Mental health literacy of school nurses in the United Arab Emirates

In the rapidly developing country of the United Arab Emirates (UAE), approximately 35% of the total population are young people (aged 0–24 years) with close to 21% aged between 0 and 14 years [Central Intelligence Agency (CIA) 2016]. Similar to other countries comprising the Gulf Cooperation Council (GCC), the focus of health care for the entire population has until recently been primarily on physical health promotion and treatment. Epidemiological data reveals significant progress in decreasing deaths from a majority of communicable diseases and injuries leading to great gains in prolonging life. Consistent with a global trend, the impact of non-communicable diseases (NCDs) across all sections of the community in the UAE is significant and is estimated to account for 65% of total deaths in the country [45]. NCDs contribute to increased disability while the prevalence of mental illnesses such as depression and anxiety disorders, especially amongst females has grown rapidly. While UAE specific data is limited, the WHO reports mental illness, neurological and substance use disorders as a significant contributor to the global burden of disease, emphasizing the urgent need to implement proven and cost-effective interventions [36]. In 2010, the Ministry of Health in the UAE identified mental health as amongst the top 5 health priorities in the UAE [22] while in 2015 the neighbouring GCC country of Qatar’s Supreme Council of Health launched a mental health strategy for the years until 2020 [43].

The recent UAE Vision 2021 aspires to achieve prosperity for the citizens of the country with world-class medical care and reduction of health hazards through a growing awareness and prevention programs [32]. The healthcare workforce in the UAE charged with the provision of quality care includes school nurses at both public and private schools in the country. The prescribed scope of practice for school nurses is comprehensive and includes the promotion of health, preventive health care, comprehensive health assessment and referral, mental health protection and intervention and the ongoing management of children with chronic and complex health needs in the school setting [27].

As improvements in health care are achieved an increasing numbers of children with chronic conditions are now attending mainstream schools leading to significant nursing challenges. Further unique cultural and environmental factors contribute to the particular challenges experienced by school nurses in the UAE seeking to meet the needs of the children and adolescents in their care. While infant mortality rates in the UAE are low in comparison with many other Arab countries [1], family units are often large with a significant prevalence of consanguineous marriages (a common practice across the GCC and wider Arab world). This has been found in epidemiological research to account for genetic disorders with high levels of morbidity and mortality such as β-Thalassemia [18, 39]. Dahdouh et al. [16] draw attention to data suggesting ‘a significant association between consanguinity and mental disorders and a higher risk of schizophrenia or bipolar disorders among offspring from consanguineous couples’ (p. 104). Environmental factors associated with rapid industrialization and high serum levels of heavy metals have also been linked to learning disabilities in the UAE [46]. Factors such as these constitute additional risk factors for the development of mental health problems particularly among the young.

Children and adolescents living with chronic conditions face ongoing challenges such as repeated hospitalization, ongoing periods of poor health, decreased physical strength and skills or changes in appearance due to illness. These challenges have the potential to impede or delay the achievement of developmental, emotional and social milestones and also represent additional risk factors for the development of mental health problems [4, 9, 12, 17, 31]. School nurses are well situated to play a vital role in not only helping children and adolescents to manage their chronic conditions but in detecting the early signs of mental distress and disorders in order to intervene promptly and appropriately.

School nurses in the UAE recently identified the management of students with complex health-care needs as the highest priority area for research along with a number of other priorities including the psychological and behavioral well-being of students [3]. If school nurses in the UAE are to adequately care for the complex needs of school children and support promotion of mental health, prevention of mental illness and early intervention for those developing mental illness, a high level of mental health literacy is required. Mental health literacy was defined by Jorm et al. [28] in 1997 as ‘knowledge and beliefs about mental disorders which aid their recognition, management or prevention’ (p. 182). Increasing attention is being given to researching mental health literacy in western countries, however, Furnham and Hamid [21] highlight the gap in understanding of mental health literacy in non-Western countries. Likewise, research assessing the mental health literacy of health professionals is limited [23, 29, 33]. There are no studies in UAE reporting on the mental health literacy of the general community, specific patient groups or healthcare professionals.

