EA PH Mental Health Charity Ideas Research Shallow Reports

Reynaly Shen Javier, Margarita Ysabel Muñoz, Glaiza Mae Superable Background on the Research Project This compilation of reports was made through the Mental Health Charity Ideas Research Project under Effective Altruism Philippines. This 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 that can improve the well-being of people living in the Philippines and in other low-to-middle-income countries. We did a four-phase research process to narrow down hundreds of ideas to the few top ideas to achieve this goal. These shallow reports were written to investigate our top six ideas and choose the top three ideas we would recommend and research in more depth. These reports are arranged here from highest to lowest ranking ideas. Table of Contents Background on the Research Project................................................................................. 1 Table of Contents................................................................................................................. 1 Web/App-Based Psychoeducation.....................................................................................4 Intervention Brief...................................................................................................................... 4 Executive Summary.................................................................................................................. 4 Overview...................................................................................................................................... 5 Review of the Evidence.............................................................................................................6 Specific interventions.........................................................................................................6 Theories of Change....................................................................................................................7 Assumptions......................................................................................................................... 7 Brief Cost-Effectiveness Review............................................................................................ 8 Limitations..................................................................................................................................8 Resources.....................................................................................................................................8 Non-Professional/Lay-Delivered Psychoeducation (Community-Based/ School-based).................................................................................................................... 10 Intervention Brief.................................................................................................................... 10 Executive Summary.................................................................................................................10 Conclusion..................................................................................................................................11 Overview..................................................................................................................................... 11 Review of the Evidence........................................................................................................... 14 Specific interventions....................................................................................................... 15 Theories of Change.................................................................................................................. 16 Assumptions....................................................................................................................... 16 1  Brief Cost-Effectiveness Review.......................................................................................... 17 Limitations................................................................................................................................ 18 Resources................................................................................................................................... 18 Self-Guided Internet-based Cognitive Behavioral Therapy (iCBT) Interventions.....20 Intervention Brief.................................................................................................................... 21 Executive Summary................................................................................................................. 21 Conclusion.................................................................................................................................22 Overview.................................................................................................................................... 22 Review of the Evidence........................................................................................................... 23 Theory of Change.................................................................................................................... 28 Assumptions.......................................................................................................................29 Brief Cost-Effectiveness Review..........................................................................................30 Limitations................................................................................................................................30 Resources................................................................................................................................... 31 Crisis Lines......................................................................................................................... 33 Intervention Brief.................................................................................................................... 33 Executive Summary.................................................................................................................33 Conclusion.................................................................................................................................34 Overview.................................................................................................................................... 35 Review of the Evidence...........................................................................................................36 Theory of Change.................................................................................................................... 40 Assumptions.......................................................................................................................40 Brief Cost-Effectiveness Review..........................................................................................42 Limitations................................................................................................................................43 Resources.................................................................................................................................. 44 Self-Guided and Digital-Based Parenting Interventions..............................................47 Intervention Brief....................................................................................................................47 Executive Summary................................................................................................................ 47 Conclusion................................................................................................................................ 48 Overview.................................................................................................................................... 48 Review of the Evidence.......................................................................................................... 49 Theory of Change..................................................................................................................... 51 Assumptions....................................................................................................................... 51 Brief Cost Effectiveness Review........................................................................................... 52 Limitations................................................................................................................................52 Resources...................................................................................................................................53 Nonprofessional-Delivered and Community-Based Parenting Interventions...........55 Intervention Brief....................................................................................................................55 2 Executive Summary................................................................................................................ 55 Conclusion................................................................................................................................ 56 Overview.................................................................................................................................... 56 Review of the Evidence...........................................................................................................56 Theory of Change.................................................................................................................... 59 Assumptions.......................................................................................................................59 Brief Cost-Effectiveness Review......................................................................................... 60 Limitations............................................................................................................................... 60 Resources................................................................................................................................... 61 3 Web/App-Based Psychoeducation by Margarita Ysabel Muñoz Researcher’s Impressions: ● This idea is worth exploring further because it can potentially help address two relevant issues: 1) the existing mental health treatment gap in LMICs; and 2) challenges in mental health service delivery/accessibility due to the COVID-19 pandemic. ● Web- or app-based interventions in general seem valuable because they present unique advantages over face-to-face interventions. These include ease in accessibility, scalability, and anonymity. ● The lack of published evidence on the effectiveness of web- and app-based psychoeducation programs does put the value of this type of intervention into question. Issues such as inequalities in access to technology as well as technology literacy would also determine the success of this type of intervention. Intervention Brief This intervention involves the delivery of psychoeducation through web- and app-based platforms. As definitions of psychoeducation can be wide in scope, web- and app-based psychoeducational programs can involve a variety of elements, including education about specific disorders, coping skills, concepts from different theoretical orientations, and practical skills such as communication and problem-solving. The delivery of these interventions can be through websites, mobile applications, e-mails, or other platforms which require the internet, each of which can make use of text, audio, video, or other interactive elements. An example of this type of intervention is the Lusog Isip mobile application in the Philippines. It makes use of text, video, and audio features to provide users with information and practical tips that would allow them to assess and improve their current level of well-being at their own pace. Executive Summary Key Points: ● Argued benefits of web- and app-based mental health programs are increased access, anonymity (which can help overcome prevailing stigma towards mental health services), and greater scalability. These are seen as especially valuable for LMICs where access to mental health information and direct services remains limited, and where an increase in mobile device usage has been observed. ● There is limited empirical evidence on the effectiveness of web- and app-based psychoeducation programs. There is also skepticism towards existing evidence as studies on these types of interventions usually involve some incentive 4  system, and so the same level of engagement or impact on mental health may not necessarily be observed in real-life settings. Overview Background Psychoeducation is an integration of psychotherapeutic and educational interventions. It involves the delivery of illness-specific information, teaching of skills for managing non-clinical or related conditions, or both. It reflects a holistic, competence-based approach which emphasizes health, collaboration, coping, and empowerment (Lukens et al., 2004). Psychoeducation programs can be delivered in a variety of ways based on format, intensity, duration, and theoretical orientation, and can focus on many different elements, such as education about specific disorders, relaxation, positive thinking, social skills, coping skills, stress management, and problem-solving skills. They can be implemented as a sole intervention or as an adjunct to treatment. Web- and app-based psychoeducational interventions One means by which psychoeducation can be delivered to a greater number of people is through digital or internet-based programs, i.e., psychoeducation made available through websites, mobile applications, e-mail subscriptions, and the like. There are arguments that web- and app-based mental health services would be particularly valuable in LMICs where health systems are commonly fragmented by geography and not supported by adequate legislation, and where mental health resources are more scarce compared to HICs. In these societies, digital technologies could significantly help increase access to mental health information and connect individuals in need of support with mental health service providers. Making these approaches more promising is the fact that mobile technology has achieved widespread adoption and use worldwide, including in LMICs. In 2020, cellular devices accounted for 53.3% of global web traffic. Cellular phone subscriptions in many LMICs exceed 80% of the population (Naslund et al., 2017) and continue to increase yearly (Merchant et al., 2020), albeit the proportion of individuals who have access to the internet is commonly lower than the proportion with a mobile subscription. In addition, remote mental health services are considered even more relevant today considering the unique challenges presented by the COVID-19 pandemic. Web- and app-based interventions are easily accessible, allow for anonymity, and provide high scalability (Harrer et al., 2021). A review conducted by Zhao et al. (2017) on studies about web- and mobile based psychoeducational interventions for depression revealed variability in content as well as the mode of delivery of such interventions. The features of these psychoeducational interventions ranged from communication tools that allowed peer-to-peer or clinician-patient communication, interactive instructional technologies in the form of videos, animations, or games, automated e-mails, and digital self-monitoring tools. A 5 separate study by Merchant et al. (2020) investigating web- and app-based mental health services for individuals in LMICs with severe mental disorders found that additional possible features of these kinds of interventions are information dissemination, building communities of support, providing self-management tips, and sending messages to facilitate medication adherence and improve clinic attendance. Van Ameringen et al. (2017) conducted a comprehensive review of mobile apps which targeted specific mental disorders, including obsessive-compulsive disorder, post-traumatic stress disorder (PTSD), anxiety, and mood disorders. The apps included in the review which may be classified as psychoeducational are those which allowed users to assess their mental health condition (assessment apps), those which allowed users to monitor their mental health condition actively or passively (tracking apps), and multipurpose apps which included psychoeducation as one component. Mental health apps can also be used as an adjunct to regular treatment. Review of the Evidence Among available web- and app-based psychoeducational interventions there is generally a lack of empirical testing (Mak et al,m 2018). The mobile app market is purportedly saturated with mental health information applications, but few receive a notable number of engagements from users, and many applications that had undergone evaluation studies were neither subjected to rigorously designed trials nor compared to control groups (Naslund et al., 2017). The specific features included in a web- or app-based psychoeducational program can influence its effectiveness and practicality. A review by Zhao et al. (2017) found that, generally, programs that involved communication tools and interactive features resulted in greater compliance from users compared to programs without these features. Programs that incorporated a greater number of features (e.g., a combination of educational modules, communication tools, and interactive features) were more effective than those which had fewer, and could result in symptom reduction that was comparable to or greater than what was experienced by a treatment-as-usual group. Van Ameringan et al. (2017) found that there was limited data to establish the validity of existing assessment and tracking apps. On the other hand, they identified Anxiety Coach as one multipurpose app that does have published evidence. Some commonly used apps that they identified but have determine to be lacking in evidence are MoodTools, Pacifica, Mindshift (for adolescents) and Self-help Anxiety management (SAM App). Specific interventions Mak et al. (2018) conducted a study in China on the efficacy of three app-based psychoeducation programs: a mindfulness-based program (MBP), a self-compassion 6 program (SCP), and a cognitive behavioral psychoeducation control (CBP). These were all contained in a newly developed app called “Living With the Heart.” The app (and website) included mood tracking functions, well-being tips, a sticker-earning feature (to track accomplishments), and a practice alarm feature. They were self-paced with suggested weekly home practices. All three programs consisted of 28 sessions which were spread out into four weekly modules. Although the researchers encountered a high attrition rate (76.5% at post-program and 83.9% at 3-month follow-up), they observed increased well-being, reduced psychological distress, increased mindful-awareness, and heightened self-compassion among users over time. Harrer et al. (2021) evaluated the effectiveness of a web- and app-based stress intervention program in reducing symptoms among distance-learning students with elevated levels of depression. The program that was examined was an adaptation of StudiCare Stress, a digital intervention for college students. It involved psychoeducation modules as well as features that facilitated the implementation of strategies for behavior change. This was compared to a control group which only provided helpful information about stress and coping (i.e., pure psychoeducation). A greater reduction in symptoms of depression was observed in the intervention group compared to the control group. The intervention group was also significantly more effective in influencing secondary outcomes such as self-compassion, perceived stress, anxiety, and work output compared to the control group. On the other hand, dropout rates were higher in the intervention group compared to the control group. In 2021, the Lusog Isip mobile application was publicly launched in the Philippines by the Philippine Department of Health (DOH) in collaboration with the United States Agency for International Development (USAID). The app provides users with tools to assess and improve their level of well-being. It includes psychoeducational content incorporated into interactive tools such as audio guides, a digital journal, a mood tracker, and self-care reminders. Additionally, it provides a list of local mental health service providers. Currently, there seems to be no published evaluation about its effectiveness and impact on users. Theories of Change EA PH MHCIR Shallow Reports Theory of Change Assumptions Psychoeducation by itself or as a supplement to another intervention can contribute to behavior change or improvements in well-being. It has benefits for both clinical and non-clinical populations.The mechanisms for this are the following: Psychoeducation can help individuals get a better understanding of the problems they are experiencing; it can help individuals identify internal strengths and external resources which they can utilize to work towards improving their own mental health; it can provide individuals facing mental health problems with a greater sense of hope and control over their situation; and it can 7 provide them with information about the kind of support that they need individuals facing mental health problems (Lukens & McFarlane, 2004). Users adhere to or consume a significant portion of the content included in the web-/app-based psychoeducation program. In order to expect substantial impact among users, it may be necessary to assume that they must have consumed or engaged in all of the essential components of the intervention. This may be a challenge for self-directed, web- or app-based interventions where adherence may be difficult to sustain. Users have the technological capacity to access the intervention. Web- and app-based interventions do allow for improved accessibility to mental health information. However, this may still be inaccessible for individuals who do not have consistent internet access or who do not have devices that are capable of running more complex applications. This may commonly be the case for individuals residing in rural locations. Brief Cost-Effectiveness Review No studies on the cost-effectiveness of this general type of intervention were found. Limitations As mentioned previously, there is generally a lack of empirical evidence on the effectiveness of this type of intervention, at least among those that are publically available. While the app marketplace is saturated with applications aiming to promote mental health, many empirically-supported apps are not yet available to the public (Van Ameringen et al., 2017). Limitations in existing studies are that user participation was often incentivized and some studies included incorporated therapist contact. This makes it difficult to isolate the impact of the app by itself, and makes questionable whether the same applicability would be observed in naturalistic settings. Additionally, studies have found that mobile apps have been rated lowest in terms of appeal, helpfulness, personal support, motivation, and credibility when compared to direct interventions, self-help books, and web-based information. These perceptions may negatively influence individuals’ receptiveness to these kinds of interventions. Other challenges that may be faced when delivering interventions through digital means are software glitches, lack of digital literacy, language issues, and gaps in access to and use of digital technologies. There is also evidence that digital technologies may have both positive and negative effects on an individual’s mental health (Merchant et al., 2020). Resources Harrer, M., Apolinário-Hagen, J., Fritsche, L., Salewski, C., Zarski, A., Lehr, D., Baumeister, H., Cuijpers, P. and Ebert, D., 2021. Effect of an internet- and app-based stress intervention compared to online psychoeducation in university students with depressive symptoms: Results of a randomized controlled trial. Internet Interventions, 24, p.100374. 