Understanding Emerging Adults’ Perspectives on Mental Health in Togo

Abstract

Mental health worldwide is extremely important to address; unfortunately, many aspects of mental health are not visibly known or treated in the world. Moreover, some developmental groups are more affected than others; in fact, emerging adulthood is a crucial developmental phase that is prone to depression. With most mental health conditions beginning before the age of 24 and depression as the leading cause of disability globally, this study sought to identify emerging adults’ understanding of depression, a common disease among this population. A qualitative study was used to understand depression during emerging adulthood in Togo. There were 35 participants recruited for this study. With the growing younger population in Sub-Saharan Africa projected to double in a decade and the dearth of studies in the mental health field on the continent, this study serves as a foundation for research into emerging adults’ mental health. Like most countries in Sub-Saharan Africa, the inexistence of a stand-alone mental health program, the shortage of qualified mental health professionals, and insufficient civil society education on mental health problems remain the fundamental barriers to accessible care in Togo. As the study indicated, there are many ways to provide new opportunities for emerging adults to self-educate about mental health. By increasing our understanding of depression among emerging adults, the findings of this research study offer valuable data as a foundation not only for future studies, but also for mental health policy development and targeted programming for emerging adults in Sub-Saharan Africa and Togo in particular.

Keywords

global health anxiety cultural context depression health health behavior health promotion mental health qualitative methods

Introduction

Togo is among the poorest countries in the world and is categorized as a low human development country, ranking 167 out of 189 countries and territories (United Nations [UN], 2019). One result of economic neglect, Togo is afflicted by a dearth of trained mental health professionals, inadequate prevention programs, screening, and diagnosis of mental health disorders, insufficient informational support for people with mental health disorders and their families, and poor education of civil society on mental health problems (Preux & Dumas, 2017). Togo lacks a stand-alone mental health program and has just three psychiatrists to meet the mental health needs of 7.8 million people (Preux & Dumas, 2017). Compounding this abysmal mental health situation, most people in Togo believe in supernatural causes for mental illness, and most policymakers do not consider that mental illness responds to conventional medical practices (Preux & Dumas, 2017).

According to the UN (2019), like most Sub-Saharan Africa (SSA) countries, Togo is characterized by rapid population growth, with the number of young people between 15 and 24 expected to increase by more than 40% by 2030 (UN, 2015). Arnett (2015) defines emerging adulthood as a transitional phase in which most individuals confront life-altering decisions (e.g., marriage, parenthood, and career choice). According to Reed-Fitzke (2020), the prevalence of depression in emerging adulthood is higher and advancing more rapidly than in other age groups. Results from Kuwabara et al. (2007) also found individuals in emerging adulthood at higher risk for depressive disorders, with one in four in this cohort reporting a depressive episode. Depression can result in significant disability at any developmental stage. Still, depression in emerging adulthood is associated with dire long-term effects of recurrent depressive episodes and worse socioeconomic outcomes (McGee & Thompson, 2015). Understanding the concept of depression in emerging adulthood is both critical and urgent to adequately address mental health promotion and prevention and increase awareness and access to care in Togo and in Africa in general (UN Population Fund [UNFPA], 2015).

Thus, understanding the attitudes and beliefs of emerging adults with mental health conditions could provide critical information to develop an entire science-based mental health care system. To date, Togo lacks a comprehensive review of its mental health system in the scientific literature. This qualitative study sought to identify key depression concepts during emerging adulthood. These concepts can inform and develop policy and treatment programs and help mental health care professionals identify mental health disorders and respond with appropriate treatments. With the younger population in Sub-Saharan Africa projected to double within a decade and the scarcity of mental health studies on the continent, information provided by this study can offer vital research data about mental health themes and subthemes among emerging adults in sub-Saharan Africa.

