Guided Self-Help Game-Based App for Adolescents in the Philippines and Low-to Middle-Income Countries

Guided Self-Help Game-Based App for Adolescents in the Philippines and Low- to Middle-Income Countries October 2021 to April 2022 Glaiza Mae Superable EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries Guided Self-Help Game-Based Application for Adolescents in the Philippines and Low- to Middle-Income Countries Deep Report Authors: Glaiza Mae Superable Research Period: October 2021 to April 2022 Executive Summary Mental health conditions are the primary cause of suffering for children and adolescents globally and are among the top contributors to death, disability, and disease in this subgroup (UNICEF, 2021). Global estimates indicate that 13% of adolescents had a mental disorder (UNICEF, 2021). This burden is unequally distributed as almost 90% of the children and adolescents are living in low- and middle-income countries wherein access to care is limited (Kieling et al., 2011). In response to this, innovative strategies are needed to make mental health (MH) services accessible to those in need. Digital mental health intervention, particularly mobile applications, is among the solutions considered given its cost-effectiveness, scalability, anonymity, and suitability for adolescents who easily adopt new technologies and spend a great amount of time using their mobile devices. The intervention ideated is a self-help game-based mobile application intervention for adolescents aged 12 - 19 years old with mental health difficulties. As a self-help format, the app aims to teach service users of concepts and help them practice skills that will aid them in addressing MH concerns. The content of the app will be based on evidence-based therapeutic modalities. The game-based format is used to enhance service user engagement and prevent dropout. It will also include assessment questionnaires that will help gauge the severity of MH distress and service users' progress. The proposed idea has undergone revisions after consultations with experts in the mental health landscape. In the first iteration, cognitive behavioral therapy (CBT) was selected as the therapeutic modality given its prevalence in the literature but was eventually revised to problem-solving therapy. The latter was found to be more beneficial due to its (1) appropriateness to the time-limited and practical concerns that adolescents may have and (2) transdiagnostic nature, meaning, the effect is generalizable across common mental health disorders. From targeting users only with elevated symptoms of common mental health disorders, eligible users were broadened to include any help-seeking adolescents who may experience mental health distress and/or perceived the need for psychosocial support. The final iteration also included minimal guidance from lay counselors to enhance engagement, provide motivational and technical support, consolidate learnings during reviews, and conduct risk assessments. To maximize counselor time, 1 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries the intervention will be delivered in groups that have shown to be acceptable among adolescent users. From relying on direct-to-consumer marketing and referrals from mental health service providers, the program will be delivered in school settings. The latter enables wide-scale implementation as it is a convenient way to reach out to the service users and provides spaces to deliver the intervention. In addition, during the formative research, school is also an ideal touchpoint to reach out to stakeholders such as parents and students. As a school-delivered intervention, the program will include sensitization activities that will normalize mental health difficulties and help-seeking, to facilitate self-referral. The program's primary strength is in its evidence of effectiveness for reducing emotional and behavioral problems and improving well-being and its acceptability among service users and mental health providers. The school-based delivery of the program is also scalable even with guidance as it uses lay counselors and a peer-to-peer framework of supervision. The program can be expensive during the first year of implementation accounting for the cost of app and content development and review. In the cost-effective analysis, every point of improvement in the well-being scale amounted to $37, while every point of reduction in emotional and behavioral problems cost $20 (intervention cost only). However cost significantly reduces as the charity scales up with an estimated 80% reduction of cost by its third year of implementation. There are identified funding opportunities focused on leveraging technology to improve access to mental health care. Furthermore, the uniqueness of the program as a mental health service focused on help-seeking adolescents may garner further funding given that this is rarely provided in a school setting. However, compared to other interventions proposed, the program might take longer to implement due to the multitude and complexity of its components, namely, lay counselor training and supervision, app development, stakeholder partnerships with schools, and mental health services for referrals. In addition, the sustainability of the program remains uncertain and will depend on the feasibility of integrating this into the government health system or its capacity to transition as a social enterprise. 2 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries Table of Contents Executive Summary 1 Introduction 5 Problem Assessment 5 Background 7 Intervention Program (Gold Standard) 7 Quality of Evidence 8 SPARX 8 Level of Guidance 9 Acceptability and Engagement 10 Completion, Attrition, and Adherence 11 Age Group 11 Implementation 12 Location 12 Acceptability 12 Funding 12 Talent 12 Scaling 13 Externalities 13 Cost-Effective Analysis 13 Weighted Factor Model 14 Recommended Intervention 15 Interview with Mental Health Experts 15 Delivery 15 Content and Therapeutic Modality 17 Quality of Evidence 18 What other therapeutic modalities can be considered that may be more culturally and developmentally appropriate to the target population? 18 What are solutions to increase uptake and adherence among service users? What types of support should be provided to the service users? 20 How can we ensure the privacy, safety, and security of the platform? 23 How can service users access the resources to avail of the intervention? 23 Are there risks associated with the use of the intervention? How can we mitigate these? 23 Implementation 24 Theory of Change 24 Eligibility Criteria 24 Mode of Delivery 25 Delivery Setting 25 3 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries Treatment Content and Components 26 Providers 27 Delivery Schedule and Format 28 Program Development and Testing 29 Target Location 29 Acceptability 31 Funding 31 EA Funding 31 Non-EA International Funding 31 Local Funding 32 Summary of funding 33 Talent 33 Scaling 34 Externalities 36 Cost-Effective Analysis 36 Weighted Factor Model 37 Barriers to the Founding of the Charity 39 Conclusion 39 References 41 Appendix A 46 4 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries Introduction This report was made through the Mental Health Charity Ideas Research Project under Effective Altruism Philippines. The project was a follow-up to Shen Javier and Brian Tan’s participation in Charity Entrepreneurship’s 2021 Incubation Program, in their region-specific track for training people to research the top charity ideas in a region. The project's goal was to find ideas that can become highly impactful and cost-effective charities in improving the well-being of people living in the Philippines and other low- to middle-income countries. It focused on children and adolescent mental health. To achieve this goal, we aimed to write deep reports such as this on the top mental health charity ideas that will come out of our four-phase research process. Our research process involved looking into the same ideas in multiple rounds of iterative depth such that the next rounds of research are deeper and only on fewer ideas than the last. We systematically evaluated all ideas, comparing them using the same criteria and the same questions. Some of the tools we used are weighted factor models that consider different factors such as implementability and acceptability of the interventions, evidence quality assessments, and cost-effectiveness analyses. In the six months of our research, a self-help game-based app 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 conditions are the primary cause of suffering for children and adolescents globally and the top contributor to death, disease, and disability, particularly for adolescents (UNICEF, 2021). Estimates indicate that 13% (166 million of 1.2 billion) of the adolescents in the world had a mental disorder (UNICEF, 2021). Of the different mental disorders experienced by adolescents, the Global Burden of Disease Study by the Institute for Health Metrics and Evaluation (IHME) estimates anxiety and depressive disorders constitute 40% of the mental health disorders experienced by adolescents (UNICEF, 2021). This is followed by conduct disorder and attention-deficit or hyperactivity disorder which make up to 20%, respectively (UNICEF, 2021). One-half of the mental health conditions experienced begin to develop by the age of 14 and have shown to have high continuity in adulthood (WHO, 2005; Kessler, 2007). Apart from immediate improvements in mental health and functionality, early treatment of mental disorders benefits the individual in the long term as it may prevent the persistence and further exacerbation of the condition (Kessler et al., 2007). Furthermore, delayed treatment of disorders may contribute to the development of secondary disorders that adds to existing impairment and may reduce responsiveness to future treatments (Christiana et al., 2000). Adolescence is a critical 5 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries period of development due to the rapid growth and maturation of the brain. Interventions directed to this age group enable them to learn and consolidate psychological resources, such as cognitive and socio-emotional skills that can become foundations for safeguarding them from mental health difficulties and promoting their well-being in the future. The burden of disease on children’s mental health is disproportionately distributed as 90% of children and adolescents are living in low- and middle-income countries (Kieling et al., 2011). Despite the global prevalence of mental disorders only a limited portion of the population gets access to appropriate treatment and care, more so in LMICs. For instance, a multi-country survey supported by WHO has shown that the proportion of individuals with serious conditions who receive treatment in the past 12 months is only 35 – 50% in developed countries and 76-85% in less-developed ones (WHO, 2008). The primary reason that contributes to this treatment gap include inadequate investments allotted for mental health services, scarcity of mental health providers, and the centralization of mental health services in big cities and large institutions, most of which are inaccessible, isolating people from key support systems, and associated with stigma (WHO, 2008). The Lancet Commission on Global Mental Health proposed innovative strategies to respond to the increasing need for mental health services (Patel et al., 2018). One, they promote improving the availability of psychosocial interventions – these are evidence-based interventions that equip individuals with resources and skills to address risk factors or consequences of mental health conditions (Patel et al., 2018). The provision of such services, alongside pharmacological ones, expands the roster of treatments available to service users and may counter barriers to accessing treatment for those who do not want medications (Patel et al., 2018). While these interventions are effective, access to psychosocial therapies is poor due to the scarcity of skilled practitioners capable of delivering them. In response to this limitation, task sharing defined as “the transfer of mental health responsibilities from specialized to less specialized staff” can serve as a feasible solution (Patel et al., 2018). Another idea for scale-up includes the direct dissemination of psychosocial therapies to the population through a self-help format. Digital technologies, such as app-based delivery of the intervention, may facilitate this dissemination given the rapid growth of mobile and internet access across the globe, even among LMICs (Patel et al., 2018). Digital mental health interventions have gained traction over the past years. Apart from its cost-effectiveness when compared to face-to-face treatments, it addresses person-specific barriers that limit individuals from accessing treatment. Patients concerned about the stigma of seeking mental health support may use the intervention anonymously and in private. Patients who are willing to get treatment but are barred from receiving it due to the expensive cost of therapy or limited MH services available are provided an alternative option (Andersson & Titov, 2014). Relative to its effectiveness, digital mental health intervention may improve the learning of concepts and enhance retention as users can return to the program and access treatment information as needed (Andersson & Titov, 2014). Especially with 6 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries mobile health apps, individuals may access intervention completely or partially online despite unstable or limited internet access (Sijbrandij et al., 2017). Background In scoping the literature there are several forms of digital mental health interventions (DMHI) available for the public but with varying purposes. A few serve as standalone self-help interventions that deliver psychotherapy through digital means in place of face-to-face therapy, while some act as more supportive tools that help individuals track or monitor health or connect with peers or support groups. In this review, our interest lies in the former. There are various ways in which digital mental health interventions (DMHI) are delivered to children and young people (CYP). A systematic review of DHMI for CYPs identified the following mode of delivery to include website, applications, games, virtual reality, text messages, and use of robots and other digital devices (e.g. fitness tracker) (Liverpool et al., 2020). Most of these interventions aim to transmit mental health information to the service users through text or multimedia, such as videos, audio, animations, and photos (Liverpool et al., 2020). Content is aimed at orienting and teaching service users concepts and skills specific to the intervention’s selected modality, wherein cognitive behavioral therapy is commonly used (Liverpool et al., 2020). Of these different modes of delivery, app-based interventions appear to be most relevant in implementing the low-resource setting as mobile phone ownership is more common than computers in underserved communities. App-based interventions are also more suitable for young people who easily adopt new technologies and spend the greatest amount of time on mobile devices compared to individuals of older age groups (Naslund et al., 2017). Children and adolescents also appear to have the digital resources to utilize this intervention. In a survey on mobile ownership conducted in the Philippines in 2015 results show that almost 60% of children own mobile phones, most received their first mobile phone at age 10, 60% of the children own smartphones, and 76% of the children own a tablet (GSMA & NTT DOCOMO, Inc. Japan., 2016). 