Effectiveness of a mental health literacy module on stigma related mental health knowledge and behaviour among youth in two educational settings in Chennai, South India: A quasi-experimental study
Introduction Mental disorders are the most common cause of disease burden and disability among young people. Most mental disorders have their onset before the age of 25 years, peaking around 13–16 years of age . By a recent estimate, one of five young people suffer from a mental disorder . This translates to a large number of young people with mental disorders in need of mental health intervention, especially in a country such as India where youth (15–24 years) constitute one-fifth (19.1%) of the total population . Many factors have been attributed to poor help-seeking for mental disorders in developing countries. These include stigma and discrimination, poor awareness of mental disorders, and inadequate mental health services in many countries including India . Mental health literacy (MHL) is defined as understanding how to obtain and maintain positive mental health, an understanding of mental disorders and their treatment, reducing stigma towards mental disorders, and promoting help-seeking for mental disorders . MHL is considered pivotal for mental health promotion, early identification and referral to mental health services and continued care . Previous studies that have implemented MHL training in developed countries were conducted in educational settings, including schools and colleges . MHL training can have an impact on stigma as shown by the school-based approach of integrating mental health literacy modules with the regular curriculum in Canada . A replication of the Canadian model in African countries has yielded similar positive results for stigma reduction in teachers ; however, impacts on youths have not been tested. Testing the impact of mental health literacy on youths can help to understand its effectiveness in reducing stigma, and inform strategies to equip young people with the knowledge and skills to foster supportive environments, promoting mental well-being and reducing barriers to seeking help. Even though many studies from India have measured mental health literacy among diverse populations including adolescents and young adults , to our knowledge, no study from India has developed and examined the impact of a MHL intervention session on stigma related mental health knowledge and behaviour among youth. This is an important area of study as reduction in stigma is associated with improved help-seeking among young people . Further, it is important to collate inputs from different stakeholders to develop MHL interventions that are acceptable, feasible, effective, and sustainable to deliver in low resource settings such as India. By incorporating perspectives from diverse stakeholders, including community members, healthcare providers, and policymakers, interventions can be tailored to address specific cultural contexts and resource constraints, ultimately enhancing their impact and scalability. Even though the definition of MHL four distinct but related components such as understanding how to obtain and maintain good mental health, understanding mental disorders and their treatments, reducing the stigma related to mental disorders, and enhancing help-seeking efficacy, in the current study, we envisioned to address the stigma related mental health knowledge and behaviour due to various factors such as the impact of the stigma on help seeking for mental health issues, and the logistics of developing and delivering interventions addressing all the components of MHL. Hence, our objectives were to develop a mental health literacy intervention suitable for young people aged between 18 and 24 years and to examine the impact (i.e., over 6 months) of this intervention on stigma related mental health knowledge and behaviour (SRMHKB) in colleges in Chennai. We had two main research questions: 1) Does a single mental health literacy session lead to improvements in SRMHKB; and 2) If so, are these improvements sustained over time (i.e., 6 months)? 

