Self-Help Workbooks for Children and Adolescents in the Philippines and Low-to Middle-Income Countries

Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries October 2021 to April 2022 Reynaly Shen Javier EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries Self-Help Workbooks for Children and Adolescents in the Philippines and Low-to-Middle-Income Countries Deep Report Author: Reynaly Shen Javier Initial Research: George Bridgewater Research Period: October 2021 to April 2022 Executive Summary It remains a challenge to solve different mental health problems in low-and-middle-income countries (LMICs) for many reasons such as stigma and lack of awareness about mental health, inaccessibility of services due to location or costs, and difficulty of implementation due to lack of support from stakeholders and lack of resources to carry out known mental health interventions. These barriers are especillay apparent in the lack of mental health services for children. We propose a self-help workbook intervention for children to be implemented by a new charity in the Philippines or other LMICs. Self-help workbooks allow individuals to get help while maintaining privacy, distancing themselves from the stigma associated with mental health which is a barrier to seeking help. Since self-help workbooks can be used inside their homes, children do not need to go far away to access some form of treatment, and families do not need to spend more to continue usage. Self-help workbooks are relatively inexpensive to create and distribute compared to other mental health interventions. While partnerships with the government and other organizations are essential, this intervention can be implemented with limited involvement from them. The recommended intervention is to develop self-help workbooks for children and young adolescents, particularly 6 to 18-year-olds. The workbook can employ bibliotherapy and art therapy and is to be done over ten weeks. Depending on the severity of mental health disorders, the workbook can be accompanied by 30-minute weekly guidance by lay counselors through telephone, email, social media, or other available platforms. Lay counselors are ideally lay health workers (LHWs), but teachers, university students, and other individuals can be considered. Parent involvement is encouraged. This intervention seems best in places with high mental health stigma and limited electricity, access to technology, and internet connectivity. There are few studies on children interventions using self-help workbooks and providing weekly guidance from lay counselors. There are many existing workbooks 1 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries and books for children but most of them have not been studied rigorously as mental health treatments. We had to look at other interventions even though they did not target children or adolescents, did not employ LHWs, and used different modes of delivery to gauge the potential effectiveness of this intervention. We also reviewed bibliotherapy and art therapy which can be adapted into the workbook and the weekly guidance. There is strong evidence supporting interventions similar to self-help workbooks. We found the World Health Organization (WHO) workbook called Doing What Matters in Times of Stress: An Illustrated Guide, which has been used as part of Self-Help Plus, a group-based psychoeducational program for adults delivered by lay health workers. The program has shown positive improvements in well-being in two large randomized controlled trials. This workbook can be adapted for children in identified places and is the shortest path of development for the workbook. However, we also encourage creating a workbook from scratch specifically designed for Filipino children or children in LMICs, given differences in culture and mental health needs. Since there is no specific workbook and guidance developed yet, there is some uncertainty about whether the positive effects recorded for these similar interventions will also reflect in ours. Given the intervention’s flexibility, there are quick adjustments to make it more effective and feasible. Our cost-effectiveness estimate for this model is $2.50 per WHO-5 improvement in a year of operation when considering the charity’s total costs. Funding and sustainability may be difficult, but different models can be explored, such as partnering with community learning hubs and publishing companies or running a social enterprise for the workbook. Identifying facilitators may also be a challenge. This self-help workbook intervention for children is part of the top four mental healthy charity ideas we developed for the Philippines and other LMICs. We believe it can be very impactful and we recommend founding a charity providing this intervention. 2 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries Table of Contents Executive Summary 1 Introduction 5 Problem Assessment 5 Background 7 Intervention Program (Gold Standard) 8 Quality of Evidence 9 Implementation 9 Target Location 9 Acceptability 10 Funding 10 Talent 10 Scaling 10 Externalities 11 Cost-Effectiveness Analysis 11 Weighted Factor Model 12 Recommended Intervention 13 Description 13 Quality of Evidence 15 Evidence for the effectiveness of self-help workbooks in improving children mental health outcomes 15 Evidence for the effectiveness of bibliotherapy in improving children mental health outcomes 19 Evidence for the effectiveness of art therapy in improving children mental health outcomes 20 Summary of evidence 21 Implementation 23 Theory of Change 23 Target Location 26 Acceptability 27 Funding 30 EA Funding 30 Non-EA International Funding 30 Local Funding 30 Summary of funding: 32 Talent 32 Scaling 33 Externalities 34 Cost-Effectiveness Analysis 34 3 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries Weighted Factor Model 36 Conclusion 37 Resources 38 4 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries Introduction This report was made through the Mental Health Charity Ideas Research Project under Effective Altruism Philippines. The project was a follow-up to Shen Javier and Brian Tan’s participation in Charity Entrepreneurship’s 2021 Incubation Program, in their region-specific track for training people to research the top charity ideas in a region. The project's goal was to find ideas that can become highly impactful and cost-effective charities in improving the well-being of people living in the Philippines and other low- to middle-income countries. It focused on children and adolescent mental health. To achieve this goal, we aimed to write deep reports such as this on the top mental health charity ideas that will come out of our four-phase research process. Our research process involved looking into the same ideas in multiple rounds of iterative depth such that the next rounds of research are deeper and only on fewer ideas than the last. We systematically evaluated all ideas, comparing them using the same criteria and the same questions. Some of the tools we used are weighted factor models that consider different factors such as implementability and acceptability of the interventions, evidence quality assessments, and cost-effectiveness analyses. In the six months of our research, self-help workbooks for children became one of the most promising interventions. Since our research process does not allow us to research all other ideas in depth, we do not necessarily take the rest as ideas that are not potentially good. It would be interesting to explore them more in future iterations of this research project. Problem Assessment Mental health issues among children continue to be an important global concern. Among children and adolescents, neuropsychiatric disorders are one of the leading causes of health-related burden, accounting for 15-30% of disability-adjusted life years (DALYs) lost during the first 30 years of life. This is significant, considering that the youth comprises almost a third of the global population. Around 90% reside in low- to middle-income countries (LMICs) where they make up about 50% of the population. There is also increasing evidence that most mental disorders begin early in the life span. One meta-analysis found a pooled prevalence of 13.4% (95% CI 11.3-15.9) among children and adolescents (Keiling et. al., 2011). These initial statistics already point to the importance of developing and implementing mental health interventions that target these formative life stages. For low-and-middle-income countries (LMICs), many challenges prevent the development and implementation of children and adolescent mental health (CAMH) 5 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries services. Zhou et al. (2020) reviewed 31 publications that talked about CAMH policy and found six major challenges, namely: poor public awareness and low political willingness, stigma against mental disorders, biased cultural values toward children and adolescents and CAMH, lack of CAMH data and evidence, shortage of CAMH resources and unintended consequence of support from international organizations and nongovernmental organizations (NGOs). Biased culture values include the belief that children’s development cannot be changed and the perception of CAMH as a luxury or something not as important as physical health. On the other hand, support from other organizations may reduce the government’s sense of urgency and lead to a narrow focus on specific aspects of CAMH, especially disorder-specific actions, due to donors’ interest. This support may also disrupt the use of CAMH services due to their projects’ short-term lengths. Juengsiragulwit (2015) also cited other obstacles in providing CAMH services which are inaccessibility of services due to low socioeconomic status, urban-focused CAMH services when there are many people in rural areas, non-allocation of mental health services for the young, inappropriate integration of CAMH services with adult services and shortage of mental health professionals. Low motivation for primary health care workers to provide CAMH services due to overloaded services, shortage of funds, and underrecognition of the services’ importance is also a problem. These challenges call for mental health interventions for children and adolescents that are low-cost, appropriately located, and easy to deliver to not burden primary health care services. While these challenges are still present even in the Philippines, there is growing interest in developing more and enhanced mental health services, as mentioned in the National Mental Health Research Agenda in the Philippines 2019-2022 (Gonzales, 2019). This interest can make way for building a charity implementing a new mental health intervention. We believe that beginning these interventions will bring awareness to individuals about mental health and help recognize its importance by the government and other decision-makers. The new charity that will come out of this report may also continue using evidence-based approaches to CAMH and start the collection of more information about CAMH in the regions where it will operate. While the unintended consequences of NGOs are a cause of concern, we believe that they are easily avoidable through prioritizing the most important populations, as further research will show, and through proper implementation of interventions, such that all stakeholders’ interests in the short-term and the long-term are considered. The intervention proposed in this report comprises the distribution of self-help workbooks to children and young adolescents, particularly 6 to 18-year-olds, that may be accompanied by weekly support from lay counselors depending on the severity 6 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries of mental health disorders. The workbook can employ bibliotherapy and art therapy. The lay counselors will guide through different mediums such as telephone, email, or social media. We could not find charitable organizations implementing