Improving mental health in Nicaraguan youth: A technology-enhanced, school-based program

Innovation summary

Nicaragua faces many economic, political, social and environmental challenges, with resulting impact on mental health, including PTSD, depression, anxiety, substance abuse and increased family violence.¹ Nicaraguans have the highest suicide rates in the region, and youth (15-24 years) have the highest rates of mental illness, addictions and suicide in the country.² But due to limited resources, few youth mental health services are available. A potential solution is to use schools as a base for service delivery and resilience-building initiatives. School-based mental health literacy programs have been found to improve mental health knowledge, coping skills and help-seeking, and reduce stigma among youth.³

The project goal is to decrease the morbidity of mental illness and addictions among Nicaraguan youth by improving mental health literacy, using a sustainable context- and evidence-based approach. Key components of the project are to:

Culturally adapt and deliver a mental health literacy curriculum: a) to teachers, and b) through teachers to students
Develop and implement an innovative tech platform to support youth self-education on mental health
Evaluate the cost-effectiveness of this model of intervention

“I have a Masters in Mental Health but I learned more in the 3 days of MHLP from Dr. Kutcher than when I was studying for my degree.”

- UNAN-Leon teacher

Impact summary

At least 75% of students in the intervention group receive the full curriculum
Improved mental health knowledge, reduced stigma and less perceived stress among intervention group students compared to the control group students
Program costs associated with lower relative rates of school drop-out rates, higher GPA, lower disciplinary issues and higher post-secondary education acceptance or progress in the intervention group compared to the control group

Innovation details

The 3 integrative project components and their related activities are as follows:

Culturally adapt and deliver a proven mental health literacy program (MHLP): i) to teachers, and ii) through teachers to students

The MHLP, developed and widely implemented in Canada, and several other countries (Brazil, Portugal, Africa and China),⁴ will be adapted for use in Nicaragua with the help of local advisory groups. This will be accomplished by:

a) Implementing a structured teacher training program to deliver the MHLP curriculum (an intensive 3-day training), with a train-the-trainer component to support sustainability. A total of 50 teachers will be trained; the first 25 trainees will teach another 25 teachers half-way through the project, allowing for supervised train-the-trainer experience. Teachers will also receive 2-day training on supporting students with mental health questions or concerns, and making appropriate health system referrals. The project team will provide the training, mentoring and supervision. An advisory group involving local community agencies, primary care, and hospitals, will help to develop a local resource and referral guide.

b) Integrating the 8-12 hour MHLP curriculum into specific final year secondary school courses and university 1st year orientation courses, targeting 500 students. Topics will include: Mental disorders and addictions among youth; stigma; stress coping/problem-solving; and help-seeking. To compare outcomes between intervention/non-intervention groups, and help identify the educational stage at which the MHLP will have greatest impact, one secondary school and one UNAN-Leon faculty will receive the MHLP, and the other secondary school and a second university faculty will be controls.

Develop and implement an innovative technological platform (Mind Cloud) to support youth self-education on mental health

To enhance and support the curriculum, an innovative, culturally-adapted e-platform (termed “Mind Cloud”) will be developed to support the project. The team hopes to partner with local advisory groups and tech companies (e.g. the Instituto Nicaragüense de Telecomunicaciones y Correos -TELCOR), to develop this multi-modal e-platform.

The platform will include:

a) Mind Web: This website of user-friendly mental health information will be modeled on Canadian mental health literacy project websites that similarly provide information on mental health, mental illness, treatment and wellness in a lay-friendly manner (e.g. www.teenmentalhealth.org, www.tigweb.org, www.camh.ca). Access will be restricted initially to MHLP intervention participants, but free public access will be granted at project end.

b) Mind Games: Short, interactive online games will promote experiential learning and skills building, by allowing students to apply their new knowledge in realistic scenarios, thus consolidating their learning. The games will link to information on Mind Web via pop-ups on interesting facts and tips and tricks for game mastery.

c) Mind Talk: A portal to online forums for MHLP intervention participants to discuss mental health issues, share knowledge and collaborate on curriculum related assignments. Forums will be available for students only, teachers only, and mixed groups. Mind Cloud will be hosted by UNAN-Leon’s website, and maintained collaboratively by local tech experts, thus becoming a long-term local resource.

Evaluate the cost-effectiveness of this model of intervention

A cost-effectiveness analyses to quantify the value for investment in the intervention will be conducted (more information in the cost-effectiveness section)

The three components are integrative. Mind Cloud will support the MHLP by being a source of supplementary information that can be accessed in-class to enhance lessons, or accessed by students and teachers independently for self-driven learning. It also offers a common platform for discussion by teachers and students across schools. At every step of the project, costs (e.g. time, money) will be tracked to assess the value added by each component and efficiencies gained.