Because of lack of prior information, a qualitative phenomenological study was conducted to understand the experiences of emerging adults in Togo, Africa. The expectation of this research was to create a baseline of information on depression in emerging adults in Togo. Depression affects an estimated 350 million people globally at the cost of roughly $1 trillion annually (World Health Organization [WHO], 2017). Depression is the leading cause of disability worldwide and a significant contributor to the overall burden of disease (WHO, 2017). According to the WHO (2017), the number of people living with depression worldwide increased by 18% between 2005 and 2015; this WHO report also conveys how adults with a major depressive episode are highest among individuals in emerging adulthood, with more than 80% of the depression burden among people in low- and middle-income countries (WHO, 2017). Nearly one-fifth of 20% of Africa’s population is aged 15–24 (UN, 2015), and it is the youngest continent, with 60% of its population under the age of 25 (UN, 2017). Nearly half (46%) of Africa’s population is under the age of 15, and 19% of the demographic is in the 15–24 age bracket (Population Reference Bureau [PRB], 2019). This data supports the need to provide more information and details on a potentially significant, at-risk population.

Methods

A qualitative methodology was used to examine the lived experience of emerging adults (age 18–25) focusing on their understanding of depression. The researchers selected a phenomenological qualitative study due to the limited research on this subject matter in Togo and the need to gather and create a baseline of information. The study helped reach the essence of the emerging adults’ lived experience of depression while ascertaining and defining the phenomenon of depression (Cilesiz, 2010); phenomenology considers human perception and subjectivity focusing on the 'lived experience’ of the individual concerned (Hoffmann et al., 2013). This type of research examines the accounts of people who have experienced it, then compares their accounts to identify the essence of what is shared between them, thereby defining the phenomenon in and of itself (Moustakas, 1994). The Moustakas modified van Kaam analysis method (1994) was used to analyze the data by horizontalizing, reducing, eliminating, identifying applicable themes and clusters, identifying, and removing nonapplicable themes and clusters, and validating meaning from the themes (Creswell, 2007). Data was hand-coded and peer-reviewed by members of the research team. California Southern University and its institutional review board approved the study protocol and ethics review.

Participants included emerging adults, aged 18 to 25, who reside in Lomé, Togo, and have at least a BAC part 2 (Baccalaureate) education level, the equivalent of a US high school diploma. People who did not fit these criteria were excluded. The participants were recruited through a recruitment notice posted on social media and local community organizations. There were approximately 30 emerging adults initially selected to participate as saturation point was achieved (Creswell & Creswell, 2018). Participants were confidentially interviewed via the Zoom video platform at a confidential, mutually agreed upon location. The researcher conducted the interviews, which lasted about 1 hour and consisted of 11 questions that covered demographic information, general knowledge about mental health, understanding of depression, and experiences with treatment options in Togo. All participants signed informed consent before the interviews and audio recording. The interview recordings were transcribed, and codes were immediately assigned to every participant to ensure de-identified data collection.

The primary researcher used a French translator, though is native to the country and speaks both French and English languages fluently. It should be noted that there are no language differences in data gathering, transcription, and during the first analyses when participants and the principal researcher speak the same language (Nes et al., 2010). In this study, however, an independent French-English translator reviewed the translated documents such as informed consent, the recruitment flyer, and interview questions for accuracy. The translator was recruited and informed of the purpose of the study, the selection criteria, and the interview questions.

To ensure the validity of qualitative research, provided measures confirmed the extent to which the data is credible, trustworthy, and authentic, according to Creswell (2007). For Moustakas (1994), validity is determined by the richness of the participant conversation. This researcher documented the procedural steps taken in establishing the research protocols and utilized a translator to review this researcher’s data transcripts for accuracy. A review of the researcher’s transcripts to ensure consistency in defining the codes can also support the reliability of the data (Creswell & Creswell, 2018) through peer debriefing.

While the interviews were conducted virtually via the Zoom platform at a mutually agreed upon location, the interview setting was designed by the researcher to enhance data security, privacy, and confidentiality for participants. The researcher provided internet access and all the communication materials for the Zoom call. Before and after each interview, the researcher recorded substantial notes in the codebook to reconstruct the environment in which the interviews took place. Audio recorded information captured the following: (1) place, time, and date of interview, (2) code identifier of participant, (3) core questions asked and additional information that may have added or detracted from the interview was noted, (4) information that was intentionally or unintentionally missed, (5) additional or remaining questions to inquire in a later session (if possible). Each log provided a realistic and accurate account of the way in which the data was gathered Table 1.

