School-based Psychoeducation in the Philippines and Low-to Middle-Income Countries

School-Based Psychoeducation in the Philippines and Low- to Middle-Income Countries October 2021 to April 2022 Margarita Ysabel Muñoz EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries Deep Report Author/s: Margarita Ysabel Muñoz Research Period: October 2021 to April 2022 Executive Summary Mental health issues in childhood and adolescence are significant global health concerns due to their associations with long-term health outcomes for individuals and, consequently, for communities. The youth in low-to-middle income countries (LMICs) are particularly vulnerable to mental health problems due to increased exposure to a variety of risk factors as well as a lack of access to quality mental health services. We propose the development of a school-based, teacher-delivered psychoeducation intervention as a means for youth in these contexts to gain access to information on mental health as well as to basic psychosocial support, resources that are commonly limited to hospital settings. This intervention entails task sharing with school teachers in order to equip them with the necessary knowledge, skills, and attitudes to be able to deliver psychoeducation in their respective schools. It is a promotive and preventive approach to addressing mental health issues within communities; i.e., it is meant for non-clinical or sub-clinical student populations and it aims to reduce the occurrence of mental health problems by promoting positive coping and resilience skills as well as fostering supportive school systems. There is substantial evidence supporting the effectiveness of school-based, teacher-delivered psychoeducation programs in improving a variety of mental health outcomes. Although the large number of ways that this type of program can be operated—depending on factors such as underlying theoretical orientation and strategies for implementation—makes it challenging to determine its overall effectiveness, school-based psychoeducation programs show promise in LMIC settings due to their value in addressing the “mental health gap.” Furthermore, school-based programs present a number of advantages. The youth spend a large amount of their time in schools, and schools are where important steps in social, cognitive, and emotional development take place. Additionally, existing school infrastructures can facilitate the large-scale implementation of mental health promotion programs. This intervention would be intended for children in grade levels 4-6. Psychoeducation for students would be conducted over 12-20 weekly sessions, each lasting approximately one hour. Psychoeducation modules would be developed based on needs assessment studies that would be conducted among stakeholders and in 1 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries collaboration with stakeholders. The charity would recruit full-time staff to serve as trainers who would be tasked with training teachers in delivering the psychoeducation modules for students in their respective schools. Training for teachers would involve information regarding how they can care for their own mental health needs, provide basic support for their students, identify students with mental health concerns, and make referrals whenever necessary. Trainers would also be tasked with providing periodical supervision for the trained teachers. Our cost-effectiveness estimate for this model is $85.93 per unit of improvement on the General Self-Efficacy Scale (GSES) in a year of operation when considering the charity’s total costs. While relatively costly to implement in initial years of implementation, it’s projected to become more cost-effective over time as the program scales up. We believe it has the potential to be very impactful and we recommend founding a charity providing this intervention. 2 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries Table of Contents Executive Summary 1 Introduction 4 Problem Assessment 4 Background 5 School-based, Teacher-Delivered Psychoeducation 6 Psychoeducation 6 Task sharing 6 Intervention Program (Gold Standard) 8 Quality of Evidence 9 Implementation 12 Target Location 13 Acceptability 13 Funding 13 Talent 13 Scaling 13 Externalities 14 Cost-Effectiveness Analysis 14 Weighted Factor Model 15 Recommended Intervention 16 Description 16 Quality of Evidence 20 Implementation 22 Target Location 25 Acceptability 26 Funding 27 EA Funding 27 Non-EA International Funding 27 Local Funding 27 Summary of funding 28 Talent 28 Scaling 29 Externalities 29 Cost-Effectiveness Analysis 30 Weighted Factor Model 31 Conclusion 32 Resources 34 3 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries Introduction This report was made through the Mental Health Charity Ideas Research Project under Effective Altruism Philippines. The project was a follow-up to Shen Javier and Brian Tan’s participation in Charity Entrepreneurship’s 2021 Incubation Program, in their region-specific track for training people to research the top charity ideas in a region. The project's goal was to find ideas that can become highly impactful and cost-effective charities in improving the well-being of people living in the Philippines and other low- to middle-income countries. It focused on children and adolescent mental health. To achieve this goal, we aimed to write deep reports such as this on the top mental health charity ideas that will come out of our four-phase research process. Our research process involved looking into the same ideas in multiple rounds of iterative depth such that the next rounds of research are deeper and only on fewer ideas than the last. We systematically evaluated all ideas, comparing them using the same criteria and the same questions. Some of the tools we used are weighted factor models that consider different factors such as implementability and acceptability of the interventions, evidence quality assessments, and cost-effectiveness analyses. In the six months of our research, School-based Teacher-delivered Psychoeducation came out as one of the most promising interventions. Since our research process does not allow us to research all other ideas in depth, we do not necessarily take the rest as ideas that are not potentially good. It would be of interest to explore them more in future iterations of this research project. Problem Assessment Mental health issues in childhood and adolescence are crucial because adaptive and maladaptive ways of functioning that develop during these life stages can have profound impacts on health outcomes in later life. Risk factors in childhood can lead to the development of mental health problems that can endure as the individual grows older, and problems that are not addressed early become much more difficult to treat in later life stages. Mental health issues during childhood may also cause biological changes (e.g. changes in brain structures and genetic expression) that affect one’s functioning. A child’s social environment can influence their ability to form effective relationships in the future, and children who are exposed to excessive amounts of stress may acquire compromised coping capacities and increased sensitivity to stressors, which may make them more susceptible to developing mental disorders (Zeman & Suveg, 2016). 4 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries It has been estimated that around 13% of youth worldwide aged 18 years and below have significant mental health problems (Murphy et al., 2017). In LMICs, mental health issues among children and adolescents are particularly pressing due to their exposure to a broader number of risk factors compared to their counterparts in HICs. These risk factors include poverty, the absence of caregivers, problems with regard to physical health and nutrition, poor quality of education, and increased exposure to violence and armed conflict. Despite increased risk for developing mental health problems, youth in LMICs have widely insufficient access to mental health information and services. This information is especially concerning considering that more than 80% of the world’s population of children and adolescents reside in LMICs (Fazel et al., 2014). One strategy towards addressing the disparity in the number of children 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). Within this framework, one approach to making mental health services more accessible to children and adolescents is by integrating mental health promotion and mental disorder prevention strategies into school systems. In the Philippines, a community-based mental health framework would be in line with the key provisions of Republic Act No. 11036 or the Philippine Mental Health Act (2018) which emphasizes access to 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 through community health centers, workplaces, and schools. Background Schools have been considered to be an important context for supporting the mental health and development of children and adolescents. The youth spend a large amount of their time in schools, and schools are where important steps in social, cognitive, and emotional development take place (Xu et al., 2020; Bradshaw et al., 2021). Additional advantages are that school infrastructures can facilitate the large-scale implementation of mental health promotion programs and that schools can provide access to additional social or health services when needed (Castillo et al., 2019, Bradshaw et al., 2021). School-based mental health programs have been found to be cost-effective and have the potential to reach a vast number of children and adolescents, making them especially advantageous in LMICs where majority of adolescents attend school but have limited access to health-facilities. 