Improving mental health literacy among young people aged 11-15 years in Java, Indonesia: co-development and feasibility testing of a culturally-appropriate, user-centred resource (IMPeTUs) - a study protocol

Evaluating a prototype digital mental health literacy intervention for children and young people aged 11-15 in Java, Indonesia: a mixed methods, multi-site case study evaluation

BACKGROUND

The Improving Mental Health Literacy Among Children and Young People in Indonesia (IMPeTUs) intervention is a co-produced, evidence-based digital intervention designed to improve anxiety and depression focused mental health literacy and self-management among people aged 11-15 in Java, Indonesia. This study aimed to evaluate the usability, feasibility and preliminary impact of our intervention.

METHODS

Mixed methods, multi-site case studies based on a theory of change. Pre-and post-assessments of a range of outcomes and qualitative interviews/focus groups with children and young people (CYP), parents and facilitators. The intervention was implemented in 8 health, school and community sites across Java, Indonesia (Megelang, Jakarta and Bogor). Quantitative data designed to understand the impact of and feasibility of evaluating the intervention collected from 78 CYP who used the intervention were analysed descriptively. Qualitative data from interviews and focus groups collected from 56 CYP, 49 parents/caregivers and 18 facilitators were analysed using framework analysis.

RESULTS

Qualitative data analysis indicated high levels of usability and acceptability for the interface aesthetic, personalisation, message presentation and navigation. Participants reported minimal burden and no negative outcomes associated with the intervention. CYP, parents and facilitators identified a range of direct and spill over effects of interventions engagement, some of which were not anticipated at study outset. Quantitative data highlighted the feasibility of intervention evaluation, with high levels of recruitment and retention across study time points. Minimal changes were identified in outcomes pre-to-post intervention, which may in part be due to a lack of scale relevance and/or sensitivity to the intervention mechanisms indicated in the qualitative data.

CONCLUSIONS

Digital mental health literacy applications are potentially an acceptable and feasible way to prevent burdens of common mental health problems amongst CYP in Indonesia. Our intervention and evaluative processes will be further refined prior to definitive evaluation.

Acceptability and Feasibility of the ProLiSMental Psychoeducational Intervention to Promote Adolescents' Mental Health Literacy on Anxiety in a School Context

The ProLiSMental psychoeducational intervention intends to promote adolescents' mental health literacy on anxiety, facilitating their access, understanding, evaluation, and use of effective mental health information. This study aimed to assess the acceptability and feasibility of that intervention in a school context and improve its content, structure, and procedure. A convenience sample of seventeen participants has been recruited: eleven students (mean age = 14.09 years, SD = 0,30) and six education and health professionals (mean age = 53.00 years, SD = 4,05). High levels of acceptability and feasibility of the ProLiSMental psychoeducational intervention were observed and important improvements were made.

Children and young people's beliefs about mental health and illness in Indonesia: A qualitative study informed by the Common Sense Model of Self-Regulation

BACKGROUND

Mental illness is a leading cause of disease burden amongst children and young people (CYP). This is exacerbated in low- and middle-income (LMIC) countries which often have embryonic care structures. Understanding and targeting illness beliefs is a potentially efficacious way of optimising the development of health prevention interventions. These beliefs remain relatively underexplored in CYP in LMIC contexts. Aim: To develop an in-depth understanding of CYPs beliefs about mental health and illness in Indonesia.

METHODS AND FINDINGS

Semi-structured interviews (n = 43) combined with photo elicitation methodology were undertaken with CYP aged 11-15 from Java, Indonesia. Our sample comprised those living with (n = 19) and without (n = 24) high prevalence mental health conditions, specifically anxiety or depression. Data were analysed using framework analysis, informed by the Common Sense Model of Self-Regulation of Health and Illness. Positive mental health and illness were dichotomised in accounts with mental health typically characterised as an absence of mental disturbance. This contributed to attributions of abnormality and the marginalisation of those with mental illness. Mental illness was conceptualised as a single entity, commonly arising from individual failings. This prompted feelings of self-stigma in those with lived experience of mental illness. Analysis identified marked differences in the perceived time dimensions of positive mental health and illness with mental illness conceived as less transient than episodes of positive mental health. Illness beliefs appeared relatively consistent across the two groups of CYP although some nuanced differences were identified. CYP with anxiety and depression were less likely to believe that mental illness could be diagnosed visually, more likely to uphold multiple causal factors and endorse the potential efficacy of professional input.