Methods 2.1 Context The current study was a part of our larger project of the National Institute of Health Research (NIHR) Global Health Research Group (GHRG) on Psychosis Outcomes: the Warwick-India-Canada (WIC) network, which focuses on first episode psychosis and youth mental health in two Indian centres. The detailed description of the research project has been published . One of the aims of this study was to understand the magnitude of mental health issues among young people in educational settings in India, and to improve their mental health. 2.2 Site We conducted the study at two city colleges in Chennai, India. Both colleges were selected as they were large colleges with a student population of approximately n = 2000, admitting both males and females, and having working relationship with the researchers of the study. The study was conducted classroom wise in each of these colleges. Permissions were obtained from the management of the educational institutions to conduct the study on their premises. The study was conducted between January 2019-December 2019. Ethical approval was obtained before the start of the study from the Institutional Ethics Committee of Schizophrenia Research Foundation (SCARF), Chennai, India (SRF/WIC-12/NOV-2017). Written informed consent was obtained from all study participants. 2.3 Study participants The participants were students between 18 and 24 years of age. We selected 6 classrooms from different departments in each of the colleges through convenience sampling. The average number of students in each classroom was 50 (Range: 40–60). The inclusion criteria for the study participants were: aged between 18 and 24 years; both males and females; and willing to provide written informed consent to take part in the study. There were no specific exclusion criteria for the study participants except that the students who were absent on the day of intervention delivery were excluded from the study. 2.4 Developing the mental health literacy intervention module First, we conducted a scoping review of the literature from developed and developing countries on existing mental health literacy modules addressing stigma related mental health knowledge and behaviour. We identified key components including the topics covered, number of sessions, duration of each session, and mode of delivery. We conducted two stakeholder meetings comprising a mix of different stakeholders, namely young people (n=8), teachers (n=4) and mental health professionals (n=3), to develop the MHL module. The stakeholder meetings were facilitated by the researchers (VR, SC and VP) who presented the findings from the literature review as a starting point for the discussions. Discussions covered each aspect of the MHL module including content, duration of the session, number of sessions, and medium of delivery. Stakeholder input was collated during the meeting to further shape the design of the MHL intervention. We conducted an internal meeting with the researchers (VR, SC, VP, and RP) and representative stakeholders (2 students and 1 teacher) to refine and finalise the structure and content of the MHL module using the consensus approach, i.e., a collaborative effort to reach a shared agreement on methodologies and processes using open communication, dialogue, and compromise to reconcile differing perspectives. Key issues discussed included: length and frequency of the module, and anticipating and planning for practical challenges that might arise during the delivery of the intervention in college settings. The final module was designed based on the multiple inputs on the structure and content of the mental health literacy module for the students such as the results from scoping review, inputs from stakeholder meetings and internal discussions among the researchers. The final module was designed as a 90-minute single session intervention delivered as an interactive discussion with the students. The module included a wide range of topics relating to mental health and aimed at reducing misconceptions leading to stigma. The MHL module was designed to maximize efficiency and engagement by structuring around key themes and interactive activities. The topics were carefully selected to ensure coverage of essential mental health literacy concepts while allowing for depth and relevance within the time constraints. Additionally, the MHL module utilized interactive methodology to deliver information to facilitate active learning and knowledge retention within the allotted time frame. presents the topics covered by the mental health literacy module and schedule in Supplementary Table 1. 2.5 Training of the facilitators Researchers (VR and SC) trained psychologists and psychiatric social workers to deliver the 90-minute mental health literacy module. A one-day training program included the contents of the module, mode of delivery, dealing with sensitive issues, etc. After the training, all the facilitators delivered the intervention in mock sessions. For our research study, we employed a semi-structured assessment proforma to evaluate the fidelity of the training process. This assessment tool enabled us to gauge various aspects of facilitator performance, including their ability to deliver the content covered in the training sessions, facilitate meaningful discussions among participants, and ensure that each session adhered to the designated time frame. Upon careful evaluation, all four facilitators who underwent training were consistently rated as effective in their delivery approach. Subsequently, these proficient facilitators were actively engaged in delivering the intervention to the target audience. Each intervention session accommodated an average of 50 students, ensuring a substantial reach and impact within the study population. 2.6 Implementation challenges We faced challenges in the delivery of the intervention at institutional, classroom, and student level. Sensitivity to mental health issues varied across institutions, some of which were reluctant to permit the programme in the classroom setting. We found it difficult to find one point of contact for each college to coordinate with the research staff. Priority was given to the academic syllabus, thus scheduling the intervention within college hours was difficult. Students found topics such as stress management, drug abuse and interpersonal relationships more engaging than mental illness, as indicated by student levels of interaction. As some classes had 50 students, involving them in the interactive session was difficult. Some students expressed the need to talk to our staff privately after the session, however, there was no private space available. Even though online assessments via mobile phones in colleges offered convenience but posed challenges such as technological limitations due to unequal access to internet and smartphones, potential distractions from the multifunctional nature of mobile devices, issues with screen size affecting readability, and disparities in performance based on digital literacy levels among students. 2.7 Study procedure Baseline assessments (i.e., sociodemographic details and mental health knowledge and behaviour) were completed prior to delivery of the 90-minute interactive session. Students were encouraged to share their experiences of mental health issues within the sessions. Facilitators encouraged open discussion through the setting the ground rules, including expectations of non-judgemental attitudes, empathetic listening, and solution-focussed discussion. The intervention was delivered in the local language, Tamil. Following the session, students’ knowledge and intended behaviour towards mental health was assessed. The same assessments were repeated at 3 and 6 months. We requested the college management to allow all the participating students to bring their mobile phones to the class on the days of assessment so that they can access the online portal to provide the responses. In case of the participants without mobile phones, we provided the mobile phones and tablets. We achieved 100% response rates for assessments at each time-point by working closely with the colleges to maintain good rapport with participants over time. 2.8 Tools administered 2.8.1 Sociodemographic details We developed a semi-structured proforma to collect socio-demographic characteristics such as age, gender and living status. 2.8.2 Mental Health Knowledge Schedule (MAKS)  This twelve-item scale comprises domains of relevant evidence-based knowledge in relation to stigma toward mental illness and has been used in previous studies from India . Items are coded on an ordinal scale (1–5). The total score is calculated by adding the points obtained for each item. Higher total scores correspond to greater knowledge. The Cronbach’s alpha for the MAKS scale was 0.749. 2.8.3 Reported and Intended Behaviour Scale (RIBS)  The RIBS comprises two subscales containing eight items in total. The ﬁrst subscale includes four statements relating to past or present contact with people with mental health problems. Each item receives a score of 1 for ‘yes,’ and 0 for ‘no’ or ‘don’t know’ (score range of the subscale: 0–4). Higher scores indicate more past or present contact. The second subscale consists of four statements relating to participants’ future behavioural intentions when they encounter people with mental health problems. Responses to the items are rated as ‘agree strongly’, ‘agree slightly’, ‘neither agree nor disagree’, ‘disagree slightly’, ‘disagree strongly’ and ‘don’t know’. For each item, a score of 5 was allocated for strong agreement, while a score of 1 was assigned to strong disagreement (score range of the subscale: 4–20). The response option ‘don’t know’, is coded as neutral (i.e., 3). Higher scores indicate more favourable behavioural intentions. RIBS was previously used in studies from India . We used the scores of the second subscale (items 5–8) of RIBS to assess the changes in the behaviour over time among the participants. 2.9 Data analysis The statistical analysis was conducted using STATA 16.0. Summary statistics provided a description of participants. A p-value of less than 0.05 was considered statistically significant. Mauchly's test for the sphericity assumption was violated for RIBS and MAKS (p<0.001). To overcome the issue of sphericity, repeated measures ANOVA with Greenhouse-Geisser corrections is reported. A Generalized Estimation Equation (GEE) was performed, as the extension to assess change in scores over time. 

