Developing & testing the feasibility of a sports-based mental health promotion intervention for adolescents in Nepal: a community engagement approach

Each year, one in five adolescents aged 10-19 experiences a mental disorder like depression or anxiety, and the rate is rising. We work in Nepal, a low-income country, where there is a large population of adolescents at risk of mental disorders, but a lack of mental health care. An intervention is needed that can protect adolescents from mental disorders, is accessible to all adolescents, and is cheap and easy to sustain. One such intervention is mental health promotion, which focuses on improving positive behaviours and characteristics that protect mental health.

Our research aims to develop a mental health promotion intervention that uses sports to engage and improve the mental health of adolescents in a rural community in Kailali, a district in the Far-Western Region of Nepal. We decided to focus on sports because there is evidence that sports activities improve mental health, adolescent participation in sports is supported by national and global adolescent policy, and adolescents across Nepal are already playing sport through a national network of sports clubs.

To develop the intervention, we will work in partnership with three stakeholder groups of: (i) adolescents, (ii) parents and teachers, and (iii) Nepalese mental health and sports experts. We will consult groups throughout the project on our research plans and findings. The adolescent group will specifically help us to understand how to ensure our intervention is accessible, by taking photos on the theme of barriers to participating in sports, and discussing these with the research team. The whole community will be invited to a funfair where, through art, talks and sports, we will help them to learn more about adolescent mental health, and provide opportunities for them to try out some mental health promoting sports activities. We will use this opportunity to collect valuable information about the community's priorities and preferences for a sports-based intervention.

To develop the theory and content of our intervention, we will draw on all the information from the stakeholder groups, the photography study, and the funfair, along with evidence from studies of sports interventions in Nepal and other low- and middle-income countries. We will refine the intervention theory through workshops with the stakeholder groups and research team. Finally, we will test the intervention among 200 adolescent boys and girls aged 10-19. We will decide whether sports coaches or adolescents themselves are best to to deliver the intervention, and whether the intervention should be based in communities or schools. Using tools that we have adapted and validated in Nepal, we will measure the intervention's effects on adolescent mental wellbeing and other indicators of mental health promotion.

Our research will lead to a larger evaluation of the intervention in Nepal. It will also contribute important knowledge on sports-based mental health promotion that can be used by governments, researchers and organisations working in other low- and middle-income countries. We will set a precedent for stakeholder involvement in intervention development research, building a strong and lasting community partnership for future research in Nepal.

Mental health promotion interventions that improve mental wellbeing, self-efficacy, self-esteem and emotion regulation, are effective in improving adolescent mental health in LMICs and could be more cost-effective than treatment approaches. We aim to develop and test the feasibility of an intervention that uses sport to promote mental health among adolescents aged 10-19 in Nepal. We selected this type of intervention because there is evidence that sport improves mental health, adolescent participation in sports is supported by Nepalese and global policy, and because of the potential scale and reach through a national network of sports clubs. We are working in Nepal because of its large population of adolescents, and their unmet mental health needs.

We will adopt a community engagement approach to intervention development, which seeks to foster respectful relationships between the researchers and the community, and build legitimacy for the research. Our study has seven steps:
(1) Consultation with stakeholder groups (adolescents, parents and teachers, and mental health and sports experts) on potential intervention content and research plans
(2) Mapping of sports for development programmes in Nepal, and a review of sports-based mental health interventions in LMICs
(3) A photovoice study to explore barriers and facilitators to adolescents participating in sports
(4) A public funfair using sports and art to mobilise communities on mental health and identify community preferences for a sports-based intervention
(5) Theory of change workshops with stakeholder groups to develop the intervention content
(6) Validation of tools to measure mental health promotion
(7) Intervention feasibility and acceptability testing among 200 adolescent boys and girls

Our research will inform a full-scale evaluation of the intervention, whilst expanding global knowledge on sports-based mental health intervention and building a sustainable research platform in Nepal.

We will develop an intervention that harnesses the ability of sport to promote mental health among Nepal's 12 million adolescents, of whom 2-3 million may already be suffering from a mental disorder. Our intervention has huge potential for use in other LMICs where large numbers of adolescents lack access to mental health care.

Several groups stand to benefit from our research.
(B1) 200 adolescent boys and girls, aged 10-19, living in Kailali, who participate in the intervention feasibility and acceptability testing. Overall we seek an improvement in their mental wellbeing, self-esteem, self-efficacy and emotion regulation, with a parallel reduction in depressive symptoms.
(B2) Rural communities in Kailali, including families of intervention participants and approximately 300 people who attend the Sports for Mental Health Mela. Communities will learn about mental health and strategies to promote it, and be mobilised to take action, increasing demand for mental services at the community level.
(B3) Stakeholder groups are integral to our research. The Adolescent Advisory Group (n=12) and Parent and Teachers Board (n=12) will have the opportunity to help develop a mental health promotion intervention that directly addresses the needs of their communities. Through the Adolescent Advisory Group we will promote the role of adolescents as active citizens in their communities. We will help group members to build confidence, and develop their communication, decision-making, and photography skills.
(B4) TPO Nepal junior and mid-level staff will receive research training and mentoring by the Co-PIs and Co-Is, and will have opportunities to develop their professional networks at national and international conference events.
(B5) Local non-governmental organisations working on sports for development and mental health in Nepal, represented on the Mental Health and Sports Specialist Panel, including Child Reach Nepal and Restless Development. These organisations have limited research capacity. We will invite staff from these organisations to participate in the research training at TPO Nepal.
(B6) Health assistants, staff nurses and doctors working at the primary health centre in the study community in Kailali, and the 10 peer facilitators or sports coaches who will facilitate the intervention. Child and adolescent mental health care capacity in Kailali is non-existent at the community level. We will address this by training health workers on the WHO mental health Gap Action Programme (mhGAP) care package, which includes diagnosis, management and follow-up of priority mental disorders. Facilitators will train in mental health promotion and referral of adolescents with severe mental illness.
(B7) Nepal Ministry of Health and Population, Nepal Ministry of Youth and Sports, All Nepal Football Association, National Sports Council and the Kailali District Football Association: We will encourage evidence-based adolescent mental health policy-making, informed through our mapping and review. We will generate a manualised intervention and training materials that can be implemented across Nepal.
(B8) Global policy makers, researchers and donors working on mental health, adolescent health, international development or education in LMICs: Through Louise Banham, senior DFID advisor and member of our Advisory Forum, our research will inform programming on mental wellbeing in the DFID's Girls Education Challenge. It could also inform revisions of the WHO mhGAP. We will expand research on how to use sport to promote mental health in low-resource settings. Our community engagement will set new standards for stakeholder involvement in research. We will share our learning on how to engage adolescents and the wider community in the process of intervention development.