CONCLUSIONS

Public health interventions to increase understanding may be necessary to develop healthcare systems to reduce treatment barriers, optimise return on investment and enhance population health effect.

A Novel, Scalable Social Media-Based Intervention ("Warna-Warni Waktu") to Reduce Body Dissatisfaction Among Young Indonesian Women: Protocol for a Parallel Randomized Controlled Trial

Background

Despite the prevalence of body dissatisfaction among young Indonesian women and its consequential negative impacts, there are currently no evidence-based, culturally appropriate interventions to tackle this issue. Therefore, there is a need to develop scalable, cost-effective, and accessible interventions to improve body image among this population.

Objective

This paper describes the study protocol of a parallel randomized controlled trial to evaluate the effectiveness of Warna-Warni Waktu, a social media–based intervention that aims to reduce state and trait body dissatisfaction and improve mood among young Indonesian women aged 15-19 years.

Methods

The trial will take place online. Approximately 1800 young women from 10 cities in Indonesia, evenly split across the ages of 15-19 years, will be recruited via a local research agency’s established research panel. Participants will be randomly allocated to the intervention condition or a waitlist control condition. The intervention consists of six 5-minute videos, with each video supplemented with up to five brief interactive activities. The videos (and associated activities) will be delivered at a rate of one per day across 6 days. All participants will complete three self-report assessments: at baseline (Day 1), 1 day following the intervention (Day 9), and 1 month following the intervention (Day 36). The primary outcome will be change in trait body dissatisfaction. Secondary outcomes include change in internalization of appearance ideals, trait mood, and skin shade satisfaction. Intervention effectiveness on these outcomes will be analyzed using linear mixed models by a statistician blinded to the randomized condition. Intervention participants will also complete state measures of body satisfaction and mood before and after watching each video to assess the immediate impact of each video. This secondary analysis of state measures will be conducted at the within-group level.

Results

Recruitment began in October 2021, with baseline assessments underway shortly thereafter. The results of the study will be submitted for publication in 2022.

Conclusions

This is the first study to evaluate an eHealth intervention aimed at reducing body dissatisfaction among young Indonesian women. If effective, the intervention will be disseminated to over half a million young women in Indonesia via Facebook, Instagram, and YouTube.

Trial Registration

ClinicalTrials.gov NCT05023213; https://clinicaltrials.gov/ct2/show/NCT05023213

International Registered Report Identifier (IRRID)

PRR1-10.2196/33596

Mental health literacy amongst children with common mental health problems and their parents in Java, Indonesia: a qualitative study

Background

Optimising mental health literacy (MHL) at the individual and population level can be an effective mental health improvement and prevention tool. However, concepts of MHL are largely based on evidence from high-income countries. Little is known about the manifestation and role of MHL in countries where collectivist health and social cultures are dominant.

Aim

This study aimed to examine the MHL of Indonesian children and young people (CYP) with experience of common mental health problems and their parents.

Methods

Semi-structured interviews with 40 participants (19 CYP aged 11-15 with experience of common mental health problems and 21 parents) from three areas of Java, Indonesia. Data were analysed using framework analysis, informed by Jorm's 1997 Mental Health Literacy Framework.

Results

Parents and CYP demonstrated relatively low levels of MHL defined from a conventional perspective. Religiosity and spirituality were salient in participants' accounts, particularly parents, as were narratives about personal responsibility. These beliefs appeared to contribute to a high level of self-blame for mental illness, self-reliance for symptom management, the foregrounding of support from spiritual/traditional healers and a reduced propensity to access professional help. CYP were heavily reliant on family support, but parents often felt they were not best placed to communicate with their children about mental health. Providing trusted, technology-based sources of mental health information were advocated by CYP.

Conclusion

Robust efforts are needed to improve MHL in low- and middle-income countries drawing on culturally appropriate approaches to reduce stigma and optimise timely, effective help-seeking for CYP. Enhancing parental and family level literacy may be efficacious, especially when combined with mechanisms to facilitate open communication, as may the development of standalone interventions directly developed to reach younger generations. Future research may usefully establish the comparative efficacy and acceptability of these different approaches.

