sign of spiritual calling. The course taught me a six-step approach I can use in persuading them to get help.

To be honest, I used to be afraid of mentally ill people and thought they should be excluded, but now I know that no one is Immune to stressors. I mean, people can always get help if we apply the right strategies by educating them, not judging and referring them for professional help. This is humanity to me

Self-confidence they began with an "asset mapping" instead of "needs analysis" in their course and that really helped us in learning about what is important to young people when it comes to applying ALGEE or making referrals.

I think people with mental illness also value being involved in meaningful things that they also enjoy, including educational achievement, material wellbeing, housing, career success, and positive relationships.

Indima Yethu's training enlightened me about self-consciousness, self-concept, and self-definition which also helped me in setting healthy boundaries and dealing with the stigma attached to having schizophrenia. People used to call me "schizo" but I am Now able to talk about my experience more openly and help others.

Apart from the ALGEE plan, I benefited mostly from the mobile application and the breathing exercises which I've taught my family. It connects me to my higher self and grounds me.

The course taught me a lot about myself and that has changed how I talk to people within my circle. I have referred over 20 people from my class for therapy since I completed the training and I am now working with primary schools.

#### **Table 2.**

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

In all honesty, I live with extended family members who use alcohol to numb their pain but I used some of my knowledge to encourage them to seek help for their trauma.

My living situation has been very volatile due to older siblings who are dealing with relationship issues and transferring aggression on others, but after taking the course, I have learned to listen non-judgmentally and give reassurance.

Since I took the course, I have been the strong one for my family through all the losses we suffered during COVID-19. I have been listening to them and encouraging therapy.

#### *Exploring the Effectiveness of Mental Health First Aid Program for Young People in South Africa DOI: http://dx.doi.org/10.5772/intechopen.108303*

which corresponds with findings from a systematic review [31], of mostly quantitative studies which found that MHFA is an effective intervention for trainees exposed to the curriculum. They also indicated that the largest effect sizes were found for the knowledge and confidence outcomes, while "attitude and behavior-only" effect sizes were within the small range.

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

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

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

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

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

FGD data, participants felt that one of the most favorable aspects of the ALGEE training program was individuation, which made them aware of their specific stereotypes and biases against themselves and others.
