Impact of Adolescent Health Education  Programme on Mental wellbeing of adolescents

G. Balamurugan¹, M. Vijayarani² 

¹PhD (N), MBA (HSM) Registrar (Administration), Head of Department of Mental Health Nursing, Ramaiah Institute of Nursing Education and Research, Bangalore
²PhD (N), Assistant Professor, ESIC College of Nursing, Indira Nagar, Bangalore 

Address for Correspondence: Dr G. Balamurugan PhD (N), MBA (HSM), Registrar (Administration), Head of Department of Mental Health Nursing, Ramaiah Institute of  Nursing Education and Research, MSRIT Post, Bangalore, Karnataka State, India. E-mail: gsvbm@yahoo.co.in, balamurugan@msriner.com

ABSTRACT: 

Background: India has the world’s largest youth population despite having a smaller population than China. Adolescence is the main period for mental well-being growth and conservation. Mental illnesses affect 10-20 per cent of kids and teenagers globally. Ten per cent of children (5 to 15 years) have diagnosable psychological issues. All around the world,  depression is the 9th driving reason for disease and disability among all young people. Based on these contexts, the present study i.e., Adolescence Health Educational Programme(AHEP)  is carried out to assess the AHEP’s effectiveness in terms of improvement in the mental wellbeing of adolescents.

Methods: One hundred twenty, 9th standard adolescents were randomly selected and allocated to the intervention and control group (60 in each). The intervention group received  AHEP sessions for 10 weeks (about 2 and a half months). The mental well-being of both groups were assessed before and after  the intervention with General Health Questionnaire, Short Form Version 2  (SF 36 V2)

Results: It showed that the majority of adolescents have an above-average level of mental well-being. The statistical test shows that there was a significant improvement in the mental well-being of adolescents from baseline to the first month; later it gradually reduced after 6 months. Further religion is associated with the mental well-being of adolescents. 

Conclusions: A consistent Adolescent Health Education Programme, in the long run, will improve and sustain the adolescents’ mental well-being 

Keywords: Adolescent; Mental well-being; Health education programme.

Introduction 

One in every six people in the world is an adolescent (WHO, 2018), and 90% of them live in developing countries (UNFPA, 2010). India is the second-most populous nation in the world with 1210 million people and above. Teenagers (10-19 years) make up a sizable part of the population, accounting for over 21% of the total population, or 253 million people.  Karnataka has a population of roughly 61 million people, with 11 million (10%) of those aged 10 to 19 years old (Census, 2011)

Globally, 10-20 percent of children and teenagers suffer from mental illnesses (Consolacion, Russell, & Sue, 2004) (Barry, Clarke, Jenkins, & Patel, 2013). Ten percent of children (5-15 years of age) have diagnosable mental disorders. (P. Shastri, 2009). In the age group 13-17 years, the prevalence of mental problems was 7.3 per cent and roughly equal in both genders in India (Gururaj G, Varghese M, Benegal V, Rao GN, Pathak K, Singh LK, Mehta RY, Ram D, Shibu Kumar TM, Kokane A, Lenin Singh RK, Chavan BS, Sharma P,  Ramasubramanian C, Dalal PK, Saha PK, Deuri SP, Giri AK, Kavishwar AB, Sinha VK, Thavody J, Chatterji R, Akoijam, 2016). As adolescents grow, several factors such as Competitive academics, peer pressure, socio economic problems, and increased availability and accessibility of technology affect their mental wellbeing. (Alcorn, 2014). Mental well-being is key to good health and prosperity and affects social and economic outcomes across life expectancy. Adolescence is the vital period for setting up the healthy development of good mental health and great emotional well-being. (Barry et al., 2013). In the world, depression is the 9th leading cause of disease and disability among young people; mental health and psychological problems account for 16% of the global burden of disease and injury in many dangerous health behaviours, such as taking substances or taking sexual risks, begin in adolescence. Poor psychological wellness in adolescence may lead to school dropout, delinquency and substance abuse. Interventions that promote positive emotional wellbeing provide adolescents with the necessary foundational abilities, supports, and resources to fulfill their full potential and overcome adversity. Academic stress, violence, including bullying,  sexual permissiveness, easy drug availability and abuse, crowding, poor infrastructure, and social divide are only a few of the significant difficulties that youth in India faces. Even in the face of adversity, an empowered youngster can cope with life’s obstacles by utilizing available resources. (Bharath Srikala, 2018) Bardhan A (2016) piloted research to find the impact of life-skills education in changing Behavioural changes. The research showed that ongoing life skills education together with organized counseling helped adolescents with Behavioural issues to develop beneficial changes. The training helped them to develop a friendly relationship between teachers, peers and parents. It also shows that continued participation with school officials, their friends and counsellors has improved adolescent mental well-being (Bardhan, 2016). An RCT conducted on a Sports-Based Youth Development Program among 664 students revealed that the intervention was effective in terms of mental well-being, psychological assets, physical fitness, and physical activity levels of teens (Ho et al., 2017). A systematic review conducted by Das K et al (2016) showed that a mixture of social competence and social inspiration methods were effective against substance abuse (Das, Salam, Arshad, Finkelstein, & Bhutta, 2016). The mediations targeting multiple drug abuse were effective in school-centered programs (Das et al., 2016). Research studies conclude that school-based alcohol prevention interventions were highly effective (Salam, Das, Lassi, & Bhutta, 2016) and improved mental well-being (Eschenbeck et al., 2019).  Research studies confirm the practicability and usefulness of incorporating mental health promotion mediations into education (Barry et al., 2013). Some of the effective interventions in improving the mental well-being of adolescents include Samata (Mazzuca et al., 2019), Mindfulness (Shambhu, Rajesh, & Subramanya, 2018), face-to-face interventions (Eschenbeck et al., 2019), teenage sexual and reproductive health, pregnant adolescent diet programs, micronutrient supplementation, youth immunization procedures and substance abuse interventions (Salam et al., 2016). A systematic review of the effectiveness of school/community-based mental health promotion interventions for the positive mental health of teenagers in low and middle-income countries, reveals that most campus-based approaches are powerful, reasonable quality, with findings signifying optimistic effects on pupils’  confidence, inspiration and self-competence. Research studies show the possibility and adequacy of coordinating emotional well-being intercessions into schooling. 