5 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries (Xu et al., 2020). Schools are located throughout both rural and urban areas of most LMICs, and rates of school attendance have improved substantially since the year 2000 (Fazel et al., 2014). School-based, Teacher-Delivered Psychoeducation The intervention we are presenting in this report entails task sharing and training of teachers to deliver psychoeducation activities in their respective schools. Psychoeducation 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 & McFarlane, 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. Task sharing 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 lay health workers. Lay health workers compose a broad group of individuals 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). Lay health workers have been identified as a potentially valuable means through which psychoeducation 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 lay health workers has 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 6 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries mental health, encourage help-seeking, improve perceptions of treatment providers, and modify culturally-based beliefs and preferences (Barnett et al., 2021). There have been movements to incorporate mental health promotion programs into school systems by involving teachers in their implementation. In addition to how teachers can facilitate students’ access to certain types of information, it can be through supportive relationships with teachers that students may become empowered to seek help. Teachers are also in a position that allows them to identify students with mental health needs and to make referrals when necessary. Despite these potential advantages of involving teachers in the promotion of mental health within schools, in LMICs, most teachers generally receive little training in mental health and feel unequipped to take on such a role (Nguyen et al., 2020). School-based, teacher-delivered psychoeducation 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 psychoeducation 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 psychoeducation programs implemented in LMICs are 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 7 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries relationship module, a 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. Several challenges have been observed in the implementation of programs that involve task sharing to lay workers, including teachers. Some of the major problems that have been identified are low compensation and lack of training and supervision— factors that may affect their motivation to participate in mental health promotion programs (Barnett, 2021). Other pertinent challenges that could influence teachers’ capacity to take on the additional role of facilitating mental health promotion activities among their students are poor role definition, challenging work conditions, problems in working relationships, issues with regard to boundaries and confidentiality, burnout and work-related stress, lack of appreciation for the role of teachers among the community, mental health stigma within the community and among teachers, and macro-level barriers (e.g. leadership and infrastructure; national, political, and socioeconomic factors)(Bunn et al., 2021; Kakuma et al., 2011; Castillo et al., 2019). Intervention Program (Gold Standard) 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 model of health promotion underlying this program was first developed in 1996 but became more established in 2002. It focuses on addressing common developmental issues among adolescents through highly participatory activities. It makes use of the infrastructure of the school and the involvement of teachers in the implementation of the program. Life skills were defined as abilities which promoted adaptive and positive behavior that empowered individuals to deal effectively with the challenges of daily life. The particular life skills targeted that the NIMHANS program aimed to develop were critical and creative thinking, decision-making and problem-solving, communication skills and interpersonal relationships, coping with emotions and stress, self-awareness, and empathy. Through the participatory learning methods mentioned above, students were able to gain conceptual understanding and to practice these skills in a non-threatening environment. The program developers emphasized that the intervention model went beyond didactic methodology and valued cultural sensitivity. The outcomes measured included self-esteem, self-efficacy, classroom behaviors, and adjustments in several contexts including the child’s home, school, and relationships with teachers and peers. This was based on the assumption that helping the youth develop alternative ways of solving real life problems would 8 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries contribute to positive improvements in these areas. The structure of this program can be modified to involve more specific discussions about various developmental and health themes, including substance use, issues regarding the use of technology, early marriage among adolescent girls, sexual abuse, bullying and violence in the community, absenteeism, professional and vocational choices, and attitudes towards political issues (e.g. corruption, dowry system in India, etc.). The activities and lessons included in the program are meant to be applicable for the general adolescent population—“bright and not so bright; outgoing and introverted; those with problems and those without; boys and girls.” A study was conducted among 14-16 year old students who underwent a year of the Life Skills Education program to assess possible improvements in several mental health outcomes (self-efficacy, self-esteem, adjustment, classroom behaviors) compared to students who had not undergone the program. The intervention group was composed of 605 students while the control group was composed of 425 students. Roughly 1000 teachers were trained to serve as Life Skills Educators. Outcomes were measured using the Pre-Adolescent Adjustment Scale (PAAS), the Strengths and Difficulties Questionnaire (SDQ), the General Self-Efficacy Scale (GSES), and the Rosenberg Self-Esteem Scale (RSES). To assess classroom behaviors, teachers were asked to accomplish behavioral checklists. The results of this study demonstrated higher scores in the intervention group compared to the control group in adjustment in several areas—particularly, general adjustment (p<.001) and adjustment in school (p<.001) and with teachers (p<.001)— as measured by the PAAS, prosocial behavior (p<.001) as measured by the SDQ, general self-efficacy (p<.001), and self-esteem (p<.002). No statistically significant differences were found in PAAS adjustment with peers, PAAS adjustment at home, SDQ-Emotions, SDQ-Conduct, SDQ-Hyperactivity, and SDQ-Peers. Additionally, behavioral checklists accomplished by teachers suggested that there were increases in positive classroom behaviors among students who had undergone the Life Skills program. Quality of Evidence A considerable number of experimental studies have demonstrated improved outcomes among children who underwent school-based psychoeducation programs both in LMICs and HICs; however, there is not much evidence regarding how well such programs could be implemented at scale, nor is there much evidence of how effective these programs would be in leading to population-wide improvements in mental health and other social outcomes (Murphy et al., 2017). Research on the effectiveness of school-based psychoeducation programs in LMICs is also generally limited. Nevertheless, these types of programs have continued to receive increasing attention in LMICs. 9 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries Murphy et al. (2017) conducted a review of school-based mental health promotion programs that have been implemented worldwide and identified the top eight programs that have had the largest reach. Namely, the programs were Positive Behavior Intervention and Supports (PBIS), FRIENDS, Positive Action (PA), Promoting Alternative Thinking Strategies (PATHS), Skills for Life (SFL), MindMatters, Good Behavior Game (GBG), and Cognitive Behavioral Interventions for Trauma in Schools (CBITS). Only SFL was developed in a LMIC (Chile). Out of these eight programs, only FRIENDS, SFL, and GBG had been implemented in LMICs. The FRIENDS program had been conducted in at least 800 schools in Brazil and a few dozen in Mexico. SFL was developed in collaboration between mental health professionals and educational professionals in the 1990s when Chile was still counted as a LMIC. GBG had been implemented in Brazil. All of the programs involved the provision of universal support to all students. FRIENDS and SFL included adaptations to their universal programs to address the needs of at-risk students. Six programs (including FRIENDS and GBG) were implemented by trained teachers in the classroom. The programs included in the review targeted various yet overlapping issues that are relevant to the youth, including social-emotional learning (SEL), internalizing and externalizing problems, anti-bullying, and well-being and resilience. All of the programs had undergone evaluations using RCTs or quasi-experimental designs. The collective evidence demonstrated that school-based psychoeducation programs can have significant positive effects on the emotional, behavioral, and academic outcomes of students. Evidence also suggested that such programs are sustainable both in LMICs and HICs, considering that the programs included in the review all have operated for more than ten years. Additionally, the researchers observed that programs which combined both universal and targeted interventions tended to be the ones with the largest scale. Based on a systematic review of school-based mental health promotion interventions in LMICs, Barry et al. (2013) contended that robust evidence existed for the effectiveness of such interventions in improving various outcomes, including resilience, coping skills, self-efficacy, and reductions in school violence, bullying, and dropout rates. It’s important to note, however, that out of the 14 studies included in their review, seven were designed for and implemented in areas affected by armed conflict. Six were multimodal in design and involved addressing problems in contexts outside of the school, such as family and community. The authors concluded that mental health promotion in schools in LMICs is feasible to implement, but among existing programs, few have been scaled up to serve larger populations of students. They added that the effectiveness of such interventions improves with increased structure and duration (Fazel et al., 2014). A more recent review conducted by Xu et al. (2020) about school-based mental health interventions for adolescents residing in LMICs found considerable evidence for the effectiveness of these programs in a variety of outcomes, albeit the 10 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries interventions widely differed in terms of the problems being targeted, the duration of the program, the components of the program, and the degree of involvement of relevant stakeholders. Eight programs that were implemented in LMICs (including China, the Philippines, Mongolia, Cambodia, and Malaysia) were considered in the review. All of them targeted adolescents 10-19 years old and were evaluated both through RCT and non-RCT studies. The topics covered by the different interventions were diverse, ranging from life skills to promote