85% of the children surveyed also indicated that they use their mobile phones to access the internet (GSMA & NTT DOCOMO, Inc. Japan., 2016). The prevalence of smartphone and internet usage may be higher than indicated from 2020 onwards due to the transition to online classes during the COVID-19 Pandemic. Although, caution should be done in interpreting these prevalence as the study did not indicate socioeconomic status of the respondents interviewed and realities of digital access may significantly differ in impoverished communities. Intervention Program (Gold Standard) This intervention involves the delivery of a psychosocial intervention via a mobile-based app to treat adolescents (12 – 19 years old) who may be experiencing 7 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries mild to moderate symptoms of depression and/or anxiety, as these are the most common mental health disorders encountered by the age group. The target population for this intervention includes digitally literate adolescents with existing access to smartphones. The application will include materials and activities to teach adolescents the psychosocial intervention, assessment functions to evaluate progress, and support features that will aid the user in using the platform. As cognitive-behavioral therapy (CBT) is the most commonly used and evidence-based therapeutic orientation in DHMI, this will be used as a framework for the app. The treatment materials may include text and multimedia detailing core CBT principles (e.g., psychoeducation on the cognitive-behavioral model, cognitive restructuring, behavioral skills, relapse prevention) and homework or activities that enable individuals to apply and/or practice lessons (Andersson & Titov, 2014). Assessment questionnaires enable monitoring of users' progress, symptom severity, and the possibility of self-harm (Andersson & Titov, 2014). The intervention will be self-guided but will have support functions in the form of automated feedback or reminders to encourage continued use and or assistance for technical queries. Among the different interventions found, the mobile app SPARX (Smart, Positive, Active, Realistic, X-Factor Thoughts) stood out as it is among the more well-studied mobile interventions designed for people aged 12 – 19. It is a self-guided app aimed to treat individuals with mild to moderate depression and is delivered in a game format (T. Fleming et al., 2021). The game includes seven modules of CBT where users learn the skills through various interactive activities designed to “support learning and behavior change and to support uptake and engagement” (T. Fleming et al., 2021). Since 2014, SPARX has been accessible as a self-guided resource for individuals in New Zealand, with an option to request helpline support as needed (Fleming et al, 2021). Most of its current users learn about the program through referrals from clinicians or schools (T. Fleming et al., 2021). The intervention will have a two-pronged promotion approach targeting (1) MH providers and other health gatekeepers (e.g. community health workers) who will refer adolescents with symptoms of depression to the app and (2) direct-to-public so help-seeking adolescents with symptoms of depression may avail the service as needed. Promotion to health practitioners includes attending conferences and dialogues with relevant organizations to promote the intervention and distributing supplementary materials to learn more about the intervention. Quality of Evidence In scoping the literature, evidence for DMHI is currently limited for low- and middle-income countries, especially when it comes to interventions for CYP. As such, most of the evidence indicated here is from high-income countries. SPARX In an RCT for help-seeking adolescents (n=187) in primary health clinics, SPARX demonstrated better outcomes than treatment-as-usual (TAU) conditions 8 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries (which involved counseling sessions with some waitlisted) (Merry et al., 2012). Depression scores for individuals under the SPARX reduce by 10.32 (95% CI 8.15 - 12.48) compared to 7.59 (5.43 to 9.75) of the TAU group in the Children’s Depression Scale-Revised (CDS-R) and had a small effect size (d=0.30) (Merry et al., 2012). There were also noted improvements in secondary outcomes, such as anxiety scores, quality of life measures, and hopelessness, with results favoring SPARX over TAU (Merry et al., 2012). SPARX has shown to be effective in improving depressive symptoms when implemented for other adolescents in other settings such as adolescents excluded from mainstream education, lesbian, gay, and transgender young people (T. Fleming et al., 2012; Lucassen et al., 2015). It was also feasible in preventing depressive symptoms in a school-based universal program (Perry et al., 2017). However, there are mixed results on the effectiveness of SPARX on anxiety symptoms, with some studies showing reductions, while some studies indicate no effect (T. Fleming et al., 2012; Perry et al., 2017). One study also detailed that SPARX had no effect on depression and anxiety, but had an impact on emotion regulation in adolescents in an alternative education system in Ireland. Authors of the latter article attribute the lack of effect to the small sample size, more targeted support for those with high levels of MH problem, or low engagement rates (70% only partially completed the program). (Kuosmanen et al., 2017) Some studies indicate SPARX is not feasible to implement in certain delivery settings and service users. For instance, it had high drop-out rates when applied to adolescents in the youth offenders’ program, as most of the participants, both in treatment and control groups, withdrew entirely from the justice program assigned to them (T. M. Fleming et al., 2019). Social workers involved in the program reported challenges encountered such as technical difficulties, operational challenges (e.g. requiring a laptop and private space), and unappealing for teens accustomed to playing high-end commercial games (T. M. Fleming et al., 2019) Level of Guidance In an overview of the systematic reviews on DHMI conducted for adolescents and young people, Lehtimaki and colleagues (2021) indicated that including human support (e.g. therapist, parent, peer) in the DHMI was more effective than fully self-administered ones. For purely self-administered studies, the effect size was small (d=.24) while studies with an human support had medium to large effect sizes (d=0.50 to 0.80) (Grist et al, 2017; Garrido et al, 2019; as cited in, Lehtimaki et al., 2021). Concurring with this review is the systematic analysis conducted by Valimiki et al (2017, as cited in, Lehtimaki et al., 2021) identified that web-based interventions with human support are also more effective. However, there are also a few systematic reviews that found human support is irrelevant to the effectiveness of the intervention. For instance, Ebert et al’s (2017, as cited in Lehtimaki et al., 2021) findings show no association between parental support in therapy and treatment outcomes for computerized CBT for anxiety and depression in youth. Aligning with these results, Harrer et al (2019, as cited in Lehtimaki et al., 2021) indicate that supervision did not affect the intervention outcomes. However, the 9 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries authors indicate that this may be due to the variability of the interventions included and the age group studied (university students). For systematic reviews, interventions vary in terms of content, therapeutic modality, and description of the in-person component. Hence, the effect of the digital intervention and level of guidance on the effectiveness of the program is difficult to isolate. In addition, the purpose and type of guidance provided in these studies are difficult to scrutinize. Including a human component in the intervention might maximize the positive effect on the outcome, however, taking into account the cost incurred in incorporating guidance and the finding that self-guided interventions can still be effective we initially maintain the position of keeping the intervention unguided. Acceptability and Engagement In a systematic review by Grist and colleagues (2019) on digital interventions for adolescents, digital modality is found to be generally acceptable in feasibility trials due to the favorable ratings in metrics such as ease of use, satisfaction, and usability ratings. The review also indicated that adolescents found the digital intervention acceptable due to familiarity and regularity of mobile apps and the privacy and discretion it provides (Grist et al., 2019). Features of the digital intervention are one of the key factors that influence users' engagement and their continued use of the intervention (Lehtimaki et al., 2021). For one, users prefer DHMI they find appealing, characterized by an interface with less text, more videos, and features such as enabling connection with peers, receiving reminders, acquiring rewards, or personalization of profile (Liverpool et al., 2020). It is also important for CYPs that intervention is easy to use, self-paced, age-appropriate, and straightforward (Liverpool et al., 2020). Lastly, CYPs appreciate interventions that can be conveniently accessed and be weaved into their daily activities, indicating a preference for mobile-based interventions (Liverpool et al., 2020). In terms of content, the perceived usefulness and helpfulness of the intervention in addressing their needs was a critical factor that affected their motivation to engage with the program (Liverpool et al., 2020). These findings are similarly replicated in the review by Lehtmaki and colleagues (2021). In addition to the abovementioned, they also indicate that CYP prefers including relatable situations, characters, or avatars that are culturally appropriate and contextualized in their local setting. They appreciate tools that are interactive, flexible, and self-paced, which enables them to decide when and where they access the intervention (Lehtimaki et al., 2021). Privacy, safety, and discretion were also found to be highly important to CYPs, especially due to concerns about mental health stigma. Hence, they approve of features that strengthen this including password protections, control of privacy settings, and site moderation by professionals (Lehtimaki et al., 2021). 10 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries Both reviews also indicate CYP’s preference for the inclusion of human contact in the intervention either by facilitating connection with peers or through support from a mental health professional (Lehtimaki et al., 2021; Liverpool et al., 2020). Completion, Attrition, and Adherence One of the key limitations found in DHMI is the high attrition rate and low adherence. Attrition refers to the percentage of people who withdraw participation from the intervention while adherence refers to the proportion of participants who complete a program or complete a specified number of sessions as designed. Completion and adherence are sometimes used interchangeably. Across the systematic reviews, the range of completion rates varies. Valikimaki reports it at 10% to 90% according (Valimaki et al., 2017 as cited in Lehtimaki et al., 2021). Grist et al (2017) cite that range is 65% to 83% for most of the studies and Clarke et al (2015) report that the average completion rate is 50%. In their overview of the studies, Lehtmaki (2021) noted that most studies included had poor reviews of attrition and adherence, with only a few studies reporting adherence. In another systematic review, Liverpool et al (2020) report that 80% of the studies they reviewed had 70% completion rates. The latter systematic review noted that there are higher retention rates for gamified interventions and apps compared to other forms of digital interventions (Lehtimaki et al., 2021). In their review, Lehtmaki and colleagues (2021) identified various factors that may affect adherence. Including a human component in the intervention is positively associated with lower attrition or improved adherence (Clarke et al., 2015; Hollis et al, 2017, as cited in, Lehtimaki et al., 2021). In addition, they also identified person-factors associated with adherence such as gender and mental health status. Females are more likely to complete the intervention than males. Individuals with poorer mental health status at baseline and longer history of mood disorders scores are more likely to complete the intervention (Lehtimaki et al., 2021). In the first clinical trial on SPARX, adherence rates were as high as 69% of the participants (n=94) completed at least 4 modules, and 60% completed 7 modules (Merry et al., 2012). Although in actual implementation, online app analytics indicate that while the app has a wide reach, adherence tends to be lower than seen in trials consistent with the literature on apps once implemented in real-world settings (T. Fleming et al., 2021). Detailed information about reduction in users and rates of adherence in naturalistic settings are not provided in the research. Age Group In terms of age, there is stronger evidence that indicates DHMI works for adolescents (12 – 18) and adults (>18). Evidence on the effectiveness of tech-delivered CBT on children (6 – 12 years old) is limited and mixed. Ebert and colleagues’ (2015) meta-analysis on internet- and computer-based CBT indicated that the intervention improves