Improving Mental Health Literacy Among Young People aged 12-15 years in Indonesia: IMPeTUs

Mental health disorders account for 13% of the global burden of disease, and are estimated to affect 10-20% of children and adolescents worldwide. Depression is the leading cause of this mental health disability and affects 6% of adolescents globally each year. Research shows that the prevalence of depression rises sharply after puberty and that over half of depressed adolescents have a recurrent episode within five years.

Adolescents account for almost one fifth of the total population in South-East Asia. Under-diagnosis and under-treatment of depression in adolescents is often higher than those in adult populations, leading to poorer health outcomes for this group. This is likely to be particularly problematic in low to middle income countries such as Indonesia, where limited resources and cultural norms reduce the likelihood of adolescents successfully seeking and obtaining appropriate treatment.

Mental health literacy can be defined as knowledge and beliefs about mental disorders which help people to prevent, recognise and manage problems. We know that low levels of mental health literacy significantly increase the risk of adolescents developing moderate to severe depression and that improving mental health literacy may a useful way to reduce the burden of depression amongst children and adolescents.

We are proposing a simple, low cost approach to improving mental health literacy in young people aged 12-15 years by developing a group of resources to be used in school and health settings. Adolescents express preference for peer and family support rather than professionally led services which indicates that our intervention may have considerable benefit for improving mental health literacy in this population. Our application arises directly from discussions with local people who identified a need to develop interventions to support mental health literacy amongst children and young people.

Our study will be undertaken in four phases:

In phase 1, a systematic review will identify the range of approaches that have been used to address mental health literacy and/or depression self-management in children and adolescents across South East Asia and identify those factors which may potentially influence the effectiveness of these approaches.

In Phase 2, we will undertake qualitative interviews with a range of people (young people, service users, carers, professionals and other key stakeholders) incorporating photo elicitation methods to understand the perception of depression in children and adolescents in Java, Indonesia.

In phase 3, we will use the findings from phases 1 and 2 and hold a series of workshops with local stakeholders to co-produce an evidence-based toolkit to promote mental health literacy and depression-focussed self-management in children and young people in Indonesia.

Phase 4 will undertake nine implementation case studies in sites chosen to represent different levels of urbanisation and implementation pathways. We will implement our intervention in schools, CAMHS services and primary care services across three areas (Jakarta, Bogor and Magelang) and evaluate the impact, acceptability and feasibility of the prototype intervention. We will produce best practice evidence-based guidelines to optimise the use of this intervention in practice.

Our project aims to improve depression-focussed mental health literacy amongst 12-15 year olds in Java, Indonesia. It will build research capacity and provide meaningful opportunities for 'user-focussed' research. We will develop a minimum of two subsequent grant applications, including a protocol to rigorously evaluate our prototype intervention, and assemble a strong Indonesia research group with the knowledge, skills and experience to undertake such a study.

Depression is the leading cause of disease burden in low-to-middle income countries. The World Health Organisation has engaged in a programme of scaling-up mental health services, but significant challenges remain. Improving mental health literacy in children and young people, a core part of recent, global health strategies has the potential to address some of these challenges. The aim of this study is to co-develop and feasibility test, a culturally-appropriate toolkit to promote depression-focused mental health literacy and self-management skills in Indonesia, for children aged 12-15 years. This mixed methods study will comprise four phases.

Phase 1 (a systematic review of peer reviewed studies and grey literature) will identify the range of approaches to mental health literacy and depression self-management and critically review current evidence regarding intervention effect.

Phase 2 will comprise semi-structured interviews with key stakeholders including policy makers, clinicians, teachers, adolescent service users, carers and young people aged 12-15 years to explore their views on depression and identify priorities for the intervention. Photo elicitation methods will be incorporated into interviews with children and young people.

Phase 3 will comprise iterative workshops with local stakeholders to present our findings and co-produce a testable, culturally appropriate toolkit to promote mental health literacy and depression focused self-management in 12-15 year olds in Java, Indonesia.

In phase 4, we will undertake nine in-depth case studies to compare three different implementation pathways (ie. schools, CAMHS services and primary care centres) in three geographically different areas in terms of levels of culture, urbanisation and health service development (Jakarta, Bogor and Magelang). We will examine the impact, acceptability and feasibility of our prototype intervention and produce evidence-based guidelines for wider implementation.

Our programme will generate theoretical, empirical and experiential knowledge to inform and optimise knowledge mobilisation. It will produce outputs of immediate and future relevance to local, national and international audiences.

A testable, co-produced intervention to improve mental health literacy and depression self-management will be provided to local services and communities. If effective, this intervention will strengthen health systems and population health through the promotion of early help-seeking and self-management behaviours. Our intervention will be culturally-appropriate and will be complemented by evidence-based guidance to maximise its adoption, implementation and reach. We will identify, via our Phase 4 evaluation, those intervention components to which fidelity is expected, and those which may be modified to enhance local implementation. This knowledge will be made available to policy makers and service managers to inform the development of emerging public health and primary mental health services in Indonesia, and across the South-East Asia region. Our research methods and outputs will be broadly relevant to individuals seeking to enhance mental health literacy in other low-to-middle income countries. At project end, we will host a one-day mixed-stakeholder dissemination conference in Java to engage a national audience, showcase our intervention, and encourage wider roll-out of our programme deliverables. We will additionally target global conferences and audiences with a strong presence of policymakers and practitioners (e.g. the World Psychiatric Association, the annual Taipei research and training conference).

We will conduct community awareness workshops in at least three different areas of Java, with a focus on low income and low literacy populations. Strong family involvement in health care is a characteristic of South-East Asian populations and can play a role in community mental healthcare. We will jointly involve CYP and family members in components of our intervention (e.g. animated DVD and interactive board game), encouraging inter-generational learning and strengthening the likelihood that adolescents will be supported in recognising/managing depression. We will make all positively-evaluated resources freely-available to health services and third-sector equivalents, and develop a one-day, face-to-face 'train-the-trainers' course to enable services to continue to facilitate our intervention when our programme ends. We will establish an evidence-based knowledge hub to drive workforce development and service improvement. We will develop an online information repository with downloadable resources and link these directly to national professional networks and organisations. We will deliver in-person presentations to multiple parties including Ministry of Health, DFID representatives, Indonesian public health experts and WHO representatives.

During the life our project, we will build research capacity in Indonesia through the mentorship and training provided to Indonesia researchers, clinicians, service users and their carers. Our research and training will inform and empower local CYP and their families to strive for a more socially inclusive community. In collaboration with study partners, we will nurture service user/carer researchers in Indonesia and build capacity for more user-focussed research. This will benefit these 'lived experience' researchers who will learn new skills (e.g. communication, analytical skills) transferable to other areas. Upskilling people with lived experiences of mental health difficulties can improve the quality of health systems research and enhance its impacts.

We will develop subsequent grant applications, including fellowship applications and a further funding application to definitively evaluate our intervention, and collaborate with our PPI representatives to ensure that these remain ethically and culturally-sensitive and address the needs of users.