Evidence and Evidence Gaps in Adolescent Health

Using intervention mapping to develop an occupational therapy informed intervention for adolescents experiencing mental health difficulties

Introduction

Current interventions provide limited success in managing mental health in adolescents with emerging difficulties. We describe using the Intervention Mapping framework to co-develop a novel occupational therapy theory-informed intervention for adolescents with emerging mental health difficulties, addressing the need for interventions tackling activity-related determinants.

Methods

We describe a mixed-method, multiphase, sequential study design informed by the six-step Intervention Mapping framework, to develop the Activity Time Use intervention. Involving a systematic scoping review, time-use survey, qualitative focus groups and Delphi consensus process informing the construction of an intervention logic model of the problem, the logic model of change and creation of an intervention programme.

Results

An eight-session intervention addresses three behavioural change outcomes: improving the balance of daily activities, improving occupational choice making abilities and improving occupational performance. The programme was positively reviewed through Patient and Public Involvement (PPI) consultation against the seven aspects of acceptability (Sekhon et al., 2017). Next steps include exploring the environmental determinants affecting implementation in different intervention delivery settings and full user acceptability.

Conclusions

This study has provided a real-world example of intervention-mapping, systematically developing an occupational therapy intervention to empower adolescents to adopt healthier time-use behaviours to improve their mental health.

A Delphi method investigation to prioritize activity-related determinants thought to affect mental health in adolescent populations

INTRODUCTION

Emergent mental illness during adolescence affects daily functioning, causing disruption to daily activities, routines, and patterns. Multiple inter-related personal, social and environmental determinants influence the onset, nature and subsequent course of those difficulties. Research suggests a bi-directional relationship exists between mental health and activity choices. Activity-focused interventions such as occupational therapy may improve adolescent mental health related outcomes. In this study, we identify and select which activity-related determinants should be prioritized in the development of an occupation therapy-based intervention for adolescents with emerging mental health difficulties using expert consensus.

METHOD

A modified two-round Delphi survey method was conducted with occupational therapists and researchers to ascertain a consensus opinion on the prioritization of specific activity-related determinants that influence 16- to 17-year-olds'.

RESULTS

Eighty-nine determinants were identified and prioritized. Fourteen of these were personal activity-related determinants including 'types of activity' in which young people engage, the 'balance of activities' in which they engage, their 'over and under consumptions of activities', and their 'underdeveloped occupation-based coping skills'. The expert panel prioritized 'personal self-confidence', 'values', and 'perception of confidence' in relation to the activities adolescents do.

CONCLUSIONS

This study generated a detailed picture of the activity-related determinants that are important in adolescence, and aligns with the adolescent model of occupational choice. Our findings have potential to inform activity-related intervention development and policy. Further research is needed, particularly to understand young people's perspectives on these determinants and to investigate the determinants that would benefit from further empirical research.

Generating evidence to inform responsive and effective actions for Aboriginal and Torres Strait Islander adolescent health and well-being: a mix method protocol for evidence integration 'the Roadmap Project'

BACKGROUND

Australia does not have a national strategy for Aboriginal and Torres Strait Islander adolescent health and as a result, policy and programming actions are fragmented and may not be responsive to needs. Efforts to date have also rarely engaged Aboriginal and Torres Strait Islander people in co-designing solutions. The Roadmap Project aims to work in partnership with young people to define priority areas of health and well-being need and establish the corresponding developmentally appropriate, evidence-based actions.

METHODS AND ANALYSIS

All aspects of this project are governed by a group of Aboriginal and Torres Strait Islander young people. Needs, determinants and corresponding responses will be explored with Aboriginal and Torres Strait Islander adolescents (aged 10-24 years) across Australia through an online qualitative survey, interviews and focus group discussions. Parents, service providers and policy makers (stakeholders) will share their perspectives on needs and support required through interviews. Data generated will be co-analysed with the governance group and integrated with population health data, policy frameworks and evidence of effective programmes (established through reviews) to define responsive and effective actions for Aboriginal and Torres Strait Islander adolescent health and well-being.

