Table 5 Summary of adaptations made/proposed to ARTEMIS based on formative research findings

Anti-Stigma Campaign

Adolescents showed interest in audio-visual and game-based methods for the anti-stigma campaign.

Interactive games which integrate anti-stigma messages were co-designed with the help of adolescents. The research team discarded some ideas like use of comic strips as they were not popular with adolescents. Audio dramas have been added to the anti-stigma IEC material based on suggestion from AEAG.

Academic pressure, parental expectations, fights between parents, substance use, and financial problems were important stressors. Gender based norms like restriction in mobility, inability to continue education or early/forced marriage were important stressors among older adolescent girls.

Street plays and audio drama stories based on themes that highlight some of the stressors faced by the adolescents have been produced. The street plays and audio dramas will provide an opportunity to discuss sensitive issues such as early/force marriages and possible negative consequences of such practices on adolescent mental and physical wellbeing. These will set the stage to enable more detailed discussions with the adolescents themselves, their parents and members of the community.

Parents were identified as important stakeholders who need to be engaged during the intervention.

There was difficulty in communication between children and parents on mental health issues.

Parental stigma was an important barrier for not seeking care.

A key activity at the start of the intervention will be to meet and actively engage with parents through meetings.

Parents of ‘high-risk’ adolescents to be specifically targeted in the anti-stigma campaign that will also be held on holidays and Sundays to increase participation.

Some of the anti-stigma campaign activities will target parents. For instance, the important role that parents could play in recognising symptoms of distress and depression in adolescents and facilitating help seeking, will be demonstrated through a street play. The street play will be followed by a discussion where the need to normalise mental disorders, overcome stigma associated with mental disorders and actively seek help will be reinforced by the implementing team.

Younger adolescents in the age group of 10–12 year recalled activities but were sometimes not clear on the takeaway message.

A list of key takeaway messages for each activity will be prepared. Field staff will be trained to deliver these messages after each activity.

mHealth

Questions related to suicide and pregnancy in the baseline survey tool and EDSS tool caused discomfort among adolescents.

The baseline tool took too much time (an hour) to administer.

Question related to pregnancy was retained only for married adolescents.

Training of field staff, community health workers and doctors to focus on sensitive ways to approach suicide related questions. For instance, during the training using the WHO mhGAP tool [8], doctors will be reassured that enquiring about suicide ideation will not trigger suicide in adolescents susceptible to or at risk of suicide; rather such an enquiry might help to reduce the ‘anxiety associated with thoughts or acts of self-harm and help the person feel understood’ [8] and prepare them to navigate such situations. Regular monitoring and check-in with doctors by the research team are planned to ensure doctors ask these questions appropriately.

The baseline tool was shortened.

Adversities related to living in the slum context was an important stressor which the baseline tool did not capture

An additional section was added to the baseline questionnaire to capture impact of slum adversity on mental health of adolescents.

Several barriers to seeking help from doctors existed, including similar working hour of UPHC and school, distance from UPHC and inability of working parents to accompany their wards to the UPHC.

Community level health camps in which doctors would visit the slums, were planned for the intervention.

Other

Stakeholders who could potentially support the intervention were identified.

In Vijayawada women’s self-help groups and community volunteers under a government programme were identified to help during the anti-stigma campaign.

The Peer Leader initiative was not found to be very popular. Adolescents were not familiar with the Peer Leaders and did not approach them.

The plan for engagement and role of Peer Leaders was revised. Instead of one or two Peer Leaders, peer groups will be formed. Peer group will be more involved in mobilising and interacting with adolescents during the anti-stigma campaign. Peer group members will be trained to increase their awareness about mental health and the importance of help-seeking. They will also be trained on how to communicate these to other adolescents in their slums using the anti-stigma materials developed by the research team.