Context The current study was a part of our larger project of the National Institute of Health Research (NIHR) Global Health Research Group (GHRG) on Psychosis Outcomes: the Warwick-India-Canada (WIC) network, which focuses on first episode psychosis and youth mental health in two Indian centres. The detailed description of the research project has been published . One of the aims of this study was to understand the magnitude of mental health issues among young people in educational settings in India, and to improve their mental health. 

Site We conducted the study at two city colleges in Chennai, India. Both colleges were selected as they were large colleges with a student population of approximately n = 2000, admitting both males and females, and having working relationship with the researchers of the study. The study was conducted classroom wise in each of these colleges. Permissions were obtained from the management of the educational institutions to conduct the study on their premises. The study was conducted between January 2019-December 2019. Ethical approval was obtained before the start of the study from the Institutional Ethics Committee of Schizophrenia Research Foundation (SCARF), Chennai, India (SRF/WIC-12/NOV-2017). Written informed consent was obtained from all study participants. 

Study participants The participants were students between 18 and 24 years of age. We selected 6 classrooms from different departments in each of the colleges through convenience sampling. The average number of students in each classroom was 50 (Range: 40–60). The inclusion criteria for the study participants were: aged between 18 and 24 years; both males and females; and willing to provide written informed consent to take part in the study. There were no specific exclusion criteria for the study participants except that the students who were absent on the day of intervention delivery were excluded from the study. 