8 Lukens, E. and McFarlane, W. (2004). Psychoeducation as Evidence-Based Practice: Considerations for Practice, Research, and Policy. Brief Treatment and Crisis Intervention, 4(3), pp.205-225. Mak, W., Tong, A., Yip, S., Lui, W., Chio, F., Chan, A. and Wong, C., 2018. Efficacy and Moderation of Mobile App–Based Programs for Mindfulness-Based Training, Self-Compassion Training, and Cognitive Behavioral Psychoeducation on Mental Health: Randomized Controlled Noninferiority Trial. JMIR Mental Health, 5(4), p.e60. Merchant, R., Torous, J., Rodriguez-Villa, E. and Naslund, J., 2020. Digital technology for management of severe mental disorders in low-income and middle-income countries. Current Opinion in Psychiatry, Publish Ahead of Print. USAID and Doh Launch Philippines' first mobile app for Mental Health: Press Release: Philippines. U.S. Agency for International Development. (2021, October 19). Retrieved January 16, 2022, from https://www.usaid.gov/philippines/press-releases/oct-15-2021-usaid-and-doh-launch-philippi nes-first-mobile-app-mental-health Van Ameringen, M., Turna, J., Khalesi, Z., Pullia, K. and Patterson, B., 2017. There is an app for that! The current state of mobile applications (apps) for DSM-5 obsessive-compulsive disorder, posttraumatic stress disorder, anxiety and mood disorders. Depression and Anxiety, 34(6), pp.526-539. Zhao, D., Lustria, M. and Hendrickse, J., 2017. Systematic review of the information and communication technology features of web- and mobile-based psychoeducational interventions for depression. Patient Education and Counseling, 100(6), pp.1049-1072. 9 Non-Professional/Lay-Delivered Psychoeducation (Community-Based/ School-based) by Margarita Ysabel Muñoz Researcher’s Impressions: ● There generally seems to be limited or mixed evidence on the effectiveness of non-professional or lay-delivered psychoeducation in terms of improving mental health outcomes or reducing rates of mental health problems. ● On the other hand, task-shifting to non-specialist workers has been widely argued to be a potentially effective way of making mental health services more accessible to people in societies where mental health service providers are insufficient. Thus, it seems valuable to further explore the applicability of this idea in the Philippines where the mental health treatment gap exists. ● Training non-specialist workers to deliver psychoeducation in communities seems much more feasible and cost-effective compared to training them in the delivery of direct mental health interventions. ● In developing an intervention based on this idea, it would be important that the intervention include components that would address prevailing stigma and ensure the sustainability of outcomes. Intervention Brief This intervention entails training and employing individuals who had not undergone specialized education in mental health to conduct mental health promotion activities in the communities in which they belong. Mental health promotion or psychoeducation activities may involve disseminating information regarding specific mental health conditions, teaching positive coping skills, reducing stigma, and encouraging help-seeking behaviors. Executive Summary Key Points: ● Task sharing of mental health promotion to non-specialist workers (which includes community health workers, lay or peer providers, teachers, non-health professionals, and other allied health professionals) has been identified as a potentially valuable solution to the mental health treatment gap. ● Community-based, NSHW-delivered mental health promotion interventions can help improve mental health literacy among community members, destigmatize mental health, encourage help-seeking, improve perceptions of treatment providers, and modify culturally-based beliefs and preferences. 10  ● While there are studies that provide evidence of the effectiveness of specific interventions, more generally, there is limited evidence of the average impact of this group of interventions. The difficulty in conducting evaluation research on this group of interventions is attributed to the large variability in how these interventions can be designed and implemented. ● The last section of this report lists important considerations for the success and sustainability of community-based, NSHW-delivered programs. Conclusion Although there is mixed evidence on the effectiveness of lay-delivered psychoeducation towards improving mental health outcomes, proponents of this type of intervention emphasize its cost-effectiveness as well as its value for societies where mental health professionals are limited and where mental health is stigmatized. Overview Background Despite the profound burden that mental health problems have on all aspects of life at both the individual and at the societal level, a low proportion of individuals in need of mental health care actually receive it due to a lack of available and accessible mental health resources as well as social barriers to treatment (WHO, 2010). One strategy towards addressing the disparity in the number of individuals in need of mental health care and the services that are locally available is the development of community-based mental health systems to complement facility-based services. A community-based mental health framework entails increasing the availability of mental health services at the community level by integrating mental health into primary health systems and the social milieu, thereby promoting accessibility, affordability, and scalability of services (Kohrt et al., 2018; Demarzo, 2012). A community-based mental health framework would be in line with the key provisions Republic Act No. 11036 or the Philippine Mental Health Act (2018) which emphasizes access mental health as a fundamental human right, and mandates initiatives toward the promotion of mental health and the prevention of mental disorders from the national level down to the community level. Psychoeducation Psychoeducation (used interchangeably with “mental health promotion” in this report) is an integration of psychotherapeutic and educational interventions. It involves the delivery of illness-specific information, teaching of skills for managing non-clinical or related conditions, or both. It reflects a holistic, competence-based approach which emphasizes health, collaboration, coping, and empowerment (Lukens & McFarlane, 2004). Psychoeducation programs can be delivered in a variety of ways 11 based on format, intensity, duration, and theoretical orientation, and can focus on many different elements, such as education about specific disorders, relaxation, positive thinking, social skills, coping skills, stress management, and problem-solving skills. They can be implemented as a sole intervention or as an adjunct to treatment. Delivery of mental health promotion services by non-specialists Task sharing, a process which involves moving tasks from highly specialized to less specialized individuals, has been identified as a potential means through which mental health services (including psychoeducation) could be made more accessible to a greater number of people. In the mental health field, initiatives in various settings have been undertaken to apply task sharing by allocating mental health promotion tasks to non-specialist health workers. Non-specialist Health Workers (NSHWs) is a broad group that has been considered to include community health workers, lay or peer providers, teachers, non-health professionals, and other allied health professionals without specialized training in mental health (Bunn et al., 2021). Non-specialist health workers (NSHWs; i.e., lay health workers) have been identified as a potentially valuable means through which psychoeducation and mental health promotion could be made more accessible to a greater number of people. Some valuable characteristics that are commonly considered in the selection of NSHWs for community-based mental health promotion programs are good interpersonal skills, language proficiency in local dialects, position in the community, and a shared cultural and linguistic background with the individuals they serve (Bunn et al., 2021). Task sharing with NSHWs have been connected to improved health outcomes, cost-savings, and decreased health disparities. Such initiatives can also help improve mental health literacy among community members, destigmatize mental health, encourage help-seeking, improve perceptions of treatment providers, and modify culturally-based beliefs and preferences (Barnett et al., 2021). A review conducted by Bunn et al. (2021) on NSHW-delivered community-based mental health promotion programs found that such programs commonly included psychoeducation on several topics, including symptoms, the causes and effects of mental disorders, available treatments, relapse prevention, and additional resources. Additionally, these programs usually involve elements which aim to reduce stigma related to mental health and to improve social inclusion. Factors that were considered important to support and sustain NSHW-delivered mental health interventions were training, supervision, compensation, and policy. Mental health promotion activities can be implemented as distinct programs, but are more usually a part of a multicomponent collaborative care intervention. They can also be universal, with the intention of disseminating information and promoting preventive strategies to non-clinical populations, or targeted to specific populations. Existing NSHW-delivered mental health programs have targeted the general public, carers of individuals with mental health conditions (e.g, caregivers, parents), or individuals suffering from 12 mental health conditions including neurological disorders, mood disorders, schizophrenia, and dementia (Kakuma et al., 2011). School-based, teacher-delivered mental health promotion There have also been movements to incorporate mental health promotion programs into school systems by training teachers in their implementation. Schools have been considered a convenient location for the promotion of mental health among children and adolescents because this is the setting in which these age groups spend the majority of their time. Schools are also where important steps in social, cognitive, and emotional development take place (Bradshaw et al., 2021). Additional advantages are that school infrastructures can facilitate the large-scale implementation of mental health promotion interventions and that schools can facilitate access to additional social or health services when needed (Castillo et al., 2019, Bradshaw et al., 2021). Similar to other more general NSHW-delivered mental health promotion interventions, school-based, teacher-delivered mental health promotion can be designed and implemented in a variety of ways based on several factors. These include the underpinning theoretical model (e.g. CBT, ACT, positive psychology), the amount of training and supervision allotted for implementers, the inclusion or non-inclusion of parental involvement, and the duration of the program. Such interventions may also vary based on the age group that is being targeted (Castillo et al., 2019). Studies included in a review conducted by Bradshaw et al. (2021) involved interventions where teachers may not have been the only implementers (i.e., they may share the responsibility with lay counselors). School-based mental health promotion programs may also be conducted as a lone program or as a component of a larger program that targets other school-related outcomes that are not necessarily related to mental health. School-based mental health programs implemented in LMICs often adapted from existing programs in HICs. Gimba et al. (2020) conducted a systematic review about programs that were directly developed and implemented in LMICs to identify characteristics and specific modules that were common among them. The programs varied in the length of sessions, the frequency of sessions, the duration of the entire intervention, and assigned implementers (teachers, school counselors, researchers, research assistants). It was also highlighted how multiple stakeholders, such as students, teachers, parents, NGOs, and policy-makers, could be involved in the development of such programs, for instance through the conduct of needs-assessment studies to inform priority areas and required interventions. Programs were either universal (for the general population), selective (targeted towards certain subclinical subpopulations), or indicated (for youth with diagnosed mental disorders). Selective interventions included modules that were specific to the subpopulation they aimed to serve, which may include students who experience cognitive, emotional, or behavioral problems, those suffering from harmful substance use, victims of war, or youth in conflict-prone areas. In general, the following modules were common among the 11 studies: an introduction module, a communication and relationship module, a 13 psychoeducation module, a cognitive skills module, a behavioral skills module, a module on establishing social networks for recovery and help seeking behavioral activities, and a conclusion module. Review of the Evidence The systematic reviews included in this report generally seem to suggest that there is limited evidence on the efficacy of NSHW-delivered mental health promotion interventions. Because there is considerable variability in how these programs can be designed, conducted, and evaluated, it becomes difficult to collate data that would give a clear picture as to the effectiveness of this general approach. Different studies often vary in targeted outcomes as well as in the measures used to assess those outcomes. Additionally, mental health promotion strategies are often just a part of multicomponent collaborative care interventions, and the direct effect of this specific component becomes difficult to isolate. There is limited outcome evaluation data on pure psychoeducation studies (Bunn et al., 2021). Additionally, Kakuma et al. (2011) state that no rigorous evaluations have been done of their effect in countries of low and middle income countries. Similarly, there is little evidence from LMICs about positive outcomes attributed to school-based mental health promotion interventions, both universal and targeted. Targeted interventions have also been suggested as being difficult to scale in LMICs because they are resource-intensive. Additionally, research conducted in LMICs on these programs are usually done in the context of armed conflict and natural disaster. There is better evidence of the feasibility, practicality, scalability, and effectiveness of universally-delivered interventions in HICs (Bradshaw, 2021). In the systematic review done by Gimba et al. (2020), varied findings were observed in 11 studies on school-based mental health promotion programs in LMICs. However, the authors concluded that, generally, all of the included programs were found to be effective. Programs that were implemented by teachers were found to be more effective than those implemented by other stakeholders. The programs involved in the study each measured a diverse range of outcomes, including interpersonal strength, emotion regulation, self-esteem, self-efficacy, coping skills, emotional reactivity, depressive symptoms and hopelessness, substance use, pro-social behavior, family involvement, school functioning, sense of mastery, sense of relatedness, family appraisal, general social support, and many others. Five programs were found to be significantly effective across all measured outcomes, assessed after a period of time ranging from 3 months to 4 years. One program found improvements in self-esteem and coping skills among adolescents after 6 months, while improvements in depressive symptoms and hopelessness were not maintained in that same amount of time. Three programs found improvements across all measured outcomes during the implementation of the program but had no data on the effects of the program after it was finished. The last three programs demonstrated varying levels of effectiveness across a multitude of outcomes. 14 Specific interventions An intervention that was based on a collaborative-stepped care model provided evidence of the effectiveness of NSHW-delivered interventions (albeit as a component of a larger program) in India. Lay health workers were trained to act as case managers, provide psychoeducation, make referrals as needed, and provide short-term interpersonal psychotherapy to symptomatic community members. An evaluation of this intervention found a decrease in rates of common mental disorders and in rates of suicide attempts over a 12 month period among beneficiaries of the services given (Patel et al., 2011; Cited in Barnett et al., 2021) The Head Start REDI (Research-based, Developmentally-Informed) program is a preventive intervention for children in pre-kindergarten. It involves social-emotional skill enrichment and language literacy skill enrichment for students as well as training modules for teachers and parents. It is delivered by teachers and can be integrated into ongoing classroom programs. Since it is implemented early in a child’s life, an assessment of its effects on one’s developmental trajectories is made possible. There is evidence that, compared to a control group, children in the Head Start REDI intervention were significantly more likely to follow optimal developmental trajectories in social behavior, aggressive oppositional behavior, learning engagement, attention problems, student-teacher closeness, and peer rejection (Castillo et al., 2019). Communities That Care (CTC) is a program that aims to prevent youth in school grades 6-9 from engaging in substance use, violence, and delinquency, with the secondary goal of reducing rates of depression and suicide and improving other mental health outcomes. It is a multiphasal program involving the identification of community stakeholders, the formation of a community coalition, development of a community profile to identify risk and protective factors related to the youth, the creation of a community action plan, and implementation and evaluation. Compared to communities that did not undergo the program, youth who underwent CTC showed reduced substance use, delinquency, and violence, later initiation of alcohol use, tobacco use, and delinquency, and lower prevalence of risky behaviors. Results were found to persist to grades 10-12 (Castillo et al., 2019). Researchers from the National Institute of Mental Health and Neurosciences (NIMHANs) in India developed a school-based Life Skills Education program (LSE) which aimed to teach adolescents basic life skills through participatory learning methods such as games, debates, role-plays, and group discussion (Srikala & Kishore, 2010). The program developers and implementers worked under the assumption that conceptual understanding and practicing of life skills could be cultivated through experiential learning in non-threatening settings. By helping youth develop alternative and creative ways of solving real-life problems, the program aimed to contribute to positive improvements in self-esteem, self-efficacy, classroom behaviors, and 15 adjustment in several contexts including home, school, teachers, peers, and general behavior. Students who underwent the program for one year were compared on these outcomes with a control group consisting of students who did not undergo the program. Results of this study found higher scores in the intervention group across all outcomes compared to the control group. There was no difference between the two groups in psychopathology and adjustment at home and with peers. The Philippine Mental Health Association’s (PMHA) Community-Based Mental Health Program (CBMHP) aims to train community health workers, including community physicians, nurses, midwives, and volunteer health workers, to educate the members of their community on topics related to mental health. After the training, they are expected to conduct lectures on “Kalusugang Pangkaisipan” (Mental Health in the vernacular) in their respective communities, composed of topics such as coping skills, help-seeking, misconceptions about mental health, and basic signs and symptoms of mental mental disorders. Additionally, the trained community health workers are equipped with technical knowledge that would allow them to identify individuals showing symptoms of mental health problems, to provide basic care, and to make referrals to qualified mental health service providers whenever necessary. To facilitate the latter point, the program also involves a workshop in which the health workers map the most accessible mental health service providers for their respective communities and create a flowchart of referral pathways. The CBMHP began as a 4-year program but was condensed into a one-year program in 2018. It has been implemented in selected communities in Metro Manila with the support of Local Government Units. In 2018, it was also implemented in the provinces of Pangasinan, Benguet, Batangas, Palawan, and Misamis Oriental with funding from the Philippine Department of Health (DOH). To measure impact, the PMHA measures improvements in knowledge levels, attitude towards mental health, and communication skills among the trained health