Adapting DIALOG+ and building capacity in schools to support mental wellbeing and resilience in post-conflict Colombia during the COVID-19 pandemic
Lead Research Organisation:
Queen Mary University of London
Department Name: Sch of Medicine & Dentistry
Abstract
It is estimated that here are around 8.5 million victims of armed conflict in Colombia. Tolima is one of the areas most affected as it was were guerrilla groups formed and it served as a key strategic corridor during the armed conflict. The national Mental Health Study (ENSM-2015) found high levels of mental distress and illness in Colombia's children and adolescents, including high levels of post-traumatic stress symptoms, in the context of poor levels of access to treatment. Tolima specifically is facing many challenges in the transition from conflict to peace, and one of the governmental programmes in place is the Development Programs with Territorial Approach (PDET) which aims to stimulate development, in part by prioritising healthcare access. Throughout the armed conflict and also as the region moves into peacebuilding, there has been a lack of access to mental health professionals, made harder by the fact that there are as few as 1.84 psychiatrists per 100,000 population in Colombia. This means that the role of teachers and school counsellors is key in providing mental health support for children and adolescents in this region. Mental health and well-being through adolescence is important for an optimal transition to adulthood and hence to sustain mental health later in life. In recent years there has been increased attention to the psychological consequences of conflict on adolescents. However, the impact of the armed conflict on children and adolescents is still poorly understood and there is a current need for a well-structured intervention to improve and deliver mental health interventions to this vulnerable group. Pontificia Universidad Javeriana has developed an online diploma to support mental health in the school community, which has proven to be effective in improving school interventions in mental health and improving the skills and knowledge of teachers. Likewise, the Queen Mary University of London team has developed and tested a mental health intervention called DIALOG+, a low-cost/cost saving evidence-based therapeutically effective mental health intervention, which has been used and assessed in many clinical contexts internationally. DIALOG+ was developed based on quality of life research, concepts of patient-centred communication, developments in information technology, and components of solution-focused therapy.
The overall aim of this study is to improve the mental health, resilience and quality of life of children and adolescents from Tolima, Colombia, taking into account the additional context of this post-conflict setting during the added stress of the current COVID-19 pandemic. This will be done by training (online and face-to-face) teachers and school counsellors from this region in mental health in order to allow them to develop strategies for the promotion of mental wellbeing and the prevention and early detection of mental health problems. Strengthening of educators' capacities will be achieved whilst modifying and exploring DIALOG+ - a proven technology-assisted tablet/smartphone-based and resource-oriented intervention - as a generic approach for mental health problems identified in adolescents. This exploratory study will provide the information required to conduct a definitive trial that will show if this intervention will help reduce the current treatment gap experienced by children and adolescents with symptoms of mental distress in this, and similar contexts.
The overall aim of this study is to improve the mental health, resilience and quality of life of children and adolescents from Tolima, Colombia, taking into account the additional context of this post-conflict setting during the added stress of the current COVID-19 pandemic. This will be done by training (online and face-to-face) teachers and school counsellors from this region in mental health in order to allow them to develop strategies for the promotion of mental wellbeing and the prevention and early detection of mental health problems. Strengthening of educators' capacities will be achieved whilst modifying and exploring DIALOG+ - a proven technology-assisted tablet/smartphone-based and resource-oriented intervention - as a generic approach for mental health problems identified in adolescents. This exploratory study will provide the information required to conduct a definitive trial that will show if this intervention will help reduce the current treatment gap experienced by children and adolescents with symptoms of mental distress in this, and similar contexts.