Methods to Generate Innovative Research Ideas and Improve Patient and Public Involvement in Modern Epidemiological Research: Review, Patient Viewpoint, and Guidelines for Implementation of a Digital Cohort Study

Background

Patient and public involvement (PPI) in research aims to increase the quality and relevance of research by incorporating the perspective of those ultimately affected by the research. Despite these potential benefits, PPI is rarely included in epidemiology protocols.

Objective

The aim of this study is to provide an overview of methods used for PPI and offer practical recommendations for its efficient implementation in epidemiological research.

Methods

We conducted a review on PPI methods. We mirrored it with a patient advocate’s viewpoint about PPI. We then identified key steps to optimize PPI in epidemiological research based on our review and the viewpoint of the patient advocate, taking into account the identification of barriers to, and facilitators of, PPI. From these, we provided practical recommendations to launch a patient-centered cohort study. We used the implementation of a new digital cohort study as an exemplary use case.

Results

We analyzed data from 97 studies, of which 58 (60%) were performed in the United Kingdom. The most common methods were workshops (47/97, 48%); surveys (33/97, 34%); meetings, events, or conferences (28/97, 29%); focus groups (25/97, 26%); interviews (23/97, 24%); consensus techniques (8/97, 8%); James Lind Alliance consensus technique (7/97, 7%); social media analysis (6/97, 6%); and experience-based co-design (3/97, 3%). The viewpoint of a patient advocate showed a strong interest in participating in research. The most usual PPI modalities were research ideas (60/97, 62%), co-design (42/97, 43%), defining priorities (31/97, 32%), and participation in data analysis (25/97, 26%). We identified 9 general recommendations and 32 key PPI-related steps that can serve as guidelines to increase the relevance of epidemiological studies.

Conclusions

PPI is a project within a project that contributes to improving knowledge and increasing the relevance of research. PPI methods are mainly used for idea generation. On the basis of our review and case study, we recommend that PPI be included at an early stage and throughout the research cycle and that methods be combined for generation of new ideas. For e-cohorts, the use of digital tools is essential to scale up PPI. We encourage investigators to rely on our practical recommendations to extend PPI in future epidemiological studies.

A systematic mapping review of interventions to improve adolescent mental health literacy, attitudes and behaviours

AIM

The onset of mental illness is most common in adolescence, therefore mental health promotion efforts frequently target this age group. Evaluation literature in this area is largely segmented into specific domains in terms of settings, countries, and/or groups of young people, but an overall understanding and comparison across these areas is lacking. The current review aims to provide such an overview of interventions/programs which attempt to improve adolescents' mental health literacy, attitudes/stigma and behaviours.

METHODS

A systematic mapping review synthesized the strengths and weaknesses of published interventions/programs to improve mental health outcomes in youth. Ten databases and grey literature sources were searched, and results were categorized according to sample, location/setting, type of information presented, delivery and testing procedures, mental health outcome/s evaluated, and limitations.

RESULTS

One hundred and forty articles met the inclusion criteria; 126 were original records and 14 were reviews. Mental health literacy and attitudes/stigma were examined most frequently, and studies were predominantly conducted in school-based environments and high income economies. Intervention/program effectiveness varied across outcome/s measured, setting, and control group usage, with mental health literacy exhibiting the most positive changes overall. Common limitations included no long-term follow up or control group inclusion.

CONCLUSIONS

Despite generally positive changes seen throughout studies in this area, effectiveness differed across a range of methodological domains. Most research is conducted in schools and higher income economies, but the lack of investigation in other contexts (i.e., internet or community) or lower income countries suggests our understanding in this area is constrained.

Improving mental health literacy among young people aged 11-15 years in Java, Indonesia: the co-development of a culturally-appropriate, user-centred resource (The IMPeTUs Intervention)

BACKGROUND

Many mental health problems emerge in late childhood and contribute significantly to the global burden of disease. Adverse outcomes can extend into adulthood if left untreated. This impact is exacerbated in low- and middle-income countries where significant treatment gaps persist. Improving mental health literacy may offer an effective strategy for early intervention but remains underexplored in these contexts.

