Efficacy of Psychoedcation on Improving Attitudes Towards Professional Psychological Help Seeking for a Mental Illness Among Teacher Trainees in Kenya

This study was aimed at determining the efficacy of psychoeducation in improving attitudes towards professional psychological help seeking among young adults in Kenya. Four out of twenty teacher training colleges were sampled. Two colleges made up the control group while the other two made up the experimental group. Both groups were assessed at baseline, before the experimental group was presented with an intervention in form of two, two-hour each psychoeducation modules using power point while sited in their normal classrooms. The second assessment was done a day after the psychoeducation, while the control group received no intervention but were assessed again two days after the baseline assessment. The control group had no improvement in the summative scores of attitudes towards help seeking, while the experimental group increased positively in their attitudes towards seeking help for a mental illness, which is in line with other studies. Globally. We conclude that with education on opinions about mental illness and expectations about counseling, the youth could improve their attitudes towards seeking help for a mental illness problem. This study recommends that young adults and college students should be given education in order to improve their attitudes to seeking help for a mental illness. Collage students should have this education in their curriculum to assist them identify mental illness and seek help for the same.


Introduction
Mental illness is the most disabling illness compared to other health problems, that bring lots of pain, and suffering to individuals, families and community, yet it's the normally given the lost priority by governments in terms of policy and funding globally, [1]. Help-seeking has been defined as a process of events that occur between the point of recognizing a problem (onset) and the stage where a patient presents self to a mental health care system (treatment point) and is able to complete at least one session, Lin et al (1982) as quoted by Al-Krenawi et al, [2]. Goldman defined Psychoeducation, 1988 based on literature concepts at the time and assumptions as "education or training of a person with Psychological Help Seeking for a Mental Illness Among Teacher Trainees in Kenya psychiatric disorders in subject areas that serve the goals of treatment and rehabilitation…." [3]. This program has been used among college students [4] and other communities [5], [6], [7] to positively change attitudes towards mental illness and help seeking globally.

Help Seeking Patterns in Africa
There is lack of literature on help seeking in Africa. African communities in West Africa have been found to prefer spiritual healers, and traditional healers compared to western medicine, [8]. Furthermore a number of barriers that include stigma, lack of knowledge on how mental illnesses are treated among other barriers bar individuals from seeking for help, [9].

Attitudes Towards Professional Psychological Help Seeking Among Young Adults
Mental illnesses strike individuals between 14-24 years of age [10], [11], [12], yet studies have found that some of these individuals who are likely to be in college do not seek help for lack of knowledge of services available, [13], and negative attitudes towards help seeking, [14]. Teaching practice (known as practicum) was found increase teacher trainee stressors and burnout, [15].

Justification
Nyavanga and Barasa, [16] found out that public primary teacher trainees in Kenya hold negative attitudes towards professional psychological help seeking for a mental illness. They recommended that psychoeducation to be given to young adults to improve help seeking. In addition, [17] found out that individuals with mental illness do not in most cases comply with psychotropic drugs due to basic beliefs and expectations. They recommended that psychoeducation of mental illness and expectations of treatment should be included in preparing community in order to improve attitudes towards seeking professional help for a mental illness. A psychoeducational programme is a recommendable because it increases individuals' knowledge of mental health problems, and increased both positive attitudes towards help seeking and supportive behaviours towards individuals with mental health problems, [18].

Significance
Teachers have an important influence on the community around them especially in the rural areas in most developing countries; and if they have positive attitudes towards professional psychological help seeking, they are likely to influence the community towards the same. Jorm, [19] identified that there was lack of knowledge of help-seeking options, treatment modalities available in community and first aid skills for the community that support those affected by mental illness, globally. Giving teachers literacy on opinions about mental illness and expectations about counseling for a mental illness, would a go along way to reach the community through the students, to the parents as well.

Overall Objective
This study aimed as determining the effectiveness of psychoeducaion in improving attitudes towards professional psychological help seeking among young adults in public primary teacher trainees in Kenya.