emotional well being, to sexual and reproductive health, de-worming, nutrition, obesity, tobacco use, and suicide. The shortest interventions took 6-12 weeks to implement, while the longest interventions took up to 36 months to implement. Some interventions addressed only a single action area (e.g., developing personal skills) while others combined several action areas, such as the development of a school health policy (e.g., integration of mental health programs into regular school curricula) and the creation of a supportive environment (e.g. renovation of grounds, improvement of latrines, enhancement of water supply) alongside the promotion of positive skills among students. Five out of the eight studied interventions delivered mental health promotion via teachers or other professionals, such as guidance counselors, psychologists, etc. Some interventions emphasized the importance of collaborating with health and other sectors, such as religious groups and local government units, in ensuring the success and sustainability of school-based interventions. Researchers argued that, in order to effectively scale a program, factors such as the acceptability of the intervention to government officials and the involvement of teachers at the early stages of programming to foster their appreciation for the process need to be considered. They also argued that an effective way to scale up and sustain a school-based mental health program is by integrating it into the school curriculum. In terms of the evidence for their effectiveness, Xu et al. (2020) found that all studies on the different interventions reported significant changes in mental health knowledge and attitudes among teachers and students. Interventions that targeted specific outcomes such as handwashing behaviors, use of contraceptives, and changes in school policies and environment also achieved significant improvements in these areas. On the other hand, ne study that aimed to promote life skills in order to foster emotional wellbeing had a small sample size, and while a significant reduction in aggressive behavior and externalizing symptoms were observed in high-risk male students, the effect sizes were only moderate (0.48 and 0.64, respectively). Additionally, school-based mental health programs have been found to improve the effectiveness of general education, and skills-based approaches tended to be more effective than lectures. It’s important to note that all the studies included in the review were pilot research in nature. Nguyen et al. (2020) evaluated the effectiveness and ease of implementation of the Mental Health & High School Curriculum Guide, a school-based mental 11 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries health literacy program, in Vietnam and Cambodia. The program was minimally adapted by the research team to be culturally-appropriate for these two contexts. In both areas, teachers were trained to implement the curriculum in select classrooms. Compared to teachers who had not undergone training, the trained teachers exhibited improvements in majority of the target outcomes, knowledge and attitudes towards mental health, mental disorder, and help-seeking. Significant increases in mental health knowledge and attitudes were also measured among students who underwent the curriculum. On the other hand, some small effect sizes indicated the need for additional research and development on certain components of the program. Nevertheless, the authors argued that these findings demonstrated the effectiveness of teacher-delivered mental health literacy programs in Southeast Asian countries, even with limited adaptation. They added that school-based mental health literacy programs were inexpensive, teacher-friendly, and relatively easy to integrate into school systems where there are positive attitudes towards “life skills” training programs. Implementation The following is a general outline for the potential steps involved in the implementation of a school-based, teacher-delivered psychoeducation program. This is based on the methodology followed by the developers of the NIMHANS LSE program: 1. Translation of the resource materials into the local language 2. Discussion with the national department of education—for the LSE program implementers in India, they had coordinated with the Adolescent Education Division of the country’s Department of State Education, Research, and Training. In the Philippines, likely equivalents of this are the Schools Division Offices specific to each city or Municipality, all under the Department of Education. 3. Identification of master trainers 4. Training of master trainers on the concepts of adolescent development, challenges and opportunities in adolescence, life skills and life skills education, facilitator methods, activities to be applied in classrooms, and training of teachers as LS educators 5. Life Skills Education awareness workshops for school administrators 6. Capacity building for teachers in identified secondary schools 7. Implementation of the LSE program in the identified schools over 12-20 weekly sessions, each lasting about an hour 8. Assessment sessions between master trainers and trained teachers every six months 9. Evaluation of the impact of the program on the sample of adolescents after one year 12 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries Target Location This type of intervention would likely be beneficial in developing countries where the mental health treatment gap exists. This community-based (particularly, school-based) approach may contribute to making mental health information more accessible to a larger proportion of the population since it aims to bring this information to the targeted communities in contexts that are a significant part of their daily lives. It would be beneficial for countries or regions where mental health services are limited in availability and often most accessible to individuals belonging to higher socio-economic classes. Acceptability As psychoeducation is a promotive and preventive approach to mental health, it’s likely to be suitable for localities where mental health is stigmatized and discussions focused on mental health problems and disorders are likely to be received negatively by the average lay person. Funding A potential source of funding for this type of program would be through tapping local government funds allotted for mental health and child health, albeit initial runs of the program could only likely be done at a small scale. At this point, no specific funding sources have been identified. Talent Program implementers would have to establish partnerships with target schools in order to recruit the teachers who would be trained in delivering the program. Scaling Close partnerships with schools would facilitate scaling-up and support the sustainability of this type of intervention. By continually communicating and demonstrating the significance of mental health promotion programs among all stakeholders, in correspondences with school administrators or refresher training sessions for educators, continued support for the program would be more likely. Adequate and well-documented data on the effectiveness and impact of the program would also be important to support the expansion of the program to a greater number of schools. Externalities As this type of program would be introducing a new set of responsibilities for teachers who will have to balance them with their regular tasks and other 13 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries ancillary roles, it is probable that trained teachers would experience heightened stress or burnout due to increased workload. This potential effect on teachers’ wellbeing may have an impact on their teaching performance and may have a “trickle-down” consequence wherein students become negatively affected as well (e.g., compromised quality of education). Indirect benefits that could potentially result from this type of intervention are improved student-teacher relations, and improved attitudes towards mental health among the school community in general. As a life skills education program deals with learning strategies for solving and coping with real life problems, the knowledge gained from it would likely contribute to improvements in other outcomes beyond those measured in the original study on the NIMHANS LSE model’s impact. Cost-Effectiveness Analysis The following presents the results of a cost-effectiveness analysis (CEA) or a school-based, teacher-delivered psychoeducation program in an LMIC-setting. Costs were estimated based on projected expenses with regard to the implementation structure of NIMHANS LSE model. We also used the Philippine context as our basis to determine average wages and average costs for conducting certain activities, particularly training sessions. Costs were estimated for the first year of implementation and the third year of implementation. This was based on the assumption that the pilot implementation of the program during year 1 would likely involve a small number of beneficiaries and thus fixed operational costs would appear disproportionately high. We argue that the CEA for the third year of implementation would represent a more accurate CEA of this type of program once it has increased in scale. Table 1 Initial cost-effectiveness analysis for school-based teacher-delivered psychoeducation - Year 1 and year 3 of implementation Year of Estimated number of Unit $ per unit, $ per unit, Operation beneficiaries total costs intervention (students) costs only 1 300 (One school) GSES 68.22 1.31 3 1500 (Five schools) GSES 26.91 3.26 The study that examined the effectiveness of the NIMHANS LSE model demonstrated improvements on several outcomes, specifically adolescent adjustment in several contexts, self-esteem, self-efficacy, and classroom behaviors. For this CEA, estimated improvements in self-efficacy—measured using the General Self-Efficacy Scale—are considered, since self-efficacy is a construct which is associated with a variety of other mental health outcomes. 