[version 1; peer review: 1 approved with reservations, 1 not approved]
No competing interests were disclosed.
Common mental disorders such as depression affects an estimated 264 million individuals worldwide
Societal beliefs and attitudes that drive help-seeking for adolescent mental health conditions are not adequately explored in our setting and rarely include multiple stakeholders including adolescents. To bridge this gap, our study aimed at exploring diverse stakeholder perspectives on mental health risks among adolescents, prevalent magico-religious beliefs, and mental health help-seeking using qualitative methodology.
Ethical clearance was obtained from Kasturba Medical College and Kasturba Hospital Institutional Ethics committee with IEC no:230/2015. The study areas included Udupi and Brahamavara educational blocks of Udupi taluk. Prior to data collection, approval was obtained from the Deputy Director of Public Instruction, Karnataka, and concerned school authorities. Written informed consent from parents of adolescents for their participation in the study and assent from the adolescents for audio recording was obtained prior to data collection. Participant information sheets (PIS) were provided as part of the informed consent process to the participants which clearly indicated that anonymized data from the study will be used for publication purposes.
The study employed a phenomenological approach to study the lived experiences of the participants. The study area included two educational blocks of Brahmavara and Udupi under Udupi taluk situated in coastal Karnataka, south India. Our study adopted a qualitative design with focus group discussions (FGDs) and in-depth interviews (IDIs) and was conducted over a span of one year and three months between October 2018 and December 2019 among 70 participants using purposive sampling. Participants included parents of adolescents, high school teachers, adolescents aged 14–16 years and mental health professionals (MHP) and a pediatrician. Parents of adolescents were identified at the community level through healthcare workers. Apart from contacting them for the study, the researchers had no prior relationships established with the participants. They were contacted face-to-face and an interview/FGD was arranged at a time convenient to them in a private space. Prior to conducting the interview or FGDs, the participants were provided details of the study and the reasons for conducting the study. The FGDs for parents were carried out at an
The qualitative approach was adopted, and data collection spanned between 2018 and 2019. Interview guides for parents, teachers, adolescents and MHP and other health professionals were developed following literature review and quantitative data analysis of our larger study involving multiple phases. These were validated by a team of health professionals including clinical psychologists, a psychiatrist and social workers. FGD and IDI guides are publicly available (
In all, three focus group discussions (FGDs) and six in-depth interviews (IDIs) each were conducted among parents and teachers; one FGD and six IDIs among adolescents and six IDIs were conducted among mental health and other professionals (
Per participants' preference, the interviews were conducted either in the local language (Kannada) or in English. The Kannada transcripts were first transcribed verbatim and translated into English prior to analysis by native Kannada speakers well versed in English who were part of the research team. Thematic analysis was performed using
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Perceived reasons for adolescent mental health conditions |
Internet and smartphone use Bullying Academic pressure Magico-religious beliefs |
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Mental health help-seeking for adolescents |
Perceived Stigma, fear of discrimination from the community and labeling as barriers to help-seeking Traditional means of care Teachers and religious leaders as a bridge in the referral gap |
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Promotion of adolescent mental health |
In all, 70 participants were included in this qualitative study including 12 adolescents aged between 14–16 years and 58 adults. Among the 12 adolescents, eight lived in nuclear families while four lived in joint families. All adolescent participants except for one had at least one sibling. Two male adolescents and four female adolescents participated in the IDIs with five of them residing in nuclear families and one in a joint family. Only one of them was a single child. The number of family members ranged from two to nine in numbers. The parents of the adolescent participants were employed largely as unskilled workers (n=20 out of 24 parents of adolescent participants).