Table 1.

Participant demographic data.

Participant demographics
Demographics		%	n =
Age
	18	13	4
	19	17	5
	20	20	6
	21	13	4
	22	20	6
	23	7	2
	24	3	1
	25	7	2
Gender identity
	Female	60	18
	Male	40	12
Marital status	Single	100	30
	Married	0	0
City of residency	Lome	100	30
Level of education
	BACII	47	14
	BACII + 2	33	10
	License	13	4
	Master	7	2
Occupation
	Student	56	17
	Apprentices	20	6
	Employed	7	2
	Unemployed	17	5
Length of residence in Lome
	Since birth	60	18
	15 years<	7	2
	10 years<	10	3
	5 years<	23	7

Note. N = 30. Participants were on average 21 years old (SD = 1.96).

Results

There were 30 participants who met the criteria of this study. These 45–60-min semi-structured interviews were conducted with emerging adults living in Lomé, Togo, to answer the following research questions: 1. What are the experiences of emerging adults in Togo with mental health? How would emerging adults in Togo describe depression? and What are current treatment options available for mental health in Togo?

The semi-structured interview process included questions assessing the participants’ understanding of depression and exploring the participants’ attitudes towards mental health and treatment in general. The following primary themes emerged: mental health (n = 30 responses), depression (n = 30 responses), perceived causes (n = 22 responses), lived experiences (n = 30 responses), and treatment options (n = 25 responses). Beyond this, the data was not quantified as it was a qualitative study.

Participants

Participation was voluntary for any emerging adult between the ages of 18–25 who was currently residing in Lomé, Togo, with an education level of at least Baccalaureate, the equivalent of a US high school diploma. Participants ranged in age from 18–25, with an average age of 21. The participants’ age groups were composed of four 18-year-olds (n = 4), five 19-year-olds (n = 5), six 20-year-olds (n = 6), four 21-year-olds (n = 4), six 22-year-olds (n = 6), two 23-year-olds (n = 2), one 24-year-old (n = 1), and two 25-year-olds (n = 2). Of the 30 participants, eighteen identified as female (n = 18) and twelve identified as male (n = 12). Participants' level of education ranged from Baccalaureate to Master (equivalent to the United States high school diploma to master’s degree). Seventeen participants identified as full-time students (n = 17), six reported being in a post-degree professional apprenticeship (n = 6), two reported being employed full-time (n = 2), and five identified as unemployed (n = 5).

Defining Mental Health

When assessing the lived experiences of emerging adults with mental health in Togo, this study sought to identify the common meaning of mental health among participants. While the participants provided varying statements about the meaning, they all demonstrated different levels of awareness about mental health as part of the general health that contributes to the overall wellbeing of people. Many of the participants described mental health as the health of the psychological side of people versus their physical health. “Mental health is part of our health; we are made of physical and psychological health; both works together and affect each other” (PT19). Some of the participants elaborated their understanding of mental health with concrete examples from their lived experiences. “Mental health for me is what empowers me in the morning to get off bed, and it is the force that helps me be physically strong and gives me energy to do my work when I am not feeling mentally well” (PT18). Some participants described mental health in the context of body-mind-spirit by stating that, while physical health focuses on the body, mental health is the health of the mind and the spirit. “I understand mental health because it represents the mechanism that makes our mind and spirit work well with our body” (PT21).

Participant PT15 provided extensive comments about the meaning of mental health that summarized the viewpoints of many of the participants of this study. Participants’ understanding of mental health encompassed the ensemble of elements that make a person’s psychological health function well:

For me, when we talk about mental health, I can say we refer to a person’s psychological health. It includes the emotional health, the mental state or the mental ability that allows the person to live a normal life. So, for me, mental health is part of health that helps people live a normal life, work, play, take care of themselves, take care of their families, and be good to people in their communities. Also, for me, I consider mental health like a complement of physical health because both goes together. If you are sick mentally, your body reacts to it and vice versa (PT15).