14 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries In our review of evaluation studies on school-based psychoeducation programs, the mental health outcomes that were targeted and measured largely varied. We were unable to find studies conducted in LMIC-settings which made use of SWLS or DALYs. This CEA demonstrates that this type of intervention might be relatively expensive during the initial periods of implementation but may become increasingly more cost-effective as it scales up. Whereas it would cost around $68 per one point increase in GSES scores per student during the first year of implementation, in the third year it would be estimated to cost around $27 per unit. Intervention costs increase over time but seem to be negligible as this intervention is generally relatively inexpensive to run. Weighted Factor Model We used the following criteria for our WFM: effectiveness (20%), acceptability (10%), ease of implementation (20%), ease of scaling (30%), and ease of funding (20%). Effectiveness refers to the quality of evidence supporting positive outcomes from the intervention. Acceptability is the extent to which people participating or implementing the intervention see the intervention as appropriate to themselves and the communities it aims to support. Additionally, it considers how much of the intervention should be changed to make it applicable to the participants. Ease of implementation refers to the minimum length of time an intervention can be at least piloted. Ease of scaling evaluates whether the charity meets the three criteria for scalability that say there shall be: 1) identified communities/delivery settings for the intervention, 2) available workforce for scaling, and 3) availability of implementation infrastructure for scaling. Lastly, ease of funding is about the intervention’s likelihood of being funded based on its timeliness or relevance in the region. We created a weighted factor model evaluation of the intervention, taking into account its perceived effectiveness based on the available evidence, its acceptability in LMICs (how well it would fit into the social milieu), and how easy it’s likely to be to implement, scale, and seek funding for. In rating ease of implementation, we mainly considered the length of time that would be required for the first full run of the intervention. We defined ease of scaling in terms of the availability of infrastructures in the targeted contexts that could facilitate the expansion of the intervention. This includes the availability of workforce. In determining ease of funding, we considered priority areas for mental health research and program development particularly in the Philippines, based on the National Mental Health Research Agenda developed by the Philippine Council for Health Research and Development. Each member of the research team individually evaluated the intervention on each factor, and the average ratings were calculated. We did this for each of the 15 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries top 8 ideas. Based on the average ratings, we attempted to identify the top 4 ideas; however, due to the ratings being close to each other as well as our own qualitative insights regarding the value of several interventions, we first identified the top 6 most promising ideas. We then narrowed down these 6 interventions by ranking each of them against each other based on the results of their respective cost-effectiveness analyses. The three ideas with the highest rankings became our top 3. For school-based psychoeducation, we arrived at the following ratings for each factor: ● Effectiveness – 3.75 ● Acceptability – 4.25 ● Ease of implementation – 3.38 ● Ease of scaling - 3.38 ● Ease of funding – 4.38 Our initial impressions of this intervention led to a final rating of 3.83. It ranked the third highest in terms of cost-effectiveness. Recommended Intervention Description In this section, we will be presenting our recommended revisions to the gold standard intervention to optimize potential implementation in the Philippines. These revisions are largely based on information gathered from interviews with Filipino experts whom we identified as being adequately knowledgeable about child and adolescent mental health, specific mental health issues prevalent among the Filipino youth, the implementation of interventions for children and adolescents in the Philippines, and the Philippine education system and education policy. In particular, we spoke with Dr. Dinah Nadera, a psychiatrist and the president of the Foundation for Advancing Wellness, Instruction, and Talents, Inc. (Foundation AWIT). We also spoke with Dr. Teresita Rungduin, a professor from the Philippine Normal University who specializes in child and adolescent psychology and psychoeducation, among other areas of knowledge. Both experts expressed having positive initial impressions about the intervention idea, stating that it’s an important advocacy and that a “school that promotes positive emotions well-being will likely be schools that produce good citizens.” They considered such an intervention to be inclusive, because in addition to drawing attention to the subclinical populations of students (“the forgotten 16 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries middle who deal with everyday challenges”), school-based mental health promotion activities would also benefit school administrators and educators. The experts mentioned that programs of this type already exist in the Philippines. As mandated by the Philippine Mental Health Law (RA 11036) as well as the GMRC and Values Education Act (RA 11476) and the Guidance and Counseling Act of 2004 (RA 9258), the Department of Education (DepEd) and the Commission on Higher Education (CHED) are required to integrate mental health promotion programs in schools based on the needs of students. DepEd has implemented a number of mental health promotion programs for students particularly during the COVID-19 pandemic. Existing government programs face a number of limitations. For one, they tend to be designed to address temporally relevant issues (e.g., coping during the pandemic) rather than focus on lifespan-oriented concepts that can be integrated into the school curriculum and continuously taught. These programs tend to be implemented in individual schools, by individual school divisions, or initiated by specific Local Government Units. Additionally, despite some of these programs being based on needs analysis studies among students, the experts noted that the information we have so far regarding the most efficient outcomes to target in promoting mental health among the Filipino youth is not enough. Both experts acknowledged a general lack of an overarching framework underlying these programs as well as a lack of a unified system for delivering such programs across schools in a consistent manner. Unless addressed, these issues can significantly diminish the sustainability of school-based mental health programs. With regard to whether curriculum-based interventions are preferable to non-curriculum-based interventions, the experts expressed some conflicting opinions. Both agreed that integrating mental health promotion into school curricula would be ideal in that it would be more sustainable and would more effectively facilitate systemic changes. Dr. Nadera acknowledged that such a task would be easier said than done. Although she advocates for the integration of mental health topics in existing school subjects, for a new charity aiming to implement a school-based mental health program, she recommended designing interventions that would aim to address a specific, timely problem (e.g. Balik eskwela, or the anxiety faced by students and teachers as they return to school). This would not only make the intervention more feasible but would also make it more appealing to potential funding agencies. With regard to the specific content of the intervention, both experts recommended identifying topics that were both developmentally appropriate and culturally grounded. Dr. Rungduin hoped to see an intervention that was rooted in Filipino values and character strengths (e.g. pakikipagkapwa). Developmentally appropriate interventions would entail focusing on mental health issues relevant during each stage of childhood (e.g. body image issues that may arise during 17 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries puberty).Dr. Nadera stressed the importance of presenting information that would be culturally and developmentally relatable for students, otherwise we would “risk leaving them with generic concepts.” The experts recommended that, at least in the early years of implementation, the intervention focus on only one grade level or a small set of grade levels (rather than all grade levels simultaneously) as this would be more feasible to implement as well as easier to monitor. In developing program modules, topics should be identified and discussed differently per grade level and ideally would build up on concepts learned from previous levels. Furthermore, the experts recommended developing an intervention for grade levels 4-6. At this stage, children are already capable of articulating their thoughts and emotions but do not yet have the breadth and depth of influence that children in junior high school have. Psychoeducational interventions presented at earlier ages would increase the likelihood of knowledge being ingrained within children compared to if the interventions were presented in later childhood. Challenges identified by the experts in terms of implementing this type of intervention were also identified. Bureaucracy in public schools would likely make the groundworking tasks for this intervention more difficult in those settings compared to private schools. Significant barriers to consider when proposing the adoption of this type of program in schools are the school administrators’ attitudes towards mental health promotion programs in general. This includes considering how much the program would be aligned with existing policies and activities that the school administrators already have in place. Another important barrier to the implementation of the intervention is the likelihood that it would not be manageable alongside the current workload of teachers. Generally, teachers in the Philippines perform many ancillary tasks aside from their regular responsibilities. Examples are their involvement in disaster response activities whenever the need arises as well as their roles as coordinators for the Pantawid Pamilyang Pilipino Program (4Ps), a government initiative under the Department of Social Welfare and Development (DSWD) that aims to provide financial support to poor households. This issue is particularly crucial to address since a significant aspect of the intervention we are proposing is that it would be implemented by trained teachers. The experts recommended that the intervention involve devising a system through which teachers could develop a community of support as well as provide means for teachers to seek assistance with their tasks whenever necessary. Providing compensation to the trained teachers would also serve as an additional motivator, but the sustainability of the compensation would have to be considered. Confidentiality and data privacy of students and teachers who