interventions similar to this proposed self-help workbook intervention in LMICs and Southeast Asia. While there are some studies in the regions for bibliotherapy and art therapy, no established organizations are working to provide this type of treatment to children continuously. We identified organizations in this report that can help create workbooks and programs for children, but none were implementing activities as mental health interventions for children. This lack of organizations only emphasizes that there is still a gap in the said regions in terms of an engaging, accessible, and implementable treatment given a low-resource setting. We also do not expect another charity to provide a similar intervention and target the same location or population at the same time as ours, given the lack of research and actions dedicated to CAMH. Given that mental health policy is also difficult to affect in developing countries, starting a charity that can provide help for children in a shorter period is necessary and can be highly impactful. Background Guided self-help is a mental health intervention that involves individuals working on workbooks and other materials independently with assistance from professionals or trained lay health workers. This intervention was Charity Entrepreneurship’s 2020 recommended charity idea for the mental health and happiness cause area (Bridgewater, 2020a). It was eventually founded as Canopie, a mobile application for preventing and treating perinatal mood disorders. This intervention was considered promising due to the strong evidence supporting the effectiveness of workbooks and due to workbooks’ minimization of staff time. Workbooks require greater engagement from the reader through written questions, tasks, handouts, exercises, worksheets, and assignments (L’Abate, 2014). Since participants interact with the workbooks independently, receiving only a few minutes of guidance from mental health workers, the intervention can reach more individuals. Because the costs are mainly for workbook distribution and for staff time which is reduced compared to other mental health interventions, and because the intervention can benefit more individuals, guided self-help was expected to be very cost-effective. Because of CE’s previous research, this research project considered this idea one of the top four ideas. However, the recommended program is different from that 7 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries of CE in terms of the target population, implementation location, and some program components. We focus on LMICs and children aged 6 to 20 with common mental health disorders, i.e., depression and anxiety. Thus, we are adjusting program components to fit the specific needs of these characteristics. The next subsections will discuss the intervention program as envisioned by CE. This form of the intervention is what served as the basis of the recommended intervention we will present by the end of this report. Intervention Program (Gold Standard) The guided self-help program created by CE will have participants interact with the program material for five to ten weeks. The length of the program will depend on the workbook or resource chosen by the charity founders. The weekly guidance that lay counselors will provide to the participants will be in the form of telephone support estimated to add up to 100 minutes for the whole program. This intervention will employ task-shifting such that trained and employed lay health workers will deliver the guidance. Lay health workers carry out functions related to health care delivery who are trained in the context of the intervention but have no formal professional or paraprofessional certificated or degreed tertiary education (Lewin et al., 2005). Each lay health worker will be able to supervise around 150 patients in any given week. Each specialist worker can supervise the work of ten to fifteen other workers. This setup can allow the intervention to reach 1500 to 2250 people each week. Aside from these advantages, guided self-help offers privacy to its recipients, which can help avoid stigma, a large barrier to implementation especially in LMICs. While the workbooks are guided, they still offer flexibility in schedule for recipients compared to when they have to set a time and travel to meet a professional. The program can be implemented in two scenarios in LMICs: Scenario 1, where new workbooks are distributed for every run of the program, or Scenario 2, where workbooks are reused with the help of a library partner. The choice relies on the charity’s ability to form partnerships and develop reusable resources. The intervention can incorporate online courses but we focus on physical workbooks since another of the top four charity ideas, game-based mobile apps for adolescents, will focus on digital interventions. This intervention has also been developed as the mobile application Canopie. Testing it as a workbook program will then offer more novel insights. Aside from telephone support, the intervention can also use Skype or other teleconferencing platforms. 8 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries The specific workbook to be used and adapted varies depending on the condition that the charity wants to address. The most common forms of therapy these workbooks use are cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and accelerated resolution therapy (ART). Here is an ongoing review of evidence-based workbooks. The workbooks vary in terms of the form of therapy, program length, target condition, support time, and support type. This intervention is not limited to one form of therapy. The target condition will depend on which condition seems the most pressing and whether there are available workbooks. Programs with non-telephone support types were still considered to allow flexibility in adapting them for telephone support. The specific level of guidance, the type of support, and the resource materials that the intervention will consider will depend on the new charity’s initial experimentations. We will further discuss options for the recommended intervention later on. These initial tests will be important given that most, if not all, of the studies on guided self-help workbooks found were set in high-income countries (HICs). Quality of Evidence CE examined 13 meta-analyses and systematic reviews and over 50 randomized controlled trials on the effects of guided and pure self-help interventions. All demonstrated a medium to large effect size on measures of depression (Cohen’s d: 0.28 to 1.37), anxiety (Cohen’s d: 0.18 to 0.98), and subjective well-being (Cohen’s d: 0 to 0.77) (“Guided self-help,” n.d.). Notably, the addition of guidance has a significant effect on treatment outcomes, with telephone support having the greatest effect. Most of these randomized controlled trials (RCTs) on workbooks had low sample sizes, either due to a low initial sample or high dropout rates. Most of the evidence was conducted in high-income countries. Thus, some of these studies' findings might not hold at a larger scale outside a controlled setting and in an LMIC context. Implementation Target Location Guided self-help is a form of therapy that is arguably well-suited for effectiveness in regions where stigma is higher as it can be practiced in private and does not require patients to visit a therapist. Patients do not need to reveal their condition to others and expose themselves to discrimination to receive treatment. No specific location was identified but developing countries and areas of marginalized groups seem to be fitting. 9 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries Acceptability Completion rates of recipients are estimated to be as high as 90% but 50% to 60% on average (Hesser et al., 2012; Johnston et al., 20210; Thorsell et al., 2011). Since attendance is still more than half, the intervention is somewhat acceptable to the participants. Some evidence suggests that dropout rates and completion rates are not significantly different from traditional face-to-face therapy (Cuijpers et al., 2010). People who live in places with high stigma will find this intervention highly acceptable since it will give them privacy. There are also people who prefer nonprofessional treatment for reasons such as normalization of mental health problems (treating depressive symptoms as normal, self-reliance and thinking professional help is not needed), fear of receiving a diagnosis and stigma (Martínez-Hernáez et al., 2014). These individuals may prefer this intervention since it still gives them autonomy on the help they can get ouf of it. CHW attrition rates vary widely between regions making it difficult to get a precise figure. Overall, total annual attrition rates varied between 3% and 44%, with an average of approximately 6.8% (Lopes et al., 2017, as cited in Bridgewater, 2020b). It seems that when we properly identify countries or regions based on CHW commitments in the past, existence of a good health system and sufficient compensation, attrition rates are unlikely to have a significant effect on the program. Funding The ability of this organization to target multiple conditions while remaining cost-effective should allow the cofounders to tailor the intervention for condition- or population-specific donors. However, we expect fundraising to be more difficult in a developing country. Smaller amounts of funding should be more easily achieved to test out the organization, but at maximum scale, funding would be the limiting factor to the charity’s impact. No specific funding sources have been specified at this point. Talent Lay health workers will be trained by more specialist staff for three to seven days for every new self-help material they will deliver. The difficulty here is sourcing them since for LHWs to take on this intervention’s tasks, the charity shall establish government buy-in or partnership. Scaling The main path to sustainability for the charity is government buy-in to ensure that talent is always available and potential recipients are reachable. Suppose this is impossible, and the charity opted to train other individuals aside from LHWs. In that 10 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries case, they can still cut costs and improve the accessibility of the intervention materials through library partnerships and partnerships with community centers. Externalities Some forms of this intervention can harm certain groups. Haeffel (2010) demonstrated that college freshmen participants who were high in rumination and experienced stress exhibited significantly greater depressive symptoms after completing the traditional cognitive skills workbook. This was the case immediately post-intervention, but symptoms decreased below baseline at the four-month follow-up. Screening would be necessary to prevent those at risk of adverse effects from gaining access. Alternatively, the cognitive change chapters associated with the negative effect could be removed. Given the significantly higher number of studies demonstrating a positive effect and as the negative findings focus on one chapter, Haeffel’s findings should not update us significantly against self-help. There is still so much work to be done in the mental health field, given the disease burden and the lack of available treatments especially in developing countries. We expect a new charity to contribute to mental health work in LMICs by influencing the allocation of mental health spending towards more effective interventions and developing evidence-based interventions. However, other organizations such as the Center for Global Mental Health, which has been operating for over ten years, or the Happier Lives Institute, which has a more explicit aim to move funds to more effective areas, are likely to have a much greater effect. Cost-Effectiveness Analysis CE made cost-effectiveness analyses (CEA) for the two LMIC-based scenarios discussed above. The