Settings and Study Population
This study adapted a convenience sampling method to identify four colleges out of the twenty existing public primary school teacher-training colleges in Kenya. This method was found appropriate for this research because it was learned that these trainees were recruited using a quota system nationally. Based on the lists from the Ministry of Education enrollment, (the Statistics Department) the effective trainee population from the sampled colleges was estimated at 3,400 out of the national approximately 17,000.

This study was part of a larger longitudinal quasiexperimental (intervention) study, "The Effects of Psychoeducation on Attitudes towards mental Health Seeking Behavior Among Students of Primary School Teachers in Training Colleges in Kenya".
All participants who consented to take part in the study were recruited to increase generalizability of the findings. These authors assumed that the primary teacher trainees would understand the working of the ATPPHS Scale and would be honest and accurate in their responses to the questionnaires. We presented 2925 questionnaires to the participants present at the college at the time of study and 2777 forms were collected fully filled, a response rate of 94.32%.

Participants
These participants were teacher trainees training in public colleges. They were of ages between 18 to 35 years, and had completed Kenya Secondary School Education with a grade C and over. These participants were training for two years, with two months of practicing teaching in local primary schools. They would qualify for a teaching certificate (P1) to teach in a primary school.

Ethical Considerations
The Kenyatta National Hospital jointly with The University of Nairobi (KNH-UON-EC) that sets forth research ethics concerning health research in Kenya approved this study. With the approval, we got permission to do the study from the Ministry of Education, since we were studying trainees. This authority and permission were used to get assistance from the college principals in arranging data collection. We explained clearly to both the college principals and the participants the purpose, plan and the implications of the study. The participants were informed that the study was voluntary with no monetary benefits and any of them would pull out of the study without any penalty. These participants were also told that their data would be kept confidentially and nothing that identifies them would be included in the data collection. They were asked to place their admission numbers, but these were for purposes of data analysis and data would be reported in groups.

Measures
The participants' completed questionnaire packet composed of demographic characteristics items and Attitudes Towards Professional Psychological Help Seeking (ATPPHS) by Fisher and Turner, 1970 [20]. The demographic scale asked participants their age, gender, the year of study and marital status.

Attitudes Towards Professional Psychological Help Seeking Scale
This scale measures individual's attitudes towards seeking psychological help for a mental illness, as well as that willingness to seek help. This Scale contains 29 items that are answered in a four point Likert scale format thus: 1= Strongly Disagree and 4= Strongly Agree. The scale has 18 items that indicate negative attitudes, but were reverse scored so that the total score (which is between 29-116) became positive. The higher the score, the more positive attitudes, while the lower the scores the more negative the attitudes. This study introduced a few changes to replace the terms "psychiatrist" and "psychiatric" with "counselors" and "psychologists" respectively, that adapted Salim's study [21].
This scale measures attitudes in a four main sub-scales of (1) Recognition of Personal Need for Psychological Help

Procedure
All procedures put up in accordance to the American Psychological Association (APA) in research with human participants were followed. The participants' were met at the college during normal college day, at an assembly and the purpose, plan and implication of the study was explained. The measures were presented to them in their normal classrooms with two classes put together of about 90 to 100 students sited together. The research assistants explained how to fill the questionnaires and stayed in each class to answer any questions the participants had.

Psychoeducation Modules
The psychoeducation was made up of two sessions thus: (1) opinions about mental illness and (2) expectations about counseling for a mental illness of about two hours each with question and answer that lasted for between30 minutes to 45 minutes each.

Opinions About Mental Illness
This module educated the participants on what is mental health, and mental illness, prevalence of mental illness, effects of mental illness, causes, symptoms, risk factors of mental illness among college students, relationship of mental illness to gender, age, social economic factors, substance abuse, and violence, treatment and mental health professionals, and myths about mental illness.

Expectations About Counseling
This module educated these participants on what is counseling, benefits of counseling components of counseling process, diagnostic process, and Termination process.