anxiety or depression symptoms in children but the effect is smaller (g=0.51, 95% CI: 0.11 to 0.92) compared in adolescents (g = 0.95, 95% CI 0.76 to 1.17). Grist and colleagues’ (2019) indicated that the impact of intervention did not vary based on age. 11 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries While Pennant and colleagues’ (2015) found computer-delivered CBT, regardless if online or not, are ineffective for children. However, the latter two research indicated that findings are inconclusive given the limited number of studies for children. Implementation Location The digital ownership and infrastructure in the Philippines limit the users who may benefit from the intervention to individuals in urban areas. The selection of this subgroup is attributed to the poor internet connectivity and limited access to devices in rural areas. Acceptability Based on the initial scope of the literature, adolescents have positive reception of mobile-delivered DHMI given its accessibility, familiarity with the modality, and privacy or discretion it provides. If a gamified app like SPARX is implemented, it also suits their DHMI preferences given that it includes rewards, and is interactive and self-paced. However, while it may be acceptable to adolescents at the onset, concerns about high attrition rates remain a watch out. Modifications on the delivery of the program may be necessary to maintain user engagement. Funding Initially, there were no identified funding opportunities for the intervention. However, intervention may be deemed relevant for funders as it addresses depressive and potentially anxiety symptoms, which are among the highest contributors to the burden of diseases in the Philippines (Philippine Council for Mental Health, 2019). CBT is among the brief evidence-based treatment for depression and anxiety; hence, may garner more support from funding agencies. The benefits of digital technology in delivering mental health services are acknowledged by the government, as observed in the launch of the self-care app, Lusog-Isip by the Department of Health. Difficulties that can be encountered during funding may stem from a preference for community-based low-technology interventions that may benefit a greater number of underserved adolescents. Talent The intervention mainly involves developing the application and marketing these to health gatekeepers, such as mental health providers, primary care clinics, and school guidance counselors. The intervention is not reliant on training, supervising, and retaining non-specialists to deliver the program. Hence, it is assumed that the talent required for scale-up may be minimal. Training of talents will focus on health gatekeeper training to identify adolescents that may benefit from the app and to provide support for queries that may arise during gameplay. 12 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries Scaling One key concern for scaling is the continuity of funding for app-based interventions as it needs routine update and maintenance. Available grants for apps are often sourced from health and research funding which is often limited and time-bound, affecting the sustainability of the app. Public-private partnerships can be considered a viable financial method to ensure the continuity of the app. Several health innovation apps in LMICs also follow this model wherein initial development and implementation are sourced from private sources and eventually integrated into the health system or adopted by government units (Labrique et al., 2018). However, this change would require policy changes that may take some time before implementation. An alternative approach to achieving financial sustainability is adopting a social entrepreneurship financial model, wherein revenue is generated to finance free or low-cost delivery of the intervention in underserved communities. Externalities The research generated from this program can contribute to the improving gap in knowledge of the feasibility and effectiveness of DHMI in LMICs. It may also enhance interest and conceptualization of future DHMIs in similar settings. Although, the founding of a charity focused on providing digital interventions for adolescents may have the unintentional consequence of widening mental health inequalities between people who have adequate access to resources, such as internet and smartphones, and impoverished populations. Cost-Effective Analysis During the initial iteration, we conducted a brief cost-effective analysis to help narrow the list of interventions that will be considered in writing the deep report. The table below describes the cost per improvement in the quality of life using the Pediatric of Quality of Life Enjoyment and Satisfaction Questionnaire (PQ-LES-Q) and per reduction in depression scores using the Children’s Depression Scale-Revised (CDS-R). Outcome metrics were selected based on what is available in SPARX literature. We included well-being as this is the final impact the charity desires to achieve and depression scores since this is the primary concern intervention aims to address. Estimates were based on the RCT conducted by Merry et al. (2012). Years of Unit $ per unit, total $ per unit, Operation costs intervention costs only PQ-LES-Q 15.32 5.26 1 year improvement 13 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries CDS-R 8.84 3.04 reduction PQ-LES-Q 4.45 0.95 improvement 3rd Year CDS-R 2.57 0.55 reduction We also estimated the intervention’s effectiveness in the third year of operation given that the bulk of the cost is allocated to the development of the intervention which includes cost items such as content ideation and technical development. We assume that the growth rate of the users of the app is 20% each year. The cost of implementation reduces by 70% during the 3rd year of operations illustrating the advantage of using app-based methods in scaling up services. Since the app is purely self-help, intervention components that remain constant include marketing direct-to-consumer and to mental health gatekeepers. Weighted Factor Model We used a different set of criteria for our WFM: effectiveness (20%), acceptability (10%), ease of implementation (20%), ease of scaling (30%), and ease of funding (20%). Effectiveness refers to the quality of evidence supporting positive outcomes from the intervention. Acceptability is the extent to which people participating or implementing the intervention see the intervention as appropriate to themselves and the communities it aims to support. Additionally, it considers how much of the intervention should be changed to make it applicable to the participants. Ease of implementation refers to the minimum length of time an intervention can be at least piloted. Ease of scaling evaluates whether the charity meets the three criteria for scalability that say there shall be: 1) identified communities/delivery settings for the intervention, 2) available workforce for scaling, and 3) availability of implementation infrastructure for scaling. Lastly, ease of funding is about the intervention’s likelihood of being funded based on its timeliness or relevance in the region. Cumulative results of our initial WFM resulted to these ratings: Criteria Initial Intervention 14 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries Effectiveness (20%) 4.63 Acceptability (20%) 3.25 Ease of implementation (10%) 3.13 Ease of scaling (30%) 4.37 Ease of funding (20%) 3.62 Recommended Intervention Interview with Mental Health Experts The interview with experts provided insights that help refine the implementation of the digital intervention in the Philippine setting. In this research, the following mental health professionals were selected due to their involvement in mental health, particularly in areas of our interest: adolescent and child mental health, app-based interventions, and community mental health programs in the Philippines. ● Dinah Nadera, M.D., M.Sc. Epidemiology, M.A. International Mental Health; President, Foundation for Advancing Wellness, Instruction and Talents (AWIT), Inc. ● Melissa Garabiles, Ph.D. Clinical Psychology; Associate Professor at De La Salle University, ● Marika Melgar, M.A. in Counselling Psychology; CBT-trained Psychologist Delivery Suitability of the intervention for a low-income population is among the key concerns raised during the interviews. For Dr. Nadera and Ms. Melgar, the lack of access to adequate internet connection and smartphones serves as a key barrier to utilizing the intervention. From their experience in community work, interventions with low technology requirements, such as group-based interventions or distribution of mental health concepts through comics, are deemed more appropriate and accessible for low-income populations. In response to the idea of distributing smartphones in select areas of the community to address this barrier, Dr. Nadera emphasizes the need to exercise caution in introducing technology to low-income settings as smartphone and internet usage may be linked to adverse effects such as upward social comparison that may lead to mental health difficulties. 15 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries In the planning of this intervention, the delivery setting should already be considered. In its pilot implementation, the setting determines the considerations when adapting the content and determining the delivery model. In the long-term, Ms. Marika shares that the sustainability of the intervention may rely on its ability to be integrated into existing programs in the community as these can be a cost-effective method of scaling up mental health programs. If implemented as a targeted program for individuals with existing symptoms of mental disorders, recruitment and assessment of service users may require further deliberation. For Ms. Melgar, engaging individuals with sub- or clinical-level symptom presentation should involve the participation of licensed mental health professionals. Dr. Nadera noted the possibility of users falsifying responses to assessment questionnaires, for instance on depression, due to its associated stigma. She also highlights the need of having appropriate referral systems in place to identify individuals in need of the service and to monitor progress. In the app-based implementation of WHO’s Step-by-step for OFWs, Dr. Garibiles indicated that service users were provided contact details to mental health providers if they require more intensive support. For instance, they were linked to UGAT Foundation, an NGO providing counseling for OFWs; and Caritas Macau, Step-by-Step’s partner implementing organization, which also offers counseling. In Step-by-Step, service users have to take an active role in accessing referrals given due to privacy policies and service users’ preference for anonymity with some opting not to disclose their real names. Given that the intervention is primarily digital, Dr. Nadera stresses the importance of safeguarding the privacy and data of service users especially since user data may be utilized for unintended purposes such as monetizing it through ads. The type of support provided for service users of these interventions is also important to consider. In working with children and youth, Ms. Melgar underscored the significance of tailor-fitting concepts and activities to the needs and capacities of her clients. The process of learning concepts is also very interactive and conducted during the session as independent learning can be difficult and tedious for the children, particularly during the pandemic when they are working on asynchronous academic modules on their own. In addition, she also stressed that for some clients, it is also beneficial to engage parents in providing a facilitative environment that reinforces the applications of learnings clients learn in therapy. In implementing a Step-by-Step, minimal remote asynchronous support is provided by graduate-level psychologists to maintain adherence and retention (Liem et al., 2020). These trained e-helpers are responsible for providing technical support, monitoring use and reminding inactive users, identifying high-risk cases, offering referrals, and encouraging contact with referrals when necessary (Liem et al., 2020). When asked about the possibility of task shifting this to lay counselors, Dr. Garabiles highlighted its feasibility. Apart from educational background, understanding the service users' context enables lay counselors to provide support. The scope of lay 16 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries counselor responsibilities should also be detailed to properly evaluate the appropriateness of task-sharing. In implementing the app-based intervention, Dr. Garibiles mentioned that among the challenges they encountered in implementation was contacting the service users. Reasons vary but this includes OFWs' limited control of their time due to work, changes in mobile number use, and preference of not taking calls from unfamiliar numbers. Dropout rates were higher than expected as the program occurred during the pandemic as some of the service users had to leave Macau. Service users mostly contacted e-helpers primarily when they encounter technical issues in the use of the app. Content and Therapeutic Modality Dr. Nadera and Ms. Melgar suggest to deliberate further the use of CBT as a therapeutic modality. Ms. Melgar noted the multitude of CBT approaches available. Hence, the program needs to specify the orientation that will best benefit the target population. In both of their clinical practice, CBT is adapted to make the concepts understandable and relevant to the context of the client. The suitability of CBT also needs to be assessed given its target population. For Ms. Melgar, CBT may require a certain literacy level if applied to children and youth, especially those coming from low-income communities. Tailor fitting content based on age and cognitive capabilities may also be considered as behavioral aspects of CBT may be more appropriate for pre-adolescents and cognitive aspects of the therapy may be introduced for older service users. For Dr. Nadera, CBT’s self-directed nature may also counter Filipinos' help-seeking behavior that prefers a more directed ‘advice-giving’ approach. Following the interview with key experts, the following questions were explored in the ideation of the final intervention: ● What other therapeutic modalities can be considered that may be more culturally and developmentally appropriate to the target population? ● What are solutions to increase retention and adherence among service users? What types of support should be provided to the service users? ● How can we ensure the privacy, safety, and security of the platform? ● How can service users without access to resources avail of the intervention? ● Are there risks associated with the use of the intervention? How can we mitigate these? 