would be undergoing the program also need to be safeguarded. It was recommended that the 18 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries training sessions with teachers should also include discussions revolving around work ethics and understanding the value of being told confidential information. In terms of ensuring the sustainability of the program, the experts suggested that the development of an overarching, culturally grounded, and developmentally appropriate framework to guide the intervention would support its consistent and continuous implementation. Additionally, this would contribute to the scalability of the program. In order expand the intervention to a greater number of schools, schools should have a unified understanding of the concepts being promoted as well as a defined catalog of activities included in the psychoeducation program. Furthermore, adequate monitoring and evaluation strategies are also valuable in ensuring the program would be sustainable and scalable. In terms of funding, Dr. Rungduin suggested that incorporating a research component to the intervention would make it possible to seek funding from institutions that offer grants for research activities. Potential funders would include the National Research Council of the Philippines (NRCP), the Philippine Social Science Council (PSSC), and agencies under the Philippine Department of Science and Technology (DOST) such as the Philippine Council for Health Research and Development. Dr. Nadera suggested that the special education fund allotted to Local Government Units could also be tapped for funding school-based programs. To summarize, based on the information that we had acquired from the experts we had interviewed, we are recommending the following revisions to the intervention: ● Design the program to be a form of action research that would aim to assess the prevailing needs of stakeholders and evaluate the effectiveness of the intervention in order to support its continual development. ● The content for the psychoeducation modules must be based on needs analyses, grounded in indigenous values, and developmentally appropriate. ● Rather than high school students, the recommended intervention would target intermediate level students (grades 4-6). ● During initial meetings with school administrators, the significance of this type of intervention must be adequately communicated and provided with a rationale vis-à-vis existing school policies, plans, and programs. These discussions may be anchored on pertinent laws that mandate the integration of mental health promotion initiatives into school curricula. ● In addition to developing program modules for students, it would also be beneficial to develop program modules for teachers that would aim to increase their awareness of mental health issues, learn skills that would 19 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries allow them to support their own mental health as well as the mental health of their students, safeguard confidentiality and data privacy, and identify students exhibiting symptoms of more severe mental health problems and refer them to the appropriate agencies. Furthermore, a system must be devised for teachers to be able to easily seek support and guidance from their fellow teachers as well as from the program implementers. ● The frequency of program assessment sessions between trainers and teachers would be conducted more frequently—bi-monthly rather than every six months. Quality of Evidence Dr. Nadera and Dr. Rungduin’s insights regarding the challenges that could be faced by trained teachers are consistent with what existing literature has stated about the challenges faced by lay workers involved in similar community-based programs. These challenges include lack of compensation, limited training and supervision, poor role definition, increased work pressure, lack of familiarity with the program, low fidelity to training models, stigma towards mental health within the community, issues related to boundaries and confidentiality, and system-level barriers (e.g., leadership and infrastructure) (Barnett, 2021; Bunn et al., 2021; Kakuma et al., 2011; Castillo et al., 2019). More specific to the Philippine context, a study conducted among elementary and high school teachers in Metro Manila found that the most common sources of stress for teachers are having too much paperwork, financial difficulties (particularly low salaries along side high costs of living), oversized classes, and having to juggle multiple roles at a given time (including continuing their own professional education, parenting, and engaging in community service)(Mingoa, 2017). Addressing these challenges would be important in order to ensure the success of a school-based intervention that would be requiring the involvement of teachers in its implementation. In addition to facilitating teachers’ engagement in the program, interventions with components that aim to reduce teacher stress and burnout can also contribute to a downstream effect wherein students benefit as well. Reductions in teachers’ self-reported stress and burnout have been found to be associated with improvements in students’ perceptions of their teachers’ support in the classroom as well as improvements in academic self-perception among students (Carroll et al., 2021). Although a unified, developmentally-informed framework for school-based mental health programs in the Philippines has not yet been created, a number of studies have attempted to formulate wellbeing frameworks for the youth that take into consideration values that are significant to Filipino culture. The BLOOMS model developed by Cristobal and Bance (2021), though focused on university students, provides an example of a framework for wellbeing that was formulated 20 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries based on Filipino experiences. The model takes into account academic, psycho-emotional, physical, social, and spiritual factors that influence wellbeing. It then proposes the following strategies towards enhancing wellbeing and promoting holistic growth: Building (caring for one’s physical health), Leveraging (optimizing resources available in one’s environment), Owning (developing awareness of negative affect), Opening (releasing thoughts and feelings), and Molding (valuing and empowering the self). Researchers have also looked into character strengths and values that, when supported, could lead to improvements in mental health outcomes. These studies validated the applicability of these constructs in the Philippine setting. For instance, Datu and Bernardo (2020) found a significant relationship between the interpersonal character strengths of fairness, teamwork, leadership, and kindness to academic achievement, engagement, and life satisfaction among high school students. This study was based on previous research that had demonstrated that Filipino students’ achievement motivations tended to be related to socially oriented motivations. In a separate study, Datu and Mateo (2020) found associations between several character strengths and positive emotions, negative emotions, interdependent happiness, and academic self-efficacy among high school students. The character strengths of fairness, gratitude, and hope were found to have positive relationships with academic self-efficacy. Love of learning was associated with interdependent happiness, and gratitude was associated with positive emotions. This study aimed to specifically highlight the importance of cultivating character strengths in non-Western societies. Studies provide examples of potential bases for the content of a psychoeducation program for children and adolescents, but further research is needed on indigenous conceptualizations of wellbeing that are relevant for the youth. In terms of conducting a needs assessment to identify the most pressing and timely concerns of the youth, it would be worth it to consider investigating and addressing the immediate mental health impacts of the COVID-19 pandemic on the youth as these have been significant and are likely to persist even as we are transitioning into a post-pandemic world. One major concern that has been identified is the loss of opportunities for cognitive and social development due to social isolation and difficulty accessing educational resources. Adolescence is a life stage characterized by rapid developmental change. During this time, access to peer groups and rapid social stimuli are crucial for healthy development. Social deprivation can inhibit or alter this development (Tatum, 2021). Rates of mental health problems among the Filipino youth also seemed to increase during the pandemic, evident in data collected by the Philippine General Hospital which demonstrated a rise in the number of mental health consultations (compared to consultations regarding other medical concerns) with adolescents from 17% in 2019 to 27% in 2020. Some of the commonly cited sources of stress were online 21 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries learning and the loss of opportunities to socialize and be physically active. The number of children living in poverty also was estimated to increase due to the return of migrant workers because of the pandemic. Furthermore, reports of child abuse during the pandemic increased in number, likely because quarantine measures have led more children to be confined with their perpetrators. Implementation In this section, the final model of the intervention will be discussed with the theory of change. A visualization of the theory of change for the intervention is shown below. Figure 1. Theory of change for school-based teacher-delivered psychoeducation The following are the key assumptions for the intervention, supported by information presented in the sections regarding the background and quality of evidence regarding the intervention. 1. Task sharing of mental health promotion activities to lay workers—in this case, teachers—would increase the accessibility of mental health information and facilitate the improvement of attitudes towards mental health in the community. Task sharing with non-professional or lay workers has been significantly gaining attention as a promising means towards addressing the mental health treatment gap. Lay workers, including teachers, often share cultural and linguistic histories with the individuals that they serve, and this puts them in an optimal position to alter prevailing attitudes within their communities. 2. Schools are an important context for supporting the mental health of children and adolescents (See Background). 