27J Contemp Med Sci | Vol. 8, No. 1, January-February 2022: 27–30 Original Mental Health Wellbeing of School Age Children is Matter: A Study to Evaluate the Effectiveness of a School-Based Mental Health Awareness Program in The Middle Schools in Oman Yusra Al Nasiri1*, Aisha Al Abri2, Afra Al Rawahi2, Al Anood Al Harrasi2, Amal Al Shuaibi2, Amina Al Owisi2, Arwa Al Rashdi3, Atheer Al Shabibi1, Balaqis Al Hakmani1, Shamsa Al Harthi4 1Oman College of Health Sciences, Nursing Program, Muscat, Oman. 2Staff Nurse, Royal hospital, Muscat, Oman. 3Staff Nurse, Bousher Dialysis Center, Muscat, Oman. 4Staff Nurse, Khoula hospital, Muscat, Oman. *Correspondence to: Yusra Al Nasiri (E-mail: yusra444@hotmail.com) (Submitted: 21 December 2021 – Revised version received: 06 January 2022 – Accepted: 21 January 2022 – Published online: 26 February 2022) Abstract Objectives: The aim of this study is to assess the effectiveness of a school-based mental health awareness program among school age children. Methods: This was a quantitative study that recruited 178 parents and 150 students from different levels (Grades 5–10) attended the awareness activity at two middle schools in Oman. A convenient sampling approach was utilized. Results: There was a significant different in mood and feelings score between the grades (P = 0.001); with grade 10 being the highest disturbed mood changes (M = 23.25, SD = 5.54). The results also showed that 55% of students experienced anxiety. From the analysis, it was found that grade 10 (M = 36.15, SD = 18.43, P = 0.05) reported higher anxiety than others groups. The results indicated also a strong correlation between experience of bullying and mental health problems (r = 0.85). The evaluation of awareness program indicated that 91% of parents reported improvement in knowledge; 89% suggested that many information they were not aware of before. 92% rated the video as informative. 93% agreed that the program activities were entertaining and informative. 92% reported that the activity increased their awareness to observe the changes in their children emotional wellbeing. 98% of parents enjoyed the activities and rated the overall program as effective and very interesting. Conclusion: There is a dire need to conduct various awareness programs in the community. Such programs are not only helpful in improving the community knowledge on the factors influencing children’s mental health, but also assist in identifying the mental health problems at early stage; which may empower them to seek early management for their children. This study suggests an establishment of a mental health program for children in Oman to identify the cases, assess the mental problems affecting children at different ages and refer them for further support and management. Keywords: Mental health, school age, children, awareness program ISSN 2413-0516 Introduction & Background Mental health and emotional wellbeing in children is just as important as their physical health. Good mental health allows children to think clearly, develop socially and learn new skills.1,2 In addition, fostering mental health helps chil- dren develop self-confidence, high self-esteem, and a healthy emotional life.3 Promoting mental health will not only help children build resilience to cope up with life stressors, but also will nurture them to grow into well-grounded healthy adults.4 Research indicates that children’s emotional health and positive attitude effect positively the children’ emotions and mood as it is reflected in their way of expression.1 Positive mood predicted learning academic and cognitive progression, motivation, and interpersonal skills of children.1 A study iden- tified the prevalence of anxiety and the relationship between anxiety and school performance among elementary, middle, and high school students (N = 478). The results revealed that 35 (7.3%) reported high level of anxiety.5 The results suggested abnormally high anxiety level that was negatively associated with school performance.6 Similarly, another study revealed a significant relationship (P > 0.05) between children’s anxiety level and educational level. This study showed that the preva- lence of anxiety was higher in boys, single children, children who had a family history of hereditary disease, and children who experienced corporal punishment at home.7 Studies also suggest that school age children suffer from depression. A cross section study aimed to explore the preva- lence of depression and its associated sociodemographic fac- tors among school-going adolescents. Among 1412 selected students, the prevalence of depression was found to be 49.2%. Guilty feelings (69.48%) was one of the most prominent clin- ical factors associated with depression followed by pessimism (58.14%), sadness (56.52%), and past failure (55.81%).1 Similarly, a high level of depressive symptoms reported among adolescents (38%). The study concluded that depres- sive symptoms was associated with poor academic perfor- mance, poor coping methods and suicidal ideations.4 Similarly, another study showed that 35% of children less than 13 years suffered from depressive disorder, and that the prevalence in the adolescent sub-group was 15%.8,9 Research also suggests an association between bullying experience and alteration in the mental health wellbeing for students. The prevalence of bullying at 6 schools in Muscat governorate revealed that 38.4% of the students reported being bullied in the past month and 34.0% of the students reported having at least one physical injury in the past year that caused at least one full day absences from usual activities or required 28 J Contemp Med Sci | Vol. 8, No. 1, January-February 2022: 27–30 Mental Health Wellbeing of School Age Children Original Y. Al Nasiri et al. medical treatment due to bullying.10 Students who experi- enced bullying were found to suffer from family abuse and had history of tobacco, alcohol and drug use.3 In a study conducted in Saudi Arabia involving 9073 students; the results indicated that 26% of adolescents reported exposure to bullying. Expo- sure