**1. Introduction**

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

improved access to professional services within rural [4] or low-resource settings, even when such programs are designed outside national clinical settings.

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

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

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

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

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

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

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

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

A MHFA training impact assessment study [18] conducted among 166 adult participants who enrolled in classes organized by a community health center in rural Kansas in the United States reported that even though the response rate was low (36%) for the online feedback survey, there was evidence of changed behaviors, attitudes, and improved mental health literacy. However, as with most impact assessments, there were suggestions for additional research to better understand change processes that occur as a result of MHFA across multicultural and diverse settings within and outside the United States. Noltemeyer et al. [19] assessed the impact of a

national rollout of Youth Mental Health First Aid (YMHFA) training among adults in Ohio who were trained as first responders to youth in crisis. The pilot study utilized data gathered from over 2180 predominantly White women within the education sector. They found significant improvements in self-confidence, openness to individuals with mental health conditions, willingness to help, and awareness of mental wellbeing resources and support, 3 months after training.

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

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

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

Globally, young people and women have the highest rate of global emotional disorder [24]. One in six people between 17 to 19 years have a mental disorder with 1 in 16 experiencing more than one mental disorder in 2017. Fifty percent of all lifetime mental illness begins by the age of 14 years and 75% by the age of 24 years [25]. In South Africa, the statistics are similar. A report from the South African Federation for Mental Health (SAFMH) [26] on the state of mental health in the country indicated that in 2o18, 18% of learners in the country (between ages 15 to 19 years) reported having suicide ideation, 18% had attempted suicide, 25% reported experiencing

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

feelings of hopelessness and sadness, and 32% of those who attempted suicide required medical treatment. Yet, the optimal methods of promoting health and the effectiveness of MHFA with young people in South Africa are not clear. However, research and interventions in other areas have shown that more awareness, MHFA, and community participation decrease the stigma and therefore increase the chances of getting help.

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

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