Conveying the same idea of mental health as psychological health, participants linked mental to the notion of the quality of the brain. They described mental health as the ensemble of information about the brain’s capacity to function correctly. “To me, mental health is something that has to do with the brain” (PT01), “Mental health is about the brain” (PT07), “Mental health is information about the brain’s health or the ability for the brain to work well” (PT09) or “It is health-related to mentality” (PT03). When further assessing the meaning of mental health for emerging adults, participants also conveyed the notion of mental health as a person’s mental state. Participants commented on the appearance, general behavior, and ability of people in the community. For participant PT06, mental health is everything that goes with a person’s behavior, which means how the person behaves in society and towards himself. Participant PT05 commented, “for me, it is very simple, I would say that mental health is someone’s ability to function well, the kind of ability that comes from his brain. It is like the person’s quality, whether the person is fit or not. I will simply say the state of a person who is not normal."

Few of the participants described mental health in the spiritual context. In this context, participants considered mental health as the spiritual wellbeing of people or the spiritual energy that animates people. “Mental health is our spiritual health, our spiritual energy that empowers our body” (PT27). Another participant commented in the same context of spiritual health:

From my personal understanding point, mental health is like the fuel or the spirit that empowers people’s physical being. So for me, I believe that people have good or bad mental health according to the quality of the spirit that animates them. When people are animated by a good spirit, they have good mental health, and if they do not, they are sick mentally (PT30).

When assessing further to understand the lived experiences of mental health in emerging adults in Togo, participants provided extensive statements about their understandings of mental health and described what they believed were the factors that cause mental illness.

Depression

When assessing the meaning of depression in emerging adulthood, all the participants understood depression as a common mental health problem. Participants identified depression as a concept related to mental health, attempted to describe it, and commented on how it affects people. While the participants provided varying accounts of depression, their diverse descriptions showed that their general knowledge categorized depression as a common psychological disorder that affects people. “Depression is a disorder or a common psychological illness that makes people’s lives difficult” (PT02). “For me, depression is a frequent mental illness that disturbs everyday life and ruins people’s life” (PT01). Participant PT29 reported their previous experience to describe depression as a psychological disorder:

From my personal experience through this COVID-19 pandemic, I can say depression is a severe psychological disorder that is worse than anything I could imagine before. I felt psychologically drained and incapable of concentrating mentally. It is hard for me to describe everything I felt, but I felt psychologically weak, and my thinking was not right (PT29).

Focusing on the effects of depression on people’s lives, participants described depression as a mood problem by reporting symptoms like lost motivation, sadness, and being worried. “The way I understand depression or the way I can describe it is that it is psychological that affects people’s moods and makes them sad” (PT27). For participant PT07, depression is a permanent sadness and a loss of motivation in the self; the person is not happy. “Depression, for me, affects your mood. Depression is when someone feels worried, confused, and lost. Many participants reported depression as sadness. The person feels sad all the time” (PT10). Or, for participant PT03, “when someone is depressed, the person is not happy.”

Many participants described depression as a social disorder that makes it difficult for people to function and participate in their communities. “The person wants to stay alone… In my personal experience, social interactions become difficult for me when I feel depressed” (PT09). Describing lived experiences about how depression impacts social life, many participants commented on losing interest in seeing friends or doing something entertaining. “Often in movies, the person who is depressed is always isolated socially, stay in bed and most of the time the person cannot do anything productive socially” (PT18).

Perceived Causes

Participants agreed on the fact that many things could cause mental illness. While participants are not sure about the exact cause(s) of mental illness, they recognize it could result from anything that affects people’s health. Participants advanced many ideas of diverse factors that could cause mental illness. “Many things can cause mental illness; things like social tensions, peer pressure, intimacy issues, I guess many things could be a factor” (PT08). “I do not know, but mental illness is too much thinking about problems, and drugs and alcohol, and it could be spiritual too.” (PT10). For participant PT09, many things can cause mental illness: “First, I will say that relationship issues like love, deception, family conflict can cause depression and stress."

Other participants also considered the use of drugs and alcohol by emerging adults as a potential cause of mental illness. “Drugs use, for example,” reported participant PT07. For participant PT03, “worries, alcohol, drugs too can cause mental illness.” In the same context, another participant noted that “I know excessive alcohol use causes mental health problems because I have witnessed many cases in my family” (PT16). Participants reported excessive alcohol use to deal with the lack of opportunities in their communities and the general economic adversities characteristic of developing countries. “I think my generation is in serious problems with the way we consume alcohol to cope with stress” (PT13).