17 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries Quality of Evidence What other therapeutic modalities can be considered that may be more culturally and developmentally appropriate to the target population? A few concerns were raised on the appropriateness of self-guided CBT for children and youth as mental health providers deliver CBT in a manner that is tailor-fitted to developmental capabilities and personalized to the unique context of their clients. In literature, SPARX content and features have shown to be effective in delivering CBT and improving outcomes for adolescents in a high-income country. However, there are limited studies supporting its generalizability outside New Zealand, particularly in LMICs. Currently, a Japanese adaptation of the intervention is being evaluated in an RCT with university students as a sample population, however, the results of the trial have not yet been released (T. Fleming et al., 2021). As such, we explored the literature for alternative evidence-based mobile applications developed in LMICs. Research directed us to POD Adventures, a lay-guided, game-based, app aimed at help-seeking adolescents aged 11 – 19 years old (Gonsalves et al., 2021). In developing interventions specific to adolescents in LMICs, researchers of POD Adventures identified problem-solving intervention as the therapeutic framework of the intervention. Problem-solving therapy is also considered to be within the umbrella of cognitive-behavioral therapies, given its aim to help individuals cope with life stressors through the use of affective, cognitive, and behavioral tools (Society of Clinical Psychology Division 12 of APA, 2018). The difference is in its content as the intervention is focused on identifying and addressing barriers to effective problem-solving to concrete life problems (Society of Clinical Psychology Division 12 of APA, 2018). Problem-solving informed intervention was selected as it was deemed most appropriate to the concrete and time-limited problems help-seeking adolescents presented during consultations with researchers (Michelson et al., 2020). It is also identified as a transdiagnostic intervention that addresses common mental health problems (e.g. symptoms of anxiety, depression, and conduct disorders) as it targets psychological processes involved in the development and maintenance of these disorders (Michelson et al., 2020). It may serve as an intervention for any adolescent seeking help for mental health difficulties, regardless if they meet the clinical threshold (Gonsalves et al., 2019). The problem-solving intervention improved individuals’ ability to cope with daily life stressors and can improve current mental health difficulties or prevent them from occurring (Gonsalves et al., 2019). Problem-solving interventions are among the evidence-based treatment components included in various interventions conducted in LMICs. Its brief and structured approach focused on concrete problems require less extensive training or complex skills for lay counselors to deliver and for service users to learn compared to more complex cognitive behavioral therapy (Chibanda et al., 2016; ). In a mobile-delivered intervention in LMIC, it was also selected as feasible to implement primarily due to its step-by-step approach (Doukani et al., 2021). 18 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries In other programs, problem-solving is delivered together with other evidence-based components responsive to the needs of the service users. For instance, this is reflected in transdiagnostic interventions developed by the World Health Organization for CMDs. In interventions for adults, Problem Management+ incorporates components of PST and behavioral treatments and includes four modules focused on managing stress (through breathing), problem-solving, behavioral activation, and strengthening social support (Dawson et al., 2015). For early adolescents, they also have Early Adolescent Skills for Emotions (EASE) aimed at addressing emotional difficulties such as symptoms of anxiety and depression. Treatment components include psychoeducation on distress, identifying emotions, emotion regulation (e.g. slow breathing), behavioral activation, and problem-solving (Dawson et al., 2019). Similarly, POD Adventures supplements problem-solving with emotional regulation strategies that help service users manage emotions associated with stressors and triggers (Gonsalves et al., 2019; Michelson et al., 2020). SPARX also bears similarities with POD Adventures as its CBT modules include emotional regulation and problem-solving strategies. PODs Adventures is at an advantage as the theoretical framework and content were ideated for adolescents in low-income resource settings, in a cultural context that is closer to the Philippines. For instance, the SPARX fantasy world is designed with Maori-styled graphics and set in New Zealand. Considering these cultural nuances, the south-to-south adaptation of interventions may be easier to implement compared to other interventions. Several studies have shown the acceptability and effectiveness of problem-solving in treating CMDs in low-resource settings both for adults and adolescents delivered in-person and through online modalities. Among the well-researched interventions include Friendship Bench in Zimbabwe where 6 sessions of PST are delivered to individuals with elevated mental health difficulties by lay health workers (Chibanda et al, 2016). The program was also adopted for Youth with HIV delivered by peer lay counselors and was also delivered through a chat-based app, Inuka Coaching, for adults in Kenya (Doukani et al., 2020 ;Simms et al., 2021). RCTs and pilot cohort studies conducted on Friendship Bench have shown that it reduced symptoms of common mental health disorders, functional impairments, and quality of life (Chibanda et al, 2016; Doukani et al., 2020 ;Simms et al., 2021). In Vietnam, a school-based program involved the delivery of PST to adolescents aged 15 – 16 years old delivered by teachers and was found to be effective in reducing emotional and behavioral problems. Although in the latter study, there is limited information on the measures used or the components of the intervention (Dang et al., 2018). Results of these studies are outlined in Appendix 1. In a feasibility study of guided app-based POD Adventures among adolescents in urbanized low-resource schools in India, the effectiveness of the intervention was demonstrated in improvements of outcome measures in 4-week and 12-week follow-ups. Total Difficulties Score of The Strengths and Difficulties Post-test evaluation demonstrated large reductions in the severity of youth’s identified top problems (effect size d=1.47, CI 95% 1.25-1.69) (Gonsalves et al., 2021). There were also reductions in presenting mental health symptoms (ES d=0.54, CI 95% 0.38 to 19 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries 0.70), well-being scores (ES d=0.31 , CI 95% 0.15 to 0.46), and perceived stress (ES d=0.41, CI 95% 0.25 to 0.56) (Gonsalves et al., 2021). RCT for POD Adventures App with guided support has been conducted but has not yet been published (PRIDE - Pilot Trial of an Online Digital Problem-Solving Intervention for School-Going Adolescents in Goa, India, n.d.) Although there is evidence showing that it is effective in producing positive outcomes, there are also indications that problem-solving may not be an adequate or appropriate intervention for adolescents in certain settings. In the delivery of PST among Youth with HIV in Kenya, lay counselors noted that they had concerns about addressing problems, particularly those that involved relationships with adults (Simms et al., 2022). In certain instances, adolescents have limited agencies and rely on the support of others to instigate changes that will help them resolve their problems (Simms et al., 2022). As such, this may affect adolescents' engagement when they select “smaller” problems feasible to tackle using the PST framework or when they encounter difficulty in brainstorming solutions for difficult problems (Simms et al., 2022). Problems that heavily affected adolescents but may not have been in their capacity to resolve include food security, parental conflicts, and poverty, to name a few. What are solutions to increase uptake and adherence among service users? What types of support should be provided to the service users? Gaming Features POD Adventures was initially implemented as a primarily self-guided workbook with minimal support from lay counselors (Michelson et al., 2020). However, findings during initial pilot testing indicated low engagement with workbooks. In the exit interviews, students’ common barriers in the use of the materials include lack of interest in reading and writing, insufficient time to complete the workbooks, difficulty understanding problem-solving concepts, and literacy issues (Michelson et al., 2020). Counselor’s guidance was found highly important in explaining the concepts, enhancing motivation, and providing corrective feedback and relational support, to name a few. Given the challenges in engagement, the intervention has been redesigned to be more counselor-led than self-guided (Michelson et al., 2020) In response, researchers explored the use of a mobile app as an alternative engaging way to deliver the intervention while reducing the time spent by the counselor per service user (Gonsalves et al., 2019). The app was designed based on user preference and incorporated evidence-based features known to improve engagement (Gonsalves et al., 2019). It contains a narrative format where users learn the concepts through story vignettes. The game was set in a three-dimensional world designed to reflect service users' environment (e.g. school, house) for an immersive experience (Gonsalves et al., 2019). User-choice was highlighted by providing learners with various options to interact with the interface (e.g. selecting conversational responses) (Gonsalves et al., 2019). Interactivity was also reinforced through the use of gameplay features, such as competition, quizzes, and rewards. For instance, there are “missions” interspersed in the story vignettes to sustain attention, 20 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries “mini-games” to practice the concepts, and quizzes to enhance the recall of concepts learned per session (Gonsalves et al., 2019). Motivational feedback from guide characters and rewarding points in the correct quiz response were also appreciated (Gonsalves et al., 2019). In-game support, in the form of a “guide” character” was also designed to provide both relational and instructional support provided by lay counselors. They offer users motivations and praise throughout the game and provide instructions and psychoeducational concepts to the users. The guides are also designed to contingent responses based on user input, for instance, a rating of low mood will prompt a sympathetic and encouraging message from the character guide. POD Adventures aligns with service users' preferences when it comes to DHMI mentioned earlier. Intervention is appealing as it has less text, and incorporates appealing visual design, characters, and stories with the relatable situation. It is interactive and engaging through the use of rewards and mini-games. It is also self-paced enabling students to complete the module in their own time, although accessibility of the app is limited as the intervention was initially available only on mobile devices that can be used in school. Both POD Adventures and SPARX fall under serious games, defined as “games used to educate, motivate, and/or persuade users, in educational, health, and other settings” (T. M. Fleming et al., 2017). There is an interest of game-based interventions in mental health as it is appealing among youth shown in the popularity of games in this age group; engaging as users consider gaming approaches as enjoyable and can be motivated either to win or to witness game narrative unfold; and lastly, can be effective in facilitating learning and behavioral change for its immersive experience, enable behavioral modeling, allow practicing and repeated rehearsal of new skills in a safe environment (T. M. Fleming et al., 2017). Human Support The initial plan for this intervention was to offer treatment purely self-guided. However, after the interview with experts, this component was reviewed to address potential challenges that may be encountered when introducing an intervention to adolescents. For instance, service users may raise questions or clarifications about the concepts introduced to them, and encounter technical challenges that inhibit them from engaging with the app. There is also a need to determine and manage high-risk cases to refer students to more intensive support. As mentioned in the earlier scoping of literature, attrition rates are also higher for unguided interventions. For self-guided SPARX, Fleming and colleagues (2021) suggest the inclusion of external support, such as school-based use and blended-care approaches, may enhance adherence to the app. POD Adventures incorporated guidance from a lay counselor based on evidence that guided self-help is more engaging and effective than unguided ones (Michelson et al., 2020). Furthermore, interviews with stakeholders indicate that self-help is a concept unfamiliar to the target population, hence, guidance may be necessary to 21 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries explain the concepts and enhance user engagement (Michelson et al., 2020). During consultations lay counselors were identified as service providers as adolescents are opposed to involving parents and teachers in counseling and counselors have less associated stigma compared to other MH professionals (Michelson et al., 2020). Lay counselors are tasked to orient and build rapport with users at the beginning, review learning upon completion, assessment and referral of high-risk users, and provide support and troubleshooting as necessary during independent gameplay (Gonsalves et al., 2021). During onboarding, lay counselors also help clients identify the problem that they would like to work on and their goals for resolving this problem (POD Adventures, n.d.). This support may be critical as the identification of a workable problem is also