Of the six IDIs among parents, three were conducted among fathers and three among mothers. Two FGDs were conducted among 15 mothers and one FGD among five fathers. A total of 26 teachers with teaching experience ranging from five to 22 years were recruited. Among the three FGDs with teachers, two were conducted in aided schools and one at a private school. The IDIs were conducted among three head teachers and three high school teachers and included one male and five female teachers from three private, two government and one aided school. Among MHP and other health professionals, the IDIs included two female and four male participants with a psychiatrist, a school counselor, a clinical psychologist, a pediatrician and two psychiatric social workers, all of whom were practicing at the time of the study. The major themes and sub themes that emerged from the study are listed in
Perspectives of each of the stakeholder groups were gleaned on the reasons that adolescents were at risk for mental health conditions. Parents, teachers and adolescent participants largely cited the increased usage of smartphones, the use of internet, social media including accessing pornographic sites as major reasons for emotional disturbances among adolescents.
Mental health professionals concurred with these life experiences and stated that reduction in communication between the parent and the child as well as developmental changes and other external factors as leading to mental health risks among adolescents.
Bullying was also cited as a major problem in the school setting. The emphasis on understanding the phenomenon of bullying in addition to bully victims was evident from the data.
The stigma surrounding mental health also prevented students from seeking the help they could receive at the school level for fear of being bullied about it.
The need to destigmatize mental health promotion and counselling at the school and community level is an important step in helping adolescents seek help at the right time.
Expectations from parents to perform better in academics was also cited by teachers.
Adolescents were an important stakeholder group who raised the concern regarding inter-parental conflict or substance abuse, commonly alcoholism, by either or both parents which caused conflict. The added burden of academics, they stated, caused them to have ‘tension.’
In the Indian context, the emphasis on academics as an indicator of the child’s development was also discussed in that parents may observe poor academic performance of their child and deal with this rather than recognize possible underlying mental health conditions, hampering early identification and treatment.
Magico-religious beliefs describe cultural beliefs that people hold surrounding mental health. The etiology is credited to supernatural activities. The belief that one’s past deeds, either of the individual or of the family, were thought to affect the present mental state which was evident from the interviews. Use of horoscopes or birth charts that predicted life circumstances, ‘Karma’ or the cycle of good and bad, and ‘fate’ was quoted often by community participants.
Interestingly, adolescents were also able to recount instances of observing practices that they termed ‘black magic.’ These narratives indicated the intergenerational transmission of such societal beliefs.
Among individuals with higher education and teachers, it was found that some participants questioned these beliefs.
Almost all community stakeholders (98%), however, ascribed their belief in God to work things through for them.
Association with terms such as ‘mental’ or ‘mad’ are deeply stigmatizing. The belief that mental health help-seeking meant taking treatment for life and its associated side effects were barriers that were identified. As stated by a participating teacher:
However, participants stated that perceptions towards reaching out to professionals for mental health help were changing.
Help-seeking was found to be complex with community determinants and personal beliefs driving it. Participants from the community stated that deity belief, performing puja (religious rituals), or having their ‘horoscope’ checked would help in managing it.
Mental health professionals stated strong beliefs surrounding supernatural entities led people to seek traditional healers, and that these magico-religious beliefs helped people cope.
Regarding providing referral to adolescents, most schools it was observed, did not have counselors. Among those who did have counselors, they were important in the chain of referral.
In the absence of counselors, teachers largely took on the role of counselors themselves. Interviews with teachers brought about insights into their informal role as channels of liaison. As one teacher shared:
Some schools took initiative and also provided mental health awareness programs.
It was of interest that religious leaders also played the role of agents of referral in the community.
At the family level, parents recognized that communication between family members was key. Family support with love and supportive school environments were thought to be important in nurturing adolescents.
The fear associated with stigma appeared to be a major barrier in seeking help. The MPH recounted that behavioral disturbances during adolescence were seldom brought to their notice. The knowledge that the first episodes of mental disorders can appear in early adolescence and were a risk for suicides was not common knowledge among parents and teachers.
Parents and teachers thus needed to be equipped with awareness on what could be considered normal
Imparting life-skills education (LSE) to adolescents through schools was seen as another important preventive measure. While some central schools did, this was not ubiquitously adopted by others.
