Advancing education-based mental health in low-resource settings during health crises: the mental health initiative of the University of the Philippines during the COVID-19 pandemic

1 Introduction

The COVID-19 pandemic led to lockdowns and school closures, negatively affecting students’ mental health (Xiong et al., 2020). Evident in a systematic review of studies globally, students reported having higher rates of anxiety, depression, fatigue, and, in general, distress during the pandemic (Xiong et al., 2020). Similarly, higher rates of mental health conditions have been reported among students in the Philippines, including anxiety and depressive symptoms (Cleofas and Rocha, 2021; Cleofas, 2022; Serrano and Reyes, 2022; Alibudbud, 2023b). For instance, suicide attempts among the youth, the age group of most college students in the Philippines, increased from 3 to 7.5% between 2013 and 2021 (Alibudbud, 2023b). These challenges related to poor mental health can lead to decreased quality of life and academic difficulties among students (Cleofas, 2021; Cleofas and Rocha, 2021; Cleofas, 2022; Aruta et al., 2022a; Alibudbud, 2023b). Therefore, it is imperative to address the mental health needs of Filipino students.

Nonetheless, the Philippines have scarce mental health resources. Mental health professionals are limited, with only about 500 psychiatrists and 1,600 psychologists serving the Philippines’ more than 100 million population (Aruta et al., 2022b; Alibudbud, 2023a). Likewise, these mental health professionals are highly concentrated in urban areas, leading to inequalities, where there might be low mental health services in rural areas (Aruta et al., 2022b; Alibudbud, 2023a). Furthermore, a report indicates that the country’s mental health funding is limited by only about 5% of the total healthcare expenditure (Maravilla and Tan, 2021; Alibudbud, 2023a).

Overall, Philippine universities and schools need to address the mental health impacts of the COVID-19 pandemic with limited and unequal mental health resources. Therefore, this brief report presented the mental health initiatives during the pandemic of a university in the Philippines, a lower middle-income country with limited mental health resources. In doing so, the challenges and insights from this brief report can serve as exemplars for other low-resource settings faced with tremendous mental health needs.

2 Sandigan, Sandalan: the University of the Philippines—system mental health initiatives

The University of the Philippines (UP) is the Philippines’ national university and premier public institution of higher learning. It is a secular public institution organized as a university system composed of 17 campuses all over the Philippines (Republic Act No. 9500, 2008; UP System Budget Office, 2020; University of the Philippines, 2023). In the academic year 2020–2021, it had a total of 54,362 comprising undergraduate and graduate students (UP System Budget Office, 2020).

Before the UP system-wide campaign, several campuses of the University had established facilities that extend mental health services and advocacies in their campuses. However, a 2018 gathering across the UP system recognized students’ persistent mental health concerns and the need for additional mental health initiatives. With the COVID-19 Pandemic ushering several challenges, including increased demand for mental healthcare and changes in teaching delivery (Cleofas, 2021; Cleofas and Rocha, 2021; Cleofas, 2022; Aruta et al., 2022a; Alibudbud, 2023b), mental health initiatives within the University are needed to enhance mental health services, health-seeking behaviors, and mental well-being among its students (Cleofas and Rocha, 2021). The University echoed these pandemic-related challenges as it considered mental health concerns, especially with the shift to distance education, as possible challenges, negatively affecting the academic-life balance of students (University of the Philippines, 2021a).

Recognizing the role of teachers and peers in advocating and supporting mental health (Shalaby and Agyapong, 2020; Sakellari et al., 2021), the UP System introduced an initiative to strengthen mental health services and advocacies among its different campuses. The strategy is founded on the potential of the university’s stakeholders, including faculty members, students, and student affairs professionals (i.e., scholarship officers, guidance counselors) (Shalaby and Agyapong, 2020; Sakellari et al., 2021), to advocate for mental health and create enabling conditions necessary to promote help-seeking behavior among university stakeholders with mental health concerns.

After a discussion with mental health professionals, the UP system’s mental health initiative considered several contextual factors within Philippine society in its programming, including the Philippine Mental Health Act, the country’s limited number of mental health professionals, mental health stigma, and economic limitations (Martinez et al., 2020; Maravilla and Tan, 2021; Aruta et al., 2022b; Alibudbud, 2023a). By 2020, UP introduced a system-wide mental health initiative to foster the mental well-being of its students. The initiative started under the umbrella program called Sandigan, Sandalan: Training and Advocacy Progams for Mental Health (University of the Philippines, 2021b). The program built the capacity of UP stakeholders to advocate mental health within the university. Between 2021 and 2022, additional components and policy changes were introduced to bolster the support offered by Sandigan, Sandalan program. The following components encompassed the program:

2.1 Designation of college mental health focal persons

Given the demand for mental health services and the need for information to improve mental health outcomes in classroom contexts among Filipino students (Cleofas, 2021; Cleofas and Rocha, 2021; Cleofas, 2022; Aruta et al., 2022a; Alibudbud, 2023b), the program requested the designation of Mental Health Focal Persons (MHFP) for each academic unit. The MHFP are faculty members and Student Affairs personnel who can serve as mental health advocates in their academic units.