ETHICS AND DISSEMINATION

Ethical approval for this study has been obtained from the Aboriginal Health Council of South Australia (Ref: 04-21-956), the Aboriginal Health and Medical Research Council of New South Wales (Ref: 1918/22), the Western Australian Aboriginal Health Ethics Committee (Ref: HREC1147), the Northern Territory Health and Menzies School of Health Research (Ref: 2022-4371), ACT Health Human Research Ethics Committee (Ref: 2022.ETH.00133), the St. Vincent's Hospital, Victoria (Ref: HREC 129/22), University of Tasmania (Ref: 28020), Far North Queensland Human Research Ethics Committee (Ref: HREC/2023/QCH/89911) and Griffith University (Ref: 2023/135). Prospective adolescent participants will provide their own consent for the online survey (aged 13-24 years) and, interviews or focus group discussions (aged 15-24 years); with parental consent and adolescent assent required for younger adolescents (aged 10-14 years) participating in interviews.Study findings (priority needs and evidence-based responses) will be presented at a series of co-design workshops with adolescents and stakeholders from relevant sectors. We will also communicate findings through reports, multimedia clips and peer-reviewed publications as directed by the governance group.

Anxiety and Depression Signs Among Adolescents in 26 Low- and Middle-Income Countries: Prevalence and Association With Functional Difficulties

PURPOSE

The aim of this study is to describe the occurrence of signs of depression and anxiety among adolescents from 26 low- and middle-income countries and explore the extent to which these are associated with difficulties across other functional domains.

METHODS

We analyzed randomly selected, nationally representative data from 26 countries with a total sample size of 123,975 adolescents aged 10-17 years. Data on functional difficulties, including signs of depression and anxiety, were collected by the Child Functioning Module, an instrument validated to identify the population of children with disabilities through household surveys. We estimated percentages and 95% confidence intervals of adolescents with difficulties across 11 domains of functioning, and of signs of depression and/or anxiety. We used multinomial regressions to estimate the association between difficulties in the different domains and having signs of depression only, signs of anxiety only, and signs of both depression and anxiety, relative to not presenting signs of depression or anxiety.

RESULTS

In total, 5.5% of adolescents were reported to have had signs of anxiety, 3.1% signs of depression, and 2.3% co-occurring signs of anxiety and depression. Compared to adolescents without functional difficulties, those with difficulties in one or more domains were three times more likely to have signs of depression and anxiety. The likelihood of presenting signs of depression only or signs of both depression and anxiety was significantly higher across all domains, and the highest among adolescent with difficulties to self-care and communicating. The likelihood of presenting signs of anxiety only was significantly higher across all domains except seeing and hearing, and the highest among adolescent with difficulties communicating and accepting changes.

DISCUSSION

Adolescents with functional difficulties in all domains analyzed, across different contexts, are more likely to experience depression and anxiety signs than those without such difficulties. Increasing the availability of population-level data on adolescent functional difficulties, including those related to depression and anxiety, is important in promoting inclusivity, participation, and the right of children to equal opportunities.

Adolescent experiences of the safe surgical checklist and surgical care processes

PURPOSE

To explore the perceptions, satisfaction, and needs of adolescent surgical patients with their perioperative pathway, including consent, the Safe Surgical Checklist (SSC), and post-operative care.

METHODS

We used qualitative methodology to examine adolescent experiences with surgical consent, SSC, and post-operative care. We purposively recruited ten patients aged 13-17 undergoing emergency and elective surgery and obtained consent from parents and patients. Semi-structured interview scripts were co-developed with an adolescent patient advisor, and interviews were performed, recorded, and transcribed verbatim. Thematic analysis was based on grounded theory and Participants were recruited and interviewed until thematic saturation was achieved.

RESULTS

Four themes emerged in thematic analysis: (1) Autonomy and Inclusion-Adolescents desire to participate in the consent process, including signing their own consent when appropriate, (2) Value of Repetition-Adolescents value the repetition of information in the pre-operative check and feel safer when the team reinforces the information, (3) Importance of Caregiver Involvement - Adolescents valued their caregivers being involved in critical conversations and decision making, and (4) Importance of Transparency in Communication-Adolescents desire to be directly given information about their surgery post-operatively and not told to parents alone.

CONCLUSION

Adolescents are situated uniquely between childhood and adulthood. Adolescents desired to be directly involved in the decision-making process of their surgery, including participation in the SSC and discussion of post-operative complications.

A systematic review of evidence-based interventions for child and adolescent mental health problems in low- and middle-income countries

BACKGROUND

Treatments for mental health problems in childhood and adolescence have advanced in the last 15 years. Despite advances in research, most of the evidence on effective interventions comes from high-income countries, while evidence is scarce in low- and middle-income countries (LMICs), where 90% of world's children and adolescents live. The aim of this review was to identify evidence-based interventions tested in LMICs to treat or prevent child and adolescent mental health problems.

