Are university health education programs addressing mental health issues?

Abstract: The importance of offering mental health courses and their rate of inclusion within university health education programs was investigated. Findings from 163 health education chairpersons (60 %) revealed that requiring mental health courses was perceived as important at the undergraduate level (55%) and at the graduate level (50%). More than one-half believed that offering an elective mental health course was important to undergraduate programs (60%) and graduate programs (61%). Mental health courses were required (68%) or offered as an elective (58%) in undergraduate programs. However, mental health courses were less likely to be required (24%) or offered as an elective (43%) in graduate programs.

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The United States Surgeon General defines 'mental health' as "the successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity. From early childhood until late life, mental health is the springboard of thinking and communication skills, learning, emotional growth, resilience and self-esteem" (United States Department of Health and Human Services, 1999, p. ix). A recent proposal describes a model whereby mental health is seen as an above normal state, a positive psychology, maturity, emotional or social intelligence, resilience and subjective well being (Valliant, 2003).

The prevalence rate for mental disorders for adults in the United States varies. Early studies report that approximately 20 percent of adults have a diagnosable mental disorder in any given year (Regier et al., 1993). However, more recent reports estimate that 5 to 7 percent of Americans, 18 years of age and older, have a mental disorder in any given year (United States Public Health Service Office of the Surgeon General, 2001; Kessler et al., 2001). In addition, it is reported that between one-tenth and one-third of American children have a diagnosable mental problem (United States Public Health Service, 2000). It is projected that by 2020, psychiatric and neurological disorders will account for 15 percent of the total global burden of disease with unipolar depression expected to rank 2nd for disease burden (Murray & Lopez, 1996).

The burden of mental illness continues to have an effect on health care costs. Coffey, et al. (2000) reported that in 1997, the latest year comparable data are available, the United States spent more than $1 trillion on health care. Approximately $71 billion of the total health care costs were spent on treatment of mental illnesses

Stigma, myths and misconceptions about mental illness still exist. The perception that those with mental illnesses, especially those with schizophrenia and other psychotic disorders, are dangerous has increased since the 1950s (Phelan, Link, Stueve & Pescosolido, 2000). The label of dangerousness leads to social distancing which is counterproductive to findings that reveal that those who have contact with a person who has a mental illness have a more positive attitude about mentallyill persons (Corrigan, Edwards, Green, Diwan & Penn, 2001; Martin, Pescosolido & Tuch, 2000; Link, Phelan, Bresnahan, Stueve & Pescosolido, 1999). Corrigan, et al. (2001) also found that, in addition to personal experience with a mentally iii person, school learning (i.e. education) is a factor in reducing prejudicial attitudes about this group.

Mental health education plays an important role in the personal health of all people and the professional decision making of health educators. Mental and physical processes interact with each other, sharing a cause-and-effect relationship. For example, it is well documented that negative mental health can affect physical health by reducing the efficacy of the immune system (Greenberg, 1999). Specifically, the numbers of lymphocytes that fight infection are reduced, resulting in increased vulnerability to infections and cancer (Dantzer & Kelley, 1989; Herbert & Cohen, 1993; Cohen & Rabin, 1998). The added dimension of mental health knowledge often reveals clues to health problems that might otherwise be overlooked. This ability may be in the form of recognizing that a seemingly physical ailment is rooted in psychological issues and vice versa. Because many health education professionals evaluate and refer persons to health care professionals, it is important that they are able to accurately distinguish the root of the ailment and refer the client accordingly.

Currently, there is a paucity of research that addresses the frequency with which units in courses or entire mental health courses are offered and the kinds of mental health topics that are covered in university health education programs. Maylath and Ubbes (1996) found that approximately 56 percent of 52 United States colleges and universities required their health education undergraduate majors and minors to take courses that emphasized mental health or mental illness. In addition, about 89 percent of the programs that offered mental health courses offered them in the health education department while about 12 percent relied on psychology or counseling departments to provide required courses. The authors concluded that "a substantial number of undergraduate professional preparation programs in health education do not require a course with an emphasis in mental health or mental illness" (p. 373).

