Back ground

We can easily conclude that living conditions of an average Kenyan is far better today than a few years before. Diseases that were once deemed unmanageable and caused large scale outbreaks like cholera, malaria, TB and leprosy can now be easily treated and a few disease like small pox and rinderpest have successfully been eradicated(Kenya. Ministry of Health, 2013). As it is a child has a chance of growing to adult-hood without worrying of once dreaded diseases like polio, measles and TB, because of the effective immunization program and improved health care system in Kenya. For this reason, children in Kenya don’t need to worry of dying from a communicable disease, rather they need a promise of long, quality and fulfilling lives. Notably, on the opposite hand cases of non-communicable diseases e.g. diabetes, hypertension, cancers and chronic respiratory tract infections, are noted to get on the increase (Helen et al., 2019). This will be attributed to changes in lifestyle and increased awareness and reporting. This has significantly contributed to increased disease burden while diverting the main target from communicable diseases to non-communicable diseases.

Surprisingly, within the height of this increased attention to non-communicable diseases, mental health disorders (MHDs) are discriminatively left behind. Consistent with World Health Organization (2001), 1 in every 4 people is suffering from mental problem at some point in their lives. Sadly, approximately 450 million people are now living with such conditions, making mental disorders among the leading causes of morbidity and disability worldwide. In Kenya approximately 25% of outpatient and up-to 40% of inpatients are affected by mental conditions (Ombuor, 2019)

Globally, in every 40 seconds someone loses their life due to suicide says World Health Organization (WHO, 2019). The numbers of suicides reported in Kenya alarmingly rose by 58% between the year 2008 and 2017. In 2017 alone, Kenya reported 421 suicide cases, 75% of whom were men, exposing us to a tragic reality of a silent epidemic that requires urgent response. Yet mental health services are characterized by stigma and discrimination and to form matters worse about two-thirds of individuals with known mental health disorders don’t seek help from a health care provider hence leaving room for superstition to thrive (Mokamba, 2019).

It’s for a fact “where there’s neglect, there’s little or no understanding. Where there’s no            understanding, there’s neglect.” (WHO, 2001). Approximately one fifth of the planet population contains youth aged 14 to 24 years, with 85 to 90 per cent of this group living in low income countries. In high-income countries, it’s estimated that about 5 per cent of the population have a significant mental disease. On a worldwide level   it’s estimated that approximately 20 per cent of youth experience a mental-health condition annually.  Young people are at greater risk of a variety of mental-health conditions as they transition from childhood to adulthood (United Nations, 2014). There is considerable burden and disability related to mental health conditions, particularly among those for whom the issues start during youth. In fact, the public health burden of MHDs, as estimated by disability-adjusted life years, is on a sharp upward trajectory; it increased by 41 percent between 1990 and 2010 and now accounts for one in every 10 years of lost health globally.  Although much of the epidemiological research supporting these estimates comes from high-income countries, studies from middle and low- income countries provide similar prevalence estimates (Kieling et al., 2011). Majority of MHDs develop before the age of 30 years with an exception of dementia and vast majority run a protracted or relapse course (Patel et al., 2015). Mental-health conditions negatively impact youths’ development, quality of life and skill to completely participate in their communities. Mental and behavioural conditions are the leading causes of health problems in children in both high- and low-resource countries, accounting for one third of all years lost productivity due to disability (United Nations, 2014). Coming to Kenya, the vulnerability of a Kenyan youth to mental health issues is overwhelmingly high. As an example, suicide is the second leading cause for mortality among young people aged between 15 and 29 years. Worse still drug and substance abuse has become a norm among the youth, further fuelled by a culture that normalizes alcohol drinking as the best way to relax and socialize with friends. Moreover, many children are silently affected by depression putting them at a state of unproductivity and uncertainty of their future (Mokamba, 2019).

It’s evident the results of this harmful behaviours is increased deaths, this is often as demonstrated by a big 3.3 million deaths recorded per annum globally attributed to harmful consumption of alcohol, representing 5.9% of all deaths(Kenya. Ministry of Health, 2015). Additionally, the harmful use of alcohol may be a causative think about over 200 diseases and injury conditions. Generally, 5.1% of the worldwide burden of disease and injury is due to alcohol, as measured in disability- adjusted life years (DALYs). Alcohol consumption causes death and disability relatively early in life. Within the age bracket 20–39 years approximately 25% of the entire deaths are alcohol-attributable. There’s a causal relationship between harmful use of alcohol and a variety of mental and behavioural disorders, other non-communicable conditions also as injuries. Beyond health consequences, the harmful use of alcohol brings significant social and economic losses to individuals and society at large (Kenya. Ministry of Health, 2015).