METHODS

We conducted a systematic review of seven major electronic databases, from January 2007 to July 2019. We included randomised or non-randomised clinical trials that evaluated interventions for children or adolescents aged 6 to 18 years living in LMICs and who had, or were at risk of developing, one or more mental health problems. Results were grouped according to the studied conditions. Due to the heterogeneity of conditions, interventions and outcomes, we performed a narrative synthesis. The review was registered at PROSPERO under the number CRD42019129376.

FINDINGS

Of 127,466 references found through our search strategy, 107 studies were included in narrative synthesis after the eligibility verification processes. Nineteen different conditions and nine types of interventions were addressed by studies included in the review. Over 1/3 of studied interventions were superior to comparators, with psychoeducation and psychotherapy having the highest proportion of positive results. One-third of studies were classified as presenting low risk of bias.

INTERPRETATION

This review shows that different interventions have been effective in LMICs and have the potential to close the mental health care gap among children and adolescents in low-resource settings.

Can Intersectoral Interventions Reduce Substance Use in Adolescence? Evidence From a Multicentre Randomized Controlled Study

Objectives: We measure the impacts of an intersectoral intervention tackling adolescent substance use implemented between 2017 and 2019 in a tri-border region of Brazil, Paraguay, and Argentina.

Methods: The intervention involved 23 institutions from different sectors and 880 adolescents, equally split between randomly selected treatment and control classes across institutions. Treatment group students were involved in the co-development of activities to tackle substance use within their institutions. Both treatment and control group students benefited from the activities developed and implemented from the second year of the intervention. We use difference-in-differences models to measure the impacts of participation in the co-development of the activities on alcohol, tobacco, and cannabis consumption.

Results: Adolescents involved in the co-development of activities are 8 pp less likely to consume tobacco and cannabis, and 13 pp less likely to consume alcohol (p<0.01), compared to those who only participate in the activities. Among cannabis users, frequent consumption is also reduced by the intervention. Peer frequency of consumption is strongly associated with individual consumption.

Conclusion: Co-development of activities by the subjects themselves can be key to decreasing substance use in this very crucial stage of life, especially if the institutions and the implementers are familiar with the area and subjects of the intervention.

Considerations for Monitoring School Health and Nutrition Programs

School health and nutrition (SHN) interventions are among the most ubiquitous public health investments and comprise a key mechanism for reaching populations that are otherwise difficult to reach through the health system. Despite the critical role of monitoring these multisectoral programs to enable data-informed adaptive programming, information to guide program implementers is scant. This manuscript provides an overview of how monitoring indicators can be selected across a SHN program's logical framework, with specific examples across five SHN implementation models. Adaptation of SHN programs in times of school closures, such as those currently being experienced globally due to the emergence of COVID-19, is also addressed. Key aspects of SHN program monitoring are explored, including: (1) why monitor; (2) what to measure; (3) how to measure; and (4) who measures. In situations of school closures, strategies to shift both program activities and corresponding monitoring mechanisms are critical to understanding the rapidly evolving situation and subsequently guiding policy actions to protect vulnerable populations.

Evaluating quality in adolescent mental health services: a systematic review

OBJECTIVES

To evaluate the quality of adolescent mental health service provision globally, according to the WHO Global Standards of adolescent mental health literacy, appropriate package of services and provider competencies.

DESIGN AND DATA SOURCES

Systematic review of 5 databases, and screening of eligible articles, from 1 January 2008 to 31 December 2020.

STUDY ELIGIBILITY CRITERIA

We focused on quantitative and mixed-method studies that evaluated adolescent mental health literacy, appropriate package of services and provider competencies in mental health services, and that targeted depression, anxiety and post-traumatic stress disorder among adolescents (10-19 years). This included adolescents exposed to interventions or strategies within mental health services.

STUDY APPRAISAL AND SYNTHESIS METHODS

Study quality was assessed using the National Institutes for Health Study Quality Assessment Tools. Data were extracted and grouped based on WHO quality Standards.

RESULTS

Of the 20 104 studies identified, 20 articles were included. The majority of studies came from high-income countries, with one from a low-income country. Most of the studies did not conceptualise quality. Results found that an online decision aid was evaluated to increase adolescent mental health literacy. Studies that targeted an appropriate package of services evaluated the quality of engagement between the therapist and adolescent, patient-centred communication, mental health service use, linkages to mental health services, health facility culture and intensive community treatment. Provider competencies focused on studies that evaluated confidence in managing and referring adolescents, collaboration between health facility levels, evidence-based practices and technology use.

