Unmet need for mental health care among adolescents in Asia and Europe.

The unmet need for mental health care is a global concern. There is a lack of cross-cultural studies examining adolescent help-seeking behavior from both formal and informal sources, including both high-and lower-income countries. This study investigates mental health help-seeking behavior in eight Asian and European countries. Data from 13,184 adolescents aged 13-15 (51% girls) was analysed using mixed-effects logistic regression with school-wise random intercepts to compare countries and genders. Although a significant proportion of adolescents considered getting or sought informal help, formal help-seeking remained exceptionally low, especially in middle-income countries (< 1%), while it ranged from 2 to 7% in high-income countries. Among adolescents with high emotional and behavioral problems (scoring above the 90th percentile on the Strengths and Difficulties Questionnaire), 1-2% of those in middle-income countries and 6-25% of those in high-income countries sought formal help. Girls generally seek more help than boys. The study shows the most adolescents do not receive formal help for mental health problems. The unmet need gap is enormous, especially in lower-income countries. Informal sources of support, including relatives, peers, and teachers, play a crucial role, especially in lower-income countries.

Exploring Adolescents' Attitudes Toward Mental Health Apps: Concurrent Mixed Methods Study.

BACKGROUND: Adolescence is a critical time in which many psychological disorders develop. Mental health promotion is important, especially during this period. In recent years, an increasing number of mobile apps geared toward mental health promotion and preventing mental illness have been developed specifically for adolescents, with the goal of strengthening their mental health and well-being. OBJECTIVE: This study aims to explore adolescents' attitudes toward mental health apps, as well as the perceived usefulness of mental health apps. METHODS: In this mixed methods study, a total of 183 adolescents (mean age 15.62, SD 3.21 years) answered a cross-sectional questionnaire, with 10 questions (eg, "What do you think about mental health apps in general?"). To complement the quantitative findings, individual interviews were conducted with 9 adolescents, during which they could elaborate on their opinions about mental health apps. RESULTS: A total of 30% (56/183) of the adolescents in the quantitative study had used a mental health app. Over half of the respondents (77/126, 61.1%) reported that they would use a mental health app if they had a mental health problem as well as that they thought mental health apps were somewhat or very useful (114/183, 62.3%). Availability was the most frequently reported advantage of mental health apps (107/183, 58.8%). Possible associated costs of mental health apps were the most frequently mentioned barrier to their use (87/183, 47.5%). Findings from the interviews also pointed to the importance of the availability of mental health apps as well as their credibility and potential to provide adolescents with autonomy when seeking mental health advice and help. CONCLUSIONS: Overall, the results indicate that adolescents have a positive attitude toward and an interest in mental health apps. However, adolescents are also more or less unaware of such apps, which might be one reason why they are often not used. The findings of this study have important implications for future research on mental health apps and for developers of mental health apps that target young people. The insights gained from this study can inform the development of more effective mental health apps that better meet the needs and preferences of adolescents.

A Universal Mental Health-Promoting Mobile App for Adolescents: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: In times of increasing mental health problems among young people, strengthening efforts to improve mental health through mental health promotion and prevention becomes increasingly important. Effective measures that support young people in coping with negative thoughts, feelings, and stress are essential, not just for the individual but also for society. OBJECTIVE: The aim of this paper is to provide a description of a cluster randomized controlled trial that will be conducted to examine the effectiveness of Opp, a universal mental health-promoting mobile app for adolescents aged 13 to 19 years that provides information and exercises to better cope with stress, negative thoughts, and negative feelings. The protocol was developed in accordance with the SPIRIT checklist. METHODS: An effectiveness study will be conducted with 3 measurement points: preintervention (T1), 2 weeks after the intervention (T2), and about 1 month after the intervention (T3). Adolescents will be recruited from middle and high schools in Norway and randomly assigned to the intervention or control groups. Randomization will be conducted on the school level. Opp can be downloaded from the Google Play or App Store but is password protected with a 4-digit code, which will be removed after study completion. Participants in the intervention group will receive a text message with the code to unlock the app. The participants in the intervention group can use Opp without limits on length or time of use. Objective data on how long or how often the participants use the app will not be collected. However, the second and third questionnaires for the intervention group contain app-specific questions on, for example, the use of the app. RESULTS: Recruitment and data collection started in August and September 2022. So far, 381 adolescents have answered the first questionnaire. Data collection was expected to end in December 2022 but has had to be prolonged to approximately June 2023. The results of the study will be available in 2023 at the earliest. CONCLUSIONS: This project will contribute unique knowledge to the field, as there are few studies that have examined the effects of universal health-promoting mobile apps for adolescents. However, several limitations have to be taken into account when interpreting the results, such as randomization on the school level, the short time frame in which the study was conducted, and the lack of objective data to monitor the use of the app. TRIAL REGISTRATION: ClinicalTrials.gov NCT05211713; https://www.clinicaltrials.gov/ct2/show/NCT05211713. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/42119.