Developing the mental health literacy intervention module First, we conducted a scoping review of the literature from developed and developing countries on existing mental health literacy modules addressing stigma related mental health knowledge and behaviour. We identified key components including the topics covered, number of sessions, duration of each session, and mode of delivery. We conducted two stakeholder meetings comprising a mix of different stakeholders, namely young people (n=8), teachers (n=4) and mental health professionals (n=3), to develop the MHL module. The stakeholder meetings were facilitated by the researchers (VR, SC and VP) who presented the findings from the literature review as a starting point for the discussions. Discussions covered each aspect of the MHL module including content, duration of the session, number of sessions, and medium of delivery. Stakeholder input was collated during the meeting to further shape the design of the MHL intervention. We conducted an internal meeting with the researchers (VR, SC, VP, and RP) and representative stakeholders (2 students and 1 teacher) to refine and finalise the structure and content of the MHL module using the consensus approach, i.e., a collaborative effort to reach a shared agreement on methodologies and processes using open communication, dialogue, and compromise to reconcile differing perspectives. Key issues discussed included: length and frequency of the module, and anticipating and planning for practical challenges that might arise during the delivery of the intervention in college settings. The final module was designed based on the multiple inputs on the structure and content of the mental health literacy module for the students such as the results from scoping review, inputs from stakeholder meetings and internal discussions among the researchers. The final module was designed as a 90-minute single session intervention delivered as an interactive discussion with the students. The module included a wide range of topics relating to mental health and aimed at reducing misconceptions leading to stigma. The MHL module was designed to maximize efficiency and engagement by structuring around key themes and interactive activities. The topics were carefully selected to ensure coverage of essential mental health literacy concepts while allowing for depth and relevance within the time constraints. Additionally, the MHL module utilized interactive methodology to deliver information to facilitate active learning and knowledge retention within the allotted time frame. presents the topics covered by the mental health literacy module and schedule in Supplementary Table 1. 

Training of the facilitators Researchers (VR and SC) trained psychologists and psychiatric social workers to deliver the 90-minute mental health literacy module. A one-day training program included the contents of the module, mode of delivery, dealing with sensitive issues, etc. After the training, all the facilitators delivered the intervention in mock sessions. For our research study, we employed a semi-structured assessment proforma to evaluate the fidelity of the training process. This assessment tool enabled us to gauge various aspects of facilitator performance, including their ability to deliver the content covered in the training sessions, facilitate meaningful discussions among participants, and ensure that each session adhered to the designated time frame. Upon careful evaluation, all four facilitators who underwent training were consistently rated as effective in their delivery approach. Subsequently, these proficient facilitators were actively engaged in delivering the intervention to the target audience. Each intervention session accommodated an average of 50 students, ensuring a substantial reach and impact within the study population. 

Implementation challenges We faced challenges in the delivery of the intervention at institutional, classroom, and student level. Sensitivity to mental health issues varied across institutions, some of which were reluctant to permit the programme in the classroom setting. We found it difficult to find one point of contact for each college to coordinate with the research staff. Priority was given to the academic syllabus, thus scheduling the intervention within college hours was difficult. Students found topics such as stress management, drug abuse and interpersonal relationships more engaging than mental illness, as indicated by student levels of interaction. As some classes had 50 students, involving them in the interactive session was difficult. Some students expressed the need to talk to our staff privately after the session, however, there was no private space available. Even though online assessments via mobile phones in colleges offered convenience but posed challenges such as technological limitations due to unequal access to internet and smartphones, potential distractions from the multifunctional nature of mobile devices, issues with screen size affecting readability, and disparities in performance based on digital literacy levels among students. 

Study procedure Baseline assessments (i.e., sociodemographic details and mental health knowledge and behaviour) were completed prior to delivery of the 90-minute interactive session. Students were encouraged to share their experiences of mental health issues within the sessions. Facilitators encouraged open discussion through the setting the ground rules, including expectations of non-judgemental attitudes, empathetic listening, and solution-focussed discussion. The intervention was delivered in the local language, Tamil. Following the session, students’ knowledge and intended behaviour towards mental health was assessed. The same assessments were repeated at 3 and 6 months. We requested the college management to allow all the participating students to bring their mobile phones to the class on the days of assessment so that they can access the online portal to provide the responses. In case of the participants without mobile phones, we provided the mobile phones and tablets. We achieved 100% response rates for assessments at each time-point by working closely with the colleges to maintain good rapport with participants over time. 