to physical violence and bullying having more frequent symptoms of depression and anxiety. Those exposed to phys- ical violence were at higher odds of having poorer academic performance.10,11 Some studies attempted to evaluate the effectiveness of mental health programs on reducing mental health symptoms affecting children. The results of a systematic suggested that the psychological program was effective and helpful in reducing anxiety in school age children. Psychological pro- grams at school can be a promising intervention targeted towards preventing the anxiety and other mental health prob- lems among school age children.12 Problem Statement Most children tend to grow up mentally healthy; however, recent literature suggests that mental problems in children and young adults are on the increase due to the changes in the way of living.7,13 The research highlights that mental health prob- lems affect about 1:10 children and young adults and alarm- ingly, 70% of the effected children were not assessed at early stage and have not had corresponding interventions at a suffi- cient early age. There are many risk factors that make children vulnerable for mental health problems these include: changes in the environment the children’s lives in; for example, divorce of parents, abuse experience, moving to a new school environ- ment, living in poverty, having a parent with alcohol or drug addict.13 Other risk factors are: having long term physical illness, educational difficulties, experienced bullying and death of a close member in the family.12 Based on the litera- ture, common mental health problems that can effect children are: Anxiety, depression, excessive worries, post-traumatic stress disorder, and self-harm.5,12,14 This study was done in response to the data received from the school health counse- lors from two middle-age schools in Muscat on the increasing number of school age children suffering from negative thoughts, anxiety and other mental health issues. Hence, this study was conducted to assess the mental health wellbeing of the students and evaluate the effectiveness of the planned school based mental health awareness program. Materials and Methods This is a quantitative study that aimed to evaluate the effec- tiveness of a school based mental health awareness program. An invitation was sent from the principals of two middle schools to parents of children to attend the awareness program that was hosted in one of the middle schools in Muscat. 178 parents and 150 students from different levels (Grades 5–10) attended the awareness activity recruited through convenience sampling approach. Prior to conducting the awareness program, the students were asked to respond to five questionnaires: 1) Anxiety scale (41 items); 2) Mood & feelings (13 items); 3) Depression (15 items); 4) Bullying (6 items). The questionnaires adopted from different studies and showed very good reliability (>0.7). Stu- dents were informed that their participation is voluntary. The students who accepted to participate were given a consent form to sign. The parents were asked to evaluate the effective- ness of the awareness program at the end of the activity using a tool that consisted of 12 items (knowledge improvement, materials, program activities, consultation service). Description of the Awareness Program The awareness program consisted of 1) A power point pres- entation mental health wellbeing in children and the factors associated with mental health problems; 2) A video on the fac- tors influencing the mental health status among school age children and the role of parents in enhancing the overall mental health wellbeing of their children. 3) Role-play illus- trated a case of a child suffered from a mental health problem due to family problems. The case was presented from the Omani community. 4) Poster presentation of the findings of a study done by the nursing students in previous years on mental health status among school age children; 5) A consultation corner by a psychologist to guide and address the parents’ con- cerns on child health mental illness and issues; 6) Material dis- tributions on mental health. The program was conducted in one of the middle schools in Muscat region. The program lasted for 5 hours. Results Data were analyzed using SPSS, v.24. One-way ANOVA was conducted to analyze the tools. Frequencies and percentages were used to analyze the program effectiveness. The age of the students ranged between (9–14 years). 85% of the students were Omanis, 15% were non-Omanis. The result from the questionnaires revealed that 60% of students had experienced mood swings. There was a significant different in mood and feeling score between the grades (P = 0.001); with grade 10 being the highest disturbed mood changes (M = 23.25, SD = 5.54). The results also showed that 55% of students expe- rienced anxiety. From the analysis, it was found that grade 10 (M = 36.15, SD = 18.43, P = 0.05) reported higher anxiety than others groups. In addition, the findings highlighted that 28.3% experienced a pre depression state. The study also attempted to correlate experience of bullying with the mental health status. The findings revealed that 89% of students experienced bullying and grade 5 were highly victimized from bullying than others group. The results indicated a strong correlation between experience of bullying and mental health problems (r = 0.85); which suggests that bullying could be a cause for experiencing mental health problems in school age children. The study also highlighted that a smaller rate of students (10.8%) had tendency for bullying. From the analysis, it was found that grade 10 (M = 4.05, SD = 3.57) had higher tendency for bullying than other groups. The evaluation tool for the awareness program indicated that 91% of parents reported improvement in knowledge after the program; 89% suggested that many information they were not aware of before. 92% rated the video as informative. 93% agreed that the program activities were entertaining and informative. 