Adolescents' Assessment of Two Mental Health-Promoting Mobile Apps: Results of Two User Surveys.

BACKGROUND: The importance of mental health promotion is irrevocable and is especially important at a young age. More mental health-promoting mobile apps have been developed in the last few years. However, their usability and quality have been rarely assessed. OBJECTIVE: The aim of this study is to investigate how adolescents assess the usability, quality, and potential goal achievement of Opp and NettOpp. Opp is a universal mental health-promoting mobile app aimed at 13- to 19-year-olds, and NettOpp is a mobile app for children and adolescents between 11 to 16 years of age that have experienced negative incidents online. METHODS: A total of 45 adolescents tested either Opp (n=30) or NettOpp (n=15) for a period of 3 weeks and answered a questionnaire. The System Usability Scale (SUS) was used to measure the usability of the apps. A SUS score above 70 indicates acceptable usability. Items from the Mobile Application Rating Scale were adapted for study purposes and used to measure the quality and perceived goal achievement that Opp and NettOpp might have on adolescents' knowledge, attitudes, and intention to change behavior. Furthermore, adolescents could answer an open comment question. RESULTS: Opp had a mean SUS score of 80.37 (SD 9.27), and NettOpp's mean SUS score was 80.33 (SD 10.30). In the overall evaluation, Opp and NettOpp were given a mean score of 3.78 (SD 0.42) and 4.20 (SD 0.56), respectively, on a 5-point scale, where 5 was best. Most adolescents who evaluated Opp rated that the app would increase knowledge about mental health and help young people deal with stress and difficult emotions or situations. Most adolescents who evaluated NettOpp agreed that the app would increase awareness and knowledge about cyberbullying, change attitudes toward cyberbullying, and motivate them to address cyberbullying. Some adolescents stated that Opp was difficult to navigate and consisted of too much text. Some of the adolescents that tested NettOpp stated that the app had crashed and that the design was a bit childish. CONCLUSIONS: All in all, this study indicates that Opp and NettOpp have good usability and that adolescents are satisfied with both apps. It also indicates that the potential goal achievement of the apps, for example, increasing knowledge about mental health (Opp) or cyberbullying (NettOpp) is promising. While there are some comments from the users that are more difficult to solve (eg, Opp is too text-based), some comments helped improve the apps (eg, that the app crashed). Overall, the user evaluation provided valuable knowledge about how adolescents assess Opp and NettOpp. However, more extensive effectiveness studies are necessary to measure their actual goal achievement.

Feeling Unsafe at School Among Adolescents in 13 Asian and European Countries: Occurrence and Associated Factors.

Background: Research on perceived school safety has been largely limited to studies conducted in Western countries and there has been a lack of large-scale cross-national studies on the topic. Methods: The present study examined the occurrence of adolescents who felt unsafe at school and the associated factors of perceived school safety in 13 Asian and European countries. The data were based on 21,688 adolescents aged 13-15 (11,028 girls, 10,660 boys) who completed self-administered surveys between 2011 and 2017. Logistic regression analyses were used to estimate odds ratios and 95% confidence intervals. Findings: The number of adolescents who felt unsafe at school varied widely across countries, with a mean occurrence of 31.4% for the total sample: 31.3% for girls, and 31.1% for boys. The findings revealed strong independent associations between feeling unsafe and individual and school-related factors, such as being bullied, emotional and behavioral problems and feeling that teachers did not care. The study also found large variations in perceived school safety between schools in many countries. Conclusion: The findings emphasize the need to create safe educational environments for all students, based on positive relationships with teachers and peers. School-based interventions to prevent bullying and promote mental health should be a natural part of school safety promotion.

An App-Based Intervention for Adolescents Exposed to Cyberbullying in Norway: Protocol for a Randomized Controlled Trial.

BACKGROUND: Adolescents exposed to negative online events are at high risk to develop mental health problems. Little is known about what is effective for treatment in this group. NettOpp is a new mobile app for adolescents who have been exposed to cyberbullying or negative online experiences in Norway. OBJECTIVE: The aim of this paper is to provide a description of the content of the intervention and about a randomized controlled trial that will be conducted to examine the effectiveness of NettOpp. This protocol is written in accordance with the Spirit 2013 Checklist. METHODS: An effectiveness study with a follow-up examination after 3 months will be conducted to evaluate the mobile app. Adolescents will be recruited through schools and will be randomly assigned to the intervention (NettOpp) group and a waiting-list control group. The adolescents (aged 11 to 16 years) will respond to self-report questionnaires on the internet. Primary outcomes will be changes in mental health assessed with the Strengths and Difficulties Questionnaire, the WHO-Five Well-being Index, and the Child and Adolescent Trauma Screen. RESULTS: Recruitment will start in January 2022. The results from this study will be available in 2023. CONCLUSIONS: There are few published evaluation studies on app-based interventions. This project and its publications will contribute new knowledge to the field. TRIAL REGISTRATION: ClinicalTrials.gov NCT04176666; https://clinicaltrials.gov/ct2/show/NCT04176666. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/31789.