Publications
| Description | This study involved three interrelated activities which all have key findings. The first component was the delivery of a schools mental health diploma to teachers in the Tolima department. 123 teachers completed the diploma, creating a cadre of teachers equipped to identify and intervene in mental health of students in the school context. The second component was the prevalence of mental distress amongst school children. For this component, a convenience sample of 657 students in the Tolima department were survey. When compared the the previous national mental health survey in 2015, our sample showed significantly higher levels of anxiety and depression symptoms, as well as higher levels of probable post-traumatic stress disorder. Participants had resilience scores that were consistent with conflict areas, and lower than Australia and the United State. Alcohol use in our sample was 17.2% compared to 5.2% in the 2015 national mental health survey. These results advocate for the high need in this population, and this was conveyed to the Secretary for Education of the Tolima, The final component of the work was the contextual adaptation of DIALOG+ to be used in schools in Tolima - both in the post-conflict Colombia but also in response to the additional stress of the COVID pandemic and associated restrictions. This was conducted in two schools in Chaparral municipality. The study was conducted in three stages: (1) Adaptation, where qualitative data from focus groups with students and teachers was used to determine the ways in which DIALOG+ needed to be adapted for use in schools. DIALOG+S was developed for use in stage 2. (2) Exploration, where 14 teachers and 70 students took part in this study, in which the adapted DIALOG+S was tested over 6 monthly meetings. Teachers were randomised to deliver either DIALOG+S or monthly meetings without DIALOG+S. Mental health symptoms, quality of life, self-esteem and resilience were measured at baseline and again after the six month intervention period. (3) Consolidation, where focus group data from teachers and students and 'think aloud' voice notes from the teachers, were analysed to understand the experience of implementing DIALOG+S, with possible suggestions about changes needed for implementation could also be generated. In terms of findings for each stage, we found that (1) Some of the domains in DIALOG+ needed to be adapted for use in the school context, and the outcome of this was the DIALOG+S application used in stage 2. Of the 11 domains in DIALOG+, six were used unchanged, Five were modified and one extra domain was added. (2) Recruitment, retention and session completeness was excellent, supporting the feasibility of the adapted intervention in this setting. The exploration phase was not powered to detect statistically significant results, but our observed data suggest DIALOG+S positively impacted on quality of life, resilience and symptoms of depression. (3) This was also reflected and reinforced by the qualitative data, supporting further work or implementation of DIALOG+S in this setting. This qualitative data also strongly supported the acceptability of the intervention for both teachers and students. Both groups felt that the use of technology was engaging and motivating to students, providing a clear way to track progress whilst improving the relationship between teachers and students. Both the students and teachers reported that they felt improvements in their wellbeing, and a reduction in meetings for conduct issues or academic progression. |
| Exploitation Route | DIALOG+S should be tested in larger full-powered trials to assess qualitatively what the impact is of this new intervention. The PIs are exploring options for this. The Colombian PI has made the Tolima Secretary for Education aware of the high need in the population, as well as the usefulness of DIALOG+S. The Colombian PI is currently exploring the development of a DIALOG+ app which could be used to disseminate this more easily. There are early discussions about incorporating DIALOG+S into the new curriculum for the schools' mental health diploma (currently being re-developed for online delivery) as well as ways in which DIALOG+S could be incorporated into other regional and national mental health programmes for University students and school-aged scholars. |
| Sectors | Education,Healthcare |
| Description | The Schools Health Diploma component of this study has been completed. Of 180 teachers who signed up, 152 started the diploma training and 123 completed and received a diploma. These teachers came from around 30 schools in 18 provinces, including some from the areas most affected by the conflict in Colombia. These teachers are now able to support students and fellow teachers in dealing with mental health issues in their schools, something that would not have been in place prior to the training/diploma. Wellbeing data from a convenience sample of 657 students shows much higher prevalence of symptoms of anxiety and depression, high probable post-traumatic stress disorder, family disfunction, low resilience and high alcohol use. These results are important when compared with the results from the 2015 national mental health survey which showed significantly lower levels of distress or disorder. These data advocate for a very high need within this population, and this was conveyed to teachers and the Tolima Secretary for Education at a dissemination meeting in February 2023. The adapted DIALOG+S app was found to be feasible, acceptable and appeared to have impacts on quality of life and mental distress which should be studied further in larger fully-powered studies. The Colombian PI is currently exploring was to create a stand alone DIALOG+S app for use in future studies, but also for implementation in existing wellbeing initiatives involving University students and school-aged scholars. The schools' mental health diploma is currently being re-developed for online delivery, and another option being explored is whether or not DIALOG+S could be included as an intervention. |
| First Year Of Impact | 2022 |
| Sector | Education |
| Impact Types | Societal,Policy & public services |
| Title | DIALOG+S |
| Description | The DIALOG+ app, available freely as an Android, IOS and progressive web app, was adapted using inbuilt facility to be able to change the domains, for use in schools as DIALOG+. This requires that each installation be manually changed. Future plans would be to create a stand-alone DIALOG+S application and initiatives are underway to see if this can be realised. |
| Type Of Technology | Webtool/Application |
| Year Produced | 2023 |