2.2 Training on mental health promotion in the teaching-learning environment

With the appointment of MHFP, it is imperative to equip them with appropriate competencies. These competencies were identified with the help of the University’s mental health experts. They encompassed mental health knowledge, skills, and attitudes on responding to Filipino students’ mental health concerns. In 2021, three batches of MHFP were trained. While the training concluded in July 2021, the learning materials were made available to colleges and university administrative units that can be utilized to orient their personnel who can also promote mental health.

2.3 Peer support training

Recognizing that students can also provide care and support to their peers (Shalaby and Agyapong, 2020), the program developed peer support training. The training helped students to become mental health advocates by equipping them with knowledge and skills on mental health support and advocacy, thereby complementing the support offered by the University. The training was then replicated on several campuses to further foster mental health advocacy among members of different student organizations.

2.4 Recognition of student mental health advocacy projects

The program also recognized innovative student-led mental health advocacy projects from student organizations and groups. It highlighted the role of student groups in mental health promotion, encouraging advocacy projects among students by featuring student-led programs that other student groups can replicate within the University. With public and mental health experts, criteria were formulated to determine model student advocacy projects. Selected projects were also featured in an online video featured during Philippine Mental Health Awareness Month. These efforts emphasized that students can partake in and advocate for mental health using different approaches.

2.5 Directory of mental health service providers

The UP system, together with the student affairs units from different campuses, prepared a directory of mental health service providers, including professionals and organizations offering various mental health support services within and near the university’s campuses. The directory provided information to students and student affairs personnel about the range of mental health services and referral systems available in their area, which was helpful for complex treatment and emergencies.

2.6 Student wellness subsidy

Despite the various efforts extended to students, the mental health services they need have not always been available on the different campuses. Among others, the cost of treatment can be a significant barrier to help-seeking, especially for students from low-to-middle-income households (Lally et al., 2019b; Maravilla and Tan, 2021). Therefore, the University allocated a budget to create the Student Wellness Subsidy. This subsidy helped address the financial burden of mental health treatment by covering a portion of the cost of psychiatric medications and services. By doing so, it encouraged students to continue their treatment with their mental health service providers.

2.7 Students-in-distress protocols

Recognizing the challenge of remote learning and the heightened mental distress during the pandemic (Cleofas, 2021, 2022; Cleofas and Rocha, 2021; Aruta et al., 2022a; Alibudbud, 2023b), protocols were formulated to mobilize the different student affairs units in the University’s campuses to respond to students experiencing severe distress. The protocols provided general guidance to the different campuses, which was especially helpful for relatively young campuses that have yet to develop mental health crisis-response procedures.

2.8 Institutionalization of the mental health initiative

On February 2022, a University office was reorganized to ensure a standard for student development within the University and expanded its scope of institutionalizing mental health promotion at all the campuses.

3 Discussion

3.1 Challenges and recommendations from the development of Sandigan, Sandalan

Overall, the Sandigan, Sandalan encompassed a range of activities, from mental health training to the institutionalization of mental health promotion within the university administration and its academic units. Several considerations were taken into account in the program’s establishment. First, the program needs to align with relevant national policy. In our context, the program aligned with the provisions of the Philippine Mental Act (e.g., Republic Act No. 11036, 2018), which mandates local educational institutions to develop policies and programs that raise mental health awareness, provide support and services for at-risk individuals, improve access to facilities and referral mechanisms for treatment and support, and employ mental health professionals (Republic Act No. 11036, 2018; Lally et al., 2019a).

The limited number of mental health professionals and the stigma attached to mental health in the country, including misconceptions (Martinez et al., 2020), posed challenges to the efficient facilitation of treatment services and the encouragement of help-seeking behaviors. To address this, Sandigan, Sandalan sought to empower the stakeholders in the university. By enhancing the capacity of these stakeholders, they were able to collaborate effectively so they can provide accurate information and promote mental health in their respective campuses. This approach not only addressed misconceptions about mental health but also optimized resource distribution, allowing the limited number of mental health professionals to focus on treatment services.

Moreover, economic conditions and the inaccessibility of mental health services have been viewed to limit access to mental healthcare in the Philippines (Lally et al., 2019b). With the Philippine economy further contracting by 9.5% during the pandemic (Angeles-Agdeppa et al., 2022), university stakeholders might hesitate to seek mental health services due to financial concerns. In light of this, it is imperative to complement mental health promotion programs with subsidies and other support services that can reduce cost of mental healthcare. Reducing the cost can encourage help-seeking behavior stakeholders, even those facing financial constraints, so they can avail the needed treatment services.