Research studies show the attainability and viability of coordinating mental health promotion interventions in education (Barry et al., 2013). The classroom environment offers a platform for promoting mental and social skills and scholarly education and offers a way of reaching a substantial number of teenage people with psychiatric problems (P. C. Shastri, 2009). However, Michelle O’Reilly argues that still there is a strong need for good evidence-based school health interventions for the promotion of adolescents’ mental well-being (O’Reilly, Svirydzenka, Adams, & Dogra, 2018). 

Further, the existing school-based interventions were focused mainly on a few specific aspects of adolescents’ health and the evidence from India was limited. With this background, a PhD study was undertaken to assess the effectiveness of an Adolescence Health Education Programme (AHEP) on the health of adolescents studying in selected schools of Bangalore, Karnataka, India. The current study is designed based on the Indian context with comprehensive coverage of all the aspects of adolescents’ health. In this project, health was assessed in terms of the physical, mental, social and spiritual well-being of adolescents. In this article, the impact of AHEP on the mental well-being of adolescents is presented in detail. 

Methods: 

Sample: 

A Randomized Controlled Trial design was used for the study. A multistage random sampling technique was used to select the sample for the experimental and control group. Bangalore consists of three districts such as Bangalore North, South and Rural.  Bangalore north was selected for the study by lottery method (Stage 1). Further Bangalore  North district has four zones like North 1, 2, 3 and 4. North 2 was selected by lottery method  (Stage 2). To keep the homogeneity of the sample, matching was done with the following characteristics of schools i. e. Private Aided, Secondary school, Coeducation, Location (Mathikere and Yeshwanthpur) and Medium of instruction (English). Bangalore North 2 zones form 190 secondary schools with various management such as the Department of Education, Government of Karnataka (11), Central government (03), Private aided (32), Private Unaided (138), and Local body (6). 

Out of thirty-two private-aided schools (Stage 3), 29 schools have coeducation and 3 schools were only for girls. Locality wise there are six schools in Mathikere and Yeshwanthpur (three in each). Out of these six schools, three schools have followed English as the medium of instruction. In that one High school was randomly assigned to the experiment and another High school was assigned to a control group (Stage 4). Further sixty, 9th standard students from each school were randomly selected for the study through the table of random numbers (Stage 5).  

Figure 1 School and sample selection

Instruments: 

Socio-demographic proforma: This self-administered questionnaire includes age, gender, religion, diet and BMI. 