Satisfaction with Life Scale (SWLS) model suggests this intervention can be highly cost-effective, costing only $8 to $20 to increase a person’s SWLS by one point. The Quality-Adjusted Life Years (QALYs) model was made to compare mental health interventions to other global health interventions. The intervention is less cost-effective at this scale, although it is important to note that less evidence was available about this measure in the literature on mental health. Table 1 Cost-Effectiveness Analyses for Two LMIC Scenarios for Guided Self-Help Scenario Description Unit $ per unit, $ per unit, total costs interventio n costs 11 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries only 1 New workbooks are distributed SWLS 20.36 8.00 for every run of the program QALY 1,165.00 556.00 2 Workbooks are reused through SWLS 8.08 2.64 the help of a library partner QALY 512.00 178.00 Note. These values were taken from CE’s SWLS CEA and QALY CEA. We made an updated version of this CEA during phase four of our research process. We only considered Scenario 1. The main changes were the support time given to the beneficiaries and the number of beneficiaries the intervention can reach, which is affected by the first change. Even though there were considerable differences from the CEA estimates, guided self-help still ranked well in cost-effectiveness with the other interventions we were looking into during that phase. Counterfactuals were not included in the computation of QALY estimates because the resulting estimates were negative and hard to interpret. Table 2 Phase 4 Cost-Effectiveness Analysis for Guided Self-Help Unit $ per unit, total costs $ per unit, intervention costs only SWLS 38.60 34.30 QALY 1,165.00 556.00 Note. The complete model is found here. Weighted Factor Model CE’s weighted factor model (WFM) evaluated ideas using the following criteria: strength of the idea, limiting factors, execution difficulty, and externalities. The strength of the idea refers to the quality of evidence for the intervention. Limiting factors are what can limit scaling the intervention, such as the availability of funding and talent and logistical bottlenecks, and what is rated is how likely and how much they can restrict the charity. Execution difficulty measures the difficulty of setting up and running this intervention well. Externalities are other positive and negative effects the charity may cause. CE rated this intervention 7, 8, 6, and 5 out of 10 for the criteria above. 12 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries We used a different set of criteria for our WFM: effectiveness (20%), acceptability (10%), ease of implementation (20%), ease of scaling (30%), and ease of funding (20%). Effectiveness refers to the quality of evidence supporting positive outcomes from the intervention. Acceptability is the extent to which people participating or implementing the intervention see the intervention as appropriate to themselves and the communities it aims to support. Additionally, it considers how much of the intervention should be changed to make it applicable to the participants. Ease of implementation refers to the minimum length of time an intervention can be at least piloted. Ease of scaling evaluates whether the charity meets the three criteria for scalability that say there shall be: 1) identified communities/delivery settings for the intervention, 2) available workforce for scaling, and 3) availability of implementation infrastructure for scaling. Lastly, ease of funding is about the intervention’s likelihood of being funded based on its timeliness or relevance in the region. We only did a quick WFM evaluation of CE’s guided self-help for phase four of our research process since it was not part of the top eight ideas we narrowed down. We arrived at the following ratings: ● Effectiveness - 4.5 ● Acceptability - 3.125 ● Ease of implementation - 4.25 ● Ease of scaling - 3.75 ● Ease of funding - 3.625 Our initial impressions of guided self-help led to a final rating of 3.8. It ranks the fourth highest compared to the eight ideas from phase four. Recommended Intervention Description This research project aims to identify top charity ideas for the Philippines and other low-to-middle income countries. During our research process, we have identified children and young adolescents, those aged 6 to 19 years, as the priority population. This recommended intervention is different from that of CE in terms of these. While CE has included LMIC scenarios in its guided self-help research, other specific program components shall be included in discussing evidence, implementation, and cost-effectiveness of a HIC-focused intervention that will be 13 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries adapted to an LMIC. These components include the systems where the intervention can enter and remain sustainable and the target communities or populations aside from the determined age group, among others. Since there is now a more specific population to target, a different set of evidence for the effectiveness of workbooks will be reviewed and more questions about the form and the activities that can be acceptable to them shall be tackled. Explorations done in this part of the report arose from the research team’s insights and from meeting with experts. For self-help workbooks specifically, we were able to discuss with Ms. Marika Melgar, a psychologist serving school-age children and adolescents. She was part of Parenting for Lifelong Health - Philippines as a project manager, content developer, and content reviewer. We also talked to Dr. Dinah Nadera, the project lead of Analyzing Mental Health in the Philippines: Perception, Access and Delivery at the Ateneo de Manila University School of Medicine and Public Health. She is a medical specialist and has done projects on community mental health and children and adolescents' mental health. She was one of the project consultants to develop the national guidelines for mental health and psychosocial support in emergencies in the Philippines. For Ms. Melgar, workbooks are good in theory. Still, they may be more complicated in practice since it may be difficult to have children interact with the material consistently without the guidance of a therapist or a parent. She emphasizes the importance of interaction, such as doing some of the activities with the child over a Zoom call and the family's involvement to help reinforce learning. She raises the challenge of expecting children to do a mental health workbook on top of the asynchronous modules that are the main means of education for Filipino students during the COVID-19 pandemic. While she uses workbooks in her practice, she gives activities piece-by-piece and not as a whole to tailor-fitted them for the clients’ needs and to guide them more per activity . For Dr. Nadera, workbooks can be promising, but she suggests incorporating more familiar and relatable topics to mental health to reduce the stigma that may be associated with the new mental health intervention. For example, instead of the content introducing mental health itself, it could talk about how sports or music benefit one’s mental health. She also suggests writing a series or making comics to make the workbook more attractive to children. Regarding the weekly guidance given, she says 20 to 30 minutes is enough time to tell a narrative or a story that can be a more engaging and memorable learning activity for children than a review or consultation session. She also echoes the difficulty of using workbooks without involving parents. 14 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries We studied these suggestions and concerns in the following sections. For an overview, the recommended intervention will be composed of distributing self-help workbooks to children and young adolescents, particularly 6 to 18-year-olds, with mild to moderate mental health disorders. 30-minute weekly support by lay counselors will accompany the workbook through telephone, email, social media, or other available platforms for children with moderate mental health disorders. The workbook can be a culturally-adapted version of an existing workbook or can be made originally and can employ bibliotherapy and art therapy. LHWs ideally deliver the weekly guidance, but teachers, university students, and other individuals can be considered. Parent involvement is advised although we were not able to determine what type and to what extent this involvement is. Quality of Evidence Evidence for the effectiveness of self-help workbooks in improving children mental health outcomes There are a large number of existing self-help workbooks for children. They address mental health conditions, including depression, anxiety, trauma, social problems, and disruptive behavior. They also tackle different situations and topics such as grief, other emotions, and self-esteem. Most of these workbooks are available outside a clinical setting. However, there is a lack of rigorous testing of these workbooks’ effectiveness, and consequently, most have not been employed as mental health interventions. In general, self-help, whether guided or unguided, is no longer a new type of intervention for children. Anxiety, depression, and disruptive behavior self-help for children up to the age of 18 years demonstrated significant moderate positive effects (Hedges’ g = 0.49) compared with a control group based on 50 RCTs dating back to the 1990s (Bennett et al., 2019). Children included showed symptoms of anxiety, depression or disruptive behavior as assessed by symptom measures and diagnostic instruments or as reported by children and their parents. The authors also compared self-help interventions on the three conditions with face-to-face treatments, but the results showed a small but significant negative effect size (Hedges’ g = -0.17). Thus, self-help interventions are better than nothing but are less effective than professional face-to-face treatment. In settings with low human resources, self-help interventions will still potentially bring some benefits. The difference in effect size between guided and unguided self-help was not significant, allowing some flexibility for charity founders when developing this intervention. Experts still recommend having some form of guidance to ensure the engagement of young participants. 