Data Management And Analysis
Collected data was coded and entered into the computer before the use of Social Package for Social Sciences (SPSS) Version 19.0 was used to analyze data. An independentsamples t-test was conducted to compare attitudes towards help seeking score at baseline and second assessment between the control and the experimental group.

Results
Effectiveness of psychoeducation (Comparing if there is any change observed before and after psycho education)  There was no a significant difference in the summative scores of attitudes towards professional psychological help seeking at baseline; (M= 62.85, SD=6.44) and at the second assessment; (M=63.16. SD=6.35); t(2,498) = -1.189, p = 0.234), among the control group However, there was a significant (not a significant) difference in the summative scores of attitudes towards professional psychological help seeking at baseline among the experimental group; (M= 62.04, SD=6.30) and at the second assessment (M=84.5, SD=6.59); t(2,904) = 93.95, p = 0.000).
These results indicate that the ATTPPHS summative scores remained uniform in the control group at the two levels of assessment while there was a significant change in the scores among the experimental group. The mean ATTPPHS summative scores at the 2 nd assessment immediately after psycho-education significantly improved after the psycho education as it was higher than at the baseline, as seen in diagram 1 above and Table 1 below. This result indicates that the intervention of psychoeducation on opinions about mental illness and expectations about counseling significantly improved attitudes towards professional psychological help seeking among these participants.

Discussion
This study aimed to determine the efficacy of psychoeducation on the attitudes towards seeking help for a mental illness. The experimental group, which was similar to the control group, improved significantly in their attitudes towards seeking help for a mental illness. This study results are consistent with other findings among various groups globally. Kelly et al, [22] in an Australian study of improving mental health literacy in order to facilitate an early intervention for mental disorder found out that in order to improve attitudes to seeking professional help for a mental illness, mental health literacy is an important strategy. Similarly, Watson et al [23] in a study in the US pointed out that a brief educational program increased attitudes towards help seeking and willingness to seek help significantly. In addition a systematic review by Wei et al [24] found out that most of the 27 articles reviewed claimed mental health literacy programs in schools improved health seeking behavior for a mental health problem. However, studies have also reported that school programs meant for educating young people on mental health and mental illness did not positively change intentions to seek help among that group in Australian Capital Territory.
Including education of mental illness to student curriculum has also been found to improve attitudes towards seeking professional help for a mental illness. Wahl, et al [25] reported that teaching a curriculum known as "breaking the silence" that teachers the next generation about mental illness, increase more accepting attitudes towards help seeking for a mental illness, even with a very short term education.
Psychoeducation for individuals with mental illness improves adherence to medication. Zhao, et al, [26] in a study of a brief psychoeducation among persons with serious mental illness, improved with adherence to medication.
Family psychoeducation has been found to positively improve the adherence to medication. A study of 30 controlled trials of family psychoeducation, Layman et al [27], concluded that when psychoeducation is provided for family with a mentally ill person, adherence to medication and reduced relapses improved among others.
These positive findings indicate that educating young adults on mental illness and expectations about counseling is an important component in positively improving attitudes towards professional psychological help seeking for a mental illness. In addition it enhances the Western world concepts of participants knowledge on causes and treatment of mental illness.
These results indicate that education can be used to remove African beliefs of causes and treatment of mental illness and reduce barriers to seeking professional help for a mental illness. It would go along way to help this community to accept that mental illnesses just like other illnesses can be treated using western models.
This study therefore recommends that college students should include mental health training and expectations about counseling to college curriculums to help African populations change attitudes towards help seeking for a mental illness.

Conclusion
A brief psychoeducation on mental illness and expectations about counseling for a mental illness significantly improves attitudes towards help seeking for a mental illness among young adults. This study had a number of limitations thus: (1) the education modules were short (lasted only for two-half hours); (2) this was a self-report questionnaire, which has disadvantages of honesty, introspective ability to provide accurate response and understanding the constructs in the questionnaire; (3) this study only looked at the short-term effects of psychoeducation, therefore need to look at the long term effects that may last up to 10 months to be able to ascertain sustainability.
This study was not funded.