These findings indicate the perceptions at the community level on adolescent mental health and the need for promoting mental health at the school and community levels as opined by mental health professionals.
This qualitative exploration was undertaken to explore facets of adolescent mental health from the viewpoint of multiple stakeholders including middle to late adolescents, high school teachers, parents of adolescents, MHP and a pediatrician. Since the study was conducted at the community level, our findings elicited community-held beliefs and attitudes indicating pathways and barriers to seeking care. Concerning risks for adolescent mental health conditions, most stakeholders including adolescents perceived that increased device or internet use, accessing pornographic material, academic stress, as well as supernatural causes, contributed. Literature supports the findings that unhealthy internet use can lead to addictions and can negatively impact physical and mental wellbeing (
Cultural beliefs and help-seeking behaviors were found to be highly connected. Seeking help from MHP was not the initial recourse sought toward the mental health of adolescents. Barriers to help-seeking included stigmatizing cultural perceptions to labels such as the use of the term ‘mad.’
Though magico-religious beliefs appeared to be barriers in seeking early professional help, the integration of spiritual care in the context of health has been discussed in the literature (
In conclusion, our study elicited community stakeholders’ beliefs and attitudes towards the mental health of adolescents and help-seeking behavior. Increasing mental health awareness and equipping adolescents with the right coping strategies and establishing pathways to early referrals were important takeaways from this study. Targeting the community on sensitizing and destigmatizing issues surrounding mental health emerged as an important step in this direction. There is a need for further studies on interventions at the community and school levels targeting important stakeholders.
Vidya Prabhu
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing
Varalakshmi Chandra Sekaran
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing
Lena Ashok
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing
Brayal D’Souza
Roles: Formal Analysis, Methodology, Resources, Validation, Writing – Original Draft Preparation, Writing – Review & Editing
Ravichandran Nair
Roles: Formal Analysis, Investigation, Methodology, Resources, Validation, Writing – Original Draft Preparation, Writing – Review & Editing
Figshare: Qualitative raw data.
The project contains the following underlying data:
Qualitative Raw Data.docx.pdf
Figshare: IDI and FGD guides.pdf.
The project contains the following extended data:
IDI and FGD guides.pdf
Data are available under the terms of the
The authors describe a qualitative study designed to understand concerns – from multiple stakeholders – about adolescent mental health with the aim of highlighting the influence of religious beliefs and the stigma that exists at the community level towards seeking mental health services. There are several things to consider that will strengthen the paper if addressed.
The review of literature highlights the prevalence of mental health disorders in India within the middle-class communities. It also focuses on the stigma associated with seeking help and the influence of religious activities on treatment seeking. However, the literature should also provide information about the term magico-religious beliefs and the past literature related to it. They define it later on in the discussion but mentioning it at the beginning of the paper provides a better understanding of the study. The literature review needs to be thorough. Related to this, the Introduction section needs to provide more specific detail and reasoning about the inclusion of particular constructs focused on in the overall aims of the study. In the concluding paragraph of the literature review, the authors could have indicated the qualitative approach selected for the study. Given that the authors have chosen a phenomenological approach, which one was selected and why was it chosen? They might also have briefly outlined the research paradigm guiding their work to provide greater clarity regarding their epistemological stance. Please describe the particular steps of implementing the qualitative method used. Please cite the primary developer of the particular method used. The sample size for this study seems large, according to typical guidelines provided for phenomenological studies. Given that this study is based on lived experiences, 70 participants is likely an unwieldy amount to manage all of the narrative responses. Related to this, although ideally having different groups of stakeholders is important, perhaps it would be better to break the groups apart into separate studies. Also, there are 52 adults and 12 adolescents in the study. A better balance of adolescents and adults would increase confidence in the adolescent perspective. It is not clear how many adolescent responses contributed to each particular theme. Similarly, it is not clear how many responses from participants in general contributed to each theme [i.e., it would be helpful if each theme included a parenthetical statement about number of participants. For example,
The authors do not acknowledge their role, preconceptions, and potential biases (bracketing or reflexive stance). This is important to include in the Limitations section. Research questions are not clearly mentioned in the paper. There needs to be an explicit limitations and future directions section at the end of the paper. In the result section the first two paragraphs can be put into a table for better comprehension, as it discusses the demographics. The numbers in the first two sentences of the Introduction section are inconsistent with each other. For example, it is stated that within India there are 197.3 million adults with mental health conditions in general, and the breakdown adds up to 906 million. The Discussion needs to be more detailed, including more integration and synthesis with existing literature. As one example, on page 8 near the end of the first paragraph of the Discussion section, examples of “parenting factors” would be helpful to increase understanding. A bit more quoting to support each theme would be helpful, including providing more context for each quote. The focus groups were about 1 to 1.5 hours and the individual interviews 45 minutes to an hour. And there were no repeat interviews conducted, including no follow-up with participants, correct? If so, it is unclear how saturation was determined and accuracy verified. In other words, how can one be certain that this amount of time is sufficient? The sentence referring to Table 1 is placed after the table and should be placed before the table.