15 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries The meta-analysis studied paper-based or digital-based interventions, and for guided ones, the support types included were telephone, email, and face-to-face. The study was not specific about who delivered the guidance but they are most likely to be professionals. Many studies were not clear about the amount and nature of guidance given so these were not analyzed in the review and we could not infer what type of guidance may be relevant to children. Other important notes about this meta-analysis are the small sample size across the individual studies and their setting, mostly in high-income countries like Canada and Australia. Results from this analysis shall then be generalized with caution due to its many differences from the intervention initially planned. Still, they suggest a positive contribution of self-help even for children, which was not the focus of the studies discussed in CE’s deep report. When it comes to similar self-help interventions in LMICs, there have not been a lot of studies done yet. We found a small randomized controlled trial done in Pakistan where the 38 adolescents aged 13 to 16 in the intervention group showed significantly reduced symptoms of social anxiety (Cohen’s d = 2.87), fear of negative evaluation (Cohen’s d = 2.40), and enhanced self-esteem (Cohen’s d = 3.21) (Amin et al., 2020). These adolescents scored more than 29.5 for the Liebowitz Social Anxiety for Children and Adolescents (LSAS-CA) Scale but do not suffer from any physical or psychological illness. At the end of the study, 65.8% of the intervention group participants had reduced scores below the threshold for the LSAS-CA Scale. It was only 26.3% for the control group. The study used a CBT-based guided self-help manual called Khushi Aur Kathoon, which included exercises for participants to recognize social anxiety, identify their social problems, understand their behavior and thinking patterns in social situations, and improve relationships with others. Guidance was provided weekly across eight weeks by a psychologist that stayed in school. This setup was to make the guidance accessible to students who could visit the professional during break times. The scope of guidance was not described. The intervention was also not delivered by LHWs and over the phone or other non-physical platforms as ideated, but this could be a suggestion for an alternative way of guiding the participants. This manual was culturally adapted such that it was written in the national language, and it used idioms, phrases, narratives and images that are locally used, thus making the exercises more understandable and relatable. This highlights the importance of cultural adaptation in the charity’s implementation of a self-help intervention. An ongoing RCT that may be worth looking into is guided self-help psychoeducational booklets for problem-solving for Indian students aged 13 to 20 with elevated mental health symptoms based on the Youth Top Problems and the Strengths and Difficulties Questionnaire (Michelson et al., 2020). The booklets were specifically designed to have colorful illustrations and simpler text to cater to 16 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries children. This intervention is delivered over six weeks with guidance by therapists through face-to-face sessions for specific weeks. Initial results show moderate to large improvements in the participants’ Total Difficulties scores for the Strengths and Difficulties Questionnaire. However, the intervention shifted its primary delivery to face-to-face sessions over four weeks, with the booklets complementing the therapist session due to issues with the feasibility of the intervention and engagement of the participants raised in the qualitative analysis. The study can still be consulted for a detailed account of the development of the workbook. They conducted intervention design workshops to align the intervention with theoretical principles, evidence, and best practices. Then they did local stakeholder interviews to identify contextual types and causes of mental health problems, coping strategies, help-seeking behavior, and preferences for psychological support. While we could not find and compare tested workbooks for children due to capped time and lack of existing research, we found two lists of children's books about mental health that may be worthy of review. Child Mind Institute lists books about abuse, anxiety, depression, feelings, trauma and more for children 3 to 12 years (“44 Children’s Books”, n.d.). The National Alliance on Mental Illness lists books about different psychological issues for children and their parents (“Mental Health Books for Children,” n.d.). Dr. Nadera suggested using the workbook Doing What Matters in Times of Stress: An Illustrated Guide by the World Health Organization (WHO) (“Doing What Matters,” 2020). It is a self-help stress management guide for coping with adversity composed of five sections or techniques: grounding exercises, unhooking from difficult thoughts and emotions, acting on one’s values, being kind to oneself and others, and making room for “bad weather.” Accompanying audio exercises are also available, and these exercises, along with the workbook itself, have been translated into and locally adapted for 21 languages or communities. The workbook is made to cater to different types of people, from parents to health professionals, in different locations, from places in conflict to peaceful communities. This workbook is used as part of the mental health program called “Self-Help Plus” (SH+) (Epping-Jordan et al., 2016). The program is a 5-session stress management course that is ACT-based and consists of the workbook and pre-recorded audio delivered by lay facilitators to large groups of up to 30 people. Each session lasts for two hours. SH+ was tested in a large RCT of 694 participants who were adult South Sudanese female refugees in Uganda (Tol et al., 2020). There were larger improvements in psychological distress (Cohen’s d = 0.26) measured by the K6 Scale and for different post-traumatic stress and depression symptoms measures for SH+ than the control group three months post-intervention (Tol et al., 17 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries 2020). It was also tested on 459 refugees and asylum seekers in Western Europe (Italy, Germany, Austria, Finland, UK). There was only a significant difference between the intervention and the control groups regarding the frequency of mental disorders and General Health Questionnaire scores at post-intervention and none at the six-month follow-up (Purgato et al., 2021). At post-intervention, the risk ratio (RR) is 50%, meaning that the frequency of mental disorders in the SH+ group is only half of the frequency of mental disorders in the control group. At a six-month follow-up, however, the risk ratio is 96%, meaning that the frequency of mental disorders in the SH+ group is 96% of the frequency of mental disorders in the control group. This is due to the frequency of mental disorders decreasing in the control group while there was no change in the SH+ group after six months. For the 5-item World Health Organization Well-Being Index (WHO-5), there was a significant improvement for the SH+ group than the control group post-intervention and maintained after six months. In a smaller RCT of 119 care home workers in Northern Italy, an online version of SH+ was compared to a similarly supervised and structured alternative activity instead of the enhanced treatment as usual (ETAU), which was the control for the first two studies (Riello et al., 2021). For Tol et al. (2020), ETAU consisted of a one-time meetup with an LHW to cover overthinking and strategies for self-management and dissemination of information on existing mental health services. For Purgato et al. (2021), ETAU participants received routinely delivered social support and information about freely available health and social services, and links to community networks providing support to refugees and asylum seekers. Riello et al. (2021) resulted in non-significant differences in reduction of anxiety and posttraumatic symptomatology in terms of frequency of mild symptoms (RR = 97%), suggesting that SH+ effectiveness as reported in other studies was due to non-specific factors and not specific factors, i.e., ACT-based contents of SH+. These non-specific factors include the provision of structured and interactive activities, stimulating reflection and expression of emotions, guided exercises and the stimulation of multiple senses through visual and auditory channels (Cujipers et al., 2019 as cited in Riello et al., 2021). Which of these factors specifically were not identified by the authors but results can strengthen the claim for effectiveness of workbooks containing exercises that are structured and guided. As will be discussed in the next subsections for evidence, the intervention will also make use of other types of therapy that can provide both a more visual and auditorial experience for the respondents. Another possible reason cited by Riello et al. (2021) for the difference in effectiveness of their study from other studies might be because of the target population since the latter had displaced individuals as participants and consequently, there were differences in the severity of conditions and availability of alternative 18 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries interventions. This supports the proposal later on of building the new charity where alternative interventions are scarce. Aside from this concern, the three studies were done on adults instead of children. However, this seems to be the most similar intervention to our ideal intervention since SH+, aside from using a self-help workbook, was made to be briefly guided by lay facilitators. The workbook Doing What Matters in Times of Stress: An Illustrated Guide is also the most readily adaptable workbook we can find. It was made with many illustrations and minimal text for low-literacy communities, which we perceive as also suitable for younger populations. Regarding the concern on the non-significant difference of SH+ compared to a similar intervention, we expect the charity to target locations that are not reachable by other mental health interventions. Thus, improvements on different mental health outcomes can still be expected. Since there is limited evidence for self-help workbooks as a mental health intervention for children, we explored forms of therapy that can be implemented through workbooks and fit the target age group. Our interviews with experts highlighted the need to make workbooks engaging and friendly so that young participants will be encouraged to use them. Examples discussed were creating workbooks resembling children’s books, then using the weekly guidance as storytelling time, and using the workbooks for art. In the next paragraphs, we will discuss the evidence for bibliotherapy and art therapy interventions for children. Evidence for the effectiveness of bibliotherapy in improving children mental health outcomes Bibliotherapy is simply the use of written materials to treat mental health problems (Yuan et al., 2018). It uses non-fiction or fiction literature and storytelling to help children address and prevent problems related to their identity, environment, emotions, internalizing and externalizing behaviors, and development. Bibliotherapy for children has been studied more broadly than general self-help workbooks. We found two meta-analyses demonstrating that bibliotherapy is more effective in improving children and adolescents’ mental health than control conditions. In Yuan et al. (2018), it led to significantly greater reductions in depression and anxiety with a standardized mean difference of -0.52. These interventions were specifically self-help books and their programs lasted from 4 to 12 weeks. It targeted children (6 to 12 years old) and adolescents (13 to 18 years old) who had a diagnosis of depression or anxiety or exceeded thresholds of different scales for anxiety and depression. Subgroup analyses showed that it is more effective in depressive participants than anxiety participants, in adolescents than children, and when there is no parent involvement than when there is. However, there was no subgroup analysis 19 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries on the existence of therapist support or the type of therapist contact (personal, telephone or email). In Montgomery & Maunders (2015), creative bibliotherapy, which uses fiction, poetry and film, showed small to moderate effect sizes for internalizing behavior (Cohen’s d = 0.48-1.28), externalizing behavior (Cohen’s d = 0.52-1.09) and prosocial behaviors (Cohen’s d = 0-1.2). It is important to note that the interventions in this meta-analysis are different from our ideated intervention since the materials were a) not necessarily self-help, b) were read aloud mostly to a group of participants, and c) delivered by psychologists, counselors, teachers or researchers. The programs were typically between two and 16 weeks in length, with sessions done once or twice a week within 30 to 60 minutes. This can still suggest that a bibliotherapy intervention can work when participants are given brief, regular support. The meta-analysis also gives the possibility of making the regular guidance by group. However, doing it over a teleconferencing platform sounds more feasible and less costly than holding it physically. A school-based intervention with teachers as