Key drivers

Training and resource gap

The project fills a training and resource need in the community, which local leaders themselves identified ahead of the project

Connections with relevant Ministries

Local project investigators are well connected, with links to the Ministry of Education and Ministry of Health, facilitating institutional approvals and support for the project

Working ahead of the scheduled timeline

The full team worked hard to develop project components and implement activities ahead of schedule, gaining a time buffer

Sustainable nature of project

The project incorporates a train-the-trainer model to enable staff trained to train others and build a network of competency, for sustainability

Challenges

Natural disasters

Earthquakes in Nicaragua in April 2014 closed all school for some weeks, which meant that the project had to be stopped for a short time

Varying education levels and knowledge amongst teachers

High school and university teachers have different levels of education and knowledge, necessitating some adjustment to training time and incorporation of booster training sessions

Continuation

The national Ministry of Education is very pleased with the project and has expressed strong interest in training all teachers in mental health using the project curriculum, contributing to sustainability.

The project team is currently in discussion with policy makers and leadership to scale up the project to all of Nicaragua, and to other countries in the region with similar needs.

Partners

University of Toronto - Department of Psychiatry (Canada)
National Autonomous University of Nicaragua Leon (Nicaragua)
Dalhousie University (Canada)

Partners

Grand Challenges Canada

Evaluation methods

The project uses a parallel group design to assess the efficacy and utility of the mental health curriculum. Half the participating students will receive the curriculum and the other half will be a control group.

Self-report measures will be used to assess changes in mental health knowledge, stigma, help-seeking, psychological distress, life satisfaction and health behaviours, between intervention and control group students. Measures will be completed at program start (baseline), post-curriculum (12 week) and at follow-up (6 months) by both intervention and control group students.

In addition, improvement in mental health knowledge and reduced stigma among teachers will also be tracked, with comparisons made between intervention group teachers who receive training in MHLP delivery, and control group teachers. Referrals from schools to local youth health services will be tracked to estimate changes in number of referrals by intervention group teachers and help-seeking by intervention group students as a result of the intervention

Cost of implementation

The total project budget is $250,000. As some final project activities are currently being completed, cost effectiveness analyses are still ongoing, but the project was completed on time and under budget.

Impact details

The primary findings are as follows:

Students

Baseline: There were about 570 students in the intervention group and 340 students in the control group at baseline. There were no differences between the groups in demographics or in scores on the self-report measures at this time point.
12 weeks: About 450 intervention students and 225 control students completed measures at 12 weeks. Results showed that compared to the control group, intervention students had better mental health knowledge (p<0.0001) and attitudes scores (p<0.0001) on the MHKAS, lower stigma scores on the YOS (p=0.003), better lifestyle scores on the HPLP (p=0.02) and lower perceived stress scores on the PSS (p<0.0001). Compared to baseline, intervention students also showed higher high-seeking scores on the GHSQ (p=0.02). There were no group differences on the other measures. The rate of attrition from the project from baseline to post-curriculum was higher in the control group (p<0.0001) than in the intervention group.
6-month follow-up: About 280 intervention students and 138 control students completed follow-up measures. Results showed that compared to the control group, intervention students continued to show better mental health knowledge (p<0.0001) and attitudes scores (p=0.006) on the MHKAS, lower stigma scores on the YOS (p=0.01) and better lifestyle scores on the HPLP (p=0.04). In addition, at follow-up, intervention students showed lower psychological distress scores on the GHQ (p=0.004) and a strong trend toward higher help-seeking scores on the GHSQ (p=0.055) than the control group.

Teachers

Post-training: Intervention teachers showed a significant improvement in mental health knowledge (p<0.001) and attitudes (p<0.001) post-training compared to pre-training.
6-month follow-up: Intervention teachers continued to show improved mental health knowledge (p<0.001) and attitudes (p<0.001) compared to pre-training. They also showed better mental health knowledge (p<0.001) and attitudes (p<0.001) compared to control teachers. Intervention teacher referrals of distressed students for specialized assessment and care also increased significantly (p<0.05) from almost none to an average of 30-40 per month, compared to no change in the number of referrals from the control schools (very low). By the end of the follow-up period, 212 students from intervention schools had received specialized care.

Secondary findings were as follows:

Students

All 570 intervention students visited the project website at least once and 300 (53%) made repeat visits.
90% of intervention teachers and students were very satisfied with the curriculum and felt it was important to continue to offer it in school programming.

Teachers

In implementation of the train-the-trainer model, the 22 intervention teachers trained by the project went on to train 76 other teachers across their schools. They also participated in training 20 teachers at the control schools after the 6-month (and final) data collection.

References

Rodgers D. (2006) Living in the shadow of death: Gangs, violence and social order in urban Nicaragua, 1996–2002. J Lat Amer Stud; 38(2): 267–292.
Obando Medina CM, Herrera A, Kullgren G. (2011) Suicidal expression in adolescents in Nicaragua in relation to Youth Self Report (YSR) syndromes and exposure to suicide. Clin Pract Epidemiol Ment Health. 7: 89-96.
Weare K, Nind M. (2011) Mental health promotion and problem prevention in schools: what does the evidence say? Health Promot Int. 2011; 26 Suppl 1: i29-69.
Wei Y, Kutcher S. (2011) School-based Integrated Pathway to Care Model: Mental Health Identification and Navigation (MH-IN) Pilot Project at Forest Heights Community School and South Shore Region, Nova Scotia.

Multimedia

GGC grantee page

Associates

Arun Ravindran Co-PI

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Country

Nicaragua

Affiliated organizations

University of Toronto Department of Psychiatry