For those with mental illnesses are subjected to discrimination against accessing work, education, reproductive health and other forms of human rights. Reports on degrading treatment practices in health facilities, physical and sexual assault, unhygienic and inhumane living conditions and neglect are common (World Health Organization, 2017). Amazingly, the magnitude of this problem has not has not been accurately established. Kenya, like most other sub-Saharan countries, is battling data gaps to reflect the precise burden of mental health disorders which deprives the country with critical information required for planning, budgeting and effective interventions. Compounding the matter, suicide cases are likely to be under-reported, partly because suicidal attempts are treated as illegal and people who survive are highly stigmatized (African Population and Health Research Center, 2019).

One would ask, is that the society cognizant of the results of their discriminatory actions to people living with mental illnesses? Why promote a culture drinking as how of unwinding and socializing with friends? Consistent with the idea of planned behaviour change, behaviour change has got to be intentional. Behaviours are guided by intentions. According to Ajzen, I. (2014) behaviours and intentions are further guided by the anticipated results of the behaviour, normative beliefs and anticipated hitches. He draws a conclusion that behaviours are goal-oriented, therefore, the result is known from the start. Using this model the intentions of engaging in harmful behaviour like alcohol use among young people are often illustrated using the diagram below:

Figure 1: Model illustrating the intentions of indulging in harmful behaviours among youth

From the above model, culture impacts our mental health given that it provides content that defines how we express ourselves and by extent defines how different genders (male & female) express themselves in same situations. Cultural differences influence risk perceptions and affect resiliency factors that relate to mental-health conditions, thereby defining prevalence and incidence rates across cultures (Patel et al., 2015). For this reason, it is unfortunate mental health consequences as a result of excessive consumption of alcohol and other harmful practices are normally not considered, while difficulties of accessing alcohol are considered minor since there are options of cheap but toxic liquor readily available.

Available mental health policies, legislations and programs that target the youth.

With this looming evidence of a crisis, why does it not receive the attention it deserves? Though existence of stand-alone law on mental health that was established in year 1989, which is by now outdated, there’s no existing dedicated authority or independent body to assess compliance of mental health legislation with international human rights. The prevailing mental health policy that was established in 2015, acknowledges the human rights of individuals living with mental illnesses are continuously violated. It identifies stigma and discrimination as the single most challenge preventing people from seeking mental health care. Therefore it sought to deal with 4 key issues; lack of effective governance and leadership for mental health , access to comprehensive mental health care services, lack of strategies for promotion of mental health , prevention of mental disorders and substance abuse disorders, and weak mental health system. However, the policy doesn’t touch on strategies for young people as a unique cohort. What does this mean? Lack of strategies within the policy that addresses mental health needs among adolescent and youth would mean there’s no enough evidence to support decision making or we don’t know how to spot young people in danger and what factors help to guard them(APHRC, 2019). Further still, the country doesn’t have any existing mental health promotion and prevention programs. While the suicide cases are reportedly on the increase, there’s no suicide prevention strategy either as a stand-alone or integrated element of the national policy (WHO, 2017).

Barriers to youth specific intervention/ policy development.

First and foremost, there is huge data gap in regards to mental health disorders, which denies the country of crucial information required to plan and deliver effective interventions and whatever little data available is not disaggregated into age sets (African population and health research center, 2019).Consequently, it is only possible to make rough estimates based on low-scale studies and developed countries’ registry, which is far from ideal, for resource allocation. A few research groups, organizations and agencies have made an effort to understand the problems affecting the youth, however, efforts do not merge the need. There is enormous gaps needs to be explored in order to recognize and understand fully youth in danger for, and those experiencing mental health conditions.
Secondly, in many countries, child and adolescent mental health services are considered a subset of general mental health services or child health services, or as a minor extension of those services. Most of the funding for mental health services is dedicated to adult services, which makes it difficult to develop appropriate child and adolescent mental health services. If child and adolescent mental health services were to be viewed as a definite category of health care with unique requirements, specific funding arrangements and policy development would be facilitated (United Nations, 2014). Fortunately, there was a mental health Bill that was brought-up in parliament. The bill sought to supply the much-needed legislative framework of ensuring that a person with mental illnesses receives the very best achievable standards of health Republic of Kenya. Kenya Gazette Supplement No. 136 Senate Bills, 2018)

Thirdly, the effect of neglecting mental health goes beyond resource allocation. Mental health professionals are insufficient to provide the much needed service. The WHO (2017) identifies that there are 0.18 Psychiatrists per 100,000 population, the registry of the rest of the cadres like mental health nurses is not available. This means this group of health care professionals are overwhelmed with huge caseloads, disallowing them time to address needs of specific groups, youths included.