alternative facilitators to LHWs can also be considered. The studies included in the meta-analyses above were set in high-income countries. However, bibliotherapy has also been tested and shown to reduce depression in 13 to 16-year-old females in the Philippines with Cohen’s d of 1.44 (Jacob & De Guzman, 2016). The researchers administered a six-week program of eight modules that took 90 minutes each. The modules were based on the theory by Rick Hanson called “Taking in the Good,” which involves four steps abbreviated as HEAL: 1) Have a positive experience; 2) Enrich it; 3) Absorb it; 4) Link positive and negative experiences. Evidence for the effectiveness of art therapy in improving children mental health outcomes Art therapy is a form of psychotherapy that uses art media as its primary mode of expression and communication to address a wide range of difficulties, including emotional, behavioral, or mental health problems (“What is art therapy?”, n.d.). The artwork becomes the medium through which clients can express and work through their issues, problems, and concerns and provides a focus for discussion, analysis and reflection to make sense of their experiences (Case and Dalley, 2006). We also found two systematic reviews on art therapy interventions. Bosgraaf et al. (2020) found 37 studies on interventions for children aged 6 to 20 that vary in terms of the art materials (two-dimensional to three-dimensional), assignments (topic-based instructions or free-working), and therapist behavior (non-directive, directive, eclectic). At least half of the studies reviewed show that all combinations of those components significantly alleviate psychosocial problems. These problems include depression, autism spectrum disorder, conduct disorder, post-traumatic 20 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries stress disorder, and mild intellectual disability (MID). Sessions were held one to 25 times and lasted 60 to 90 minutes. Cohen-Yatziv & Regev (2019) studied 13 articles grouped into children's characteristics with the following groups of interest to us: 1) children dealing with traumatic events, 2) children with special educational needs and disabilities, 3) children with no specific diagnosed difficulty and 4) juvenile offenders. Most of these studies suggest a positive effect on the appropriate children's outcomes, such as trauma symptoms, self-esteem, self-perception, and other behavioral and social measures. There are only one to three studies available for each group. The programs were done in 8 to 15 sessions lasting 45 to 60 minutes. For both reviews, most programs were also delivered to groups which can be noted as an alternative form of delivery for the charity’s intervention. The programs were also not all self-help and in workbook form so they still need to be adapted. Using art therapy in the workbooks may make the intervention more costly since art materials shall be provided, and support shall take on the form of online video calls to better facilitate activities. A quick search of art therapy in the Philippines showed a couple of organizations implementing art therapy, including MAGIS Creative Spaces, a center that provides preventive and rehabilitative services through expressive arts (“MAGIC Creative Spaces,” 2021). There were also qualitative articles with one about the use of expressive arts in dealing with traumatic experiences of survivors of the supertyphoon Typhoon Yolanda (Parr, 2015). However, this paper only presented the experiences of the participants and did not evaluate the intervention. Summary of evidence The evidence for guided self-help workbooks for a younger population shares the difficulties found for a general population. These difficulties include limited testing, small sample sizes, high-income country settings, and a wide variety in implementation in terms of program length, type of support or contact, and who delivers the intervention. These same problems exist even when we look into more specific forms of therapy–bibliotherapy and art therapy–that can be adapted into workbooks. The new charity shall be cautious in generalizing the evidence found. Nonetheless, the evidence is still positive and it may only be a matter of choosing the right combination of components that will make up the charity’s final intervention and culturally adapting it. Based on the studies above, here are potential alternatives to the ideated self-help workbook intervention for children. 21 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries 1. Target condition: There is still good evidence supporting self-help, bibliotherapy and art therapy for depression and anxiety. Other conditions that can be targeted are trauma and externalizing behaviors which were the other most commonly measured outcomes in the studies above. 2. Age range: Participants were usually between the ages of 6 to 18. This can be narrowed down to adolescents (ages 13 to 18), which experts we talked to suggested as a good age range where literacy and awareness can support the use of the intervention materials. 3. Program length: CE suggests a program lasting 5 to 10 weeks, but the studies above suggest a longer program, possibly 8 to 12 weeks. 4. Accompaniment of support: The studies above also looked into unguided self-help interventions. While they are considered less effective, evidence shows they still lead to positive effects. Thus, if funding and other concerns restrict implementation, a workbook made to be unguided can be explored. 5. Support time: CE estimated that the overall support time received weekly by each participant will add up to 100 minutes only, but the studies we saw suggest at least 30 minutes of support time per week. The support times from the studies were even longer at 45 to 90 minutes, but this might be because these concern interventions that were non-self-help and were reliant on the support or session only. Reducing support time is possible since workbooks will be the main source of support. 6. Support type: The initial intervention only intended telephone support. The charity can explore other types such as email, another common option aside from telephone support based on the studies. SMS, social media and teleconferencing platforms like Zoom or Skype can also be used. The support type will most likely be dependent on which type is the most accessible to the target population. If conditions allow, the support can be held physically. 7. Facilitator: There were no studies discussing LHWs delivering either workbooks, bibliotherapy or art therapy interventions. However, we think it is still possible to train them to do so. Some studies also suggest having teachers deliver and making the intervention school-based. However, this will raise another set of challenges in its implementation, such as partnering with schools and convincing teachers to take on more responsibility. Professionals can also provide the support, but funding and talent sources will be important factors for this decision. 8. Program activities: Most research on self-help books, bibliotherapy, and art therapy delivers interventions to groups. While the workbooks are still self-help, the charity can consider doing regular support in groups. This will change the type of support to something more appropriate such as teleconferencing platforms but this will also affect implementation costs and 22 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries accessibility for the participants. This will also affect the privacy of individuals and the charity must check whether that is fitting for the chosen population. Implementation In this section, the final model of the intervention will be discussed with the theory of change. A visualization of the theory of change for the intervention is shown below. Theory of Change Figure 1. Theory of change for self-help workbooks for children The charity will hire mental health specialist staff that will participate in the creation of the workbook and the training and supervision of the service providers. Before the workbook is created, there will be a needs assessment of the identified recipients of the intervention. This will help the staff specify the topics, activities and design to be included in the workbook. Although we have identified common mental health disorders as the target conditions, a needs assessment may also lead us to a different condition that is most pressing to address. As discussed in the sections on quality of evidence, service providers or lay counselors can be LHWs or teachers, depending on the chosen community of the charity. Making this intervention school-based can help recruit participants, ensure their participation, and try group-based approaches. The main concern here will be 23 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries how effective teachers can be as lay counselors, given their existing responsibilities. It is still possible to do a school-based model with other individuals as lay counselors visiting the school. Graduate studies students from Psychology and other related courses may also be lay counselors through the educational institution adapting this intervention as a program. Examples of this model are Ateneo de Manila University’s UGAT SandaLine and the University of the Philippines Diliman Psychosocial Services. This is a good model for sustainability since there will be lay counselors easily available already. Lay counselors can also be other individuals who are specifically determined to deliver the intervention as long as they will be able to fulfill their weekly support tasks and other related tasks but more research is needed to identify their qualifications. Participants will be recruited and screened to know which of them will be directed to a purely self-help workbook program, a guided self-help program or referrals. The evidence discussed in the previous sections tell us that self-help with guidance is more effective than self-help without guidance. However, there are still benefits to be gained from unguided self-help, and allowing the intervention’s workbook to be accessed by other participants who are less in need of assistance will increase the reach of the charity. Screening participants also allows the charity to focus its limited staff time on those who need guidance the most and avoid serious harms from dealing with severe cases when professional treatment is more appropriate. With that said, while this intervention is expected to reduce depression, anxiety, and other targeted mental disorders, if any, in children, it is meant to address mild to moderate cases only and is not meant to replace professional help. A scoping of professional mental health services available to the recipients will be done to set up referrals for children with severe depression or anxiety. For the workbook, many therapy approaches can be used. In CE’s initial research, the workbooks usually employ CBT, ACT and ART. We encourage using bibliotherapy and art therapy since this may be of more interest to children. Topics will depend on the needs assessment done at the start of implementation, but they may cover understanding emotions, learning about identity, facing social anxiety, and building relationships. An example set of treatments delivered through a workbook is from Amin et al. (2020). The program is called Khushi Aur Kathoon and the set of treatments supported by worksheets are: 1) identifying symptoms and possible reasons for anxiety; 2) explanation of the basic principle of behavioral activation and increasing social, creative, personal, professional and entertainment activities; 3) identifying problems and solutions in social situations; 4) understanding the cycle of emotion, physical symptoms, behavior and thinking process; 5) identifying cognitive errors; 6) learning how to improve relationships and to deal effectively with any 24 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries situation by expressing emotions