Is the work clearly and accurately presented and does it cite the current literature?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Not applicable
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Is the study design appropriate and is the work technically sound?
Partly
Are the conclusions drawn adequately supported by the results?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
No
Reviewer Expertise:
Clinical Psychology, Addiction Recovery, Psychology of Religion and Spirituality.
We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.
This qualitative study aimed to explore perspectives of parents, adolescents and educators on adolescents' mental health experiences, perceptions and help seeking behaviours. The authors present an important topic and interesting findings, but major methodological and ethical issues are raised in this study.
The introduction lacks literature about how mental health is framed by religion or different religions within the Indian context. The authors should give an idea about which religion/s they are discussing in their article. How do these religions frame mental illness and what does it advise for treatment? The authors talk about religion as a very general and vague category, separating it from other socio-demographic factors that have major impact on perceiving and managing mental illness.
There is minimal mentioning of previous studies on the topic, and how this research builds on these studies, and its findings.
The recruitment has several problems:
Having the health care providers (HCPs) as those to recruit patients is problematic due to the hierarchy issues. HCPs could promote the study, and ask their patients to contact researchers if they are interested to participate. Same regarding teachers and educators. They were recruited by the school, which is also problematic due to hierarchy issues. The authors talk about purposeful sampling while they do not address their strategy to recruit participants. Although they mention the use of HCPs to help them, but still not clear how did they continued with those contacted by HCPs. There’s no mentioning of inclusion and exclusion criteria, which is key factor in purposeful sampling.
Ethically: what strategies did they used to manage psychological distress through the interviews? Even if they did not have this, what strategies did they prepared to deal with this sensitive research?
Did they include those who are experiencing a depressive episode at the time of the study?
Applying focus group discussions/interviews and guided interviews do not fit at all with exploring the lived experience approach.
What is the framework that guided the phenomenological study?
Confidentiality within FGDs especially with adolescents: how did they manage that? How did they guarantee no use of any information by any adolescent? We know how at this age, persons might use these data to bully their colleagues. How did the researchers work to avoid that, if at all?
Based on calculating the number of individual interviews and the number of focus groups, it seems that the focus groups included 12-14 people each, which is problematic by itself in phenomenology and lived experience research.
Atlas.ti is used more for content analysis rather than thematic analysis that uses applies interpretation to identify patterns and abundance in the data.
The authors state that they used inductive and deductive: what is the theory that they have used in their deductive analysis? Deductive analysis is not something that is used in lived experience research. The results do not reflect deductive analysis.
Is the work clearly and accurately presented and does it cite the current literature?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Not applicable
Are all the source data underlying the results available to ensure full reproducibility?
Partly
Is the study design appropriate and is the work technically sound?
No
Are the conclusions drawn adequately supported by the results?
No
Are sufficient details of methods and analysis provided to allow replication by others?
No
Reviewer Expertise:
Sociology and anthropology of health and illness.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.