| Impact | This is the first time that DIALOG+ has been used in the school context, and represents a significant extension on the use of this intervention. We anticipate that the adapted version, DIALOG+S, will be suitable for use with all scholars and students, including those in tertiary education. There are existing initiatives and programs in Colombia where this is now being considered. |
| Description | A focus group with students who participated to learn about their experience of DIALOG+S |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | Conducted a focus groups with the students who participated in the exploratory phase of the adaptation of DIALOG+ to the school context to learn about their experience. We obtained the opinions of the students about their experiencie, the acceptability and feasibility of implementing DIALOG+ in schools. |
| Year(s) Of Engagement Activity | 2022 |
| Description | A focus group with the teachers who participated in the study to learn about their experience of using DIALOG+S |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | Conduct a focus group with the teachers who participated in the exploratory phase of the adaptation of DIALOG+ to the school context to learn about their experience. We obtained the opinions of the teachers about their experience, the acceptability and feasibility of implementing DIALOG+S in schools. |
| Year(s) Of Engagement Activity | 2022 |
| Description | A meeting to introduce the study to principals to elicit participation from students. |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | Introduce the SMART project and the prevalence study to the principals of schools in Rioblanco Municipality in order to invite students to participate. |
| Year(s) Of Engagement Activity | 2022 |
| Description | A presentation for the principal of Manuel Murillo Toro School to introduce the SMART project. |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | A talk was held with the principal of Manuel Murillo Toro School in order to introduce the SMART project and establish a collaboration with the school. The principal agreed to collaborate by sending invites and informed consents to the parents of the students to participate in the prevalence study. |
| Year(s) Of Engagement Activity | 2021 |
| Description | A presentation for the principal of Medalla de la Milagrosa School to introduce the SMART project. |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | A talk was held with the principal of Medalla de la Milagrosa School in order to introduce the SMART project and establish a collaboration with the school. The principal agreed to collaborate by sending invites and informed consents to the parents of the students to participate in the prevalence study. |
| Year(s) Of Engagement Activity | 2021 |
| Description | A presentation for the principal of Nuestra Señora del Rosario School to introduce the SMART project. |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | A talk was held with the principal of Nuestra Señora del Rosario School in order to introduce the SMART project and establish a collaboration with the school. The principal agreed to collaborate by sending invites and informed consents to the parents of the students to participate in the prevalence study. |
| Year(s) Of Engagement Activity | 2021 |
| Description | A presentation for the principals of schools in Ataco Municipality to introduce the SMART project. |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Schools |
| Results and Impact | A talk was held with the principals of schools in Ataco Municipality in order to introduce the SMART project and establish a collaboration with the schools. One principal agreed to collaborate by sending invites and informed consents to the parents of the students to participate in the prevalence study. |
| Year(s) Of Engagement Activity | 2021 |
| Description | A training workshop on school mental health and the use of DIALOG+ for teachers and school counsellors of Martín Pomala School (Ataco, Tolima) |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | A training workshop was conducted for 65 teachers and counsellors from the Martín Pomala School (Ataco, Tolima) on school mental health, the use of DIALOG+ and the importance of the prevalence study. The SMART Project Coordinator gave a lecture to the teachers and counsellors on mental health and provided a broad overview of what DIALOG+ is and how it should be used. |
| Year(s) Of Engagement Activity | 2022 |
| Description | An international symposium on adolescents and school mental health: Challenges and opportunities. |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Policymakers/politicians |
| Results and Impact | A symposium to present, amongst others, the preliminary results of the prevalence study and the adaptation of DIALOG+ to the school context as well as the experience of the diploma course in school mental health. A presentation was also made by the UK PI to describe work done globally on adapting DIALOG+ to other settings. Related work with adolescents in Colombia was also presented, with the launch of an arts project based book and exhibition. |
| Year(s) Of Engagement Activity | 2022 |
| Description | Dissemination meeting in Ibague on the 10th of February 2023 |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Schools |
| Results and Impact | A meeting to disseminate the results of the SMART project with the participating schools and other schools in the department, as well as with entities responsible for health and education decisions in Tolima. Local radio also reported on the event, and interviewed the PIs. Participants learned about the results of the study on the prevalence of mental health problems and the adaptation of DIALOG+S to the school context and and some strategies for addressing the most prevalent mental health problems in this school context were also presented. The UK PI also presented on the context of how DIALOG+ has been tested in other global health study settings. Opportunities to continue to use DIALOG+ and to roll this out in other settings was also discussed. |
| Year(s) Of Engagement Activity | 2023 |
| Description | Event to introduce the school mental health diploma to teachers and school counsellors who have enrolled onto the course. |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Schools |
| Results and Impact | An event was held for teachers and school counsellors who have enrolled onto the school mental health diploma to introduce the course, alongside the project leads and politicians. During the event, the inaugural conference and the general plan of the diploma course were presented. |
| Year(s) Of Engagement Activity | 2021 |