Many participants described the causes of depression according to their lived experiences and general knowledge. Participants provided varying accounts of what they believed were the causes of depression. Many participants noted that traumatic events like losing a loved one could cause depression. “I believe a sad event like the death of a family member or something in your past that traumatized you can cause depression” (PT03). Some participants reported their upbringing in poverty and adverse childhood experiences as traumatic factors that could cause depression. “For me… hunger is depressing and especially for a child… It is difficult me when I think about the struggles of my parents to feed us” (PT24).

Lived Experiences

When assessing the meaning of depression in emerging adulthood, participants commented on their lived experience with depression. When participants described depression in young adults’ everyday lives, they consistently referred to sadness and loneliness. Most of the participants described moments where they felt depressed, referring to their moments of despair:

“The experience I had with depression, first of all, is not good. I was feeling much sadness, but I did not have any support. My depression was related to my experience of painful menstruation twice a month. I was deeply sad and felt like I wanted to die but I could not tell my family” (PT09).

Some participants reported no personal experience with depression but reported cases close to them and stated that depression makes people feel lonely. “In my opinion, depression is mostly when the person does not have people around him. It is when he feels a little lonely and thinking about it causes depression” (PT04).

I never felt personally depressed, but, in my mind, the word depression means feeling lonely or people around ignoring you. It is like being there but invisible at the same time. Yes, in my opinion, depression is mostly when the person does not have people around him. It is when he feels a little lonely and thinking about it causes depression (PT04).

In providing further information about their lived experiences, many participants who identified depression as sadness also coupled it with loneliness. “In those moments, I feel lonely and avoid my friends” (PT05). Reporting a similar experience, participant PT09 also commented on loneliness. “I cry a lot alone sometimes… It is lonely moments that I do not like” (PT09).

Treatment Options

While many of the participants agreed on the treatability of mental illness, their varying accounts exposed a lack of information about mental services in their community and a lack of awareness about treatment options and modalities. Many participants acknowledged there are treatment options available for mental illness, but there was a lack of information. “Yes, it can be treated… Yes, it is possible… but I do not know how it is done… I know there is a hospital for crazy people” (PT07).

When gathering further information on treatment option themes to analyze participants' awareness about mental health, medical treatment and traditional or spiritual healing were the two specific treatment options that came up from the participants' responses:

Generally, mental problems could be treated medically. I think some medications could treat mental illnesses. You can also talk to a psychologist if the mental problem is not too severe because sometimes just talking about the mental problem can help. It is not easy to find information about treatment here in Lomé. Sometimes, they do not have money to see a psychiatrist, and even if they could, there is a problem finding one that has time to see them because the demand is high. In desperate situations, people choose to seek traditional healing in their villages, or they seek help from their pastors or priest through prayers and spiritual cleansings (PT29).

While discussing awareness about medical treatment options, most of the participants directly named the psychiatric hospital of Zebevi, the only official inpatient psychiatric treatment center in Togo, as a reference to get mental health services. “The only place I heard you could take people with mental illness to is Zebevi” (PT10). Participant PT07, who also made a similar comment, reported, “Zebevi is the only place I know that deals with psychiatric problems.” Some participants who seemed to be more informed about the medical treatment options reported other governmental establishments and non-governmental organizations (NGOs) from civil society. “I know you cannot get psychological help at the University hospital named CHU Campus in Lomé, but I do not know more than that” (PT20).

Discussion

Togo suffers from poverty, which has an impact on population health, including mental health. One subset of the population that may be particularly affected by adverse mental health are emerging adults, as a rapid increase within this age distribution group is occurring within this country. Because little to no data exists on Togo regarding mental health in emerging adulthood in Togo, this qualitative study was used to understand participants experiences and information on mental health. These participants’ knowledge provides a baseline of information for future research related to this vulnerable population.

