Enhancing adolescent mental health through gamification and peer support
- FHS Comms
Most mental health problems begin in adolescence. In South Africa, current estimates suggest that about 20 to 30 percent of adolescents have depressive symptoms. Depression interferes with education, employment and relationships, and can hinder young people's ability to reach their full potential. It is also a significant risk factor for suicide. While effective psychological treatments to address depression exist, the reality is that most young people do not have access to them. The Digital delivery of Behavioural Activation to overcome depression and facilitate social and economic transitions amongst adolescents (DoBAt) Study sought to address this gap.
Access to care for people with depression in low- and middle-income countries (LMICs) is hampered by insufficient public expenditure on mental health and a gross shortage of mental health professionals. Stigma and low levels of mental health awareness also inhibit people from seeking care. Digital delivery of psychological treatments holds potential to overcome these barriers, and is increasingly relevant for adolescents in LMICs given the global trajectory of smartphone ownership and internet access.
Image: Participatory workshop to develop the narrative game, September 2020
A rapidly growing evidence base supports the effectiveness of digital psychological treatments to address depression amongst adults in both high-income contexts and LMICs. However, amongst school-aged adolescents (10-19 years), there is much less evidence. Indeed, in LMICs only two or three randomised control trials have been conducted to assess the effectiveness of web or app-based digital psychological treatments among adolescents.
The DoBAt Study, based at the MRC/Wits Rural Public Health and Health Transitions Unit (MRC/Wits-Agincourt), aimed to develop and evaluate a digital psychological treatment to address depression among adolescents. The Kuamsha app is based on behavioural activation’s (BA’s) core principles. Weekly phone calls from trained peer mentors support the six-module interactive narrative game. Behavioural activation is an evidence-based psychological therapy based on the theory that changing one’s behaviour affects how one thinks (cognitions) and feels (affect). BA, which takes an action-oriented approach, may be easier to adapt for diverse language and cultural groups than other psychotherapies, such as cognitive behavioural therapy.
Image: Adolescent gives feedback on the DoBAt Study Theory of Change, March 2023
Very few mental health apps have been developed for adolescents in low-resource contxets
“While there are a lot of mental health apps on the market, very few have been specifically developed for or rigorously evaluated amongst adolescents in low-resource or culturally diverse contexts,” says DoBAt project manager Dr Bianca Moffett. The Kuamsha app was developed through a participatory design process with over 160 adolescents and other stakeholders in South Africa and Uganda. Gamification and telephonic support from peer mentors were employed to keep adolescents engaged, as many mental health apps are only used once or twice.
So far, adolescents like and use the Kuamsha app
Adolescents are using the Kuamsha app far more than researchers expected. “Adolescents liked the idea of having options, such as an app they could use in their own time, support from a peer mentor, and for those with severe symptoms or higher risks, linkage to in-person care from a mental health professional,” says Moffett.
Food insecurity and a wide array of social issues play substantial roles in depression rates. “It’s never going to be an app alone – but an app holds an opportunity as a bridge to care,” says Moffett.
Image: Kuamsha app homepage
Peer mentorship may play an important role in adolescent mental healthcare
Peer mentorship holds potential to overcome the stigma associated with mental health concerns and should be explored further as an avenue for providing psychosocial support. “Adolescents liked the idea of having someone a little older than themselves that could provide support through telephone calls” said Moffett.
Peer relationships are particularly critical in adolescence, and peer influence can be beneficial. Adolescents can encourage each other to make positive, healthy decisions.
Mental health conditions have increased in the past 15 years
This is echoed by the research conducted by Dr Sarah-Jayne Blakemore at the Developmental Cognitive Neuroscience Group at Cambridge University. Blakemore was recently at Wits to present findings from various adolescent mental health studies. She notes that most mental health problems start in adolescence and include eating disorders, depression, anxiety, substance misuse and personality disorders.
“Adolescence is a unique period of biological, psychological and social transition. It is characterised by heightened neuroplasticity which confers opportunity and vulnerability,” said Blakemore.
While Blakemore has recently focused on the link between social media use and depression, she noted that the onset of mental illness is often due to multiple factors.
Importantly, “peer influence is heightened,” which can be used in healing and therapeutic ways. “We think that a peer-supported digital intervention, such as the Kuamsha app, is a real opportunity to overcome the gap in adolescent mental healthcare in an LMIC setting, and look forward to sharing the results and lessons learnt from our pilot trial”, said Moffett.
Image: DoBAt Study multistakeholder workshop, March 2023
Acknowledgements:
The DoBAt Study was supported by the MRC Newton UK-South Africa Joint Initiative on Mental Health (MR/S008748/1). Prof. Kathleen Kahn (University of Witwatersrand) and Prof. Alan Stein (Oxford University) are co-Principal Investigators of the DoBAt Study.
The results of the Pilot Randomised Control Trial will be made available soon.