22 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries 3. School infrastructures can facilitate the large-scale implementation of mental health promotion programs and can help provide access to additional support when needed (See Background). Below is a general outline of the activities that would be involved in the development and implementation of the intervention: ● Needs assessment Development of the program modules must be grounded in a comprehensive assessment of the current needs and issues faced by Filipino children and adolescents. This may involve gathering data from students, educators, school administrators, professionals who specialize in child and adolescent mental health in the Philippines, and relevant government agencies (e.g. DepEd, CHED). This study should take into consideration potential differences in responses between public and private schools, between rural and urban areas, and across different geographical locations and ethnolinguistic groups. Additionally, it would be worthwhile to conduct a comprehensive review of extant literature regarding culturally-specific constructs or associated constructs that have been linked to wellbeing outcomes in children and adolescents. ● Development of modules for trainers, teachers, and students Based on the data gathered from the needs assessment, separate modules must be developed for trainers, teachers, and students. In addition to the relevant constructs identified during the needs assessment, the modules for trainers and teachers must also include education about child development as well as about risk and protective factors that are most significant during childhood. Modules for trainers would include guidelines for establishing rapport, maintaining coordination, and providing supervision to the trained teachers. Modules for teachers would involve discussions about the mental health needs of educators, skills for supporting one’s own mental health, and where they could seek support. Modules for students would involve psychoeducation and positive skills-building activities that are grounded on cultural conceptualizations of wellbeing. Similar to the NIMHANS Life Skills Education program discussed in the Background, it would be valuable for this intervention to make use of participatory learning methods such as role-plays, debates, and games. ● Recruitment and training of trainers Trainers would be recruited as full-time staff. Training of trainers would be held over five days. Trainers would be educated about the program framework and trained in the delivery of the program modules. They would also receive guidance on establishing rapport, maintaining communication with trained teachers, providing supervision, and facilitating monitoring and evaluation of the program. 23 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries ● Meetings and orientations with school administrators Initial meetings with school administrators of prospective partner schools must involve discussions about the importance of mental health and the significance of the school context in determining optimal child development. Program implementers must determine along with the school administrators the number of teachers that would be trained and involved in the program based on the school’s workforce, the student population, and the teachers’ regular workload. This meeting may also involve an assessment of existing mental health services that are accessible to the school community. ● Capacity building and training for teachers Training for teachers would be done over the course of three to five whole day sessions. The feasible duration for the training sessions would be determined during consultations with school administrators. It would be worthwhile to consider providing incentives for the teachers who would be participating, such as Continued Professional Development (CPD) credits, food and transportation allowances, or financial compensation. A portion of the training program would be focused on identifying mental health issues commonly experienced by teachers and discussing ways in which teachers could support their own mental health. The rest of the training program would be focused on guidelines for implementing the modules for students. Additionally, teachers would be trained on handling issues regarding confidentiality, common signs of emotional and behavioral problems among children, and systems of referral for students needing specialized services. Lastly, the teachers would be oriented as to the tools and strategies for monitoring and evaluating the program. ● Implementation of the psychoeducation program for students Teachers would be facilitating weekly psychoeducation sessions with their students, each lasting one hour and delivered over 12-20 weeks. They would be asked to prepare periodical accomplishment reports regarding the activities conducted as well as the number of students that were reached. Accomplishment reports may also include data regarding the number of students that were screened for emotional and/or behavioral problems as well as the number of referrals that were made. ● Supervision sessions with teachers Trainers would have group supervision sessions with teachers every two months. In these sessions the teachers would present their accomplishments during the period. This would also an opportunity for them to seek support regarding any challenges they may face while delivering the psychoeducation program. Despite these scheduled sessions, teachers should have an easily accessible line of communication with trainers for consultation whenever they require clarification regarding the 24 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries modules or other forms of assistance. The information collected from teachers during supervision sessions would be included as data for program evaluation. ● Continuous evaluation of the program’s process and impact Measures of mental health outcomes for students and for teachers would be collected throughout implementation. Other sources of data would be accomplishment reports submitted by teachers as well as feedback obtained from classroom discussions and supervision sessions. ● Research and continual development of program The data collected would not only be integral for the continued improvement and development of the program but could also contribute to research on mental health issues among children and on the effectiveness of school-based mental health promotion programs, particularly in the Philippine setting. Theoretical and practical aspects of the program such as module content, the length of training sessions, the duration of psychoeducation sessions, and frequency of supervision may be modified based on the results of the evaluation. Target Location Our research is focused on identifying the best mental health interventions in low-resource settings. Our main criterion for choosing the target location is the scale of the problem of mental health in different regions. Ideally, we would use country data to compare all low-to-middle-income countries. However, due to the lack of easily analyzable data, we first compared the Disability-Adjusted Life Years (DALYs) burden of mental disorders of world regions, as specified by the World Health Organization (WHO) then the DALYs burden of mental disorders of the countries in the top region. We used data from the Global Burden of Disease (GBD) 2019. Data was available for individuals aged 5 to 24 years old which is of a similar range to our priority age group. Southeast Asia turned out to be the region with the highest burden of mental disorders, depressive disorders and anxiety disorders in number of DALYs among the six world regions. The rest of the regions are ranked in descending order of number of DALYs as follows: African Region, Americas, Western Pacific Region, Eastern Mediterranean Region and European Region.  Income demographics vary across countries per region and this is important to note to make sure that targeted locations are indeed low-resource. For all regions except Southeast Asia, depression and anxiety combined make up more than half of the DALYs burden of mental disorders. Thus, we looked into other mental disorders when analyzing the DALYs burden for Southeast Asian countries. Indonesia, the Philippines and Vietnam make the top 3 countries with the highest number of DALYs lost to mental disorders, depressive disorders, conduct disorder and autism spectrum disorders in the region. Myanmar replaces Vietnam 25 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries as the country having the third highest number of DALYs lost to anxiety disorders. Indonesia remains the first while Vietnam ranks second and the Philippines ranks third for the highest burden of substance use disorders in number of DALYs. Indonesia and the Philippines rank first and second respectively as the countries having the highest burden of attention-deficit/hyperactivity disorder (ADHD) in number of DALYs with Thailand joining as the third top country. Substance use disorders are not considered mental disorders in the GBD report but they are included in our PICO framework and are commonly addressed by the studies we found across interventions. Conduct disorder, ADHD and autism spectrum disorders are excluded in our PICO framework but they are common target conditions in children in the studies we found. Singapore is the only Southeast Asian country classified as high-income. Malaysia and Thailand are upper-middle income countries and the rest are lower-middle income countries. Thus, Indonesia, Philippines and Vietnam shall be prioritized. Due to the researchers’ location and expertise, this research focuses on the Philippines. We still expect the results to be somewhat generalizable to these other two countries due to their similarities since the interventions we are investigating are made for low-resource settings and to target common mental health disorders. In the Philippines, there is no available local data that can guide us in prioritizing a specific region or community. The target location then is most likely to be determined by where the charity can gain the most access to funding, partnerships, talent and participants. Whether there are organizations doing similar work shall be considered too. Acceptability Insights from the experts that we had interviewed highlighted important factors that are likely to influence the acceptability of this type of intervention among the targeted populations. Barriers that may make it more difficult for this intervention to be accepted and adopted include prevailing stigma towards mental health, lack of perceived value for this type of program among school administrators, reluctance among teachers to learn and deliver psychoeducation