Adolescents' experiences of the information they received about the coronavirus (Covid-19) in Norway: a cross-sectional study.

BACKGROUND: In the first months of the coronavirus (Covid-19) pandemic, many countries took radical prevention measures. Authorities had to communicate with the public regularly to explain and ensure compliance with these measures and promote safety. The information given by authorities was mainly developed for adults, but children and adolescents may have different needs when it comes to information. This study examined how adolescents perceived information about Covid-19 provided by the media and other sources, and about what topics adolescents reported they lacked information during the first months of the Covid-19 pandemic. METHODS: Three hundred seventy-seven adolescents in 11th, 12th, and 13th grade in Norwegian upper secondary schools (67% girls) completed an online questionnaire. Analyses included descriptive statistics, in addition to Generalized Linear Mixed Models analyses to examine gender differences in adolescents' satisfaction with the information provided about Covid-19, to what extent the pandemic affected their everyday life, and to what extent they were concerned about becoming infected with Covid-19. RESULTS: The results showed that the majority of adolescents used the internet as the main source of information about Covid-19, followed by (online) newspapers. About half (49%) reported that they were satisfied with the information available, while 39% were neither satisfied nor dissatisfied, and 12% were dissatisfied. Adolescents wanted more information about the school situation, as well as virus- and future-related topics. A total of 21% reported that they were concerned about becoming infected with Covid-19. There was no significant gender difference in overall satisfaction with the information provided about Covid-19. Girls reported being significantly more affected by the pandemic than boys, and that they were significantly more concerned than boys about becoming infected with Covid-19. CONCLUSIONS: This survey provides important knowledge to professionals working with adolescents, as well as to authorities, about what information channels can be used to reach adolescents, and what information they lacked about the Covid-19 pandemic.

Cyberbullying status and mental health in Norwegian adolescents.

The aim of the present study was to examine how the cyberbullying status (not involved, cyber-victim only, cyberbully only, cyber-victim and bully) is related to the mental health of the adolescents when controlled for traditional bullying experience. We also examined the potential moderator sex on the relationship between cyberbullying status and mental health. Univariate analyses of variance were conducted to predict mental health problems using the Strength and Difficulties Questionnaire total difficulties score and its five scales. The model consisted of five predictors in addition to an interaction term between cyberbully status and sex. Of the 2,117 adolescents, 50% were girls. The vast majority did not have any cyberbullying experience (87%), 9% of the adolescents were cyber-victims only, 1% were cyberbullies only and 3% were both cyber-victims and bullies. Overall, girl's mental health seems to be more compromised when exposed to or involved in cyberbullying than boys mental health. In general, adolescents who are not only cyberbullies and cyber-victims, but also cyber-victims only had a worse mental health compared to adolescents without cyberbullying experience. Being exposed to cyberbullying is a unique contributor to mental health problems. Preventing cyberbullying is therefore important. Especially girl's mental health seems to be negatively affected when exposed to cyberbullying.

Help-seeking behavior in Norwegian adolescents: the role of bullying and cyberbullying victimization in a cross-sectional study.

BACKGROUND: Help-seeking is considered a constructive coping style. However, the threshold at which many adolescents seek help is relatively high, and the outcomes are not necessarily always positive. OBJECTIVE: The main aim of this study was to examine if bullying and cyberbullying victimization predicted help-seeking behavior among Norwegian adolescents. METHOD: Help-seeking behavior was predicted using three different Generalized Linear Mixed Models. In addition to demographic characteristics and mental health, these models controlled for bullying and cyberbullying, respectively. RESULTS: 2054 adolescents answered questions on help-seeking behavior and if they had felt the need to seek outside help with their problems, feelings, behavior, or emotional troubles within the past 6 months. Two hundred (9.7%) reported seeking outside help. Being exposed to bullying increased the likelihood of help-seeking behavior, while being exposed to cyberbullying did not. Only when forms of bullying or cyberbullying, respectively, were added to the models, did the threat of having rumors spread, both in real life and online, increase the likelihood for seeking help. CONCLUSIONS: Many factors affect whether adolescents seek help for a problem. The fact that adolescents exposed to bullying seek help more often than those not exposed may be considered a success, as this behavior is encouraged by many adults, mental health professionals, and anti-bullying interventions. However, adolescents exposed to cyberbullying did not seem to seek help. Future studies should identify factors that lead to more and successful help-seeking among bullied and cyberbullied adolescents.