Tools administered 2.8.1 Sociodemographic details We developed a semi-structured proforma to collect socio-demographic characteristics such as age, gender and living status. 2.8.2 Mental Health Knowledge Schedule (MAKS)  This twelve-item scale comprises domains of relevant evidence-based knowledge in relation to stigma toward mental illness and has been used in previous studies from India . Items are coded on an ordinal scale (1–5). The total score is calculated by adding the points obtained for each item. Higher total scores correspond to greater knowledge. The Cronbach’s alpha for the MAKS scale was 0.749. 2.8.3 Reported and Intended Behaviour Scale (RIBS)  The RIBS comprises two subscales containing eight items in total. The ﬁrst subscale includes four statements relating to past or present contact with people with mental health problems. Each item receives a score of 1 for ‘yes,’ and 0 for ‘no’ or ‘don’t know’ (score range of the subscale: 0–4). Higher scores indicate more past or present contact. The second subscale consists of four statements relating to participants’ future behavioural intentions when they encounter people with mental health problems. Responses to the items are rated as ‘agree strongly’, ‘agree slightly’, ‘neither agree nor disagree’, ‘disagree slightly’, ‘disagree strongly’ and ‘don’t know’. For each item, a score of 5 was allocated for strong agreement, while a score of 1 was assigned to strong disagreement (score range of the subscale: 4–20). The response option ‘don’t know’, is coded as neutral (i.e., 3). Higher scores indicate more favourable behavioural intentions. RIBS was previously used in studies from India . We used the scores of the second subscale (items 5–8) of RIBS to assess the changes in the behaviour over time among the participants. 

Sociodemographic details We developed a semi-structured proforma to collect socio-demographic characteristics such as age, gender and living status. 

Mental Health Knowledge Schedule (MAKS)  This twelve-item scale comprises domains of relevant evidence-based knowledge in relation to stigma toward mental illness and has been used in previous studies from India . Items are coded on an ordinal scale (1–5). The total score is calculated by adding the points obtained for each item. Higher total scores correspond to greater knowledge. The Cronbach’s alpha for the MAKS scale was 0.749. 

Reported and Intended Behaviour Scale (RIBS)  The RIBS comprises two subscales containing eight items in total. The ﬁrst subscale includes four statements relating to past or present contact with people with mental health problems. Each item receives a score of 1 for ‘yes,’ and 0 for ‘no’ or ‘don’t know’ (score range of the subscale: 0–4). Higher scores indicate more past or present contact. The second subscale consists of four statements relating to participants’ future behavioural intentions when they encounter people with mental health problems. Responses to the items are rated as ‘agree strongly’, ‘agree slightly’, ‘neither agree nor disagree’, ‘disagree slightly’, ‘disagree strongly’ and ‘don’t know’. For each item, a score of 5 was allocated for strong agreement, while a score of 1 was assigned to strong disagreement (score range of the subscale: 4–20). The response option ‘don’t know’, is coded as neutral (i.e., 3). Higher scores indicate more favourable behavioural intentions. RIBS was previously used in studies from India . We used the scores of the second subscale (items 5–8) of RIBS to assess the changes in the behaviour over time among the participants. 

Data analysis The statistical analysis was conducted using STATA 16.0. Summary statistics provided a description of participants. A p-value of less than 0.05 was considered statistically significant. Mauchly's test for the sphericity assumption was violated for RIBS and MAKS (p<0.001). To overcome the issue of sphericity, repeated measures ANOVA with Greenhouse-Geisser corrections is reported. A Generalized Estimation Equation (GEE) was performed, as the extension to assess change in scores over time. 

Results A total of 600 study participants (300 male, 300 female) were recruited (convenient sampling) and followed-up (100% retention). The average age of study participants was 19.6±1.8 years. All the study participants were single, and most of them lived with their parents. The baseline mean scores on the MAKS and RIBS were 20.2±3.4 and 12.4±3.3, respectively . 3.1 Changes in stigma-related knowledge scores assessed by MAKS The repeated measure ANOVA determined the difference in mean value of the MAKS score to be statistically significant between assessment stages (0, 90 min, 3 months, and 6 months) (F(1.700,1016.83) = 339.18, p < 0.001). Post hoc tests using the Bonferroni correction revealed an increase in the value of MAKS score immediately after the intervention and at the other assessment points [20.2±3.4, 24.0±2.0, 23.6±2.1 and 22.6±2.3, respectively] p < 0.001. shows the generalized estimating equation (GEE) results. 3.2 Changes in the stigma-related behaviour scores assessed by RIBS A repeated measures ANOVA determined that the difference in mean value of the RIBS score was statistically significant between assessment stages (0, 90 min, 3 months, and 6 months), (F(2.000,1195.734) = 557.665, p < 0.0005). A post hoc test using the Bonferroni correction revealed an increase in the value of RIBS score immediately after the intervention, and at 3 and 6 months [12.4±3.3, 17.5±2.61, 17.0±2.5 and 16.0±2.5, respectively] p < 0.001. There was significant change in RIBS score at 90 mins (5.1 units), 3 months (4.6 units) and 6 months (3.6 units) as compared to baseline . presents changes in the MAKS and RIBS scores over time. Overall, the GEE results indicate that after the invention is delivered, there is an immediate increase in MAKS (3.8 units) and RIBS (5.1 units) scores when compared to baseline. After the 3rd (MAKS 3.4 and RIBS 4.6 units) and 6th (MAKS 2.4 and RIBS 3.6 units) month, the scores decreased slightly in MAKS and RIBS scales. Gender was controlled during the above mentioned analysis. 