Kittleson (1989) examined six current college general health textbooks to assess the emphasis placed on positive aspects of mental health (self-esteem, communication skills, decision making skills, and values) and traditional aspects such as mental illness topics. It was found that the textbooks gave limited space to the positive mental health components leading to the conclusion that "health educators have not been teaching students about mental health, but about mental illness" (p. 40).

Several recommendations and characteristics for "fully prepared" health educators in stress management and mental health have been identified (Schiraldi, Spalding & Hofford, 1998). In addition to being able to recognize mental illness symptoms and raise awareness of treatment strategies, health educators should have the ability to teach cognitive-behavior primary prevention skills, communication skills, conflict resolution and coping skills. From a college/university health education perspective, the issue is not deciding if mental illness issues are more or less important than other mental health components, it is determining if positive mental health is getting equal time and recognition in the college/university health education curriculum.

Therefore, this study poses three exploratory questions. How important is mental health education to college/university health education undergraduate and graduate programs? How often are mental health courses required or offered as electives at both undergraduate and graduate levels? Do college/university mental health courses focus on mental illness or do they address positive aspects of mental health?

METHODS PARTICIPANTS

A list of 270 university health education chairpersons was obtained from the American Association for Health Education (2001) register and served as the sample population to complete a survey regarding mental health teaching and curriculum issues.

MATERIALS

A 4-page, 24-item questionnaire was developed. Thirteen items addressed mental health teaching and curriculum issues. Eleven items addressed demographic information. Four items had a 5-point Likert-type scale with responses ranging from "extremely important" to "not important at all". Most items required respondents to select their response from a series of potential answers. Despite the dosed-structure format of the survey, seven items allowed for short responses designated as "Other-Please specify". To establish content validity, the questionnaire was sent to four published authorities on university mental health education. Based on their suggestions, changes were made in the form of wording and format of the questionnaire.

DESIGN AND PROCEDURE

A three-wave mailing procedure was used during fall, 2002. The first two waves included a cover letter, survey and stamped, self-addressed return envelope. The second wave was mailed two weeks after the first mailing. A postcard reminder was mailed as a third wave mailing one-and-a half weeks after the second mailing.

The cover letter assured confidentiality and explained that participation was voluntary. The 4-page survey was printed on blue paper and arranged in booklet form.

DATA ANALYSIS

SPSS 10.0 for Windows was used to analyze the data. Descriptive data were created for individual items (e.g., frequencies, percentages and ranges) and measures of central tendency (e.g., means and standard deviations) were calculated for selected variables.

RESULTS DEMOGRAPHICS AND BACKGROUND CHARACTERISTICS

A total of 279 questionnaires were sent to university health education chairpersons. Nine questionnaires were nondeliverable (e.g., moved or retired). A total of 163 surveys were returned resulting in a 60 percent (163/270) return rate. The majority of respondents were male (52%), full professors (89%), had doctoral degrees (92%) and were full-time faculty (76%). The majority of health education departments had between one and five full time faculty (59.5%) members. Bachelor degree programs were the level of education most often offered by respondents (80.3%), followed by master's degree programs (58.8%), and doctoral programs (17.1%).

Respondents were asked to indicate the level of education that included mental health topics. At the undergraduate level, personal health (92%) and community health (75%) accounted for the vast majority of courses that included mental health. At the graduate level, health behavior accounted for the highest inclusion (50%) of mental health topics.

A mental health course was more likely to be taught in the health education department than outside of the department, whether it was required (69%) or offered as an elective (57%). 'Stress' or 'Stress Management' was the class most likely to be offered at the undergraduate level (39%) and graduate level (21%).