workers, using evaluation instruments developed by program developers. Unfortunately, evaluation studies about the program have not been published, and there seems to be no existing means through which outcomes are measured among community members. Theories of Change EA PH MHCIR Shallow Reports Theory of Change Assumptions Psychoeducation by itself or as an adjunct to another intervention can contribute to behavior change or improvements in well-being. It has benefits for both clinical and non-clinical populations.The mechanisms for this are the following: Psychoeducation can help individuals get a better understanding of the problems they are experiencing; it can help individuals identify 16 internal strengths and external resources which they can utilize to work towards improving their own mental health; it can provide individuals facing mental health problems with a greater sense of hope and control over their situation; and it can provide them with information about the kind of support that they need individuals facing mental health problems (Lukens & McFarlane, 2004). The lay workers implementing the program have the necessary comprehension skills, interpersonal skills, and emotional resilience to deliver it effectively. For accurate knowledge transfer, the NSHWs recruited to implement the intervention must be able to adequately comprehend and restate the content of the lecture. This may be made difficult if the content of the program includes technical information related to mental health, if it is in a language different from the local vernacular (and in some cases, some concepts may not have local equivalents) or if the material tackles topics that are perceived differently in the community (i.e., more susceptible to reinterpretation based on existing beliefs). Additionally, the NSHWs recruited to deliver the psychoeducational intervention ought to have the necessary communication skills to adequately disseminate information among community members. It’s also important to select lay workers with some level of emotional resilience, as working conditions in LMICs can be challenging due to lack of resources, insufficient workforce, stigma, and system-level factors (e.g. government support, political and socioeconomic factors). The lay workers implementing the program have a positive relationship with the members of the community in which they belong. Community-based NSHWs tend to have a shared cultural and linguistic background with the members of the community in which they belong. They also may hold an existing position or have a relatively close personal relationship with the members of the community. This places them in an advantageous position that may allow them to serve as a bridge between the community and mental health service providers and academics. NSHWs can help community members develop trust towards relatively “foreign” concepts and systems, thereby destigmatizing mental health, encouraging help-seeking behaviors among community members, improving perceptions of treatment providers, and modifying possible negative culturally-based beliefs and preferences. Brief Cost-Effectiveness Review Cost-effectiveness would depend on factors such as the length of the training program, the media through which the psychoeducation activities would be implemented, and whether the NSHWs would receive compensation for their involvement in the program. Generally, however, NSHW-delivered mental health interventions are widely considered as being more cost-effective than interventions being delivered by mental health professionals. Psychoeducation is also likely to be much more inexpensive and much simpler to implement compared to direct mental health interventions. 17 Limitations As mentioned in previous sections of this report, there is limited evidence on the effectiveness of NSHW-delivered mental health promotion interventions. In addition to this, there are several key conditions that must be addressed to ensure the effective and sustainable implementation of NSHW-delivered, community-based mental health promotion programs. A challenge that NSHWs may face is marginalization within the same communities that they are serving. They may experience unequal compensation and limited training and supervision, and these factors may affect their motivation to participate in mental health promotion programs (Barnett, 2021). Other potential challenges in the implementation of these programs are the following (Bunn et al., 2021; Kakuma et al., 2011; Castillo et al., 2019): ● Poor role definition ● Increased work pressure for NSHWs ● Lack of professional advancement opportunities ● Challenging work conditions ● Problems in working relationships ● Experience and education level of implementers ● Issues with regard to boundaries and confidentiality between NSHW and community members ● Problems in working relationships between NSHWs and health professionals ● Lack of appreciation for the role of NSHWs and skepticism regarding their capacity ● Insufficient training (including lack of standardized training approaches and lack of assessments to determine implementer competence) ● Low fidelity to training models ● Lack of supervision ● Burnout, work-related stress, and managing emotional well-being ● Macro-level challenges and system-related barriers (e.g., leadership and infrastructure; national, political, socioeconomic factors) ● Mental health stigma within the community and among NSHWs Resources Barnett, M.L., Sanchez, B.E.L., Rosas, Y.G., & Fingert, S.B. (2021).Future directions in lay health worker involvement in children’s mental health services in the US. Journal of Clinical Child & Adolescent Psychiatry, 50(6), 966-978. Bunn, M., Gonzalez, N., Falek, I., Weine, S., & Acri, M. (2021). Supporting and sustaining nonspecialists to deliver mental health interventions in low- and middle-income countries: An umbrella review. Intervention, 19(2), 155-179. Castillo, E., Ijadi-Maghsoodi, R., Shadravan, S., Moore, E., Mensah, M., Docherty, M., Aguilera Nunez, M., Barcelo, N., Goodsmith, N., Halpin, L., Morton, I., Mango, J., Montero, A., Rahmanian Koushkaki, S., Bromley, E., Chung, B., Jones, F., Gabrielian, S., Gelberg, L., Greenberg, J., Kalofonos, I., Kataoka, S., Miranda, J., Pincus, H., Zima, B. & Wells, K. (2019). Community Interventions to Promote Mental Health and Social Equity. Current Psychiatry Reports, 21(5). 18 Gimba, S.M., Harris, P., Saito, A. et al. The modules of mental health programs implemented in schools in low- and middle-income countries: findings from a systematic literature review. BMC Public Health 20, 1581 (2020). https://doi.org/10.1186/s12889-020-09713-2 Kakuma, R., Minas, H., Ginneken, N., Dal Paz, M.R., Desiraju, K., Morris, J.E., Saxena, S., & Scheffer, R.M. (2011). Human resources for mental health care: current situation and strategies for action. Lancet, 2011(378), 1654-1663. Kohrt, B.A., Asher, L., Bhardwaj, A., Fazel, M., Jordans, M.J.D., Mutamba, B.B., Nadkarni, A., Pedersen, G.A., Singla, D.R., & Patel, V. (2018). The role of communities in mental health care in low- and middle-income countries: A meta-review of components and competencies. International Journal of Environmental Research and Public Health, 15. Lukens, E. and McFarlane, W. (2004). Psychoeducation as Evidence-Based Practice: Considerations for Practice, Research, and Policy. Brief Treatment and Crisis Intervention, 4(3), pp.205-225. Srikala, B., & Kumar, K. (2010). Empowering adolescents with life skills education in schools - School mental health program: Does it work?. Indian Journal Of Psychiatry, 52(4), 344. doi: 10.4103/0019-5545.74310 World Health Organization. (2010). mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings.  Retrieved from http://www.who.int/mental_health/publications/mhGAP_intervention_guide/en/. 19 Self-Guided Internet-based Cognitive Behavioral Therapy (iCBT) Interventions by Glaiza Mae Superable Researcher's Impressions: ● Generally, evidence on the iCBT indicates that it can yield positive results. Apps seem to be preferable for their accessibility. ● For interventions directed to children and youth, the most that we can target if fully-self guided, are adolescents who are already self-directed. In the brief scoping of literature, the youngest users tapped for self-guided interventions are participants aged 12 - 15 years old. While some were considered self-guided, some of these interventions involve contact with the researchers or minimal forms of support. ● The population that would benefit most from the app are urban areas with adequate access to the internet. More gamified interventions tend to be more engaging but require a certain amount of mobile data. The proliferation of online mobile games even among the lower-income segment may indicate that urban adolescents can have the resources to use data-intensive applications on their phones. However, pursuing data-intensive apps would touch on issues of inclusivity as this might neglect the needs of more impoverished groups who also have limited options for treatment. ● Since engagement is a key concern given the high attrition rates of apps, less data-intensive workarounds may be available. For instance, having automated reminders or setting up peer support groups buddy systems. However, the extent to which this is effective in enhancing uptake, particularly among youth is limited. A key discussion in the future might involve deciding between a more data-intensive app that caters to urban adolescents versus a less data-intensive app, albeit less engaging and/or effective, but with a wider user base. ● In terms of business model, it might be best to have partnerships between mental health professionals and tech companies to ensure continuous maintenance and development of the app, or else the app would run obsolete after some time. A social enterprise model might work for this type of intervention. EA’s extensive network of individuals involved in mental health app development may provide support in ideating the best model for this idea. ● Even paid apps can be made accessible to indigent groups through subsidies or external funding. This has been done for MoodGym and SPARX where the intervention was made free for individuals in Australia and New Zealand but is paid when availed elsewhere. In the Philippines, a potential idea might be to partner with local government units that distributed tablets to students in their district during the pandemic and make the app available on these devices. Agreements with schools and universities, private or public, may also widen the user base of the app and reduce the burden on mental health professionals. Lastly, partnership with telco companies to provide mobile data allowance may also be considered. Alternatively, this can also be part of the app bundles that 20  can be accessed when subscribing to prepaid mobile data plans for education, as telco companies have done with Google Classroom and Zoom. Intervention Brief This intervention involves the comprehensive delivery of cognitive-behavioral therapy via app- or web-based platform. The platform may include assessment questionnaires to determine symptoms and treatment materials that enable users to learn and practice core CBT principles such as cognitive restructuring, behavioral activation, mood tracking, and psychoeducation on the relationship of affect, cognition, and behavior to name a few. The intervention assumes that users will complete the program unguided. Executive Summary Key Points: ● There are several existing interventions on iCBT, with mobile apps growing in relevance over the years for its accessibility. The interest in iCBT can be attributed to its advantages: cost-effective than face-to-face treatments and and an alternative form of treatment to individuals who may not have access to MH providers or are concerned about the stigma associated to help-seeking ● ICBT interventions are developed through the collaboration of universities and tech companies. Key considerations in forming partnerships include maintenance and development of the app, the extent of ownership of the content and design of the intervention, and strategies for app dissemination. ● Most of the evidence on iCBT indicates that it results in a positive impact on target outcomes, the most common symptoms of depression and anxiety. ● There are limited studies on the effectiveness of self-guided iCBT interventions specific to low- and middle-income countries. The shallow report identified a few RCTs, non-randomized controlled trials, and naturalistic observation studies on iCBT. ● There are limited studies on self-guided iCBT as applied to children and youth, however, there are several studies on the more general topic of computerized CBT (digitally delivered CBT via mobile, computer, offline or online platforms) that points to its effectiveness Key Limitations: ● Barriers in the successful adoption of the app in the Philippines include limited internet connectivity, expensive cost of internet connection, potential incompatibility with outdated software. ● High attrition rates among iCBT users are a key limitation, hence the need for effective distribution strategies to increase the uptake and use of the app. 21 Conclusion Relative to other interventions, self-guided iCBT interventions have a stronger evidence base indicating positive results. Although, less information is available when applied in LMIC. This intervention is also more scalable as it is self-guided. implementability might be eased by modeling service and business frameworks from evidence-based mental health apps already existing in the market. Overview Background Internet-delivered Cognitive Behavioral Therapy (iCBT) is an intervention where CBT is delivered via the internet, in the form of a web-based or app-based platform. There are various online instruments based on ICBT but may vary in their purpose. A few apps or websites comprehensively deliver CBT and act as standalone treatment in lieu of face-to-face therapy. Other tools may only use specific components of CBT - users can use these tools on their own or as support to engagements with their mental health provider (e.g. mood tracking apps or behavioral activation apps). As a standalone treatment, users login-in to a secure website to “access, read and download online materials arranged into a series of lessons or modules” (Andersson & Titov, 2014). iCBT software often consists of treatment materials, assessment questionnaires, and support functions to aid the user in using the platform. The treatment materials may include text, videos, or audio detailing core CBT principles (e.g., psychoeducation on the cognitive-behavioral model, cognitive restructuring, behavioral skills, relapse prevention) and homework or activities that enable individuals to apply and/or practice lessons (Andersson & Titov, 2014). Assessment questionnaires enable monitoring of users' progress, symptom severity, and the possibility of self-harm (Andersson & Titov, 2014). iCBT can be delivered as guided, with some form of therapeutic guidance, or unguided without any support related to the therapeutic content. Support function, in the case of self-guided iCBT, entail automated feedbacks that aid and encourage users to continue the use of the platform, such as scheduled reminders (Andersson et al., 2019; Karyotaki et al., 2017). More recently, smart-phone based iCBT interventions, particularly mobile apps, have been gaining popularity due to their accessibility (Wilhelm et al., 2020). Within the iCBT mobile health apps landscape, interventions may take various forms. Mobile health apps can be designed especially for symptom monitoring, developing a single CBT skill (e.g., cognitive restricting), supplement or support therapist in sessions (such as access to patient symptom diary), and apps designed as a standalone intervention that incorporates techniques from CBT (Wilhelm et al., 2020). iCBT has gained traction as a form of treatment in the past years for several reasons. Apart from its cost-effectiveness when compared to face-to-face treatment, it addresses barriers that limit individuals from accessing evidence-based treatment. 22 Patients that do not engage in help-seeking behaviors due to concerns mental health stigma can use the intervention on their own. Similarly, patients who are willing to get treatment but are barred from receiving it due to the expensive cost of therapy or limited mental health (MH) professionals are provided an alternative option (Andersson & Titov, 2014). In other words, patients who may have remained untreated for many years may be given evidence-based psychological treatment for the first time(Andersson & Titov, 2014). Relative to its effectiveness, iCBT can improve the learning of CBT principles and skills and enhance retention as users can return to the program and access treatment information as needed (Andersson & Titov, 2014). Especially with mobile health apps, individuals may access intervention completely or partially online despite unstable or limited internet access (Sijbrandij et al., 2017). Mobile apps are also designed for brief frequent use throughout the day. This is more facilitative of learning as users can easily access tools whenever their symptoms arise (Wilhelm et al., 2020). The creation of a digital intervention requires collaboration between clinicians, academics, and a technological arm responsible for the development, maintenance, and perhaps distribution of the intervention (Hill et al., 2018). The development of iCBT interventions is often university-led, with grants provided to clinicians and academics. Once funded, lead researchers need to determine the best model for the app or website development. Their options include creating and building their own technical team, commissioning the service of technology companies for one-off engagement, or partnering with tech companies to build and commercialize the app (Hill et al., 2018). All of these options have their advantages and disadvantages that need which needs to be assessed thoroughly. In particular, collaboration with tech companies will ensure the sustainability of the app through potential commercialization and will maximize dissemination, however, it limits the researchers' ownership and control of the design of the intervention (Hill et al., 2018). If a tech company is commissioned solely for developments, handling of technical troubleshooting or intervention iterations can be a concern in the future(Hill et al., 2018). Beyond intervention design and development, dissemination strategies should also be considered early on to ensure that the intervention reaches a wide audience thereby increasing chances of usage. Review of the Evidence General evidence for effectiveness The current literature is filled with research on iCBT interventions with several metanalyses, systematic reviews, and RCTs focus on depression and anxiety disorders, with some targeting specific populations such as people with chronic illnesses and children and youth. The majority of these studies involve a combined analysis of both guided and unguided interventions. While few studies specifically focus on self-guided iCBT, systematic reviews or meta-analyses on iCBT conduct subgroup analysis to identify the impact of guidance in the treatment outcome. 23  Current evidence indicates that guided iCBT programs tend to be more effective than self-guided ones (Baumeister et al, 2014 as cited in Andersson et al., 2019). Although, the definition of guidance varies significantly in the studies. In some situations, clinicians may take a more active role in the intervention providing personalized feedback and responding to the client’s queries (Andersson et al., 2019). In other instances, support can be offered by non-clinicians and maybe more administrative such as monitoring of progress, encouraging usage of the intervention, or troubleshooting technical concerns (Andersson et al., 2019). The form of guidance and its correlation to the outcomes is critical to note as this provides insight into strategies that could be adapted in place of health worker support to maintain or enhance the positive impact of a fully self-guided intervention. There is still substantial evidence that self-guided iCBT is effective in the treatment of depression and anxiety. In the literature, one common method of reporting its effectiveness is the use of effect size, which details the magnitude of the effect of the intervention and the extent to which the outcome can be attributed to the intervention. Meta-analyses have shown the intervention reduces depressive symptoms, with a small effect size compared to control conditions (Karyotaki et al., 2017; SPEK et al., 2007). Similarly, self-guided iCBT for anxiety also yielded a small effect size on target outcomes compared to control conditions in individuals with chronic illnesses (Mehta et al., 2019). Interestingly, in the same meta-analysis, self-guided and guided iCBT for anxiety had similar effect sizes. The authors attributed the comparable results of unguided and guided ICBT to factors in the interventions that contribute to enhancing the intervention’s impact, such as providing automated messages that improve adherence (Mehta et al., 2019). These meta-analyses noted high heterogeneity in the studies attributed to differences in the components of the intervention. Interventions in low-to-middle-income countries Studies surveying the effectiveness of self-guided iCBT interventions specific to low- and middle-income countries are limited. There is one meta-analysis of digital interventions in LMIC, however, it did not distinguish the effects of CBT-specific from other forms of intervention (Fu et al, 2020). Despite this, the study helps identify various iCBT interventions with RCT trials conducted in LMIC up until 2020. 