Finally, youth with mental-health conditions face considerable stigma, which is a serious barrier to seeking help. United Nations (2014) identifies that discrimination is probably going to be greater in developing countries where there’s less recognition and awareness of mental health issues. Help-seeking behaviour is a smaller amount likely among young people who are even more likely to be impacted by stigma, embarrassment and therefore the lack of basic knowledge about mental health.
Delayed action, distorted information and competing priorities are single most blinding factors limiting policy-makers from identifying the position of mental disorders in contribution to disease burden and disability worldwide( WHO,2001).

What must be done?                   

The Mental health bill-2018 brought renewed hope for people living with MHDs in Kenya. However, it is important for legislatures to hurry up the assent and implementation of the same. (Republic of Kenya. Kenya Gazette Supplement No. 136 Senate Bills 2018). A dedicated authority to assess compliance of mental health legislation with international human rights must be put in place (WHO, 2017). This should also be charged with authority to ensure well-defined policies and programmes, youth-focused to improve youth’s access to full range of services.

This services will bring understanding of youth with mental-health disorders,             also as those that struggle with learning disabilities, which is usually synonymous with mental health conditions. Without this, the crisis will soon get out of hand.    Additionally, this will not only affect service coordination and delivery, but also on resource allocation and accountability (Kieling et al., 2011).

Countries with elaborate community based approaches have shown that their policies have included requirements for schools to both implement preventive programming, e.g. training in social-emotional learning and positive behaviour supports, and to market the mixing of the complete continuum of prevention programs and mental-health services(United nations, 2014). Additionally both national and county government should intensify efforts to supply mental health care and develop the required infrastructure for mental health services (Republic of Kenya. Kenya Gazette Supplement No. 136 Senate Bills, 2018).

Secondly, it’s important to increase public awareness on the impact of mental health also become cognizant of negative mental health consequences that follows on indulging in behaviours like harmful consumption of alcohol and substance abuse. This may include addressing cultural elements, including social attitudes, generation norms, religious beliefs, family values and other sociocultural factors, are strongly associated with the behaviour of youth (United Nations, 2014). Awareness and respect for these, and other cultural factors, as well the underlying social circumstances of people, must be considered when addressing youth mental-health concerns. Why? Because culture impacts mental health by providing content for its expression, yielding different forms of expression in different cultures even for the same mental-health conditions. Cultural differences affect the risk and resiliency factors that relate to mental-health conditions, thereby influencing prevalence and incidence rates across cultures. Culture should thus have an impact on the selection and adaptation of appropriate prevention and intervention strategies (United Nations, 2014). One way of doing it is through adopting a public-health approach to the prevention of behavioural and mental health. This approach includes existence of suicide prevention strategy that ought to be either as a stand-alone or integrated to national policy/plan as a section of selective interventions (WHO, 2017). Other interventions are need specific looking on different levels of risk. Variety of effective prevention models have been developed to deal with a variety of risk factors at the extent of the family, school, contemporaries, community and workplace. Specific models that are likely to prove effective in low- and middle-income countries include nurse home-visitation programmes for young parents, which benefit both the young parents and their offspring, within the short and future. Multi-tiered prevention models for addressing behavioural and mental-health needs have also demonstrated promise in several countries by targeting parents and therefore the community. Variety of school-based programmes focused on promoting competencies – like emotion-regulation, social skills, behavioural inhibition and conflict resolution – also hold promise for implementation in low-resource settings. Community-wide frameworks- Awareness campaigns to increase mental health literacy and address stigma and discrimination (United Nations, 2014).

Legislation on protection of human rights of persons suffering from mental, neurologic and drug abuse disorders-that draw upon community partnerships and are guided by local data have also demonstrated significant impacts on a diverse mental-health outcomes. Workplace-based programmes are shown to reduce stress and mental health problems (United Nations, 2014).