Respondents were asked to indicate specific mental health topics that were addressed in the content of classes that were not 'mental health classes'. At the undergraduate level, stress was the topic most likely to be covered (69%) followed by eating disorders (65.4%), substance abuse (65.1%), emotional well being (62.9%), and self-esteem (62.6%). At the graduate level, substance abuse was most likely to be covered (26.4%) followed by stress (23.6%), emotional well being (17.5%), eating disorders (16.3%), self-esteem (14.7%), and anxiety (14.4%). Mental illness topics (mood disorders, personality disorders and dissociative disorders) accounted for approximately 40 percent of the mental health topics covered in undergraduate programs and less than 13 percent of the mental health topics covered in graduate programs.

PERCEIVED IMPORTANCE OF REQUIRING A MENTAL HEALTH COURSE VS. THE NUMBER OF PROGRAMS REQUIRING A MENTAL HEALTH COURSE

At least one-half of the respondents thought that it was "Important" to "Extremely Important" to require a mental health course at the undergraduate level (55%) and at the graduate level (50%) (see Table 1). Sixty-eight percent of undergraduate programs and 24 percent of graduate programs required a mental health course. School health (33.9%) and community health programs (29.4%) were most likely to require a mental health course, whereas, public health (6.8%) and worksite health (5.5%) programs were least likely to require a mental health course (see Table 2).

Respondents were asked to rate the importance of offering a mental health course as an elective in undergraduate and graduate programs. Sixty-six percent indicated that offering an elective mental health course at the undergraduate level was "Important" to "Extremely Important" and 61 percent indicated the same at the graduate level (see Table 1). However, only 58 percent of undergraduate and 43 percent of graduate programs offered a mental health course as an elective (see Table 2).

BARRIERS TO OFFERING MENTAL HEALTH COURSES

Department chairpersons were asked to identify their perceived barriers to offering mental health courses from a list of six potential responses. Having no time in the curriculum was cited as the most significant barrier (23.9%). Students taking mental health courses in other departments (18.4%) and having no faculty trained in mental health topics (17.2%) were also cited. Lesser barriers included other departments not permitting health education departments to offer mental health courses (4.3%), faculty do not think mental health courses are important (2.5%), and no interest in mental health courses by students (1.8%) (see Table 3).

BENEFITS TO OFFERING MENTAL HEALTH COURSES

Chairpersons were also asked to identify the benefits to offering mental health courses from a list of eight potential responses. Five items were selected by more than half the respondents: provides students with greater understanding of mental health (76.7%), helps students understand the interaction that mental health plays in physical disease and illness (76.1%), validates the inclusion of mental health as a component of the definition of health (71.8%), provides students with positive aspects of mental health versus negative aspects of mental health (67.5%), and prepares future health professionals with information to help dispel myths and misinformation about mental health (64.4%). Less than half felt that stigma is lessened (46.6%) or that mental health provides an additional area of research (34.4%), while one-in-four felt that offering mental health courses makes a health education program more attractive to students (25.2%) (see Table 4).

FACULTY SIZE AND INCLUSION OF MENTAL HEALTH AS A REQUIREMENT

Independent t-tests were used to determine if the number of faculty in the health education department was influential in whether mental health courses were required. Faculty size was divided into two groups, those with 1 through 5 members and those with 6 or more members. These groupings were made based on demographic findings in this study that the average size of faculty was 1 to 5 members. Thus, it was decided to compare average size of faculty with programs whose faculty exceeded the average. Results indicated no significant difference between faculty with six or more members compared to those with one to five members for all health education tracks that were surveyed: school health (t=.88, df=46, p=.39), health promotion (t= 1.79, df=19, p=.09), community health (t=1.33, df=38, p=.19) and worksite health (t=1.26, df=7, p=.25).