| Description | Focus group with students who took part in the DIALOG+S study |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | Conduct a focus group with students who participated in the exploratory phase of the adaptation of DIALOG+ to the school context to learn about their experience. We obtained the opinions of the students about their experience, the acceptability and feasibility of implementing DIALOG+S in schools. |
| Year(s) Of Engagement Activity | 2022 |
| Description | Focus group with teachers to elicit suggested adaptations to use DIALOG+ in the school context. |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | Conduct a focus group with teachers to present the DIALOG+ tool and learn about the necessary adaptations for use in the school context. DIALOG+S was developed for implementation in the randomised exploratory study. We obtained the opinions of the teachers about the usefulness of the tool and the domains that should be kept, eliminated or modified to be used in the school context. |
| Year(s) Of Engagement Activity | 2022 |
| Description | Focus group with teachers to present DIALOG+ and learn about adaptations necessary to implement this in schools. |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | Conducted focus group with teachers to present the DIALOG+ tool and learn about the necessary adaptations for the school context. Based on this feedback, DIALOG+S was developed for testing in an exploratory randomised study. |
| Year(s) Of Engagement Activity | 2022 |
| Description | Focus group with teachers who took part in the DIALOG+S study |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Professional Practitioners |
| Results and Impact | Conduct a focus group with teachers who participated in the exploratory phase of the adaptation of DIALOG+S to the school context to learn about their experience. Carry out the focus groups with the teachers who participated in the exploratory phase of the adaptation of DIALOG+S to the school context to learn about their experience. |
| Year(s) Of Engagement Activity | 2022 |
| Description | Focus groups with students to present DAILOG+ to students to learn about necessary adaptations |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | Carry out the focus groups with students to present the DIALOG+ tool and learn about the necessary adaptations for the school context. From this feedback, DIALOG+S was created for testing in a small exploratory study. |
| Year(s) Of Engagement Activity | 2022 |
| Description | Focus groups with students to present DIALOG+ and to elicit necessary adaptations for delivery in the school context. |
| Form Of Engagement Activity | A formal working group, expert panel or dialogue |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | Conduct a focus group with the students to present the DIALOG+ tool and learn about the necessary adaptations for the school context. DIALOG+S was developed on the basis of this feedback. We obtained the opinions of the students about the tool and the domains that should be kept, eliminated or modified to be used in the school context. |
| Year(s) Of Engagement Activity | 2022 |
| Description | Meeting of schools and principals to describe the study and elicit participation. |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | A meeting to introduce the SMART project and the prevalence study to the principals of schools in Rioblanco Municipality in order to invite students to participate in the SMART study. |
| Year(s) Of Engagement Activity | 2022 |
| Description | Meeting of schools and principals to introduce the study and elicit participation. |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | A meeting to introduce the SMART project and the prevalence study to the principals of schools in Rioblanco Municipality in order to invite students to participate. |
| Year(s) Of Engagement Activity | 2022 |
| Description | Meeting with Secretary of Education and Culture of Tolima province to organise a dissemination meeting |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Policymakers/politicians |
| Results and Impact | A meeting with the Secretary to discuss findings, and organise a meeting to disseminate the results of the project with the teachers and school counsellors of the department of Tolima, The date, place and agenda of the event were defined, as well as the logistics for the invitation of participants. |
| Year(s) Of Engagement Activity | 2023 |
| Description | Meeting with the principal of Soledad Medina School to discuss the SMART project. |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | A talk was held with the principal of Soledad Medina School in order to introduce the SMART project and establish a collaboration with the school. The principal agreed to collaborate by sending invites and informed consents to the parents of the students to participate in the prevalence study. |
| Year(s) Of Engagement Activity | 2021 |
| Description | Presentation of SMART project and the school mental health diploma to principals of the PDET municipal schools. |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | Presented the SMART project and the school mental health diploma to the principals of the PDET municipal schools in order to invite teachers and school counsellors to participate. The principals of the schools reported interest in the project and aimed to send the information to the teachers and school counsellors about the diploma as well as the link to register for it. |
| Year(s) Of Engagement Activity | 2021 |
| Description | Presentation on SMART for the Secretary of Education and Culture of Tolima. |
| Form Of Engagement Activity | A talk or presentation |
| Part Of Official Scheme? | No |
| Geographic Reach | Regional |
| Primary Audience | Policymakers/politicians |
| Results and Impact | The purpose of the presentation was to introduce the SMART project to the Secretary of Education of Tolima and the Quality Director of the Secretary of Education of Tolima. Aim to collaborate to convene teachers and school counsellors to participate in the diploma course. The outcome of the presentation was the Secretary of Education sent an official letter to schools with the invitation to participate in the diploma. |
| Year(s) Of Engagement Activity | 2021 |
| Description | School visit (Soledad Medina School), Training on school mental health and DIALOG+ for teachers. |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | Local |
| Primary Audience | Schools |
| Results and Impact | Conducted a training session with 52 teachers from Soledad Medina School on school mental health to sensitise teachers and discuss what is DIALOG+. The training session, lead by the SMART Project Coordinator, involved a talk on depression and suicide, as well as an introduction on DIALOG+. |
| Year(s) Of Engagement Activity | 2021 |