one of the challenges encountered in the previous implementation of PST among youth (Simms et al., 2022). In school-based delivery, POD Adventures was also delivered in a group setting to maximize counsellors time. In the group sessions, brief onboarding and consolidation sessions were done as a group, and the remaining sessions and time were spent in independent gameplay. Interviews with participants indicate that group format delivery is acceptable (Gonsalves et al., 2021). During exit interviews, some of the students mentioned that doing the activity with other individuals in the room helped in maintaining engagement even if they didn’t have to interact with each other (Gonsalves et al., 2021). Counselor time spent per student remained minimal, with each counselor spending an average of 10 minutes per student throughout the intervention in the group format. When compared with individual delivery, the group format had a lower satisfaction rating although the difference is minimal (-1.07 difference in mean satisfaction scores) (Gonsalves et al., 2021). During this format of implementation, students' privacy was maintained as they did not have to interact with group members or disclose personal information (Gonsalves et al., 2021). POD Adventures was also delivered remotely to the service users, who may download the app using their or their family members’ phones. Even with remote access, service users are still supported by the lay counselors tasked with the same role as in-person counselors although delivered via phone calls (POD Adventures, n.d.). Currently, there is limited research on the outcome of the remote delivery of the app. Sensitization Activities Stigma on mental health challenges is among the barriers individuals encounter in help-seeking. As such, sensitization activities were also included to promote the intervention to the service users and stakeholders to initiate the referral process. The brief 20 – 30 minute session is aimed at informing service users about the signs and symptoms of common mental health problems, normalizing mental health difficulties, and raising awareness about the intervention, referred to as a “stress reduction and problem-solving program” to reduce mental health stigma (Gonsalves et al., 2021; Michelson et al., 2020 ). Apart from being presented with video materials, group 22 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries discussion also ensues after the presentation. Service users are then given referral forms with questions that help them identify mental health problems. Summary of Uptake and Adherence Incorporating all these elements, POD Adventures has shown to be acceptable and engaging to students. Acceptability of the intervention manifested in high uptake with almost 18% (n=319) of the students oriented (n=1772) self-referred themselves to the program (Gonsalves et al., 2021). High adherence to the intervention was also noted as 92.7% of students who were included in the study (n=248) completed the intervention. Users also had high satisfaction ratings (m =3.66, SD=0.40, maximum score of 4) and found the program helped them effectively deal with their problems. How can we ensure the privacy, safety, and security of the platform? To safeguard the privacy and confidentiality of the service users in the app, privacy policies can be presented in-app through adolescent-friendly language that is easily comprehensible to the service users. As done in POD Adventures, the material should include details about the type of information that will be collected; how this data will be acquired, used, and stored; and specific circumstances that which it will be shared (e.g. indications of risk to self or others) (Gonsalves et al., 2021). In light of the findings that service users may also have the differing attitude to the type of data they are willing to share, options may be made available to help users determine and control the information they provide and the scope of its use (Huckvale et al., 2020) How can service users access the resources to avail of the intervention? To address possible limitations of resources, such as internet connectivity and mobile devices, digital mental health interventions can be made more accessible if there are community partnerships that would enable service users to access digital tools in private spaces. For instance, POD Adventures was delivered via mobile devices distributed to schools and can be used in school-allotted spaces (Gonsalves et al., 2019). In the school-based delivery, the intervention was also ensured to be functional offline even if this might limit the ideation of features (Gonsalves et al., 2019). These strategies addressed limitations in access but also responded to parents' and service providers' concern about the amount of time that children are spending on their phone (Gonsalves et al., 2019). In addition, accessing the intervention in safe spaces with the support of lay counselors also addresses experts' initial concern about the adverse effects of introducing technology to low-income settings especially without equipping them with digital literacy in using these technologies. Are there risks associated with the use of the intervention? How can we mitigate these? Currently, in the implementation of SPARX and POD Adventures, there were no mentions of adverse events to the service users. For both applications, they consider managing risk and safety as integral to their duty of care to service users. For SPARX, a clinical monitoring group was present to oversee problems that may be encountered in the use of the app. Users were also provided clear directions on when and how to seek further help if needed (T. Fleming et al., 2021). For POD Adventures, human 23 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries support was also essential in managing risk among individuals in need of more specialized care (Gonsalves et al., 2021). Individuals who report having a very low mood in the app’s routine pre-game questionnaire are instructed to approach the lay counselor to commence risk assessment and referrals to more specialized services (Gonsalves et al., 2021). During recruitment and implementation of the intervention, there were no reported incidents of individuals reported to outside care. Implementation Taking into consideration the findings from the experts interviewed and the review of literature that followed, modifications were applied in the blueprint of the intervention. This revised blueprint is reflected in the final theory of change. Theory of Change Eligibility Criteria The intended service users remain to be adolescents aged 13 – 19 years old, representing Junior and Senior High School grade levels in the Philippines. Intervention can be availed by any help-seeking by adolescents who refer themselves to the program. Students will be guided in identifying mental health distress by providing them questionnaires and orientation activities that will help in identifying their need for referral. The move to replace diagnostic-specific criteria (e.g. symptoms of depression or anxiety) with more dimensional criteria (e.g. general mental health difficulties) accords with the recommendations in the literature. In a stepped care model, it is essential to support individuals who may not have a diagnosis but experiences non-specific distress (Patel et al., 2018). Addressing the needs of this 24 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries population can also prevent further exacerbation of their conditions to specific mental health disorders. The demand for this type of support also appeared during formative research on POD Adventures, where they noted that a significant proportion of students requested mental health support despite not falling within the clinical criteria (Gonsalves et al., 2019). To manage risk, assessments will be conducted to determine high-risk cases (e.g. suicidality and self-harm) and will be referred to more appropriate mental health services. Mode of Delivery The intervention will be delivered through an app provided with minimal guidance from a lay counselor. The app will be designed with features in a way that enhances user engagement. This may include emphasizing user-choice and interactivity and incorporating missions, quizzes, and rewards throughout the games. A guide character may aid in explaining the concept, assist users as they navigate the app, and provide motivational feedback. Apart from the content, visuals and characters in the app will be contextualized to ensure it is culturally appropriate for the target population. Delivery Setting The intervention is prioritized to be delivered in school. Schools serve as a convenient location for large-scale implementation as adolescents spend the most time in this setting. Schools may also facilitate interaction and collaboration with key stakeholders (e.g. parents and adolescents) and allocate resources such as designated spaces to conduct the intervention. In the initial phase of the program where evidence for feasibility and efficacy first needs to be established, the school appears to be an ideal setting to conduct action research programs. Apart from facilitating user recruitment, it may be easier to track and follow up service users on post-implementation evaluations. Working with school stakeholders, from staff, parents, and students, during development may also increase the acceptability of the intervention as they are involved in the end-to-end development process. In addition, setting intervention in school also addresses the neglectedness of mental health services in school settings, especially in public schools with limited allocations for mental health programs. While providing mental health services is promoted in the Mental Health Strategic Plan, discussions with experts as well as scoping of literature indicate that efforts are usually centered on universal mental health promotion activities. For instance, DepEd has launched online discussions on mental health for adolescents and educational programs with storytelling and art activities for children (Department of Education, 2021). For help-seeking adolescents needing targeted interventions, available services may be limited to helplines (Department of Education, 2021). While there may be specialized interventions available, some of these are also designed as a response to disasters and emergencies such as Psychological First Aid (PFA) and Mental Health and Psychosocial Support (MHPSS). The charity is ideally implemented in public schools in urban settings where adolescents are more familiar with smartphones. 25 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries In the long run, intervention may also be rolled out to the community via government and non-government organizations working with adolescents with resources, such as workforce and facilities, that enable the program implementation. For instance, #MentalhealthPH and Youth for Mental Health Coalition are two of the active NGOs working in this space in the Philippines. There is also potential to collaborate with NGOs that may not be focused on adolescent mental health but acknowledge the need for MH services in their respective communities. Faith-based organizations may also be tapped given their prevalence in the Philippines. Local Government Units with a strong MH agenda can also be engaged to integrate the intervention into primary care. Although it should be emphasized that if the population using the intervention deviates from the initial eligibility criteria of school-going adolescents, then intervention would have to be tested and adapted to account for the unique context of children in other delivery settings. For instance, key learning in SPARX, adolescents from the juvenile justice program were not able to utilize the application. Identifying unique risk factors adolescents in our target group is also needed. For instance, there are specific guidelines or proposed interventions better suited for adolescents in conflict areas and teenage moms (World Health Organization & United Nations Children’s Fund (UNICEF), 2021). Treatment Content and Components Intervention includes brief problem-solving therapy supplemented with emotional regulation strategies. In summary, intervention is found to be appropriate for the service users given adolescents' demand for more practical solutions to managing concrete time-limited problems and its transdiagnostic nature that can address multiple mental health difficulties such as emotional and behavioral disorders. Problem-solving concepts will be taught through story vignettes of relevance to the service users. They will also be guided to use the concepts learned and apply these to their own difficulties. In the ideation of content, it is important to involve adolescents and key stakeholders such as parents, teachers, and mental health providers to determine adolescent’s challenges, coping strategies, and help-seeking behaviors to ensure the appropriateness of the treatment component and content for the service users (WHO & UNICEF, 2021). Developmental stage, such as early (10 – 14 years old) or late adolescent (15 – 19 years old), and transition periods (junior high to senior high) may also be considered as key variables since these may impact the nature of the problem and their coping mechanisms (WHO & UNICEF, 2021). In the Philippines, local cultural context, such as geographic area (rural vs urban) or ethnic groups, may also be relevant factors in development or adaptation. Gender can also be a mediating factor in the uptake and completion of DMHI and can be considered in ideation. For instance, males tend to experience and perpetuate stigmatization compared to females due to gendered cultural norms (WHO & UNICEF, 2021). In addition, females are likely to complete intervention compared to males (Lehtimaki et al., 2021). In POD Adventures, identified relevant vignettes revolved around academic pressure, bullying, difficulties in romantic relationships, and parental and peer 26 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries influences, which may still be relevant in the Philippines. In addition, expert interviews indicate that transition to face-to-face classes may result in interpersonal difficulties or self-esteem concerns due to physical image as adolescents acclimatized to interaction with peers. In POD Adventures, emotion regulation strategies identified included imagery, breathing, and muscle relaxation, while in Friendship bench, only breathing exercises were used (Chibanda et al., 2016; Gonsalves et al., 2019). Discussions with service