DISCUSSION

Findings reveal that the majority of respondents believed that mental health courses were important components of health education programs. There were also indications that faculty at undergraduate health education programs have incorporated mental health into their curricula. This study found that about 68 percent of undergraduate programs required a mental health course as compared to Maylath and Ubbes (1996) who found that about 56 percent required a mental health course for health education undergraduate majors and minors. This increase suggests that mental health issues are being given increasing consideration in undergraduate health education curricula. Given that this study found that 55 percent of respondents believed that mental health was important to undergraduate programs, is a positive finding that mental health issues are being addressed at an increasing rate. Conversely, graduate health education programs appear to rarely require or offer mental health courses. This is especially of concern since 50 percent of those responding felt that mental health is important to graduate programs. Even though undergraduate programs seem to place some emphasis on mental health, there is still room for improvement. Slightly more than 30 percent of undergraduate programs do not require or offer a mental health course.

It is of concern that public health and worksite health concentrations are least likely to require or offer a mental health course. Like all health professionals, persons in these areas are highly likely to encounter mental health issues in their employment capacities, whether one is working in a health department or whether one is a health-wellness coordinator for a manufacturing facility. These areas of health education need to consider the importance of including mental health topics in order to graduate individuals who are able to recognize compromised mental health and promote positive mental health in stressful environments such as the workplace.

Where mental health topics are being addressed, there is a slight emphasis on mental illness rather than on positive aspects of mental health. This finding is supported by Kittleson (1989) who found that positive mental health topics were limited in general health textbooks. The respondents in the present study may teach mental health topics/classes with supplemental materials that reflect positive mental health aspects, thus, providing more balance between mental health and mental illness.

This study revealed that the number of faculty in health education departments had no bearing on whether mental health courses were included in the curriculum. However, 17 percent of respondents said that having no faculty trained in mental health was a barrier to offering mental health courses. Because few graduate programs train students in mental health issues, it is highly likely that health education departments do not have sufficient pools of applicants who have the knowledge to teach in this area. Thus, the cycle of not teaching mental health courses because few are trained to teach them continues to be a significant barrier to breaking this pattern.

While respondents reported that approximately 18 percent of health education programs have students take mental health classes outside of the health education department, it is important to note that these courses do not necessarily give the student a complete view of mental health. While taking clinical or abnormal psychology is certainly desired above taking no mental health courses, the focus of such classes is one of preparing clinical-counseling professionals to identify and treat mental illness-disorders. Therefore, these classes are less likely to emphasize additional mental health issues that are important to the health educator such as communication, stress management, self-esteem issues and mental health care policy. Thus, university health education program directors need to evaluate the quality and breadth of mental health requirements to ensure that health education students are receiving more than one aspect of what mental health entails.

The nature of this study is exploratory and descriptive. Further research should focus on quantitative and predictive aspects. The reason(s) why mental health is not included in the absence of multiple barriers needs to be assessed. Research should also explore solutions to barriers. How mental health courses are presented, such as comparing the use of textbooks to personally selected supplemental material, needs to be analyzed for effectiveness and comprehensiveness.

There exist some threats to external validity. Health education chairpersons were surveyed in this study. Therefore, opinions regarding the importance of requiring and offering mental health courses cannot be generalized to the faculty who teach those courses. Health education programs in the United States only were surveyed. Therefore, these findings may not represent the status of mental health courses in health education programs at institutions outside the continental United States.

Threats to internal validity include the possibility that questions, especially those regarding the importance of requiring and offering mental health courses, were answered in a socially desirable way. Another potential threat to internal validity is the dosed format nature of the questionnaire. However, this threat was minimized by allowing respondents space to include additional comments. The return rate (60%) may be a threat to the internal validity of the findings if the nonrespondents have different mental health courses or issues than did the respondents.

CONCLUSION

If we, as health educators, believe that the definition of 'health' includes mental well being, and if mental health is important to a health education program, then we must reassess our requirements to ensure that students are at least introduced to positive mental health issues and mental illness issues. We must also emphasize the importance of positive mental health issues and mental illness issues as components to optimal health that share equal influence with physical and social aspects.