SF 36 V2: General Health Questionnaire Short Form Version 2 consists of 36 items. It includes eight health domains: physical functioning, role participation with physical health problems (role-physical), bodily pain, general health, vitality, social functioning, role participation with emotional health problems (role-emotional), and mental health. All these eight-scale profiles are reduced to Physical Component Summary (PCS) and Mental  Component Summary (MCS) without substantial loss of information by Scoring Software 2.0 (Ware et al., 2008). Mental well-being is measured in terms of MCS: the higher the MCS score is better the mental well-being. 

Intervention: 

Adolescents in the experimental group had received Adolescence Health Education Programme (AHEP) for 10 weeks. The adolescents were asked to fill the socio-demographic proforma and General Health Questionnaire Short Form Version 2 (SF 36 V2) before AHEP. AHEP has three components. First, an interactive teaching-learning session of 90 mins/week, which covers topics such as growth and development, healthy nutrition, HIV/AIDS and Reproductive Tract Infection, life skills, substance abuse, assertive communication, anger management and spiritual well-being. Second, meditation sessions of 90 min/week. Third, a structured physical exercise session for 90 min/week. After 10 weeks of AHEP, adolescents were instructed to follow the meditation and physical exercises on their own. Post-tests were conducted after the first and sixth months of AHEP. Control group adolescents were undergoing regular school activities. Ethical aspects: This study is approved by the Ethical Review Board  of M.S. Ramaiah Medical College and Hospitals, Bangalore, Karnataka, India.

AHEP is designed to provide information regarding adolescence’s health with regards to Physical well-being – Growth and Development of adolescent, Healthy Nutrition, Physical activity, HIV / AIDS & Reproductive Tract Infection; Mental well-being – life skills & Substance abuse; Social well-being – General Concepts of social wellbeing, Assertive communication, Assertive communication & Anger management; and Spiritual wellbeing – Relationship between spiritual wellbeing and health & Ways to improve spiritual well being.  The programme was carried out for 2 hrs. / Week of classes, 2 hrs. / Week of physical exercise and 2 hrs. / Week of meditation. This was delivered by the research Scholar and Physical education teacher for consecutive 10 weeks. 

Results: 

Sociodemographic profile:

Table 1: Socio-demographic profile of adolescents n = 120 (60+60)

Variable	Experimental group	Control group f (%)	Chi-Square value (p-value)
Age (years) 14 15	40 (67) 20 (33)	41 (68) 19 (32)	0.038 (0.854)
Gender Male Female	30 (50) 30 (50)	30 (50) 30 (50)	–
Religion Hindu Muslim Christian	44 (74) 11 (18) 5 (8)	37 (62) 16 (26) 7 (12)	1.8642 (0.393)
Diet Vegetarian Non-vegetarian	10 (17) 50 (83)	19 (32) 41 (68)	3.6832 (0.054)

Table 1 shows that more than half of the adolescents were 14-year-old Hindu, non-vegetarians. The chi-square test shows that both groups are homogenous in their socio-demographic characteristics. 

Fig 1: BMI of adolescents 

Fig 1 shows that adolescents underweight and overweight are slightly more in number in the experimental group than in the control group. Whereas, adolescents with a normal range of BMI are higher in the control group (30%) than in the experimental group (22%).

The chi-square test shows that both groups are heterogeneous in terms of BMI (χ² = 1.9123, p = 0.384).

Effectiveness of AHEP on mental well-being Table 2: Comparison of Mental well-being between groups n = 120 (60+60) 

Group	Experimental group Mean (SD)	Control group Mean (SD)	t-test value (p-value)
Baseline	78.92 (12.241)	75.65 (17.806)	1.171 (0.244)
Post-test 1	87.58 (2.770)	78.57(18.275)	3.779 (< 0.001)
Post-test 2	85.28 (9.279)	75.17 (19.277)	3.663 (< 0.001)

Table 2 reveals that there was no significant difference in Mental Component Summary (MCS) between experimental and control group at baseline (t = 1.171, p = 0.244); while the MCS  score was significantly higher in experimental group in post-test 1 (t = 3.779, p < 0.001) as well as post-test 2 (t = 3.663, p < 0.001) than control group. It shows that the AHEP has significantly improved the mental well-being of adolescents. 