Ascertaining the knowledge and beliefs of school nurses regarding mental illness is integral to the development of targeted educational and mental health promotion initiatives. This is the first study that has systematically sought to examine mental health literacy in school nurses in the UAE. The findings reported focus on two aspects considered to be central to mental health literacy, knowledge of mental health disorders (ability to recognize a disorder) and beliefs about the helpfulness of treatments. Although the scenarios provided align with DSM-V, the diagnostic framework employed by mental health services in the UAE, the results revealed that a significant number of respondents (the main providers of health care for school aged children and adolescents in the UAE) had difficulty identifying specific disorders accurately (49.35% correctly identifying ‘depression with suicidal thoughts’ to 38.6% recognition of ‘psychosis’). At best only half of the respondents surveyed were able to identify a potentially lethal mental health disorder (depression with suicidal thoughts). This limited ability to recognize a mental health disorder may well result in a delay in timely access to much needed treatment. Similar research studies report that mental health professionals surveyed in Switzerland were largely able to recognize schizophrenia and depression [34], while pharmacists surveyed in Australia exhibited high levels of mental health literacy [35].

Beliefs regarding treatment for the specific mental disorders likewise differed from the recommended clinical practice guidelines as used by psychiatry in the UAE. Treatment preferences varied according to the vignette being presented. For example, when asked about the most helpful treatment activity to assist “Miriam” (PTSD vignette) 85.2% of the respondents thought that ‘Reading the Koran or Bible’, would be helpful and 84.4% selected ‘Getting information about the problem and available services’ as the most helpful activity for Abdul’s problem (depression with suicidal thoughts). For Saed’s problem (psychosis) 82.3% of respondents selected ‘Psychotherapy focusing on changing thoughts and behaviors’ (cognitive behavior therapy) as the most helpful treatment activity. These responses are in sharp contrast to the recommendations found in the clinical practice guidelines that inform psychiatric care in the UAE [7, 10, 19].

In contrast, respondent’s selection of preferred medications tended to reflect the recommended treatment practices. For example, almost half of the respondents identified an “antidepressant’ as the most helpful medication for Abdul’s problem (depression with suicidal thoughts) and 38.6% of respondents noted that an antipsychotic would be helpful for the psychosis vignette. However, a concerning 39.1% thought that ‘Medication to help you relax’ (e.g. xanax, valium) would be helpful for Miriam’s problem of PTSD. Research evidence has demonstrated that the use of benzodiazepines in the treatment of PTSD is problematic and should be avoided as they can lead to significantly worsened outcomes [25].

When asked about appropriate treatment providers, mental health professionals were most frequently selected for all clinical vignettes with psychiatrist preferred by 79.6 and 77.8% for the depression with suicidal thoughts and psychosis vignettes respectively. Interestingly, psychologists were the treatment providers most frequently selected by respondents as being helpful at 83% for the PTSD vignette. These same respondents also choose ‘reading religious texts’ and the use of benzodiazepines as helpful in the treatment of PTSD.

Reflection on the outcome of correlations between the K10 scores and other variables (such as being able to select the right diagnosis) is an important aspect of this study. The most consistently noted factor influencing responses selected that can be considered indicative of lower mental health literacy was the level of psychological distress as reflected in the K10 score. For example, those with lower K10 scores tended to correctly identify Miriam problem as PTSD and were more likely to prefer psychologist and antidepressants as helpful treatment choices for the same vignette. With regards to Abdul’s problem (depression with suicidal thoughts) those with higher K10 scores (indicative of higher levels of psychological distress) were more likely to select “Vitamins and Minerals” as a helpful medication, however those who were younger and had less clinical experience were more likely to selected an antidepressant as being helpful for Abdul. While it is acknowledged, that the findings from this cross-sectional use of the K-10 cannot be interpreted as unequivocal, the implications do require careful consideration. Findings suggest that respondents with higher levels of personal psychological distress selected responses that may delay recognition and appropriate treatment for people experiencing mental illnesses. In some vignettes (e.g. PTSD) the age of respondents (e.g. younger participants) with low psychological stress (K10 < 22) themselves were more sensitive to mental health problems and the associated stress than others who had higher stress levels. Respondents with lower scores on the K-10 (K10 < 22) reported less symptoms of mental health problems compared with others with high stress.