Changes in stigma-related knowledge scores assessed by MAKS The repeated measure ANOVA determined the difference in mean value of the MAKS score to be statistically significant between assessment stages (0, 90 min, 3 months, and 6 months) (F(1.700,1016.83) = 339.18, p < 0.001). Post hoc tests using the Bonferroni correction revealed an increase in the value of MAKS score immediately after the intervention and at the other assessment points [20.2±3.4, 24.0±2.0, 23.6±2.1 and 22.6±2.3, respectively] p < 0.001. shows the generalized estimating equation (GEE) results. 

Changes in the stigma-related behaviour scores assessed by RIBS A repeated measures ANOVA determined that the difference in mean value of the RIBS score was statistically significant between assessment stages (0, 90 min, 3 months, and 6 months), (F(2.000,1195.734) = 557.665, p < 0.0005). A post hoc test using the Bonferroni correction revealed an increase in the value of RIBS score immediately after the intervention, and at 3 and 6 months [12.4±3.3, 17.5±2.61, 17.0±2.5 and 16.0±2.5, respectively] p < 0.001. There was significant change in RIBS score at 90 mins (5.1 units), 3 months (4.6 units) and 6 months (3.6 units) as compared to baseline . presents changes in the MAKS and RIBS scores over time. Overall, the GEE results indicate that after the invention is delivered, there is an immediate increase in MAKS (3.8 units) and RIBS (5.1 units) scores when compared to baseline. After the 3rd (MAKS 3.4 and RIBS 4.6 units) and 6th (MAKS 2.4 and RIBS 3.6 units) month, the scores decreased slightly in MAKS and RIBS scales. Gender was controlled during the above mentioned analysis. 