METHODS

An intervention was co-developed with children and young people (CYP) by undertaking a needs analysis combined with stakeholder consensus activities. A systematic review of mental health literacy interventions in South-East Asia was undertaken in addition to semi-structured interviews with 43 children and young people (19 with and 24 without experience of anxiety and depression), 19 parents of children with experience of mental health problems and 25 education and health professionals. A focus group was also held with 8 key stakeholders immersed nationally in policy and practice. Interview schedules explored participants' experiences of mental health, unmet needs and priorities for intervention. Data were synthesised and presented at a 3-day co-production workshop. Attendees included 13 CYP, 6 parents/guardians, 2 teachers, 8 health professionals, 2 academics and 3 game designers. Consensus exercises were utilised to identify the preferred format, content and delivery of the intervention. A smaller group of patient and public involvement contributors worked with designers to further iterate the intervention.

RESULTS

An immersive storyline digital application was co-developed for young people aged 11-15 with the primary aim of improving mental health literacy and self-management. The intervention comprises two chapters; one depression focussed, and the other anxiety focussed. The storyline format is interspersed with interactive games and exercises to promote engagement and encourage self-management. CYP also take part in group sessions delivered by trained facilitators before and after intervention use to discuss outcomes of and issues raised during the game.

CONCLUSION

The IMPeTUs intervention has been co-designed for CYP aged 11-15 to improve mental health literacy and enhance self-management abilities. To the best of our knowledge, this is the first Indonesian digital intervention to improve mental health literacy and self-management for this population. Implementation, acceptability, and impact are currently being explored in a multi-site case study evaluation.

Adolescents' Empowerment for Mental Health Literacy in School: A Pilot Study on ProLiSMental Psychoeducational Intervention

Adolescence is a critical life phase for mental health and anxiety an emerging challenge for adolescents. Psychoeducational interventions to promote mental health literacy (MHL) on anxiety in adolescents are needed. This study aimed to test the primary outcome of a future full-scale trial: improvement of adolescents' anxiety MHL components on recognition, prevention strategies, and self-help strategies. A sample of 38 adolescents, 24 (63.2%) females and 14 (36.8%) males, with an average age of 14.50 years (SD = 0.89) participated in this study. Each class was allocated to the intervention group (IG, n = 21) or the waiting list control group (WLCG, n = 17) with single-blinded randomization. MHL was assessed using the QuALiSMental. The ProLiSMental psychoeducational intervention consists of four or eight weekly sessions of 90 or 45 min for adolescents, using different active pedagogical methods and techniques. There also are initial and final sessions with adolescents, legal guardians, and teachers. There was a significant improvement with a small to relatively strong effect size in many dimensions of anxiety MHL components. This study suggests the progression to the full-scale trial and values the important role of mental health and psychiatric nurses in the adolescents' empowerment for MHL in schools.

Design thinking as an approach for innovation in healthcare: systematic review and research avenues

Design thinking has been increasingly adopted as an approach to support innovation in healthcare. Recent publications report design thinking application to various innovation projects, across medical specialties, including paediatrics, psychiatry, radiology, gastroenterology, oncology, orthopaedics and surgery, as well as to innovation in hospital operations and healthcare management. Current literature in the area typically focuses on single case descriptions. With the recent increase in the number of cases, there is an opportunity to assess multiple cases to identify patterns and avenues for further research. This study provides a systematic review of published design thinking projects in healthcare. The aim of the study is to provide an overview of how design thinking has been applied in the healthcare sector. Data collection was based on Institute of Scientific Information (ISI) Web of Science, PubMed and Scopus databases. The systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 32 original pieces of research was selected for analysis, being classified and assessed. The paper presents current status of research and practice from various perspectives, including the design thinking progression phase—inspiration, ideation, implementation—and the prevalence of design thinking tools. Avenues for further research include the need to increase focus on the inspiration phase, the opportunity for platforms for leveraging the integration of individuals in innovation projects, and the opportunity to enhance the role of lead users in healthcare innovation.