7 out of the 22 studies evaluated in the review employed iCBT interventions, but most involved guidance from clinicians or counselors who monitored their progress or provided personalized feedback (Burton et al., 2016; Marcela et al, 2018; Tulbure et al, 2015; Tulbure et al, 2018; Moeini et al, 2018; Knaevelsrud et al, 2015). Yo Puedo Sentirme Bien (I can feel better) is the only iCBT intervention that requires minimal support. The intervention is a Colombian adaptation of the efficacious iCBT program Space from Depression used in the United Kingdom and Ireland. Support was provided by trained volunteers who were tasked to monitor the progress of the respondent and provided 10-15 min feedback, mostly in the form of encouragement (Salamanca-Sanabria et al., 2020). The training involves asking volunteers to complete the program with the support of a clinical psychologist, whom they eventually modeled 24 when supporting the participants (Salamanca-Sanabria et al., 2020). The outcome of this research will further be discussed in the later section. In another systematic review of research on digital interventions in LMIC conducted by Naslund et al (2017), there were mentions of studies on online self-help programs in LMIC studied through various methodologies such as open trial RCTs and naturalistic observations. Of these, there are three retrievable studies on self-guided iCBT interventions targeted for depression, social anxiety, and obsessive-compulsive disorder, all of which resulted in improvements in target outcomes. In one pilot RCT conducted in Russia, the Association Splitting Manual, a text-based CBT intervention for OCD was provided to participants via email attachment. Among the participants (n=48, 67% of the 72 baseline users) that completed the 4-week intervention, significant improvements were noted in their obsessive and depressive symptoms (Moritz & Russu, 2013). In another controlled trial conducted in China, an iCBT program on Social Anxiety Disorder was adopted from a Swiss program and administered to participants recruited from a community sample (Kishimoto et al., 2016). The study intends to evaluate the effectiveness of the intervention against the control group and compare outcomes of self-guided versus therapist-guided iCBT, with guidance limited to enhancing motivation (Kishimoto et al., 2016). Among the participants (n=94, 48% of 197) that completed the follow-up assessment, the intervention was found effective in reducing social anxiety and social phobia compared to waitlist controls (Kishimoto et al., 2016). Interestingly, there were no differences in outcome between therapist-guided and self-guided programs. Adherence to intervention, defined as the number of modules completed, was comparable for both programs (Kishimoto et al., 2016). The last research included in the review is a 4-year naturalistic study on Ayuda para Depression (Help for Depression, HDep), a web-based iCBT intervention for depression conducted in Mexico (Lara et al, 2014). This study provides insight into how users engage in an open-access website for Depression. Information regarding the platform was disseminated through radio and television and the website was promoted as a top search on the Web through a grant from Google (Lara et al, 2014). A total of 28 078 individuals accessed the website, but only 61% of these registered and used the website (Lara et al, 2014). Most of the participants were female as HDep was designed for women, age 18-40 years old, lived in urban areas, and the majority had higher than HS education. Variables predicting the use of the intervention include being female, age 30 and below, having reported disability, and previous suicide attempts (Lara et al, 2014). The attrition rates were high as only 5% of the total respondents were able to complete the 7 modules. (Lara et al, 2014) Adherence rates to activities in each module also tend to be low to moderate (30-65%) (Lara et al, 2014). Despite these, participants rated each module were rated highly in helpfulness and usefulness (Lara et al, 2014). Only 79 individuals completed the final user evaluation for HDep and most reported to have benefited from the intervention by lifting their mood and changing their perspective in life (Lara et al, 2014). 25 Interventions as applied to children and youth The most recent metanalysis on computerized CBT (computer, internet, mobile-delivered) as applied to children and young adults aged 12 to 25 was conducted by Christ et al (2020). Unfortunately, there are no articles specific to self-guided iCBT, similar to research trends in adults, studies often consider the level of guidance in the analysis. In her review of the literature, there is already cumulative evidence from past three meta-analyses on cCBT and internet-based mental health interventions have shown resulted to positive outcomes, with moderate effect sizes on depression and anxiety on children and youth (Ebert et al, 2015; Pennat et al, 2015; Gris et al, 2019; as cited in Christ et al, 2020). Compared to the previous meta-analyses on cCBT, their study aimed to address gaps in research by exploring the sustainability of treatment effects in follow-ups, differences in effects when compared to passive (i.e. waitlist groups, information group) and active controls (i.e., face-to-face CBT, TAU), and exploring whether variables such as age, guidance level and treatment adherence have a significant impact on the treatment outcome (Christ et al, 2020). Overall, research aligns with the findings from the previous meta-analysis that showcase cCBT effectiveness in reducing anxiety and depression post-treatment. Although, effects size (small to medium) differs compared to previous reports (medium) (Christ et al, 2020). Among the studies that reported long-term effects, it was found that the cCBT’s reduction of depressive symptoms can be sustained over time, with small effects (Christ et al, 2020). Long-term effects for anxiety cannot be concluded since studies did not monitor this outcome in the reports. Consistent with earlier research, cCBT and active treatment controls (e.g. face-to-face CBT) had similar effects on reducing anxiety symptoms but active controls were better than cCBT at reducing depressive symptoms (Christ et al, 2020). Analyzing the variables of interest has shown that level of guidance, age of the respondent, and treatment adherence did not impact the treatment outcomes (Christ et al, 2020). At present, evidence on the effect of these variables is mixed, with some indicating that these are critical variables moderating outcomes while other studies do not. As such, a more in-depth analysis of these factors can be done in the future to create more accurate models for predicting charity’s impact. Specific interventions that look promising The interventions below were culled from the literature review and were selected as these are iCBT programs that have been to applied children and youth or have been adapted to or created in a low- and middle-income country. SPARX (Smart, Positive, Active, Realistic, X-Factor Thoughts) is an iCBT intervention designed for people aged 12 – 19 with mild to moderate depression and delivered in a game format (Fleming et al, 2021). The game includes seven modules of CBT where users learn the skills through various interactive activities designed to “support learning and behavior change and to support uptake and engagement” (Fleming et al, 2021). In multiple RCTs, it has consistently demonstrated effectiveness 26 in reducing symptoms of depression and anxiety in various adolescent populations, including indigenous Maori and LGBT groups, as well as, youth outside mainstream education (Fleming et al, 2021). Since 2014, SPARX has been accessible as a self-guided resource for individuals in New Zealand, with an option to request helpline support as needed (Fleming et al, 2021). Most of its current users learn about the program through referrals from clinicians or schools (Fleming et al, 2021). Japanese adaptation of the program is also available in apps stores in Japan for a minimal cost (Fleming et al, 2021). The effectiveness of the SPARX Japanese adaptation is still evaluated in ongoing clinical trials. Mood gym is an online iCBT self-help program for individuals age 16 and above designed to (1) assess users’ symptoms associated with mood disorders like anxiety and depression (2) equip users with the skill to help them cope with these problems (moodgym, n.d.). The program was founded and developed for 15 years by the researchers of Australian National University (moodgym, n.d.). It consists of five modules grounded in the principles of CBT and includes various features such as interactive games, relaxation audio files, worksheets, workbooks to aid learning of skills. Recently, development and delivery have been undertaken by Dialogue Health Technologies Inc, a virtual healthcare and wellness platform based in Canada (moodgym, n.d.). It used to be a free platform servicing individuals in need worldwide but has since commercialised the service for non-Australian users. Australian users can still freely use the program through Australian government funding (moodgym, n.d.). The program demonstrates effectiveness in reducing symptoms of anxiety and depression as evidenced by RCTs conducted in various settings, location, age group, and with and without guidance. Furthermore, the program has been used in different countries(albeit high-income ones) and has been translated into various languages (e.g. Finnish, Norweigan, Dutch, Chinese) (moodgym, n.d.). Woebot is a conversational agent, powered by artificial intelligence and naturalistic language processing, that aims to deploy principles of cognitive-behavioral therapy and other evidenced-based orientations in a conversational manner, mimicking interactions with a therapist (Woebot Health, n.d.). The platform is able to understand users' emotional and cognitive states and respond adaptively. It also encourages users to monitor their moods and practice therapeutic strategies (Woebot Health, n.d.). Part of the features of the app is the capacity to evaluate users' symptoms over time, determine best interventions based on users’ responses, and triage individuals in need of more intensive support (Woebot Health, n.d.). Most research conducted in the app yields favorable reviews in terms of effectiveness, acceptability, and usability (Woebot Health, n.d.). One RCT has demonstrated that the app was effective in reducing symptoms of depression and anxiety among youth (18 – 28) with moderate or severe forms of depression (based on PHQ-9) from a university community sample (Fitzpatrick et al., 2017). Space from depression is an iCBT intervention designed for adults with depressive symptoms. It consists of 7 modules covering core concepts of CBT for depression and includes sections on symptom monitoring, mood tracking and 27 emotional literacy, behavioral change, cognitive restructuring, countering automatic negative thoughts, and concludes in the creation of a wellness and safety plan. The module consists of various activities to deliver content from introductory quizzes, video and text content, interactive activities, homework, and narratives from individuals who have benefited from the program. Results of an RCT in Ireland indicate that the program is effective in reducing symptoms of depression, anxiety, and functional impairment compared to control conditions among adults with mild-to-moderate depression (Richards et al, 2015). Reduction of anxiety and depression were replicated in the Colombian adaptation of the program, Yo Puedo Sentirme Bien (Salamanca-Sanabria et al., 2020). Although in the latter study, the high attrition rate was a primary concern as only a limited proportion of the treatment group (9%) completed the course despite the provision of support (Salamanca-Sanabria et al., 2020). Further research on user retention must be conducted, especially identifying variables contributing to attrition and determining initiatives that can encourage user retention even in a fully self-guided program. Treadwill is an online iCBT intervention designed and delivered by researchers at the Indian Institute of Technology Kanpur (Ghosh et al., 2021). The intervention is a six-module program containing psychoeducation materials (e.g. slides, video, text, infographics) of CBT principles, interactive dialogue with an automated virtual patient, and interactive quizzes (Ghosh et al., 2021). In addition, features have been added to enhance user engagement given that the trial is conducted purely online and the program in itself is fully self-guided (Ghosh et al., 2021). These add-on features include interactive games, peer discussion boards that enable users to convene and share experiences, tailoring of content based on user’s life stage (i.e. student, working professional), and an optional buddy feature that allows users to invite their friend or family member to receive updates of their progress and maybe tasked to motivate the participants if Treadwill is not used regularly(Ghosh et al., 2021). Evidence from RCT conducted indicates that Treadwill is effective in reducing symptoms of depression and anxiety(Ghosh et al., 2021). The additional features were also effective in increasing user engagement and improving user retention (Ghosh et al., 2021). There are also several CBT-based apps founded by individuals involved or previously associated with Effective Altruism. One example of which is Mind Ease, an app intended to help with stress and anxiety through the aid of calming various exercises that are quick (can be done in less than 10 minutes) and evidence-based. UpLift is another app offering twelve 45-minute weekly sessions of iCBT and toolkits for mood tracking, enhancing emotions, and other interactive activities to enhance learning. Theory of Change EA PH MHCIR Shallow Reports Theory of Change Assumptions 28  Users will use the digital intervention unguided. One of the key concerns confronting unguided digital interventions is the high dropout rates, defined as the number of individuals who stopped using the intervention. In one systematic review of internet-based treatment programs, drop-out rates of 19 studies had a weighted average of 31% (Melville et al, 2010 as cited in Andersson et al., 2019). In another meta-analysis of self-guided iCBT for depression, 27% of the respondents dropped out from the intervention (Karyotaki et al., 2017). Moreover, dropout rates in the trial setting do not translate in a real-world setting. Scoping different interventions, Ghosh et al (2021) reported that even widely-evaluated programs such as MoodGym and Deprexis have adherence rates ranging from 7% to 15%. As such, further research needs to be conducted exploring participant and program variables associated with uptake and adherence to treatment. For instance, treatment is considered more effective when the program is user friendly (i.e. comprehensible, not technically advanced), set a clear deadline or duration of the treatment, and is equipped with “persuasive technology” elements, for instance, the use of dialogue (Andersson & Titov, 2014). With regards to participant characteristics, gender, age, educational level, the disorder of concern, are factors often considered influencing outcome (Andersson et al, 2019). In LMIC settings, the acceptability of digital interventions also needs to be evaluated as there can be unique structural and psychosocial factors that influence the uptake of digital interventions. Research on this is limited in the Philippines but key learnings from implementation studies on digital interventions done in other LMICs may serve as a guide. For instance, cultural adaptation through language translation or the use of more context-appropriate content is one strategy that can improve user engagement and program effectiveness (Cuijpers et al., 2019). Reduction of clinical symptoms improves well-being. Most studies on self-guided iCBT assess posttreatment and short-term effects of the intervention on symptoms of common mental health disorders such as depression and anxiety. There are limited studies that use well-being as an outcome measure of the intervention. Hence, estimates of this may be determined using findings of research outside the scope of self-guided iCBT interventions. Users have the tools and resources needed to use digital interventions. In 2022, smartphone penetration in the Philippines is relatively high at 72%, while the internet user penetration rate is at 50% (World Bank, n.d.; Statista, n.d.). While this provides further support that Filipinos have the resources and tools to access digital interventions, a more in-depth assessment of the demographics of internet users and quality of internet connectivity provides a nuanced understanding of the individuals that are likely to benefit from this intervention. For instance, a recent study that mapped out the digital poverty in the Philippines has shown internet connectivity is significantly high in urban areas and rural areas suffer from poor connectivity due to the limited internet infrastructures (Araneta et al, 2021). The digital infrastructure in the Philippines already limits the users who may benefit from the 29 intervention to individuals in urban areas. While a sizeable proportion of the population resides in urban areas creating a significant positive impact on this group, selecting this intervention may further neglect the needs of individuals in rural areas, where MH resources are more limited. Apart from internet infrastructure, other factors that may be considered in the implementation of the program include users’ technological capabilities and device characteristics (e.g. storage, software) that may affect the use of the intervention. Brief Cost-Effectiveness Review There are limited studies on the cost-effectiveness and cost of implementation of digital health interventions, particularly in low and middle-income countries (Naslund et al., 2017). Interviews with key resource persons on digital mental health intervention may provide information on the cost incurred in designing, delivering, and maintaining such intervention. Limitations Poor internet connectivity, particularly among rural areas, may limit users of the app to the urban population. In addition, indigent users may encounter other barriers affecting the adoption of the digital intervention, which may include poor digital literacy or limited resources (e.g. expensive mobile data charge, low phone storage, or outdated software) There is an array of interventions to choose from and narrowing the best option would require an assessment not only of its effectiveness but also its acceptability, usability, cost of implementation that is not often reported in the literature. Most of the studies indicate that more interactive interventions often yield higher user engagement, hence, improve effectiveness. However, in an LMIC setting, weighing of acceptability and usability of the app against more practical considerations such as data-intensiveness or capacity to run across operating systems should also be considered. In the Philippines, an application that can run with minimal data or offline will likely be more preferable to users. Given the high attrition rates even among popular evidence-based digital interventions, the importance of distribution strategies is highlighted to enhance uptake and use of the app. For the intervention to reach a wide network, partnership with public and private health care services or educational institutions can complement direct-to-customer marketing. Apart from increasing the interventions user base, this approach may also improve acceptability and increase user engagement due to the referral of credible stakeholders (e.g. health workers, clinicians, counselors, etc.) 30 Resources Andersson, G., & Titov, N. (2014). Advantages and limitations of Internet-based interventions for common mental disorders. World Psychiatry : Official Journal of the World Psychiatric Association (WPA), 13(1), 4–11. PubMed. https://doi.org/10.1002/wps.20083 Andersson, G., Titov, N., Dear, B. F., Rozental, A., & Carlbring, P. (2019). Internet-delivered psychological treatments: From innovation to implementation. World Psychiatry, 18(1), 20–28. https://doi.org/10.1002/wps.20610 Araneta, A., Carrasco, B., Rahemtulla, H., Balgos, S., & Stephanie Sy, S. (2021, February 22). Mapping digital poverty in PH. The Philippine Daily Inquirer. Retrieved January 13, 2022, from https://business.inquirer.net/318223/mapping-digital-poverty-in-ph Burton, C., Szentagotai Tatar, A., McKinstry, B., Matheson, C., Matu, S., Moldovan, R., Macnab, M., Farrow, E., David, D., Pagliari, C., Serrano Blanco, A., Wolters, M., & Help4Mood Consortium (2016). Pilot randomised controlled trial of Help4Mood, an embodied virtual agent-based system to support treatment of depression. Journal of telemedicine and telecare, 22(6), 348–355. Cuijpers, P., Eylem, O., Karyotaki, E., Zhou, X., & Sijbrandij, M. (2019). 8—Psychotherapy for depression and anxiety in low- and middle-income countries. In D. J. Stein, J. K. Bass, & S. G. Hofmann (Eds.), Global Mental Health and Psychotherapy (pp. 173–192). Academic Press. https://doi.org/10.1016/B978-0-12-814932-4.00008-2 Center for Technology and Behavioral Health. (n.d.). Space from Depression. Retrieved January 12, 2022, from https://www.c4tbh.org/program-review/space-from-depression/ Fitzpatrick, K. K., Darcy, A., & Vierhile, M. (2017). Delivering Cognitive Behavior Therapy to Young Adults With Symptoms of Depression and Anxiety Using a Fully Automated Conversational Agent (Woebot): A Randomized Controlled Trial. JMIR Mental Health, 4(2), e19. https://doi.org/10.2196/mental.7785 Fleming, T., Lucassen, M., Stasiak, K., Sutcliffe, K., & Merry, S. (2021). Technology Matters: SPARX - computerised cognitive behavioural therapy for adolescent depression in a game format. Child and adolescent mental health, 26(1), 92–94. https://doi.org/10.1111/camh.12444 Ghosh, A., Cherian, R. J., Wagle, S., Sharma, P., Kannan, K. R., Bajpai, A., & Gupta, N. (2021). TreadWill: Development and pragmatic randomized controlled trial of an unguided, computerized cognitive behavioral therapy intervention in a lower middle-income country. MedRxiv, 2021.11.24.21266799. https://doi.org/10.1101/2021.11.24.21266799 Hill, C., Creswell, C., Vigerland, S., Nauta, M. H., March, S., Donovan, C., Wolters, L., Spence, S. H., Martin, J. L., Wozney, L., McLellan, L., Kreuze, L., Gould, K., Jolstedt, M., Nord, M., Hudson, J. L., Utens, E., Ruwaard, J., Albers, C., … Kendall, P. C. (2018). Navigating the development and dissemination of internet cognitive behavioral therapy (iCBT) for anxiety disorders in children and young people: A consensus statement with recommendations from the #iCBTLorentz Workshop Group. Internet Interventions, 12, 1–10. https://doi.org/10.1016/j.invent.2018.02.002 Knaevelsrud, C., Brand, J., Lange, A., Ruwaard, J., & Wagner, B. (2015). Web-based psychotherapy for posttraumatic stress disorder in war-traumatized Arab patients: randomized controlled trial. Journal of medical Internet research, 17(3), e71. https://doi.org/10.2196/jmir.3582 Karyotaki, E., Riper, H., Twisk, J., Hoogendoorn, A., Kleiboer, A., Mira, A., Mackinnon, A., Meyer, B., Botella, C., Littlewood, E., Andersson, G., Christensen, H., Klein, J. P., Schröder, J., Bretón-López, J., Scheider, J., Griffiths, K., Farrer, L., Huibers, M. J. H., … Cuijpers, P. (2017). Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data. JAMA Psychiatry, 74(4), 351–359. https://doi.org/10.1001/jamapsychiatry.2017.0044 Kishimoto, T., Krieger, T., Berger, T., Qian, M., Chen, H., & Yang, Y. (2016). Internet-Based Cognitive Behavioral Therapy for Social Anxiety with and without Guidance Compared to a Wait List in China: A Propensity Score Study. Psychotherapy and Psychosomatics, 85(5), 317–319. https://doi.org/10.1159/000446584 Lara, M. A., Tiburcio, M., Aguilar Abrego, A., & Sánchez-Solís, A. (2014). A four-year experience with a Web-based self-help intervention for depressive symptoms in Mexico. Revista panamericana de salud publica = Pan American journal of public health, 35(5-6), 399–406. 31 Marcela Tiburcio, Ma. Asunción Lara, Nora Martínez, Morise Fernández & Araceli Aguilar (2018): Web-Based Intervention to Reduce Substance Abuse and Depression: A Three Arm Randomized Trial in Mexico, Substance Use & Misuse, DOI: 10.1080/10826084.2018.1467452 Mehta, S., Peynenburg, V. A., & Hadjistavropoulos, H. D. (2019). Internet-delivered cognitive behaviour therapy for chronic health conditions: A systematic review and meta-analysis. Journal of Behavioral Medicine, 42(2), 169–187. https://doi.org/10.1007/s10865-018-9984-x Moritz, S., & Russu, R. (2013). Further evidence for the efficacy of association splitting in obsessive-compulsive disorder. An internet study in a Russian-speaking sample. Journal of Obsessive-Compulsive and Related Disorders, 2(2), 91–98. https://doi.org/10.1016/j.jocrd.2012.12.002 Moeini, B., Bashirian, S., Soltanian, A. R., Ghaleiha, A., & Taheri, M. (2019). Examining the Effectiveness of a Web-Based Intervention for Depressive Symptoms in Female Adolescents: Applying Social Cognitive Theory. Journal of research in health sciences, 19(3), e00454. moodgym. (n.d.). Welcome to moodgym. Retrieved January 12, 2022, from https://moodgym.com.au Naslund, J. A., Aschbrenner, K. A., Araya, R., Marsch, L. A., Unützer, J., Patel, V., & Bartels, S. J. (2017). Digital technology for treating and preventing mental disorders in low-income and middle-income countries: A narrative review of the literature. The Lancet. Psychiatry, 4(6),486–500. PubMed. https://doi.org/10.1016/S2215-0366(17)30096-2 Richards, D., Timulak, L., O'Brien, E., Hayes, C., Vigano, N., Sharry, J., & Doherty, G. (2015). A randomized controlled trial of an internet-delivered treatment: Its potential as a low-intensity community intervention for adults with symptoms of depression. Behaviour research and therapy, 75, 20–31. https://doi.org/10.1016/j.brat.2015.10.005s Salamanca-Sanabria, A., Richards, D., Timulak, L., Connell, S., Mojica Perilla, M., Parra-Villa, Y., & Castro-Camacho, L. (2020). A Culturally Adapted Cognitive Behavioral Internet-Delivered Intervention for Depressive Symptoms: Randomized Controlled Trial. JMIR Mental Health, 7(1), e13392. https://doi.org/10.2196/13392 Sijbrandij, M., Acarturk, C., Bird, M., Bryant, R. A., Burchert, S., Carswell, K., de Jong, J., Dinesen, C., Dawson, K. S., El Chammay, R., van Ittersum, L., Jordans, M., Knaevelsrud, C., McDaid, D., Miller, K., Morina, N., Park, A.-L., Roberts, B., van Son, Y., … Cuijpers, P. (2017). Strengthening mental health care systems for Syrian refugees in Europe and the Middle East: Integrating scalable psychological interventions in eight countries. European Journal of Psychotraumatology, 8(sup2), 1388102–1388102. PubMed. https://doi.org/10.1080/20008198.2017.1388102 SPEK, V., CUIJPERS, P., NYKLÍČEK, I., RIPER, H., KEYZER, J., & POP, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis. Psychological Medicine, 37(3), 319–328. Cambridge Core. https://doi.org/10.1017/S0033291706008944 Statista. (n.d.). Smartphone penetration rate as share of the population in the Philippines from 2017 to 2025. Retrieved January 13, 2022, from https://www.statista.com/statistics/625427/smartphone-user-penetration-in-philippines/ The World Bank. (n.d.). Individuals using the Internet (% of population) - Philippines. Retrieved January 13, 2022, from https://data.worldbank.org/indicator/IT.NET.USER.ZS?locations=PH Tulbure BT, Szentagotai A, David O, Ștefan S, Månsson KNT, David D, et al. (2015) Internet-Delivered Cognitive-Behavioral Therapy for Social Anxiety Disorder in Romania: A Randomized Controlled Trial. PLoS ONE 10(5): e0123997. https://doi.org/10.1371/journal.pone.0123997 Tulbure, B. T., Andersson, G., Sălăgean, N., Pearce, M., & Koenig, H. G. (2018). Religious versus Conventional Internet-based Cognitive Behavioral Therapy for Depression. Journal of religion and health, 57(5), 1634–1648. https://doi.org/10.1007/s10943-017-0503-0 Wilhelm, S., Weingarden, H., Ladis, I., Braddick, V., Shin, J., & Jacobson, N. C. (2020). Cognitive-Behavioral Therapy in the Digital Age: Presidential Address. Behavior Therapy, 51(1), 1–14. https://doi.org/10.1016/j.beth.2019.08.001 Woebot Health. (n.d.). Clinical Results. Retrieved January 12, 2022, from https://woebothealth.com/clinical-results/ 32 Crisis Lines by Glaiza Mae Superable Researcher's Impressions: ● There is value in offering crisis lines targeted to more underserved communities such as children and youth, or non-Tagalog speaking groups. More in-depth evaluation of the importance of such service may be determined by consulting existing crisis line providers regarding the proportion of calls received from this population and identifying challenges met in servicing these groups. ● If the service is underutilized by these groups, it can be checked if this can be attributed to a marketing concern marketing concern (e.g. people in need are not well-informed about the availability of the service) or an acceptability issue, with groups preferring alternative sources of support other than crisis line centers. It may help to identify regions that have the highest incidence of suicidality as a potential area for setting-up new crisis line centers. ● In servicing children and youth, setting up chat and text services may be considered as these are modalities acceptable and effective to this population. Offering this modality can also differentiate the new crisis line against other existing crisis lines in the Philippines. ● Crisis lines tend to be insitution-based rather than community-based. This may be attributed to the fact that setting up requires mental health (MH) professionals capable of training and superivising responders, and well-connected to MH network to provide adequate referral services. Hence, if this idea is pursued, it would be best to partner with existing institutions that already have such capacity such as Universities offerring graduate programs on psychology. Intervention Brief This is a single-session crisis intervention delivered by trained responders aimed at reducing users’ crisis states and equipping users with adaptive coping strategies to ensure their safety and promote their well-being. The intervention is free of cost, can be delivered through multiple modalities, such as telephone, mobile, online platforms, and maintains the anonymity of the user. Executive Summary Key Points: ● There is a need to determine the service model of the crisis line intervention as applied in PH. Often, standards services include risk assessment and interventions to improve mood. Provision of referral services to link users to appropriate social welfare, medical, and mental health institutions, and emergency rescues would depend on the available resources in the community. 33  ● In the systematic reviews, most studies had a high risk of bias. The strength of evidence is also affected by the use of unvalidated approaches and tools, high attrition rates among those in the follow-up groups, and limitations in design. ● There are limited to no RCTs available in evaluating the effectiveness of crisis lines but alternative methods are available to measure this. Given the different variables used to measure outcomes, the target outcome needs to be determined when ideating the crisis line. ● There are multiple crisis lines in the Philippines, however, there are limited studies about it. In the literature, only one study on effectiveness was conducted in LMIC. ● Evidence indicates most assumptions are generally supported: crisis lines are acceptable and satisfactory to intended users, effective in reducing suicide, self-harm, and client distress, and users utilize the service referrals. However, the long-term impact of crisis lines is difficult to assess as there are limited studies on this. Key Limitations: ● There are multiple crisis lines already available in the Philippines. ● It might be difficult to predict the cost-effectiveness and long-term impact of a crisis hotline given the problems encountered in estimating its effectiveness and the limited studies on cost-effectiveness. ● The intervention serves only as an adjunct service to existing mental health services and programs in the community. The sustainable long-term effects of crisis hotlines would depend on its ability to refer users to appropriate services such as mental health providers for treatment and extended care. ● Unlike other interventions that can eventually be adapted to business models that can be sustainable on their own, crisis lines need continuous external funding to maintain their operations. ● Apart from funding, the sustainability of crisis line operations also depend on the availability of talents willing to participate in the program as crisis line responders or as crisis line supervisors and trainers Conclusion Although already present in the Philippines, there are still opportunities to refine crisis lines offered in PH. Despite the limited high-quality studies on its effectiveness, general evidence on the crisis line indicate positive outcomes. Its main drawback might be the need for external funding to sustain operations and limited impact on long-term wellbeing unless supported by other mental health interventions. 34 Overview Background Crisis lines, also known as helplines or hotlines, is a form of intervention mainly aimed at reducing users’ crisis states, psychological distress, and risk of suicide and securing users’ long-term safety (Gould et al., 2013; Hoffberg et al., 2020; Mathieu et al., 2021). Crisis intervention involved a single session engagement with trained volunteers or paid mental health providers who may work part-time or full-time and are equipped with competencies to reduced psychological distress and connect individuals with the support they need (WHO, 2018). A key hallmark of this service is its confidentiality and anonymity as well as accessibility. Users are only required to provide minimal information and confidentiality is maintained unless they are at risk of imminent harm. In the event of such, active rescues through partnerships with police or emergency medical services may be deployed. Service is free of charge, with some available 24 hours a day, seven days in a week, and delivered using accessible platforms, traditionally telephone but has since evolved to accommodate technological advancements such as SMS/text messaging or online modalities such as video or chat-based platforms. Crisis lines are relevant in a comprehensive public health strategy as it enables the provision of immediate support to individuals in distress (WHO, 2018). The anonymity and confidentiality of the service facilitate help-seeking for individuals who may be concerned about the stigma surrounding mental health (WHO, 2018). Crisis lines also offer immediate relief for individuals who are unable to access supportive connections due to factors like isolation attributed to chronic mental or physical illness and distance from mental health providers (WHO, 2018). The intervention is focused on addressing the crisis, which is defined as time-limited “upset states precipitated by events with which individuals currently felt unable to cope”(Kalafat et al., 2007). These states result in heightened anxiety, narrowing individuals’ cognitive capacities and limiting their problem-solving capabilities, which may lead them to use maladaptive coping strategies, such as interpersonal violence, suicide, alcohol use that further yields negative outcomes (Kalafat et al., 2007). As such, crisis lines offer various forms of psychosocial and practical support services to promote adaptive coping strategies. Risk assessment is one of the primary services offered by crisis line responders. They evaluate whether or not a client is at risk of harming themselves or other individuals, and provide the necessary support based on standard protocols. For situations when the client is considered high risk, such as individuals who may have concrete plans of suicide or is currently attempting suicide, more well-networked crisis lines as those within the government system, may have the capacities to intervene by identifying the caller’s location, notifying authorities in the area, and enabling the provision of immediate emergency response. While this is not an option for all crisis lines, crisis lines workers are trained to reduce the distress until the crisis 35 is averted. Across all forms of distress, crisis line workers offer empathic and non-judgemental listening and may also engage users in collaborative problem-solving to address their concerns (WHO, 2018). These strategies vary from stress-reduction strategies to attenuate users’ distress, encouraging users to seek help from networks of support and identifying practical solutions to their concerns. As needed, users are also provided referrals to various community services available such as mental health, medical, and other forms of social services. In scoping the current research, crisis lines have been established for various psychosocial concerns and targeting different populations. More prominent are the crisis lines for suicide, but there are also crisis lines specific to substance abuse, domestic violence, disaster-related concerns. Although, the majority of the crisis lines are non-specific and tend to address various types of mental health concerns. Crisis lines have also been established specifically for children and young adolescents given their unique context and developmental stage may necessitate a different approach to intervention compared to adults. Review of the Evidence General Review of Effectiveness Evidence of the effectiveness of crisis lines was sourced from the recent systematic review on crisis lines conducted by Hoffberg et. al. (2020). This is supplemented by another systematic review on assessing the state of research on crisis lines conducted by Matthieu et. al. (2021). Overall results of both reviews indicate that crisis lines yield a positive direct impact on its users in various target outcomes. Specific outcomes will be discussed in the succeeding section of the report. In this section, a description of the studies evaluating effectiveness will be discussed. The effectiveness of the crisis lines has not been evaluated using randomized controlled trials due to the nature of the intervention. In particular, users of crisis lines may be individuals at risk of imminent harm hence requiring immediate interventions. Hence, studies use alternative measures for assessing the effectiveness. In some studies, they use rates of referral provided and service utilization as measures of outcome (Hoffberg et al., 2020). Although these can be unreliable because there are confounding variables that may mediate the outcome and the selected measures, for instance, the effective response may reduce the users’ motivation to seek additional services or users may consider other support systems instead of the one listed in the referral (Kalafat et al., 2007). In a few studies, effectiveness is determined via cross-sectional studies comparing the rates of suicide in a population before and after the introduction of the intervention (Chavan et al., 2012; Hoffberg et al., 2020). Alternatively, more common are the studies that use repeated measures design where individuals are assessed on target outcomes before and after the intervention (Gould et al., 2013; Hoffberg et al., 2020; Kalafat et al., 2007). In the literature, measurements of outcome also vary. Most involved silent monitors or observers who evaluate live or 36 taped recordings or chat logs of the interaction, while a few involve direct inquiry of the user's experience of the intervention. In determining its effectiveness, a common area of research also includes identifying intervening variables that may impact the outcome. An example of this is evaluating the impact helper characteristic or responses or platform modality in the resolution of the clients’ concerns. Apart from the heterogeneity in study design and measurements of the outcome, studies also vary in target outcomes measured and the instruments use to assess these outcomes. Generally, studies assess users’ state of distress through subjective or observational ratings of their anxiety, depression, anger, fatigue, confusion, hopelessness. The risk of suicide is determined based on users’ ratings of their suicidal thoughts and behavior such as suicide intent and urgency of plans. Caller satisfaction is also considered. Common validated measures used in the study include the following: Crisis Call Outcome Rating Scale (CCORS), Profile of Mood States Modified (POMS), Mini-International Neuropsychiatric Interview (MINI). Most of the studies only considered the proximal outcome of the intervention defined as changes to the user’s psychological state in the duration of the engagement. These are also researches that assessed the distal effects of the intervention through a single follow-up after the intervention, which can range from 1 week to 3 months. During this assessment, the individual’s mood states were determined and compliance to action plans and utilization of the referrals discussed in the initial call was also evaluated. It is worthwhile to note that studies on effectiveness were generally rated as having a high risk of bias, hence, low-quality evidence. Some of the sources of bias include selection bias due to the exclusion of high-risk crisis line users and inconsistency in the selection of respondents. The strength of evidence was also affected by the use of unvalidated approaches and tools, high attrition rates among those in the follow-up groups, and limitations in study design which makes excluding confounding variables difficult to do. Specific interventions that look promising Given that there are limited studies on interventions as applied in LMIC, interventions included herein refer either to specific intervention protocols or programs that can be modeled in an LMIC context Applied Suicide Intervention Skills Training (ASIST) ASIST is a gatekeeper training program developed by LivingWorks, a social enterprise based in Canada dedicated to creating evidence-based suicide intervention programs. ASIST suicide intervention model consists of three phases of caregiving (Gould et al., 2013). In the connecting phase, counselors are tasked to explore users presenting problems and their subjective experiences with the intention of identifying the meaning of the problem for the user and its linkages to suicidal thoughts (Gould et al., 2013). The understanding phase delves into the user's reasons for dying and living (Gould et al., 2013). The last phase involves assisting which requires the development 37 of a safe plan to address the risk users have prompted (Gould et al., 2013). In the only RCT conducted on suicide interventions, ASIST-trained were compared to non-ASIST trained counselors providing support for the National Suicide Prevention Lifeline's national network of crisis hotlines in the United States. All participants are knowledgeable of suicide management as part of their routine training as crisis responders. However, ASIST-trained counselors yield better user outcomes, with callers feeling less depressed, less suicidal, less overwhelmed, and more hopeful than non-ASIST trained counselors (Gould et al., 2013). ​ Kids Help Phone Kids Help Phone is a 24/7 crisis line provider in Canada that has been in service for 30 years. They stand out from other crisis line providers as they have recently partnered with Facebook Canada to utilize the platform for crisis response (McGill, 2020). Individuals interested in availing of their service can visit Facebook Messenger or their Facebook page to access help (McGill, 2020). This initiative intends to increase access to crisis lines among under-connected communities in Canada (McGill, 2020). The same initiative may work in the Philippines given how Facebook is among the top-used apps in the country and remains to be widely accessible due to its free version that enables users to access the app even without mobile data. Interventions in low-to-middle-income countries Most studies on crisis hotlines were conducted in a high-income country with only one conducted in LMIC (Chavan et al., 2012). The study involved an evaluation AASHA (translates to Hope), a 24-hour suicide prevention helpline set up by the Government Medical College and Hospital in India (Chavan et al., 2012). AASHA’s service model involved telephone counseling provided by psychologists, with the support of supervisors and on-call psychiatrists (Chavan et al., 2012). It also included a crisis intervention team that serves as emergency responders for high-risk cases that require home visits and first aid (Chavan et al., 2012). In the end, the decline in suicide rates in the six years that the study was being conducted was attributed not only to the helpline but also the initiatives that the team implemented as part of their suicide prevention program (Chavan et al., 2012). This includes public psychoeducational initiatives on mental health, capacity building of media entities in the appropriate reportage of suicide, and partnership with the police to monitor areas high-risk for suicide (Chavan et al., 2012). While it is difficult to isolate the effects of the helpline due to the supplemental initiatives that act as confounding variables, this study provides insight into user characteristics and key concerns of helpline users in the context of LMIC. Apart from counseling, individuals use the helplines to assess the nature of their conditions and to seek information regarding their treatment (Chavan et al., 2012). In addition, it was also common for household members to consult on behalf of their families (Chavan et al., 2012). 