and discussing disagreements; 7) improving social relationships and staying healthy, and 8) exposure techniques. Adaptation of existing workbooks can be made if there are limited resources and if they fit the needs assessment of the target population. Aside from Khushi Aur Kathoon, another workbook discussed earlier and can be culturally adapted is Doing What Matters in Times of Stress: An Illustrated Guide. These workbooks do not explicitly state mental health, with the former focusing on social situations and relationships and the latter focusing on stress. An advantage of this type of workbook is that its topics are familiar and may less likely prompt bias against mental health services. Using bibliotherapy will deliver treatments in workbooks and weekly guidance through nonfiction and fiction stories with colorful illustrations, poems, guided reading and storytelling. On the other hand, art therapy uses different mediums such as drawing and painting for expression and reflection of behaviors through the directive or nondirective participation of the lay counselor. For the weekly support, experts suggest using this brief time creatively. From what was mentioned above, lay counselors can story tell or facilitate art therapy during these weekly meetings. The reduction in the experience of mental health disorders in children from engaging with the workbook and receiving weekly support is then expected to improve their well-being. It is important to acknowledge that the charity can ensure the accessibility and quality of the intervention, but the intervention may not be solely responsible or may not be responsible for changes in children's well-being. We also noted a potential indirect effect of the intervention–improving mental health awareness–assuming that individuals, the recipients or the people surrounding them, take action for their mental health problems based on the information they can get from the intervention directly. This effect is harder to measure than the main effect although there are indicators that can be gathered, such as reduced reports of negative perception around mental health and increased uptake of mental health services. The key assumptions are the following: 1. Laypersons can be trained to provide mental health services. We believe there is low uncertainty about this assumption holding since task-shifting has been a widely-recognized option for delivering different healthcare services, especially in low-resource settings. In Sub-Saharan Africa, 10 out of 11 studies showed significant positive results on depression scores (Galvin & Byansi, 2020). Seven of these interventions were held individually while the rest were 25 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries in groups. In another systematic review of LHWs’ experience in task-shifting mental health interventions, LHWs were satisfied with the training and emphasized the importance of more robust supervision (Shahmalak et al., 2019). More advanced training, more opportunities for networking with other counselors, and more time to take in information were cited as improvement points for task-shifting training. 2. Children interact with the workbooks and show up for weekly support. The discussion on the intervention’s acceptability supports this assumption. The accompaniment of weekly support can encourage the use of workbooks and developing workbooks creatively through the help of different organizations and professionals can help ensure that children will find the activities very engaging. Target Location Our research is focused on identifying the best mental health interventions in low-resource settings. Our main criteria in choosing the target location are the scale of the problem of mental health in different regions. Ideally, we would use country data to compare all low-to-middle-income countries. However, due to the lack of easily analyzable data, we first compared the Disability-Adjusted Life Years (DALYs) burden of mental disorders of world regions, as specified by the World Health Organization (WHO). Second, we compared the DALYs burden of mental disorders of the countries in the top region. We used data from the Global Burden of Disease (GBD) 2019 (Global Burden of Disease Collaborative Network, 2021). Data were available for individuals aged 5 to 24 years old, which is similar to our priority age group. Southeast Asia turned out to be the region with the highest burden of mental disorders, depressive disorders and anxiety disorders in the number of DALYs among the six world regions. The rest of the regions are ranked in descending order of number of DALYs as follows: African Region, Americas, Western Pacific Region, Eastern Mediterranean Region, and European Region. Income demographics vary across countries per region and this is important to note to make sure that targeted locations are indeed low-resource. For all regions except Southeast Asia, depression and anxiety combined make up more than half of the DALYs burden of mental disorders. Thus, we looked into other mental disorders when analyzing the DALYs burden for Southeast Asian countries. Indonesia, the Philippines and Vietnam make the top 3 countries with the highest number of DALYs lost to mental disorders, depressive disorders, conduct disorder, and autism spectrum disorders. Myanmar replaces Vietnam as the country 26 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries having the third-highest number of DALYs lost to anxiety disorders. Indonesia remains the first while Vietnam ranks second, and the Philippines ranks third for the highest burden of substance use disorders in the number of DALYs. Indonesia and the Philippines rank first and second respectively as the countries having the highest burden of attention-deficit/hyperactivity disorder (ADHD) in the number of DALYs, with Thailand joining as the third top country. Substance use disorders are not considered mental disorders in the GBD report but they are included in our PICO framework and are commonly addressed by the studies we found across interventions. Conduct disorder, ADHD and autism spectrum disorders are excluded in our PICO framework but they are common target conditions in children in the studies we found. Singapore is the only Southeast Asian country classified as high-income. Malaysia and Thailand are upper-middle-income countries and the rest are lower-middle-income countries. Thus, Indonesia, Philippines and Vietnam shall be prioritized. Due to the researchers’ location and expertise, this research focuses on the Philippines. We still expect the results to be somewhat generalizable to these other two countries due to their similarities since the interventions we are investigating are made to target common mental health disorders in low-resource settings. In the Philippines, there is no available local data that can guide us in prioritizing a specific region or community. The target location is most likely to be determined by where the charity can gain the most access to funding, partnerships, talent and participants. Whether there are organizations doing similar work shall be considered too. We believe it is important to leverage this intervention's low-resource suitability. Communities with limited electricity and internet access shall be prioritized since workbooks are one of the easiest mental health interventions to deliver to them. Of course, there shall still be sufficient access to telephones, phones and other gadgets for those who will need weekly support from lay counselors. Acceptability We will discuss the acceptability of this intervention to the beneficiaries, the beneficiaries’ community and the service providers. In Michelson et al. (2020), only six out of 45 participants completed all 15 sections of the intervention workbook pilot. Workbooks were also not completed in-between guided sessions for at least once for 80% of the adolescents. Difficulties cited for workbook engagement were lack of interest in reading or writing, lack of retained knowledge or conceptual understanding, and insufficient time due to 27 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries academic requirements. Sessions with psychologists compensated for these difficulties by providing corrective feedback, encouragement, explanation of difficult concepts, and generating solutions to their problems. Good feedback was received about the relatability of the character-based narratives in the workbook and its brief and topic-specific handout format. In Yuan et al. (2018), the acceptability of bibliotherapy for depression and anxiety disorders in children and adolescents was measured in terms of the proportion of patients who discontinued treatment. The risk ratio value was 1.66, meaning that the intervention groups had 66% more treatment discontinuation than the control groups. However, the difference in proportions for treatment discontinuation between both groups was not significant. This suggests that introducing a bibliotherapy intervention will not reduce individuals’ efforts to seek treatment. Both the young and their parents found self-help and guided self-help interventions to be acceptable based on self-reported satisfaction scores qualitatively analyzed by Bennett et al. (2019). Some of the studies found guided treatment to be more preferred by the parents and their children than unguided treatment. Some showed a lower preference for self-help compared to face-to-face treatment. Since the charity will work on both mild and moderate cases of mental disorders, it should ensure that the workbook to be created will still engage children with milder cases. Eighty-four percent of adolescents completed the intervention for Michelson et al. (2020), defined as attendance to 75% or more guidance sessions for six weeks. All of them reported satisfaction with the service, although 18% of the participants also reported dissatisfaction due to the minimal amount of support. Since we are only setting up half an hour of weekly support due to low-resource settings for the intervention, the workbook shall be made to be understandable enough that weekly guidance is simply complementary. Other concerns about these sessions were confidentiality and uncertainty about what counseling will involve. Thus, assurance of privacy and confidentiality and setting expectations for the weekly support to be given is important to have. When it comes to the involvement of parents in the intervention, the studies were not very specific but Bennett et al. (2019) included ones that were in some way undertaken by parents too as long as child outcomes were considered. There was also a guided parent-delivered CBT intervention that involved a self-help book and 20- to 60-minute therapist support that demonstrated treatment gains to anxiety even at a follow-up of three to five years (Brown et al., 2017). Seventy-seven percent of the 28 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries participating families completed at least 50% of the treatment suggesting parent involvement in mental health programs for their children is feasible. The potential reasons for involving parents in bibliotherapy include 1) children usually have established trust and rapport with their parents and 2) parents are more broadly present and available in their children’s life (Yuan et al., 2018). These can help encourage higher engagement with the workbooks. Experts we talked to agree with this, emphasizing that younger populations are not expected to initiate working on the activities and participating in sessions independently. However, parent involvement shall not be too heavy that working parents may not be able to do it, thus hindering children’s progress in the program. Parent attitudes may have changed over the past few years due to the pandemic. In the Philippines, public education has used modules delivered house-to-house to continue learning amidst the health restrictions. Children and their parents may consider a mental health workbook an additional burden to both the children and the parents who assist them since it is similar to what they already spend time on daily. Children or adolescents’ preference for privacy as mentioned earlier is also a concern. This preference for parent involvement should be one of the first things the new charity should test. Families or participants may also have concerns with LHWs, who are also members of their community, knowing their private information. These concerns may lead to low participation but can be avoided through the LHWs’ training and by protecting anonymity even when giving the weekly support. Lastly, we still face the acceptability of the intervention for lay health workers, who are the ideal service providers. Attrition rates of community health workers from two studies set in LMICs were 21.1 % and 49.6% for projects that lasted 15 years and seven years, respectively (Tekle et al., 2022; Nyaga et al., 2018). The incidence rate for both studies were 3.1% and 4.68%, respectively. These suggest that attrition is low per year and turnover can be properly accommodated. The main reasons for leaving were low incentives, dearth of career development opportunities, high workload and other psychosocial factors such as family influence and health problems (Tekle et al., 2022). Attrition was also associated with a lack of interest in peer organization, the absence of refresher training, and receiving no feedback from supervisors (Nyaga et al., 2018). The new charity shall focus on addressing these concerns. 