regarding the subject matter due to lack of familiarity with it, and the possibility that the added responsibilities presented to teachers by this task sharing intervention would compete with their other existing roles. Recognizing that some of these barriers are unavoidable, the implementers of the final intervention ought to work closely with school administrators and teachers, not only to communicate the significance of promoting mental and emotional wellbeing in childhood and adolescence and to dispel misconceptions regarding mental health, but also to determine each school’s capacity to integrate such a program into existing systems so that the intervention could be adapted with the resources available. The modules for teachers as well as the increased strategies for supervision that would be 26 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries included in the final intervention may also address issues regarding heightened stress and burnout among teachers that tend to result from increased workload. Funding EA Funding There is currently no funding opportunity for mental health charities from Effective Altruism organizations aside from the seed funding that may be granted by Charity Entrepreneurship at the end of their incubation program. The charity can apply for the EA Global Health and Development Fund but they are not open to applications at the moment and no mental health charity has received funding from it in the past. Non-EA International Funding There is very limited funding allotted for mental health projects in places outside developed countries. Two promising sources are listed below: 1. Wellcome is a foundation supporting research on mental health, infectious diseases and climate and health. They offer funding schemes for mental health research and interventions. 2. The National Institute of Mental Health is the United States’ lead federal agency for mental disorders. They only offer grants for research which the new charity can apply for pilot testing the intervention. They have Scale-Up Hubs to conduct implementation research on evidence-based mental health interventions for LMICs in the following regions:  East Asia and the Pacific; Europe and Central Asia; Latin America and the Caribbean; Middle East and North Africa; South Asia; Sub-Saharan Africa. Their research networks in Asia have not reached the Philippines yet. Local Funding In the Philippines, there are government agencies and other organizations that can provide funding: 1. The Department of Science and Technology offers various grant opportunities although they are also mostly for research. Calls from its attached agencies Philippine Council for Health Research and Development (PCHRD) and Philippine Council for Industry, Energy and Emerging Technology Research and Development will be the most appropriate to apply for. The latter provides grants for startups. It's worth noting that, in 2018, the PCHRD released the National Mental Health Research Agenda, which highlights priority areas in terms of research and program development in the Philippines. One of the recommendations made in this agenda was the conduct of evaluation (“what works and what doesn’t) and action research regarding mental health interventions, relevant and appropriate to the Philippine setting, at individual, community, and institutional levels. 27 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries 2. The National Research Council of the Philippines also gives research grants. 3. As this intervention will be done in a school setting, the Department of Education and the Commission on Higher Education may provide assistance. The charity can also directly partner with schools, particularly private schools, to get an allocation of their budget and for easy access to recipients. 4. Companies doing corporate social responsibility efforts may be worthy to contact. The League of Corporate Foundations in the country have programs for health, education, environment, arts and culture and enterprise development. We think it is likely that they are open to mental health initiatives. 5. Local Government Units may also be reached out to but interest in creating a mental health program will vary across regions. 6. Other agencies and organizations can be identified based on the population the intervention will service. Some populations mentioned by experts are disaster survivors and drug users. The mental health intervention can be part or developed as a rehabilitation program by different agencies and organizations both locally and internationally. Summary of funding We expect there to be funding for pilot testing a mental health intervention since most of the opportunities available are for research projects. Depending on the target population’s location or mental health-related condition, other sources may also be available. Funding for the actual implementation and scaling up will be more difficult to receive but partnerships with the government and other organizations may open up and be easier if the pilot test is successful. Talent The trainers to be recruited do not necessarily need to be licensed mental heath professionals but preferably should have some background in education, psychology, or learning and development. For the training of trainers, partnerships with organizations that provide technical seminars and workshops on mental health promotion can be sought. One such organization is the Philippine Mental Health Association, Inc (PMHA), which itself has conducted capacity-building activities for community health workers and school teachers to be able to advocate for mental health in their respective communities and schools. The currently proposed model of this intervention recommends recruiting trainers as full-time staff, but an alternative approach would be to enlist volunteers to fulfill this role. Several organizations have organized volunteer programs that prioritize school-based initiatives in LMICs. For instance, TELUS International, a Canadian technology company, has supported the renovation of schools in the Philippines in line with DepEd’s Brigada Eskwela (National Schools Maintenance Week) and has distributed learning and hygiene kits among students in partner schools in the Philippines through its Days of Giving volunteer program. 28 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries Hands On Manila is a group that organizes volunteer services for non-government organizations and community-driven programs. The teachers that would be trained to deliver the intervention would be selected and recruited in coordination with partner school administrators or school division officials. Scaling The most effective and sustainable strategy towards scaling up the program would be to integrate it with government initiatives to promote mental health in schools, in line with what is mandated in the Philippine Mental Health Law (RA 11036). However, large scale implementation of this program may be difficult in the first few years of implementation and would only be feasible once there is ample evidence of its impact. It may be more feasible to begin with seeking to scale the program within school divisions or districts before seeking city- or region-wide adoption. Within a country, differences in community characteristics may be observed between rural and urban areas, different ethnolinguistic groups, and other social groupings. This is a potential barrier to scaling as these differences could mean that the intervention might turn out to not be generalizable to all contexts. Externalities The externalities that were identified in the background for this type of intervention would likely still apply for our final model. One difference is that the impact of the program on teachers’ wellbeing would now be considered a direct outcome rather than an externality. Despite the addition of mental health modules for teachers as well as increased supervision, it’s still possible for the intervention to add to their existing workload and contribute to burnout if not coordinated well and tailored according to the needs of school administrators and teaching staff. An additional benefit that could result from this type of intervention would be increased awareness and improved attitudes towards mental health within the school system, not limited to the direct beneficiaries of the program. Furthermore, as mentioned in the background, improvements in mental health outcomes that may result from this intervention can subsequently have positive impacts on students’ general academic performance. Cost-Effectiveness Analysis Modifications were made to variables included in the previous cost-effectiveness analysis to take into account revisions made for designing the final intervention. The following CEA considers projected costs for the development of the training modules for trainers and teachers, which would likely involve outsourcing professionals in child mental health, child development, 29 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries educational psychology, and/or other related fields. Excluding the co-founders, the estimated number of full-time staff for the charity in its first year of implementation was raised to five from the original three. These full-time staff would serve as the trainers. They would deliver training, maintain coordination, and provide supervision to the identified teachers. The final CEA takes into account the estimated expenses for initial orientations and meetings with school administrators (“groundworking” costs) and three whole-day training sessions for teachers. The latter would be the optimal length for the training of teachers given the comprehensiveness of the modules, but in practice the duration of this may vary based on the teachers’ availability. For this CEA, it was estimated that 10 teachers would be trained during the pilot implementation in order to reach approximately 300 students (30 students per individual teacher). These figures are average approximates, but the number of teachers and students may differ in practice based on each school’s available workforce, the number of class sections per grade level, and the number of students per section (which vary across schools). Estimated costs for holding bi-monthly supervision sessions and for monitoring and evaluation activities were also included in the CEA. This model includes providing financial compensation to trained teachers based on the average hourly wages for teachers in the Philippine context. Similar to the previous CEA, estimated improvements in mental health outcomes as a result of the intervention are represented by changes in GSES scores. The following table presents our final CEA