The demographic profile of respondents reveals that a considerable number of the respondents originate from conflict ridden countries in the Middle East or North Africa or are separated from their families and beloved ones (Indian sub-continent, Philippines). Each of these will likely have left their home country looking for a better life and safety. Given that relocation and separation from home, culture and family are identified risk factors for increased levels of psychological distress, it could be argued that a potential impact of the elevated levels of psychological distress in these respondents may be a reduced capacity to detect the signs and symptoms of mental health problems among the children, adolescents and families with whom they interact [24, 26].

Noteworthy was the impact of cultural and religious influences on respondents’ choices on treatments deemed most helpful, for example, for PTSD reading of religious texts was identified as the most helpful activity. This finding is consistent with previous research identifying the impact of religious and cultural influences on both healthcare professionals’ identification and management of mental health problems and on community members’ presentation of their illnesses and health seeking behaviors as reported in the national UAE literature [2], and international literature [6, 11, 13‐15, 37, 44].

Research designed to assess the attitudes of Arab Muslim female students in the UAE, Jordan and Israel towards mental health treatment and help seeking, reported that preferences varied from seeking help from professional treatment providers in times of need to using prayers and religious practices to manage their psychological distress [2]. More recently, Slewa-Younan et al. [40] drew attention to the pluralistic nature of treatment preferences amongst people from non-Western countries and Islamic cultural contexts. While, cultural and religious activities have been described as an integral component of appropriate mental health care [38], of concern is the difficulty the respondents in this study displayed in recognizing mental illness and identifying evidence-based treatments. For school nurses working with children and adolescents and the even more vulnerable subset of this group, i.e. those with chronic conditions, an ability to respond effectively to both promote mental health and to recognize developing mental illness is essential. The importance of the school nurse role in addressing both physical and mental health needs of students is well documented [5, 20, 27, 41].

These findings have implications for mental health promotion and education in the UAE and other countries within the GCC. Low levels of mental health literacy amongst these respondents in combination with religious and cultural factors highlight the need for curriculum enhancements for future health professionals and a targeted program of culturally appropriate professional development focused on mental health promotion for those in clinical practice. The levels of psychological distress noted in this cohort also signals a need to ensure that appropriate supports are available for clinical staff employed in schools, regular clinical supervision is encouraged and peer support is in place to promote early and appropriate help seeking. Possible screening of clinicians in conjunction with ready access to programs designed to support mental well-being will also serve to develop and support the clinical workforce caring for children and adolescents in the school setting.

Limitations include the length of the survey. Each person was presented with the three scenarios, however, the time required to complete the full three surveys limited the number of completed surveys received. While healthcare professionals are generally fluent in English varying levels of English literacy amongst respondents may have influenced responses and limited funding and a small research team precluded the administration of the surveys by bilingual researchers. As this is the first study evaluating mental health literacy to date published in this region, no comparative data was available. Finally, the scenarios used in the survey while culturally adapted are adult-based rather than child or adolescent focused. Nevertheless, the low levels of mental health literacy identified in this sample are of concern given that respondents had completed tertiary level studies in their profession and could thus reasonably be expected to be able to recognize the three conditions covered in the survey and to identify evidence-based treatments.

The focus of the healthcare system in the UAE has been directed towards improving physical health with beneficial impact, and yet much remains to be done in improving health literacy in general and mental health literacy in particular. Improved mental health literacy has the potential to increase early intervention, improve promotion of mental well-being and enable effective support of the community. This study focused on mental health literacy in health professionals providing care for children and adolescents (a vulnerable section of the community whose developmental needs and in some cases chronic illnesses predispose them to mental health problems), The low levels of mental health literacy in the school nursing healthcare workforce demonstrated in this study requires urgent attention.