The 45–60-min semi-structured interviews conducted with emerging adults aged 18 to 25 in Lomé, Togo, elicited five themes from the three questions asked of participants. When queried about the general meaning of mental health, participants responded based on lived experiences, with answers ranging from a biological understanding of mental health (e.g., the brain’s function), to mental health being described as a factor of one’s belief system. In terms of the cause(s) of mental illness, respondents overall expressed uncertainty, providing a variety of possible contributing factors such as substance abuse, the social environment, and genetic factors. Personal belief systems and spiritual issues were also identified, underlining the pervasive belief in supernatural causes and remedies for mental illness in Togo. While participants expressed the understanding that mental illness can affect wellbeing, there was a lack of awareness about the prevalence of mental health issues in Africa, combined with an awareness of the cultural stigma attached to mental illness. Africa is a continent where a blind eye is often turned to mental illness by governments and the population (Sankoh et al., 2018). Overall, disclosure about mental health issues was guarded and challenging, with some participants initially denying a mental health issue but later describing experiences with depression.

The data indicated participants viewed depression as a psychological problem that affects mood and social wellbeing. They used words such as worried, sad, lazy, or lacking interest to define depression and indicated that depression is marked by loneliness and impacts social wellbeing. Most participants identified and reported lived experiences with depression. The causes of depression were identified as illness, traumatic events, relationship issues, social pressure, or unknown causes. Participants reported causes like the death of a family member, stress caused by everyday life, relationship problems, a traumatic experience, or sickness as causes of depression. When queried about the perceived consequences of depression, participants expressed understanding of the negative consequences associated with depression. They gave examples including suicidal ideation, social withdrawal, substance misuse, and academic problems. Nonetheless, when asked about the treatment of depression, participants expressed a remarkable lack of awareness. None of the participants reported receiving treatment for depression or discussing treatment options with family members. Participants’ understanding of treatment was basic (e.g., counseling via a mental health professional). Some participants reported prayer as a treatment option. This finding underscores the country’s generalized belief in supernatural causes of mental illness (Preux & Dumas, 2017).

Other data suggested participants lacked knowledge of the treatability of mental illness, treatment options, and awareness about mental health treatments. Most participants in this study possessed insufficient information about options and services available, underscoring Togo’s deficient level of access to mental health services and a scarcity of resources (Maiga & Eaton, 2014). An analysis of some of the participants' responses revealed that the belief that mental illness is not treatable is due to a lack of information about mental health issues and the role of mental health professionals, treatments, and support services. These results support findings which reveal that youth in Ghana expressed a link between decreased family support and increased depressive symptoms (Roche et al., 2016). This suggests that promoting intra-family support systems can reduce depressive symptoms among youth by disrupting generational cycles of indifference.

Additionally, social support has been shown to be a significant factor among students in Ghana experiencing depression, with one study showing that both familial and social support are tied to depression in young people (Kugbey et al., 2015). This study revealed a significant correlation between levels of support from friends and family and rates of depression, with researchers reporting that the highest levels of support were linked to the lowest levels of expressed psychological pain. Based on these findings, the researchers suggest that students receive support from parents as well as trained peer counselors because emerging adults may be more willing to talk about psychological issues to same-age supports. The authors also suggest that anxiety and stress should be screened as influences on depression among the student age population.

Our results are consistent with similar studies in comparable populations, especially in Africa. In particular it has been shown that risk for depression among adolescents in Nairobi County, Kenya is tied to variables including traumatic life experiences, peer pressure, and school-related issues (Mugambi & Gitonga, 2015). Study data revealed that respondents’ experience of disrupted social systems are among the major risk factors for depression, with more comprehensive research recommended in order to survey the depth of psychosocial risk factors for depression in Kenya.

Further underscoring our results, a study of 3775 randomly sampled students from all public secondary schools in Nairobi, Kenya show that prevalence rates of depressive symptoms requiring intervention are no less than those seen in Western settings. Ndetei et al. (2008), found that 43.7% of all students evaluated had clinical diagnostic scores for depression. Additionally, half (49.3%) of participants who completed the Ndetei-Othieno-Kathuku (NOK) scale for Depression and Anxiety had positive scores for moderate to severe anxiety with or without depression, suggesting the need for further research into mitigating mechanisms for depression among emerging adults.