users may help narrow vignettes to be selected as well as emotion regulation strategies to be adapted. Given the impact of stigma on health-seeking behaviors, sensitization activities are also an important component of the treatment that will facilitate referral. Apart from normalizing and identifying mental health difficulties for adolescents, sensitization activities may also be directed to individuals of relevance to the students, such as personnel in the delivery setting and parents. The aim is to create a community where adolescents are comfortable sharing their mental health difficulties and feel supported in accessing mental health services. As mentioned above, there may be instances when the intervention is not sufficient for the needs of adolescents. Within the scope of the intervention, partnerships with mental health services providers can be established to create systems of referral for students requiring high-intensity treatments. Currently, groups that may be engaged to provide support include government organizations such as the National Center for Mental Health, or educational institutions offering psychological services such as Ateneo Bulatao Center for Psychological Services or University of the Philippines Diliman Psychosocial Services (UPD PsycServ). If the program is implemented on LGUs that are already providing mental health services, these institutions can also be onboarded as part of the referral system. Difficulties mentioned in using PST among Kenyan Youth with HIV are reminders that individuals’ mental health is influenced by the context in which they are embedded. The proximal social environment such as family, and economic domains, such as poverty, are all relevant aspects influencing the individuals' well-being. While it is not within the scope of this intervention, pragmatic concerns raised by students may be collated so the charity can ideate ways to connect students with resources that can help alleviate these problems. There may also be a need to strengthen certain program components, such as orientation with parents, to address these issues as they arise. Providers Lay counselors, individuals without formal training related to psychology or mental health, will be recruited and trained to deliver the intervention. While it is an option to task-share responsibilities to school staff, the viability of this model is challenged by the excessive workload already handled by the teachers. It is also cost-effective to task shift responsibilities to already existing health gatekeepers in the delivery setting, such as guidance counselors, but schools have varied and often limited capacities to accommodate this. To illustrate, only 42% of guidance-related 27 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries positions are filled in the DepEd plantilla given the limited number of individuals interested in the profession due to the poor compensation (Manilla Bulletin, 2020). In the absence of mental health counselors in the school, the charity will finance the employment of the lay counselor. Selection criteria may include the following: individuals age 18 and above, with adequate reasoning capacity and interpersonal skills evaluated based on interviews and standardized tests. Training may involve 1-week of didactic sessions with roleplaying activities facilitated by psychologists from the charity’s technical team. Lay counselors from each school will be given weekly 1-hour group supervision facilitated by a psychologist aimed at providing support for challenges and evaluating the fidelity of the program execution. Individual lay counselor calls to the supervising psychologist may also be conducted as necessary. As such, the charity will need to employ a supervising psychologist during the school or community-based implementation model of the intervention. To address concerns about the cost and limited workforce for supervising psychologists, the program includes the preparation of lay counselors for peer-to-peer supervision, where they can be provided structured scales and feedback manuals to assess the quality of the intervention. Concerns and challenges that are not resolved during peer supervision may be escalated and consulted with the charity’s supervising psychologist. Remote supervision can be conducted using digital tools through mobile calls or online conferencing. These strategies are also recommended approaches to deliver supervision for interventions in LMICs (Patel et al, 2018). Some challenges may be met in the implementation of PST via lay counselors in LMICs that warrant attention during the ideation phase. In India, lay counselors had difficulty supporting students' autonomy during problem-solving as some prefer the direct “giving the right answer” approach (Gonsalves et al., 2019). In Vietnam, staff trained as lay counselors provided students with direct actions to take outside of the PST sessions instead of supporting them as they engage in their own problem-solving. (Dang et al., 2018) In both school-based approaches, the hierarchal teacher-student upbringing in these cultures may undermine the essence of PST that advocates for individuals to be active and autonomous agents addressing their problems. In the delivery of PST via peer counselors (18 – 24 years old) in Zimbabwe, some facilitators had difficulty establishing their credibility to service users given their age which impeded some from sharing their problems at the onset (Simms et al., 2022). Delivery Schedule and Format The intervention will consist of four 30 – 40 minute sessions that are spanned for 2 – 4 weeks, with two sessions conducted in the first week. The number of sessions was designed to reduce rates of dropout which occurs as the number of sessions increases and dosing was planned to enhance counselor-user rapport in the first week. The first session will include an onboarding session where the counselor 28 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries will orient service users to the app and a review session will be conducted in the last session to consolidate service user learning. Both of these sessions may take 10 minutes of each session, and the rest will be used for independent gameplay. The intervention is currently ideated to be delivered in a group session, with 5 – 6 members each, to maximize counselor time. In this format, the lay counselor will deliver onboarding and review sessions in a group setting, and independent gameplay will be conducted with adolescents in the same room although spaced apart for privacy. Program Development and Testing The updated intervention also takes into careful consideration the steps and resources required to develop or adapt interventions in the Philippine setting. During this phase, key tasks include convening a technical group to spearhead the ideation of the program design, content, and delivery model; conducting discussions with adolescents and other relevant stakeholders such as mental health professionals, parents, and delivery setting personnel; creating manuals and material needed for implementation, such as manuals app delivery and sensitization activities. The technical group will also design and conduct research activities to evaluate the feasibility, acceptability, and effectiveness of the intervention during the first year of implementation Building research capacity will also be an essential component of the program. This includes determining the appropriate methods to test the effectiveness and feasibility of the intervention. Currently, in scoping of literature, RCTs remain to be the most common method to determine effectiveness. However, the lengthy process required to conduct RCTs can be a concern considering the rate at which technology is evolving and intervention becomes at risk of being outdated before being fully implemented (Liem et al., 2020; Liverpool et al., 2020). In addition, RCTs may also not sufficiently provide information on effective implementation strategies (Liem et al., 2020). There are suggestions to adapt new methodologies and frameworks that can be utilized to produce timely output necessary as the intervention is being developed (Liverpool et al., 2020). For instance, in the development of Step-by-Step for Filipinos, they implemented a hybrid effectiveness-implementation framework, a novel approach that aims to “accelerate the translation of clinical effectiveness research to implementation strategies” (Liem et al., 2020). Target Location Our research is focused on identifying the best mental health interventions in low-resource settings. Our main criteria in choosing the target location 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. 29 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries 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 disorders, and autism spectrum disorders in the region. Myanmar replaces Vietnam 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 the number of DALYs. Indonesia and the Philippines rank first and second respectively as the countries having the highest burden of attention-deficit/hyperactivity disorder (ADHD) in the number of DALYs with Thailand joining as the third top country. Substance use disorders are not considered mental disorders in the GBD report but they are included in our PICO framework and are commonly addressed by the studies we found across interventions. Conduct disorder, ADHD and autism spectrum disorders are excluded in our PICO framework but they are common target conditions in children in the studies we found. Singapore is the only Southeast Asian country classified as high-income. Malaysia and Thailand are upper-middle income countries and the rest are lower-middle income countries. Thus, Indonesia, Philippines and Vietnam shall be prioritized. Due to the researchers’ location and expertise, this research focuses on the Philippines. We still expect the results to be somewhat generalizable to these other two countries due to their similarities since the interventions we are investigating are made 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. Given the decentralization of responsibilities of delivering social services to Local Government Units (LGUs), it becomes critical to identify LGUs that have strong leadership and governance in mental health. The recent Healthy Pilipinas Award organized by the Department of Health identifies LGUs in the Philippines with commendable mental health infrastructures and policies, which can 30 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries be viable centers for pilot implementation. Some of these cities and municipalities include Quezon City, Baguio City, Borbon and San Remigio in Cebu, Mansalay in Oriental Mindoro, Claveria in Cagayan (Department of Health, 2022). Given these available locations, it may be best to prioritize implementation in urban areas where adolescents are more acquainted with the use of mobile phones. Acceptability Game-based mobile-delivered intervention remains to be acceptable to students due to their familiarity with the modality and the app’s engaging features. Although group-based delivery may counter adolescents' preference for privacy, implementation of POD Adventures may indicate that effective sensitization activities may help subdue mental health stigma and promote a supportive community toward help-seeking individuals. The extent to which this can be generalizable to the Philippine population still needs to be confirmed. Initial concerns about attrition rates are also addressed by providing human support and delivery in a school-based setting. During experts' interviews, concerns about the suitability of CBT, accessibility, and safety of the program were raised, indicating that the initial program may be met with hesitations by other mental health providers. However, addressing these concerns in the current iteration of the program may lend the program more acceptable. In addition, the new program specifies the importance of stakeholder engagement in the development of the intervention which may enhance acceptability ratings for both service users and the community by improving the relevance and appropriateness of treatment components and mode delivery. 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. Problem-solving interventions aforementioned, Friendship Bench in Zimbabwe and POD Adventures in India, were also financed through the support of the Wellcome Foundation. The evidence-based impact of previously funded interventions may enhance interest in similar interventions as applied in a different context. 31 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries 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 of the intervention. They have Scale-Up Hubs to conduct implementation research on evidence-based mental health interventions for LMICs in the following regions:  East Asia and the Pacific; Europe and Central Asia; Latin America and the Caribbean; Middle East and North Africa; South Asia; Sub-Saharan Africa. Their research networks in Asia have not reached the Philippines yet. 3. Grand Challenges Canada is a nonprofit organization funded by the Government of Canada and other partners that funds innovations in low- and middle-income countries and supports the use of science and technology, and social and business innovation in creating positive impact. In the global health domain, their priorities include providing funding to seed and scale-up mental health interventions targeted at underserved youth in LMICs. They are also among the primary funders of Friendship Bench in Zimbabwe 4. Philips Foundation is a charity established in 2014 that aims to reduce healthcare inequality in disadvantaged communities by improving access to care through digital innovation, strengthening community-based care and primary care, and supporting scalable health care delivery models. They were initially involved in the development of the Inuka Coaching app in Zimbabwe. 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 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. Among their priority areas include serious games as part of creative industries. 2. The National Research Council of the Philippines also gives research grants. 3. If this intervention will be done in a school setting, the Department of Education and the Commission on Higher Education may 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. More details about working with schools can be found in the deep report on school-based psychoeducation. 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. 