38  In the Philippines, there are several crisis lines available set up by various organizations and institutions such as the national government, universities, and mental health clinics. Since the enactment of the Mental Health Law, the government is mandated to provide a national mental health crisis hotline, hence, the creation of NCMH (National Center for Mental Health) Crisis Hotline in 2019 (Department of Health, 2019). The more publicized non-government crisis line in PH include Hopeline by New Good Feelings’ Mindstrong (previously Natasha Gouldbourn Foundation), UGAT Sandaline by UGAT Foundation, and In Touch Community Crisis line. Most of these are services operating from the National Capital Region, with crisis line responders more fluent in Tagalog. As such, Tawag ng Paglaum Centro Bisaya was established by The Department of Health - Region VII together with Vicente Sotto Memorial Medical Center (VSMMC) to provide crisis intervention in Visayan-speaking regions (Tawag ng Paglaum – Centro Bisaya, n.d.). In the Philippines, there are no know crisis lines dedicated to providing psychosocial interventions for children and youth. Specific to this population, known hotlines include Bantay Bata 163, the child welfare arm of ABS-CBN Lingkod Kapamilya Foundation, Inc (Inquirer.net, 2019). However, the crisis hotline is dedicated to reporting children experiencing abuse to facilitate their rescue. Crisis lines have significantly grown in number since the COVID-19 pandemic in response to the growing demand for psychosocial support due to pandemic-related difficulties (Rappler, 2020). However, some of these services were offered only for a specific duration and some may have ceased their operations. One key challenge encountered in evaluating these helplines includes the lack of research on their effectiveness and limited information on their service model. Interventions as applied to children and youth There are several studies conducted on helplines for children and youth, with one recent systematic research summarising the literature on the usage of helplines by this specific demographic (Mathieu et al., 2021). All of the studies were conducted in high-income countries, with only one aggregating data from seven global regions. There were only two studies assessing the effectiveness of the helpline in youth and the majority examined users’ awareness and attitudes towards helplines, counselor-client interaction during counseling, main reasons for using the intervention, user characteristics, with several studies focus on youth suicidal thoughts and behavior. Crisis lines facilitate children and youth in help-seeking as it enables them to seek mental health support without the intervention of adults. Apart from the increased likelihood of disclosure, this enhanced agency becomes critical when children’s safety is at risk, especially in the case of abusive households. Helplines for the children and youth are delivered using multi-channel modalities which include telephone, mobile, SMS, and chat. In terms of modality, the use of chat or text-based platforms has also gained traction for children and youth. For some, apart from ease and accessibility, a key motivation for selecting these platforms over call-based intervention is enhanced privacy and anonymity which may improve the quality of their engagement with the crisis line responder. 39  Despite the lack of controlled studies, existing evidence indicates that children and youth utilize helplines as sources of support and aid in addressing the various psychosocial problems they encounter. Theory of Change EA PH MHCIR Shallow Reports Theory of Change Assumptions Users of crisis lines find the service acceptable and satisfactory. Studies assessing user satisfaction of crisis lines indicate users are generally satisfied with the service they receive. In two studies conducted in the USA of local and national crisis hotline, users provides positive responses during follow-up assessments and expressed that they were able to talk about their concerns, the helper was warm, caring, and patient and they were equipped with a clear or new perspective in thinking about their concerns (Gould et al., 2007; Kalafat et al., 2007). In another study of a Canadian Inuit crisis line, users indicated that crisis lines enabled them to feel better, provided avenues for emotional release, reframed their perspective, and aided in ideating solutions (Tan et al, 2012) . However, a few respondents also noted negative experience with crisis line often involving problems with referral or responders’ responses or characteristics (e.g. appear condescending, lack concern, abrupt, unable to identify problems, provided unhelpful solutions, asked too many questions) (Gould et al., 2007; Kalafat et al., 2007). Crisis lines are also deemed acceptable to youth and children. In a unique study that compared the call metrics of crisis line for children and youth (CY) with the total population of its intended users, it was found 4%-11% of the CY population in UK, Netherlands, and Ireland that specific point in time utilized the intervention. Although the study was published in the 1990s and may not already be reflective of the present technological and social context, it remains interesting as it was the only study that compared crisis line usage vis-a-vis country population (Christopherson, 1992). Another global data source from Child Helpline International has shown that its affiliate crisis lines centers have responded to over 23 million calls of children worldwide in over a 10-year span (Fukkink et al, 2016). There were limited studies specific to children and youth that assessed user satisfaction. The crisis line is effective in reducing target negative outcomes such as suicide, self-harm, or interpersonal violence. The most common target outcome that is monitored in the crisis line studies include suicide risk and there are no mentions of reductions in interpersonal violence. One study in the systematic review evaluating 100 calls to Kids Helpline Australia indicates immediate reductions in suicide risk at the end of the call, with a 40% decline in cases tagged imminent risk, and a 56% increase in cases categorized no suicide urgency (King et al., 2003). Changes in suicide behavior vary per study. In another 40 research that analyzed 1206 calls to Quebec suicide prevention centers in Canada, suicide urgency decreased only in 16% of the calls. No changes in suicide urgency were observed in 76% of the calls, and in fact, increased in 7.8% of the calls (Mishara et al, 2016). Another method for assessing the success of the intervention is evaluating the number of rescues initiated due to the crisis lines. One study reviewed 20,942 calls to EPES public emergency healthcare service of Andalusia, Spain indicate that 73% of the calls resulted in emergency rescue, 18% rest of the calls were resolved in situ or referred to the professional, while only 2.46% of the calls (n=516) resulted to caller death before evacuation (Mejias-Martin et al, 2018). It is worthwhile to note that suicide attempt averted may not indicate long-term survival for the individual as suicide reattempts may reoccur later in life. In a retrospective cohort study conducted in Hongkong that analyzed death by suicide among elderly users and non-users of crisis outlines, outcomes indicate that helpline users accounted for 14% of suicides in Hongkong after a four-year (2012 - 2015) follow-up (Chan et al, 2018). Significant predictors of suicide include being of older age, male, living alone, and with self-reported mental illness (Chan et al, 2018). Hence, studies on utilization of referrals provided during the call may provide further information on the lasting outcome of helplines. Use of crisis line is effective in reducing client distress. Three studies indicate a decline of the caller’s overall distress and related measures such as confusion, depression, anger, anxiety, helplessness, hopelessness, during the course of the intervention although the extent of change varies per study and may need more nuanced evaluation (Mishara et al, 2016; Ramchand et al, 2017; Kalafat et al, 2007). This decline in distress in the use of telephone helplines can also be observed among users of chat helplines (Mookenstorm et al, 2017). There are indications that improvements in mood can be sustained after the call. In one study that followed-up helpline callers two weeks after their initial call, mood significantly improve from the end of the call to follow-up. Although caution should be made in the interpretation of studies that assessed mood after a specific interval. Given the lack of control in design, changes may be attributed to other variables apart from the intervention. Crisis line responders are equipped with the necessary competencies to respond to callers’ needs effectively. In practice, crisis lines may have limited initiatives in monitoring the quality of their intervention, especially measures to identify if the responder meets the minimal standards of practice to yield the desired outcomes in the user. The importance of monitoring was emphasized in one study that analyzed the impact of helper response and characteristics in producing positive outcomes such as the decline in suicide risk or improvements in the crisis state. In this study, assessment of the 2,611 calls made to the Hope Line Network has shown that half of the callers were not asked for suicide ideation, while 15% of the calls fail to meet the acceptability standard of helper 41 response, manifest in the lack of empathy and respect, poor initial contact (Mishara et al, 2007; Mishara et al, 2007). In the same study, it was found that helper behavior associated with positive outcomes includes providing supportive and good contact (e.g. providing moral support, reframing, validation of emotions) and engaging collaborative problem-solving. Further explorations of studies on helper response and crisis intervention frameworks may be conducted in the future to identify the most effective and feasible service model for a crisis line in the Philippines. As crisis lines can be staffed by paid employees or volunteers, studies evaluating the difference in outcomes of the two types of service providers were also explored. In one study (Mishara et al, 2016), it was found that there were no significant differences between the outcomes of paid employees and volunteers. Experience, defined as the number of hours in client contact, is the more important variable. At the end of the call, responders with over 140 hours of call experience had better client outcomes: greater decline in suicide urgency and crisis state, higher safety contract compliance rates, and less likely to exacerbate suicide risk. Users will follow-through plan of actions discussed and utilize the service of the referrals provided. In several studies (Mishara et al, 2007; Kalafat et al 2007; Gould et al, 2012), a significant proportion (30-55%) of the individuals assessed at follow-up complied with the agreements made with the counselor on the succeeding steps to take after a crisis calls, such as consulting mental health referrals offered or engaging in adaptive plans of action (e.g. reaching out to a friend). Follow-through with the plan of actions and service referrals would improve users well-being. There are limited studies assessing the long-term effects of crisis line services on well-being. It is also difficult to conclude to what extent these agreed action plans impact the long-term well-being of the individual as these vary depending on users’ needs. At most, some studies only consider the percentage of users who consulted a mental health provider. Brief Cost-Effectiveness Review One study assessed the cost-effectiveness of De Zelfmoordlijn, a Flemish suicide chat and helpline service by using data from its 3785 users in 2011 to predict helpline’s distal future effects in a 10-year simulation (Pil et al., 2013). Results of the study suggest that the presence of the helpline could avoid 36% of completed suicide and suicide attempts in a high-risk population (Pil et al., 2013). An estimate of the Quality Adjusted Life Years (QALY) gained by individuals availing this service range from 0.063 QALYs (95% confidence interval, CI 0.030–0.097) and 0.035 QALYs (95%CI 20.026–0.096) for male users of the telephone- and chat service respectively (Pil et al., 2013). The corresponding values for females were 0.019 QALYs (95%CI 20.015–0.052) and a QALY-neutral result of -0.005 (95%CI 20.071–0.062) (Pil et al., 2013). There are differences in QALY estimates based on helpline modality and gender due to the demographic of the user and their associated suicide behaviour (Pil et al., 2013). 42 Telephone hotlines have a greater impact on QALY than chat services as its users tend to be older people and are likely to commit suicide than younger people (Pil et al., 2013). Males also gain more QALYs than females because men are more likely to commit suicides than females (Pil et al., 2013). In terms of investment, for each euro invested in the suicide helpline, the national health insurance gains almost €7, especially by means of the telephone service (Pil et al., 2013). Limitations Given the prevalence of crisis lines in the Philippines, it would be best to conduct a more thorough assessment of the pros and cons of setting up new crisis lines versus enhancing existing ones. Given the limited scholarly literature on crisis lines in the Philippines, information on crisis lines may best be sourced from key opinion leaders involved in crisis line operations. Assessment may include identifying the cost of service delivery, the service model used, and measures to evaluate the effectiveness of their service model. Knowledge of the current gaps in service may also help in ideating services addressing the underserved needs in the community. In the brief scoping of crisis lines in the Philippines, there seem to be limited programs servicing non-Tagalog speakers or specializing in children and youth. Research on the effectiveness of crisis lines is met with various concerns such as lack of controlled studies due to the nature of the intervention, varied target outcomes, and outcome measures, heterogeneity of the service model of crisis lines assessed. Given the problems encountered in estimating its effectiveness, it might be difficult to predict the cost-effectiveness and long-term impact of a crisis hotline. Estimates of its distal effects will depend on statistics that may not be relevant in the LMIC setting. For instance, studies of crisis lines’ effectiveness have been conducted in High-Income Countries that have better systems or infrastructures responding to crises. The intervention serves only as an adjunct service to existing mental health services and programs in the community. The distal long-term effects of crisis hotlines would depend on its ability to refer users to appropriate services such as mental health providers for treatment and extended care. Given that referral is one of its primary services, it is important for founders of this charity to be well-connected to institutions or professionals offering mental health services or emergency rescues. Unlike other interventions that can eventually be adapted to business models that can be sustainable on their own, crisis lines need continuous external funding to maintain their operations. In the Philippines, funding depends on the organization and institution offering the services. Previously, the Department of Health (DOH) provided funding and support for Hopeline PH, a suicide and crisis support helpline initiated. However, funding was discontinued as DOH established NCMH Crisis Line services (Department of Health, 2019). At present, Hopeline maintains its operations through NGF’s resources, crowdsourcing funding, and partnership with other non-profit organizations such as the Philippine Red Cross. Another 24/7 crisis line in the country is provided by In Touch Community services, a non-profit 43 non-governmental organization that offers various mental health services (In Touch Community Services, n.d). The organization offers paid capacity-building workshops for mental health providers and counseling services while keeping their crisis line free. Crisis line responders volunteering in their program undergo certified training for a cost but can be provided subsidies. Funding of their crisis lines is not specified on their website. Other crisis lines services are associated with University-led initiatives. For instance, Ugat Sandaline is a crisis line dedicated to providing crisis intervention for Filipinos, especially seafarers and Overseas Filipino Workers (UGAT Sandaline, n.d.). It is funded by Ugat Foundation, a non-profit organization based in Ateneo de Manila University providing psychological interventions to underserved communities (Ateneo de Manila University, 2012). Partnership with for-profit organizations also aids in the dissemination of and access to the intervention. For instance, Hopeline collaborated with HealthNow, an app offering telehealth services, enabling app users to reach out to crisis line responders with just a click (Torres, 2020; Sunstar Cebu, 2021). Various crisis lines and tele-counseling services such as Hopeline and University of the Philippines-Diliman Psychosococial Services (UPD PsycServ) has partnered with telecom companies, primarily Globe, to enable toll-free access to hotline services among Globe and Touch Mobile subscribers. Apart from funding, the sustainability of crisis line operations also depends on the availability of talents willing to participate in the program as crisis line responders. Most of the above-mentioned crisis lines have posted calls for volunteers who will undergo crisis intervention training before performing duty as hotline responders. In order to have a more accurate estimate of the cost of operations, there is a need to determine the extent to which crisis lines are run by paid staff and volunteers. Given volunteers can also drop out of the program, then cost of training needs to be weighed against the volunteer’s duration of service before dropping out of the program. One potential service model that can address concerns on talent availability is observed among univeristy-led crisis lines or tele-counselling programs. A proportion of the staff consists of students from the graduate program of psychology who are required to take practicum. Training and supervision is shared among paid staff, some of whom may be members of the faculty. As such, there is a higher chance for the program to be sustainable given the presence volunteers committed to provide service for a specified duration and mental health professionals that can offer supervision and training. Apart from supporting the mental health needs of the community, these service model also benefits the graduate programs as it eases the process of finding practicum opportunities for their students. This may serve as a viable model for service delivery that can be replicated in other universities who may have graduate programs in psychology but have not set-up their own tele-counselling or crisis line services Resources Ateneo de Manila University. (2012, October 30). Ugnayan at Tulong para sa Maralitang Pamilya Foundation, Inc.Retrieved January 17, 2022, from https://www.ateneo.edu/ugnayan-tulong-para-sa-maralitang-pamilya-foundation-inc Chavan, B., Garg, R., & Bhargava, R. (2012). Role of 24 hour telephonic helpline in delivery of mental health services. Indian Journal of Medical Sciences, 66(5), 116. https://doi.org/10.4103/0019-5359.114196 44 Chan CH, Wong HK, Yip PS. Exploring the use of telephone helpline pertaining to older adult suicide prevention: a Hong Kong experience. J Affect Disord. (2018) 236:75–9. doi: 10.1016/j.jad.2018.04.093 Christopherson RJ. The impact of children’s helplines: an international comparison. Practice. 