Psychosocial barriers tied to cultural stigma is a key component in the emergence of depression in African American youth (Breland-Noble et al., 2011). Researchers suggest that successful recruitment strategies address cultural attributions of depression including supernatural beliefs. Failing to recognize and account for these embedded beliefs is not only culturally insensitive, it may result in compromised recruitment of African American youth for depression research and treatment. Community-partnered activities involving community members as equal partners and diverse staff in leadership roles are recommended parts of initiatives to encourage youth and family involvement in depression research and treatments.

The findings of our study have important implications for professional practice and further research. First, results reveal that participants found information about depression via the internet, mobile phones, and social media, suggesting that future mental health literacy be disseminated across these platforms. It is recommended that student-led mental health information clinics be established on university campuses to target and reach the emerging adult audience. Second, introducing a national mental health prevention and promotion program is suggested, and this is also one of the UN’s sustainable development goals to be achieved by 2030. Study data shows the dire need for expanded mental health services, as well as easier access to services, not just in Togo but in Sub-Saharan Africa overall. There are just three psychiatrists in Togo (Preux & Dumas, 2017) and there is no stand-alone national mental health care program. Third, according to Preux and Dumas (2017), Togo’s healthcare system infrastructure is relatively well equipped. Study data lends itself to the recommendation of integrating mental health services for emerging adults into the existing primary care system. Integrating psychological and physical care at the same service point could reduce stigma, ease access to psychological support, and increase the number of trained mental health support service providers. Finally, it is recommended that qualitative research be conducted to assess for culturally sensitive descriptions of depression and mental illness symptoms to develop a culturally sensitive lexicon and relatable reports of depression and mental health symptoms among emerging adults. Some participants identified supernatural causes as mental illness triggers, and further research should examine how to respect these perceptions while at the same time delivering appropriate services. Additionally, most policymakers do not consider conventional medical practices as effective in the treatment of mental illness, so awareness efforts should be targeted to this cohort. (Preux & Dumas, 2017).

Study limitations include a relatively small sample size compared to the country’s population of 7.8 million people (Preux & Dumas, 2017). Scrupulous due diligence was exercised to preserve the meaning and accuracy of participants’ responses, but there was a French-English translator involved in data collection. Overall, participants’ discussion of mental health issues was guarded and challenging due to the general stigmatization of mental health issues in Africa. A final study limitation was the use of a semi-structured interview, with which its loose flexible structure can decrease validity as remaining similar to other participants can be challenging.

Conclusion

This study on the meaning of depression during emerging adulthood is the first of its kind in Togo and provides a unique perspective reviewing depression and other mental health outcomes in Sub-Saharan Africa. Analysis of the 30 emerging adult participants’ lived experiences and understanding of depression and mental health revealed information about the meaning of depression and mental health, and treatment options that expanded on and aligned with previous literature. Overall, the experiences with mental health of emerging adult participants in Togo are marked by a lack of awareness about mental illness and insufficient informational support for people with mental health issues and their families. Participants demonstrated limited general knowledge of mental illness as a disease that affects brain functioning and people’s mental states. Participants of this study also had a basic knowledge of depression and described it as a mental illness that affects people’s moods and social activities; that said, participants exposed limited knowledge about current treatment options and services available for mental health in Togo.

As a noteworthy corollary to our research, and similar studies on depression in youth in Africa, we want to mention research tied to student retention efforts. Multiple studies show that depression prevalence among youth and emerging adults may be mitigated by school-based prevention and intervention efforts. Findings from a study using the National Income Dynamics Survey in South Africa offers compelling evidence that South African Child Support Grants (CSG) are associated with higher levels of enrollment for older teens, thus potentially providing a larger window of time for depression treatment options for youth. (Eyal & Burns, 2014).