32 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries 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 Initially, the intervention did not require a workforce for implementation. However, given the importance of human support to improve uptake, adherence, and risk management for adolescents, lay counselors were incorporated as an essential component of the intervention. Concerns over limited talent are addressed given the feasibility of task-shifting of human support to lay counselors. In the initial implementation, the charity would have to hire its own lay counselors for this to be implemented in schools. In the long run, the cost of employing lay counselors may be devolved to the LGU or the public school offices. In other delivery settings, such as NGO communities, the organizations may be held responsible in nominating talents to train as lay counselors in their community. Supervision and mentorship is also an essential element of the program to ensure fidelity to the intervention and to provide support for challenges that may be encountered during implementation. Similar to counselors, there is also a shortage of specialists who can provide this support. However, the shortage of talents can be remedied by providing layered support, with peer supervision as the source of the bulk of the support and specialists can be reserved for more special cases. In terms of app development, various gaming companies are present in the Philippines that can be engaged in the technical development. Some of these are listed in Game Developers Association of the Philippines (GDAP). The gaming industry has experienced exponential growth in recent years, with almost a third of the revenues sourced from serious games, and almost 40% are dedicated for mobile phone or tablet games (Philippine Board of Investments, 2017). While we may have not identified key developers with experience in mental health games, these statistics indicate there are talents that can be sourced locally to develop the program. Evidence-based DMHI are also often created through the collaboration of clinicians, academics and technological teams (Hill et al., 2018). In our initial ideation, a tech company will be commissioned for the development of the app and continuous maintenance of the app. However, if intervention is scaled as a social enterprise, the charity may eventually need to create and build its own team or partner with other tech companies, to enable continuous development of the app and leverage the tech companies’ experience in dissemination and commercialization. 33 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries Scaling Previously concern on scaling revolved primarily around app maintenance. However, as charity incorporates new components, such as human support, supervision, and distribution of devices, achieving sustainability becomes more difficult. It remains ideal that the program is integrated into the health system, with DOH and DepEd as key partners for school-based delivery. However, the model of social enterprise may still be feasible. Once the program has been proven to be effective, it can be packaged and provided to partners in other delivery settings to generate revenue, such as private for-profit schools. For instance, Inuka Coaching offers its platform to employees in for-profit organizations globally and allocates a portion of their revenue to finance free use of the platform for underserved communities. Another mental health app that uses this model is Canopie in the United States. For one, cost-effectiveness analysis of the intervention can be conducted to increase buy-in from government institutions and funders. Currently, there are limited studies on the cost-effectiveness of DHMI interventions in LMIC (Naslund et al., 2017), resulting in the difficulty of comparing interventions using this criterion. Apart from the economic benefits, evaluating the social impact of the intervention, such as increased productivity or school attendance, may also help concretize benefits for other stakeholders and amplify interest in funding or adopting the intervention. We view the final iteration of the intervention as the most ideal implementation as program components, such as school-delivery and human support, contribute to attaining the goal of providing safe, engaging, effective and accessible mental health services. However, given the cost of implementation, it may be beneficial also to consider direct-to-consumer approach and purely self-help delivery. For example, school-based delivery without lay counsellor support may still maintain user engagement, uptake, and adherence as users are provided a structured and safe environment (e.g. designated schedule and space) to access the intervention. Group-delivery formats may be maintained if shown to be effective in enhancing engagement in the Philippines. In addition, the pandemic has facilitated the innovation in learning modalities in the country, with DepEd offering multiple avenues for remote learning. For instance, learning modalities include distance learning where students use online or offline digital modules and blended learning which makes use of TV, Radio programs, printed or digital modules to transmit information (Enicola, 2021). Some local government units also procured and distributed devices, such as tablets to students to enable online learning. The presence of these infrastructures may be leveraged as the program ideates other models of delivery. A potential idea might be to partner with local government units and schools that distribute tablets to students and make the app available on these devices. Intervention can be introduced to students utilizing mediums of instruction used by DepEd such as TV and Radio programs, as well as, online and offline digital modules. If support is found necessary, it can be provided synchronously or asynchronously in the same way teachers assist students in these alternative learning modalities. 34 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries However, feasibility of these models will depend on the extent that the government will maintain these alternative learning modalities post-pandemic. The remote delivery of POD adventures during the pandemic can serve as a model to the direct-to-consumer approach. Students who have access to smartphones and the internet were able to download the app. Although, it is important to note that even in remote delivery, counselor support was provided to students via phone calls to fulfill onboarding in the first session and review of learnings in the final session. Sensitization activities were also maintained to facilitate self-referral. In urban areas in the Philippines, we stated in the introduction the high prevalence of internet and smartphone usage that can pave the way for a direct-to-consumer approach. Among adolescents and families with smartphones but may not have allocated data to access the internet, partnership with telco companies to provide mobile data allowance may also be considered. Establishing these partnerships appears feasible since companies like Globe have shown firm support of mental health initiatives demonstrated by offering toll-free access to NGO lifelines. Alternatively, this can also be part of the app bundles when subscribing to prepaid mobile data plans for education, in the same way telco companies have done with Google Classroom and Zoom. In applying this model of delivery, several considerations may first need to be evaluated. For one, a key task for the charity is determining the best model for marketing the intervention to adolescents in a manner that incorporates sensitisation activities of normalizing psychological distress and identifying the need for psychological support. In assessing feasibility of direct-to-consumer method without lay support, further studies also need to be conducted to isolate effects of lay counsellor support and the game component of the intervention. As mentioned above, even in game-based apps like SPARX, lower uptake and completion rates were observed in naturalistic open-access delivery. Even with POD Adventures that included lay counsellor support, remote delivery had affected the uptake of the app, indicating that the blended approach with in-person counselor support is essential in uptake and acceptability (Chabria, 2021). Apart from maintaining adherence, lay counsellors also helped in risk management and facilitating referrals for service users in need of specialized care. Hence, a critical discussion in removing lay counsellors entails determining the charity’s duty of care to their service users. In apps like SPARX and Step-by-Step, referrals were included so users can contact help as needed. As self-help apps, responsibility of seeking further care is placed entirely on the service users. While this can be a feasible approach, interviews with experts highlight concerns on risk and safety and the importance of human support which leaves us with the impression that removing lay counsellors may impact acceptability of the program for mental health providers and other community stakeholders. Although it might also be possible that changes in the intervention’s content and aim, from a CBT app for adolescents with depression to a self-help stress management for help-seeking adolescents, may change their perception of the purely self-help modality. In any case, risks associated with the use of the app in our target population first need to be assessed to ensure that we abide with the tenet of doing no harm. 35 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries Given these concerns, remote delivery and purely self-guided approach can be explored as a viable option in the future once the program has been developed and evaluated in school-setting. Further studies need to be conducted to determine revisions that need to be implemented to maintain acceptability, adherence, and risk associated with these delivery formats. Externalities The initial concern about widening the treatment gap between individuals with access to digital interventions is addressed given the school-based delivery where the provision of devices is included as an intervention component. With the inclusion of sensitization activities directed to students, school staff, and parents, the intervention may also improve awareness of mental health in the community and help alleviate the stigma associated with mental disorders. The intervention also promotes the use of staging or stepped care approach to mental health where individuals at different levels of mental health pathway, from well-being to different stages of disorders, are provided adequate support suited to their needs (Patel et al., 2018). In this case, individuals who may not have a diagnosis but experience non-specific distress are provided resources that may help address their current distress and facilitate coping for future ones. The program serves to complement existing population-wide school-based interventions that promote well-being. Cost-Effective Analysis The cost-effective analysis conducted was based on existing metrics available from POD Adventures, as it is the only guided self-help game-based intervention using PST. Herein, the main metrics include subjective well-being using Short Warwick-Edinburgh Mental Well-Being Scale and mental health symptoms by the total difficulties score of the Strength and Difficulties Questionnaire (SDQ). Years of Unit $ per unit, total $ per unit, Operation costs intervention costs only SWEMBS 69.47 36.97 improvement 1 year CSD-R 36.89 19.63 reduction SWEMBS 11.41 5.99 rd 3 Year improvement 36 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries CSD-R 6.06 3.18 reduction Compared to the previous CEA, the cost for implementation was adjusted to reflect the addition of new components, such as salaries for lay counselors and supervisors, technical team for content development, logistics, and materials for intervention activities (e.g. orientation materials, gadgets). This significantly increased intervention cost in the first year of implementation by 200% compared to the previous iteration. The uptake and completion rates were also modeled based on the results from the initial implementation of POD Adventures. Compared to direct-to-consumer delivery of the app, school-based delivery has shown to have higher uptake, adherence, and wider reach which affected the total impact of the intervention. However, the external validity of the uptake and completion rates in naturalistic settings may need to be confirmed as the active presence of the researchers and the novelty of the intervention may have contributed to the high ratings. As such, discounts for this are provided. In the modest assumption that the intervention will be delivered to two new schools each year, the cost of implementation reduces by 83% in its third year. While the intervention appears more expensive at the onset compared to the previous iteration, cost reductions are significantly higher, as school-based delivery enables us to reach a wider proportion of adolescents over time. Weighted Factor Model Recommended and initial intervention are both game-based applications for adolescents but they deviate in terms of therapeutic modality, key outcomes concerned with, and mode of delivery. In the existing literature, there is strong evidence that PST is effective in reducing functional impairments and mental health symptoms, as well as improving quality of life and subjective well-being as applied in studies conducted in LMICs. While most of these studies are conducted in adults, there are also studies conducted for adolescents. Despite the strong evidence of PST, the game-based intervention selected is still in its preliminary implementation. Randomized controlled trials are needed to have firmer conclusions about its effectiveness and naturalistic studies to deduce its external validity. Hence, the lower effectiveness rating. The higher completion rates of brief school-delivered games-based interventions may also improve its effectiveness rating, although there is insufficient information on the impact of dosing frequency on intervention outcomes to evaluate this. The recommended intervention is assumed to have higher acceptability ratings due to revisions in its intended goals, the inclusion of new components, and the appropriateness of therapeutic modality to the intended service users. First, it addresses mental health stigma, a key barrier to help-seeking, by promoting the program as a “stress management” tool and adding sensitization activities that enhance awareness and normalization of mental health difficulties. Second, providing 37 