Patel et al (2016) makes the following summary of interventions that have been found to be cost-effective and easily scalable for the purpose of promotion and scalable prevention intervention that need to be promoted as per the table below:

Figure 2. Cost effective mental health promotion interventions

Type of disorder	Preventive intervention	Psychosocial interventions
Alcohol consumption disorders(6.9% of total MNS DALYs)	Excise taxes***Restriction on sales**Adjust minimum legal age**Drunk driving counter-measures**Advertising bans*Restrictions on density*Opening and closing hours and days of sale* Family interventions*	Family support*Motivational enhancement, brief advice, CBT** Screening and brief interventions*** Self-help groups
Illicit drug use disorders(contribute 7.8% of total MNS DALYs)	Psychosocial interventions with primary school children, such as the Good Behavior Game or Strengthening Families Program*	Self-help groups, psychological interventions, CBT*
Suicide and self-harm( account for 1.47% of GBD; 22.5 million YLLs or 62.1% of suicide YLLs are attributed to mental and substance use disorders in 2010	Policies and legislation to reduce access to the means of suicide (such as pesticides)*** Decriminalization of suicide* Responsible media reporting suicide	Social support and psychological therapies for underlying MNS disorders, Planned follow-up and monitoring of suicide attempters*
Conduct disorder(2.2% of total MNS DALYs )	Life skills education to build social and emotional well-being and competencies;** parenting skills training;** maternal mental health interventions	Parenting skills training***• CBT*
Anxiety disorders(2.3% of total MNS DALYs)	Parenting skills training;** maternal mental health interventions**	CBT**

Notes: CBT = cognitive behavioral therapy; DALY = disability-adjusted life year; GBD = Global Burden of Diseases;

MNS = mental, neurological, and substance use; YLLs = years of life lost. *** = evidence of cost-effectiveness; ** = strong evidence of effectiveness but not cost-effectiveness; * = modest evidence of effectiveness and either no cost-effectiveness or no evidence of cost-effectiveness

Source: Patel et al. (2016, pp.10-13).
Thirdly, deliberate efforts are needed to beat stigma regarding mental-health conditions in youth across their life course. Increased education and awareness of mental-health conditions is probably going to reduce the perceived stigma related to seeking treatment and disclosing symptoms to professionals and other adults in positions to assist (United Nations, 2014). Social-marketing campaigns and national programmatic efforts aimed toward raising social awareness of the problems of mental health are a critical next step within the effort to scale back the stigma among children with mental-health conditions. Our society must appreciate that mental disease is simply that; an illness. That way, it’ll be easier to make sure community participation in the mental well-being of children. The govt should support community based care and treatment for persons with mental disease. We should always all provide safe spaces for ourselves and for people with mental illness to support their journey to recovery and integration into the community (United Nations, 2014). WHO (2001) through her “New understanding, new hope” report, calls on governments to form intentional decisions and choices to realize acceptance and treatment of mental disorders. Through this interventions, majority of mental and behavioral disorders are often successfully treated, importantly much of this interventions are affordable and that they provides a chance for those affected by this disorders to be productive and contribute to their society. Actually 80% of these with schizophrenia are often freed from relapse by the top of year one among adherent treatment with antipsychotics and social support. Up to 60% with major depression can recover given a correct combination of antidepressant drugs and psychotherapy. Up to 70% of these with epilepsy are often seizure free when treatment with “simple, inexpensive anticonvulsants Majority of mental and behavioural disorders are often successfully treated(WHO, 2001).

Improved surveillance and programme monitoring and evaluation will aid in the identification of both the risks and protective factors to be targeted through preventive interventions. It’s critical that data be collected regularly regarding a broad range of risk and protective factors and mental-health outcomes. Although surveillance efforts are developed in various countries, few initiatives are sustained or broad enough in scope to guide practice (United Nations, 2014).
Additional research is required to document the impact of promising programmes in middle and level-income countries. Although an outsized number of programmes and policies are identified as effective, the overwhelming majority of the research has been conducted in high-income countries (APHRC, 2019).

References

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Helen, K., Gladwell G., Calestus, N., and Wangia, E. (2019). ‘Life style diseases-An Increasing Cause of Health Loss’, Policy brief. Kenya. Ministry of Health [online]. Available at:  http://www.health.go.ke/wp-content/uploads/2019/01/Revised-Non-Communicable-Disease-Policy-Brief.pdf (Accessed: 7 March 2020).

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Ombuor, R. (2019) ‘Kenya Holds First Mental Health Conference’, Africa section of The Voice of America News, 22 November [online]. Available at: https://www.voanews.com/africa/kenya-holds-first-mental-health-conference (Accessed: 01 March 2020).

Patel, V., Chisholm, D., Dua, T., Laxminarayan, R., Medina-Mora, M. E. (2016). Disease Control Priorities, Third Edition: Volume 4. Mental, Neurological, and Substance Use Disorders. Disease Control Priorities. Washington, DC: World Bank [online]. Available at: https://openknowledge.worldbank.org/handle/10986/23832 (Accessed: 06 March 2020).

Republic of Kenya. Kenya Gazette Supplement No. 136 Senate Bills 2018: The Mental Health (amendment) bill page 577(2018) Nairobi: Government printer.

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