CONCLUSIONS AND IMPLICATIONS

There is limited evidence on quality measures in adolescent mental health services (as conforms to the WHO Global Standards), pointing to a global evidence gap for adolescent mental health services. There are several challenges to overcome, including a need to develop consensus on quality and methods to measure quality in mental health settings.

PROSPERO REGISTRATION NUMBER

CRD42020161318.

Education in youth-friendly genetic counseling

Genetic counselors have long recognized the challenges of working with adolescents and young adults (AYA) and their families. In 2010, a framework of Youth-friendly Genetic Counseling was developed by an expert reference group with the aim to improve both care for AYAs and the experience of health professionals delivering that care. Subsequently, an education workshop was developed aimed to upskill genetic health professionals in youth-friendly genetic counseling. The workshop was piloted with genetic counselors in Australia and New Zealand. A purpose designed, pre- and post-workshop survey and post-workshop focus group was utilized for evaluation. Mean confidence scores increased pre- and post-workshop. Participants also demonstrated increases in knowledge regarding: adolescent development; developmental theory; social factors impacting on health; the needs of young people; practice challenges; youth-friendly engagement, communication, consent and confidentiality; practice approaches; principles of adolescent healthcare; ethical issues; and available services and resources. Focus group data revealed several themes relating to practice challenges, learning gains, barriers, and enablers to clinical translation and workshop feedback. Results demonstrate utility of the workshop in up-skilling genetic health professionals in the provision of youth-friendly genetic counseling. Consideration of adaptation and sustainability, by embedding this theoretical and skills-based workshop as a module within genetic counseling education, is required to ensure practice competence and the best health outcomes for young people and their families.

Mental Health Literacy: A Strategy for Global Adolescent Mental Health Promotion

Background:

Adolescence is defined by key transitional elements which are considered within a cross-cultural context. The importance of building mental health capacity for adolescents in low- and middle-income countries (LMICs) as well as high-income countries (HICs) is reviewed.

Objectives:

To review the developmental period of adolescence, global needs for mental health promotion, the needs of LMICs while emphasizing building adolescent mental health capacity, and the importance of efforts to promote mental health literacy.

Methods:

Mental health literacy (MHL) is presented as a strategy that can increase public awareness regarding mental health issues among adolescents. Increased awareness through an MHL framework is discussed as a way to build adolescent mental health capacity; with this work ideally occurring through global communities of practice (COP), dialogue, collaboration, and mutual support that aim to build innovation in systems of mental health promotion.

Results:

The authors review structural components in research, practice, and policy that seek to build global adolescent mental health capacity, nested within COPs involving HICs and LMICs working together to advance mental health promotion for children, adolescents, and young people.

Conclusion:

The article concludes with a discussion of how the three structural components (i.e., research, practice, and policy) can address gaps in the provision of global mental health services for adolescents to meet adolescent mental health needs in LMICs and HICs. A multi-sectoral approach emphasizing a global COP is presented as a way to scale up capacity and maximize outcomes.

A framework for youth-friendly genetic counseling

Young people represent a unique cohort in the context of both healthcare and genetic risk. Genetic counselors have long recognized and documented the challenges of working with young people and their families compared with working with older adults. Challenges for health professionals include engagement with the young person, communication, developmentally appropriate psychosocial assessment, and working with the young person and their family. Likewise, young people also report experiencing challenges within the genetic counseling process. In response to these challenges, and increasing numbers of young people presenting for genetic testing, genetic counselors at the Parkville Familial Cancer Centre (Peter MacCallum Cancer Centre, Australia) formed a collaboration with the ONTrac at Peter Mac Victorian Adolescent & Young Adult Cancer Service. Consisting of a multidisciplinary expert panel who provide care to young people with cancer and their families, the collaboration identified the need to develop an evidence-based framework to ensure the delivery of youth-friendly care and support for young people and their families facing genetic risk. To guide this work, a working party comprising of experts in genetic counseling, adolescent and young adult (AYA) oncology, adolescent health, clinical ethics, and clinical research was established. A literature review was undertaken and based on expert and consumer input and feedback, a consensus-based framework for youth-friendly genetic counseling was developed over several stages. This paper describes the evidence base supporting the development of this framework, the process of development, and the resulting framework of youth-friendly genetic counseling.