Despite the initial considerations in its establishment, Sandigan, Sandalan encountered challenges related to scale due to the large size and the complex structure of the university. As an initiative of a large public institution, the program is expected to serve a multitude of stakeholders despite having limited mental health resources. To maintain its operations and obtain support for further development, the program must consistently draw attention to create enabling conditions. This ensured the public and financial support of the university’s top managers, that can aid its operations and possible expansion. Further, being a program for students, it is imperative that the program shares structures similar to other student development services. This alignment ensures seamless implementation by student affairs personnel alongside existing student development initiatives. This effectively optimizes its reach while complementing other functions of the university.

Drawing from our experience in the Sandigan, Sandalan, several recommendations can be considered by other educational institutions with tremendous mental health needs and in low-resource settings faced. First, it is necessary to design an initiative that can advocate the program across various levels of university stakeholders, from the top management to the academic staff. This fosters a collaborative approach to ensure unified effort in addressing mental health challenges. Doing so also helps ensure public support and financial and human resources so mental health programs are given priority status within different academic units of the university.

Secondly, the establishment of clear program objectives and the effective communication of achievable outcomes is crucial. Our experience underscores that mental health outcomes are often inadequately comprehended, often confined to instances of suicide. By disseminating reasonable expectations, organizations within educational institutions can effectively align their efforts while creating awareness about the broad spectrum of positive impacts that result from promoting mental well-being.

Third, it is necessary to recognize the authority of mental health experts and professionals and the role of advocates in the conduct of the program and in creating an environment that cares for the mental well-being of university stakeholders. It is imperative to create venues such as technical working groups where experts and advocates can share their perspectives and experiences and collaborate in instituting mental health promotion within the context of student services. These venues offer the opportunity to align different student development initiatives to ensure seamless implementation alongside other university programs.

Fourth, recognizing the importance of empowering university stakeholders is necessary to surmount the challenges presented by the university’s limited number of mental health service providers and resources (Shalaby and Agyapong, 2020; Sakellari et al., 2021). For instance, stakeholders who have direct contact with students can be empowered about the importance of mental health so they can assume nurturing roles as teachers and peers in various learning contexts. Building their capacity will allow them to assume critical roles in responding to students’ mental health concerns and needs.

Fifth, the replicability of the program within the different campuses should be considered. Mental health program should be designed considering the context of a university campus with the least financial and social resources. Doing so ensures its continued implementation so it can be scaled up eventually.

Lastly, attention must be given to program publicity and visibility. This step serves to reinforce the gains derived from the program, while also motivating other organizations to extend their support. Publicizing mental health programs not only sustains commitment but also reinforces the program’s feasibility, cultivating a perception that mental health initiatives can be implemented by stakeholders across different university campuses despite limited resources.

3.2 Limitations and opportunities for enhancement

The implementation of the Sandigan, Sandalan program highlights key areas for designing education-based mental health initiatives, particularly in the context of a university operating in a low-resource setting. While the continued implementation of this program offers an opportunity to empower university stakeholders to address mental health promotion challenges, it is crucial to identify areas to optimize allocation of the university’s limited resources and leverage complementary student development services and academic initiatives.

Moreover, it must be noted that the Sandigan, Sandalan program was crafted based on the information available to its implementers, taking into account the challenges faced by students during the COVID-19 pandemic. Mechanisms for monitoring the program’s relevance will be essential to identify emerging concerns that could impact students’ mental wellbeing due to changes in the learning environment, especially among vulnerable populations like women and LGBTQ+ people (Alibudbud, 2022; Cleofas and Alibudbud, 2023). These insights will be relevant to ensure support can be gathered for the program’s sustainability.

4 Conclusion

Overall, the global ramifications of the COVID-19 pandemic have significantly augmented the extant mental health impediments faced by students on an international scale, a circumstance that has equally transpired within the academic milieu of the Philippines. Therefore, several measures were undertaken by the University of the Philippines in light of this exigency—an undertaking of paramount significance given the nation’s constrained mental health resources. The program, “Sandigan, Sandalan,” was configured to enable the university’s stakeholders to champion mental health, notwithstanding the impediments posed by limited resources and the expansive purview of the university. An important result of this effort is the emphasized role of educational institutions in creating a supportive environment, offering valuable insights into improving students’ mental well-being, even amidst challenges like limited resources and logistical difficulties. Drawing from this initiative, several salient recommendations can be undertaken by similar organizations with limited resources, including fostering stakeholder collaboration, clarifying program objectives, leveraging mental health expertise, empowering stakeholders, designing replicable models, and enhancing program visibility.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Author contributions

RG: Conceptualization, Resources, Supervision, Writing – original draft, Writing – review & editing. RA: Conceptualization, Writing – original draft, Writing – review & editing.

Funding

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Acknowledgments

The authors wish to thank the staff of the UP OVPAA, UP Office of Student Development Services, the UP academic and administrative staff who supported the programs, and the UP students who participated in and supported the various Sandigan, Sandalan activities from 2020 and 2022. The authors also wish to thank the Philippine Mental Health Science Academe and Research (MHSAR) Task Force for recognizing the value of work as inputs in the formulation of consensus statements and recommendations on mental health promotion for Philippine Higher Education Institutions.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

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References

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