Researchers found that CSG recipients had overall enrollment rates at least ten percent higher than non-beneficiaries, with enrollment rates of above 15% in 2012 recorded among learners of color and those in Gauteng and the Western Cape. The monetary support is intended to ease poverty, thus indirectly affecting developmental outcomes such as nutrition and education. Based on the findings that older teen CSG beneficiaries have higher school enrollment rates versus non-beneficiaries of similar income levels, researchers assume that the causal mechanism is mainly through the alleviation of income constraints related to mitigation of familial cost of school attendance. Based on research included in this paper, it is recommended that further research be conducted into the link between monetary awards such as CSG and decreased youth depression rates in Africa since there is a higher enrollment of these beneficiaries in an environment where psychosocial support may be available. Specifically, this cohort would theoretically benefit from school-based resources including trained peer counseling for depression thereby impacting the overall rate of depression among African youth and emerging adults.

The data collected in our study could be used for future research on improving mental health programs and policy development that collectively include policymakers, mental health professionals, stakeholders from civil society, and emerging adults with lived experiences of mental health. With a more extensive and more diverse sample covering Togo, further research should study emerging adults’ health sources of information and quality of mental health literacy to identify specific programming needed to raise awareness, fight misconceptions, and enhance mental health literacy.

Supplemental Material

Supplemental Material - Understanding Emerging Adults’ Perspectives on Mental Health in Togo

Supplemental Material for Understanding Emerging Adults’ Perspectives on Mental Health in Togo by Tara R. Zolnikov, Ezui Florian Kodjo, Frances Furio, Tanya Clark, and Deborah Chambers in Emerging Adulthood

Footnotes

Acknowledgments

The authors would like to acknowledge and thank all participants in this study as well as every child, adolescent, and emerging adult in Togo and the rest of Africa.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

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

Transparency and Open Science Statement

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3. For qualitative analyses, are the list of questions and coding manuals openly available for download? YES

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5. Did this study include a pre-registration plan for data collection and/or analysis? NO

a. If yes, did you include a link to the pre-registration plan in the manuscript?

b. If yes, were deviations from the pre-registration plan clearly indicated in the manuscript?

ORCID iD

Tara R. Zolnikov

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Tara Rava Zolnikov earned a PhD in Developmental Science from North Dakota State University. She has published extensively in some of the world’s most renowned public health and global health journals, including The Lancet Oncology, American Journal of Public Health, AIDS and Behavior, Science of the Total Environment, and many more. She is the editor of Dialogues in Health and a fellow at the Explorers Club.

Ezui Florian Kodjo has a PysD from California Southern University. He studied depression and mental health outcomes and treatment in Togo. He also has a thriving online social media site that focuses on mental health.

Frances Furio, PsyD, LCSW (she/her) is an Assistant Professor in the School of Social Work at California State University, Sacramento (CSUS). She received her PsyD at California Southern University and her MSW at CSUS. In addition to her work at CSUS, she provides mental health services in the community and remains active in research related to the topics of mental health, forensic social work, and social and environmental justice. As an instructor, licensed clinician, and qualitative researcher, she is interested in understanding people’s lived experiences and highlighting the strength and resiliency of communities that continue to face barriers and injustice. She is passionate about the promotion of equity, inclusion, and peaceful and progressive social work practice.

Tanya Clark is a writer whose research focuses on the ways in which the natural and built environments impact and influence mental health and well-being. Dr. Clark earned a PsyD in Psychology from California Southern University, a M.A. in Humanities from California State University Dominguez Hills, and a second M.A. in Psychology from Pepperdine University. She is a former clinician and professor now focused on investigating and communicating mission-critical human health and welfare issues for professional and lay audiences alike.

Deborah Chambers, MPH, MHA, is a Healthcare Administration Program Coordinator who manages diverse undergraduate and graduate public health and healthcare administration programs. She is also a health promoter and global health researcher. Ms. Chambers is a doctoral candidate in Health Administration at National University. She earned a B.A. degree in Psychology from Daystar University, Kenya, a Master of Public Health, and a Master of Healthcare Administration program from the National University, San Diego, CA. Ms. Chambers focuses part of her time on qualitative health research in Kenya and the United States while collaborating with public health and healthcare administrators at the American Public Health Association (APHA) as a section member of the Engagement & Mentoring committees, Membership Ambassador, and Campus Liaison under the APHA Student Assembly. She also leads the Daystar University Alumni Association (DUAA), her alma mater diaspora chapter, as the current Co-Chair.

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