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries human support preferred by adolescents also enhances acceptability. Third, the intervention responds to the mental health experts' initial concerns about the program, primarily the suitability of CBT, managing risk, and access to resources to avail of the intervention. From evaluation, program implementation may take 12 months or longer given the time required to conduct stakeholder consultation, program development or adaptation, technical app development, hiring and training of lay counselors, and establishing partnerships with public schools that may be met with bureaucratic challenges. Hence, the rating is lower than the initial intervention. The use of lay counselors and peer-to-peer supervision enables the scaling of the intervention in a low-income delivery setting. However, using schools as the delivery setting and the need for referral systems pose another challenge as charity needs to continuously build partnerships with the educational and health institutions in different localities as they grow over time. Both internationally and locally, there are funding opportunities for evidence-based mental health interventions that leverage digital technologies for scale-up. Similar intervention using PST in low-income countries such as Inuka Coaching, Friendship Bench, and POD Adventures provides precedents that charity could receive funding, especially since most of these interventions are founded in Africa and South Asia, and no similar intervention are available in South East Asia. In addition, the intervention can also gain further support as it aligns with the Philippine Mental Health Strategic Plan of integrating mental health services in schools and addresses the neglectedness of targeted interventions for help-seeking adolescents. Criteria Initial Intervention Recommended Intervention Effectiveness (20%) 4.63 4.5 Acceptability (20%) 3.25 4.5 Ease of implementation (10%) 3.13 3 Ease of scaling (30%) 4.37 4 Ease of funding (20%) 3.62 4 Average 3.924 4.1 38 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries Barriers to the Founding of the Charity While there is significant evidence that indicates the effectiveness and feasibility of DHMI for adolescents, there are limited studies on the use of this modality when it comes to LMICs. As such, research becomes an essential component of the charity, and commensurate resources should be allocated, in the development or adaptation of the program and its effectiveness once implemented. In previous literature reviews on DHMI in LMICs, some limitations raised include low patient engagement and high dropout rates, challenges with comorbidity and acute crisis, and tailoring intervention to client needs (Naslund et al., 2017). Through gamification, close collaboration with clients for ideation, and employing transdiagnostic treatments, these concerns are addressed. We initially proposed to have referral systems available for acute cases and non-responders, however, the feasibility of including this in the program is uncertain given the fragmented and limited mental health services available in the Philippines. While we have identified potential organizations and LGUs that can aid in establishing these referral systems, partnership with these service providers will depend on their capacity to take on cases from the program. In literature reviews, there are also mentions that mental health professionals may have a cautious attitude toward DHMI as they raise concerns about accessibility and data privacy (Naslund et al., 2017). The experts we have interviewed also reflect these sentiments. Hence, the final iteration of the program was revised to account for these issues. However, the benefits of developing a costly app versus the more economical workbook, already used in community work, need to be strongly demonstrated in discussion with mental health providers to gain firm support. Even POD Adventures was initially ideated as a workbook as it is more cost-effective and digitization was only considered given the limited engagement with the material which they addressed by enhancing counselor support. In the same way, these challenges may need to be demonstrated in the Philippine setting to strengthen interest in this mode of delivery. In addition, we can reinforce the benefits of app delivery by capitalizing on its potential to be scaled up through remote or direct-to-consumer approach once effectiveness has been established. The sustainability of the mental health program post-development remains to be a key concern. While there are solutions offered, such as institutionalization in mental health services or social entrepreneurship, more information is needed to evaluate their feasibility. For instance, interviews may be conducted with implementers who have gone through similar processes to identify external and program factors that contribute to the success of these models, especially in LMIC settings. Conclusion One of the key strengths of the research is its prioritization of evidence-based intervention at the onset as we began with a systematic scoping of the interventions 39 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries available in the academic literature. After identifying major clusters of intervention, we continued with the shallow report with the intent of exploring the strength of evidence and feasibility of implementation in LMICs. The charity ideation followed an iterative process wherein the initial program was presented to mental health providers to determine its feasibility in an LMIC setting and was refined based on their comments. From the experts’ interviews, we gathered information that is not present in the formal literature, predicted challenges that may be met during implementation, and discerned mental health providers' reception of the program. Positioning experts’ interviews midpoint of the research process was beneficial as it allowed us to revisit the literature to determine solutions to concerns identified and to revise the program as necessary. However, due to the restrictions in time, experts interviewed were limited to mental health providers in the Philippines. It would also be beneficial to engage with program implementers of the interventions we have identified to understand pragmatic concerns in development and implementation which may have been included in research existing literature and to check the openness to establishing partnerships abroad to adapt the program in other cultural settings. In addition, it would also have been advantageous to hold interviews with our critical stakeholders such as adolescent service users and representatives of educational or health institutions involved in the delivery of mental health services to assess their needs, attitude, and receptiveness towards the identified program. The guided self-help game-based stress management intervention is a viable and cost-effective program that can be implemented in LMICs. There is strong evidence supporting the effectiveness of PST as a therapeutic modality and of self-help game-based apps with minimal guidance as a mode of delivery. Of the different interventions encountered, the final program has also been ideated and implemented in a low-resource setting, enhancing the generalizability of its acceptability, feasibility, and effectiveness if used in a similar context. While expensive at the onset, the intervention is cost-effective when implemented at scale as more schools are onboarded, and may improve further in this criteria given its potential of transitioning to a remote and direct-to-consumer intervention. Considering the step-care approach to mental health, the program is also theoretically cost-effective as it targets the needs of a large portion of the population experiencing non-specific distress instead of focusing on specific symptomatic ones. It addresses service users' present mental health difficulties and may prevent these from reoccurring by equipping them with generalizable skills. There are also identified funding opportunities for the program, especially given the traction of tech-enabled digital mental health intervention in recent years. In the Philippine setting, intervention complements currently implemented mental health promotion programs in school-based by providing a low-intensity intervention for those help-seeking adolescents experiencing non-specific forms of distress. This intervention may gain funding interest as it aligns with the recommended stepped care model found in Philippine Mental Health Strategic Plan. 40 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries While we expect initial funding can be raised for the intervention, financing intervention at scale and in the long-term becomes one of the primary concerns. While there are potential workarounds for this, via government integration or social entrepreneurship, further research needs to be done to determine and include considerations necessary to make these transitions. This is a concern, not only for digital interventions but across various mental health interventions. Examples of digital mental health interventions that transitioned to these models provide precedents that these may also be possible even in an LMIC setting. An additional challenge in the implementation is the provision of referrals for those who may be non-responsive to the intervention. This is also a systemic issue given the dearth and the unequal distribution of mental health services in the Philippines. Although we have identified organizations that may support the demand for referral, the charity will have to partner with more organizations once demand increases as the charity scales up in the long run. Despite these limitations, this report indicates potential sustainability models and mode of delivery for scaling. 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Intervention Description Outcome Friendship ● PST consisting of 6 sessions ● “Intervention group Bench by lay health workers participants had fewer in-person symptoms than control group Zimbabwe participants on the SSQ-14 ● Participants: adults (>18 yrs (3.81; 95% CI, 3.28 to 4.34 vs (Chibanda et al., old) with symptoms of CMDs 8.90; 95% CI, 8.33 to 9.47)” 2016) (indicated by SSQ-14 score <9) ● “Similarly, there was improvement in depression ● N=573 enrolled in the symptoms…for the PHQ-9 research (intervention = 286; 46 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries control = 287); 521 (90.9%) scores (AMD, −6.36; 95% CI, completed follow-up −6.45 to −5.27; P < .001). ● RCT comparing intervention ● “There was also improvement with enhanced usual care in the tertiary outcomes (brief counseling, symptoms of generalized psychoeducation on CMDs, anxiety measured by GAD-7 option medication) scores (AMD, −5.73; 95% CI, −6.61 to −4.85; P < .001), disability measured by WHODAS 2.0 scores (AMD, −6.08; 95% CI, −7.46 to −4.71; P < .001), and health related quality of life measured by EQ-5D scores (AMD, 0.12; 95% CI, 0.08 to 0.17; P < .001) Zvandiri ● PST, as an additional ● “There was strong evidence of adolescent peer component to TAU delivered an apparent effect on common counseling by trained lay peer counselors mental health outcomes (SSQ program with >=8: 2.4% versus 10.3% [AOR ● TAU (HIV care, counseling, =0.19; 95% CI 0.08, 0.46; p < PST (Youth home visits, support groups) 0.001]; PHQ-9 >=0: 2.9% Friendship versus 8.8% [AOR = 0.32; 95% Bench) ● Delivered to adolescents (10 – CI 0.14, 0.78; p =0.01]). 19 years old) living with HIV Prevalence of EQ-5D index Zimbabwe with elevated symptoms of score <1 was 27.6% versus CMD (indicated by SSQ-14 38.9% (AOR =0.56; 95% CI (Simms et al., score <8) 0.31, 1.03; p =0.06).” 2022) ● N=842 enrolled in the research; with n=765 completed follow-up evaluation for CMDS ● Clustered RCT comparing TAU + PST vs TAU only Inuka Coaching ● Components: Problem ● “The findings indicated that Solving Therapy delivered in there was a significant Kenya 4 sessions; also based on the difference between pre- and Friendship Bench post-scores on the SRQ-20, (Doukani et al., (t(59) = 6.94, p < 0.001), 2021) ● Text-based mobile-delivered PHQ-9 (t(27) = 3.98, p < guided lay health workers 0.001), and GAD-7 (t(27) = 3.33, p < 0.001).” ● Delivered to adults age 18 and above with symptoms of CMDs (as indicated by score of 8 or higher on SRQ) ● Total N=80; n=60 completed 4-week assessment; n=52 47 EA Philippines Mental Health Charity Ideas Research, Deep Report Guided Self-Help Game-based Application for Adolescents in the Philippines and Low- to Middle-Income Countries completed 3-month follow-up ● Pilot Cohort Study using pre- and post-test measures ACES ProS ● PST is delivered by teachers ● “In the main analysis of the in-person to 15 – effects of ACES ProS on T2 Vietnam (Dang 16-year-old adolescents functioning, the effect of et al., 2018) Group was significant on both ● Components of PST used were emotional problems (F[1,91] = not clearly outlined 7.39, p < .01) and behavioral problems (F[1,91] = 13.40, p < ● Students who had emotional .0005), with ACES ProS and behavioral difficulties (as students showing lower T2 indicated by elevated SDQ scores than control condition scores on these respective participants on both scales) dimensions” ● Total N=100; 95% completed ● Omega-squared (𝜔2) effect post-test evaluation sizes were 𝜔2 = .06 for ● RCT comparing treatment emotional problems, and 𝜔2 = against the no-treatment .12 for behavior problems condition Footnote: ● Shona Symptom Questionnaire (SHQ), an indigenous measure of common mental disorders (CMD) in the Shona language in Zimbabwe ● Self-Report Questionnaire (SRQ), a screening tool developed by WHO evaluates the presence of the following: anxiety and depression, somatic symptoms, reduced vital energy, and depressive thoughts in the past month ● WHO Disability Assessment Schedule (WHODAS) assesses six levels of functioning including cognition, mobility, self-care, life activities, getting along with people, participation in the community ● Patient Health Questionnaire (PHQ-9) scale that assesses the presence of symptomatic criteria of a major depressive episode and the severity of each symptom over the last two weeks. ● Generalized Anxiety Disorder-7 (GAD-7), a self-report scale used to screen for Generalised Anxiety Disorder in primary care settings ● Shona Symptom Questionnaire (SSQ-14), a locally validated screening tool for common mental disorders ● Strength and Difficulties Questionnaire (SDQ-20) is a brief emotional and behavioral screening questionnaire for children and young people 48