92% reported that the activity increased their awareness to observe the changes in their children emotional wellbeing. 98% of parents rated the overall program as effec- tive and very interesting. 97% enjoyed the activities provided for them on that day. 29J Contemp Med Sci | Vol. 8, No. 1, January-February 2022: 27–30 Y. Al Nasiri et al. Original Mental Health Wellbeing of School Age Children Discussion Creating awareness to parents on mental health wellbeing of school age children was effective as it led to improve knowl- edge of parents after the program. Our findings were similar to the findings of study.12,15 The study found that the awareness program was very effective and helped improve the commu- nity knowledge regarding depression and anxiety. The pro- gram assisted people to assess signs of depression and offered them management options. The implementation of the awareness program was fea- sible and activities were very interesting to the parents. The activities planned made suitable for different age group of chil- dren & parents; older parents were able to grasp the informa- tion easily and able to track the program without any hassle. Some studies supported the intervention we developed.12 The study of created a public awareness program on health and the findings suggested that the program was feasible and suc- cessful and empowered patients to seek early care and inter- ventions. Similarly, one study developed an anti-stigma awareness program and found that the program improved the public knowledge on various mental health problems and facilitated seeking of psychological support.16 To our knowledge, this was first study that assessed the mental health status among school age children in Oman. The findings yielded from the study were alarming and highly important; which necessities the need to raise an awareness in the Omani community on the importance of enhancing mental health status in children. Community awareness serves as a means to disseminate the findings revealed from the study, shed the light on the common mental health problems in chil- dren, highlight the factors contributing to mental health prob- lems and suggest ways for enhancing children’s mental health. Limitations The sample size was very small; which limits the generaliza- tion of the findings to other settings. Also, cross section designs do not examine the cause – effect relationship, data was only collected at one-time point and therefore, the causes of the reported percentages and changes in the children cannot be related to any causes. Longitudinal studies are therefore recommended. Recommendations It is recommended to replicate the study with more sample size from different schools and regions in Oman. Implications of the Project Conducting awareness yielded two fold advantages. First, it created an awareness in the community about the importance of maintaining mental health wellbeing for school age chil- dren. Second, it created more attention to public about certain factors that may affect the mental health wellbeing of children. Moreover, it helps to inform the nursing practice regarding the need to establish a mental health program in schools to target mental health problems affecting children. Conclusion Mental health and emotional wellbeing in children is just important as their physical health. This study assessed the mental health wellbeing of school age children at two middle age schools in Oman. The study created a community aware- ness program to parents and their children on the importance of enhancing mental health wellbeing. The program was crea- tive and effective in improving the parents’ knowledge on dif- ferent mental health problems affecting school age children such as depression, anxiety, worries and mood changes and bullying. Parents were provided with various guidelines to inform them about their roles in assessing and seek early man- agement of the health issue. Parents felt supported and cared. The information presented were simple and clear that could be understood by all parents from different age groups. In con- clusion, there is a dire need to conduct various awareness pro- grams in the community to help people feel supported, cared and valued. Such programs are not only helpful in improving the community knowledge on the factors influencing chil- dren’s mental health, but also assist in identifying the mental health problems at early stage; which may empower them to seek early management for their children. This study suggests an establishment of a mental health program for children in Oman to identify the cases, assess the mental problems affecting children at different age and refer them for further support and management. Ethical Consideration Prior conducting the study, ethical approval of the Oman College of Health Sciences was obtained. Also, the approval of the schools’ principal was obtained. Consent form was given to the students prior to data collection. Acknowledgements We would like to thank Dr. Salem Al Touby, an associate professor and dean of College of Nursing and Pharmacy for his support and guidance. We also thank Dr. Nasir Al Balushi, a child psychologist at Sultan Qaboos University Hospital for participating in the implementation phase of this study. Conflicts of Interest Disclosures There is no conflict of interest.  References 1. Jha K, Singh S, Nirala S, Kumar C, Kumar P, Aggrawal N. Prevalence of depression among school-going adolescents in an Urban Area of Bihar, India. Indian J Psychological Med, 2017;39(3):287–293. 2. Patel H, Varma J, Shah S, Phatak A, Nimbalkar S. Profile of bullies and victims among urban school-going adolescents in Gujarat. Indian Paed. 2017;54 (10):841–843. 3. Mello F, Silva J, Oliveira W, Prado R, Malta D, Silva M. The practice of bullying among Brazilian schoolchildren and associated factors. National School Health Survey. Ciencia & Saude Coletiva. 2015;22(9):2939–2948. 4. Chauhan S, Panna L, Harsavardhan N. Prevalence of Depression among School Children aged 15 years and above in a Public School in Noida, Uttar Pradesh. 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