29 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries Funding EA Funding There is currently no funding opportunity for mental health charities from Effective Altruism organizations aside from the seed funding that Charity Entrepreneurship may grant at the end of their incubation program. The charity can apply for the EA Global Health and Development Fund but they are currently not open to applications and no mental health charity has received funding from it in the past. Non-EA International Funding There is minimal funding allotted for mental health projects outside developed countries. Two promising sources are listed below: 1. Wellcome is a foundation supporting research on mental health, infectious diseases, climate, and health. They offer funding schemes for mental health research and interventions. 2. The National Institute of Mental Health is the United States’s lead federal agency for mental disorders. They only offer grants for research which the new charity can apply for pilot testing of the intervention. They have Scale-Up Hubs to conduct implementation research on evidence-based mental health interventions for LMICs in the following regions: East Asia and the Pacific; Europe and Central Asia; Latin America and the Caribbean; the Middle East and North Africa; South Asia; Sub-Saharan Africa. Their research networks in Asia have not reached the Philippines yet. Local Funding In the Philippines, government agencies and other organizations can provide funding: 1. The Department of Science and Technology offers various grant opportunities, although mostly for research. Calls from its attached agencies Philippine Council for Health Research and Development and Philippine Council for Industry, Energy and Emerging Technology Research and Development will be the most appropriate to apply for. The latter provides grants for startups. 2. The National Research Council of the Philippines also gives research grants. 3. If this intervention will be done in a school setting, the Department of Education and the Commission on Higher Education may assist. The charity can also directly partner with schools, particularly private schools, to allocate their budget and for easy access to recipients. More details about working with 30 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries schools can be found in the deep report on school-based teacher- delivered psychoeducation for children. 4. Educational institutions can also adapt this as programs for their graduate studies from which they can receive funding. 5. Companies doing corporate social responsibility efforts may be worthy of contacting. The League of Corporate Foundations has programs for health, education, the environment, arts and culture, and enterprise development. We think it is likely that they are open to mental health initiatives. 6. We can try being involved in Local Government Units, but interest in creating a mental health program will vary across regions. 7. Other agencies and organizations can be identified based on the intervention's population. Some populations mentioned by experts are disaster survivors and drug users. The mental health intervention can be part of or developed as a rehabilitation program by different agencies and organizations both locally and internationally. There are funding sources specific to this self-help workbook intervention. The National Book Development Board has a book development trust fund, although the book requirements vary every year. The Cultural Center of the Philippines may also have funding opportunities such as their recently launched comic grant and partnership opportunities such as their “Batang Sining” creative expression workshop involving storytelling and art-making. Funding to support the creation and the distribution of workbooks can also come from partnerships with public and private libraries, publishing companies, and nonprofit organizations focused on educational activities, whether or not they are specifically for children. We listed a few of them here. Another organization that may be of interest is Save the Children Philippines. They work on humanitarian response, health, education, and children’s rights in a hundred countries worldwide. Last year, they held the Validation and Training of Trainers on the Mental Health and Psychosocial Support Module for the Bangsamoro Learners, which suggests an openness in holding interventions like ours. Additionally, our expert interviews noted that mental health response is important in post-disaster and post-conflict areas, and funding for rehabilitation can be tapped to support mental health interventions. This intervention can also be implemented under projects of public offices. In particular, we see this as a fit for projects like the Community Learning Hubs launched in 2020 by the Office of the Vice President in the Philippines to support students who lack the gadgets or the internet connections needed for distance and blended learning during the COVID-19 pandemic (Lalu, 2020). 31 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries Summary of funding: We expect funding for pilot testing of the mental health intervention since most of the opportunities available are for research projects. Other sources may also be available depending on the target population’s location or mental health-related condition. Funding for the actual implementation and scaling up will be more difficult. Still, partnerships with the government and other organizations may be easier if the pilot test is successful. Because of the workbook and educational nature of the intervention and its focus on children, there are various organizations or sources that may be interested in supporting it. Talent Training talent may take longer than the initial three to seven days per self-help material planned by CE. It will depend on a) the characteristics of the service providers such as literacy, familiarity with mental health, familiarity with the target population, and familiarity with the medium of support, b) the level of support to be given to the participants, and c) the availability of specialist staff. Regardless, we believe it is possible to train lay health workers, teachers, or university students to provide support, and the pool will be more about issues of acceptability and funding. The training of the LHWs will include a background on mental health, mental health in their community, the objectives of the intervention, case identification, delivering the intervention, etc. Their training on delivering weekly guidance to children with moderate cases of depression or anxiety will depend on the therapy approach applied to the workbook. In terms of creating workbooks, we think there are enough professionals knowledgeable in self-help, bibliotherapy or art therapy that can be consulted in the creation or adaptation of the workbook for it to be complete in its therapeutic approach. We also found organizations that the new charity may consult in the creation process: 1. Habi Education Lab makes well-designed learning experiences for students, teachers, and professionals. They create modules, develop programs, and curricula training to improve how people learn. They designed the Playdate+ Module for Save the Children Philippines, which serves as a toolkit for parents and caregivers on caregiver well-being, indoor play, outdoor play, and health and nutrition. 2. AHA! Learning Center solves education inequity by providing after-school learning for low-performing but high-potential public school students. They help improve students’ academic performance, leadership, and self-mastery 32 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries skills and promote parent-teacher engagement. They have their own collection of original children's stories and songs written in the Filipino language, adapted into this intervention’s workbook. 3. Adarna House produces quality reads for Filipino children to enjoy and learn from. Their books discuss family, friendships, and even poverty, disasters, and history. The charity may also coordinate with academic institutions. For example, the Department of Human and Family Development Studies of the College of Human Ecology (CHE-DHFDS) in the University of the Philippines - Los Baños published Tsikiting Stories to address children’s mental health amidst the COVID-19 pandemic. “Tsikiting” is a Filipino colloquial term from Spanish “chiquitin,” which means young child in English. Stories explain concepts such as quarantine, social distancing, wearing of masks, and handwashing in a simple way and through colorful illustrations. Scaling Government buy-in is the ideal route to the sustainability of the intervention in terms of funding and access to talent and recipients but we expect that more evidence is needed before getting government support. Adoption of the intervention by larger organizations is plausible too. Aside from the government agencies and organizations already mentioned in the funding section, if adoption as a separate intervention is not possible, the intervention, the distribution of workbooks specifically, can be under educational, health or rehabilitational programs of the government. The weekly support can be under similar services such as the free crisis line facilities of the National Center for Mental Health and the Philippine Mental Health Association. The workbooks can take a for-profit model to scale and reach more children with mild depression, anxiety, or other mental health disorders. This model may also support the provision of workbooks for poorer populations through a buy-one-give-one model. It is also possible to adapt the intervention for moderate cases with weekly guidance as a for-profit model. However, this may defeat the purpose of developing an intervention made for low-resource settings if the intervention is not affordable or shifted its focus on populations that can afford or access other forms of help. Overall, operating the intervention at a larger scale seems feasible due to its flexibility. It can be adapted as a whole intervention, an aspect of a bigger program or a social enterprise. The final model will depend on the charity’s ability to build partnerships and stakeholder interest. Since this seems to be the first workbook on 33 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries mental health for children, we expect the need for it to continue for