REFERENCES

American Association for Health Education. (2001). Directory of institutions. American Journal of Health Education, 32 (3), 153-168.

Coffey, g. M., Mark, T, King, E., Harwood, H., McKusick, D., & Genuardi, J. (2000). National estimates of expenditures for mental health and substance abuse treatment, 1997 (Rep. No. SAMHSA Publication SMA-00-3499). Rockville, MD: Substance Abuse and Mental Health Services Administration.

Cohen, S. & Rabin, B. S. (1998). Psychological stress, immunity and cancer. Journal of_the National Cancer Institute, 90, 3-4.

Corrigan, P. W., Edwards, A. B., Green, A., Diwan, S. L., & Penn, D. L. (2001). Prejudice, social distance, and familiarity with mental illness. Schizophrenia Bulletin, 27 (2), 119-225.

Dantzer, R., & Kelley, K. W. (1989). Stress and immunity: An integrated view of relationships between the brain and the immune system. Life Sciences, 44, 1995-2008.

Greenberg, J. S. (1999). Comprehensive Stress Management (6th Ed.). Columbus, O H: McGraw-Hill.

Herbert, T. B., & Cohen, S. (1993). Stress and immunity in humans: A meta-analytic review. Psychosomatic Medicine, 55, 364-379.

Kessler, R. C., Berglund, P. A., Bruce, M. L., Koch, J. R., Laska, E. M., Leaf, P. J., Manderscheid, R. W., Rosenheck, R. A., Wakers, E. E., &Wang, P. S. (2001). The prevalence and correlates of untreated serious mental illness. Health Services_Research, 36 (6), 987-1007.

Kittleson, M. J. (1989). Mental health vs. mental illness: A philosophical discussion. Health Education, 20 (2), 40-42.

Link, B. G., Phelan, J. C., Bresnahan, M., Stueve, A., & Pescosolido, B. A. (1999). Public conceptions of mental illness: Labels, causes, dangerousness, and social distance. American Journal of Public Health, 89 (9), 1328-1333.

Martin, J. K., Pescosolido, B. A., & Tuch, S. A. (2000). Of fearing and loathing: The role of disturbing behavior,' labels, and causal attributions in shaping public attitudes toward people with mental illness. Journal of Health and Social Behavior, 41 (2), 208-223.

Maylath, N. S., & Ubbes, V.A. (1996). Professional preparation in mental health/illness education. Journal of Health Education, 26 (6), 370-374.

Murray, C.J.L., & Lopez, A. D. (1996). Summary: The global burden of disease. Harvard University Press: Boston.

Phelan, J. C., Link, B. G., Stueve, A., & Pescosolido, B.A. (2000). Public conceptions of mental illness 1950 and 1996: What is mental illness and is it to be feared? Journal of Health and Social Behavior, 41 (2), 188-207.

Regier, D. A., Narrow, E., Rae, D. S., Manderschied, R.W., Locke, B. Z., & Goodwin, E K. (2003). The de facto U.S. mental and addictive disorders service system. Epidemiologic catchment area perspective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 50 (2), 85-94.

Schiraldi, G. R., Spalding, T. W., & Hofford, C.W. (1998). Expanding health educator's roles to meet critical needs in stress management and mental health. Journal of Health_Education, 29 (2), 68-76.

U.S. Department of Health and Human Services (1999). Mental Health: A Report of the_Surgeon General-Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

U.S. Public Health Service. (2000). Report of the Surgeon General's Conference on Children's Mental Health: A National Action Agenda. Washington DC: Superintendent of Documents.

U.S. Public Health Service Office of the Surgeon General (2001). Mental health: Culture, race, and ethnicity: A supplement of mental health: A report of the surgeon general. Rockville, MD: Department of Health and Human Services, U.S. Public Health Service.

Valliant, G. E. (2003). Mental health. American Journal of Psychiatry, 160 (8), 1373-1384.