Table 3: Comparison of Mental well-being within groups n = 120 (60+60)

Group	Baseline Mean (SD)	Post-test 1 Mean (SD)	Post-test 2 Mean (SD)	F ratio (p-value)
Experimental	78.92 (12.241)	87.58 (2.770)	85.28 (9.279)	14.868 (< 0.001)
Control	75.65 (17.806)	78.57 (18.275)	75.17 (19.277)	0.596 (0.5521)

Table 3 explains that the MCS is significantly different within the experimental group (F=14.868, p <0.001), while it is not significant within the control group (F = 0.596, p=0.5521).Even though the MCS is increased in post-test 1, there is a reduction in post test 2 in the experimental group. Further post hoc results found that the mean difference from baseline to post-test 1 (8.667, p<0.001), baseline and post-test 2 (6.367, p<0.001) experimental group are statistically significant.

Table 4: Association between Socio-demographic variable and mental wellbeing at baseline n = 120 (60+60) 

Variable	f	Mean (SD)	t test value / F ratio (p value)
Age (years) 14 15	81 39	78.41 (15.595) 74.95 (14.594)	1.161 (0.248)
Gender Male Female	60 60	74.92 (15.063) 79.65 (15.298)	-1.708 (0.090)
ReligionHindu Muslim Christian	81 27 12	74.79 (16.027) 82.74 (13.495) 81.83 (9.656)	3.460 (0.035)
Diet Vegetarian Non-vegetar ian	29 91	78.97 (7.576) 77.10 (14.695)	0.054 (0.816)
BMI Underweigh t Normal range Overweight	85 31 4	77.68 (15.727) 74.35 (13.514) 77.60 (21.582)	0.184 (0.946)

Table 4 shows that Muslim adolescents are having significantly higher well-being, followed by  Christian and Hindu (F = 3.460, p=0.035), while other socio-demographic variables are not significantly associated with mental wellbeing.

Discussion: 

The AHEP has significantly improved the mental well-being of the adolescents in the present study. Similarly, life skill training programme has improved the adolescent mental well being (Bardhan, 2016); a Sports-Based Youth Development Program was effective in improving mental well-being (Ho et al., 2017); Research studies conclude that the school-based improved mental wellbeing (Eschenbeck et al., 2019). However, in the present study, the MCS score of adolescents was above average, this may be because of the family structure in the study locality; these students are taken care of by their parents, so they may have fewer worries about the future, finance and other aspects of life.

This present study shows that there is a significant association between the MCS and religion and there is no significant difference between boys and girls in terms of mental well-being. A study conducted by Sankar R, Wani M A and Indumathi R showed the contradictory finding that there was a statistically substantial distinction between boys’ and girls’ mental health scores. (Sankar, Wani, & R., 2017) Dey M, Gmel G and Mohler-Kuo M conducted a study to find the link between Body Mass Index (BMI) and health-related Quality of Life. (Dey, Gmail, & Mohler-Kuo, 2013),(Dixon, Rice, Lambert, & Lambert, 2015). This finding was contradictory to the present study, where the result shows no association between the MCS and BMI. 

Conclusion: 

Mental health problems among adolescents are of sincere concern. Unhealthy  Behaviours during adolescence represent major public health challenges. To achieve optimal adolescent health and well‑being, the planning of policies in health and allied fields should be multi-dimensional. School-based awareness programmes among young people need to be given prime importance, so that vulnerable adolescents are aware of their choices that form risky Behaviour. Mental issues have become one of the main problems that affect adolescents in their day-to-day life. As the psychological concerns of adolescents are more delicate and difficult to handle, proper measures need to be undertaken by the high schools to prevent mental health issues in the children.

To achieve mental health, measures should be taken to prevent mental disorders and to foster and promote mental health and wellbeing. Mental health cannot be carried out only if disorders are prevented or treated. We need to tackle the problems that hurt school children’s psychological well-being, such as vulnerability, drug abuse, poverty, violence, substance use, domestic violence, conflicts in the family and society, insecurity and ill health. The present study found that the AHEP has helped the children in developing the mental wellbeing of all religious backgrounds. In this present study, the parents were not involved, hence we recommend that the upcoming research needs to focus on the involvement of the parents in the programmes, as it may influence parenting habits and for the provision of a better home environment. The present study also suggests that the AHEP is replicable in a school setting and the mental health program in the school may be made most effective with AHEP. The teachers also may be trained as facilitators in AHEP. Frequent assessment of the mental health of the schools’ children may also be done. The findings and inputs may be given to the children to improve their ability and competency in the required areas. We conclude that a consistent Adolescent Health Education Programme in the long run may improve the mental wellbeing of adolescents.

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