1992;6:299-306. Department of Health (2019, May 2). Launch of the NCMH crisis hotline. Department of Health. https://doh.gov.ph/press-release/launch-of-the-NCMH-crisis-hotline Department of Health. (2019, June 28). DOH Statement on Hopeline. Retrieved January 17, 2022, from https://doh.gov.ph/press-release/DOH-Statement-on-HOPELINE Fukkink, R. G., Bruns, S., & Ligtvoet, R. (2016). Voices of children from around the globe: An international analysis of children’s issues at child helplines. Children & Society, 30(6), 510- 519. https://doi.org/10.1111/chso.12150 Gould, M. S., Kalafat, J., HarrisMunfakh, J. L., & Kleinman, M. (2007). An Evaluation of Crisis Hotline Outcomes Part 2: Suicidal Callers. Suicide and Life-Threatening Behavior, 37(3), 338–352. https://doi.org/10.1521/suli.2007.37.3.338 Gould, M. S., Cross, W., Pisani, A. R., Munfakh, J. L., & Kleinman, M. (2013). Impact of Applied Suicide Intervention Skills Training on the National Suicide Prevention Lifeline. Suicide and Life-Threatening Behavior, 43(6), 676–691. https://doi.org/10.1111/sltb.12049 Gould MS, Munfakh JL, Kleinman M, Lake A M. National suicide prevention lifeline: enhancing mental health care for suicidal individuals and other people in crisis. Suicide Life Threat Behav. (2012) 42:22–35. doi: 10.1111/j.1943-278X.2011.00068. x Hoffberg, A. S., Stearns-Yoder, K. A., & Brenner, L. A. (2020). The Effectiveness of Crisis Line Services: A Systematic Review. Frontiers in Public Health, 7, 399. https://doi.org/10.3389/fpubh.2019.00399 Inqiurer.net (2019, November 13). Toll free calls to Bantay Bata#163 for all Globe customers. Retrieved January 17, 2022, from https://business.inquirer.net/283231/toll-free-calls-to-bantay-bata-163-for-all-globe-custome rs In Touch Community Services. (n.d.). Crisis Line by In Touch. Retrieved January 17, 2022, from https://www.in-touch.org/join-crisis-line.html Kalafat, J., Gould, M. S., Munfakh, J. L. H., & Kleinman, M. (2007). An Evaluation of Crisis Hotline Outcomes Part 1: Nonsuicidal Crisis Callers. Suicide and Life-Threatening Behavior, 37(3), 322–337. https://doi.org/10.1521/suli.2007.37.3.322 King, R., Nurcombe, B., Bickman, L., Hides, L., & Reid, W. (2003). Telephone Counselling for Adolescent Suicide Prevention: Changes in Suicidality and Mental State from Beginning to End of a Counselling Session. Suicide and Life-Threatening Behavior, 33(4), 400–411. https://doi.org/10.1521/suli.33.4.400.25235 Mathieu, S. L., Uddin, R., Brady, M., Batchelor, S., Ross, V., Spence, S. H., Watling, D., & Kõlves, K. (2021). Systematic Review: The State of Research Into Youth Helplines. Journal of the American Academy of Child & Adolescent Psychiatry, 60(10), 1190–1233. https://doi.org/10.1016/j.jaac.2020.12.028 McGill (2020, Oct 28). Kids Help Phone Now Provides Crisis Support via Facebook Messenger. McGill. https://www.mcgill.ca/definetheline/channels/news/kids-help-phone-now-provides-crisis-sup port-facebook-messenger-325723 Mejias-Martin Y, Marti-Garcia C, Rodriguez-Mejias C, Valencia-Quintero JP, Garcia-Caro MP, Luna J, et al. Suicide attempts in Spain according to prehospital healthcare emergency records. PLoS ONE. (2018) 13:e0195370. doi: 10.1371/journal.pone.019537 Mishara BL, Chagnon F, Daigle M, et al: Which helper behaviors and intervention styles are related to better short term outcomes in telephone crisis intervention? Results from a silent monitoring study of calls to the U.S. 1–800- SUICIDE network. Suicide Life Threat Behav 2007; 37:291–307 Mishara BL, Chagnon F, Daigle M, et al: Comparing models of helper behavior to actual practice in telephone crisis intervention: a silent monitoring study of calls to the U.S. 1–800-SUICIDE network. Suicide Life Threat Behav 2007; 37:308–21 Mishara BL, Daigle M, Bardon C, Chagnon F, Balan B, Raymond S, et al. Comparison of the effects of telephone suicide prevention help by volunteers and professional paid staff: results from studies in the USA and Quebec, Canada00/00/0000 00:00:00. Suicide Life Threat Behav. (2016) 46:577–87. doi: 10.1111/sltb.12238 Mokkenstorm JK, Eikelenboom M, Huisman A, Wiebenga J, Gilissen R, K.erkhof A, et al. Evaluation of the 113Online suicide prevention crisis chat service: outcomes, helper behaviors and comparison to telephone hotlines. Suicide Life Threat Behav. (2017) 47:282–96. doi: 10.1111/sltb.12286 45 Pil, L., Pauwels, K., Muijzers, E., Portzky, G., & Annemans, L. (2013). Cost-effectiveness of a helpline for suicide prevention. Journal of Telemedicine and Telecare, 19(5), 273–281. https://doi.org/10.1177/1357633X13495487 Ramchand R, Jaycox L, Ebener P, Gilbert ML, Barnes-Proby D, Goutam P. Characteristics and proximal outcomes of calls made to suicide crisis hotlines in California. Crisis. (2017) 38:26–35. doi: 10.1027/0227-5910/a000401 Rappler.com (2020, April 19). LIST: Groups providing free online counseling during the pandemic. Rappler. https://www.rappler.com/moveph/257641-list-groups-providing-free-online-counseling-durin g-the-pandemic/ Sunstar Cebu. (2021, January 6). Hopeline 24/7 mental health support now on HealthNow app. Sunstar. Retrieved January 17, 2022, from https://www.sunstar.com.ph/article/1881955/cebu/lifestyle/hopeline-247-mental-health-suppo rt-now-on-healthnow-app Tan JC, Maranzan KA, Boone M, Vander Velde J, Levy S. Caller characteristics, call contents, and types of assistance provided by caller sex and age group in a Canadian Inuit crisis line in Nunavut, 1991-2001. Suicide Life Threat Behav. (2012) 42:210–6. doi: 10.1111/j.1943-278X.2012.00083.x Tawag Paglaum - Centro Bisaya. (n.d.). Tawag Paglaum - Centro Bisaya. Retrieved January 17, 2022, from https://www.facebook.com/Tawag-Paglaum-Centro-Bisaya-212062179304454/ Torres, T. (2020, April 17). Mental health check: How digital psychotherapy helps us cope with pandemic anxieties. Nolisoli. Retrieved January 17, 2022, from https://nolisoli.ph/78357/mental-health-check-ttorres-20200417/ UGAT Sandaline. (n.d.). About Us. Retrieved January 17, 2022, from https://www.facebook.com/UGATSandaLinePage/about World Health Organization. (‎2018)‎. Preventing suicide: a resource for establishing a crisis line. World Health Organization. . License: CC BY-NC-SA 3.0 IGO 46 Self-Guided and Digital-Based Parenting Interventions by Reynaly Shen Javier Researcher's Impressions: ● This intervention is promising mostly because of its ease of implementation and because there are a variety of programs to choose from. However, there is less certainty about its strength of evidence compared to other interventions. ● Questions about the digital use of the young also arise from this intervention. This was not explored in this report yet but should be noted if it reaches the next research phase. Intervention Brief These are interventions aimed at parents to improve their children’s mental health outcomes through a self-guided digital platform. The digital delivery of these interventions can be in the form of websites, apps, videos and podcasts. Executive Summary Key Points: ● There is considerable evidence suggesting that online parenting interventions lead to improvements in children behavioral problems but weaker evidence for improvements in children anxiety and depression. ● There are a lot of existing programs that can make it easy for a charity to build theirs and get advice. However, it should be noted that some program components are more associated with program effectiveness than others. ● Implementation and scaling seems to be easy because it is digital-based. However, internet connection costs and limited internet connectivity across the country shall be kept in mind. There also seems to be government interest in supporting a charity doing this intervention. ● Second sort assessment shows this is on the cheaper side compared to the other top 10 interventions. Key Limitations: ● The scale of children behavioral disorders in the Philippines is uncertain. ● Attrition rates can be high. Thus, digital interventions should be easy to implement and use. ● The intervention might be difficult to compare with others. 47 Conclusion This intervention still seems worth looking into during the Deep Reports phase. While the evidence supporting the intervention is difficult to assess because of different metrics, they still point to a positive direction. It is also cheap and easy to implement and scale up. The scale of the problem in the country is uncertain and seems to be the strongest reason to not start a charity doing an online parenting intervention. Overview Background Parenting practises can affect children’s well-being and behavior and contribute to the development of mental health problems. Early interventions are important not just because problems start early but also because when they are established, they can be harder to treat. Parenting interventions serve as these early interventions for children usually in the ages of 3 to 12 years. Child-specific outcomes addressed are usually behavioral problems, anxiety, depression and stress. Behavioral disorders can show as acting oppositional and aggressive around others and violations of rules and social norms. These interventions also have parent-specific consequences and many of the studies we found are focused on this. These are usually measured by their parental efficacy, parenting behavior, mood, depression, anxiety, and stress. We will focus however, on children outcomes since these are the end goal of improving parenting practices. Most of these measures are parent-reported so risk for performance bias is high. Digital technologies will allow us to be flexible and reduce professional support while cutting costs and reaching a wider population. Online parenting interventions we found during the research vary in length from single-session ones to 3-month programs. They identify parenting concerns including positive parenting strategies, parental emotional regulation, parenting recommendations for anxiety and depression, and adolescent substance use. Approaches employed include Cognitive Behavioral Therapy (CBT) and psychoeducation although these interventions are generally agnostic about the approach and are mostly categorized depending on the parenting problem. Some are fully self-guided while some offer therapist or peer support. They take on various forms such as websites, videos, apps, games and podcasts. They also cover different levels of prevention (universal, selective and indicated) and target populations with some focusing on a specific group of children (e.g. with traumatic brain injury) or parents (e.g. foster parents, new parents). 48 Review of the Evidence Studies on Self-Guided and Digital-Based Parenting Interventions General evidence for effectiveness Studies we found can be categorized into 2 groups according to children outcomes: studies targeting children behavioral outcomes and studies targeting children anxiety and depression. We found four meta-analyses on online parenting interventions aiming to improve children behavioral problems. All of these studies found significant improvements although they vary from medium- to large-sized effects. Children behavioral outcomes were usually measured using ECBI, CBCL and SDQ scales for the individual studies and are pooled for the meta-analyses using Hedges’ g. Note however that the studies included in the meta-analyses are diverse in terms of program components, lengths of intervention and follow-up, number of participants and target populations. For some results, the heterogeneity is significant. In one meta-analysis, removing a component i.e. regular therapist contact made heterogeneity non-significant but this reduced the effect size although it remained significant (Tarver et al., 2014). Aside from this, the meta-analyses provided other insights on program components: 1. Programs which helped parents addressing a specific issue (e.g. foster parenting, helping with the transition in becoming a parent) seemed to be more successful than general programs for common parenting support (Nieuwboer et al., 2013). 2. Synchronous and asynchronous types of communication were not related to outcomes(Nieuwboer et al., 2013). 3. Fully self-guided programs resulted in higher outcomes for parental knowledge while the guided programs produced higher outcomes for parental attitude and behavior (Nieuwboer et al., 2013). 4. All programs that included sending parents reminders to work on the program were highly effective in reducing behavioral problems. All programs with phone calls were less effective (Thongseiratch et al., 2020). 5. There was no significant difference between levels of human support in terms of behavioral outcomes (Bausback & Bunge, 2021). Some of these insights are in conflict with each other so we still have to look into the components further but there seems to be good evidence that online parenting interventions do improve children behavioral problems. Relative to the category of studies above, studies on online parenting interventions for children anxiety and depression are few. We were not able to find any meta-analyses focusing on these types of outcomes although some of the 49 meta-analyses we talked about above included one to two of these studies. So far, we only found three individual studies measuring anxiety and depression in children. One of these studies showed significantly greater improvement over time in child anxiety symptoms for the intervention group than the control group and for two other measures–anxiety life interference and anxiety disorders rate (Morgan et al., 2017). The two other studies however, are less conclusive (Cardamone-Breen et al., 2018; Yap et al., 2019). Both studies targeted parenting risks and protective factors known to influence adolescent anxiety and depression. While both studies showed significantly greater improvement on parenting risks and protective factors in the intervention group, there were no significant intervention effects on adolescent anxiety or depression symptoms. However, the target population for the first study is children aged 3 to 6 years while for the second and third studies, it is adolescents aged 12 to 15 years. This may suggest that parenting intervention work better on younger children. A meta-analysis mentioned above also looked into effect on children emotional problems including anxiety and depression and found that online parenting interventions significantly reduced related outcomes. Due to positive effects being more established in children behavioral outcomes, it might be best to focus on this for a potential intervention. Thus, we need to check for evidence of its connection with children well-being. This will be done in the Theory of Change section. Specific interventions that look promising Positive Parenting Program or Triple P (Triple P Implementation) This is the most common program evaluated in the studies we found and is widely found to be effective outside these. It gives parents strategies to reduce the prevalence of behavioral and emotional problems in children with levels of interventions for specific groups of children and different intensities of behavior problems. Triple P can be flexibly delivered via face-to-face individual or group sessions and digital ones. The five studies we found were delivered via website and via podcast (Sanders et al., 2012; Sanders et al., 2014, Sanders et al., 2008; Franke et al., 2020; Morawska et al., 2014). All found significant improvements on children behavioral problems. However, Triple P is expensive to run since it is copyrighted. There are also other programs repeatedly included in the meta-analyses that may be of interest. Robila (2020) compiled some parenting programs in Europe. Cool Kids This is the program used in Morgan et al. (2017) (see 5). It consists of 8 online weekly modules that include written information, videos, audio narration, interactive worksheets and activities, and parent stories. Parents could request telephone support from a psychologist. 50 Interventions in low-to-middle-income countries Most interventions evaluated in the meta-analyses and the individual studies we found are set in developed countries such as in the US, the UK, Sweden and mostly in Australia and New Zealand. The five studies on Triple P are all set in either Australia or New Zealand although it has been implemented in 30 countries around the world including some countries in Asia and Africa but still mostly in America, Europe and Oceania. The study on Cool Kids was set in New Zealand and we are unsure about where else it has been used. In the Philippines, there are already a few parenting programs but their aim is to reduce violence against children and they are non-online. The country’s Department of Education has launched a 5-week online parental support intervention on effective parenting in the midst of covid-19 for parents and caregivers of learners (Department of Education Ilocos Sur). It aims to engage with parents in protecting the health, safety and well-being of their children. This may suggest an interest in partnering with a charity doing an online parenting intervention. Theory of Change EA PH MHCIR Shallow Reports Theory of Change Assumptions The Review of the Evidence section focused on the effectiveness of online parenting interventions in improving child-related outcomes. In this section, we will discuss the other assumptions regarding the intervention. Children behavioral problems are related to their well-being. Children behavior and emotional problems are commonly associated with poor academic and psychosocial functioning (Orugndele, 2018). Parenting practices and behavior are related to children well-being. Two of the meta-analyses above also measured parenting practices and behavior (Tarver et al., 2014; Nieuwboer et al., 2013). There were small to moderate but significant improvements on parental attitude and behavior including reducing harsh discipline and improving lax and permissive discipline. These suggest a relationship wherein there are improvements in child behavioral problems when there are improvements in parental behaviors. The studies on children anxiety and depression show mixed evidence. Morgan et al. (2017) showed minimal effects on improving overprotective parenting but significant improvements on anxiety symptoms. Cardamone-Breen (2018) and Yap (2019) showed improvement in parenting but not for anxiety or depression symptoms. 51 There are, however, multiple studies outside what we’ve mentioned in the general evidence for effectiveness discussing this assumption. One led to results saying maternal and paternal autonomy granting and responsiveness were positively associated with adolescents’ well-being (Filus et al., 2019). Parental well-being is related to children well-being. Similarly, one of the meta-analyses on children behavioral outcomes measured parental mood and parental stress, revealing small but significant improvements in both (see 1). Another one measured parental mental health and also resulted in significant improvement (see 3). These suggest a positive association between parental well-being and children behavioral problems as well. The studies on children anxiety and depression only measured parenting behavior. This relationship is generally known to occur. Depression in parents is associated with adverse outcomes in children with the presence of additional risk factors (e.g., exposure to violence, comorbid psychiatric disorders, clinical characteristics depression). Parental functioning, prenatal exposure to stress and anxiety and stressful environments appear to contribute to the development of adverse outcomes in children too (National Research Council and Institute of Medicine, 2009). Children are at greater risk of developing behavior disorders when their parents have mental health conditions like substance use disorders, depression, or attention-deficit/hyperactivity disorder (ADHD) (Centers for Disease Control and Prevention. , 2021). After checking the assumptions, we can see that there is strong evidence for the relationship between parenting practices and children behavioral problems and weaker evidence for the relationship between parenting practices and children anxiety and depression. There is some support for the relationship between parental well-being and child behavioral problems and less for the relationship between parental well-being and general children well-being. Thus, it might be best for a charity to focus on improving parenting practices and behavior to improve children well-being. This is reflected in the Theory of Change figure. Brief Cost Effectiveness Review No cost-effectiveness studies specifically on digital interventions were found. Limitations The scale of child behavioral disorders in the Philippines is uncertain. There seem to be no large-scale research on this and we only found one study on Grade 1 pupils in South Cotabato (Rose et al., 2015). It found that the pupils have singly and collectively moderate levels of emotional and behavioral disorders with males having 52 higher levels than females and pupils from highly urbanized schools having higher levels than those from less urbanized schools. A study of 128 6 to 12 year-olds in India found 39% have abnormal scores in terms of total difficulties using the Strengths and Difficulties Questionnaire (SDQ). Conduct problem was the most prevalent behavioral disorder among all the subscales of SDQ with 48.70% of the children having abnormal scores (Datta et al., 2018). We can expect the scale of children behavioral disorders in the Philippines to be at a similar rate. The attrition rates can be high ranging from 3% to 15% as mentioned in the studies above. It is uncertain which analysis populations were used in most of the studies so it is difficult to gauge how attrition rates affected the results. Factors for high attrition rates may be being stigmatized as a bad parent, gender factors, socioeconomic status and lack of time and resources (Bausback & Bunge, 2021). Digital-based parenting interventions should consider these and also be easy to implement and use. The intervention might be difficult to compare with others. The measures used in the studies are mostly the same but we have not seen how they can be converted to the common measures used in studies for other interventions. Resources Bausback, K., & Bunge, E. (2021). Meta-Analysis of Parent Training Programs Utilizing Behavior Intervention Technologies. Social Sciences, 10(267). Behavior or Conduct Problems in Children. (2021). Centers for Disease Control and Prevention. https://www.cdc.gov/childrensmentalhealth/behavior.html Cardamone-Breen, M. C., Jorm, A. F., Lawrence, K. A., Rapee, R. M., Mackinnon, A. J., & Yap, M. B. H. (2018). A Single-Session, Web-Based Parenting Intervention to Prevent Adolescent Depression and Anxiety Disorders: Randomized Controlled Trial. Journal of Medical Internet Research, 20(4). https://doi.org/10.2196/JMIR.9499 Datta, P., Ganguly, S., & Roy, B. N. (2018). The prevalence of behavioral disorders among children under parental care and out of parental care: A comparative study in India. International Journal of Pediatrics and Adolescent Medicine, 5(4), 145–151. https://doi.org/10.1016/J.IJPAM.2018.12.001 Filus, A., Schwarz, B., Mylonas, K., Sam, D. L., & Boski, P. (2019). Parenting and Late Adolescents’ Well-Being in Greece, Norway, Poland and Switzerland: Associations with Individuation from Parents. Journal of Child and Family Studies, 28(2), 560–576. https://doi.org/10.1007/S10826-018-1283-1/FIGURES/2 Franke, N., Keown, L. J., & Sanders, M. R. (2020). An RCT of an Online Parenting Program for Parents of Preschool-Aged Children With ADHD Symptoms. Journal of Attention Disorders, 24(12), 1716–1726. https://doi.org/10.1177/1087054716667598 Morawska, A., Tometzki, H., & Sanders, M. R. (2014). An evaluation of the efficacy of a triple P-positive parenting program podcast series. Journal of Developmental and Behavioral Pediatrics : JDBP, 35(2), 128–137. https://doi.org/10.1097/DBP.0000000000000020 Morgan, A. J., Rapee, R. M., Salim, A., Goharpey, N., Tamir, E., McLellan, L. F., & Bayer, J. K. (2017). Internet-Delivered Parenting Program for Prevention and Early Intervention of Anxiety Problems in Young Children: Randomized Controlled Trial. Journal of the American Academy of Child and Adolescent Psychiatry, 56(5), 417-425.e1. https://doi.org/10.1016/J.JAAC.2017.02.010 53 National Research Council (US) and Institute of Medicine (US) Committee on Depression, P. P. and the H. D. of C., England, M. J., & Sim, L. J. (2009). Associations Between Depression in Parents and Parenting, Child Health, and Child Psychological Functioning. Nieuwboer, C. C., Fukkink, R. G., & Hermanns, J. M. A. (2013). Online programs as tools to improve parenting: A meta-analytic review. Children and Youth Services Review, 35(11), 1823–1829. https://doi.org/10.1016/J.CHILDYOUTH.2013.08.008 Ogundele M. O. (2018). Behavioural and emotional disorders in childhood: A brief overview for paediatricians. World journal of clinical pediatrics, 7(1), 9–26. https://doi.org/10.5409/wjcp.v7.i1.9 Online Parental Support Intervention on Effective Parenting in the midst of COVID-19 for Parents and Caregivers of Learners | DepEd Ilocos Sur. (n.d.). Retrieved December 29, 2021, from https://depedilocossur.info/?p=4600 Robila, M. (2020). Parenting Education in Europe. Rose, A., Ganado, F., & Cerado, E. C. (2015). Emotional and Behavioral Disorders (EBD) and Achievements of Grade 1Pupils. Saudi Journal of Medical and Pharmaceutical Sciences, 1(4), 103–112. http://scholarsmepub.com/sjmps/Website:http://scholarsmepub.com/ Sanders, M. R., Baker, S., & Turner, K. M. T. (2012). A randomized controlled trial evaluating the efficacy of Triple P Online with parents of children with early-onset conduct problems. Behaviour Research and Therapy, 50(11), 675–684. https://doi.org/10.1016/J.BRAT.2012.07.004 Sanders, M. R., Dittman, C. K., Farruggia, S. P., & Keown, L. J. (2014). A comparison of online versus workbook delivery of a self-help positive parenting program. The Journal of Primary Prevention, 35(3), 125–133. https://doi.org/10.1007/S10935-014-0339-2 Sanders, M., Calam, R., Durand, M., Liversidge, T., & Carmont, S. A. (2008). Does self-directed and web-based support for parents enhance the effects of viewing a reality television series based on the Triple P - Positive Parenting Programme? Journal of Child Psychology and Psychiatry and Allied Disciplines, 49(9), 924–932. https://doi.org/10.1111/J.1469-7610.2008.01901.X Tarver, J., Daley, D., Lockwood, J., & Sayal, K. (2014). Are self-directed parenting interventions sufficient for externalising behaviour problems in childhood? A systematic review and meta-analysis. European Child & Adolescent Psychiatry, 23(12), 1123–1137. https://doi.org/10.1007/S00787-014-0556-5 Thongseiratch, T., Leijten, P., & Melendez-Torres, G. J. (2020). Online parent programs for children’s behavioral problems: a meta-analytic review. European Child and Adolescent Psychiatry, 29(11), 1555–1568. https://doi.org/10.1007/S00787-020-01472-0/FIGURES/5 Triple P Implementation | Official Corporate site. (n.d.). Retrieved December 28, 2021, from https://www.triplep.net/glo-en/home/ Yap, M. B. H., Cardamone-Breen, M. C., Rapee, R. M., Lawrence, K. A., MacKinnon, A. J., Mahtani, S., & Jorm, A. F. (2019). Medium-Term Effects of a Tailored Web-Based Parenting Intervention to Reduce Adolescent Risk of Depression and Anxiety: 12-Month Findings From a Randomized Controlled Trial. Journal of Medical Internet Research, 21(8). https://doi.org/10.2196/13628 54 Nonprofessional-Delivered and Community-Based Parenting Interventions by Reynaly Shen Javier Researcher's Impressions: ● This intervention is interesting because Parenting for Lifelong Health from the World Health Organization has been adapted for Philippine use already. However, the evidence supporting PLH is still limited and not conclusively positive. Intervention Brief These are interventions that are delivered by non-professionals aimed at parents in specific communities to improve their children’s mental health outcomes. Executive Summary Key Points: ● It was difficult to find studies on the intervention but we found Parenting for Lifelong Health (PLH) which has parenting programs for different child age groups. ● There is already an adaptation of PLH in the Philippines (Masayang Pamilya Para Sa Batang Pilipino Parenting Programme) and it is promising in terms of reducing overall maltreatment of children. ● PLH programs are publicly available and given the local adaptation of one, there are many resources that can make it easy to found another similar program in the Philippines. Key Limitations: ● Evidence for effectiveness of parenting interventions on different child and parent outcomes is weak and with one study showing negative treatment effects. ● The intervention we might end up with might not directly address child well-being. The local adaptation of PLH addresses violence against children but interventions addressing mental health risks like this might not be the prefered charity to found. ● The intervention seems too expensive to implement and not very cost-effective. A cost-effectiveness analysis done on a PLH adaptation costs $2645 per DALY averted. ● The scale of behavioral disorders among children in the Philippines is uncertain. ● The intervention might be difficult to compare with others. 55 Conclusion The general evidence for effectiveness is weak but can be worth researching further because of an existing local adaptation of a known parenting intervention. Overview Background Parenting practices can affect children’s well-being and behavior and contribute to the development of mental health problems. Early interventions are important not just because problems start early but also because when they are established, they can be harder to treat. Parenting interventions serve as these early interventions for children and may be implemented for various age groups. For nonprofessional-delivered and community-based parenting interventions, child-specific outcomes addressed are usually violence against children, behavioral problems and depression. Behavioral disorders can show as acting oppositional and aggressive around others and violations of rules and social norms. These interventions also have parent-specific consequences and many of the studies we found are focused on this. These are usually measured by their parental efficacy, parenting behavior, mood, depression, anxiety, and stress. We will focus however, on children outcomes since these are the end goal of improving parenting practices. There is limited research done on parenting programs that are not delivered by health or mental health professionals. However, we were able to find a program, Parenting for Lifelong Health, which is delivered by trained community workers and is widely documented. The program has different versions for children age group and has been adapted in many low- and middle-income countries (LMICs) all over the world. Thus, there is also some heterogeneity within the programs and their effectiveness which we explored in the next sections. Review of the Evidence Studies on Nonprofessional-Delivered and Community-Based Parenting Interve… General evidence for effectiveness It was difficult to find meta-analyses or systematic reviews on nonprofessional-delivered and community-based interventions. Most parenting interventions considered in these studies are facilitated by specialists. However, we did 56 find a systematic review on family and parenting interventions in low- and middle-income countries for child mental health outcomes(Pederson et al., 2019). The majority of the studies favored the intervention but it is difficult to review since the quantitative outcomes are not summarized. Also, note that only 14 out of the 32 studies are parent-focused (others are family-focused) and only 13 studies are delivered by non-specialists. We only found one study, a randomized controlled trial on Sinovuyo Teen, an adaptation of the program Parenting for Lifelong Health (PLH), that fits the intervention requirement of being delivered by nonprofessionals (Cluver et al., 2018). The study’s primary outcomes are abuse and parenting practices but they also measured secondary outcomes including adolescent mental health (specifically, depression and suicidality) and behavioral problems. The intervention was associated with less abuse and improved parenting practices (some only by caregiver-reported measures, some by both caregiver-reported and adolescent-reported measures) but there was no improvement in adolescent mental health or behavioral problems. There was only a significant reduction in the adolescents’ alcohol and substance use. We will discuss PLH more in the following section. Specific interventions that look promising Parenting for Lifelong Health (PLH) PLH is a suite of parenting programs specifically made for low-resource settings where interventions delivered by professionals and through technological components are difficult to implement (World Health Organization). This is a collaboration between the World Health Organization (WHO), the United Nations Children's Fund (UNICEF) and other NGOs and universities. It has been used in 20 LMICs in Sub-Saharan Africa, South-eastern Europe, Southeast Asia, and the Caribbean including the Philippines (see next section). There are parenting programs designed for parents of infants (conception to 6 months), toddlers (1 to 5 years), young children (2 to 9 years) and teens (10 to 17 years). Sinovuyo Teen, the program adapted for South Africa for the PLH trial above, is a 14-session parent and adolescent programme (10 jointly attended by caregivers and adolescents, 4 attended separately) delivered by trained community members. Its content covers building positive relationships, emotional regulation, problem-solving, protecting adolescents from violence and exploitation and financial management. This study is the only study on PLH for teens with results in the linked research in the WHO page. There are two studies on PLH for Young Children and they are both set in South Africa. The first study found the intervention group to have significantly higher observed positive child behaviors and significantly fewer parent-reported child problem behaviors compared to the control group (Ward et al., 2020). This is alongside significantly higher parent-reported and observed positive parenting strategies in the intervention group compared to the control group. The second study found significant 57 negative treatment effects i.e. a decreased frequency of positive behavior in the intervention group in comparison to controls (Lachman et al., 2017). There were no other significant differences between the intervention and the control in terms of child behavior problems and observed negative behavior. It also showed no significant differences between groups for parent-report of child maltreatment but there were significantly more frequent parent-reported positive parenting. The conflicting results are said to be likely due to cultural acceptability and program complexity. There is also a study on PLH for toddlers which focused on book-sharing and toy-play interactions (Murray et al., 2016). It resulted in infants in the intervention group showing a significantly higher rate of prosocial behaviour. PLH programs are known to be effective in improving parenting strategies and behavior. They target different children outcomes from language development to maltreatment. Summarizing PLH evidence on the outcomes we are more concerned about for this research, for mental health-related risks, there is some promise for the effectiveness of PLH on reducing alcohol and substance as well as for reducing child maltreatment (more on this in the LMIC interventions). PLH seems to be effective on some measures of children behavior especially for young children. PLH did not show positive effects for improving adolescent mental health. Given the range of the PLH programs, it is still possible that we come up with an effective intervention if we consider the target population carefully. Interventions in low-to-middle-income countries PLH has been adapted for use in the Philippines in the form of Masayang Pamilya Para Sa Batang Pilipino Parenting Programme (MaPa, “Happy Family for Filipino Children”) (Lachman et al., 2021). The parenting intervention was delivered as part of the conditional cash transfer program called Pantawid Pamilyang Pilipino Program (4Ps). The study primarily measured the effectiveness of MaPa in reducing violence against children and found significantly less overall maltreatment and frequency of emotional abuse in the intervention group compared to the control. The intervention group also had reduced risks of physical abuse and neglect. They also reported increased parenting efficacy and fewer daily child behavior problems (but not as assessed by ECBI). While the results for child behavior problems are not as strong and there is no evidence yet on the effectiveness on other mental health outcomes like children depression and anxiety, the adaptation of PLH in the Philippines suggests that building a charity doing PLH programs can be easy to implement due to available adapted manuals and to a higher possibility of funding. Based on the 2015 National Baseline Study on Violence Against Children: Philippines, 80% of the 4,000 children reported having experienced some of violence in their lifetime (UNICEF Philippines, 2016). This shows that MaPa can be impactful in terms of scale. 58 Theory of Change EA PH MHCIR Shallow Reports Theory of Change Assumptions The Review of the Evidence section focused on the effectiveness of nonprofessional-delivered and community-based parenting interventions in improving child-related outcomes. In this section, we will discuss the other assumptions regarding the intervention. The assumptions are similar to those of self-guided and digital-based parenting interventions with the addition of the relationship between violence against children and their well-being since this is the common measure outcome we saw from the studies above. We also check the evidence for the assumptions using the studies we have discussed in the Review of the Evidence. Violence against children is related to their well-being Children exposed to violence have higher rates of anxiety, depression, other mental health problems and suicide (WHO). Children behavioral problems are related to their well-being Children behavior and emotional problems are commonly associated with poor academic and psychosocial functioning (Ogundele, 2018). Parenting practices and behavior are related to childwell-being There are multiple studies outside what we’ve mentioned in the general evidence for effectiveness discussing this assumption. One led to results saying maternal and paternal autonomy granting and responsiveness were positively associated with adolescents’ well-being (Filus, 2019). All of the studies we reviewed showed improvements in some parenting practices and behaviors but as discussed in the Review of the Evidence, the same interventions do not necessarily result in improved outcomes for children. Parental well-being is related to child well-being The studies we have reviewed give us mixed insights about the relationship between parental well-being and child well-being. Cluver et al. (2018) reduced parental depression and parental stress but it did not reduce adolescent depression. If we consider other child outcomes, Ward et al.(2020) showed higher positive child behaviors and fewer parent-reported child problem behaviors compared to the control and reduced parental depression but greater parental stress. Lachman et al. (2017) did not show significant difference between the intervention and the control in terms of child behavior problems and child maltreatment as well as for parental depression and parental stress. Lachman et al. (2021) showed less overall maltreatment but not less parental depression or parental stress. 59  However, a positive relationship is generally known to occur. Depression in parents is associated with adverse outcomes in children with the presence of additional risk factors (e.g., exposure to violence, comorbid psychiatric disorders, clinical characteristics depression). Parental functioning, prenatal exposure to stress and anxiety and stressful environments appear to contribute to the development of adverse outcomes in children too (National Research Council and Institute of Medicine, 2009). Children are at greater risk of developing behavior disorders when their parents have mental health conditions like substance use disorders, depression, or attention-deficit/hyperactivity disorder (ADHD) (Centers for Disease Control and Prevention, 2021). It might only be the case that the interventions were not effective in improving parental well-being but there are still improvements in child outcomes due to the interventions being effective in improving parenting practices which we discussed in the previous assumption. We can see then that the strongest chain in the Theory of Change is improving parenting practices to reduce violence against children and child behavioral problems and eventually improve child well-being. However, even the evidence for this chain is mixed. Brief Cost-Effectiveness Review A cost-effectiveness analysis of Sinovuyo Teen estimated the costs of the intervention at scale to be $266 per family, and the cost-effectiveness of the intervention to be $972 per emotional or physical abuse incident averted, equating to $2645 per DALY averted (Redfern et al., 2019). Limitations Evidence for effectiveness on different child and parent outcomes is weak. There is also one study that showed negative treatment effects that could be attributed to the complexity and the cultural acceptability of the intervention. The intervention we might end up with might not directly address child well-being. Evidence found suggests focusing on child behavioral problems or violence against children. There has not been a strong preference to address mental health risks in mental health charity research. The intervention seems too expensive to implement and not cost-effective. Most of the health charity ideas that Charity Entrepreneurship looks into are around $2o to $200 per DALY inverted. The scale of children behavioral disorders in the Philippines is uncertain. There seem to be no large-scale research on this and we only found one study on Grade 60 1 pupils in South Cotabato (Rose et al., 2015). It found that the pupils have singly and collectively moderate levels of emotional and behavioral disorders with males having higher levels than females and pupils from highly urbanized schools having higher levels than those from less urbanized schools. A study of 128 6 to 12 year-olds in India found 39% have abnormal scores in terms of total difficulties using the Strengths and Difficulties Questionnaire (SDQ). Conduct problem was the most prevalent behavioral disorder among all the subscales of SDQ with 48.70% of the children having abnormal scores (Datta et al., 2018). We can expect the scale of children behavioral disorders in the Philippines to be at a similar rate. The intervention might be difficult to compare with others. The measures used in the studies are mostly the same but we have not seen how they can be converted to the common measures used in studies for other interventions. Resources Behavior or Conduct Problems in Children. (2021). Centers for Disease Control and Prevention. https://www.cdc.gov/childrensmentalhealth/behavior.html Cluver, L. D., Meinck, F., Steinert, J. I., Shenderovich, Y., Doubt, J., Romero, R. H., Lombard, C. J., Redfern, A., Ward, C. L., Tsoanyane, S., Nzima, D., Sibanda, N., Wittesaele, C., de Stone, S., Boyes, M. E., Catanho, R., Lachman, J. M. L., Salah, N., Nocuza, M., & Gardner, F. (2018). Parenting for Lifelong Health: a pragmatic cluster randomised controlled trial of a non-commercialised parenting programme for adolescents and their families in South Africa. BMJ Global Health, 3(1). https://doi.org/10.1136/BMJGH-2017-000539 Datta, P., Ganguly, S., & Roy, B. N. (2018). The prevalence of behavioral disorders among children under parental care and out of parental care: A comparative study in India. International Journal of Pediatrics and Adolescent Medicine, 5(4), 145–151. https://doi.org/10.1016/J.IJPAM.2018.12.001 Filus, A., Schwarz, B., Mylonas, K., Sam, D. L., & Boski, P. (2019). Parenting and Late Adolescents’ Well-Being in Greece, Norway, Poland and Switzerland: Associations with Individuation from Parents. Journal of Child and Family Studies, 28(2), 560–576. https://doi.org/10.1007/S10826-018-1283-1/FIGURES/2 Lachman, J. M., Alampay, L. P., Jocson, R. M., Alinea, C., Madrid, B., Ward, C., Hutchings, J., Mamauag, B. L., Garilao, M. A. V. F. v., & Gardner, F. (2021). Effectiveness of a parenting programme to reduce violence in a cash transfer system in the Philippines: RCT with follow-up. The Lancet Regional Health - Western Pacific, 17, 100279. https://doi.org/10.1016/J.LANWPC.2021.100279/ATTACHMENT/1850D3FC-A401-4B74-9FF3-B33 36B35A97E/MMC1.DOCX Lachman, J. M., Cluver, L., Ward, C. L., Hutchings, J., Mlotshwa, S., Wessels, I., & Gardner, F. (2017). Randomized controlled trial of a parenting program to reduce the risk of child maltreatment in South Africa. Child Abuse & Neglect, 72, 338–351. https://doi.org/10.1016/J.CHIABU.2017.08.014 Murray, L., de Pascalis, L., Tomlinson, M., Vally, Z., Dadomo, H., MacLachlan, B., Woodward, C., & Cooper, P. J. (2016). Randomized controlled trial of a book-sharing intervention in a deprived South African community: effects on carer-infant interactions, and their relation to infant cognitive and socio-emotional outcome. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 57(12), 1370. https://doi.org/10.1111/JCPP.12605 National Baseline Study on Violence against Children: Philippines EXECUTIVE SUMMARY. (2016). UNICEF Philippines. https://www.unicef.org/philippines/media/491/file/National%20Baseline%20Study%20on%20Vi olence%20Against%20Children%20in%20the%20Philippines:%20Results%20(executive%20su mmary).pdf 61 National Research Council (US) and Institute of Medicine (US) Committee on Depression, P. P. and the H. D. of C., England, M. J., & Sim, L. J. (2009). Associations Between Depression in Parents and Parenting, Child Health, and Child Psychological Functioning. Ogundele M. O. (2018). Behavioural and emotional disorders in childhood: A brief overview for paediatricians. World journal of clinical pediatrics, 7(1), 9–26. https://doi.org/10.5409/wjcp.v7.i1.9 Parenting for Lifelong Health. (n.d.). World Health Organization. Retrieved January 2, 2022, from https://www.who.int/teams/social-determinants-of-health/parenting-for-lifelong-health Pedersen, G. A., Smallegange, E., Coetzee, A., Hartog, K., Turner, J., Jordans, M. J. D., & Brown, F. L. (2019). A Systematic Review of the Evidence for Family and Parenting Interventions in Low- and Middle-Income Countries: Child and Youth Mental Health Outcomes. Journal of Child and Family Studies, 28(8), 2036–2055. https://doi.org/10.1007/S10826-019-01399-4/FIGURES/2 Redfern, A., Cluver, L. D., Casale, M., & Steinert, J. I. (2019). Cost and cost-effectiveness of a parenting programme to prevent violence against adolescents in South Africa. BMJ Glob Health, 4, 1147. https://doi.org/10.1136/bmjgh-2018-001147 Rose, A., Ganado, F., & Cerado, E. C. (2015). Emotional and Behavioral Disorders (EBD) and Achievements of Grade 1Pupils. Saudi Journal of Medical and Pharmaceutical Sciences, 1(4), 103–112. http://scholarsmepub.com/sjmps/Website:http://scholarsmepub.com/ Violence against children. (n.d.). World Health Organization. Retrieved January 2, 2022, from https://www.who.int/news-room/fact-sheets/detail/violence-against-children Ward, C. L., Wessels, I. M., Lachman, J. M., Hutchings, J., Cluver, L. D., Kassanjee, R., Nhapi, R., Little, F., & Gardner, F. (2020). Parenting for Lifelong Health for Young Children: a randomized controlled trial of a parenting program in South Africa to prevent harsh parenting and child conduct problems. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 61(4), 503. https://doi.org/10.1111/JCPP.13129 62