estimates for this intervention: Table 2 Final cost-effectiveness analysis for school-based teacher-delivered psychoeducation - Year 1 and year 3 of implementation Year of Estimated number of Unit $ per unit, $ per unit, Operation beneficiaries (students) total costs interventio n costs only 1 300 (One school) GSES 85.93 4.34 3 1500 (Five schools) GSES 35.81 4.82 In its first year of implementation, cost-effectiveness estimates are $85.93 per GSES unit for total costs and $4.34 per GSES unit for intervention costs. While the estimated total cost per unit is relatively high during year one, it decreases to around $35.81 per GSES unit in the third year of implementation. These results are based on the assumption that fixed costs for the charity remain consistent over time (or increase only marginally) while the number of beneficiaries increases by a large amount during the same period. This suggests that this is a potentially 30 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries cost-effective intervention; however, it would be difficult to compare these results with CEAs conducted for other interventions due to differences in the mental health outcome measures used. Weighted Factor Model There is a substantial body of evidence supporting the effectiveness of school-based psychoeducation in improving a variety of mental health outcomes; however, it’s difficult to make conclusive statements regarding the impact of this type of intervention in general due to the diversity in theoretical basis and strategies for implementation among existing interventions. As the final intervention would be grounded on needs assessments in the local context and consultations with partner communities/schools, it can be expected that its acceptability would be higher than an adaptation of a similar intervention that was developed in another culture. Implementation of the final intervention may be a bit more difficult and may require more time due to the inclusion of needs assessment studies, modules for teachers, and intensified supervision and monitoring and evaluation procedures. In terms of scaling, the school-based nature of the intervention provides the infrastructure to facilitate large-scale implementation. The primary concern would be sustainable talent, albeit the final intervention would include strategies for mitigating this, as explained above. Criteria Initial Intervention Recommended Intervention Effectiveness (20%) 3.75 3.75 Acceptability (20%) 4.25 4.5 Ease of 3.38 3.00 implementation (10%) Ease of scaling (30%) 3.38 3.5 Ease of funding (20%) 4.38 4.5 Average 3.825 3.900 There are still many improvements that can be made to our recommended intervention. Nevertheless, we think its current form is worth pursuing. Over time, modifications will likely be made to its design based on feedback from stakeholders. 31 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries Conclusion This intervention, as well as the other top mental health charity ideas identified through this research, were the result of a review process that emphasized evidence-based and contextually-sensitive decision-making. We assessed these ideas based on the quality of the available evidence surrounding them, the feasibility of their implementation, their cost-effectiveness, and their value specifically in LMIC settings. Additionally, insights that we had obtained from experts in relevant fields allowed us to further contextualize our models for these ideas and evaluate their applicability in real-life settings. In doing so, we were also able to identify challenges that must be anticipated once these ideas are put into actual practice. Our recommendations for the implementation of these ideas sought to address these challenges. Through this process, we propose these ideas as viable and potentially impactful charities that could be developed in LMIC contexts. This report highlighted a prospective model for the implementation of the third ranked charity idea—school-based teacher-delivered psychoeducation— in the Philippine setting. Whereas in many societies, mental health initiatives tend to focus on interventions that aim to address existing mental health problems, over the years, increased attention has been directed towards strategies that seek to prevent the onset of problems by mitigating risk factors and/or promoting resilience factors. One application of this approach is through the promotion of positive mental health concepts in school settings. Several advantages to implementing mental health programs through school systems have been identified in this report, including the fact that the youth spend much of their time in this setting and existing school infrastructures can facilitate the large-scale implementation of such programs. Furthermore, school is a context wherein much of a child’s social, cognitive, and emotional development takes place, and empowering them with the knowledge and skills to promote their wellbeing in this setting during their formative years potentially can have significant impacts on health outcomes in later life. The type of intervention that was the focus of this report involves task sharing with teachers; i.e., training teachers to deliver psychoeducation to students in their respective schools. Task sharing to non-specialist workers is a particularly valuable strategy in LMICs where there is commonly a great lack in the accessibility and availability of mental health information and services. Overall evidence for school-based, teacher-delivered psychoeducation programs demonstrate their effectiveness in promoting protective factors among children, including self-efficacy, relationship skills, emotion coping skills, and others. There is limited data on the effectiveness of these programs in reducing 32 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries existing symptoms of psychopathology or in decreasing rates of mental health problems in later life. Additionally, the diversity in the design and implementation of such programs makes it difficult to make conclusions on the general effectiveness of this type of intervention. In the Philippine context, significant challenges to the implementation of this program include the likelihood that teachers would be unable to balance additional responsibilities with their existing duties, as well as prevailing negative attitudes towards mental health which may influence the willingness of schools and communities to adopt such programs. Regardless of these limitations, the advantages this intervention offers for communities where the mental health gap exists and where stigma towards mental health is prevalent make it a potentially valuable intervention for LMIC contexts. Recommendations presented in this report propose a model for this intervention that seeks to address these limitations and provide a general protocol for a school-based psychoeducation program that is responsive to the needs of target populations and is culturally-appropriate. Cost-effectiveness analyses suggest that this intervention is relatively costly during initial years of implementation but is expected to become more cost-effective over time. The development of school-based mental health programs has been mandated by local laws and has been identified as a priority area in mental health research, and these may facilitate the acquisition of funding for this type of initiative. 33 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries 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. Barry, M.M., Clarke, A.M., Jenkins, R., & Patel, V. A systematic review of the effectiveness of mental health promotion interventions for young people in low and middle income countries. BMC Public Health 2013, 13(835). Bradshaw, M., Gericke, H., Coetzee, B., Stallard, P., Human, S., & Loades, M. (2021). Universal school-based mental health programmes in low- and middle-income countries: A systematic review and narrative synthesis. Preventive Medicine, 143, 106317. https://doi.org/10.1016/j.ypmed.2020.106317 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. Carroll, A., York, A., Fynes-Clinton, S., Sanders-O'Connor, E., Flynn, L., Bower, J., Forrest, K. and Ziaei, M., 2021. The Downstream Effects of Teacher Well-Being Programs: Improvements in Teachers' Stress, Cognition and Well-Being Benefit Their Students. Frontiers in Psychology, 12. 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). Cristobal, N. and Bance, L., 2021. Come into BLOOM: A grounded theory of well-being among Filipino university students. Philippine Social Science Journal, 4(4), pp.40-49. Datu, J. and Bernardo, A., 2020. The blessings of social-oriented virtues: Interpersonal character strengths are linked to increased life satisfaction and academic success among Filipino high school students. Social Psychological and Personality Science, 11(7), pp.983-990. Datu, J. and Jose Mateo, N., 2020. Character strengths, academic self-efficacy, and well-being outcomes in the Philippines: A longitudinal study. Children and Youth Services Review, 119, p.105649. Fazel, M., Patel, V., Thomas, S. and Tol, W., 2014. Mental health interventions in schools in low-income and middle-income countries. The Lancet Psychiatry, 1(5), pp.388-398. 34 EA Philippines Mental Health Charity Ideas Research, Deep Report School-Based Teacher-Delivered Psychoeducation for Children in the Philippines and Low- to Middle-Income Countries 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. Mingoa, T. (2017) Filipino teachers’ stress levels and coping strategies. Research Congress 2017 De La Salle University, Manila, Philippines Murphy, J., Abel, M., Hoover, S., Jellinek, M. and Fazel, M., 2017. Scope, Scale, and Dose of the World’s Largest School-Based Mental Health Programs. Harvard Review of Psychiatry, 25(5), pp.218-228. Nguyen, A., Dang, H., Bui, D., Phoeun, B., & Weiss, B. (2020). Experimental Evaluation of a School-Based Mental Health Literacy Program in two Southeast Asian Nations. School Mental Health, 12(4), 716-731. doi: 10.1007/s12310-020-09379-6 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 Tatum, M., 2021. The impact of a year indoors for Filipino children. The Lancet Child & Adolescent Health, 5(6), pp.393-394. Xu, T., Tomokawa, S., Gregorio, E., Mannava, P., Nagai, M. and Sobel, H., 2020. School-based interventions to promote adolescent health: A systematic review in low- and middle-income countries of WHO Western Pacific Region. PLOS ONE, 15(3), p.e0230046. Zeman, J. & Suveg, C. (2016). Developmental psychopathology: Basic principles. In J.E. Maddux & B.A. Winstead (Eds.). Psychopathology: Foundations for a contemporary understanding (4th Edition, pp. 18-26). New York: Routledge. 35