Responsibilities and Competencies for Health Educators (CHES Area) Responsibility VII--Communicating Health and Health Education Needs, Concerns, And Resources Competency A: Interpret concepts, purposes, and theories of health education.

JoAnn Kleinfelder, MEd

Susan K. Telljohann, HSD, CHES

James H. Price, PhD, MPH

JoAnn Kleinfelder, MEd is a Graduate Assistant in the Department of Public Health at the University of Toledo. Susan K Telljohann, HSD, CHES is a Professor of Public Health at the University of Toledo. James H. Price, Ph.D., MPH is a Professor of Public Health at the University of Toledo. Address all correspondence to JoAnn Kleinfelder, MEd, The University of Toledo, College of Health and Human Services, Department of Public Health and Rehabilitative Services, Toledo, Ohio, 43606-3390, PHONE: [phone], FAX: [phone], EMAIL: [e-mail]

Table 1. Importance of Requiring or Offering a Mental Health
Course (N=163).

Item                                                       n    %

Importance of requiring at undergraduate level:
  Extremely important                                      50   30.7
  Important                                                39   23.9
  Moderately important                                     43   26.4
  Slightly important                                       19   11.7
  Not at all important                                      7    4.3
Importance of requiring at graduate level:
  Extremely important                                      41   25.2
  Important                                                40   24.5
  Moderately important                                     43   25.4
  Slightly important                                       19   11.7
  Not at all important                                     14    8.6
Importance of offering as an elective at
   undergraduate level:
  Extremely important                                      53   32.5
  Important                                                55   33.7
  Moderately important                                     31   19.0
  Slightly important                                       12    7.4
  Not at all important                                      6    3.7
Importance of offering as an elective at graduate level:
  Extremely important                                      58   35.6
  Important                                                41   25.2
  Moderately important                                     35   21.5
  Slightly important                                       13    8.0
  Not at all important                                     10    6.1

Table 2. Health Education Programs That Require or
Offer an Elective Mental Course (N=163).

                         Required    Elective

Major & Degree Program   n     %     n     %

School Health
  Bachelors              46   28.3   27   16.5
  Masters                 9    5.6    8    4.8
  Doctoral                0    0.0    3    1.8
Health Promotion
  Bachelors              15    9.2   22   13.6
  Masters                11    6.8   15    9.3
  Doctoral                1    0.6    5    3.1
Community Health
  Bachelors              37   22.7   35   21.4
  Masters                11    6.7   18   11.0
  Doctoral                0    0.0    5    3.0
Public Health
  Bachelors               5    3.1    6    3.7
  Masters                 6    3.7   13    7.9
  Doctoral                0    0.0    2    1.2
Worksite Health
  Bachelors               7    4.3    5    3.1
  Masters                 2    1.2    2    1.2
  Doctoral                0    0.0    1    0.6

Table 3. Perceived Barriers to Offering Mental Health
Courses (N=163)

                   Item                      n     %

No time in curriculum                        39   23.9
Students take abnormal/clinical psychology
  in another department                      30   18.4
No faculty trained in mental health          28   17.2
Other departments will not permit us to       7    4.3
  offer mental health courses
Faculty do not think it is important          4    2.5
No interest by students                       3    1.8
Other                                        14    8.6

Table 4. Perceived Benefits to Offering Mental Health
Courses (N=163).

Item                                                   n    %

Provides students with a greater understanding
  of mental health                                    125  76.7
Helps students understand the interaction that
  mental health plays in physical disease and
  illness                                             124  76.1
Validates the inclusion of mental health as a         117  71.8
  component of the definition of "health"
Provides students with positive aspects of mental
  health versus negative aspects of mental health     110  67.5
Prepares future health professional with information
  to help dispel myths and misinformation about
  mental health                                       105  64.4
Lessens stigma                                         76  46.6
Provides an additional area of research for students
  and faculty                                          56  34.4
Makes a health education program more attractive to
  students                                             41  25.2
Other                                                   7   4.3