Discussion The aim of our study was to examine the impact of a 90-minute mental health literacy (MHL) module on stigma related mental health knowledge and behaviour (SRMHKB) among young people attending college in Chennai. Our results showed a significant increase in scores at each time point indicating that a single 90-minute MHL session might have a positive impact on SRMHKB among youth in South India. One of the most widely studied MHL interventions is Mental Health First Aid (MHFA). Standard adult MHFA comprises 12 hrs training, and has been adapted (e.g., shorter sessions for young populations) and widely adopted in different settings across the globe. In a recent meta-analysis, Liang et al. (2023) found that MHFA increased student knowledge and confidence, and that shorter sessions (<10 h) were preferred. However, the authors did not identify any studies in developing countries. To the best of our knowledge, the current study is the first to develop and test a brief MHL module for youth (informed by stakeholder input) for use in resource poor settings. We observed that a single 90-minute MHL interactive session can possibly achieve improvements in stigma related mental health literacy and behaviour. Whilst there was a small decline in scores at 3- and 6-month follow-up, increases in scores from baseline were still significant, implying gains might be maintained for at least 6 months. In our study, we involved psychologists and social workers to deliver the MHL modules to the participating students in the colleges. This is based on the following reasons: psychologists and psychiatric social workers possess specialized knowledge and skills in areas such as counseling, psychotherapy, and mental health assessment, making them well-suited for facilitating interventions aimed at promoting mental health literacy and reducing stigma; their professional background enables them to provide tailored support and guidance to participants, addressing their unique needs and concerns effectively; and involving psychologists and psychiatric social workers in intervention delivery enhances the credibility and effectiveness of the program, potentially increasing participant engagement and adherence. However, this approach would have an impact on the scalability and replicability in intervention delivery in real world settings. The observed increase in SRMHKB scores suggests that even a single, relatively brief MHL session can yield meaningful improvements in mental health literacy among college students. This finding underscores the potential of targeted educational interventions to challenge misconceptions, reduce stigma, and promote more informed attitudes and behaviors related to mental health. Moreover, the positive impact of the intervention highlights the importance of incorporating mental health education into academic curricula and campus initiatives to foster a supportive and inclusive environment for young people. Stigma significantly affects individuals living with mental illness, their families, caregivers, and healthcare professionals. In low- and middle-income countries (LMICs), cultural, socio-economic, and religious factors shape perceptions of mental health, health-seeking behaviours, and the attitudes of individuals and healthcare providers. To combat stigma, it is crucial to implement inclusive mental health policies, culturally-adapted awareness programs, workforce capacity building through task-shifting, and better integration of mental health services with primary healthcare . At the individual level, insight about the illness could play an important role in help-seeking among persons with mental disorders, especially psychotic disorders . Our study has limitations. First, we utilised a quasi-experimental pre-post study design with no control group, which means that concrete conclusions regarding the impact of the training on the outcome measures cannot be made. Thus, our results should be considered preliminary pending corroboration with randomised controlled trials. Second, we tested the intervention in only two colleges in urban settings in Chennai. Therefore, the generalisability of the intervention for different cities, and in rural populations is unclear. Further, the intervention was tested in colleges that were more receptive to such programmes. Further work is needed to consider how MHL programmes can be promoted across India to increase engagement across colleges. Third, we did not assess longer-term effects (more than 6 months) of the MHL module. Future studies might examine outcomes over longer periods to determine the frequency of booster sessions ( . Fourth, the simplicity and straightforwardness of the last four items of the Reported and Intended Behavior Scale (RIBS) could potentially lead to minimal variance in responses due to social desirability bias. Finally, the MHL intervention was delivered by social workers and psychologists. As there is a documented shortage of trained mental health professionals in India, future work might examine the efficacy of college teachers in delivering the intervention. In conclusion, our study suggests that a single 90-minute interactive MHL session might achieve sustained improvements in mental health knowledge and behaviour in students in India. These preliminary findings require corroboration with randomised controlled trials. Future research might also explore the sustained impact of repeated or extended MHL interventions over time, how to increase uptake of MHL training across colleges and regions, and ways of disseminating the intervention to young people outside of educational institutions. 

This study/project is funded by the National Institute for Health Research ( 10.13039/100006662 NIHR ) [NIHR Group on Psychosis Outcomes: the Warwick-India-Canada (WIC) Network (Award number: 16/137/107 )]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. 

Ethical approval was obtained before the start of the study from the Institutional Ethics Committee of Schizophrenia Research Foundation (SCARF), Chennai, India (SRF/WIC-12/NOV-2017). Written informed consent was obtained from all study participants. 

Caroline Meyer: Funding acquisition, Conceptualization. Maximilian Birchwood: Funding acquisition, Conceptualization. Rakesh Chadda: Funding acquisition, Conceptualization. Mamta Sood: Funding acquisition, Conceptualization. Mohapradeep Mohan: Project administration, Methodology, Conceptualization. Ramakrishnan Pattabiraman: Project administration. Vimala Paul: Project administration. Sujit John: Project administration, Methodology, Formal analysis. Jothilakshmi Durairaj: Writing – review & editing, Formal analysis, Data curation. Jai Shah: Writing – review & editing, Supervision, Conceptualization. Greeshma Mohan: Supervision, Project administration, Methodology, Conceptualization. Srividya Iyer: Writing – review & editing, Supervision, Methodology, Funding acquisition, Conceptualization. Richard Lilford: Funding acquisition, Conceptualization. Padmavati R: Writing – review & editing, Methodology, Formal analysis, Conceptualization. Graeme Currie: Funding acquisition, Conceptualization. Swaran Singh: Supervision, Project administration, Methodology, Funding acquisition, Formal analysis, Conceptualization. Jason Madan: Funding acquisition, Conceptualization. Thara R: Writing – review & editing, Project administration, Funding acquisition, Formal analysis, Conceptualization. Vivek Furtado: Funding acquisition, Conceptualization. Sangeetha Chandrasekaran: Project administration, Investigation. Vijaya Raghavan: Writing – review & editing, Writing – original draft, Supervision, Project administration, Formal analysis. 

The authors declare no potential conflict of interest. 