The Relationship between Family Harmony with Stress, Anxiety, and Depression in Adolescents

Introduction: Adolescents are a group vulnerable to mental health problems, including stress, anxiety, and depression. This study aimed to examine the interlink of a harmonious family with stress, anxiety, and depression in adolescents.Methods: This study employed descriptive correlational design with cross-sectional approach and examined 851 high school adolescents aged between 16-18 years who were recruited using a total sampling method from five high school in Malang City. Stress, anxiety and depression in adolescents was assessed employing the Depression Anxiety Stress Scale (DASS - 21), while, to assess family harmony, a questionnaire   developed by the researcher was used. Data were analyzed through descriptive statistics and bivariate tests using Spearman Rank Correlation.Results: It was revealed that 428 adolescents (50.3%) were male, 321 adolescents (37.7%) came from parents who worked privately, and 482 adolescents (56.6%) had their parents' social status above the minimum wage standard. Eight hundred and two adolescents (94.2%) had harmonious families, while the remaining 49 adolescents (5.8%) had non-harmonious families. Our study concluded that family harmony had a significant relationship with adolescent stress levels (p-value 0.013). On the other hand, the analysis showed that family harmony was not related to adolescents' anxiety (p-value 0.071) and depression level (p-value 0.13). A harmonious family makes children mentally healthy, able to adapt to the environment while a family that is not harmonious can trigger stress because conditions are not as expected, coupled with the burden of schoolwork, stressors from teachers and peers.Conclusion:The results of the research showed that harmony in the family had a significant effect on stress in adolescents. Therefore, it is necessary to provide education and counseling to the family to prevent fights in the family so that it can reduce the emergence of stress in adolescents.

Mental health literacy about depression among rural left-behind children in China: a comparative and cross-sectional study

BACKGROUND

Mental health literacy (MHL) is vital for raising mental health awareness, reducing stigma, and improving health-related decision making, which may have lifelong consequences for patients with mental disorders.

AIMS

To examine MHL about depression among rural left-behind children (LBC) in China and explore differences between LBC and non-left-behind children (NLBC).

METHODS

A total of 3456 rural school children (mean age = 13.02 years) in fourth to ninth grades who were living in Sichuan, Anhui, and Henan provinces were surveyed in April and July 2018 using stratified random cluster sampling.

RESULTS

More NLBC correctly recognized depression compared with LBC (p < 0.05). The most common sources of mental health information were the TV and the Internet. LBC felt more uneasy if they asked for help (p < 0.01). Statistical differences in help-seeking barriers were observed between LBC and NLBC (p < 0.05).

CONCLUSIONS

Respondents showed low levels of depression-related MHL compared with peer groups in other countries, LBC showed lower MHL than NLBC in terms of the correct recognition rate of depression, attitude toward seeking help, etc. More school-based interventions should be implemented in rural schools, and parent involvement and digital-based educational strategies should be considered.

Understanding mental health and its determinants from the perspective of adolescents: A qualitative study across diverse social settings in Indonesia

Poor mental health is a leading contributor to the burden of disease experienced by adolescents, including in resource constrained settings. However, little is known about how adolescents in these countries conceptualise mental health and its determinants which is essential to informing effective responses. This study aimed to explore how adolescents in Indonesia (a populous and rapidly developing country) conceptualise mental health and what they identify as important determinants. Eight focus group discussions (FGDs) were conducted with 86 Indonesian adolescents (aged 16-18 years), sampled from schools and community settings from Jakarta and South Sulawesi. FGDs were recorded, transcribed, translated and thematically analysed. Mental health was recognised as a significant concern by adolescents in Indonesia. Good mental health was conceptualised as emotional wellbeing and happiness. By contrast, poor mental health was predominantly described in terms of substantial mental illness manifesting as behavioural and physical disturbance. Further, poor mental health only happened to 'other' people, with stigmatising views prevalent. Absent from the discussions were common symptoms of poor mental health (stress, loneliness, poor sleep) and common mental disorders (e.g. depression, anxiety) or a conceptualisation that reflected poor mental health to be a normal human experience. Discussions around determinants of poor mental health suggested that family connections (particularly with parents), school pressures, and adverse exposures on social media were important drivers of poor mental health, with religion also surfacing as an important determinant. In highlighting mental health as an important issue for Indonesian adolescents, this study provides a foundation for targeted responses.