Circumventing stigma with strengths-focused interventions

It is well-established that stigma around mental health inhibits help-seeking in many LMICs. In Kenya, for example, mental health problems are commonly viewed as signs of personal weakness, and stigma is common among youths (Ndetei et al., Reference Ndetei, Mutiso, Maraj, Anderson, Musyimi and Mckenzie2015). Thus, one challenge for intervention developers involves circumventing stigma.

One strategy for reducing stigma involves avoiding or reducing explicit reference to psychopathology that arises from terms such as ‘depression,’ ‘anxiety,’ ‘therapy,’ or ‘mental illness.’ Guided by this reasoning, we designed an intervention framed around character strengths rather than psychopathology. We drew inspiration from interventions within the positive psychology movement that are construed as cultivating strengths, improving relationships, and promoting well-being (Seligman, Reference Seligman2019). We reasoned that interventions focused on locally valued character strengths would be well received, even in contexts where traditional mental health interventions might confer stigma. Thus, we reviewed the literature on empirically supported character strength interventions and discussed this literature with Kenyan collaborators. This process – in which we first generated a list of evidence-based options and then narrowed it down with community partners – helped us select intervention modules that were evidence-based and culturally acceptable.

Our effort was evidently successful; students provided highly positive ratings of Shamiri's acceptability and helpfulness. Additionally, school officials were enthusiastic about bringing Shamiri to their students. We credit this response in part to our decision to focus the intervention on character strengths. This focus appeared to circumvent stigma and to stimulate enthusiasm.

Expanding access by working in schools

In many LMICs, government funding for mental health care is extremely low, and the mental health infrastructure is limited (Patel et al., Reference Patel, Flisher, Hetrick and McGorry2007). As a result, one challenge for investigators involves designing innovative ways to deliver mental healthcare that do not rely on the kind of mental healthcare infrastructure that might be found in HICs. One strategy for addressing this challenge involves disseminating interventions in schools; this approach offers several advantages that are especially relevant in LMICs. First, delivering interventions in schools increase their scalability, as school-based interventions have the potential to reach a large portion of Kenyan youth. Second, school-based interventions are often cost-effective: they can draw on existing resources (e.g. classrooms, worksheets, and computers) and reduce transportation costs (see Wasil et al., Reference Wasil, Kacmarek, Osborn, Palermo, DeRubeis, Weisz and Yates2020a for a cost-effectiveness evaluation of a school-based intervention in Kenya). Third, schools are a natural setting for learning and practicing skills. Previous research has shown that adolescents are accustomed to learning in school, which can enhance their ability to understand and retain mental health lessons (Chodkiewicz and Boyle, Reference Chodkiewicz and Boyle2017). Additionally, adolescents encounter many stressors and challenges in schools, which makes schools a natural setting for students to apply and practice skills they learn from mental health interventions (Chodkiewicz and Boyle, Reference Chodkiewicz and Boyle2017).

Generating buy-in from local stakeholders

Securing buy-in from local stakeholders, such as school officials, can be challenging. We employed several strategies to engage school officials. First, as mentioned previously, we centered Shamiri around character strengths that appealed to school officials. Second, the inclusion of the study skills control condition was especially helpful in receiving buy-in from school officials. Because we included an active control condition, school officials were enthusiastic about the fact that students in both conditions could learn useful skills. Additionally, they expressed an especially strong interest in programs that could improve students' grades. Thus, we believe that one way of generating buy-in among school officials may involve including interventions that have a chance to improve students' academic performance. Third, we worked with school officials to ensure that the timing of intervention sessions did not conflict with other school events. Finally, to avoid tokenizing the opinions of local stakeholders (Jumbam, Reference Jumbam2020), we were willing to make changes to our study design and intervention content based on feedback from local stakeholders. As an example, we initially brainstormed a longer version of Shamiri that included additional weeks of content. Feedback from school officials helped us develop the brief 4-week version of Shamiri. Using these strategies, we worked with 10 schools over the last 2 years.

Adapting the intervention via multicultural collaboration

In addition to working with multicultural experts from Kenyan institutions to adapt our intervention, we relied on the perspectives of recent high school graduates in Kenya. One was a core member of our research team, and we recruited others as lay counselors. We reasoned that Kenyan high school graduates would be familiar with the pressures of the Kenyan education system, common challenges that high school students face, and potential barriers that could arise when delivering our intervention.

Importantly, the lay counselors were not only meant to deliver intervention content – we included them as active members of our team, and we worked with them to adapt our intervention content. We explained that our intervention was based on research, yet most of this research had been conducted with western samples. Therefore, while there were some aspects of our intervention that we were unlikely to change, there were many aspects of the intervention delivery that could be tailored for delivery in Kenya. Our approach was consistent with the idea that interventions consist of core components (i.e. essential and indispensable parts of an intervention) and an adaptable periphery (i.e. elements that can change based on the context in which the intervention is implemented; see Damschroder et al., Reference Damschroder, Aron, Keith, Kirsh, Alexander and Lowery2009). To receive feedback on the adaptable periphery of our intervention modules, we prompted lay counselors to think about how high school students currently conceptualized each character strength (i.e. gratitude, growth, and values) and to discuss any challenges that could arise when delivering the intervention.

Using this process, we discovered several ways to adapt the content for Kenyan students. For example, we replaced the term ‘values’ with ‘virtues’ as Kenyan students were more familiar with the latter. Additionally, in our module on growth, we initially emphasized the malleability of personality traits (Schleider and Weisz, Reference Schleider and Weisz2018). However, we learned that the term ‘personality’ was not universally understood and did not have a clear Kiswahili translation. As a result, we replaced references to ‘personality’ with those of ‘character traits’ and ‘personal qualities.’ Each lay counselor also shared personal stories related to each character strength: they shared a growth story (a time when they struggled at something and then improved through effort), reflected on things they were grateful for in a high school, and listed virtues that they found most important. We incorporated these examples into the intervention content and encouraged lay counselors to share these examples with students. Finally, the lay counselors helped us anticipate potential challenges that might occur during intervention delivery and brainstorm strategies to address those challenges.

Applying Insights from LMICs to HICs

Global mental health work does not only have implications for those in LMICs. Just as interventions developed in high-income settings can be adapted for LMICs, lessons learned in LMICs can be ‘reverse-engineered’ to support individuals in HICs (Singla and Hollon, Reference Singla and Hollon2020). Each of the strategies we discussed are principles that could also be applied to enhance the impact of interventions in HICs as well. As an example, our work in LMICs (Osborn et al., Reference Osborn, Rodriguez, Wasil, Venturo-Conerly, Gan, Alemu, Roe, Arango, Otieno, Wasanga, Shingleton and Weisz2020a; Wasil et al., Reference Wasil, Park, Gillespie, Shingleton, Shinde, Natu, Weisz, Hollon and DeRubeis2020b) has informed recent efforts to support university students in the United States during the COVID-19 crisis (Wasil et al., Reference Wasil, Taylor, Franzen, Steinberg and DeRubeis2020c). To adapt our interventions for American students, we applied the lessons we learned: we framed our interventions around character strengths to reduce stigma, deployed the interventions in universities to maximize reach, generated buy-in from university stakeholders, and worked with American students to adapt the interventions. In our experience, these strategies were useful both in LMICs and HICs, illustrating the importance of reverse engineering (Singla and Hollon, Reference Singla and Hollon2020).