years. Thus, we expect interest in supporting the intervention to grow in the future as well. Externalities We list three more effects the charity may have aside from the externalities discussed in the background. First, given the emphasis of this intervention on using stories and art to engage children with mental health resources, the existence of this new charity will encourage the field to explore more creative ways to make mental health services more accessible and more effective. Second, there is still the concern for LHWs that this new mental health task will harmfully affect their original set of health tasks. It may interfere with their primary responsibilities. The key here is identifying the individuals with similar tasks as the intervention requires, e.g., teachers teaching values or health education, making it easier to accommodate new tasks. Individuals identified to be trained to deliver this task without the affiliations of the aforementioned facilitators above, may also be considered. Lastly, the intervention may inform the community of the recipients about mental health and bring to surface existing mental health difficulties. However, this awareness may cause more harm than good if it does not come with other services to refer severe cases to or if there are no services available for other types of individuals. Cost-Effectiveness Analysis For this cost-effectiveness analysis (CEA), we used the model described in the Theory of Change. Specialist staff will train laypersons to deliver weekly support to children’s self-help workbooks. These workbooks aim to improve children's well-being. The charity will employ 20 lay staff working 20 hours per week. Thus, they can provide weekly guidance to 800 people. The weekly guidance is 30 minutes long and delivered via telephone or other remote communication platforms and will be provided over ten weeks. The weekly guidance time and program length were based on the studies investigated for quality of evidence, although this might still change after pilot testing. Since the program will last for ten weeks, the charity can implement four runs in a year, meaning 3200 beneficiaries can be reached with the workbook and lay counselor support per year. We assume that we can reach half the number of beneficiaries for those receiving workbooks only. We considered the workbook effects on well-being and the costs of setting up the charity and the intervention. Ideally, the CEA considered counterfactual costs, but the studies discussed in the previous sections led us to use different mental health 34 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries measures. These measures do not have conversions to existing data on other charities’ impact which are in satisfaction with life scale (SWLS) or quality-adjusted life years (QALYs). The estimates of effects on well-being were based on studies from Tol et al. (2020) and Purgato et al. (2021). These were two out of the three studies SH+. We chose the WHO-5 scale since it is a common measure between the two studies, and it is closest to Subjective Well-Being and Satisfaction with Life Scale which are commonly used for mental health CEAs. The WHO-5 comprises five positively phrased items that respondents rate from 0 to 5 depending on how well the statements applied to them in the past two weeks (Topp et al., 2015). The scores range from 0 (absence of well-being) to 100 (maximal well-being). Further research on what improvements in this scale mean for the children shall be done. Note that the SH+ studies had adult participants and the sessions were held in groups so the effects were discounted during calculation. Other uncertainties to note are the average years the effects last and how much they will hold at scale. We kept CE values for these two. Costs were based on costs in the Philippines. The main drivers of costs were staff salaries and the creation of workbooks. Table 3 Cost-Effectiveness Analysis for Self-Help Workbooks Recommended Intervention Year of Operation Unit $ per unit, total $ per unit, costs intervention costs only WHO-5 2.67 2.02 1st Year improvement WHO-5 2.11 1.79 3rd Year improvement Note. The full CEA model is found here. The estimates tell us that improving well-being in terms of WHO-5 using a self-help workbook intervention can be highly cost-effective. The initial estimates from CE are $20.36 per SWLS for total costs and $8.00 per SWLS for intervention costs. However, the estimates are not directly comparable since the mental health measures used are different. At its third year, the intervention can be expected to be 20% and 8% more cost-efffective than the first year for total costs and intervention costs respectively. 35 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries This is due to increased capacity to hire support staff, thus, increasing the number of beneficiaries that can be reached. Weighted Factor Model Table 4 Weighted Factor Model Comparing the Initial and the Recommended Interventions Criteria Initial Intervention Recommended Intervention Effectiveness (20%) 4.5 4.5 Acceptability (20%) 3.125 3.5 Ease of 4.25 4.5 implementation (10%) Ease of scaling (30%) 3.75 4.5 Ease of funding (20%) 3.625 4 Average 3.8 4.2 There is strong evidence supporting positive treatment effects of self-help workbooks, bibliotherapy and art therapy on children's mental health outcomes but since the exact intervention that will be implemented by the charity may not be exactly the same as those studied, we couldn’t give a perfect rating for effectiveness. Since the recommended intervention will still need to be created from scratch or have to go through cultural adaptation, its acceptability is still low but higher than that of the initial intervention since we have identified how it can apply to children specifically. We think the recommended intervention is fairly easy to implement and can be pilot tested within 6 to 9 months, with most of the time creating the workbook. There are many options for communities, workforce, and infrastructure to support the scaling of the program, although the best models are still left to be identified. Lastly, we believe that there will always be a need for accessible and innovative mental health services for children, making this recommended intervention appealing to funders. While there are various funding sources, the charity may still be limited by the activities or children populations these potential funders are focused on. There are still many improvements that can be made to our recommended intervention but overall, we think its current form is worth pursuing. 36 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries Conclusion This mental health intervention was adapted from Charity Entrepreneurship’s recommended mental health charity idea in 2020, so it has undergone extensive research even before this report. Aside from CE’s findings, this intervention also reached our team’s top ten ideas during phase two of our research process. We rated 37 idea clusters from a systematic search of mental health studies and a review of CE and Happier Lives Institute’s lists of mental health interventions. We looked at fewer ideas with more depth for each phase of our four-phase research process. Thus, while we generated and narrowed down ideas based on different forms of evidence from the start, our best ideas were limited only to the ideas we were able to generate during the ideation phase and based on the shallow evidence we were able to find in earlier phases than this deep report. It is possible that we overlooked promising ideas because the shallow research done in previous phases says otherwise. We were also limited in the amount and quality of research we could do within the research project’s timeline of six months. We did not get to review all existing self-help workbooks or books for children or even for other age groups for this project specifically. We could not set more interviews with experts, especially with mental health professionals who have experience in cultural adaptation, creating workbooks or similar materials, and training lay counselors. We were also unable to talk to organizers of educational projects to ask about the development of educational materials and communication with stakeholders. There is strong evidence supporting interventions similar to self-help workbooks. While it is difficult to generalize the studies and we have not arrived yet at a concept for a specific workbook, we believe that whatever specific workbook and delivery the charity will come up with based on this report can be highly impactful. The many ways for the intervention to be implemented make it easier to adapt to be more effective, accessible, and easier to scale. It is even open to options for parent involvement and looking for alternative service providers. While the intervention gives room for a lot of flexibility, we suggest taking advantage of its unique qualities. This self-help workbook intervention preserves privacy or anonymity, removing stigma, which usually hinders individuals from seeking treatment. It is also easy to scale to reach a lot of beneficiaries since the workbooks are self-help and can be taken home and the weekly support is delivered remotely. For example, while the intervention can be done in a school-based manner or delivered in groups or face-to-face, it shall be considered that these will remove privacy or increase the difficulty of implementation due to higher costs and more logistical concerns. Another situation is when choosing a location of implementation, it might be easier to access urban areas. However, urban areas usually have better access to gadgets and the 37 EA Philippines Mental Health Charity Ideas Research, Deep Report Self-Help Workbooks for Children and Adolescents in the Philippines and Low- to Middle-Income Countries internet. Thus, rural areas that can only access mental health services through non-digital means ought to be prioritized. The intervention encourages creativity in developing children’s mental health services which we think will manifest in the workbooks and keep the children engaged and more likely to benefit from the program. While it may be challenging to create a mental health workbook in the country, there is a lot of talent from mental health professionals and designers that can support its development. Since the workbook from this charity may be the first workbook for children’s mental health, this intervention will fill a gap. We expect the interest from different stakeholders to increase once there is evidence to support the specific intervention the new charity will pilot. This intervention can be very cost-effective at $2.50 per WHO-5 improvement in a year of operation. However, it is difficult to compare its cost-effectiveness with other mental health or global health interventions. Another main limitation of this idea is its acceptability, especially concerning workbook engagement. This can be addressed by tailoring the workbook and guidance to the age group. The studies reviewed above considered children and adolescents aged 6 to 20 with one study favoring targeting adolescents. More research is needed to narrow down the age group. There was also not enough information from the studies to identify which components of the guidance delivered by lay counselors to individuals with moderate cases work for our target population. Funding to pilot test the intervention seems easy, but setting it up for a larger scale, it may be difficult. Focusing on a population, location, or condition with available funding can be done. Partnering with existing organizations doing similar work and using a for-profit model are viable options. Lay health workers still seem to be the best fit for the role of facilitator, but we are uncertain about the effects of additional work for them, especially in a low-resource setting’s community health system. 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